Two things are driving discussion. There are cost issues—how to pay for the roughly $1 trillion price tag—and content issues—what the bill must include in order to make healthcare cheaper for patients. The debate over a government-run insurance plan has swallowed up the lion's share of attention on the second point, but another major headache is figuring out how to encourage doctors and hospitals to provide high-quality care rather than just a lot of it.
Many ideas are on the negotiating table, some of which involve radical changes in the ways doctors practice and get paid. One is the so-called "medical homes" model, an approach that in recent years has popped up in almost every state and has some big fans in Washington. These aren't actual physical homes but more like organizational structures. Rather than practicing in relative isolation as they do now, primary-care doctors work with specialists in teams and are linked by state-of-the-art technology. Patients can access their health records online. Primary-care doctors, supporters argue, become like "health coaches," shifting their focus back to patient care. According to a recent study, this approach could reduce healthcare costs by nearly $70 billion a year by keeping patients in closer contact with doctors.
Baucus has championed medical homes. So have moderate Democrats in the House. But as Paul Nutting, a professor of family medicine at the University of Colorado Health Sciences Center, says, there are still a lot of questions. Nutting and a team of researchers earlier this year published a study that looked at several dozen physicians' offices that tried to "transform" themselves into medical homes. The verdict was mixed; the transformations were costly and time-consuming. "What we are proposing is that we follow these practices for another eight to 10 years," says Nutting.
Congress, of course, doesn't have eight years. So the House bill calls for funding demonstration programs to further test this model; if the demos are successful, the bill says, they should be expanded "on as large a geographic scale as practical and possible." But the money the House sets aside for them is pretty modest, about $1.6 billion over five years.
Baucus and friends clearly want to avoid the sort of damning verdict the CBO gave the House bill, so they've been working methodically and quietly for weeks to reach a comprehensive agreement that has a shot in the Senate. Clearly, top Democrats think they're on to something. "A decision was made to give them more time for the Finance Committee," Reid said Thursday. "I don't think it's unreasonable. This is a complex, difficult issue." In the end, one month more of debate might not be enough.
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