There are two types of visitors to Washington, D.C. The first group consists of the 15 million tourists who visit the capital each year, making it the fourth most popular city to visit in the country. After all, Washington, D.C., is home to countless attractions, almost all of which are free to visit. You can get lost in one of its world-class museums, such as the Smithsonian, which happens to be the world’s largest, holding more than 120 million specimens. There are the monuments honoring soldiers who died in the Civil War, both World Wars, Korea, and Vietnam. The District’s restaurant and bar scene is hopping; The Washington Post rates nearly 900 restaurants located within the confines of its 61 square miles. The architecture is interesting and varied, with elements of neoclassical, modern, gothic, and Georgian design reflected in many of the stately stone edifices. During the War of 1812, British forces invaded the capital in a raid known as the Burning of Washington. The Capitol, Treasury, and White House were burned and gutted during the attack. Though peace has reigned since then between the U.S., Canada, and Great Britain, I suspect that the residents of D.C. did not want to take any chances using wood construction to rebuild their city. After all, can you really trust those wily Canadians?
The other steady stream of visitors to D.C. consists of those citizens who come to meet with their elected representatives regarding all matters of business. One can usually discern the two groups fairly easily: The tourists are constantly snapping photos and their casual attire generally distinguishes them from their nattily dressed compatriots who are in town doing business in D.C.—and doing business in D.C. means lobbying politicians.
I recently had an opportunity to spend a couple of days in Washington as an engaged citizen and invited guest of the ACR Board of Directors annual spring meeting. One of the highlights of this meeting is the board’s annual trek to Capitol Hill to meet with our legislators. We were divided into small groups based upon our state residency so that we could visit the legislators who represent us. Hailing a convoy of cabs, we descended upon the Dirksen Office Building bright and early on a warm Thursday morning—so early in fact, that we successfully avoided the lengthy security check-in lines that typically form later in the day and last until closing.
The Dirksen Building was built in the 1950s at a time when cost constraints precluded the incorporation of expensive ornaments or grand interiors into the construction plans. The building’s stone exterior façade, alternating with multistory dark window columns, suggests an ornate interior. This prediction is quickly dispelled: upon entering through the heavy bronze doors situated at the building’s corners and walking into the exceedingly small and simple lobby, I was reminded of the generic medical office building that many of us inhabit. Perhaps the most striking aspect of the Dirksen’s design is its long hallway corridors that are bare except for the occasional cluster of flags that mark the entrance to a senator’s office suite. Once inside, the visitor is told to sit in a waiting room whose walls are adorned by an array of sports-related memorabilia. There are photos and newspaper clippings depicting winning goals and Super Bowl touchdowns or other iconic items, such as autographed team jerseys. On mahogany desktops, I noticed many signed baseballs, basketballs, and hockey pucks. It must be fun representing a region like Boston with so many championship teams! Invariably, there is the requisite photograph of the politician shaking hands and/or sharing a joke with a recent president; in general, that president is Ronald Reagan if the politician is a Republican and Bill Clinton if said politician is a Democrat.
At each office, we were greeted by the perpetually smiling, well-caffeinated, friendly young staffers. These legislative aides (LAs) are a very devoted bunch. They reminded me of their medical peers, the hardworking residents and fellows that we have the privilege of working with every day. They are cut from the same cloth, except they probably chose not to major in pre-med studies in college. Both groups are of similar age, smart, upbeat, hardworking people who are poorly paid for their efforts. Since they work in Congress, I doubt that work-hour rules apply to them. No matter, they seem to thrive on the arcane minutia of the legislative process.
Fixing the SGR
During our limited time with the staffers, we raised the thorny issue of how to fix the Medicare Sustainable Growth Rate (SGR) in a way that recognizes the value of our professional services to our patients. The SGR is essentially an equation that was created in 1997 as a way for Medicare to control rising physician fees. It tries to ensure that the yearly increase in the federal expense per Medicare beneficiary does not exceed the growth in the Gross Domestic Product (GDP). However, the methodology behind SGR is considered by many observers to be highly suspect.
For the past several years, the calculations have yielded results that would significantly reduce future Medicare payments. Yet these cuts have never been enacted because Congress realizes the repercussions of such a decision. Payment reductions are anathema to physicians and their implementation could lead to more doctors refusing to take care of Medicare patients. This would create anger and frustration for many Medicare recipients, and politicians are keenly cognizant that senior citizens vote. According to a recent analysis published in the U.S. News & World Report, 61% of citizens aged 65 or older voted in the 2010 election compared with just 37% of Americans between the ages of 25 and 44. Since 2002, Congress has displayed rare flashes of bipartisanship by voting to approve 14 temporary patches to avert the SGR cuts. Right now in 2012, we are facing a potential 30% reduction in Medicare fees for 2013.
Most legislators claim to be sympathetic to doctors, and many have gone on record decrying the folly of the SGR. Recently, four former Medicare administrators testified to the Senate Finance Committee that the SGR must be replaced with a better method of calculating future payments. However, in order for Congress to replace it, legislators must find another way to recover the cost of higher-than-anticipated Medicare payments to physicians.
The Devil Is in the Details
Most legislators claim to be sympathetic to doctors, and many have gone on record decrying the folly of the SGR. Recently, four former Medicare administrators testified to the Senate Finance Committee that the SGR must be replaced with a better method of calculating future payments. However, in order for Congress to replace it, legislators must find another way to recover the cost of higher-than-anticipated Medicare payments to physicians. Not surprisingly, the devil is in the details. The budget fix required to correct this problem once and for all is estimated to be $300 billion. During our visit, it was pointed out that, had the fix occurred a few years ago, the cost would have been substantially less. As one Congressional chief of staff lamented, there is little interest in Congress in passing legislation that could save more money in the future; given the current political climate, he stressed that the savings must occur immediately, even if the proposal ends up saving less money in the future.
So, how will the government pay to correct the SGR? Simply stated, the SGR legislative fix is based on rules that sound eerily similar to those of a childhood game known as “chicken.” In the Washington version, there are multiple players, representing both parties in the House and Senate as well as the White House. The strategy is simple: each participant waits to see whether their opponents blink first and accede to their demands. The game gets even more exciting as the legislative session’s clock starts to wind down. For example, the SGR fix for 2012 was passed after the 2011 Congressional session had ended. But wait—how could Congress pass a law after the deadline? We are dealing with Congress. They are free not only to play the game but to serve as their own referees, too.
During our visit we heard about a bill sponsored by Congressman and emergency medicine physician Louis Heck (R-NV) and Congresswoman Allyson Schwartz (D-PA), who have proposed to permanently fix the SGR by using the money that was previously budgeted for use in Iraq and Afghanistan but was never spent.1 As ACR board member Gary Firestein, MD, professor of medicine at the University of California at San Diego, quipped: “It’s like using virtual money to pay off a virtual deficit.” Although some members of Congress have signed on as cosponsors of the bill, its passage is far from certain. The word we heard on the Hill was that many members from both sides of the aisle wanted to see real dollars removed from other parts of the budget to offset the cost of the fix.
So What’s a Rheumatologist?
Though the SGR itself is based on a flawed calculus, it is apparent that correcting these types of errors often requires more than an “act of Congress.” This simple reality drove home the most important point of our day on Capitol Hill: if constituents want to have any impact on the drafting of legislation, they need to have their voices heard prior to the passage of the bill. As Lady Macbeth astutely observed: “What’s done cannot be undone.”
In order for us to be heard, it might be helpful for the listeners to know a bit about who we are and what we do. Many of the staffers we met were not familiar with our specialty, but we came prepared. Each member of the ACR delegation sported a bent fork on their jacket lapel or blouse. (This month’s “President’s Perspective,” p. 4, features some more photos of the fork pins.) This brilliantly simple lapel-pin design is a key feature of the ACR’s Simple Tasks public relations campaign (www.SimpleTasks.org). These forks served as great conversation starters. Although one of us was asked whether we represented the food and beverage industry, most Congressional staffers seemed to experience that “aha!” moment when they juxtaposed the metaphor of the bent fork with the definition of what a rheumatologist does. It gives us a face and an identity by highlighting the struggles that our patients face every day.
Walking through the hallways of Congress, it was hard not to notice that many of our fellow citizen visitors to Congress were easily identifiable. For example, there were the swarms of realtors sporting teal blue T-shirts bearing their organization’s logo. I sell houses and I vote! Then there were the bikers wearing worn leather vests that were adorned with a variety of patches, mostly related to their military service to the country. I ride motorcycles and I vote! Years ago, I recall taking a cab from the Minneapolis airport to the convention center where the annual meeting of the ACR was being held. I realized that I must be getting close to my destination when I began to notice clusters, then droves of men wearing beige khaki pants and blue blazers, the standard colors of the rheumatologist circa 1985. For those ACR members who still adhere to this dress code, adding the bent fork lapel pin will just make you look that much cooler. I can vouch that our female colleagues visiting the Hill looked pretty sharp sporting their bent cutlery, too!
Seriously, it is time for rheumatologists to stand up and be heard. We are reaching a critical juncture in the politics of healthcare. If we don’t make the case for ourselves and for our patients, then no one else really will. Yes, there are several large medical organizations of which some of us are members, whose lobbyists patrol the halls of Congress. However, they are paid to represent the diverse views of many medical specialties, not just ours, which means that our specific needs and requests may not always be advocated. No doubt this reality led to the creation of the RheumPAC a few years ago (www.rheumatology.org/advo cacy/rheumpac). According to the Center for Responsive Politics, in 2011, RheumPAC lobbying catapulted it into the Top Ten list of physician-led political action committees.
As Gary Bryant, MD, associate professor of medicine at the University of Minnesota and RheumPAC chair has stated, “It is critical that Congress recognize the value of rheumatology in care coordination and in treating and diagnosing patients with complex conditions.” We observed this first hand when we had breakfast with Representative David McKinley (R-WV).
He recalled meeting with one of his constituents with a serious rheumatic disease and hearing about all the challenges that she faced. It had a profound effect on his thinking, he said, and he now has a greater appreciation for the challenges of living with and treating rheumatic diseases. Being a member of the House Energy and Commerce Committee, which hears many bills that are of great interest to physicians, his support could be crucial.
This is why it is so important for all of us to take a moment and reconsider our own personal commitment to the politics of rheumatology. You can donate to the RheumPAC, sign up for the 2012 Advocates for Arthritis Capitol Hill fly-in at www.rheumatology.org/advocacy, or you can wear a fork in your lapel. It looks great on all colors of blouses and blazers. I am a rheumatologist and I vote.
Dr. Helfgott is physician editor of The Rheumatologist and associate professor of medicine in the division of rheumatology, immunology, and allergy at Harvard Medical School in Boston.