The U.S. congressman, a senior member of the House Ways and Means Committee and deputy whip and vice chairman of the Joint Economic Committee, recently visited the Texas Medical Center to hear firsthand from local leaders and physicians. Brady met with TMC News to discuss one of the most pressing issues on his radar: Medicare.
Q | Tell us about your early days, and what lead you to this career path.
A | I grew up in Rapid City, South Dakota. My family was very involved in the community and politics. A bit of a tragedy early on—my father took on a tough case for the local church and was threatened and unfortunately the man followed through, so he was killed in a courtroom shooting. I was 12. My mom raised five of us by herself; we have a remarkable mother—she just passed away. She taught us to be independent, to be optimistic, to give back to the community and to have faith in God. She was just really remarkable, very involved growing up, in school and sports—all of that. Same in college.
I chose chamber of commerce work for a profession. Which is this great job, because you are working with the best community leaders—volunteers who are here to help small businesses build the right business climate, recruit in the community, recruit in the industry. For 18 years, I did that in Rapid City, South Dakota, and then in Beaumont, and then in The Woodlands area—I was a chamber exec for about 111⁄2 years there. Toward the end of that, I was elected to the Texas legislature. Then when Jack Fields retired from Congress, I ran and won his seat.
I never expected to go into politics, never dreamed of being in Congress, and certainly didn’t expect to be able to work my way up and be in a leadership role on the Ways and Means Committee. That’s what has brought us here. For a number of years, my focus on Ways and Means was really on tax reform, as chairman of the trade subcommittee. Obviously trade is a big driver of the Houston area. For the last two and a half years, I took over the Health Subcommittee for Ways and Means at, I think, a really critical time. One, the roll out of the ACA and all that goes with that. But more importantly, the chairman of the committee, Dave Camp, essentially said, ‘Your number one priority is to help find a solution for how we pay our local doctors, Medicare, the sustainable growth ratio (SGR).’
Q | Can you tell us a bit about your work on the Ways and Means Committee?
A | The problem that has plagued us for 15 years was really becoming a looming crisis in health care.
I had the opportunity to work with Republicans and Democrats in the House and Senate. Together with state, local and national physician groups, we came together and we did find a solution. And it was a good, solid one. We worked with the speaker and other leaders to find a way to finance it. So earlier this year, the president signed it. It’s important for two reasons—if there is any population that needs to see a doctor they know, and who knows them, it’s our seniors in Medicare. Fewer and fewer doctors are able to see Medicare patients and that means terrible trends for the country, certainly for growing states like Texas and regions like Houston.
The importance of it may be three things. First, we are moving away from volume and how many procedures, to value and quality outcomes that are not measured by Washington, but measured by the physicians who practice, which I think is the right way to do it. Done gradually. Innovation is already occurring here at the medical center, and can ultimately be matched by that one- and two-person physician in rural Texas. You have got to bring everyone together in this country. It is the first significant reform of Medicare in some time and coupled with some other reforms we made to pay for it, will strengthen Medicare by almost $3 trillion over the long term. It is not the final solution, but it is a huge first step.
We just celebrated the 50th anniversary of Medicare and it was worth celebrating. It is such an important program. More than 50 million Americans rely on it, and that will only grow. Financially, it is just not designed for the long haul—one, because health care costs continue to increase, and two, the demographics—more and more seniors, fewer workers. The math doesn’t work. If we want to celebrate a second 50th birthday of Medicare, Republicans and Democrats are going to have to work together now to save it.
The first step, we succeeded on: fixing how we pay our doctors. The second step is improving the way we pay other health care providers in Medicare, from the testing, diagnosis and evaluation leading into the hospital, the inpatient care here, the outpatient care, and post-acute care—whether it is at the long-term acute health care facility or the school of nursing hospital facilities, or home health care. So we have already begun work on step two of health care reform, which is to address some pressing issues, like two midnight policies and the rack audits. In the bigger picture, trying to, as we have seen here at the medical center, align the incentives, get them right. Aligning them toward the patient, encouraging the innovation and saving quality care.
We have laid out a draft bill with what I call the ‘demolition derby’ of reimbursements between inpa- tient and outpatient care, as well as other bipartisan improvements that Republicans and Democrats on the Ways and Means Committee are working together on. Some of those include an idea on how we design indirect medical education reimbursement, per discharge from inpatient. More and more procedures are occurring outpatient. So how do we make sure that those who are teaching our future physicians have a consistent certainty of funding going forward?
Before I left for August, we laid out reform ideas on post-acute care, value-based purchasing and, we think, a much better approach than what CMS has proposed—it really rewards quality and excellence in the post-acute care setting. As a committee, Kenny Marchant from Texas introduced a bill to make sure that disproportionate share funding in states that didn’t expand Medicaid are on a level playing field with those that did expand funding. We think that is very important for Texas, as well. What I’m hopeful for is that before Congress and this presidential election start to shut things down up there in Washington, that we can pull together a bipartisan package of hospital reforms and other improvements in health care that have been worked on for years, but have never gotten a chance because of the sustainable growth ratio. For those to see some life.
And then, step three to saving Medicare for the long-term is really creating smarter, more personalized care for seniors. Step three will really begin to take shape next year, following our hospitals and post-acute reforms. Two examples would be combining part A and B, creating an out-of-pocket cap for seniors, more co-insurance that gives them more certainty and rewards preventative behaviors on their part and engagement. Essentially, taking today what for seniors is the equivalent between part A, B, D and supplemental—the equivalent of buying five insurance policies for your car. We think you can simplify it, make it more understandable, smooth out the cost for seniors and make sure they never face catastrophic costs going forward.
The other part of step three will be more personalized Medicare. Some call it ‘premium support,’ but it is taking what we know has worked in Medicare Advantage and in the part D prescription drug program and giving seniors the option. They don’t have to stay in traditional Medicare forever. But if they want to have Medicare more personalized for them and their family, going forward, give them that option.
Over time, if we do it right, it will help improve solvency in Medicare and make sure that we can give both quality care and affordability. We can do one or the other pretty easy. Doing them both is a trick.
Final point: How do we go about this? To save Medicare for the long-term, we can go with sort of the stale, old ideas—which is cost control out of Washington, more mandates out of health care, and a question of micro-managing every aspect of the experience—or we can look to fresher, more 21st century approaches, which mean more competition, more innovation, great freedoms to take on patient care, integrate and coordinate it, take on that risk and be rewarded for doing that. Given those choices, seeing what we know works here at the Texas Medical Center, innovation, competition, and freedom to treat and risk and coordinate works.
As we go forward, those are the sides that I hope we can get our lawmakers to go to. None of this is easy. Health care is complex. Most people believe, wrongly, that Congress won’t take the necessary steps to fundamentally redesign and save Medicare for patients in the future. I am absolutely convinced we can. While we may have differences on issues like the Affordable Care Act and others, there is an awful lot of common ground going forward. Part of the reason I spend a lot of time with health care leaders in the Texas Medical Center is that the innovation you see here, the thoughtfulness, it is just a gold mine of knowledge and practice. The medical center and our organizations and leaders here are just so impressive.
Q | You have been actively involved in addressing how physicians receive payment from Medicare. Can you talk about those efforts?
A | My job as chairman of the Health Subcommittee was really to help bring lawmakers who had long interests in solving this problem together with physician groups—state, local and national—who wanted this solved. Of course, on the score-keeping side, making sure we could do all of this, fix this problem in a way we could afford Medicare, which, again, financially is just not designed for the long-term. It wasn’t easy.
It took a great deal of time, but we found that way forward. Part of it was it was really a 10-year transition. The first four years, we just called time-out on the drama—year-to-year potential 20 or 30 percent in cuts, it was embarrassing for everybody. So we called a time-out on that so everyone can stabilize in Medicare.
After four years, we moved to really reimbursement based on quality measurements. Again, we spent a lot of time in our discussions making sure that CMS and Washington were not driving the quality of measurements that our local physicians are using, but our physicians are driving those standards and registries and other happenings. After year four, we really start transitioning into those quality missions. In year seven, eight and nine, we were encouraging physicians to join together and find ways to innovate. Try out new models where they may be paid on fee-for-service, but they are trying out models that work better on quality. Later in year seven, eight and nine, we really start rewarding based on quality and efficiency, and cost as well, but that is a harder target to hit. You need more time to do it. It is a major challenge for physicians in rural communities and small practices.
That is how that whole process of moving from volume to value will go. There are areas I want to keep improving. While the solution streamlined some of the penalty payments for physicians coming up in the next three years, we did not streamline the entire overhead that is coming out of Washington and landing on our physicians. I think we can do much better than what we have. The SGR is a good program, but it still needs improvement. I rely on Harris County Medical Society. It is very key in helping find a national solution as we went through the various segments of the SGR. For my office, they were very helpful in working through some of the sticking points. The final product reflects it.
Q | You recently spent a day here visiting with Texas Medical Center leaders and physicians. What is the takeaway from your visit?
A | One of my frustrations in the design of the Affordable Care Act is that when I come down here and listen to our health care leaders, virtually no one in Washington was asking their opinion on how you deliver better health care in America. I think that was a huge mistake, because we have every model in the world here. We have some of the brightest minds in the world here, and I think had those who designed that bill listened more carefully, frankly, they would have designed a better product that was working better and had better support.
Secondly, I really am impressed by [Texas Medical Center] President Robbins’ idea to make this more of a national health policy source. Certain lawmakers like me—there is so much we can learn here. Not that we apply every model here to every region in America, but they have experienced many of those challenges, so I think we can leap-frog into some of the better next models of health care delivery here. I think that is a smart move for everybody—the medical center and the country.
Q | In an ideal world, what do you hope for the next few years?
A | That Congress and this president or the next take significant steps to saving Medicare for the long term. We do that not only in a bipartisan way, but we stop clinging to the old school approach of ‘Washington knows best, so let’s mandate that solution.’ We really focus on the innovation and competition, and really the freedom to practice and take that risk-and-reward approach. That’s what I’m hopeful for in the next couple of years.
Step three of Medicare will be difficult, but here’s the point: I think a lot of people here in America are discouraged by Washington, because they don’t see us tackling the big issues. There is nothing bigger than Medicare—it is not the 800-pound gorilla, it is the 8,000-pound gorilla in our budget and delivery of health care. I think making strides and achieving progress in a bipartisan way can help build some confidence that Washington can help take on other big issues too. It is exciting. Health care is going through a dramatic change. In some ways, it is almost overwhelming, whether you are that physician or hospital. Part of it is that it is hard for them to incorporate all of these changes in a fairly short timetable. Again, the Texas Medical Center is a tremendous help because they are incorporating these changes more quickly and learning the lessons from it. Which helps us a lot.