Friday, August 3, 2018

An Immigrant's Tale


There are many things that make me proud of the American College of Physicians. 

ACP’s courageous leadership in standing up for those seeking to immigrate to the United States is one of them.  Over the past 18 months, ACP has issued a comprehensive statement on immigration policy affirming its opposition “to discrimination based on religion, race, gender or gender identity, or sexual orientation in decisions on who shall be legally admitted to the United States as a gross violation of human rights,” opposed the President’s original Executive Order barring immigrants from six majority Muslim countries because it was discriminatory, and would adversely affect non-U.S. born IMGs seeking to study, train, or provide medical care in the United States; joined in an amicus brief to the U.S. Supreme Court urging that the court overturn a modified version of the ban for the same reasons; issued a statement expressing concern that the Supreme Court upheld the ban; advocated for legislation to provide permanent legal status, and eventually citizenship, for persons enrolled in DACA (Dreamers); successfully advocated to end delays in processing H-1B visa applications from IMGs that were stalled or denied due to increased scrutiny regarding prevailing wage data; objected to the administration’s “zero tolerance” policy of separating immigrant children from parents, or detaining parents and children together in detention facilities, because of the harm to the health of children and their families.

Many other medical organizations have shied away from immigration policy, maybe because it is considered to be too controversial, too complicated, too political, and too divisive, among their own members and the public.  Some may feel that immigration policy is not their area of expertise.
For sure, there are reasons to be cautious about entering the fray: immigration is controversial, complicated, political, and divisive, and physicians are not experts on how to enforce U.S. immigration laws or control access to our borders.

But physicians are experts on how public and social policy affects the health of the public and their patients.  While immigration policy is complicated and controversial, so are many other issues, from gun violence, to high prescription drug prices, to what happens if people are denied access to affordable coverage. Yet, many physician professional societies have tackled those issues, because of their abiding concern for patients. 

While my own family experience has no bearing on ACP policy, it is one of the reasons why I am especially proud of ACP’s willingness to speak out on the impact of immigration policies as a public health and human rights issue.

My father, Jack Doherty, was born poor in Ireland, in a thatched cottage with no plumbing or electricity.  He originally emigrated with my grandmother and grandfather to New York City as an infant. For reasons unknown to me, my dad at age two returned to Ireland with my grandmother, without my grandfather. My grandmother raised my dad as single mother in Ireland on a subsistence farm for eight years, during which they had no contact with my grandfather. When my father was 10, they got a letter from my grandfather asking them to return to NYC to be with him.  They sailed in steerage once again to NYC and were reunited with my grandfather.

My grandfather, Thomas, was a bar-owner and bartender at Doherty’s Bar in Woodside, Queens, NYC.  My father told me he had a very difficult relationship with his father, given that my grandfather had abandoned him and my grandmother for so many years, and my father had grown up without knowing his dad.

Thomas died when my father was only 16. My widowed grandmother took over and ran Doherty’s Bar until my father was 18, and then my father ran it—not as an absent owner, but an owner-bartender who worked six days a week, 10 hour shifts behind the bar, serving shots and beer to blue collar workers.  He married my mother, Marilyn, a few years later, a U.S. born and college-educated woman who  came from a working class Irish-German background.

The bar ended up being successful enough for my mom, three sisters, and I to enjoy a middle-class lifestyle, enabling my siblings and I to go to good schools and colleges and have just about everything we wanted and needed. 

When I was in college, I was the third generation of Doherty men to work behind the bar while  on summer break from college.

Fast forward: my dad decided that being a bartender/bar-owner with only a high school diploma was not giving enough back the country (the U.S, not Ireland) that he so loved. While still tending bar 10 hours a day, six days per week, he went to college at night to get his B.A. in history, and then, a Masters in secondary education. He sold the bar in the late 1970s and became a NYC public school teacher, in a high school that taught mostly underprivileged minority students. He said he wanted to teach disadvantaged minority kids who faced discrimination and hardship because he had been a poor child himself, facing discrimination (the Irish at that time were not welcome by many Americans) and hardship.

Because my grandmother, grandfather, and father came to America to escape dire poverty, my sisters and I had great schooling and a college education. One of my sisters is a U.S. diplomat, one’s an award- winning theater costumer designer; one is a social worker who has spent most of her professional life counseling poor and emotionally troubled teenagers. I, of course, have spent my career advocating for internal medicine physicians.  The advantages we have had have been passed on to our children.

My dad passed away 11 years ago.  His immigrant story, like millions of others, is what truly makes America great: unskilled, poor people coming to America to improve their lives, and by doing so, improving America. 

So, when ACP speaks out for the unskilled, poor people coming to America today to improve their lives, it resonates with me. And makes me so proud. 

Today’s questions:  What is your view on ACP taking on immigration policy?  And do you have a family immigration story you want to share?

Friday, July 13, 2018

FOUR things you should know about Medicare’s “historic” changes to physician payments

The word “historic” is often used by PR professionals to hype something that is, well, pretty run-of-the-mill.  They figure that no one is going to read a news release that announces “[Name of organization] proposes small change that really won’t make much of a difference.”  The problem is that when something is done that really measures up to being historic, the recipient is less likely to believe it, kind of like the constant Breaking News chyrons loved by cable news shows. 

Yesterday, CMS—the agency that runs Medicare—issued a press release announcing “Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship.”  You know what? This one may actually live up to the billing!

CMS is proposing to radically overhaul how it pays physicians for office visits and other evaluation and management (E/M) services; to lift restrictions on payment for telehealth consults and other physician services that are not part of the office visit itself; and to ease the myriad of crushing administrative tasks imposed on physicians to document their services or to get credit for participating in Medicare’s Quality Payment Program.

Both of CMS’s proposed rules are thousands of pages long, so few readers of this blog will be up to reading them. (Never mind trying to decipher the technical and legalistic language used for federal rulemaking!)  Fortunately, ACP’s crackerjack regulatory affairs staff was at it late last night and early this morning (when do they sleep???), to go through it and find out what is to like, and not like, about it.

They found that there is much to like.  Based on their review, ACP released a statement just a short while ago that expressed optimism that many of the proposed changes will “streamline burdensome administrative and documentation requirements –a proposal that is in line with ACP’s Patients Before Paperwork initiative” as Ana María López, MD, MPH, FACP, president, ACP, put it.  ACP also cautioned, though, that one of the biggest changes proposed by CMS—paying a flat fee for most office visits, regardless of their complexity—needed greater examination because of its potential to undervalue the skill and training required of physicians to take care of patients with more complex medical conditions.

There are 4 BIG changes proposed by CMS that are noteworthy:

1.  CMS proposes to make it less burdensome for physicians to participate in its Quality Payment Program, including streamlining the Promoting Interoperability MIPS category by removing the separate components within the Promoting Interoperability (formally Advancing Care Information) Category score to create a streamlined scoring methodology, increasing the ways in which physicians and other clinicians can qualify for the low-volume threshold  and removing a number of quality measures deemed by the agency to be of low-value, consistent with recommendations by ACP and its Performance Measurement Committee.

2.  CMS proposes to pay for more physician services that are not part of a face-to-face office visit. CMS proposes to add new reimbursable codes for “virtual check-ins,” remote consults of patient videos and photos, and interprofessional online consultations.

3.  CMS proposes to take major steps to reduce the documentation requirements associated with evaluation and management (E/M) services, by allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff. ACP strongly supports these changes, as they will reduce the documentation burden on clinicians, limit redundant information in the medical record, and cut down on duplicative time spent on re-documenting existing information.  CMS also proposes to create add-on codes for primary care visit complexity.

4.  CMS proposes to create a flat, single blended payment for most office visits, regardless of their complexity.  ACP expressed concern that this proposed payment structure potentially could have an adverse impact on internal medicine physicians and subspecialists and their patients, since internists typically take care of elderly patients with multiple chronic conditions.  “While we acknowledge the potential benefit of simplifying billing and associated documentation of E/M services by bundling levels 2-5 together, ACP will be assessing whether this change will have the unintended impact of undervaluing the work associated with caring for more complex and frail patients” Dr. López observed. “Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients.”

There is much more to the proposed rules, including several areas where it fell short in ACP’s opinion.

Still, the overall direction of easing the burdens of participating in Medicare’s QPP, simplifying requirements to document office visits, paying for telehealth consultations and other work that falls outside of an office visit, and yes, the proposal to pay a flat fee for office visits of varying levels of complexity (whether this turns out to be a good idea or not after further examination of its impact), might just live up to being “historic.” 

Today’s question: what do you think of CMS’s “historic” proposals to change Medicare payments to doctors and its Quality Payment Program?

Wednesday, May 23, 2018

Physician activism as an antidote to burnout

The growing number of physicians evidencing symptoms of burnout has many causes.  Yet one element stands out, according to research: a perceived loss of control over their time, working conditions, and other stress contributors.   ACP has launched a Physician Well-being and Professional Satisfaction Initiative that includes resources promoting individual well-being, advocating for system changes, improving the practice environment, and fostering local communities of well-being.  ACP’s Patients Before Paperwork is about challenging administrative tasks that contribute to burnout.

Yet over the past three days, I’ve observed another promising antidote to burnout:  individual and collective physician activism to change policies that affect their daily work and professional development.  Nearly 400 ACP members from 48 states and the District of Columbia came to Washington, DC to participate in our  annual Leadership Day on Capitol Hill.  Yesterday, they learned about how to be effective advocates with their elected lawmakers, the political and legislative environment in Congress, and the issues that ACP was asking them to bring to Congress. 

This morning, they heard from Rep. Peter Roskam (R-IL), chair of the Ways and Means health subcommittee, on the subcommittee’s Medicare Red Tape initiative, which gives clinicians the opportunity to inform lawmakers about administrative tasks that could be modified to make them less burdensome, if not eliminated altogether. Then, former CMS administrator CMS Andy Slavitt, recipient of ACP’s 2018 Joseph F. Boyle award for Distinguished Public Service, suggested to the attendees that health care proposals should be evaluated based on a simple test: does it make it easier or harder for patients to get the care they need? 

The attendees then headed to Capitol Hill, meeting with members of Congress and staff from their own states, presenting ACP’s ideas, as supported by their own personal experiences with patients, for improving patients’ care and physicians’ daily lives and professional development.

What does all of this have to do with physician burnout?  The doctors and medical students I observed this week were anything but a dispirited or despairing group, but happy and enthusiastic activists for their patients, and their profession.

When you think about it, it makes perfect sense that physician activism is a powerful antidote to burnout.  If burnout is about losing control, activism is about taking it back.   Physician-activists don’t accept a status quo that devalues the doctor-patient relationship, they advocate for policies to make things better.  As Margaret Meade once said, “Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.”

There is nothing more empowering than that.