Friday, December 7, 2018

How a single tweet from the NRA helped ACP reach millions of people on gun violence

On November 7, the National Rifle Association tweeted this about ACP’s new policy paper on firearms violence, published in the Annals of Internal Medicine:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

As a co-author of the ACP paper, I immediately posted a reply to the NRA:

Passing laws to stop kids from getting shot by unsecured guns, reducing the lethality of mass shootings, keeping guns from domestic violence offenders who will use them to kill their intended victims—oh yes, these are all in doctor’s lanes.  Like any other public health threat. 

Within hours, thousands of physicians tweeted why gun violence was in their lane, accompanied by the hash tags #ThisIsOurLane and #ThisIsMyLane.  Many included graphic photos of the carnage and blood they’ve experienced in treating gunshot patients; I continued to tweet often on the topic, sharing their testimonials and information about ACP’s policy recommendations.

I just learned that in the past 4 weeks since I first replied to the NRA, my tweets on ACP’s behalf reached 8,300,000 people!  Think about that: 1 tweet from the NRA, resulted in more than 8 million people being exposed to ACP’s advocacy message on gun violence (and a few other topics sprinkled into my tweets) in just 30 days.  Never before has my efforts to spread the word on ACP advocacy garnered so much visibility.

Yet it’s hardly just me that helped get the word out.  As of this hour, there are over 23,000 responses to the NRA’s original tweet, overwhelmingly in support of physicians’ speaking out on gun violence. The backlash from physicians has received extraordinary coverage in the mainstream press, from the New York Times (Doctors Revolt After NRA Tells Them to ‘Stay in Their Lane on Gun Policy’), to the WallStreet Journal (After NRA Rebuke, Many Doctors Speak Louder on Gun Violence), to CNN (Doctors Start Movement in Response to the NRA, calling for more gun research), to NPR (After NRA Mocks Doctors, Physicians Reply: This Is Our Lane)—and hundreds more print, digital, cable and TV outlets.  That the NRA’s tweet appeared just hours before another mass shooting at a Florida night club, and just a few weeks before another one at a hospital in Chicago, no doubt contributed to physicians’ fervor to take them on, and the coverage that resulted. 

Altmetric, a firm that tracks how much attention published research is getting from the news and social media, found that Annals’ publication of ACP’s firearms policy paper is now one of the top attention-getters, all time, of the millions of research outlets it has tracked:

Altmetric has tracked 12,258,221 research outputs across all sources so far. Compared to these, this one has done particularly well and is in the 99th percentile: it's in the top 5% of all research outputs ever tracked by Altmetric.  [Ranked 224 out of more than 12 million research outputs, and #2 out of the over 10,000 research outputs published by Annals and tracked by the firm.]

The NRA’s attack on physician advocacy on gun violence has also spawned editorials from physicians in the most prestigious peer-reviewed medical journals, including in Annals (Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane,  co-authored by Annals editors Drs. Christine Laine and Darren Taichman, and Dr. Sue Bornstein, chair of ACP’s Health and Public Policy Committee); and in  NEJM (#ThisIsOurLane — Firearm Safety as Health Care’s Highway, co-authored by Drs. Megan Ranney, Marian Betz, and Cedric Dark).

For too long, the NRA has dictated much of the debate over gun violence, bullying those who offered other ideas.  No longer: the NRA has awakened a sleeping giant, the hundreds of thousands of physicians and their professional societies who feel both obligated and emboldened to speak out on the dangers to the health of their patients of unrestricted access to firearms.  Now, the challenge and opportunity going forward is for ACP, and other professional societies that share our commitment to reducing gun violence, to make sure that This Is Our Lane becomes a sustained movement, not just a moment.

Today’s question: What do you think about physicians’ and ACP’s response to the NRA and the This Is Our Lane movement?

Wednesday, November 7, 2018

It’s health care, stupid

This seems to be the big take-home message from voters in the mid-term election held yesterday, which bodes well for preserving gains from the Affordable Care Act and expanding coverage.   Health care was the number 1 issue for voters according to several exit polls, beating out immigration, the economy, and gun violence, among others, with voters strongly favoring Democrats as the party more likely to protect patients with pre-existing conditions.  Preserving the ACA’s protections for pre-existing conditions arguably may have been the single greatest contributor to Democrats taking control of the House of Representatives from Republicans, gaining at least 30 seats. 

Yet Republicans not only kept control of the Senate, they also expanded the number of Senate seats they control, adding at least 3 seats to be held by members with strongly conservative views. This raises questions about how much of the electorate’s desire for Congress to act to make health care more affordable to them and their families will translate into action in Congress; preserving existing patient protections may be the most likely outcome.

The story at the state level is very different: more states seem poised to expand Medicaid coverage; yet on other health care issues, like women’s access to reproductive services or reducing gun violence, the prospects at the state level are more mixed.

Here’s my take on five health care issues likely to be affected by the mid-term election results:

1.  Obamacare repeal and replace is dead. The Democratic-controlled House of Representatives will not allow legislation to advance to repeal, or repeal and replace, the Affordable Care Act. 

Except . . .Congress will have to do something to preserve protections for preexisting conditions, if the courts ultimately rule in favor of a case brought by 20 GOP-led states and supported by the Trump administration that seeks to have the ACA’s protections for pre-existing conditions ruled unconstitutional.  A decision by a conservative Texas judge is imminent and should he rule for the plaintiffs, as many expect, it will assuredly be appealed to the higher courts; it may be up to the Supreme Court to ultimately decide.  Stripping pre-existing condition protections via a court decry will be hugely unpopular with the electorate, and almost all of those elected yesterday promised to protect them (even when their own voting records suggest otherwise). However, it’s by no means certain that a Democratic House, Republican Senate, and President Trump could agree on a path forward to reinstate them.  The best outcome would be for the courts to find that the case has no merit and rule against the plaintiffs.

And . . . while there may be interest in both political parties to advance bills to make the ACA more affordable for those who are not eligible for premium subsidies because they earn too much to qualify, it is hard to see a path forward that could bridge the ideological divide between Republicans and Democrats.  House Democrats will also try to advance bills to overturn the administration’s decisions to allow sale of short-term plans that do not cover essential benefits, yet such bills likely would die in the Senate, or face a veto from the president.  States that have elected Democrats as governors and to the statehouses may pass legislation on their own to ban or regulate sale of short-term plans.

2.  More low-income people will gain coverage from Medicaid expansion, upwards of half a million of them.  Voters approved Medicaid expansion via referenda in three GOP-leaning states: Idaho, Nebraska, and Utah. The election results in three other states, Maine, Wisconsin, and Kansas, also bode well for expansion.  Montana voters, however, voted down a referendum to continue to fund their version of Medicaid expansion via higher tobacco taxes, potentially placing coverage for their residents at risk.  Republicans elected or re-elected to the governorships in other states are unlikely to expand Medicaid, and/or will seek to include work requirements that may make it more difficult for people to qualify.

3.  Prospects for policies to address the high cost of prescription drugs may advance at both the state and federal levels.  In his initial remarks today on the midterm elections, President Trump suggested that common-ground could be found with Congress and the Democrats on lowering the cost of prescription drugs. Many Democrats newly elected to the governorships and state legislative seats favor policies to require transparency in drug pricing.

4.  Common-sense policies to reduce gun violence may be advanced in additional states, as voters elected candidates to governorships and legislatures who favor such policies; yet in other states, voters elected or re-elected candidates opposed to such policies.  Voters in Washington state approved a referendum to advance restrictions on firearms. NBC’s exit poll found that 60% of those who casted votes favored stricter gun control policies, including 46 percent of gun owners compared to 76% of those who don’t own firearms; just one-in-ten ranked it as the most important issue facing the country. Democrats are likely to advance gun violence policies in the House, yet it is unlikely that a more conservative Senate and the Trump administration will accept them.  On the other hand, the House will almost certainly reject concealed carry reciprocity, should it be taken up next year by the Senate.  (In the current Congress, such legislation passed the GOP-controlled House, but was not taken up by Senate).

5.  It’s a mixed bag for women’s health.  The House of Representative will not advance or accept legislation to defund Planned Parenthood and other women’s health clinics.  It may try to advance bills to overturn the administration’s efforts to allow broad “conscience exemptions” to contraception coverage, yet it’s hard to imagine those being accepted by the Senate.  With more states under partial or complete Democratic control (governors and statehouses), bills to ensure women’s access to reproductive services may fare better in those states than in the past; voters in several other states yesterday advanced measures to greatly restrict access to such services.  For many women, access to necessary services will depend on where they live. 

There are many other issues that are less partisan and may find common-ground in the new Congress, including improvements in the Medicare Quality Payment Program, payment for primary and comprehensive care, reducing barriers to chronic care, addressing the opioids epidemic, and reducing administrative tasks imposed on physicians and patients.

One thing is sure: voters yesterday ranked health care as the most important issue behind their votes, and politicians who ignore them, or let partisan divisions lead to inaction, will do so at their own risk.  

Monday, August 27, 2018

Finding a winning way forward on CMS’s proposals to restructure physician payment

Last month, I wrote about CMS’s “historic” proposals to change how physicians would be paid for their office visits and the documentation that would be required of them. 

I noted then that while ACP expressed strong support for the push to reduce the documentation burden on clinicians, we also expressed concern that flat blended fee could have an adverse impact on internal medicine physicians and subspecialists and their patients.  In an official statement of ACP’s initial reaction to the proposal, issued the day after the proposal was released, ACP President Dr. Ana María López had this to say:

“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.”

Since then, ACP has heard from many internists who are greatly concerned about the adverse impact of paying a single flat blended fee for levels 2-5 evaluation and management services.  They passionately believe that paying the same amount for the most complex office visits as less complex ones would harm their patients, and must be opposed by ACP.

We agree—CMS’s proposal for flat fee for E/M services is not acceptable.  At the same time, we believe that that the agency’s plan to reduce documentation requirements for E/M services has great value, because E/M documentation is a major contributor to physicians’ frustrations with their EHRs. In a 2015 position paper, Clinical Documentation in the 21s Century, developed by our Medical Informatics Committee, ACP observed that current E/M documentation requirements have fundamentally changed the nature of the clinical note:

 “In place of a thoughtfully written review of systems that listed pertinent positive or negative findings, clinically meaningless terms such as “ten point review of systems was negative” were introduced into the record to satisfy E&M guidelines. Instead of clinical needs determining the level of detail of the physical examination, documentation of the examination was driven by the required number of “bullets” to fulfill the requirements for a specific code.. . what is now illogically considered to be the gold standard of a good note comes not from clinical professors and mentors but from professional coders and corporate compliance training. An imbalance of values has been created, with compliance, coding, and security trumping patient care, clinical well-being, and efficiency. A harshly negative ‘gotcha’ mentality that saps the professionalism out of physicians has also appeared.”

This is still the case, and CMS’s proposals to reduce E/M documentation requirements are a good start in addressing this highly dysfunctional situation.  The problem is that CMS says it can’t reduce E/M documentation unless it goes along with paying a flat fee for E/M services. That’s not a rationale, or trade-off, that ACP can accept. We think that CMS can reduce E/M documentation while preserving the principle that more complex cognitive care should be paid more than less complex care.

ACP, through its regulatory affairs staff with oversight and direction from the physician-members on our Medical Practice and Quality Committee (whose chair and vice chair are both practicing internists in smaller independent practices), is in the process now of drafting official comments on CMS’s proposed rule, due September 10.  While not yet final, I anticipate that our comments will articulate the following key points:

  1. ACP strongly believes that cognitive care of more complex patients must be appropriately recognized with higher allowed payment rates than less complex care patients. CMS’s current proposal to pay a single flat fee for E/M levels 2-5, even when combined with proposed primary care and specialist add-on codes and payment for prolonged services, undervalues cognitive care for the more complex patients, potentially creating incentives for clinicians to spend less time with patients, to substitute more complex and time-consuming visits with lower level ones of shorter duration, schedule more shorter and lower-level visits, and potentially, avoid taking care of older, frailer, sicker and more complex patients. It could also create a disincentive for physicians to practice in specialties, like geriatrics and palliative care, that involve care of more complex patients. Accordingly, the proposal to pay a single flat fee for E/M levels 2-5 must not be implemented.

  1. ACP appreciates and supports the overall direction of CMS’s proposals to reduce the burden of documentation for E/M services, yet strongly disagrees that such improvements should be contingent on acceptance of CMS’s proposal to pay a single flat fee for E/M levels 2-5. While we understand CMS’s concerns that changes in E/M documentation requirements, without changes in the underlying payment structure for E/M services, could create program integrity challenges, we believe that CMS should consider testing of alternatives that would allow it to move forward on simplifying documentation, ensure program integrity, and preserve the overarching principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services.
  1. ACP urges CMS not to establish a regulatory deadline (e.g. January 1, 2019 or January 1, 2020) for finalizing and implementing its flat E/M fee proposals or possible alternatives that change how E/M services would be paid, and instead, to take the time to “get it right.” Sufficient time must be allowed to engage the physician community to develop and pilot-test alternatives that preserve the principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services, while allowing CMS to move forward on simplifying E/M documentation while ensuring program integrity. The stakes for patients, clinicians, and the Medicare program are too great for CMS to rush changes
Instead of just telling CMS all of the things that are wrong with their proposal for flat E/M bundled payments (and there are plenty of them, to be sure), we should point them toward a truly winning outcome for physicians, patients, and the program, one that reduces E/M documentation (that has resulted in “compliance, coding, and security trumping patient care, clinical well-being, and efficiency)” while preserving higher payment for more complex cognitive care.

Today’s question: what would you like to hear ACP say in its response to CMS’s proposals?