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?

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?