Thursday, November 30, 2017

Warning: Congress’ tax reform bill is bad for your health

If legislation harmful to health was required to carry a Surgeon’s General warning like tobacco, the tax bill being voted on today by the Senate would surely qualify.  It will harm health care for many millions of Americans, leading to more uninsured persons and higher premiums.  It also will lead to automatic scheduled cuts to Medicare and many other programs that are vital to health care.  Yet despite all of this, the Senate is poised to vote later today on the Tax Cuts and Jobs Act, and right now, it looks more likely than not it will pass the chamber by a party-line, Republican only majority vote (all Democrats are expected to vote against it).

Here are 2 things you need to know about the bill and how it will hurt patients and their doctors:

1.  By repealing the Affordable Care Act (ACA) requirement that people purchase a qualified health insurance plan or pay a penalty to the government, people who buy coverage in the individual insurance market will see double-digit premium increases, many insurers will bolt from the markets resulting in less competition and choice, and 13 million people will become uninsured. The individual insurance requirement is needed because without it, many people will wait until they get sick to enroll in coverage, knowing that the ACA prohibits insurers from charging sick people more.  With more sick people and fewer healthy people in the insurance pool, insurers will have no choice but to jack up premiums for everyone, or simply, decide not to see insurance at all in the individual market.  The American Academy of Actuaries has warned that repeal of the individual mandate would lead to premium increases, weaken insurer solvency, cause an increase in insurer withdrawals from the market, and "lead to severe market disruption and loss of coverage among individual market enrollees." According to a report by the non-partisan Congressional Budget Office, repealing the individual mandate would increase the number of uninsured by four million in 2019 and 13 million in 2027 and "average premiums in the non-group market would increase by about 10 percent in most years of the decade."

2.  Medicare and other vital health care programs will be cut by billions of dollars to pay for the tax cuts that go mainly to corporations.  Under a 2010 law called Statutory Pay-As-You-Go Act (SPAYGO), any law that will add to the federal deficit must be paid for with spending cuts, increases in revenue or other offsets.  Automatic cuts are imposed, through budget sequestration, if Congress does not enact the required offsets.  The Senate tax bill is projected to increase the federal deficit by $1.5 trillion over the next 10 years, so automatic across-the-board cuts will be triggered next year unless Congress passes separate bills to offset the cost in some other way.  Medicare would be automatically cut by $25 billion in 2018, which will result in an average cut of 4 percent in Medicare payments for health care services provided by  doctors, hospitals, clinical laboratories, graduate medical education programs, and other "providers."  For doctors, this cut will be on top of a near 3 percent cut that Congress previously imposed on them in 2013, 14, 15, 16, and 17—combined, Medicare payments to physicians will have been cut 7 percent less as a result.   Many other vital health programs, like the Centers for Disease Control and Prevention (which we all count on to help prevent infectious diseases, whether it is this year’ seasonal flu, or global pandemics that could sicken millions worldwide), will also be subjected to deep, across-the-board spending cuts to pay for the tax bill; some will be completely eliminated.  The New York Times has a very useful list and graphic of what will be cut, and by how much.

Is it any wonder then that the American College of Physicians, the nation’s largest physician specialty society, and second largest physician membership organization, came out today in opposition to the Senate bill? 

Should the Senator ignore ACP’s advice and pass the bill, it doesn’t mean that the fight is over, since the Senate would have reach an agreement on a identical tax bill that both chambers could support (the House passed its own, but different version, several weeks ago).  But any Senator who votes for Tax Cuts and Jobs Act must be held accountable by their constituents for  voting for a bill that is bad for their health, while disregarding doctors’ warnings about the harm it will do. 

Tuesday, October 31, 2017

Before Patients Over Paperwork, there was Patients Before Paperwork

The Centers for Medicare and Medicaid Services’ (CMS) new initiative to reduce the paperwork burden on doctors and patients, deemed Patients Over Paperwork, is remarkably similar to ACP’s campaign, called Patients Before Paperwork, to accomplish the same.   Whether the agency was directly inspired by ACP’s campaign, down to coming up with an almost identical name for it, or came up with a similar moniker on its own, what matters is that the message ACP has been pushing for more than two years now, that doctors are being squeezed by unnecessary administrative tasks that take time away from patients, is being heard now at the highest reaches of the federal government.  What I do know is that prior to CMS’ launch of the initiative last week, ACP has held several meetings with and previously wrote to CMS officials pressing our recommendations to reduce unnecessary regulations and other administrative tasks. 

In her remarks yesterday to the Health Care Learning and Action Network Fall Summit, CMS Administrator Seema Verma explained what CMS hopes to accomplish from Patients Over Paperwork:

Since assuming my role at CMS, we are moving the agency to focus on patients first. To do this, one of our top priorities is to ease regulatory burden that is destroying the doctor-patient relationship. We want doctors to be able to deliver the best quality care to their patients. 

We often hear about this term – “regulatory burden” – but what does it actually mean? Regulations have their place and are important to ensuring quality, integrity, and safety in our health care system. But, if rules are misguided, outdated, or are too complex, they can have a suffocating effect on health care delivery by shifting the focus of providers away from the patient and toward unnecessary paperwork, and ultimately increase the cost of care. 

I saw this during a recent trip to Hartford, Connecticut, where I met with providers.

One told me she was going to close her practice after decades in medicine because spending so much time away from her patients doing paperwork just wasn’t worth it for her anymore. 

In Cleveland, Ohio, I heard a story of a physician who was overwhelmed by having to personally fax patient records…in 2017 we are still faxing patient records. Just thinking about that frustrates me…having to do it, I’m sure is even worse. 

Doctors are frustrated because they got into medicine to help their patients. But, paperwork has distracted them from caring for their patients, who often have waited weeks, if not months, for the brief opportunity to see them. 

We have all felt this squeeze in the doctor’s office…we have all seen our doctors looking at a computer screen instead of us. I hear it from patients across the country. This must change.

The primary focus of a patient visit must be the patient. Just last week, CMS announced our new initiative “Patients Over Paperwork” to address regulatory burden. This is an effort to go through all of our regulations to reduce burden. Because when burdensome regulations no longer advance the goal of patients first, we must improve or eliminate them.   

At CMS, our overall vision is to reinvent the agency to put patients first. We want to partner with patients, providers, payers, and others to achieve this goal. We aim to be responsive to the needs of those we serve. We can’t do that if we’re simply telling our partners what to do—instead of listening and—most importantly—having our policies be guided by those on the 
front lines serving patients. 

Touche!  ACP couldn’t have said it better.  Today, we sent a letter to Administrator Verma to pledge our support for her Patients Over Paperwork initiativeWe shared with her our policy paper, Putting Patients First By Reducing Administrative Tasks in Health Care, which proposes an entirely new framework to evaluate the intent and impact of existing or proposed new tasks, so that those that are not justified by their intent, or that have such an adverse impact on doctors and patients that they cannot be justified even if the original intent is sound, can be challenged and then eliminated or at least ameliorated.  We urged that CMS adopt this framework to evaluate its own regulations and administrative tasks.

ACP’s letter also advised her that we were encouraged by her announcement of a new “Meaningful Measures” initiative to ensure that quality measures, which are a critical component of paying for value, are streamlined, outcomes-based, and truly meaningful to clinicians and their patients.  This initiative appears to be well aligned with ACP's comments to CMS last year on the Quality Measure Development Plan. 

Whether it is putting patients before or above paperwork—both are needed—it is great news for doctors that ACP’s two-year plus campaign to reduce administrative tasks on physicians has found support in the highest reaches of government, coming from the head of an agency, CMS, that can do more to ease red tape than any other. 

Today’s question: if you were CMS Administrator Verma, what is the first Medicare administrative task you would recommend she review?

Wednesday, September 6, 2017

Doctors Defending Dreamers

Why should physicians care about President Trump’s decision to end the Deferred Action for Childhood Arrivals (DACA) program?

Because it brings “great harm” to health care, to medical education, and to the country, said the American College of Physicians in a statement issued moments after Attorney General Jeff Sessions announced the President’s decision.

Directly affected by the decision are Dreamers enrolled in U.S. medical schools.  “According to the Association of American Medical Colleges, in 2016, 108 students with DACA status applied to medical school, and 34 matriculants with DACA status entered medical school, bringing total medical school enrollment to approximately 70 students,” ACP noted in its statement. “Without the protections afforded to them by DACA, these students would be forced to discontinue their studies and may be deported. As these students train to become physicians, they will have the experience and background necessary to treat an increasingly racially and ethnically diverse patient population to fulfill the cultural, informational, and linguistic needs of their patients…”  Also affected are Dreamers “studying to be nurses, first-responders, scientists, and researchers, and approximately 1,000 foreign-born recruits who enlisted in the military under the protections offered by DACA could face deportation, according to the Washington Post.”  

Public health will also be adversely affected, according to ACP. “If the nearly 800,000 people who are currently benefiting from DACA have their protections removed, many will avoid seeking health care in order to reduce the risk of detection and deportation, and as noted above, those who seek to serve in the health care professions will be denied that opportunity.  Many will be forced to return to violent, war-torn and dangerous countries with poor health care services.”

That the President will delay full enforcement of his decision to end DACA “in no way mitigates the harm that will be done to the 800,000 law-abiding persons who have achieved permits under DACA to work or study in the United States without fear of deportation” said ACP. “They are now at risk of losing their jobs, being forced to drop out of school, and being deported in just a matter of months.” 

ACP called on President Trump to reverse his decision and continue protections for those with DACA-status—even though there is virtually no chance that he will.  More likely, Congress will need to act, by enacting legislation to block the deportation of Dreamers and to create a pathway for citizenship, as proposed by S. 128, the Bar Removal of Individuals who Dream and Grow our Economy (BRIDGE) Act, and S. 1615, the DREAM Act of 2017.

ACP’s decision to stand up for Dreamers reflects our long-standing commitment to creating a national immigration policy that recognizes the enormous contributions that immigrants make to the United States, and to health care in particular.  In 2011, ACP issued a policy paper that called “for a national immigration policy on health care that balances legitimate needs and concerns to control our borders and to equitably differentiate in publicly supported services for those who fully comply with immigration laws and those who do not, while recognizing that society has a public health interest in ensuring that all resident persons have access to health care.”  Further, ACP asserted in this paper that “Any policy intended to force the millions of persons who now reside unlawfully in the U.S. to return to their countries of origin through arrest, detention, and mass deportation could result in severe health care consequences for affected persons and their family members (including those who are lawful residents but who reside in a household with unlawful residents— such as U.S.-born children whose parents are not legal residents), creates a public health emergency, results in enormous costs to the health care system of treating such persons (including the costs associated with correctional health care during periods of detention), and is likely to lead to racial and ethnic profiling and discrimination.”

On January 30 of this year, ACP’s Board of Regents released a comprehensive statement on immigration policy, expanding on the 2011 paper, which “strongly opposes 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.”  Based on this policy, ACP has opposed President Trump’s executive orders to bar persons from several majority Muslim countries from entering the United States. 

ACP also said that “Priority should be given to supporting families in all policies relating to immigration and lawful admission to the United States to live, study, or work.”  Accordingly, “ACP opposes deportation of undocumented medical students, residents, fellows, practicing physicians, and others who came to the United States as children due to the actions of their parents (‘Dreamers’) and have or are eligible for Deferred Action for Childhood Arrivals (DACA) status. We urge the administration to preserve the DACA action taken by the previous administration until such time that Congress approves a permanent fix. The College also urges Congress to promptly enact legislation to establish a path to legal immigration status for these individuals to ensure that ‘Dreamers’ are permanently protected from deportation.”

For ACP, concern about immigration policy and its impact on health care clearly is nothing new.  What is new, regrettably, is that the current administration has chosen to embrace immigration policies that are discriminatory against persons based on their religion and country of origin, threaten to split up families that have members here both lawfully and unlawfully,  make it less likely that immigrants who lack legal residency will access needed health care services, and now, threaten with the deportation of Dreamers, who for all practical purposes, are as American as the rest of us, having lived almost their entire lives in the United States, and who stand to contribute so much to our country if the country has the wisdom to welcome them.   
This is why it is more important than ever that doctors defend Dreamers, and others who would be harmed by the current administration’s ill-advised immigration policies.

Today’s question: what do you think of ACP’s response to President Trump’s decision to discontinue DACA?