Thursday, January 4, 2018

What did ACP advocacy achieve in a year of unparalleled challenge?

What did ACP advocacy achieve in a year of unparalleled challenge?

2017 was the most challenging year that I have experienced in my 38 years of advocating for internists.

To put things in perspective, I joined the governmental affairs staff of the American Society of Internal Medicine in January 1979, during the presidency of Jimmy Carter.  I had the privilege of helping ASIM advocate for internists for 19 years, until ASIM merged with ACP on July 1, 1998, and then continuing after the merger as Senior Vice President for ACP’s Division of Governmental Affairs and Public Policy.  From Jimmy Carter to Ronald Reagan, to George H.W. Bush, to Bill Clinton, to George W. Bush, to Barack Obama, I have seen both ASIM and ACP skillfully navigate the challenges associated whenever there is a new occupant in the White House, and also, changes in which party controls the House and Senate. 

If you choose to participate in advocacy in Washington, or in state capitals for that matter, change and disruption are par for the course. For instance, it is hard to overstate how big a change Ronald Reagan’s policy agenda was from the policies pursued by Jimmy Carter, or Barack Obama’s compared to George W. Bush’s.

Yet there has never been a more challenging, and disruptive shift in policies and priorities than since President Trump was elected and became president, just shy of one year ago. After all, he ran on a platform of ending as much of President Obama’s legacy as possible, including a promise to repeal Obama’s signature achievement, the Affordable Care Act (ACA), “on day one” of his presidency.  With the Republicans controlling both chambers of Congress, there was reason to believe he would succeed, if not on day one, during the first year of his administration.

As a result, ACP spent much of last year playing defense on the ACA, which we support, and also on several other priorities, where the current administration's and congressional leadership's priorities were at odds with long-standing ACP policy.  This was not our choice: as a strictly non-partisan organization, our hope is always to find common ground with a new president and Congress wherever possible, to compromise when needed, and to resist only when necessary.  And in some cases, we have been able to find common ground with President Trump and Congress.  Yet we have also had to defend repeated attacks on programs, policies and priorities that we believe are essential to the health and well-being of patients.

So how did we do, in such a year of unparalleled challenges to our advocacy agenda?  Pretty darn well, I’d say:

  • On Coverage and Access:  While many Americans believe otherwise, the ACA was not repealed.  Except for repeal of the ACA’s requirement that individuals purchase insurance, all the rest of the ACA remains the law of the land, including coverage of essential benefits, preexisting condition protections, no lifetime limits on coverage, and premium and cost-sharing subsidies.  Medicaid was not capped and cut.  ACP specifically helped derail the Graham-Cassidy bill, which would have radically devolved responsibility for funding and regulating coverage from the federal government to the states, causing tens of millions to lose coverage and benefits.  Repeal of the individual mandate, which was included in the tax bill, is of concern to the ACP, because it likely will further destabilize insurance markets.  Nonetheless, the fact that the rest of the ACA has survived, despite President Trump’s repeated calls for repeal followed by repeated (failed) votes in Congress to repeal it, is a huge win for ACP advocacy.
  • On women’s access to health care: Planned Parenthood was not defunded.  And the administration's interim final rule to allow employers to opt out of contraceptive coverage, which ACP opposes, has been blocked by two recent court decisions, at least for now.
  • On health care expense and tuition interest deductions:  ACP achieved several big wins in the tax legislation that passed Congress in late December:  the deductibility of student loans and medical expenses was preserved, even though an earlier version of the bill passed by the House of Representatives would have repealed both.    
  • On insurer mergers: The courts blocked two mega insurer mergers that would have reduced competition and harmed physicians and patients.
  • On non-discrimination against transgender persons: The courts stepped in to block the administration's ban on transgender persons serving in the military, consistent with ACP’s opposition to the ban
  • On immigration and health: Court decisions have also resulted in the administration substantially modifying its original executive order on immigration in a way that, while still concerning, is less damaging to the ability of physicians trained in the affected countries to enter and remain in the United States under legal visas. 
  • On reducing paperwork: We were able to advance our policy agenda as it relates to Patients Before Paperwork to the point where the administration has launched a similar initiative, called Patients Over Paperwork. 
  • On improving quality payments: We achieved substantial wins in improving the Medicare Quality Payment Program and payment for internists' services, particularly by easing the burden on smaller practices. Dr. Louis Friedman, an ACP member, was asked to testify on his experiences with the CPC+ APM model before the Energy and Commerce health subcommittee, invited by both the majority (R) and minority (D) leadership of the committee—a testament to the high regard that both parties hold of ACP when it comes to payment and delivery system reforms. 
  • On addressing the opioids crisis: The President’s Commission on Opioids issued a report that is largely consistent with ACP’s recommendations, including a recommendation to establish drug courts in all jurisdictions.
  • On prescription drug pricing: The National Academy of Medicine issued a report on prescription drug pricing that also closely reflected ACP’s recommendations; several ACP-supported bills were introduced in Congress to address the high cost of prescription drugs.
  • On climate change: While the administration's approach to climate change remains very concerning, states, localities, and businesses have stepped up to adopt measures to mitigate climate change. 
  • On firearms: ACP and its Florida chapter had a big win when a federal appeals court overturned a Florida law that prohibited physicians from discussing gun safety with patients. Many states and localities have stepped in to adopt policies consistent with ACP's recommendations, by expanding background checks and other common-sense regulations while beating back the gun lobbies' efforts to make guns even more available.  

Of course, ACP didn’t achieve all of these wins completely on our own. Advocacy is never won through the efforts of only one engaged actor; rather, it is the result of many with shared interests joining together to combine their efforts to achieve a common end.  2017 was the year that 6 physician professional organizations—ACP, the American Academy of Pediatrics, American Academy of Family Physicians, American Osteopathic Association, American Congress of Obstetricians and Gynecologists, and the American Psychiatric Association came together to form the “Group of 6” coalition, representing a combined membership of over half a million doctors and medical student members.  The Group of 6 has now become one of the most influential (and largest!) health care coalitions in Washington, with 6 leadership fly-ins to Capitol Hill in 2017 and another scheduled for next week.

Particularly in challenging times, determined advocacy is what is most needed to make a difference for the better.  In 2017, ACP passed the test, with flying colors.

Today’s question: what is your take on ACP’s advocacy in 2017?

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?