Wednesday, December 7, 2016

Preparing ACP for the post-election political environment

It’s often said that elections have consequences, and this is especially true of the 2016 election. The election of Donald S. Trump, combined with continued GOP control of Congress, will rock the health care world, starting with the GOP pledge to begin to repeal and replace the Affordable Care Act early in the new Congress. 

But it’s not just the ACA: the Trump administration may try to privatize the VA, end U.S. commitments to reduce emissions contributing to climate change, reverse Obama’s executive actions on firearms violence prevention, convert Medicare into a defined contribution (voucher) program rather than an open-ended entitlement, and much, much more.  While these are highly concerning to ACP, we believe that there will be many opportunities to find common ground on improving access to mental health, healing the opioids epidemic, reducing barriers to chronic care management, reforming the medical liability system, and especially, reducing regulatory burdens on physicians and their patients.

In order for ACP to be effective, we have to start by stepping back and assessing what the impact of the elections will likely be on our priorities, recalibrating as needed to achieve our objectives.  To be clear, this does not mean stepping back on our commitment to issues like universal coverage, mitigating the public health impacts of climate change, reducing gun violence, and ensuring access to care for all persons without regard to race, religion, ethnicity, gender and gender identity, and sexual orientation; these are overarching core principles and policy commitments the College has made to the public, they can’t be negotiated away.  But we can and will assess how best to advance or defend them given the changed political circumstances.

Here is what your ACP advocacy team in Washington has been doing to help ACP prepare for the new administration and Congress:
  • We provided suggestions to ACP President Dr. Nitin S. Damle on his November 17 email to all ACP members, U.S. and international, on the implications of the 2016 election.
  • We are working with Dr. Damle on responding to several dozen e-mails from members in response to his letter.
  • We are doing a comprehensive staff assessment of all of our key public policy priorities; for each of them, we are evaluating whether there is a threat or opportunity or threat and opportunity, whether it’s from Congress, the Executive Branch, or both; and whether we need new or revised policy direction from the ACP policy committees, regents and governors.
  • In particular, we are examining how the GOP may use a “repeal, delay, and replace” legislative strategy to undo as much of the ACA as possible through budget reconciliation, which requires a simple majority vote, while delaying for a couple of years the date(s) when those provisions would expire, which in theory gives them a time to develop a replacement plan (which is much easier said than done, which I will address in a future post).
  • For some of our priorities, we are doing a much deeper policy dive; for instance, examining possible GOP alternatives to the ACA overall and specific elements of it; the impact of possible efforts to privatize the VA system; implications of turning Medicaid into a block grant program; potential threats to Graduate Medical Education funding; and policies affecting women’s health access, among others.
  • Our regulatory affairs team is preparing specific recommendations to the new administration and Congress on changes in federal regulations, quality measurement, EHRs and “meaningful use” requirements, documentation guidelines, and on other ways to ease administrative burdens on physicians.
  • We are reaching out to other health-advocacy organizations, not just within the medical profession, but with business leaders, hospitals, insurers, and consumer groups, to see where our interest may align and where we may differ; and how we might work together when we are in agreement.
  • We are continuing to encourage members to sign up to participate in our grass roots Advocates for Internal Medicine (AIMn) program while making enhancements to it.  The strength of this program will to a large extent determine how effective we can be advocating with the new Congress.

Even as we are devoting so much of our time to prepare for the new administration and Congress, we are ensuring that ACP’s voice is heard now, as the lame-duck 114th Congress completes work on several outstanding health care bills, including the CURES Act and a temporary resolution to fund the federal government into early next year.  We are also providing extensive comments to the outgoing Obama administration on the 2017 Medicare physician fee schedule final rule and the MACRA final rule.  Oh, and we are developing new and updated resources and tools to help members be successful as Medicare’s new Quality Payment Program (created by MACRA) begins to be rolled out on January 1. 

In my view, ACP advocacy is more important now than ever before.  On issues ranging from ensuring  that internists’ patients don’t lose their health insurance coverage, easing the regulatory burden on physicians,  protecting GME from budget cuts, ensuring that women don’t lose access to care, supporting the many ACP members in the VA system and the veterans they serve from ill-advised “reforms’,  advocating for medical liability reforms,  opposing policies that would be discriminatory against LGBTQ persons, and continuing to advocate for policies to reduce the health consequences of climate change,  ACP will be there, ensuring that internists’ voices are heard in this tumultuous time for American (and global) health care. 

Today’s question: What policies do you think are most important for ACP to advocate with the new Trump administration and Congress?

Thursday, November 3, 2016

Fear and Loathing on the Campaign Trail, 2016 Edition

Many regard Hunter S. Thompson’s book, Fear and Loathing on the Campaign Trail, which covered the 1972 Nixon versus McGovern campaign, as the best account yet of a modern U.S. presidential campaign.  Hunter’s reporting was based on his own conversations, often over copious amounts of alcoholic beverages (and sometimes, other illicit recreational substances) with the people involved in both campaigns, from George McGovern himself to the front-line worker bees whose job it was to get out the votes. In an introduction to the 40th anniversary edition of the book, re-issued in 2012, journalist Matt Taibbi observed that, “What makes the story so painful, and so painfully funny, is that Hunter chooses the presidential campaign, of all places, to conduct this hopeless search for truth and justice. It’s probably worse now than it was in Hunter’s day, but the American presidential campaign is the last place in the world a sane man would go in search of anything like honesty.  It may be the most fake place on earth.”

I think we would agree that the 2016 American presidential campaign is far worse than it was in Hunter’s day.  Polls show that for many voters, this election is viewed as a choice between two evils, or as Hunter put it in Fear and Loathing,  “How many more of these stinking, double-downer sideshows will we have to go through before we can get ourselves straight enough to put together some kind of national election that will give me and the at least 20 million people I tend to agree with a chance to vote FOR something, instead of always being faced with that old familiar choice between the lesser of two evils?”  (I know that many supporters of Mr. Trump or Mrs. Clinton would strongly disagree with the “lesser evil” description of their own preferred candidate, yet polls consistently show that both of them have historically high disapproval/approval ratios).

Framing the election as a “lesser of two evils” choice can’t obscure the fact that there are very real differences between Mr. Trump’s and Mrs. Clinton’s views on just about everything—including health care policy.  They disagree on climate change (Mrs. Clinton is for expanding on Obama’s policies to limit emissions; Mr. Trump has said the climate change is a hoax and pledges to increase production of fossil fuels), on firearms injury prevention (she wants to expand background checks and limit access to assault weapons; he opposes any intrusion on an individual’s “Second Amendment” rights to own guns, supports  greater enforcement of existing laws but opposes any new restrictions, and advocates a national “right to carry” law). 

Mr. Trump promises to repeal the Affordable Care Act (Obamacare) and replace it with a plan that would allow people to enroll in tax-free Health Savings Accounts to pay for their out-of-pocket costs, make premium payments by individuals tax deductible, create state pools to insure “high risk” patients who have not maintained continuous coverage, allow insurers to sell insurance across state lines, and convert Medicaid to a block grant program, where the states would get a fixed amount of federal funding per beneficiary to redesign the program as they see fit.  Mrs. Clinton pledges to preserve, build upon and improve on the ACA by increasing tax credit subsidies so families pay no more than 8.5% of income; working with states to establish a public option to compete with private plans in the marketplaces; allowing individuals aged 55-64 to buy into Medicare; create fallback for HHS to block unreasonable rate increases; repealing the “Cadillac Tax” on high premium employer-sponsored plans;  requiring plans to cover 3 “sick” visits per year without deductibles; creating a new tax credit of up to $2500/$5000 per individual/family for out-of-pocket expenses in excess of 5% of income; ensuring consumers pay no more than in-network cost-sharing for care received in a hospital in their plan’s network (surprise bills); providing 100% federal match for first 3 years if states adopt expansion, regardless of when they start; and allowing undocumented immigrants to buy coverage from exchange plans at their own cost.

The Rand Corporation conducted an analysis of the candidate’s proposals, and concluded that Mr. Trump’s proposals would add tens of millions of people to the ranks of the uninsured, while Mrs. Clinton’s plan would expand coverage to tens of millions.

No matter who the voters elect next week,  however, the new President will have great difficulty translating their plans into policies that have a chance to be enacted into law.  Should we have a President-elect Hilary Clinton, and even if Democrats narrowly take control of the Senate, she likely will have to deal with a Congress where  the House of Representatives will still be controlled by Republicans who have no interest in strengthening Obamacare, and where Senate Republicans can still use the filibuster to thwart her initiatives.  And she would still have to deal with dozens of states that will continue to be controlled by GOP governors and legislators who are not likely to jump on the Obamacare bandwagon.

Should Mr. Trump get elected, he likely will benefit from a Republican-controlled House and  continued GOP control of the Senate.  Expected Democratic gains in the Senate though likely will make it easier for Democrats to use the filibuster to thwart efforts to repeal Obamacare.  And, practically speaking, repealing Obamacare would mean kicking 20 million people off of the health insurance coverage they have gained from it, pulling the plug on federal funding of Medicaid expansion, and taking away some very popular consumer protections, like the guarantee that insurers can’t deny coverage or charge more to people with pre-existing conditions.

For sure, there are many things a Clinton administration could do to strengthen the ACA through regulations should legislation become impossible.  There are things that a Trump administration could do to ease Obamacare’s requirements on insurers and states through regulations should legislative repeal become impossible. 

Yet, unless we see a marked change in our political culture as a reaction to the 2016 election, the current toxic stew of partisanship, polarization, and gridlock likely will get worse before it gets better. “The American electorate has grown increasingly divided along party lines in recent decades, by political attitudes, social values, basic demography, and even beliefs about reality,” observed political scientist Gary Jacobson in an analysis published late last year in the Annals of Political and Social Science.  “Deepening partisan divisions have inspired high levels of party-line voting and low levels of ticket splitting, resulting in thoroughly nationalized, president- and party-centered federal elections. Because of the way the electoral system aggregates votes, however, historically high levels of electoral coherence have delivered incoherent, divided government and policy stalemate.”
The question is whether the 2016 election will lead to continuation and even intensification of the “incoherent, divided government and policy stalemate” that has engendered growing voter rage and historic declines in trust in government, and even in our democratic system of government itself?  Or act as a catharsis for voters and politicians to begin pulling us back from the brink?

As Abraham Lincoln said in his first address to Congress in December 1862, when our nation’s politics had grown so toxic that the country was in the first year of a bloody civil war, “We can succeed only by concert.  It is not ‘can any of us imagine  better?’ but, ‘can we all do better?’ The dogmas of the quiet past, are inadequate to the stormy present. The occasion is piled high with  difficulty, and we must rise – with  the occasion. As our case is new, so  we must  think anew, and act anew. We must disenthrall ourselves, and then we shall save our country?”

Now, to be clear, I don’t believe that the stakes in this election are anywhere near what President Lincoln confronted, we aren’t going to fall apart at the seams and start taking up arms against each other.  But if we the voters don’t begin to “save our country” by embracing politicians who believe that compromise to achieve a common good—so “we can all do better”—is a virtue, instead of voting for those who put their own partisan and political interests and ideological purity above what is best for all, then we will continue to weaken and undermine our great American democracy.  This, I believe, is what we should fear and loath most long after the ballots are counted next Tuesday.

Today’s question: What do you think is at stake in the 2016 election, and afterwards, for healthcare, and our democracy itself?

Friday, October 7, 2016

My answer to direct primary care evangelists

One thing I’ve  learned is that physicians who have gone into direct primary care (DPC) practices are passionate about their decision: they not only believe that DPC is better for their patients and their own professional and career satisfaction; many  assert it is the answer to just about everything ailing primary care.  There is an evangelical fervor among some DPC advocates to spread the word and convert other primary care physicians to their cause.

It’s no surprise to me, then, that many of them have expressed frustration—to put it mildly—that ACP has decided not to endorse or promote DPCs. Instead, our 2015 position paper, for which I was the lead author on behalf of the College’s Medical Practice and Quality Committee, aims to provide a balanced and evidence-based assessment of the potential impact on patients of practices that have one or more of the following 3 features:

They charge monthly per patient retainer or subscription fees.

They do not participate in insurance contracts.

They have reduced their patient panel sizes well below the norm. 

The American Academy of Family Physicians says that “Generally, DPC physicians have a panel of between 600 and 800 patients. In typical FFS settings, the patient panels tend to range from between 2,000 and 2,500 per family physician.”

One of the challenges ACP found in assessing the impact of direct primary care is that it is only one variation of practices that charge retainer fees, do not participate in insurance, and/or have smaller patient panels.  For example, practices often described as “concierge” practices often charge much higher monthly per patient retainer fees than most DPCs say they charge.  (Many DPC proponents fiercely object to being labeled as concierge practices). 

Yet ACP found little in the literature that defines the accepted range of monthly fees charged by DPC compared to “concierge” practices—Medical Economics magazine says they typically range from $50 t0 $150 per month, citing AAFP.   A study in the Journal of the Board of Family Medicine (JBFM), which was published after ACP had completed the literature search for our paper, reported that “Practices that used the phrase DPC on average charged a lower fee than practices that used the term concierge to describe their model: $77.38 compared with $182.76, respectively. Of 116 practices with available price information, 28 (24%) charged a per-visit fee, and the average per visit charge among this group was $15.59 (range, $5 to $35). Thirty-six of these 116 practices charged a one-time initial enrollment fee, and the average enrollment fee among this group was $78.39 (range, $29 to $300).” 

The wide variations in the monthly fees charged begs the question:  at what point, does the monthly fees charged by DPC practices make them concierge? 

Our paper found examples of DPCs that provide low cost and accessible services to all types of patients, including Medicaid patients.  Yet we also observed that there is a potential that less well-off patients, who can’t afford to go without insurance or pay a monthly fee, might be disadvantaged.  Guided by our Committee on Ethics and Professionalism, we accordingly urged physicians who are considering DPC, concierge or other practice arrangements that have one or more of the features described above to consider steps, like waiving or lowering monthly fees for patients who can’t afford them, to mitigate any potential impact on undeserved patients.  Perhaps most importantly, we called for more research on the potential impacts of such models. 

This reasoned position, neither endorsing nor opposing DPCs,  instead calling for more research and consideration by physicians who enter into such practices of steps that could mitigate any adverse impact on poorer patients, has been misinterpreted by some DPC advocates as ACP being opposed to  DPCs.  This is not the case.  Our paper clearly states that physicians should have a choice of entering into practice arrangements that provide ethical and accessible care to their patients, which can include DPCs that meet the ethical considerations laid out in paper.

In a recent letter published in the Annals of Internal Medicine, I responded to a letter from Dr. Martin Donahoe that was highly critical of what he called “luxury care clinics,” especially in academic medicine.  I cautioned against painting too broad a brush in characterizing the motivations of physicians who charge monthly retainer fees and have downsized their patient panels:

“I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients.  Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient's income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.” 

I am heartened that Dr. Bob Centor, chair-emeriti of the ACP Board of Regents and a long-standing proponent of direct primary care, blogged that my Annals letter was “a very thoughtful rebuttal” to Dr. Donahoe’s broad condemnation, noting that “ACP has an excellent position paper on direct primary care,” referring to our 2015 paper.

Yet some DPC evangelists remain unsatisfied with the College’s position that we need more research on the impact of DPCs  on quality, access and cost, especially for underserved populations.  One DPC evangelist—a DPC physician himself, and one of the co-authors of the AJFM study cited above—called the analysis by ACP, our Medical Practice and Quality Committee and our Ethics, Professionalism and Human Rights Committee “ignorant”—even though his own ABFM study concluded that “Most DPC practices are young and small and thus lack sufficient quality and cost data to assess outcomes thus lack sufficient quality and cost data to assess outcomes.”  Calling one’s colleagues in another primary care field “ignorant” is a sure fire way to win people over!

Finally, it needs to be acknowledged that there is a significant crossover between DPC advocates and anti-Obamacare physicians.  Just do a Google search of “direct primary care as an alternative to Obamacare” and you’ll find dozens of commentary about why DPC is a “free market” alternative to the Affordable Care Act’s insurance regulations, alternative payment models, and other features.  ACP, which strongly supports the ACA’s benefit requirements, subsidies, and consumer protections, would have difficulty embracing a movement that many of its own advocates assert is intentionally designed to subvert the ACA.  DPC, on the other hand, could be a reasonable option that exists as already permitted by the ACA, as long as it doesn’t weaken the law’s consumer protections.

So this is how I see things.  It is fine for DPC advocates to promote the benefits of this model.  It is fine that many physicians are considering going into a DPC, motivated by their desire to  desire to spend more time with their patients, although I would encourage them to consider the steps recommended in our paper to mitigate any adverse impact on poorer patients.   It is fine—in fact, imperative—that there be more research on the impact of DPCs on quality, cost, and access.  However, the evangelical strain of the DCP movement that seeks to convert ACP, and everyone else, to endorsing the movement—you're either for or against them—is not going to result in the respectful, evidence-based dialogue that is needed. 

Today’s question: what is your opinion of Direct Primary Care?