The ACP Advocate Blog

by Bob Doherty

Friday, May 15, 2015

Internal Medicine and ACP: The “Conscience of the Medical Profession”

Three weeks ago, ACP celebrated its 100th anniversary during our annual scientific meeting in Boston, Massachusetts.  I was glad to be there for the festivities, which included the release of a book, Serving Our Patients and Our Profession: A Centennial History of the American College of Physicians, 1915-2015, now available for sale through the ACP book store.

I was especially honored to co-write, with ACP President-emeriti Dr. Lynne Kirk, the book’s chapter on public policy and advocacy.  With a particular focus on the College’s support for universal coverage, which many current and former leaders told us they were most proud of, our chapter covers the first 60 plus years when the College tread lightly, if at all, into public policy issues (including its silence in the debate over Medicare); its awakening in the 1970s to the importance of advocacy, to the opening of its Washington office in 1983, to its first foray into advocating for universal coverage in 1990, to its support for—and great disappointment over the defeat of—the Clinton healthcare plan; the merger with ASIM in 1998, to the College proposing  in 2002 its own “7 year” plan for universal coverage, through enactment of the Affordable Care Act in 2010, to the present day.  Dr. Kirk and I summarized the College’s public policy journey this way:

"Although it wasn’t until the 1980s that the College made public policy and advocacy a principal concern, and not until the 1990s that it called for universal coverage, the history recorded in this chapter shows that once ACP became engaged in the cause, it did so courageously and diligently . . . In doing so, it demonstrated that it is possible for a physician membership organization to 'put the interests of patients first' by advocating for policies supported by the evidence and developed through consensus-the 'ACP way' of public policy and advocacy.”   

In writing the chapter, we were asked to produce a scholarly account, supported not only by internal documents, but by outside independent sources—which we tried, and I think, succeeded in doing, supporting our account with 118 citations.

What one thinks of one’s own history, of course, matters less than what others think of it.  I was heartened, then, to read an article in The Lancet, the highly respected and independent UK medical journal, called "Osler redux: the American College of Physicians at 100," written by Dr. Charles S. Bryan and published just days after our own centennial celebration.  Describing internal medicine and (quoting directly from Dr. Kirk’s and my chapter), Dr. Bryan describes our role in advocacy thusly:

“. . . perhaps most importantly, internal medicine has in many ways served as a conscience for the medical profession at large. The early decision by the ACP to abstain from political controversy led to the formation in 1956 of a closely-allied American Society of Internal Medicine to represent internists' concerns in the halls of US Government. In 1998, the two organisations formally merged. In the meantime, in 1978, the ACP decided to engage more directly in public policy 'as a fresh, scholarly, non-self-serving, medical voice that would become known as a valuable resource to legislators and regulators'. Since then, the organisation has—in addition to its leadership in continuing medical education, medical ethics, and quality assurance—endeavoured to promote the public interest even when its recommendations might run counter to the financial best interests of its membership.”

The conscience of the medical profession—has a nice ring to it, doesn’t it?

I think Dr. Bryan captures what makes the internists, and ACP, so different from other specialties and their professional associations:

We are not like other professional or trade association, or labor unions, formed to promote the self-interests of members.  Rather, we have a philosophy of “put the patient first” as Dr. John Ball, the first head of the ACP Washington office and later the College’s CEO, characterized it when he was interviewed by us for the centennial book chapter.

It is this commitment to “put the patient first” that just this week, led us to take on the issue of lesbian, gay, bisexual, and transgender(LGBT)  health care disparities.  In a position paper published on Monday in the Annals of Internal Medicine (web-first version), we recommended that gender identify, independent and fundamentally different than sexual orientation, be included in nondiscrimination and antiharassment policies, that medical schools, hospitals, physicians' offices, and other medical facilities adopt gender identity as part of their nondiscrimination and anti-harassment policies,that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would to all other beneficiaries, all hospitals and medical facilities to allow all patients to determine who may visit and who may act on their behalf during their stay, regardless of their sexual orientation, gender identity, or marital status.  We also came out in support of civil marriage rights for same-sex couples, recognizing that the denial of such rights can have a negative impact on the physical and mental health of these persons and contribute to ongoing stigma and discrimination for LGBT persons and their families.  We oppose the use of “conversion,” “reorientation,” or “reparative” therapy for the treatment of LGBT persons.

Our commitment to “put patients first” is also why we continue to take on the controversial issue of regulating firearms.  At ACP’s meeting in Boston, we announced that more than two dozen organizations, endorsed a paper published earlier this year by ACP, seven other national health professional organizations, and the American Bar Association, calling for policies to help mitigate the rate of firearm injuries and deaths in the United States, including universal background checks and bans on large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. As of today, 31 organizations have signed on in addition to the original eight.

And it is our philosophy of “put patients first” that has led us to champion, since 1990, the cause of universal health insurance coverage, including our ongoing efforts to preserve and protect the  Affordable Care Act from judicial and legislative efforts to undo the gains in coverage that have resulted from it.

To be sure, there are risks to ACP taking on these, and many other, controversial issues that may not result in a direct economic benefit to its membership.   There is a thin line between being perceived as the “conscience of the medical profession” and being self-righteous: on most of these issues, there are people of conscience who disagree with ACP’s views, and such differences should be respected, not dismissed.

There is a risk of ACP being viewed as “too political” and “too ideological”, as one unhappy member has written about our stance in support of civil marriage for same-sex couples.   The College, though, doesn’t approach issues from the stance of what is politically correct, or where it fits on the ideological spectrum, but based on what we think is best for patients—while recognizing that engaging in the political process is the means to achieve many of the policies we favor.

There is a risk that ACP members may feel that we aren’t doing enough to support their own interests, even though the College’s advocacy for the public  interest does not conflict with, nor take away from, our parallel efforts to advocate for better reimbursement for internists and for eliminating unnecessary regulations on them.

Yet I think most ACP members, and certainly the ones we interviewed for our centennial history chapter, are proud that the College “endeavor[s] to promote the public interest even when its recommendations might run counter to the financial best interests of its membership.”  Someone, after all, needs to be the conscience of the medical profession, and I’m glad that it’s internists, and ACP, that have chosen to fill that role.

Today’s questions: What do you think of ACP’s reputation as the “conscience of the medical profession”? And about our new policies on LGBT health care disparities?

Wednesday, April 15, 2015

Goodbye and Good Riddance to the SGR

Yesterday’s 92-8 vote in the United States Senate to join the House in passing the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2, represents a remarkable milestone for the Medicare program, and for ACP advocacy on behalf of internists and patients:

It is remarkable not only because it eliminates the failed Medicare SGR—how often does Congress admit it made a mistake, and then correct it?—but because it also fundamentally revamps how Medicare pays physicians.

It is remarkable that Congress did not take the easy way out and do what is had always done before, pass another short-term “patch” to stop the currently scheduled 21% cut—which would have been the 18th patch over the past 12 years.

It is remarkable because the bill passed both chambers with overwhelming majorities of Republicans and Democrats alike—an extreme rarity in today’s hyper-polarized world. (When was the last time a major and expensive bill had the support of Speaker of the House John Boehner, Minority Leader Nancy Pelosi, Senate Majority Leader Mitch McConnell, Senate Minority Leader Harry Reid, the chairs and ranking members of all three Medicare authorizing committees, the House Republican “doc caucus” and Democratic physician members of Congress—and President Obama?  I can’t think of any other).

It is remarkable because Congress passed the bill despite strong objections by self-described fiscal conservatives—fueled by powerful groups like the Heritage foundation--to its costs not being entirely paid for with cuts to someone else.

It is remarkable because the legislation includes entitlement reforms—including higher Medicare Part B and D premiums for wealthier beneficiaries, and a $250 Medigap deductible—that many liberals (and AARP) dislike.

Yet liberals and conservatives, in the end, came together to embrace the bill, recognizing that compromise was the only way to get a bill passed that would end the SGR.
It is remarkable in that organized medicine was more united than I have ever seen it, not just on repealing the SGR (that part was pretty easy!), but on the harder challenge of reaching agreement across the specialties and states in support of policies to further align Medicare payments with value, with over 750 physician membership organizations, national and state, endorsing it.

It is remarkable because ACP and other physician membership organizations were at the table all through the process, shaping the underlying bill last year, but also tweaking it this year and then working hand-in-glove with congressional leadership to get it enacted.  ACP, for example, helped get strong incentives included for Patient-Centered Medical Homes, a concept we have been championing for many years but that, until now, had limited opportunities for enhanced reimbursement under Medicare.  AMA deserves special credit for organizing and leading the broad physician coalition in support of the bill.

It is remarkable that our combined memberships again answered the call to pressure their own representatives and Senators to vote for the bill, even though so many times before their efforts led to disappointment.  The lopsided vote totals in favor of the bill demonstrate the power of grass roots physician advocacy.

Yes, enactment of MACRA was a remarkable advocacy achievement for organized medicine, not only for the successful result, but for the way it was achieved: through bipartisanship, compromise, pragmatic engagement with the process of crafting legislation rather than staying on the sidelines criticizing it, determined and persistent grass roots advocacy, and through remarkable unity across medicine, enabling us to achieve yesterday’s historic win for physicians and their patients.

I will have much more to say in future posts about the legislation itself—how it offers physicians numerous opportunities to achieve higher updates, how it encourages alternative payment models like Patient-Centered Medical Homes, how it offers the potential of harmonizing and streamlining quality reporting, and much more.  For now, you can read ACP’s statement congratulating Congress on the bill’s enactment, and my previous blog posts (like my entries from March 20th, March 24th, and March 27th) about the legislation.

Our advocacy is far from over, of course.  Like any law, H.R. 2 is imperfect—there are parts of it that we know will be quite challenging for our members.  We will have to influence its implementation by CMS, especially the selection of measures and the criteria for alternative payment models. We will have to work to ensure that it doesn't just add more complexity and more administrative burdens on physicians.   And if CMS doesn't do what’s needed, we may have to seek legislative changes later on. And we have a whole host of other issues that need attention from Congress—and getting rid of the SGR give us the opportunity to do so, instead of spending almost all of our political capital on one issue, the SGR, year after year after year.  

Yesterday’s vote shows what can happen when physicians are unified and engaged in the political process in pursuit of a shared goal. Wouldn't it be nice if we could replicate it on other issues of concern to physicians and their patients?

Today’s question: what is your reaction to Congress’s remarkable bipartisan vote for SGR repeal and H.R. 2?


Tuesday, April 14, 2015

Will the SGR still be with us tomorrow morning?

As I write this at 4:30 pm EST, the Senate had yet to take up the Medicare Access and CHIP Reauthorization Act of 2015, H.R. 2, which will repeal the SGR formula, reverse the 21% SGR cut that applies to claims for services provided on or after April 1, provide stable and positive updates for four and a half years starting in July, consolidate and streamline existing Medicare reporting programs into a new Merit-based Incentive Payment System, and create incentives for Patient-Centered Medical Home and other alternative payment models.  It needs to pass the bill, without making changes to what the House already passed, by midnight, or Medicare will begin applying the 21% cut tomorrow, April 15, for claims for services provided on April 1.  This will continue on a rolling basis until both the House and Senate approve identical legislation.

Senator Majority Leader Mitch McConnell and Minority Leader Harry Reid have expressed optimism that H.R. 2 will pass the Senate before midnight.  Reportedly, they are seeking unanimous agreement for up to six amendments to first be voted on, three from Republicans and three from Democrats.  All but one of the amendments would require 60 votes, making it very unlikely that the Senate will approve them.  One amendment, requiring that Congress find savings by the end of the fiscal year to offset the entire cost of the full cost of the legislation (instead of it only being partially offset as is currently the case), would require a simple majority vote.  If this amendment (or any of the other amendments) were to pass the Senate, then the 21% SGR cut will begin to be processed starting tomorrow morning, because there is no prospect that the House would be able, or inclined, to consider amendments that would upend the overwhelming bipartisan majority for the bill it passed last month.  Requiring that the entire bill be paid for would also certainly invite opposition from Democrats (who would be concerned that it would lead to entitlement cuts) and provider groups, like hospitals, who would be concerned that their Medicare payments would be at risk.

Keep checking ACP’s website, www.acponline.org, and my twitter feed, @bobdohertyACP, for developments this evening.  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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