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 But, if rules are misguided, outdated, or are too complex, they can have a suffocating effect on health care delivery by shifting the focus of providers away from the patient and toward unnecessary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?

Thursday, August 10, 2017

Physicians’ efforts to save the ACA are a redemptive moment for the medical profession

While many people contributed to the defeat of the current efforts by Congress to repeal the Affordable Care Act (ACA), physicians had a big role in organizing opposition to repeal, individually and collectively through their professional societies—including through the American College of Physicians. It was a redemptive moment for American medicine, making up in part for its sad, sorry history of opposing health insurance for all.

It is sobering to review the medical profession’s century-long history of being unyielding opponents of universal coverage. To put a finer point on it, it was organized medicine—mainly the American Medical Association (AMA) and state medical societies—that opposed universal coverage or even partial steps toward it, since specialty societies for the most part were not involved in advocacy until the 1970s or later. Even when the specialties began to take on advocacy, they mostly addressed narrow issues that directly affected their own disciplines. This left the AMA and the state medical societies to speak for doctors on issues like access and coverage. 

In 1920, the AMA’s House of Delegates officially came out against what was called “compulsory health insurance” which “was viewed as a threat to professionalism itself, requiring acceptance of mandatory fee schedules, work reviews, organizations outside the doctor-patient relationship over which doctors have no control; and limits on patient choice of physician,” wrote Rosemary Stevens in her insightful book American Medicine and the Public Interest, originally published in 1971 and updated in 1998.  

The AMA’s opposition to universal coverage was so powerful that President Franklin Roosevelt did not include national health insurance with the recommendations that formed the basis of the Social Security Act of 1935 because “he feared, probably correctly, that because health insurance had such strong opposition from physicians [namely, the AMA] and others, if it were included in his program for economic security, he might lose the entire program,” wrote Robert M. Ball, in “Reflections on How Medicare Came About” in Medicare: Preparing for the Challenges of the 21st Century. Ball ran the Social Security program from 1962 to 1973, and he helped design Medicare for the Johnson administration.

When President Harry S. Truman advocated for national health insurance in 1948, “the AMA’s opposition approached hysteria,” Ball continued, noting that the AMA raised a “$3.5 million war chest—very big money for the time—with which it conducted a campaign of vituperation against the advocates of national health insurance.”

In the early 1960s, the AMA vehemently opposed the enactment of Medicare, even though Medicare as originally proposed by the Kennedy and Johnson administrations would have applied only to hospital services (coverage for physician services through the voluntary Medicare Part B program was added late in the process at the request of Congressman Wilbur Mills, the then-chairman of the Ways and Means Committee). “If physician services were left out entirely, we reasoned, the AMA’s opposition would have less standing,” Ball wrote. “By that time it was clear that the elderly had the most political appeal and potentially the most muscle.We wanted to get something going, and this seemed a plausible first step.” The AMA also opposed Medicaid, the sister program to provide coverage to some categories of poor women and children.

Although the AMA lost its fight against Medicare and Medicaid, both of which were signed into law by President Johnson on July 30, 1965, it continued to resist most efforts to expand the government’s role in health care through the 1970s and 80s. By the 1990s though, the AMA had tempered its views, and while it never got behind President Clinton’s failed Health Security Act, it also was no longer an unyielding opponent. The AMA even put its support behind programs to incrementally expand coverage, including the Children’s Health Insurance Program enacted in 1998.

This brings us to Obamacare. The AMA engaged constructively with President Obama and the congressional leadership on the Affordable Care Act, offering its qualified support for the bill leading up to its enactment in March, 2010. And, the AMA opposes the current efforts by President Trump and the GOP-controlled Congress to repeal and replace Obamacare with something that would cover fewer people and offer less protection for people with preexisting conditions. A sign of how much things have changed for the AMA is when its House of Delegates in June of this year resoundingly voted to oppose any legislative proposals to cap Medicaid—in other words, to keep it an open-ended entitlement program. This is not your grandfather’s AMA, for sure.

The AMA’s evolution to supporting some variations of universal coverage is welcome and necessary. Its speaking out against the current efforts to repeal the ACA should be applauded. Yet, it also must be acknowledged that many other physician organizations, representing even more doctors than the AMA can now claim as members, have made it their mission and their passion to advocate for universal coverage and against ACP repeal. 

I am particularly proud of the ACP’s leadership. The ACP first came out for universal coverage in the 1990s, gave qualified support to President Bill Clinton’s Health Security Act, and became a leading advocate during President Obama’s administration for what became the Affordable Care Act. But the current efforts by President Trump and the GOP-controlled Congress to repeal the ACA really tested ACP’s mettle. And the College passed the test, with flying colors.

ACP helped organize and lead a coalition of six front-line physician membership organizations—the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American Osteopathic Association, and American Psychiatric Association—to advocate for preserving coverage and opposing efforts to repeal and replace the ACA with alternatives that would leave millions more without health insurance. Collectively, the coalition represents over 560,000 physician and medical student members, the vast majority of front-line physicians in the United States. The six allied groups above have conducted 5 separate fly-ins (2-2-17, 3-7-17, 5-11-17, 6-28-17, 7-12-17) involving the leadership of those six front-line physician organizations, the most recent one was July 12. Meetings were held with targeted representatives and senators. 100 letters were hand delivered on June 28 to all Senate offices, signed by the group of six, containing state-specific data on the harmful impact of the Senate’s Better Care Reconciliation Act in each state.  

ACP, on its own, sent at least 36 action alerts to our grassroots network across the country, which includes targeted alerts to key House members and senators; conducted a “write to Congress” letter-writing campaign for all of our 50 chapter governors during our March Board of Governors meeting; launched 7 separate full-scale action campaigns for our 50 chapters that also involved targeted campaigns for 8-10 states with Republican senators who had expressed concerns about the repeal bills; sent 15 ACP National letters to Congress; sent 14 coalition letters to Congress; had 3 TV appearances on MSNBC, on “the Last Word” and with Kate Snow; sent 28 ACP and/or joint releases/statements on repeal efforts;  conducted local TV interviews that reached 16.2 million people with 549 airings of the content; and organized a social media campaign (including through my @BobDohertyACP twitter account) to organize opposition to repeal. And this is only a partial list of our efforts! You can learn more about ACP’s activities on our website

Our efforts, and those of so many others, paid off in the wee hours of July 28 when Senator John McCain joined Senators Susan Collins and Lisa Murkowski to cast their votes against Majority Leader McConnell’s last ditch effort to get repeal through the Senate.

That ACP, our sister coalition partners, today’s AMA, Doctors for America, the National Physicians Alliance, and many other organizations representing physicians, have done so much now to save coverage and access for millions cannot completely make up for a century of doctors failing their patients by opposing Medicare, Medicaid, and universal coverage. It doesn’t change the fact that there is a strong minority of physicians today who continue to believe, like the AMA in 1920, that universal coverage is “a threat to professionalism itself, requiring acceptance of mandatory fee schedules, work reviews, organizations outside the doctor-patient relationship over which doctors have no control; and limits on patient choice of physician”—one of whom, Dr. Tom Price, is now Secretary of the Department of Health and Human Services;  every current Republican physician who serves in Congress today holds similar views. It doesn’t change the fact that many other physician membership organizations were missing-in-action in opposing the current efforts to repeal coverage for millions, including most of the surgical specialty societies and many of the state medical societies. So yes, too many physicians today still hold views that led their predecessors to oppose every reasonable effort by the government to extend coverage to everyone.

But a much larger majority of physicians today have taken a stand for coverage, for their patients, and against efforts to take it away from them. Nothing can change history, when that was not the case, but it is redemptive to see the medical profession today do the right thing by their patients.

Today’s question: What do you think of the medical profession’s century-long history of opposing universal coverage, and the efforts by many physicians today to stand up for coverage and against ACA repeal?