The ACP Advocate Blog

by Bob Doherty

Friday, September 11, 2015

September 11 reflections

Today is a day for remembering and reflecting on what happened on that terrible day, 14 years ago, when terrorists killed and injured thousands of Americans.   As time goes on, memories will fade, witnesses will pass away,  and there will be fewer first-hand accounts, not just of what happened, but how it felt—just like there are so few left that remember the “date that will live in infamy” when the Japanese attacked Pearl Harbor.  I think  this explains why so many of us who remember 9/11, especially who were in New York City and Washington DC when the attacks took place, feel it is necessary to document what we saw and felt, adding our own small piece to the historical record while we can.  A few years ago, I posted an account in this blog on what I saw and felt on that terrible day, excerpted below:

 I remember Washington the way it was on the day that our nation was attacked. I remember listening to my car radio on the way to work, and hearing that a “small” plane had collided with the Twin Towers in my home city of New York. I remember gathering with my co-workers to watch the event unfold on TV. I remember going to the roof of our office building to watch the smoke rising from the Pentagon. I remember hearing that another hijacked plane was heading to Washington, maybe to the White House, only four blocks from our office, an intended missile that never came to us because we later learned that it was brought down by courageous passengers in rural Pennsylvania.

I remember hearing rumors of more attacks—bombings at the State Department, in Metro subway stations, rumors that were not true, but we didn’t know that then. I remember not knowing what to tell our employees to do—go home, stay in the office until we got further word? Nothing in my training had prepared me for my city being under possible attack. I remember the traffic gridlock as millions tried to flee. I remember the eerily empty streets of DC, many hours after the traffic finally cleared and people hid in their homes.

I remember the helicopters endlessly circling the city. I remember days later, when we were able to return to work, seeing the intersections of the nation’s capital patrolled by tanks and National Guards troops with automatic weapons, something I never expected to see in my life. And I remember a few days later, taking Amtrak to an ACP chapter meeting in Connecticut, looking out the window as we passed Manhattan, and seeing through my tears the smoking, gaping hole where the World Trade Center once stood.

And I remember trying to make sense of the senseless to my young children, trying to reassure them that they were safe when in my heart I was never sure we’d ever feel safe again.

Much has changed in the years since, but in a world where terrorism remains a threat here and abroad, and where mass shootings have become an almost weekly event in the United States, I must still question if we’ll ever truly feel safe again.

Today’s question: What are your reflections on September 11, 2001?

Wednesday, September 9, 2015

ACP to Medicare: Pay internists better!

This is, in a nutshell, what ACP told the Center for Medicare and Medicaid Services (CMS) in a 47-page comment letter on the agency’s proposed rule for the 2016 Medicare Physician Fee Schedule.  Of course, it wouldn’t be effective for ACP to just say that its members should be paid more; we would have to show the agency why (the value to patients) and how (what changes specifically need to be made) to improve Medicare payment policies.

Among its many recommendations, ACP:

- Called on CMS to expand the Comprehensive Primary Care (CPC) Initiative both to additional geographic regions, as well as in existing CPC initiative areas.  The CPC initiative, a Medicare-funded pilot test of the impact of advanced Patient-Centered Medical Homes on quality and cost of care, is currently limited to approximately 500 practices in 7 market areas.  These practices are receiving a risk-adjusted average of $20 per Medicare patient per month, in addition to their usual Medicare fee-for-service payments, and they have the opportunity to share in savings to the program if they can reduce costs while maintaining or improving quality. The College believes that there is sufficient evidence of its effectiveness in improving quality and/or achieving savings to support making it widely available to beneficiaries and practices across the country.  ACP recommended that CMS seek out agreements with other payers in additional regions of the country to join with Medicare to support practices that wish to participate in the CPC initiative, and to open up participation to more practices in the current CPC initiative regions.

- Supported CMS’s proposal to allow Medicare reimbursement for advance care planning services. While this proposal is an important step to improve care for Medicare patients with serious illness, ACP urged that reimbursement for advance care planning be made uniformly available to all physicians and their Medicare patients through a national coverage determination, rather than leaving it to each regional Medicare carrier to decide whether to cover the service.

- Urged CMS to reduce barriers to physicians getting reimbursed for the Chronic Care Management (CCM) Code and allow reimbursement for CCM services that require additional time.  ACP recommended that CMS develop add-on codes for time increments greater than 20 minutes such as 21-40 min; 41-60 min; and greater than 1 hour.  ACP also recommends that the electronic care plan sharing requirement for providing the CCM service be suspended until the time that EHRs have the ability to support such capabilities.

- Encouraged CMS to use payment approaches that are aligned with the goal of moving payments away from volume to value-based care such as by exploring bundling of codes for certain chronic diseases. More specifically, ACP recommended that a code bundle for Diabetic Care Management (DCM) be developed to emphasize better care coordination, communication, and integration of the care team aimed at a better overall outcome cost of care for the Medicare beneficiary.

- Supported CMS’ recognition of the need to value the delivery of behavioral health services within the Physician Fee Schedule.  ACP recommended that the “collaborative care” model described in the proposed rule be implemented through a Center for Medicare and Medicaid Innovation (CMMI) demonstration and be rapidly expanded within Medicare through the Secretary’s authority based upon the results of this demonstration.

- Recommended that CMS investigate the adequacy of payment for physician services that typically take place outside of a face-to-face patient encounter. The College urged CMS to recognize non-face-to-face services-- such as telephone and email consultations-- that facilitate care coordination by internists and other primary care physicians.

ACP ‘s letter also offered comments on:

- Additional specific coding issues, such as Practice Expense (PE) determination, moderate sedation valuation, and surgical global periods.
- Physician Quality Reporting System (PQRS)
- The Value-Based Payment Modifier and Physician Feedback Program
- Physician Compare
- The Medicare Shared Savings Program (MSSP)
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
- CMS’s request for comments on issues relating to the  Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation

ACP’s comments were the result of countless hours of analysis by the College’s regulatory affairs staff, and from the volunteer physician leadership on its Coding and Payment Policy Subcommittee, Medical Practice and Quality Committee, Subspecialty Advisory Group on Socioeconomic Affairs, and the ACP representatives to the RVS Update Committee (RUC).

So when someone says the College doesn’t do anything to advocate for its members, or that we care “only” about the big and controversial policy issues like immigration and health, reducing harm from firearms, and LGBT healthcare disparities, it just isn’t so.  While we do care deeply about -- and are proud of our advocacy on -- issues that directly affect individual and population health, we devote at least as much of our advocacy resources and staff to improving the economic and regulatory environment for our members—proudly and justifiably so!

Today’s questions: What do you think of ACP’s recommendations to improve Medicare payments for internists’ services?  What would you recommend?

Wednesday, August 26, 2015

Why physicians must speak out against mass deportation of undocumented immigrants

Mass deportation, as proposed by Donald Trump, and echoed to varying degrees by other politicians, would have a catastrophic effect on the health of the approximately 12 million undocumented residents of the United States.  Physicians accordingly have an ethical responsibility to speak out, individually and collectively, for the health of these people, and against mass deportation.

That the medical profession is obliged to advocate for the health of all persons, without regard to their legal residency status, is well-established.  ACP’s Ethics Manual, Sixth Edition, affirms that “All physicians must fulfill the profession's collective responsibility to advocate for the health, human rights, and well-being of the public.”  “Health and human rights are interrelated,” it continues. “When human rights are promoted, health is promoted. Violation of human rights has harmful consequences for the individual and the community. Physicians have an important role to play in promoting health and human rights and addressing social inequities. This includes caring for vulnerable populations, such as the uninsured and victims of violence or human rights abuses. Physicians have an opportunity and duty to advocate for the needs of individual patients as well as society.”

It is indisputable that people who are undocumented, and at risk of deportation, are especially vulnerable to adverse and inequitable health consequences:

- “Worries about their legal status and preoccupation with disclosure and deportation can heighten the risk for emotional distress and impaired quality of health.”
- “Restricted mobility; marginalization/isolation; stigma/blame and guilt/shame; vulnerability/ exploitability; fear and fear-based behaviors; and stress and depression are specific to undocumented immigrants and have health and mental health implications.”
- The psychosocial impact of deportation include “the trauma of sudden and imposed family separation” . . . “drug use and less interaction with medical or treatment services (including HIV testing, medical care, and substance abuse treatment” . . .adverse “changes in family structure and stability. ”
- “The aftermath of deportation impacts entire communities as it instills fear of family separation and distrust of anyone assumed to be associated with the government, including local police, school personnel, health professionals and social service professionals.”

Such adverse health impacts would be exponentially higher if the United States were to attempt to remove by force every person who is in the country unlawfully.

Recognizing this danger, the American College of Physicians asserted in a 2011 position paper on immigrant access to health care 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.”

Instead of mass deportation, ACP advocated “for a national immigration policy on health care that balances the needs of the country to control its borders, provides access to health care equitably and appropriately, and protects the public’s health.”

In the same paper, the College also cautioned that a policy of mass deportation could compromise the patient-physician relationship, if it required that physicians report on the legal status of their patients:

 “Any law that might require physicians to share confidential information, such as citizenship status to the authorities, that was gained through the patient–physician relationship conflicts with the ethical and professional duties of physicians. National immigration policy should respect the boundaries of this relationship and the ethical obligations of physicians and not require physicians to reveal confidential information. Therefore, federal policies should not intrude upon a physician’s obligation to treat patients, regardless of legal status, and physicians should not be required to report on the immigration status of patients.”

Finally, ACP advocated that:

“U.S.-born children of parents who lack legal residency should have the same access to health coverage and government-subsidized health care as any other U.S. citizen” noting that “as outlined by the 14th Amendment to the U.S. Constitution, all persons born or naturalized in the U.S. and subject to the jurisdiction thereof are citizens of the U.S. and of the state wherein they reside. This means that a child born in the U.S. to immigrant parents automatically becomes a citizen . . . U.S.-born children should not be at a disadvantage from receiving the benefits of U.S. citizenship because of their parents’ immigrant status and fear of deportation.”

ACP clearly was prescient in anticipating the current debate over mass deportation and the citizenship of U.S. born children of undocumented persons, addressing the issue solely from the standpoint of advocating for the individual and collective health of the all persons, without regard to legal residency status.  But given that the direction of the debate has taken a decidedly wrong turn in the four years since ACP released its recommendations, it is high time for physicians, and their professional associations, to raise their voices now, individually and collectively, against mass deportation of undocumented persons, for the constitutionally-guaranteed right of their U.S. born children to have the same access to health coverage and government-subsidized health care as any other U.S. citizen,  and against any policy would require that physicians report on the on the immigration status of their patients or otherwise compromise their ethical obligation to provide care for all.

Today’s question:  Will you take up the call to speak out against mass deportation and for policies to ensure access to healthcare for all U.S. residents, regardless of legal residency status?

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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

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