The ACP Advocate Blog

by Bob Doherty

Thursday, November 6, 2014

The Self-Destructive Power of Cynicism

Cynicism appears to have replaced idealism as America’s defining characteristic.  So many of us just don’t trust the government, scientists, the clergy, journalists, business CEOs, labor unions, lawyers, or just about anyone for that matter, to say or do the right thing.

Two years ago, the National Journal reported that as a consequence of the Great Recession, “Americans are losing faith in the institutions that made this country great.”  The Pew Research Center finds that public trust in government has “reached an all time low;” in 1958, a whopping 73% of Americans expressed trust in the federal government; by 2013, only 24%, said they  trusted it much of the time.

The Gallup organization has surveyed the public over the past four decades about how much trust they place in various institutions and professions.  The Economix blog has converted Gallup’s data into an interactive graph that tracks changes in opinion over the decades.  “Click on almost any category charted in the graph,” Catherine Rampell wrote for Economix, “and you’ll see that confidence has generally been falling.”

Even the medical profession, which has relatively enjoyed higher “confidence” ratings and hasn’t suffered as steep declines as other sectors, does not fare so well when compared to other countries. Harvard researchers found that “based on data from an international health care survey, the United States is near the bottom of the list when it comes to public trust in the medical establishment”—ranked 24th in the world, on par with Croatia.

The public’s lack of trust in science and scientists is particularly alarming.

Take the Ebola controversy.  The National Journal’s Ron Fournier says that “the scariest thing about Ebola” is what it says about trust in U.S. government and institutions.

“Once again,” he observed, “Americans are reminded of the limits of U.S. social institutions—in this case various state, local, and federal government agencies and private-sector health systems that responded to the Ebola crisis slowly, inefficiently, and with a lack of candor that Americans, unfortunately, have come to expect.”  Such lack of faith in leadership, he noted in a follow up commentary, has led to “outrageous” policy outcomes, like mandatory quarantines of nurses and doctors.  Why is this so?

“The governors don't trust the scientists who oppose a mandatory quarantine for health care professionals exposed to Ebola,” writes Fournier. “The White House doesn't trust the governors. The governors don't trust the White House. Doctors don't trust nurses. Nurses don't trust hospital administrators. Hospital administrators don't trust federal officials, and the Feds don't trust them. Nobody trusts the media. The public trusts nothing. This rampant lack of faith in each other and in our institutions is how we got to a place where the state of New Jersey is holding a courageous 33-year-old nurse hostage.”

As ACP noted in its own statement, “mandatory quarantines for asymptomatic physicians, nurses and other clinicians, who have been involved in the treatment of Ebola patients, whether in the United States or abroad, are not supported by accepted evidence on the most effective means to control spread of this infectious disease. Instead, such mandatory quarantines may do more harm than good by creating additional barriers to effective treatment of patients with Ebola and impede global efforts to contain and ultimately prevent further spread of the disease.”  The CDC, the Infectious Diseases Society of America, and Dr. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, are all in agreement with us.

The problem is that Americans don’t trust what the experts tell them: 71 percent of them back mandatory quarantines of health professionals that treated Ebola patients in West Africa.

Or take the growing numbers of Americans who refuse to vaccinate themselves or their children. A recent study found that “In some areas, nearly one out of five children has not received their recommended vaccines. The consequences are serious not only for those unprotected children, but for the rest of society as well. ‘Herd immunity’ is threatened as more and more parents free ride off of the community's dwindling immunity, and outbreaks of diseases thought to have been conquered have already occurred.”

Opposition to vaccinations actually increased when anti-vaccine parents were given accurate scientific information about them, another study found.  “Researchers focused on the now-debunked idea that the vaccine for measles, mumps and rubella (or MMR) caused autism. Surveying 1,759 parents, researchers found that while they were able to teach parents that the vaccine and autism were not linked, parents who were surveyed who had initial reservations about vaccines said they were actually less likely to vaccinate their children after hearing the researchers messages.”

Or take climate change.  The Washington Post reports on a study that confirms that 97% of scientists agree that human activities are causing the planet to warm.  A new report from the United Nation’s Intergovernmental Panel on Climate Change concludes that "If left unchecked, climate change will increase the likelihood of severe, pervasive and irreversible impacts for people and ecosystems.”  The World Health Organization concludes that global warming will affect “the social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter.  Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhea and heat stress.  The direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture and water and sanitation), is estimated to be between US $2-4 billion/year by 2030.  Areas with weak health infrastructure – mostly in developing countries – will be the least able to cope without assistance to prepare and respond.”

Yet too many Americans are disbelieving of the scientific consensus: Gallup reports that more than four out of ten say that the seriousness of global warming is exaggerated.

If we allow the cynics to carry the day, we will all pay a steep—and perhaps lethal—price.

If we don’t trust the scientists, doctors, and public health agencies on Ebola, then what will happen if we have a flu pandemic that threatens millions?  Will we tune out the recommendations from the experts about what science tells us needs to be done to limit spread of the disease? How many will die as a result?

If we don’t trust scientists, doctors, and government agencies on the safety and effectiveness of childhood vaccinations, won’t we be condemning thousands of kids to die from diseases that could have been prevented?

 If we don’t trust the scientific consensus on health consequences of global warming, aren't we putting millions of lives around the world at risk of harm and even death from diseases, unsafe water, poor air, insufficient food, and insecure shelter?

British historian and author Kenneth Clark once said that “We can destroy ourselves with by cynicism and disillusion, just as effectively as by bombs.”  I fear that the rising tide of American cynicism may be bringing us closer to that day.

Today’s questions: Why are Americans so cynical? Are you one of them?  Do you agree that cynicism, and especially distrust of science and scientists, are putting us at risk?

Wednesday, November 5, 2014

What does the 2014 election mean for Obamacare?

By decisively taking control of the U.S. Senate and increasing their majority in the House of Representative, the Republicans now have a chance to force some modest changes in the Affordable Care Act, but they will not be able to repeal or reverse it.  But Republican gains in state legislatures and governorships may put the brakes on Medicaid expansion, leaving millions without coverage.

First, let’s start by acknowledging that although the mid-term election may have been a referendum on  President Obama, it wasn’t a referendum on Obamacare. Exit polls show that only 25 percent of voters named Obamacare as the top issue for them compared to 45 percent who named the economy.  47 percent of those who cast ballots in the mid-term elections said that Obamacare went too far, but another 48 percent said that the law was just about right or did not go far enough.

Second, even though Republicans will have sizeable majorities in both chambers of Congress, they will not be able to repeal Obamacare, because they don’t have the 60 votes required to overcome a Democratic filibuster, and if they were somehow able to get a repeal bill to the president, they don’t have the two-thirds super-majority in both chambers needed to override a veto by President Obama.

Third, the Republican-controlled Congress may be able to advance legislation to alter parts of Obamacare that are peripheral, but not essential, to getting people covered, like the taxes on medical devices and insurance companies, and repeal of the Independent Advisory Board, potentially with enough Democratic votes to get a bill to the president.  (Practically speaking, IPAB is probably dead in the water anyway, since IPAB appointees would have to be confirmed by the Senate, and there is no realistic prospect that a majority of Republican senators would agree to confirm appointments to a body that they oppose in the first place).  One problem for Republicans is that repealing the medical device and insurance taxes, and eliminating IPAB, would be scored by the Congressional Budget Office as increasing the budget deficit, unless Republicans find alternative savings or revenues to make up the difference, whether they're from the ACA itself or from somewhere else.

Other Obamacare changes that Republicans can be expected to pursue would include cutting off funding for the subsidies to insurers that are available if insurers experience adverse selection in the ACA’s exchanges, which most Republicans view as a taxpayer “bailout” to insurers.  They will also try to eliminate the requirement that large employers provide coverage for full-time employees, and if they can’t repeal the mandate altogether, they will try to modify how many hours count as full-time employment for the purposes of the mandate.  (Health policy experts disagree on how essential the employer mandate is to the success of the Affordable Care Act).  While the GOP will try to pass a bill to repeal the tax penalty on people who do not buy ACA-qualified coverage—the so-called individual insurance requirement—President Obama would veto it.  Republicans may also seek to make it easier for people whose insurance is “cancelled” to keep their policies, but this would be difficult to achieve without driving up premiums for everyone else.

The GOP may also try to block administration efforts to do a work-around on the Supreme Court’s Hobby Lobby ruling that the federal government cannot force “closely held” companies to provide coverage for certain types of contraceptives.  They could also try to overturn the administration’s ruling that members of Congress and their staffs, who are required to buy insurance coverage through the ACA’s exchanges, can continue to get the premium contribution that the federal government usually makes to its employees as part of their compensation package, which some Republicans have [mis]characterized as a “special subsidy” or exemption. They could also try to cut funding to federal agencies for ACA implementation.

Republicans likely will try to attach the changes they are seeking in the ACA to “must pass” bills like the debt ceiling, repeal of the Medicare SGR formula, and appropriations bills to fund the federal government.  They may also try to get changes in budget reconciliation, which requires only a simple majority. But no matter what vehicle they use to pass the bills, the only changes that Republicans will be able to make in the ACA are ones that the President agrees to, which means that the most important parts of the ACA will remain intact.

Fourth, Republicans will use their control of Congress to exercise more oversight over the administration’s implementation of the ACA.  Expect more adversarial hearings on, especially if there are problems with the next enrollment period that starts on November 15, or if people start getting new cancellation notices, or if premiums go up.  Expect Congress to exercise more oversight over Medicare’s Center on Medicare and Medicaid Innovation and the ACA’s Prevention and Public Health Fund, which some Republicans view as unaccountable “slush” funds that are outside of Congress’s budget control.

Fifth, two programs important to primary care physicians may face tough sledding in the new Congress, because they were created by the ACA.  One is Medicaid primary care pay parity, which is set to expire at the end of this year, unless Congress authorizes an extension of it during the upcoming “lame duck” session.  Otherwise, it will fall to the new 114th Congress to decide whether to reestablish it.  The other is the Medicare 10 percent primary care bonus program, which sunsets at the end of 2015.  Because both of these programs were created by “Obamacare” and because they cost money, many Republicans will be disinclined to support their continuation.  Physicians will have their work cut out in trying to  persuade Republican lawmakers to support both programs on their own merits—as programs crucial to ensuring access to primary care doctors—rather than viewing them as extensions of Obamacare.

Sixth, with more states having Republican governors and legislatures, continued progress in expanding Medicaid may be slowed, leaving millions of poor Americans in the “coverage gap” (ineligible for Medicaid, ineligible for Obamacare’s premium subsidies).  The New York Times reports that:

“Republicans in Florida, Wisconsin, Maine and Kansas won their bids for re-election. Three of them — Scott Walker in Wisconsin, Sam Brownback in Kansas and Mr. LePage in Maine— oppose expansion of the program. Rick Scott, the Republican governor of Florida, has endorsed the expansion, which would extend coverage to an estimated 848,000 people, but has never advocated for it forcefully, and he is not expected to now. And one state that has expanded its program might reverse course. In Arkansas, the legislature has to reauthorize the program every year with a three-quarters majority, leaving the expansion vulnerable to political shifts. Asa Hutchinson, a Republican who appears to be unenthusiastic about the expansion, was elected governor. And opponents of expansion picked up two critical votes in the state Senate.” 

In other states, GOP gains in state legislatures may make their states even more resistant to expanding Medicaid, even if the governor supports it.  Wisconsin may be one of the few remaining big-state wildcards on Medicaid expansion: although the voters re-elected Republican governor Scott Walker, an ardent opponent of Medicaid expansion, they also overwhelmingly passed a non-binding referendum calling on the state to accept federal dollars to expand Medicaid.  Whether the referendum will soften Governor Walker’s opposition remains to be seen.

So the bottom line of the 2014 election is this: Obamacare is here to stay, the Republican-controlled Congress will likely be able to get some peripheral elements of it changed but will not be able to repeal or reverse it, and recent progress on Medicaid expansion may be slowed, leaving millions without coverage.

Today’s question: what is your take on the impact of the 2014 elections on Obamacare?

Thursday, October 9, 2014

Is assimilation inevitable for independent physician practices?

Fans of Star Trek: The Next Generation will recall that the most disturbing aliens encountered by the Federation were The Borg, a part-cyber, part human collective race that functioned as an integrated and cyber-connected whole that existed only for the good of the collective, rather than as distinct individuals with their own thoughts and personalities—much like honey bees work together as a collective for the protection of the queen and the survival of the colony.  When the Borg encountered a humanoid species, they would forcefully assimilate them and their technologies into the collective, or destroy them, preceded by only one warning:


The Borg did not consider themselves to be evil though, explains the data base, because “the Borg only want to ‘raise the quality of life’ of the species they ‘assimilate.’"

I expect that many physicians in independent practices feel the same way as the unfortunate humans that encountered the Borg: they are under unrelenting pressure to be assimilated into hospital-owned or other large group practices, giving up their independence in the process, with the promise (of course!) that assimilation will  “raise their quality of life”!

But is assimilation the only option for independent practices?  Is resistance futile?

My answer: No to the first, and yes to the second.

Let me explain.  I believe that independent physician practices can survive, and even thrive, because they offer something valued by most patients: an ongoing relationship with a physician who lives in the community, and who knows them and their families.  A practice where, like Cheers, everyone knows your name - from the front office receptionist to the practice’s physician assistant or RN to the physicians themselves.

 I don’t believe that patients want these practices and their physicians to be forcefully assimilated into large groups that may be located some distance from their homes, where when they arrive for an appointment they are forced to wait for a long time in an overcrowded waiting room, just take a number please, to be seen by someone—a nurse, or a PA, or maybe if they are lucky, a physician—who they never met before and won’t be around next time they need to be seen.  (Now, before I get angry comments about this characterization from ACP members in large group practices, I am not saying that this is how all or even most large groups operate—most provide excellent and personalized and attentive care, often in community-based practices—even though the individual physicians and have chosen to be part of a larger group.  And there are small practices where patients are treated brusquely by inattentive staff and physicians.  My point is that if assimilation into a larger group means the loss of a personal relationship with a physician they know and trust, many patients will be opposed).

But I also think that for independent practices, resistance is futile—if this means resisting making the changes that may be required of them to survive in an increasingly competitive economic environment. It is futile to reject participation in all performance measurement programs; physicians in independent practices should, however, insist on measures that measure the right things for them and their patients.  It is futile to reject the move to electronic health records, but physicians in independent practices should demand that government and private payers facilitate the creation of EHRs that are functional, interoperable, and useful.  It is futile for physicians in independent practices to try to hold onto FFS and summarily reject bundled payments, risk-adjusted capitation, and physician-directed models like Patient-Centered Medical Homes and Accountable Care Organizations. Instead, they should see how their practices can embrace these changes.  (Many independent practices have done quite well, for instance, by becoming PCMHs).   It is futile for independent physician practices to reject being accountable for their cost of care—especially when they may find, as one recent study concluded, that hospital owned physician practices have higher prices and higher levels of spending than physician-owned independent practices!  Armed with such data, independent practices can demonstrate to  payers that they are the best value in healthcare.

And while big is not always better, smaller independent physician practices should explore ways to share information systems, data, and even risk with other independent practices, achieving economies of scale without losing their independence.

Independent physician practices do not have to be assimilated, then, but they have to have to be willing to embrace changes that will better position them to be successful without losing their values, their relationships with their patients, and their independence.

For the unfortunate victims of the Borg, assimilation meant losing everything they valued—their independence, their creativity, their individualism, their personal relationships, their values.  But Star Trek’s Federation learns how to prevail against the Borg, not by becoming part of them, or defeating them militarily, but by showing that an independent Federation of free people, voluntarily working together for the public good, is a better model of survival then a cyborg collective that snuffs out innovation and creativity.  With the right support, I believe that independent physician practices, provided that they are willing to embrace innovation on their own terms, will be able to show that they offer something of extraordinary value to patients and payers, allowing them to survive and even thrive without losing their independence.

Today’s questions: Do you think independent physician practices will be assimilated?  Is resistance futile for them?

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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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