Tuesday, December 23, 2008

Twas the Night Before Christmas ...

Twas the night before Christmas, and through DC town,
The ladies were picking out their inaugural gowns
And Detroit's "Big Three" had nary a care,
Because all knew Obama soon would be there.

Their CEOs would soon be snug in their beds,
While visions of bail out danced in their heads.
And I had just donned my New York Mets cap,
To head home for dinner and a long winter's nap.

When out on the Mall there arose such a clatter,
I turned the corner to see what was the matter.
Away past the Tidal Basin I flew like a flash,
As fast as my middle aged legs were able to dash.

The moon on the breast of the new-fallen snow,
Gave the lustre of mid-day to objects below.
When, what to my wondering eyes should appear,
But Barack Obama and running mate Joe!

With a teleprompter and oratory, so hopeful, not grim,
I knew in a moment it could only be HIM.
More rapid than eagles his coursers they came,
Barack whistled, and shouted, and called them by name!

"Now Rangel! Now, Pelosi! Now, Reid and Baucus!
On, Teddy! On, Henry! On, Democratic caucus!
Our time has come! We must get on the ball!
We have money to spend! We must spend it all!"

As dry leaves that before the wild hurricane fly,
When they meet with an obstacle, mount to the sky.
So up to the Capitol the coursers they flew,
With a stimulus bill full of money, and Obama too!

And then, in a twinkling, I heard on the roof,
The prancing and pawing of each lobbyists' hoof.
As I drew in my head, and was turning around,
The lobbyists arrived with a leap and a bound!

They were dressed in Brooks Brothers, from head to foot,
All had arrived for their share of the loot.
A wish list of projects they had in their grip,
For the good of the people, they happily quipped!

Barack's eyes twinkled! But he didn't seem so merry.
His cheeks began to redden, a bit like a cherry!
His gleaming smile turned to a frown,
His demeanor headed decidedly down.

The stump of a cigarette he held tight in his teeth,
And the smoke it encircled his head like a wreath.
(He had tried to quit but had to confess
He resumed his bad habit because of the stress).

All they want is money, he grumbled to himself,
Who do they think I am, some jolly old elf?
Still, the people need jobs, he thought in his head
$850 billion should do it, he finally said.

So he handed out his gifts to all who were near,
to doctors and builders and road engineers!
He then said goodbye with a twitch of his nose,
(And the next day, even the Stock Market rose)!

As he sprang to his limo, to his team gave a whistle,
And away they all drove away like the down of a thistle.
But I heard him exclaim, 'ere he drove out of sight,
"Happy Christmas to all, and to all a good-night!"

With apologies to Clement Clark Moore, I hope you enjoyed this Washington version of the famed verse I will now be taking a holiday hiatus, resuming with my blogging on January 5.

No question to our readers today, just my best wishes to you and your loved ones for joyful holiday season and prosperous New Year! And I invite you to post your own holiday wishes to your fellow ACP Advocate readers.

Monday, December 22, 2008

Say it ain't so ... CBO

Last month, I blogged about the important role the Congressional Budget Office (CBO) will likely play in determining the fate of health care reform.

I am reprising this topic because the CBO just released a 200 plus page report, on options to fund health care reform. But as Robert Pear writes in The New York Times, "many of the health care proposals championed by President-elect Barack Obama and other Democrats would carry a high price tag and would generate only modest savings."

By and large, the CBO projects savings from proposals to cut payments to physicians and other "providers" or impose new mandates on them. Approaches that rely more on carrots than sticks to create positive incentives for change are assumed to increase spending.

For instance, CBO says that paying for a medical home for chronically ill beneficiaries will increase Medicare expenditures by $2.1 billion over five years. It acknowledges that "the medical home concept has the potential to improve the health and health care of chronically ill Medicare beneficiaries" but "cannot estimate whether the net result ... would be to increase or decrease spending."

Giving primary care physicians a 5% Medicare payment bonus for adopting health information technology will increase Medicare spending by $370 million, says CBO. But imposing a 5% pay cut (penalty) on all physicians who do not adopt health information technology (HIT) would save $65 million. Mandating that "providers" use HIT as a condition of participation in Medicare would save over $2 billion.

When it comes to price cuts, CBO has no trouble projecting savings. Reduce fees to physicians in areas with unusually high spending? $4.9 billion saved. Cut Medicare pay rates for primary care physicians who do not meet benchmarks for vaccination? $530 million saved. These are just a few of the dozens of pay cuts CBO says will save money.

The CBO does not make policy, and its new report is just a set of options, not recommendations. Still, my fear is that CBO report may make it easier for Congress to pay for health care reform through payment cuts and mandates on physicians and hospitals because the agency will "score" them as saving money.

At the same time, the Patient-Centered Medical Home and other innovative delivery system reforms may not get the funding needed because CBO "cannot estimate whether the net result would be to increase or decrease spending."

Today's question: How do you think ACP should respond to the CBO report?

Thursday, December 18, 2008

Is Obama's health reform plan a back door to single payer?

The health plan touted by President-elect Obama during his campaign is not a single payer, Canadian-style, national health insurance plan. Yet, there are some who worry - and others fervently hope - that it will end up being the back door entry way to a single payer system.

Let's begin by recounting all of the reasons why the Obama proposal is not a single payer plan.

It doesn't eliminate private insurance, it subsidizes it. People who don't have access to affordable coverage through their employer would receive federal subsidies to buy coverage through a "National Health Insurance Exchange." The Exchange would allow people to choose from hundreds of different private health insurance plans, just like federal employees do. No one has to switch plans though; anyone who has private insurance through an employer, and likes it, could keep it.

Obama proposes to mandate that people buy coverage for their children, opening up more business growth opportunities for the insurance industry. America's Health Insurance Plans (AHIP) has proposed to expand this to an "enforceable individual coverage mandate" for everyone, not just kids, to buy coverage.

But the Obama plan also grows government's role. Obama proposes to expand enrollment in government-run (public) plans like Medicaid and the State Children's Health Insurance Program.

And, in addition to giving subsidies to individuals to choose from hundreds of private insurers, he would give them the choice of enrolling in a public plan, similar to Medicare. Robert Pear reports in yesterday's New York Times that the public plan, according to HHS Secretary-designee Tom Daschle, would be "modeled after Medicare" and would have "tremendous clout to bargain for the lowest prices" from health care providers.

AHIP argues that because of cost-shifting, the new proposed new public program could lead to higher costs for people who already had private insurance.

The insurance industry's biggest concern is that the government plan will undercut private insurance. As a result, enrollment in the public plan would grow over time, while private insurance enrollment would contract.

This - coupled with the planned expansion of Medicaid, SCHIP, and the inevitable growth of Medicare associated with an aging population - could get the country to a single payer system, or something close to it.

It wouldn't be a single payer system created by legislative fiat, but one that comes from "competition" (fair or unfair as it may be) between private insurance and public coverage.

ACP members who favor single payer will be encouraged by this scenario. Others, who distrust giving government so much control over health care, will view it with dismay and trepidation.

What is certain is the creation of a "public plan" option will be among the most controversial elements of the Obama plan.

Today's question: Do you believe that people should have the option of choosing between a subsidized private insurance plan and a public plan like Medicare?

Wednesday, December 17, 2008

Stimulate this!

If life insurers, automakers, banks, and stockbrokers can get stimulus money from Washington, why not primary care?

Much has been said about primary care being the keystone (as Senator Baucus so aptly described it in his white paper) of a high performing health care system.

Yet we also know that primary care is experiencing death by a thousand cuts. Established primary care practices are struggling to survive. Young physicians in droves are turning to higher paid specialties.

President-elect Obama seems to understand. During the campaign, he observed that "primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation's health. Yet, the numbers of both are dwindling."

His comments are on the mark: two recent studies published by the Association of American Medical Colleges and Health Affairs project a shortage of about 44,000-46,000 primary care physicians for adults.

When I met with the Obama transition team a few weeks ago, one of his staffers closed with a question, "What could be done in an economic stimulus package to help the economy and lay the foundation for comprehensive health care reform?"

ACP's answer: provide economic assistance to internists and other primary care physicians.

In a letter delivered today to Senator Tom Daschle, Obama's pick for Secretary of Health and Human Services, ACP proposed that primary care physicians receive a 10% Medicare payment bonus for all approved charges paid by Medicare through 2010.

We also proposed creation of economic incentives, directed toward primary care physicians in smaller practices, to acquire specific health information technology applications to support care coordination in a Patient-Centered Medical Home.

The letter goes on to make the case that the loss of even one primary care practice in a community during these tough economic times will put thousands of patients in the impossible situation of trying to find a new primary care physician, when most of the surviving primary care practices already are at full capacity and unable to take on any new patients.

We know that even a 10% increase in Medicare payments for primary care will not bring primary care earnings up to the point where they are competitive with other specialties, given the wide gaps that currently exist. But it would help struggling primary care practices keep their doors open for the next 18 months. It would also send a signal to medical students and residents that the new administration and Congress are committed to taking an important first step to making primary care an attractive and competitive career choice.

Today's questions: Do you agree that primary care should receive economic stimulus dollars? And how much more do you think primary care would need to be paid to be a competitive career choice?

Monday, December 15, 2008

Primary care has no value?

So says Dr. Jonathan Glauser, an emergency physician and MBA. Writing in Emergency Medical News about proposals to increase funding for primary care, Dr. Glauser had this to say:

"To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Oh, there's more. "How could we as physicians ever allow a doctor to call himself primary care when he can't manage simple chronic illness; cannot definitively treat acute illness or injury; often has no skills to save lives and no access to equipment if he had the skills; and does not even see patients at their own (the customers') convenience?"

And this: "Their unparalleled record of failure and complete dispensability does not merit even a second thought of throwing dollars their way."

Complete dispensability and no value to society? To put it as kindly as I can, it appears that Dr. Glauser didn't do his homework.

If he had, he would have known about the hundred-plus studies, annotated by ACP, which show that primary care is consistently associated with better outcomes and lower cost of care.

He would have known from our review that "states with higher ratios of primary care physicians to population have better health outcomes, including decreased mortality from cancer, heart disease, or stroke; individuals living in states with a higher ratio of primary care physicians to population are more likely to report good health than those living in states with a lower ratio; and the supply of primary care physicians is also associated with an increase in life span."

He would have known that "an increase of just one primary care physician per 100,000 population reduces ER visits by 10.9 percent."

The ranting of one emergency room doctor might not be worthy of comment, except I wonder how many other ER physicians share his distorted and uninformed view of primary care.

ACP plans to send a response to Emergency Medical News. You can help us by posting a response to today's blog. The most interesting comments are likely to be quoted (with your permission) by ACP.

Today's question: How would you respond to Glauser's view that primary care (and by implication, general internal medicine) is "singularly inept at performing anything of value to society, is pure folly and a waste of precious health care dollars?"

Thursday, December 11, 2008

Why, why ... PQRI?

The next phase of the PQRI program will start on January 1. I doubt, though, that many internists are wishing it a Happy New Year.

The PQRI, which was authorized by Congress in 2006, is the Physicians' Quality Reporting Initiative, the federal government's first foray into pay-for-performance for doctors. Starting on July 1 through December 31, 2007, physicians who agreed to voluntarily report on selected quality measures were promised they could earn Medicare bonus payments of up to 1.5 percent of total allowed charges.

By the federal government's own account, the program was a less than a resounding success. The Centers for Medicare and Medicaid Services (CMS), the agency that administers the program, reports that "approximately 16 percent of eligible professionals participated (submitted at least one quality data code) in the program. Of those who participated, just over half were successful in meeting the program and reporting requirements and as a result received an incentive payment."

CMS acknowledges that there were many problems with the program, including claims-based reporting mechanisms issues, National Provider Identifier (NPI) numbers not being included on the claims forms, incorrect quality reporting data or claims submission errors and the content of the feedback reports to physicians.

It promises to do better in 2009.

In my mind, the agency will have to do a lot better. The way the PQRI program was designed and implemented almost seemed designed to discredit the idea of P4P among (already skeptical) physicians. Successful quality improvement programs provide regular feedback to clinicians on how they are doing. Rewards for reporting should be greater than the costs and hassles of reporting. The rewards should be predictable (if I do x, I will receive y). And the timing of providing the rewards should be closely linked to when the reporting took place.

None of this was the case with PQRI. PQRI physicians largely were kept in the dark about how they were doing. The maximum bonus payments likely didn't even cover their costs. Physicians didn't receive their performance-based payments, if they received anything at all, until as much as six months after the reporting year closed.

Internists now have to decide whether to give the PQRI another go in 2009. This time, the stakes are higher: successful reporting can result in bonus payments of up to 2 percent of allowed charges. ACP has extensive resources on the PQRI to help you decide, which are being updated for the new program year.

Despite the problems with PQRI, I believe that performance measurement and reporting are here to stay. Medicare views the PQRI as one of the first steps towards value-based purchasing, as do key legislators like Senator Max Baucus (D-MT) and Chuck Grassley (R-I0). Done correctly, reporting on quality measures may help internists deliver better care to patients - and earn higher payments for doing so.

Today's questions: Did you participate in the 2007 and 2008 PQRI programs? Why or why not? What was your experience if you did - and how can it be improved? Will you participate in 2009?

Wednesday, December 10, 2008

Is pharma friend or foe?

I write this blog on an Amtrak train from Philly to Washington, returning from one of the occasional roundtable discussions ACP leadership has with representatives of the pharmaceutical industry. We had a lively discussion of issues of concern to both physicians and drug manufacturers, such as improving care of patients with chronic diseases, the patient centered medical home, primary care workforce, and comparative effectiveness research.

Reaching out to other stakeholders, including pharma, is an important part of my job. Sometimes, such discussions enable us to weigh in on the same side of public policy issues, with greater clout than either could bring on our own.

Other times, we end up agreeing to disagree. For instance, pharma generally opposes including cost-effectiveness in evaluations of the relative effectiveness of different drugs and medical treatments, while ACP believes it is important to consider both clinical efficacy and cost-effectiveness. ACP does not favor direct-to-consumer advertising (and we call for greater regulation to the extent it is permitted), while the pharmaceutical industry obviously supports it with lobbying and advertising dollars.

Still, I think it is better to understand our differences than to take positions uninformed by the views of the others.

Discussions among multiple stakeholders have taken on a heightened importance as the country takes up health care reform. ACP is involved in several different forums to explore the possibility of achieving a health care reform consensus among physicians, health plans, consumers, businesses, pharma, health plans, and others. The thinking is that agreement among such diverse but powerful interest groups - call us strange bedfellows, if you will - could be a breakthrough event for health care reform. The alternative is for each stakeholder to duke it out, recognizing that any one of us might have the power to block health care reform to protect our own respective interests.

I recognize that some internists have a very negative view of pharma. It is not unusual for ACP members to approach me at chapter meetings to vent - with a great deal of passion - about the high cost of prescription drugs. Some internists go as far as to advocate that ACP sever all ties with pharmaceutical manufacturers.

On the other hand, there are many ACP members who recognize the importance of pharma in developing new drug therapies and providing appropriate sponsorship and unrestricted grant support for medical education and research on quality improvement. It also is not uncommon to find ACP members in senior management positions within pharmaceutical companies.

ACP's leadership generally believes that it is better to seek a shared understanding with the pharmaceutical industry (and other health care industries) than to close off dialogue. Certainly, we have to guard against being co-opted by any industry group. We have to speak clearly for the interests of ACP members and their patients when they collide with those of industry. But I believe that respectful dialogue among all those with a stake in health care reform is healthier than categorizing each other as friend or foe.

Today's questions: What do you think - should ACP try to find common ground with drug manufacturers on public policy issues? Where do you see us having shared interests - or potentially irreconcilable differences?

Tuesday, December 9, 2008

Do patients really want to see their doctor's report card?

Consumer-driven health care has been the cause du jour for large employers, consumer groups, and the Bush administration. The idea is that if "consumers" (patients) are given "transparent" information on the quality and cost of care of individual clinicians and health care facilities, they will choose the ones that offer the best value. Physicians and hospitals would then be "incentivized", so the theory goes, to improve their care and lower their prices, leading to overall quality gains and cost savings.

Often, health quality report cards are linked to financial models, such as health savings accounts, designed to encourage patients to set aside money to pay for their own care.

Underpinning consumer-driven care is the belief that patients want to see health quality report cards. And, that they will use quality and cost comparisons to prudently select physicians and hospitals that offer the best value.

But what if patients prefer to make health care decisions on intangible things - like a recommendation from a next door neighbor - that can't be captured on a report card?

Niko Karvounis writes in the Health Beat blog that "patients' health care priorities aren't entirely rational - and so relationships, and not rankings, are important ... Interaction is paramount." He cites an October Kaiser Family Foundation survey, which found that less than half of patients who come across comparative data on health care providers actually use it.

ACP has supported efforts to provide patients with physician-specific information on the quality and cost of care - with safeguards. Earlier this year, we expressed support for the "Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs", which has been endorsed by leading health plans, consumer, business, and physician groups. It includes the following principles:

- Measurement is based on sound national standards and methodology.
- Both consumers and physicians have input into the measurement process and how results are reported.
- Measurement is a transparent process so that both consumers and physicians can understand the basis upon which performance is being measured and reported.
- Physicians have adequate notice and opportunity to correct any errors.
- Physicians will have information that helps them improve the quality of care they provide.

Still, the Kaiser survey suggests that performance measurement and reporting programs may work best - if they work at all - when incorporated into models, such as the Patient Centered Medical Home, which support the relationship between physicians and their patients. The Patient Centered Medical Home encourages patients to have a personal relationship with a physician who is responsible for helping the patient get all the care they need, supported by a better payment system (including payment for services that fall outside of the office visit) and practice-based health information systems.

PCMHs report on the quality and efficiency of care, but it is the physician-patient relationship that is at its heart.

Today's questions: Do you think patients should have information on your health care quality and efficiency grades? Do you think such information will lead patients to make wiser choices in picking doctors or hospitals?

Monday, December 8, 2008

What is your (health care) holiday wish list for the new President?

The Washington Post reports that the Obama administration is determined not to repeat the mistakes Bill Clinton made fifteen years ago in pursuing health care reform. This means "moving fast, seizing momentum and not letting it go."

Other lessons learned: don't develop your proposals in secret, and engage the broader public. (The Clinton administration was criticized for developing its Health Security Act in secret, excluding participation by the general public, members of Congress, and key stakeholders.)

Obama's official website encourages individuals to host a "health care community discussion over the holidays" (will eggnog be served?) or to submit comments "on why health care is important to you, or what you'd like to see an Obama-Biden administration do and where you'd like the country to go."

Last week, I met with the Obama health care transition team to discuss ACP's views on health coverage and the primary care workforce crisis. And, in keeping with the theme of transparency, the Obama people asked to post the ACP papers I shared with them.

A cynic might view all of this as just politics, but politics is the way to achieve policy. "Born in a policy hothouse, the Clinton plan wilted in the cold winds of politics" observed Jacob Hacker in the May/June issue of Health Affairs.

Over the next weeks and months, ACP will have many opportunities to bring internists' wish list to the new administration.

And on February 2, ACP will be hosting its annual "State of the Nation's Health Care" briefing at the National Press Club in Washington. We will release a new ACP report on what the new administration and Congress should do to create a health care system that works for all Americans.

I am looking to the posts on this blog for your ideas. I also encourage you to consider hosting a health care community forum and to submit ideas directly to the Obama website.

Today's question: What would you put on the ACP holiday wish list for the new president?

Friday, December 5, 2008

Are small businesses allies for health care reform?

Opposition from small businesses is generally viewed to be one of the reasons why Bill Clinton was unable to achieve health care reform. In 1993-94, the National Federation of Independent Businesses (NFIB) and the health insurance industry trade association (now called America's Health Insurance Plans) effectively joined forces to derail Clinton's Health Security Act.

Small businesses face the greatest barriers in finding affordable health coverage, lacking the access to pooling arrangements, community rated plans, and self-insurance options that benefit larger employers. Yet small businesses historically have opposed mandates that they provide coverage. Even when such mandates are linked to subsidies, insurance market reforms, and pooling arrangements to make coverage more affordable, as Clinton proposed to do, and as Obama is now proposing.

Now, as Joanne Kenen writes in the New Health Dialogue Blog,
small businesses want major reforms to make coverage affordable, and are open to solutions from right to left.

She writes that "a new survey of 400 small businesses (fewer than 50 employees) that currently pay for some portion of their workers' health insurance shows they are open to considering all sorts of different forms of change from left, right, and center." Slightly more than half of the respondents said they could support a four percent payroll tax on businesses with 10 or more employees who do not provide health coverage and/or requiring that all employees be offered at least one public plan (like Medicare) and one private plan, without regard to age or pre-existing conditions. (Keep in mind these are the views of small business owners who already offer health insurance, and may not reflect the views of businesses that currently don't provide health benefits to their employees.)

And this time around, the NFIB has proposed principles to achieve universal access, although the association continues to state that employer mandates or "pay or play" requirements are not acceptable.

Many internists - a majority of ACP members - are small business owners themselves. Like other business owners, they struggle to find affordable coverage for themselves and their families. But as physicians, most feel especially obligated to try to provide such coverage.

Today's questions: If you are an internist who owns a small business (practice), would you support a requirement that businesses with more than 10 employees provide coverage or pay a four percent payroll tax to help fund coverage for the uninsured - if it gave you and your employees access to subsidies and affordable coverage options without regard to age or pre-existing conditions?

Thursday, December 4, 2008

Will the renewed attention to primary care really change things?

Primary care is the flavor of the day. At least, that is what one might conclude from the flurry of articles, blogs, studies and reports that detail the crisis in primary care.

Jason Larkin writes in The Harvard International Review that Senator Tom Daschle, Obama's pick for secretary of Health and Human Services, is intrigued by the idea of creating a "national 'health corps, analogous to the Peace Corps ... [where] doctors finishing their training would be encouraged to do a year or two of domestic service in communities with uneven access to health care professionals.'" Larkin argues, though, that a "health corps should be part of a wider strategy to deal with one of the biggest problems in the American health system: the shortage of primary care physicians" citing ACP's recent white paper.

Paul Testa reflects in the New America Blog on a report by Karen Brown on NPR's All Things Considered about the troubles experienced by 440,000 newly-insured persons in Massachusetts in getting access to primary care doctors.

Victoria Knight writes in the Wall Street Journal Health Blog that it is "lack of access to primary care," not the uninsured, that is clogging up emergency rooms. She suggests that rather than "moving people into the hallways" a better solution is "better incentives for medical students who choose to go into primary care and more pay for physicians who work after hours." (The American College of Emergency Physicians, by the way, takes issue with the idea that "non-urgent" visits to emergency rooms are major factors in ER wait times).

As a good internist might say, awareness that there is a problem is the first step to curing it.

Yet I worry that there still is not the needed sense of urgency among key decision-makers. When I talk to staff on Capitol Hill, they acknowledge the need to do "something" for primary care. But then they add caveats: Where will the money come from? Won't the specialists object? It has to be "politically feasible."

Many don't yet seem to grasp that primary care won't be around much longer unless something big is done now to turn things around. Without a sense of urgency, we could end up with minimalist, non-controversial policies - small steps that are too little, too late, to save primary care.

Today's questions: Do you think your representatives, senators, patients, and neighbors understand the urgency of saving primary care? What are you doing to get them to understand?

Wednesday, December 3, 2008

What Price is Life?

The subject of today's blog - What Price Is Life? - may sound like I am heading into the realm of philosophy instead of public policy. But it is a question that the country will need to consider as it explores ways to reduce health care costs.

On Sunday, the Washington Post reported that many experts believe that the U.S. "is not getting what we pay for" and that "better data [on the comparative effectiveness of different treatments] may address what Dartmouth College researchers describe as large, 'unwarranted' variations in medical spending ... as much as 30 percent of medical spending - or $700 billion - does nothing to improve care."

The idea of funding research on comparative effectiveness is supported by Peter Orzag, former head of the Congressional Budget Office and President-elect Obama's choice to head the White House budget office, and by former Senator Thomas A. Daschle, Obama's choice to head the Department of Health and Human Services.

ACP supports more research on comparative effectiveness. In an article published in the Annals of Internal Medicine earlier this year, ACP proposes that such research should include both relative clinical efficacy and relative cost-effectiveness:

"Cost-effectiveness information is a necessary complement to comparative clinical effectiveness information for all health care stakeholders. This information will help patients and their personal physicians make treatment decisions that better reflect the needs and preferences of the patient and support the profession's commitment to a just distribution of finite resources."

Written on behalf of ACP's Medical Services Committee and based on a broader ACP position paper, the authors acknowledge "concerns by patients and their advocates that use of any cost data will inappropriately limit access, be used primarily for cost-containment, and be a substantial step toward rationing of care" but finds that with "appropriate safeguards ... use of cost-effectiveness data when making policy is a reasonable approach to controlling the escalating rise in health care."

One only needs to look at Great Britain to understand why introducing comparative effectiveness research into the U.S will be controversial.

In today's New York Times, reporter Gardiner Harris tells the story of a patient, Mr. Bruce Hardy, whose kidney cancer spread to his lungs. Britain's National Health Service denied him access to a pill, called Sutent, which delays cancer progression for six months at an estimated treatment cost of $54,000. The story reports that "any drug that provides an extra six months of good-quality life for 10,000 pounds - about $15,150 - or less is automatically approved [by the National Health Service], while those that give six months for $22,750 or less might get approved. More expensive medicines have been approved only rarely." The article ends with a heart-tugging comment from Mr. Hardy's wife of 45 years:

"It's hard to know that there is something out there that could help but they're saying you can't have it because of cost," said Ms. Hardy, who now speaks for her husband. "What price is life?"

It is unlikely that the United States will use comparative effectiveness research to deny coverage for drugs based on a dollar threshold of extra months of "good-quality" life.
But as the U.S. explores ways to reduce health care expenditures, questions of cost and benefit - and yes, the price of life - will be part of the conversation.

Today's questions: Do you believe that the United States should fund independent research on the relative comparative effectiveness and use such research to inform clinical and coverage decisions? Should relative cost-effectiveness be part of the assessment?

Monday, December 1, 2008

Medical Doctors and Advanced Practice Nurses: Can't We All Just Get Along?

This fall, I attended ACP chapter meetings in Michigan, Nebraska, California, Texas, and Delaware. A hot topic of concern among ACP members is the role of nurses - specifically advanced practice nurses - in primary care.

In Dallas, an anxious general internist said he was worried that nurses were trying to replace general internists. He reasoned that with fewer physicians going into primary care, the government would turn to nurses as a solution. I heard similar comments from other internists.

The heightened attention to the role of nurses in primary care stems from several developments.

One is nurse-doctorate degree programs, creating concern among physicians that the public would be "confused" or "mislead" into thinking nurses have the same training and skills of allopathic and osteopathic doctors. The Nurse Practitioner Roundtable says "recognition of the title, 'Doctor', for doctorally prepared nurse practitioners facilitates parity within the health care system."

Another is efforts by advanced practice nurses to lead patient centered medical homes. In December 2007, the American Academy of Nurse Practitioners released a position paper that argues that practices led by advanced practice nurses meet all of the principles of a patient-centered medical home as defined by ACP, the American Academy of Family Physicians, American Academy of Pediatrics and the American Osteopathic Association.

And then there is the decision by the National Board of Medical Examiners to provide assessment services to the Council for the Advancement of Comprehensive Care (CACC), a leadership group in the Doctor of Nursing Practice (DNP) community.

One can understand, then, why many general internists might conclude that nurses could replace physicians as the principal source of primary care in the United States.

But is this really so? Renee Zerehi, ACP's manager of health policy, says that "two recent workforce studies suggest that greater use of nurse practitioners and physicians assistants will not have enough of an impact on the primary care physician shortage":

"Colwill et al found that 42 percent of patient visits to NP/PAs in office-based practices are in offices of specialists - not generalists. In addition NP graduation rates fell from 8,199 to 5,920 between 1998 and 2005. They may decline further as master's-level NP programs are replaced by clinical doctoral programs by 2015. The Association of American Medical Colleges predicts a shortage of 124,000 physicians by 2025, and estimates that primary care will account for 37% of the total projected physician shortage - nearly 46,000 FTE primary care physicians. The baseline demand scenario assumes a continuation of current supply, use and demand patterns. It also assumes that PA and NP supply would grow by at least 26%, with PAs and NPs maintaining their proportion of services provided. The study found that although it is more likely that NPs and PAs will continue to serve an important role in the provision of care, their numbers will not be sufficient to eliminate the emerging physician shortage."

In other words, the demand for primary care may grow so fast that there will be a need for more advanced practice nurses and physicians to meet the need.

Today's questions: Do you think advanced practice nursing can, should or will replace primary care physicians? Do you think it is possible for both professions to find common ground on their respective roles in primary care - and if so, how?

Wednesday, November 26, 2008

A smorgasbord of interesting health blog posts

The ACP Advocate Blog will be taking a break for the rest of this holiday week, resuming with new commentary on Monday, December 1.

In the spirit of Thanksgiving, a day when most of us will be dining on a smorgasbord of different foods, you might want to sample a variety of intriguing blog postings I've come across recently:

Niko Karvounis has a two part posting on the Health Beat blog on how "we can create a health care system that nurtures primary care physicians instead of breaking their spirits."

Scott Henley debunks "Five Health Care Myths" in the Wall Street Journal's Health Blog, including the myth that the U.S. has the best health care in the world. (Interestingly, ACP debunked the same myth in a position paper published this past January 1 in the Annals of Internal Medicine.)

And John Goodman writes in the Health Affairs blog about how the best features of candidate Obama's, McCain's, and Romney's health plans could be combined into a single plan. He argues that Obama actually needs to incorporate key features of his Republican rivals' plans to be successful.

I wish you the best for an enjoyable holiday with family and friends!

Tuesday, November 25, 2008

What happens if no one is home ... at the medical home?

David Harlow, writing in HealthBlawg says that recent news on the medical home is good. He cites a post by Arnold Milstein in the Health Affairs blog on "four primary care physician-led practices with average or above-average quality scores whose care enables their patients to consume 15-20% less total payer spending per year on a risk-adjusted basis than patients being treated by regional peers. Mobilizing impressive business ingenuity, they achieved this result in a U.S. payment environment that typically punishes physicians who invest to prevent costly near-term health crises."

(To learn more about the patient-centered medical home, go to ACP's new PCMH web page, a comprehensive collection of information, resources and demonstration projects to assist in planning for a complete patient-centered medical home.)

But Harlow raises an important caveat: the viability of medical homes assume a sufficient supply of primary care physicians. He quotes the following from the New York Times:

"A growing shortage of doctors willing to practice general medicine has left some [provider networks] desperate for qualified candidates and, in the long term, stands as a major obstacle to overhauling the nation's health-care system ...

Almost all changes under consideration include a central role for what used to be known as the family doctor - today generally an internist or family practitioner - who can save the system money ...

Although such primary-care doctors were once the cornerstone of American medicine, their numbers have dwindled as younger doctors have been drawn to specialty fields by money and the lure of new technology. So today ... a rising demand is confronting a declining supply."

Here's the kicker. The New York Times article was published 15 years ago, when the Times reported that in 1992 "only 14.6 percent of medical students decided to go into general medicine, an all-time low." Last month, the Journal of the American Medical Association reported that only two percent of fourth year medical students plan to go into general internal medicine.

We've known for a decade and a half that primary care is in trouble, and we also know what needs to be done about it (starting with better reimbursement), but there has been enormous political and institutional resistance to doing more than token measures.

This time around, policymakers have to get serious about fixing the problem. The patient-centered medical home has enormous potential to refocus health care around the relationship between primary care physicians and patients - supported by better reimbursement and health information systems to achieve the best possible results. The hope, of course, is that the PCMH will also make primary care more attractive and viable.

But we also need comprehensive reforms to provide immediate, sustained, and sufficient increases in reimbursement to general internists and other primary care physicians, reduce the "hassles" of practice, re-orient medical education around primary care, and allow medical students who select primary care to graduate debt-free.

Otherwise, we can build the loveliest of medical homes, but no doctors will be there when the patients arrive.

Today's questions: What do you think needs to be done to overcome decades of resistance to meaningful reforms to support primary care? And do you see the patient-centered medical home as being part of the solution?

Friday, November 21, 2008

Paperwork, paperwork, paperwork!

A recurring theme on the ACP Advocate blog is the frustration internists have with paperwork. The "Happy Hospitalist" writes, "I could double or triple the number of patients I see if my daily reality wasn't controlled by third party rules and regulations that require me to document thousands of words in thousands of key places thousands of times a day." Dr. Jay Larson says that "Increased non-clinical paper work for primary care physicians is one of 3 major reasons medical students decide to choose a different career than general internal medicine." He notes that over 95% of the physicians in the Physicians Foundation survey reported increased non-clinical paper work over the past 3 years.

"Dr. JH07" paraphrases a quote from Forrest Gump, "'It rolls downhill', this became a reality for PCP's [primary care providers] with regard to referrals, preauthorizations of drugs and radiology studies, CMN's, care plans, letters of medical necessity, FMLA forms, scooter store forms, DMV forms, routine pre-op H&P forms on healthy patients who were to have surgery, signing orders for home care agencies to justify their care and existence, work notes, disability forms, nursing home forms..."

What can be done to reduce paperwork and the associated administration costs?

As I see it, the policy options are:

- Reduce the number of payers to one. Advocates of a single payer system argue that reduced administrative costs are one of its big advantages over the US's "pluralistic" system. A single payer would have one set of rules relating to benefits, eligibility, billing, and utilization review, unlike a pluralistic system where each insurer has its own requirements. Single payer systems, though, are quite capable of generating their own paperwork hassles for physicians. Consider all of the paperwork involved with traditional Medicare fee-for-service, which is "single payer" for elderly and disabled patients.

- Let physicians and patients set their own terms. Go back to the days when patients "contracted" with their physicians for services; the fee charged and the services provided were determined by the doctor and the patient. Eliminate price controls and "balance billing" limits. Provide health insurance coverage only when out-of-pocket expenses exceed a high dollar threshold (e.g. health savings accounts).

- Eliminate fee-for-service. Paperwork may be the consequence of paying doctors based on the volume of visits and procedures. Pre-authorization and retrospective utilization review, medical necessity and DME authorization forms, coding and documentation requirements - all these (and more) are designed to control "inappropriate" utilization. Paying doctors on a "bundled" or capitation basis, linked to measures of performance, could reduce the need to second-guess physicians' decisions. But physicians have been reluctant to embrace bundled payment systems and the associated financial risk it places on them.

- Standardize and simplify. Get insurers to agree to uniform credentialing, eligibility, billing and transaction systems, or require them to do so. Substitute retroactive claims review with "real time" claims adjudication. Go after and eliminate specific paperwork that does not make sense. (How about submitting insurers' utilization review to the evidence-based standards of effectiveness demanded of physicians?) It seems, though, that every time progress is made in eliminating one silly rule, another one crops up to take its place.

- Use technology. Imagine if every patient had a "smart card" that included their insurance eligibility, co-payments, deductibles, and covered benefits that could be "read" by every doctor's office? Or if all insurance transactions were billed electronically using a common platform? Or if interoperable and standardized health information technology allowed physicians, hospitals, and laboratories to seamlessly share patient information with each other, linked to patients' own personal health records?

The first two options - single payer or letting physicians and patients set their own terms - have strong proponents within the medical profession, but in my view are the least likely to be accepted by policymakers. More likely, a policy to reduce paperwork will involve alternatives to fee-for-service, standardization of insurance transactions, and health information technology.

Today's questions: Which of the above approaches do you believe would be most and least effective in reducing paperwork? Are there other options that should be entertained?

Wednesday, November 19, 2008

The worst of times for primary care?

Woody Allen once said, "More than any other time in history, mankind is at a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let's pray we have the wisdom to choose correctly."

Replace mankind with primary care and you get a good idea of how primary care doctors view their future. At least, this is the conclusion one would draw from a survey of 12,000 (mostly primary care) physicians released by the Physicians' Foundation:

- 78% believe there is a shortage of primary care doctors in the United States today.
- 49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
- 60% would not recommend medicine as a career to young people.

Other surveys show less pessimism. The Center for Studying Health System Change found that 83.6% of primary care physicians surveyed in 2004-2005 said they were somewhat or very satisfied with their careers, only marginally less than the 84.7% of specialists who said the same. (A new CSHSC survey is in the field, and it will be interesting to see if primary care physicians have grown more dissatisfied).

Still, the Physicians' Foundation survey is a wake up call. Think of the impact on access if half of the primary care physicians in the U.S. reduce the number of patients they see or stop practicing.

It may be a mistake, though, to suggest that primary care is all about gloom and doom. I don't discount the very real concerns, but do we really want to tell young doctors and medical students that primary care is a dying field?

Today, the American College of Physicians releases a new white paper to make the case for primary care. The report doesn't mince any words about the dire circumstances surrounding primary care, but makes the positive case that primary care will improve outcomes and lower the costs of care.

Will policymakers listen? Last week, Senator Baucus aptly called primary care the "keystone" of a high performing health care system and proposed to increase Medicare payment to primary care doctors. During the campaign, President-elect Obama proposed "to expand funding - including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions" for primary care.

Today may be the worst of times for primary care, but the best of times could still be ahead.

I say this not because I am hopelessly optimistic (I work in Washington, after all), but because I believe policymakers can be shown that primary care offers the best value in U.S. health care. Policies to support primary care will follow suit. Isn't this a better message to give medical students and young doctors than (only) telling them how bad things are?

Today's questions: Do you believe that this is the worst of times for primary care? Do you believe that the best of times for primary care could still be ahead?

Tuesday, November 18, 2008

Health care reform is all about affordability

When the Kaiser Family Foundation asked voters to name the top health care issue that they wanted the candidates to discuss, affordability came out as number one in its October poll. By affordability, the voters meant how they are paying for health care and health insurance.

It shouldn't come as any surprise that voters are concerned about affordability. Victoria Knight, writing in the Wall Street Journal's blog, observes that the health insurance tab is creeping toward half of family income. Susan Block reports in USA Today that the average employee's health care costs, including premiums and out-of-pocket expenses, will increase 8.9% in 2009, far outstripping wage increases and overall inflation.

Making health care affordable to individuals and families should be a goal of health care reform. But health care also needs to be affordable to the country as a whole - that is, the nation has to be able to produce enough wealth to sustain a given level of health care spending, which is not the same thing as personal affordability.

On this score, the public is unconcerned. The same Kaiser tracking poll found that only 6% of voters identified "reducing the total amount the country spends on health care" and only 7% cited "reducing spending on government programs like Medicare/Medicaid" as issues that the candidates should address.

In my mind, reducing (or at least limiting the rate of increase) in health care spending is the central issue. One could envision reforms that on paper make health care affordable to individuals, such as by capping out-of-pockets costs or premiums, but bankrupt the country in the process. In reality, the only effective way to make health care affordable is to lower health care spending.

The problem is that controlling health care costs will require trade-offs that the public seems disinclined to consider, such as restrictions on access to tests or procedures of uncertain value.

Let's not blame the voters though. Politicians haven't been profiles in courage in explaining why the country needs to reduce health care spending, and how. Nor have stakeholders - hospitals, health plans, unions, drug companies, device manufacturers, and yes, organized medicine - been rushing to say what they're willing to give up to lower spending. (Each is pretty good though at pointing out how someone else should cut their spending.)

Today's questions: What do you think can be done to make health care affordable - not only to individuals, but the country as a whole? What should physicians be willing to give to help cut spending?

Monday, November 17, 2008

The "It's a Wonderful Life" approach to "scoring" health care reform

The post-election discussion of health care reform has been focused on what the new president and Congress will do. In the shadows, though, are an unelected few with enormous influence over the outcome. Presidents and lawmakers defer to them. Get their blessing, and legislation moves forward. Earn their disapproval, and legislation stalls.

No, I am not talking about a hidden cartel of Washington insiders that secretly pull the strings. The people I am talking about work for our elected lawmakers.

The Congressional Budget Office (CBO) is a non-partisan agency, created by Congress to provide non-partisan advice on federal budget policy. One of its roles is to provide estimates to Congress on the cost (to the federal government) of proposed laws.

This is how the process works:

Proposed legislation is sent to the CBO for a "score". A "favorable score" means that CBO decides that the law will save the government more than it will cost. An "unfavorable score" means that CBO decides that the bill will cost the government more than it saves. The CBO score matters, because under "pay as you go" rules created by Congress, higher spending on entitlement programs, like Medicare, must be offset by cuts or "revenue increases" (taxes) somewhere else.

(By now, you are probably thinking that I am getting into some really arcane Washington insider stuff, but stay with me.)

The CBO was created for good reason. Members of Congress know that they can't trust themselves to honestly predict the costs of bills in which they have a vested stake. The problem is that CBO's influence is so great that good ideas often do not go forward if they receive an unfavorable score.

For example, say a member of Congress introduces legislation to increase Medicare payments to primary care physicians. If the CBO concludes that paying more for primary care will save the government more than it costs, the bill would get a favorable score and move forward. But if the CBO conservatively calculates that paying primary care doctors more will increase Medicare expenditures, the legislation will likely stall - unless Congress finds budget "offsets", such as cutting fees paid to non-primary care physicians, to pay for it (easier said than done).

The same would be true of proposals to expand coverage or make other improvements in health care delivery.

David Kendall of the Progressive Policy Institute writes that CBO's "conservative" approach to budget scoring could stymie health care reform, because CBO will be reluctant to count savings from changes in health care delivery. Without "score-able" savings from delivery system reform, there may not be enough money to cover the uninsured. As an alternative, Kendall suggests that CBO first projects the high health care spending that will occur without any delivery system reform and "if the savings from reform exceed the projections, the extra funds can be automatically applied to coverage for the uninsured."

This "It's a Wonderful Life" approach to budget scoring makes eminent sense. It wouldn't require that advocates of delivery system reform prove to the CBO that changes will lower federal spending; only that federal spending would be higher without them. It would, for instance, allow ACP to make the case to CBO that health care spending will be higher if reforms aren't enacted to increase the numbers of primary care physicians.

This is precisely what ACP plans to do. On Wednesday, we are releasing a new white paper, How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?, that makes the case that without primary care, costs will be higher and the quality of care lower. I will write more about this paper on Wednesday's blog post.

Today's questions: From your own experiences, do you think that health care spending will be higher if something isn't done to reverse the decline in the numbers of primary care physicians? Why or why not?

Friday, November 14, 2008

Who Will Guide Us Out of Health Care Turbulence?

Writing a blog at 34,000 feet, on a flight to Dallas going through an unusual bout of turbulence, is a rather disconcerting experience. The captain advises us that there is "no good air" at any elevation except 16,000 feet, but then says flying at the lower altitude would burn fuel at twice the usual rate - so we'd never get there. (He means to be reassuring, but I don't think the words "never get there" are ones that a captain should ever utter to nervous passengers!)

This reminds me of the turbulence in the U.S. health care system. We are looking to the new captain in Washington - Barack Obama - to guide us to calmer circumstances. But the U.S. health care system is burning its fuel - the dollars that businesses, government, and individuals are paying into health care - at a rate that can't be sustained.

The airplane analogy only goes so far. Our captain knew from years of experience how to get us through the bumps.

But, no president has experience with the degree of turbulence that is now unfolding in the U.S. health care system, the U.S. economy, and world financial markets.

Instead of thinking of President-elect Obama as the steady airline captain who relies on experience to guide passengers to the calm he knows is ahead, we should instead look at him as an engineer who is trying to redesign a broken heath care system before it crashes and burns.

He can't do it alone. He will have to rely on the advice and support of many to reform a health care system that costs too much, covers too few, delivers less than optimal quality, and has too few primary care doctors.

The American College of Physicians (ACP) is providing President-elect Obama and members of Congress with our ideas on building a better health care system. Earlier this year, ACP published a position paper in the Annals of Internal Medicine that compares U.S. health care to the experiences in other countries and draws lessons to guide U.S. health care policy. One of those lessons is that all high performing health care systems are based on a strong foundation of primary care, a topic that John Iglehardt writes about in today's Health Affairs blog. We also found that all effective health care systems in other countries guarantee, by law, that all residents have access to affordable coverage.

We just recently updated ACP's own proposal, called our seven year plan, on how to create a pathway to universal coverage that builds upon our current employer-based system. Next week, we will be releasing a new white paper that summarizes over 100 studies that shows that the availability of primary care is consistently associated with better outcomes and lower costs.

We also need your ideas. In each of my blog posts, I will continue to ask you for your comments on how to improve the health care system. (Thanks to the many of you who have submitted thoughtful comments on prior postings.)

Today's question: if there was a single piece of advice that you would want to give to President-elect Obama on how to steer the U.S. health care system out of turbulent times, what would it be?

Thursday, November 13, 2008

Senator Baucus' Answer to Who Should Pay for Primary Care?

Yesterday, Senator Max Baucus, chair of the Senate Finance Committee, released his plan for reforming U.S. health care. The plan offers a road map for expanding health insurance coverage and improving health care delivery--with a strong emphasis on primary care, which he calls the "keystone of a high performing health care system."

He offers several specific ideas to strengthen primary care:

* A process would be created to reduce payments for services found to be overvalued under the Medicare physician fee schedule and redistribute them to increase payments for undervalued primary care services. The paper implies that this review would take place outside the usual RVS Update Committee (RUC) process.
* Medicare payments for evaluation and management services furnished by primary care practitioners would be increased. Congress would mandate a process for identifying which specific services would qualify for the increase and criteria for determining if a practitioner is truly focused on primary care.
* Medicare's testing of the Patient-Centered Medical Home would be expanded to include more practices that are able to demonstrate that "patients truly receive the primary care and care management services that the medical home is designed to deliver."
* The Medicare sustainable growth rate (SGR) formula might be replaced with multiple expenditure targets based on sub-sets of services. The paper suggests that separate targets have the advantage of "reallocating resources from high-growth, potentially overpaid aspects of health care to underutilized, potentially more valuable services such as primary care and prevention."

The changes in physician payment will be budget neutral, meaning "that any increase to primary care providers requires a corresponding cut to specialist services." The paper acknowledges that such redistribution "has the potential to create significant controversy among physicians."

No kidding. Every effort over the past twenty years to increase payments for primary care has created enormous controversy within medicine.

Senator Baucus' paper is a powerful statement that primary care has arrived as a top concern of policymakers. But the question of "who will pay for primary care?" remains a central challenge.

Today's questions: Do you agree with Senator Baucus that primary care is the "keystone" of a high performing health care system and needs to be supported with higher fees, even if that means taking money from other specialists, including some internists? If you don't believe specialists' fees should be cut, then how would you recommend Senator Baucus and his colleagues pay for higher primary care payments--if at all?

Wednesday, November 12, 2008

Senator Baucus' health reform proposal

Another lesson from President Bill Clinton's unsuccessful effort to reform health care is that Congress needs to be involved from the beginning. The Clinton administration developed a complex bill behind closed doors and then sent it to Congress, expecting that Congress would get behind the administration's proposal. The proposal died for many reasons, but one was that key members of Congress - the chairs of the congressional committees with jurisdiction over health care - were left out.

Members of Congress are determined not to let this happen again. Early indications today are that the Obama administration may be willing to defer to Congress on the development of legislation, as long as it meets the new President's key principles and priorities.

Today, Senator Max Baucus, Democrat from Montana, released an executive summary and detailed paper on his approach to health care reform legislation (FYI the complete document is over 100 pages so readers may think twice before downloading it). His views are critically important, because he chairs the Senate committee with jurisdiction over tax legislation, Medicare, Medicaid, and SCHIP.

I will provide more commentary on the Baucus plan tomorrow. Of interest, the proposal emphasizes the need to provide coverage to all Americans, to guarantee access to preventive services, and to strengthen primary care and chronic care management. Senator Baucus calls primary care "the keystone of a high performing health system."

More on the Baucus plan in tomorrow's post.

Tuesday, November 11, 2008

Who should pay for coverage?

Health care reform will ultimately come down to one basic question:

Who should pay and how much?

Politicians would like to duck this question, of course, because the politics of requiring someone to pay more, especially if they are paying more so someone else can get care, are tough.

Realistically, the options come down to these:
-Increase taxes
-Require that employers provide coverage to their employees or pay a penalty
-Require that individuals buy coverage, if they are able to afford it
-Require that individuals contribute a share of the cost through higher premiums and cost-sharing, which could be income-based
-Pass the costs onto future taxpayers by borrowing the money and driving up the deficit.

It likely will end up being a combination of these options.

During the campaign, President-elect Obama proposed to pay for his health care proposal by repealing some of the Bush tax cuts for people with incomes above $250,000; to require "larger" employers to "pay or play"; and to mandate that parents buy coverage for their kids. Although he argued that his plan pays for itself this, this assumes cost savings from reforms, like prevention and health information technology, that may not add up in the end.

As controversial as the "who pays" issue will be, the current method of financing health care, which is largely through employee and employer contributions administered through direct contributions and deductions from wages, probably cannot be sustained.

Economist Uwe Reinhardt writes that rising health care costs will soon swamp the wages of many workers. He writes that for a family who today has an assumed gross wage base of $60,000, that gross wage might grow by 3 percent per year over the next decade, to $80,600 by 2017, while total family health spending might grow by, say, 8 percent per year over the same time frame, to $33,700 by 2017. For this worker, 41 percent of the family's gross wage base would be taken up by health care alone, before any deductions for taxes or fringe benefits.

His conclusion:
"Before long the gross wage base earned by American households will become too small a donkey to carry the load of the family's spending on health care."

This, he says, will leave the country with only two unpalatable choices: require higher income workers to pay more, or have a two tiered system where the well off get a rich package of benefits and lower wage workers get only "bare-bones" health care.

Today's questions: How do you think that affordable coverage for all can be paid for? Should higher income persons be required to pay more?

Monday, November 10, 2008

Who will pay for primary care?

Jeff Goldsmith, writing for the Health Affairs blog, proposes three health care reform scenarios that the Obama administration could pursue. One of his scenarios is to start out by laying the groundwork for improving health care delivery and putting off more controversial and costly coverage decisions to a later day:

"Obama could move aggressively and quickly to expand primary care physician payment under Medicare (through a version of the Medical Home idea), double federal funding for community health centers, and create a medical student loan forgiveness program for students entering geriatrics and primary care specialties ..."

I share Mr. Goldsmith's view that policies to rebuild the physician primary care workforce must be part of health care reform. As the Commonwealth of Massachusetts has found, giving people health coverage does not ensure access to care if there aren't enough primary care doctors around to take care of them. I am uncomfortable, though, with Mr. Goldsmith's suggestion that health coverage might be put off to another day, since primary care and health coverage are two sides of the same access coin.

Expanding and improving primary care physician payment will itself be controversial. I am writing this blog from the American Medical Association's House of Delegates meeting, where primary care and medical homes are both major topics being discussed. Many of the physicians lining up at the microphones have expressed support for primary care - as long as it doesn't involve redistribution of dollars among physicians.

It is not a good sign that some physician specialty societies already are drawing such lines in the sand.

From a political (and maybe a policy) standpoint, it would be less controversial if an Obama administration found a way to improve payments for primary care physicians without taking money from other doctors. The administration could find that there is sufficient data to conclude that higher payments for primary care and the medical home will pay for itself by reducing preventable hospital admissions paid under Medicare Part A. A portion of such Part A anticipated savings could then be used to raise primary care payments.

But what if the Congressional Budget Office isn't persuaded that primary care will pay for itself through savings in Medicare Part A? Where then will the money for primary care come from? Or what if President Obama and Congress decide that higher paid specialties should as a matter of policy and fairness give up something to raise payments for primary care?

The choice could come down to doing nothing to help primary care, or paying for primary care at least in part by redistributing dollars from higher paid specialists.

I would like to hear the views of Internal Medicine generalists and IM subpsecialists (and even from surgeons who might read this blog) on the following:

Should higher paid physician specialties be asked to give up something to increase payments for primary care? If not, then where should the money come from? Should ACP support reforms to improve payments for primary care - even if this will result in reduced payments to some IM subspecialists?

Friday, November 7, 2008

Will single payer advocates get behind Obama-style health reform?

One reason why President Bill Clinton was unsuccessful in his effort to reform health care is that although the opposition was unified, the advocates for universal coverage were split. One reform camp was willing to support a pluralistic model, as proposed by President Clinton, as long as it included guaranteed (mandated) coverage. The other insisted that a single payer plan - often described as Medicare for all - was the only acceptable outcome.

Jacob Hacker, professor of political science and resident fellow of the Institution for Social and Policy Studies, had this to say in the May-June issue of Health Affairs:

"Born in a policy hothouse, the Clinton plan wilted in the cold winds of politics."

He argues that a successful effort this time "will require updated strategies including a greater willingness to compromise on means, yet greater clarity on ends" and "serious efforts to bring on board ... reformers who support a universal Medicare plan, to provide them with the guarantees and arguments they need to embrace a less inspiring but more politically palatable approach."

President-elect Obama's health care reform proposal builds upon existing employer-based coverage provided principally by private insurers, instead of a "Medicare for All" approach. (Click on ACP's election tool for more information about the Obama plan and how it compares to ACP policies)

ACP understands why a single payer approach is appealing to some. Based on an evidence-based review of the experiences of other countries' health systems, ACP recommended that policymakers consider one or the other of two pathways to achieve universal coverage: a single payer financing model or a pluralistic model with coverage guaranteed by law. The paper notes that either have significant advantages and disadvantages that would need to be considered, but both are preferable to status quo of pluralism without universality.

The political reality, though, is that President Obama will not ask Congress to enact a single payer plan.

Today's questions: Will the "Medicare for all" camp be behind the Obama approach, even though it may be the "less inspiring but more politically palatable approach?" Or, will they hold out for a day when the political environment might allow for a single payer plan - at the risk of losing any chance for reform now?

Thursday, November 6, 2008

What do we do now to bring about health care reform?

In the closing moments of the 1992 movie The Candidate, Senator-elect McKay, played by Robert Redford, turns to his top political advisor and anxiously asks "What do we do now?" as throngs of journalists pour into his hotel room. He never receives an answer.

The same question must be going through the minds of President-elect Obama and his transition team. The President-elect must organize his administration and decide on his priorities for the first 100 days.

One of the lessons from President Bill Clinton's failed attempts to reform health care is that it must be a top legislative priority from the very beginning. The Clintons waited months before unveiling their health care reform plan, and the delay allowed their precious political capital to be consumed by other issues.

Where does health care reform fall on President-elect Obama's "to do" list?

Just four days before the election, CNN's Wolf Blitzer asked Senator Obama to rank his priorities. Senator Obama named stabilizing the economy as the top priority. "We don't know yet what's going to happen in January," Obama said. "None of this can be accomplished if we continue to see a potential meltdown in the banking system and financial system. So that's priority No. 1: making sure the plumbing works." (Could this be a job for Joe the Plumber???)

Senator Obama's priority number two was energy independence; priority number three was health care reform; tax reform/tax cuts was number four; and improving education was fifth. After naming health care reform as third, Senator Obama said this:

"I think the time is right to do it."

Voters agree. The New Health Dialogue Blog reports that a "a stunning two-thirds [of voters] expressed concern about affording health care" in exit polls taken on Tuesday and that "62 percent of respondents in that latest Kaiser tracking poll stated 'it is more important than ever to take on health care reform.' " (According to Drew Altman of the Kaiser Family Foundation, exit polls are a good indicator of whether voters have sent a message to politicians that is strong enough to create a mandate to reform health care).

The question of "What do we do now" can also be asked of health care reform advocates, like the American College of Physicians, who agree that the time is right. Just because a new President wants to reform health care doesn't mean it will happen. ACP needs to do its part so the opportunity to reform health care does not once again pass the country by.

In January, we released a candidate's pledge that described how ACP felt the candidates should shape their health care proposals, based on the College's key health reform priorities. ACP's election tool has been updated to show how President-elect Obama's positions compare to ACP's policies and priorities. Links are given to additional resources to learn more about the Obama plan.

Today's questions: Do you agree that the "time is right" to reform health care? How should ACP answer the question of "what do we do now?" to bring about health care reform?

Wednesday, November 5, 2008

The 2008 election and health care reform

There is one word in my mind that best describes the 2008 election: extraordinary.

And, I say this from a purely non-partisan standpoint. Whether one voted for Senator Obama or Senator McCain, it is undeniable that the outcome of this election is extraordinary.

That the voters elected the first African American to the Presidency of the United States is in itself an extraordinary occurrence. I will leave it to others more eloquent than me to describe what this means for the country.

Instead, I will focus on the extraordinary re-alignment of political power in Washington created by this election, and what it may mean for health care.

President-elect Barack Obama is the first Democrat to get more than 50% of the vote since Jimmy Carter. He scored the biggest Electoral College victory since Bill Clinton in 1996. He won in parts of the country - the South, the Midwest, and the Mountain states - that in the past two presidential elections were out of reach for Democratic candidates. He is the first Senator to be elected President since John F. Kennedy.

He has the political fortune of being able to work with a Congress where both chambers are controlled by his own political party. When all the votes are counted, it looks like the Democrats will gain another 20 or so seats in the House of Representatives, and another 5 to 7 seats in the Senate, leaving them just a few votes short of the 60 votes needed to overcome Senate filibusters. President Bill Clinton had similar congressional majorities in his first two years, but came to office with the decided disadvantage of having won only a plurality (43%) of the total votes cast in the election.

Few presidents have had as great an opportunity to shape the nation's politics, priorities, and policies at a time when the country is facing so many crises, both domestically and abroad.

One priority will be health care reform. Health care reform is the holy grail of the Democrats. From Harry Truman to Bill Clinton, Democratic presidents have sought to achieve universal coverage, only to find the politics and policies too difficult.

Will an Obama administration be any different? Some observers speculate that an Obama administration will back away from health care reform, because it costs too much, the deficit is too high, and there are too many competing priorities.

I disagree: President Obama and the congressional leadership will not allow the best chance in a generation to achieve lasting health care reform to pass them by.

I expect the new president and the leadership of Congress to make a push early in 2009 for comprehensive reforms to expand coverage - starting with reauthorization and expansion of the State Children's Health Insurance Program (SCHIP), which expires on March 31 - and then moving beyond that to try to enact income-based subsidies and insurance market reforms to close gaps in employer-based coverage. They will also take on Medicare physician payment reform.

Will they succeed? That depends largely on whether President-elect Obama and his congressional allies have learned the lessons from the last time the country had a serious debate over health care reform. Over the next few days I will post and invite commentary on some of those lessons, and the extraordinary opportunities and challenges health care reform poses for the American College of Physicians.

Today's question: What do you believe the 2008 election means for health care?

Tuesday, November 4, 2008

Will physicians reverse the pattern of voting at a lower rate than lawyers or the general public?

In a landmark 2007 study, ACP members David Grande, David Asch and Katrina Armstrong found that "Physicians have lower adjusted voting rates than lawyers and the general population, suggesting reduced civic participation," and that this dates back to the late 1970's (Do doctors vote? JGIM. 2007; 22: 585-9).

The authors speculate that "physicians may view their clinical work as having a greater social purpose [than voting]. As a result, civic participation might appear less important. Voting in particular may be viewed as trivial relative to the significance of physicians' daily clinical encounters."

The Physicians' Charter on Professionalism endorsed by the ACP, states that civic engagement is integral to professionalism. "Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession." [Emphasis added].

Public advocacy can involve many things, but in my mind it starts with voting.

It is understandable that some busy internists, faced with a choice between spending hours in line to vote, or devoting the same time to encounters with patients, might choose the clinical encounter over voting.

But as Drs. Grande, Asch, and Armstrong put it, "the U.S. health care system is widely recognized as plagued with major problems, including the intractable number of uninsured and thousands of associated deaths . . . As members of a profession, physicians should be participating in public affairs and contributing solutions."

I encourage our physician readers to show up at the polls today. You can help make 2008 the year that the medical profession participates in the voting process, at least to the same degree as your patients.

Today's questions: Did you vote today? Why or why not?

Tomorrow: my initial thoughts on what the election results mean for health care.

Monday, November 3, 2008

How will we know if the 2008 election created a "mandate" for health reform?

By the end of the day tomorrow, we should know who will be the new President of the United States come January 20th. We should also have a pretty good idea of how many seats the Democrats and Republicans will gain or lose in the new Congress.

How will we know, though, if the election produced a voter mandate for health care reform?

I will post some preliminary thoughts on Wednesday. It is likely, though, that it will be weeks, even months, before we know how the new President views his mandate.

Still, there are things you can be looking for tomorrow.

Drew Altman from the Kaiser Family Foundation describes the four stages of what he calls "the critical path to health reform." The first stage is the general election, for which he poses two questions:

1. Was there "a big debate on health care" that elevates the issue and engages the public?
2. If there was a big debate, do the exit polls show health care was a voting issue, sending a message to politicians that is strong enough to create a mandate?

In my view, the answer to the first question is a guarded yes. Health care reform was a major issue debated by Senators McCain and Obama. The candidates presented voters with radically different views on how to move forward.

How engaged the voters were, though, is less clear. Kaiser's own October health care tracking poll found that "the rising tsunami of economic problems swamped health care and every other issue to dominate the agenda in the weeks before the November vote. Health care remains roughly tied for second, but this ranking is somewhat misleading: it is 50 percentage points lower than the economy, as is the other former top tier issue -- Iraq."

So tomorrow, look at what the exit polls tell us about health care. Then stay tuned for the next stage in Dr. Altman's path: the new President, and whether he makes health care a priority and exercises leadership on this issue.

As the votes come in on Tuesday, post your comments on what you think the election means for health care reform. (But please, no partisan attacks on the candidate you don't like!)

Friday, October 31, 2008

The big issues the candidates are not addressing: The cost of health care

The cost of health care

Question to our readers:

What is the greatest fiscal challenge facing the United States?


Health care costs.

Many readers might be surprised by this answer, since a more obvious choice, given today's headlines, is the sub-prime mortgage and credit crisis. But rising health care costs are likely to have even more catastrophic consequences for the federal budget and the national economy.

Peter Orzag, the director of the Congressional Budget Office, a non-partisan agency that advises Congress on budget policies, had this to say:

"Rising health care costs and their consequences for Medicare and Medicaid constitute the nation's central fiscal challenge. Without changes in federal law, the government's spending on those two programs is on a path that cannot be sustained."

The CBO is concerned because the rising costs of Medicare and Medicaid will add to an explosion of federal debt and consume an ever growing share of the federal budget, leaving diminished budget resource available for other purposes. Medicare has a payroll tax structure that depends on more people paying in than taking money out, but there will be a continued decline in the number of taxpayers paying into the program and a huge increase in the number of people claiming benefits. (The Kaiser Family Foundation has an excellent chart the illustrates the problem.)

Dr. Orzag's slide presentation from a lecture he gave at Stanford University describes the problem and possible solutions. He observes that most discussions in the media misdiagnose the problem, attributing it to aging and demographics, when most of the fiscal problem is due to rising cost per beneficiary (not number or type of beneficiaries). His slides present some fascinating observations from behavioral science about the reasons for increased health care spending, including what can be learned by studies on how the size of containers affects consumption of fresh and stale popcorn (see slides 24-26)! (The popcorn slides refer to a study in the Journal of Nutrition Education and Behavior, which found that "container-size influence is so powerful that even when the popcorn was disliked, people still ate 33.6% more popcorn when eating from a large container than from a medium-size container.")

What have Senators Obama and McCain been saying about the costs of health care, and specifically, Medicare? Again, just as was the case with the primary care crisis discussed in yesterday's blog, not too much. As shown in ACP's web tool that compares the candidate's positions, they have some modest proposals to create incentives for prevention and wellness; to improve care coordination; increase transparency by reporting on quality and cost of care; to fund comparative effectiveness research; and to increase use of health information technologies. Few experts believe, though, that such measures alone will solve the problem.

Without serious policies to slow the growth in health care, the next President--particularly if he is fortunate (or unfortunate) enough to be elected to a second term--could face a "Medicare meltdown" that exceeds the challenges posed by today's economic crisis. Bailing out Wall Street is tough enough, but what will it take to bail out the almost 62 million people who will be on Medicare by 2020?

Today's questions to our readers: Do you agree with Dr. Orzag that health care spending is the greatest fiscal challenge facing the Unites States? If so, what would you recommend the new President and Congress do about it?

Thursday, October 30, 2008

The big issues the candidates are not addressing: Access to primary care

Access to primary care

Between now and Election Day, I will be inviting your comments about the big health care issues that neither Senator McCain nor Senator Obama are addressing--or at least not emphasizing in the campaign.

Today's topic: the impending collapse of primary care medicine in the United States.

In January 2006, the American College of Physicians warned that primary care was heading for collapse, citing the decline in the numbers of young physicians choosing primary care specialties like general internal medicine, and evidence that general internists were leaving the field in greater numbers than subspecialists. The paper received a lot of favorable comment, but also a fair amount of comment that the word collapse overstates the problem.

Now, few argue the point that the United States is facing a huge shortage of primary care physicians for adults. A study published in Health Affairs estimates a shortage of 35,000 to 44,000 primary care doctors for adults by 2025. The Journal of the American Medical Association reports that only two percent of fourth year medical students plan to go into general IM. The message is getting out to the broader public as well: the November Reader's Digest writes that "soaring office costs demanding insurance companies, low Medicare payments, staggering debt, and politicians who refuse to make hard choices are driving primary care physicians out of business." ACP President-elect Joe Stubbs, a general internist in Albany, Georgia, was quoted by Reader's Digest as calling the primary care issue "an evolving crisis of unprecedented proportion."

Yesterday's Washington Post reported that the experiences in the two states have guided the health care reform proposals of Senators McCain and Obama: Senator Obama has looked to the Massachusetts experience, and Senator McCain has looked to Minnesota. As the Post noted in its article, "the large number of people who have gotten insurance [under the Massachusetts plan] and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors" in the Commonwealth.

So what have the candidates said about primary care? Not too much. As ACP's comparison of the candidate's positions shows, Senator Obama's plan mentions the importance of primary care and the need to reduce medical education debt, but that is about it. Senator McCain's plan does not propose any policies to address the primary care shortage, although the GOP's convention platform mentions its belief "in the importance of primary care specialties and supporting the physician's role in the evaluation and management of disease."

The problem for the next President is in the absence of policies to reverse the collapse of primary care, access and outcomes will be poorer and costs higher. Even if the new President and Congress could agree on a plan to dramatically reduce the number of uninsured, they may find that there aren't enough primary care doctors left to take care of them, just as Massachusetts has found. Giving someone an insurance card doesn't give them access if they can't find a primary care doctor to take care of them.

Today's questions for our readers: Do you agree that primary care is nearing collapse? If so, what should the next President do about it?