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?