Wednesday, December 23, 2009

How the Grinch Stole Health Care

Tomorrow, the Senate is expected to pass its version of health care on a 60-40 party line vote. Visit our website to learn how the bill stacks up against ACP policies and to read the letter ACP sent to the Senate leadership.

Since the vote will be taking place on Christmas Eve, I have taken the liberty of borrowing from, and in the process, butchering much of the rhyme scheme, from Dr. Seuss's famous tale of the Grinch, casting the GOP in the role of doing everything it can to stop ObamaCare from coming. Please ... all of this is intended in good fun, not a partisan or political statement. I will be taking the rest of this week and next off, so I extend my best wishes to you and your loved ones for the happiest of holidays!

Every Dem
In the Senate
Wanted health care, a lot ...

But the GOP
Who sat to their right,
Did NOT!

The GOP hated ObamaCare! The whole legislative season!
Now, please don't ask why. No one quite knows the reason.
It could be their base is far to the right.
It could be, perhaps, that money is tight,
But I think that the most likely reason of all
Is Republicans like their government small.

But,
Whatever the reason,
Their base or their views,
They stood there on Christmas Eve, hating the bill,
Staring down with a sour, disapproving frown
They vowed they would slow the whole thing down.

"They're buying off votes!" they snarled with a sneer.
"Yet Obamacare is coming! It's practically here!"
Then they growled, with their fingers nervously drumming,
"We MUST find a way to keep health care from coming!"
For, tomorrow, they knew...

...The Dems in the Senate
Would wake up bright and early. And vote for the bill!
Then the Democrats, young and old, would sit down to a feast.
And they'd feast! And they'd feast!
And they'd FEAST! FEAST! FEAST! FEAST!
On taxpayers' dollars to feed the government beast
Which was something the GOP could not stand in the least!

And the more they thought of the Democrats winning,
The more they thought, "We must stop the whole thing!
Why all year long we've put up with it now!
We MUST stop ObamaCare from coming!
... But HOW?"

Then they got an idea!
An awful idea!
THE GOP
GOT A WONDERFUL, AWFUL IDEA!

"We know just what to do!" They laughed in their throat.
“We'll stop them from ever taking a vote!"
And they chuckled, and clucked, "What a great GOP trick!
We'll filibuster the bill until they grow tired and sick!

"All we need is one Democrat ..."
They looked around.
But soon discovered there was none to be found.
Did that stop the GOP...?
No! They simply said,
"We'll make them read the bill instead!"
All 2000 pages, every chapter and verse
Sitting through that ... what could possibly be worse?

Then they took to the floor, with a smile most unpleasant,
Around the whole room, and demanded all be present!
Through a snowstorm! At night! You must all be here!
No matter how late! Whether far or near!

It was quarter past dawn ...
When the reading was done
But that wasn't the end of the GOP fun
They did everything they could to bring things to a halt
While telling the public it was the Democrats fault,

"Pooh-pooh to the Dems!" they were heard to be humming.
"At this rate they'll find no ObamaCare is coming!
They're just waking up! I know just what they'll do!
Their mouths will hang open a minute or two
Then all the Dems in the Senate will all cry BOO-HOO!

"That's a noise," grinned the GOP,
"That we simply must hear!"
So they paused. And the GOP put a hand to their ears.
And they did hear a sound rising over the snow.
It started in low. Then it started to grow ...

But the sound wasn't sad!
Why, this sound sounded merry!
It couldn't be so!
But it WAS merry! VERY!

They stared down at the Democrat side
The GOP popped their eyes!
Then they shook!
What they saw was a shocking surprise!

All 60 Democrats, from big states and small,
Had voted for the bill! Reid had gotten them all!
They HADN'T stopped ObamaCare from coming!
IT CAME!
Somehow or other, it came just the same!

And the GOP with their feet ice-cold in the snow,
Stood puzzling and puzzling: "How could it be so?
It came despite death panels! And Rush and Glenn!
Despite the Tea Parties and their angry young men!"
And they puzzled three hours, 'till their puzzler was sore.
Then they thought of something they hadn't before!
"Maybe ObamaCare," they thought, "means something more.
Maybe it would help to provide coverage to even the poor."

And what happened then...?
Well ... in Washington they say
That the GOP took heart
And vowed to fight on anyway!
"We can still kill the bill, if we just do it right,
We'll do it in conference, we'll continue this fight
Next year, we promise the voters, at least

...WE OURSELVES ...!
Can still slay the ObamaCare beast!"

Today's question: How will you be spending the holidays?

Thursday, December 17, 2009

Liberals Attack "Government-Takeover" of Health Care!

The seemingly endless noise over what passes as a health care debate gets more bizarre by the day. (Yet there are still people who want to drag it on longer.) Yesterday, the self-described "Tea Party Patriots" came back to D.C. to rant again about "government take-over" of the health care system. At the same time, prominent liberals went apoplectic about the Senate bill, with former governor and DNC chair Howard Dean leading the charge.

I'm confused. If the Senate bill is a government-taker over of health care, as the Tea Party crowd says, and liberals like Dean are opposed to the Senate bill, doesn't this mean that liberals are against a government-take-over of health care?

Of course, I am being facetious. In my view, the House and Senate bills were never about a government take-over of health care, as much as many liberals have hoped and many conservatives have feared.

Both bills give private insurance companies the central role in providing health coverage. The so-called more "liberal" House bill has a public option, but it would be available only to the 30 million or so Americans who lack private coverage, and of those, the Congressional Budget Office says that only about 6 million would end up the public plan, compared to 168 million in private health insurance offered by their employers. The public option, was never going to be big enough program to have all that much of an impact on coverage, despite the over-heated rhetoric by ideologues on both sides.

Yes, both bills will expand the federal government's role by regulating and subsidizing private insurance and enrolling tens of millions of more people in Medicaid, but private insurers were always going to be the way most Americans would get their coverage, just as they are today. Conservatives can and should make the case that there is too much regulation, and liberals can and should make the case that it has too little regulation, but they should both at least stick to the facts about what the bills will and will not do.

Many liberals see things quite differently than Howard Dean. Read this from the New America Foundation, a progressive think tank, and 20 questions for the left's "Kill the Bill" crowd by Nate Silver, founder of the 538.com web site.

Columnist Ruth Marcus, writing in today's Washington Post, says it best "The bill isn't perfect, although my worries about it are more about whether it does enough to drive down costs and whether it will turn out to be affordable than about whether it gives too much to insurers. The alternative is not, as Dean would have it, starting from scratch and getting it through the Senate with 51 votes; Senate rules, for better or worse, will not let lawmakers get much done that way. The alternative is squandering this opportunity -- leaving millions of Americans uninsured and without the prospect of getting coverage far into the political future."

Today's question: What do you think about the attacks from the liberal "Kill the Bill" crowd?

Wednesday, December 16, 2009

Pushing drugs to doctors and patients

Another day has gone by without the CBO producing a "score" of the revised bill. Until it does, the Senate is unable to proceed on scheduling the first of several procedural votes needed to get the bill passed before Christmas. But, I did find a fascinating CBO report on promotional spending on prescription drugs. The CBO director's blog summarizes the highlights. Among the key findings: in 2008, spending on detailing to physicians was by far the biggest outlay of funds ($12 billion); followed in order by direct-to-consumer advertising ($4.7 billion); sponsorships of meetings and events ($3.4 billion); and advertisements in professional journals ($0.4 billion). Total promotional expenditures, "equaled 10.8 percent of the U.S. sales reported by the Pharmaceutical Research and Manufacturers of America, in line with most years since the early 1990s, during which time that share has remained between 10 percent and 12 percent."

Also of interest, according to the full report:

* The growth of pharmaceutical manufacturers' overall promotional spending has slowed from a double-digit annual pace in 2003 and 2004 to a rate that is close to zero. That slowdown is probably related, at least in part, to the decline in the number of new drugs that have received FDA approval since 2000.
* In the second half of the 1990s, the FDA approved an unusually large number of drugs, some of which were the first on the market to treat certain conditions and a number of which treat widespread conditions. Not only are fewer new drugs being approved of late, but more drugs also face competition from generic versions. Those factors may be particularly important in explaining declining spending on DTC advertising, which peaked at $5.2 billion in 2006, because pharmaceutical manufacturers tend to use more DTC advertising for drugs that have especially broad potential markets, drugs with few or no substitutes, or drugs with some combination of those characteristics.
* Of the more than 2,000 drugs included in CBO's data set, 700 to 800 have some promotional spending reported in any given year. For nearly all of those drugs, some spending on detailing was recorded. However, manufacturers purchased DTC advertisements for fewer than 100 of those drugs in each of the years since 1995, the year the data set begins to encompass DTC advertising, making DTC advertising the least frequently used form of drug promotion . . . . Journal ads and professional meetings are used to promote fewer drugs than detailing but more drugs than DTC advertising.

As someone who watches a lot of sports broadcasts -- and with them, way too may ads for ED -- I was frankly surprised that DTC is "the least frequently used form of drug promotion." Most of the money is still being spent the way it always has: to influence physicians and clinicians to prescribe a particular drug product.

The CBO reports a relationship between promotion to physicians and advertising to consumers: "When pharmaceutical manufacturers promoted drugs to consumers, they also spent more, on average, promoting those drugs to physicians. For those drugs in CBO's data set with reported spending on DTC advertising, their manufacturers spent an average of $40.5 million per drug in 2008 on promotional activities directed to physicians -- 14 times the average amount they spent when promoting drugs exclusively to physicians That difference may indicate that manufacturers use promotional activities directed to physicians and DTC advertising to reinforce each other."

The relationship between money spent to persuade consumers to ask for new drugs, and for doctors to prescribe them, will continue to be scrutinized by policymakers. (For relevant ACP policy, see our policy paper on direct-to-consumer advertising and our ethics resources about physician industry relations.) The CBO report makes an important contribution in increasing understanding of how and why the dollars flow where they do.

Today's questions. Why do you think drug companies still spend most of the money on promoting their products directly to physicians? What are your own policies on engaging with drug company sales persons?

Tuesday, December 15, 2009

Waiting for Godot (a.k.a. Senator Joe)

With apologies to Samuel Beckett, I take the liberty of adapting lines from his great play, "Waiting for Godot," to describe how President Obama and Majority Leader Reid must be talking about Joe Lieberman:

Obama: Let's go.
Reid: We can't.
Obama: Why not?
Reid: We're waiting for Senator Joe.
Obama: (despairingly) Ah!

Later:

Page: (in a rush) Senator Joe told me to tell you he won't come this evening but surely tomorrow.
Obama: Well, shall we go?
Reid: Yes, let's go. (They do not move.)

In the week since the Democrats announced a tentative deal on a compromise on the public plan option, President Obama and Majority Leader Reid have been waiting for Senator Joe Lieberman (I-CT) to inform them if he will give them the 60th vote needed to overcome a Republican filibuster. This, plus the wait to get a new estimate from the Congressional Budget Office. They need and want to go to the next step, but they dare not move.

The Washington Post reports that Senator Joe is "warming" to the bill, now that Senator Reid has agreed to drop any form of the public plan and a Medicare buy-in. This is what Senator Joe had to say:

"We've got a great health insurance reform bill here. And the danger was that some of my colleagues, I think, were just trying to load it up with too much. And what happens then is that you run the risk of losing everything. So I think what's beginning to emerge -- though I know some people are not happy about it -- is really a historic achievement, health care reform such as we've not seen in this country for decades."

This doesn't mean the bill it out of the woods yet. Lieberman's statement stopped short of the unequivocal "I now promise that I will vote for the bill" commitment that Reid and Obama want. There are still a few other uncommitted Democrats that Reid needs -- most notably, Ben Nelson of Nebraska, who has threatened to vote with the GOP to filibuster bill if language on abortion coverage is not changed to his liking. And the Democrats hold out some hope that Republican Olympia Snow (R-ME) will vote with them.

The problem for the Democrats is that Reid must file the first procedural cloture vote no later than Thursday, if he has any hope of getting it passed by Christmas.

The death of the public option has angered many progressives. But a bill that would expand coverage to 94% of all legal residents, begin to bend the cost curve, and regulate insurance industry practices that deny access to needed care still has a lot to say for it. We'll find out in the next 48 hours if 60 members of the U.S. Senate agree.

Today's question: What do you think of the decision to drop the public option and Medicare buy-in to win the vote of Senator Joe and other uncommitted Democrats?

Monday, December 14, 2009

Should federal spending and taxes be taken away from Congress?

The Senate debate on health care reform is on hold until the Congressional Budget Office (CBO) produces a "score" (estimate) of the impact of a compromise negotiated between Democratic centrists and liberals. The new score will update a previous CBO analysis, which estimated the Senate bill "would yield a net reduction in federal deficits of $130 billion over the 2010-2019 period" and "small" reductions over the next decade. The CBO has estimated that the House-passed bill will reduce deficits by about $102 billion over the 2010-2019 period, and continue to have a modest positive impact on deficits in the next ten years.

Some believe that the CBO under-states the cost-saving. David Cutler and Commonwealth Fund President Karen Davis argue the bills will have a much greater impact because "an aggressive approach to health care modernization could result in significantly greater cost reductions." President Obama's Council of Economic Advisers (CEA) has issued a new report that concludes, "The [House and Senate health reform] bills would also significantly lower the Federal budget deficit in the upcoming decade, and extend the solvency of the Medicare Trust Fund by five years."

Robert Samuelson, writing in yesterday's Washington Post, disagrees. He believes that the bills will increase national health care spending and make the deficit worse, in part because he is skeptical that Congress has the will to allow the intended savings to go into effect.

Skepticism about Congress' ability to make tough choices isn't limited to critics of President Obama's health reform initiative. The President's economic advisers tout the benefits of having an Independent Medicare Advisory Board, as proposed by the Senate bill, which "would recommend changes to the Medicare program that would both improve the quality of care and also reduce the growth rate of program spending . . . Absent Congressional action, these recommendations would be automatically implemented."

And today, The Peterson-Pew Commission on Budget Reform issued a report that "calls on policy makers to enact both spending cuts and tax increases to shift our nation's fiscal course." This bipartisan group, headed by former members of Congress, recommends that the White House and Congress adopt a target to reduce the public debt to 60 percent of GDP by 2018; negotiate a specific package of spending reductions and tax increases that are gradually phased in to protect the recovering economy; and create an automatic enforcement mechanism that would require that "any breach of the target would be offset through automatic spending reductions and tax increases . . . [applied] equally to spending and revenue."

I understand the rationale of taking decisions on spending cuts and tax increases away from Congress. Politicians have shown themselves to be chronically incapable of voting for unpopular tax increases and spending cuts.

But I am uneasy about turning over the "power of the purse," which our founding fathers gave exclusively to the people whom the voters elect to Congress, to an unelected commission - or to a process to impose cuts and tax increases automatically if a target is breached. We tried that with the SGR - which triggers cuts in payments to physicians when the SGR target is breached - and we all know how that worked out.

Today's question: What do you think about taking the decisions needed to bring federal spending and revenue into line away from Congress?

Thursday, December 10, 2009

Poor Grandma!

The news that Senate Democrats may have reached a tentative deal on a substitute for the public option has lead to another round of rhetoric about what will happen to poor old Grandma.

The proposal reportedly includes a new national network of private health insurers administered by the federal government and a Medicare buy-in for people 55 to 65 who don't have employer coverage. Details about the proposal are few, and key Senators are reserving judgment until the Congressional Budget Office comes back with a new estimate of its impact on the budget.

Still, the lack of details hasn't stopped people from staking out a strong position against the proposal, and especially against the Medicare buy-in. As reported in The Hill blog, Senator Chuck Grassley (R-IO), the ranking Republican on the Senate Finance Committee, opposes the Medicare buy-in because "The last thing you want to think about when the Titanic is sinking [is to] put grandma and more of your family on the boat." (Medicare is taking on the role of the Titanic, I presume.) Last week, Senate critics repeatedly made a similar argument that Grandma would suffer as a result of proposed Medicare cuts in the bill. (Given the average age of U.S. Senators, I would think that their own grandmas would be well over 100 years old, but that is another matter.)

The ACP has not yet taken a position on the public option compromise and the Medicare buy-in, because we would like to see the details before deciding. It is a complicated issue, and accordingly, deserves a thorough understanding of what is being proposed. But I would suggest that there is fundamental illogic to a key argument being made by critics. The argument goes like this:

Medicare is going broke. Therefore, cutting Medicare is wrong because it takes money from a program already facing bankruptcy. Therefore, adding people 55-65 to the program will further accelerate Medicare's demise.

The first statement is true - Medicare Part A is estimated to run out of money by 2012.

The second statement makes no sense. The Medicare cuts (which for the most come from reductions in the rate of payment increases to non-physician providers) in the Senate bill will mean that almost a half a trillion fewer dollars will flow out of the program over the next decade, delaying by years the date when the trust fund will run out of money. As any family knows, if you currently are spending more than you are taking in, and then you start to spend less, your money lasts longer.

The third statement might be true, but then again, it might not. Allowing some people 55 to 65 to buy into Medicare, out of their own premium dollars, would have no impact on the solvency of the rest of the program, if the premiums collected are high enough to cover the costs for this age group and the funds are segregated from the rest of Medicare. If people aged 55 to 65 have lower annual health care costs than those 65 and older, and if their contributions are intermingled with the rest of Medicare, they could actually help the solvency of the rest of Medicare, since it would spread risk more broadly among a healthier beneficiary population. If the Medicare buy-in attracts a sicker group of 55 to 65 year olds and the premiums collected from them are too low, it could hurt the solvency of the rest of the program by drawing funds out of the other trust funds to make up the shortfall.

Beyond the issue of whether the buy-in will help or hurt Medicare's solvency, there is a real concern about the impact on physicians and hospitals of having more patients paid under the discounted Medicare rates. Even here, though, much would depend on whether the buy-in would be open only to people 55-65 who don't have health insurance coverage through an employer or retiree plan, or to all people 55 and older. If the former, the number of people added to Medicare would be relatively modest, and doctors and hospitals would at least be sure of getting Medicare rates for care that they may now be providing on an uncompensated and charitable basis. If the latter, it likely would have a big adverse impact on the bottom line.

I am not suggesting that the current Medicare buy-in proposal is one that the ACP should support, but it deserves a serious analysis - not a knee-jerk response - once we know the actual details. I do know that the argument that taking money out of Medicare will accelerate its insolvency, as the Senate and House bills would do to help pay for health reform, makes no sense, since it will do the opposite and extend the life of the trust fund. It remains to be seen if allowing some people 55-65 to buy Medicare coverage will help or hurt Medicare's fiscal outlook, and what it will do to the "bottom-line" for physicians and hospitals.

Today's questions: What effect do you think the Medicare cuts in the health reform bills will have on Grandma? What about a Medicare buy-in for people 55 to 65?

Monday, December 7, 2009

New member survey shows broad support for ACP's views on health reform

Some internists who disagree with the ACP positions on health reform assert that we should survey membership before taking a position. They assume that a survey would show that most other ACP members share their opposition to policies advocated by the College.

ACP does not develop policies based on an opinion survey. Instead, as my colleague Jack Ginsburg wrote on this blog several months ago, we develop policy through a consensus process that involves the hundreds of internists and medical student members who sit on the College's committees, councils, Board of Governors, and Board of Regents. As we develop policy, we conduct a review of the evidence, and seek external review by outside experts, consumers, business leaders, and stakeholders.

Such a deliberative process, I believe, results in policies that are more thoughtful, nuanced, credible and evidence-based than if we made our decisions based on an opinion poll, yet they should lead to positions that most members would support.

Surveys are not the best way to make policy, but they can be useful in quantifying member opinions at a given point in time. In October and November, ACP's Research Center fielded a web survey of a random sample of 2,000 U.S. non-student, non-retired, current ACP members ages 65 and younger. It received 290 responses, a 15% response rate and a margin of error of plus or minus 8%. The number-crunchers on the research staff did not find any evident respondent bias, with the demographic and practice characteristics of the respondents generally mirroring those of the 2009 ACP Membership Survey, which had a higher response rate.

Below are the key findings from the Research Center's report:

"11% of respondents are very or extremely familiar with ACP's position on health reform, 59% are somewhat or moderately familiar, and 30% are not at all familiar. 59% of respondents are somewhat or very satisfied with ACP's position on health reform, 16% are neither satisfied nor dissatisfied, 14% are somewhat or very dissatisfied, and 11% are uncertain about their level of satisfaction."

"Respondents were asked whether or not ACP should support twelve different positions for achieving health reform. There was heavy support (over 85% of respondents) for the following five proposals:
- Health reform must include reforms in the medical liability system in order to be effective in controlling costs (93.5%).
- Individuals and small businesses should be able to have a choice of affordable plans through a purchasing pool (exchange) that gives them the same ability as larger companies to get the best group rates (93.5%).
- Insurance companies should not be allowed to turn away patients because they have medical conditions (90.2%).
- All legal residents should have access to affordable health insurance and financial help, when they can't afford it (85.7%). This is in line with data from the 2009 Member Survey (conducted before the executive and legislative branches began to debate health care reform), which show that 71% of members believe 'guaranteeing by law that all Americans have access to affordable coverage, with government subsidies for those who cannot afford coverage' should be given somewhat high (22%) or very high (49%) priority on ACP's advocacy agenda.
- The federal government should create incentives to encourage medical students and young doctors to go into primary care internal medicine (85.5%).This is in line with data from the 2009 Member Survey, which show that 84% of members believe 'policies to increase the number of general internists and other primary care physicians including improved reimbursement and loan forgiveness' should be given somewhat high (28%) or very high (56%) priority on ACP's advocacy agenda.

There was moderate support (between 50% and 85% of respondents) for the following five proposals:
- Insurance companies should be required to cover evidence-based practices that have been shown to prevent disease, as well as screening tests that detect diseases at no out-of-pocket cost to the patient (79.3%).
- Larger employers (defined by such factors as number of employees and payroll) should be required to offer health insurance to employees or pay into a fund to help pay for coverage for their employees (71.8%).
- All Americans should be required to buy health care coverage, as long as there are federal subsidies to make coverage available for those who can't otherwise afford it (65.1%).
- A public plan option should be available to compete with private health insurance plans on a level playing field as long as it has competitive payment rates and participation isn't mandated (63.7%).
-Insurance companies should not be allowed to charge patients more because they have medical conditions (61.8%)

The proportions of respondents who support the final two proposals reflect the fact that the proposals are correlates:
- The federal government should increase Medicare payments to primary care physicians even if this would result in lower pay for other specialties (66.5%).
- The federal government should increase Medicare payments to primary care physicians only if it does not involve reductions to other specialists (30.6%).

There were no differences in the proportion of respondents from different age, primary professional activity and practice size groups in their support for the twelve specific positions on reform ... A higher proportion of general internists (91%) than subspecialists (51%) feel ACP should advocate for the federal government to increase Medicare payments to primary care physicians even if this would result in lower pay for other subspecialties." (ACP has expressed a strong preference for increases for primary care to be funded in a way that does not cause budget neutral cuts to other subspecialists.)

As a very high level survey on broad priorities advocated by ACP (they weren't told what ACP's position was on each), the survey doesn't tell about the questions that weren't asked, like their opinion on raising taxes or the impact on the deficit. Still, it is reassuring to me that large majorities of ACP members support the College's priorities and positions on even on the most controversial issues - like individual and employer mandates, subsidies for health insurance, health exchanges, higher fees for primary care, and the public plan option - that are addressed by the pending House and Senate bills.

Today's question: What do you think the member survey tells us about ACP's advocacy agenda?

Friday, December 4, 2009

Physician organizations split (again) on health care reform

During the past few days, organized medicine has lived up to its reputation as being anything but organized.

As reported by Jacob Goldstein in his Wall Street Journal health blog, several large physician membership organizations, have come out squarely "opposed" to the Senate bill. The opposition is being led by the American College of Surgeons and 19 surgical specialty societies. Goldstein characterizes the American Medical Association as taking a "middle ground" approach.

What is the basis given by the opposition physician groups? It is not over the big philosophical and ideological issues - like the debate over the "public plan" or the role of government or tax increases or deficits and debt. Instead, the surgeons' opposition is focused principally on issues of payment issues, and particularly, changes that could cause redistribution of dollars among and across physician specialties. Among the policies behind the surgeons' opposition, according to the ACS letter, are:

"Establishment and proposed implementation of an Independent Medicare Advisory Board whose recommendations could become law without congressional action;
- Mandatory participation in a seriously flawed Physician Quality Reporting Initiative (PQRI)program with penalties for non-participation;
- Budget-neutral bonus payments to primary care physicians and rural general surgeons."

(The latter has to do with a 10% increase in Medicare payments for designated services by primary care physicians, and for general surgeons in health professional shortage areas only, half of which would be funded by a one-half-of-one-percent decrease in payments for all other physician services.)

Today, the American College of Physicians sent its own letter to the Senate. Like the ACP has done throughout the legislative process, we determine our positions on the bills based on how closely they meet key ACP priorities and policies. ACP's letter noted that the Senate bill includes important and essential reforms that overall are consistent with ACP, citing provisions in the bill that would expand access to 94% of all legal U.S. residents, train more primary care physicians, reduce student debt for physicians who go into primary care, increase Medicare primary care payments, and accelerate the adoption of new payment and delivery models, like the Patient-Centered Medical Home. ACP also expressed "significant concerns" about other provisions. Some of ACP's concerns, like opposition to penalizing physicians with pay cuts for not reporting on quality measures, are similar to the concerns of the surgeons. But on other issues, like the independent Medicare Commission, ACP recommended ways to improve the provision by adding more safeguards, rather than coming out in opposition to the whole bill.

The surgeons have said that they support the House health reform bill, and that "While we must oppose the Patient Protection and Affordable Care Act as currently written, the surgical coalition is committed to the passage of meaningful and comprehensive health care reform that is in the best interest of our patients."

The problem, though, is that if physician opposition denies the bill the 60 votes needed to pass, it is "game over" for health care reform. Not just now, but for a very long time. Paul Krugman writes in the New York Times if the Senate bill fails "it would be a long time before anyone was willing to take on the challenge again; remember that after the failure of the Clinton effort, it was 16 years before the next try at health reform."

On the basic question of whether the country would be better or worse off if health reform fails, ACP's view is that the country will be better off if Congress passes legislation to provide affordable coverage to all Americans, expand the primary care workforce, and improve payment and delivery, even as we seek changes in positions we don't like. Opposition to the Senate bill by some physicians could kill health care reform, and with it, the best chance in a generation to put health care on a sustainable path.

Today's question: What is your view of the different approaches taken by physician groups to the Senate bill?

Wednesday, December 2, 2009

The Politicization of Breast Cancer Screening

I just returned from a hearing of the House Energy and Commerce Committee's health subcommittee on the U.S. Preventive Services Task Force (USPSTF) breast cancer screening guidelines. Donna Sweet, MD, MACP, a general internist and HIV/AIDS specialist from Wichita, Kansas, testified on ACP's behalf. Dr. Sweet is a past chair of the ACP Board of Regents and a member of the College's Clinical Efficacy Assessment Subcommittee (CEAS), which has responsibility for developing the ACP's evidence-based clinical guidelines.

The first several hours of the hearing--and much of the grilling from the subcommittee members--were concentrated at chair and vice chair of the U.S. Preventive Task Force. The Task Force witnesses agreed that they could have done a better job in communicating the revised screening recommendations to the public but stood their ground on the evidence behind the recommendations. The USPSTF witnesses also made the point that breast cancer screening recommendations were voted on and approved late last year, before the Obama administration took office, so the politics of health reform had no role in their deliberations.

This didn't stop the politicians, though, from introducing politics into the USPSTF's recommendations. The headline from Reuter's says it all: "U.S. debate over mammograms splits along party lines."

Who knew that there was a Republican and Democratic view on the value of breast cancer screening? But in today's hyper-partisan and polarized politics, there is no issue that won't be used to divide the voters. Republicans argued that the USPSTF's recommendations were driven by a desire to cut costs - a charge that the USPSTF's witnesses steadfastly denied. (Fact check: the Agency for Health Care Research and Quality website specifically states that "economic costs" are never a consideration in the USPSTF's recommendations.) Republicans also argued that the House and Senate health reform bills would prohibit health insurers from offering prevention benefits that have not received an A or B evidence rating from the USPSTF, ultimately leading to U.K-style rationing. Democrats argued that the recommendations from the USPSTF would set a floor - not a limit - on the preventive services that insurers would have to cover. Both sides accused the other of mis-representing the truth.

ACP's own reading of the bills is that the Task Force's recommendations would improve access to evidence-based preventive services by establishing a floor, not a ceiling on benefits. On this point, ACP, the American Cancer Society, the National Breast Cancer Coalition, and the Susan Susan G. Komen for the Cure Advocacy Alliance all were in agreement.

Why did ACP wade into this fight? Well, for one thing, the USPSTF recommendations were published in our own Annals of Internal Medicine website. For another, in 2007, ACP issued its own guideline on screening mammography for women between the ages of 40 and 49, which recommended that clinicians and patients conduct an individualized risk assessment, discuss the risks and benefits of mammograms for this age group, and make their own judgment. But the biggest reason is that ACP believes that the politicization of evidence-based medicine is not in the public's interest.

This is what Dr. Sweet had to say:

"One lesson is that the public is ill-served when assessments of clinical effectiveness are politicized. For clinicians and patients alike to have confidence in the evidence, we need to know that it has been developed through a process that is independent of political pressure.
...Politicization [of evidence-based assessments], if left unchallenged ... could result in politically-driven changes so that future evaluations are influenced by political or stakeholder interests - instead of science."

Harold Pollack, writing in The New Republic blog, gives ACP high marks for its advocacy. Calling ACP "one of America's most respected medical organizations," he goes on to say this about ACP's stand against the politicization of evidence-based research:

"In its own wonky way, within an often-disheartening health policy debate, that's Change We Can Believe In."

Today's question: What do you think about the ACP's stand on the politicization of evidence-based clinical research?

Tuesday, November 24, 2009

Emptying the cost control tool kit

Imagine that it is 2013, and a new President is sitting in the Oval Office. (If you prefer, imagine it is 2017, and we have a new President.) To make things interesting, let's imagine that the new President is a Republican. Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs. To make things even more interesting, let's imagine that the Obama administration was able to get a substantial expansion of health insurance coverage enacted into law, but that most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.

What is a new President to do?

Because the most promising approaches to gradually "bend the cost curve" - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out the health reform bills, the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke? You either incur the wrath of the largest generation in history - the tens of millions of boomers who now depend on Medicare - or the younger tax payers who will be called upon to bail out the program.

(If you prefer, you can run a similar scenario with another Democrat President - only in this case, the most likely option is that the new President would propose a complete, U.K. style take-over of the health care system, to give the government all the regulatory levers it needs to control costs.)

These scenarios are very real if the critics of the cost controls in the current health reform bills have their way. Right now, notwithstanding the oft-repeated charge that the House and Senate bills "do nothing" to control costs, Marc Aminder writes in The Atlantic that the cost-benders in the legislation are getting praise from well-respected economists, Republican and Democratic alike.

But the same cost-benders are under unrelenting attack.

John Wennberg and Shannon Brownlee blog in Health Affairs about the efforts by some academic medical centers and hospitals to discredit and explain away Dartmouth Atlas data on regional variations in quality and cost. They fear that the research will lead to policies to reduce such variation, at their institutions' expense. Some physician membership organizations are flatly opposed to any policies that would redistribute payments among physicians based on efficiency and outcomes of care, specialty, or any other criteria, for that matter. They also don't like the idea of an independent commission to develop recommendations to control costs under a fast-track legislative review process. The end-of-life counseling in the House bill has been falsely labeled as leading to death panels. Research on the comparative effectiveness of different treatments has been called rationing of care. A public option is called socialized medicine. Even the medical home, which was developed by physician membership organizations, is labeled as this decade's version of HMO-style limits on care.

My point is that the politicians and interest groups who criticize these and other cost-benders may find that if they succeed in emptying the toolkit of the most promising approaches to gradually slow the cost curve and improve outcomes, they may leave a future President and Congress with nothing but draconian and enormously unpopular cuts in benefits and provider payments, tax increases, or the much-feared government take-over of health care. And it could be their guy and their party who will be in charge when the day of reckoning arrives.

(Oh, and by the way, Happy Thanksgiving to you and your loved ones!)

Today's question: What do you think about the above scenario? And what is your favorite Thanksgiving dish?

Thursday, November 19, 2009

A good (and not so good) day for health reform

Yesterday's unveiling of the revised Senate bill on health reform ordinarily would have constituted a good day for health reform, moving the ball yet another few yards closer to the goalposts. The Washington Post reports that Senate Democrats were "jubilant" that the CBO estimates that the new bill will reduce the deficit by $130 billion over the next decade while providing coverage to 94% of uninsured legal residents. Majority Leader Harry Reid (D-NV) plans to bring the bill to the Senate floor on Saturday for a procedural vote, requiring 60 votes, to halt a GOP filibuster and to allow debate on the bill itself. A final vote, which would require getting 60 votes to overcome more procedural hurdles, likely will not take place until December. ACP is in the process of analyzing the bill compared to policy, so I will have more to say about it in a future blog post, and we also will post updated information on www.acponline.org/advocacy.

At the same time as Democrats were celebrating the release of the Senate bill, the flap over the new mammography guidelines from the U.S. Preventive Services Task Force (USPSTF), published in ACP's own Annals of Internal Medicine threatened to undermine public support for health reform. Now, I am a health policy wonk, not a clinician, and have absolutely no opinion on the guidelines themselves, but I can comment on the political fallout from the guidelines.

In one sense, the mammography guidelines have absolutely nothing to do with health reform. They were in the works long before the current administration took office, they would have come out even if health reform was not on the national agenda, and the guidelines themselves are purely advisory.

But in another sense, they have everything to do with health reform. The House and Senate health reform bills would require that health insurers provide coverage for preventive services recommended by the USPSTF - although insurers would be allowed to offer additional benefits. The Chicago Tribune notes that research on comparative effectiveness is a "central idea in the push to improve American medical care and control its cost: experts studying the effectiveness of treatments and procedures to determine which work best."

KevinMD opines that health reformers should be very worried about what the backlash to the guidelines means for the future of comparative effectiveness research: "If recommendations from an entity like the USPSTF - as non-partisan and robust as it gets - gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."

NPR reports that Republican opponents of the Democratic bills have used the controversy over the guidelines to argue that it will lead to rationing and "the insidious encroachment of government between the patient and their doctor" according to Rep. David Camp (R-MI). (Notwithstanding the fact that under the bills, the USPSTF's recommendations would still be advisory, or that the independent scientists on the USPSTF are hardly government bureaucrats.) Seeing the threat being created by the backlash, and fearing that the GOP criticisms will resonate with votes, the Obama administration distanced itself from the USPSTF guidelines in a statement attributed to HHS Secretary Kathleen Sebelius.

All of this goes to show why reforming the health care system is so difficult. Scientists would like to believe that we people can rationally make health care decisions based purely on science and evidence. But health care is very personal and emotional, and even the best science will be rejected if people sense that it will take decision-making away from them or limit their choices. And if taxpayers are going to subsidize coverage, decisions will have to be made on what services will be covered, and as this incident shows, such decisions will not come without generating intense debate and opposition.

Today's question: What do you think the flap over the mammography guidelines means for health reform?

Wednesday, November 18, 2009

How important is it really to provide health coverage to all?

Many issues relating to health reform are creating deep divisions among Americans, including taxes, mandates, and the public plan option. Yet I had assumed that there was a general consensus that everyone should have access to affordable coverage, and the disagreement was mostly over how to achieve it, not whether this should be a major objective.

I was wrong: many critics of the current effort believe that covering everyone is not all that important, at least when compared to other priorities.

For instance, the House GOP's health reform proposal, according to the Congressional Budget Office, would reduce "the number of nonelderly people without health insurance by about 3 million in 2019 and leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019 - 83 percent - would be roughly in line with the current share." Instead, the GOP plan focuses more on providing more (and less costly) coverage options for people who already have health insurance.

In a recent Washington Post column, Robert Samuelson makes the case why providing health insurance to everyone is less important than keeping government spending under control:

" . . almost everyone thinks that people in need of essential medical care should get it; ideally, everyone would have health insurance. The pursuit of these worthy goals can easily be projected as a high-minded exercise for the public good. It's false for two reasons. First, the country has other goals - including preventing financial crises and minimizing the crushing effects of high deficits or taxes on the economy and younger Americans -- that 'health-care reform' would jeopardize. And second, the benefits of 'reform' are exaggerated. Sure, many Americans would feel less fearful about losing insurance; but there are cheaper ways to limit insecurity."

Is Samuelson right that the issue is mostly about reducing "insecurity?" For many of the uninsured, it is much more than that. According to a new Harvard study, people without health insurance are 40 percent higher risk of death than those with health insurance, and 45,000 Americans of them die each year as a consequence. Similarly, in 2002, the Institute of Medicine found people without health insurance are more likely to suffer poor health and die prematurely. And in 2008, the Urban Institute updated the IOM report and estimated that 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.

Providing all Americans with access to affordable health insurance coverage is a top priority for the American College of Physicians, and one of the many reasons why the College has expressed support for many of the key policies in H.R. 3962.

I am ambivalent about the question of whether health care is a right, but I firmly believe, as does the ACP, that covering everyone is the right thing to do. I don't disagree that the country has other important goals, as Samuelson argues, like minimizing crushing deficits. But if the annual death toll of not having coverage is akin to the total U.S. deaths suffered during the Vietnam War, how can preventing such deaths not be an essential purpose of health reform?

Today's questions: Do you believe that uninsured people are more likely to die prematurely? Do you believe that providing all Americans with health coverage should be an essential purpose of health reform?

Monday, November 16, 2009

How the critics' lies are making it harder to control health care costs

An op-ed by Rep. Earl Blumenauer (D-OR) in yesterday's New York Times is a "must read" account for anyone who wants to understand why the health care reform bills don't do more to control health care costs. He writes about how an eminently sensible, modest (and bipartisan!) provision to reimburse physicians for discussing advance directives with their patients became fodder for critics who willfully distorted the proposal as creating "death panels" that would pull the plug on grandma.

One of the principal villains in Rep. Blumenauer's story is Betsy McCaughey, former Lieutenant Governor of New York, now with the Hudson Institute, who first made the claim that "would make it mandatory, absolutely require, that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." Her statement was immediately disproven by respected and independent fact-checking organizations, including the Pulitzer-prize winning PolitiFact.com and Factcheck.org, but this didn't stop her lie from becoming a staple of the attacks on the bill.

McCaughey is at it again: in a November 7 Wall Street Journal op-ed she makes so many false or misleading claims about H.R. 3962 that it is almost impossible to keep up with them all, but one is of particular concern to ACP. Citing a provision that would fund Medicare pilots of the patient-centered medical home, she opines that "the medical home is this decade's version of HMO-restrictions on care." She never bothered to check with ACP, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association - the four organizations who authored the joint principles on the medical home, and who have called for the health reform bills to include expanded testing of the model - before making this ill-informed and misleading claim.

Blumenauer's account explains why the willingness of some critics to say anything to scare the public - what is more scary than putting old people to death? - is denying the American people a serious debate about how best to control health care costs. Many of the critics like to have it both ways: decry the lack of cost controls in the bill, and then do everything possible to undermine public backing when ideas are proposed to lower costs. Even ideas that the medical profession itself has championed and that have had strong bipartisan support in Congress - advance directives, care coordination in a medical home, and research on comparative effectiveness - become branded as government rationing.

It shouldn't be surprising then that the health reform bills don't do enough to control costs, but that they do so much, despite the attacks and falsehoods. John Iglehart writes in the New England Journal of Medicine that "the bills contain no shortage of ideas for reforming the delivery system, enhancing the quality of care, and slowing spending. Pretty much every proposed innovation found in the health policy literature these days is encapsulated in the measures."

Could the bills do more to control costs? Sure, but I don't see that happening as long as the Betsy McCaughey's of the world - and politicians who echo them - are willing to make truth a casualty in their battle to stop the health reform bills from becoming law.

Today's question: What is your reaction to Rep. Blumenauer's story and what it bodes for health reform?

Tuesday, November 10, 2009

AMA reaffirms support for health reform -- with caveats

Late Monday, the AMA House of Delegates rejected, by an overwhelming majority of 350-167, efforts by dissident delegates to put the organization on record as not endorsing H.R. 3962. (The Associated Press/Washington Post has a good story on the organization's deliberations).

The House of Delegates did, however, pass a number of policies that require that the AMA Board of Trustees "oppose inclusion" of cost controls in the Senate Finance Committee bill that would result in redistribution of payments among physicians. With these actions, and the AMA's previous letter of support for H.R. 3926, the AMA effectively (and perhaps ironically) has allied itself with the House-passed bill, which some analysts label as the more "liberal" of the bills because it spends substantially more money than the Senate Finance bill. Among the policies opposed by the AMA are redistributing payments to physicians based on their outcomes and efficiency, redistributing payments from some specialties to increase payments for other (read primary care) specialties, penalizing physicians who do not successfully report on quality measures, and creation of a Medicare commission that would recommend and implement changes in payment and delivery systems to achieve specific savings unless Congress enacted an alternative. Many of the policies opposed by the AMA are the same as those opposed by a coalition of surgical specialty societies. Unlike the surgeons' letter, though, the AMA House action doesn't commit the AMA to opposing a Senate bill that includes such policies, only to advocate that they not be included. It will be interesting to see what the AMA will do, though, if the Senate bill ends up including many of the policies that the House of Delegates has directed it to oppose.

ACP shares some of the concerns about the provisions in the Senate Finance bill, but we have also noted the many policies we support and proposed alternatives -- such as more safeguards over the Medicare Commission -- rather than flatly opposing it.

Whether health reform legislation gets passed or not (and I still think it has a better chance of getting passed), it seems to me that policymakers, both within and outside of government, will insist on changes in payment systems to align incentives with the value of care being provided, which means that there will be redistribution among physicians and specialties depending on the value of the care provided. Just opposing such changes will not be effective if physicians want to influence their design.

Today's questions: Do you believe that organized medicine should oppose efforts to redistribute payments among physicians based on quality, outcomes, and efficiency? Or from other specialists to primary care?

Monday, November 9, 2009

Tap-dancing through a minefield

I write today's blog from the back row of the American Medical Association's House of Delegates meeting, where the main topic of debate is whether the House will back its own elected Board of Trustees' decision to support H.R. 3962, the Affordable Health Care for America Act of 2009. The House of Delegates is considering resolutions that would either force the AMA to withdraw support for the bill and/or set a list of non-negotiable set of pre-conditions for the AMA to continue to support health reform. Yesterday, I sat through over eight hours of debate in front of a "reference committee" of House of Delegates members charged with hearing testimony and then drafting recommendations on the resolutions introduced by state and national medical specialty societies. The vote on the reference committee recommendations will take place this afternoon or evening.

As I've listened to the debate here, and also Saturday's debate in the U.S. House of Representatives, the image of tap-dancing through a minefield keeps popping into my head. To get a narrow majority to vote to pass H.R. 3962, Speaker Nancy Pelosi had to step around a series of political minefields, any one of which could have blown the bill apart. As reported in the Washington Post, the decision by Pelosi to allow a vote on an amendment to preclude federally-subsidized health plans from offering coverage of abortion was necessary to win the support of "pro-life" Democrats, but "pro-choice" advocates in both the House and Senate are vowing to block a final bill if it includes the same prohibition. Abortion, like it so often is in American politics, may end up being the single biggest minefield, because it is not suitable for "split the differences" compromises used to overcome other divisions.

The AMA is tap-dancing through its own minefields. If the delegates vote to overturn the organization's support for H.R. 3962, it could well paralyze the ability of its own Board of Trustees to continue to negotiate for its members, since the administration and Congress will lose confidence in the AMA's leadership to deliver. Yet there is a very vocal group of conservatives within the AMA House of Delegates who oppose H.R. 3962 on deeply held philosophical, political and ideological grounds, and they argue that the AMA will lose members if it does not change course.

There are many other delegates who believe with equal fervor that the AMA Board of Trustees did the right thing, and that the AMA stands to lose members if it reverses course. There are delegates who believe it is unwise for the AMA to reconsider its support for H.R. 3962, even if some of them have their own misgivings about the bill. They want the House of Delegates to set pre-conditions, or at the very least a list of top priorities and concerns, to guide future decisions by the Board of Trustees. The reference committee attempts to tip-toe through the minefield by affirming the House of Delegate's support for health reform in accord with established policies, even as it expresses "strong concerns about inclusion of" several provisions in health care reform legislation that would reduce payments to physicians who do not report on quality measures, reduce payments to higher resource use physicians, redistribute Medicare payments among physicians based on outcomes, quality, and risk-adjustment factors "that currently do not exist," and Medicare payment cuts for all physician services to partially offset bonuses for primary care services. (Interestingly, these provisions come from the Senate Finance Committee's version of the bill, not H.R. 3962.) I expect though, that efforts will be made today by conservative members of the House to turn these concerns and other issues into non-negotiable pre-conditions for continued support by the AMA and/or to substitute the original resolutions to reverse support for H.R. 3962.

The ACP, for its part, believes that H.R. 3962 advances important long-held policy objectives. (Our website has just been updated to provide a detailed list of answers to frequent questions about the ACP's views.) Our delegation to the AMA believes it would be a huge mistake for the House of Delegates to force the AMA to either withdraw support for H.R. 3962 or set "my way or the highway" pre-conditions, some of which are neither desirable nor achievable, which effectively would result in the AMA coming out against the current health reform effort.

No matter how the vote goes today in the House of Delegates, the AMA's slogan of "Together, we are stronger" does not reflect today's reality. Organized medicine will continue to be divided on health reform, reflecting the deep divisions among physicians on the role of government in health care, just as the close vote in the House of Representatives reflects the deep divisions on the same among the American people.

Today's question: What would you do if you were the AMA?

Thursday, November 5, 2009

Will the House reform bill reduce health care costs?

The House of Representatives is poised to vote, as early as Saturday, on H.R. 3962, the Affordable Health Care for America Act. Passage of the bill would be a historic milestone. At no other time in American history, has either the House or Senate passed legislation to extend health insurance coverage to (almost) all Americans.

Of course, like other milestones, there are many more miles to travel before health care reform legislation becomes law. The Senate leadership has yet to figure out how to combine and modify the Senate Finance Committee and Health, Education and Labor and Pensions Committee into a single bill that can get 60 votes. And then the House and Senate would have to reach agreement on what likely will be very major differences between the two versions, and when they do, another vote would have to take place in both chambers before it becomes law.

H.R. 3962 is closely aligned with ACP policies on coverage, workforce, and payment and delivery system. On November 2, ACP sent a letter of support to the House leadership that details the dozens of provisions in the bill that merit ACP's support.

Of course, critics are doing what they can to derail the bill. One unfortunate tactic is the resurfacing of a chain email, about the earlier H.R. 3200, that has been discredited by two independent fact-check organizations. A new partisan critique of the bill repeats several of the same false claims, according to a new analysis from Politifact.com.

On a more substantive basis, the bill is getting criticized for not doing enough to control costs.

But as Timothy Jost blogs in Health Affairs, H.R. 3962 actually includes many policies that "will in fact work important changes in the American health care system" to improve health care delivery and lower costs. Among them: accelerated pilot tests of medical homes and accountable care organizations, increased payments for primary care, quality and efficiency incentives for Medicare Advantage plans, comparative effectiveness research, promotion of shared decision-making, gainsharing, reporting on infections acquired in hospitals and ambulatory surgical centers, and workforce initiatives to increase the numbers of primary care physicians

I keep hoping that we can get to the point where there is a substantive debate on whether the bills do too much or too little to control costs; have too much or too little regulation; or spend too much or too little to make coverage affordable. The critics can surely do better than relying on discredited falsehoods, like the one that claims that H.R. 3962 would prohibit people from buying private insurance, to make their case.

Today's question: Do you think the House bill begins to put in place the right policies to expand coverage and control costs?

Tuesday, November 3, 2009

My rockin' the U.S.A tour

Twenty-one days on the road and 17,200 miles travelled since Labor Day.

Stops in Wichita, Kansas; Lead, South Dakota; Osage Beach, Missouri; Charleston, South Carolina, Phoenix, Arizona; Winston-Salem, North Carolina; Stowe, Vermont; and Rochester, Minnesota. Coming up next: 4000 miles and four days in Houston, Texas, followed shortly by a return to the Lone Star state, and then Sacramento, California. Upcoming early next year: Las Vegas, Nevada; Tyson's Corner, Virginia; and Hattiesburg, Mississippi.

No, this isn't the itinerary for Bruce Springsteen and the E Street Band. It is what I have been doing since Labor Day, meeting with physicians, mainly at ACP chapter meetings, to talk about health care reform.

Keeping in mind Will Roger's truism that "This country has come to feel the same when Congress is in session as when the baby gets hold of a hammer" shouldn't I instead remain in Washington, keeping an eye on Congress? Well, no. Although my job is to represent the interests of internists in Washington, D.C., I feel that I can't do that effectively if I don't spend time meeting with internists. We have a top-notch advocacy staff in D.C. that keeps me informed about everything, and modern technology allows me to be a mouse click from being (virtually) on the scene.

I mention all of this because some commentators on this blog have taken me and ACP to task for not listening to its members. I don't take it personally or defensively, but I doubt that there is anyone else who has listened to as many internists, in as many different places, as I have in the past three months.

What have I learned? First, I have not encountered a single instance of an ACP member reacting with "town hall" style hostility to my explanations of the ACP's views on health reform. This is not to say I found uniformity; internists, like the American people generally, have a wide and diverse range of views.

Like the young Med-Ped physician who I met with in South Dakota, who believes with all of his heart and soul that the current bills will lead to a loss of liberty, crushing taxes and debt, and government rationing of services. Like the ACP member in Vermont, who believes with all of his heart and soul that only a government-financed, not-for-profit, single payer system can provide Americans with equitable and affordable care. These ACP members, and many like them, are at polar opposites on the political spectrum, yet they expressed their views to me with civility and with a high degree respect for the ACP.

Internists' views also differ depending on where they live, but not as much as one might expect. Physicians in "red states" like Kansas and South Carolina are more likely to be concerned about the plans being developed in Washington, and those in "blue" states like Minnesota and Vermont are more likely to support them. But you find a range in all regions. In Charleston, SC, for instance, the first question to me came from a conservative doctor who was concerned that ACP was in favor of "government-run" health care, while the very next question was from a single payer proponent.

The most common sentiments I've encountered are confusion about what is in the bills; general agreement with ACP's views; hopefulness that the reforms will improve things; and anxiety that they could make things worse. To address the confusion, ACP continues to update its resources for ACP members, including a new snapshot tool that compares the new House health reform bill with ACP policies.

I have come away from my travels encouraged that most internists want health care reform, and that they place a high degree of confidence and trust in the ACP to do the right thing, an obligation I take very seriously. I am committed to continuing my efforts to listen to as many internists as possible, but even though I am listening, it doesn't mean I will always agree with you.

Today's question: Do you feel that there is "common ground" in internists' views on health care reform and of ACP?

Friday, October 30, 2009

Who wins from the House reform bill? Follow the money and find out.

Estimates by the Congressional Budget Office of how legislation affects the federal budget can tell a lot about Congress' priorities. Provisions in bills relating to specific health care sectors (e.g. physicians, hospitals, drug manufacturers, insurers) that the CBO scores as producing "savings" means that that particular sector is going to be hit with payment reductions or tax increases to fund other priorities in the bill. Provisions scored by the CBO as adding to federal budget expenditures means that the bill's sponsors have decided that the affected sector is a priority deserving of more federal dollars.

What does the CBO's preliminary estimate of the new House health reform bill tell us about Congress' priorities? That primary care and prevention are the sectors that Congress has identified as deserving as more federal spending, above all others, and that insurance companies in the Medicare Advantage program is the sector that will take the biggest hit. Other sectors facing steep reductions are hospitals (reduction in their market basket increase and disproportionate share payments), drug companies and home health agencies.

In fact, primary care physicians get the single largest bump in spending of any sector in the entire bill. Here is how:
$ 57 billion more will be spent over the next 10 years to increase Medicaid payments to primary care physicians so that they equal the Medicare rates. This is more than any other sector of providers, suppliers and health professionals will get, bar none.
$ 4.7 billion more will be spent to increase Medicare payments to primary care physicians for office, hospital, nursing home, home and emergency room visits.
$ 2.3 billion more will be spent to fund two Medicare and Medicaid pilots to reimburse primary care physicians for care coordination in a Patient-Centered Medical Home.
$ 1.5 billion more will be spent on Medicare GME, much of it directed at increasing primary care training.

Prevention and wellness programs will also get tens of billions in additional federal spending. The bill creates a $34 billion trust to fund public health investments in wellness and prevention, and another $10.7 billion to fund coverage of preventive services under Medicaid.

Now, I know that many of the regular commentators for this blog will respond with a shrug to the increased spending on primary and preventive care, because they will say that it is not enough to prevent a catastrophic shortage of primary care physicians. And they will have a point: I don't think the policies in this bill, by themselves, will suddenly result in thousands of more medical students choosing primary care, or necessarily persuade those in practice that there is a brighter future ahead, but I do believe that they begin to put in place programs that will help. Still, it is undeniable that the Congress has decided that primary care and prevention are priorities that deserve a lot more money: the combined $100 billion that the House proposes to spend directly on primary care, prevention and wellness over the next decade represents more than 10% of the bill's total net cost of $894 billion. The fact that primary care is now viewed as a top priority also is evidenced by introduction today of a bill, supported by the House leadership, that would repeal the Medicare sustainable growth rate and replace it with a new update system that will allow payments for primary care and preventive services to grow at a faster rate than all other services.

By any standard, a combined expenditure of almost $100 billion on primary care, prevention and wellness represents a huge shift in the priorities of the federal government, and one that I think deserves our recognition and support.

Today's question: What do you think the increased spending on primary care and prevention could mean to internists and their patients?

Thursday, October 29, 2009

Revised House bill would expand Medicaid, offer public option, cover 96%, and lower the deficit

Today, Speaker of the House Nancy Pelosi (D-CA) released a new version of the health care reform legislation that is derived from an earlier bill (H.R. 3200) approved by the House's three health committees. I am still making my way through the bill, so will have more to say about it in future posts. As reported in The Washington Post, the bill is likely to attract broad support among Democrats but no Republican votes.

The biggest difference with H.R. 3200 is that the bill expands Medicaid to all persons up to 150 percent of the federal poverty level, instead of 133% in the earlier bill. Medicaid, once the poor sister of the popular Medicare program, would now be the single largest source of health insurance in the United States. To increase physician participation in Medicaid, the bill would increase Medicaid payments to primary care physicians over several years until they at least equal Medicare pay rates in all states.

It is also substantially less expensive than H.R. 3200, with an estimated cost of less than $900 billion over 10 years, according to the CBO, and would reduce the deficit by $104 billion over the same ten years. One reason that the cost has gone down is that it is cheaper to enroll people in Medicaid than to offer them subsidies to buy private health insurance coverage. It also removes the cost of repealing the Medicare SGR physician pay formula from the legislation; instead, the House leadership has introduced a separate bill that would repeal the SGR and create two separate spending targets, a higher one for evaluation and management and preventives services, and a lower one for all other services, although both categories would be allowed to grow faster than under the current SGR. How the House plans to move the SGR bill outside of health reform legislation remains to be seen.

The bill includes a permanent 5% Medicare bonus for office and hospital visits provided by primary care physicians, 10% in health professional shortage areas. There would be a modest expansion of graduate medical education (GME) training positions for primary care, and new and expanded loan repayment for primary care clinicians who satisfy a service obligation.

And, on the public plan, the new bill would offer individuals who qualify for subsidized coverage the ability to enroll in a government-administered plan that would negotiate its payment rates with physicians and hospitals instead of using the Medicare rates.

Today's question: What is your initial reaction to the new health reform bill?

Wednesday, October 28, 2009

The Public Plan Rorschach Test

The idea of offering people the option of enrolling in a public plan, similar to Medicare, has become the Rorschach test for health reform. Many conservatives see it as a foot-in-the-door that will lead to government-run, socialized medicine. Many liberals see it the same way, as the first step to achieving a single payer system, although fewer will admit to it.

If you distrust and dislike insurance companies, you like the public plan. If you distrust and dislike government, you despise it.

Then there are the deal-makers, the people in Congress who have to find a way to bridge these differences so that they can get a majority in the House and a 60 vote super-majority in the Senate. For them, the policy is less important than the votes they need to pass a bill. They are the ones who dream up things like "triggers", so the public plan would only go into effect if private insurers don't cover enough people and keep costs under control, or state opt-out or opt-ins, so each state could decide whether or not to participate. The deal-makers also have to decide if they will get more votes by having a "robust" public option (meaning that it would pay doctors or hospitals based on the Medicare rates), as the liberals insist, or whether it would use negotiated rates, as many of the "centrists" prefer.

The Hill newspaper is reporting that Speaker Nancy Pelosi (D-CA) will be unveiling an agreement tomorrow to have a public plan option that would use negotiated rates instead of Medicare. Last week Senator Majority Leader Harry Reid (D-NV) announced that the Senate bill will have a public plan with a state opt-out.

But one way or another, the public plan has come back from the dead, as captured in this Halloween illustration brought to us by The Washington Post cartoonist Tom Toles.

The scary thing about the public plan though, may be what it doesn't do, as Fred Hiatt, writes in The Washington Post. He argues that the public plan allows the politicians to pretend they are controlling health care costs while for the most part ducking the issue. Robert Samuelson, also writing for The Post, makes a similar argument, that the debate of the public plan allows Congress to "fake it" when it comes to controlling costs.

I see the public plan in the similar fashion as they do. Although the public plan has become the defining issue for many, I think there is a lot less to it than meets the eye. Depending on how it is structured, it could do some good in introducing some needed competition to the insurance industry, but I hardly believe that its inclusion or not is going to make or break health care reform. Especially since the deal-makers likely will water it down so much it won't have that much negotiating clout in the market.

Today's question: How important do you believe the public option is to health care reform?

Thursday, October 22, 2009

Coming soon! Medicare Part E!

The Hill reports that the House Democratic leadership has decided to rebrand the "public option" as Medicare Part E, that is, Medicare for everyone. But are they really proposing that everyone should be able to enroll in Medicare, fulfilling the wildest hopes of single payer advocates?

Not likely. The House's version of Medicare Part E could more aptly be labeled as the Medicare Part UPWDNHATAEHCAWDNQFMOS program , standing for Uninsured Persons Who Do Not Have Access To Affordable Employer Based Health Coverage And Who Do Not Qualify For Medicaid Or SCHIP. Barring a complete re-write of the House bill, the re-branded public plan option would be available only to the 30 million or so people who fall in the UPWDNHATAEHCAWDNQFMOS category and are eligible to receive federal subsidies to buy coverage through a health alliance. Calling it Medicare for Everyone doesn't make it so.

Still, it might be a very good political move. People like Medicare and don't associate it with "government run" health care (remember the reports of seniors at the August town hall meetings screaming "keep government out of my Medicare?").

The Hill also reports that the plan will be "the 'robust' option or 'Medicare Plus 5' in the jargon that has emerged on Capitol Hill, [which] ties provider reimbursement rates to Medicare, adding 5 percent."

The American College of Physicians has said that it could be appropriate for people eligible for the health exchanges to have the option of choosing either a qualified private insurance plan or a public health plan, provided that the public option is funded through premiums and is not tied to Medicare physician participation agreements or Medicare rates. ACP wrote:

"Proposals to use the current Medicare reimbursement structure as a basis for reimbursement under the public plan option raise significant concerns. In particular, payment levels for physicians participating in the public plan would amount to price controls that insufficiently compensate physicians for their work. It is widely believed that the current Medicare fee schedule is ineffective in promoting quality care and incentivizes volume-based rather than value based health care. In its March 2009 report to Congress, MedPAC stated that it was dissatisfied with the current fee schedule updating mechanism for physician payments. Further, the Medicare fee schedule has resulted in improper utilization of services rather than cost containment. Proponents of the public plan option have cautioned that hospital closures, stifled innovation of new technology, and limited access to physician services could result if a government-run health plan strictly limits payments to providers under a public plan ... To be successful, a public health plan would not have to control prices to maintain access, promote quality care, and limit cost efficiencies ... Instead, the government (or the plan's administrator) should negotiate with providers in a manner similar to the private market."

Especially given the Senate's failure yesterday to repeal the Medicare Sustainable Growth Rate (SGR) formula, it doesn't make sense to build the new Medicare E program on a payment structure that Congress itself knows doesn't work and would require that they close a $240 billion budget shortfall to stop the scheduled physician pay cuts. The same payment structure that Congress acknowledges undervalues primary care and rewards volume over value. Yet Speaker Pelosi wants the flawed Medicare fee schedule to be the foundation for the new public option?

My guess is that the decision to base the public plan on the Medicare rates is principally a negotiating tactic in anticipation of a conference committee with the Senate, which is not likely to include a "robust" public option in its bill. A compromise might be to accept the House's proposal for public plan option, but to divorce it from the Medicare rates and instead allow the public plan to negotiate rates with physicians, hospitals and other providers. Yet in one form or another, it seems more likely than ever that some kind of public option will end up in the final bill. Call it Medicare E if you want, even though most of us will not have access to it.

Today's questions: What do you think about re-branding the public option as Medicare Part E? Should it pay physicians and hospitals based on the Medicare rates (plus 5%) or should the rates be negotiated?

Wednesday, October 21, 2009

Congress again fails to end the SGR lunacy

Just a few days ago, it looked like Congress might actually do the right thing and end the annual cycle of enacting short-term measures to stop Medicare payment cuts caused by the Sustainable Growth Rate (SGR) formula, only making the problem harder and more expensive to fix the next time around.

But today by a 47-53 vote, the Senate - including 13 Democrats - voted against a motion to end a filibuster against S. 1776, the Physician Payment Fairness Act of 2009, even though the bill had the support of the White House, Senator Finance Committee Chair Max Baucus (D-MT), and Senator Chris Dodd (D-CT), acting chair of the Senate HELP committee during the (late) Senator Ted Kennedy's illness. S. 1776 would have repealed the SGR and eliminated all of the accumulated cuts caused by the formula.

S. 1776 failed despite a huge grass roots push by the ACP, American Medical Association, and other physician organizations, and despite the fact that AARP, the voice of America's seniors, supported the bill.

The bill was victim to the dysfunctional political environment today that makes consensus so difficult. Many Republicans viewed the bill largely as a Democratic effort to "buy" physicians support for health care reform (a cynical and unsupported allegation - more on this later) and they wanted to deny the Democrats a victory on anything having to do with health care reform. They also wanted the cost of the SGR repeal to be counted against the cost of the health reform bill, so that the bill would be seen as blowing a hole in the deficit. (Never mind that the SGR, which has led to all of the accumulated cuts and costs we are now facing today, was created by the Congress in 1997, when the GOP was in control, and that past Congresses, Republican and Democratic alike, have failed to take the steps needed to fix it. The SGR problem and its cost would be with us today, even if there was no health reform bill.)

It also seems many Democrats have had the equivalent of a death-bed conversion to fiscal responsibility, or at least a make-believe version of fiscal responsibility that says that pretending to save taxpayer's money is the same as saving them money. The Senators know that the $245 billion price tag for SGR repeal is itself a budget fiction, because it requires that we suspend disbelief and assume that Congress will actually allow double-digit cuts in physician payments to go into effect. They won't and they know it. Medicare will end up spending the $245 billion anyway, but that doesn't matter, as long as the Senators can tell voters that they didn't vote for a bill that would add to the deficit.

ACP has released a statement that is harshly critical of the Senate vote and vowing to continue to push for SGR repeal. The statement takes on the charge that S. 1776 was offered in exchange for physician support of health reform:

"The American College of Physicians rejects the cynical charge made by some that physicians' support for health care reform is conditioned on repeal of the SGR. Instead, ACP supports health care reform because we believe that all Americans should have access to affordable care. Our positions on the pending health reform proposals will continue to be based on how they align with ACP's long-standing policies on ensuring coverage, reversing a catastrophic shortage of primary care physicians, and testing and implementing new models of payment and delivery to align positive incentives with the value of care provided. At the same time, we believe that repeal of the SGR is necessary to provide the stability needed to achieve real and lasting physician payment reform, to implement payment reforms to support the value of care provided by primary care physicians, and to assure seniors' access to care."

Where does this leave us on the SGR? Right where we were in . . . 2008, 2007, 2006, 2005, 2004, 2003, 2002, and 2001 . . . with Congress saying that they know the SGR has to go, that they won't allow the cuts to go into effect, that they know that have to find a permanent solution, but not now, some other time. Like the Chicago Cubs and a World Series appearance, it seems it is always "wait til next year" when it comes to repeal of the SGR.

Today's question: What is your opinion on the Senate's rejection of SGR repeal?

Thursday, October 15, 2009

Finally, a plan to end the lunacy of the Medicare SGR

Yesterday, I joined representatives from the AMA and other physician organizations in a meeting with the Senate Majority Leader Harry Reid (D-NV), Senator Max Baucus (D-MT), Senator Chris Dodd (D-CT) and Nancy Ann Deparle, the head of the White House Office for Health Reform, to discuss a plan to get rid of the Medicare SGR formula, once and for all. We learned that Senator Reid will ask the Senate to vote next week on a bill to repeal the SGR and all its accumulated scheduled cuts to physicians for the next 10 years.

It's about time. I can't think of a single other issue that has so bedeviled physicians and Congress alike as much as the SGR.

Under the Medicare sustainable growth rate (SGR) formula, physicians have faced deep annual cuts in payments since 2002. Congress has stepped in all but one year to enact a temporary "patch" to stop the next year's cut. But rather than accounting for the difference between the lower payments mandated by the SGR, and the higher payments under the patch, Congress has assumed that the higher spending will be made up with even an even deeper SGR pay cut the following year. This is why the "patch" for an estimated 5 percent SGR cut in 2008 resulted in a scheduled 10.5 percent SGR cut in 2009. And why the patch for the 10.5 percent SGR cut in 2009 balloons to a scheduled 21 percent cut in 2010.

To illustrate how crazy all of this is, imagine you worked for a small business, and imagine that your boss told you that your wages would be cut by 10 percent this year. Later, your boss announces that your company will not cut your wages, but that the only way the company can afford to stop the 10 percent cut will be to pretend to reduce your wages by 20 percent the following year. She tells you not to worry, though: they will just do the same thing next year - prevent the 20 percent cut by pretending that the cost will be made up by cutting your wages by 40 percent the following year. She adds, though, that the company has no intention of ever allowing the 40 percent cut to happen. They just have to pretend they will so their accountants will allow them to stop the immediate pay cut.

No small business would actual run its payroll budget this way. Yet this is the budget lunacy that Washington has employed to hide the true costs of stopping Medicare physician payment cuts.

On Monday, Senator Reid will bring S. 1776, the Medicare Physician Payment Fairness Act, to the Senate for a vote. The bill, introduced by Senator Debbie Stabenow, simply sunsets the SGR and eliminates all of the scheduled cuts in 2010 and subsequent years. Instead of using gimmicks to hide the cost of SGR repeal, as Congress has done in the past, the costs would be reflected in the estimates going forward of Medicare spending. Following Senate action, the House of Representatives is expected to take up the issue.

Once the SGR is repealed, Congress would have to design a new system for updating physician services with the input of the medical profession.

I applaud Senators Reid, Baucus, Dodd and the White House for making this commitment to end the lunacy created by the SGR, including the smoke and mirrors budget accounting designed to make the costs look lower than they really are. Getting the bill approved by the Senate is no sure thing, though. Senator Reid will need at least 60 votes to overcome procedural obstacles to its consideration. You can help him and ACP get the votes needed to get rid of the SGR, once and for all, by making a call to your Senators today. Click here for more information.

Today's question: What will you be doing to get your Senators to vote for S. 1776 and permanent repeal of the SGR?