Friday, February 27, 2009

Should we pay patients to stay healthy - and punish them if they don't?

Writing in the Wall Street Journal blog, Sarah Rubenstein reports that a new study finds that paying smokers to quit is effective and "succeeds far more often than those who got no cash reward."

There is a catch: "Most study participants were relatively well-educated whites with higher incomes, and it's possible the incentives might not work as well with other groups," Rubenstein notes, citing comments by Kevin Volpp, the study's lead researcher.

(The same research team found that paying obese people to lose weight also is effective, but that the results were not fully sustained over time.)

Some people advocate more punitive measures. The Happy Hospitalist, a regular commenter on the ACP Advocate Blog, says in his blog that smokers should get lower wages than non-smokers because "by decreasing a smoker's wage, you are making up for their increased consumption of benefits compared to non smokers. . . If you don't you are discriminating against non- smokers."

I understand the appeal of creating positive incentives for people to lose weight or stop smoking. But I am concerned about the consequences of reducing wages or cutting benefits to people who can't or won't stay healthy.

The West Virginia Medicaid program is being sued by a public interest law firm over a policy that cuts children's benefits when their parents don't sign a pledge to take steps to improve their kids' health, according to the Kaiser Daily Health Policy Report. The report observes that "ninety percent of West Virginia children enrolled in Medicaid have had their benefits reduced because their parents have not signed the pledge."

Is it right for children to get fewer health care benefits because their parents don't sign an agreement that promises to take them to the doctor for regular check ups and not use emergency rooms for routine visits?

The premise behind programs that reward people for healthful choices and punish them for bad ones is that their health is largely a product of choices, made freely by adults who should know better.

But is smoking really a choice, when we know that most smokers start as adolescents and nicotine is a highly addictive drug? Is being overweight just a bad choice, when we know that culture and upbringing, genes, lack of availability of healthful food in some lower-income communities, the super-sizing of portions, and marketing of fast food and soft drinks all play a role?

"Reward or punishment" programs may have the effect of widening health care disparities, because some cultural and ethnic groups and underserved populations - as in West Virginia - have much higher rates of smoking and obesity.

It is one thing for a well-off person to run down to the neighborhood gym, meet with their personal trainer, and pick up nutritious groceries at Whole Foods. They might like getting some extra cash in their pockets to reward them for their healthy "choices."

But what about people in the inner city or Appalachia, who don't have the same resources, education, literacy, and choices available to them?

Today's questions: Should patients be paid to quit smoking, lose weight, or other healthful behaviors? Should they be punished - higher premiums, lower wages, reduced benefits - if they don't?

Wednesday, February 25, 2009

Are the salaries that medical schools pay to physician-executives anyone's business?

Three of the top four (and eight of the top 10) highest-paid employees of U.S. colleges and universities were physicians, reports Jacob Goldstein in his Wall Street Journal health blog. (The top spot went to a college football coach, U.S.C's Pete Carroll, at $4.4 million.) The next three highest earners were physicians:

David N. Silvers, a Columbia dermatologist, $4,332,759.

Michael M.E. Johns, Emory's executive vice president for health affairs, $3,753,067.

Arthur H. Rubenstein, University of Pennsylvania executive vice president and dean, school of medicine, $3,335,767.

Goldstein comments that, "The leading place of docs on the list is a reminder of just how much money flows through medical schools and academic medical centers, both in the form of reimbursements for patient care and federal research dollars."

The comments posted in response are well worth a read.

Some expressed concern that a misperception may be created that all physicians are paid so handsomely when those in the trenches - especially primary care doctors - make only a small fraction of the money paid to these executives. One physician commenter asked "What message on the campus does it send to medical students? Does this represent nationality priorities when 40+ million people have no health insurance?"

Another physician writes "Academic medicine has lost its mind. They preach dumb healthcare policy while collecting overinflated salaries. What hypocrisy. I would bet the barn that not one of these guys could survive the rigors of the real world practice of medicine in the trenches of primary care. Yet they pontificate from their ivory towers. Eventually these towers will fall."

Others noted that the reported compensation levels are not out of line when compared to other CEOs of successful companies and other learned professions.

My favorite: "If only the docs learned to coach football ..."

Is it really anyone's business what these physician-executives are paid?

Believers in market-based capitalism would say no, physician executives, like anyone else, have the right to earn what the market will bear. And academic medical centers, like any business, have the right to pay top dollar to attract top talent.

The counter to this is that medical colleges and academic medical centers are not like any other business. They serve a public mission of teaching the art and science of medicine to the next generation of physicians. And they receive billions of dollars from federal and state governments.

My guess is that at a time when the salaries of executives in other businesses receiving federal funding are under scrutiny, physician compensation in academic medicine will be viewed as fair game.

Academic medicine will have to address a public perception that taxpayers can't afford to subsidize high physician executive salaries, when millions of Americans have no health insurance coverage, when medical students graduate with an average of $140,000 in debt, and when primary care physicians in patient care earn 5% of the amount paid to the lowest of the top four physician-executives employed by medical colleges.

They might be well-advised to have a chat with their school's football coach on how to run a good defense.

Today's questions: Do you think it is anybody's business what physicians in academic medical centers are paid?

Monday, February 23, 2009

Entitlement Reform: It's all about the numbers, or is it?

Today, President Obama convenes a bipartisan "summit" on "fiscal responsibility," which is expected to initiate a dialogue on ways to rein in spending on the big three federal entitlements - Medicare, Medicaid, and Social Security.

Entitlements is a term used to describe programs where the government is obligated, by law, to pay benefits to qualified participants (beneficiaries). They differ from discretionary programs, where the amount of spending is determined on an annual basis, based on a recommendation by Congress's appropriations committees.

Think of spending on an entitlement program as an airplane on automatic pilot. The airplane (Medicare) will continue to burn fuel (taxpayer dollars) at an unsustainable rate unless the pilot (Congress) takes it off automatic pilot and orders a change in course. Except this airplane keeps adding passengers, continually is re-fueled in flight, and the cost of fuel per passenger keeps rising, with no end in sight.

How President Obama decides to tackle entitlement spending will have huge implications for doctors and patients. And, as Al Froomkin blogged yesterday in the Washington Post, the White House is trying to navigate between the views of fiscally conservative Democrats active in the "entitlement reform movement" which is "currently focused on establishing a blue-ribbon commission that would present Congress with a finished proposal - presumably calling for steep cuts in the nation's bedrock social safety programs - for an up-or-down vote," and liberals who are concerned that this would lead to unacceptable cuts in Medicare benefits and eligibility.

As I see it, here are the options available to President Obama:

1. He can embrace the views of the entitlement reform movement, which views spending on Medicare as essentially a numbers problem that can be solved by internal restructuring of the program. The numbers problem can be boiled down as follows: Medicare isn't sustainable because the number of beneficiaries in the program will continue to grow from 40 million in 2000 to 47 million in 2010 to 79 million by 2030. The number and costs of services per beneficiary will increase at a much greater rate than overall inflation. Yet the number of workers who pay into the program will decrease from four workers per beneficiary in 2000 to 2.4 workers per beneficiary in 2030. Viewed this way, the way to make Medicare "sustainable" is to do some combination of the following: make fewer people eligible for the program, such as by pushing back the age of eligibility or implementing "means-testing" so wealthier beneficiaries either get reduced or no benefits; reduce benefits guaranteed by the program (i.e. by putting explicit limits on coverage); raise taxes; make beneficiaries pay more out-of-pocket; or reduce the costs of services, principally by cutting payments to "providers."

2. Or he can adopt the views of those who see Medicare as the tail being wagged by the dog of overall health care costs. That is, rather than viewing Medicare as a numbers problem to be solved principally by restructuring eligibility and benefits and raising taxes, this camp sees Medicare's woes as being driven principally by the overall increase in health care expenditures, which are then passed on to Medicare. The answer then is to adopt comprehensive reforms to make health care more efficient, which would then lead to lower Medicare costs per beneficiary. Under this approach, some restructuring of Medicare benefits and eligibility will still be required, but likely would be less draconian than if Medicare is viewed as a problem to be solved unto itself.

Right now, it appears that President Obama's views are more in the second camp: fix the health care cost problem, and you can fix Medicare without requiring unacceptable cuts in benefits and eligibility. But instead of Medicare being the tail being wagged by the dog of health care costs, he and his advisers see an opportunity to have Medicare lead the way to a more efficient and effective health care system.

The political problem for the president is that fixing the overall health care system so it is less expensive will take time, and enormous political capital. Will fiscally conservative Democrats be willing to wait for overall health care reform to do its magic before demanding an "up or down" vote on restructuring Medicare benefits, eligibility and taxes?

Today's question: How do you think President Obama should tackle reform of Medicare entitlements?

Thursday, February 19, 2009

Words matter!

Any hope that the debate on health care reform might be conducted in a serious manner, without the fear-mongering seen in the early 1990s, may have been dashed by the rhetoric hurled at the heath programs in the economic stimulus bill.

Advocates across the ideological spectrum saw the stimulus bill as pre-cursor to the next big debate on health care reform.

For conservatives, it was viewed as the first skirmish in a battle against "government run" health care. For liberals, it was viewed as a "first step" toward using the power of government to guarantee universal coverage and "transform" the health care delivery system. For many of us in the middle, the ideological debate was strangely at odds with the actual substance of the legislation.

Conservative critics alleged that the health information technology and comparative effectiveness programs would lead to government rationing of health care. The Washington Times went so far as to compare these programs to Hitler's program to euthanize "elderly people with incurable diseases, young children who were critically disabled, and others who were deemed non-productive."

Yesterday, ACP's Chief Executive Officer, Dr. John Tooker, joined with his counterpart with the AARP, Mr. Bill Novelli, to take The Washington Times on for its "unconscionable" reference to Nazi Germany. These two CEOs, writing on behalf of the second largest physician membership organization and the largest consumer advocacy group in the United States, wrote that their members "would strongly oppose any attempt to limit any doctor or hospital from providing the best possible care to any patient. So it is especially galling that this editorial would present these two solutions as part of a plan to cut off care for older Americans."

Let's look at the facts. This is what the actual report language for the final House-Senate agreement says:

"The conferees do not intend for the comparative effectiveness research funding included in the agreement to be used to mandate coverage, reimbursement, or other policies for any public or private payer. The funding shall be used to conduct or support research to evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition. Conferees recognize that a 'one-size-fits all' approach to patient treatment is not the most medically appropriate solution to treating various conditions."

Not exactly the stuff of the National Socialist Party, is it?

It is not just the right that uses words to score ideological points. The left often says that health care is a right, but once something is defined as a right, it paints people who disagree as wanting to deny those same rights. This places people who have legitimate concern about the role of government in health care in the same category as, say, past generations who opposed a woman's right to vote or stood in the schoolhouse door.

Health care reform deserves a good debate, and there is plenty of room for spirited, informed, respectful and evidence-based disagreement on the role of government. But the public is not served when words are used to mislead on the issues, to create fear, or to demonize those who disagree with you.

Today's question: What do you think - can we get to a respectful and informed debate on health care that avoids rhetoric that seems more designed to create fear than bring light to the issues?

Tuesday, February 17, 2009

Will Physicians and Nurse Practitioners Find Common Ground?

In several previous blog postings, I have discussed what I consider to be the two biggest political challenges to rebuilding the primary care workforce capacity in the United States.

One is the risk that medicine will split into a civil war between primary care physicians and other specialties over the issue of "how to pay for it."

The other is that the coalition of advocates for primary care - physicians, nurses and physician assistants - will splinter over each profession's contributions and importance.

Today, the ACP releases a new policy monograph on Nurse Practitioners in Primary Care. The paper makes the case that respectful and true collaboration is in the best interests of both professions and the patients they serve. It defines collaboration as "ongoing interdisciplinary communication regarding the care of individuals and populations of patients in order to promote quality and cost-effective care."

ACP offers principles on collaboration, include recognizing each profession's complimentary roles as defined through their professional practice acts, appropriate sharing of information, and mutual acknowledgment of, and respect for, each professional's knowledge, skills, and contributions.

In developing the paper, ACP met with several highly-regarded nurse practitioners active in their respective professional associations to seek their insight, even on issues where they didn't quite see eye-to-eye with ACP.

The paper does not shy away from controversial issues.

On training and skills, ACP has this to say:

"Physicians and nurse practitioners complete training with different levels of knowledge, skills, and abilities that while not equivalent, are complementary."

"Patients with complex problems, multiple diagnoses, or difficult management challenges typically will be best served by physicians, working with a team of health care professionals that may include nurse practitioners."

On credentials and the doctor of nursing degree:

"Patients should have the right to be informed about the credentials of the person providing their care to help them distinguish among different health care professionals."

On the Patient-Centered Medical Home:

"Patients are best served by a multidisciplinary team led by a physician" although PCMH demonstration projects could also test the effectiveness of nurse practitioner-led PCMH practices operating within state scope of practice acts and meeting the same eligibility standards as physician practices.

On how many NPs and primary care physicians are needed to meet the growing shortage of primary care clinicians for adults:

"Training more nurse practitioners does not eliminate the need nor substitute for increasing the numbers of general internists and family physicians trained to provide primary care" and "workforce policies should ensure adequate supplies of [both] primary care physicians and nurse practitioners."

Although the focus of this new paper is on the role of NPs in primary care, ACP also recognizes the essential role that physician assistants play as members of the primary care team. The role of PAs in primary care will be the subject of a future policy paper, to be developed with input by respected members of their profession.

As an evidence-based document that reflects consensus, ACP's paper will likely disappoint the more extreme voices within each profession.

NPs who claim that they can replace primary care doctors will take issue with ACP's conclusion that the U.S. need more primary care physicians and NPs. They likely will disagree with ACP's view that patients with multiple chronic illnesses are typically best served by a team led by a primary care physician.

Primary care physicians who insist that the only acceptable practice model is one in which NPs work for them will likely take issue with ACP's emphasis on collaborative models of care that involve "mutual acknowledgment of, and respect for, each professional's knowledge, skills, and contributions."

The issue in my mind really shouldn't be about which profession works for the other. Rather, it is making sure that all members of the health care team are working as effectively as they can for patients.

Developing more effective models of collaboration between physicians and nurses not only makes for good health policy, it also makes for good politics.

Today's questions: Do you agree with ACP's views on the role of NPs in primary care and its emphasis on promoting collaborative models of care?

Thursday, February 12, 2009

Urban myths about the stimulus bill

Within the next day or so, Congress is expected to give final approval to the stimulus bill. I have not yet seen the final language that House and Senate negotiators signed off on yesterday, but it appears likely that it will include three of ACP's top priorities: funding for health information technology, training of more primary care clinicians, and research on comparative effectiveness.

Some ACP members, though, have told me that they are concerned - as one long-time ACP member in California described it - that the bill will "allow the government to track everything we do for our patients and dictate the care we provide." The source of his information was a widely-circulated commentary by Betsy McCaughey, a fellow with the Hudson Institute and a former lieutenant governor for New York State.

Ms. McCaughey says that "Your medical treatments will be tracked electronically by a federal system ... One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective [which] would allow the government to track the care that doctors provide to patients."


The legislation codifies the role of the National Coordinator of Health Information Technology (which, by the way, was created by the Bush administration). The National Coordinator has absolutely no authority to require that physicians submit treatment data to the federal government. Instead, it will work with the private sector to make sure that electronic health records (EHRs) meet standards of usefulness and interoperability - something most physicians and patients should welcome.

The bill also gives physicians the opportunity to apply for Medicare payment subsidies - as much as $40,000 per physician - to help them buy a certified EHR. If a physician chooses to accept the incentives (it is voluntary, after all), he or she will have to agree to use the technology for meaningful uses that will improve patient care and provide some documentation that this really is the case. Meaningful purposes will be defined in more detail later on, but will be things like using the EHR to generate reminders that a patient is due for preventive screening, or making it possible for physicians to electronically participate in quality measurement and reporting programs. This in turn will create market incentives for EHR manufacturers to make sure that their systems actually have the capabilities needed to support such "meaningful purposes" that contribute to better patient care.

Think about it this way. Would you want taxpayers to subsidize EHR systems that don't have the functions needed to help clinicians make meaningful improvements in patient care? Why would physicians want to buy such systems? And what physician wouldn't want to use their EHRs to making meaningful improvements in patient care, as long as the EHR has the necessary capabilities?

It is true that physicians will eventually be subjected to Medicare payment cuts if they don't have a certified EHR. ACP has expressed concern about the penalties, and will work to assure that a number of pre-conditions are met - like true interoperability, affordability and functionality of EHRs - before any penalties could go into effect.

Finally, there is nothing in the legislation that gives the federal government the authority to mandate plans of care. The funding for comparative effectiveness research will go to two well-respected research entities, the National Institutes of Health and the Agency for Healthcare Research and Quality, not some new regulatory super-agency. This is what the Senate Finance Committee has to say:

Q: Can the government use the results of this [comparative effectiveness] research to tell me, or my doctor, what tests and treatments I can or cannot have?

A: Absolutely not. In fact, the Senate bill specifically prohibits the government from making any coverage decisions based on this research, or even from issuing guidelines that would suggest how to interpret the research results. The sole aim is to disseminate the results of the research to the public, so that patients and their doctors can make the best decisions for their specific situations, together.

It is one thing to make a philosophical argument against the government subsidizing things like EHRs, primary care, and comparative effectiveness. It is another thing to make wild exaggerations that have little or no basis in fact.

Today's question: What do you think of Ms. McCaughey's claims and my response to them?

Wednesday, February 11, 2009

Will comparative effectiveness research lead to government-run health care?

Out of the more than $800 billion in economic stimulus being considered by Congress, a provision to spend a little over $1 billion on comparative effectiveness research (CER) is drawing outsized attention from conservative critics.

George Will says that "CER, which would dramatically advance government control - and rationing - of health care, should be thoroughly debated, not stealthily created in the name of 'stimulus.'"

Today, The Wall Street Journal opines that "giving government exclusive control over electronic health information and reporting is a step toward 'comparative effectiveness' research. That in turn will be used to impose price controls and deny some types of medical treatment and drugs. And because government is able to skew the whole health system through Medicare and Medicaid, comparative effectiveness could end up micromanaging the practice of medicine."

If this were true, why would the National Business Group on Health urge Congress to support CER? (The Fortune 500 companies that are members of the NBGH aren't types that usually favor government-run health care.)

If this were true, why would ACP, which represents the very same practicing doctors who the WSJ says will be subject to micromanagement, support CER?

The answer is that rather than leading to micromanagement of clinical decision-making, CER has the potential to improve decision-making by patients and their physicians.

CER "will provide critical information to physicians and their patients to allow them to engage in an informed shared clinical decision-making process" concludes ACP in a 2008 position paper. It "has the potential to reduce unwarranted variations in treatment among providers, increase patient accuracy in expected treatment outcomes, and provide patients with greater comfort in the treatment choice made."

It isn't as if physicians and patients aren't already subject to controls and micro-management. Every day, decisions are made by insurers on which services will be covered. Doctors have to produce reams of paperwork to justify deviating one iota from the insurers' guidelines. But the processes used by insurers to decide what will be covered or not are done in widely inconsistent ways, lack transparency, and don't always rely on the best available evidence.

In my mind, CER isn't about giving the government control over health care, but giving physicians and patients transparent and evidence-based information to make their own decisions.

The WSJ usually sings the praises of "consumer-directed" health care. But how can patients direct their own health care if they and their doctors don't have access to the best available research evidence on the relative effectiveness of different treatments?

Today's question: Do you think that funding an independent effort to conduct research on comparative effectiveness will (1) help improve physician and patient decision-making or (2) lead to government micro-management and control over health care decisions?

Monday, February 9, 2009

Health care reform, stimulus, and beyond

With Friday's announcement of an agreement among "centrist" senators, President Obama seems to have the votes he needs (but barely) to get the economic stimulus package passed by the Senate.

Not that this will be the end of the story.

There are major differences between the (modified) Senate bill and the version passed by the House of Representatives. These differences have to be worked out between House and Senate negotiators and then voted on again by both chambers. Concessions to the House could make the package vulnerable in the Senate, where a switch of just one vote could bring it down. Too many concessions to the Senate, though, will be resisted by House Democrats and their allies.

On Friday, ACP weighed in with our priorities for stimulus. How did we fare?

The Senate agreement preserves more than $20 billion in funding for health information technology and more than $1 billion for comparative effectiveness, but eliminates $600 million for primary care training programs supported by ACP. It trims COBRA subsidies for people who lose their jobs. Both the House and Senate provide the same amount of money to prop up state Medicaid programs. Unlike the House, the Senate does not give additional money to the states to extend Medicaid coverage to temporarily unemployed low-income persons. ACP will ask Congress to restore the money for primary care and increase the funding for COBRA and Medicaid.

Although the stimulus bill is the big story today - as it should be, given the amount of money involved and the stakes for the economy - it is only a down payment, at best, on broader health care reforms. Which raises the question: what will President Obama and Congress decide do next?

Jonathan Cohn writes in the New Republic blog about Obama's plans to make health care reform a "central focus" of his first budget. He quotes the New America Foundation's Len Nichols, an economist and longtime reform advocate: "If they put [health care] in the budget, and fully fund it, then they are demonstrating a profound commitment to health care as an integral part of the agenda. And I welcome that."

Me too.

And in other good news for health care reform, the New Health Dialogue blog writes that "Two key Senate Democrats, Max Baucus and Edward Kennedy, jointly and publicly reiterated their commitment to major health reform this year, with or without the help of Tom Daschle."

Today's question: After stimulus, what do you think the President and Congress should do next to reform health care?

Thursday, February 5, 2009

How can we afford NOT to spend money to make health care more effective?

A Washington Post editorial today criticizes President Obama for seeking a stimulus package that is (in the President's own words) "not merely a prescription for short-term spending" but a "strategy for long-term economic growth in areas like renewable energy and health care and education." This, the Post says, is "precisely the problem" and "even potentially meritorious items, such as ... billions more to computerize medical records, do not belong in legislation whose reason for being is to give U.S. economic growth a 'jolt.'"

The Post was writing about an opinion piece by President Obama, in which he takes on "misguided critics" of his plan who say that "we can ignore fundamental challenges such as energy independence and the high cost of health care and still expect our economy and our country to thrive." Instead, the President says, "Now is the time to protect health insurance for the more than 8 million Americans at risk of losing their coverage and to computerize the health-care records of every American within five years, saving billions of dollars and countless lives in the process."

As I write this, a group of U.S. Senators is working to strike from the stimulus bill funding for a variety of programs that, in their view, will not provide immediate help to the economy.

Let's think about this. Health care costs are, in the words of the Congressional Budget Office (CBO), the "greatest fiscal challenge" facing the United States.

Spending money on health IT will likely produce jobs in the short-term (someone has to design, sell, install, update, maintain the systems, and provide support to practices on implementation and use). But the benefits of spending money on health IT can't just be measured by the numbers of jobs produced. Health IT has the potential to lower health care expenses by billions of dollars, reduce medical errors, and improve quality (CBO).

Other programs in the stimulus bill, like funding for comparative effectiveness research and training more primary care physicians, can bring enormous benefit to the economy by creating the infrastructure needed to improve health care outcomes and reduce the costs of care. Yet they are also vulnerable to being struck.

On this issue, the president has it right, and his critics, wrong. In a letter sent this afternoon to all U.S. Senators, ACP urged that programs to fund health IT, comparative effectiveness research, and primary care be kept in the bill.

Today's question: If you had $800 billion to spend, would you spend it: (1) only on programs that may create jobs in the short-term, but may produce little long-term economic gain for the economy or (2) programs that can create jobs now and help the economy over the longer haul by lowering health care costs?

Tuesday, February 3, 2009

The road to health reform gets bumpier and bumpier ...

A few minutes ago, the White House announced that Tom Daschle withdrew his name from nomination for Secretary of the Department of Health and Human Services. Faced with increasing Senate opposition over his failure to pay over $100,000 in back taxes, Daschle apparently concluded that he had no choice but to pull his name.

Daschle's withdrawal puts a big bump in the road to health reform.

With no obvious runner up, there likely will be weeks of delay in identifying, vetting, nominating, and confirming the next Secretary of HHS. In the meantime, HHS will be rudderless.

Rudderless at a time when HHS may soon have to figure out how to distribute tens of billions of dollars for health care and information technology included in the economic stimulus bill.

Rudderless at a time when the agency is required to conduct a policy review of regulations inherited from the Bush administration.

Appointments to other key agencies that fall under HHS, including the Administrator of the Centers for Medicare and Medicaid Services, will remain unfilled as long as the secretary position is vacant.

President Obama also loses his right hand man on health care reform. Daschle had been hand-picked by the president to spearhead the administration's health reform initiative, to the point of being given an office in the White House. But this role too is now gone. "I will not be the architect of America's health-care reform, but I remain one of its most fervent supporters," Daschle said in announcing his withdrawal.

Daschle's views on health care reform - in particular his support for primary care - provided a window into President Obama's health reform priorities. Now, this window is closed.

Daschle's withdrawal is hardly fatal to the President's efforts to reform health care. After all, we are only two weeks into the Obama administration, and there is time to get things right and get health care reform back on track.

But there also can be no denying that Daschle's departure is a setback for the new President and for his hopes to reform health care.

Today's questions: What kind of person do you think President Obama should be looking for to run HHS and carry out his vision for health care reform?

Monday, February 2, 2009

What is the State of the Nation's Health Care?

This is the time of year when the President usually makes his State of the Union address. Although President Obama has not yet announced when he will make his report to Congress, ACP didn't wait to release its own assessment of the state of the nation's health care.

At a briefing this afternoon at the National Press Club in Washington, ACP President Jeff Harris, MD, FACP, and I presented the report, Assuring universal access to health coverage and primary care: A Report by America's Internist on the State of the Nation's Health Care and Recommendations for Reform, to reporters.

The report challenges policymakers to ensure that every American has access to health insurance coverage, and to a primary care physician. It proposes the following policies:

- Enactment of legislation to help people keep their coverage during the recession followed by a comprehensive plan to guarantee affordable coverage. As coverage is expanded to more persons, there should be simultaneous, sufficient and sustained policies to grow the primary care workforce.

- Develop specific and measurable goals on the numbers and proportions of primary care clinicians needed and benchmarks to evaluate the impact of federal policies to attain those goals.

- Take immediate steps to make primary care compensation competitive with other specialties. For instance, Medicare payment increases of 7-8% per year over five years would be needed for primary care compensation to be at the 80th percentile of all other specialties. Right now, the average compensation of primary care doctors is 55% that of other specialists. Commercial payers would need to implement comparable increases.

- Expand the Patient-Centered Medical Home model to more states, more practices, and more patients.

- Conduct a systematic review of paperwork burdens.

- Increase funding for primary care training programs and create new programs to eliminate medical education debt for primary care physicians in a critical shortage area or clinic.

Finally, the report recommends that President Obama issue an Executive Order on Increasing Primary Care Workforce Capacity to ensure that all federal agencies are working together seamlessly to design, implement, measure, and evaluate programs to increase primary care workforce capacity.

A presidential executive order would send a powerful signal to young physicians and medical students - as they are about to make life-time career decisions - that the federal government is serious, really serious, about making primary care a competitive career choice. It would also send a powerful signal to primary care physicians in practice that they need to hang on, that better days are ahead.

I urge you to read ACP's report and the supporting materials included with it.

Today's question: Do you agree with ACP's assessment of the state of the nation's health care and our recommendations for reform, including increasing primary care compensation to be competitive with other specialties?