Friday, July 31, 2009

Congress to recess without finishing health reform (me too!)

Congress today effectively wrapped up action on health reform until September. The House leaves town today, the Senate at the end of next week.

The Hill reports that the Energy and Commerce Committee has reached an agreement to win the support of dissident conservatives and liberal Democrats. As a concession to conservative "Blue Dog" Democrats, the Energy and Commerce agreement reportedly will require that a public plan negotiate rates with physicians and hospitals, up to the prevailing rates of private insurers in the market, instead of using Medicare rates. As a concession to liberal members, who have sharply criticized what they view as a "weakening" of the public plan option, the bill will allow the federal government to negotiate drug discounts under Medicare Part D. ACP supported both of these changes.

In the Senate, the HELP committee has done its part, but Senator Max Baucus (D-MT), chair of the Senate Finance Committee, announced that he needs the August recess to complete an agreement that he expects will win some GOP support.

Even so, health reform legislation has advanced further in Congress than it ever did when Bill Clinton was president.

During the next few weeks, voters will be subjected to an onslaught of advocacy advertising, robo-calls, town hall meetings, and presidential speeches, all designed to swing voters to support or oppose the legislation. Polls show a public conflicted by two impulses: large majorities still support major reform or even a complete rebuilding of the health care system, but there is rising anxiety about the cost and the impact on their own care. The battle being waged is over which sentiment will prevail.

I continue to believe that physicians' views will be critical in shaping public opinion, yet as long as the profession remains sharply divided, it will have less influence than if there was a sense of common purpose.

ACP, for its part, continues to believe that health reform is essential. Not any reform, but reform that delivers on ACP's priorities.

- Affordable coverage that builds upon and creates incentives for employers to provide coverage and for individuals to buy it;
- Subsidies to help people buy qualified coverage through a large group purchasing pool, giving them access to the best rates;
- Insurance market reforms so that health plans compete on improving patient care, not cherry-picking healthy patients;
- Increased Medicare payments, scholarships and loan forgiveness to retain and recruit more primary care internists;
- Putting an end to the annual cycle of Medicare doctor payment cuts due to the flawed Sustainable Growth Rate (SGR) formula;
- Reducing the enormous costs associated with frivolous malpractice lawsuits and defensive medicine.

I know that internists don't agree on some aspects of health reform, but these are "common ground" priorities that came from ACP members, long before the current administration and Congress were elected. Except for the inexplicable unwillingness of Congress and the President to deal with the medical liability problem, the bills pending in Congress have policies that advance each of our priorities, but none of them will be passed "as is" and they all need work. As they are revised, internists need to remain engaged to shape the final outcome, and I hope you will support us as we work to ensure that any final bill includes the above priorities.

As Congress recesses, so will I. Next week, my family and I are traveling to the United Kingdom to spend a few weeks with my sister, a career foreign service officer who works at the American embassy and lives in London. We also planned a side trip to Paris. You won't be hearing much from me until I return in a few weeks. (No, I won't be blogging about the U.K and French health care system, unless our vacation takes an unfortunate turn of events!) But this blog will remain active: several of my ACP colleagues have graciously agreed to post "guest blogs" and I will be leaving a few to be posted in my absence.

Cheers and au revoir!

Wednesday, July 29, 2009

What's the deal with the deals?

The late-breaking news from Washington is that deals have been made in both the House and Senate to trim the cost of health care reform. Not a lot of details yet, but the Washington Post reports that House Democrats have reached a tentative deal with conservative "Blue Dog" Democrats to cut "$100 billion from the cost of the legislation and would not pay health-care providers [under a public plan option] based on Medicare reimbursement rates." A final vote on the bill will be put off until after the August recess. In return, the Blue Dogs agreed to allow the final committee of jurisdiction, the House Energy and Commerce Committee, to complete the process of considering amendments to the bill so it can be voted out before the House recesses on Friday.

On the Senate side, Senator Max Baucus (D-MT), chair of the Senate Finance Committee, has reached a preliminary deal with three Republican Senators to lower the cost of the bill by $900 billion over ten years. The Washington Post says the deal will substitute non-profit regional health care cooperatives for a public plan and make additional cuts in Medicare, including provisions to "scale back Medicare payments to physicians, a long-promised but costly provision." (I think what the Post writer meant to say is that the bill will scale back relief from the Medicare SGR payment cuts, not pile on more cuts in addition to the SGR.) The deal reportedly will also replace broad based tax increases on upper income earners with "targeted" tax increases and to create "incentives" for employers to provide coverage instead of taxing those who do not.

From one standpoint, the deals will help move the legislation forward by winning support from conservative Democrats and at least a few Republicans. Rising public opposition to broad-based tax increases may be ameliorated.

The risk is that the changes will lose the support of liberal Democrats and their progressive allies who will recoil at the process of "watering down" health reform by removing a public plan option and employer mandate. How far will the cost-trimming move back the goal posts from providing the vast majority of Americans with affordable coverage? (The Washington Post says that the Baucus deal would cover 95% of Americans, compared to 97% in the current version of the House bill. But this has not been verified.) Taking more money out of Medicare could lose the support of beneficiaries (where will the AARP come down?) and on providers who likely will bear the brunt of the cuts. Going back on plans to fund long-term relief from Medicare physician payment cuts could cost physician support. And you have to wonder if plans to spend billions of Medicare dollars to fund payment increases to primary care physicians are at risk of being dropped to meet the cost-saving targets. (Nothing specific to this effect has been reported, but one has to assume that any additional Medicare spending on physicians is vulnerable.)

The give and take of legislation inevitably leads to compromise, and some of the changes - like eliminating a requirement that a public plan pay doctors and hospitals based on the Medicare rates - are likely to win support from more doctors and hospitals. But at what point will the cost-trimming unacceptably compromise some of the principal goals of health reform, including providing everyone with access to affordable coverage and reversing the shortage of primary care physicians?

I expect that there will be later deals to change these deals, many of which will take place over the August recess, so this is hardly the end of the process. We will all have a chance to make our cases for an even better deal. For ACP, maintaining funding for primary care, stopping the SGR payment cuts, and ensuring that the legislation provides enough help to the uninsured remain critical objectives that must not be dealt away.

Today's question: Do you like what you hear about the deals being made to trim the cost of health reform?

Friday, July 24, 2009

Singing the health reform blues

The headlines in today's newspapers will give health reformers a bad case of the blues:

"Senate Won't Hit August Deadline" (Wall Street Journal)

"Health Reform Deadline In Doubt Process Could Be Slow and More Contentious" (Washington Post)

"For Public, Obama Didn't Fill in Health Blanks" (New York Times)

There is no question that the prospects for fast action on health care reform took a hit with yesterday's announcement by Senator Majority Leader Harry Reid that the Senate will not schedule a vote until after the August recess. In the House of Representatives, completion of the "mark up" by the House Energy and Commerce Committee has been delayed because of in-fighting between "Blue Dog" fiscally-conservative Democrats and more liberal members of the caucus.

From my standpoint, these setbacks mask the fact that substantial progress is being made. The negotiations in the House of Representatives may be more contentious and taking longer than many had expected, but I believe that the Democrats will reach agreement on ways to trim the cost of the bill that will bring most of the Blue Dogs on board, without losing too many liberal members.

The nature of the Senate is such that it always takes a long, long time to get agreement. Even with the Democrats so-called "filibuster proof" majority of 60, the party leadership can't afford to lose a single Democratic vote - this gives each Senator enormous negotiating power, which inevitably slows down the process. Senator Max Baucus, chair of the Senate Finance Committee, continues to report that "progress is being made" on reaching agreement that could win the support of two or three Republicans. (Although any agreement he reaches with Republicans runs the risk of alienating fellow Democrats whose votes will be needed in the end.) If the Senate Finance Committee reaches agreement on a bill, it will still have to be reconciled over the August recess with legislation reported out of Senator Kennedy's Health, Education, Labor and Pensions Committee.

Then the really tough negotiations will take in the fall. The House and Senate versions will have to be reconciled, and then the final product will need 60 votes in the Senate and a simple majority in the House to pass.

Yet despite all of these obstacles, there actually is pretty solid agreement among the Democrats (and even some Republicans) on the many of the core elements of health reform legislation: expansion of Medicaid to cover the poor with the federal government picking up the tab; sliding scale tax credits to help people buy coverage through a purchasing pool or alliance; an individual insurance mandate; improved coverage for preventive services; insurance market reforms to ban cherry-picking by insurers; workforce and payment policies to increase the numbers of primary care physicians; and payment reforms to link payments to the value of care rendered instead of the volume of services. These policies all are closely aligned with ACP's recommendations.

The remaining issues are tough ones: how to pay for health care reform and reduce the cost of the package (taxes and savings); the role of a public plan; and employer-mandates. Yet, I don't think any of those issues are beyond the capacity of Congress and the President to find common ground.

Despite the gloom and doom headlines, the fact is that health care reform has already advanced further in the legislative process than at any time in history, with two of the three House committees of jurisdiction and one Senate committee approving their respective versions (and in the House, all three committees are working together to produce a single bill). Congress never got anywhere near this close when Bill Clinton was president.

Today's question: Do you think the recent developments are bumps in the road to health care reform, or an indication that the whole effort is heading for collapse?

Tuesday, July 21, 2009

"Don't tax him. Don't tax me. Tax that man behind the tree!"

This quote, famously attributed to the late Senator Russell Long of Louisiana, pretty much sums up reaction to the various ideas being put forward to pay for health care reform.

Both the New York Times and the Wall Street Journal report that Speaker of the House Nancy Pelosi hopes to scale back or even eliminate the tax surcharge proposed on "higher income" households, which will require that the House go back and revise its bill, H.R. 3200, to find more savings or "offsets." The Senate, for its part, has signaled that it is disinclined to pay for health care through an income tax surcharge, and reportedly is looking at taxing high cost insurance plans, limiting the amount of employer-sponsored health insurance that is treated as tax free income, and raising taxes on sugary and alcoholic beverages and other "health-related" taxes, among other options. Each of these options, though, will surely be opposed by those whose oxen will be gored.

The reality, of course, is that no one likes seeing their taxes go up, especially for something that that they think they are getting tax free. But are they really?

No, because each and every one of us already pays for the uninsured. We just don't see it as a line item on our IRS 1040s. In 2004, the ACP published a white paper that cited studies on the estimated costs associated with lack of health insurance. One respected peer-reviewed study found that total medical care received by the uninsured in 2001, including both the full-year and part-year uninsured, was $98.9 billion. This is almost exactly the same as the little over $100 billion per year that the CBO estimates would be the cost to provide coverage to just about everyone under the House bill.

Another study co-funded by ACP Foundation and the New York Academy of Medicine, found that over two-thirds of internists treat uninsured patients who are unable to pay the physician's usual fee, charging them a reduced or no fee and/or creating a payment plan. Approximately 60 percent of internists who provided any charity care provided between a quarter of an hour and five hours per month, while another 15 percent provided six to 10 hours monthly. The Institute of Medicine found that for the entire uninsured population of roughly 41 million Americans in 2002, the aggregate, annualized cost of diminished health and shorter life span was estimated to be between $65 billion and $130 billion for each year of health insurance forgone.

In other words, we all pay for the uninsured: through higher health insurance premiums and higher Medicare payroll taxes associated with cost-shifting, from the lost productivity and lower earnings that result when people don't have health insurance, from higher federal, state and local taxes to pay for safety net programs, and from the uncompensated care provided each and every day by physicians.

The debate today shouldn't be over raising taxes to cover the uninsured. Instead, it should be over whether it is better to continue to hide the $98 billion we already spend on the uninsured, or to make it explicit by having the federal government collect the taxes and find the savings needed to cover everyone. The price tag is about the same - just about $100 billion per year plus or minus. But one would continue a "hidden tax" that still leaves 47 million without health insurance, while the other would help fund coverage for 97 percent of Americans.

Factoring in the enormous human and economic costs of being uninsured, it seems to me that it would be cheaper to increase taxes and find the savings needed to cover everyone. We should debate who should be taxed and how, but let's not pretend we aren't already paying.

Today's questions: Do you think it is more effective for the government to collect taxes to pay for universal coverage - or to maintain the current system of paying for the uninsured through cost-shifting to others? If taxes need to be raised, who would you tax?

Monday, July 20, 2009

Winners and losers under the House's health reform proposal

On Friday, the CBO released new estimates of H.R. 3200's impact on coverage and the federal budget. CBO's estimates allow us to "follow the numbers" to locate the winners and losers.

The biggest winners? People who can't get insurance because they can't afford it or because they are sick. CBO estimates that 97% of Americans would have coverage by 2019. Also, persons eligible for both Medicaid and Medicare, who will benefit from a new prescription rebate program, and beneficiaries who would get expanded prescription drug coverage to cover Part D's infamous "doughnut hole."

Where would most people get coverage? Through employer-based (private) insurance, not the public plan option. Here is CBO's breakdown. By 2019:

- The number of uninsured would drop by 37 million compared to current law (from a projected 54 million uninsured to 17 million uninsured).

- The number of persons covered by their employers would increase by 2 million, from an estimated 162 million to 164 million persons.

- The number of people covered through the health exchange would go from zero to 30 million persons. (Of these, CBO previously estimated that 8 t0 9 million would be in the public plan.)

- The number of people covered by Medicaid and SCHIP would increase by 11 million, from a projected 35 million to 46 million. (This is mainly due to the bill's requirement that Medicaid cover everyone up to 133% of the FPL.)

- The non-group (individual) insurance market would see a decrease of 6 million persons, from a projected 14 million persons to 8 million persons. This is likely due to the fact that the bill requires that all insurers, including those in the individual insurance market, abide by rules relating to acceptance of patients with pre-existing conditions, guaranteed renewability, and modified community rating.

The other winners? Physicians, who would benefit from higher spending at time when most other "providers" will be subjected to payment cuts. The CBO has this to say:

"Provisions that would result in the largest savings include permanent reductions in the annual updates to Medicare's payment rates for most services in the fee-for-service sector (other than physicians' services), yielding budgetary savings of $196 billion over 10 years ... [emphasis added in italics].

The provision that would result in the largest increase in Medicare spending would change payment rates for physicians' services to replace the 21 percent reduction in payment rates scheduled for January 2010, under the existing "sustainable growth rate" formula, with an inflation-based update. In subsequent years, rates would reflect separate updates for "evaluation and management" services and for all other services. CBO estimates that those changes would cost $228 billion over the 2010-2019 period (before taking into account interactions). Including those interactions, the net cost of the changes in physicians' payment rates would total $245 billion." [emphasis added in italics.]

CBO also estimates that Medicare will spend $6.4 billion more on designated services by primary care physicians.

The CBO's estimates could be wrong, since modeling behavior over 10 years is an uncertain science. Still, the "bottom line" is that the bill would provide affordable coverage to almost all Americans. They will get their coverage mostly from employer-based private insurance. No one would be turned down or overcharged because of a pre-existing condition. Physicians will benefit from the hundreds of billions of dollars being spent to end the Medicare SGR cuts, while payments to insurers, hospitals and drug companies would be cut by hundreds of billions of dollars. Primary care doctors would get even more.

Today's question: What is your take on the CBO's report?

Friday, July 17, 2009

The battle for doctors' hearts and minds (day three)

Well, the critics of our decision to support the House bill are certainly having their say. My posting from yesterday brought out the predictable howls of protest. Rather than focusing on the issues, though, a few of the comments engaged in over-the-top attacks on the honesty and motivations of their physician colleagues who are in leadership positions in organized medicine. I allowed some of them to be posted (including one that accused us of treachery), because otherwise, I would have been accused of suppressing criticism.

By the same token, though, I view this blog as place for people to have a respectful exchange of views. I don't think most our readers want this to become a place where people can just "flame" other people. Other bloggers may be more interested in fanning outrage rather than an informed discussion of the issues, but this isn't the palace for that. If you submit comments that cross the line from respectful discourse to invective, don't be surprised if they aren't accepted.

Most of the critics, though, were heartfelt in explaining the issues that concerned them. The biggest concern continues to be that the public plan option would lead to government-run (some called it "socialized" medicine). As I reported yesterday, the public plan is set up in a way that this isn't likely to happen. Under the House bill, the public plan option would be limited to only those who are eligible to get coverage through a health exchange (basically, those who don't have employer-sponsored coverage and don't qualify for Medicaid, SCHIP and Medicare). Of those persons, the CBO estimates that only about 8 or 9 million will likely enroll in the public plan, mainly because physician participation in the plan is completely voluntary. What about everyone else? 164 million would be covered by employer-sponsored plans, and the rest in Medicare, Medicaid, and SCHIP, according to CBO. This is two million more people who would be covered by employer-based private insurance than what the CBO expects would be the case under current law. (If the critics have data to show that the CBO is wrong, and everyone will end up in a public plan, I'd like to see it.)

I also expect that the public plan option is likely to go through many, many changes before (or even if) it becomes law. There is that other chamber of Congress - the Senate - and they are looking at things very differently.

Others criticized the tax surcharge on the well-off. To be clear, ACP did not endorse the tax surcharge, because we are guided by policy, and our policies only address tax issues that are directly related to health (like tax credits for the uninsured). Our letter to the House had this to say: "Although we do not have policy on the specific tax surcharge provisions called for by the bill, the College urges Congress to consider a variety of approaches to finance coverage including ones that encourage individuals to make prudent decisions affecting use of health care resources." This is another case where the Senate has other ideas and I would expect the financing to be substantially changed later in the process.

Some expressed concern that the bill will add to the federal deficit and the nation's debt, citing a new statement from the CBO that calls into question whether the House bill will pay for itself without adding to the deficit. Congress' own budget rules require that health care reform be fully paid for, so I expect that adjustments will be made in the legislation to bring down the costs.

Others vent that the House bill makes nurse practitioners equivalent to doctors. It is true that the bill defines NPs as primary care providers in several places, mainly to make them eligible for scholarships and loan forgiveness and to allow them to participate in pilots of the medical home. But nothing in the bill allows them to practice beyond the scope of their state licenses. The bill doesn't change Medicare's rules that pay NPs at a lower rate than physicians. The programs in the bill are directed at increasing the numbers of primary care physicians and NPs, not substituting NPs for physicians.

Finally, some felt that ACP and AMA were settling for too little. As I have said before, H.R. 3200 is by no means perfect. It falls short in several important respects - most notably, the Medicare payment increases for primary care are not enough, by themselves. ACP will continue to work for strengthening the payment reforms for primary care, but we are in a much better position to do this than by being supportive. Legislators help those who help them. The opposite is also true.

H.R. 3200 is just the beginning of the process. I stand by my view that most of the policies in the bill are good for patients and doctors, but we will have plenty of chances to make improvements before a bill is signed into law.

I look forward to continuing this discussion, and have a good weekend.

Thursday, July 16, 2009

The battle for physicians' hearts and minds (part two)

The natural tendency for most people, is to put off a difficult choice as long as possible. So instead of taking definitive positions on controversial issues, we sit on the fence.

Before too long, though, fence-sitting can be pretty darn uncomfortable. When the fence separates two warring parties, getting off requires that we make a decision on which side to join. Staying on the fence, though, guarantees that we'll get caught in the crossfire.

Release of the House's health care reform bill is forcing physicians to get off the fence. They are deciding if they want to be on the side that wants President Obama and Congress to succeed in getting health care reform enacted this year. Or, to join forces with those who want to stop them.

(Opponents of the current bills will say that they aren't against health care reform, just against how the Democratic majority and President Obama plan to go about it. Fair enough. But as a practical matter, the opponents don't have the votes to pass their alternatives - whether it is small government, market-based reform from the right, or a single payer system from the left. So if they are successful in getting Congress to defeat health care reform for this year, they likely will have killed health care reform for the remainder of Obama's presidency. Which, I suspect, is what most of the opponents really want, when all is said and done.)

Choosing sides is particularly hard when you represent a diverse membership like ACP's - or the American Medical Association's. We have liberals and conservatives and everything in between. We have generalists and subspecialists, city dwellers and country doctors, red-staters and blue-staters, solo doctors and doctors in mega-group practices. We have the glass-half-empty pessimists and the glass-half-full optimists. We have starry-eyed idealists and rock-ribbed cynics. I hear from them all.

It is also hard when you are a non-partisan organization, like ACP, knowing that any decision you make on supporting a bill that is being championed by one political party (in this case the Democrats) will be opposed by most members of the other political party (in this care, Republicans). We had the reverse a few years ago when ACP took its lumps from Democrats for supporting the Republican-championed Medicare Part D drug bill.

I think it is significant then, that the largest medical organizations in the United States, representing the most diverse memberships, have all decided to be supportive of the House bill. Letters of support have been sent by the American Medical Association, ACP, the American Academy of Family Physicians, American Academy of Pediatrics and the American Osteopathic Association. The American College of Surgeons is also expected to support the bill.

Why did these organizations, which collectively represent the vast majority of physicians in the United States, decide to get off the fence and take a stand in favor of the House bill? One explanation is that we all are suffering from mass insanity, as one commenter said about ACP in response to my post yesterday. If one assumes though that we haven't all lost our collective minds, then I would hope that the critics of our positions would consider our reasons for support, and offer a considered rejoinder if they disagree.

For ACP, the reasons for our support are pretty clear: the bill does much of what we asked Congress to do in terms of coverage, support for the primary care workforce, payment and delivery system reform, based on long-standing policies that have been adopted by this organization. We would support any bill that accomplishes our goals in a way that is consistent with ACP policy, whether championed by Republicans or Democrats, but prefer when they are supported by both. (This, regrettably, is rarely the case these days.) Most importantly, we believe that the status quo is not in the best interests of doctors or patients, and that the risk of staying with the status quo is greater than the risk of change.

This doesn't mean we are fully satisfied with the bill. We will, for instance, continue to seek more meaningful improvements in pay for primary care and push our ideas on how a public plan should operate. But we have to stay at the table if we want to make such improvements, because the game will go with or without us.

Today's questions: Do you think it is possible for large and diverse physician membership organizations, like ACP and AMA, to keep their membership (mostly) together on issues as controversial as health reform? If so, how?

Wednesday, July 15, 2009

A battle for physicians' hearts and minds

Yesterday, the chairmen of the three House committees with jurisdiction over health released America's Affordable Health Choices Act of 2009, H.R. 3200, a comprehensive bill to reform U.S. health care. With release of the bill, we can expect to see an intensification of the battle that is underway already to sway physician opinion.

ACP has concluded that the bill goes a long way in addressing the College's priorities for health reform.

On coverage, it creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage. It reforms the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. It provides for sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.

On workforce, it would create an advisory process to set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians, and includes polices to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need.

On payment and delivery system reform, the bill would eliminate the accumulated Medicare SGR payment cuts, provide a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and create a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care. It increases Medicare payments for designated services provided by primary care physicians - not as much as we would like, but it is a start. It raises Medicaid payments for primary care until they are equivalent to Medicare. It provides funding that is provided to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home.

H.R. 3200 also would fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making, as called for by ACP. It also include provisions in the bill to simplify and reduce the costs associated with interactions with health plans.

So what's not to like? These are the principal arguments that critics are using to sway doctors to oppose the bill:

The say that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.

The idea that the public plan would destroy private insurance is not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many of 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons - 164 million, an increase of two million persons compared to current law - would be covered by employers.

Opponents also argue that Comparative Effectiveness Research would lead to rationing of care by government bureaucrats. Actually, there is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.

I understand that died-in-the-wool conservatives aren't likely to support H.R. 3200, because of the cost and the expanded role for government. Just as I wouldn't expect support from died-in-the-denim liberals who believes that Canadian-style health care is the only answer. But on the policies that matter most to ACP, I believe that the bill moves things in the right direction and deserves internists' support.

Today's questions: Who do you think will win the battle for physicians' hearts and minds? Health reform advocates who support expanded government regulation of insurance and subsidies to help people buy it - and a strong public plan? Or critics who argue that Congress' approach to health reform will lead to a government take-over of medicine and rationing of care?

Friday, July 10, 2009

Are doctors and non-physicians speaking the same language when they define primary care?

I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.

The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.

The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.

As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.

The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.

I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.

But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.

Today's question: Do you think primary care means the same thing to the different health professions?

Wednesday, July 8, 2009

The summer of internists' discontent

A review of the comments posted to the ACP Advocate blog would suggest that internists (or at least those who take the time to read and respond to my posts) are a pretty disgruntled bunch.

Primary care internists express unhappiness that health care reform is not going to raise their fees by enough to achieve parity with other specialties. Many also resent the encroachment of nurse-practitioners. As one of commenter wrote, "Far from having a rejuvenated PCP workforce, we will end up with an angry, bitter, fed up and revolting specialty workforce, with manifestations such as disinclination to take call, cherry picking referrals, early retirements and other such actions that will make a PCPs life far more difficult." Even when the news is positive, such as my blog about a Medicare proposed rule to yield a 6 percent increase in total allowed Medicare charges to general internists, the reaction was, well, less than enthusiastic - "tossing primary care a bone" is how one comment described it.

Subspecialists aren't a happy lot, either. Cardiologists are livid that their total Medicare allowed charges would be cut by 10% under the same CMS proposed rule. Endocrinologists are upset about a proposal to eliminate higher Medicare fees for consultations and to redistribute the savings to other evaluation and management codes.

Single payer advocates are mad that the College hasn't endorsed a Canadian-style health care system. Conservatives take issue with just about anything that smacks more government involvement in health care. Some of our members want ACP to enthusiastically embrace a public plan option, while others want us to vigorously oppose it.

Even ideas championed by ACP itself, like paying internists for the work involved in care coordination through a qualified Patient-Centered Medical Home, are viewed with skepticism by some ACP members, especially those in smaller practices, and outright hostility by some.

I bring this up not because I have a problem with internists' expressing their views, even when sharply critical of proposed health care reforms and the ACP itself. The blogosphere is not a place for thin-skinned people.

But as we debate what is wrong with the health care reform prescriptions coming from Washington, I hope we don't lose sight of the consequences if health care reform fails.

Does anyone really believe that doctors and patients will be better off if health reform falters and we continue the status quo? If the ranks of the uninsured are allowed to grow? If insurance companies are allowed to continue to turn down or charge exorbitant rates to people with pre-existing conditions? If small businesses can't hire people and pay decent wages or even keep their doors open because of the rising costs of health plan premiums? If the Medicare trust fund is allowed to go broke? If health care reform dies, and along with it, our best chance to begin to restructure workforce and payment policies to support primary care?

I believe that the U.S. health care system is a train wreck in waiting, and that 2009 may be our best and perhaps only chance to put it on a safer track. We have within our grasp the chance to enact legislation to provide affordable coverage to most Americans, to make the cost affordable and sustainable for families and businesses, and to begin to rebuild the primary care physician workforce. Yes, I understand why so many internists are unhappy with the way things are, and distrustful of the changes being proposed to make things better. I also respectfully suggest that there will be far more reasons for internists to be discontented if health care reform is allowed to fail.

Today's question: Do you think internists and patients will be better off if the effort to reform health care collapses?

Tuesday, July 7, 2009

Hospitals to Obama: Deal us in!

The hospitals are the latest to strike a cost-cutting deal with the White House, according to the Washington Post. While the details have not yet been released, the hospitals reportedly have agreed to a $155 billion cut over ten years, mainly from phasing down extra payments for indigent patients (called disproportionate share payments) as coverage is expanded to the uninsured. Last month, the pharmaceutical industry struck a similar deal to trim Medicare Part D expenditures by $80 billion over the same time frame, bringing the combined savings from the hospitals and drug companies to some $335 billion, or about a third of the estimated trillion dollars required to fund pending health care reform legislation. The Wall Street Journal reports that the insurance industry is poised to chip in another $100 billion in savings.

Opposition to cuts that adversely affect their members is part of the DNA of these powerful health care sectors. Why are they now agreeing to cuts? What's in it for them?

One is that such deals may ward off even bigger cuts, like the $200 billion in cuts to hospitals that Obama proposed in his budget. It also gives the industry groups more leverage over other elements - for instance, the hospitals reportedly received assurances that the public plan option will not be based on Medicare rates.

Not everyone in Congress is pleased with such deals. Politico reports that some powerful House Democrats are stewing because the agreement with drug companies could deny them access to the "tens of billions of dollars that House Democrats would argue were given away to drug manufacturers as part of the bargaining in the Republican-backed Medicare prescription drug."

Despite the rumblings in some quarters in Congress, the White House clearly welcomes agreements with industry that would cut the costs of health care reform. Especially if such deals keeps industry from launching "Harry and Louise" style attack ads.

Notably absent (at least so far) from such deal-making are physicians as represented by the American Medical Association. The AMA was part of the "bending the curve" group that promised to trim the rate of growth in health care expenditures, but to my knowledge, the AMA is not making promises to the White House that lock in a certain level of savings or cuts from physicians.

This underscores that fact that physicians are in an unusual place in the health care reform debate. Congress is planning to spend more money on doctors, and even more on primary care doctors - the only question being how much more - while other sectors are being asked to agree to trim spending by hundreds of billions. Because of Medicare's sustainable growth rate (SGR) formula, physicians are facing a 21 percent payment cut next year, and unless Congress scraps the SGR, such cuts will continue, year-after-year-after-year. It will take hundreds of billions of dollars in increased spending on physicians just to wipe out the accumulated SGR cuts.

One simply can't expect a lot of savings from doctors when they already are facing deep cuts, and when they have not seen their Medicare fee updates keep pace with inflation for at least the past seven years. Also, initiatives that could generate long-term savings, such as payment reforms designed to align physician payment incentives with the value of care provided, are going to take years to roll out and not likely to achieve immediate budget savings.

Congress and the White House may not ask physicians to pony up more savings, but they do expect that physicians will recognize and support their efforts to wipe out the accumulated Medicare pay cuts and raise primary care fees, and that doctors ultimately will be on board in support of health reform.

Today's question: What do you think about the deals being made with industry? Should the medical profession itself be offering its own savings?

Thursday, July 2, 2009

Obama uses regulatory authority to give raise to primary care doctors

Yesterday, the Obama administration began to deliver on its promise to improve payments to general internists and other primary care physicians.

A proposed rule released yesterday by the Centers for Medicare and Medicaid Services would make major revisions in Medicare payment policies that "Taken together ... would increase [total Medicare] payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule)," according to the agency's press release. This shift occurs because the administration proposes changes in the Medicare relative values units (RVUs) for physician work, practice expenses, and medical liability expenses that generally are favorable to primary care, although some surgical and medical specialties also would benefit from the changes. CMS proposes to update the practice expense relative values to use the latest data on physician practice costs from a new AMA survey; this survey, which was co-sponsored by ACP and other specialty societies, show that internists' practice expenses are much higher than CMS previously had assumed.

This change alone would increase total Medicare allowed payments to general internists by 4 percent. Internists would also benefit from changes in the physician work RVUs (another 1 percent) and malpractice RVUs (another 1 percent) for a 6 percent total gain. In aggregate, total allowed Medicare payments to general internal medicine would increase by an estimated $10,061,000, according to CMS, more than any other specialty. (On a percentage basis, some specialties come out higher than general IM, but IM does the best in total dollars because the specialty starts with more Medicare allowed charges than others.)

Not all physicians will be cheering CMS's moves -- by law, changes in RVUs are budget neutral. The agency proposes a big cut in payments for imaging procedures, which would result in deep cuts to cardiologists and radiologists. It also proposes to eliminate the policy of paying for consultations at a higher rate than other initial hospital visits; these dollars would be redistributed to non-consultation visit codes. Many internal medicine subspecialists will likely object to eliminating the distinction between the work involved in consultations and the usual initial hospital visit.

Another change will win the applause of all doctors. The administration proposes to remove physician-administered drugs, like chemotherapy, from the definition of physician services under the Sustainable Growth Rate (SGR) formula. This would have the effect of reducing the negative updates (cuts) to physicians that are triggered whenever spending on physician services (which will no longer include the costs associated with physician-administered drugs) comes in higher than the allowable SGR target. It will also reduce the budget cost to Congress of enacting a long-term solution to the SGR problem by incorporating these costs into the Medicare baseline. ACP, the AMA, and other physician groups had long argued for removal of drugs from the SGR formula.

Public comments on the proposed rule will be accepted through August 31. The Medicare payment changes proposed by CMS, if included in the final rule following public comment, would go into effect on January 1, 2010. ACP will be analyzing the proposed rule, and will seek input from internists, generalists and subspecialists alike.

While ACP may not end up agreeing with every aspect of the proposed rule, it is a very positive sign that the Obama administration has decided not to wait for Congress to begin re-aligning Medicare payment policies toward primary care. Any changes that Congress may subsequently enact, such as providing a primary care bonus payment, would be on top of the new payment scale proposed by CMS.

Another indication of the administration's interest in primary care is that Dr. Fred Ralston, ACP's President-elect and a practicing general internist from Fayettsville, TN, and I will be participating in a primary care roundtable, hosted today by Nancy Ann Deparle, director of the White House Office of Health Care reform, at the White House. You can watch the proceeding via streaming video from 2 p.m. to 3:30 today, EDT.

Today's question: Do you agree that these proposed new policies show that the Obama administration is serious about improving payment for primary care?

Wednesday, July 1, 2009

No we can't! No we can't!

The defining symbol of Obama's campaign was thousands of people joining together to chant "Yes we can! Yes we can!"

The defining symbol of health care reform, at this critical juncture, could be the growing chorus of "No we can't!" to health care reform - or, at least to the parts of reform not to a particular group's liking.

Hospitals are saying "No we can't!" to Medicare pay cuts to fund health care reform.

Labor unions are saying "No we can't" to taxing health benefits (above a certain premium cost) to pay for health coverage for the uninsured. They also are saying "No we can't!" to health reform that doesn't include a public plan option like Medicare - and some unions are even attacking Democrats who disagree.

Insurance companies are saying "No we can't!" to health reform that includes a public plan option like Medicare.

Employers, for the most part, are saying "No we can't" to mandates that they provide coverage to employers or pay into an insurance pool. Today's announcement that Walmart supports an employer mandate is one welcome, and highly notable, exception.

To be fair to the groups mentioned above, most of them say they want health care reform to happen this year. Some have shown a great deal of leadership in promoting positive reforms in the health care system. They would tell you that their objections to specific elements are in the spirit of getting a "good" bill passed.

What about physicians? My sense is that there is a broad range of opinions on issues like the public plan. Most physicians still believe reform is necessary, but some are focusing on the things they don't like (like expanded roles for nurses), and there is a vocal minority of doctors who are hoping that the whole thing "tanks" (as one physician commented yesterday in response to my blog post on Obama's views on primary care).

For its part, ACP believes that health care reform is imperative, and we support the broad outlines of the draft proposal being considered in the House of Representatives: sliding scale subsidies for people to buy affordable coverage through a health exchange, insurance market reforms, and payment reforms and funding for primary care.

It is one thing to express concern about particular elements of reform, but it is another thing to issue non-negotiable, take-it-or-leave it, line-in-the-sand, my-way-or-the highway statements that leave no room for consensus or compromise. There will come a point where the chorus of "No we can't" on particular elements will begin to drown out the more compelling reasons why we need health care reform, and undermine public support in the process.

Health care reform is about making sure that each and every American has access to coverage at a price they can afford, that no one is turned down because they have a pre-existing condition, and that they have access to a personal primary care doctor. It is also about creating a health care system that won't bankrupt American families, businesses, and taxpayers. In my mind, we can't afford not to achieve those goals.

Today's question: Do you think that those who are laying down firm markers on what they can't support will ultimately derail health care reform?