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.


LKleininDC said...

I was just given what is apparently language from the house bill from the section entitled "Protecting the Choice to Keep Current Coverage" "Limitation on New Enrollment." This language apparently reads "Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day" of the year the legislation becomes law. One of my patients who is a political consultant says this means that individuals who currently have private individual coverage won't be able to change it and that those who leave a company to work for themselves will not be able to purchase private insurance. The only option in these cases will be to participate in the public option. Is this correct? If so, won't this basically lead over time to most individuals not covered by Medicare and Medicaid becoming part of a public system based on Medicare rates?
Thanks for clarifying this.

John S. O'Shea, MD said...

I appreciate Bob Doherty's comments and responses to critics of the decision by the ACP, AMA, and now the American College of Surgeons to support H.R. 3200. The largest issue of contention, as he pointed out, is the inclusion of a public plan option to compete with private insurance.

I would, however, point out that the CBO estimate of 8-9 million is likely to underestimate the number of people who will enroll in the public plan. In testimony before the House Energy and Commerce Committee, The Lewin Group, a non-partisan health care research organization, estimated that as many as 113.5 million people may actually enroll in the public program, largely due to the "crowd out" effect on private insurance.

Bob Doherty is also correct that physician participation in the public plan will be "voluntary." However, as we learned from the managed care experience, if large numbers of patients are enrolled in a certain plan, the decision to participate is not completely voluntary.

The Lewin Group also estimates that physician incomes in general will decrease if the public plan option is included. Certainly, the public plan option will also increase the already considerable involvement of the government in the private practice of medicine.

Most importantly, the legislation has no chance of curtailing health care spending, according to the most recent estimate by the CBO. Although essentially all physicians want to see the American health care system become all it can be, it is difficult to see how H.R. 3200 will help accomplish the goal.

John S. O'Shea, MD
413 Stuart Circle
# 1D
Richmond, VA 23220

732 259-2892

Eb64MD said...

I strongly support the majority of the features of HR 3200. I do feel more attention needs to be given to measures to "bend the upward curve" of health care costs over time, downward.

jfddoc said...

Could "Capitation" be coming soon to Massachusetts in order to control the escalating costs of their universal health care plan?

the holmster said...

I am supportive of all that you've said. We have to have the public plan to be able to solve the problems resulting from the system of private insurance. My concern has to do with making sure the public plan saves money. If it ends up like Medicaid, which is out of control whatever drug and whatever procedure is wanted... then we are going to lose a grand opportunity to control costs. I think we need to help design a public plan that is bare bones cost effective. Agree?
Rick Holm SD

BDoherty said...

First, let me respond to LKeininDC's post:

The person who told you that the language on "Limitation on New Enrollment" would prohibit private insurance misunderstands the legislation. This misinformation may have come from an editorial in Investor's Business Daily, which also got it wrong.

The section on Protecting the Choice to Keep Current Coverage" "Limitation on New Enrollment" is in reference to a requirement that all insurers, whether offered through an exchange or outside it, comply with insurance market reforms, including prohibitions on excluding persons with pre-existing conditions, guaranteed renewability, and modified community rating, after an effective date. Insurers that do not meet such requirements would not be able to enroll additional persons but the legislation provides for a “grandfather” period, though, where people can elect to keep their current individual coverage even if it doesn't meet the new requirements. ACP policy has long favored requiring that all insurers, including those in the individual insurance market, comply with the insurance market reforms in H.R. 3200.

So the short answer is that the "grandfather" period would allow people to keep an individual insurance plan even if it doesn't meet the insurance market requirements, but after the effective date, insurers could not enroll additional persons if they don't meet the requirements. This would not "kill" private insurance but instead would eliminate cherry-picking and underwriting practices by private insurers that exclude coverage of people with pre-existing conditions, which is a good thing for patients.

In response to Dr. O'Shea's comments, the Lewin analysis on enrollment in a public plan was done months ago based on a hypothetical public plan option, not the public plan and insurance market exchanges as proposed in H.R. 3200. I believe that the CBO analysis is more reliable because it is an analysis of the provisions in H.R. 3200 itself, not hypotheticals. The CBO acknowledges that there is uncertainty in the public plan enrollment estimates but their estimates are far, far lower than the Lewin numbers, mainly because the public plan in H.R. 3200 is available only to the estimated 30 million persons who can by coverage through an exchange, and of those, the CBO believes that only 8 to 9 million would enroll in the public plan--the vast majority would remain under employer-based coverage mainly because of the employer mandate in the bill.

John S. O'Shea, MD said...

I present the Lewin numbers not to argue, but only to show that the CBO numbers MAY significantly underestimate the impact and I think this is important.
I think what the CBO has correct is that the plan, as is, will not control spending and will actually increase the federal deficit.

Another problem is that the Medicare Economic Index was used by Medicare in the 1970's. Like all the efforts so far by Medicare to set prices and global spending targets, it did not reduce health care spending and was abandoned. I have not seen anything to make me think it will be more successful this time around. Although most physicians will take comfort in the fact that they won't be facing 21 per cent cuts in January, 2010,
using the MEI for future updates should not be confused with reform. We are likely to be back where we started in short order. (Spiraling costs and physicians being blamed)

BDoherty said...

On Friday, the CBO released an updated report on the impact of H.R. 3200. A few highlights:

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). 97% of Americans would have coverage.

By 2019, the number of persons covered by their employers would increase by 2 million, from an estimated 162 million to 164 million persons.

By 2019, 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 2019, 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 requirment that Medicaid cover everyone up to 133% of the FPL).

The only coverage sector that would see a decrease is the non-group (individual) insurance market, which would see a decrease of 6 million persons, from a projected 14 million persons to 8 million persons. This is likely do 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.

Still, any way you slice and dice the numbers, the vast majority of persons would continue to receive coverage under employer-based (private) insurance. But unlike our current insurance system, almost everyone would have access to coverage, within income based subsidies as needed, and no one could be turned down or charged an exorbitant rate because they have a pre-existing condition or got sick.

Could the CBO be wrong? Sure, making projections about coverage, especially over ten years, is difficult. Still, the "destruction of private insurance" criticism is clearly not supported by the CBO's analysis--they would have to have be off by hundreds of millions of Americans.

John S. O'Shea, MD said...

First of all, LKleinDC brings up a legitimate concern that should be part of the discussion and not dismissed out of hand.
Also, although the number of people with "health care coverage" under this plan will increase, as you know, health care coverage is not necessarily the same as health care.

For example, take the Medicaid program. In states like New Jersey, that has the lowest physician reimbursement rates in the nation, physician participation rates in the Medicaid program is dismal. Reimbursement rates often do not cover the cost of providing the services. According to data from the CDC, Medicaid patients use the emergency room for non-urgent problems at four times the rate of patients with private insurance. Simply increasing Medicaid eligibility may not be as good as it sounds. This also needs to be discussed.

Lastly, I would like to mention some numbers that you left out of the updated CBO analysis. have quoted them below:
"By the end of the 10-year period, in 2019, the coverage provisions would add
$202 billion to the federal deficit, CBO and JCT estimate. That increase would be
partially offset by net cost savings of $50 billion and additional revenues of
$86 billion, resulting in a net increase in the deficit of an estimated $65 billion. "
This is important.

BDoherty said...

I certainly am not dismissing anyone's comments out-of-hand, just trying to provide answers based on our analysis, CBO's and others. We have validated our understanding of the "Limitation on New Enrollment" with outside experts and Hill staff.

Dr. O'Shea is correct that the CBO shows that the bill will add about $219 billion to the federal deficit, but the principal reason for this is because the bill spends $245 billion over 10 years to stop scheduled Medicare SGR pay cuts to doctors, something that ACP, AMA and others have long advocated. The House instead could have done what every other Congress has done, enact a stop-gap halt to the following year's cut paid for by even deeper cuts in later years, and then repeating this cycle year after year after year while driving up the budget price tag that then has to be made up by cuts somewhere else under pay-as-you go rules. So physicians need to understand that it is because the House wants to do the right thing by physicians that the bill is projected to add to the deficit. Otherwise, it would have paid for itself. Congress will ultimately have to find the money to pay for the whole thing, without adding anything to the deficit, because its own budget rules require it to do so.

John S. O'Shea, MD said...

Let's please be clear, the fact that doctors were facing 21% fee cuts is not the fault of doctors. It is due to a flawed Medicare payment system. The idea that we are somehow being "let off the hook" because Congress feels benevolent is somewhat disingenuous.
We should also be clear that using MEI for future updates will not reform the payment system. It's been tried. It is part of the history of how we got here.

Unknown said...

An update on Read the Bill:
Read the Bill please
I apologize that my prior posts are signed only with my first name. I could not get the software straight.

Christie Hopkins, MD
Columbia, SC