Tuesday, November 24, 2009

Emptying the cost control tool kit

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

What is a new President to do?

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

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

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

But the same cost-benders are under unrelenting attack.

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

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

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

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

Thursday, November 19, 2009

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

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

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

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

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

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

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

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

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

Wednesday, November 18, 2009

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

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

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

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

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

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

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

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

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

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

Monday, November 16, 2009

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

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

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

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

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

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

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

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

Tuesday, November 10, 2009

AMA reaffirms support for health reform -- with caveats

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

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

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

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

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

Monday, November 9, 2009

Tap-dancing through a minefield

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

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

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

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

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

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

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

Thursday, November 5, 2009

Will the House reform bill reduce health care costs?

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

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

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

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

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

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

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

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

Tuesday, November 3, 2009

My rockin' the U.S.A tour

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

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

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

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

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

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

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

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

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

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

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