Wednesday, December 23, 2009

How the Grinch Stole Health Care

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

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

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

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

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

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

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

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

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

Then they got an idea!
An awful idea!

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

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

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

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

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

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

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

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

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

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

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

Can still slay the ObamaCare beast!"

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

Thursday, December 17, 2009

Liberals Attack "Government-Takeover" of Health Care!

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

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

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

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

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

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

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

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

Wednesday, December 16, 2009

Pushing drugs to doctors and patients

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

Also of interest, according to the full report:

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

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

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

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

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

Tuesday, December 15, 2009

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

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

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


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

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

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

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

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

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

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

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

Monday, December 14, 2009

Should federal spending and taxes be taken away from Congress?

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

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

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

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

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

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

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

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

Thursday, December 10, 2009

Poor Grandma!

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

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

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

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

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

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

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

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

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

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

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

Monday, December 7, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday, December 4, 2009

Physician organizations split (again) on health care reform

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

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

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

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

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

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

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

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

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

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

Wednesday, December 2, 2009

The Politicization of Breast Cancer Screening

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

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

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

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

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

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

This is what Dr. Sweet had to say:

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

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

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

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