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?


PCP said...

None is surprised by the action of the Surgeons. I suspect Medical Proceduralists will have many of the same issues.
Once again I reiterate, that the root cause of this is the severe distortions in physician manpower and income levels caused by the AMA endorsed RUC, and the RBRVU system, which severely tilts work RVUs in favor of proceduralists.
Once again while you so diplomatically state that the AMA has come out in the middle, they have made it clear that they categorically oppose the formation of a Medicare commission. The AMA has always, still does and until it is unable to do so, will support the RUC. As long as the RUC sets payment policy, the status quo will prevail. That is the bottom line, make no mistake about it.
As I have repeatedly said, if we all agree that we all bring value to the health system, that we each have a collegial respect for the work we do, then we have a starting point for rational discussion. If on the other hand, the oft heard condesencion amongst proceduralists for PCPs is the order of the day, no compromise is ever possible. Needless to mention to this audience, the job of PCP is an arduous one, it is filled with long hours, with dealing with a lot of non medical issues, much more paperwork, and a whole lot more hassle which I am sure readers are familiar with. It is nonetheless vitally needed work, Needed for everything from good quality care to continuity of care, for timely care as well as cost effective care. Its virtues are well documented.
I have always maintained that once we premise the discussion on mutual respect within the profession that we should be able to agree that the ultimate arbitrators of this ought to be our medical students with their career choices. When 2% feel General IM is where they want to be, I put the blame largely in the court of the RUC and its decisions over the last 12 yrs. We can no longer afford to sweep this issue under the rug. This issue must be brought to the fore, and addressed.

Rich Neubauer MD said...

Of course, this won't surprise you, but I'm totally behind the ACP approach. As a physician, as a patient, as a citizen of a country I love, I find the current "system" of care delivery to be shameful. I want to see this first major step taken to reform of that system and remain convinced that expanding coverage to all or nearly all is that first step. Whatever cost controls that will survive in the current debate will be important but likely not enough. But we cannot move ahead much without taking the necessary first steps.

Medicine as a profession will adapt. There need to be adjustments within the system that acknowledge the importance of cognitive specialties that have suffered under the current payment system.

ACP has done the best job of any organized medical professional association at finding the best path through the swamp.

Steve Lucas said...

The ACP view is focused on front line doctors, with the unintended consequence is that patients also benefit. Expanded access, and an evidence based approach to medicine will only, in the long run, make medicine more affordable and assist in meeting its primary goal of helping people.

Many of the medical societies are primarily interest in protecting their members financial interest. We can see with the breast cancer screening issue that those with the greatest financial interest were those who protested the most about changing the guidelines.

In the electronic version of the WSJ we find:
December 3, 2009, 2:44 PM ET
How the Drug Industry Spends $20 Billion a Year On Marketing

In both the electronic and print versions of the WSJ we find the long story of Abbott's TriCor. By changing dosage and capsules to tablets Abbott has managed to maintain patent protection on a drug discovered in the 1960s.

As a business person I have always been struck by the amount of money involved in medicine and the ways the system is gamed to produce large profits.

Dr. Robert Centor recently posted a piece by: "My good friend, Yul Ejnes, a private practice internist who becomes the Chair-Elect of the ACP Board of Regents in April,"

Dr. Ejnes writes about the very really financial pressure of balancing patient care with financial need. Seeing fewer patients per day than many we find in private practice today, he pays a very real financial price for his willingness to put patients first.

My personal disappointment is that many medical societies no longer even use the pretense of patient care in their political activities, but are blatantly promoting their members financial interest. Repeated testing, and even repeated invasive testing, have become the goal of some doctors. The long term physical and psychological damage is swept away with a wave of the hand as necessary for the patient (and cash flow).

It is sad that the interest of self has over come the interest of the patient, or society. Doing well is no longer an acceptable goal. One must be at the top. If this requires the financial ruin of the patient, or society, than they should have planned better, because I need and deserve, the often millions of dollars per year I receive in compensation.

While I understand that this attitude does not reflect the view of all doctors, Dr. Ejnes as an example, it does infect a large enough number to drive policy.

Steve Lucas

Arvind said...

It may come as no surprise that I actually agree more with the surgeons than with my own organization on these issues.

The idea of Independent Medicare Advisory Board is exactly what should not happen - it will only increase the barriers to better physician-patient relationship (which should be the focus of any real reform).

As a free society with a constitutional democracy, all of us should be opposed in principle to the idea of government redistribution of wealth in any industry. Ben Franklin would be livid if he lived in our times.

The PQRI is a sham built on flawed concepts and is a prime example of why government-run health care will only make the status quo look very good. If we don't like things now, wait till the government runs the largest insurance plan and sets practice standards. Its ironic that the ACP promotes itself as the voice of Internists, even when a majority of them oppose this line of action. I would like to know if the ACP leadership has ever conducted a secret ballot amongst its members - if publicly held corporations with millions of shareholders can conduct secret ballots, why can't the ACP? Are we afraid to know the truth?

Jay Larson MD said...

Physician organizations are just that organizations for physicians.

In our current commercialized health care system, patients are on the bottom rung just above primary care internists.

If a physician organization feels that supporting current health care reform efforts would truly hurt patient care (and not the wallet of the docs) then they should support what they feel is best for their patients.

If the physician organization is supporting only the physicians in that organization and not focusing on what is valuable for patient care, then it is time for them to retake professionalism 101.