The ACP Advocate Blog

by Bob Doherty

Friday, January 30, 2009

Uh, oh!

Just 10 days into the Obama administration, there are signs that comprehensive health care reform might be put off until next year. And that the partisan and ideological differences that stalled prior reform efforts may again rear their heads.

Reporting on yesterday's Senate vote to reauthorize the State Children's Health Insurance Program, the Washington Post notes that, "The rancorous debate - on a program that once basked in bipartisan popularity - raised doubts about whether the two parties can unite to pass broader health reform later this year, several moderate Republicans said."

And Congressional Quarterly reports that House majority Leader Steny Hoyer (D-MD) has predicted that health care reform might be delayed until 2010. Other key lawmakers, including Senator Max Baucus (D-MT), chair of the Senate Finance Committee, and Rep. Pete Stark (D-CA), chair of Ways and Means' health subcommittee, have said the same.

2010 will be an election year, with all 435 seats in the House of Representative and a third of the Senate up for grabs. Typically, election years tend to harden partisan differences, making it less likely that controversial issues will get through.

Before deciding to delay, President Obama and his congressional allies should consider that they are riding an unprecedented wave of public support for health care reform.

A whopping 90% of voters rated health care reform as the either the "highest" or a "higher but not the highest" priority for the new president and Congress, according to a January 16 ABC-Washington Post poll.

Who knows if the public will feel the same a year from now? Who knows if President Obama will still have the political mojo to get it done?

President Obama has an enormous opportunity - perhaps the greatest of any President - to achieve comprehensive health care reform, leading to health coverage for all.

But as the saying goes, he needs to strike while the iron is hot.

Today's question: Do you think health care reform can wait until next year?

Tuesday, January 27, 2009

Where is the AMA on primary care?

Yesterday, I blogged about the controversy over where to find the money needed to increase payment to primary care physicians. The American Medical Association (AMA) addresses this question in a commentary by AMA Board chairman Joseph M. Heyman, MD. He says,

"This issue [increasing the number of primary care doctors], on which we all agree, threatens to break professional unity, cause rancor, divide us and result in everybody - including our patients - losing. We all want to do something to improve the state of primary care. So we need to be certain we are all on the same page when it comes to investing in primary care in this country. We must present a unified front." He then makes three points:

"The American Medical Association absolutely supports this important investment in primary care. Payments to primary care physicians must increase.

The American Medical Association absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool. Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician.

The American Medical Association absolutely is committed to working with Congress and the administration to find alternate pathways to offset the required increases in primary care payments."

ACP has urged Congress to consider ways to fund primary care outside of the usual budget neutrality physician payment rules. We have argued that primary care pays for itself by reducing preventive hospital admissions, duplicate testing, and so forth. We hope that argument is being accepted by policymakers. And to be frank, ACP will have its own membership issues if increased payment for general internists comes at the expense of reducing payment to IM subspecialists.

It should be acknowledged, though, that budget neutrality adjustments are made every year in Medicare payments to doctors, whenever new procedure codes and relative values are added to the fee schedule. Those adjustments benefit one group of physicians - the ones who do the procedures - at the expense of other physicians who do not. For the most part, primary care physicians are not the ones who benefit (except every five years or so when changes in the relative values for visit codes are put on the table).

Rather than drawing lines against any particular funding option, the conversation needs to shift to how primary care will be funded, recognizing that someone (maybe even some doctors) will have to give up something if primary care is to survive.

Today's question: What do you think of Dr. Heyman's commentary?

Monday, January 26, 2009

Where, oh where, will we find $ for primary care?

As I've reported in several blog postings, it seems like everyone agrees, or at least they say they agree, that the U.S. needs more primary care physicians.

But when it comes to figuring out where the money for primary care should come from, well, the consensus just isn't there.

Dr. Benjamin Brewer, a primary care doctor, suggests in his Wall Street Journal column that the government could fund primary care by taking money from Medicare Advantage plans, cutting payments to hospitals for "high margin" surgeries and radiology services, revoking tax exemptions for hospitals that don't fulfill a mission of community service, or lowering Medicare pay for specialty care and procedures.

Noting Dr. Brewer's ideas, Jacob Goldstein asked readers of his Wall Street Journal blog what they thought of five different options for reducing spending to free up money for primary care.

These are the results from the 500+ plus respondents:

21%: cut Medicare Advantage.
20%: cut hospital pay for high margin services
26%: cut pat to specialists
11%: money shouldn't come out of existing health care spending
22%: primary care doesn't need more money

Granted, this was not a scientific poll. And Goldstein left out options that could have more support, such as prospectively applying some of the anticipated savings from reductions in preventable hospital admissions associated with primary care and using them to boost primary care fees.

Still, the fact that none of the options received more than one out of four votes (except for cutting specialists - barely - and one can imagine how that will play out in the political world) suggests trouble. And with 22% saying "primary care doesn't need the money," the consensus for primary care may be weaker than it appears.

The Wall Street Journal polls support two basic truths in politics. It easy to get people to agree to spend more money, but it is a heckuva lot harder to get agreement on where to cut. And those who have an interest in protecting themselves from cuts always start out with a political advantage over those seeking money at their expense.

Today's questions: Do you agree that the only way to fund primary is to take money from someone else in health care?

Friday, January 23, 2009

Should sunshine on my pharma make me happy?

With apologies to the late songwriter John Denver, will doctors be happy if their ties with drug companies are exposed to sunshine?

If Senators Chuck Grassley (R-IA), and Herb Kohl (D-WI) have their way, it won't matter - disclosure will be required by law.

Medical Marketing & Media news reports that the senators have re-introduced the Physician Payments Sunshine Act. The bill would require companies to disclose payments or transfers of value to physicians of $100 or more. The bill is similar to a bill they introduced in the last Congress, but this time, it has more hefty enforcement penalties.

According to the article, "beginning in April, 2011, companies would be required to report payments and other transfers of value for: consulting fees; compensation for other services; honoraria; gifts; entertainment; food; travel; education; research; charitable contributions; royalty or license fees; current or prospective ownership or investment interests; CME speaker fees and grants, along with anything else the HHS secretary deems necessary. Where payments are related to marketing, education or research specific to a covered drug, device, biological or medical supply, the company would be required to furnish that information, including the name of the therapy.

Manufacturers or group purchasing organizations that fail to report payments can be fined between $1,000 and $10,000 per infraction, up to a total fine of $150,000 per company per year, where failure to report is deemed an oversight. For 'knowing failure to report,' the ceiling on total fines goes up to $1 million per company."

ACP has not yet analyzed the bill nor determined our position on it. Last year, we declined to take a position on the bill, based in large part on the advice of our Ethics, Professionalism and Human Rights Committee. Some members of the committee felt that a mandatory disclosure requirement would actually undermine professionalism, because it could send a signal that acceptance of gifts are okay as long as they are disclosed (by someone other than the physician, in this case) or fall below the $100 threshold. (ACP policy on physician-industry relations says that "the acceptance by a physician of gifts, hospitality, trips, and subsidies of all types from the health care industry that might diminish, or appear to others to diminish, the objectivity of professional judgment is strongly discouraged.")

With the focus in Washington on "transparency" it is likely that some version of the Grassley/Kohl bill could become law. The sense is that the public is served when potential conflicts are exposed to sunshine, whether it applies to lobbyists' contacts with federal officials, freedom of information requests to federal agencies, or doctors' financial ties to pharma.

Today's questions: Do you think companies should be required to disclose contributions of $100 or more of value to doctors, including gifts, consultant fees, honoraria, education, research, and charitable contributions? What impact do you think this will have on medical education, research, or other potentially beneficial arrangements?

Thursday, January 22, 2009

Would you like some sticks to go along with your carrots?

A few minutes ago, the House Ways and Means Committee, chaired by Rep. Charlie Rangel (D-NY), completed its work on provisions of the economic stimulus bill under its jurisdiction. Among these are the creation of Medicare payment incentives for physicians and other clinicians to acquire health information technology.

According to a summary of the Ways and Means package voted upon today, a "carrots and sticks" approach will be used to get doctors to buy health information technology. Physicians will be eligible for $40,000 to $65,000 for showing that they are meaningfully using health information technology, such as through the reporting of quality measures. The payment incentives start at $15,000 in the first year, calendar year 2011, phasing down to $2,000 in the fifth year, 2015.

After that, though, sticks will be used to beat the non-compliant into submission. The bill would decrease total Medicare Fee Schedule payments for physicians and other "providers" who don't use certified electronic health record (EHR) systems beginning in 2016 by one percentage point a year until 2018. Beginning in 2019, if the percentage of eligible EHR users is less than 75 percent, the HHS secretary would be able to lower the fee schedule amount for the non-compliant to 96 percent of the fee schedule and lower it again to 95 percent in 2020. Individuals could be able to be exempted by the Secretary for "significant hardships" on a case by case basis.

Other provisions of the bill will lead to the development of standards by 2010 to allow for the nationwide electronic exchange and use of health information technology (HIT) to improve quality and coordination of care; strengthen federal privacy and security law to protect identifiable heath information from misuse as the health care sector increases its use of HIT; provide funds to states for low-interest loans to help providers finance HIT and grants to regional health information exchanges to unite local providers.

From the federal government's standpoint, I understand why carrots would be followed by sticks. The argument being, that it is the taxpayers' money being used to help doctors acquire HIT, so there should come a point where taxpayers can reasonably expect that everyone will get with the program. If you don't, well, they'll just make you.

But what happens if the positive incentives aren't enough to make the "business case" for a small primary care practice? If the vendors really aren't able to produce systems that have the functions needed? If there isn't enough support - such as training and problem-solving help as inevitable implementation problems arise - available to practices from trusted sources?

For smaller primary care practices in particular, the HIT incentives need to be combined with broader payment reforms to help sustain the economic viability of their practices. Otherwise, large multi-specialty group practices, the ones who already are most able to afford to buy EHRs, will get most of the money. And smaller primary care practices, the ones who most need the help, might find that the incentives aren't big enough to get them over the digital divide, and the penalties for non-compliance so big that it puts them out of business.

Today's question: Do you support the Ways and Means Committee's "carrots and sticks" approach to HIT adoption?

Wednesday, January 21, 2009

Day One

Yesterday, I was one of the two million or so people who gathered in downtown Washington to witness the inauguration of President Barack Obama. Or, more accurately, I tried to.

On television, the inauguration was a grand spectacle, worthy of the occasion. On the streets of Washington it was a different story. Would-be viewers of the swearing in were required to enter the National Mall through one of about a half dozen security check points, which quickly became overwhelmed. One DC cop told me that "absolute chaos" ensued as the Secret Service closed checkpoints, with thousands still waiting in line, without informing local authorities. By the time President Obama was sworn a little after noon, many of those waiting found themselves on the outside looking in. I was one of them - after hours of trying and failing to access the Mall I ended up rushing to catch it on my office TV.

I relate my experience not in the spirit of whining about what was a truly moving and historic occasion. I was still glad I was there. That things didn't go smoothly is not at all surprising, given that Washington had never before handled an event of this size and the circumstances demanded extraordinary security.

I offer it instead, as a metaphorical and cautionary tale for the new President. President Obama takes office at a time when the demand for help from the government could outstrip its capacity to deliver, just as the demand from millions to watch the swearing in exceeded the government's ability to accommodate them.

This may especially be true of health care. The demand is overwhelming. The recession will cause millions of Americans to join the already bloated ranks of the uninsured. State governments are pleading for help from Washington for funds to keep their Medicaid programs afloat. Employers want help paying their employees' premiums. Will the Obama administration have the capacity to organize a federal response sufficient to meet the demand? And with a trillion dollar deficit, will it have the wallet needed to deliver on its will to reform health care?

Obama isn't dissuaded. In yesterday's inaugural address, he had this to say:

"The question we ask today is not whether our government is too big or too small, but whether it works, whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified ...

We will restore science to its rightful place and wield technology's wonders to raise health care's quality and lower its costs ... All this we can do. And all this we will do."

I was struck by the words he chose - helping families get the care they can afford, using technology to raise health care and lower costs. And by the words he did not say. No mention of universal coverage or health care for all.

Now, I still believe that President Obama is committed to covering everyone. After all, people without health insurance coverage are the least likely to have "care they can afford." But his choice of words also says to me that controlling health care costs will be a focus of his administration.

As hard it is may be to get agreement on how to extend health insurance coverage to everyone, controlling the cost of care will be an even bigger challenge. Experts tell us that as much as $700 billion is wasted each year on unnecessary or inefficient care. But that "waste" and "inefficiency" represents someone else's income, hospital bed, MRI, or profit from sales of drugs and medical devices. Getting control over that will test the capacity of our new President to bring about the change we need.

Today's questions: Do you think President Obama will be able to deliver on his promise to control health care costs and provide everyone with care they can afford? How will you help?

Friday, January 16, 2009

Stimulate this: Part 2

As I noted in yesterday's blog, the House of Representatives soon will be taking up a massive economic stimulus package.

I am still making my way through the massive proposal. (It takes awhile to digest $850 billion in new federal spending!) My initial reaction is positive, in that the proposal would fund some of ACP's top priorities: making health information technology more available to clinicians; training more primary care doctors; funding comparative effectiveness; ramping up the overall federal investment in health sciences research; and helping states maintain Medicaid coverage.

Still, I have some early questions:

Will the money on health information technology be spent wisely?

There are skeptics. Charlie Baker writes in the Health Care blog that HIT hardly meets the definition of "shovel-ready:"

"To put this in 'shovel ready' terms, if someone decides to put a new kitchen in their house, or a new bathroom, or a new bedroom, they usually put together plans that outline their end game before they begin. States that build roads, or renovate schools do the same thing. Plans, drawings, blueprints - call them what you will - but they lay out, in advance, how the goals and aspirations of each project are supposed to be achieved. Putting billions into Health IT without putting the plans together first - which is, in fact, what health care reform is all about - seems exactly backward to me."

ACP, in its own letter to HHS nominee Daschle, urged that HIT funding be prioritized and distributed to support applications that will help physicians achieve the capabilities to provide patient-centered care through a medical home.

Will the funding for primary care training result in Congress declaring victory - when there is so much more that will need to be done?

It is good to see that the bill proposes to spend $600 million to train more primary care clinicians through the National Health Services Corps (although it's not clear how much of this will go to physicians versus other professions). By itself, though, expanding the NHSC will not be enough to address a primary care workforce crisis that is spinning out of control. Just last week, the Institute of Medicine reported that 16,261 additional primary care physicians are now needed to meet the demand in currently underserved areas.

To be clear, I think it is good thing that the stimulus bill recognizes the importance of primary care and health information technology. And the provisions to help states maintain their safety net programs and to assist people who may lose health insurance are essential.

I also think though that the HIT funding needs to be targeted to do the most good. And a heckuva lot more is needed to save primary care - including raising primary care payments so they are competitive with other specialties.

Today's questions: Do you support the priorities in the stimulus bill? Would you spend the money differently or better?

Thursday, January 15, 2009

Extra! Extra! Read all about it! Health care to get billions in federal dollars

Today, Representative David Obey (D-WI) released the contents of the economic stimulus bill that will be considered next week by the Appropriations Committee. According to a press summary released by his office, the bill includes tens of billions of funding for health care, including:

- Health Information Technology: $20 billion to jumpstart efforts to computerize health records to cut costs and reduce medical errors.
- Training Primary Care Providers: $600 million to address shortages and prepare our country for universal healthcare by training primary healthcare providers including doctors, dentists, and nurses as well as helping pay medical school expenses for students who agree to practice in underserved communities through the National Health Service Corps.
- Prevention and Wellness Fund: $3 billion to fight preventable chronic diseases, the leading cause of deaths in the U.S., and infectious diseases.
- Healthcare Effectiveness Research: $1.1 billion for Healthcare Research and Quality programs to compare the effectiveness of different medical treatments funded by Medicare, Medicaid, and SCHIP.
- Community Health Centers: $1.5 billion, including $500 million to increase the number of uninsured Americans who receive quality healthcare and $1 billion to renovate clinics and make health information technology improvements.
- National Institutes of Health Biomedical Research: $2 billion, including $1.5 billion for expanding good jobs in biomedical research to study diseases such as Alzheimer's, Parkinson's, cancer, and heart disease - NIH is currently able to fund less than 20% of approved applications - and $500 million to implement the repair and improvement strategic plan developed by the NIH for its campuses.
- COBRA: $30.3 billion to extend health insurance coverage to the unemployed, extending the period of COBRA coverage for older and tenured workers beyond the 18 months provided under current law.
- Medicaid Coverage for the Unemployed: Provide 100 percent federal funding through 2010 for optional State Medicaid coverage of individuals (and their dependents) who are involuntarily unemployed and whose family income does not exceed a State-determined level, but is no higher than 200 percent of poverty, or who are receiving food stamps.

The funding priorities seem to be consistent with ACP priorities: more money for health information technology, medical research, primary care training programs, prevention, comparative effectiveness, and health insurance coverage.

Of course, the devil will be in the details and distributing the money so that it has the biggest impact will be a challenge. (For example, just throwing money at health information technology will not do a lot of good, if it doesn't get directly to the physicians who need the most help, or if it ends up being spent on health information systems that don't have the functions needed to improve outcomes.) I will have more to say about the stimulus bill in tomorrow's blog.

Today's questions: At first glance, do you agree with the health care funding priorities in the stimulus bill?

Wednesday, January 14, 2009

Have you been RUCed?

Roy Poses, MD, takes on the RUC in the Health Care Renewal blog.

He calls the RUC an "opaque and unaccountable process [that] has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for 'cognitive' medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation." In a similar vein, Dr. Bob Centor (a member of the ACP Board of Regents), partly blames the RUC for the shortage of primary care doctors. And Drs. Berenson, Bodenheimer, and Rudolf wrote this in an Annals of Internal Medicine Perspectives:

"The RUC process favors increases in procedural and imaging reimbursement for 3 reasons: specialty society influence in proposing RVU increases, the specialist-heavy RUC membership, and the desire of RUC specialists to avoid increases in evaluation and management RVUs. With their ability to create new codes and influence RVU updates, many procedural specialists can influence fees in a way that observers find to substantially overvalue procedural and imaging services. Moreover, high fees may encourage physicians to increase the volume of profitable services, leading to even higher income gains and greater spending growth."

The RBRVS Update Committee (RUC) is a panel of physicians hosted and chaired by the American Medical Association and made up of representatives from major physician specialty societies, including ACP. The RUC provides recommendations to the Centers for Medicare and Medicaid Services (CMS) on the physician work relative value units (RVUs) under the resource-based relative value scale. A simplified expression of the formula that CMS uses to set Medicare physician payment rates goes like this:

Physician work RVUs x Practice Expense RVUs x Professional Liability RVUs x $ multiplier = payments

The RUC provides advice mainly on the first piece - physician work RVU. This represents about 55% of the total RVUs for each procedure code. CMS accepts most of the RUC's recommended RVUs.

The RUC argues it is being unfairly maligned. Dr. Bill Rich, the RUC's chair, wrote this in response to the Annals of Internal Medicine:

"The RUC recommended significant increases to E&M (evaluation and management) services, which were implemented by the CMS on 1 January 2007. These permanent increases result in an additional $4.5 billion in E&M services payments each year! To imply that they are small and insignificant is preposterous. Family physicians may see their overall Medicare payment increase by 5% or more. A document on the American College of Physicians' Web site states: 'ACP estimates that internists will typically see an increase of $5,000 to $10,000 in total Medicare allowable charges'."

My sense is that the RUC's critics have a point, but so does Dr. Rich. The RUC deserves credit for the evaluation and management increases, and more recently, for estimating the physician work involved in care coordination for the Medicare medical home demonstration project.

But the RUC does need to look at its own composition and processes. It needs to be more representative of primary care and more transparent in its deliberations. The new Obama administration and Congress would be well-advised to insist that the processes Medicare uses to determine the values of physician services be as transparent as possible, and include sufficient and appropriate representation and expertise from primary care. They should also require a better process for identifying overvalued services.

But making the RUC the main villain in a system created and run by the government misses the mark. We have to remember that it is Congress and CMS, not the RUC, who makes the rules. As long as the Medicare payment system pays based on volume instead of rewarding prevention and care coordination, primary care physicians' incomes will lag behind specialties that can generate more volume, because primary care doctors can only increase volume by cramming more patients into an already over-scheduled day. This would be true even if the RUC were reconstituted to include more primary care doctors.

And, we need to ask if the RUC were to disappear, who should recommend the work involved in physician services? Economists and physicians hired by the federal government?

Today's questions: What do you think about the RUC? Does it need to change? Or should it be replaced- if so, with what?

Monday, January 12, 2009

Will primary care's "coalition of the willing" stay together?

Tom Daschle is the latest "mover and shaker" to climb on the primary care bandwagon. In an opening statement to a Senate Health, Education and Labor and Pensions Committee confirmation hearing on his nomination as HHS Secretary, Daschle had this to say:

"Even Americans who do have health insurance don't always get the care they need, especially high-value preventative care. In some cases, this is due to a shortage of providers - especially primary care providers in rural areas ... CMS must focus on prevention and primary care, steering its resources toward wellness rather than sickness."

Still, it will be a tough slog, as Donald Rumsfeld so famously said about the Iraq war, before we'll be able to say that primary care's poor fortunes have been reversed.

Right now, primary care enjoys the support of leading organizations representing physicians, consumers, employers, and nurses. Yet this coalition could weaken if the following occurs:

1. Primary care could split into an uncivil war between doctors and nurses. Workforce studies project that the demand for primary care is so great that the U.S. will need more doctors and nurses. Yet primary care physicians and nurses could end up battling each other for a share of the pie.

2. Opposition by specialists could cause division in organizations that represent generalists and subspecialists - including ACP. An email from a rheumatologist-member of ACP has this to say about ACP's advocacy for a 10% pay increase for primary care:

"I did not see any mention of Internal Medicine subspecialties in your letter. We probably reflect about one half of the 126,000 members that are claimed. However, it seems to me that you do not represent me (as well as the other sub specialists) any more."

It is not pre-ordained that these conflicts have to happen. If we put patients' needs first, internists (both generalists and subspecialists) and nurses should be able to come together and agree on the need for more primary care clinicians, doctors as well as nurses. But it will require constant care and attention to make sure that primary care's coalition of the willing does not fall apart because of divisions within its own ranks.

Today's question: Do you believe that internists, generalists and subspecialists alike, and nurses will be able to stay together on the need for more primary care clinicians?

Thursday, January 8, 2009

Will the "Blue Dogs" have doctors singing the blues?

Having a big Democratic majority in Congress doesn't guarantee smooth sailing for the Obama administration.

The Washington Post notes that "the last two Democratic presidents, Jimmy Carter and Bill Clinton, saw their party leaders on Capitol Hill turn against them, leading to electoral disasters for the party in 1980 and in 1994. An energy crisis helped to do in Carter, while a failed health-care proposal contributed to a Republican congressional landslide two years into Clinton's first term."

Getting the support of a coalition of fiscally-conservative "Blue Dog" House Democrats may be Obama's biggest challenge. With 47 members, the Blue Dogs have enough votes to block expensive government programs if joined by their GOP colleagues.

What makes a Blue Dog bay all night? The federal budget deficit, which is expected to grow to over $1 trillion in current budget year.

To stop the flow of federal red ink, Blue Dogs want to require that every dollar of new spending be paid for by cuts somewhere else. The Democrats had such a pay-as-you go (pay-go) rule in the last Congress. As an internal operating rule, it wasn't legally binding on them, so they could (and sometimes did) waive it when inconvenient. Writing pay-go into law, as the Blue Dogs propose, would force Congress to make the necessary budget offsets. Think if it as pay-go on steroids.

Jared Allen writes in The Hill that so far, the Blue Dogs are taking Obama's commitment to tackle spending "on faith." Before long, though, I expect that the Blue Dogs will want a lot more than promises from the president's bully pulpit.

Faith might get a believer into heaven, but it won't balance the federal budget.

Doctors may be the ones singing the blues if the Blue Dogs carry the day and pay-go becomes law. Physicians want Congress to eliminate accumulated physician payment cuts caused by Medicare's SGR formula, which will cost upwards of $300 billion, according to the Congressional Budget Office. Congressional leaders are considering "re-basing" Medicare spending so that Congress isn't forced to find $300 billion in offsets. If the Blue Dogs don't go along, it will be very hard to get an agreement on eliminating the SGR.

As fiscal conservatives, Blue Dogs might - and I hope they will - be persuaded by the evidence that primary care doctors deliver better care at lower costs, and therefore should be paid competitively with other specialties. But if they aren't, then higher Medicare pay for primary care might have to be offset by cutting payments to other doctors.

Fiscal discipline is a good thing, but I worry about creating a fiscal straitjacket which will make it harder to for the government to do the things that really need to be done. Like improving pay for primary care, eliminating accumulated Medicare pay cuts, and expanding health insurance coverage.

Today's question: Do you believe that Congress should be required to pay for new spending with dollar-for-dollar cuts in other programs or revenue (tax) increases, even if this makes it harder to get agreement on needed health care reforms?

Wednesday, January 7, 2009

Who is to blame for health care spending?

One way to look at health care costs is to do an evidence-based analysis of the factors contributing to expenditure growth, and based on the evidence, come up with remedies.

But that isn't very much fun, is it? The first recourse for most of us is to point the finger at someone else, usually based more on our own personal experiences.

So doctors will blame "greedy" lawyers and lawyers will blame "greedy" doctors. Conservatives will blame the government. Liberals will blame for-profit companies. John Q. Public gets his share of the blame, too - for not doing enough to stay healthy and then demanding too much when sick. Even McDonalds gets the blame for making us obese.

And just about everyone blames the drug companies. I've seen internists stand up at ACP chapter meetings to fume about how drug companies rip off patients. If only we could bring down drug prices, they say, we could bring overall health costs under control.

Maybe, but the data suggests otherwise. Prescription drug spending is a smaller factor in rising health costs than say, physician and hospital services.

Yesterday, Health Affairs published the Medicare's actuaries' annual report on health care spending. The title pretty much says it all: National Health Spending In 2007: Slower Drug Spending Contributes To Lowest Rate Of Overall Growth Since 1998.

In 2007, total national expenditures were $2,241.2 billion. Out of this, $227.5 billion was spent on prescription drugs, $696.5 billion on hospital care, and $478.8 billion on physicians and other professional services.

One reason that prescription drug spending decelerated is because of increased dispensing of generic drugs. The authors explain that "loss of patent exclusivity for several major blockbuster medications in 2006, including Flonase, Pravachol, Zocor, and Zoloft, had a large impact on the 2007 prescription drug trend, as six month generic exclusivities expired for some of these drugs and additional generic medications became available". They also attribute the drop-off it to an increase in the number of "black box" warnings issued by the FDA.

I know ... I know ... The big drug companies don't deserve credit for a slow down that was driven by increased competition from generics and people being scared off of their products. And we are still spending a lot of money on prescription drugs. Still, as Jacob Goldstein observed yesterday in the Wall Street Journal health blog, it's a tough time to be in the drug business.

Following the rule of "going where the money is" (which, Wikipedia says, is wrongly attributed to bank robber Willie Sutton), it would seem like prescription drugs would not be the first place to look for big savings.

Today's questions: Do you agree or disagree that the big savings aren't in prescription drugs? Where are they, then?

Tuesday, January 6, 2009

Oh, Canada!

As primary care gets more attention in the health policy blogosphere, we are seeing increasing pushback from those who have something to lose.

Jacob Goldstein reports in yesterday's Wall Street Journal blog that "if Barack Obama makes good on his promise to increase access to health care for America's 45 million or so uninsured, a lot more people are going to be trying to squeeze in appointments with busy primary care doctors." Citing a story in Canada's National Post Goldstein writes that some Canadian doctors fear that U.S. demand might be met by recruiting their family doctors to cross the border.

Eh???

(Wikepedia tells us that Canadians use eh, in place of huh? or what? ... My reaction to the idea that we'll solve our primary care crisis by raiding Canada's family docs)

Last month, in the same WSJ blog, Sarah Rubenstein wrote about ACP's proposal to use the stimulus bill to fund a 10% increase in Medicare payments for primary care.

The many comments she received are well worth review and commentary by The ACP Advocate Blog readers. Among them:

"Primary physicians really need this 10% increase in fees, at least until we decide what physicians should earn."

"This investment makes sense for the long term. 80% of our doctors are specialists while in other industrialized countries 80% of their doctors are GPs. America spends more but ranks lower than other nations so it would seem this is "carrot" to improve our primary care system will pay off."

"A highly appropriate and justified request. Primary care is a pillar of this country's health care infrastructure, it is in grave need of repair and restoration."

But not everyone agrees, to put it mildly:

"It boggles me how some of you say that primary care physicians are 'ridiculously underpaid' ... I work in 2 hospitals and I've seen the payroll and to think that they deserve even more than that is ludicrous."

"The letter from [ACP President] Dr. Harris is mostly nonsense anyway. The 'shortage' of primary care physicians in Massachusetts for example is due to the sudden increase in patients stemming from the availability of insurance to otherwise uninsured individuals. It has nothing to do with physician pay."

"Pathetic! Next the primary care docs will claim hunger and homelessness."

The comments on primary care, even the extremely negative ones, show that ACP is succeeding in making the public and policymakers aware of the crisis. Otherwise, why would people care about what we say?

But it also shows that even a very modest first step to help primary care, like ACP's proposal for a 10% bonus, will bring out opposition.

Today's questions: What do you think about the idea that the U.S. will solve the primary care crisis by taking doctors away from Canada? And how would you respond to comments like it is "pathetic" and "nonsense" to seek higher pay for primary care?

Monday, January 5, 2009

Ins and outs of health care in 2009

Around the first of the year normally rational people get into the prediction business. This happens even though experience tells us that no one, including the best experts, is particularly good at seeing the future. Think about it. One year ago, how many economists predicted that the year would end with a global economic meltdown? How many political pundits predicted Barack Obama would be elected president?

Still, in keeping with the spirit of a new year and with a full expectation of being proven wrong, this is my list of the health care trends that will be out and in style for 2009.

Out vs. In

Health care deregulation VS. Insurance market regulation
Health Savings Accounts VS. First dollar coverage of prevention
Buy coverage through individual markets VS. Buy coverage from a group health exchanges
Consumer-directed care VS. Patient-Centered Care
Medicare Advantage plans VS. Traditional Medicare
Pay for treatment of chronic diseases VS. Pay for prevention and management of chronic diseases
Pay-for-performance VS. Accountable care organizations
Fee-for-service VS. Bundled payments
States take the lead to expand Coverage VS. States cut back and look to Washington
Doctors accept gifts from pharma VS. Small gifts banned; mandatory disclosure of financial ties
Limited federal monies for HIT VS. HIT to get tens of $ billions
Fund special projects through earmarks VS. Fund special projects out of stimulus
46 million uninsured VS. Coverage for everyone
Disease management companies VS. Patient-centered medical homes
No federal regulation of tobacco VS. FDA to regulate tobacco
Flexible spending accounts VS. Tax credits to buy coverage
Medical necessity determinations VS. Comparative effectiveness research
Radiology, orthopedics, anesthesiology, and dermatology - the ROAD specialties VS. General internists, surgeons, and FPs


The list reflects the drawing to an end of the domination of health care policy-making by those with a fealty to market-based approaches. The new crew in Washington instead pledges to use the enormous power of the federal government to regulate health care insurance and benefits; to subsidize and guarantee coverage; to reform physician payments; to expand public programs like traditional Medicare; to rein in drug prices; to influence physician specialty choice; to fund health information technology; and to do so many other things.

Of course, whether the public will prefer the more regulated and subsidized health care system that could result will be a matter of a great debate.

Today's questions: Do you agree or disagree with my list of trends that will be in and out of style in 2009? What trends would be on your in and out list?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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