The ACP Advocate Blog

by Bob Doherty

Tuesday, March 31, 2009

Are the surgeons misdiagnosing the physician workforce crisis?

The American College of Surgeons, joined by other surgical specialty societies, has created Operation Patient Access (OPA), a campaign to "bring into focus the urgent issues facing access to quality surgical care in the United States ... and to call attention to urgently needed policy changes to address gaps in the availability of quality surgical patient." According to the OPA website (which is pretty nicely done, by the way), 400 surgeons - sporting "Will a surgeon be a there when you need one?" buttons - descended on Capitol Hill last week to urge lawmakers to "consider a wide range of solutions, such as providing more funding for graduate surgical education, reducing liability costs, expanding the National Health Service Corps, and implementing alternative payment methods for health care. If we fail to act now, these shortages will undermine attempts to expand access to health care and will further endanger the lives of all our citizens."

If this sounds familiar, it is because the surgeons' diagnosis and policy prescriptions are virtually identical to the case that ACP has been making on the primary care physician shortage.

Which is a problem, because it blurs the urgent need to rebuild the primary care physician workforce in the United States by suggesting that the crisis in surgery is of greater concern. The tools to increase the numbers and proportions of primary care physicians in the United States - payment reform, scholarships and loan forgiveness in exchange for service obligations, and graduate medical education funding - will be ineffective if the limited funding for such programs are broadly diverted to increase the numbers of surgeons, including some surgical specialties where there is scant evidence of a shortage. The OPA website speaks broadly of shortage of surgeons, when the evidence that I've seen - including the evidence on the OPA website - suggests that the shortage is principally in general surgery and a few of the surgical subspecialties and in certain parts of the country, particularly rural areas.

On payment reform, there is very strong evidence that the disparities in payment between primary care and other more highly compensated specialties is a principal reason why so many young physicians are choosing the higher paid specialties over general internal medicine, family practice and pediatrics. Yet the OPA website suggests that "reimbursement policies" are one of the contributors to the surgical workforce shortage. The OPA, not surprisingly, makes it clear that it will oppose any effort to increase payment for primary care physicians at the expense of surgeons.

Perhaps the most troubling aspect of the OPA campaign is that it diminishes the crisis in primary care physician workforce, by arguing that the surgical workforce "crisis" is "different" because non-physicians can substitute for primary care physicians but not for surgeons. This is what surgeon George Sheldon, MD, FACS, writes in the OPA blog:

"Regions around the country are facing shortages of nurses, primary care physicians, other health care workers and certain specialists. We certainly understand the concern and urgent need to fill these positions. But, you may be wondering, what's different for surgeons? What's different is that there is no substitute for a surgeon. While internal medicine and family practice physicians and advanced practice nurses often overlap in their roles, surgical specialties do not overlap with other health providers or with each other. An urologist cannot fill in for a neurosurgeon. A cardiothoracic surgeon cannot fill in for an orthopedic surgeon. And only a trained surgeon can perform an operation."

To be clear, I believe that the United States needs a national workforce policy to determine the appropriate mix and distribution of all physician specialties including primary care and general surgery. I am sympathetic to the concerns about the shortage of general surgeons as well as shortages in some other surgical and medical subspecialty areas - these too should be addressed in workforce planning and polices.

But the evidence is overwhelming that primary care in the United States is heading toward collapse, that urgent action is required to reverse the primary care shortage, and that the quality of care will be lower, and the cost higher, without enough primary care physicians. (For a good review of the evidence, see the testimony that ACP President Jeff Harris, MD, FACP, presented last week to the House Energy and Commerce Committee, complete with over 51 scholarly references).

The answer to the crisis in primary care is not to substitute non-physicians for primary care doctors. Or to blur the lines so that the public policy tools available to increase the numbers and proportion of primary care physicians are diverted to other specialties.

Today's question: What is your reaction to the surgeons' Operation Patient Access campaign?

Monday, March 30, 2009

Will physicians embrace "the change we need?"

Health Affairs has published a scathing blog critique of the medical home by Dr. Caroline Poplin, a primary care internist. Her post, in my view, represents a deep misunderstanding of the model. In response, my colleague, Dr. Michael Barr, and I responded on the ACP's behalf.

I don't plan to repeat our response to Dr. Poplin here, although I invite you to read the exchange and post your own comments, here or on the Health Affairs blog.

Her commentary represents a broader problem, though. Most primary care physicians are keenly dissatisfied with the current system. Yet when a new idea is proposed to fix the status quo, like the medical home, it is greeted with skepticism, cynicism, and even downright hostility.

For example, primary care physicians intensely dislike the financial pressures to increase the numbers of patients they see per hour, yet this is largely the consequence of a fee-for-service payment system that rewards doctors for seeing patients face-to-face and ordering more procedures. But proposals to sever the link between payment and volume, as the Patient-Centered Medical Home would begin to do, are greeted with deep distrust.


Primary care physicians loath the constant barrage of "hassles" imposed on them. Pre-authorization, utilization review, documentation guidelines - the list goes on and on - are rightly viewed by physicians as intrusions that sap the energy and satisfaction from their professional lives. Yet much of the paperwork associated with practice is the result of fee-for-service. Why? Because any system that bases payment on volume invites "controls" to reduce the volume of "unnecessary" procedures, as determined by the payer. A different payment model that rewards physicians for efficient, effective and high quality outcomes, not volume, could reduce or even eliminate the need for such intrusive utilization controls.

I understand why physicians, and particularly primary care doctors, are skeptical. Primary care physicians have had a long history of being subjected to the latest reforms (think RBRVS, gatekeeper, capitation and pay-for-performance) that are supposed to make their lives better, only to find that they either fell short or made things even worse. One ACP member has described it to me as "death by a thousand cuts" from well-intentioned health reformers. I would be the last to suggest that ideas like the medical home should not be subjected to scrutiny and challenge - that is why, for instance, ACP supports pilot testing of the medical home before it is adopted more widely. What concerns me though is when healthy skepticism becomes outright cynicism.

The other challenge is trying to explain the latest new ideas to physicians. As Dr. Poplin's commentary demonstrated, even when ideas are developed by the primary care physician organizations themselves, they may be poorly understood by rank and file primary care physicians.

Going forward, it is self-evident that we need new payment and delivery models, not just for primary care physicians, but also for specialists. Such models should move away from pure fee-for-service reimbursement to basing compensation on accountability for the quality and effectiveness of care provided.

Today's question: Will physicians embrace the changes we need in how care is organized and paid, or allow their distrust and cynicism to rule the day?

Thursday, March 26, 2009

Budget resolutions are good news for primary care, maybe health reform, but now comes the hard part

Late last night, the House Committee on Budget approved a budget resolution that provides direction to the authorizing and appropriations committees on how much they can spend in the fiscal year 2010. The resolution, which still needs to be voted on by the entire House of Representatives, creates a "budget neutral" reserve fund for health care reform, and another "current policy" reserve fund for physician payment reform, including reforms to ensure appropriate reimbursement for primary care. As I write this, the Senate Budget Committee is meeting to consider its version of the budget resolution.

First, let me give you a brief tutorial on budget resolutions. (Bear with me, a basic understanding of the arcane congressional budget process will help you understand why the resolutions matter so much.)

A budget resolution provides direction to all of the authorizing and appropriations committees on how much they are allowed to spend on programs under their jurisdiction. The resolutions leave the specific polices to the committees. For instance, a budget resolution doesn't tell the Medicare authorizing committees how to change Medicare payment rules to stay within the spending constraints set by the resolution, as long as the end result stays within the specified funding levels.

Once the Senate Committee on Budget completes action today on its resolution, both the House and Senate will have to schedule votes on their respective versions. Unlike most Senate legislation, the budget resolution can be adopted by a simple majority vote. Differences between the House and Senate versions will then be worked out in a conference of the two chambers, followed by a vote in both chambers on the joint resolution. Later in the process, the decisions made by each committee need to be "reconciled" with the funding amounts and authority specified in the resolution, a process called budget reconciliation.

Typically included within a budget resolution are funding devices called reserve funds. Reserve funds allow the committees of jurisdiction to spend more than the initial amount given to them by the resolution, but only for specific prescribed policy reasons.

There are at least two kinds of reserve funds. One type is a budget neutral reserve fund, which allows the authorizing committees to spend more than their initial allocation, but they have to offset the additional spending, dollar for dollar, with tax/revenue increases or budget cuts elsewhere on programs under their jurisdiction.

The other type is a policy reserve fund, which permits the committees to spend more than their allocated amount, with no budget offsets required, but only for policy purposes specified by the resolution.

The House resolution approved yesterday by its budget committee, and the pending Senate budget resolution, both create a budget neutral reserve fund for health care reform. This means that Congress won't be able to duck the need to find savings (likely including "provider" pay cuts and measures to make health care more efficient) and/or raise taxes to pay for health care reform. Congress, of course, will try to pay for some of this with popular reforms like paying for prevention and wellness but the Congressional Budget Office isn't likely to count these as saving much money.

The House budget resolution also creates a separate current policy reserve fund to "change incentives to encourage efficiency and higher quality care in a way that supports financial sustainability, improve payment accuracy to encourage efficient use of resource and ensure that primary care receives appropriate compensation, improve coordination of care, or hold providers accountable for their utilization patterns and quality of care." (Emphasis added.)

The pending Senate budget resolution includes a budget neutral reserve fund for Medicare improvements to "encourage physicians to train in primary care residencies and ensure an adequate supply of residents and physicians" among other purposes.

The fact that both the Senate and House versions include reserve funds to help primary care is good news indeed, although the House's approach is better because it would not require that the cost be offset by cuts somewhere else. The caveat, though, is that even in the House version, the funding allowed by the reserve fund isn't likely to be enough to increase pay for primary care and reverse pending doctor payment cuts from Medicare's sustainable growth rate (SGR) formula over the long haul. Congress may still need to find savings somewhere else to fix the SGR and also create incentives for primary care.

The bottom line is that the budget resolutions lay the groundwork for Congress to enact legislation to enact comprehensive health care reform, prevent doctor pay cuts, and raise payments for primary care doctors. Now comes the hard part: charting a political strategy to find the money to pay for all of this without losing the support of key stakeholders, and ultimately, the public.

Today's question: If health care reform and adequate pay for primary care has to be funded in a budget neutral manner, what do you think physicians should be willing to give up to pay for these reforms? What would you be willing to give up?

Wednesday, March 25, 2009

Why is CBO primary care's "Dr. No"?

Listening to the opening statements of members of Congress at yesterday's Subcommittee on Health hearing of the House Energy and Commerce Committee was a bit like listening to Girl Scout campers sing Kumbaya. Legislator after legislator sang the praises of primary care. Two of the witnesses, ACP President Jeff Harris, MD, FACP, and Dr. Fitzhugh Mullen, shared ideas on how solve the primary care workforce crisis.

The Congressional Budget Office (CBO), though, continues to sing a discordant note. In March 10th testimony to the same subcommittee, the CBO had this to say about the medical home and primary care:

"Savings from some initiatives may not materialize because incentives to reduce costs are lacking. For example, proposals to establish a 'medical home' might have little impact on spending if the primary care physicians who would coordinate care were not given financial incentives to economize on their patients' use of services. Those proposals could increase costs if they simply raised payments to those primary care physicians."

The CBO's view that proposals that raise payments to primary care physicians "could increase costs" misses the point. (The CBO also seems to misunderstand the medical home, but that is a topic for a future blog.) As ACP has pointed out many, many times, there is extensive evidence that the supply of primary care physicians is consistently associated with better outcomes and lower per capita expenses.

There also is solid evidence that increasing pay for primary care, so that it is competitive with other specialties, is a pre-requisite to getting doctors to go into primary care.

Think of it this way:

Higher pay for primary care = More primary care doctors = lower per capita health costs.

The CBO, though, can't seem to get beyond the first part of this equation.

If CBO continues to be the "Doctor No" on the value of increasing pay for primary care, Congress will likely have to find budget offsets (cuts to someone else - most likely other physician specialists) to fund primary care payment increases and the medical home. This, in turn, will increase the political opposition, making it less likely that Congress will enact meaningful reforms to increase primary care pay, expand the medical home, and take other steps to reverse the primary care shortage, leading to higher costs over the long haul.

Go figure.

Today's question: What do you think can be done to get Congress to increase pay for primary care, given CBO's view that "simply" raising payments to primary care physicians will increase overall costs?

Monday, March 23, 2009

Is the federal deficit a Catch-22 for health care reform?

The Congressional Budget Office has decided that President Obama's proposed budget will add trillions of dollars to the deficit, substantially more than the administration's own budget office estimates:

"As estimated by CBO and the Joint Committee on Taxation, the President's proposals would add $4.8 trillion to the baseline deficits over the 2010-2019 period. CBO projects that if those proposals were enacted, the deficit would total $1.8 trillion (13 percent of GDP) in 2009 and $1.4 trillion (10 percent of GDP) in 2010. It would decline to about 4 percent of GDP by 2012 and remain between 4 percent and 6 percent of GDP through 2019. Our estimates of deficits under the President's budget exceed those anticipated by the Administration by $2.3 trillion over the 2010-2019 period. The differences arise largely because of differing projections of baseline revenues and outlays. CBO's projection of baseline deficits exceeds the Administration's estimate (prepared on a comparable basis) by $1.6 trillion."

Writing for the Wall Street Journal, John McKinnon suggests that the new deficit numbers could "imperil his health-care overhaul." He quotes several influential senators, Republican and Democrats alike, who reacted to the budget numbers by stating that the President's spending plans, will at least need to be scaled back. Some Republicans have gone further. Senator Judd Gregg (R-NH) argues that this "country will go bankrupt" if Obama's budget is adopted. Senator Gregg's views are particularly important, because he is the kind of Republican from a blue state whose votes the President will need to get his budget, and then health care reform, enacted.

It strikes me, though, that the view that the deficit makes health care reform unaffordable has it backwards. As the CBO itself has stated, the rising cost of health care continues to be the single greatest fiscal challenge to the United States. There is no realistic way to bring the federal budget anywhere close to being in balance without controlling the costs of Medicare. There is no realistic way to make Medicare expenditures sustainable without addressing the larger issue of reducing the rate of growth in overall national health care expenditures. And there is no way to make individuals financially secure without controlling the amount they pay for health care - and by guaranteeing them access to affordable coverage that can't be taken away.

The argument that the deficit makes health care reform unaffordable is a classic Catch-22. We can't afford to fix health care because it will add to the deficit ... but we can't afford not to fix health care because it will add to the deficit. It sets up the idea that deficit reduction and health care reform are on a collision course, when in fact one of the former cannot be accomplished without the latter.

Today's questions: Do you believe that the rising deficit numbers mean the country can't afford health care reform? Or do they make health care reform even more important?

Thursday, March 19, 2009

Do surgeons believe that non-physicians can "substitute" for primary care?

Yesterday, ACP President Jeffrey Harris, MD, FACP, testified at a hearing of the House Committee on Small Business examining the impact of President Obama's budget on "small providers."

(Maybe because I am still in the St. Patrick's Day mindset, I keep thinking of "small providers" as being the U.S health care system's equivalent of leprechauns, the legendary "little people" of Irish lore. I digress, though.)

Dr. Harris' statement made a strong argument on why the federal budget should support primary care physicians, especially those in smaller practices, noting that 82 percent of office visits are furnished in practices with five or fewer physicians.

I was struck, though, by the testimony of John Preskitt, MD, who was testifying on behalf of the American College of Surgeons. His statement makes the argument that the U.S. is also facing a shortage of surgeons, including but not limited to general surgeons. Fair enough: I think there is little disagreement that general surgery is also facing a shortage. I found one part of his argument to be quite provocative, though, to physicians in primary care specialties:

"With trauma care and surgical emergencies, there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist. Surgical training is vastly different from other physician training programs. Mastery in surgery requires extensive and immersive experiences that extend over a substantial period of time. Surgical residencies require a minimum of five years and often several more years for specialties such as cardiothoracic surgery. However, the prospects of declining payment coupled with rising practice costs; increasing liability premiums and the escalating threat of litigation; a crippled workforce leading to more on-call time, higher caseloads, and less time for patient care; and an uncertain future for the U.S. health care system understandably deter would-be surgeons from making the extra sacrifices necessary to become a surgeon." (emphasis added)

Is the American College of Surgeons really implying that there are good non-physician substitutes for primary care physicians, but not, of course, for surgeons because "mastery" of surgery is so much more difficult and takes so many more years of training than primary care?

The American College of Physicians recognizes that nurse practitioners and physician's assistants are valuable members of the primary care team, working collaboratively with primary care physicians. We have also unequivocally stated that their skills are complementary, not equivalent, and that workforce policies "should recognize that training more nurse practitioners does not eliminate the need nor substitute for increasing the numbers of general internists and family physicians trained to provide primary care."

Today's questions: What is your reaction to the American College of Surgeons statement "that there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist ... Surgical training is vastly different from other physician training programs"? Do you read this as implicitly stating that non-physician extenders can substitute for primary care doctors, and if so, how would you respond to this assertion?

Tuesday, March 17, 2009

A Bit of Irish "Poetry" on St. Paddy's Day!

Today, of course, is St. Patrick's Day, an important occasion for celebration for we Irish Americans, especially those of us who are first generation. (My beloved late father, Jack Doherty, hailed from County Leitrim and owned and tended bar at Doherty's Bar in Woodside, Queens, New York for over thirty years.)

One fond Irish tradition is the art of writing limericks, which are short Irish verses, of a humorous nature, with a set rhyme scheme. In honor of today's occasion, and health reform, here are a couple of limericks written by yours truly:

In 1995, health reform died
Although Hill and Bill surely tried,
Will Obama prevail?
Where others did fail?
Or will the people again be denied?

Another one:
Obama wants health care reform,
But will the lobbyists make him forlorn?
They all say health reform is okay
(Just don't make us the ones who pay)
Their arguments are so tired and worn.

And finally:
If Senator Max Baucus has his say
Primary care will soon see a better day
But for them to be paid more
Someone's ox will be gored
Will the surgeons be forced to pay?

That's it for today.
Slainte! (Irish for Good cheer!)

Today's question: Do you want to try your hand at writing a health care reform limerick? (If so, post it here.)

Friday, March 13, 2009

Who do voters trust on health reform? (Doctors!)

There is brand new research that finds very strong and deep public support for health care reform, including from Republican voters.

In a survey taken in the first week of February, Celinda Lake and Associates found that voter support for reform (after hearing a series of arguments for and against) is strong across partisan lines, with the strongest support among Democrats (67% favor, 21% oppose) and Independents (59% favor, 27% oppose), and with over half of Republican voters on board (52% favor, 42% oppose).

This is important, because the major "con" argument tested by the pollsters - that health care reform will allow bureaucrats to make decisions best left to doctors and patients - is the strongest card critics have to play. That it doesn't resonate with voters - including a majority of Republican voters - bodes well for health care reform.

There were some surprises.

"By very wide margins (+56 points) voters support instituting comparative effectiveness reforms to supplement doctors' clinical knowledge, but voters need to be reassured that scientific and cost effectiveness data do not replace their doctor's judgment. Seventy three percent of voters (45% strongly) support creating an independent organization that supports health providers by giving them information about best treatments to rely on in addition to their own judgment."

The surprise is that Republican voters are more likely than Democrats and Independents to support comparative effectiveness research if it explicitly mentions cost instead of just clinical effectiveness. Why is this surprising? Because its was conservative critics, like the Wall Street Journal's editorial writers, who argued that CER would result in the government denying care found to be too costly.

Voters see it differently: "Messages that focus on providing doctors with scientific and cost effectiveness evidence, modernizing the health care system with health information technology, and controlling overuse of the health care system are seen by voters as both supporting doctors and improving care for patients." (emphasis added). This may be because, "Voters have a great deal of confidence in their doctors ... They trust their doctors and consistently support changes to help their doctors do their jobs."

One thing this tells me is that doctors - and by virtue of this, physician organizations like ACP - have enormous credibility in the health reform debate. If we say that programs like comparative effectiveness will help our doctors do their jobs well, we are more likely to be believed than, say, some non-physician editorial writer ranting about bureaucrats telling doctors what to do.

Another interesting finding is that although the public like and trust their doctors, they don't mind getting care from someone else. "By an overwhelming margin (+57 points), voters support allowing health professionals other than doctors to provide more care to free up doctors and help control costs."

Voter opinion can still change, of course, and hundreds of millions of dollars will be spent trying to shape it. But the advocates for health reform start out with a decided advantage. The critics will have to come up with something more persuasive than trying to scare voters about rationing, especially if their doctors tell them otherwise.

Today's question: How do you feel physicians - and physician membership organizations - should take advantage of the high degree of trust and confidence that patients have in doctors to influence health care reform?

Thursday, March 12, 2009

Health care reform: is it real this time?

In many of my blog posts, I have shared my views on the reasons why President Obama has the best opportunity of any president to achieve health care reform. As well as why he could still fail.

Tonight at 7 p.m., I am moderating a Webinar that will provide the latest information on the political and policy environment surrounding health care reform - including what we can learn from last week's White House health reform summit and the President's budget.

As part of my presentation, I will be sharing some brand new polling data from a highly respected research firm on the public's attitudes on health care reform, comparative effectiveness research and other "hot button items."

The pollsters tested how voters responded to two competing questions on redesigning the health care delivery system.

One favored reforms to "provide the right information and incentives for doctors not just to provide more health care, but the most effective high quality health care based on scientific evidence."

The other warned "this so-called reform is about putting the government in charge of our personal health care decisions, tying the hands of your own doctor and creating a one-size fits all health care system run by a huge, costly new bureaucracy that we can't afford in these tough economic times."

Which version had the most support from the public? I encourage you to join tonight's webinar to find out. You can register at:

https://acponline.webex.com/mw0305l/mywebex/default.do?siteurl=acponline

(Disclosure: there is a modest $25 fee to participate in the webinar to offset the ACP's costs of producing it. None of the money from the registration fees will go to me.)

I promise that you will have an opportunity to ask questions, and yes, you can go at me if you disagree.

Today's questions: How would you respond to the two competing questions above? How did you think the public responded?

Tuesday, March 10, 2009

Do FPs do it better than internists?

A study in this month's issue of Health Affairs finds that Medicare spending by general internists and subspecialists is significantly higher than for family physicians.

The article's abstract says the following:

"Based on analyses of data from the 2001 - 2004 Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians. Variation in spending might be the result of training differences among primary care specialties." The article goes on to say that such "significant variation persisted after control variables and disease case-mix were adjusted for."

As a possible explanation for the variation, the authors cite another study, which concludes that "internal medicine resident training is not well suited for primary care populations." The article ends by saying, "Differences in the training of physicians who are serving as usual sources of care might account for different practice styles associated with greater and potentially avoidable spending, and thus it merits further investigation, particularly in light of current interest in the patient-centered medical home."

The study was conducted by the Graham Center, a research arm of the American Academy of Family Physicians.

I will leave it to others with more expertise than me to comment on the study's methodology and the suggestion that internal medicine training may not be well suited for primary care and the patient-centered medical home. I know that many internists will take issue with the study and the authors' discussion of the policy implications.

My concern is that at a time when family medicine, pediatrics and internal medicine are united on the need to institute policies to support primary care provided by all three disciplines, can there be anything more divisive than for each specialty to get into an argument over which one does the job better?

Vested interests who do not want to see primary care gain at their expense would love to see the primary care physician specialties get into a fight among themselves. Just like they would like to see primary care physicians and NPs battle over their respective roles.

This is not to say that we shouldn't do research to learn more about the impact of physician training on variations in effectiveness and cost of care. Such research should be subjected to critique and commentary, as I am sure the AAFP's Graham Center's study will be. But it will be regrettable if this article ends up creating a war of words on the value of family medicine versus internal medicine, when we should remain united on the essential contributions of both.

Today's question: What do you think of the Graham Center's finding that family physicians are less expensive than internists, and their suggestion that internal medicine training is not well-suited for primary care populations and the medical home?

Monday, March 9, 2009

Can Obama take the deja out of vu?

The current issue of Roll Call has a fascinating interactive timeline on legislative efforts in the United States to enact a national health insurance plan. The timeline goes all the way back to 1883, when German Chancellor Otto von Bismarck created the world's first national health insurance program.

The U.S. misadventure starts in 1915 (coincidentally, the same year that ACP was founded) when the "American Association for Labor Legislation proposes a 'model bill'" for compulsory national health insurance---with initial support from the American Medical Association! (As we all know, within a few years the AMA had switched to oppose any kind of national health insurance plan.)

Click on any of the highlighted dates, and a window will open with more information on what happened (or more often did not happen) that year.

The tool is a lot of fun for armchair health historians like me. Except for the four dreaded words that show up throughout the timeline:

"Congress rejects the plan."

1939: "Sens. Robert Wagner (D-N.Y.), James Murray (D-Mont.) and Rep. John Dingell Sr. (D-Mich.) introduce a national health bill in February. After hearings from April to July, the measure dies in committee."

1946: "The Wagner-Murray-Dingell measure is reintroduced. During April hearings before the Senate Education and Labor Committee, the sponsors carefully avoid the word 'compulsory' when discussing the legislation. Sens. Robert Taft (Ohio) and Joseph Ball (Minn.) and Rep. Margaret Chase Smith (Maine) offer a Republican alternative that provides grants to the states for medical care to the poor. The debate is repeated again in 1947 and 1949."

1974: "President Richard Nixon propose[d] a Comprehensive Health Insurance Act after calling for universal access to health insurance in his last State of the Union address. The plan builds on existing private employer-based health insurance, adding subsidies for the self-employed and small businesses. Congress rejects the plan."

1979: "Congress rejects Carter plan."

1994: Majority Leader George Mitchell abandons Senate reform efforts, marking the end of the Clintons' Health Security Act. Republicans take control of Congress in the November elections for the first time in 40 years.

Fast forward now to March 5, 2009. President Obama tells the VIPs at last week's White House summit:

"Health care reform cannot wait, it must not wait, and it will not wait another year."

If Obama is right, he will achieve something that eluded FDR, Truman, Kennedy, Johnson, Nixon, Carter, and Clinton.

Like Captain Kirk from the old Star Trek series, Obama must be so supremely confident in his abilities that he believes he can go where no president has gone before. Or he understands that something has fundamentally changed in the United States that makes the conditions for reform more favorable than at any time since Bismarck. Or maybe it is both.

Today's questions: Why do you think President Obama believes he will succeed when the history of health care reform in the U.S. is really a story of how "Congress rejects the plan" over and over again?

Thursday, March 5, 2009

What a difference a 15 years makes!

Just a few minutes ago, President Obama wrapped up his White House Summit on Health Reform.

Dr. Jeffrey Harris, MD, FACP, represented ACP at the summit.

I will write more about the summit in future posts, but a few first impressions:

1. This President really, really wants health care reform. He believes - as he said in his opening remarks - that the U.S. has reached the point where "there no longer is a debate about whether to have health care reform, but how that reform should look and work."

2. He rejects the notion that the economic crisis works against health care reform. To the contrary, he made it clear that you can't fix the economy or sustain entitlement programs, like Medicare and Medicaid, without controlling health care costs.

3. He is willing to take on liberal activists, pointedly telling them that they are not going to be able to achieve universal coverage without controlling costs.

4. He understands the importance of primary care. During the question and answers period, he unequivocally stated that, "We have to produce more primary care physicians." Amen!

He also is determined to do everything possible to not to repeat the mistakes that the Clintons made fifteen years ago. Instead of a secret health care task force, he launched his health reform effort today by bringing together key stakeholders and members of Congress from both political parties.

None of this guarantees success. The health care NIMBY-ism that I blogged about on Monday still could cost us health care reform. But in my mind, today was a good start on beginning a process that actually might bring home the "holy grail" of health care reform.

For more information about the summit, go to http://www.healthreform.gov/.

Question: Did today's White House summit make you more or less optimistic about the prospects for achieving comprehensive health care reform?

Wednesday, March 4, 2009

Will Obama's budget put an end to annual Medicare doctor fee cuts?

One feature of President Obama's budget framework is a proposal to change the way that the costs associated with stopping scheduled payment cuts to doctors, due to Medicare's sustainable growth rate (SGR) formula, will be accounted for in budget forecasting.

Dr. Peter Orszag, who heads the White House's Office of Management and Budget, had this to say in testimony before the House Budget Committee:

"Our Budget includes the Administration's best estimate of future SGR relief given the agreed-to fixes for Medicare physician reimbursement in past years. As a result, projected deficits are about $400 billion higher over the next ten years than they would otherwise be. In contrast, past budgets accounted for no SGR relief in any years. (Although our Budget baseline reflects our best estimate of future SGR relief given past policy actions on SGR, as discussed below we are not asserting that this should be the future policy and we recognize that we need to move toward a system in which doctors face stronger incentives for providing high-quality care rather than simply more care.)"

In other words, the administration is assuming that avoiding what Orszag calls "sudden cuts to doctors" will add $400 billion to Medicare baseline spending over the next ten years.

If Congress agrees, the legislative prospects for a long-term fix of the SGR will greatly improve.

A little background first.

The SGR is a key element in the formula used by Medicare to determine annual fee updates to doctors. It sets a target rate of growth in physician expenditures based on per capita GDP growth. When spending on physician services exceeds growth in the economy as measured by per capita GDP, Medicare payment updates to physicians automatically are subject to across-the-board cuts. Since 2002, Congress has stepped in just about every year to enact temporary "patches" to stop the SGR cut, but hasn't come up with a permanent replacement.

Congress has used budgetary slight-of-hand to fund the "patches." Rather than honestly acknowledging that each annual "patch" will increase Medicare baseline spending - the difference between the lower amount mandated by the SGR, and the higher amount paid out under the patch - Congress has just pretended that the higher spending will be made up with even an even deeper SGR pay cut the following year.

This is why the "patch" for an estimated 5% SGR cut in 2008 resulted in a scheduled 10.5% SGR cut in 2009. And why the patch for the 10.5% SGR cut in 2009 balloons to a scheduled 21% cut in 2010.

Think of it this way. Imagine that your boss told you that your wages would be cut by 10% this year. Later, she announces that your company won't cut your wages, but that the only way the company can afford to stop the 10% cut will be to pretend to reduce your wages by 20% the following year. She tells you not to worry, though: they'll just do the same thing next year - prevent the 20% cut by pretending that the cost will be made up by cutting your wages by 40% the following year.

Even though the company has no intention of every allowing the 40% cut to happen. They just have to pretend they will so their accountants will allow them to stop the immediate pay cut. Ridiculous, right? Yet this is exactly the type of dishonest accounting that Congress and the Bush administration engaged in.

Obama's proposal to acknowledge in the budget that Congress will not allow "deep and sudden cuts" in payments to physicians will trouble the deficit hawks. But it provides a way for Congress and the President to reach an agreement on a permanent solution to prevent the physician fee cuts. By telling the truth: preventing pay cuts to doctors will mean that Medicare must spend more.

Today's question: Is Obama right to add $400 billion to the deficit to stop Medicare fee cuts to doctors?

Tuesday, March 3, 2009

Obama and the health care NIMBYs

Just about everyone has had experience with the "Not in My Backyard" (NIMBY) crowd. NIMBYs inevitably show up at community forums to object to proposals to build schools or add new retail or residential development, just about anything that they decide might adversely affect their property values and quality of life, no matter how meritorious.

Health care has its version of NIMBY-ism. Every health care interest group in Washington is for health care reform - until, that is, someone asks them to help pay for it.

In which case, the health care NIMBYs (call them lobbyists, if you like) come with a refrain that sounds something like this:

"Not in my backyard, they say,
We all want health reform ... some day
Just as long as we don't have to pay!"

President Obama's speech to Congress, and release of his budget outline, brought the health care NIMBYs out in force. He proposes to create a $634 billion fund for health care reform that would be paid for by raising taxes on persons earning more than $250,000 per year. He also proposes to reduce payments to Medicare Advantage insurers ($174 billion saved over 10 years), reduce drug prices ($29 billion saved), lower payments to hospitals with high rates of readmissions ($26 billion saved), and reduce home health expenditures ($37 billion saved).

Karen Ignagni, CEO of America's Health Insurance Plan, a health insurer trade group, says the Medicare Advantage cuts "would jeopardize the health security of more than 10 million seniors enrolled in Medicare Advantage and would turn back the clock on innovative payment incentives to improve the quality of care that patients receive," reports Julie Rovner and April Fulton in a National Public Radio story. (To be sure, AHIP has proposed its own plan for universal coverage, which does not include cuts to Medicare Advantage plans).

The Pharmaceuticals and Research Manufacturers of America issued a guarded statement congratulating President Obama for his commitment to funding health reform but warning "against the adoption of policies that could undermine innovation and disrupt patient access to life-saving medicines."

Even with President Obama's proposed savings, Robert Leszewski argues in his Health Affairs blog post that "President Obama hasn't made anywhere near the hard decisions that need to be made." Leszewski argues that "we need to reduce what we pay physicians" to get real savings but that "it is also the most politically problematic for all the clout the physician lobby has."

I think the reaction to the budget shows the challenge President Obama will face in getting health care reform enacted. The health care NIMBYs will try to block any reforms that will affect their own backyards.

To be fair, I am not pointing the finger at other interest groups - ACP would almost certainly object to "savings" that come at internists' expense.

President Obama knows he is in for a fight. The Huffington Post has a video that quotes President Obama as saying "I know these steps won't sit well with the special interests and lobbyists who are invested in the old way of doing business, and I know they're gearing up for a fight. My message to them is this: So am I."

This is a message he likely will repeat to ACP and the key stakeholders invited to Thursday's White House summit on health care reform.

Today's questions: Do you think health care NIMBY-ism will kill health care reform? What would you advise President Obama do to overcome it?

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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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