The ACP Advocate Blog

by Bob Doherty

Wednesday, April 29, 2009

Health care reform on day 100

All of the media are agog with stories about Obama's 100th day in office. I will resist the temptation to join them, but instead focus on major developments on health care reform that have occurred in the last 48 hours.

One, is the confirmation of Kathleen Sebelius. Although her views on health care reform remain largely unknown, her confirmation will allow the administration to finally gets its health care team together, including subsequent appointments of the CMS administrator and Surgeon General.

Second, is the approval today by the House of Representatives of a joint budget resolution, which is expected to be voted upon later today in the Senate. The resolution is a mixed bag for physicians. It does not include funds to permanently eliminate the Medicare SGR payment cuts. Instead, it would at best prevent the cuts for two or three years, after which payment updates would again be subjected to deep cuts. President Obama had proposed that Congress honestly account for the costs of preventing the SGR cuts in its assumptions of Medicare baseline spending - which basically would have meant acknowledging what everyone knows to be true, which is that Congress won't let the cuts go into effect so it might as well just acknowledge the cost involved as contributing to the deficit. Instead, Congress opted for another stop-gap approach that masks the true costs of getting rid of the SGR and preventing further pay cuts.

The budget does call on Congress to enact legislation to improve payments for primary care physicians, which is a good thing, but there is a catch - increased payments would have to be offset by cuts to someone else.

Third, Senators Max Baucus (D-MT) and Charles Grassley (R-IO) released an options paper on health care delivery system reform. It calls for increases in payments to primary care physicians of "at least five percent per year" for designated evaluation and management codes, above the baseline for other physicians. These increases would be budget neutral, paid for by lowering payments for all other codes. It also calls for an accelerated process to test and then implement new payment models - the medical home is listed as an example - to improve care coordination. They also propose to pay primary care physicians a separate fee for "proven interventions" to help the transition from the hospital for recently hospitalized patients with chronic illnesses.

On the SGR, Baucus and Grassley would provide a one percent update to physicians in 2010 and 2011, and a 0 percent in 2012, after which physicians would face a deep SGR Medicare pay cut. Unless Congress bails them out again.

The Baucus/Grassley options paper provides some encouraging ideas on how to design a framework to recognize the value of care provided by general internists and other primary care physicians, but more work is needed to ensure that these and other policies are up to the task.

Finally, my only comment on Senator Specter's switch to the Democrats is that getting 60 Senators to vote in unison on an issue as controversial as health care reform still will be very tough, no matter the party label that they wear.

Today's question: What do you think of the developments in the past 48 hours?

Tuesday, April 28, 2009

Everyone wants Patient-Centered Primary Care ... but will they pay for it?

I am blogging today from a jam-packed meeting of health care leaders convened by the Patient-Centered Primary Care Collaborative (PCPCC), a coalition representing 400 of the most powerful stakeholders in American health care, physicians, employers, consumers, purchasers, and insurers alike. Today's meeting is to discuss opportunities and solutions to advance the patient-centered medical home model of health care delivery. Attendees are hearing from physicians who are implementing team-based care through the PCMH in the real world of practice, from the senior government official who is running the Medicare Medical Home demonstration, from experts in the role of health information technology in facilitating care coordination, from communication experts on the importance of presenting the benefits of the PCMH in way that resonates with consumers, and from yours truly, who will be discussing the political environment surrounding primary care and the PCMH. (Information on the presentations will be posted on the Patient-Centered Primary Care Collaborative web site - http://www.pcpcc.net/ - following today's meeting.)

The fact that so many people, representing the most influential constituencies in health care, are united to advance patient-centered primary care is good news indeed. Much has been accomplished.

On the political front, Senator Max Baucus (D-MT), chair of the Senate Finance Committee (SFC), is expected to release a paper later today that outlines his proposals to reform the health care delivery system, including advancing primary care (more about this tomorrow) and models to support prevention and care coordination like the Patient-Centered Medical Home. As I blogged about last week, Democrats and Republicans alike during last week's SFC roundtable, expressed a strong bipartisan commitment to reforming physician payments to support the value of primary care.

But as Robert Pear writes in yesterday's New York Times, translating the support on Capitol Hill for primary care into legislation will run right into the challenge of finding the money in a budget-neutral environment. The article quotes a spokesperson from a non-primary care physician organization who flatly rejected the idea that higher paid specialists might have to give up something to support their colleagues in primary care.

The hope of many of us is that Congress will decide that the value of primary care is such that it deserves a commitment of more federal funding, without running it through the usual budget-neutrality constraint that requires that more money for primary care come from other physicians or "providers." ACP has consistently advocated that Congress consider the demonstrated impact of primary care in achieving overall improvements in outcomes and reductions in health care spending, much of it related to reductions in preventable hospital admissions under Medicare Part A. The regular budget neutrality rules don't allow for savings in one part of Medicare (in this case, Part A) to be allocated to another (payments for primary care under Part B).

The challenge though is we may soon be facing tough choices. If Congress won't agree to put more "new" money on the table for primary care, the funding will have to come from someplace else. Yet I still have not heard anyone step up to the collection plate to commit the resources needed to adequately fund primary care so that it is competitive with other specialties, even though just about everyone says they agree on the need.

Unless payments for primary care are increased to the point where primary care is considered to be a viable and attractive career choice for young physicians and to sustain those already in practice, we can build all of the medical homes we want, but there will be no one home when the patient shows up for care.

Today's question: What advice would you give to Congress on finding the money to support higher payments for primary care, given budget-neutrality rules and resistance from other physicians and providers to redistributing money to primary care?

Friday, April 24, 2009

Restoring R-E-S-P-E-C-T to primary care internal medicine

The American College of Physicians today released two major new policy papers proposing comprehensive solutions to the crisis in primary care. One paper recommends restructuring physician payment models used by Medicare and other payers to support the value of care provided by internists and other primary care physicians and to achieve overall better value for the health care system. This paper has two key components:

- Giving the federal government the authority to implement, evaluate and then rapidly expand new models of physician payment to align incentives with the value of care provided, not just the volume of service - including models that specifically support patient-centered primary care. ACP proposes specific criteria for identifying the models with the greatest potential to result in improved outcomes, which could then also be used to develop benchmarks for evaluating their impact on a pilot basis. Finally, the paper calls for a fast track way to expand the most effective models, with input from outside experts, so that they can be adopted more widely without getting bogged down in the usual, and painfully slow, Medicare demonstration project bureaucracy and rules.

- Concurrently improving payments for primary care under the prevailing fee-for-service system used by Medicare and other payers. ACP calls for providing annual bonus payments for primary care physicians beginning in 2010 until overall payments reach parity with other specialists; re-examining the processes Medicare uses to get expert input on the relative value units (RVUs) for physician services; creating a better way to identify potentially mis-valued services, which could then be redistributed back to primary care and other under-valued services; correcting distortions in the practice expense RVUs for advanced imaging; and providing separate payment for e-mail and phone consultations provided by primary care physicians and other specialists involved in care coordination.

The second paper released today calls for a creation of a new national workforce commission to recommend the appropriate numbers and mixes of physicians and other health professionals, including increasing the numbers and proportions of primary care physicians, and policies to achieve such goals. ACP proposes a comprehensive and coordinated strategy including payment reforms, as discussed more fully in the payment paper described above; emphasizing the value of primary care in medical schools and graduate medical education training programs; increasing the number of GME-funded primary care training positions; eliminating student debt for physicians who provide primary care in critical shortage areas; increasing funding for the National Health Services Corps and the Title VII primary care training program; reducing paperwork burdens on primary care physicians; and funding the patient-centered medical home and other models to provide primary care physician practices with financial and other resources needed to coordinate care effectively.

Combined, the two papers address the major causes of dissatisfaction so many general internists attending IM 2009 have expressed to me in conversations over the past few days: insultingly low and dysfunctional payment policies; enormous paperwork burdens; high levels of student debt; and a medical education system that contributes to the sense that the prestige lies in fields other than primary care. Underlying all of these concerns, though, is what I would describe as a profound sense that what they do is not valued or respected by society. Turning this around will require a coordinated national strategy that addresses every point of influence, from medical school through residency, of how their services are valued and reimbursed throughout their careers, for primary care internists to regain the respect they so rightly deserve, because of the importance of what they do for their patients.

Today's question: What do you think are the most important things that can be done to end the lack of respect for general internists and other primary care physicians?

Thursday, April 23, 2009

Slip slidin' away, slip slidin' away ...

Paul Simon probably wasn't thinking health care reform when he sang "slip slidin' away, slip slidin' away ... the nearer the destination, the more you go slip slidin' away" but he might as well have been. It seems like every time the U.S. gets closer to the destination of universal coverage and delivery system reform, something comes up to send us slip slidin' away.

It looked from the Senate Finance Committee roundtable on delivery system reform on Tuesday that we are getting close to agreement on bipartisan reforms to improve health care delivery. But today comes word that a fight between Republicans and Democrats over using "budget reconciliation" to enact health care reform could grind things to a halt. (Budget reconciliation would enable health care reform to be passed on a simple majority vote, a tactic that most Democrats favor but is fiercely resisted by the Republican minority.) A few hours ago, confirmation of Governor Sebelius as Secretary of the Department of Health and Human Services was held up because of more partisan squabbling.

On an optimistic note, E.J Dionne opines in the Washington Post that health care reform has become "irresistible" so we should not assume "that [every] snag, controversy or disagreement over the effort to pass comprehensive health-care reform" represents a collapse of the process.

I certainly hope Mr. Dionne is right. But eternal vigilance will be required of health reform advocates. Right now, polls show that voters are solidly behind the Obama administration's broad goals for health reform, but they will soon be getting an onslaught of opposition messages designed to make them think twice.

One of the opposition messages will be to invoke the "slippery slope." We've already seen this in the debate of government funding of comparative effectiveness research (CER). The argument being made is that although CER funding appears benign enough - providing clinicians and patients with comparative efficacy data based on head-to-head trials of different clinical treatments - it will inevitably result in the government using such information to deny access to care based on economic criteria, not quality. In other words, give the NIH money today to do clinical trials of different treatments, and tomorrow we'll be throwing grandma under the bus to save money.

Now, to be clear, I don't believe that the slippery slope argument - and its rhetorical sister, the "foot in the door" analogy - are totally without merit. An ACP member, who I highly respect, told me yesterday that she was concerned that CER would be a slippery slope to rationing based on cost. She pointed to the experience in the United Kingdom, where CER is used to deny care to people when their projected cost of care, over their estimated months of quality life, exceeds a dollar threshold. Those of us who favor CER need to take such concerns seriously and accurately describe how CER should, and should not, be used. This morning, Dr. Hal Sox, editor of the Annals of Internal Medicine and chair of a new Institute of Medicine committee on CER, gave the best argument I've heard yet on why internists should support CER to a packed gathering of internists at the opening session of ACP's annual scientific meeting.

The problem with the slippery slope analogy is that it ultimately becomes an argument for the status quo: Any new policy change can potentially lead to other changes that may not be desired or intended, so why take the risk of changing things? It assumes a degree of inevitability in public policy that in my experience isn't the case. In a democratic society with a representative government, one thing doesn't have to lead to another, if the voters don't want it to.

Finally, we know that if we don't change the health care system, the U.S. health care will slide into more uninsured persons, exploding costs, lower quality and enormous budget deficits caused by spending on Medicare and Medicaid. This is the one slippery slope that is inevitable unless we have the desire and will to change things.

Today's question: Do you buy the "slippery slope" argument that health care reform will result in the government taking control of health care decisions?

Wednesday, April 22, 2009

Democrats and Republicans don't seem to agree on much ... except primary care

Yesterday, the Senate Finance Committee convened a roundtable to get ideas on improving the health care delivery system. Senator Max Baucus (D-MT), restated his commitment to getting a bill through his committee by June to reform health care delivery and provide affordable coverage to all Americans. Senator Charles Grassley (R-IO), the committee's ranking minority member, expressed his commitment to working with Senator Baucus to achieve bipartisan health reforms.

The hope though that Republicans and Democrats will be able to agree on a bipartisan bill was called into question, when the committee took a break from the roundtable to vote on the nomination of Kathleen Sebelius as secretary of the Department of Health and Human Services. Every Democrat on the committee voted to recommend that the full Senate confirm Governor Sebelius, but all but two Republicans voted no. The only GOP "yes" votes were from Senator Pat Roberts, who supported his home state nominee, and Senator Olympia Snowe (R-ME). Senator minority whip Jon Kyle (R-Arizona) said he opposed Sebelius' nomination because she wouldn't commit to prohibiting the use of comparative effectiveness research in making Medicare coverage decisions.

Now, for the good news: Republicans and Democrats alike sang the praises of primary care and their shared commitment to federal policies to recognize and support the value of primary care. One way to tell what was on the Senators' minds is to go to the C-SPAN video library archive of yesterday's roundtable, click on "watch" and then the "search text" feature, insert primary care into the search window, and see how often it popped up in the Senators' remarks and the comments from the invited experts. You can use this feature to listen to, or read, the transcript of the roundtable and the specific discussion of primary care.

One of the invited experts was ACP's own Chief Executive Officer (CEO) and Executive Vice President. Dr. Tooker was the only representative of a physician membership organization invited to participate in the roundtable, an indication of the high regard that Senator Baucus and Senator Grassely have for Dr. Tooker and ACP.

Dr. Tooker was specifically asked to by Senators Snowe and Orrin Hatch (R-UT) to address the crisis in primary care and potential solutions. Click on this link to listen to or read the transcript of Dr. Tooker's response to Senator Snowe. Dr. Tooker made several key points on ACP's behalf, including the demonstrated value of primary care in improving outcomes and reducing costs and the need for comprehensive reforms - including a national workforce policy and reforms of physician payment systems - to increase the numbers of primary care physicians in the United States. (Click on this to read ACP's written statement for the record, the opening remarks of Senators Baucus and Grassley, and the testimony of the other invited witnesses.)

It is highly encouraging that national policymakers "get it" when it comes to the critical role of general internal medicine and other primary care physician specialties in creating a better performing health care system. Republicans and Democrats have deep disagreements on issues ranging from comparative effectiveness research to offering the public the choice of enrolling in a Medicare-like public plan, but not on the need to have more primary care physicians in their communities.

It is also encouraging to note the enormous credibility that ACP has earned by the quality of our policy analyses and recommendations. No other organization is in as good a place as ACP to influence the health reform to help ensure that it meets the needs of internists and their patients. I wonder though how much more effective we could be if every internist belonged to the ACP.

Today's questions: Do you think Congress will deliver on the bipartisan support for primary care? And how can ACP get the word out to ACP members and non-members alike on how well regarded and well-positioned the College is to influence health reform to create a better future for internists and their patients?

Monday, April 20, 2009

Will bans on drug industry sponsorship have unintended consequences for patients?

Today and for the rest of the week, I will be blogging from the Philadelphia Convention Center, where ACP will be holding its annual scientific meeting. Convention center workers are now doing all of the prep work for a successful medical convention, including setting up the exhibit hall.

I think it is timely then to think about the relationships between pharmaceutical companies, individual physicians, and physician membership organizations like ACP. There are some who argue that the links between industry and physicians should be severed - no funding for CME, no exhibit halls, no gifts, no free drug samples, no drug company symposia, nada. Others argue for a balanced approach, one that recognizes that industry support for CME and other professional activities can support a public good (such as making it possible for physicians to have access to top-notch CME at relatively low cost to them) but with controls over the inherent conflicts of interest that may be created.

The current issue of Health Affairs offers two interesting perspectives. Jonathan Han, MD, a family physician, writes about the unintended harm to indigent patients that resulted when his academic medical center prohibited distribution of free drug samples. His institution ended up backing off from an outright ban, cobbling together what Dr. Han calls a "morally suspect compromise" to ensure that patients get the medications they need. "It's ... untenable for doctors and other health care providers to be put in a position where you're damned if you do - and patients die if you don't," he laments.

Melinda Morton, a medical student, eloquently writes about her struggle in keeping her resolve not to accept free lunches and drug samples at her academic medical center, given what she calls the "pervasive" presence of freebies from drug companies.

For its part, the American College of Physicians continually re-examines its policies relating to physician-industry relations, and makes sure that every activity at its scientific meeting is fully in accord with such policies. ACP's current policy "strongly discourages" acceptance by individual physicians of industry gifts and calls on physicians "to gauge regularly whether any gift relationship is ethically appropriate and evaluate any potential for influence on clinical judgment. In making such evaluations, it is recommended that physicians consider such questions as 1) What would the public or my patients think of this arrangement? 2) What is the purpose of the industry offer? 3) What would my colleagues think about this arrangement? 4) What would I think if my own physician accepted this offer? In all instances, it is the individual responsibility of each physician to assess any potential relationship with industry to assure that it enhances patient care and medical knowledge and does not compromise clinical judgment."

Another ACP policy paper discusses the organizational relationships between physician organizations and industry. This paper says that acceptance of industry support from CME and other medical society activities is acceptable within strict guidelines to ensure the objectivity and transparency of any activities funded.

It is one thing to take the broad brush stance that acceptance of support from industry should be verboten, but bans can have unintended adverse consequences for patients, as Dr. Han found when his indigent patients could no longer get the free drug samples they depended upon. A premier scientific meeting like ACP's clearly services a public good (helping doctors keep up-to-date in their clinical knowledge and skills), and drug industry support, within strict guidelines, helps keep the meeting affordable. If industry support for CME was to be prohibited, I wonder where the money would come from to allow internists to continue to have access to CME at a price they can afford.

Today's questions: Should physicians be prohibited from distributing free drug samples to patients? What about drug industry support for CME programs like ACP's scientific meeting?

Friday, April 17, 2009

It's time to talk about the R word

Public opinion researchers have warned advocates of health reform to avoid using the "R" word. Lake Research Associates, a Democratic leaning polling firm, found that 62% of voters would express more doubts about health care reform if told it will lead to rationing.

Yet, a serious discussion about rationing is beginning to take place in the health care blogosphere.

One school of thought says that the United States already rations care, but irrationally and unfairly, based on ability to pay. This is how health economist Uwe Reinhardt describes it in the New York Times Economix blog:

"Evidently, many Americans do sincerely believe that when a public health plan refuses to pay for a procedure it is 'rationing,' while denial of health care to an uninsured, low-income individual who cannot afford to pay for that care is not. But as textbooks in economics explicitly teach, the role of prices in a market economy is precisely to ration scarce resources among unlimited demands. The American health system has rationed health care by price and ability to pay all along for a sizeable segment of the United States population. In its report "Hidden Cost, Value Lost," for example, a distinguished panel of experts convened by the Institute of Medicine of the National Academy of Sciences estimated that some 18,000 Americans die prematurely for want of health insurance and timely medical care. That is rationing life years."

Others acknowledge that the American health care system provides unequal access to care, but they favor rationing by markets, over rationing by government. This comment from conservative blogger Andrew Sullivan, responding to a reader's comment, says that markets enable rich people to buy more care than they need while leaving poorer people with less:

"And why should we have a problem with free people choosing to 'pour everything they have into high intensity, high tech, high cost, but in the end marginal extensions to their lifespan'? And isn't the market a more neutral and less politically manipulable form of rationing than government? I think you really do have to live in a socialist system to see how rational it looks from the outside and how mediocre, passive and bureaucratic it feels from within."

I think it is good that we are at least beginning to have a serious discussion about rationing, and that the question being addressed is not if the U.S. rations care (we do), but whether markets or government will do a better job. Even if the public and politicians don't want us to talk about it.

Today's questions: If rationing is inevitable, who do you think would do a better job at it - the government based on guidelines on cost and effectiveness, or markets based on ability to pay?

Thursday, April 16, 2009

Will conventional wisdom kill health reform?

One of the biggest threats to achieving health care reform in our time is the growing chorus from Washington insiders urging Obama and Congress to go slow and set their sights low.

Former House Majority Leader and failed presidential candidate (D-MO) Dick Gephardt is the latest to counsel such. John Harwood writes in the New York Times Caucus blog that Gephardt is advising Democrats to focus first on costs of care, and put off universal coverage to another day. Gephardt believes that universal or near universal coverage cannot be enacted this year - that the best that might get done is to expand coverage to most children. Gephadt is quoted as saying that universal coverage "is absolutely imperative, and it needs to be dealt with. But the way to get to it is to show that we can deal with some of these [the cost of health care] problems first."

Let's see if I have this right. Universal coverage is absolutely imperative, but it would be a mistake to pursue now. But if not now, when? Will the political conditions for universal coverage be better a year, or two, or five, or ten years from now?

I understand Mr. Gephardt's caution. The safe bet, after all, is that this President and this Congress will unable to achieve universal coverage, since that has been the case with all who tried before them. We need to remember, though, that this is not a game of cards, but gambling with the tens of millions of Americans whose lives and economic security are placed at risk because they don't have health coverage.

From a pragmatic standpoint, I disagree with the idea that delivery system reform - controlling costs - is easier than expanding coverage. Delivery system reform will involve dishing out a lot of pain, but unless it is linked to universal coverage, it will be pain without the gain of providing all Americans with the security of health insurance that can't be taken away.

Today's question: What do you think of Mr. Gephardt's advice that Obama and Congress go slow and set their sights low?

Tuesday, April 14, 2009

Will health reform be good for doctors?

Hot off the press is a report from the Center for American Progress (CAP) that argues that health care reform will be good for doctors and other health professionals. The report was co-authored by Bob Berenson, MD, a fellow of the American College of Physicians, writing on his own behalf.

Dr. Fred Turton, MD, FACP, chair-elect of ACP's Board of Regents, participated in a CAP-organized event today to get reaction to the report from "distinguished members of the health professional community." He spoke favorably about the report, which makes a solid case that health care reform will help physicians provide better care to their patients, improve clinical decision-making, promote wellness and prevention, and improve the lot of primary care physicians.

I know from many of the comments posted to this blog that there is a great deal of skepticism, bordering on cynicism, among many physicians. Primary care physicians, in particular, seem burned by past promises that reforms will make things better for them (remember the RBRVS?), only to see that their work continues to be systematically devalued. And many physicians have principled concerns that health care reform will give the government too much authority to dictate clinical decision-making. Their concerns need to be addressed by those of us who believe that health care reform is essential and right for doctors and patients, not treated dismissively.

For many doctors, health care reform is a case of "trust but verify" as Ronald Reagan famously said about the Russians. These physicians want a better health care system, but they don't trust Washington to get it right.

The next several months will be a battle for the hearts and minds of physicians, because physicians have such a high degree of credibility with the public. If doctors embrace health care reform because it is right for them, and right for their patients, the public will feel far more confident in the outcome. If doctors end up echoing the concerns of those who are worried that health care reform will take decisions away from doctors and patients, then health care reform will lose the support of the public and ultimately falter.

Today's questions: Do you believe that health care reform will be good for doctors? Why or why not?

Friday, April 10, 2009

Is a "public plan" option worth all of the fuss?

Steve Pearlstein writes in today's Washington Post about the political brouhaha over proposals to give Americans a choice of a Medicare-type public plan, which he correctly observes has become a "litmus test" for the Republican right and the Democratic left. He argues, though, that "this is hardly the most important issue in health-care reform" because:

"It is possible to design a system that could control costs, improve quality and increase access to care without giving everyone the chance to sign up for a government-run health-insurance plan modeled after Medicare. It's also possible to design a system that includes a public option."

I know many will take issue with Pearlstein's view. For instance, see Maggie Mahar's two-part Health Beat blog (Part 1 and Part 2) and on why Obama should stand firm on a public plan and Conn Carroll's post on the Heritage Foundation blog on why a public plan "must be avoided at all cost."

In my view, though, Pearlstein hits the nail on the head as he asks whether the public plan would simply replicate the existing flaws in Medicare physician payment:

"If by 'public option' you mean the current Medicare fee-for-service plan - a plan that makes no attempt to manage and coordinate care and pay for that care on the basis of the quality of the outcome - then a public option would be an awful idea and move the system in exactly the wrong direction."

The design of the public plan has largely been overlooked by the "are you for it or against it" crowd.

If the proposal is to offer the American people a public plan that undervalues primary care, rewards fragmentation and volume of services, and has a built-in self-destruct formula (SGR) that triggers physician payment cuts every year, which Congress then has to step in and stop with stop-gap measures which only make the problem worse the next year - well, then, it is hard to see why this is a model that should be offered to everyone. But, as Pearlstein also notes, it is possible to create a well-designed public plan that private competitors would be forced to emulate.

The American College of Physicians, for its part, has not taken sides (yet) on the public plan option, despite enormous political pressures from the left and the right. We want to see the details. What would the benefits be - considering that Medicare fee-for-service doesn't cover most preventive services? How will physicians be paid - would the public plan increase payments for primary care and support models to coordinate care, like the Patient-Centered Medical Home? How would the selection process and federal subsidies for the public and private insurance plans work? What would competing private insurers be required to do in order to be qualified to participate in the program?

Raising these questions isn't ducking the issues, it is asking those on the left who favor a public plan to explain what it would look like and how it would work, rather than just saying it is essential. And asking those on the right to better explain their opposition - what is it about a public plan that they would find to be unacceptable (since I don't think most of them are in favor of repealing Medicare for the elderly) other than they don't like big government?

Today's questions: Do you think a public plan option is essential or absolutely unacceptable, and why? Or do feel that it might or might not be acceptable - depending on the details?

Wednesday, April 8, 2009

Should we be doing it like the French?

Ezra Klein, an editor at The American Prospect, writes in the Los Angeles Times that "When it comes to health care, the U.S., Britain and Canada are hurting" noting that in Canada and Britain "the two countries most often cited in discussions of what nationalized healthcare might mean, some patients report having to wait months for some elective treatments." But he also observes that "we've got waiting lines too - along with 50 million uninsured and a system that costs more than twice as much per person as that of any other country. We've just managed to hide our lines through clever statistical gimmickry."

He also notes that Germany, France, Japan and Sweden are examples of countries that have achieved universal coverage without long waits, and "all of them have more of a mix of public and private options" than the U.K. or Canada. The American College of Physicians reached a similar conclusion in a 2008 position paper that my colleague Jack Ginsburg and I co-wrote for ACP's Health and Public Policy Committee. It was approved by our Board of Regents in October, 2007 and the edited version appeared in Annals.

We looked at a dozen different health care systems around the world, and found that they all outperformed the U.S. on most measures of access, quality, and cost of care. We also found that the best performing systems could be found in countries like France and Germany that combined publicly-funded and guaranteed coverage with private coverage options. (Canada actually scored second to worst, with the U.S. taking last place, on most of the elements of a high performing health care system as defined by the Commonwealth Fund, one of our principal sources).

Now, to be clear, we didn't find any one country had it all together. There were some advantages associated with single payer systems. And countries with mixed systems of public and private options tend to be less egalitarian. We found, though, that either a pluralistic model with guaranteed coverage, or a single payer model, would out-perform the U.S. on most metrics and therefore had elements that should be considered by the U.S. as it tackles health care reform. We also recognized that any solution for this country would be uniquely American.

President Obama and top congressional leaders also seem to be looking more to France than Britain or Canada. They are putting together legislation that would combine subsidized private insurance, a public plan option, and guaranteed coverage. They aren't advocating a single payer model, despite the exaggerated fears in some conservative circles that this is exactly what they are hoping to achieve, and to the great disappointment of those on the left who argue, with great passion, that single payer is the "only" answer to the U.S. health care crisis.

Today's questions: Do you believe that it is possible to achieve universal coverage in the U.S. without long waits for appointments? And what do you think of doing it the French way - a mix of public and private options - instead of Canada's single payer model?

Monday, April 6, 2009

With opening day almost behind us, now comes the hard part

Last night was opening night for the 2009 Major League Baseball season, although I haven't ever quite accepted the idea of baseball opening with a night game. So let's call today opening day.

Opening day is a time, of course, when every baseball fan is brimming with optimism about their team's prospects, even the stalwart fans of the Pirates, Royals and Nationals, when all logic should tell otherwise.

The same might be said of health care reform. President Obama and other advocates of health reform have done what they can to lay the groundwork for success. But the time for optimism is over. Now comes the hard part of finding a winning strategy to prevail over the long haul.

By the dog days of summer (August congressional recess), health care reformers will have a pretty good idea if they are close to bringing home the title of health care reform or are falling out of contention. By fall, they likely will know if it is really going to happen, or whether they'll be left crying "wait until next year" as Cubs fans have been doing for over 100 years (which is about how long the U.S. has been trying, and failing, to enact health care reform).

Let's look at where things stand today. Obama can point to some successes: reauthorization of SCHIP and the health care "down payments" in the stimulus bill. The pending House and Senate budget resolutions give a green light to the President's health care reform agenda, but with the big catch that it will all need to be paid for with savings, budget cuts, or revenue (tax) increases.

For physicians, the biggest challenge going forward may be whether the profession will embrace the need for comprehensive reform of the health care delivery system, including physician payments, or fight to keep a status quo that is failing so many patients and physicians.

The budget resolution approved by the House of Representatives does something very clever to force the issue among doctors. It basically would forgive the hundreds of billions of dollars in accumulated federal debt associated with the annual Medicare payment cuts associated with the Sustainable Growth Rate (SGR) formula, without requiring that this cost be offset by budget or pay cuts or revenue increases somewhere else. Wiping out this accumulated cost would allow Congress to enact a long-term solution to the SGR.

But for physicians to get the SGR money, they will have to be on board with reforms, according to the budget resolution, to create "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."

The Senate budget resolution, although it talks about the need to make Medicare improvements to support training of more primary care physicians, doesn't provide access to the funds needed to get rid of the SGR and make other payment reforms, including reforms to support primary care, without making cuts somewhere else. The House and Senate will need to resolve these and other differences, and a final vote on a joint budget resolution is expected when Congress returns from its spring recess. ACP is strongly supporting the House language, because it creates a roadmap for eliminating the SGR cuts and reforming payments to ensure appropriate payment for primary care, to improve care coordination, and make health care more effective and efficient.

My sense, though, is that much of the medical profession isn't quite prepared yet to embrace the "quo" of supporting reforms to improve payment for primary care and holding physicians accountable in exchange for the "quid" of getting the SGR money.

And since physician payment and health care delivery reforms are considered to be essential ingredients of comprehensive health care reform, how physicians respond to this challenge will have a lot to do with whether President Obama and other health care reformers will be able to celebrate a historic October victory, or whether they will once again be disappointed, as so many baseball fans also will be.

Today's question: Do you think physicians are ready to support payment reforms to ensure better payment for primary care , improve efficiency and quality, and improve accountability - in exchange for getting rid of the Medicare SGR pay cuts?

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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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