Wednesday, December 22, 2010

The Twelve Days of Health Reform

Today's blog will be my last for 2010, as I will be taking a break to spend the Christmas and New Year’s holidays with family and friends.

In keeping with a tradition I started two years ago, I again have taken the liberty of mangling a beloved holiday song, story, or rhyme to give a humorous (I hope!) perspective on current politics. In December, 2008, I adapted “Twas the Night Before Christmas” to convey President-elect Obama as being a not-so-jolly old elf besieged by lobbyists demanding stimulus gifts. Last year, I depicted the GOP as the Grinch trying to stop “ObamaCare” from coming.

Today, I’ve re-written the “Twelve Days of Christmas” carol so that it is the government bestowing “gifts” (based on actual provisions of the Affordable Care Act) that the new Congress may later take away. (Of course, in the real world, the ACA’s changes won’t take place over 12 days, but over many years.) Here goes:

“On the first day of health reform, the government gave to me,
A promise of health care, available universally.

On the second day of health reform, the government gave to me,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the third day of health reform, the government gave to me,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the fourth day of health reform, the government gave to me,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the fifth day of health reform, the government gave to me,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the sixth day of health reform, the government gave to me,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the seventh day of health reform, the government gave to me,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the eighth day of health reform, the government gave to me,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the ninth day of health reform, the government gave to me,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the tenth day of health reform, the government gave to me,
Low cost insurance through an exchange,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the eleventh day of health reform, the government gave to me,
A fine if I don’t buy coverage,
Low cost insurance through an exchange,
Medicaid for my self-employed cousin,
Better benefits in my company’s plan,
Higher Medicare payroll taxes,
More money to my primary care doctor,
Free Medicare visits for my mom,
Tax credits for my small business,
Insurance for my adult kids,
Coverage of my pre-existing conditions,
And a promise of health care, available universally.

On the Twelfth day of health reform, John Boehner gave to me,
No funding for the Affordable Care Act,
No fine if I don’t buy coverage,
No low cost insurance through an exchange,
No Medicaid for my self-employed cousin,
No better benefits in my company’s plan,
No higher Medicare payroll taxes,
No more money to my primary care doctor,
No free Medicare visits for my mom,
No tax credits for my small business,
No insurance for my adult kids,
No coverage of my pre-existing conditions,
And a “Hell no!” * to health care, available universally!"

*On March 22, the day health reform passed the House, Rep. John Boehner (R-OH), who in January will become majority leader, famously invoked the “Hell No” mantra in expressing his opposition.

Today’s question: No question today, just my hope that you have a happy, prosperous holiday season and new year with family and friends!

Thursday, December 16, 2010


If you appreciate irony, it doesn’t get much sweeter than this:

A GOP-appointed judge rules that a GOP idea, recently embraced by a Democratic president who a few years ago campaigned against it, is unconstitutional, possibly paving the way for a government-run program.

Strange, but true. A Republican-appointed judge in Virginia has ruled that the ACA’s individual mandate is unconstitutional (although two other federal judges appointed by Democrats have upheld it, and the Supreme Court will ultimately decide). The irony is that the roots of the individual mandate can be found in conservative proposals from the early 1990s.

In 1990, the conservative Heritage Foundation developed a plan for universal coverage that described the individual mandate as a “social contract” between the government and individuals:

“Under this social contract, the federal government would agree to make it financially possible, through refund able tax benefits or in some cases by providing access to public-sector health programs, for every American family to purchase at least a basic package of, including catastrophic insurance. In return, government would require, by law every head of household to acquire at least a basic health plan for his or her family.”

The individual mandate was then incorporated into bills proposed by GOP stalwarts Orrin Hatch (R-UT) and Chuck Grassley (R-IO) as an alternative to “Hillary Care.” It later became a lynchpin of the Massachusetts health reform plan championed by then governor (and likely 2012 presidential candidate) Mitt Romney (R-MA).

That was then, this is now.

The Heritage Foundation now argues that the individual mandate is “unprecedented” and “unconstitutional”- conveniently ignoring its own past ownership of the idea. A few days ago, Senator Hatch hailed the Virginia judge’s decision to overturn the individual mandate as “a great day for liberty. Congress must obey the Constitution rather than make it up as we go along. Liberty limits on government, and today those limits have been upheld.”

The irony isn’t limited to Republicans. During the Democratic primary, candidate Barack Obama not only opposed an individual mandate, he used it in attack ads against Hillary Clinton:

"What's [Clinton] not telling you about her health care plan?" an announcer asks. "It forces everyone to buy insurance, even if you can't afford it."

That was then, this is now.

Following the Virginia ruling, the White House had this to say:

“Opponents of reform claim that the individual responsibility requirement – the requirement that all Americans carry a minimum level insurance by 2014 – exceeds Congress’ power to regulate interstate commerce because it penalizes economic ‘inactivity.’ Make no mistake -- individuals who choose to go without health insurance are actively engaged in economic decision making – the decision to pay for health care out-of-pocket or to seek uncompensated care. Every year millions of those who have chosen to go without health insurance actively seek medical care, which is evident in the billions of dollars spent on uncompensated care every year.”

(I wonder what Obama’s Secretary of State would have to say about this now, but of course, she can’t.)

The above is fact – you can look it up. More speculative is the part about the Virginia ruling possibly leading to a single payer plan. But the Washington Post’s Ezra Klein plausibly writes:

“The individual mandate was created by conservatives who realized that it was the only way to get universal coverage into the private market. Otherwise, insurers turn away the sick, public anger rises, and, eventually, you get some kind of government-run, single-payer system, much as they did in Europe, and much as we have with Medicare.”

If Ezra Klein is correct, could anything be more ironic?

Today’s question: What do you think about the irony involved in today’s debate on the individual mandate?

Monday, December 13, 2010

Your comments, my responses

I started responding to specific comments from readers on two of my recent blogs, but have decided that they raise issues important enough to make up today’s entire post.

On “What happens if universal coverage is allowed to slip away” commenter ryanjo writes that there “is rapidly evaporating support for the ACA.” I think we pay too much attention to polls, but I took a look at recent survey data to see if she is right. Instead, I found that polls taken since the November elections do not show declining support; rather, public opinion remains pretty well split in half between those favoring repeal and those who want to keep or expand the Affordable Care Act; as it has been for months. A McClatchy-Marist of all registered voters found that 16% want to “let it stand” and 35% want to “change it so it does more” compared with 11% who said “change it so does less’ and 33% who said “repeal it completely. CNN/Opinion Research poll found that 24% want to leave the new law as is, 24% want to expand it, 49% want to “repeal and replace” and 4% were unsure. A Quinnipiac University poll found that 30% want to expand it, 18% want to leave it as is, 47% want to repeal it, and 6% were unsure. While it is true that a lot of Americans don’t like the ACA, there are as many or more who want to keep or expand it.

Her observation that the ACA will leave [more than] 20 million without health insurance is correct but doesn’t tell the whole story, because a big portion of them would be people who are not legal residents. The Congressional Budget Office estimates that the ACA will “reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent”-- a huge and historic step toward universal coverage.

I’ve addressed the issue of Medicare “cuts” in past blogs, but the bottom-line is that the reductions in payments to hospitals and Medicare Advantage plans extends the long-term solvency of the program (because the Trust fund will spend less, and therefore the funds will last longer).

I share the concern that ryanjo expresses about Medicaid’s “shaky” finances. But if the ACA was repealed, the continued decline of employer-sponsored health insurance would result in millions more Americans ending up on Medicaid anyway, but without an influx of federal dollars to help states afford it. (Last year, almost 4 million people ended up on Medicaid, the biggest increase since the program was created.) A new report by the Urban Institute think tank finds that the ACA will put Medicaid on a much more solid funding foundation with “potential savings for state Medicaid budgets which, even in a worse-case scenario, would outweigh costs associated with the health reform law.” The analysis shows that “savings could range between $40.6 billion to as high as $131.6 billion during 2014-2019.” The ACA also increases Medicaid payments to primary care physicians in 2013 and 2014 so they are no less than the Medicare rate, at no cost to the states.

As far as the link between employment and coverage is concerned, once the ACA is fully implemented in 2014, people who lose their jobs or can’t get coverage from an employer will have access to subsidized coverage through the state health exchanges or from Medicaid if eligible. In the short-term, employers like McDonald’s that offer so called “mini-med” plans are seeking waivers from the ACA’s requirements, but such plans have been criticized as providing bare-bones, inadequate coverage to low-wage employees. Once 2014 comes around, these companies and their employees will have more options to choose from but they won’t be able to stick their employees in plans that don’t cover the medical care they need.

The above improvements will happen, of course, only if Congress doesn’t pull back from the ACA’s promise of providing affordable coverage to (nearly) all Americans.

In response to my post “Looking out for internists . . . and patients”, ryanjo thanked ACP for its efforts but she rightly pointed out that many ACP members called their own legislators. I agree that any successes that ACP has in its advocacy efforts is directly related to the willingness of its members to engage in the political process, so my hats-off to ryanjo and the many others who took the time to call Congress.

PCP and Arvind posted comments suggesting that “not losing” or “playing defense” isn’t the same as winning, but any successful football coach, battlefield general, or political strategist would tell you that defense and offense are equally important in achieving victory. Jay Larson is right that the 10% Medicare increase and relief from the SGR cut is “welcome” but not enough to “stop war weary general internists from leaving practice or infuse internal medicine” but it’s a start.

The members of ACP’s Council of Subspecialty Societies who wrote ACP’s “medical home neighbor” position paper would likely disagree with Arvind that ACP has left subspecialists out to dry. Also, the Medicare and Medicaid payment increases to general internists and other primary care physicians that are mandated by the ACA do not come from reducing payments to other specialists, but are completely paid for by the federal government.

I appreciate the comments made by ryanjo, Arvind, PCP, Jay Larson and the many others who take the time to read my commentary and add their own. We clearly don’t agree on some of the issues, and I don’t expect to change many minds. But this blog is all about providing a forum for respectful dialogue. and although I can’t respond directly to every comment, I read them all and am genuinely interested in your views.

Today’s question: Are there other issues that have been raised here, or elsewhere, that you would like to see addressed in future ACP Advocate blogs?

Thursday, December 9, 2010

Looking out for internists . . . and their patients

A defining characteristic of the American College of Physicians is that it has a very broad public policy/advocacy agenda that emphasizes what it believes to be best for the public. In the past 15 months alone, ACP has published position papers on such topics as health care transparency, racial and ethnic disparities, EHR quality based measurement and reporting, tobacco control and prevention, accountable care organizations, FDA regulation of prescription drugs, and controlling the costs of health care.

The downside of having such a broad agenda is that some ACP members question if the organization also is looking out for their interests. They want to know if the ACP understands the daily frustrations faced by practicing internists – the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay.

The answer is yes. While ACP prides itself on addressing broad societal issues that affect access to care, much of ACP’s advocacy is directed at reversing, preventing, or altering policies that threaten to make members lives miserable, and getting policies adopted to make things better.

Yesterday, Congress cleared legislation for President Obama’s signature to exempt physicians from the FTC’s “red flags” rule. The FTC rule would have defined physicians as “creditors” and as creditors, physicians would have been required to implement burdensome procedures to prevent and detect identity theft. ACP joined in a lawsuit to challenge the rule and was part of a coalition of professional organizations to persuade Congress to get involved. Now that Congress has expressly exempted physicians from the Red Flags rule, judicial intervention should no longer be necessary to prevent the FTC from imposing more hassles on doctors.

Also, today the House of Representatives joined the Senate in passing bipartisan legislation to prevent a 23% Medicare pay cut that would have gone into effect on January 1 and extend current rates through 2011. President Obama has promised to sign it into law. For many years now, putting an end to the cuts caused by the Medicare SGR formula has been a top ACP priority. Most recently, ACP distributed to Capitol Hill a video of internists making a heartfelt plea for Congress to “just fix” the SGR. Although the bill passed by Congress doesn’t provide the permanent solution to the SGR sought by ACP, physicians can at least be ensured of stable updates through the end of next year. For most physicians, this means a continuation of their current Medicare rates for another year, but as a result of ACP advocacy, primary care internists stand to get a big Medicare raise on January 1.

The Affordable Care Act directs Medicare to provide a 10% bonus payment to primary care physicians for designated “primary care services” – office, nursing home, home and custodial care visits. To qualify, the ACA requires that a physician be in a recognized primary care specialty (internal medicine, pediatrics, family medicine, and geriatrics) and that 60% of their total Medicare billings must come from the designated primary care visits.

Originally, CMS interpreted the ACA as requiring that Medicare count hospital visits and ancillary procedures against the 60% billing requirement. ACP pointed out to CMS that this would exclude many office-based internists who see patients in the hospital or operate an in-office lab from the bonus. Now, in response to ACP’s comments, CMS has decided that hospital visits and ancillary procedures no longer will count against a primary care physician in determining eligibility for the bonus. With this change, the vast majority of general office-based internists will get the 10% increase in pay for their primary care services. For an office-based general internist with a typical number of Medicare patients and primary care services, the result will be a $12,000 increase in total Medicare payments, starting on January 1 and continuing each year through 2015, or an average total gain of $60,000 over next five years for each eligible internist. (Internists with an above average mix of Medicare patients and primary care visits will do even better.)

ACP is unapologetic about caring deeply about broad societal issues that affect the public, including ensuring that all Americans have access to affordable health insurance coverage, but advocacy on such issues does not come at the expense of looking out for the interests of members. The fact is that in recent weeks ACP has achieved several substantial victories for its members: preventing a federal agency from imposing another unnecessary administrative burden, ensuring stable Medicare payments for 12 more months, and ensuring that most primary care internists get a raise. More needs to be done to slow the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay, but these wins will certainly make things better for most ACP members.

Today’s question: What is your reaction to ACP’s successful advocacy on exempting doctors from the FTC’s red flags rule, stopping the SGR cuts, and ensuring that most general internists will qualify for increased Medicare payments?

Tuesday, December 7, 2010

What happens if universal coverage is allowed to slip away?

One of the things about the health care reform debate that has bothered me the most is how little of it has been about the uninsured. The Republicans have not offered a plausible plan to cover the uninsured, and the Democrats have mostly emphasized the benefits for people who already have insurance (while assuring them that they can keep their doctor and their health plan). But the Affordable Care Act makes only modest improvements (like better coverage of preventive services) for people with insurance. Instead, most of its benefits will go to subsidize coverage for people who otherwise couldn’t afford health insurance.

This makes the law a harder sell for the 80% of U.S. residents with health insurance, and may help explain why support for the law seems stuck in the mid-to-high 40s in most polls. (Seniors, for instance, are the least supportive of the ACA. Could this be because they already have universal government-run health coverage – Medicare – and don’t see much to gain by extending coverage to others?)

But I think it is critically important that the debate over the future of the ACA focus on the uninsured – and the enormous consequences for our country if Congress turns its back on the promise of ensuring that nearly all Americans have access to coverage.

As I wrote in an article that appears today in the web version of the Annals of Internal Medicine, the United States is facing an unprecedented crisis in access to affordable health insurance coverage. Last year, a record 50.7 million residents had no health insurance and the percentage of Americans with private, employer-based coverage decreased for the ninth consecutive year. Many of them had chronic illnesses, and more were from middle-class families than in previous years.

A new study in Health Affairs finds that, “Throughout the past decade, even in good economic times, the number of Americans with employer-sponsored insurance has fallen, and the number of uninsured Americans has increased. . .”

This might not matter too much if the uninsured receive the same care and had as good of an outcome as the rest of us. But they don’t: the IOM found that each year, lack of health insurance leads to unnecessary suffering and premature, preventable death for tens of thousands of Americans.

The good news is that Affordable Care Act will “largely end the link between employment loss and insurance coverage”, meaning that Americans will have guaranteed access to affordable health insurance, not only in good times but especially in the bad times when millions can no longer count on a job, or if employed, can no longer count on their employer to provide them with affordable health insurance.

The Great Recession has taught us that being uninsured isn’t someone else’s problem, but a crisis that can touch each and everyone one of us. There are a lot of elements of the ACA that should be debated, and if there are ideas on how to improve it, all the better. But as I wrote in Annals, “providing all Americans with affordable health care coverage is a moral and medical imperative to prevent needless suffering and death, and must not be allowed to go ‘slip slidin' away.’”

Today’s Question: What is your reaction to my Annals article, and my premise that it is imperative that Congress not turn its back on providing all Americans with access to affordable coverage?

Friday, December 3, 2010

“Death Panels” redux

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients life-saving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times has a story today on Arizona’s decision to deny certain transplants to Medicaid enrollees - “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states, “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.”

Lacey writes that the state based its decision on “analysis . . . of the transplants that were cut, which many health experts now say was seriously flawed. For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months. But outside specialists said the success rates were considerably higher, particularly for leukemia patients in their first remission.”

As a non-clinician myself, I don’t feel qualified to express an opinion on whether the evidence supports the efficacy of transplants for patients with these conditions. But if you take Arizona Medicaid officials at their word, Arizona is making decisions based on the expected quality and longevity of life that may result from a given intervention and the cost of that intervention. Isn’t this the kind of “rationing” that critics of “government-run” health care rail against, only in this case it is a conservative-run state governor and legislature that is implementing such restrictions to save the state’s taxpayers some money?

Transplants, because the demand will always exceed the supply, have always been rationed based on medical criteria, although Arizona is taking it to a different level by explicitly taking cost into account.

The problem with Arizona’s approach is that the impact will fall disproportionately hard on the state’s poor. They don’t have access to private health insurance coverage that includes transplants and they don’t have the resources to fund transplants on their own.

The larger point is that the United States already limits access to health care, as all countries must do - because it isn’t possible for everyone to get everything they want or need. There is a superb discussion of this point in the November 24 issue of JAMA. Drs. Meltzer and Detsky write:

“Rationing already takes place [in the United States] in many ways in health care. Managed care is exactly a form of rationing in which a private insurer determines whether patients should or should not receive services. In addition, private sector rationing injects profit motives into the calculations. . . It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.”

Tossing around words like “death panels” and “death by budget cuts” instills fear, when what we need is a reasoned discussion of how finite health care resources should be allocated equitably and rationally, and by whom - not just in Arizona, but throughout the United States.

Today’s questions: What is your reaction to Arizona’s decision to deny coverage for some transplants? Do you agree that all countries, including the U.S., ration care in some manner, and if so, is there a better way?

Wednesday, December 1, 2010

“Cowardice”—or bravery--on health care costs?

In assessing the “best and worst” of the recommendations from the National Commission on Fiscal Responsibility, Washington Post blogger Ezra Klein accuses the Commission of “cowardice” in addressing health care spending:

“The plan's health-care savings largely consist of hoping the cost controls . . . and various demonstration projects in the new health-care law work and expanding their power and reach. . . In the event that more savings are needed, they throw out a grab bag of liberal and conservative policies . . . but don't really put their weight behind any. . .[their] decision to hide from the big questions here is quite disappointing . . . ”

Pretty harsh words, considering that in other respects Klein gives the Commission high marks. But I think there is a lot more to the Commission’s recommendations on health spending than meet’s (Klein’s) eyes, even though I have my own doubts about the advisability and political acceptability of many of them:

Medicare SGR cuts: Give the Commission credit for acknowledging the truth: the Medicare SGR cuts to doctors are “phantom savings . . . from . . . cuts that will never materialize.” The Commission proposes to eliminate the SGR and its deep scheduled cuts; instead, payments to physicians would be frozen at the current (2010) level through 2013 and cut by one percent in 2014.

I don’t think physicians will welcome a multi-year freeze followed by a “small” cut that will result in Medicare payments not keeping pace with their costs. Non-primary care physicians in particular are likely to balk. Although not mentioned by the Commission, most primary care physicians would implicitly be protected from having their Medicare payments fall below overhead costs because of the Primary Care Incentive Program created by the Affordable Care Act (ACA). Under this program, most primary care physicians will see their Medicare payments for office visits and other designated visits increased by 10%, starting in 2011, and continuing each year for the next five years--through 2015.

New physician payment system: The Commission would require that CMS “develop an improved physician payment formula that encourages care coordination across multiple providers and settings and pays doctors based on quality instead of quantity of services.” The proposal “would reinstate the SGR formula in 2015 . . . until CMS develops a revised physician payment system” that would cost less than spending under the SGR. In other words, fee-for-service would be replaced with payment for quality and care coordination, or the SGR (and its deep cuts) would come back.

Expanded pilot-programs: The basis for the new payment system would likely come out of accelerated adoption of pilots created by the ACA “to test delivery system reforms which have the potential to reduce costs without harming quality of care” like accountable care organizations, patient-centered medical homes, and bundled payments. Medicare would be directed to “implement any pilot projects that have shown success in controlling costs without harming the quality of care by 2015.”

Cuts to teaching hospitals: The federal government would save $60 billion over the next ten years by bringing GME and IME payments “in line with the costs of medical education by limiting hospitals’ direct GME payments to 120 percent of the national average salary paid to residents in 2010 and updated annually thereafter by chained CPI and by reducing the IME adjustment from 5.5 percent to 2.2 percent.” I find it interesting that the Commission not only doesn’t allow for any increased funding for residency programs facing shortages (like general internal medicine) but would cut spending across-the-board.

Medical liability: The Commission recommends adoption of reforms to reduce the costs of defensive medicine, including creation of “specialized ‘health courts’ for medical malpractice lawsuits, an approach that ACP believes has promise. It stops short of recommending caps on awards; instead calling on Congress to “consider” and “evaluate” caps.

Other cost controls: The Commission would limit the amount of an employer’s contribution to health insurance that is treated as tax free-income, establish a “global” health care budget that would limit spending increases to the GDP plus one percent with an automatic enforcement mechanism if spending exceeds the budget (starting in 2020 and subsequent years); cut hundreds of billions out of “discretionary spending” including health programs funded out of appropriations; give more power to the Independent Payment Advisory Board established by the ACA; and pilot-test converting Medicare to a premium support program.

Whether you agree with the Commission’s recommendations or not, I think they are a serious—and bold—effort to put on the table ideas to reduce health care spending. The likelihood is that the Commission’s report won’t go anywhere—for now. It may not even get the required of 14 out of 18 members for Congress to take it up. I expect, though, that many of its ideas may get serious attention later, because the U.S. will have no choice but to tackle the challenge of rising deficits and debt, with health care spending being the single largest threat to fiscal solvency.

Today’s question: What is your reaction to the Commission’s recommendations on health care spending?

Monday, November 29, 2010

“Just fix it!”

Earlier today, the American College of Physicians announced that it had sent to congressional leaders a short video that features internists – speaking in their own words – issuing a heartfelt plea for Congress to avert the scheduled Medicare Sustainable Growth Rate (SGR) cut and work toward putting an end to the repeated cycle of cuts.

The 3 minute and 25 second video, which also is featured on YouTube, emphasizes how patients will be hurt by the scheduled cuts. The videos are the second phase of an ACP initiative to break down the firewall between members of Congress and physician-constituents by combining old-fashioned story-telling with the kinds of short video links popularized by YouTube.

The new video clip may not be as entertaining as the usual YouTube fare, but it tells a compelling story, in the words of the physicians themselves, about the damage being done to patients by the SGR. Excerpts:

From New Haven, Connecticut:

“I urge you to figure out how to make this SGR problem go away. It is very difficult to imagine that physicians are going to be willing to jump on the health reform bandwagon when at the other end of the equation Medicare is threatening these cuts.”

From Charlottesville, Virginia:

“For 35 years I ran an internal medicine intern program … I spent many hours giving career choices to med students. Over past 10 years they’ve become quite aware of the SGR and the uncertainties it provides in reimbursement for primary care physicians.”

From Delray Beach, Florida:

“My overhead goes up, my hard working, diligent employees need and deserve raises. My overhead increases, my supplies increase, I need to be able to afford to stay in business so that I can be there for my patients.”

From Cleveland, Ohio:

“In my family I’ve had a family member who lost his physician and spent the last four years of his life without a primary care physician because none of the primary care doctors in his community where taking on new Medicare patients. So I’ve seen the effect both in my patients and my family.”

From Middleton, Delaware:

“We cannot sustain our [solo] medical practices when receiving such a cut.”

From Thomson, Georgia:

“Where are my patients going to go if my doors close?”

From Lexington, Kentucky:

“It needs to be fixed … yesterday …”

From Sacramento, California:

“… not only for the people over 65… but also for the members of our military services and their families and the retirees and their families.”

From Seattle, Washington:

“I am urging you to repeal the SGR … to do this sooner will cost less … not only in dollar amounts but also in patients’ lives and our physician practices.”

From Tucson, Arizona:

“Just fix it.”

A few hours after ACP released the video, the House joined the Senate in passing legislation to keep current Medicare rates in effect through the end of this year. President Obama is expected to sign it within hours, thereby averting a 23% cut scheduled for December 1. Now, to be sure, I am not attributing enactment of this short-term fix to ACP’s video clip. The video is just one part of the effort being made by ACP, the AMA, AARP, and many, many others to get Congress to stop the cut.

The lame-duck Congress still must take action to prevent another SGR cut schedule for January 1, 2011. Then, the new 112th Congress must work on a bipartisan basis with the White House to enact a longer-term solution that leads to permanent end to the cycle of Medicare physician payment cuts.

That is, Congress still needs to heed physicians’ pleas to “just fix it” - not just for another four weeks, or for another year, but permanently.

Today’s questions: What do you think of the ACP video? How would you make the case to Congress to “just fix it” - once and for all?

Monday, November 22, 2010

Insurance companies to spend more $ on patients? Now that’s a reason for thanksgiving.

Today, the Department of Health and Human Services released an interim final rule to require that health insurers spend more money on patients and less on themselves. The rule codifies a provision in the Affordable Care Act, which requires that large insurers spend 85% of the premium collected on patient care - for small insurers, it will be 80% - instead of on their own bureaucracies and profit. Starting in 2012, health plans that aren’t in compliance will have to send a rebate to their enrollees (or the enrollee’s employer) for the difference.

One of the more interesting decisions made by HHS is that quality improvement activities that are “grounded in evidence-based practices, take into account the specific needs of patients and be designed to increase the likelihood of desired health outcome that can be objectively measured” don't count against meeting the 80-85% trigger for a rebate. According to the agency, “Insurers are not required to provide initial evidence in order to designate an activity as quality improving when they first implement it, however to ensure value, the insurer will have to show measurable results stemming from the QI activity in order to continuing to claim that it does in fact improve quality.”

As Joe Biden said in a different context, the new regulations are a big [blankety-blank] deal for patient and physicians. Insurers will have a strong incentive to keep their administrative costs down. This means that more of the premium collected will go for patient care expenses, which can include payments to the physicians who deliver the care.

Physicians and patients also will benefit from HHS’ determination that claims administration and utilization review processes are not “patient care expenses” (as the insurance industry argued) but administrative ones. This will create an incentive for insurers to streamline and eliminate excessive (and costly) claims and utilization review requirements that do not directly result in measurable improvements in quality.

Many pre-certification requirements could very well fall in to the category of an unnecessary administrative expense that insurers may decide to forgo. Today, the American Medical Association released a survey of physicians’ experiences with pre-certification. The AMA reports that its survey of “approximately 2,400 physicians indicates that health insurer requirements to preauthorize care has delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions.”

It is conceivable that insurers may try to persuade HHS that pre-certification is a quality improvement activity to protect patients from being subjected to unnecessary (and potentially harmful) tests and procedures. To qualify as a quality improvement activity, though, they would have to show that the pre-certification requirements are based on evidence, and subsequently would have to demonstrate “measurable results stemming from the QI activity in order to continuing to claim that it does in fact improve quality.”

In other words, this would turn the table from physicians having to constantly justify to insurers that the things they do for patients are evidence-based and improve quality, to insurers have to justify that their pre-certification rules are evidence-based and improve quality. Now, that is something to be thankful for!

Today’s questions: Do you think that the new rules to require insurance companies to spend more on patient care and less on administration will benefit physicians and patients? How?

P.S. Speaking of thanks, I will be taking a few days off to celebrate thanksgiving with my family, so you won’t see any more of my blogs until next week. I do want to thank all of you who read (put up with may be a better description!) this blog, and especially those of you who have taken the time to post your comments (yes, including those of you that take strong exception!). Happy Thanksgiving to you and your loved ones.

Friday, November 19, 2010

Is "compete and succeed" better than "repeal and replace"?

Senator Scott Brown (R-MA) thinks so. So does Senator Ron Wyden (D-OR). And Bernie Sanders (I-VT).

Senators Brown, Wyden and Sanders have introduced the "Empowering States to Innovate Act." Ezra Klein blogs that the Senators may have found a way forward on health reform.

"If a state can think of a plan that covers as many people, with as comprehensive insurance, at as low a cost, without adding to the deficit, the state can get the money the federal government would've given it for health-care reform but be freed from the individual mandate, the exchanges, the insurance requirements, the subsidy scheme and pretty much everything else in the bill," Ezra Klein writes. "If conservative solutions are more efficient, that will be clear when their beneficiaries save money. If liberal ideas really work better, it's time we found out. Forget repeal and replace, or even reform and replace. How about compete and succeed?"

The Wonk Room reports that Wyden, Brown, Sanders, who co-sponsored the original innovative waivers amendment, believe that their home states of Oregon, Massachusetts, and Vermont are leading the pack in adopting innovative approaches. These include the well-known Massachusetts program that Brown voted for as a state legislator, and single payer bills that have been introduced in Vermont and Oregon. The bill, though, also could appeal to states seeking a more conservative, less regulatory solution, since they would be able to decide how they wanted to provide comprehensive coverage to the uninsured, free of most of the ACA's mandates.

ACP's own proposal to provide all Americans with access to affordable coverage, initially developed in 2002 and revised by the Board of Regents in 2008, supports a similar state option. The very first recommendation in that paper supports:

"Giving states the ability to opt out of any national framework for universal coverage by establishing their own programs for expanded coverage and to redesign health care delivery and financing to emphasize prevention, care coordination, quality, and use of health information technology through the Patient-Centered Medical Home (PCMH), subject to federal guidelines and standards. States should be required to show that they can achieve enrollment in state approved coverage (private health plans or public programs) that is at least equal to the coverage that would occur without a waiver, taking into account the number of insured individuals, covered benefits, access to participating health care providers, and costs to the consumer."

There are reasons to be skeptical that the Wyden-Brown-Sanders bill will defuse the political confrontation over health reform. Republicans have vowed to "repeal and replace" the Affordable Care Act. It is unlikely that most will now buy into the idea that all Americans should have access to affordable and comprehensive coverage, but with states given more flexibility to come up with their own ideas on how to achieve this goal. States couldn't propose something that would result in fewer people having affordable coverage than under the ACA's mandates and subsidies.

President Obama and congressional Democrats can be expected to be extremely wary that the Wyden-Brown-Sanders approach could be a Trojan Horse that would lead to erosion of the ACA's consumer protections over insurance companies and guarantees of near-universal coverage.

Still, the idea of state innovation and experimentation makes enormous intuitive political and policy sense, especially given the fact that many GOP-controlled states are resisting the ACA's mandate and prefer a less heavy-hand, market-based approach. Liberals have always wanted the chance to implement a single payer plan on the state level, if not possible to achieve on a national scale.

The ACA won't be replaced and repealed by the 112th Congress, but its effective implementation could be weakened. As I wrote in this blog a few days ago, "There is another option than for both parties to engage in a no-win fight over repeal. They could look for ways to make improvements that preserve the key elements of the ACA - including the promise to provide coverage to most Americans - but allow for testing by states of free-market approaches to delivering such coverage." I would now add that Senators Wyden, Brown, and Sanders have an even better idea, which is to allow for testing by states of free-market approaches and more regulatory public options (including single payer) to delivering such coverage.

Today's question: Would you support allowing states to "compete and succeed" in designing plans to provide affordable coverage to all instead of "repeal or replace" or maintaining the ACA as it is?

Thursday, November 11, 2010

Is there an alternative to re-fighting health care reform?

Everything seems to be pointing toward two years of partisan and ideological confrontations over health reform. The leadership of an emboldened Republican party has made it clear that it will use its newfound House majority to seek to "repeal and replace" the Affordable Care Act (ACA), and if that doesn't work, to "defund" it. Huge GOP gains in statehouses make it likely that more states will resist implementation. Meanwhile, President Obama has stated that he is open to "tweaking" the law but not "re-litigating" the health reform debate.

This is a debate that neither side is likely to win.

Let's start with the Republicans. They believe that they have a mandate to seek repeal of the ACA, but they won't be able to deliver. The House GOP will run smack dab into a Senate that will do what the Senate does best, which is to bury legislation that comes out of the House. Senate Democrats will use their majority - and the filibuster, if needed - to block efforts by the House to repeal or reverse key provisions, and President Obama will use his veto pen if necessary.

Plus, when it comes to specific changes, the GOP may find that they don’t have the public's support. Do voters really want the new Congress to repeal the prohibitions against insurance companies charging more to people with pre-existing conditions? Do they want to give up their "free" preventive services and annual Medicare wellness exam? Will they want to give up the promise made by the law that if they lose their jobs starting in 2014, they won't lose their health benefits?

What about physicians? Do they really want Congress to take away the 10% increase in Medicare payments for primary care to be in effect for the next five years? Do they want Congress to withdraw funding to raise Medicaid primary care payments to the Medicare rates? Do physicians want Congress to defund programs intended to reverse a growing shortage of primary care physicians? Do they want Congress to halt the redistribution of unused residency positions to general internal medicine and family medicine residency programs? Do they want Congress to stop the federal government from enforcing rules to require insurance companies to standardize, simplify and reduce paperwork on physicians and patients?

What about the programs created to lower costs and improve outcomes? Will the new GOP House, which has complained that the Affordable Care Act doesn’t do enough to control costs, want to eliminate funding for comparative effectiveness research and the new Center on Medicare and Medicaid Innovation - two of the most promising avenues to lower costs and improve outcomes? And if the GOP were to repeal the savings in Medicare from reducing payments to hospitals and Medicare Advantage plans without finding offsets, the result would be a whopping $500 billion increase in the budget deficit, according to the CBO.

By committing itself to a "repeal and replace" agenda, the GOP risks alienating many voters for trying to dismantle popular parts of the law, disappointing its base for failing to get rid of it, and upending its promise of deficit reduction.

This doesn't mean that President Obama or the Democrats necessarily will have the upper-hand. The fact is that the President has been unable to persuade a huge chunk of the electorate that the Affordable Care Act will make health care more affordable. Instead, many believe it will lead to higher premiums, more government spending, and more debt. As long as this is so, the Affordable Care Act will continue to be politically vulnerable, and many Democrats who support it will continue to be at electoral risk.

There is another option than for both parties to engage in a no-win fight over repeal. They could look for ways to make improvements that preserve the key elements of the ACA - including the promise to provide coverage to most Americans - but allow for testing by states of free-market approaches to delivering such coverage.

They could start by allowing states a great deal of flexibility in setting up the health exchanges. The Washington Post reported on Tuesday that with GOP gains at the state level, "two models are likely to appear: Democratic governors and legislatures are likely to emphasize vigorous regulation and government oversight, while Republican state leaders are likely to put greater stock in privatization and other free-market approaches." States could experiment, for example, by offering health savings accounts on an equal playing field with other insurance products. HHS Secretary Sebelius has already signaled a willingness to consider states' requests for waivers from certain ACA requirements.

President Obama and Congress could also agree to expand upon and accelerate the authority granted by the ACA to allow insurance to be sold across state lines. They could agree to a serious effort to make real reforms in the medical liability system, such as authorizing and funding a national demonstration project of health courts. They could even commit to a bipartisan effort to reform Medicaid to make it a more effective and affordable program. And while they are at it, they could get a bipartisan deal on reforming physician payments and repealing the Medicare SGR.

For all of this to happen, though the GOP would need to back down from repeal being the only acceptable option and accept the law's commitment to provide most Americans with affordable coverage. President Obama and his congressional allies would have to be willing to give the states more options to implement market-based reforms, to recognize that not every program created by the ACA is of equal importance for funding, and to show courage in making medical liability reform a priority.

The political dynamics are such that none of this is likely to happen, but I think the country would be better off if they tried.

Today's question: Do you think President Obama and the GOP can agree on improvements to the ACA, or is the polarized debate on "repeal and replace" our inevitable future?

Thursday, November 4, 2010

To repeal or not to repeal, that is the question

Did the mid-term elections produce a mandate to repeal the Affordable Care Act?

Yes, says John Boehner (R-OH), Speaker of the House in waiting. Within hours of learning that the GOP had picked up at least 60 House seats, he pledged to "do everything we can to try to repeal this bill and replace it with common sense reforms to bring down the cost of health care." Senate Minority Leader Mitch McConnell (R-KY) chimed in by promising to push for outright repeal, and if that doesn't work, to try to undo it "piece by piece."

Meanwhile, Senator Harry Reid (D-NV), who presumably will remain as Majority Leader in the new 112th Congress, albeit with a much smaller majority, offered to consider "tweaking" the legislation but not to "denigrate the great work we did." A chastened President Obama also indicated a willingness to consider "reasonable changes" in the law but said that it was the "right thing to do." He also acknowledged that the process that produced the legislation was an "ugly mess" but that the "outcome was a good one."

The truth is that the voter's gave a split decision - literally. According to exit polling of a random sample of more than 18,000 voters conducted for the Washington Post, almost half of the voters said that the law should be repealed. But "almost the same number" felt it should be kept or expanded. Moreover, health care lagged well below the economy as an issue, with over 90% expressing concern about the economy while only 18% mentioned health care as a top voting concern. Many Democrats who voted for the Affordable Care Act were voted out of office, but so were many who voted against it.

The results from state referenda also were mixed. Colorado voters voted down a "symbolic" referendum to exempt the state's residents from some of the law's mandates, but voters in Oklahoma and Arizona gave approval to similar measures.

An article that appeared in the New England Journal of Medicine a few days before the election predicted the voters' split decision. Robert Blendon and John Benson analyzed 17 independent polls and found that "more than 7 months after the health care reform law was enacted, a majority of Americans neither favor nor oppose it." Many provisions of the law are popular, they report, but Americans also are concerned that the law will damage the economy and add to the federal debt. On the question of whether the law should be repealed, "18% of registered voters believed that Congress should implement the bill as it currently stands, 31% thought Congress should make additional changes to increase the government's involvement in the country's health care system, and 41% believed that Congress should repeal most of the major provisions of the bill and replace them with a completely different set of proposals."

The bottom-line is that the evidence - from numerous polls taken before the election and from the exit poll of those who actually cast their votes - does not show a mandate for repeal. Rep. Boehner and Senator McConnell, though, are accurately reflecting the views of most registered Republicans, who overwhelming disapprove of the law. Democrats, on the other hand, mostly support it, and independents are divided.

This is not to suggest that President Obama has been successful in selling the country on health care reform. Quite the opposite: the fact that seven months after it passed, most voters still don't know how they feel about it, suggests that the White House has not persuaded a skeptical public that it will be good for the country. But the GOP also has not persuaded a skeptical public that it should be repealed.

Instead, over the next weeks and months - and quite likely, through the 2012 Presidential election - the battle to influence public opinion will continue. But right now, the public's views are unsettled enough that neither the politicians who advocate for repeal, nor the politicians who advocate for staying the course (maybe with some "tweaks"), can have all that much confidence that they have the public on their side.

Today's question: What do you think the voters were saying about repeal of the health reform law?

Tuesday, November 2, 2010

Apple pie, attack ads ... and a return to civility?

Well, it is almost over. By the end of today, we should see a (temporary) end to the onslaught of negative campaign ads that are poisoning the well of political discourse. Hallelujah!

As bad as it has been, over-the-top attacks on your political opponents are "as American as apple pie" says Reason magazine's bloggers. The libertarians at Reason have used actual quotes from Thomas Jefferson and John Adams and their supporters to craft some very funny modern-day candidate attack ads. The 1:43 minute You Tube video starts with comments from TV reporters and President Obama decrying the negativity of this year's campaign, followed by made-up - but historically accurate - campaign ads "from" Jefferson and Adams.

According to Reason, Jefferson really did call John Adams a "blind, bald crippled toothless man" ... "who secretly wants to start a war with France" ... "while he's not busy importing mistresses from Europe." Adams' supporters predicted that if Jefferson was elected, "Murder, robbery, rape, adultery and incest will be openly taught and practiced, the air will be rent with the cries of the distressed, the soil will be soaked with blood and the nation black with crimes." Makes the Sharon Angle/Harry Reid slug-fest seem tame by comparison, doesn't it?

It is reassuring in a way that personal attacks on opponents go back to the earliest days of the Republic. Yet I worry that the 24/7 media amplification of negative attacks have coarsened our political culture, making reasoned dialogue close to impossible.

And it is one thing when politicians engage in a Mud Fest, but should physicians be held to a higher standard of political discourse?

Yes, says Dr. John Tooker, who recently retired as the Chief Executive Officer for the American College of Physician. (Dr. Tooker continues to serve in an advisory capacity for the ACP.) He blogs on KevinMD that ACP's ethics manual calls on physicians to "work toward ensuring access to health care for all persons; act to eliminate discrimination in health care; and help correct deficiencies in the availability, accessibility, and quality of health services, including mental health services, in the community."

"These very patient care issues - access, discrimination and quality of care" he says, "were front and center in the recent national health care reform debate, to the credit of the physicians that fully engaged in the debate, whether one agrees with the final Affordable Care Act legislation or not."

Yet physicians did not always express their views with the civility, says Dr. Tooker:

"Unfortunately, during the political conversation within our profession, there were also instances of incivility - remarks and statements made by physicians that went beyond the bounds of decency, and at times were perceived as threatening by the recipients of the comments. Instant and reflex electronic communication facilitated such comments - hitting send before thinking twice or thrice - and the opportunity for civil discourse was lost."

He argues that, "Policy makers and politicians are looking to physicians to provide leadership at every level. Because of the standing based on moral principles and education that physicians have within our society, there are and always have been great leadership opportunities to improve the care of our patients and the satisfaction of our profession. If we don't act professionally, we diminish our standing and ability to lead."

Dr. Tooker closes with a reference to another founding father. "There is a small but revealing book, Rules of Civility, by Richard Brookhiser, that describes the moral code that guided George Washington as the first president of our republic during very difficult times. The first rule is: 'Every action done in company ought to be done with some sign of respect to those that are present.'"

Amen! I hope that Dr. Tooker's admonition is something all of us - physicians and non-physicians alike - take to heart as we express our views tomorrow on the results of today's election.

P.S. I was humbled to learn that the ACP Advocate blog has been recommended as "one of the top 10 health care bloggers we are thankful for" by a company that describes itself as a leading source of health management news for 50,000 health executives. I was especially heartened that they characterized the blog as managing "to offer calm, level-headed commentary on topics that often can lead to superheated, highly polarized debates in other forums." Exactly the type of civil discourse I seek to encourage!

Today's questions: What do you think Jefferson, Adams and Washington would make of today's political discourse? And do you think physicians should be held to higher standards of civility, as Dr. Tooker argues?

Thursday, October 28, 2010

Mr. Roger's (Medical Home) Neighborhood

My image of Pittsburgh has been one of a blue-collar, rough-and-tumble town: perogies, Heinz ketchup, steelworkers, football, and Roberto Clemente. But an exhibit in Pittsburgh's airport the other day informed me that Pittsburgh also is the home of the iconic Mr. Roger's Neighborhood, the gentle PBS show that entertained toddlers for generations. Mr. Rogers always started the show off with the following verse:

"It's a beautiful day in this neighborhood,
A beautiful day for a neighbor,
Would you be mine?
Could you be mine?

It's a neighborly day in this beautywood,
A neighborly day for a beauty,
Would you be mine?
Could you be mine?

I have always wanted to have a neighbor just like you,
I've always wanted to live in a neighborhood with you.

So let's make the most of this beautiful day,
Since we're together, we might as well say,
Would you be mine?
Could you be mine?
Won't you be my neighbor?

Won't you please,
Won't you please,
Please won't you be my neighbor?"

Fittingly, the same week that I was reminded of Mr. Roger's Neighborhood, the American College of Physicians released its "medical home neighborhood" position paper. The paper was developed by a workgroup of ACP's Council of Subspecialty Societies (CSS), which is comprised of representatives of internal medicine subspecialty societies and related organizations.

The paper proposes ways that internal medicine subspecialty practices can be recognized as Patient-Centered Medical Home Neighbors (PCMH-Ns). A specialty/subspecialty practice recognized as a PCMH-N engages in processes that:

- Ensures effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care;

- Ensures appropriate and timely consultations and referrals that complement the aims of the PCMH practice;

- Ensures the efficient, appropriate, and effective flow of necessary patient and care information;

- Effectively guides determination of responsibility in co-management situations;

- Supports patient-centered care, enhanced care access, and high levels of care quality and safety; and

- Supports the PCMH practice as the provider of whole-person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health care professionals.

The paper proposes a set of "aspirational principles" for developing "care coordination agreements" between the PCMH-N and the PCMH to "define the types of referral, consultation, and co-management arrangements available." ACP also proposes that incentives be aligned to support PCMH-Ns, including "some form of enhanced payment to cover the time and infrastructure costs of providing services consistent with the PCMH-N definition."

I think that the PCMH-N concept is critical to building a health care system that supports the value of primary care provided in a PCMH, but also recognizes that the model cannot work without the engagement of specialists in working together with the medical home to deliver the best care possible. It belies the notion that the PCMH is only for primary care physicians, or that ACP is uninterested in helping its subspecialist members.

If the paper's vision is realized, subspecialists should be able to give a resounding "yes" when asked by a primary care physician, "Won't you please, Won't you please, Please won't you be my neighbor?"

Today's question: What do you think of the Patient-Centered Medical Home concept as proposed by ACP's Council of Subspecialty Societies?

Tuesday, October 19, 2010

Breaking through the legislative firewall

Anyone who has taken the time to contact members of Congress has probably found it to be a wholly unsatisfactory experience. Old-fashioned "snail mail" letters are sent for irradiation to a facility in New Jersey to kill possible anthrax spores (really) before being delivered to congressional offices, meaning that it may be many weeks before the letter is even read, and many more weeks before you get a "canned" response.

E-mail will get the message to them faster, but "canned" emails prepared by interest groups won't get as much attention as a personalized email. Even if personalized by you, though, this doesn't mean you will get a personalized response. Congress gets so many emails that you might only receive a standard reply. Don't bother writing to members of Congress outside your own district and state, since lawmakers consider such emails the moral equivalent of spam, and most will automatically filter them out.

Phone calls are better. If you are persistent and polite, you should be able to get through to your lawmaker's "legislative assistant" who will take notes on your conversation. At times when a key vote is scheduled and Congress is inundated, you may only get through to a receptionist.

But no matter how you choose to express your views, a well-run congressional office will make sure that someone at least is keeping a running total of the views expressed by constituents, especially when it is as simple as counting how many voters support or oppose a particular bill.

The best way to get your views across is to develop a relationship with your legislators. If you are known to the lawmaker and are viewed as a respected opinion-leader, your calls will be returned and your emails answered (and you may even be fortunate enough to get your member’s personal email or cell phone number). Such relationships can be created by showing up at town hall meetings (but be polite!) and/or volunteering for the lawmaker's health care advisory committee (if they don't have one, you could offer to help them form one). Constituents who contribute to a politician's campaign, either as an individual or through a Political Action Committee, will have an easier time developing the kind of relationship that ensures that your views are given particular attention.

National and state membership societies usually will get more attention than an individual constituent, and they have tools and programs to help their own members get their views across, such as ACP's key congressional contact program.

It is especially hard to get your voices heard when it involves a recurring issue, like the Medicare Sustainable Growth Rate (SGR) formula, where everything seemingly has been said so many times before. Politicians don't expect to hear anything new from constituents, and constituents get tired of sending yet another email or letter, when it seems likely that the result is more of the same.

But how about trying new ways to break through to Congress, which would combine old-fashioned story-telling, email, and the kinds of short video links popularized by YouTube?

Last month, the American College of Physicians asked its state chapter leaders (ACP governors) to record a short video message, using an inexpensive hand-held "flip" camera, which would explain in their own words the impact of the Medicare SGR cuts on their patients, practice, colleagues, and community. The videos were edited to no more than a minute or two by ACP's public affairs staff using free Microsoft Movie Maker. Each of the ACP chapter leaders then personally emailed the health staffer for their members of Congress to consider their plea on the SGR: 1) by viewing the personal video clip from the physician, which was included in the email as a URL and 2) by reviewing the "ask" (what action they want their Senators to take) which was included as an attached PDF, ACP's congressional affairs staff (lobbyists) then followed up with each Senator's legislative assistant. View the SGR videos for Nevada, Kentucky, Ohio, and California.

The videos may not be as entertaining as standard YouTube fare, but I think they make an extraordinarily heartfelt and effective case on why Congress needs to stop the Medicare SGR cuts. Realistically, I don't expect that a single video from a constituent will break the decades-long impasse on the SGR. But stories from constituents can be the most effective of all advocacy tools, and ACP's new "Video Advocacy Project" offers a simple and creative way to bridge the legislative firewall between constituents and their elected lawmakers.

Today's questions: What methods have you found to be effective in getting through to Congress? And what do you think of ACP's new "Video Advocacy Project"?

Monday, October 18, 2010

Record Number of Uninsured, While Millions More Look to the Government for Help

Last month, the U.S. Census Bureau released its annual survey on health insurance coverage. The results were startling, yet few politicians seemed to take notice.

- The number of people with health insurance declined for the first time ever in almost two decades. In fact, as reported by CNN this is the first time since the Census Bureau started collecting data on health insurance coverage in 1987 that fewer people reported that they had health insurance: "There were 253.6 million people with health insurance in 2009, the latest data available, down from 255.1 million a year earlier." The percentage of the population without coverage increased from 15.4 percent to 16.7 percent.

- Almost 51 million U.S. residents had no health insurance coverage at all, a record high, and an increase of almost five million uninsured from 2008.

- Fewer Americans received health insurance coverage through their jobs, continuing a decade-long trend. The number covered by employment-based health insurance declined from 176.3 million to 169.7 million, reports the Census Bureau. Based on the Census numbers, the Economic Policy Institute observes that "the share of non-elderly Americans with employer-sponsored health insurance declined for the ninth year in a row, down from 61.9% in 2008 to 58.9% in 2009, a total decline of 9.4 percentage points since 2000."

- More people than ever relied on government programs for coverage and fewer on the private sector. The number with Medicaid coverage increased from 42.6 million to 47.8 million. According to the Census Bureau: "Comparable health insurance data were first collected in 1987. The percentage of people covered by private insurance (63.9 percent) is the lowest since that year, as is the percentage of people covered by employment-based insurance (55.8 percent). In contrast, the percentage of people covered by government health insurance programs (30.6 percent) is the highest since 1987, as is the percentage covered by Medicaid (15.7 percent)."

These are the facts on the ground, folks, no matter how much the politicians choose to ignore them. Without Medicaid and Medicare, many tens of millions more Americans would be without health insurance. Financially-strapped states already are picking up much of the tab of enrolling millions more in Medicaid. And the Great Recession has shown us that most of us are just a lay-off away from losing our health insurance.

The Affordable Care recognizes the unreliability of our current health insurance system and fills the gaps. If it is allowed to be implemented, the ACA would give people who don't have job-based coverage access to subsidized and affordable private health insurance. The federal government would pay the states more for enrolling low-income people in Medicaid (100% of the cost initially, dropping to 90% by 2020); this would be money the states would be able to count on, instead of being buffeted by higher Medicaid costs whenever there is an economic downturn.

The Great Recession should also have taught us that lack of health insurance isn’t someone else's problem, but everyone's concern. The fact that "nearly every demographic and geographic group posted a rise in the uninsured rate" last year shows how vulnerable we all are to losing our health insurance coverage. The Affordable Care Act isn't perfect, but at least it would provide coverage to 95% of all U.S. residents, a far cry from the record number of uninsured in 2009.

Today's question: What is your reaction to the Census Bureau findings and what does this mean for health reform?

Tuesday, October 12, 2010

"Clowns to the left of me, jokers to the right ... Here I am stuck in the middle with you."

While driving in my car the other day, I came across this chorus from a 1970s hit song by the long-forgotten British band, Stealers Wheel. It reminds me of the sad state of American politics today. Voters seeking a sensible center instead, find themselves caught between the "clowns" and the "jokers:" the talking heads from the right and left alike who take delight in the most extreme politics and rhetoric imaginable.

Senator Susan Collins (R-ME) writes in Sunday's Washington Post that, "It's a tough time to be a moderate in the U.S. Senate. Sitting down with those on the opposite side of a debate, negotiating in good faith, attempting to reach a solution -- such actions are now vilified by the hard-liners on both sides of the aisle. Too few want to achieve real solutions; too many would rather draw sharp distinctions and score political points, even if that means neglecting the problems our country faces."

She's not alone in her concern. 130 former members of Congress, from both political parties, have taken the unprecedented step of urging all current members to work across the aisle:

"The divisive and mean-spirited way debate often occurs inside Congress is encouraged and repeated outside: on cable news shows, in blogs and in rallies. Members who far exceed the bounds of normal and respectful discourse are not viewed with shame but are lionized, treated as celebrities, rewarded with cable television appearances, and enlisted as magnets for campaign fund-raisers. Meanwhile, lawmakers who try to address problems and find workable solutions across party lines find themselves denigrated by an angry fringe of partisans, people unhappy that their representatives would even deign to work with the 'enemy'."

William Galston, a policy adviser in the Clinton administration and elections expert for the Brookings Institution, tells the New York Times that "The center has disappeared."

A new poll by the Washington Post, Kaiser Family Foundation, and Harvard University finds that, "Although Democrats and Republicans have rarely seen eye to eye, the gap between the two has widened significantly over a decade of partisan polarization..." Yet the same poll also shows that the electorate's views on government aren’t easily labored as right or left. While confidence in the federal government is at an extraordinarily low level, "support for government action on such issues as national defense, health care and fighting poverty remains high, in some cases just where it was a decade ago..."

The poll finds the electorate deeply divided over health care reform. "The polarizing debate over health care has left its mark on Republicans and independents far more than on Democrats. Ten years ago, three-quarters of independents said they favored more government involvement to ensure access to health care coverage. Today, half do. Among Republicans, the falloff is more dramatic, sliding from 53 to 21 percent."

Henry J. Aaron, a senior policy analyst at the Brookings Institution, opines that the continued partisan split over health care reform doesn't bode well for the country. He notes that most Republicans have pledged to repeal the Affordable Care Act, but President Obama likely would use his veto pen to block repeal.

"Perhaps the more likely - and in some ways more troubling - possibility is that the effort to repeal the bill will not succeed, but the tactic of crippling implementation will" he observes. "The nation would then be left with zombie legislation, a program that lives on but works badly, consisting of poorly funded and understaffed state health exchanges that cannot bring needed improvements to the individual and small-group insurance markets, clumsily administered subsidies that lead to needless resentment and confusion, and mandates that are capriciously enforced.

Such an outcome would trouble ACA opponents: their goal is repeal. It would trouble ACA supporters: they want the law to work. But it should terrify everyone. The strategy of consciously undermining a law that has been enacted by Congress and signed by the president might conceivably be politically fruitful in the short term, but as a style of government it is a recipe for a dysfunctional and failed republic."

A sensible center would instead try to find a way to bridge the differences over heath care reform and make improvements. But as the former members of Congress sadly observed in their letter a politician who tries to "find workable solutions across party lines [would likely] find themselves denigrated by an angry fringe of partisans, people unhappy that their representatives would even deign to work with the enemy."

And you wonder why the refrain "Clowns to the left of me, jokers to the right ... Here I am stuck in the middle with you" keeps replaying itself in my mind?

Today's questions: Do you think the center has disappeared from American politics? And what do you think of Henry J. Aaron's view that the continued partisan polarization over health care reform could lead to "zombie legislation" and "is a recipe for a dysfunctional and failed republic?"

Wednesday, October 6, 2010

Should Medicare pay less for less effective care?

From its inception, Medicare has been agnostic about the effectiveness of different treatments when it sets payment rates. Once a treatment is found to be "reasonable and necessary," Medicare establishes a payment rate that takes into account complexity and other "inputs" that go into delivering the service. But it is prohibited by law from varying payments based on how well an intervention works.

This would change under a "dynamic pricing" approach proposed by two experts in this month's issue of Health Affairs. The article itself is available only to Health Affairs subscribers, but the Wall Street Journal health blog has a good summary. The researchers propose that Medicare pay more for therapies with "superior" results and the same for two therapies with comparable effectiveness. A new service without any evidence on its relative effectiveness would be reimbursed in the usual way for the first three years, during which research would be conducted on its comparative effectiveness. If such research found that the service was less effective than other interventions, Medicare would have the authority to reduce payments; if it was found to be more effective, Medicare could pay more than for other available interventions. The WSJ blog gives an example of how this would work:

"They [the authors] use intensity-modulated radiation therapy, which was rolled out in the early 2000s, as an example. Medicare's reimbursement for the treatment was set at about $42,000 for prostate cancer treatment, compared to $10,000 for an older form of radiation - though there were no gold-standard studies comparing the risks and benefits of the two procedures. Hospitals bought the spiffy new equipment ... and Medicare spent an estimated $1.5 billion more on prostate cancer treatment, the authors write. If that reimbursement rate had been guaranteed only for three years before being revisited, there'd have been an 'incentive for manufacturers and clinicians to perform the research needed to evaluate the clinical performance of the new therapy in comparison to the standard three-dimensional treatment,' the authors write."

Arguably, such dynamic pricing could save Medicare (and taxpayers) many billions of dollars and improve outcomes by encouraging more research on effectiveness and rewarding physicians and hospitals for providing more effective treatments. Such a radical departure from Medicare agnosticism on clinical effectiveness, though, would almost certainly be opposed by manufacturers and providers with a vested interest in sustaining higher payments. Consumers and patients might worry that Medicare would use pricing to reduce their access to potentially beneficial services s just to save money. Physicians might chafe that the government is cutting their reimbursement based on population-based research that might not take into account the unique circumstances of their own patients. Politicians likely would scream that the government would be allowed to use its new pricing authority to "ration" care. (The accusation that Comparative Effectiveness Research could lead to "rationing" resulted in Congress writing language in the Affordable Care Act to expressly prohibit Medicare denials based "solely" on such research.)

On the other hand, at a time when rising health care spending threatens to break the (federal) bank, can the country afford Medicare's agnosticism in what it pays for services of differing effectiveness?

Today's question: Do you think Medicare should pay less for less effective treatments and more for more effective ones?

Friday, October 1, 2010

Yabba Dabba Doo! (And health care too)!

Like most kids who grew up in the 1960s, I spent many a night watching the adventures of Fred, Wilma, Barney and Betty, the coolest cavemen ever (sorry, GEICO). It is hard to explain the appeal of the Flintstones, which yesterday celebrated the 50th anniversary of its first broadcast. Its animation was primitive, the stories campy and cliché, and it was horribly sexist - but the characters were lovable, the dialogue funny, and who could not love the way it depicted "modern conveniences" (like washing machines) using only stone-age technologies (bones, stones and dino-power)?

What does Fred Flintstone have to do with health care? Not much, really, although Fred was the victim of a medical error. According to, "A 1966 episode had Fred can't stop sneezing, so he goes to the doctor for some allergy pills. The prescription gets mixed up with another package of pills which, when taken, transform Fred into an ape! Only Barney witnesses this metamorphosis, and naturally he can't convince anyone what is happening ... until a fateful family outing at the Bedrock Zoo." (Of course, this all might have been prevented if they had e-prescribing in those days.)

But the Flintstones weren't the only cartoon to make the news yesterday; a new one came out to explain health care reform. No, it wasn't a case where Fred decided to pull an Andy Griffith and endorse health care reform (despite his unfortunate encounter with the health care system) since Fred is way too media-savvy to risk his popularity! Instead, it is "YouToons" characters explaining the Affordable Care Act in a 10 minute animated film, Health Reform Hits Main Street, released by the Kaiser Family Foundation. It is the best, most entertaining, and balanced explanation of the law I have seen, and I highly recommend it to anyone who is confused about the Affordable Care Act (and who isn't?).

Today's questions: Did you watch the Flinstones, and if you did, what was your favorite episode? What do you think of the new animated film on the Affordable Care Act?

Friday, September 24, 2010


We live in a time when optimism is in short supply. Large majorities of voters believe the country is on the wrong track. We don't trust insurance companies, Wall Street, or the news media, and we especially don't trust the government. The Pew Research Center characterizes it as "a perfect storm of conditions associated with distrust of government - a dismal economy, an unhappy public, bitter partisan-based backlash, and epic discontent with Congress and elected officials." But ratings "are just as low for the impact of large corporations (25% positive) and banks and other financial institutions (22%). And the marks are only slightly more positive for the national news media (31%) labor unions (32%) and the entertainment industry (33%)."

It was refreshing, then, for me to hear a committed public servant today tell the ACP's Board of Governors that "optimism is the crucial resource" in improving the American health care system. The public servant is Dr. Don Berwick, the administrator of the agency (CMS) that runs Medicare and Medicaid and that is responsible for much of the implementation of the Affordable Care Act.

Dr. Berwick described his vision of CMS as an agency that supports innovation by the private sector - "we have to do this together." He spoke of "partnerships" with physicians, nurses, hospitals, pharmacists and patients to design systems to achieve the "triple aim" of better care, better health, and lower per capita costs. (To learn more about Berwick's triple aim, see this Health Affairs blog from April 20.)

He said that top-down mandates from the federal government won't work. Instead, he spoke of an unparalleled opportunity for physicians to be leaders in designing systems to improve care and the heath of the population, and to reduce health care costs. Cost reductions, he argued, can be achieved "without ever harming a single hair on the patient’s head," if we commit to eliminating treatments that have no benefit to the patient. He sees the government playing a supporting role by providing funding and re-aligning incentives to support innovation at the community-level. His optimism is ground in the many examples where physicians have been leaders in building better systems to reduce fragmentation, improve patient safety, and reduce costs.

But Dr. Berwick also suggested that there needs to be an authentic commitment by all involved to creating a better health care system and that those who instead want to repackage the status quo will not serve the public interest. He praised ACP for its leadership in proposing ways to reduce ineffective care while improving the care of patients and the overall health of the population. ACP's Board of Governors reacted very positively to Dr. Berwick's remarks, with many of the governors offering ideas on how to achieve his triple aim.

Now, I anticipate that given the intense levels of distrust of government, some who read this blog will react to my description of Dr. Berwick's remarks dismissively. You'll probably tell me that ACP is being taken in by yet another "bureaucrat" who heads an agency that, in the minds of many physicians, exemplifies big and unresponsive government - even though this goes against the grain of everything that Dr. Berwick has said and written about how change must come from the bottom-up.

The question in my mind really isn't whether we can or should "trust" the government to do the right thing, even when led by good people like Dr. Berwick, but whether we have confidence in ourselves. Confidence that the can-do spirit that has made America such a great country still lives. Confidence in our own capacity to build a health care system that achieves Dr. Berwick's triple aim of better care, better health, and lower costs. If we can regain such confidence in ourselves, then there is every reason to be optimistic about the future of American health care.

Today's question: How optimistic are you that we can build a better health care system that achieves Dr. Berwick's triple aim?