Friday, March 19, 2010

Why ACP supports a "yes" vote ... the facts

I expected spirited commentary on ACP's position on the final health reform bill, including taking our fair share of lumps. Particularly at a time when emotions are running high, I think the debate needs to be informed by the factual and substantive reasons for ACP's posture.

ACP's website has a new two page summary, a more detailed section by section analysis of how the legislation compares with ACP policies, and responses to Frequently Asked Questions about the legislation.

Anyone who is willing to review the materials with an open mind should find that there is much in the legislation consistent with policies that have long been advocated by ACP's membership.

Our overall approach, as largely mirrored in the legislation itself, is hardly radical - it builds upon and improves the current private employer-based health insurance system, principally relying on tax credit subsidies for individuals and small businesses and group purchasing arrangements to expand coverage, and appropriate and needed regulation of the insurance industry to ensure that it does not engage in practices that help their bottom line by excluding persons with pre-existing conditions. There is no public option or new government run health plan. These are policies that ACP itself advocated at least as far back as 2002, and in some cases much longer, way before this President and Congress took office.

I challenge those of you with a dissenting view to identify the specific policies in the bill that ACP supports - and why you disagree with them? Do you disagree with providing advance refundable tax credits to help people and small businesses buy insurance? To group purchasing arrangements from small businesses and individuals? To giving small businesses, self-employed persons, and others without access to employer-sponsored coverage a wide choice of qualified health plans? To prohibiting insurance companies from turning down or overcharging people with pre-existing conditions? To providing coverage of evidence-based benefits with no cost-sharing? To increasing Medicare and Medicaid payments to primary care physicians? To increasing funding for the National Health Services Corps and Title VII programs? To closing the Medicare Part D doughnut hole? To funding wellness and prevention programs? To standardizing insurance company transactions to reduce administrative costs? To funding research on comparative effectiveness to inform clinical decision-making? To providing coverage, principally through private insurance, to 95% of legal residents in the United States?

On tort reform, yes, we would have liked for the legislation to do more. But caps on non-economic damages, which we continue to support, are not the only alternative to the current trial by jury lottery system. Even when the Republicans controlled the White House, the House of Representatives, and the Senate, they never got tort reform enacted into law. (Caps passed the House on several occasions, but never got a majority of GOP Senators.) I don't make this observation for a partisan reason, only to point out that Washington's inability to enact caps is a bipartisan legacy that both political parties share. Given the long-standing and continued impasse in Washington on caps, it makes sense to explore other solutions on a state level, like funding for health courts.

Some of you have questioned how ACP arrives at its policies. ACP has a very inclusive policy development process that involves review of all policies by our elected Board of Governors and our Council of Student Members, Council of Subspecialists, Council of Young Physicians, Council of Associates, and Council of Student Members, before they are voted on by the Board of Regents. The policies originate in policy committees that are made up of rank and file ACP members. Any ACP member can recommend to their state's chapter governor that a resolution be introduced into the ACP Board of Governors. The resolutions to be discussed at the April Board of Governors meetings are now available for comment by ACP members until April 1. Several of the resolutions are directly relevant to the positions ACP has taken on health reform.

And yes, we have surveyed the membership, although we do not believe surveys - which any researcher will tell you are at best snapshots of opinion at a given time - are a good way to establish policy. The 2009 Membership Survey asked members for their priorities on health reform. On page 96 of the survey, you'll see that there is very broad support among membership for ACP's support for universal coverage, with 70% agreeing that "Guaranteeing by law that all Americans have access to affordable coverage, with government subsidies for those who cannot afford coverage" should be a somewhat high or very high priority. In October through November 2009, a more detailed survey was fielded by ACP's Research Center that also showed strong support from membership for the key policies advocated by ACP - including support for many of the more controversial policies.

Finally, the notion that the volunteer physicians who have dedicated their time to positions of leadership in ACP are a disconnected "elite" is inaccurate and unfair. I know these people, and I have the greatest respect for them. Our current President, Joe Stubbs, is a general internist in small private practice in Albany, Georgia. Our President-elect, Fred Ralston, is in private practice in Fayetteville,Tennessee. The chair of our Medical Service Committee, Yul Ejnes, is in a private internal medicine practice in Cranston, Rhode Island. The chair of our Health and Public Policy Committee, Rich Neubauer, provides care to Alaskan Natives in Anchorage, Alaska. The chair of our Board of Regents, Fred Turton, hails from a long background as a private practice internist in Sarasota, Florida. Yes, we include ACP members who also are in academic practices, as we should - all voices in the ACP membership are represented. But by no means is the ACP leadership detached from the realities of private internal medicine practice, when private internal medicine practice is still the bread and butter of much of our current leadership.

I understand and respect that there is a philosophical and substantive basis for some to disagree with ACP's views. For over a year now, the country has debated such issues as how much the government should be involved in regulating and subsidizing health care. Like the broader public, some ACP members will conclude that the legislation gives the government too much of a role, some too little, and like Goldilocks, some will decide that it gets it just right. But the time has come for Congress to decide one way or another. I believe that ACP has arrived at a strong, factual, evidence-based, and balanced position that serves its members well, by championing improvements that will expand access and coverage to millions of patients in a fiscally responsible way.

Today's questions: (For those who disagree with ACP), what are the specific policies in the bill that ACP supports that you disagree with, and why? (For those who agree with ACP), which specific policies that ACP supports do you agree with, and why? For those who are still unsure, what policies do you think are most important for ACP to continue to advocate?


Anonymous said...

datratrubYu have a very poor understanding of the economics of the health care reform bill. For the sake of a short term solution that will preserve physician incomes, you are willing to sell our economic future as a nation out.

Rich Neubauer MD said...

You've outlined very well in your blog entry the specific parts of the reform package that are of interest to me and prompt my support.

The overriding part of the package that is most attractive to me is that it expands coverage to nearly all Americans. I view this as a key component. In my view, without that we have no chance of addressing cost control.

I fully anticipate that problems with access vs. coverage will be unmasked by the current reform package, but these problems are there now, we are just sweeping the access problem under the carpet by calling visits to the ER "access". Primary care is helped by this bill, but not enough. That still needs to be worked on. Cost control may be somewhat helped by this bill, but it is hard to be sure. My guess is that much work still needs to be done in this area.

As has been stated again and again, the status quo looks exceedingly poor when juxtaposed to the reform package that is on the table. Those to my left may feel that holding out for a single payer system is preferable to passage of the current package, but that seems like political fantasy. Those to my right seem to feel that further incremental tweaks of the status quo are the right way to go, but this seems to have failed miserably for too many years now. While this particular package is far from perfect, it beats all the alternatives I can see.

Harrison said...

I don't oppose the bill as proposed but I live in a district where the Republican representative very much opposes it. And as far as I can tell his reason is related to the budget deficit. He feels that it is not possible to believe the CBO and that this will really saddle the country with a huge debt.
He bases this on the fact that Medicare taxes are already not used for Medicare and so the country is really already incurring a Medicare debt and that by counting savings for this in the future is double counting something as a positive that shouldn't be counted for a positive at all.
He doesn't really suggest what he would do to change this, other than the qualitative and not quantitative suggestions that tort reform will help and that there is money to be gained by cracking down on fraud.
He doesn't at all address the problems of the uninsured -- and ignores the fact that at least 20% of his constituents do not have health insurance.
More philosophically, many people strongly oppose government involvement in health care. They want this to be reduced and not increased.

I do try to understand the Republican opposition. I'm sure I do not do it justice because I cannot find myself getting anywhere near as vitriolic about this as they are able to do.

I would hope that those ACP members who feel this issue is enough of a difference for them that they would cease to be members will reconsider.
The ACP has a resolution process that allows members to influence policy.
Resolutions are considered by the Board of Governors, and then the Regents --- and it is certainly possible to suggest that ACP lobbying priorities be changed.

We have a stronger voice in the health care debate together.
I think that the ACP leadership is working hard to represent divergent interests. Primary care physicians and specialists have much in common and the ACP can represent those interests, and can also represent those interests that are more specific -- and we can do this by keeping the interests of our patients in mind.


Robert J. Sobel, M.D. said...


Thanks for keeping it flowing. Realistic's rant provides a nice overview of multiple imbalances in the status quo. We do need to push very hard on basic adjustments in fair fee for service. I am convinced the added bureaucratic layers, from medical home to pharmacy databases, will introduce complexity beyond their utility. We shall see.

I remain insistent that the price of new drugs needs urgent attention. The only way to control them is to prorate the cost over time with indefinite exclusivity. The manufacturing rights insanity in the current system is absurd, beyond the FDA's capacity, and the artifice brought about by the Hatch-Waxman Act. Let us advocate for effective reform in this domain. It remains a huge part of the unpaid overhead of primary care.

Apply Regulated Royalties to hospitals, new procedures, high end chemo, and the biologicals, and you save billions immediately. The fallout would be manageable. Any patent attorneys to the rescue?

Realistic said...

Bob, read these , and you will learn whats wrong with the bill.

What Doctors and Patients Have to Lose Under ObamaCare

Joanne Lynn said...

No matter what the nation does now, health care costs cannot continue to rise as they have. We will have to learn how to live within our means. This bill at least gets us all into the lifeboat (or almost all). I think it will accelerate the day of reckoning on costs - and that is just as well. But having everyone in on the issue is more likely to yield useful answers than having 1/5 of Americans uninsured and easily bypassed as legitimate claimants on the shared resource pool

BDoherty said...

I thank Realistic for forwarding the links to several articles about the health care legislation to support his concerns. By doing so, he can allow us to begin having a discussion of specific provisions in the legislation, as I requested in my post, rather than engaging in broad generalities about the legislation.
The articles, though, include statements that are factually inaccurate or misleading:

The Obama healthcare team wants to give CMS the power to decide when a cheaper medical option will suffice for a given clinical problem and, in turn, when Medicare only has to pay for the least costly alternative. (From the Physicians’ Weekly article).

I can’t comment on what the Obama team “wants” to do, but I can say that the legislation does not give Medicare the authority to deny care based on cost. I suspect that the writer is referring to a provision in the bill that funds independent research on the comparative effectiveness of different treatments. But the legislation also explicitly prohibits use of such research to deny coverage or ration care. An excellent summary of the legislation from the Kaiser Family Foundation summarizes the bill’s CER provision as follows: “by establishing a Center for Comparative Effectiveness Research within the Agency for Healthcare Research and Quality to conduct, support, and synthesize research on outcomes, effectiveness, and appropriateness of health care services and procedures. An independent CER Commission will oversee the activities of the Center. Provides that comparative effectiveness research findings may not be construed as mandates for payment, coverage, or treatment or used to deny or ration care.” The independent fact-check organization,, has debunked the argument that the legislation gives the federal government the authority to use CER to ration care.

Dr. Wolf writes in the Washington Times that “consider the implications of Obamacare's financial penalty aimed at your doctor if he seeks the expert care he has determined you need. If your doctor is in the top 10 percent of primary care physicians who refer patients to specialists most frequently - no matter how valid the reasons - he will face a 5 percent penalty on all their Medicare reimbursements for the entire year.”

But the fact is that there is no such provision in the bill. An earlier version would have imposed reductions in payments for physicians who were in the top tenth percentile in costs (not directed specifically at primary care physicians, by the way) but this was removed from the version that the Senate passed and it is not in the current legislation. ACP objected to the original provision, so we had a role in its removal.

There is still a provision, which ACP opposes, in the legislation that would authorize CMS to create a “value index” to adjust payments, but the provision doesn’t take for several more years, and ACP will work to change it in future legislation.

As I’ve made clear from the beginning, ACP doesn’t support everything in the current legislation—it is imperfect and falls short in some respects, and we are committed to getting changes in the future. But we stand by our view that it would substantially advance ACP goals on coverage, workforce, payment and delivery system reform. As internists debate the merits of the legislation, I hope we can focus on what is really in the bill, and put to rest some of the claims made by supporters and opponents alike that are not supported by the facts.

Realistic said...


You "cherry picked " several item from the list I sent. I am not so confident that the "comparative effectiveness " boards will be so benign and not have the number one driver be cost as it pertains to their decson. It wil be a completely political structure reeady to make decisions which will please the government. Now Sobel , Harrison , and the rest of you let me give you a pop quiz. Do you know what the NICE is? If you dont you should . Its the analagous structure in UK that does its"comparative effectiveness " assessments. It has made many cancer and surgical treatment decisions thatare completely cost driven . You hould read about the NICE.

Bob, what about Gottliebs article on the insurnace manadate and penalty incentivizing millions of Americans into the exchanges. Thats 3/4 to one payer. BTW for the record where do the poeple on this blog stand on single payer and you also BOB