Wednesday, June 30, 2010

How can you learn what is really in health reform?

Recent polls show that the public remains split on the merits of the health reform law, although the most recent polling shows a modest uptick in support, with a small plurality of Americans now expressing support of the legislation in polls conducted by the Kaiser Family Foundation and USA Today/Gallup; other polls show a narrow plurality of voters continue to view the legislation unfavorably. The overall trend, though, appears to be toward increased support and decreased opposition, based on an aggregation of polls on the website. The shift, though, is modest, and the country remains deeply divided by political affiliation and other characteristics of respondents.

One constant, though, is that a substantial percentage of Americans describe themselves as being "confused" about the law. The latest Kaiser poll has roughly four in ten respondents describing themselves as at least somewhat confused by aspects of the law, although larger percentages describe themselves as being aware (and generally supportive, except for the individual mandate) of key provisions of the legislation.

Who does the public trust most on health reform? A March survey by Gallup shows that 77% of respondents trust in physicians to recommend the right thing for health care reform, the highest of any sector.

The problem is that physicians also are confused. Mark Blumenthal wrote in April's National Journal that "Doctors report on high levels of confusion, panic or anxiety expressed to various physicians, including patients asking if their doctors are "going to be able to keep seeing me" or 'pushing for surgery now' in fear it might be denied in the future. Even more important, many of the doctors are as confused about the new law as their patients. 'Quite honestly,' one doctor told the Times, 'I don't know how to answer their concerns.'"

In my recent talks about health reform with physicians in Massachusetts, Maryland, Wyoming, Mississippi, Washington state, and the District of Columbia, I too have heard from many physicians who are unsure themselves about the specifics of health reform, yet they are being asked (besieged?) by patients asking for help in understanding it.

Here's the good news: today, the American College of Physicians released An Internist's Practical Guide to Understanding Health System Reform; ACP's press release describes the guide "as the single most comprehensive, clear, and objective explanation of the new law, and what it might mean for internists and their patients." The 90 plus-page PDF document is designed to be super-easy to use, allowing readers to navigate to key descriptions of the legislation, organized by date and topic, with a single mouse click. ACP is making the guide generally available for redistribution, free of charge, on a not-for-profit basis with attribution ACP.

The guide was written by the staff for ACP's Division of Governmental Affairs and Public Policy, which I direct, so I recognize that there is a bit of self-promotion on my part in recommending the guide. But I encourage anyone who has an interest in learning about what is actually in the legislation to download it and give it a test run. Whether you agree with the legislation or not, I hope you will agree that the guide fills an urgent need to provide practical, thorough, unbiased information on the "nuts and bolts" of the legislation, and by doing so, can help reduce the rampant confusion that exists among doctors and patients.

Today's questions: Have you downloaded the new ACP guide? What do you think of it?

Friday, June 25, 2010


After months of dithering, delaying, denying, and defaulting on a decision, Congress ended up . . . doing as little as possible to address the Medicare physician pay cut problem.

Last night the House of Representatives acceded to the Senate’s bill to provide physicians with a 2.2% update retroactive to June 1. This respite, though, lasts only through the end of November, when physicians and patients will again face another double-digit cut. And if the past is prologue, a lame-duck Congress then will wait until the very last minute to enact another short-term patch, or worse yet, allow the cut to go into effect on December 1 and then pass some kind of retroactive adjustment.

You know that the situation has gotten ridiculously bad when the President says this about the bill he just signed into law:

"Kicking these cuts down the road just isn't an adequate solution."

and when Speaker Pelosi (D-CA) calls it "inadequate" and a "great disappointment"
and the best that any had to say about it was this from SFC ranking member Charles Grassley (R-IA):

"This action was critically needed so there’s no disruption in services for anyone."

But it's too late.

As I told Katherine Hobson, who writes for the Wall Street Journal blog,
"the damage has [already] been done, resulting in a growing lack of confidence in the [government's] ability to deliver on promises to Medicare patients."

Yeah, I am fed up with the situation, just as I am sure most doctors are. What is especially galling this time around is that Congress had multiple opportunities over the past year-and-a-half to advance a permanent solution, but ended up just kicking the can.

The Senate could have passed an ACP-supported bill, approved by the House of Representatives in November, which would have completely repealed the SGR and replaced it with a better update framework to allow higher updates for all services and an additional bump for evaluation and management and preventive service visits. It did not.

The Senate could have passed an amendment, offered last year by Senator Debbie Stabenow (D-MI), to eliminate all of the accumulated SGR cuts. It did not.

Just a few weeks ago, the House and Senate leadership appeared to have settled on a plan, developed in consultation with ACP, to provide five years of positive and stable updates and to begin to move to a better payment update framework, based on the bill passed by the House in November. Lacking the votes they needed, they scaled it back to three-and-a-half years, still with a higher bump for primary care and preventive services. This too, was dropped because they didn’t have the votes. The House then passed a 19-month reprieve and the Senate a six-month reprieve (neither of which moved policy to a better payment framework).

Then, for four days this week, the chambers remained at an impasse, until the House acceded last night to the Senate’s six-month patch.


What can be done now? Well, physicians need to hold their elected representative and Senators accountable when Congress returns to their states and districts looking for votes over the Independence Day holiday recess. Tell them how Medicare’s unreliability and instability is affecting you and your patients. Get them to commit to doing whatever is needed to enact a long-term solution that Democrats and Republicans alike will support. Don’t let them get away with blaming someone else.

As ACP President Fred Ralston said on Monday, "physicians and patients don't want to hear that it is the Democrats' fault, or the Republicans', or the President's, or the Senate's, or the House's. They don't want to hear politicians claim that they are for repealing the SGR, as they withhold their vote from any practical plan to achieve repeal . . . They want to hear that members of Congress, on a bicameral and bipartisan basis, have agreed on a long‐term solution to replace the unworkable SGR."

Get them to commit to doing that, and maybe we won’t be sticking seniors with another turkey of a bill come November.

Today’s question: How will you be holding your own member of Congress accountable for the Medicare SGR debacle?

Wednesday, June 23, 2010

Patients Held Hostage, Day 23

Remember when TV news broadcasts recorded the running total of each day that American diplomats were held hostage in Iran under the banner "America Held Hostage, Day [ ]?" Well, I wouldn't be surprised if America's seniors are feeling like they are being held hostage by a hostile government, as Congress' continued stalemate over the Medicare SGR physician payment cut enters the 23rd day since a 21% cut went into effect.

(Yes, I am engaging in a bit of hyperbole, because as bad as the SGR situation is for patients and their physicians, it doesn't rise to the terror inflicted by the Americans captured by a revolutionary Iranian government.)

Yesterday evening, ACP issued a statement blasting Congress for all of the excuses and finger-pointing offered by politicians to justify the impasse:

"It is past time for politicians from both political parties and both chambers to stop blaming someone else for the impasse. Physicians and patients don't want to hear that it is the Democrats' fault, or the Republicans', or the President's, or the Senate's, or the House's. They don't want to hear politicians claim that they are for repealing the SGR, as they withhold their vote from any practical plan to achieve repeal.

"They want to hear that they people they elected can work together to solve the problem.

"They want to hear that the House and Senate have resolved their differences and enacted legislation to immediately reverse the 21 percent cut and make physicians whole for the damage already done.

"They want to hear that members of Congress, on a bicameral and bipartisan basis, have agreed on a long-term solution to replace the unworkable SGR. Such a solution, at a minimum, would provide stable, reliable and positive payments for all services that covers physicians' costs, provides for higher updates for primary care visits and preventive services, and lead to repeal of the SGR.

"Absent such agreement, physicians and their patients will continue to lose faith in Medicare and TRICARE, causing potentially irreparable and permanent damage to both programs."

ACP also sent out a blast email alert to its 6,000 plus "key congressional contact" grass roots network urging them to call their legislators to demand action.

Many of have told us that they made the calls. Some, though, have said that they see no point, since they don't believe that Congress is listening.

I understand their frustration and sense of powerlessness. But I also know that if physicians don't hold their elected senators and representatives to task, they are essentially engaging in unilateral disarmament. The most powerful tool to influence Congress is grass roots engagement by the people whose votes they will be seeking for re-election. The reaction to an intransigent Congress should be to increase the pressure from voters, not to back off out of frustration.

Lastly, I continue to hear from some ACP members who argue that organized medicine should have "insisted" or "demanded" SGR repeal as the price for supporting health care reform. I addressed this issue in my post from Friday, so won't restate all of the reasons why the SGR is an inherited problem separate from health care reform, or all of the policy reasons (including getting all Americans covered) that ACP supported health care reform even without an SGR fix.

But let me address the fallacy behind the idea that organized medicine could have successfully "demanded" that Congress fix the SGR as part of health care reform. The fact is that a majority of the House of Representatives voted to repeal the SGR. But in the Senate, it would have required 60 votes. Every Republican member of the Senate had vowed to vote against health reform, even if it included an SGR fix. The only way that the SGR fix could have been included in health care reform, then, would have been if all 60 Democrats in the Senate (that is, before Scott Brown took the Senate seat previously held by Democrat Ted Kennedy) were willing to vote for the over $200 billion additional cost of including the SGR in health reform. The simple fact is that there were a half dozen or more Democrats who wouldn't agree to the added SGR cost, no matter how much organized medicine might have "insisted" that it be included. And the fact is that once the Democrats lost a filibuster-proof majority after Senator Brown's win, there was no way for SGR repeal to be included in the health reform bill without at least one GOP vote for the broader legislation. This isn’t to excuse Congress' inaction, or to blame one political party over the other, only to explain why "demanding" that the SGR be included in health reform was never a realistic strategy.

I hope that physicians can stop beating up on each other by second-guessing the decisions made by their professional organizations on the SGR, and direct their outrage where it can really do some good: holding their members of Congress accountable for the irreparable harm it is inflicting on Medicare.

Today's question: What changes are you making in your practice because of the SGR cut? And are you holding your members of Congress accountable?

Monday, June 21, 2010

Coverage the U.S. can't afford? Think again.

A staple of the anti-health reform chorus is that the United States can't afford the promise made to extend coverage to tens of millions more people. Even though the Congressional Budget Office has said that the legislation will reduce the deficit by about $141 billion over the 2010-2015 period, and by about a trillion dollars over twenty years, the critics don't buy it. They argue that the CBO has been wrong before, or that the savings and revenue increases underlying its analysis will never happen, or that the CBO didn't take into account the costs of things that pre-dated and aren't related to the costs generated by the legislation itself, like the SGR physician payment fix. Usually, it is all of the above.

My own view - as I stated in my recent perspectives article in the Annals of Internal Medicine - is that there is a great deal of uncertainty in long-term budget forecasting, and it is certainly possible that the CBO under-estimated the costs and over-estimated the revenue and savings offsets to pay for it. It is also possible that the legislation might save more than the CBO estimated, because it generally did not assign any savings to innovations (like accountable care organizations and patient-centered medical homes) designed to align payment incentives with the value of care provided.

Now, though, a brand new study by the prestigious, non-partisan Rand Corporation reaches a stunning conclusion:

"The recently enacted federal health care reform law provides health insurance coverage to the largest number of Americans while keeping federal costs as low as reasonably possible" according to Rand's news release.

Rand goes on to report that, "The only alternatives that would have covered more Americans at a lower cost to the federal government were all politically untenable - substantially higher penalties for those who don't comply with mandates, lower government subsidies and less-generous Medicaid expansion."

Now, I know this won't put an end to an argument, because Rand's analysis attempts to answer only the question of whether it was possible to cover more people at less cost to the government. On that score, the Patient Protection and Affordable Care Act is a highly efficient use of taxpayer dollars. Many of the critics of the current legislation do not believe, though, that covering everyone (or most everyone) should be an essential goal of health reform, especially if it adds more costs to the federal treasury.

Certainly, one can conceive of alternatives that would have covered a lot fewer people, at less cost to the taxpayers - but those would have left us with the human, societal, and economic costs of leaving tens of millions of Americans without health insurance coverage. One can also conceive of ways to cover more people at less cost, but according to Rand, those generally involved more punitive mandates for people who choose not to buy coverage or much lower premium subsidies (meaning much greater out of pocket costs to them).

In my mind, the argument about whether the country can afford to provide health insurance coverage is an important one but one that probably can't be resolved, because it comes down more to a value judgment than an economic argument: How important is it to you to ensure that all Americans have access to health insurance they can afford? If you believe that society has an obligation (I am not going to get in the argument over whether it is a right) to provide all Americans with access to affordable coverage - as ACP believes it does - then the Patient Protection and Affordable Care Act was a highly prudent and efficient use of federal dollars, covering the most people at the least possible cost. But if you believe that it is not the role of government to ensure that its residents have affordable health insurance, then you probably aren't going to view any substantial increase in federal spending on the uninsured as a good use of taxpayer dollars, even though the legislation covered the most people at the least possible cost to taxpayers.

Today's question: Do you think Rand's analysis will make much of a difference in the endless argument over the costs and benefits of health reform?

Friday, June 18, 2010

The SGR and Health Reform

Today, the Senate - in a rare stroke of bipartisanship - voted by unanimous consent to reverse the 21% SGR cut and provide positive updates of 2.2% through November, 2010. The legislation is fully paid for by offsets in other spending programs. Unfortunately, though, the cut remains in effect and claims are being processed at reduced rates, because the House of Representatives has recessed for the weekend and won’t be back until Tuesday. At that time, I expect that the House will pass the Senate's six month reprieve and Medicare will make doctors "whole" for the period of time that the cut was in effect.

Not that any of this is a cause for celebration. In the meantime, claims still are being paid at reduced rates, creating havoc for physicians and patients. Kicking the can down the road for another six months doesn't get us any closer to a permanent solution. It doesn't lower the overall cost, now estimated at over $200 billion, to dig out of the SGR hole. It doesn't provide the stability and reliability that physicians and patients need to view Medicare as a trusted partner. It does mean that we will be back again, this summer and fall, fighting to forestall another double-digit cut.

My views on the current SGR mess were quoted today by Politico:

"With nearly three weeks worth of Medicare bills being paid at 21 percent below 'normal' levels, providers are getting angry. The American College of Physicians warned that lawmakers of both parties are 'playing with fire.' I have never seen physicians more frustrated with the cuts and cynical about Congress' willingness or ability to do the right thing for patient access, ACP lobbyist Bob Doherty told Pulse."

Now, with the latest developments on the SGR, we are being accused (again) by some of failing to ensure that the SGR would be taken care of in the health reform law itself. That's interesting, because it ignores the facts leading up to the current SGR mess. It also overlooks the multitude of other policy reasons why ACP supported health reform.

As I wrote today in response to my earlier post on "Who should doctors be angry at", ACP supported health care reform legislation because it advanced ACP policies to provide almost all Americans with affordable health insurance coverage, to end insurance practices that deny people affordable coverage because they have a pre-existing condition or lose their jobs, to create incentives to train more primary care physicians, to pilot-test innovative payment and delivery models like the Patient-Centered Medical Home, to fund research on comparative effectiveness of different treatments, and to cover preventive services with no cost-sharing.

Policies that will help keep alive the tens of millions of Americans that studies show die each year because they lack health insurance. Without health reform, the Census Bureau estimates that more than 60 million people, one out of five of us, would lose health insurance over the next decade.

We supported health reform because it begins to reduce the disparity in Medicare and Medicaid payments for primary care.

We supported health reform because it will allow for pilot-testing and expansion of innovative programs to reduce the rate of increase in health spending.

I will put our record against anyone's of successfully influencing the legislation to include policies long advocated by internists, particularly on coverage, workforce, and payment and delivery system reforms.

Our support was not unqualified: as I have stated many times before, there are parts of the law that we don't like, but on balance, the legislation was the right thing for patients.

It would have been the height of cynical deal-making, the kind that our critics decry, for us to say that the only policy that mattered in the health reform debate was repealing the SGR. The SGR is important, but it doesn’t trump every other policy designed to make affordable health care available and affordable to tens of millions of Americans. We would never cynically trade all of our other policies to support better patient care in order to achieve a single policy objective, even one as important as the SGR. The SGR matters, but so does providing almost all Americans with access to affordable coverage.

And, let's be clear on the history: the SGR was passed by a GOP-controlled Congress and signed into law by a Democratic President, Bill Clinton, in 1997. The current state of affairs exists because Republicans and Democrats alike for more than a decade have failed to work together in a bipartisan fashion to enact a system to replace the SGR. We would have been dealing with the SGR even if health reform had never seen the light of day.

Finally, I sincerely doubt that those who now criticize our support of the health reform legislation because they philosophically disagree with its overall approach would be supporting it now if the SGR fix had been included in it. Let's at least be honest on this point.

Today's question: What do you think about the efforts by critics to link health reform and the SGR?

Thursday, June 17, 2010

Why do some medical schools do primary care better?

A new study published in the Annals of Internal Medicine, ACP's flagship journal, finds that medical schools vary greatly in producing more primary care physicians and getting them into under-served communities.

- "Public schools graduate higher proportions of primary care physicians" than private schools.
- "The 3 historically black colleges and universities with medical schools (Morehouse College, Meharry Medical College, and Howard University) score at the top" in training primary care physicians who then go on to practice in under-served communities. (Click here for an interview with two recent graduates of historically black colleges and with Wayne Riley, MD, FACP, who is the president and CEO of Meharry Medical College in Nashville, Tennessee and a regent of the American College of Physicians.)
- "The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas."
- Some institutions defy the trend: "Four large research institutions (University of Minnesota; University of Washington; University of California, San Diego; and University of Colorado) are in the top quartile of medical school recipients of NIH funding and of primary care output rankings. In addition, University of Washington and University of Minnesota are in the top quartile for overall social mission score."
- "Compared with other U.S. regions, the Northeast, with its preponderance of private, traditional, and research-intensive medical schools, had the lowest scores in ... [producing] primary care [physicians] and [serving] underserved areas..." Schools in urban areas, in general, scored lower on these dimensions than schools in less populated communities.

(Click here to see how your state's medical school rank on social mission.)

This study is likely to generate a highly controversial public policy debate.

If politicians want more primary care physicians, especially ones who are committed to practice in under-served communities, they could put more money into programs focused on the recruitment and training of underrepresented minority medical students.

They might increase support for public medical schools over private schools.

They might ask medical schools and grant making institutions, like NIH, to examine why research funding promotes technical medicine over primary care, and why some schools that receive substantial research funding buck the trend.

They might give preference to building or locating medical schools in less urban communities.

(Related, the Obama administration announced yesterday an investment of $250 million to support training of more primary clinicians, including $168 million for training more than 500 new primary care physicians by 2015, $32 million for supporting the development of more than 600 new physician assistants, $30 million for encouraging over 600 nursing students to attend school full-time, $15 million for the operation of 10 nurse-managed health clinics, and $5 million for states to expand their primary care workforce by 10 to 25 percent over ten years. ACP released a statement of general support for the administration's investment in primary care.)

The authors of the Annals study conclude with a challenge:

"Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform."

If medical schools won't re-examine their priorities on their own, aren't they inviting politicians to force change - by shifting funds to schools that have a better primary care track record?

Today's questions: Do you think medical schools should be accountable for training more primary care physicians? Should politicians shift money to medical schools (public, historically black, less research-oriented, and less urban) with a better primary care track record?

Monday, June 14, 2010

Is "private contracting with benefits" the answer to Medicare's woes?

My blog today is from the American Medical Association's House of Delegates meeting, where much of the discussion is over Congress' continued inability to reach agreement on the Medicare SGR physician pay cut. Many of the delegates have coalesced around the idea of private contracting as the solution.

Currently, physicians and Medicare patients are allowed to enter into private contracts for their services, provided that they mutually agree to forgo any Medicare reimbursement for a two year period. This is true private contracting in that it gets the government completely out of the picture: Medicare beneficiaries voluntarily agree to give up their Medicare physician benefits to enter into a private payment contract with their physician.

The AMA delegates, though, seem to have a different kind of contractual relationship in mind, where the Medicare patient could still receive full reimbursement from Medicare for their physician services, but their doctor would not be bound by the legal limits that Medicare places on how much their doctor could charge above Medicare's allowed amounts. Instead, there would be an agreement between the physician and the patient on how much the beneficiary would be expected to pay for services above Medicare's allowed charges. This approach might be described as "private contracting with benefits"- since it tries to have it both ways, maintaining current Medicare benefits, while allowing physicians to charge their patients more than Medicare allows, with the patient's consent.

I understand the appeal of private contracting with benefits. At a time when Congress is incapable of agreeing on legislation to ensure that Medicare will pay physicians a fair fee for their services, private contracting with benefits provides an "escape valve" to get around Medicare's price controls. The argument also goes that seniors shouldn't be penalized with a loss of benefits for entering into a private contract. Private contracting with benefits could help maintain access for seniors who are at risk of losing their doctor, and provide a lifeline to practices that are struggling financially.

I don't see private contracting with benefits, though, as the answer to the immediate 21% SGR cut, or for that matter, for most of the problems with Medicare's dysfunctional payment system. For one thing, I see no chance, nada, that the current Congress and administration would agree to allowing seniors to enter into private contracts and maintain their Medicare benefits. This will be viewed by a majority in Congress, and by the current administration, as opening the door to a massive cost-shift to seniors. At a time when seniors are already worried that they will be losing benefits under the new health reform law (they actually will get better benefits under traditional Medicare, but many don't believe it), I don't think many politicians would vote for something that would likely be viewed by many seniors as eroding their benefits by requiring them to pay more out-of-pocket. AARP, which has been allied with organized medicine in support of repealing the SGR, likely would fiercely oppose opening the door to physicians charging seniors more than Medicare’s allowed charges.

Even if the political winds change and Congress ultimately comes around to support private contracting with benefits, this won't happen in time to avert the current 21% SGR cut. Tying reversal of the current SGR cut to private contracting with benefits is not a winning formula to get 60 votes in the current U.S. Senate and majority of the House of Representatives.

The other problem with private contracting with benefits is a more substantive policy one. If Medicare patients are going to be allowed to enter into private contracts that allow their doctors to charge more without giving up their Medicare benefits, then legal safeguards would need to be included. ACP policy, first adopted in 1998 but reaffirmed by the Board of Regents in 2010, supports private contracting, but with safeguard s to protect patients:

"The American College of Physicians supports the primacy of the relationship between a patient and his/her physician, and the right of those parties to privately contract for care, without risk of penalty beyond that relationship.

Such statutes should include the following patient protections: (1) a requirement that physicians disclose their specific fee for professional services covered by the private contract in advance of rendering such services, with beneficiaries being held harmless for any subsequent charge per service in excess of the agreed upon amount; (2) a prohibition on private contracting in cases where a physician is the "sole community provider" for those professional services that would be covered by a private contract; (3) a prohibition on private contracts in other cases where the patient is not able to exercise free choice of physician; (4) a prohibition on private contracting for dual Medicare-Medicaid eligible patients; (5) a requirement that private contracts cannot reduce patient access to care in cases of emergency or life-threatening illness; and (6) a requirement that the Centers for Medicare & Medicaid Services and the Medicare Payment Advisory Commission monitor Medicare beneficiary access to health care and report to Congress and the public if access problems develop as a result of private contracting."

In other words, there is a place for "private contracting with benefits" as part of a total restructuring of Medicare payment policies, but such an option would need to be constructed in a way as to allow for true price (and quality) transparency and to protect vulnerable seniors who really would have no choice. Private contracting with benefits does not eliminate the need to restructure Medicare payments to provide better value to seniors and taxpayers or support the value of primary care. And it won't help get us the votes needed now to reverse the 21% Medicare SGR cut.

Today's question: Do you see private contracting as the solution to the SGR cut? Do you agree that the safeguards proposed by ACP should be included?

Friday, June 11, 2010

Tough choices on the SGR

With the clocking ticking down to the point where Medicare will have no choice but to start implementing the 21% SGR cut, Congress still has not been able to agree on a solution. The House has passed a short-term, 19-month fix that will replace the cut with positive updates through 2011. The Senate has yet to act on the House’s bill or decide on its own alternative.

Part of the problem, though, is that physicians are not united on what they want. Although everyone in medicine agrees that we want the SGR repealed and replaced, the simple fact of the matter is that there is no way to get 60 votes in the Senate (or for that matter, a majority in the House) to vote for repeal when the price tag is over $230 billion—money which would have to be found by cutting Medicare somewhere else, reducing Social Security benefits, or raising taxes under pay-as-you go laws.

ACP’s position has been that if Congress decides on an approach that falls short of repeal, it should at least provide more stability than 19 months, and it should begin to move payments to a better framework that could be the basis for eliminating the SGR in subsequent legislation. With ACP’s support, House and Senate leaders, just a few weeks ago, were hoping to get agreement on a plan to provide five years of stable updates, during which payments for the last three years would be based on a new formula that would allow physician services to grow at a higher rate than the SGR, with an additional growth factor for primary care visits and preventive services. This approach was abandoned, in part, because it did not have across-the-board support within medicine. The House then proposed a similar approach, but for only three-and-a-half years. When that failed to attract enough support, the House came up with its 19 month fix.

Now, the Senate is considering offering an amendment to go back to the House’s idea of a three-and-a-half year plan that would begin to move policy in the right direction. ACP expressed support for the plan, in a letter to Senator Debbie Stabenow (D-MI), the likely sponsor of the amendment. The American Academy of Family Physicians and American Osteopathic Association also support it. But its prospects remain uncertain, at least in part, because not all of medicine is rallying behind it, and some Senators are still unwilling to commit to anything that has a practical chance of stopping the cut and moving payments to a better system.

We all want SGR repeal, but at some point, the question becomes a simple one. Do we go along with another 19-month patch that does nothing to move to a better system? Or do we rally behind a plan to provide longer-term stability that also begins to move us to a better payment structure, one that would allow spending on all physician services to grow at a higher rate than the SGR and provide an additional spending growth allowance for primary care visits (including visits billed by subspecialists) and preventive services code? Or do we say we can only support complete repeal , when there aren’t the votes for repeal, and we likely will then end up either with the cut, or a short-term patch that does nothing to move to a better payment system?

Today’s question: What would you choose?

Thursday, June 3, 2010

Is "more care, newer care, and more costly care" better care?

It has become pretty much an article of faith among health policy experts that higher spending on health care doesn't always buy better outcomes.

Studies by the Dartmouth Atlas have shown that show that high-spending areas of the country often have poorer outcomes than lower spending areas, even after taking into account differences in the populations being treated. Analyses of health care in other countries suggest the same: the U.S. spends far more than other westernized countries, yet by most measures, the health of our population isn’t any better and in some cases, worse.

An ACP position paper published in the January 1, 2008 Annals of Internal Medicine put it this way:

"Health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health. Current international comparisons of measures of health (life expectancy at birth, infant mortality, and deaths per 100 000 for diseases of the respiratory system and for diabetes) indicate that population health in the United States is not better than in other industrialized countries despite the greater U.S. expenditures."

(Full disclosure: I was a co-author of this paper, developed on behalf of ACP's Health and Public Policy Committee.)

Related, many see great promise in evidence-based medicine as being the best way to level out the variations, the idea being that if physicians and patients based treatment decisions on the best available evidence, there would be fewer differences in utilization and outcomes from area to area, and overall costs associated with over-treatment might be reduced.

The problem is that the public isn’t buying it. A new study in Health Affairs finds that much of the public holds values and beliefs that are at odds with evidence-based approach principles. Much of the public believe that all care meets minimum quality standards; that medical guidelines are inflexible; that more care, newer care, and more costly care is better. The authors write:

"For health care experts, variation - in quality among health care providers, the evidence base regarding therapies, and the effectiveness and cost-effectiveness of treatment options - is a well-established fact of the health care delivery system, documented extensively in the published literature and well understood after years of careful study. Yet such concepts are unfamiliar to many Americans and may even seem threatening, to the extent that they raise unwelcome questions about the quality of medical care that people receive."

Related, the New York Times reports today against a growing backlash against Dartmouth's study on regional variations. The reporter, after citing the arguments made by Dartmouth's critics, goes as far as to conclude that "... there is little evidence to support the widely held view, shaped by the Dartmouth researchers, that the nation's best hospitals tend to be among the least expensive."

The Dartmouth Atlas responded by saying that there were at least five factual errors, and several misrepresentations in the Times article, and that "What is truly unfortunate is that the Times missed an opportunity to help educate the American public about what our research actually shows - or about the breadth of agreement about what our findings mean for health care reform."

This brings the discussion full circle back to the public's views. I am among those of the view that the data are strong enough to suggest that higher spending doesn't always mean better quality, notwithstanding the controversy over Dartmouth's research. If we are going to as a country "bend the cost curve" - and we must - then decisions will need to be made on what treatments people will get. I would rather such decisions be made by my physicians and me - informed by the best available evidence on effectiveness, including both outcomes and cost.

But in a democratic country, such decisions can't be made without public understanding and support. As long as the public believes that more care, newer care, and more costly care is better care, then it is going to be almost impossible to get a handle on costs.

Today's question: What is your reaction to the backlash against evidence-based medicine and the studies of regional variation?

Tuesday, June 1, 2010

Who should doctors be angry at?

Instead of blogging (again) about Congress's failure to stop the 21% Medicare SGR cut, which went into effect today, I could just re-run my April 16 post. I wrote then:

"It is the failure of both political parties, over many years, to honestly deal with the SGR, including the cost of getting rid of it, which has resulted in the current ongoing SGR farce. And yet members of Congress wonder why the public holds them in such low regard."

Blogging in DB's Medicare Rants, Dr. Bob Centor captures the outrage felt by most physicians:

"I am mad. Every physician I know is mad. Patients should join us in expressing anger. Physicians cannot trust Congress if they cannot repair this absurdity."

(Bob references ACP's statement, released on Friday; click here to read it in its entirety.)

That Congress allowed politics again to get in the way of doing what is best for patients makes my blood boil. Voters can and should hold them accountable.

But I also have to tell you, anger directed at ACP by some members also makes my blood boil. Typical is one who emailed that "ACP has been suckered just like everyone else" for "trusting" Congress to fix the SGR in exchange for supporting health care reform.

The effort to link the SGR to ACP's position on health care reform makes my blood boil, because the SGR has been around since 1997. It has nothing to do with health reform. The fact is that Republicans and Democrats alike have been unwilling over the past decade to come up with the political will (and money) to repeal the SGR, and we now are facing the accumulated consequences of their failure. (To be fair, a majority of the House of Representative passed legislation late last year to repeal the SGR, but it never advanced in the Senate.)

Here again, Bob Centor has it right when he explains that he supported health care reform because "addressing the problem of the uninsured was so important that it trumped the weaknesses in the bill."

Bob continues: "This was the chance to start down the road to universal coverage. I see SGR as a totally separate issue. The lack of the SGR fix represents profound weakness of our political process. This issue tells us that both parties are more interested in posturing than solving problems."

It makes my blood boil when uninformed people cynically allege that ACP supported health care reform in exchange for SGR repeal. The thing is, there never was any such deal, nor should there have been. ACP favored health reform because every American should have access to affordable health insurance coverage, and because the legislation advances most of the organization's policies on coverage, workforce, and delivery system reform.

Yes, repeal of the SGR is and was a top priority, with or without health reform.

And yes, it is maddening that we can't get a majority of the House and 60 U.S. Senators to vote to fix the SGR, once and for all.

Members of Congress, Democratic and Republican alike, need to hear from doctors and patients that you are mad, and why.

Anger may help light a fire under Congress' feet, but it probably won't be enough to ensure 60 votes in the U.S. Senate for getting rid of the SGR.

Instead, it is going to fall to doctor's professional organizations, like ACP, to do the hard work of finding an approach that will actually pass. Sure, be angry - but direct your anger at those responsible for the SGR debacle, not at those of us who are trying to fix it.

Today's question: Are you angry about the SGR? If so, what are you saying to your members of Congress?