Tuesday, August 31, 2010

Whatever happened to the Patients' Bill of Rights?

One of the more surprising twists and turns in the continuing debate over health care reform is that many physicians who now object to the Affordable Care Ac t (ACA), were, just a few years back, advocates for more federal regulation. In fact, in the early 2000s, more than 200 "provider" and consumer groups - including many state medical and national medical specialty societies that now oppose the ACA because of concerns about "excessive regulation" - were among the fiercest champions of federal legislation to mandate that health insurers comply with a Patients’ Bill of Rights. A bipartisan bill introduced by Senator John McCain (R-AZ) and the late Senator Ted Kennedy (D-MA) would have ensured that patients have the "right" to appeal insurance company denials to independent reviewers, to choose a specialist of their choice, and to access emergency room services when needed. This effort to enact a federal Patent Bill of Rights failed, because of opposition from the insurance industry and President George W. Bush.

I bring up this history lesson because most of the key provisions in the McCain-Kennedy bill are now the law of the land, thanks to the Affordable Care Act. Yet instead of applauding the new protections, many of the same physician organizations who called for a federal Patients' Bill of Rights now want to "repeal" the same consumer protections established by the ACA.

I understand that times, circumstances, and opinions change. It is not unreasonable, for instance, for physicians who advocated for the Patient Bill of Rights to now object to a almost one trillion dollar price price-tag associated with the coverage provisions in the ACA.

But the history of the Patient Bill of Rights is illustrative in one very important sense. It shows that physicians (like most of the rest of) have not held consistent views on the question of whether we need more or less federal regulation of health care. When the issue was in opposition to insurance company "gatekeepers" that limited access to specialists, most physicians were quite willing to have the federal government prohibit such practices.

Similarly, a staple of mainstream conservative thought is that the federal government should not pre-empt state "rights"- but not always. For instance, when it comes to medical liability reform, most conservatives (including right-leaning doctors) favor enactment of a federal law to impose limits on non-economic damages on states that do not have such caps.

I also don't know of many physicians who would repeal Medicare, or the Food and Drug Administration, or the National Institutes of Health.

My point is that Americans - including most physicians - accept the idea that the federal government has a responsibility to regulate health care, and even the most conservative doctors have championed MORE federal regulation (e.g. in the case of the Patient Bill of Rights and tort reform) when it has been in their interest. The debate, then, should be over how much federal regulation is needed, instead of oversimplifying the issue as one of being "for" or "against" federal regulation.

Today's questions: How much federal regulation of health care is needed?


james gaulte said...

This commentary makes me wonder if conservatives and libertarian leaning physicians are welcome in the ACP.What is served by a spokesman for ACP attacking conservatives? The logic of claiming that it is inconsistent to lobby for tort reform and oppose ACA escapes me.

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

Another quantity over quality question. Is the regulation effective, efficient, fair, and cost-effective? The Bill of Rights embraces principles that are put at risk by many of the current constructs in health care. Did we address these key drivers? I do not think information technology, consolidation in bigger institutions, and administrative growth were value added. Fixing the following remain on the agenda:

1) Divest insurance companies and health care providers from publically-traded, investor-owned status.

2) Reform the Hatch-Waxman Act, so that the cost of new drugs (and address technologies) does not swallow the service side of health care.

3) Regulate hospital infrastructure carefully.

The drug/CME/conflict of interest issues would all be reduced if independent practices were allowed to focus on patient care without the expanding third-party interference that is increasingly more obstructive. Patients are being punished as bystanders in the brand-generic warfare.

ryanjo said...

Every time I read this column, I feel like the tone is to thrash mainstream practicing physicians. What is the point of this commentary...that physicians have to be either for government regulation of medicine or against it?

Doctors may well be in favor of a Patient Bill of Rights, but against the onerous and costly PPACA, which is flavored with small sprinkles of common sense like patients' rights and pre-existing conditions relief, but lacking any meaningful reforms.

Some of my patients, hopeful that the ACA provides some opportunity to acquire health insurance at reasonable cost, are thwarted by the absurd fine print. Can I get a policy despite my diabetes -- only if no insurance in effect for 6 months. Can my child age 25 be covered by my plan -- only at the time the plan is renewed. Can I get health insurance competitively from a regional clearing house -- maybe in California, and not even there yet. Dozens of other states are suing the feds rather than comply.

It sounds like the ACP leadership is still savoring these tiny morsels to allay the painful memory of putting on their white coats to stand behind Mr. Obama for the photo op, while many of us members watched incredulously. So you believed that supporting ACA would result in payment reform, paperwork reduction and relief from our government's harassment of medicine? How sad.

Write a column about how you were so taken in by the grandiosity of the whole idea, that you forgot to read the details. That the promise to address physician concerns is as dead and distant a memory as Senator Kennedy. And even if you can't come to terms with that, tell us ACP will take the lead for physician organizations to actively oppose any implementation of ACA until and unless it meets ALL of the principles of fairness and fiscal responsibility that the ACP has stated as its goals.

"I bring up this history lesson" because those who who choose to forget the past are condemned to repeat it.

Arvind said...

I agree with James Gaulte. Why is our supposed "Advocate" attacking us? A wise ex-chief once told me "Don't bite the hand that feeds you, its going to come back and hurt you". I keep that in mind every day and humbly suggest that you. Bob, try and remember that as well.

As far as your question is concerned, the best Bill of Rights that a patient has is his/her freedom to select the type of doctor he/she feels is the best value for him/her. The current government's actions have slowly but surely eroded this unique freedom.

Last week, a 74-year-old male patient of mine asked me "why can't my wife see you?" When I explained that as of Jan 2010, Medicare does not recognize consultation with a Specialist, so we do not accept any new Medicare patients. Contrary to what one would expect, he did not get upset. Instead, he said "I completely understand your position, doc. Unfortunately the government is taking away the choices we seniors have, one by one. I must thank you for all you have done to teach me how to be a smart diabetic, over the years. My family doctor is great, and he tried for many years, but I would not have been here today without your help. So I will go to Rep. Alyson Schwartz's office right now, and ask her why the government is taking away our rights?"

These are the real-life Bill of Rights, Bob. And the ACA will only exacerbate this process. All other things are of little comfort. So keep blaming Bush for all the problems; just don't do it as our representative.

junebug388 said...

who are you masked man, Bob Doherty??

BDoherty said...

The point of this blog post is not to “attack” conservatives, but simply to point out that the current polarized debate - in which people are asked to decide whether they are for or against “big government” or “government-run health care” - doesn’t do justice to the substantive issues facing the country. There are times when doctors, including normally conservative state medical society and specialty societies, have championed a bigger federal role (as is the case with the Patient Bill of Rights and Medical Liability reform). There are times when liberals, who usually favor more government at the federal level, oppose it (like when they oppose federal caps on non-economic damages). I also don’t believe consistency is always a virtue - an issue-by-issue basis, there are times that argue for a stronger government role, and there are times when the government should get out of the way. There are times when the states should run things, and there are times that the federal government can do a better job. The over-heated rhetoric from both sides, today though, suggest that it is a much more black-and-white choice of being for or against government intervention in health care, when the reality is that we all pick and choose, many liberals and conservatives alike, when we want the government to regulate someone else, and when we don’t. We should at least recognize the inconsistencies and nuances involved.

Harrison said...

I think Mr. Doherty and the ACP have done a good job of understanding the details of the PPACA, and outlining them.
This link represents some of their work towards that end:


All around the country, when I pay attention to the political news, it seems that the flavor of the day is the notion of conservatives feeling that they are being attacked.
And then they don't seem to be able to meaningfully get past that point.

I don't think Mr. Doherty is attacking conservatives.


junebug388 said...

I am not interested in the argument at all. Difference does not have to create distance. You create this division by your inflammatory editorials about your own personal agenda.
I am interested in taking care of patients. I am not interested in being rich , powerful or even being in control. Physicians are quietly doing the work of patients across this country and they are worn out, broke, and have no stability in payment system to have a business plan that can last longer than 2 months.
We have seen MORE government and they have not kept their promises while I kept mine..... now many conservatives and liberals alike would like to see less government. I personally was cautiously optimistic, anticipating single payer system... silly me. If the medicare catastrophe is an example, thanks but no thanks. Imagine the last 8 months with 0% income instead of 50% income.
Who are you advocating for, Mr. Doherty? When I log onto ACP I am looking for advice, support or education, not criticism.
When was the last time YOU cared for people for free who have been laid off, couldn't work anymore or had no family who wanted to help them.
I am weary of our "advocate" treating physicians as money hungry control freaks. We already have plenty of folks outside our own society that do that.
Linda Ray, M.D.

BDoherty said...

Dr. Ray,
If I have given you the impression that I think doctors are “money hungry control freaks” I apologize, since nothing could be further from the truth. I have the greatest respect for what you and your colleagues do for patients and for society. I don’t know you, but I assume that you take care of your patients with extraordinary skill, commitment, and professionalism, even when the system seems to be stacked against you and your patients. There is a reason that I have devoted almost my entire working life—more than 31 years—to advocating for internal medicine: I believe in what you do, the values you represent, and the policies adopted your professional society, my employer. Sure, I collect a paycheck from ACP, but my own values wouldn’t allow me to work for a profession, cause or interest I didn’t respect and believe in with all of my heart and soul. I have often told people that I work for the greatest group of people, internists, and the greatest organization, ACP.

I view this blog as a forum to discuss ideas, commentary and studies that I think are relevant to health care delivery and, particularly, to internal medicine. This includes airing ideas that may be very controversial , provocative, and apparently, sometimes offensive to some readers. I don’t like reading blogs that only tell me what I want to hear, and I believe that most readers of this blog would feel the same. It might be less risky for me, and for ACP (which gives me free rein to write this blog) to stick with safe and non-controversial topics, but I don’t think that will contribute to an informed discussion of the issues.

So when I write that surveyed patients believe that physicians are too close to the drug industry, or that influential critics like Dr. Atul Gawande believe that a culture of medicine has taken hold in some communities that puts revenue ahead of patient care, or that studies show that a substantial amount of care provided in the United States is unnecessary, or that payment and delivery systems aren’t serving the interests of physicians or patients, well, I am sharing perspectives that I think deserve our attention, because they are influential in policy circles, propose ideas that challenge the conventional way we think about things, or offer data and evidence that may cause us to reconsider our own pre-conceptions. I always end the blog by asking for you, and other readers, to comment on what you read, and disagree if you don’t like what you’ve read—and if you read the comments, readers don’t hold back.

I also try to explain why ACP has taken the positions it has, even on the most controversial issues like the health reform law, because I believe readers have a right to know. I use the blog to correct information that I know to be untrue, because I believe that political debate should be about policies, principles and evidence, not falsehoods offered by advocates from either side of an issue.

Perhaps at times my posts haven’t been written as diplomatically as they might have been, but as you know, my style is to direct and intended to elicit a (spirited) response.

Most of my blog posts have been about the challenges facing internists by a system that devalues your services, second-guesses your judgment, hassles you and your patients, undermines the doctor-patient relationship, and puts you at constant risk of being sued without cause. It are these things that I, am ACP, are fighting to change, even when you and others may not agree with our policy prescriptions.

Bob Doherty

ryanjo said...

Mr. Doherty, many of us are waiting to see something of value come of the effort ACP made for health care reform. But instead we read an article authored by political insiders, in our own organization's Annals, that physicians should play along with ACA or perish. Did the Annals give editorial space for another opinion? Sadly, no.

I have read many of your recent blog posts. A newly appointed government bureaucrat lecturing medical students about respect for patient autonomy, shortly after showering praise on a national health system that, according to its customers, has no regard for patients or doctors. A medical student who criticizes doctors for calling attention to oppressive paperwork, failed payment and tort reform, as if these problems have nothing to do with patient care. A contrived explanation on how ACA is going to save Medicare, the gist of which is refuted in ACP's QD: News of the Day issue of the same date.

I read the many negative comments on your blog and the response to the Annals article. They represent a broad spectrum of ACP members who have valid points of view, and disagree with the positions that ACP is taking on health reform.

The reason that the system is stacked against me and my patients is that the organization that I belong to, after functioning as an enabler for the ACA, has now decided that the debate is over, the job is done. We don't need any more celebrating about how grand the ACA is. We need to hear that and how ACP is "advocating" for us.

Jay Larson MD said...

The comments on this blog have highlighted the ongoing concern and sensitivity about the role of government in health care. What I would like to know is what the role of corporate America is in the health care system.

The question asked of bloggers is akin to asking a patient how much pain they are experiencing using a scale of 1-10. This issue cannot be distilled to a simple black or white belief.

The ACA is like using a new chemotherapy regiment for a terminal cancer. No one knows the ultimate effect, we just hope it helps. Our current health care system has many providers that do the right thing for patients despite the current adverse environment, very much like T-helper cells. Our current health care system also has a significant malignant component driven by profit and nothing else.

The future of the US healthcare system with or without ACA is bleak no matter what the political belief system.