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?