Monday, December 13, 2010

Your comments, my responses

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

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

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

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

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 But if the ACA was repealed, the continued decline of employer-sponsored health insurance would result in millions more Americans ending up on Medicaid anyway, but without an influx of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

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

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

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

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

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

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

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


Arvind said...

Its good to read a response once in a while. However, I would like to respond to the response.

I am still waiting for one single action from the ACP that actually helps its sub-specialty members. I would like the members of ACP’s Council of Subspecialty Societies who wrote ACP’s “medical home neighbor” position paper to please explain how this paper actually helps us.

Second, it is completely false that the raise to PCP's did not come at the expense of the sub-specialists. How do you explain the loss of income after a unilateral decision by CMS to deny payment for "Consultation codes" since Jan 2010? This is an automatic 15-25% cut in payments. Did anybody miss the massive cuts to other procedures such as cardiac catheterization, stress tests, etc. totaling up to 25%? While you are trying to defend CMS, you might try telling the whole truth, Bob.

Finally, "not loosing" should not be confused with "defense". Any leader will tell you that you never approach a game or contest or war with the idea of not loosing. This is a sure way to ensure that you are not going to win! And it is pretty clear to me that with the ACA, not only did we as physicians, not win, but we actually lost (everything that was of critical importance - SGR repeal, tort reform & most importantly the physician-patient relationship and the concept of private practice, as acknowledged by the administration's mouthpieces in the Annals).

So, while you rattle off your statistics, it pays to look at the big picture and see the potential devastating impact of this Law. It would be a refreshing change to see you acknowledge some of the major problems that could result from the ACP's position of supporting the ACA.

Jay Larson MD said...

The problem is Arvind that you signed up with a losing team…an intellectual subspecialty. Even before you were in medical school the system was stacking up against the cognitive specialties. In the past 2 decades, the number of procedures, medications, and treatments have exploded at a substantial cost to the system. To keep costs from sky rocketing, something had to be squeezed and that is us. When Medicare added coverage for new procedures, coverage for medications, and started giving money to insurance companies to run Medicare part C, the choice for CMS was to increase the budget substantially or not give more value to E and M visits. We know how that turned out.

If you want to be angry at anything, be angry that the healthcare system does not value what you do. Be angry that the system does not reward you for spending extra time to review pump downloads, making sense of blood glucose logs smeared with blood from finger sticks, or understanding pituitary hormone levels.

As far as the ACA, it is just like every thing else we deal with on a daily basis. There are benefits and there are adverse effects. It all depends on what you want or need from the health care system.

Arvind said...

Actually Jay, I agree. But I am not mad at Congress for bring the ACA to our doorstep, but at those organizations like the ACP, that are supposed to represent us. When I entered Fellowship, my chairman made me take the oath of poverty. But in reality, that should be the case in a true free market. As one of my patients asked yesterday "there aren't too many docs that do what you do, especially the way you do it. So, shouldn't you be in greater demand and have a bigger clout with the insurance companies, doc?" My answer was "yeah, that would be true if there was a free market in medicine."

I wonder how Bob would answer that question, since he truly seems to believe that the ACP is actually helping to better the prospects of its sub-specialty members....

Jay Larson MD said...

Your chairman was a wise person if they made you take an oath of poverty.

For the free market to really help the cognitive based physicians, E and M codes have to be removed from the RBRVU system and insurance companies can't dictate to those physicians what they have to take for services provided and they have to abolish the "preferred providers" lists so that patients really can choose the provider they want to see.

If patients could choose the physicians they want to see and physicians could practice medicine the way it should, healthcare costs would plummet and quality would increase.

That would give the power back to the patient and the doctor and no CEO would want that.

BDoherty said...

I have to respond to following comment from Arvind:

“Second, it is completely false that the raise to PCP's did not come at the expense of the sub-specialists. How do you explain the loss of income after a unilateral decision by CMS to deny payment for "Consultation codes" since Jan 2010? This is an automatic 15-25% cut in payments. Did anybody miss the massive cuts to other procedures such as cardiac catheterization, stress tests, etc. totaling up to 25%? While you are trying to defend CMS, you might try telling the whole truth, Bob.”

As I said in the blog post itself, the 10% raise in Medicare payments to primary care physicians for their office visits and other designated services did not—repeat did not—come at the expense of subspecialists. It is paid for by the taxpayer, at a cost of several billions of dollars. Congress specifically chose not to fund the primary care increase by taking money from other physicians, even though it would have been less expensive to fund it in this way rather than from the taxpayers. ACP supported Congress’ decision to fund the increase without taking money from other physicians. The same is true of the increase in Medicaid payments for primary care that will go into effect in 2013 and 2014. This provision, which will cost over $5 billion, is paid for entirely by taxpayers, not from other physicians.

Arvind is mixing up two regulatory decisions made by CMS that did adversely affect some subspecialties but had nothing to do with the provisions of the Affordable Care Act and the raises for primary care that are mandated by the ACA. CMS decided to eliminate separate payment for consultation codes and redistributing the relative values for those codes to all other evaluation and management services, and a separate regulatory decision to update the survey data used to calculate the relative values for imaging services. These changes were made by CMS through its usual rulemaking processes independent of any changes made by the Affordable Care Act. (CMS’ regulatory changes pre-dated the enactment and implementation of the ACA, and the change in relative values for imaging has its origins in a decision by the Bush administration to obtain updated survey data on practice expenses associated with imaging.)

I can understand why Arvind is unhappy with CMS’s regulatory changes, but the health reform legislation (ACA) is not the culprit, and my blog posting that the primary care increases from the ACA were not at the expense of other physicians is 100% accurate and I stand behind it. ACP is working with its Council on Subspecialty Societies on a solution to the consult code issue that would also address CMS’ concern that the consult codes often were billed inaccurately, which was the agency’s rationale for eliminating separate payment for them and redistributing the payment to other evaluation and management codes regardless of the specialty that bills them (not limited to primary care).