Friday, January 28, 2011

State of the Union, Part 2

Is it possible to find bipartisan common ground on improving the Affordable Care Act?

And can the United States have a serious conversion on how to conserve and allocate limited health care resources?

Conventional wisdom says no. Instead of working together to improve the ACA, both parties seem to be locked into a no-win battle over repeal. Discussion of conserving resources and controlling costs seems always to lead to unproductive charges and counter-charges about rationing.

But yesterday, in its annual State of the Nation’s Health Care report, the American College of Physicians challenged conventional wisdom.

ACP argued that common ground is possible on sustaining and improving the Affordable Care Act, including incorporating improvements usually associated with Republicans. ACP also expressed its belief that the country must confront the necessity of making hard decisions on conserving and allocating limited health care resources, but in a way that is in accord with distinctly American values.

I had the honor of joining ACP President Fred Ralston, MD, FACP, to present ACP’s recommendations at a press conference in Washington, D.C.

We made the case that the United States is facing an unprecedented health care crisis: more uninsured than ever before, the erosion of private employer-based coverage, more people on under-funded public safety net programs, a growing shortage of physicians in critical specialties including primary care, and rising costs that will bankrupt the country. We presented ACP’s firm belief that the Affordable Care Act has policies that are essential to addressing these challenges, and should not be repealed.

But we also argued that the law could be improved by giving states more options, earlier, to design their own systems to cover as many people and/or to enter into agreements to sell insurance across state lines; to replace the Medicare SGR formula with one that provides higher updates to all physicians and improved payment for primary care; and to reform the broken medical liability system—an issue traditionally associated with the GOP that President Obama said on Tuesday he is open to addressing. In addition to advocating for caps on non-economic damages, ACP urged Congress to fund a national pilot of health courts, a “no fault” model where claims would be heard by a judge with special training and access to independent medical advice.

We also released a major new ACP position paper, How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently, which argues that the United States, like all countries, must address the fact of rising health care costs that threaten the economic health of the nation.

ACP believes that decisions on conserving and allocating resources, at the patient-physician level and societal level, should be informed by evidence of clinical effectiveness with consideration of cost. The paper makes a distinction between explicit medical rationing (as exists in many other countries) and making rational allocations decisions informed by evidence:

"We recognize that discussion of the most effective and appropriate ways to make such decisions, to the benefit of individual patients and the broader population, are undermined when the debate becomes polarized over whether or how care in the United States should be “rationed”—a term that is poorly understood, emotionally driven, and not conducive to reaching consensus. Achieving a national consensus on how best to use health care resources effectively, efficiently, and rationally should instead seek to distinguish between medical rationing, in which decision-makers determine which scarce medical resources are provided and who receives them, and rational medical decision-making, by which judicious choices are made among clinically effective alternatives. We emphasize that choosing among clinically effective alternatives based on medical evidence to provide clinically appropriate and effective care that maximizes value is not the same as rationing, which results in denial of care."

I am a realist, and I don’t expect that ACP’s recommendations will magically overcome the partisan divide on repeal of the ACA. Nor do I expect that everyone suddenly will join hands, sing kumbaya, and reach agreement on how to allocate limited health care resources, fairly and judiciously.

At some point, though, I hope it will become apparent to all sides that the ACA won’t be repealed, but that it can be improved. ACP’s recommendations can contribute to finding such bipartisan common ground.

And I hope that responsible people across the ideological spectrum will soon realize that the best way to avoid explicit medical rationing, as exists in many other countries, is to confront the issue now on what the United States can afford. But such decisions must be done through an open, transparent, and participatory process that empowers people to make decisions based on evidence, instead of imposing limits on them.

Today’s questions: What is your reaction to ACP’s efforts to urge the political parties to seek common ground on improving the ACA? And to our proposal to start a conversation on conserving and allocating resources based on evidence?


doc777 said...

When a building is unstable because it was built on a weak foundation, one does not try to fix the building. Instead, the building is tore down and rebuilt on a strong foundation. Those of us wanting the ACA repealed and replaced with reforms that will actually address the disaster facing our health care system believe the same thing. The ACA cannot be fixed! It is a huge new entitlement program, which despite efforts to convince us otherwise, will add 100s of billions of dollars to our country’s debt at a time when we can barely pay the interest on that debt.

Adding 16 million people to the Medicaid program, the most dysfunctional health care program in the country, is not the solution. Many physicians I know would rather see charity cases than see Medicaid patients. Our hospital systems and their associated physicians do everything in their power to limit their Medicaid exposure and the FQHCs (who by the way get cost-based reimbursement) don’t have near the capacity. Patients at our free clinics dread going on Medicaid. In addition, our states are broke. Many need to trim a billion dollars or more from their Medicaid programs in order to keep from going bankrupt. As for the other 16 million people, setting up a huge new bureaucracy and administrative structure (much of which is unfunded) to give people money to purchase health insurance in heavily regulated state insurance exchanges sounds like another brilliant idea, NOT!

Bob quoted the recent AP poll on repealing the ACA but he conveniently forgot to mention the flawed methodology used in the sampling. Maybe he could mention the Rasmussen poll from yesterday which found that 58% of likely voters favor repeal of the ACA (47% strongly favor repeal). I guess that might be asking too much.

Fortunately today we are now one step closer to the demise of the ACA thanks to Judge Vinson’s ruling in favor of the 26 states that challenged the law. Not only did he conclude that the individual mandate was unconstitutional, but that it is not severable, requiring that the entire act must be declared void. Further, he did not issue a stay of his ruling which could threaten the application of many of the provisions of the law.

Contrary to the views of the current ACP leadership, there are reforms that could be implemented that would significantly reduce costs while improving quality. Our state currently has some of the highest quality, lowest cost health care in the country. Even within our state we have areas where costs are 25% lower than the rest of the state. True free-market forces exist in those communities and the systems are well integrated and aligned in a way that reduces waste and focuses more on outcomes instead of productivity. Having said that, those systems still have much they could do to further improve efficiency and quality. It does not take much of an imagination to see the enormous potential to dramatically reduce health care costs in this country if the right conditions are put into place to make it happen.

ryanjo said...

I agree with doc777's comments. Unfortunately, the ACP leadership continues to hold onto the vanishing hope that the ACA can be saved or renegotiated. This won't happen, no matter how much the polls or media tries to tip the issue.

I have not spoken to a single patient who believes the ACA offers anything to them, or even cares. They don't want to lose their doctor. They want the SGR issue to go away. They don't want to be hearing from my office that their healthcare depends on clerks issuing preauths and denials.

ACP members like me (who don't own rose-colored glasses) fear that ACP leadership's unrealistic commitment to the ACA is failing to advance the cause of real healthcare reform. As ACA flounders and dies, where will we be? Why isn't ACP reaching down to its physician grassroots, finding out what is working (and not), as doc777 reports from his area? The lost opportunity isn't the dreadful healthcare legislation that we have now, it is the lack of intelligent thought on how to replace it.

Harrison said...

If you owned an insurance company is there any premium you would charge to cover a 90 year old? An 85 year old? A 50 year old with diabetes and s/p CABG?

If we give that patient with significant medical problems a voucher and the freedom to use it on the market, will that patient be able to find insurance coverage?
At all?

Medicare and Medicaid cover those people because nobody else will.
At all.
For no amount of money.

My rose colored glasses allow me to see those people and I hope we can figure out a system that includes them.


Steve Lucas said...

The following link may be of interest:

The results of this survey are not encouraging when discussing acceptance of the new health care reform law.

Steve Lucas

Arvind said...

I couldn't agree with doc777 and ryanjo any more. The ACP has lost its position of being able to suggest changes to the ACA because of its bias towards preserving it (after strongly supporting its enactment). Bob, don't be so sure that the ACA will not be repealed.

The ACP could have made amends by actually consulting its practicing membership before coming out with this ill-advised paper. Of course, I would not expect it, knowing how the ACP leadership has behaved in the recent years. With each of these pronouncements, the ACP risks marginalizing itself even further amongst practicing Internists and sub-specialists.

ryanjo said...

I dispute that only Medicare will offer insurance to patients over age 65. Certainly this was the case when the Medicare program was enacted, but now 1 out of 5 Medicare beneficiaries are in Medicare Advantage plans, managed by private insurers, and proving enormously profitable to those insurers.

What is needed is a fresh look at providing healthcare coverage for those patients (something that ACA does NOT do). A first step would be to examine the obscene profits of insurance companies and ask why they continue to cherry-pick covered lives. Enabling fairness and opportunity is the function of government, not providing insurance products and the bureaucracy to (mis)manage them.