Wednesday, March 30, 2011

Can the “miracle of the free market” really work when it comes to drug prices?

The Washington Post’s front page yesterday reported on the furor over the “stunning” $1500 per dose price tag for a newly approved drug to prevent babies from being born prematurely. The drug, sold under the brand name, Makena, reportedly uses compounds that previously were available for $10 to $20 a shot. The article says that if all eligible women receive the drug, $4 billion would be added to the national health care bill.

The company that makes the drug argues that “the price is reasonable, given that it is spending more than $200 million to develop the drug and conduct follow-up studies that the Food and Drug Administration demands,” according to the Post. The company also promises to ensure that every woman who would benefit from the drug will be able to get it.

As of this morning, the website of the of the Pharmaceutical Research and Manufacturers Association had no comment on the Makena controversy, but a 2005 speech by then-PhRMA president Billy Tauzin makes the industry’s case that R and D costs are the reason why new drugs cost so much:

“Only 1 in every 5000 compounds gets all the way from the lab through FDA approval. For those that do, the average research cost comes to about a billion dollars. It takes about 14 years of research and clinical trials to bring a drug to market. At that point, the company only has six years at most left on the patent to try to recover their costs. Of those drugs that make it all the way to market, how many manage to recover their costs? Only three out of ten. As the math makes clear, it’s the handful of blockbuster drugs that foot the bill for all of our industry’s R&D – an investment that last year came to almost $39 billion. Let’s put that in context: That’s more than the operating budget of the National Institutes of Health… It’s 19 times as much as pharmaceutical companies were spending in 1980, when I first came to Congress. .. This kind of research is possible for one reason, and one reason only – because of the miracle of the free market system, and its ability to pull together the needed resources.” Now that really would be a miracle drug.”

The problem with PhRMA’s argument, though, is that it doesn’t seem to apply to Makena. “The main study used to demonstrate the drug’s effectiveness was a $5 million project conducted by the National Institutes of Health — paid by taxpayers” writes the Post, and the drug is based on compounding pharmacies, which were previously widely available at very low cost but were of questionable purity and consistency.

So what should a policy-maker do? Eat the cost and pay the $1500 per dose? But wait—unlike other parts of the health care sector (like physicians), drugs generally are not subject to government price controls. Deny eligible women access to the drug? Pass the cost on to everyone else?

I understand that price controls are a blunt instrument that can do more harm than good. A 2008 position paper I co-authored for ACP, published in the Annals of Internal Medicine, compared U.S. health care to other countries’ systems, including how different systems control costs. It concluded that “Cost savings can be achieved through the use of government power to negotiate prices . . . but may result in shortages of the services that are subject to price controls, delays in obtaining elective procedures, cost shifting, and creation of parallel private sector markets for health care services for those who can afford to buy services from sources not subject to price controls.”

Yet as the pricing of Makena demonstrates, not giving government the power to negotiate prices, may result in shortages, delays in obtaining care, cost-shifting, and different access for those who can afford to buy the drug and those who can’t.

Maybe Makena is an outlier, and PhRMA is right that the “miracle of the free market system, and its ability to pull together the needed resources” is the engine behind the development of beneficial new drugs. But you have to wonder, as appears to be the case with Makena, when there is no competition for the drug, when the number of people who will benefit is great, when the taxpayers footed most of the bill for the R and D that led to the drug’s development – and yet there is no ability for the government to condition coverage on negotiating a reasonable price.

Today’s questions: Should the federal government be able to regulate or negotiate prescription drug prices? And what does the Makena controversy say about the broader argument that “the miracle of the free market,” not more government regulation, is the answer to the country’s access and cost problem?

Friday, March 25, 2011

The Peter Pan reaction to controlling health care costs

The New York Times reports on Washington state’s efforts to “to determine which medical devices and procedures Washington will cover for state employees, Medicaid patients and injured workers, about 750,000 people in all.” An expert panel, appointed by the state, is getting national attention, writes the Times, “in part because its process is public and open. . . [and] provides a living laboratory of the complexities of applying evidence-based medicine, something that is becoming more common as a way to rein in health care costs.” The American College of Physicians, in its policy paper on Conserving Health Care Resources, similarly called for a transparent process to allocate resources based on evidence: ACP wrote:

“There should be a transparent and publicly acceptable process for making health resource allocation decisions with a focus on medical efficacy, clinical effectiveness, and need, with consideration of cost based on the best available medical evidence. The public, patients, physicians, insurers, payers, and other stakeholders should have opportunities to provide input to health resource allocation decision-making at the policy level.”

So, how is that working out in Washington? Well, according to the Times, although many of the expert panel’s recommendations have generated little controversy, the panel’s decision to limit coverage for spinal injections to control pain was compared to “waterboarding and other forms of torture” by a medical journal editorial writer.

I don’t know whether the panel got it right about spinal pain injections. But the Washington state efforts shows the obstacles that will face any effort to limit coverage of medical treatments, even when done in an open and transparent manner with broad publication:

- Personal stories of patients who claim to have been helped by a particular medical intervention will carry more impact than evidence from clinical trials. Clinical trials are dry, technical analyses that most of the public doesn’t understand. But a patient being denied treatment for something that they swear helps them will trigger an evidence-be-damned reaction from much of the public.

- Medical device manufacturers have a vested interest in preserving access to their products and will not go quietly into the night. They will seek to ally themselves with patient advocacy groups and physicians who specialize in particular treatments to blunt any effort to deny or limit coverage. And they often will prevail.

- The experts making the determinations will be attacked for not having the required expertise—meaning that unless they actually perform the procedures being evaluated, it will be said that they don’t understand it and therefore aren’t qualified to issue a ruling. The counter-argument is that physicians with expertise in review of medical evidence don’t have to be trained in a particular procedure to assess the strength of the evidence. And, packing panels with specialists that have a vested interest in maintaining access to a procedure that they perform creates an obvious potential for conflicts of interest. But I expect that much of the public will buy the argument that only those physicians who perform a procedure are qualified to rule on its effectiveness.

David Leonhardt, in a January New York Times Economix blog, compared the public’s views on rationing to Peter Pan’s wish to stay a child forever:

“Opposition to health-care rationing is a little like opposition to growing up. It sounds great. It’s just not very practical.”

It seems to me that Washington state deserves credit for trying to have an adult conversation about how best to allocate limited resources, but is facing a Peter Pan reaction by much of the public and medical profession to its decisions.

Today’s question: What do you think can be learned from Washington state’s experiment?

Friday, March 18, 2011

Irish (style) wit . . . and the 2011 IM match

Several readers of this blog answered yesterday’s call for limericks by penning some of their own. How about this one, from Dr. Daftary, on the attraction of concierge practices?

Poor Saint Paddy he must be a quaking,
At the direction Internal Medicine is taking,

Internists no more,

They head for the door,

For a course in concierge training.

Or this one, from Carol Dembe, on health care costs?

Spend less on healthcare, they all cry,
But. . . I want my MRI.

The healthcare share

Might be more fair

Like teamwork, with no "I."

Perusing the internet on my own, I found this one, which pretty much sums up how I feel about the partisan debate on health care:

Why does health care reform light a fuse
About what our citizens choose?

Can’t the Dems and the Reps

Agree to take steps

That will bring our great nation good news?

And here is a new one from me, on yesterday’s news that there has been an increase in medical students choosing internal medicine and family practice residencies:

More students have chosen primary care
Even though the pay isn’t fair.

But will this year’s match

Produce a big enough batch

To ensure that a doctor is there?

ACP said it was “cautiously optimistic” that “the increase in the number of U.S. medical students choosing internal medicine residencies in 2011 is a positive sign toward easing the primary care workforce shortage.” But ACP also pointed out that “the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career. In 1985, 3,884 U.S. medical school graduates chose internal medicine residency programs. And the 18.9 percent of U.S. seniors that matched internal medicine in 2011 is the same percentage as 2007.”

The American Academy of Family Physicians attributed the gains for family medicine, at least in part, to “primary care [becoming] much more visible as a result of the discussion about improving our health care system . . . [as] “more people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.”

Kevin Pho, the internist-author of the highly respected KevinMD blog, takes a more contrarian view, blogging that “There’s a dire shortage of primary care doctors today. The 2011 Match doesn’t lead me to believe that there will be a substantial change in that trend going forward.”

Dr. Bob Centor, author of DB’s Medical rants, “begs to differ” with Kevin’s pessimistic assessment, writing that “the increases are significant, but not earth shattering” and “will likely continue.” Bob predicts that “As the number of US grads increases each year, students understand that the number of slots in radiology, anesthesiology, neurosurgery, dermatology, orthopedics, etc. will not increase. The numbers will send more US grads into internal medicine and family medicine . . . but unless we have more residency slots, we will not produce more family physicians or internists. We will have less IMGs, but the totals will not change.”

Today’s questions: What do you think—is the 2011 increase in the match rate for primary care (internal medicine, family medicine and pediatrics) a “positive step” toward easing the primary care shortage or no substantial change in the trend going forward? And why do you think more of this year’s medical student crop chose theses specialties?

Thursday, March 17, 2011

John Boehner is an . . . .

As long-time readers of this blog know, I come from a decidedly Irish-American background. My beloved late father, Jack, was born in a thatched cottage in Drumshambo in Leitrim, Ireland, emigrating to the United States with his mother at the age of ten. His father had come over several years earlier to open up Doherty’s Bar in Woodside, Queens, New York, and when my grandfather passed away a few years after my Dad’s arrival, the bar became his. He ran and worked behind the bar until it was sold in 1978. When I was in college, my father put me behind the bar—the third generation of Doherty “behind the stick” as the old-timers would say.

Like any good Irish bar, Doherty’s celebrated Saint Patrick’s Day in high style. On March 17 it was filled to the brim with celebrants eager to sing a song, down a few, and engage in the traditional Irish sports of story-telling and blustery argument. It's probably because of this that I (usually) enjoy my work as a lobbyist and policy wonk in Washington, a town that more than any other lives on blarney and argument.

Two years ago, I started the practice of penning a few limericks--a five verse poem named after the famous Irish city—to honor Saint Patrick's Day. Here’s a few to celebrate this year’s occasion:

The GOP wants to cut spending
So funding for Sesame Street is ending

But if they dare

To cut Medicare

It could be their political upending.

John Boehner is an S-O-B

The son-of-a-bartender, just like me

We helped clean up the floors

Showed customers the doors

Can you blame us if we cry at the memory?

The Internists were in quite a stew

The public didn’t understand what they knew

And if you declare

They’re “just” primary care

They’ll tell you it’s much harder to do what they do

Now, try your hand---send me your St. Patrick’s Day limericks, and the best one’s (IMHO) will be published tomorrow!

Today’s question: No question, just a wish for a Happy Saint Patrick’s Day!

Wednesday, March 16, 2011

When will insurers really do something real to save primary care?

A few days ago I received an email from a general internist about my posts about concierge practices. I have known this physician for over 20 years, and he has great insight into the challenges facing health care. This email was no exception; he had this to say how his group took the “middle way” of pursuing private funding for the Patient-Centered Medical Home (PCMH):

“My practice includes 3 primary care physicians and has invested heavily in IT infrastructure. We have re-engineered our workflows and have achieved benchmark levels of quality and service. We have won NCQA certification for our PCMH. Yet so far no payer has stepped up to underwrite our investment. So we have joined Privia Health in forming a ‘membership practice.’ Patients are asked to pay a small monthly membership fee. In return they receive some special attention . . . Plan sponsors and payers are invited to pay the fee on behalf of their employees. . . Patients like having same day access. They like secure email communication with their doctor. They like having a personal health record. They like having a case manager helping them navigate the system. And they like going online in the evening to make their own appointments. ACP policy supports the medical home but is silent on the question of what a medical home is to do before local payment realities catch up. I owe my patients my efforts to assure that when I retire an eager young internist will welcome the opportunity to take over my practice. Absent public or private funding for the medical home that is just not going to happen.”

This good doctor is absolutely right—“absent public or private funding for the medical home [it] is just not going to happen.”

In my view, it is a damning indictment of the health insurance industry that even though this physician’s practice has re-engineered its workflows, invested heavily in information technology, achieved benchmark levels of quality and service, and won NCQA certification as a PCMH—everything that primary care practice are being asked to do by payers!--not a single one of them has stepped up to underwrite the investment. This, despite the fact that dozens of health insurers are listed as members of the Patient-Centered Primary Care Collaborative, a coalition of “major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home.” (ACP is a founding member of the Collaborative and sits on its governing board.)

Now, I anticipate that health insurers will cry foul about my blanket indictment of their lack of support for primary care practices. They will, with some legitimacy, point to the 27 multi-payer pilots in 18 states that are being supported, at least in part, by health insurers. I wonder, though, how many of those pilots are paying the practices anything close to what it really will take to restore primary care as a viable practice model and to reduce the inequities in primary care compensation compared to other specialists. Not many, I expect.

In a couple of weeks, the Patient-Centered Primary Care Collaborative will be hosting a “stakeholder’s meeting” billed as PCMH: A Foundation for Transformation and Reform. I imagine that many health insurers will be at the meeting to talk about all of the wonderful things they are doing for primary care. And some of them, no doubt, believe that they are making things better. But the fact remains that primary care is in crisis, and not enough health insurers--and for that matter, government and employers--have demonstrated that are willing to put their money where their mouth is.

Enough with the happy talk by well-meaning people at yet another conference about how they really care about primary care when the facts on the ground suggest otherwise. Instead, I have just one question for them: when will they really do something real to save primary care?

Today’s questions: Do you think the insurance industry is really committed to saving primary care? And yes, I’d love to hear from the insurance companies). And if not, what can be done to get them to step up and put their money where their mouths are?

Wednesday, March 9, 2011

You say you want a revolution … Part 2

I knew that wading into the issue of retainer practices—and getting into a friendly debate with my friend Bob Centor (although I don’t think we really disagree on that much, as discussed later in this blog), would get a spirited reaction from some readers.

Yesterday’s posting, though, really didn’t say much of anything about the merits of retainer practices. My point was that whatever any of us may personally believe about retainer practices, the evidence so far is that they are a small—but slowly growing—niche found mostly on the East and West coasts and certain metropolitan areas. And whatever we believe about primary care physicians turning away from Medicare, the evidence (so far, at least) is that Medicare participating rates are at an all time high, and only a very small percentage of Medicare patients report “big problems” in finding a physician or getting a timely appointment. Our individual beliefs and personal experience matter, but good policy requires that our belief be tested and validated by evidence and data to the extent possible.

As I wrote yesterday, “I don’t question [Bob Centor’s] overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives.” No one wants a good internist to go out of business, and if “their choices are retainer practice, cash only practice, hospital medicine or retirement” they shouldn’t be criticized for choosing the retainer option.

It is one thing, though, to say that retainer practices are a reasonable and sometimes necessary reaction by individual practices and patients in response to economic pressures, and another to offer them up as solution to problems facing primary care.

According to a studies done by the University of Chicago and the Government Accountability Office (GAO), “retainer physicians tend to have smaller patient loads and fewer appointments daily, compared to their non‐retainer counterparts. The retainer physicians who responded to the GAO survey reported having, on average, 491 patients. The average number of patients physicians had the year before they started their retainer‐based practice was 2,716.”

Let’s do the math. If more primary care practice go the retainer route, they will have to offload as many as 2000 patients, made up mostly of patients who can’t afford to pay an average of $1500 in annual retainer fees. They will have to find care somewhere else, but busy non-retainer practices won’t have the capacity to pick up them, leading to even longer waits for appointments and more trips to the emergency room. And for each primary care physician seeing fewer patients, the country would have to train even more primary care physicians to keep up with demand, or train non-physicians to take care of them.

We could end up with a two-tiered primary care system, one for those who can pay more to participate in a retainer practice, and one for people who can’t afford the retainer fee and will have to queue up for care from underfunded clinics led by non-physicians.

A more promising solution is to reimburse practices for providing team-based, patient-centered care led by a personal internist or other primary care physician.

This is the idea behind the Patient-Centered Medical Home. Under the PCMH model, patients would have access to same-day appointments when needed, just like in retainer practices. Internists would be able to spend more time with the patients who can benefit from internal medicine specialist care, because health professionals in the practice who have less training could see the less complex patients, and some of the follow up would be handled by electronic communications rather than a face-to-face visit. Instead of the practice asking patients to pony up a retainer fee, Medicare and private insurers would pay the practice a monthly, risk-adjusted payment per patient for the time spent managing and coordinating care and to help cover the investments in information systems and team-based support staff. Physicians in the practice also could share in savings from preventing unnecessary hospital admissions and achieving quality benchmarks.

Six years ago, I wrote in ACP’s monthly magazine (then called the ACP Observer, now called the ACP Internist) that:

“The medical home would, in other words, offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities. Like the medical home concept, retainer practices appeal to growing numbers of patients and physicians because they offer patients the promise of timely access to a personal physician. But boutique practices typically require patients to pay a larger retainer fee not covered by insurance, making such practices more suitable to wealthier patients. The medical home model would be financed by insurance coverage so it would not be limited to patients with higher incomes. And unlike boutique practices, medical homes would be publicly accountable for the quality and efficiency of care they provide.”

The medical home has come a long way since then, and unlike retainer practices, we now have a lot of evidence to support the effectiveness of the PCMH model. But the concept remains the same. Patient Centered Medical Homes can offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities.

Today’s questions: What do you think of the premise that Patient-Centered Medical Homes offer the best elements of retainer practices, without the accompanying inequities?

Tuesday, March 8, 2011

You say you want a revolution. . .

Dr. Bob Centor blogs that primary care physicians are staging a “quiet rebellion” by forming concierge practices and opting out of Medicare:

“The system has constrained primary care fees while systematically increasing overhead. The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement. The system has undervalued the value of a good primary care physician. The system has, without consciously meaning to, held primary care in contempt.

So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit.

So decreasing numbers of primary care physicians are taking Medicare or Medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.

The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.”

I have the greatest respect and affection for Dr. Centor. He writes the always interesting (and entertaining!) DB's Medical Rants blog and has been a mentor to me on the fine art of blogging, As a member of the ACP Health and Public Policy Committee (which I help staff), Bob is unafraid to challenge conventional thinking, often expressing healthy skepticism about the latest policy fad of the day.

But now, I am the one who is skeptical. Bob’s premise that “decreasing numbers of primary care physicians are taking Medicare . . . “and that “so many primary care physicians . . . are retreating to retainer practices” just didn’t read true to me.

So I went looking for the evidence, and found that retainer [otherwise known as concierge] practices are growing—but they constitute a very, very small niche of perhaps several hundred physician practices, concentrated mostly on the East and West coasts. I also found, counter-intuitively, given the ongoing specter of Medicare payment cuts--that the percentage of general internal medicine physicians who participate in Medicare reached an all-time high in 2010.

• Six years ago, the GAO did a study that found that "Concierge care is practiced by a small number of physicians located mainly on the East and West Coasts. Nearly all of the 112 concierge physicians responding to GAO's survey reported practicing primary care.

• An updated 2010 report on retainer-based practices, conducted by the University of Chicago for the Medicare Payment Advisory Commission "found listings for 756 retainer-based physicians, which could be seen as a lower limit for the number of physicians practicing this model of care. This is an increase from the 146 retainer physicians identified by the U.S. Government Accountability Office (GAO) for a 2005 report...the vast majority of retainer physicians are primary care physicians. Of the 333 physicians for whom we were able to collect specialty information, more than three quarters were internists, and a fifth specialized in family medicine." The study also found that the presence and distribution of concierge practices is very uneven by geographic area, with most concierge practice being on the East and West coasts and many states have few if any retainer practices.

• According to official CMS data files, in 2010, over 97% of internal medicine physicians signed an agreement to participate in Medicare (and accept the Medicare rates), a record number, and the percentage of internists participating in Medicare has increased each and every year since 2000 (when it was a little over 90%).

• ACP’s 2009 membership survey found that that only 0.5% of respondents said that they would switch to concierge/boutique medicine when asked to describe their expected professional situation in the next one to three years.

I don’t question Bob’s overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives. But at least so far, it doesn’t appear that internists are dropping out of Medicare, or that very large numbers see retainer practices as the solution.

I believe it will take a revolution in the way that primary care is educated, financed, organized, reimbursed, and delivered to elevate it to status and influence it should have in our health care system, and to make the beleaguered internist feel better about their futures. But when it comes to retainer practices being the solution, I have to answer like John Lennon did when he wrote the lyrics to the Beatle’s cynical “Revolution” in response to the revolutionary fervor of the 1960s:

“You say you got a real solution,
Well you know,
We’d all love to see the plan.”

Can retainer practices, which depend on primary care physicians seeing fewer patients and charging them out-of-pocket for improved access and time with the doctor, be the real solution to the crisis in primary care? Well, you know, I love to see the plan. Retainer practices may work for some physicians, and some patients, in some markets, but I don’t see the plan for them to be a real solution, and so far, it seems like most primary care physicians don’t either.

Today’s questions: What do you think of Dr. Centor’s premise that primary care physicians are staging a quiet rebellion manifested by more joining retainer practices or dropping Medicare? And do you see retainer practices as a real solution?

Friday, March 4, 2011

A confused and contradictory lot, continued ...

Several of the frequent commentators to this blog took issue with my characterization of Americans being a confused and contradictory lot when it comes to their views of the federal budget.

But the fact is—and yes, I am talking about fact, not opinion— that most Americans have no clue about how the federal government spends their taxes and the trade-offs involved in balancing the budget. Yesterday’s Washington Post fact-checker blog goes as far as to give the American people four "pinnochios" (the site’s worst possible rating for accuracy) "for not knowing the basic facts about how the U.S. government spends taxpayers' money." I know, some of you are going to say that the Washington Post can’t itself be trusted because it is part of the Washington establishment. I ask, though, that you first read the fact-checker post, in its entirety, because the bloggers support their assessment by citing extensive evidence from surveys and studies. Most Americans, for instance, think that the federal government spends more than one out of four dollars collected on foreign aid, but the real number is less than three percent.

The fact-checker blog does more than decry Americans state of blissful ignorance about the budget; it also offers a nice interactive webpage to help people understand where their money is really going now compared to 1981. You can click on any programmatic area of spending and get a nice graphical illustration of how much spending has increased.

And guess what? The biggest increases, by far, have been spending on Medicare (more than 400% increase) and all health care spending combined (more than 500% increase). Nothing else comes close.

The answer to the federal budget deficit, then, ultimately will come down to getting a handle on health care costs. Whacking away at discretionary programs that largely benefit the poor, as the House of Representative’s Continuing Resolution would do, will not get us there. Nor will circling the wagons to protect Medicare from cuts, as liberal Democrats are prone to do, get us there. We have to spend less on health care, period, end of story. And this can only be done if physicians take a leadership role in explaining to their patients and the public the consequences if we allow unrestrained spending on health care to continue. Physicians must also be willing to take responsibility to reduce unnecessary, inefficient, duplicative or marginal care.

ACP’s is trying to do its part. ACP has released a major new paper on why and how the United States must make decisions about conserving and allocating limited health care resources, rationally and effectively. It is also asking its members to participate in the High Value, Cost Conscious Care initiative, which will help identify the benefits, harms and cost of different tests and procedures.

If you care about the deficit—as we all should—then help ACP start a national conversation about controlling health care costs. And help us disabuse the public that deficit reduction can happen by cutting foreign aid or funding for education or assistance to the poor, while leaving Medicare and other health programs untouched and without asking anyone to pay more with higher taxes.

Today’s question: What is your reaction to the evidence presented in the Washington Post’s fact-check blog about Americans “not knowing the basic facts” about the budget and the trade-offs involved, the fact that health care spending trumps all other parts of the budget in terms of increased spending over the past thirty years, and ACP’s efforts to address the cost problem with the public and with its members?

Tuesday, March 1, 2011

What does Obama’s speech to the governors, professional ethics in Wisconsin, and consumer health education have in common?

They are examples of how the American College of Physicians has taken leadership roles in influencing health policy to the betterment of patients and their physicians.

Within the last 48 hours, ACP has:

- Reminded physicians that professional ethics does not allow for them to sign off on false “sick notes” to excuse patients to engage in political advocacy or other purposes. ACP referenced reports from Wisconsin that physicians have been signing off on false sick notes to excuse public employees so that they could participate in the demonstrations, and emphasized that there is “universal ethics principle” at stake. “Honesty is a core professional obligation and lying, even for a patient, is a breach of that obligation," J. Fred Ralston Jr., MD, FACP, president of the American College of Physicians (ACP) reminded all physicians, including the organization's 130,000 internal medicine physician and medical student members. (ACP has not taken any position on the Wisconsin dispute over collective bargaining by public employees.) In the same spirit, I also encourage you to read DB’s Medical Rants posting on the same.

- Applauded President Obama for supporting a bipartisan bill, the Empowering States to Innovate Act, to give states more flexibility, earlier than now allowed by the Affordable Care Act, to design their own programs to cover their residents. The bill, introduced by Senators Scott Brown (R-MA), Ron Wyden (D-OR), and Mary Landrieu (D- LA), would advance by three years a provision in the ACA to exempt states from many of the ACA’s mandates if they can come up with their own programs to provide comparable levels of coverage to as many people without adding to the deficit. ACP’s statement noted that President Obama was embracing an idea advocated by ACP in its January 27 State of the Nation’s Health Care report. I first blogged about the Empowering Patients to Innovate bill back in November of 2010, when I referenced Ezra Klein’s blog post that argued that the proposal could point the way forward to bipartisan agreement on health reform by allowing states to “compete and succeed” rather than “repeal and replace.” It is good to see President Obama get on board with the idea, but will any Republicans (other than Senator Brown) take him up on it???

- Joined with a coalition of respected health organizations to announce the launch of a new website,, to educate consumers about the Affordable Care Act and how it could affect them. The website explains that “the Health Care and You Coalition is made up of some of our country’s leading organizations that represent consumers, patients, physicians, nurses, hospitals and pharmacists. Our goal is to provide the public with easy-to-understand information about the health care law. is a place where individuals, families, small business owners and health care professionals can turn for help in understanding the law and how it impacts them.” In addition to ACP, the coalition partners are the American Medical Association, American Nurses Association, American Academy of Family Physicians, Catholic Health Association, National Community Pharmacists Association, the Cancer Action Network-American Cancer Society, and AARP. The latest Kaiser Family Foundation tracking poll shows how much confusion there continues to be about the law and why truthful and understandable information from trusted sources—the goal of the Health Care and You coalition—is critically important. The poll showed that one out of five Americans believe incorrectly that the Affordable Care Act and has been repealed and another 26% aren’t sure.

Advocacy for universal ethics principles that places honesty above all else, including lying on behalf of patient. Preserving the Affordable Care Act--while seeking bipartisan support to make it better-by giving states more options, sooner. Educating and informing consumers about the law. These activities, individually and together, help deliver on ACP’s mission to “to advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members.”

Today’s question: What do you think about ACP’s activities on the ethics of false sick notes, support for a bipartisan bill to give states more coverage options, and the new consumer website?