Thursday, May 26, 2011

Cynicism versus Engagement

“We can destroy ourselves by cynicism and disillusionment, just as effectively as by bombs."

This observation, from the late, great British historian Kenneth Clark, could be a warning sign to the medical profession. Some of the more incendiary commentary in blogs, editorials, and medical publications today display the classic characteristics of cynicism, which is a profound pessimism accompanied by a deep distrust and even the disparagement of the motivations of others. Physician cynics not only direct their anger at the usual suspects – members of Congress, insurance companies, and government “bureaucrats”—but even at their own colleagues, including the leadership of their own professional societies.

Now, to be clear, I am not talking about principled disagreement and debate over the best policies or course of action, which is good and healthy. It is only when such disagreement becomes “personal”—assuming the worst motivations of others, even when you don’t personally know them—that it becomes the type of self-destructive cynicism described by Clark.

Take the cynics’ charge that the leaders of physician professional associations, including ACP, are living in “Ivory Towers” disconnected from the “real world” of practice, and that they “sold out” the rest of the medical profession by their actions. Really? I know many of these leaders, and they are as grounded in the “real world” of practice as anyone, but with one crucial difference: they are taking time out of their busy lives to help make things better for their colleagues and their patients.

On Sunday and Monday of this week, two of ACP’s key policy committees met in Washington, D.C. Want to know who they are and what they do? The Medical Practice and Quality Committee, which recommends ACP policy on payment and delivery system reform, has 13 members, eight of whom are in private practice (two of them in solo practices!), one is a medical student, one is an internal medicine resident, one is a chair of a department of medicine, one is an assistant professor of medicine, and one is a medical director for a large group practice that has its own associated health insurance company. The Health and Public Policy Committee, which recommends ACP polices relating to workforce and health insurance coverage, has 13 members, four of whom are in private practice, one is the CEO of a medical college, three are professors of medicine, one is an assistant dean, one is a chair of a department of medicine, one is a medical student, one is a hospitalist, and one is an internal medicine resident. Also attending the meetings was the chair of the Board of Regents (private practice doctor) and the ACP president (a professor of medicine).

Then there are the almost 400 medical students, IM residents, and physician members from all types of internal medicine practice and parts of the country who took a minimum of two days out of their busy personal and professional lives to participate in ACP Services Leadership Day on Capitol Hill. If cynicism is the poison, then engagement in trying to make things better is the antidote. Unlike the cynics, these physicians have decided to address their shared frustrations with the state of medicine today by learning about the issues, politics, and policies—from administration officials, ACP staff, members of Congress from both political parties, congressional staff from key health committees, and from a well-known cable TV political analyst—and then to walk the halls of Congress to seek support for ACP’s top legislative priorities.

And this is why that I don’t think that Kenneth Clark’s warning predicts the future of the medical profession. Yes, cynics get a lot of attention, but there are many, many more physicians who are grounded in all of the glorious diversity of internal medicine practice today, who understand that the best way to achieve change is not to reflexively dismiss the ideas and the motives of others, but to engage in the political process through their professional associations for the betterment of the profession and the patients they serve.

Today’s question: Do you think Kenneth Clark’s quote predicts the future of the medical profession?

Wednesday, May 18, 2011

When did support for primary care become a partisan issue?

You’d think that ensuring that there will be enough primary care doctors would not become a partisan issue. If you are a Republican congressman from Texas, or a Democratic Senator from California, you’d want your constituents to have access to a primary care doctor, right?
Apparently not: in the hyper-polarized and ideological world in which we now live, even modest steps to support primary care have been caught up in the worst kind of partisanship. The Washington Post reported on Sunday that funding for a new expert commission authorized by the Affordable Care Act (ACA), which was to examine barriers to careers in primary care, has been blocked by Republicans:

“When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care. So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.

The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago. . . Having voted four months ago to repeal the entire Patient Protection and Affordable Care Act, as the law is called, the House GOP has proposed a budget that ‘makes the case ... no new taxpayer dollars will be directed to fund the law,’said Conor Sweeney, spokesman for House Budget Committee Chairman Paul Ryan (R-Wis.)”

No new taxpayer dollars will be directed to fund the law? Think about what this means. The ACA—or “Obamacare” as the GOP derisively calls it—includes hundreds of programs that in a rational world would have the support of Republicans and Democrats alike. In addition to the workforce commission, the ACA authorizes funding for primary care training programs, expansion of the National Health Service Corps, community health centers, patient-centered medical homes, primary care residency programs in non-hospital settings, and higher Medicare and Medicaid payments to primary care physicians. Republicans used to believe in these kinds of programs, for instance, in 2009, the Wall Street Journal reported that Senator Chuck Grassley, then the ranking Republican on the Senate Finance Committee, argued that “Plans to overhaul the U.S. health insurance system must make primary health care a more attractive career field.”

But now most Republicans apparently want to block funding for provisions in the ACA [to] make primary care a priority because of their single-minded opposition to all things related to “Obamacare.” The budget plan passed by the House of Representatives, which was crafted by Representative Ryan, would repeal the entire Affordable Care Act (except for cuts in Medicare payments to hospitals and Medicare Advantage plans, but that is another story), not just funding for primary care, but also, other programs that should appeal to fiscal conservatives because they have the potential to improve care and lower health care costs, like research on the comparative effectiveness of different treatments and support for prevention and wellness programs.

I don’t really believe that most Republicans are against funding for primary care, prevention, wellness, and clinical research. If each of these programs were voted upon based on their own merits, as they would be in a more rational world, most of them would have broad support from Republicans and Democrats alike. But because they are included in a broader health care reform law that Republicans have vowed to repeal, programs to increase the numbers of primary care physicians may not get funded, and the result will be longer wait times for appointments with primary care doctors, poorer health outcomes, and higher medical care costs.

Today’s question: How do you think GOP members of Congress can be persuaded to support funding for programs in the ACA to support primary care, even though they have pledged to repeal the entire law?

Wednesday, May 11, 2011

Doctors call for an end to Medicare fee-for-service

For many, many years, organized medicine has fought tooth and nail to preserve the Medicare fee-for-service (FFS) payment system. The battlegrounds have been over the procedure codes that define each service and the AMA’s ownership of the codes (CPT), the relative values assigned to each procedure code (and who and how those values are determined—including the role of the RUC), geographic adjustments in practice costs and wages, of course, the annual fight over payment cuts resulting from Medicare’s sustainable growth rate (SGR) formula.

So it is truly remarkable that last week, organized medicine essentially called for the end to Medicare FFS. Not right away, mind you, but over the next decade. In their respective statements for the record of a May 5 hearing by the House Energy and Commerce Committee, the American Medical Association (AMA), American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American College of Surgeons (ACS), and American Osteopathic Association (AOA) called for a staged process that would result in the current Medicare FFS system being replaced with new, value-based payment models.

Frances Correa with International Medical News Group reports that, “Although the groups’ approaches to an SGR fix vary, their plans share some similarities: a full repeal of the SGR and creation of a new payment model that break away from a “once size fits all” model. They also suggest a 4-5 year transition period in which physicians can participate in the new payment plan on a voluntary basis. Additionally, they call for a transition to value-based payment systems and increased emphasis on patient-centered medical homes. The ACS, the AAFP, and the ACP all specifically include the need for higher reimbursements for primary care in their plans.”

ACP, in its statement to the committee, proposed a comprehensive, step-by-step plan to transition from the SGR formula and fee-for-service payments to broad adoption of new models to align incentives with better value for patients:

“Stage 1: 2012-2016, Medicare would stabilize and improve payments under the current Medicare fee schedule by eliminating the sustainable growth rate (SGR) as a factor in establishing annual updates and by ensuring higher payments and protection from budget neutrality cuts for undervalued evaluation and management services. Also, during this stage, physicians who voluntarily participate in specific, designated Physician Payment Innovation Initiatives—including Patient-Centered Medical Homes, Accountable Care Organizations, and other models that meet ACP’s suggested criteria for value to patients—could qualify for appropriately higher payments.

Then, during stage 2, beginning in 2016, physicians would be given a set timetable to transition their practices to the models that Congress and the Department of Health & Human Services (HHS) has determined to be most effective based on experience with the payment initiatives evaluated during stage 1, leading to permanent replacements to the existing Medicare payment system.”

The fact that organized medicine is united on wanting to get rid of the SGR is nothing new. But it is big news that the leading physician professional membership societies now understand that it is not a winning strategy to ask Congress to pump hundreds of billions of taxpayer money into reversing the SGR cuts unless it leads to a “permanent, sustainable solution to the Medicare physician payment problem” that “reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary” as the House Energy and Commerce committee wrote in its March 28 request to the physician groups for their ideas.

Getting from the current flawed FFS system to models that pay for services according to the value will be daunting. For all of the problems with FFS, it is the system that most physicians and patients are used to, and as I blogged about a few weeks ago, given the history of other failed policy interventions, skepticism trending toward cynicism is a perfectly justifiable reaction from internists to the new alphabet soup of unproven payment models.

But the alternative is fighting to hold onto a FFS payment system that is broken, and like Humpty Dumpty, can’t be put back together again.

Today’s question: Do you support the call by organized medicine and Congress for a transition to new payment models that pay for services according to their value to the patient?

Tuesday, May 3, 2011


I remember Washington the way it was on the day that our nation was attacked. I remember listening to my car radio on the way to work, and hearing that a “small” plane had collided with the Twin Towers in my home city of New York. I remember gathering with my co-workers to watch the event unfold on TV. I remember going to the roof of our office building to watch the smoke rising from the Pentagon. I remember hearing that another hijacked plane was heading to Washington, maybe to the White House, only four blocks from our office, an intended missile that never came to us because we later learned that it was brought down by courageous passengers in rural Pennsylvania.

I remember hearing rumors of more attacks—bombings at the State Department, in Metro subway stations, rumors that were not true, but we didn’t know that then. I remember not knowing what to tell our employees to do—go home, stay in the office until we got further word? Nothing in my training had prepared me for my city being under possible attack. I remember the traffic gridlock as millions tried to flee. I remember the eerily empty streets of DC, many hours after the traffic finally cleared and people hid in their homes.

I remember the helicopters endlessly circling the city. I remember days later, when we were able to return to work, seeing the intersections of the nation’s capital patrolled by tanks and National Guards troops with automatic weapons, something I never expected to see in my life. And I remember a few days later, taking Amtrak to an ACP chapter meeting in Connecticut, looking out the window as we passed Manhattan, and seeing through my tears the smoking, gaping hole where the World Trade Center once stood.

And I remember trying to make sense of the senseless to my young children, age 12, 10 and 8, trying to reassure them that they were safe when in my heart I was never sure we’d ever feel safe again.

Now the man who introduced fear into my children’s lives is gone. I applaud our intelligence officers, our brave Navy Seals, and our presidents, Obama and Bush, who pursued Osama bin Laden with patience and relentlessness. I yearn for the sense of unity that our country had after 9/11, even as I know that we will soon be back to arguing about health care and the budget. Our national unity over the death of bin Laden already is being threatened by a growing debate over whether the intelligence that led to his capture was derived, in part, from “extraordinary interrogation” methods authorized by President Bush but defined as torture by many human rights advocates and repudiated by President Obama. ACP, for its part, is among those that have said that waterboarding and other forms of torture can never be justified.

I don’t know if we are safer today than 48 hours ago, but I feel safer with bin Laden gone. I don’t know if our country will ever be able to square its adherence to liberty and the rule of law with the temptation to use whatever methods are available to protect ourselves, even when they violate the same liberties and rule of law we are trying to protect.

Years from now, I will remember the day that I learned that justice was served with the death of Osama bin Laden. It doesn’t erase the memories of that terrible September when we were under attack, but maybe now the memories of September 11 no longer will rekindle in me the same degree of fear and uncertainty.

Today’s question: What are your reflections on what bin Laden’s passing means for America?