Thursday, June 30, 2011
An ACP member in Rhode Island recently gave this example:
“I was just asked by my Medicare Advantage plan to sign a form for [a well-known pharmacy benefit manager]. This form is to be faxed to them in order for them to send me a prior authorization form for a med. So in other words, I had to complete a form in order to get another form. This is nuts!”
Or how about this, from another ACP member in a private internal medicine practice:
“The documentation that is getting to me, is that documentation that the ‘durable medical equipment people want including repetitive- recurrent documentation, whenever we see a patient to document "continued need". The list of things we have to document, sign, approve or prior authorize, I believe is what makes most physicians think they chose the wrong field. A PBM letter to me about my prescribing practices today nearly did me in! Luckily I just shredded it. If I am kicked out of this business, I am so close to retirement it would be a blessing!”
“In 2011 we now have to complete the ‘Home Health Face to Face Encounter form, a one and a 1/2 pager that is required for every patient starting home health care, in addition to the plan of care forms. IMHO, this is getting ridiculous. Any one of these is really no big deal, but the collective volume of these forms is stifling and is taking away from time with my patients and my family. If I happen to have a med student with me, they can't help but notice the significance of the volume of paperwork in my ‘paperless office, that delays me entering the exam room.”
Wouldn’t it be great if there was a law to require insurance companies to reduce paperwork requirements on physicians and patients?
There is. A law recently passed by Congress requires the following:
--By January 1, 2012, the federal government must seek input as to whether the process by which physicians and other providers enroll to participate in a health plan can be made standard and electronic, including whether a uniform application form is viable.
--By October 1, 2012, the federal government must establish a system that provides a unique identification number for each health plan. Ensuring that each health plan has only a single identification number should improve the ability of physician practices to manage their administration interactions with health plans.
--By January 1, 2013, insurance companies will be require to abide by a standard set of rules to facilitate electronic transactions, including use of machine readable identification cards, to enable physician practices to verify patient health insurance coverage eligibility and obtain the status of claims submitted to bill for services. Physicians will be able to determine the insurance product that covers the patient, whether a specific service is covered, any patient financial responsibility, prior to or at the time of the patient encounter; whether the insurer received the claim submitted and the status of an accepted claim in the processing cycle, and be able to access information on how a determination is made whether to pay a claim and how to appeal adverse determinations.
--By January 1, 2014, insurers will be required to comply with standards on electronic funds transfers (EFTs) and claims remittance/payment. They must allow for automated reconciliation of the electronic payment the physician receives and the corresponding remittance advice that the health plan provides.
--By January 1, 2016, the federal government will implement a standard set of rules for the administrative transactions: health claims; referral; certification; and authorization. Standardization related to these transactions is intended to decrease the burden on physicians and patient that comes with required use of different forms for different payers. Also, insurers will have to comply with a standard and associated set of operating rules that pertain to health claim attachments.
The best part is all insurers will be required to comply—and will be fined if they don’t.
Do you know what this new law is called? The Affordable Care Act (ACA)--yes, the same health reform law derided by some as putting more “bureaucracy” into the doctor-patient relationship. (To learn more about the ACA’s administrative simplification requirements, go to ACP's Practical Guide to Health System Reform, and under the table of contents organized by topic and year, click on the heading Simplifying Administrative Requirements the Health Care System Imposes on Physicians.)
The ACA may not entirely solve the paperwork problem, and it undoubtedly will create some of its own paperwork, some of which will have to be challenged. But it will put in motion the most comprehensive and systematic federal effort ever to streamline, standardize, automate, and reduce paperwork associated with health insurance transactions.
That is, to reduce the kind of paperwork that causes internists to pull out their hair and scream “This is Nuts!”
Today’s questions: What do you think about the federal government requiring insurance companies to streamline, standardize, automate, and reduce paperwork associated with health insurance transactions? And were you aware that the ACA requires this?
Update: CMS today issued an interim proposed rule to make it easier for physicians to check patient eligibility and status of claims.
Monday, June 27, 2011
You know, in 2008, physicians weren’t facing huge Medicare cuts. Medical liability awards were capped across the country. Everyone had health insurance. Government regulation was non-existent. Physicians could order any test they wanted without second-guessing by insurance companies. Young medical students were beating down the doors to become primary care physicians, and patients had no problem getting same day appointments with their internist.
You don’t remember it this way? Of course not, because it wasn’t so. But given some of the over-heated rhetoric from some physicians who are critical of the Affordable Care Act, you’d think that everything that is bad about medicine today is a consequence of “ObamaCare”--even though most of the law hasn’t even taken effect!
In 2008, before Obama got elected, before the Affordable Care Act became law, physicians faced double-digit Medicare SGR cuts and skyrocketing med mal premiums. In 2008, 46 million people didn’t have health insurance and there was a projected shortage of over 40,000 primary care physicians. In 2008, the U.S. scored poorly compared to other countries in two measures of access to doctors, having to wait more than 6 weeks to get an appointment and getting same day appointments. In 2008, more than nine out of ten primary care doctors reported an increase in time spent on non-clinical paperwork over the prior three years.
How then can anyone fairly pin these things on the ACA, which wasn’t enacted until March 2010, and won’t become fully effective until 2014?
A fairer yardstick would be whether the ACA makes these things better, worse or makes no difference
By this yardstick, the ACA didn’t solve the medical liability problem nor eliminate the SGR cuts, but neither did previous administrations and Congresses.
By this yardstick, the ACA will invest billions of dollars in dozens of programs to increase the numbers of primary care physicians and improve payments for their services, even though it doesn’t solve a workforce shortage that pre-dates it.
By this yardstick, 34 million people who today are uninsured at least will have health insurance, and with it, improved access and better outcomes, although wait times for appointments initially may go up as a result.
By this yardstick, the ACA didn’t end paperwork the paperwork burden on clinicians, but it will require insurance companies to streamline and simplify authorizations, transactions, and eligibility verification and to spend more money on patient care and less on administration, even as some of its other programs may add to red tape.
Perspective is important. The U.S. health care system had big problems before the ACA and, it will have some big problems after it. The ACA makes some big things much better (getting people covered), makes a stab at improving other things (training more primary care doctors, reducing insurance red tape), may make some things worse (longer appointment waits because more people will be covered), has some things that need to be changed (like getting rid of regulations that could add more red tape), and doesn’t fix some things that need fixing (SGR and medical liability reform). But this doesn’t fit in with the critics’ narrative that everything that is wrong with American health care is the ACA’s fault, including all the things that physicians and patients didn’t like before it.
Unless, of course, you buy into the fantasy that 2008 was the golden age for American medicine, until the ACA came along to destroy it.
Today’s question: Do you think it is fair to pin on the ACA the problems that existed before it?
Friday, June 24, 2011
I just came back from five days in Chicago, observing the American Medical Association's (AMA's) House of Delegates meeting. This year's meeting was one of the most fascinating and consequential that I’ve observed during thirty-some years of going to the AMA.
Fascinating, because the AMA had to come to grips with a deep split among its membership on continued support for the key tenets of the health reform law. Consequential, because the decisions by the AMA at this meeting would determine if it would remain a voice for continued implementation of the Affordable Care Act’s reforms to ensure that all Americans would have access to affordable health insurance, or join the camp of those seeking repeal.
The specific issue at stake was whether the AMA would rescind its long-standing support for the requirement that all Americans purchase health insurance, coupled with tax credit subsidies to help people buy coverage. Last November, a dissident ---and highly organized--- conservative faction of the AMA House of Delegates tried to get the organization to withdraw support for the mandate. Instead, the issue was referred back to the AMA's Council on Medical Service (CMS) for further study. The Council submitted a report for consideration at this week's meeting, recommending reaffirmation of AMA policy to support of the individual insurance requirement.
The dissident factions, led by the Kansas Medical Society and supported by about a half dozen state and specialty societies, countered the CMS report by introducing a resolution to replace support for the mandate with tax credits and other incentives to purchase health insurance.
The American College of Physicians (ACP) led the fight in favor of the individual insurance requirement, introducing its own resolution of support for the mandate. ACP's resolution was co-sponsored by 19 national and state medical societies, including several of the largest specialty societies in the United States.
The battle lines were drawn, and it was unclear which side would have the votes to prevail. Testimony on the competing resolutions and the CMS report was intense, highly polarized but generally respectful of the other side's motives and intentions. The dissidents argued that the individual mandate was an "unconstitutional" threat to liberty; proponents pointed out that the courts, not the AMA, will decide the legal issues, and that the AMA should speak to the health impact on patients if more of them end up uninsured.
The dissidents argued that there are less coercive ways to get everyone covered; proponents cited evidence that 16 million more people would go without coverage without the individual insurance requirements.
The dissidents argued that lack of health insurance does not guarantee access to care; ACP and other proponents countered that although health insurance by itself does not ensure access, there is compelling evidence that lack of health insurance results in people living sicker and dying younger. (See my post from last week on the consequences for patients if the individual insurance requirement is found to be unconstitutional).
Who won? Well' after several days of intense debate' the AMA decisively voted, by a 66% to 33% margin, to re-affirm support for the individual insurance requirement, preserving it as a key element of the AMA's overall plan to ensure universal access to affordable coverage. The margin of support among the delegates for staying the course was far greater than most of us anticipated going into the meeting. And, while the AMA will continue to seek changes in the ACA that are opposed to its policies, it will not join the camp of those who want to repeal it, lock, stock and barrel.
I wouldn’t necessarily argue that this vote shows a permanent shift to the left within the AMA, since many of the delegates who voted for the mandate based their vote on pragmatic considerations that an individual insurance requirement is the only way to ensure coverage for nearly all Americans while preserving private health insurance, not on their own personal political ideology. The AMA's elected leadership showed conviction and courage, and many of the delegates rallied around their leaders.
Yet this week's vote shows that although there remains a determined and very vocal minority of delegates at the AMA who hold a strong, anti-government ideology, they are now in the distinct minority, and physicians who believe that the federal government must guarantee access to affordable health insurance are in ascendancy. Following the AMA vote, some of the dissidents argue that conservatives should leave the AMA in droves, but a continued conservative exodus from the AMA will only further diminish their influence within the AMA House of Delegates.
But the real winners are the tens of millions of uninsured Americans who know that the nation's largest physician membership organization (yes, AMA is still the largest) remains on their side in fighting to ensure that everyone has access to affordable health insurance coverage.
Today’s questions: What is your reaction to the AMA's decision to stay the course on health coverage for all? And ACP's leadership at the AMA in helping to bring this about?
Tuesday, June 14, 2011
I, like most people, have my own opinion on the legality of the law (I support it), but I am the first to admit that the issues are complex, far more so than the simplistic political arguments made by proponents and opponents alike. It isn’t as simple as saying that if the courts uphold the individual insurance requirement, the government can compel people to do anything it wants, like eat broccoli. Health care is unique, since the decisions I make on buying insurance or not has an impact on everyone else needing health care. But it is also it is not as simple as arguing that Congress can simply mandate any type of individual behavior it determines is needed to achieve a desired policy objective. The U.S. constitution puts boundaries around the government’s authority, and the question in this case is whether or not the ACA exceeded those boundaries.
Also, a federal court can’t overturn a law just because it disagrees with the policies included in it. The federal government’s “most powerful argument”, Jost suggests, may have been that “While the courts have the authority to determine whether a statute is constitutional or not, they cannot strike down a statute simply because they disagree with it as a matter of policy. Courts that exceed their constitutional authority by rejecting legislation because they dislike a policy decision Congress has made are just as great a threat to our democracy as a Congress that adopts legislation that does not fall within its constitutional authority. Indeed, they are a greater threat, because the people can vote Congress out if they dislike the policies it crafts, but judges are appointed for life . . .”
While I am not qualified to predict with any confidence what the courts will decide, I can say with a great deal of confidence what the impact on our health care system will be if the courts find that the individual insurance requirement is unconstitutional:
- It will lead to millions more Americans going without health insurance. According to the Congressional Budget Office (CBO), “Eliminating the individual mandate to obtain coverage . . . would increase the number of uninsured by about 16 million people, resulting in an estimated 39 million uninsured in 2019 . . . That increase in the number of people who are uninsured relative to current law [the Affordable Care Act] would be the net result of about 4-5 million fewer individuals with employer sponsored coverage, about 5 million fewer people with coverage obtained in the individual market (including individual policies purchased in the exchange or directly from insurers in the non-group market), and about 6-7 million fewer individuals with Medicaid or CHIP coverage.” With more uninsured persons, more Americans will suffer unnecessarily and many will die prematurely, according to the Institute of Medicine.
- It will make the ACA’s popular prohibition against insurers excluding or charging more to people with pre-existing conditions completely unworkable. If insurers can’t turn down people or charge them more (except for tobacco use and age, within certain limits), then some people will choose go without health insurance until they get sick. When they do apply to get insurance (subsidized by the taxpayers in many cases!), they will drive up costs to everyone else who had bought insurance all along, and as premiums go up, more people will drop their coverage, leading to even higher premiums for everyone else. The likely result would be a death cycle that leads to the collapse of private insurance markets.
- If private insurance markets collapse, the government would be the only recourse for ensuring that everyone has access to affordable coverage. Mark Pauly, a noted conservative health economist at the University of Pennsylvania who favors free-market solutions, recently noted in Ezra Klein’s Washington Post blog that the “CBO says that you leave about 40 percent of the uninsured population without coverage” [with the subsidies and without the mandate] so “If we want to close that gap, then either we have to have a mandate or make insurance free for everyone and run by the government.”
Next week, the American Medical Association (AMA) will be debating whether to withdraw its support for an individual insurance requirement. The AMA’s Council of Medical Service will recommend that the AMA continue to support the requirement, while a resolution from the Kansas Medical Association calls on the AMA to call for its repeal. ACP has introduced a resolution, supported by 19 other national, state and medical specialty societies, which calls on the AMA to continue to advocate for the individual insurance requirement, while also directing the AMA to explore alternatives should the courts find that it is unconstitutional. ACP’s position isn’t based on ideological or constitutional arguments, but on the evidence that without an individual insurance requirement, millions more people will be uninsured and will experience poorer health outcomes and even premature death as a result.
Today’s questions: Do you think it is possible to cover everyone without an individual insurance requirement, other than the government covering everyone in a public plan? If so, how?
Thursday, June 9, 2011
So argues Dr. Rita Redberg, a cardiologist and professor of medicine at the University of California, in a provocative op-ed published in the New York Times. She writes that Medicare “spends a fortune each year on procedures that have no proven benefit and should not be covered” and offers the following examples:
“Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure.”
“The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.”
“Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.”
“Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death . . . Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.”
“A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.”
If Dr. Redberg is correct that these interventions offer no benefit, why then does Medicare continue to pay for them? She offers several explanations: the contractors who process Medicare claims have no incentive to clamp down on unnecessary procedures, denying payment after a procedure is performed “invites the wrath of both patient and physician” and “our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test.” (I would throw in defensive medicine as another factor.)
But for Medicare to pay only for care that is necessary and effective, as Dr. Redberg favors, more research will have to be done on the effectiveness of different treatments, and Congress would have to allow Medicare to use such evidence in making coverage determinations.
As a first step. the Affordable Care Act creates a new public-private institute to fund research on comparative effectiveness, but prohibits such research for being used to deny coverage based on cost or to “ration” care. Even so, some conservative lawmakers want to cut off government funding for the institute because they “do not believe that the government can rationally measure effective and ineffective treatments and steer funding away from the latter to the former.”
It is hard to see how the country can make progress to reduce Medicare costs when even a small first step get the evidence on what works and what doesn’t is under political attack, and when denying coverage “invites the wrath of both patient and physician.”
In the meantime, Medicare will continue to “squander” taxpayers’ money by obligating them to pay a fortune each year on procedures that have no proven benefit. If this isn’t the kind of government waste that should make the fiscal conservatives’ blood boil, I don’t know what is.
Today’s question: Do you think Medicare should continue to pay for care not supported by the evidence? If not, who should make such determinations?
Wednesday, June 8, 2011
“An act relating to the privacy of consumers of alcoholic beverages; providing that a licensed medical care practitioner or health care facility may not record information regarding ownership or consumption of alcoholic beverages in a patient's medical record;
providing an exception for relevance of the information to the patient's medical care or safety or the safety of others;
providing that unless the information is relevant to the patient's medical care or safety or the safety of others, inquiries regarding alcoholic beverage consumption or possession should not be made by licensed health care practitioners or health care facilities;
providing an exception for emergency medical technicians and paramedics;
providing that a patient may decline to provide information regarding consumption of alcoholic beverages;
clarifying that a physician's authority to choose his or her patients is not altered by the act;
prohibiting discrimination by licensed health care practitioners or facilities based solely upon a patient's consumption of alcoholic beverages;
prohibiting harassment of a patient regarding consumption of alcoholic beverages by a licensed health care practitioner or facility during an examination;
prohibiting denial of insurance coverage, increased premiums, or any other form of discrimination by insurance companies issuing policies on the basis of an insured’s or applicant's ownership, possession, or consumption of alcoholic beverages . . . violation of the provisions of [this act] are grounds for disciplinary action.”
*Not really: of course there is no “docs and cocktails” law in Florida. No one in their right mind would prohibit doctors from asking their patients about consumption of alcoholic beverages, right? Not even the well-financed distillery trade association.
But the legislative language above is verbatim from Florida’s infamous “Docs and Glocks” law, except I replaced all references to firearms ownership and possession with consumption of alcoholic beverages, to make the point that Florida’s ban on doctors asking patients about gun ownership is no less absurd.
Most people would recoil at the idea that the government would tell doctors that they can’t ask their patients about consuming alcoholic or entering information about their drinking habits in the medical record, yet when it comes to firearms, the Florida legislature overwhelming approved such a ban. If such a ban stands up in court, is it really out-of-the-question that manufacturers and sellers of whiskey, or red meat, or even marijuana, might want to do the same?
Yes, I know that the possession of firearms is a constitutional right, but having firearms in the home is also a known contributor to accidental shootings. Physicians have every right and responsibility to ask about firearm ownership and to counsel their patients about preventing accidental shootings, just like they have every right to ask their patients about how many drinks they have. Yet unless the courts intervene, physicians in Florida could be disciplined if they ask their patients about guns. And as Florida goes, you can be sure that much of the rest of the country will follow.
ACP’s Florida chapter is among four physician groups that have joined in a lawsuit to overturn Florida’s law as an unacceptable and overly vague infringement on first amendment rights. Hooray for them! But where is the outcry from physicians and patient advocates around the country about government telling doctors what they can say to their patients? Why are so many silent on this absurd and unacceptable government intrusion into the doctor-patient relationship? Why are not more of them up-in-arms (pun intended) about this blatant violation of the first amendment right to free speech?
Today’s question: Why do you think more physicians are not speaking out against Florida’s efforts to ban free speech?
Thursday, June 2, 2011
The Innovation Center’s website says all of the right things:
“The Innovation Center has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that deliver better health care at lower cost.
Our Mission: better care and better health at reduced costs through improvement. The Center will accomplish these goals by being a constructive and trustworthy partner in identifying, testing, and spreading new models of care and payment. We seek to provide
- Better health care: by improving all aspects of patient care, including Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity (the domains of quality in patient care as defined by the Institute of Medicine).
- Better health: by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventive care.
- Reduced costs: by promoting preventative medicine, better record keeping, and improved coordination of health care services, as well as by reducing waste, inefficiency, and miscommunication. These efforts will reduce the national cost of health care and lower out-of-pocket expenses for all Medicare, Medicaid or CHIP beneficiaries.”
This mission statement echoes CMS’ Administrator Don Berwick’s view, quoted in the Health Affairs blog that health care transformation “won’t yield to a massive top-down national project.” Instead, Berwick argues that, “Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right.”
And it is encouraging that the Innovation Center has also recruited a top-notch – but small – staff that includes doctors who are grounded in the real challenges of private practice medicine and experienced in community-based innovation, including two masters of the American College of Physicians, Dr. Rich Baron and Dr. Nancy Nielsen.
Yet, skeptics wonder whether the Innovation Center can deliver on Dr. Berwick’s recognition that “in the end each local community, and only each local community, actually has the knowledge and skills to define what is locally right.” Such skepticism has increased with the publication of the Medicare’s proposed rule on Accountable Care Organizations (which came out of the Innovation Center). For instance, Vince Kuraitis in the Health Care Blog writes that “CMS loses points for micromanagement and a controlling mindset” even as he expressed “kudos to CMS for a surprisingly aggressive and well reasoned ACO Rule.”
Even if the Innovation Center wants do the right thing by supporting bottom-up innovation, I wonder if others in the administration will get in its way. The White House’s Office of Management and Budget, and Medicare’s own independent actuary, seem to be fixated on only allowing money to be spent only on projects that can be guaranteed to produce measurable savings. By law, they will have to sign off on any disbursement of funds from the Innovation Center. Such insistence on unrealistic guarantees of savings may be why the bar for participation was set (many would say unrealistically) high in the ACO proposed rule.
And even if the Innovation Center is able to find the right balance between supporting community-based innovation and ensuring that taxpayers’ dollars are spent prudently, will Congress take away it’s funding? Some key House Republicans have promised to go after the Innovation Center’s dedicated funding, labeling it a “10 billion slush fund.”
Yet it is important that those of us on the outside do everything we can to help ensure that the Innovation Center lives up to its billing. The one thing that liberals and conservatives should be able to agree on is that without substantial reforms to reduce per capita health care spending, the country will not be able to improve its fiscal health. The Innovation Center offers perhaps the best chance for Medicare to support community-based innovation to improve outcomes and lower costs, and if it fails, the likely alternative will be more top-down price and capacity controls and explicit rationing of care.
Today’s question: What do you think Congress and the Medicare program can do to promote innovation in delivery system reforms at the community level, and what shouldn’t they do?