Friday, December 21, 2012

The Fiscal Cliff is Coming to Town

If you had to describe the current state of affairs in Washington, which of the following famous quotes would you use?

Ronald Reagan: “There they [he] goes again”

Yogi Berra: “Déjà vu all Over Again” or

Mark Twain:  “Suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself.” 

How about all of the above?   Congress once again is going home for the holidays, without agreeing on a bill to prevent massive cuts in Medicare payments to physicians.  We went through this last year—but this time is different, and worse.  The physician payment cut is steeper—nearly 30%.   The impasse is not only on Medicare payments, but hundreds of billions of dollars of across the board “sequestration” cuts in federal programs and tax cuts that are set to expire on the first of the year.

The latest non-development was when Speaker Boehner found last night he didn’t have enough votes in his own GOP caucus to pass his “Plan B” (renewing tax cuts for people who earn less than a million dollars—nothing about stopping the Medicare SGR cut), greatly weakening his leverage in any renewed negotiations with President Obama, should they occur.  The Senate will recess today.  This will leave Congress with only 6 days at most—yes, SIX days—to reach an agreement with President Obama after it returns to Washington on December 26. 

Sure, a Christmas miracle could happen, but I wouldn’t bet on it.  Right now, it looks more likely that the impasse will not be resolved until after that automatic cuts and tax increases go into effect on January 1.  Yes, that means physicians should plan for the likelihood that the Medicare physician payment cut will happen, and may not be reversed for several weeks. ACP members can keep up the latest news about how the cut will affect them and what they can do to prepare at ACP’s Running Your Practice resource page.  And please keep the up the pressure on your own members of Congress.

Eventually, there will be a deal.   Once the physician payment cut happens, and Medicare patients can’t find doctors, and taxes go up on just about everyone, and agencies have to start laying off the federal employees who keep our food and drugs safe, and the Pentagon’s ability to defend our country is weakened, a deal will be reached.  But a lot of folks will be hurt in the meantime.

ACP is doing everything it can to get Congress and the President to reach an agreement to stop the cuts and enact a fiscally responsible alternative, offering them this week our own three-step plan to eliminate the SGR by the end of next year.  Last week, incoming Board of Regents chair, Chuck Cutler, MD, FACP, traveled to Capitol Hill to lobby Congress with his counterparts at the AMA, American Academy of Family Physicians, American College of Surgeons, and American Osteopathic Association. 

I know the situation isn’t funny. But this is the time of year that is supposed to be joyous, and I have a tradition of having my last post before Christmas being a humorous (I hope) adaption of a Christmas Classic to reflect the latest in Washington. So here’s my latest, sang to the tune of Santa Claus is Coming to Town:

The Fiscal Cliff Is Comin' To Town"

You better watch out
You’ll want to cry
You’ll want to pout
I'm telling you why
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

Congress is making a list,
Checking it twice;
Gonna cut programs, it ain’t gonna be nice.
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

It will cut your pay while you're sleeping
It will raise your taxes when awake
It will cut programs, both bad and  good
Even Medicare, for goodness sake!
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

You better watch out
You’ll want to cry
You’ll want to pout
I'm telling you why
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

The Fiscal Cliff is coming
The Fiscal Cliff is coming to town

(Coming to town)
Congress is a busy place, they have no time to play
But they’re putting coal in your stocking this Christmas day
(The Fiscal Cliff is coming to town)
(Coming to town)
(The Fiscal Cliff is coming to town)
(Coming to town)!

Today’s question: No question today, just my best wishes to you and your loved ones for a peaceful holiday, notwithstanding the mess Washington has created.

Monday, December 17, 2012

Is the medical profession doing enough about gun violence?

Are any of us?  This is the question that we all must ask ourselves, in the wake of the incalculably sad massacre of little school children in Newtown, Connecticut.

I have struggled for days now to find the right words—how can I, or anyone else for that matter, find the words to describe the indescribable shared grief we have about the indescribable horror of that day and its aftermath?  But I have to say something, we have to say something.  Something about what this says about our country, and its repeated inability to rise to the occasion to address the causes and consequences of gun violence.  Silent reflection in the face of tragedy is a necessity for most of us. But silence in the public policy arena means acquiescence to the cynical and powerless view that there is nothing that can be done to prevent the next Sandy Hook, or Virginia Tech, or Aurora, or Columbine.

Yesterday, President Obama found a way to speak truth to the people of Newtown, and to the country.  He said that “This is our first task — caring for our children.  It’s our first job.  If we don’t get that right, we don’t get anything right.  That’s how, as a society, we will be judged. And by that measure, can we truly say, as a nation, that we are meeting our obligations?  Can we honestly say that we’re doing enough to keep our children — all of them — safe from harm?  Can we claim, as a nation, that we’re all together there, letting them know that they are loved, and teaching them to love in return?  Can we say that we’re truly doing enough to give all the children of this country the chance they deserve to live out their lives in happiness and with purpose?  I’ve been reflecting on this the last few days, and if we’re honest with ourselves, the answer is no.  We’re not doing enough.  And we will have to change.”

We are not doing enough.  We will have to change.

So, those of us who work for, or are members of health professional societies that are dedicated to improving health and well-being of the American people, must ask ourselves, are we doing enough?  Is the medical profession, the healing profession, doing enough?  How will we be judged?

My employer, the American College of Physicians, has been on record since 1996 (policy reaffirmed in 2006) calling for policies to prevent firearm injuries, including a ban on assault weapons, like the one used in Sandy Hook.  Banning assault weapons and high capacity ammunition may not prevent tragedies like Sandy Hook, but simple logic tells us that there would be fewer casualties resulting from them.   Most recently, ACP has called for “best practices” to reduce injuries and deaths from firearms, as well as the right of physicians to ask patients about firearms in the home.

Some members of Congress, who previously had the highest ratings from the National Rifle Association, agree that the time has come for “rational gun control” and “meaningful action” on guns including even a ban on assault weapons.  But many others remain opposed to any new restrictions on gun ownership.

We also have to acknowledge that even if future sales of assault weapons were banned tomorrow, there are millions of them that would legally remain in persons’ hands, because they were acquired before the ban. Some will end up in the hands of people who want to inflict the maximum harm to others, but most won’t.  We have to acknowledge that most gun owners, including owners of assault weapons who use them only for recreational target-practicing, would never harm anyone or wish harm on anyone. They too care about their children and they care about ours.

An evidence-based analysis would have to acknowledge that the deaths from homicides reached a 50 year low in 2010, even as restrictions on gun ownership have been loosened across the country and even without a ban on assault weapons.  An evidence-based analysis would also acknowledge that a good part of that decline may be due to better emergency care for trauma—large numbers of people are still getting shot, but not as many of them are dying from it.  An evidence-based analysis would acknowledge that it isn’t just the massacres we need to care about, it is the men, women and children who are murdered or injured everyday on city streets and buses and workplaces and in their own homes.

An evidence-based analysis would also acknowledge that many disturbed and potentially dangerous people don’t have access to mental health services in the United States. It would acknowledge that the vast majority of those with mental illness pose no threat to others.   An evidence-based analysis would acknowledge that people with mental illness benefit from having the loving support of their families.  But it would also acknowledge that being in a loving family, and having access to mental health services, does not guarantee that very distributed persons will be able to control their violent impulses.  Just read this heartbreaking account from a loving Mom about her challenges in controlling her sometimes violent son, despite having access to mental health services.

To be clear, I believe, and ACP believes, that limiting access to assault weapons and high capacity ammunition can help reduce the death toll.   But it is just one piece of the puzzle.  We will need to carefully examine all of the evidence that we can find on the most effective strategies to minimize deaths and injuries from firearms, and strive to seek a national consensus to implement them.

But the complexity of the problem and possible solutions should not be used as an excuse to delay action or to accept the status quo.  “No single law — no set of laws can eliminate evil from the world, or prevent every senseless act of violence in our society, “observed President Obama yesterday. “ But that can’t be an excuse for inaction.  Surely, we can do better than this.  If there is even one step we can take to save another child, or another parent, or another town, from the grief that has visited Tucson, and Aurora, and Oak Creek, and Newtown, and communities from Columbine to Blacksburg before that — then surely we have an obligation to try.”

We have an obligation to try, including asking whether the healing professions are doing enough about to curb gun violence in the United States.

Today’s questions:  Is the medical profession doing enough to advocate for policies to reduce injuries and deaths from firearms?  Are any of us?

Tuesday, December 11, 2012

Cliff Notes

Many in Washington are worried that the U.S. will soon do a real life imitation of Thelma and Louise, driving the U.S. treasury off the fiscal cliff created by hundreds of  billions of expiring tax breaks (mainly, the Bush tax cuts) and across-the-board spending cuts (sequestration).

But I think a better cliff metaphor comes from a different movie: the scene when Butch Cassidy and the Sundance Kid, pursued to the edge of a cliff by a relentless Pinkerton man, must decide whether to jump to near certain death or be captured and hung for their crimes.  Here's how their conversation went:

Butch Cassidy: Alright. I'll jump first.
Sundance Kid: No.
Butch Cassidy: Then you jump first.
Sundance Kid: No, I said.
Butch Cassidy: What's the matter with you?
Sundance Kid: I can't swim.
Butch Cassidy: Are you crazy? The fall will probably kill you.
Sundance Kid: Oh, sh . . .

Well, imagine House Speaker John Boehner and President Obama having the same type of conversation in their one-on-one meeting yesterday at the White House.

For a deal to be struck, Obama has to jump off the cliff of accepting hundreds of billions in cuts in entitlement programs--with Medicare topping the list--knowing that this will probably kill his support from unions, AARP and liberal members of Congress.

For a deal to be struck, Boehner has to accept hundreds of billions in tax increases, including raising the marginal tax rate on higher income earners, knowing  that this will probably kill his support among his Tea Party allies and wealthy GOP donors.  

If they don't jump together, taxes will go up on just about everyone and spending will be cut on just about everything, taking hundreds of billions out of the economy and likely plunging it back into recession. 

Of the two, Boehner has the toughest challenge, kind of like the Sundance Kid not being able to swim. 

He and his members have to face re-election and potentially primary challenges from the right if they "sell out" on taxes.  Some say even his speakership could be at risk.  There is no guarantee that if he strikes a deal with the President, he can deliver the votes in his restive and very conservative caucus. 

Obama, of course, doesn't have to face re-election, polls show that the public is on his side and that they will blame failure to get a deal on the GOP, not the President.

We know what Butch and Sundance ended up doing--they jumped over the cliff, and miraculously lived to fight another day.  Whether President Obama and Speaker Boehner can do the same, with only a few legislative days left before the Christmas break, is anyone's guess. 

If they do hold hands and jump together on a plan to raise taxes and reduce entitlement spending, this is what the deal will look like:

1.    The Bush tax cuts will be renewed for people below an agreed upon income level, allowing it to rise automatically for higher income earners on January 1.
2.    The congressional committees with responsibility for tax policy will be instructed to develop legislation to reform and simplify the tax code to achieve hundreds of billions more in increased revenue (how much more still needs to be decided), with details to be worked out next year.
3.    Congressional committees with jurisdiction over Medicare and Medicaid will be instructed to find hundreds of billions in savings to those programs, details to be worked out next year.
4.    The near-30% scheduled Medicare physician payment cut will be put off for another six months or year, perhaps with instructions to the committees to develop legislation to permanently eliminate the Medicare SGR formula and transition to value-based payment models, details to be worked out next year.
5.    The devastating, across-the-board budget "sequestration" cuts to health to defense, Medicare, and other programs will be replaced with instructions to Congress' appropriators to find the same or greater savings through targeted policy changes, again--guess what!--with details to be worked out next year. 

Those are a whole lot of details to be worked out next year! 

But a broad framework agreement is probably about as much as can be realistically accomplished before the end of the year.  And to be clear, the "details" to be worked out next year likely will include consideration of painful cuts that could directly affect physicians--cuts in payments to Graduate Medical Education programs, canceling scheduled increases in Medicaid payments to primary care physicians, reducing payments for so-called "over-priced" procedures, and tightening or eliminating the Stark in-office ancillary services exception have all been discussed as ways to trim entitlement spending.  ACP, for its part, won't go along with cuts that threaten GME and other key priorities--for instance, ACP helped organize a massive effort by organized medicine to persuade Congress to not take money out of Medicaid primary care payments to pay for the fiscal cliff.  At the same time, ACP will continue to press Congress to come up with a fiscally and socially responsible alternative to the fiscal cliff, sequestration and the SGR cuts, focusing on the true cost drivers in American medicine, like over-use of marginal and ineffective medical tests and treatments driven in part by defensive medicine.

So if the country has to go over a cliff, wouldn't you rather it happen the way Butch Cassidy and the Sundance Kid did it, risking everything to take the plunge together and miraculously surviving to fight another day, over how Thelma and Louise did it, accelerating over the edge, roll the credits, the end?

Today's question: Do you think President Obama and Speaker Boehner will channel Butch and Sundance and go over the cliff together, risking it all to agree to tax increases and entitlement cuts? 

Tuesday, December 4, 2012

Why Competition May be the Wrong RX for Lowering Health Care Costs

A  staple of conservative political ideology is that free market competition  is the answer to controlling health care spending, not government mandates. The theory, of course, is that if “consumers” (patients) are given accurate information about the price and benefits of available health care services, they will choose the option that offers them the most bang for their buck.   It works in other parts of the economy, it is said, so why not health care?

But what if competition actually works to increase costs?


Health care is unlike most  other market choices that we make.   How many other choices do we make that potentially are life-and-death situations?  (Choose an incompetent barber, you get a bad hair cut.  Choose an incompetent doctor, and you die. Although I do recall a bad hair cut in 9th grade that made me want to die!). 


How many of us have the knowledge to select the medical alternative that gives us the best value?  Can we trust the information being delivered to us, much of  it from drug companies, hospitals, and device manufacturers that want us to order more care that is more expensive, not less care that is less expensive?


We don’t need to look to academic literature to understand why competition might actually increase costs by stoking demand for unnecessary care.  Just look at your own daily newspaper and favorite TV shows.


Yesterday,  as I flipped through the Washington Post over my morning cup of coffee, I came across a full-page advertisement on page A-14, touting a “Limited Time Offer” by INOVA hospital (Northern Virginia’s largest hospital system) and its partner HealthFair, to get a battery of ultrasound tests for your heart and arteries.  For only $139 I could get a stroke/carotid artery ultrasound test, plus an abdominal aortic aneurysm ultrasound, plus an EKG, plus an Peripheral Arterial Disease Test, plus a Hardening of the Arteries (ASI) test—ordinarily valued at $1800!  For another 60 bucks, I could get an EKG ultrasound test, regularly priced at $150!  And a 5 year disease risk and lipid panel—Results While You Wait!—for $99!  And if combined both packages, I would get another $20 off!


What a deal!  And, to make it convenient for me,  the HealthFair screening trucks would be coming to 17 sites throughout the region over the next month!  Happy Holidays!


Maybe I don’t need all of these tests, I thought to myself.  After all, I  saw my internist for a physical only five months ago, and he ordered some (but not all) of these tests for me.  But wait a minute . .. what if I die because I don’t get the tests?  The ad included two testimonials from individuals who say their lives were saved by getting the same tests.  Mr. Maurer was quoted as saying that “The ultrasound revealed that my right carotid artery was 75% blocked. . .  Within a few days, a vascular surgeon confirmed the health screening’s findings and I was told that I needed surgery on my carotid artery or I would not be around much longer.  The surgery solved the problem . . . I now have new outlook on life and cherish every moment.”    Linda Covey recounted how the screening for her husband found “something that needed to be checked.  We made an appointment right away at the hospital and found out that he had an ascending aorta aneurism. Surgery took place shortly after that and he is a new man again . . .Go get checked, it may save your life too.”  (Interesting that these examples led to the patient’s getting surgery in the hospital, which I am sure benefits Inova’s bottom-line).


To be clear, I have no reason to doubt that the screening tests benefited Mr. Maurer and Mr. Covey.  And I’m not a clinician, and maybe it is the standard of care for me to get all of these tests.  But if so, why didn’t my internist order them for me?  Maybe it isn’t the standard of care,  but how would I know?  Can I really afford to risk my life by not getting them, especially with such a great “Limited Time Offer”!??


Then, last night, I watched Monday Night Football. (Great win, Redskins over Giants).  Along with trying to get me to drink more beer and eat more pizza than would be good for me, there were the usual ED and “you gotta go” Direct-to-Consumer drug advertisements.   No further comment needed, other than it is pretty clear that the advertising was intended to increase demand for health care, not decrease it.  (I am not questioning that the advertised drugs have benefit—only that the millions being spent to hawk them on national  TV  clearly has one purpose, which is to increase demand for them).


A few nights ago, I was watching CNN, and I saw repeated ads for motorized scooters (tells you something about CNN’s viewer demographics) with a promise by the company that they’d even help get them covered by Medicare at “no cost”!  Too bad for them, but I am bit too young for that, and can get around just fine on my own, thank you very much.  But what about my elderly mother?
This is what health care competition looks like: millions spent to get people to spend health care dollars, either out of their own pocket or from someone else’s through insurance, to buy tests, devices and treatments that may benefit them, or may not, but that surely make money for the companies pitching them.   We can decide not to get the advertised products,  but what do we know?  Especially since if we go without them, might we end up “not being around much longer?”


There is a role for competition—provided that it is regulated and accompanied by consumer protection safeguards.  For instance, the Affordable Care Act will give millions of people a choice of health plans sold through a state—or federal exchange—but strict rules will apply to how the health plans can market themselves.


But the idea that poorly-regulated competition alone will result in people making wiser choices on health care expenditures is belied by the best evidence of all: the unrelenting newspaper and television advertisements that play on our emotions and take advantage of our lack of clinical knowledge to convince us that when it comes to health, more is always better than less.  Especially when it is 20% off the regular price!


Today’s question: What do you think the millions spent to get people to buy more health care says about the idea that market competition is the best way to lower costs?

Thursday, November 29, 2012

"Honest Abe" and ObamaCare

“Passed by corruption, aided and abetted by the purest man in America” is how anti-slavery Congressman Thaddeus Stevens described President Lincoln’s successful effort to enact the 13th amendment, banning slavery.   This historically accurate quote, which runs counter to the public image of “Honest Abe” Lincoln, is among the many  fascinating  stories recounted in the Steven Spielberg’s masterpiece  “Lincoln” playing  now in movie theaters nationwide.  

The movie doesn’t claim to get every fact right, but its description of Lincoln’s single-minded determination to get the 13th amendment passed by Congress in the final months of the Civil War-- over the objections of his own advisors and knowing he initially was at least 20 votes short-- is spot on.  And to get the votes he needed, Lincoln did whatever he thought was necessary, including offering jobs to lame-duck members of Congress who had lost re-election.  (This practice was not illegal at the time, although undoubtedly ethically suspect).   Today, offering jobs for votes would be against the law and grounds for impeachment.
 
But the movie depicts Lincoln’s commitment to banning slavery in an extraordinarily favorable light.  Human bondage was such a moral wrong, the source of misery for enslaved millions, and the cause of heart-breaking bloodshed for the entire country, that if there ever was a case of the ends justifying the means, this surely was it.

The film depicts “politics as hand-to-hand combat, and it portrays Lincoln not as idealist or moralist but as pragmatist and realist. Doing so does not diminish him but elevates him.”   For his efforts, though, Lincoln was called a tyrant by his critics.

There are lessons from Lincoln that we might keep in mind as we consider our current political divisions.   As much as the fight over taxes and spending cuts seem like a big deal to us, and seemingly outside the reach of compromise in an ideologically polarized Congress, it is not even close to the stakes and divisions Lincoln faced over the 13th amendment.   The movie shows the unseemly side of politics but also shows members of Congress acting in an extraordinarily honorable ways:  voting their consciences, voting against the position of their own (in this case, Democratic) political party, and putting their careers at risk for voting for the amendment.  It shows abolitionist Thaddeus Stevens tempering his rhetoric in favor of full equal rights for African-Americans in order to win votes for the amendment. 

Wouldn’t it be something if there were more members of Congress today who would vote their consciences and buck their parties?  Who would be willing to hold their tongues and compromise when needed to advance long-term priorities?

The lesson we can learn from Lincoln is that politics can be both high-minded and unprincipled.  The process of getting legislators to vote your way always has, and always will, involve some degree of wheeling and dealing. So it was in Lincoln’s time, so it is today.

To be clear, I am not arguing in favor of offering jobs or money for votes, or selling out to the highest bidder, or even bending the rules by flying members of Congress around in corporate jets to elite golf outings.  Those things today are for the most part illegal, and we are better for it. 

But let’s stop looking at politics through Rose Colored glasses.  ObamaCare’s critics got themselves into high dudgeon over the “backroom deals” the Obama administration made to win support from interest groups and individual Senators (The Democrats were equally indigent when House Republicans kept the vote on Medicare prescription drug coverage open for four hours in 2005 to arm-twist the final votes they needed for passage).

The promises made to get interest groups and lawmakers on board with Obamacare (all legal, by the way) don’t come close to the “do what every is necessary” Realpolitik exercised by Lincoln.   But as the National Journal’s Jill Lawrence writes “If Lincoln were operating now, though, Americans would be following all the wheeling, dealing, and good-government lamentations in real time on Twitter and cable TV. I’m guessing there would be plenty of cynicism, and certainly no halo — at least until decades later.”

I am not equating ObamaCare to ending slavery, by the way.  For all of the good that health care reform may do in my opinion, it doesn’t rise to ending slavery.  Nor am I saying that Obama is the measure of Lincoln:  no one today can say how Obama’s presidency will be viewed by historians, and Lincoln sets such a high bar that it unlikely that any contemporary politician will come close.
But I am saying  that sometimes achieving a principled end—like covering the uninsured—requires a certain degree of arm-twisting and deal-making.  Sometimes, the end (within reason) does justify the means.  Jill Lawrence concludes that the film “exalts ends without sugar-coating means, and holds out the promise of vindication — in history, if not their lifetimes — for leaders who wield their ‘immense power’ to perfect the nation as they see it.”   Just take it from Honest Abe.

Today’s question: What lessons do you draw from the account of Lincoln’s deal-making to pass the 13th amendment?

Wednesday, November 21, 2012

Thanksgiving

In the spirit of tomorrow’s celebration, here is a list of ten things, related to health care, for which I give thanks:

1.     I am thankful that my immediate family and I are in good health, to the best of my knowledge.

2.    I am thankful that when my family members and I get sick, as we all will someday, we have good health insurance and won’t have to worry about being bankrupted because of high health care costs or having to go without care because we can’t afford it.

3.    I am thankful that a little over a year from now, when the Affordable Care Act becomes law, as many as 32 million uninsured Americans, and many millions more of us with pre-existing conditions, will be able to say the same.

4.    II am thankful that I have the privilege of working for an association of internal medicine physicians—the American College of Physicians—that has have shown remarkable prescience, leadership, determination and commitment to advocate for what they believe to be best for patient care, taking on the really tough issues of universal coverage, cost, payment and delivery system reforms.

5.    I am thankful that I was able to play a role in helping ACP develop its policy positions on universal health insurance coverage, the rational allocation of health care resources, and many other challenging issues--and subsequently seeing so many of them accepted into law and regulation.

6.    I am especially thankful for my contributions to getting coverage to nearly all Americans through ACP’s advocacy on behalf of the ACA.

7.    I am thankful to have gotten to know so many physicians through my work that are everything one could ask for from the medical profession: smart, dedicated, and compassionate women and men who spend their days and nights making health care better, by taking care of patients, by teaching the next generation of physicians, and by helping ACA develop and advocate for responsible patient-centered policies.

8.    I am  thankful that I have the opportunity to work with so many other people—my friends colleagues on the ACP staff, the people I know who work for other health advocacy organizations, and the many dedicated and unfairly maligned public servants who work in government—who also have dedicated their careers to improving American health care.

9.    I am thankful that I live in a country where public policy decisions on controversial issues, like the ACA, can be debated freely and with decent respect for each other’s views.

10.    I am thankful for  those of you who put up with my musings In this blog, whether your just read or take the extra time to post comments on it, even and especially when you disagree with me (as I am sure some of you will about my expressions of gratitude for the ACA!). 

I wish each of you a peaceful and restful day of Thanksgiving with your loved ones!
Today’s question: If you made your own list of ten things related to health care for which you would give thanks, what would they be?

Tuesday, November 13, 2012

Rooting for the ACA’s Failure?

Beyond stating what now should be quite obvious—that ObamaCare is here to stay—what does the 2012 election mean for health care reform?  On one hand, the voters have spoken, re-electing a Democratic president who is committed to full implementation of the law over a Republican candidate who promised to repeal it on “Day One”—while expanding Democratic control over the Senate and reducing the Republican majority in the House.   As a result, there is no realistic scenario where there will be the votes in Congress to roll back the law.  Also, exit polling suggests that just one-quarter of voters favor complete repeal of the Affordable Care Act.  On the other hand, it would be a gross misreading of the election to say that voters have enthusiastically embraced ObamaCare.  The same exit polling shows that voters are split nearly down the middle on the law’s future, with slightly more (47%)  being in favor of keeping or expanding it compared to the 45% who said they thought it should be fully or partially repealed.

In other words, complete repeal is off the table, at least for the next four years. But the proponents of ObamaCare haven’t yet won the hearts and minds of a solid majority of voters.  That likely will only happen if the law is successfully implemented at the federal and state levels, and voters find from their own actual experience that it is a good thing.  But if its implementation is messy, confusing, uneven, unsatisfying, and/or too costly, then the public could yet render a judgment against it. 

What worries me is that the ACA’s opponents, having failed in their “three year war against ObamaCare”, will decide that their best remaining option is to do their darndest to make implementation confusing, uneven, unsatisfying, and/or too costly for the public.  Then they can say “we told you so” and hope that the public agrees. 

So, for instance, a large number of conservative states might decide not to set up the  state health exchanges through which federally-subsidized insurance will be sold to qualified residents, hoping that it simply is too much work for the federal government to effectively set the exchanges up and run efficiently for millions of persons in (potentially) dozens of states.  They might decide not to accept federal dollars to expand Medicaid to their poorest residents, as at least a half dozen states are threatening to do, thereby ensuring that implementation will be at best uneven, leaving behind many of the most vulnerable people who were supposed to get coverage under ObamaCare.  Also, under the ACA, hospitals and other safety-net clinics will get fewer federal dollars to offset the costs of treating indigent patients because they were supposed to be fewer of them as Medicaid is expanded.  But if their state doesn’t agree to the expansion, those same safety net institutions still have to treat the indigent patients that will be denied access to Medicaid, but with a lot less funding—potentially forcing them to close or at the very least resulting in cost-shifting to those with insurance.  And then the politicians in those states could say, see, it is all ObamaCare’s fault, even though it was their own opposition to the Medicaid expansion that made the law untenable for their safety net clinics!

And setting up the law to fail in the states that oppose it is precisely the advice being offered by some ObamaCare critics.    Arguing that the federal government can’t “competently operate dozens of exchanges. . . Republican governors should allow the feds to live with the mess they created rather than clean up for them” writes Philip Klein in the Washington Examiner.   And, at the federal level, the House GOP could again try to use its leverage over spending to try to deny the administration the funds it needs to implement the law, although this wasn’t very successful in the outgoing 112th Congress, and will likely be even less so in the new one.

If the critics of ObamaCare decide to do everything they can to undermine its implementation, they are essentially putting patients at risk to make a political point.  States that refuse to set up the exchanges or agree to the Medicaid expansion will be making it harder for their residents to get access to health insurance.  By refusing to lending a hand to the federal government’s effort to make the law work in their states, they may succeed in making it more confusing for the public and less likely to achieve the law’s goal of facilitating enrollment in qualified health plans, but how can it be good public policy to make it harder for people sign up for coverage?

There is a better way, which is to get over the polarized, ideological and hyper-partisan political debate over ObamaCare, accept that it is here to say, to acknowledge that a majority of voters could have elected a President and Senate committed to its repeal but didn’t, and instead seek bipartisan avenues to improve it.  USA Today reports that some Republicans and Democrats are beginning to talk about ways to “come together and fix it” rather than continuing the fight over killing it on one hand or keeping it exactly as is on the other.   History reminds us that this is what happened when Medicare and Medicaid were enacted in 1965: after initially being fiercely opposed by conservatives, and after several election cycles where voters chose the candidates that favored continuing those programs rather than the ones promising to repeal it, the cries for repeal faded, the efforts to disrupt implementation ceased, and repeated Congresses and administrations found a way to enact bipartisan legislation to make them work better. 

Isn't it time for the country to come together to try to make the Affordable Care Act work, including fixing things that are wrong with it, rather than rooting for (and even trying to facilitate) its failure in delivering on the promise of accessible, affordable health insurance for all?

Today’s question: How would you answer the above question?

Wednesday, November 7, 2012

ObamaCare is here to stay

With the re-election of Barack Obama and Democrats retaining control of the Senate, the debate over the future of ObamaCare is over: it is the law, will remain the law, and will be fully implemented in 2014. To the extent that there is still a question about its future, it is whether the states will agree to expanding Medicaid to all of the poor and near poor and to set up marketplaces to buy subsidized private insurance. Every state that says no to either or both will take away from the law's promise of taking of covering nearly all Americans. And the fact remains that the public remains deeply divided about the law. Still . . . there is a chance, a hope, a promise, a potential, that the country can move past the polarized, ideological debate over repealing ObamaCare on one hand (won't happen) to making it better (could happen). The election doesn't settle which choice the country will make, except that it will not be repealed. But I hope that when realization sets in among the public that ObamaCare won't be repeated, there will be a renewed willingness to take what is good about the law, especially coverage of the uninsured, and make changes where needed (how about real medical liability reform as a start?) to make it better Today's question: What do you think the election mean for ObamaCare?

Monday, November 5, 2012

The Election

So it all comes down to this: tomorrow voters will be deciding not only on who they want in the White House and in control of Congress, but also on two fundamentally different views on the role of government in health care.  President Obama proposes to continue to expand the federal government’s role in financing, funding and regulating health care and continue Medicare and Medicaid as defined benefit programs; Governor Romney wants to turn more responsibility over to the states, cut federal healthcare spending, and convert Medicare and Medicaid from defined benefit programs to defined contribution programs, limiting the federal government’s contribution to each.

I expect that most readers of this blog have decided which approach you favor and who you will vote for, based not only on their positions on healthcare but on the economy, national security and other issues that matter to you.   It would be presumptive of me to evaluate the candidates for you and, as a matter of policy, law and good sense, ACP does not endorse candidates for political office.  We have and will always be strictly non-partisan, taking positions on the issues based on ACP policy, not positions on the candidates themselves.

As a resource for those of you who want to learn more about the issues at stake, here are links to content that I hope you will find to be of interest, some from previous posts to this blog, some from the ACP  and Annals website, others from respected advocates, commentators, and journalists:

ACP’s comparison of President Obama’s views compared with College policies

ACP’s comparison of Governor Romney’s views compared with College policies

NEJM article from President Obama on how he “would secure the ACA’s future”

NEJM article from Governor Romney on how he would “replace ObamaCare with real reform”

My article from this week’s ACP Internist publication on how the election may decide four critical health policy issues

Annals perspectives from health policy experts David Blumental, Gail Wilensky and Bob Berenson on what the elections mean for healthcare

Article from the ACP Advocate Newsletter discussing how healthcare was addressed in the presidential debates

Medical Economics magazine article that quotes me, AAFP’s President, and others on how the election might affect primary care

NPR report on the prospects for ACA repeal should Governor Romney be elected

Blog post from the Washington Post’s Ezra Klein on why healthcare is the most important issue in the 2012 elections

My blog post on the ten things that bother doctors the most that are being overlooked by the candidates

Analysis from NPR’s Julie Rovner on how Governor Romney would reform healthcare and how his approach differs from President Obama

My Annals of Internal Medicine article on the Supreme Court, the elections, and the ACA’s future

My recent blog posts on the leadership deficit of both candidates and who is to blame, the secret truth behind Medicare vouchers and their unpredictable risk and benefits, and how the candidates’ positions on Medicare are a triumph of nonsense over substance.

No matter what your views are on the candidate’s and their positions on healthcare, I hope that my blog posts and links to others’ expert analysis have helped inform you about the issues at stake.  And, once the dust settles and we know who won the election, I will post my own post-election thoughts and share insights from other experts, and like always, seek your thoughts as well.

Today’s question: How are the candidates’ views on healthcare influencing your vote?

Friday, November 2, 2012

A Proud SOB’s Perspective on Healthcare and the Election

I am a proud SOB—Son of a Bartender—just like John Boehner (R-OH), the Speaker of the House of Representatives.  We both grew up helping out in our Dads’ working class bars—in my case, I was the third generation to tend bar (summer job while in college) in Doherty’s Bar in Woodside, Queens, NY, owned, operated and tended by my late father Jack Doherty, an Irish immigrant.  Where I respectively disagree with Speaker Boehner is on whether the Affordable Care Act (ObamaCare if you prefer) will help or hurt working class people, like the longshoremen, cops, construction workers and firefighters who patronized my Dad’s establishment.  I believe it will help them and should be fully implemented, Speaker Boehner believes it will hurt them and should be repealed.

I am sure we can both cite statistics and studies to back up our views, yet I think it is important to go beyond the numbers and look at how it specifically will affect real people with real healthcare needs in real jobs, such as those who tend bar or wait tables for a living.   Which brings me to a Missouri bartender I met back in 2009,  before ObamaCare became law, who overheard a conversation between me and Dr. David Fleming, the then-governor of our Missouri chapter and now a member of ACP’s Board of Regents.  This is an excerpt from what I wrote then in this blog:

"I was in Missouri attending the ACP chapter meeting. Over several beers at the hotel bar, Dave Fleming, the ACP Missouri chapter governor, and I were debating whether health care is a right, privilege or societal responsibility. Our bartender overheard our conversation and asked if health care reform would help her and her family.

"She said she has some serious health problems that require expensive medications, which are only partly covered by the health insurance plan offered by her employer. Her company plan also covers her 19 year old dependent daughter with a serious mental health condition. Her husband, an independent contractor who can't find coverage on his own, also relies on his wife's plan for coverage. She said that even with the insurance, her premiums and out-of-pocket health care bills are so high that "I don't know how we'll make it." She was planning to take a day off from work to plead with state Medicaid office to cover her daughter, even though she had already been advised over the phone that her daughter wouldn't qualify.

"Dr. Fleming and I explained that health care reform might make her daughter eligible for Medicaid, because the pending bills would require the program to cover anyone up to 133% of the poverty level (we didn't ask her how much she and her husband earned). We also told her that she might be able to get subsidized coverage through a health exchange, and that insurers wouldn't be allowed to turn down her daughter or charge higher premiums because of her pre-existing mental health condition. She wistfully responded, ‘I hope so’ but sounded unconvinced that the politicians in Washington would do these things for her.

"As the politicians continue to debate the intricacies of such things as excise taxes, budget offsets, health exchanges, subsidies, mandates, and public options, I hope we don't lose sight of this Missouri bartender, and the millions of working American families, who can't afford health care and are looking to Washington for help. None of the bills making their way through Congress are perfect - far from it. But I believe the litmus test of whether the results are worth it is whether our Missouri bartender and her family can get good coverage at a price that they can afford."

Today, three years later, and just four days before the election, I can say that the politicians in Washington did come through for her:  the Affordable Care Act will expand Medicaid to everyone with incomes up to 133% of the FPL, and provide sliding scale subsidies to buy private insurance for people up to 400% of the FPL through state-run health exchanges.  Less certain is whether the politicians in Jefferson City, MO, will come through for her, because they have to agree to the Medicaid expansion and the exchanges.  But if they do, this Missouri bartender, her self-employed husband, and her disabled adult daughter should have guaranteed, affordable health insurance coverage for the rest of their lives.

I can understand why many voters have concerns about the ACA, mainly because they believe it is too expensive and gives too much power to the government.  But as a proud SOB myself, I hope that we keep in mind  that because of ObamaCare,  this Missouri bartender, and so many others like her, will for the first time in their lives no longer have to worry about not having access to affordable health insurance coverage, unless the voters decide otherwise next Tuesday.

Today’s question:   What do you think is at stake in the election for this Missouri bartender, and so many others like her?

Wednesday, October 31, 2012

Who you gonna call when your health is in danger?

How is this for a Halloween metaphor?  When it comes to emergencies that threaten our health and safety, we all expect the federal government to come to the rescue, just like the fictional Ghostbusters (from the 1984 movie of the same name) were the ones to call if  you find yourself haunted by surly ghosts.

But today, I write about something that is truly scary, the actual and potential loss of life from two unfolding health crises, one caused by nature (Hurricane Sandy) and one by human negligence (a fungal meningitis outbreak caused by an unsafe compounding pharmacy

As much as ideologues on the right argue that the federal government can’t do anything right,  that we should just leave protecting our health to free markets—and only if absolute necessary, the states, never ever the feds-- these  disasters show us that there is no substitute for calling on the federal government for help.

Here’s the story.  When the towns of New Jersey and the streets and tunnels of lower Manhattan and Brooklyn and Staten Island were overrun by Sandy’s water, the officials of those states knew that they couldn’t depend only on their own resources to get through it.  Yes, the committed first responders from the local community, the police, firefighters, EMTs, doctors and nurses who came to rescue and care for their neighbors, were essential and deserve everyone's admiration and appreciation.   Local and state governments played essential roles in preparing for disaster and organizing relief in the aftermath.  But they rightly expected the federal government also to ride to the rescue, in the form of Obama administration and its Federal Emergency Management Agency (FEMA), to provide federal resources.  So maligned for its Katrina performance, FEMA is aware that this time it has to pass the test. And so far it has: New Jersey Governor Chris Christie, a champion of small government, declared that “The President has been outstanding in this and so have the folks at FEMA.”

Then there is the fungal meningitis outbreak that has led to 28 deaths, hundreds sickened, and potentially thousands of being at risk of illness or death.  This man-made public health disaster appears to be the result of unsanitary and unsafe practices by a compounding pharmacy, the New England Compounding Center (NECC) that is exempt from federal regulation but subject to state regulation.  The Massachusetts agency responsible for regulating compounding pharmacies operating in the state said that it “didn’t have the power they needed to keep tabs on NECC.”

So let’s get this straight: the FDA, the federal agency that we rely on to ensure that the prescription drugs that we put into our bodies under a doctor’s orders are safe and effective is barred by federal law from regulating the compounding pharmacies that mix those drugs, and the states by their own admission lack the power they need to keep tabs on them?  If there is every a case for the federal government to exercise its constitutional authority to regulate Interstate Commerce (the compounded drugs in question were sold and administered throughout the country), this should be it, yet Congress and federal courts instead has told the FDA to keep its nose out of the compounding pharmacy business? 

Sadly, this isn’t the first time people have died because regulation of compounding pharmacies was left left to under-funded state regulators with inadequate enforcement powers to protect us from unsafe compounded drugs.

In observing that our health would be better protected if the FDA was able to regulate compounding pharmacies just as it does drug manufacturers, and that we rely on the federal government to help state and local authorities out when confronted with life-threatening disasters, I am not arguing that all federal regulation is good and necessary or that the federal government always gets it right.  Nor am I arguing that there isn’t a role for market competition and state regulation.  But I am saying that there are some things that are so critical to our health—the safety of our drugs and our food, the availability of resources to help us when confronted by storms and earthquakes and pandemics and other terrifying things that can kill or sicken us on a massive scale, that there is no substitute for all levels of government--local, state and federal--working together to help the common good.  The libertarian/conservative argument that the federal government should just get out of the way and let state and local governments and the private sector go it alone just doesn't hold water. Just ask the people who lost their homes in New York and New Jersey, or the families of loved ones who lost their lives because the FDA isn't allowed to regulate the safety of compounded drugs and the states aren't up to the job.

And although not as immediate or as readily seen on TV, I would add lack of access to health insurance to the list of health crises that require a national response.  We know from the Institute of Medicine and Urban Institute that lack of health insurance kills tens of thousands annually, far more than have died from fungal meningitis outbreak of from Hurricane Sandy.  We know that leaving the problem to the states to solve doesn’t work—if it did, we wouldn’t have states like Texas where one out of five people are without health insurance, while other states (most notably, Massachusetts) manage to cover almost everyone.  If it is true that we need the federal government to protect us from loss of life due to unsafe drugs no matter where in the U.S. we live or where the drugs were mixed or manufactured, shouldn’t we also be protected from loss of life due to lack of access to health insurance, no matter where we live?  And if we recognize that states can’t go it alone when it comes to stemming loss of life from natural disasters,  shouldn’t we also recognize that states can’t go it alone when it comes to ensuring that we all have access to health insurance, no matter where we live?

The message from Hurricane Sandy and the fungal meningitis outbreak is that we are all in it together.  We are safest when Washington partners with state and local governments and the private sector to protect public health and safety.  But only the federal government has the reach and resources and ability to organize a national response to national crises, whether it is responding to life-threatening national disasters or ensuring that our prescriptions are safe or guaranteeing that all Americans have access to health insurance.

Today’s questions:  So who you gonna call to help protect the public from human- and natural disasters that threaten lives and safety on a grand scale?  Only your state and local officials?  Your neighbors?  The business community? The federal government?  How about all of the above?

Tuesday, October 23, 2012

The Imaginary ObamaCare Bogeyman

Do you remember the good old days, say 2009, when doctors were able to spend as much time with a patient as needed,  when there weren’t any pre-authorization forms to fill out, when no one questioned your performance, and primary care doctors were paid what they are worth?  Of course you don’t, because it wasn’t that way.  But some physicians critical of ObamaCare have conjured up an imaginary version of the law,  one that blames it for everything they don’t like  about the healthcare system, like too much red tape and not enough pay, when really most of the things they don’t like pre-dated the law—sometimes by decades!  

 It is one thing to say that the ACA didn’t do enough to address the daily intrusions that that so aggravate physicians and patients alike, it is another thing to say that ObamaCare caused it all, and that somehow it would all go away if the ACA is repealed.

Here are some examples:

Mandate to adopt ICD-10 codes?  Nothing to do with ObamaCare.  The ICD-10 mandate was proposed in 2008  by Michael Leavitt, HHS Secretary under the George W. Bush administration, and the legal authority for it comes from the HIPAA legislation enacted in 1996.  The Obama administration delayed the rules implementation for another year.

Medicare pay for performance?  Started at least three years before ObamaCare. The first version of what is now called the Physicians’ Quality Reporting System began in 2007, three years before ObamaCare was enacted into law.  Yes, the ACA continues the program, but it certainly didn’t create it.

Primary care paid too little?  Nothing new here, except ObamaCare makes things a bit better.  Internists have been objecting to the undervaluation of primary care for decades. A 2006 ACP position paper talked about payment systems “Undervaluing the evaluation and management (E/M) clinical services that are predominately provided by primary care physicians.”   But it goes back much further than that. The first public policy that I wrote for internal medicine was a 1981 paper on improving payments for cognitive services,  written on behalf of the American Society of Internal Medicine,  my then-employer, which merged with ACP in 1998.  The fact is that ObamaCare at least starts to make things better for primary care, including an annual 10% Medicare primary care bonus  over five years, raising Medicaid payment rates to no less than Medicare’s in 2013 and 2014, and paying 500 advanced primary care practices soon to get an average of $20 per beneficiary per month for care coordination. 

Too much insurance company red tape?   A growing problem over many decades, but one that ObamaCare at least begins to take on by standardizing some insurance practices.  In 1990, the American Society of Internal Medicine wrote a paper titled America’s Health Care System: Strangling in Red Tape and defined the hassle factor as “The increasingly intrusive and often irrational administrative, regulatory review and paperwork burdens being placed on patients and physicians by the Medicare program and other insurers.”  It is a theme that ASIM (and certainly since the merger, ACP) have hit upon repeatedly in its advocacy for internal medicine.  ObamaCare  won’t make the hassle factor go away, and it may add some of its own aggravations, but it also impose fines on insurance companies if they don’t standardize and  streamline their enrollment, verification, electronic funds transfer, and authorization requirements to ease hassles on physicians and patients alike.

I get it that many physicians had expected (hoped) that health care reform legislation would have been mostly about getting rid of the “micro” issues that drive them crazy, when ObamaCare is mostly about reducing  barriers to people getting health insurance coverage.  This disconnect about what physicians find most bothersome about health care, and what ObamaCare is really intended to do, fuels the discontent that some physicians have with the ACA. But at the same time, a fair evaluation of ObamaCare would give it credit for what it does try to accomplish—provide tens of millions more Americans with health insurance. A fair evaluation would acknowledge that it does have provisions to reduce insurance company red tape and increase primary care reimbursements.  A fair evaluation would point out the need for more reform that addresses the daily intrusions on the patient-doctor relationship.

But it’s not fair to imagine that everything was hunky-dory for doctors before ObamaCare and that everything will be fine if it goes away.  It is not fair to engage in imaginary thinking that ObamaCare is the reason why doctors are drowning in red tape and primary care doctors aren’t getting paid enough.  Sure, let’s agree  that the ACA doesn’t do enough about these problems--even as it has some things that should help--but let’s not make ObamaCare the imaginary bogeyman for things that have frustrated doctors for many, many years, long before it became the law of the land, things that would still be with us if ObamaCare was repealed.

Today’s question: Do you think it is fair to blame ObamaCare for regulations, hassles, and unfair payment policies that existed long before it became law?

Thursday, October 18, 2012

Worried about a government take-over of health care?

You should be, but it isn’t the bureaucrats and politicians in Washington that you should be most concerned about.  Instead, it is the growing propensity of state legislators to dictate to physicians what they can and can’t say to their patients, what tests they must provide, and what advice they must give to them—the patient’s wishes, the medical evidence, and the physician’s clinical judgment be damned. 

Today, the nation’s largest and most influential national medical specialty societies came together to say that enough is enough when it comes to government interference in the patient-doctor relationship.

Joining with his counterparts in the American College of Surgeons, American Academy of Family Physicians, American College of Obstetrics and Gynecology, and American Academy of Pediatrics, ACP’s EVP/CEO Steven Weinberger co-authored an editorial in the New England Journal of Medicine warning  against  “legislation [that] inappropriately infringe on clinical practice and patient–physician relationships, crossing traditional boundaries and intruding into the realm of medical professionalism.”  (Disclosure: I contributed to the piece by providing content review and background information at several stages of the manuscript preparation.)

The article cites four categories laws that do not have the proper “respect for the importance of scientific evidence, patient autonomy, and the patient–physician relationship”:

1.    Legislation that “prohibits physicians from discussing with or asking their patients about risk factors that may affect their health or the health of their families, as recommended by evidence-based guidelines of care. In 2011, for example, Florida enacted the Firearm Owners' Privacy Act, which substantially impaired physicians' ability to deliver gun-safety messages to patients.”

2.    Laws that “require physicians to discuss specific practices that may not be necessary or appropriate at the time of a specific encounter with a patient, according to the physician's best clinical judgment.”  For example, “New York legislation that was enacted in 2010 and became effective in early 2011 requires physicians and other health care practitioners to offer terminally ill patients “information and counseling regarding palliative care and end-of-life options appropriate to the patient, including . . . prognosis, risks and benefits of the various options; and the patient's legal rights to comprehensive pain and symptom management.”  The authors note that “This is an area in which one size does not fit all and in which physicians are best able to determine what discussions with patients and families are necessary or appropriate at a given time. Yet failure to comply with the law can result in fines of up to $5,000 for repeat offenses and a jail term of up to 1 year for willful violations.”

3.    Laws that “would require physicians to provide — and patients to receive — diagnostic tests or medical interventions whose use is not supported by evidence, including tests or interventions that are invasive and required to be performed even without the patient's consent” citing a Virginia law” requiring women to undergo ultrasonography before having an abortion would have mandated the use of transvaginal ultrasonography for a woman in the very early stages of pregnancy.”    “As the Virginia chapter of the American College of Physicians stressed in a letter urging Governor Bob McDonnell to veto the bill, ‘opposition to the legislation does not reflect our opinions individually or collectively on the practice of abortion itself,’” they wrote,“but rather the conviction that ‘this legislation represents a dangerous and unprecedented intrusion by the Commonwealth of Virginia into patient privacy and that it encroaches on the doctor–patient relationship.’”

4.    Laws limiting the information that physicians can disclose to patients, to consultants in patient care, or both. Four states (Pennsylvania, Ohio, Colorado, and Texas) have passed legislation relating to disclosure of information about exposure to chemicals used in the process of hydraulic fracturing (“fracking”).

The authors conclude by noting that “Our objection to legislatively mandated health care decisions does not translate into an argument that physicians can do whatever they want. Physicians are still bound by broadly accepted ethical and professional values. The fundamental principles of respect for autonomy, beneficence, nonmaleficence, and justice dictate physicians' actions and behavior and shape the interactions between patients and their physicians. When physicians adhere to these principles, when patients are empowered to make informed decisions about their care, and when legislators avoid inappropriate interference with the patient–physician relationship, we can best balance and serve the health care needs of individual patients and the broader society.”

ACP, in a related statement of principles that pre-dates and helped inform the joint NEJM statement, suggested a series of questions that should be asked of any proposed law to regulate the patient-physician relationship:

“Is the content and information or care consistent with the best available medical evidence on clinical effectiveness and appropriateness and professional standards of care?

Is the proposed law or regulation necessary to achieve public health objectives that directly affect the health of the individual patient, as well as population health, as supported by scientific evidence, and if so, is there any other reasonable way to achieve the same objectives?

Could the presumed basis for a governmental role be better addressed through advisory clinical guidelines developed by professional societies?

Does the content and information or care allow for flexibility based on individual patient circumstances and on the most appropriate time, setting, and means of delivering such information or care?

Is the proposed law or regulation required to achieve a public policy goal –such as protecting public health or encouraging access to needed medical care – without preventing physicians from addressing the healthcare needs of individual patients during specific clinical encounters based on the patients’ own circumstances, and with minimal interference to patient physician relationships?

Does the content and information to be provided facilitate shared decision-making between patients and their physicians, based on the best medical evidence, the physician's knowledge and clinical judgment, and patient values (beliefs and preferences), or would it undermine shared decision-making by specifying content that is forced upon patients and physicians without regard to the best medical evidence, the physician’s clinical judgment and the patient’s wishes?

Is there a process for appeal to accommodate for specific circumstances or changes in medical standards of care?”

It is good that ACP and the other leading national specialty societies have taken a firm stance for patients by objecting to laws that inappropriately inserts government into the relationship between patients and their doctors, but rank-and-file physicians must do their part and hold their state legislators accountable for such laws.   Unless and until physicians rise up in broad opposition, legislators will continue to tell you what you can and can’t say or do for your patients, causing grave damage to patient care. 

Today’s questions:  What do you think of the joint NEJM editorial?  What will you do to hold your state legislators accountable?

Wednesday, October 10, 2012

Needed: Less macro, more micro health policy

Much of what passes for debate on health care during this election year is focused on the macro side, on big issues like how do we cover the uninsured or restructure Medicare and Medicaid financing.  But for all of the talk about vouchers and block grants and insurance mandates, the candidates are missing the micro issues that really matter most to doctors and their patients, which is how health care policy directly affects the quality of the patient-physician encounter.

Talk to physicians around the country, as I regularly do, and these are some of the issues that have them most concerned:

1.    Will anyone do anything about the oppressive burden of paperwork and red tape?
2.    Will the candidates' "macro" proposals for reforming healthcare and entitlements result in more or less paperwork and red tape?
3.    I already don't have enough time to spend with patients but now I am expected to counsel them on preventive care, lifestyle choices, and the effectiveness of different treatments?   How is this possible?
4.    Electronic health records, great concept, but they don't really streamline the process as advertised, if anything, they just make things more difficult, and besides, they still don't communicate with other systems.
5.    Everyone wants to measure me, but the measures don't agree with other, they measure the wrong things and they are difficult to report on.   And who is measuring the value and effectiveness of the measures themselves?
6.    Okay, I am supposed to practice cost conscious care, but who is going to stop a lawyer from suing me if I don't give a patient the test they asked for?
7.    Why is my cognitive care paid so little while procedures and drugs are paid exorbitant rates?
8.    Payers and government keep imposing more penalties, for not e-prescribing, for not converting to ICD-10, for not meaningfully using my electronic health record, for not complying with their pay for performance schemes.  By the time they get done fining me for noncompliance, I will have had to shut my office. Then who will take care of my patients?
9.    And who has the time to keep track of all of these mandates, incentives, rules, and penalties?  I would have to hire a full-time person keep on top of everything. Who is going to pay for that?
10.     So I am supposed to transform my practice?  Well, we all want to do our part, but who is going to pay for that?  Besides, my patients seem to think my practice is just fine as it is

Now, I don't really expect Obama and Romney to come out with plans to address these micro health policies.  But it is reasonable to hold their macro proposals to a standard of whether they will make all of these aggravations and intrusions better or worse.  And at some point, policymakers--no matter their political leanings and plans to reform healthcare at the macro level, need to pay attention to what is happening at the micro patient-doctor encounter level.  After all, the boldest of big ideas won't make healthcare better if it makes it harder for physicians to give their patients the care they need.

Physician advocacy organizations also need to pay attention to the micro issues.  ACP prides itself on taking on the big issues like controlling health care costs and allocating health care resources rationally.   But the College puts at least as much effort into the micro issues, from objecting to the latest EHR mandates to offering alternatives to ICD 10 coding to advocating for higher payments.

The goal must be to fashion public policies that improve care at the macro level -- universal access to coverage, spending health care dollars more wisely, and improving healthcare delivery systems -- while also removing barriers at the micro level that intrude on the patient-doctor relationship.  Both are equally important.

Today's question: what policies do you think are needed to remove the barriers to the patient-physician relationship?

Wednesday, October 3, 2012

The real deficit is leadership, but don’t blame the candidates

The National Journal reports that jobs and the deficit are likely to dominate tonight's presidential debate, but the most important deficit is the candidates' absence of leadership on unsustainable health care spending, not the federal budget. But before you blame Governor Romney and President Obama, first look in the mirror: politicians don’t level with voters about the sacrifices required to lower health care costs because we would vote them out of office if they did.

Tonight’s 90-minute debate is on domestic issues only. The first 45 minutes will be on the economy, followed by 15-minute segments on health care, the role of government, and governing. But even though health care is supposed to get only its 15 minutes of fame, you really can't talk about the other topics without talking about health care spending. Because, if you solve the health care spending problem, you solve the deficit and you improve the economy. And controlling health care spending involves fundamental questions of how the candidates and the general public view the role of government and approaches to governing. Problem is, we the voters won’t allow either President Obama or Governor Romney to tell us the truth about health care spending, because we wouldn't like what they would have to say, even as we bemoan the lack of straight talk from politicians.

Because this is what an honest answer to the question, "What should the United States do about health care costs and access?" would sound like:

"The simple fact is that we can’t afford our health care system. It is too expensive, even as it leaves tens of millions of us without any health insurance coverage. My opponent and I disagree on how best to lower spending, but there is no disagreement that health spending has to come down—soon, by a great amount, and in ways that none of us will like.

Here is why: spending on health care is the biggest single cause of our exploding budget deficit and debt. We can't balance the budget without reducing how much we spend on Medicare and Medicaid. As our population ages, Medicare is covering more and more people, even as we have fewer younger people supporting it with their taxes. Yes, all of us pay into Medicare during our lifetimes, but get much more from it in return than we put into it.

An average-wage worker pays $60,000 into Medicare in their working years, but receives $170,000 in benefits if a man, $188,000 if a woman. The rest comes from our grown children, but there won’t be enough of them to pay for the many millions of baby-boomers—I am talking about my generation—not without massive tax increases on them. Or we can borrow the money, plunging us more into debt, debt that will also be passed on to our kids.

Our health care system provides excellent care to many of us, and we lead the world in medical advances and innovation. But millions of us do not get good access to care. Forty-six million have no health insurance coverage. And we know that people without health insurance delay getting needed care, and many of them suffer more serious illnesses or die from illnesses that could have been prevented with better access. And the rest of us end up paying for their care. One thing the two of us have in common (pointing to the other candidate) is that we both have signed laws to cover most Americans, in Massachusetts and on a national basis through ObamaCare, yet we and our country remain terribly divided on whether the national law should be implemented, improved, or repealed, and if repealed, what would replace it.

It is possible to cover everyone in the United States and still spend much less, because every other modern industrial country, the countries that we have to compete with in a global economy, have managed to cover all of their citizens at half to two-thirds of what we spend.

And we know that much of the money we spend on health care in the United States is wasted, as much as $700 billion each year, according to studies on medical care, that have little or no benefit for the patient. And we wonder why we can’t afford our health care system!

Here's the rub: solving the health care spending crisis won’t be easy. We will all have to give something, to sacrifice for the greater good. A solution will involve people who can afford paying more for their care. It will involve modest increases in Medicare taxes now rather than huge tax increases or benefit cuts later. It will mean that some drugs, physicians, and hospitals will be paid less. It may mean asking our seniors to wait a few years longer to enroll in Medicare—but if we do, we are obligated to help them get coverage in the meantime so they don’t join the ranks of the uninsured.

It will mean some of health care benefits will have to be curtailed, so we pay only for the things that are most effective in improving health. It will mean changing the way we pay doctors, so we pay them based on how well they help people stay healthy rather than how many services they provide. It will mean forgoing unnecessary tests, like an MRI for back pain, when studies tell us they offer little or no benefit. It will mean finding an alternative to lawsuits against doctors and hospitals that result in unnecessary testing and higher health care costs. It will mean requiring our doctors and hospitals to work together to improve health and lower costs and holding them accountable for the results. It will mean that each of us has to take more responsibility for keeping ourselves well.

In other words, all of us working together to make tough decisions on what we can afford to spend on health care, what we can’t, and how to get the best bang for the buck. The days when everyone can get all of the health care they want, whenever they want, are over, and the sooner we recognize this, the better.

Yet out of all of this, I am confident that through American ingenuity, we can build a better health care system, one that covers and provides good access to care for everyone but at a cost we can afford. Are you with me?"

Now, what would happen to a candidate who made such remarks? The pundits would declare the he lost the senior vote and blew the election. Physicians, hospitals and drug companies would immediately express fierce opposition to cuts. The trial lawyers would go bananas over reforming the med mal system. Ideologues on the right would blast the candidate for proposing government-run rationing, higher taxes and universal coverage, ideologues on the left for cutting benefits, delaying Medicare eligibility and charging patients more.

How likely would it be that the voters would reward the candidate who said something like the above? The Pew Research Center reports that seniors are "highly resistant to Medicare changes" and "A wide majority of seniors (66 percent) said people on Medicare already pay enough of the cost of their health care, compared with 24 percent who said people on Medicare need to be responsible for more costs to keep the program financially secure" and a majority in all age groups say that preserving Medicare and Social Security benefits is more important than reducing the deficit.

So don’t expect honest answers from Governor Romney and President Obama tonight. The deficit in leadership from the candidates on tackling health care costs is because that is exactly what we voters say we want from them.

Today’s questions: Do you agree that there is a deficit in leadership among both candidates in addressing health care costs? And who is to blame, them or us?

Thursday, September 20, 2012

Behind the lines of socialized medicine

Obamacare can be described as a lot of different things, but it surely is not socialized medicine.   No self-respecting socialist would favor having the government write checks for 16 million people to buy coverage from private (and often for-profit) private health insurance companies.  Plus, the Affordable Care Act maintains the employer-based coverage system from which the vast majority of Americans will continue to get coverage.  Heck, it doesn’t even have the public option favored by liberals! 

I write this blog today from a country that has the real thing: Canada!  ACP’s Board of Governors is meeting this week in beautiful Vancouver, British Columbia.   Coincidentally, one of the policy resolutions being debated this morning by the governors is a call for ACP to support a single payer system, like Canada’s.  (Resolutions can be introduced by any ACP chapter, so the fact that this resolution is being discussed does not mean that it is, or will become, ACP policy.  Plus, resolutions adopted by the Board of Governors are advisory to the College’s Board of Regents, which has the final authority to set organizational policies.)

So what can we learn from Canada?  I wouldn’t say that my brief visit here makes me an expert on Canada’s socialized healthcare system.  But so far, I haven’t seen masses of extremely ill patients desperately queuing up in long lines to get health care from beleaguered doctors and hospitals, even though this is the image conjured up by critics of Canadian healthcare, such as this description from a conservative Canadian physician  “Thus, at a time when Canada’s population was aging and needed more care, not less, cost-crunching bureaucrats had reduced the size of medical school classes, shuttered hospitals, and capped physician fees, resulting in hundreds of thousands of patients waiting for needed treatment—patients who suffered and, in some cases, died from the delays.” 

Actually, the Canadians I’ve seen in this Pacific Northwest coast city seem pretty darn fit and healthy! But casual observations, of course, aren’t really a fair way to evaluate Canada’s socialized healthcare system.  It is certainly possible that lurking behind a seemingly healthy and contented Canadian population is a system that is denying needed care and causing unnecessary suffering and death. 

So instead of casual observation and conjecture, what does the evidence tell us about Canada’s experience and how does it compare to the United States?

The highly respected, non-partisan Annenberg Public Policy Center runs a website, www.factcheck.org, that factually evaluates the evidence behind competing public policy claims.  It’s short answer to the question “Is health care better in Canada?” is that “ Wait times are longer in Canada, but health and doctor quality don’t seem to suffer.” 

More specifically, the Annenberg Center reports that “A study by the Commonwealth Fund, a nonpartisan research foundation that promotes improved health care access and quality, showed that 57 percent of adults in Canada who needed a specialist said they waited more than four weeks for an appointment, versus only 23 percent who said so in the U.S. For emergency physician visits, 23 percent of Canadians and 30 percent of Americans said they could get in to see the doctor the same day, but 23 percent of Americans and 36 percent of Canadians waited more than six days. Wait times for elective and non-emergency surgery were even more disparate: Thirty-three percent of Canadians reported a wait time of more than four months, but only 8 percent of Americans had to wait that long. In another study, 27 percent of Canadians said that waiting times were their biggest complaint about their health system, versus only 3 percent of Americans.”

But wait a minute, does Canada’s longer waits for some specialty care result in poorer clinical outcomes and poorer health?  No, says the Center, because “on most measures of patient-reported physician quality, Canada comes out slightly ahead of the U.S. . . Fewer reported physician errors, lab errors, medication errors and duplicate tests north of the border, and Canadians report more satisfaction with their doctors. General health is also better up north, according to the World Health Organization: Life expectancy and healthy life expectancy are both higher in Canada; infant mortality is lower, and maternal mortality is significantly lower. There are fewer deaths from non-communicable diseases, cardiovascular diseases and injuries in Canada, though marginally more deaths from cancer. It’s not clear how much of the divergence is attributable to medical care, rather than other standard-of-living differences between the two countries . . . But these statistics simply don’t support the notion that universal, single-payer health care is crippling the health of Canadian citizens compared with that of U.S. citizens.”

And the Center reports that both the Canadian or U.S. healthcare “score low on health measures compared with other industrialized nations.  “In the Commonwealth Fund’s overall ranking of health system performance, Canada came in fifth and the U.S. came in sixth, out of six countries. On the other hand, the WHO’s 2000 World Health Report gave Canada a slightly better review, ranking it 30th for overall health system performance – above three of the other countries from the Commonwealth study (Australia, New Zealand and the U.S.) but below the other two (the U.K. and Germany). All of these countries, except the U.S., have publicly funded health care, as does every major country in the WHO’s top ten.”

My take-away is that Canada’s system, like the U.S, has strengths and weaknesses.  Canada isn’t the healthcare Nirvana that some liberals believe it to be, but neither is it the healthcare hell that conservatives describe.  It is a system that covers everyone, with lower administrative costs and at a much lower overall cost than the United States, with longer waits for some care than U.S. residents are accustomed to, but with comparable (and in some cases better) outcomes.  The U.S. provides coverage to only 85% of its residents, leaving 46 million without health insurance.  We don’t wait as long for care as our northern neighbors, but our outcomes are no better (and in some cases worse) and it costs us much, much more.  Obamacare would take us a step closer to Canada, in the sense of extending coverage to 92% of U.S. residents, but through a decidedly non-socialistic model of subsidized private and public health coverage, at a much higher cost.

Today’s questions:  What is your view of single payer healthcare and the Canadian healthcare system?  Do you foresee it ever being adopted by the U.S.?

Thursday, September 13, 2012

FFS: What fee? What Service?


The debate over fee-for-service physician payment often is misunderstood to be about the technicalities and relative merits of the RUC, relative value units, P4P and the SGR.  It isn’t—instead, it’s what the fee itself represents (and who decides), and what the service being provided actually is (and how it’s described).

Let me explain.  As I blogged last week, analysts across the political spectrum agree that the health care system needs to move away from fee-for-service, although the reality is that FFS is likely to remain as a component  of new payment models, albeit in a very different form.  They say that we have to change the process for determining the fee itself, and how we define the service being provided to a patient—to one that reward “value” not “volume.”  But how a physician, or payer, or patient defines value may be very different.  Consider the following:

What fee?  From the standpoint of many practicing physicians, the “fee”—to their chagrin-- is what the government allows them to charge, when what they really want is the ability to set their own fees.  Their mindset is that no one else is qualified to determine the value of their service.  No one else—not the government, not MedPAC, not the RUC, and certainly not a “relative value scale” originally developed by Harvard professors-- knows how hard they work, what it costs to run their practice, or how  much value that their own patients place on their care.  They would like to scrap the price controls, scrap the RBRVS, scrap the RUC, scrap the SGR, scrap limits on balance billing, and let every doctor set his own fee and let patients decide if they are worth it.

But from a payer’s perspective, the fee is a very different thing—they want to get the best value for the dollar spent.   Since third party payers are responsible for paying most of the fee, the payer’s interest is getting the highest quality it can at the lowest possible fee.  They accordingly use their purchasing power to drive fees toward the level that gets them the best bang for the buck.  In the case of private payers, they exercise their purchasing power through contracts negotiated with physicians. In many cases, the private payer has such a big share of covered lives that physicians have little choice but to agree to their fee schedule and contractual limits on balance billing.  In the case of government, regulation and rate-setting are how it uses its purchasing power to get the best possible deal for taxpayers. 

Government has other interests in deciding what the fee will be: trying to make sure that the payments are fair and don’t advantage some physicians or specialties or localities over others, protecting beneficiaries from excessive out-of-pocket costs, having some consistency in what the government pays, and using fee setting to achieve specific policy goals, like increasing Medicare and Medicaid payments to primary care physicians to get more to participate or adjusting payments based on performance.

From the patient’s point-of-view, the fee usually comes down to a simple calculation: how much do I have to pay out-of-pocket, can I afford it, is the cost predictable or am I going to be stuck with a huge bill?  Some of them may be able to pay more, but I don’t see a lot of patients telling their doctors please, please charge me more because I think you are worth it.  It’s not that they don’t think their doctors are great and worth every penny.   It’s just that it goes against human nature to pay more for something if you can get it for less—or have someone else pay for it!  Plus, most patients already are paying about as much as they can afford out-of-pocket, so they really aren’t interested in proposals (like getting rid of balance billing limits) that would allow doctors to charge them more.

What service?  From the physician’s point-of-view, the “service” is the expertise, skill, time and compassion she brings to a patient encounter. So the service rendered really isn’t an “office visit” or “colonoscopy” or a CPT code –it’s the physician herself!  

But from the payers’ perspective, the service is something that can be described consistently across clinicians, be documented, audited, reported and coded properly.   They want to be sure that the service being billed by Dr. Smith is roughly equivalent to that by Dr. Jones, so that their subscribers are getting approximately the same service for the same premium.  They want to be sure that the actual service rendered is the same as the code descriptor says it is.  They want to be sure that the physician can provide documentation to support the service that was billed. They rely on tools like the RBRVS and the CPT coding system to try to establish such consistency and auditability.  And the government, in particular, has a statutory mandate to reduce fraud and abuse so that taxpayers don’t pay for a service that is different than the one billed to the government (that’s called program integrity).

From a patient’s point of view, the service isn’t an office visit per se.  It is the doctor’s expertise—but it is also much more than that.  It is how much time the doctor spends with them.    It is whether they have to wait 45 minutes “because the doctor is running late.”  It is whether their doctor clearly explains what is wrong with them and what can be done about it.   It is when and how well the doctor communicates about a worrisome test result.   It is whether they are herded or heard when they ask questions.  It is whether their doctor helps them get well.  Their values can’t be readily captured by CPT code or a so-called relative value unit.

The point is that each of these three perspectives—the physician’s, the payer’s, the patient’s—on what is the fee (and who should decide) and what is the service that is being provided (and how is it described, billed, documented, and validated) reflects their own particular place in the health care system. As such, their interests will inevitably clash.  This is really what the fight over relative values, the SGR, documentation requirements, and balance billing is all about—each one trying to align fee-for-service with their own interests, the physician’s in being able to control his or her own fees, the payer’s in getting the most bang for the buck, the patient in getting care that is centered on their needs at a fee they can afford.   

Of the three, it is patient’s interests that ultimately must be paramount.  As policymakers drive physicians and the system to new payment models (including changes in fee-for-service), they need to ensure that the fee paid gets the patient the best value possible—great outcomes delivered efficiently, but at a rate that  ensures that there are enough skilled doctors to take care of them, not more, not less.  Policymakers need to recognize that from the patient’s point of view, the service being paid for isn’t an office visit, or procedures, or CPT code or RVU per se, it is high quality, patient-centered, compassionate care delivered by a highly skilled physician of their choice.  And policymakers need to recognize that a payment system that devalues a physician’s training, knowledge and skills, that forces them into delivering assembly-line care, and that drives the best out of medicine serves no one’s interest, but especially not patients’.

Today’s question: What do you think about my explanation of the different perspectives that physicians, payers and patients bring to the debate over fee-for-service?