Monday, January 9, 2012

Emptying the Cost Control Tool Kit (Revisited)

“Imagine that it is 2013, and a new President is sitting in the Oval Office... Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs... To make things even more interesting, let's imagine that [although]... expansion of health insurance coverage [was] enacted into law... most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.

What is a new President to do?

Because the most promising approaches to gradually ‘bend the cost curve’ - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out of the health reform law... the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke?”

The above comes from a post I wrote in November, 2009, four months prior to the Affordable Care Act becoming law. I bring it up again because here we are, less than a year from the presidential election, and in my view, things are turning out just as I had feared. Critics of the ACA, mostly from the right, are doing everything they can to discredit even the most modest programs to lower health care costs, while at the same time deriding “ObamaCare” for not controlling costs! The result may be that a new President—are you listening, President Romney, Santorum, Gingrich, Huntsman or Perry?—may have nothing left in the tool kit to tackle health care spending, other than shifting costs onto patients and cutting their benefits. Let’s say that President Obama is re-elected; he too may find that the most effective tools to lower health care spending have been damaged by the political effort to turn the public against them.

Case in point: Grace-Marie Turner’s breathtaking distortion that Washington is funding research on the effectiveness of different medical treatments for the purpose of “setting up the systems to direct doctors to practice Washington-approved medicine.” (Turner is the Executive Director of the Galen Institute, which describes itself as “a non-profit public policy research organization devoted exclusively to advancing free-market ideas in health policy.”)

Independent fact-check organizations long ago discredited the idea that CER “is being used to build a ‘scientific’ case for government rationing of health care” as Turner claims. In August 2009, the Pulitzer Prize winning “PolitiFact” said that a similar claim by [now Speaker of the House] Rep. John Boehner was false, pointing out that “it's a stretch to call giving patients better information about which treatments and drugs are most effective ‘rationing.’ In fact, given specific language in the bill to the contrary, we think it’s outright wrong... to claim the research findings would be used by the government to ration care.” (The law says that “Nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer.”), a project of the Annenberg Public Policy Center, also said that it is “false” to say that CER will allow government to “decide what care I get (a.k.a. they won’t give grandma a hip replacement).” Yet this doesn’t stop the Grace-Marie Turners of the world from repeating this discredited claim over and over again, probably because they know that scaring people into believing that the government will ration their care is the most effective way to undermine support for health reform, facts be damned.

It is this type of shamelessly cynical attack that former CMS administrator Don Berwick decried in uncensored remarks delivered a few days after leaving government:

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels”– the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas…

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

The fact is that the next president, whether it is in 2013 or 2017, will have to deal with the fact that health care costs are rising at an unsustainable rate—and this will be true, regardless of whether the Affordable Care Act survives or not. Empowering doctors and patients by giving them information about what treatments work well, and what doesn’t, is the kind of program that conservatives should embrace, because “markets” don’t work if people do not have the information needed to make a comparative choice. Helping patients make their own decisions about how they want to be treated when their life is coming to an end is good and compassionate care, not a government death panel. But the unrelentingly cynical attacks on such common sense ideas to help improve care and reduce costs may actually work in persuading the public to reject them, leaving the new president with nothing in the tool box other than cutting benefits and raising taxes.

Today’s questions: What is your take on the continuing claims that comparative effectiveness research equals government rationing? And what will this mean for the ability of the next president to lead a discussion on controlling health care costs?


Steve Lucas said...

When Congress returns various pilot organizations will once again introduce legislation to modify the FAA’s Third Class medical. This was last done during the Clinton administration where it was found that there is no evidence that this increases safety.

Since that time additional evidence has been gathered and modifications have been made to other parts of aviation that once again prove safety is not improved with the addition of this requirement.

A recent article by a doctor in an area aviation publication shows the straw man and logical fallacies employed to maintain the current system.

It cost a lot to fly therefore pilots should be willing to spend the time and money working their way through a medical system. This has no bearing on safety and raises any number of questions.

Would instructors like to sign off a pilot with an undiagnosed condition, undiagnosed means that neither the pilot nor their personal physician is aware of the problem. A Third Class medical is not intended to be so thorough as to find undiagnosed problems, it is a review.

Pilots with medical issues are approved to fly. Why then have a system that only adds cost and complexity? The FAA spends tens of millions of dollars maintaining this system and pilots spend hundreds of millions of dollars complying with this system.

The old standby of the current system works, why change? How do you disprove a nonevent?

Then as now I don’t think doctors are sitting around just waiting for a pilot to come in for a physical so they can pay the light bill. Financial hardship was the reason sighted by one doctor’s organization and the reason these changes were not approved over a decade ago.

In my community the Third Class physical is used as a driver for additional test and office visits. Pilots often find themselves passing a test only to find the doctor has made approval conditional upon additional testing.

Doctors either believe, or do not believe, in evidence based medicine. I would hope they would set aside their financial interest and support this move on the part of the pilot organizations. The reality is that pilots interact with their personal physicians and these same physicians do not want to become involved with a government agency. This is where this decision should be made, between the patient and their personal physician.

Disclosure, I am a private pilot and aircraft owner. While a member of AOPA I hold no position within the organization.

Steve Lucas

PCP said...

The gov't has already decided what they are going to do. It is the profession that has to figure out what they each would like to do.
The Gov't wants to promise everything to everyone, put aside a certain percentage of GDP toward that impossible task, allow lobbyists to secure increasingly larger share of that pie to corporate interests, inflate away the dollar somewhat with money printing if necessary, and forcibly or otherwise attempt to extract more from us for less. They even want to show some benevolence toward us by asking us to cut costs after creating the proverbially impossible to feed monster of federalized health care.
Anyone remotely familiar with the workings of the private practice of medicine especially in Primary care is well aware of the poor financial returns available here. This is surely no secret by now. Yet we repeatedly hear about the emerging shortages. It is ironic that Mass. with one of the highest densitynof physicians in the union is struggling with a lack of PCPs. The key point here is that theynare about 3-4 yrs ahead of the nation and if they are in rhis situqtion then what of the rest of the nation.
The control over the practice of medicine needs to be 100% returned to Patients and Physicians, The focus of gov't and insurers should solely be in extracting costs from all other areas, negotiating best prices with providers of all the goods and services.........the corporate interests that have lobbied their way to prosperity.
Look at the stock prices of Insurers, Pharma, PBMs, Home health, etc etc. This so called Trillions or more of "value" created on the back of Medicare dollars, is quite simply phony. Just look at the ROI margins of these companies and it becomes apparent that they are negotiating pretty good deals frpor themselves at the expense of the Doctor-Patient relationship and the public purse.
Instead of fighting this crony capitalism head on, we are squeezing out some of the most most efficient lean operating small business in the land, with some of the lowest margins.
How can anyone justify the role of CHCs, FQHCs, RHC etc. that apparently exist solely on the rationale that their populations are underserved. The void quite simply created by poor reimbursement rates. The void then filled by the aforementioned entities with all their attendant practices. Te stunning aspectofit all for me is that the federak gov't then reimburses these practices at twice sometimes thrice the rate a private practice doctor would recieve if he/ she were to set up shop next door. With such lunacy in federal policy, why is organised medicine doubling down on dumb? Why should we as a profession ask to take less and less? Lets get rid of or fix dumb first.

ryanjo said...

Don Berwick did nothing to change the climate of wasted opportunities and the influence of corporate medicine while he filled the directorship of CMS. He allowed the pharmacy benefit managers to increase harassment of patients & their physicians. He did nothing to help practicing physicians, who continue to be crushed by the paperwork and restrictions that the agency he ran for over a year spews forth. For example, under his management, I now have to fill out a form for home health care to justify signing another form!

So his comments on cynicism are particularly ironic, given that yet another "reformer" has cut and run after finding that the government is pathetically unsuited to manage health care. And then blames the problem on the people -- no longer trusting, sick of government waste & malfeasance. They are looking for alternatives, i.e., the right.

All our medical leadership, including ACP, should follow Dr. Berwick out the door. The only acceptable option of healthcare reform is the patient and their physician in charge.

PCP gives a very concrete example why government reimbursement policy is destructive to the efficiency of medical practice. But you have to listen to the people who live here on the ground floor.

Robert J. Sobel, M.D. said...

Looking back to November 2009, it seems we are seeing very similar arguments. I do think you are being a bit unfair to the criticism. I believe PCP and ryanjo are right on target. My concern on the futility of the current approach remains unwavering. Look at the ACP Internist for February and the intrusion state governments are having on our ability to communicate freely with patients. You really should not defend this authorized harassment (ACA dictates, the extraneous processes inherent in medical homes and pay for performance), especially as it comes from a coercive cost-saving mindset where income is generated by doing less. The call for professionalism rings hollow when it involves further tying us to the service of corporate or government medicine.

I fear the recrudescence of managed care (corporate entities that promise to save states money on Medicaid) is a further act of desperation that will back fire. How can reimbursement to physicians be so discounted, yet the cost of care for a Medicaid patient still approaches Medicare costs? Yes, the population is by definition in a higher risk socioeconomic state. But, I would argue that the financing of the commodities (drug costs, new technologies) are only marginally less expensive and sabotage true cost savings.

The current fight between Walgreens and Express Scripts is one of many I foresee (the former has a fair point, the latter is a profiteering entity that Hatch-Waxman cost disparities engender, even though its m.o. is to demean clinical decisions). It is unfathomable that Dr. Berwick is questioning our professionalism while selling us out to administrative constructs (ACO's) that are unproven and with inherent conflicts of interest. The big entities have won again.

Mr. Lucas' comments are consistently unfavorable to our profession. I have no doubt he is reflecting a modern reality. We should all respectfully address the excesses we may see and the service degradation that can come from high volume medicine. Nevertheless, it is not through further squeezing primary care that solutions will be found. A concerted effort to refinance drugs, regulate for-profit entities, and stream-line the insurance industry into a level, not-for-profit, utility-like financing structure is where we must go. More restrictions on patient and physician behavior are Orwellian and should be strongly condemned. This is not a problem that the proliferation of EMR's and e-prescribing will solve. A replacement of Hatch-Waxman remains a great offset for the SGR fix. Forget the rebate absurdity in the ACA. A fee schedule for the commodities is only fair, especially as it will address the shortage issue that is now pervading the "old drug" market. If you don't protect physicians now, Medicare is in real danger.