Wednesday, February 29, 2012

Much ado about IPAB

Congressional Republicans and some Democrats have set their sights on eliminating the Independent Payment Advisory Board (IPAB) authorized by the Affordable Care Act.

Today, the House Energy and Commerce Committee voted 17-5 to repeal IPAB, with the support of Frank Pallone (D-NJ), the ranking Democrat on the committee. The House likely will take up and pass the IPAB repeal bill later this year. Prospects for IPAB repeal in the Senate are far less certain, but even if repeal were to pass the Senate, President Obama could veto it. So IPAB likely will remain on the books for now.

Even if IPAB survives, it is unlikely to do much of anything for at least another six years. The members of IPAB won’t even be named by the President until 2014—and they would have to first be confirmed by the Senate (where their nominations likely would be subject to a filibuster by IPAB opponents). Then, assuming the President is able to get IPAB members confirmed, the board will submit recommendations to Congress to reduce costs only if spending exceeds a target rate of growth set by the statute. That likely won’t happen until 2018, at the earliest, according to HHS Secretary Kathleen Sebelius. IPAB’s recommendations would then automatically go into effect unless a “Super Majority” of Congress voted to override it. Even so, IPAB is prohibited from making any recommendations to ration health care, raise revenues or Medicare beneficiary premiums, increase Medicare beneficiary cost sharing, or otherwise restrict benefits or modify eligibility criteria.

(You can learn more about how IPAB is supposed to work in “The Internist's Practical Guide to Health System Reform,” published by ACP’s governmental affairs division.)

So IPAB hardly is a clear and present danger to anyone, if it ever will be.

Yet you wouldn’t know that from the rhetoric being hurled at it—with some calling IPAB a “death panel” or “rationing board.”

And, as Don Taylor explains in the Incidental Economist blog, some prominent Republicans—who today are ardent foes of IPAB—proposed similar unelected cost control boards. The Patients’ Choice Act, introduced in 2009 by Rep. Paul Ryan (R-WI), now chair of the House Budget Committee, would have created an unelected quality commission with authority “to make recommendations to the Secretary to enforce compliance of health care providers with the guidelines, standards, performance measures, and review criteria adopted [by the commission]. Such recommendations may include the following, with respect to a health care provider who is not in compliance with such guidelines, standards, measures, and criteria: (1) Exclusion from participation in Federal health care programs . . . and (2) Imposition of a civil money penalty on such provider.”

The point is that many Republicans and Democrats used to agree that an independent board of health care experts and clinicians could help the country decide on the difficult tradeoffs involved in controlling health care costs, outside of the usual political process where powerful health care industry lobbies can effectively block any legislation that hurts their economic interests.

For its part, ACP “believes that an independent board of physicians and other healthcare experts would be more likely to achieve needed Medicare changes, and be less affected by undue special-interest influence,” than Congress. The College believes that the IPAB has the potential to serve this role, but requires some significant modification—including amending the law to allow Congress to reject IPAB’s recommendations with a simple majority vote.

Maybe a future Congress will be able to demonstrate that it can make tough cost control decisions on its own, even if this means going against the special health care interests that fund the lawmakers’ campaigns. Maybe it doesn’t need an independent group of experts who really understand health care to help it figure out the most effective policies—and provide political cover for the unpopular tradeoffs involved. Maybe…but why in the world would anyone believe that Congress is up to the task?

Today’s questions: Do you think an independent board of health care experts is needed to help Congress make decisions on controlling health care costs? What do you think about the argument that IPAB will lead to rationing and “death panels”?

Friday, February 24, 2012

The Candidates offer up a budget fantasyland

“If I had a world of my own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn't. And contrary wise, what is, it wouldn't be. And what it wouldn't be, it would. You see?”
- Alice, from Lewis Carroll’s Alice's Adventures in Wonderland & Through the Looking-Glass, 1865

Alice could have been talking about the budget fantasyland conjured up by the 2012 presidential candidates.

Recall that in his Republican response to President Obama’s State of the Union address, Governor Mitch Daniels (R-IN) promised that if the GOP prevails in the election, 2012 will be “the year we strike out boldly not merely to avert national bankruptcy but to say to a new generation that America is still the world's premier land of opportunity.”

So you might assume then that the Republican presidential candidates have plans to reduce the debt, right?

You might, but you would be wrong.

“The national debt would balloon under tax policies championed by three of the four major Republican candidates for president,” according to an independent study by the bipartisan Committee for a Responsible Federal Budget (CRFB), reported in yesterday’s Washington Post. Former Pennsylvania Senator Santorum would add $4.5 trillion and former House speaker Newt Gingrich would add $7 trillion to the debt by 2021, “pushing the portion of the debt held by outside investors to well over 100 percent of the overall economy,” writes the Post.  Former Massachusetts Governor Mitt Romney's plan would add about $2.6 trillion.

The only Republican with a plan to lower the debt is Congressman Ron Paul, who proposes even bigger cuts in government programs than the revenue that would be lost from lower taxes, bringing down the debt by $2 trillion over the next decade. But Paul assumes a wholesale dismantling of most federal agencies and an end to entitlements—cuts that are not likely to be accepted by a majority of voters or ever be enacted by Congress.

The fact that three of the four GOP candidates would add trillions to the debt doesn’t let President Obama off the hook. In a separate analysis, CRFB finds that the under the President’s proposed FY 2013 budget request, “deficits would total $6.7 trillion (3.3 percent of GDP), with debt reaching $19.5 trillion (76 percent of GDP)” by 2022.

This, from a president who said that “if we don’t act, the growing debt will eventually crowd out everything else, preventing us from investing in things like education, or sustaining programs like Medicare.”

To recap, this is the year when:

the country will elect a new President from a Republican party that promises to “avert national bankruptcy”


we will re-elect a President from the Democratic party who said “if we don’t act, the growing debt will eventually crowd out everything else”

and this is how much more their tax and spending plans would add to the public debt:

Romney: +$2.6 trillion

Santorum: +$4.5 trillion

Obama: +$6.7 trillion

Gingrich: +$7 trillion

“If [they] had a world of [their] own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn't. And contrary wise, what is, it wouldn't be. And what it wouldn't be, it would. You see?

Today’s question: Will the voters see through the candidate’s budget fantasyland and demand real answers on taxes and spending?

Friday, February 17, 2012

“We are playing a silly little game with doctors and Medicare patients.”

This is the best description I’ve heard of the short-term Medicare SGR “patch” that passed the House and Senate today. It didn’t come from a press release from organized medicine, but from someone directly involved in the process, House Minority Whip Steny Hoyer (D-MD). Here is the full quote from his speech today on the floor of the House, minutes before it voted to extend Medicare payments to doctors for another 10 months:

“We are playing a silly little game with the doctors and with Medicare patients, and this silly little game pretends we are going to extend SGR for 10 months. That's baloney and everybody knows it. We are going to extend SGR over and over and over again. We should have done it permanently in this bill. We should have done it permanently last year in the Congress which I was the Majority Leader. We should have done that. So with respect to SGR, ladies and gentlemen, we are playing a game, and the doctors all over this country and the Medicare recipients all over this country know we're playing a game. We're giving them no certainty, no confidence that come this September, October, November, we won't have another one of these silly little debates.”

Now, a cynic would point out that Congressman Hoyer is a Democrat in a Republican-controlled House, so it is easy for him to take pot shots now. But at least he was honest in saying that getting rid of the SGR should have been done permanently last year when his party controlled the House and when he was the Majority Leader.

So maybe we should all stop referring to the Sustainable Growth Rate as the SGR, and start calling it the SLG—Silly Little Game—that has been played by Washington politicians from both political parties on doctors and patients for a decade now. But it won’t seem so silly, or much like a game, when patients no longer can find a doctor.

Today’s question: Are you going to tell your members of Congress to stop playing this silly little game with you and your patients?

Thursday, February 16, 2012

A surgeon, an internist and a family physician walk into . . .

. . . a congressional office (sorry, not a bar!), and actually speak with one voice on an important health care issue. No joke! Despite the reputation that doctors (deservedly so) have for not being able to agree on much of anything when it comes to health care policy, the American College of Surgeons, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association recently joined forces to lobby Congress on repeal of the Medicare Sustainable Growth Rate (SGR) formula.

And, when it became clear last night that Congress would not go along with repeal, the groups today collectively told Congress that the announced deal to extend the current Medicare rates for 10 months “neither solves, nor moves us closer to solving, the Medicare physician payment crisis.” The doctors noted that after the extension expires, the next cut will be steeper—an estimated 32 percent cut on January 1, 2013—and that “as a result, the threat to access will be greater, the budget price tag to eliminate the cut will be even higher, and the barriers to comprehensive payment reform will be even steeper.”

The four organizations represent a combined membership of nearly 400,000 physician and medical student members, which if they were one organization, would make them by far the largest single physician membership organization in the United States, representing almost 65% of all active U.S physicians! The AMA remains the largest single physician membership organization, with about 215,000 members in 2010, the most recent information I can find. ACP is second, with 132,000 members. (This is not to say that the loose coalition formed by the four specialty membership groups can or should replace the AMA—there remains a need for a national membership organization whose membership includes all physicians, without regard to their specialty, and includes strong representation from geographic (state) societies. The AMA is the only organization that fits the bill.)

But if ACP, ACS, AOA, and AAFP can continue to find common ground, just think about how much influence they could carry—and how much good it could do for the public! Even the idea that surgeons and primary care physicians can agree defies the usual expectation that their economic interests inevitably will collide with each other.

Now, I am not being Pollyannaish about the possibilities of cross-specialty collaboration. The potential for conflict remains, especially if the issue is one of redistributing dollars from one group of specialties to another. But as I look at the big issues facing medicine, I sense that there are wonderful opportunities for surgeons, internists, and family physicians, both MDs and DOs, to find common ground on such things as:

· Promoting high-value, cost-conscious care
· Ensuring that there are enough physicians in all fields to meet the demand for health care services
· Improving coordination and transitions of care
· Reducing red tape and regulatory hassles
· Reducing the costs of defensive medicine
· Influencing new models of health care payment and delivery, from ACOs to patient-centered medical homes
· Ensuring that health information technology works to the benefit of both physicians and patients
· Establishing team-based models of care that recognize each specialty’s contributions, and the contributions of non-physicians (including nurse practitioners and physician assistants)

Collaboration on such issues for the purposes of health care advocacy would parallel the movement at the practice level away from “siloed” physician practices to team-based and collaborative models.

It may take some time for the four biggest specialty organizations, and the specialties they represent, to put aside decades of suspicion and distrust, resulting mainly from battles over redistribution of money under the RBRVS, but the potential is there. This initial collaboration of ACP, ACS, AAFP and AOA may not have won the day (yet) on the SGR, but it was an important step forward to bringing the largest and most influential specialty organizations together. And that may have been the best thing to come out so far from what otherwise is another huge disappointment from Congress’ ongoing failure to fix the SGR.

Today’s question: Do you think surgeons, family physicians, and internists, DOs and MDs, can speak with one voice on critical health care policy issues? On which issues? And what should the next step be in the emerging relationship between ACP, ACS, AOA, and AAFP?

Wednesday, February 15, 2012

Here they go again

Congress is expected to reach final agreement tonight on another "patch" to the Sustainable Growth Rate (SGR) cuts: 10 month continuation of current (2011) rates, followed by a 32% cut on January 1, 2013. In other words, the same old thing that Congress has been doing year-after-year, month-after-month: enact a patch that puts off a long-term solution. Even worse, the patch, like the others before it, will only make the next cut bigger (from 24.7% now to 32% on January 1). And, as the cut gets bigger, the cost to the budget of preventing it--and all future scheduled cuts--grows by tens of billions of dollars.

What is particularly difficult to understand is that Congress had an exit ramp this year from the whole SGR debacle. It could have used unspent money from overseas military operations that will never take place to prevent cuts from the SGR that Congress will never allow to happen. This would have produced more than enough money for Congress to fully repeal the SGR, without having to offset the cuts by goring someone else's ox. Just about every physician, hospital and seniors group had urged Congress to take this exit ramp but in the end, it decided to stay on the same familiar path of putting off the solution (and finding the money for it) to another day, another time.

To be fair, there were some members of Congress, Republicans and Democrats, who urged their colleagues to use the unspent operations money to get rid of the SGR, once and for all, but unfortunately, they didn't carry the day.

Where does this leave organized medicine? I expect it will fall to a post-election, lame-duck session of Congress to come up with a plan to eliminate the January 1, 2013 SGR cut, as well determining the future of the Bush tax cuts (also expires at the end of the year) and across-the-board budget sequestration cuts scheduled for 2013. ACP will continue to push for a permanent solution as the only right thing to do--but I wouldn't bet on it.

Some of you will no doubt want to blame one political party or the other. But the fact is that an institutional failure to enact a permanent solution to the SGR has been the legacy Congress' and administrations stretching back to 2002, the first time an SGR cut went into effect, no matter which party was in control at the time.

And some of you no doubt will blame your professional organizations for Congress not enacting a permanent solution. Criticism is fair game, and I would welcome ideas on what we might do differently next time. But other than taking steps that violate physicians' own professional ethics, like organizing strikes and boycotts, I can't think of what we might have done or do differently.

Today's question: What will you say to your members of Congress about the latest SGR patch?

Tuesday, February 14, 2012

“My love for you is like health care cost growth: out of control”

Policy wonks have a reputation as being rather serious folks who can talk incessantly about things like medical loss ratios, CBO scoring, and risk pools – not exactly fodder for a knee-slapping good time or a romantic night on the town.

But many of us do have a sense of humor, as evidenced by the Health Policy Valentines shared on a new Twitter hash tag. The hash tag, started by a federal government staffer to share with her friends, has gone viral, getting thousands of responses and inviting attention from the Washington Post and New York Times, among other “mainstream” media. (For those of you who are not Twitter savvy, a hash tag is a way of organizing Twitter discussions around a central theme. So the #happyvalentinesday hash tag allows Twitter subscribers to create and share their own health policy-related Valentines.)

But you don’t need to be on Twitter to enjoy the Health Policy Valentines. The headline for this post is one of my favorites, written by Sara Kliff, a health reporter for the Washington Post. I wrote and Tweeted several myself (my Twitter “handle” is @bobdohertyACP if you want to follow me):

Will our love have a sustainable growth rate? Or will our hearts be broken, year after year after year?

Hey, sweetheart, the CBO isn't the only one who knows how to score!

My love, I'll define my contribution if you'll define my benefit.

Sweetheart, I've paid into this relationship for all these years, so I'm entitled to be your Valentine.

My love, please don't repeal and replace me!

I'll show you my medical loss ratio if you'll show me yours!

If love was like health reform, does that mean that people could shop around for a better deal through an exchange?

If love was like health reform, it would be universal and portable. Kind of like San Fran in the Summer of Love.

If love was like health reform, everyone would have to have a partner, or pay a penalty.

Is a broken heart a pre-existing condition? If so, will you mend mine or exclude me?

I promise to be true to you in good times and bad, with guaranteed renewability and no life-time limit on my love.

Some of my favorites (not penned by me):

No court would ever strike down this love!

You are my statistically significant other.

Roses are red, violets are blue, I could never ration my love for you!

How about trying your hand and posting your own Health Policy Valentine as a comment to this blog? And Happy Valentine’s Day!

Today’s question: Can you write and post a Health Policy Valentine, in 140 characters or less?

Wednesday, February 8, 2012

The Myth of the Well-heeled Senior

One constant public policy challenge is that some things that people fervently believe to be true—often based on their personal observations—just aren’t so. Take the myth that most senior citizens are well-off—and can afford to pay more for their health care.

If you believe this to be true, then it makes eminently good sense to raise Medicare co-payments. Or to lift the restrictions on doctors charging more than Medicare’s approved amounts. Or to give seniors a voucher so they can shop around for coverage, even if though this might mean they would have to pay the difference between the voucher amount and the actual premium. They can afford it, right?

Not really. Most seniors are less Warren Buffet and more all-you-can-eat buffet types, searching for ways to stretch their limited fixed incomes. The Census Bureau’s data on household income by age shows that the median income for households whose occupants are 65 and older is only $31,354, the lowest of all groups except those aged 15-24. For all households, all ages, the median is $49,177.

There’s more. Crunch the Census Bureau numbers, and you’ll find that 47% of senior households have incomes of less than $25,000. Twice as many senior households reported incomes below $15,000 (19%) as those with more than $100,000 (9%). Some 12% of senior households have incomes between $50,000 and $75,000. Thirty percent of senior households have incomes between $25,000 and $50,000.

[Note that the above figures are from 2009 Census data, the most recent I could locate. Given the deep and abiding economic slowdown since then, there is no reason to expect that things are much different today.]

And the Census Bureau data probably overstates individual seniors’ incomes. A study by the Urban Institute for the Kaiser Family Foundation reports much lower median incomes for Medicare beneficiaries, most likely because the Census Bureau data cited above is for households with occupants age 65 or older, which may include more than one senior in the household. The 2010 median income for individual seniors, according to the Urban Institute study, was only $22,000, and less than 1% had incomes above $250,000. Most also had very limited assets and savings.

Also, most seniors depend on Social Security for their incomes. “For more than half (55%) of elderly beneficiaries, Social Security provides the majority of their cash income. For one-quarter (26%), it provides nearly all (more than 90%) of their income. For 15% of elderly beneficiaries, Social Security is the sole source of retirement income,” reports the Center for Budget and Policy Priorities.

And seniors on Medicare already pay a lot for their health care. Another study for the Kaiser Family Foundation finds that “median out-of-pocket health spending as a share of income increased from 12% in 1997 to 16% in 2006,” and “1 in 4 Medicare beneficiaries spent 30% or more of their income on health expenses in 2006; while 1 in 10 beneficiaries spent more than half their income on health expenses.”

So here’s the rub: many of the proposals to reform Medicare essentially shift more costs to seniors, or at least to some of them—through vouchers, higher deductibles, higher co-insurance, or raising the age of eligibility—yet most seniors don’t have the means to pay more. Some surely could, of course—and from a fairness point of view, plus bringing in some more revenue, it might make sense to ask them to pay more. But it won’t bring in enough revenue to solve the fiscal crisis facing Medicare, and it could put many seniors at risk of not being able to afford their health care. Is that what we really want to do?

There also are strong arguments—like the right of patients and physicians to privately contract for services—that can be made for lifting the restriction on doctors charging seniors more than Medicare’s approved amount, especially as long as the government continues to threaten them with double-digit cuts because of the Medicare SGR formula. But let’s not kid ourselves: relatively few seniors have the financial resources to make up the difference between what Medicare pays and what their doctor considers a fair fee. And can physicians really know which of their patients can afford to pay more and which ones should be charged less? Even seemingly well-off patients may not be doing as well as they seem, and many might not want to discuss their personal financial circumstances with their doctor. Appearances, after all, can be deceiving.

It is undeniable that the financing structure for Medicare will need to be changed, and some recipients will have to pay more for it. But we need to proceed with caution, and not allow the myth of the well-heeled senior to drive public policy decisions, when most seniors are just getting by.

Today’s question: What is your reaction to the data that most seniors are not well-off, and what do you think it means for proposals to require them to pay more?

Wednesday, February 1, 2012

A tip of my hat to ACP’s physician leadership

One of the things that I like most about my job is engaging with ACP’s physician leadership—the internal medicine doctors who dedicate enormous amounts of time, at great personal sacrifice, to represent the interests of our members and their patients.

One of the things that I like least is when an ACP member (or non-member physician) caustically dismisses their efforts, usually because they disagree with some aspects of ACP policy. It is one thing to disagree with ACP’s policies and priorities or to be frustrated with the pace of change, but it is another thing altogether to label your colleagues (whom you probably don’t even know) as being “out of touch” or “Ivory Tower” doctors! I can’t think of anything that is more insulting to physicians than a colleague implying that they aren’t “real” doctors taking care of real patients.

Why am I worked up about this today? Because yesterday I witnessed what ACP’s physician leadership do for ACP’s members and the enormous challenges and sacrifices involved. Yesterday, ACP’s president, Dr. Virginia Hood, and ACP’s chair of the Board of Regents, Dr. Yul Ejnes, came to Washington to join with the leaders of the other three largest national specialty societies to lobby Congress to end the cycle of Medicare payment cuts, once and for all. Along with the leaders of the American College of Surgeons, the American Osteopathic Association, and the American Academy of Family Physicians, they spent a grueling day meeting with 22 members of the House and Senate and their staffs to urge SGR repeal, paid for by money that has been budgeted—but will never be spent—on military operations in Iraq and Afghanistan.

What did this involve? Drs. Hood and Ejnes had to come in on Monday night, after a full day at their real jobs—being internal medicine physicians. To be here, they had to reschedule all of their Tuesday appointments, when I know that inconveniencing patients is the last thing they want to do. On their flights to DC and late in their hotel rooms, they had to read arcane explanations of how the Congressional Budget Office “scores” federal spending (not exactly what they learned in medical school!) They had to be at a 7:30 a.m. breakfast on Tuesday to meet their counterparts from the other participating societies and to be briefed in advance of the Hill meetings. Then, they spent the rest of the day being directed around Capitol Hill to their respective meetings, one after another, all day long.

And the Hill meetings themselves were hardly a walk in the park. Yes, some of the members of Congress and their staff welcomed them enthusiastically and indicated support for their request. Others listened politely but didn’t commit. Others were at best skeptical. Some lectured the doctors and tried to get them to choose sides in the partisan fight over health reform. A few were even dismissive or hostile.

What did they accomplish? Lobbying is a slog, and we won’t know for a few more weeks what Congress is going to do about the SGR. But we know that the good doctors accomplished one very big thing: they showed Congress that the four largest national physician specialty organizations, representing more than half a million doctors, speak with one voice on the need to repeal the SGR. And by taking the time to come to Washington, they showed Congress how deeply they care about patients and their profession—as only real doctors who take care of real patients could do.

So I hope that next time you know of someone who is tempted to blast ACP’s leadership as being out of touch, remind them of this: ACP’s leaders are just like them, except that they have chosen to dedicate a substantial portion of their professional lives to organizational efforts to make things better for their colleagues and their patients.

And by doing so, they are living up to Alexis de Tocqueville’s famous 1831 observation that:

“Americans of all ages, all conditions, all minds constantly unite. Not only do they have commercial and industrial associations in which all take part, but they also have a thousand other kinds: religious, moral, grave, futile, very general and very particular, immense and very small; Americans use associations to give fĂȘtes, to found seminaries, to build inns, to raise churches, to distribute books, to send missionaries to the antipodes; in this manner they create hospitals, prisons, schools. Finally, if it is a question of bringing to light a truth or developing a sentiment with the support of a great example, they associate.”

Yesterday, Drs. Hood and Ejnes came to Washington to unite with other physicians to bring light to a truth and develop a sentiment in Congress to end Medicare cuts, using their own great example as internal medicine physician specialists who care deeply about their patients. I tip my hat to them. They would have made de Tocqueville proud.

Today’s question: What do you think of my view that it is simply wrong for physicians to dismissively label the leaders of ACP (and other professional associations) as being “out of touch” and “Ivory Tower” doctors (no matter what you think of the organizations’ policies)—when in fact they are real doctors, taking care of real patients, who have chosen to live up to de Tocqueville’s perhaps idealized view of America?