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?