Thursday, December 19, 2013

The Twelve Weeks of Obamacare

On the first week of Obamacare, The government gave to me
A promise of good healthcare, for me and my family

On the second week of Obamacare, the government gave to me
A website that wasn’t working
And a promise of good healthcare, for me and my family

On the third week of Obamacare, the government gave to me,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family

On the fourth week of Obamacare, the government gave to me,
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the fifth week of Obamacare, the government gave to me,
Navigators that weren’t navigating
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the sixth week of Obamacare, the government gave to me,
Call centers that weren’t calling
Navigators that weren’t navigating
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the seventh week of Obamacare, the government gave to me,
More time to sign up
Because of call centers that weren’t calling
Navigators that weren’t navigating
To replace a plan that needed replacing,
Requiring a tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the eighth week of Obamacare, the government gave to me,
Eligibility for premium tax credits,
More time to sign up,
Because of call centers that weren’t calling
Navigators that weren’t navigating
To replace a plan that needed replacing,
Requiring a tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the ninth week of Obamacare, the government gave to me,
More information on my health plan choices,
Eligibility for premium tax credits,
More time to sign up,
With help from call centers that started calling
Navigators that started navigating
To help me replace a plan that needed replacing,
With a tech surge to start repairing
A website that had begun working
And a promise of good healthcare, for me and my family.

On the tenth week of Obamacare, the government gave to me,
No lifetime limits on my coverage,
More information on my health plan choices,
Eligibility for premium tax credits,
More time to sign up,
With help from call centers that started calling
Navigators that started navigating
To help me replace a plan that needed replacing,
With a tech surge to start repairing
A website that had begun working
And a promise of good healthcare, for me and my family.

On the eleventh week of Obamacare, the government gave to me,
A plan with no pre-existing condition exclusions,
And no lifetime limits on coverage,
Selected from a menu of health plan choices,
With eligibility for premium tax credits,
And with more time to sign up,
And help from call centers that started calling
And navigators that started navigating
I was able to replace the plan that needed replacing,
Thanks to a tech surge that was successful in repairing
A website that finally was working
So I could have good healthcare, for me and my family.

On the twelfth week of Obamacare, the government gave to me,
Confirmation that I had actually enrolled!
In a plan with no pre-existing condition exclusions,
And no lifetime limits on coverage,
Selected from a menu of health plan choices,
With eligibility for premium tax credits,
And with more time to sign up,
And help from call centers that started calling
And navigators that started navigating
I was able to replace a plan that needed replacing,
Thanks to a tech surge that was successful in repairing
A website that finally was working
So I now have good healthcare, for me and my family.*
*As promised

To the readers of this blog, I hope you enjoyed my tongue-in-cheek adaption of the Twelve Days of Christmas to describe the roll-out of Obamacare.  I will be taking the next two weeks off for vacation and the Christmas and New Year’s holidays, so this will be my final post of 2013. 

As always, I have enjoyed sharing my thoughts in this blog about the latest in health care policy, and I appreciate hearing back from you (yes, even when you don’t agree with me).  For what it matters, according to, this blog got approximately 573,000 page views in 2013, and 1,870,621 since I started writing it in July, 2007, not counting this post.  Thank you!

Today’s question:  No question, just my wishes to you for a Happy Holiday and New Year!

Tuesday, December 17, 2013

What Should Physicians Expect When the ACA goes live on January 1?

Starting on January 1, the ACA will begin to transform how millions of Americans get health insurance coverage, although most of us will find that the plans offered by our employers are largely unchanged because they measure up to federal standards.  To the extent that some employers are imposing "negative changes, which include higher premiums, co-pays and deductibles, they've all been happening for more than a decade" because of employers wanting to curtail their health benefit costs. "Nor are there any signs that the Affordable Care Act has accelerated the trend."

Yet Obamacare will continue to be blamed for any changes in healthcare that the public dislikes.  Critics of the law will continue to stoke groundless fears in their relentless efforts to oppose and undermine it.  It will be important for supporters of the ACA to provide accurate information on what the law does including the better consumer protections it offers most of us that have insurance, like no lifetime limits on coverage, and access to affordable coverage for millions of uninsured persons--while acknowledging that not everything will be hunky-dory on January 1. 

There will be problems and unintended consequences, especially in the early start up months.  Physicians especially, need to be prepared for concerns and problems that will occur in the new year as patients show up with insurance that differs from what they had before, if they even had insurance before the ACA.  Especially for the heretofore uninsured, learning what health insurance does, and doesn't do, for them will be a steep learning curve.

Here are five things physicians need to be prepared for that can or will happen on or after January 1:

1.  There will be more Medicaid patients, a lot of them, many of them won't have a personal physician so will be looking for a physician who will agree to see them. They will be very low income people who were uninsured before, so this is good news overall, but it remains to be seen how many physicians will be available and willing to accept larger numbers of Medicaid patients.  How many there are will also be highly variable, depending on whether the physician and patients are in a state that is going along with the Medicaid expansion.  This is one reason that ACP is asking Congress to extend the Medicaid primary care pay parity program, set to expire at the end of 2014, for at least two more years. This program, created by the ACA, pays primary care physicians and some medical specialists no less than the Medicare rates for designated services provided to Medicaid enrollees.

2.  Patients who select silver and bronze plans will have substantial cost-sharing requirements (60-69% of the value of the covered benefits for bronze, 70-79% for silver).  For previously uninsured people, even a plan with high deductible/co-pays is better than having no coverage at all, and for their physicians, it is better than the care they provide to these patients being entirely uncompensated.  Also, the high deductibles are mitigated to some degree by first-dollar (no cost to the patient) coverage for USPSTF preventive and screening tests and procedures. Total out of pocket expenses are capped at approximately $12,600 for a family, and $6,300 for an individual, with reduced cost sharing for those with incomes up to 250% of the FPL.  (And of course the uninsured who are now able to get Medicaid generally will pay little or nothing out of pocket).  Also, most of the people buying coverage through the exchanges will get tax credit subsidies that limit the amount they must pay for premiums, pegged at a silver plan level. Still, for some patients, especially those who are new to health insurance or who had lower deductibles under their "cancelled" individual insurance plans, the high cost sharing could be problematic, and they may not realize that they have to pay their physician out of pocket until the deductibles or total out of pocket limits are reached.

3.  The prescriptions their physician has ordered for them may not be on the formulary exchange plan they chose.  This is particularly a concern for patients who must receive treatment for an ongoing chronic condition, like HIV, or an acute condition like a cancer patient getting chemotherapy.  Health plans offered through the exchanges should be transparent in what is included in the formularies and the criteria they use for making such determinations, and have an exceptions or appeals process for patients whose drugs are not covered, similar to what exists under Medicare Part D.  The administration's request to insurers that they continue to cover such drugs for patients with acute conditions may help, but a regulatory fix may be needed.  At the same time, it is not realistic to demand that all prescriptions be covered if the evidence does not support their effectiveness compared to other available prescriptions. And since many insurance plans in the traditional individual insurance market did not include any medication coverage, patients overall will benefit from the ACA's requirement that all plans cover medically appropriate drugs in all categories.

4.  Physicians or their hospitals may not be in the network of the exchange plan the patient chooses.  We don't know how often this will be the case, and narrow networks are becoming increasingly common under Medicare Advantage and private insurance unrelated to the ACA.  There should be an exception process to treat a physician as an in-network provider for patients who are undergoing treatment for an acute condition, especially if the physician is willing to accept the network payment rates.  There needs to be transparency in how insurers make these decisions.  The federal government and states should ensure that the ACA's network adequacy standards are being met, not just the letter of the law but in spirit.  Physicians should be able to challenge being "de-selected." And patients should have real time and accurate info on participating network providers when they choose a plan through the exchange.

5. Some patients may think they successfully signed up for insurance but their insurance company doesn't know it.  This could be the case if the patient didn't pay the premium by December 31, the new deadline set by the administration.  Or it could be the case if the federal government's troubled didn't provide accurate enrollment information to the insurance company, a problem the federal government insists is mostly solved but the insurance industry says continues to a problem.  In this case, physicians may not know for several weeks if their patient had insurance, and who to bill for services provided during the interim.

I brought many of these issues up at a White House meeting that ACP's CEO Dr. Steve Weinberger and I attended last month, and we will continue to seek answers and solutions. The administration subsequently took steps to work with the insurance industry to mitigate some of these and other issues.  But more will likely need to be done as we learn what issues arise on or after January 1.

The fact that not everything will go exactly as was intended by the ACA when most of its biggest changes start to go live at the start of the new year should surprise no one.  Health care is complicated, our health insurance system is even more complicated, people--even the usually well-informed--don't understand it, and the ACA is trying to put in place complicated changes in coverage to close gaps in this very complicated and complex system, even as many are doing everything they can to make it fail. But the policies it is trying to implement are necessary and appropriate as a matter of social justice: no one in America should have to go without health insurance because of their age, their health status, their gender, where they live, where they work, and how much they make.  In a less polarized political environment, the mantra as problems arise with ACA implementation would be fix it, not nix it.  Until we get to that point, we'll have to muddle through, documenting problems as they come up and seeking the most feasible solution available given the political constraints. 

Today's question: what do you think will be the biggest "nuts and bolts" challenges for physicians and patients when the ACA's coverage expansions start to go live on January 1?

Thursday, December 12, 2013

Congress Takes Giant Step Toward Repeal of Medicare SGR

At a time when Republicans and Democrats, House and Senate, can't seem to agree on anything, Medicare physician payment reform is the exception to the rule.  Today, the House Ways and Means and Senate Finance committees reported out nearly identical bills to repeal the Medicare SGR formula and begin to move Medicare more rapidly toward paying physicians based on quality improvement activities--the closest Congress has ever gotten to reaching a bipartisan, bicameral accord on permanently repealing the SGR.

Today's action is not the end of the story, though.  The House recesses on Friday for its annual holiday break and the Senate will recess next week.  When Congress returns in January, the House must first reconcile the Ways and Means bill with an earlier (but similar in many respects) bill approved unanimously in July by the House Energy and Commerce Committee, which shares jurisdiction with Ways and Means on Medicare physician payment issues. Then, the House and Senate must reach agreement on an identical bill that can pass both chambers.  And perhaps the biggest hurdle is to find about $120 billion in offsets (cuts or higher fees to someone else) to pay for it all--a difficult task that will test the fragile bipartisanship that has gotten Congress to this point. 

In the meantime, Congress was also expected to pass a three month bridge to prevent the near 25% SGR cut scheduled for January 1, 2014--replacing it with a 0.5% update through March 31, 2014.  The thinking is that this will give Congress time to wrap up agreement on the permanent SGR legislation and budget offsets during the first quarter of next year.

ACP supports the bills reported out today, even as we will continue to seek improvements.  We had a direct hand in developing many of the policies behind them, getting positive changes in them throughout the process, and rounding up votes for them. We organized coalition letters with AAFP and AOA, and the Internal Medicine coalition letter. 

The bills are not perfect--what is?  We haven't gotten everything we want--who does? But compared to current law--which has resulted in scheduled (and growing) cuts year after year, for more than a decade now--the bills reported out today are a huge improvement.  Here are ten reasons why. The bills:

1. End the SGR cuts forever.
2. Add $120 billon to physician pay over the next 10 years.
3. Cancel the 2016 PQRS Meaningful Use penalties.
4. Provide a 5% bonus to physicians in new alternative payment models, such as PCMHs and ACOs.
5. Create options for physicians to earn positive updates for participating in a new Value-based payment program.
6. Combine and harmonize the existing Medicare PQRS, Meaningful Use, and Medicare Value Modifier Index into a single VBP reporting program.
7. Establish a process to improve the accuracy of relative value units (RVUs).
8. Provide funding to help smaller practices successfully participate in the new value-based payment program or in alternative payment models.
9. Increase federal funding for development of quality measures
10. Helps ensure that Medicare patients will continue to have access to physicians, the most important of all the changes it makes from current law.

And finally, there is now a chance that 2014 will finally be the year that we can move on from constantly having to re-fight the SGR battle, so we can concentrate on other things--like addressing administrative requirements that take time away from the patient-physician relationship.  Now, wouldn't that make for a happy new year?

Today's question: What is your reaction to the steps Congress took today to enact permanent repeal of the Medicare SGR?

Tuesday, December 3, 2013

Why I Fight for Obamacare

Readers of this blog and my tweets know that I am a passionate advocate for the Affordable Care Act, or Obamacare if you prefer.  It isn’t that I have a Pollyannaish view of the law itself, or the tortured political process that produced it—far from it. The ACA is an imperfect law, created by imperfect people through an imperfect process, with imperfect results. After almost 34 years of experience in Washington advocating with Congress and federal agencies, no one needs to tell me about the difficulties involved in successfully legislating and implementing the kind of sweeping changes required by the ACA. 

Yet, I will continue to fight for successful implementation of the Affordable Care Act, warts and all, and against efforts in Congress or by the states to undermine, block, defund or repeal it.  Here’s why:

First, my employer, the American College of Physicians, supports the ACA, and I am professionally obligated and personally committed to doing everything I can do to advocate for the policies established by our Board of Regents.  If I was unable or unwilling to advocate in support of the ACA, I would seek different employment.

Second, and more to the point, I am proud to work for a physician organization that has championed the cause of universal health insurance coverage for more than two decades now, and which today views the ACA as the best chance this country has had to ensure that nearly all Americans will have access to coverage.  That the College would be in favor of a law that has the potential to expand coverage to up to 95% of all U.S. resident should have come as no surprise to anyone who has followed ACP policy. 

In May, 1990, ACP said that, “A nationwide program is needed to assure access to health care for all Americans, and we recommend that developing such a program be adopted as a policy goal for the nation. The College believes that health insurance coverage for all persons is needed to minimize financial barriers and assure access to appropriate health care services.”

In 1992, the College editorialized in the Annals of Internal Medicine that, “No one should go without medical care for lack of money.  As physicians, we struggle daily against the chaos of illness and injury, whether in the context of clinical, laboratory, or administrative practice.  We try our utmost to restore or to preserve health, yet the lack of access to care for many Americans increasingly frustrates our best efforts.  In this issue of Annals, the American College of Physicians proposes a plan to ensure high-quality care for everyone.”  The editorial was accompanied by a policy paper that proposed specific policies to achieve universal coverage. 

ACP later went on to support the Clinton health care plan, and after that plan failed to get through Congress, promoted incremental steps to expand coverage. Then, in 2002, ACP proposed its own plan to get everyone covered through tax credit subsidies to buy private health insurance plans offered through state marketplaces and by expanding Medicaid to everyone below the federal poverty level (sound familiar?), phased in over seven years.  ACP’s plan was the basis of bipartisan legislation introduced in consecutive Congress’s by Senators Jeff Bingaman (D-NM), Steve LaTourette (R-OH), and Marcy Kaptur (D-OH).  ACP’s proposal was updated in 2008 to recommend giving the states more options to develop their own plans for universal coverage.  Then, in February, 2009, ACP called on newly elected President Obama and the 111th Congress to “provide affordable and accessible health care to all Americans.”   On January 15, 2010, ACP offered Congress detailed recommendations on the bills making their way through Congress to deliver on President Obama’s commitment to enact guaranteed coverage for all Americans, which later became the Patient Protection and Affordable Care Act (Affordable Care Act).  One month before the ACA became law, ACP issued a statement of overall support for the bill, citing the many specific policies in it that were aligned with the College’s own policies. 

The version of the Affordable Care Act that passed Congress a month later was almost identical to ACP’s own proposals, going as far back as 2002, to expand Medicaid to all persons at or near the federal poverty level, to require that large employers provide coverage, and to provide tax credit subsidies for people to buy qualified coverage through state-run marketplaces.

So why, then, do I fight for the ACA?

Because it is the position of the American College of Physicians—developed over many decades of analysis, and consensus--that every American should have guaranteed access to health insurance coverage, no matter where they work or live or how much they earn.

Because universal coverage is a moral and medical imperative.

Because the ACA comes close to providing universal coverage.

Because the ACA’s key policies, including tax credits to buy qualified health plans and Medicaid expansion, are identical to the College’s own proposals.

Because if the ACA fails, we will have turned our backs on the tens of millions of our fellow Americans who are at greater risk of living sicker and dying younger, simply because they lack health insurance.

Oh, and one more thing:, this is personal.  I have spent my entire professional life fighting to expand coverage for the uninsured, only to see it fail, time and time again, because of unrelenting political and ideological opposition. I first started working as an advocate for internal medicine at the American Society of Internal Medicine in January, 1979.  Since then, I have seen the cause of universal coverage fail under successive administrations and congresses.  I have seen it fail despite all of the well-meaning reports and commissions that challenged us to do better.  I have seen it fail as the number of uninsured has grown, year after year, decade after decade. I lived through the debacle of President Clinton’s failure to achieve universal coverage, and then I saw it put aside for another 16 years, until President Obama vowed to try again.  I lived through the contentious debate preceding the ACA’s enactment in March, 2010.  I am living through the ongoing political wars to block, defund, or repeal it.  I am living through the challenges created by the law’s troubled implementation. 

But if I have any influence whatsoever, I am not going to watch it fail this time, not when we are so close to providing affordable coverage to nearly all Americans, the  moral and medical imperative described by the American College of Physicians almost a quarter century ago. 

Today’s questions: Is the ACA worth fighting for? Why? Or why not?

Tuesday, November 26, 2013

Guess what! Obamacare is working . . .

…quite well, in some places, for quite a large number of people.  But you wouldn’t know that from the constant media drumbeat about the problems with the enrollment portal and the relatively small percentage (fewer than 6%) of the population whose individual insurance policies have to be replaced because they don’t meet the law’s benefits and ratings standards.

Now, before I get a rash of comments about how I can be so na├»ve about the problems with the Obamacare launch (I know, I will probably get them anyway), let me state from the outset that it is inexcusable that the administration launched an enrollment website,, that clearly was not ready.   It is completely inexcusable that a toxic combination of poor management, politics, under-performing contractors, and an apparent complete lack of transparency and accountability resulted in such a chaotic launch.  It is also clear that the President’s promise—“if you like your health plan, you can keep it”—was false.

The website problems, the cancellations, and Obama’s broken promise have led to weeks of negative news stories about Obamacare.  Support for Obamacare has fallen as result, although most Americans do not want it repealed.

Some have pointed to the roll-out problems as evidence that Obamacare is fundamentally doomed because, as Bill O’Reilly claims, “the federal government is not capable of running the health care system.”

But the fact is that Obamacare already is working as it is supposed to in many states.  Just look at California and Kentucky.  California is a “blue” (reliably Democratic) state that is so large that it often is a national trendsetter, although it also is the state with the biggest numbers of uninsured behind Texas.  Kentucky is a small, poor, southern state that votes “red” (reliably Republican) in presidential elections, although it has a conservative Democratic governor and legislature.  They couldn’t be more different, except when it comes to the ACA: both states are fully on board with Obamacare, and both are having very promising initial success in signing people up.

Kaiser Health News reports that as of November 19, 80,000 people had signed up for coverage in California’s ACA marketplace, and nearly 23% were between the ages of 18 and 34, which “more or less matches their makeup statewide.”

Kentucky’s rollout also is going smoothly.  The Washington Post published a striking account of the poor, rural Kentuckians who are signing up in droves for ACA coverage, and what it means for them and their families. “If the health-care law is having a troubled rollout across the country, Kentucky — and Breathitt County in particular — shows what can happen in a place where things are working as the law’s supporters envisioned,” writes Post reporter Stephanie McCrummen.  She tells us about Courtney Lively, “who has been signing people up since the exchanges opened in early October.” Lively told her that, “people have been ‘pouring into’ her office” and “one woman cried when she was told she qualified for Medicaid under the new law.”

But it isn’t just California and Kentucky where Obamacare enrollment is picking up.  The fourteen states running their own marketplaces are reporting an “enrollment surge,” doubling enrollment to about 150,000 from 79,000, according to state and federal statistics.

So if Obamacare is fundamentally unworkable, as it critics claim, then how can it be working in California, Kentucky and most of the other 12 states that are running their own ACA marketplaces?  And if it isn’t working so well, so far, in the remainder that are being funneled through the troubled website, isn’t that at least partly the fault of the governors of those states that chose not to set up their own marketplaces, leaving it to the feds to do the job for them?  And if the federal government fundamentally is incapable of running a health care system, then how do we account for the fact that it has been successfully running Medicare for 48 years now, and very few Americans (even die-hard conservatives) are in favor of ending government-run Medicare as we know it?

It would take Rose-colored glasses to not see that the federal government’s  incompetence in rolling out the web portal has been nothing short of disastrous.  But one would have to be blinded by ideology to not see that Obamacare is working the way it is supposed to in California, Kentucky and many other states, signing up tens of thousands of people who otherwise would be without affordable health insurance coverage.

With apologies to New York City and Frank Sinatra, if Obamacare can make it there (in California and Kentucky), it can make it anywhere.  Once the feds get that darn website fixed, that is.

Today’s question: What do you think the promising rollout of the ACA in California, Kentucky and most of the other states that are running their own marketplaces bodes for Obamacare?

Friday, November 8, 2013

Is it “paternalistic” to set minimum standards for health insurance?

Dr. Bob Centor, author of the always provocative and thoughtful DB’s Medical Rants, suggests that the deep divide over the Affordable Care Act is based on “a major philosophic disagreement” over the respective roles of government and of individuals in choosing what is best for them:

“The administration and their supporters believe that government’s job is to protect citizens from their bad choices. They want to decide what the people need and thus impose regulations. The opposition wants the right to make their own decisions about what defines good insurance.”

(Disclosure: Dr. Centor is chair-elect of the ACP Board of Regents, although his blog posts are his own personal opinions, not ACP policy.  I, of course, work for ACP, as its senior staff advocate on public policy.)

He goes on to cite a New York Times editorial supporting the cancellation of substandard policies, and suggests that, “This editorial, and the law in general, take a paternalistic view of health insurance. This is the philosophical position that defines the problem. The response to policy cancellations and marked increased insurance costs is typified (in the New York Times editorial]..This represents the current talking point – bad insurance. But who should determine what defines bad insurance?”

Is it really paternalistic for the government to set minimum standards for health insurance?  Paternalism means that someone—in this case—the government, is second-guessing the choices that I might make for myself and my family, because it believes that it knows better than me.  But is that what is really going on with Obamacare’s minimum standards for health insurance?

Of course, taking bad products off the market does limit my individual choices.  But the real purpose of Obamacare’s essential benefits and consumer protection standards is to regulate practices by the insurance industry that can cause direct and indirect harm, both to insured persons who is stuck with a bad plan, but also to the rest of us.  The regulations are designed to ensure that insurance companies no longer profit by selling insurance on the individual market that is deceptive and often unsafe and harmful.  The regulations are designed to end the insurance industry’s systematic cherry-picking of who they choose to insure, pitting the healthy against the unhealthy.

How is this any different than the government imposing product safety standards in so many other areas, and appropriately so?   Automobiles that don’t meet federal safety standards—seat belts, air bags, and protection from front end collisions—can’t be sold by auto manufacturers.  Sure, there are “grandfathered” used cars available that don’t meet such standards—fewer and fewer of them as time goes by—but cars sold after such federal standards were mandated have to comply.  Is reducing the number of Americans killed because manufacturers sold them unsafe cars—remember Ralph Nader’s Unsafe at Any Speed book, which started the modern consumer protection movement in the United States—motivated by paternalism?  Perhaps in the sense that the federal safety experts understand that drivers will make mistakes.   The federal safety standards, though, make it far less likely that we will pay for our driving mistakes (and the mistakes of other drivers on the road with us) with our lives.

And yes, by requiring that cars have mandatory safety features, the federal government is forcing us to pay more for them—even features we might think we will never need.  I have been fortunate in my almost forty years of driving to have never had a collision with another vehicle, other than being rear-ended twice by another car (both at low speeds when my car was stopped, and neither seat belts or air bags come into play with rear end collisions).  But I am sure glad that because of government regulation all of my cars have seat belts and airbags, because you never know, they might save my life, or my wife’s or children’s lives.  

Is it paternalistic for the government to regulate the safety of our food?    Henry Aaron, a highly respected expert on health care policy, compares Obamacare’s health insurance standards with the federal government setting food safety standards:

“Imagine a new law enacted to promote food purity. As it is being debated, you are told: ‘If you like what you eat, you can keep on eating it.’ The new law takes effect, and one day, you find that the market no longer carries certain foods you have been buying. As it happens, those products included elements found to be bad for your health. The pure food act barred their use. Obamacare is analogous to the pure food law. It bars certain common practices of insurance companies that most people find unacceptable at best, outrageous at worst.”

Or take today’s announcement that the FDA proposes to ban Trans Fats in food because of the evidence that they cause deaths and disability from preventable heart disease.   Is this paternalism?  It does involve the government inserting its judgment into what foods can be sold to us, limiting the choices of what we can eat.  (Although I suppose we could “grandfather” our favorite prepared pastries made with Trans Fats by stocking up on them before they are banned.)  Or is this just another case of necessary and appropriate regulation to protect lives?

There certainly are other government policies that come closer to paternalism, because they limit our choices directly, not just what can be sold to us.  Take cigarettes—they can be legally sold to adults, but the government mandates warning labels because, well, they and we know that some of us will choose to inhale carcinogens that might sicken or kills us, and when we do, we impose costs on everyone else.  Or take state laws that require that motorcycle riders wear helmets—a direct mandate on individual riders that requires that they spend money on something they might not want or feel they need, but that will help keep them alive (and keep them from shifting their health care costs to everyone else if they end up hospitalized from an accident).  But most of us, physicians especially, would agree that these mandates are a reasonable exercise of government regulation.

This brings me back to Obamacare’s regulation of health insurance.  The standards prohibit the sale of health insurance policies that can cause great harm because they deceptively leave people exposed to bills that can bankrupt them.  They prohibit insurance companies from turning down or canceling coverage because they get sick.  They prohibit cherry picking, signing up healthy people at a discounted premium at the cost of charging more or denying coverage to the less healthy. They require that insurers cover ten essential health care categories, not exotic or unnecessary things, but the basics--like prescription drugs, hospitalizations, doctor visits and preventive services, not because the government thinks it knows better than me, but because these are the benefits that evidence shows are effective in improving outcomes.  Because if your insurer doesn’t cover them, and you get sick, hospitals and doctors will treat you anyway, but your “uncompensated” care costs will be shifted to the rest of us. And you will probably go bankrupt in the process.

They mandate that the benefits be pegged to “benchmark” plans in each state offered by large employers or to state government employees, ending the benefit discrimination that now exists against people in the individual insurance market.  They end discrimination against women, by requiring all plans to offer maternity coverage, instead of excluding it from coverage (as is often the case now) or requiring women pay more to get it.  (As far as the argument against requiring men to pay for maternity coverage, well, it isn’t as if women get pregnant on their own, as one women physician tweeted to me a couple of days ago.) 

Washington Post columnist Ruth Marcus reminds us that Obamacare is trying to remedy a marketplace for insurance that was doing great harm to patients and society.  She recounts the story of Patrick Tumulty, a late middle age man (and brother of one of her colleagues) with Asperger’s who tried to do the right thing by buying himself coverage on the individual insurance market.

“That is where insurance came in — theoretically” Marcus writes. ‘Unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous,’ warned the Web site of Assurant Health, which sold Patrick his policy. Its policy, Assurant promised, “provides the peace of mind and health care access you need at a price you can afford.’ Except it didn’t. Assurant balked at paying Patrick’s claims. In just four weeks, he had racked up more than $14,000 in bills. ‘And that was just to figure out what was wrong with him,” wrote Patrick’s younger sister, now my Post colleague. ‘Actually treating his disease was going to be unimaginably more expensive.”

As I blogged last week, I sympathize with the people whose insurance is getting canceled now because it doesn’t meet the new federal standards.  I agree that the President’s promises that people could keep their insurance plans was misleading, something he apologized for today.  I understand that some of the people who had an affordable plan on the individual insurance market liked it and didn’t want to see it canceled.  A small number of them may have had “good” plans that offered most but not all of the benefits now required by Obamacare—but they were plans offered by insurers who were allowed to pick and choose who they wanted to cover and what benefits they would offer to the exclusion of someone else. And for every one of the “winners”  who came out ahead in the pre-Obamacare individual insurance market, there are many, many more who couldn’t get good insurance at any price, or who found that their insurance didn’t really protect them from bankruptcy when they got sick, like Patrick. 

I don’t think it is an unduly paternalistic to set safety and consumer protection standards on the sale of  products that can have a direct impact on our health and safety—think cars, tobacco, food, motorcycle helmets, and yes, health insurance.  All such regulation limits our individual choices to some degree, but only to the extent that they prohibit manufacturers from selling something to us that is harmful, unsafe, and deceptive, all of which describes the products that typically were available in the individual insurance market, albeit with some exceptions, before Obamacare. The goal isn’t to paternalistically second-guess our own choices, but to ensure that the products we can choose from are safe, effective and do what they promise, health insurance included.  

Today’s questions: Do you think it is paternalistic for the federal government to set consumer protection and benefit standards for all health insurance sold in the United States?  Or necessary and appropriate regulation to end the sale and marketing of health insurance products “ that most people find unacceptable at best, outrageous at worst.”

Friday, November 1, 2013

Goodbye SGR! Hello PCMH and P4P!

Yesterday, the chairs and ranking members of the Senate Finance and House Ways and Means committees released a bipartisan, bicameral plan to repeal the Medicare SGR and reform physician payments.  And this time, it looks like the effort could actually succeed: never before has there been agreement between the House and Senate, Republicans and Democrats, on a plan to repeal the SGR, never mind on what they would replace it with.  Their goal is to get the bill enacted and signed into law before the end of this year, and before the scheduled SGR cut of almost 25% would go into effect on January 1.

There are still a lot of details to be worked out and questions to be answered--including the toughest one, which is how they propose to pay for it--but physician should start thinking now, about how the proposal will change the way that they are paid, and the changes that they will need to make to be ready.  Because this proposal creates a very ambitious timetable and powerful incentives that will link escalating amounts of Medicare payments to physicians' performance on quality, efficiency and effectiveness measures--starting with their performance in calendar year 2016.  It also creates strong incentives for physicians to convert their practices into Patient-Centered Medical Homes, and even bigger incentives to enter into risk-sharing practice arrangements such as Accountable Care Organizations. 

Will they be ready?  Will you be ready?

But before physicians have another  "why are they doing this to us" reaction of exasperation, keep in mind that there are many good things in this proposal--a lot of them, and it is not just that it gets rid of the SGR.  So many good things that ACP issued a very positive statement about it yesterday, even as we will work to improve it.

Here are the top things you need to know about it:

1.  It repeals the SGR, permanently, and with it, prevents the almost 25% scheduled cut on January 1.

2.  Although annual baseline annual FFS updates for the next ten years would be flat (zero percent), there will be opportunities for physicians to earn substantially greater payments for (a) participating in a new budget neutral incentive payment program (described below) or (b) participating in an alternative payment model that has financial risk.  In addition, as described below, Medicare would begin paying for complex chronic care management services in PCMHs or PCMH-neighborhood (specialty) practices.

3.  Starting in 2017, it replaces the existing Medicare PQRS, Value-based Modifier, and Meaningful Use reporting and incentive programs with a single budget neutral incentive payment program.  The existing penalties for the current reporting programs would be sunsetted, which would restore $10 billion to the physician payment pool over ten years.  (These are the existing penalties that it gets rid of: 2 percent reduction for failure to successfully report on PQRS; budget neutral adjustment based on quality and resource use (VBM), and failure to demonstrate Meaningful Use--3 percent penalty in 2016 that can increase up to five percent in 2019). 

4.  The new Value Based Payment Program (VBP) that replaces these programs would assess eligible professionals’ performance in the following categories: quality, resource use, clinical performance improvement activities, and EHR meaningful use. Professionals would be assessed and receive payment adjustments based on a composite score that encompasses all of the applicable composite categories and measures.

       A.  The Clinical Practice Improvement Activities category creates strong incentives for PCMHs: "Because many of [the listed] criteria are components of Medical Homes, a primary care or specialist physician practicing in a certified medical home would receive the highest possible score for this category.  A professional participating in any Medicare Alternative Payment Model would automatically receive half of the highest possible score and could achieve the higher possible score by engaging in other clinical performance activities."

       B.  The VBP incentive program is budget neutral, meaning that the incentive payments to physicians who receive higher composite scores would be offset by lower payments to those with lower composite scores.  However, the proposal would allocate increasing amounts of money to the VBP incentive payments; in 2017, the funding would be equal to 8 percent of the total estimated spending for eligible professionals (the amount tied to current reporting incentive programs); funding would increase to 9 percent in 2018, 10 percent in 2019, and starting in 2020, the Secretary would have the authority to increase, but not lower, the funding pool.  What this means is that each year, from 2017 to 2019, an increasing portion of Medicare FFS payments to physicians will be linked to performance in the new incentive program, but the available total amount of incentive payments to physicians and other health professionals will also increase.

5.  Physicians that participate in "advanced" Alternative Payment Models that involve financial risk and a quality measurement component would receive a 5 percent bonus payment each year from 2016-21. 

6.  The proposal establishes payment for complex chronic care management services, beginning in 2015, for eligible professionals in patient-centered medical home or comparable specialty practice certified by an organization recognized by the Secretary.

7.  The proposal mandates a GAO study of the RUC, allows HHS to survey physician directly to improve the accuracy of relative values, and sets an annual target to reduce misvalued RVUs of one percent of the estimated amount of expenditures in the physician fee schedule in 2016, 2017 and 2018.  If the target is met, the amount would be redistributed back within the physician Medicare fee schedule (as ACP urged).  If it is not met, the fee schedule payments would be reduced by the difference between the target and the amount of misvalued services identified that year, which allows approximately $3 billion in reduced expenditures to remain in the physician payment system.

Over the past year, ACP worked diligently to ensure that any plan to repeal the SGR also results in new payment system that also crea1tes opportunities to better recognize the value of care provided by internal medicine specialists.  This new proposal goes a long way to achieving those objectives: by rewarding internists who in are in Patient-Centered Medical Homes with higher pay for performance bonuses and payment for chronic care management; by eliminating the existing penalties and payment reductions from the Meaningful Use, PQRS and the Medicare Value Modifier, replacing them with a single and more harmonized reporting and incentive program; by reducing over-priced relative value units and redistributing the savings back to physicians; and by creating very substantial incentive payments for physicians in ACOs and other risk-sharing arrangements. 

By doing so, internists who are willing and able to report on the quality and effectiveness of care they provide, and/or are willing and able to become a PCMH, ACO, or other alternative model, will have multiple pathways and opportunities to earn higher pay that is aligned with the value of care that they provide.

But will they be ready? Will you be ready?

Today's question: What is your reaction to this proposed new bipartisan, bicameral plan to repeal the SGR and reform physician payments?

Wednesday, October 30, 2013

Canceled policies, or better policies?

First, critics of Obamacare cited the troubled launch of the  Obamacare enrollment site to make the case that the law is a “train wreck.”  Now, they are citing the health insurance cancellation notices that have gone out to hundreds of thousands of policyholders.  

But these are two very different things.  The technical problems with the enrollment portal are not evidence of any inherent problem with Obamacare itself.   Quite the contrary: the subsidies to help people afford coverage, the ability for consumers to shop and compare health plans in a competitive marketplace, the bans on insurance companies excluding people with pre-existing conditions or charging them more, an end to annual and lifetime limits on coverage, and the requirement that all plans offer “essential” benefits—all of these, and more, are necessary and desirable changes created by Obamacare.   The problem with the website is that people have not yet been able to fully avail themselves of these benefits—yet. 

The insurance cancellations are another thing altogether, because they are the direct result of changes mandated by Obamacare, not unintended mistakes in its execution.  But are the cancellations really evidence of Obamacare imposing “bad” policy on the American people, as the critics argue? 

Let’s walk through what is happening, and why. 

First, President Obama’s repeated assertion, that if you like your plan, you can keep it, is misleading.  While this is true for the vast majority of Americans who get their coverage from a large employer, or from a government program like Medicare, Medicaid, and the VA, there is a relatively small subset of the population (more on this later) that are now finding that they can’t keep the policies they purchased on the individual insurance market.  This may be a surprise to people owning those policies, but it couldn’t have been a surprise for the administration, since the law itself—and the administration’s own regulations--require people who have substandard health plans  (plans that do not comply with federal benefits  requirements) to switch to plans that meet federal standards.  It also wasn’t a surprise to me, and others who really understand how the Affordable Care Act is supposed to work.  

Second, the number of people getting the cancellation notices is very small relative to the overall population.  About 15 million people—five percent of the population—get their coverage from the individual insurance market, explains the Washington Post’s Sarah Kliff, and seven to 12 million of them may get cancellation notices because their current plan doesn’t measure up to the ACA’s requirements.  (Put another way, 95% of us will not be required to change our insurance plans.)  And constant turn-over in the individual insurance market is common, pre-dating Obamacare.  “Most individuals don't stay in the individual market very long” writes Kliff. “One study, published in the journal Health Affairs, found that 17 percent of individual market subscribers purchased the same plan for two straight years or longer.” 

Third, many of the plans being cancelled are previously “grandfathered” plans that were in place before Obamacare became law but no longer meet the ACA’s benefit requirements, explains Kliff.   “These cancellations are, essentially, a lot of grandfathered plans exiting the insurance marketplace. From an insurance company's vantage point, grandfathered plans are a bit of a dead end: They can't enroll new subscribers and are really constrained in their ability to tweak the benefit package or cost-sharing structure. There's not a whole lot of business sense, for a managed care company, in maintaining a health plan that doesn't meet the health law's new requirements.”

Fourth, no one is actually losing coverage—people who get the cancellation notices are being given the opportunity to enroll in health plan offered through the Obamacare marketplaces, or to buy another plan in the individual insurance market that meets the law’s requirements.  Many of them will be eligible for income-based premium subsidies to help them buy a new plan (sliding scale subsidies are available for people with incomes up to 400% of the federal poverty level, approximately $94,000 for a family of four).  If there incomes fall between 100 and 250% of the poverty level, their deductibles and co-payments will be capped at an even lower level then the standard cost-sharing levels that apply to people who earn more. 

Fifth, the substandard, cancelled “grandfathered” plans are being replaced with ones that generally offer better benefits and consumer protections.  Kliff again: “There are lots of insurance policies, especially on the individual market, that are really bare bones. Some argue they shouldn't even be called insurance coverage, because their coverage is too sparse to insure against financial ruin. One report from the Obama administration, issued in 2011, found that 62 percent of individual market plans don't offer maternity care. Eighteen percent do not cover mental health benefits and 9 percent do not pay for prescription drugs . . . insurance companies cannot, under the Affordable Care Act, keep selling the plans that they used to sell -- the ones that don't cover prescription drugs and maternity care. And that means that some people who liked purchasing coverage without maternity care and prescription drugs won't be able to keep those plans. The cancellation notices are a feature of the Affordable Care Act, not a bug. The idea was to make insurance coverage more robust -- and that means cancelling policies that offer less thorough coverage.” 

Georgetown University’s Health Policy Institute agrees that, “For most people shopping on the marketplace, the policies available there will be a better value than anything they have been able to buy on the individual market. First, they will no longer have to worry that if they get sick, their insurer will jack up their premium – that’s prohibited under the ACA. Second, many will be eligible for premium tax credits to make their plan more affordable. And, as noted above, all the plans will meet minimum standards for benefits and cost-sharing – no more swiss cheese coverage.”

Now, none of the above explanations change the reality that some people are very (and understandably) unhappy about losing their current individual insurance plans.  If you were one of the lucky ones who benefited from insurance company cherry-picking—the industry practice of selling low cost health insurance to healthy and young people, while excluding those who are older and sicker--you are not going to like the fact that you may now have to pay more for insurance.   (Even though the result also is that your neighbors with pre-existing conditions will now be able to afford health insurance.)  If you had a low-cost, bare bones policy that suited you just fine, you won’t be happy about having to pay more for one that offers better benefits and consumer protections.  (Even though you might have found out later, once you got sick, that your bare-bones plan didn’t cover the medical care you needed—shifting costs onto the rest of us.)  And if you earn too much to benefit from the income-based premium subsidies, you won’t be happy that you’ll be paying more, albeit for a plan with better benefits and consumer protections, without any financial help from the government to make it more affordable.  (Even though your less well-off neighbors will benefit from the subsidies.) 

I fully sympathize with people who find themselves in the situation of having to replace their current coverage with a more expensive (but better) plan.  For some of them, the higher premiums will be a stretch. 

But the bottom-line is that the overwhelming majority of Americans won’t have to change their health insurance plans; those that do will be getting a plan with better benefits and consumer protections (and many of them will qualify for premium subsidies to bring down the cost), and people who are older and sicker in particular will benefit from reforms that prohibit insurance company cherry-picking.  As the Washington Post editorialized today, “Reform still might not sound like a great deal to people who are young, feel healthy and don’t want to pay for coverage. Yet having lots of healthy people paying into the new system on its terms will not only limit their financial risk, but also their participation will allow others who have been priced out of the health-insurance market — those with serious preexisting conditions, for example — to obtain good coverage. They deserve compassion, too. None of this is an outrage. It’s the predictable result of a defensible policy choice embedded in the reform.”

Today’s question:  What is your take on some people being required to replace their substandard plans with insurance that meets the new federal standards?

Tuesday, October 15, 2013

An Honest Assessment of Obamacare: Week Two

If House Republicans hadn't shutdown the government over a futile campaign to defund or delay the Affordable Care Act, today's headlines would be about the troubled launch of the government's enrollment web portal.  And the headlines would be ugly, very ugly, for the Obama administration.

Actually, they already are--it is just that the message has been overtaken by the government shutdown and debt ceiling debacle. Just take a look at what is being said about the Obamacare launch--by well-respected people who usually are supportive of the Obama administration and the ACA. The Washington Post's Ezra Klein calls it a "disaster" :

"So far, the Affordable Care Act's launch has been a failure. Not 'troubled.' Not 'glitchy.' A failure. But 'so far' only encompasses 14 days. The hard question is whether the launch will still be floundering on day 30, and on day 45." 

Former Obama press secretary Robert Gibbs called the launch "excruciatingly embarrassing" and suggested that someone should be fired:

“When they get it fixed, I hope they fire some people that were in charge of making sure that this thing was supposed to work,” said Gibbs. “We knew there were going to be glitches, right? But these were glitches that go, quite frankly, way beyond the pale of what should be expected.”

The Daily Show's Jon Stewart mocked the "team incompetent" responsible for the website and grilled HHS Secretary Kathleen Sebelius on why the ACA's individual insurance requirement shouldn't she be delayed. 

Ouch, and this is from the administration's friends!

Mainstream press reports also have reported that the administration knew, or should have known, about the technology problems that have plagued the enrollment hub.  The New York Times reports that in March, 2013 "the chief digital architect for the Obama administration’s new online insurance marketplace, told industry executives that he was deeply worried about the Web site’s debut. “Let’s just make sure it’s not a third-world experience,” he told them.

So here it is, just the 15th day of the launch of an unprecedented national effort to expand health insurance coverage to tens of millions of uninsured persons and to protect the rest of us from being dropped from insurance coverage or from going bankrupt because we get sick, and some already are ready to declare the ACA's launch a failure?  Really?

To be clear, I share the frustration over the technology issues that are making it difficult, if not impossible, for people to sign up for coverage from the ACA's government portal.  I think the administration's unwillingness so far to be forthcoming in explaining why the problems occurred, and what they are doing to fix them, is inexcusable, because it adds to the perception that they have something to hide or even worse, have no idea or plan to make the web portal work as intended. And, as I blogged last week, the technology problems--if not fixed soon--will pose a much bigger threat to the ACA than conservative Republicans' ham-handed efforts to defund or delay it. 

So yes, it is concerning that the administration embarrassed itself by launching a not-ready-for-prime-time web portal.  And yes, they got some explainin' to do.  And yes, they need to have a clear and transparent plan, with clear deliverables, to fix it.  And yes, the people in charge should be held accountable. 

But let’s get real, the tech problems do NOT mean that the ACA is a failure.  Not after just two weeks and one day from the date that the marketplaces opened.  And not when there is almost six months left to go before the marketplace open enrollment period ends.  Not when the problem isn't with the ACA itself--the subsidies, the guaranteed essential benefits, the price competition it creates between competing health plans, the limits on annual and lifetime limits on coverage, the benefits for preventive care at no cost to the patient, all of these are good and necessary reforms.  Now we "just" need to get the technology fixed so the millions who will benefit from such reforms can avail themselves of them. 

Today's question: Do you think after only 15 days, it is time to declare the ACA a "failure" because of the tech problems with its enrollment site?

Friday, October 11, 2013

Failed Technology, not Congress, Is the Biggest Threat to Obamacare

Remember when House Republicans were insisting that they would not agree to re-open the federal government unless Obamacare was defunded or delayed?  Well, that was then, this is now.  Ten days into a partial government shutdown that was caused by the GOP-controlled House passing a funding extension that also delayed Obamacare, and just a week from when the Treasury Department says that the debt ceiling will be breached, the GOP leadership seemingly has dropped changes in Obamacare from its list of demands.

 Instead, as Roll Call’s David Hawkin’s notes, House Budget Chairman Paul D. Ryan has, “come out with a roster of proposals on which he thinks both sides can come to agreement — and none of them has anything to do with limiting or altering Obamacare.”   Politico reports that, “The emerging House GOP plan would come with some conditions, although not the kind of sweeping demands to defund or repeal Obamacare. Republicans would vote to lift the debt ceiling until Nov. 22 — just before Thanksgiving — while prohibiting the Treasury Department from using extraordinary measures to lift the borrowing limit.  Boehner said Republicans would also demand a formal House-Senate conference on larger budget issues, a process Senate Republicans have been blocking since their Democratic counterparts approved a budget resolution earlier this year.”

 It remains unclear if the House leadership would be able to get restive Tea Party conservatives behind such a temporary increase in the debt ceiling without requiring other cuts and/or changes in the Affordable Care Act, or whether President Obama and Senate Democrats will agree to it.  And a temporary increase in the debt ceiling would not end the government shutdown itself—the House, Senate, and White House would still need to come up with a bill to restore funding to federal agencies, and Senate Majority Leader Harry Reid (D-NV) reaffirmed today that the Senate will not negotiate with Republicans until they re-open the government. But a temporary debt ceiling would (for now) avert the economic calamity that would occur if the U.S. Treasury can no longer borrow money after October 17.  

So it is looking now like the GOP fight to use the debt ceiling and the shutdown as leverage to delay Obamacare will end not with a bang, but a whimper, paraphrasing T.S. Elliot.   That the GOP lost the fight to defund or delay Obamacare was entirely predictable: they never had the votes.  As John McCain told CNN’s Wolf Blitzer last night, “We started this on a fool’s errand, convincing so many millions of Americans and our supporters that we could defund Obamacare…[That] obviously wouldn’t happen until we had 67 Republican senators to override a presidential veto.”

So Obamacare will survive the current effort to kill it in Congress, just as it survived the Supreme Court and two elections.  Now, Obamacare’s biggest obstacle may be itself: the technical infrastructure that has performed so poorly in its first ten days that millions of people have been frustrated in their efforts to access information through the government’s enrollment website,  The New York Times reported that, “The technical problems that have hampered enrollment in the online health insurance exchanges resulted from the failure of a major software component, designed by private contractors, that crashed under the weight of millions of users last week. ”  Time magazine reports that if the problems persist into November, then, “the health law’s future could be imperiled, according to a former high-ranking health care official … ‘By November—certainly the middle of November—the sites have to be able to handle major traffic for people to be able to set up accounts and purchase coverage,’ says Joel Ario, who served as director of the Office of Health Insurance Exchanges at the U.S. Department of Health & Human Services (HHS) from August 2010 to September 2011. ” 

So the biggest threat to Obamacare is not the Republicans in Congress, or even the  Republicans in states that are resisting it—it is the administration’s own failure so far to fix what Time rightly calls “crippling computer glitches” that are frustrating the people who are trying to buy coverage.  The administration says that things are getting better day by day, as it has increased server capacity and fixed other “bugs” in the system.  Maybe they are, and I certainly hope so.   But until they can show that the system is working reliably and consistently, the Affordable Care Act is at risk, and for this, the administration has no one to blame but itself.

Today’s questions: What do you think of congressional Republicans apparently giving up on their efforts to defund or delay the Affordable Care Act?  And of the technical problems plaguing Obamacare enrollment?

Tuesday, October 1, 2013

Openings and Closings

Today is an odd day, even by the strange standards of American politics today.  At exactly the same time much of the federal government was forced to shut down over the Affordable Care Act (ACA)—12 midnight Tuesday morning—that last and most important big piece of the ACA went into effect, the opening of health coverage marketplaces in all 50 states and the District of Columbia. 

The shutdown was the result of House Republicans insisting on defunding or delaying Obamacare, a demand they knew Senate Democrats and President Obama would never accept.  So, when the President and Senate did what everyone knew they would do—rejecting GOP demands that Obamacare be traded away to keep the rest of the government open—there was no time left to reach an agreement that would continue to fund most federal agencies and functions when the end of the fiscal year was reached at midnight.    Immediately thereafter, federal agencies began to methodically close all but their most critical functions.   The CDC immediately terminated support for its annual flu vaccine program and scaled back surveillance of disease outbreaks, the NIH ceased enrolling people in new clinical trials, the FDA ended its routine food safety activities—as the nation’s largest employer, the federal government, furloughed millions of its employees without pay.  But other so-called mandatory programs and payments—including Medicare claims payments and Social Security checks—were unaffected by the partial shutdown, at least for now.

The government shutdown was a sad reflection of the ideologically-driven politics of today, and also a sad day for the country, which will now have to suffer the consequences associated with a suspension of federal programs that almost all of us want, need and depend on to one extent or another.  Our food may be less safe, and we may rue the day when the CDC shutdown left us unprepared for flu and other potentially lethal disease outbreaks.    Many of the poor will go without assistance.  Millions of our neighbors will be temporarily out of work, and because they will have less money to spend, their furloughs will hurt local stores, businesses and services that are still struggling to make it out of the last economic downturn.  The ripple effect, if the shutdown lasts for more than a day or two, could be very destructive to our fragile national economy. 

But for all of the bad news, there was also a reason to celebrate when the clock struck midnight.  Starting at midnight today, the last and most important elements of Obamacare opened for business.  The shutdown managed to shut down much of everything else, but it didn’t shutdown the ACA, which is funded out of “mandatory” dollars that are outside of the usual congressional appropriations process.

Today is a day to celebrate because the ACA, for the first time starting today, will begin to provide guaranteed access to affordable health insurance plans for millions of Americans who can’t get affordable coverage from their employers.  Today is a day to celebrate, because the ACA, for the first time beginning today, will open the doors for persons with pre-existing conditions, like heart disease or asthma, to get affordable insurance coverage. 

Today is a day to celebrate because the ACA, for the first time starting today, begins to put the United States on the path toward near-universal health insurance coverage.  It won’t all happen today or even during the six month open enrollment process that ends in March.  And especially in the first days and weeks, there likely will be marketplace glitches that may slow enrollment. (In fact, initial interest in enrollment today was so high, and so above expectations, that it caused federal and state enrollment websites to crash.)  It won’t all happen this year and next—it is projected that only about 7 million people will sign up for coverage in 2014.  But over the next months and over the next several years, as more Americans become familiar with and enroll in the marketplaces, and as more states accept federal dollars to expand Medicaid, the United States for the first time ever will come close to guaranteeing access to affordable health coverage to nearly all U.S. residents.

So yes, I am celebrating the fact that the Affordable Care Act (Obamacare) is open for business today—having survived the Supreme Court, two national elections, ongoing state obstructionism, and the unrelenting (but ultimately futile) continuing efforts by some in Congress to stop it. 

Today’s questions: What is your reaction to the government (mostly) closing, and Obamacare (mostly) opening today?

Monday, September 30, 2013

Dr. Seuss and Obamacare

During his marathon one-man, 21-hour show to try to stop Obamacare, Senator Ted Cruz (R-TX) read from his daughters’ favorite bedtime story, Green Eggs and Ham, the story of a Sam-I-Am who is stubbornly opposed to trying something new (green eggs and ham), and then to his surprise, ends up liking it. (Some observers have noted the irony—isn’t the Senator, and others like him who absolutely know that they don’t like Obamacare before they and the country have even tried it, aren’t they the ones acting like Sam-I-Am?)

But I was reminded of a post on this blog from December, 2009, when I re-wrote my favorite Dr. Seuss story, How the Grinch Stole Christmas, into a humorous account of Republican Senators’ efforts, at that time, to block a final Senate vote on the ACA by filibustering it. (They didn’t succeed, of course.)  I was struck by how, almost four years later, so little has changed—the GOP is trying one more time to block Obamacare from going into effect, this time by insisting that the law be delayed a year as a condition of keeping the federal government funded past midnight tonight—even though the current effort has even less chance of success than the December 2009 failed filibuster.

So in the spirit of trying to bring a bit of levity into what otherwise is a depressing day on Shutdown Eve in Washington, DC, I have updated the 2009 verse, to reflect the current GOP effort to stop Obamacare. (Note to my readers, especially Republicans—this is all meant to be in good fun.  I am really not suggesting that the GOP’s motivation for opposing the ACA is akin the Grinch hating Christmas.  But it works for the rhyme scheme).

How the GOP (Tried) to Stop Obamacare

The Democrats
In Congress
Liked Obamacare, a lot...
But the GOP
Who sat to their right,
Did NOT!
The GOP hated ObamaCare! The whole legislative season!
Now, please don't ask why. No one quite knows the reason.
It could be their base is far to the right.
It could be, perhaps, that money is tight,
But I think that the most likely reason of all
Is Republicans want to keep government small.

Whatever the reason,
Their base or their views,
They stood there on September 30th, hating the bill,
Staring down with a sour, disapproving frown
And vowed they would bring Obamacare down.

"It’s socialized medicine!" they snarled with a sneer.
"Yet Obamacare is coming! It's practically here!"
Then they growled, with their fingers nervously drumming,
"We MUST find a way to stop it from coming!"
For on Tuesday, they knew...

The marketplaces in each state
Would open up bright and early.  And offer insurance
To the young and the old,
Then the uninsured would sign up for a government feast.
And they'd feast! And they'd feast!
On taxpayers' dollars to feed the government beast
Which was something the GOP could not stand in the least!

And the more they thought of Obamacare coming,
The more they thought, "We must stop the whole thing!
The time has come, it must be now,
We MUST stop Obamacare from coming!
... But HOW?"

Then they got an idea!
An awful idea!

"We know just what to do!" They laughed in their throat.
“We’ll shutdown the government without an ACA delay!"
And they chuckled, and clucked, "What a great GOP trick!
Even if it shuts the government down, this time, and we’ll make sure that it sticks!”

"All we need is for the Senate to agree ..."
They looked around.
But soon discovered support from the Senate was not to be found.
Did that stop the GOP...?
No! They simply said,
"The government must shut down until Obamacare’s declared dead
We must stop all 2000 pages, every chapter and verse
We must stop the uninsured from living off the taxpayers’ purse.”

Then they took to the floor, with a smile most unpleasant,
Around the whole room, and demanded to all present!
No matter what it takes!  We must stop Obamacare from coming,
Even it if cuts off all government funding.

It was right before midnight...
On Monday when government funding was set to expire
But no matter the consequences, no matter how dire
Government funding was allowed to come to halt
As the GOP declared it was the Democrats’ fault,

"Pooh-pooh to the Dems!" they were heard to be humming.
"They’ll soon find out no Obamacare is coming!
They're just waking up! I know just what they'll do!
Their mouths will hang open a minute or two
Then all the Dems will all cry BOO-HOO!”

"That's a noise," grinned the GOP,
"That we simply must hear!"
So they paused. And the GOP put a hand to their ears.
And they did hear a sound rising, it started out low
Then it started to grow...

But the sound wasn't sad!
Why, this sound sounded merry!
It couldn't be so!
But it WAS merry! VERY!

They stared down at the Democratic side
The GOP popped their eyes!
Then they shook!
What they saw was a shocking surprise!

Obamacare had opened, everywhere, in states big and small,
The uninsured would be able to get insurance, it was now the law,
They HADN'T stopped Obamacare from coming!
Somehow or other, it came just the same!

And the GOP couldn’t figure out where they should go,
They stood puzzling and puzzling: "How could it be so?
It came despite death panels! And Rush and Glenn!
Despite the Tea Parties and their angry young men!"
And they puzzled three hours, 'till their puzzler was sore.
Then they thought of something they hadn't before!
"Maybe Obamacare," they thought, "means something more.
Maybe it will help provide coverage to even the poor."

And what happened then...?
Well ... in Washington they say
That the GOP took heart
And vowed to fight on anyway!
"We can still kill Obamacare, if we just do it right,
We'll do it in the debt ceiling, we'll continue this fight
This time, we’ve promised our Tea Party base, our efforts won’t cease

Can still slay the ObamaCare beast!"

Today’s question: What Dr. Seuss story do you think best describes the current situation in Washington?

Friday, September 27, 2013

Four Days

In just four days from now--Tuesday, October 1--health care armageddon will descend upon America, if one accepts the predictions of Obamacare's opponents.  The start of the six month open enrollment period for qualified health plans offered through the ACA's state health insurance marketplaces will lead to the end of the patient-physician relationship, death panels, rationing, socialism, bankruptcy and the total destruction of personal liberty, or so they say.

Or, in just four days from now, on Tuesday, October 1, tens of millions of Americans who can't find coverage will finally be able to buy affordable health insurance, creating a health care nirvana where no one will go bankrupt because of their health, where everyone will have a doctor, where outcomes will be better, and where costs will be lower, or so say the ACA's supporters. 

Also, in just four days from now, on Tuesday, October 1, the federal government will shut down because Congress and the President were unable to agree on a bill to keep it funded.  The Centers for Disease Prevention will immediately stop its disease surveillance programs, the NIH will stop enrolling patients in clinical trials, federal employees (including those in uniform) won't be paid, parks will close, people won't be able to sign up for Social Security and Medicare Part B (although the checks will still flow to those already enrolled), and medical care for veterans may be disrupted.  (You can read the technical, gory details of which programs would shut down in this Congressional Research Service report. The Washington Post also has a good explanation of what the shutdown would mean for government services). But, even though the fight over funding the federal government is mostly over Republican's efforts to defund Obamacare as a condition of passing a spending bill, one government program that won't be shut down is the health care marketplaces created by the ACA that go live on Tuesday!  That's because the ACA is mostly funded by what are called "mandatory" federal dollars that are outside of the "discretionary" dollars subject to the disputed spending bill. 

Or, somehow an agreement will be reached over the next four days that will fund the federal government past September 30, perhaps only for another few weeks.  One thing that I can say with confidence is that such a bill will not include language to defund Obamacare, no way, no how will President Obama or the Democratically-controlled Senate agree to it.  (Most other independent experts agree with me.)

So either way--a government shutdown or agreement is forged to keep the government funded--Obamacare's marketplaces will go live four days from now.

As they should.  It is time to move on from the talking points about what Obamacare might do to allowing people to actually see what coverage is  available to them from the marketplaces, and decide for themselves it if is a good deal for them and the country.  Although there is much that we don't know and can't know until the marketplaces start up and people start enrolling over the next six months, I am sure of two things.  It will not result in the healthcare Armageddon that is the fancy of Obamacare's critics.  (You don't need to take my word for it, the Pulitizer prize winning independent and nonpartisan found that much of what the critics say about it just simply is untrue-- it is not socialized medicine or a government take-over, it won't lead to rationing or death panels, it won't take away your doctor, and it doesn't put the IRS in charge of your health.  But it also won't result in a healthcare Nirvana--yes, millions more people will get coverage and far fewer will go bankrupt because of health care expenses, and outcomes will be better as a result, but there will still be substantial financial and other barriers to care, we still won't have enough primary care doctors, we will still spend too much on paperwork and insurance company profits and overhead, and we don't yet know what the ACA's impact on cost ultimately will be, even though current trends (lowest cost increases in fifty years) are encouraging.

But if Obamacare ends up extending health insurance coverage to nearly all Americans, that in itself will be a very good--even historic--achievement for this country and its residents.  And it all begins in four days, even if much of the rest of the government shuts down over the certain-to-fail effort to defund Obamacare.

Today's questions: Are you ready for the roll out of the ACA's marketplaces on Tuesday?  And what do you think of the brinkmanship of shutting down the government over Obamacare?

Wednesday, September 18, 2013

A Way Out of the Uncivil War Between Physicians and Nurses

A recent post by @KevinMD observed that the “highly charged scope-of-practice” fight between the medical and nursing professions has resulted in social media hate speech—too often, from physicians directed at other physicians. “Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments” write the authors.  They propose the following “principles for civil discourse” which I believe should apply more broadly to all social media commentary, not just on the physician versus nurses conflict:

“Anecdotes are fine, but avoid drawing generalizations from one story. (‘We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.’)

Identify the underlying emotion of a comment that irks you, and name it when you respond. (‘Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….’)

Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( ‘SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.’)

Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, ‘NPs simply should not be practicing without some sort of physician supervision,’ say ‘I don’t think NPs should practice without any physician supervision.’)
Consider phrasing your comment in the form of a question. (‘I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?’)

Go for the win-win. (‘The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.’)

Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (‘NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.’)”

If such principles were broadly accepted by all of us involved in social media commentary, they would result in a much better informed, respectful and constructive discussion than name-calling and personal attacks. Civil discourse, though, by itself won’t be enough to end the uncivil war between the nursing and medical professions.  What’s needed is a way to get to the “win-win” point where the legitimate interests and concerns of both professions are recognized and addressed.   

A few days ago, the Annals of Internal Medicine, ACP’s flagship peer reviewed journal, published a paper titled, “Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper” which I believe could become the basis of such a win-win outcome. (Full disclosure: I am the principal author of this paper, along with my co-author and colleague Ryan Crowley, which was written by us on behalf of ACP’s Health and Public Policy Committee and Board of Regents). 

Our goal in developing the paper was to constructively address the legitimate concerns of both professions as a step toward renewed dialogue between them.  Nurses have legitimate concerns about being held back by restrictions on their licenses and physician supervision arrangements that limit their ability to provide care to patients, that is within nursings’ skills and competencies.  Physicians have legitimate concerns that their unique and more extensive years of medical training are being devalued by the calls to substitute independently practicing advanced practice nurses for primary care physicians.  Both professions assert that their views are based on what is best for patients.

Our paper asserts that professionalism is the answer to resolving such differences. “Professionalism” we wrote “requires that all clinicians—physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals—consistently act in the best interests of patients, whether providing care directly or as part of a multidisciplinary team. Therefore, multidisciplinary clinical care teams must organize the respective responsibilities of the team members guided by what is in the best interests of the patients while considering each team member’s training and competencies.”

The goal, then, must be to assign, “specific clinical and coordination responsibilities for a patient’s care within a collaborative and multidisciplinary clinical care team" and that it, "should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the patient’s clinical needs and preferences are met. If two team members are both competent to provide high-quality services to the patient, matters of expedience, including cost and administrative efficiency, may contribute to division of that work.”   While we affirm the importance of, “patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home” we also state that, “Dynamic teams must have the flexibility to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.” 

“Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams…well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”  We observe that, “especially in physician shortage areas, it may be infeasible for patients to have ‘an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and that, “in such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient’s health care needs, are imperative.”

On the debate over each profession’s role in solving the primary care workforce shortage, our answer is, “a cooperative approach including physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address physician shortages.”

And on the most divisive issue—state regulation of nursing scope of practice—we state that, “Clinicians within a clinical care team should be permitted to practice to the full extent of their training, skills, and experience and within the limitations of their professional licenses as determined by state licensure and demonstrated competencies. All clinicians should consult with or make a referral to other clinicians in disciplines with more advanced, specific, or specialized training and skills when a patient’s clinical needs would benefit from such consultation and referral.”  We assert that,  “Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services” and called on state legislatures and licensing authorities, “to conduct an evidence-based review of their licensure laws” and “consider how current or proposed changes in licensure law align with the documented training, skills, and competencies of each team member within his or her own disciplines and across disciplines and how they hinder or support the development of high-functioning teams.”

Now, I know that the paper will not please everyone in the medical and nursing professions, but we hope that it can be the starting point of a renewed dialogue between the professions.  We end the paper by noting that, “ACP offers these definitions, principles, and examples to encourage positive dialogue among all of the health care professions involved in patient care—in the hope of advancing team based care models that are organized for the benefit and best interests of patients. ACP also hopes to inform policymakers to ensure that regulatory and payment polices are aligned with, rather than creating barriers to, dynamic team-based care models. ACP encourages discussion of dynamic clinical care teams that puts patients first.”

Let’s get this dialogue started—with civility, of course.

Today’s questions:  What do you think of the “principles on civility” presented above?  And ACPs’ principles for dynamic clinical care teams?