Wednesday, February 27, 2013

Dumb and Dumber

Sequestration is a dumb idea—plain and simple.   It is a dumb idea if you are a Democrat. It is a dumb idea if you are a Republican.  It is a dumb idea if you are an independent.  Even dumber is that fact that Congress and the President inflicted this dumb (and totally unnecessary) crisis on us and are wasting time now by  blaming each other for who came up with the dumb idea in the first place—rather than solving it.

(For the record, sequestration—across the board budget cuts that will go into effect on March 1--is the handiwork of both parties.  The President proposed it to break the impasse on re-authorizing the debt ceiling in the summer of 2011, a fiscal crisis  brought on by House Republicans who refused to pass a routine bill to increase the ceiling without an agreement to cut spending.  To overcome this impasse, majorities of Republicans and Democrats in the House and Senate then voted for the Budget Control Act of 2011, which included sequestration as a back-up plan to reduce the deficit that was intended to go  into effect only if a congressional “Super-committee” couldn’t come up with an agreement on a better way to achieve savings.  The “Super-committee”—made up evenly of Republicans and Democrats, House and Senate—deadlocked and couldn’t produce a plan, and as a result, the Act required that sequestration be instituted on January 1 of this year. On January 1, 2013, both the House and Senate reached a last-minute bipartisan agreement, signed into law by President Obama, to postpone sequestration until March 1.  And here it is now, with fewer than 48 hours left, and there has been no serious effort by either party, by the House and Senate, or by the White House, to come up with a bipartisan plan to stop sequestration.)

How dumb is sequestration?  Well, let’s say you were the mayor of a mid-size city, your budget is deeply in the hole, creditors are at the door, and you realized you have no choice but to reduce your debt.  Would you:

1.     Cut all of your expenses by the same percentage amount—the money set aside to stop an unsafe bridge from collapsing;  the money allocated to pay the salaries of teachers, police and firefighters; the taxpayer money you asked for to buy nicer furniture for your own office; the money for that all-expense-paid trip to Palm Springs (golf included) that you and the city council want to take to “network” with other mayors (including attending that cool symposium on how to control your city’s spending), and the budget for medical care and shelter for the homeless?

2.    Prioritize your spending, cutting some categories by more, some by less, and some not at all—protecting the money set aside to stop an unsafe bridge from collapsing, the money allocated to pay the salaries of teachers, police and firefighters and the budget for medical care and shelter for the homeless, over new furniture for your office and the trip to Palm Springs?

3.    If prioritizing your spending isn’t enough to close the gap, ask your wealthiest residents to pay a little bit more to help preserve funding for the most essential and effective programs that benefit everyone, but especially, the least well-off in your city?

Most of us, I think, would agree that #2 and #3 are pretty smart, and #1 is just plain dumb.  Yet #1 is exactly what sequestration is all about--it cuts federal programs by the same amount, no matter how  good or bad, how essential or non-essential, how effective or ineffective, how important or  unimportant, how many are helped by the program cut. 

And although there are some in and outside of Washington who argue that sequestration will do no harm,  the sequestration cuts to healthcare will have a real impact on access, quality and public health and safety, maybe not all at once, but before too long, and the longer they are allowed to remain in effect, the greater the damage.  ACP’s State of the Nation’s Health Care report, released last week, documented the impact, including:

1.    Medical research to prevent and cure diseases will be curtailed.  The cuts would result in 2,100-2,300 fewer NIH research grants, and  Research Proposal Grant (RPG) success rates would drop from 18 percent in FY2011 to 14 percent in FY2013.

2.    Funding for programs to train more physicians, especially primary care physicians in under-served areas, will be slashed: 295 fewer scholarships for minority and disadvantaged health profession students,  a loss of funding midway through their training for 14 primary care residents; 2,315 primary care physician and physician assistant trainees adversely affected by reduced funding for the Title VII Primary Care Training and Enhancement Program, and 14,760 fewer public health professionals trained through the Title VII Public Health Training Center Program.

3.    Patient access will suffer and jobs will be lost as Medicare payments to hospitals, physicians, and physician residency programs are cut. Altogether, Medicare will be cut by $11 billion in 2013 under sequestration resulting in a loss of nearly 500,000 U.S. jobs. But the biggest impact will be on seniors and disabled persons who rely be on Medicare coverage to enable them to access quality health care. Although guaranteed benefits will not be directly reduced by sequestration, cuts in payments to physicians and hospitals will force many of them to lay-off staff, curtail services, and limit how many Medicare patients they can see. Physicians and other clinicians may have to lay off as many as 62,000 employees if sequestration goes into effect. In the case of physicians, the sequestration cut is a prelude to a much larger scheduled cut on January 1, 2014 as the result of Medicare’s flawed Sustainable Growth Rate formula.

4.    The federal government’s ability to prevent and control diseases and to ensure the safety of food and drugs will be compromised. Funding for the Food and Drug Administration will be slashed by $191 million and for-the Centers for Diseases Control and Prevention by $444 million over 10 years starting in 2013.

How dumb it that—to train fewer primary care physicians when we know that the country is facing a massive shortage, to lose our edge in  medical research, to make it harder for Medicare patients to find doctors, to make our food and drugs less safe, to make it harder to detect and prevent the next flu outbreak or pandemic? When there are far better ways to reduce unnecessary health care spending?

But before we just blame the politicians for their cognitive impairment when it comes to the federal budget, we should look in the mirror.  Polls show that a majority of Americans want the focus of deficit reduction to be mostly on spending reductions rather than tax increases, but this general support for spending cuts doesn’t translate into support for cutting any specific category of spending.  Rather, a recent poll shows that the public rejects spending cuts for 18 out of 19 categories of spending; the “only exception is assistance for needy people around the world. Nonetheless, as many say that funding for aid to the needy overseas should either be increased (21%), or kept the same (28%), as decreased (48%).”  (Only 22% favored cuts in health care spending, and only 15% supported cuts in Medicare). 

So we Americans want to cut the deficit, we want deficit reduction to focus mainly on spending cuts rather than higher taxes, but we reject cutting anything other than the miniscule amount of federal money spent on foreign aid?  That is, no cuts in any program that benefits us directly.  Now, how dumb is that?

Today’s questions: What is your take on the budget sequestration mess? How should the country get out of it?

Thursday, February 21, 2013

Time is on My Side

Time very well may be on your side if you are Mick Jagger and Keith Richards (they‘re still rockin’ after all these years!) but not for doctors and patients. The pressure on physicians to spend less time with patients is part of an unrelenting assault on the patient-physician relationship, declared the American College of Physicians in a report released yesterday on the state of the U.S. health care.  ACP President David Bronson, MD, FACP described it this way at a press briefing announcing the reports, “System-wide efforts to improve the healthcare system won’t succeed on their own in improving access and quality if the physicians that the system is counting on to deliver care are over-hassled, over-stressed, harried, hushed and rushed.”

Or, as I put it in my remarks at the same briefing, “None of us want our doctors to spend more time on paperwork than listening to us, yet we have a system that buries physicians in administrative tasks to the exclusion of patient care. None of us want our physicians to be rushed from patient-to-patient, from task-to-task, but that often is the only kind of medicine that the system allows.”

Lack of time with patients was one of seven barriers to the patient-physician relationship identified by ACP:

“Lack of time with patients. Current payment, coding and relative value systems discourage physicians from spending time with patients. Also, as physicians spend more and more time each day complying with unnecessary administrative tasks and mandates (see below) imposed by payers and government, they have even less time to spend with their patients.

Excessive, Unnecessary and Unproductive Administrative Tasks. A recent study found that U.S. physicians spend $31 billion annually on interactions with health plans. More specifically, physicians reported spending almost a half-hour each day, three hours each week, and three weeks per year, interacting with health plans. Primary care physicians spend significantly more time (3.5 hours weekly) than other medical specialists (2.6 hours) or surgical specialists (2.1 hours).

Electronic Health Records that Do Not Meet Clinicians’ and Patients’ Needs. Electronic health records were intended to improve care but many physicians are frustrated that they lack the capabilities needed while adding more inefficiency to their daily workflow, compounded by well-intended government “meaningful use” standards that might make things even worse.

Performance measures that can result in unintended adverse patient care consequences. Performance measures can be difficult to report on, may measure the wrong things, and they do not always agree with each other. Physicians appropriately ask: who is measuring the value and effectiveness of the measures themselves?

Growing and excessive number of mandates on physicians enforced by penalties. Payers and government keep imposing more penalties on physicians: for not e-prescribing, for not converting to a complex ICD-10 diagnosis coding system, for not meaningfully using electronic health records, and for not successfully reporting on measures. Physicians wonder how they can even find the time to track all of these mandates, incentives, rules, and penalties, while keeping their practices open.

The adverse consequences of a dysfunctional medical liability system. Physicians feel continually exposed to the risk of medical liability lawsuits, and feel pressured to perform “defensive medicine” to reduce the risk of being sued. At the same time, patients who are truly harmed by medical errors often wait years for a court to decide on their compensation, if they receive compensation at all.

Direct government intrusion into the patient-physician relationship. The patient-physician relationship is undermined by laws that tell physicians what they can and cannot say to their patients or what tests or procedures they must compel their patients to obtain, without regard to the physician’s clinical judgment or the patient’s interests.

What can be done about it?  ACP offered the following nine proposals to reduce  such intrusions:

1. Public and private policymakers and payers must ensure that any payment reforms have, as an explicit goal, allowing physicians to spend more appropriate clinical time with their patients.

2. Payment and delivery reforms that hold physicians accountable for the outcomes of care (measurable performance on quality, cost, satisfaction and experience with care) should concurrently eliminate the layers of review and second-guessing of the clinical decisions made by physicians.

3. CMS should harmonize (and reduce to the extent possible) the measures used in the different reporting programs, work toward overall composite outcomes measures rather than a laundry-list of process measures.

4. CMS should provide more clinically relevant ways to satisfy the requirement that physicians must transition to using ICD-10 codes for billing and reporting purposes.

5. Congress and CMS should consider working with physicians to encourage participation in quality reporting programs by reducing administrative barriers, improving bonuses to incentivize ongoing quality improvements for all physicians, and broadening hardship exemptions. If necessary, Congress and CMS should consider delaying the penalties for not successfully participating in quality reporting programs, if it appears that the vast majority of physicians will be subject to penalties due to limitations in the programs themselves.

6. The government, the medical profession, and standard-setting organizations should work with EHR vendors to improve the functional capabilities of their systems, to improve the ability of those systems to report on quality measures and to ensure that those systems improve rather than adding to workflow inefficiency.

7. Medicare and private insurers should move toward standardizing claims administration requirements, pre-authorization, and other administrative simplification requirements even in advance of, and in addition to, the simplification rules included in the ACA.

8. Congress should enact meaningful medical liability reforms including health courts, early disclosure errors, and caps on non-economic damages.

9. State and federal authorities should avoid enactment of mandates that interfere with physician free speech and the patient-physician relationship.

ACP’s report didn’t just focus on policies to reduce intrusions on the patient-physician relationship; it also proposed ways to improve the health care system overall—by building on the progress in expanding coverage and lower costs, by creating incentives for primary care, but putting a stop to across-the-board budget cuts to vital health programs, by eliminating the Medicare SGR, and by preventing deaths and injuries from firearms.  ACP doesn’t buy into the argument that one has to choose between expanding coverage to the uninsured and reducing hassles for physicians and patients—we need to do both. 

Dr. Bob Centor, chair-elect of the ACP Board of Regents, puts it this way in his DB’s Medical Rants post on ACP’s proposals:

“Often readers of this [DB’s Medical Rants] blog impugn the ACP and other national organizations. They charge that we are not in sync with practicing physicians.  I challenge you to read these positions and say that here. You may disagree with parts of the ACA, but most of you do want to see broader coverage for patients.  I know that you care about payment and making primary care a more desirable option. You have told me often that government is intruding into our practices, and I contend that the ACP's positions should be most agreeable.

We are proud of our agenda.  We believe that most internists will agree with the majority of our positions.  We wish the Congress and their staffs, the White House and state legislatures would pay attention.  We can improve health care AND spend less money.  We can decrease physician burnout without harming quality. And please note my favorite point – one that readers of this blog will recognize: Payment reforms must allow physicians to spend more appropriate clinical time with their patients.”

The need to change the things that drive physicians and patients crazy is a theme I blogged about last fall, and it is good to see ACP give such prominent attention to the issue in its new report (Disclosure: I was the principal staff author of the report).

Putting time back on the side of patients and their physicians won’t be easy—harried and rushed medicine is deeply engrained in our system---but it is essential if we are to have the kind of health care that patients want and deserve. Let’s rock n’ roll to make it happen.

Today’s questions: What do you think about ACP’s description of the “unrelenting assault on the patient-physician relationship”, and its policy proposal to end it?

Friday, February 15, 2013

Not in My Lifetime

An elderly doctor passes away, and he find himself standing before the Pearly Gates.  The Almighty greets him and says,  “In recognition of your stellar life of service to your patients, family and community,  I welcome you to paradise.  And because I know that doctors have a great sense of curiosity about all things, you can now ask me any question—any—and I will answer it.”   The doctor ponders for a moment or two,  thinking about all of the mysteries of the world, and comes up with the one question that has troubled him the most.  “Can you tell me, your greatness, whether Congress will ever get around to repealing the Medicare SGR?”   God hesitates for a moment, and responds, “Yes . . . but not in my lifetime.”

(A version of this joke has been around for years, only the question asked was whether Congress would ever enact universal health insurance coverage.  With the ACA getting us close to universal coverage, I thought that substituting the SGR would make for a more timely question for the good doctor to ask the Almighty!)

And after more than a decade of botched efforts, who can blame doctors if they begin to think that it will take an eternity—or longer, if that is possible!—for Congress to finally get around to repealing the SGR.   Year after year, they have seen the same tired script replayed.  CMS announces that the SGR will cut physician payments (by an escalating amount each year).  Members of Congress pledge that it won’t happen and that this will be the year when the SGR will be repealed.  You can believe us for sure, this time will be different, we promise you, wink, nod.   They then ask physicians not only for ideas on replacing the SGR  but also commitments (like agreeing to be measured on their performance).  Physicians dutifully offer serious proposals and commitments, Congress thanks them, then dithers for months, gets itself into a partisan spat about how to pay for SGR repeal, waits to the very last minute before the cut is supposed to go into effect ( and in some instances past the last minute, requiring a retroactive fix) and then finally—hallelujah!—passes something that averts the cut for a few months, or maybe a year or two (at best). 

And then we start the whole darn thing all over again.  If that isn’t the earthly equivalent of eternity, it is pretty darn close.

But maybe, just maybe, there is now cause for hope that this year could be different. 

First, the Congressional Budget Office cut in half its estimate of the cost of repealing the SGR, down from $244 billion to $138 billion (over ten years).   Yesterday, Glenn Hackburth, chair of the Medicare Payment Advisory Commission, told the House Energy and Commerce Committee that “In effect, SGR repeal is now on sale. But the sale may not last forever.”  (Still a lot of money, but with the new CBO numbers, it makes it easier for Congress to find a way to pay for SGR repeal.)

Second, for the first time in a very long time, there actually is a draft plan on paper to eliminate the SGR that has the support of congressional leadership.   The plan, offered by the Republican leadership of the two House committees with jurisdiction over Medicare, would eliminate  the SGR in three phases and begin to link future updates to physicians’ participation in quality improvement efforts or new payment models.

Third, Congress actually is talking about putting partisanship aside—imagine that, what an idea!—to come up with an SGR repeal plan.   Rep. Fred Upton (R-MI), chair of the House Energy and Commerce Committee, said his hope is to get a bill on the floor of the House by August, and that he would seek support from Democrats on a bill that could pass the Senate. Related, a bipartisan bill, the Medicare Physician Payment Innovation Act, to repeal the SGR, stabilize payments, provide higher updates for undervalued evaluation and management services, and  transition to new models was re-introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck (R-NV).   The bill, which is strongly supported by ACP, is in many respects similar to the one proposed by the House committee leadership. 

Finally,  Congress is actually listening to the doctors!  The plans being floated directly reflect ideas offered by ACP, AMA, and more than 100 physician organizations—demonstrating an unprecedented degree of unity.

It still may require divine intervention for Congress to enact legislation to repeal the SGR, and I wouldn’t bet on it.  But at least for the first time in a decade there is at least a prayer of making some progress.

Today’s question: What do you think of the latest developments on the SGR?