Friday, May 31, 2013

Is this the year when medicine finds its Holy Grail?

Getting rid of Medicare’s SGR formula has been organized medicine’s Holy Grail.  But medicine has gotten no closer to finding a solution to the SGR than the medieval knights did in their search.  This year could be different, though.  The House and Senate both are working on bipartisan plans to repeal the SGR and reform Medicare payments, plans that are being developed with the input of physicians.
Yes, you heard that right, bipartisan plans.  At a time where Republicans and Democrats can’t seem to agree on which way is North and which way is South, they have put aside their differences (at least for now) in their search for a solution to the SGR conundrum.

And yes, you heard that right, they are listening to physicians.   On May 7, Dr. Chuck Cutler, the Chair of ACP’s Board of Regents, appeared as a witness at an SGR hearing convened by the Ways and Means Health Subcommittee.  Unlike the usual process for hearings, where the party in charge (in this case, the Republicans) picks witnesses that they know will support their views, and the minority party (in this case, the Democrats) gets to invite just one “minority” witness to represent an opinion that is usually at odds with the majority party’s views, Dr. Cutler (and the other invited witnesses) were selected on a bipartisan basis.   Dr. Cutler’s testimony proposed a pathway to repeal the SGR, provide positive and stable payments, and a transition period to better payment models aligned with value to the patient. 

Then, on May 28, the House Energy and Commerce Committee, which shares responsibility for Medicare payment policies with the Ways and Means Committee, released a draft bill to repeal the SGR, provide a period of stable payments, and create an annual fee-for-service (FFS) incentive update program for physicians who report on measures relating to core clinical competencies, with an opt-out from the competency incentive program for physicians who participate in alternative payment models, such as Patient-Centered Medical Homes and Accountable Care Organizations.  The draft bill, by the committee staff’s own admission, lacks many details, such as the dollar amounts and percentage increases in the annual updates and competency update incentive program, how long the period of “stable” payments would last, and whether there would be penalties (lower FFS payments) instead of just positive incentives if physicians did not successfully participate in the competency update program.  ACP, like other medical organizations, was asked to provide the committee with recommendations on the draft bill by June 10.

Meanwhile, over at the Senate side, Senate Finance Committee chairman Max Baucus (D-MT), and ranking Republican Orrin Hatch (R-UT) invited ACP, the AMA, the American College of Surgeons and other specialty societies to provide them with input on several key questions they plan to address in an SGR bill, including how to improve the accuracy of the relative values used by Medicare to determine FFS payments, address over utilization that may be encouraged by the FFS system, and help physicians transition to new value-based payment models.  ACP’s response proposed 19 specific ways to improve the Medicare physician payment system and reduce excess and inappropriate utilization.  To improve the Medicare physician fee schedule, we recommended that Congress direct CMS to gather independent data—in addition to the Relative Value Update (RUC) process—to improve RVU accuracy; that it authorize CMS to pay physicians for the work that falls outside of a visit involved in care coordination; and that it require Medicare to redirect payments for overvalued procedures to undervalued evaluation and management services, among other steps. 

To address overutilization, ACP’s recommendations to the Finance Committee included: creating an add-on to evaluation and management codes when physicians document that they have incorporated high value care clinical guidelines (such as guidelines from ACP’s High Value Care Initiative and the ABIM Foundation’s Choosing Wisely campaign) into their practices and engaged their patients in shared decision-making based on such  guidelines; developing alternatives to pre-authorization that would focus on encouraging use of appropriateness criteria by “outlier” practices rather than requiring all physicians to jump through hoops to get a test ordered; and providing physicians with transparent information on the quality and cost of care of their physician colleagues and hospitals in their community to allow them to make more informed referrals.  And, ACP proposed a step-by-step approach to stabilize Medicare payments and create positive incentives for physicians who participate in programs to improve clinical outcomes, efficiency and effectiveness.

When you think about it, the Holy Grail is to improve the Medicare physician payment system so it helps physicians deliver high quality and cost-effective care, not just to get rid of the SGR.   The result will be big changes not only in the way Medicare pays for services, but in how physicians organize and deliver care.  Getting there will not be easy, and we may again get lost along the way, but for once Congress and the medical profession together appear to be heading in the right direction.

Today’s questions:  Are you encouraged by the movement on Capitol Hill on bipartisan plans to repeal the SGR and reform payments?  What changes would you make in the Medicare payment system to help physicians deliver high quality and cost-effective care?

Thursday, May 16, 2013

If having health insurance doesn’t matter . . .

Would you give your health insurance up and become uninsured?  And cancel your loved ones’ policies?

Why do I ask?  Because one of the principal argument made against ObamaCare—and specifically, the option for states to expand Medicaid to the poor and near-poor—is that having health insurance coverage really doesn’t matter very much.  The argument pretty much goes along the following lines. The uninsured already have good access to care through free charitable clinics.   Hospitals aren’t allowed to turn them away. Health insurance just gets inbetween doctors and patients. Health insurance really doesn’t ensure access and good outcomes. Offering the uinsured coverage will cost a lot of money.  So it isn’t a good use of taxpayer dollars to extend coverage to the uninsured, they are doing okay without it.

Funny thing is, the people who argue that health insurance doesn’t matter are for the most part well-off people who have generous health insurance coverage for themselves and their families, usually through their employers.  It is a big part of their compensation package and employee benefits.  My guess is that they value having the peace of mind that health insurance gives them and their families.  They and their employers have made a cost-benefit calculation that health insurance is worth it.  But for the poor and near-poor (most of the uninsured), the same peace-of-mind  and cost-benefit calculation apparently doesn’t apply. 

Now, before someone accuses me of making a straw man argument—that is, my premise that many critics of ObamaCare believe that providing health insurance to the uninsured really isn’t that important—let me back it up.   A new study that compares the experience of previously uninsured persons who won a lottery to be covered by Oregon’s Medicaid plan, to those who remain uninsured, has been seized upon by ObamaCare critics to argue not only against expanding Medicaid—but against the very idea that having health insurance really matters that much when it comes to better health outcomes.

The Washington Post’s Sarah Kliff posted an excellent (as she always does) blog explaining how the study’s principal finding—that the Oregon expansion didn’t result in better health outcomes on cholesterol, blood pressure and blood sugar levels for the new Medicaid enrollees (after two years) compared to the uninsured—has been seized upon  by opponents of ObamaCare’s Medicaid expansion.  But although it is true the study didn’t find any improvements in these three common measures of outcomes, it did show one huge benefit—the people who were able to join Medicaid no longer had to worry that getting sick would result in a financial calamity, as Jonathan Cohn explains  in his New Republic post:

“The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.”

The same study also found a substantial reduction in reported incidents of depression—which (I am just speculating) might have had something to do with recipients no longer having to choose between paying rent or getting health care!

So on one side, you have conservative critics of ObamaCare’s Medicaid expansion concluding that the new study validates their view that it is a big waste of money because putting people on Medicaid won’t improve health outcomes.  On the other side, you have liberals who argue that the study shows that putting people in Medicaid protects them from financial catastrophe and is well worth the cost, even if it doesn’t result in immediate gains in health outcomes.

If the argument was just about Medicaid, that would be one thing—surely one can make a credible argument that there are better ways to provide coverage to the poor than expanding Medicaid (although I have yet to see a plausible conservative alternative), but some conservatives are citing the study to argue against the very idea of providing health insurance coverage (not just Medicaid) to the poor.

The Washington Post’s Robert Samuelson opens his latest column, Why ObamaCare is Oversold, with this provocative statement (citing the Oregon Medicaid study):

“It’s the great moral imperative behind the Affordable Care Act (“Obamacare”): People should not be denied health care because they can’t afford insurance. Health status and insurance are assumed to be connected, and opponents have often been cast as moral midgets, willing to condemn the uninsured to unnecessary illness or death. The trouble is that health status and insurance are only loosely connected. This suggests that Obamacare may result in more spending and health services but few gains in the public’s health.”

He continues:

“The most overlooked finding [from the Oregon study] is that the uninsured already receive considerable health care. On average, the uninsured annually had 5.5 office visits, used 1.8 prescription drugs and visited an emergency room once. Almost half (46 percent) said that they ‘had a usual place of care,’ and 61 percent said that they had ‘received all needed care’ in the past year. About three-quarters (78 percent) who received care judged it ‘of high quality.’ Health spending for them averaged $3,257.  Much of this was known — or could have been surmised — during the debate over Obamacare. The Congressional Budget Office reported that the uninsured typically received 50 to 70 percent of the care of the insured. A study in 2007 of the 1965 creation of Medicare — insurance for the elderly — concluded that it had ‘no discernible impact on elderly mortality’ in the first 10 years but improved recipients’ financial security by limiting out-of-pocket expenses.”

And then this:

“ ‘Health insurance is a financial product that is aimed at providing financial security,’ the study says. On that ground, the expansion succeeded; by most clinical measures, it didn’t. Perhaps it is too early. The expanded Medicaid coverage was only two years old at the time of the study. Maybe greater health improvements will emerge. But maybe they won’t, and not only because the uninsured already receive care. Many uninsured are relatively healthy; insurance won’t make them healthier. For others, modern medicine can’t cure every health problem. Still for others, bad luck or bad habits are hard to change. About two-fifths of Oregon’s uninsured were obese or smoked; Medicaid didn’t alter that.”

And Samuelson concludes with this stunning attack on the motivations of those, like me and ACP, who support ObamaCare, arguing that is our sense of moral superiority (rather than concern for the poor) that motivates our support for universal coverage:

“Obamacare’s advocates ignored these ambiguities. They were too busy flaunting their moral superiority. Universal health insurance is a legitimate goal, but 2009 — in the midst of a major economic crisis — was the wrong time to pursue it. Predictably, it polarized public opinion and subverted confidence for what seem to have been, based on the available evidence, likely modest public health improvements. The crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.”

Wow . . . “the crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.”    Really? 

I would say that extending health insurance coverage to everyone, so that no one has to worry about a financial catastrophe because they get sick, is in itself enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare.

If protecting the uninsured from health related financial catastrophe wasn’t enough, I would say that the preponderance of evidence shows having health insurance will reduce tens of thousands of preventable deaths,  notwithstanding the Oregon study—which by itself would be enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare.  The esteemed Institute of Medicine in 2009 looked at all of the evidence on being uninsured, and found that there is a “chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death.”

I don’t support ObamaCare because of my own self-worth, but because I believe that the evidence shows that it will provide enormous  economic benefit (for sure)  and health benefits (most likely) to the 30 million or so uninsured (and mostly) poor who now have no access to coverage. 

But don’t take my word for it.  Listen to this interview with a real person who explains to  Kaiser Health News reporter what being brought under Oregon’s Medicaid plan has meant for her:

Q: How did lacking insurance affect your medical care?

A: “At one point I needed some cortisone for my asthma and they wanted to do a complete heart work-up to make sure that my troubled breathing wasn’t congestive heart failure. You're always telling them, ‘No, no, no, this is the only thing I want.’ It's like trying to buy the burger with no fries at McDonald's. You have this resistance all the time, because doctors and nurses look at you with these big soft eyes and say, "But it would be so important to know your level of cardiac health, I'm really concerned. I'm sure the doctor there will work out something and make payment arrangements." And it sounds so good and you do it and it never works out. The discount isn't there or you fill out something wrong and all of a sudden you have a $300 bill in collections. So you have to make sure none of that happens to you.”

Q: How has your health changed since you went on Medicaid?

A: “Over the course of nine months or a year I was able to drop two different blood pressure medicines, which is nice because they had side effects I didn’t like. So I'm down to half a pill of one of the medicines and my blood pressure is still stable. For about a five-year period I thought my thyroid medicine was too low and I couldn’t afford the doctor visit to have the lab slip to get a new prescription. That whole procedure is about $300 so I just stayed with the same medicine. With Oregon Health Plan I was able to go back to the doctor and when she said wanted to check my thyroid levels I could say, ‘Yes, I'll go to the lab and get that done.’ They were low again. I was able to get that increased and that made a big difference in how much energy I had and how much better I felt.”

Q: If you had hadn't won the Medicaid lottery, where do you think you'd be financially and medically?

A: “Financially, I'd be maybe $100 a month poorer. I would not be monitoring my blood sugar. I would not be paying as much attention to my cholesterol. I probably would have lost some weight but I don't think I would have lost so much, and I don't know if I would have been so good at keeping it off. I'd be much more anxious about what could go wrong. One of the things you get in Oregon is you get your teeth cleaned and X-rayed once a year. I hadn't been to the dentist in six or eight years except to have a tooth pulled. So it was really nice to have my teeth cleaned and find out I don't have cavities and don't need my teeth pulled. My father died of melanoma and there's a lot of melanoma in my family—one of my sons had skin cancer when was he was 15—and so that's a worry. Being able to go to the doctor and have my moles checked was a big weight off my mind. I'm a lot surer I'm going to be able to make it to 70 without being crippled or in a wheelchair and not being able to take care of myself.

And there's something about just feeling like you're part of regular life. There's a lot of emphasis on how everyone should be healthy and everyone should live longer, and you don't want to be a burden on society. If you don’t have medical insurance, you're kind of not part of that. It's hard to explain, but there's an element of participating in society that being able to go to the doctor gives you. Everybody always asks everyone how you're doing, and to be able say ‘My doctor says I’m doing really well,’ that's nice, instead of being in a group of people and saying, ‘Well, I don't really go to doctors.’”

Q: The Oregon study did not find significant health improvements for those who won the Medicaid lottery versus those who did not, with the exception of improvements in self-reported depression. Some commentators have seized on these findings to argue that having Medicaid does not lead to better health. Do you agree with that?

A: “ Some people have completely lost track of what health insurance is supposed to be. We're talking about somebody being able to get their broken arm fixed if they fall out of a tree. My blood pressure is still not perfect, but over the last two years I have stopped taking two different blood pressure medicines and am only taking half of a third. That is a health improvement but it doesn't necessarily show up in the study. My blood sugar is not perfect, but it's more consistently in the right zone. But according to the study, I haven't improved. Most of the people who are going to be on Medicaid are going to be working. What are you supposed to do if you're working at McDonald's 30 hours a week? You're working all the hours they give you. Why shouldn't they be able to go to the doctor? Why should they have to lose everything they own if they break their arm and have to go to the emergency room? Everybody can't go to college and get a good job. Somebody is always going to work in the nursing home. Somebody is always going to work part-time at JC Penney even though they want to work full time, because the store only wants them there on Saturday and Sunday. Those people need to make enough money to live on, they need to have enough food to eat and they need to be able to go to the doctor when they're sick.”  [Emphasis added by me in italics]

So yes,  I admit that I feel that it is a great moral imperative to extend coverage to people like this woman.  Medicaid is by no means perfect, but expanding it to her and others who are “working at McDonald's 30 hours a week” will give them financial protection.  Why shouldn’t they be able to go to the doctor?  Why should they have to lose everything if they break their arm and have to go to the emergency room?  Why shouldn’t they have enough money to live on, enough food to eat, and be able to go to the doctor when they get sick. Why shouldn’t they be able to feel like they are just part of regular life—like you and me who are fortunate to have health insurance for ourselves and our families?

So if you really feel that this woman, and the millions like her, don’t need health insurance, how about canceling your own insurance (and your family coverage, to boot) and see what it is like to depend on free clinics for your medical care?  And to make it a truly comparable experience, try to go without health insurance while living on a  minimum wage. 

If you aren’t willing to make the choice of going uninsured for you and your family members, then is it too much to ask that you support extending health insurance coverage to everyone, and especially, the poor and near poor? (And if you don’t like Medicaid and ObamaCare, explain how else you would make coverage available to everyone?).  If having health insurance matters to you, it matters to them, it matters to everyone, it is the right policy to pursue, and yes, it is a great moral imperative that we try.

Today’s question: If you oppose expanding health insurance coverage to everyone because health insurance “doesn’t matter” or it is too expensive, would you give up your own health insurance?  Why or why not?