Friday, August 16, 2013

How exactly does Obamacare “destroy” the patient-doctor relationship?

It doesn’t.  If anything, it will strengthen it, as I’ll explain later in this post.  But many of the law’s fiercest critics keep saying that Obamacare will “destroy” the patient-physician relationship.  Yet there is little if anything they can point to that is actually in Obamacare that would get between patients and their physicians.  

Typical is a letter that Docs4PatientCare, a self-described” organization of “concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship” wants physicians to give to their patients.  The letter “to all of my patients” is written as if it is coming from a patient’s own personal physician when it really was written and produced by a national advocacy organization.   The letter, which was originally distributed prior to the 2010 mid-term elections,  claims that “This new law politicizes medicine and in my opinion destroys the sanctity of the doctor-patient relationship that makes the American health care system the best in the world”  and expressly threatens retribution against Democratic candidates for Congress.  “Please remember when you vote this November that unless the Democratic party receives a strong negative message about this power grab our health care system will never be fixed and the doctor patient relationship will be ruined forever.” Finally, the letter concludes by telling the patients that the doctor “will be glad to discuss this with you at the end of our consultation.”  

(Before I get into the lack of support for their argument about Obamacare bringing ruin to the patient-physician relationship,  isn’t this group’s efforts to hijack a physician’s medical consultation with a patient  to “send a strong negative message” to Democratic candidates about Obamacare, in itself destructive of the patient-physician relationship, and even borderline unethical? The AMA’s Council on Ethical and Judicial Affairs cautions that “Conversations about political matters are not appropriate at times when patients or families are emotionally pressured by significant medical circumstances.”  When is a patient more emotionally pressured and vulnerable than in a medical consultation with their doctor?  What is more political than a physician telling them how they should vote?)

Now back to their point about Obamacare destroying the patient-doctor relationship.  The letter says that Section 1311 of the ACA (Obamacare) establishes “care-guidelines that your doctor must abide by or face penalties and fines. In making doctors answerable in the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions.” 

Except Section 1311 doesn’t say that, and you won’t find it anywhere else in Obamacare. You can look it up here and you’ll find that Section 1311 describes the benefits that health plans must offer to patients in order to be sold on the state health insurance marketplaces.  It establishes certification criteria for qualified health plans, requiring such plans to “meet marketing requirements, ensure a sufficient choice of providers, include essential community providers in their networks, be accredited on quality, implement a quality improvement strategy, use a uniform enrollment form, present plan information in a standard format, and provide data on quality measures.”   It also requires that health plans “publicly disclose, in plain language, information on claims payment policies, enrollment, denials, rating practices, out-of-network cost sharing, and enrollee rights . . . and requires such plans to provide information to enrollees on the amount of cost sharing for a specific item or service.”

This destroys the patient-physician relationship how?   It seems to me that providing patients with more choices of health insurance, better benefits, and transparent information on claims payment policies, enrollments, denials, out-of-network cost-sharing would be good for the doctor-patient relationship.

The Docs4PatientCare letter could be referring to another section of the law that continues the Medicare Physician Reporting Program, a program that was in affect long before Obamacare became law.  The PQRS uses a carrots and sticks approach of positive updates and penalties depending on how well physicians do on reporting on quality measures for the Medicare population.   One can take certainly take issue with the program and even philosophically disagree with linking payments to performance measures, but to say it destroys the patient-physician relationship is an over-reach.  (Others might argue that it has the potential to improve the patient-physician relationship, because the purpose of the program is to improve outcomes to patients.)

And, the idea of linking physician payments to performance measures is hardly unique to or the creation of Obamacare.  In case you weren’t paying attention, the Energy and Commerce Committee’s bill to repeal the Medicare SGR, which was developed by the Republican majority and received unanimous support from all of the members of the committee, Democrats and Republicans alike, would mandate an even more robust pay-for-performance program for Medicare beginning in 2019.  As I wrote in an earlier blog post, “The bipartisan message from Congress is clear: if physicians choose to remain only in FFS, their annual updates going forward will be very modest, 0.5% for the next five years, and no more than 1.5% and as low as -0.5% depending on where they rank in the new quality reporting system that would begin in 2019.  (And if they don’t participate in the quality reporting system at all, or one of the Alternative Payment Models, they would get an annual 5% cut).”

The  Docs4PatientCare letter continues with the inevitable “rationing by government panels” charge against Obamacare.   But where in Obamacare would you find these government rationing panels?  You won’t, because they don’t exist.  It could be that they are referring to the much maligned and misunderstood Medicare  Independent Payment Advisory Board (IPAB), a board that hasn’t yet been appointed, that will be made up of independent experts--not government bureaucrats—nominated by the President and confirmed by the Senate (assuming that the President’s nominees could get confirmed, which would be no sure thing) ,that is purely advisory to Congress (Congress can accept or reject its recommendations), that is empowered to make recommendations to Congress to reduce Medicare spending only if a statutory spending threshold is exceeded, which isn’t expected to happen for several more years, and that is expressly prohibited from reducing benefits or rationing care.  IPAB is by no means perfect, but it is at most a paper tiger, and even if/when it is appointed and confirmed and starts making recommendations to Congress,  which Congress can then accept or reject, it will still be just an expert advisory group that is expressly prohibited from rationing care.   You don’t need to take my word for it.   Read what independent fact-checking sites have ruled:

“But the law doesn’t establish any kind of board that would make decisions on what care seniors get as they’re waiting in hospital beds, or anywhere else. . . .the Independent Payment Advisory Board, cannot, by law, ‘ration’ care or determine which treatments Medicare covers. In fact, the IPAB is limited in what it can do to curb the growth of Medicare spending” concluded FactCheck.

Addressing a claim from a 2012 Senate candidate that “the patient-doctor relationship will be eliminated" under Obamacare, the Pulitzer Prize winning PolitiFact ruled it as “pants on fire” falsehood: “That’s a hefty charge. And there’s little proof to substantiate it. Provisions in the health care law allow changes to payments to health care providers and influence what’s covered by certain insurance plans, but nothing in the bill prevents physicians and patients from making health care decisions together.”

So what else in Obamacare might threaten the doctor-patient relationship?  The Heritage Foundation  claims that it “Destroys the doctor-patient relationship. Obamacare’s massive amount of red tape and regulations will tear apart the doctor-patient relationship. Doctors will have to focus increasingly on government rules rather than the specific needs of their patients . . .   In addition, Obamacare links payment for providers to adherence to government measurements of care.“   

I’ve already addressed the misleading claim that “Obamacare links payment for providers to government measures of care”—it only continued the Medicare quality reporting program that was already in effect.  And the measures used in that program aren’t government measures, they came from physician specialty societies and other clinical experts.

I agree that physicians are faced with too much paperwork, and that this can weaken the patient-physician relationship, but the Heritage Foundation piece doesn’t name any specific regulations from Obamacare that will “tear apart” the doctor-patient relationship.  The truth is that almost all of Obamacare’s rules are imposed on insurance companies, not on physicians.  The rules on insurance companies are mostly about making sure that they provide adequate benefits, spend most of the premium dollar on patient care rather profit and administration, and that they don’t turn people down because they are sick.   On the other hand, Obamacare requires insurance companies to standardize enrollment procedures and codes edits used to flag claims for further review, standardize the process for determining patient eligibility,  to standardize electronic funds transfers, and standardize rules for the administrative transactions including health claims; referral; certification; and authorization requirements.  

To sum up: there are no rationing panels in Obamacare, no bureaucrats telling doctors what treatments they can and can’t provide to their patients.  Obamacare continues the existing Medicare pay-for-reporting program (PQRS), but to be fair, the idea of linking physician payments has strong bipartisan support in Congress and is the linchpin of the Republican-drafted bill to repeal the Medicare SGR.   Obamacare imposes more rules on insurance companies so that they will be required to offer better benefits, spend more money on patient care, and standardize health insurance transactions, but such rules can actually help the doctor-patient relationship by financial reducing barriers to patients getting the care their physician recommends and by simplifying claims processing. 

In other words, there is nothing, nada, to support the claim that Obamacare will destroy the patient-physician relationship, but there is much in it that can strengthen it.  Because the biggest benefit of Obamacare is that it will provide access to affordable health insurance for tens of millions of patients.   The Institute of Medicine has found that:

“Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions.  Uninsured children are 20 to 30 percent more likely to lack immunizations, prescription medications, asthma care, and basic dental care. Uninsured children with conditions requiring ongoing medical attention, such as asthma or diabetes, are 6 to 8 times more likely to have unmet health care needs. Uninsured children are also more likely than insured children to miss school due to health problems and to experience preventable hospitalizations. Among working-age uninsured adults, 40 percent have one or more chronic health conditions such as asthma, hypertension, depression, diabetes, chronic lung disease, cancer, or heart disease. Uninsured adults with such chronic conditions are two to four times more likely than their insured counterparts to have received no medical attention in the prior year. Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high  blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services . . .“

So what could be better for strengthening the patient-physician relationship than giving patients access to affordable health insurance coverage, as Obamacare will do, so that they don’t need to “delay or forgo doctors’ visits, prescription medications, and other effective treatments?”

Today’s questions:  How do you think Obamacare will affect the patient-physician relationship?   And if you think it will “harm” or even “destroy it” tell me how, tell me what exactly in the law does this?


james gaulte said...

Your commentaries lately have been talking a lot about ethics (some would say as defined by the ACP). My question is what exactly do you mean by "borderline unetical"? which is what you seem to accuse one organization's anti-ACA efforts of.Seems to me something is either ethical or not.

BDoherty said...
This comment has been removed by the author.
BDoherty said...

I cited the position of the AMA Council on Ethics and Judicial Affairs, which expressed caution about physicians bringing up political issues in a situation where the patient is vulnerable for medical and emotional reasons. One can draw one’s own conclusion on whether a physician distributing a letter to a patient, during a medical consultation, that expresses a clear position on a highly political issue (Obamacare) and even urges that patient to "send a message" to Democrats (and only Democrats are mentioned) is consistent with CEJA opinion. You may be right that something is either ethical or not, but the CEJA opinion suggests that it is up to the physician to decide if he or she is expressing political views to patients at a time and place where the patient is emotionally or emotionally vulnerable. Thus, my use of the term "Borderline" in the sense that it is up to each physician to determine if the Docs4PatientCare crossed the line of being inappropriate as defined by CEJA. I don't claim to be a medical ethicist, although ACP's Center on Ethics and Professionalism used to report to me within the ACP staff management structure, so it is an area that I have considerable understanding of (I used to regularly attend and contribute to all ACP Ethics Committee meetings). I think it is fair for anyone, within the profession or within the general public, to look to the ethical principles that ACP, AMA and others in the profession have developed, and raise questions about how those ethical principles might apply to specific circumstances involving physicians and their patients, including those relating to discussions of their views on Obamacare or, as I discussed in previous post, answering questions from patients who are seeking help in understanding if and how they should sign up for coverage under Obamacare.

james gaulte said...

Thanks for your explanation of what you meant by "borderline unethical" . Does that suggest the following?If a physician judges a patient to be emotionally vulnerable she should not express political views but if the physician finds vulnerability is not apparent nor likely then political views could then be expressed.
I agree it is fair for anyone to reference published ethical precepts and principles and express an opinion regarding a particular practice or activity carried out by physicians.But let me respectfully suggest than you are not just "anyone".Whether in this particular commentary you were acting under the direction or at least the approval of ACP leadership I do not know but you clearly write commentaries under their banner, on their website and it is certainly likely that some of your readers will assume that you are expressing the views of ACP.I doubt that writing in the first person and using phrases like "in my view"will convince many readers that there is any distance between your views and those of ACP leadership.If you views are not those of ACP, perhaps a disclaimer would be appropriate.

Harrison said...

The patient physician relationship is in transition and has been for a while.
The romantic notion of this relationship is a primary care doctor who does just about everything.
Serves the whole town.
Probably played baseball in his youth, and can't go back (to borrow from a movie).

Then came specialists.

Then came specialists who did shifts and specialized by location -- like ER and anesthesia and then hospitalists and now SNFists.

Now we are moving away from fee for service so the goal of doctor visits is changing.
And for some visits we don't need an physician but instead an NP or a PA.

It is all changing ever faster.

But maybe if we could all go back to the Field of Dreams.
Burt Lancaster was a great doctor.