Thursday, July 25, 2013

Does professionalism require physicians to help patients sign up for Obamacare coverage?

One of the most  disheartening developments in the unrelenting political fight over the health reform law is the organized effort by its opponents to dissuade the public from signing up for coverage. Having failed in efforts to block Obamacare in the Supreme Court, or to elect a president or Senate that would work for its repeal, they are now working to kill the law by persuading people to not sign up for coverage through the health exchanges, knowing that if not enough younger and healthier people sign up, premium costs will go up because the people who do sign up will be older and sicker.  Then, if premium costs escalate, they figure the whole law will collapse.

This effort to sabotage the law is "unprecedented and contemptible" the conservative-leaning American Enterprise Institute's congressional scholar Norm Ornstein writes in the National Journal:

"It is important to emphasize that this set of moves is simply unprecedented. The clear comparison is the Medicare prescription drug plan. When it passed Congress in 2003, Democrats had many reasons to be furious. The initial partnership between President Bush and Sen. Edward Kennedy had resulted in an admirably bipartisan bill—it passed the Senate with 74 votes. Republicans then pulled a bait and switch, taking out all of the provisions that Kennedy had put in to bring along Senate Democrats, jamming the resulting bill through the House in a three-hour late-night vote marathon that blatantly violated House rules and included something close to outright bribery on the House floor, and then passing the bill through the Senate with just 54 votes—while along the way excluding the duly elected conferees, Tom Daschle (the Democratic leader!) and Jay Rockefeller, from the conference committee deliberations.

The implementation of that bill was a huge challenge, and had many rocky moments...Almost certainly, Democrats could have tarnished one of George W. Bush's signature achievements, causing Republicans major heartburn in the 2004 presidential and congressional elections—and in the process hurting millions of Medicare recipients and their families. Instead, Democrats worked with Republicans, and with Mark McClellan, the Bush administration official in charge of implementation, to smooth out the process and make it work—and it has been a smashing success."

He continues:

"What is going on now to sabotage Obamacare is not treasonous—just sharply beneath any reasonable standards of elected officials with the fiduciary responsibility of governing...When a law is enacted, representatives who opposed it have some choices (which are not mutually exclusive). They can try to repeal it, which is perfectly acceptable—unless it becomes an effort at grandstanding so overdone that it detracts from other basic responsibilities of governing. They can try to amend it to make it work better—not just perfectly acceptable but desirable, if the goal is to improve a cumbersome law to work better for the betterment of the society and its people. They can strive to make sure that the law does the most for the Americans it is intended to serve, including their own constituents, while doing the least damage to the society and the economy. Or they can step aside and leave the burden of implementation to those who supported the law and got it enacted in the first place.

But to do everything possible to undercut and destroy its implementation—which in this case means finding ways to deny coverage to many who lack any health insurance; to keep millions who might be able to get better and cheaper coverage in the dark about their new options; to create disruption for the health providers who are trying to implement the law, including insurers, hospitals, and physicians; to threaten the even greater disruption via a government shutdown or breach of the debt limit in order to blackmail the president into abandoning the law; and to hope to benefit politically from all the resulting turmoil—is simply unacceptable, even contemptible."

Ornstein doesn't address the medical profession's role and responsibility to help their patients sign up for Obamacare coverage, but one has to wonder, will physicians who are against the law also discourage eligible patients from enrolling in it?  Will they tell their younger, healthier and uninsured patients to reject buying coverage from the exchanges and applying for the law's premium subsidies?  Will they discourage the poor and near-poor (in states that have agreed to expand Medicaid) from enrolling in Medicaid?  Or instead of actively discouraging enrollment, will they use a more passive resistance approach of doing nothing to help their patients understand the new coverage options available to them?  Or will they encourage and help their patients sign up, notwithstanding their own partisan leanings and ideological objections to Obamacare?

I would argue that the medical profession's own standards of ethics and professionalism obligate physicians to help their patients understand and take advantage of the health insurance coverage options and subsidies offered by Obamacare.  The Physician's Charter on Professionalism, which was endorsed by ACP and-dozens of other physician membership organizations including AMA, states the following:


"Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession."

ACP's ethics manual, Sixth Edition, offers the following guidance:


"The physician's first and primary duty is to the patient. Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting."

And this:

"They should work toward ensuring access to health care for all persons; act to eliminate discrimination in health care; and help correct deficiencies in the availability, accessibility, and quality of health services, including mental health services, in the community."

The Institute of Medicine has concluded that lack of health insurance causes tens of thousands of people to die prematurely and unnecessarily.  Obamacare will provide access to affordable coverage to people who now can't afford it or can't obtain it because of pre-existing conditions. 

A physician's primary duty to their patient then, in my mind requires that physicians offer help to patients on obtaining coverage through the exchange or (expanded) Medicaid programs.  Accordingly, a physician who discourages patients who would benefit from such coverage would be acting in a way that is in conflict with their professional and ethical obligations as determined by their own professional societies.

To be sure, ethics and professionalism do not preclude physicians from engaging in the political process to change or repeal laws they disagree with, and to elect candidates who share their views. But when patients come to them and ask for help in understanding the coverage options available to them under Obamacare, as they will, physicians should direct them to resources to help them, independent of their personal opposition to the law. Under no circumstances should they discourage patients from obtaining coverage.

Society expects much from physicians, much more than we expect from politicians.   The medical profession rightly demands much of itself.  I hope that even the most militantly anti-Obamacare doctors will recognize that their primary duty to their patients requires that they help them sign up for Obamacare coverage, even if they wish to continue to engage in the political process to get it changed or even repealed. 

Today's questions: Do you agree that professionalism and ethics require that physicians, including those who are opposed to Obamacare, help their patients sign up for coverage?  Do you agree with Ornstein that it is "contemptible" for politicians to discourage the public from signing up for coverage in order to sabotage the law?

Friday, July 19, 2013

House SGR bill promotes Medical Homes

Last night, the House Energy and Commerce Committee released a bipartisan bill to repeal Medicare’s SGR formula, replacing it with a system that will involve quality reporting under the fee-for-service (FFS) system combined with strong incentives for physicians to move into alternative payment models. While the bill offers a lifeline to physicians who choose to remain in FFS, the incentives favor physicians who are willing to take the necessary steps to become Patient-Centered Medical Homes, Accountable Care Organizations, or other models that enhance care coordination, patient safety, prevention, and patient experience with the care provided.  The bill promotes many of the goals that ACP has advocated to  Congress through its comments on prior drafts of the legislation, including repeal of the SGR, providing five years of stable and positive payments to all physicians, creating opportunities for physicians to get incentive-based quality payment updates, and establishing a transition period and pathway for physicians to participate in alternative payment models.

Highlights:

Repeals the SGR, immediately upon enactment.

Provides for positive but modest, annual Medicare fee schedule updates in 2014 through 2018 of O.5%. 

Establishes a Quality update incentive program beginning in 2019 for physicians who choose to continue to be paid under FFS.  Physicians would self-select a “clinical cohort” applicable to their specialty and type of practice, and would be measured based on how well they performed on clinical performance measures and clinical practice and care delivery systems appropriate for their cohort.  Emphasis would be on measures that improve care coordination, patient safety, prevention, and patient experience with the care provided.  Physicians would be scored on a scale of 1 to 100, and those scoring in the top third would get an annual FFS update of 1.5%, those scoring in the next third would get a 0.5% update, and those in the lowest third would get a MINUS 0.5%.  Those who declined to participate in the quality reporting program, or to join in an approved new Alternative Payment Models, would get a 5.0% cut in their total Medicare payments each year starting in 2019.

Creates a process for physicians to recommend and participate in Alternative Payment Models to Medicare.  Alternative Payment Models selected by CMS would not participate in the quality update incentive program; instead, physicians in those models would be paid under the payment rules applicable to the particular model. For instance, an approved ACO might be paid under a shared savings arrangement; a PCMH under a risk-adjusted capitation system combined with FFS and shared savings.

Medicare would be directed to begin paying physicians, starting in 2015, for care coordination of patients with complex chronic diseases.  However, in order to qualify for such payments, physicians would have to be in a Patient-Centered Medical Home, or a Patient-Centered Medical Home specialty practice, as recognized by the National Committee on Quality Assurance (NCQA) or another certification process as established by the Secretary.

The bottom-line for physicians is that the bill gets rid of the annual specter of double-digit SGR cuts, stabilizes FFS payments, offers FFS physicians the opportunity to improve their FFS updates for successfully reporting on quality measures, promotes the importance of care coordination and especially, the Patient-Centered Medical Home model, and creates incentives and opportunities for physicians to recommend and participate in medical homes and other Alternative Payment Models that would be paid under their own rules instead of the FFS quality update program.  

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).  But physicians who are willing to become certified PCMHs, or become specialty practice medical home neighbors, or enter into ACOs or other alternative models, won’t have to report on the measures for the quality update program or be subject to annual FFS quality update incentives.  Instead, they will have more opportunities to be reimbursed for complex chronic care coordination and share in savings to the Medicare program from improving care coordination, patient safety, and patient experience with the care provided.

Because the bill has support from both Republicans and Democrats, it has a reasonably good chance of making it through the House of Representatives.  The Senate is working on a similar approach.  So if you are a physician who has been on the fence on whether it is worth it to become a PCMH or an ACO, well, the incentives are now clearly pointing you in that direction.

Today’s question: What is your reaction to the bipartisan SGR repeal, physician payment reform bill?

Wednesday, July 10, 2013

What, Me Worry?

. . . could pretty much characterize how Obamacare supporters are reacting to the news that the administration is delaying or modifying the implementation of some of its requirements.  Like Mad magazine’s Alfred E. Neuman, they are expressing a public confidence that there is no reason to worry,  everything is fine, the announced delays aren’t really that important, and Obamacare will be up and running and ready to start enrolling people on October 1.  No worries.

The Sky is Falling
…could pretty much characterize how Obamacare opponents are reacting to the same news.  Every decision that the administration makes to delay any part of the law’s implementation is used by opponents to argue that the whole thing is falling apart and the only solution is to repeal the entire law.  The sad reality is that Obamacare supporters and critics are worlds apart in their reaction to the delays, just as they have been on just about everything having to do with this law.

So what is really going on with the delays? 
The administration postponed for one year a requirement that larger employers (those with 50 or more full-time employees) provide their employees with health insurance or pay a fine.  The White House characterized the delay is being responsive to businesses' concerns by giving them an additional 12 months to comply with the requirement but insisted that, “We are full steam ahead for the Marketplaces [health exchanges] opening on October 1.”

Whether you think delaying the employer mandate was a good idea or not, and no matter what you may think it bodes for the rest of the law being ready on October 1, the fact is that the delay will have a very small impact on how many people will get coverage under Obamacare.

Timothy Jost writes  in the Health Affairs blog that, “As a practical matter, most employers subject to the mandate already offer insurance.  The mandate only covers employers with more than 50 full-time or full-time-equivalent employees.  Ninety-eight percent of employers with more than 200 employees offer health insurance, as do 94 percent of employers with 50 to 199 employees.  The vast majority offer insurance that is both affordable and adequate, as those terms are defined in the ACA.  All of the reasons employers now have for offering coverage to their employees — significant tax subsidies, recruitment and retention of employees, and increased productivity and decreased absenteeism when employees are healthy — will continue to exist without the mandate penalty.”

In addition to the employer mandate delay, the Washington Post’s Sarah Kliff writes about “three Obamacare delays you haven’t heard about relating to verification of consumers’ claims that they do not have health insurance coverage, scaling back federal oversight of what people say they earn, and requiring state Medicaid programs to send out electronic notices on benefits and subsidies to beneficiaries and applicants.  Kliff writes that the “upshot of this delay is that you could see some people who shouldn’t qualify for tax subsidies, because of their employer-sponsored insurance, getting them anyway. This wouldn’t be unprecedented: During the initial roll out of Medicare Part D, some seniors who should not have received low-income subsidies got them anyway.”   And, finally, the administration announced last week that smokers will get a one-year reprieve from an ACA provision that allows insurers to charge smokers more than non-smokers because of a “computer system glitch.”   The result, the CBS news report continues, is that “Older smokers are more likely to benefit from the glitch, experts say. But depending on how insurers respond to it, it's also possible that younger smokers could wind up facing higher penalties than they otherwise would have.”

Each of these delays—and there likely will be more—do not fundamentally affect the big changes that Obamacare will bring later this year and next; the health exchanges (marketplaces), community-rated health plans, tax credit subsidies, individual insurance requirements, prohibiting annual and lifetime limits on coverage, requiring insurers to accept all applicants without regard to their health status (pre-existing conditions) and limiting how much more they can charge them, all of these appear to be on track to be implemented on time. 

So, an accurate, non-political, non-partisan, non-ideological take-away from the Obamacare delays announced to date is that most people who were expected to  benefit from the Affordable Care Act will still benefit, including the uninsured and under-insured and people with pre-existing conditions.
The administration is putting off the requirements that are less important, so they can focus on, and devote the limited resources that Congress has given them, to ensure that the changes that are most critical to expanding coverage—the exchanges, the subsidies, the Medicaid expansion, the consumer protections against insurance practices that limit coverage—are implemented on time, and effectively.   This may or may not be good politics on the administration’s part, but triaging the requirements was probably their only practical recourse.

Are there delays that would pose a big problem for Obamacare?  Yes, any delay relating to the following would be a big reason to worry:

If the federal exchanges and state exchanges and information hubs are not open for business on October 1 and ready to enroll people on 1/1/14

If navigators and call centers are not ready to assist consumers

If the Treasury department isn’t ready to administer the subsidies

The administration insists all of the above will be ready, but no one can be sure until they actually are up and running.

Then, of course, there is the one big delay that already is in effect, one that is outside of the administration’s control, which is the Supreme Court ruling that the Medicaid expansion is optional. The decision by some states to delay or reject the Medicaid expansion will result in 2/3 of low-income persons who were supposed to get Medicaid under Obamacare being left out in 2014, according to an Associated Press analysis.  Now that is something to worry about!

So the sky isn’t falling on Obamacare, no matter how the critics try to parlay the decisions to delay some parts into an admission that the whole law is unworkable and should be repealed.  Yet I wouldn’t exactly say that there is no reason to worry, either, since it is apparent that the administration is struggling to get the big pieces implemented on time and as effectively as possible, given the funding limits imposed by Congress, conservative state resistance/non-cooperation, and the unrelenting efforts by critics to do everything possible to make it fail. 

Today’s question: What do you think the delays announced to date bode for Obamacare?

Wednesday, July 3, 2013

If extreme partisanship and ideology didn’t rule the day . . .

Then the Obama administration’s decision to delay the requirement that employers provide health insurance or pay a fine would have been greeted by Obamacare’s critics as a sign that the administration was willing to meet them halfway.  And they would have responded in kind, by offering to work with the administration to smooth out other concerns about the law, rather than citing the delay as being another reason to repeal Obamacare.

If extreme partisanship and ideology didn’t rule the day . . .

Then the Obama administration’s repeated willingness to allow more conservative states to enroll Medicaid recipients in private health insurance plans would have been greeted by the states that are resisting Medicaid expansion as a sign that the administration was willing to meet them halfway.  And they would have responded in kind, rather than continuing their effort to block the expansion and with it, the entire law.  A few did, but most did not.

If extreme partisanship and ideology didn’t rule the day . . .

All members of Congress would help their constituents understand and enroll in the new coverage options created by Obamacare, even though some of them disagree with it, because that is what members of Congress are supposed to do, help constituents navigate government programs, not just the programs they voted for.  But many anti-Obamacare members of Congress have indicated that they will do nothing to help their constituents understand the law and get the Obamacare benefit that they are entitled to. 

If extreme partisanship and ideology didn’t rule the day . . .

Then conservative critics of Obamacare would acknowledge that, “The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s.”

If extreme partisanship and ideology didn’t rule the day . . .

Democrats and Republicans would work together to enact changes to improve the law and fix its flaws, just like they did with Social Security, Medicare, and Medicare Part D, laws that also were very controversial at the time,  just as they’ve done with just about every other major law enacted over the past 75 years.  But this is all but impossible in the hyper-partisan, hyper-ideological 113th Congress, with the result that those “seeking changes are finding, to their dismay, that in a polarized Congress, accomplishing them has become all but impossible.”  The only way they can get changes, then, is when the Obama administration itself provides more flexibility.

(If you have any doubt that extreme partisanship and ideology rules the day to an unprecedented degree, read what the “carefully nonpartisan” congressional scholars Norm Ornstein and Thomas Mann wrote in their provocative book, It’s Even Worse than It Looks, in which “they posit that democracy in America is being endangered by extreme politics.”

The fact of the matter is that Obamacare is the law, and starting as soon as October 1, it will provide tens of millions of Americans with new coverage options.  It could be made better, but partisan gridlock in Congress makes it impossible to make legislative changes.  It is complex, because our health care system is complex, so of course closing the gaps was never going to be a walk in the park.  Doing nothing to help people understand it won’t make the law go away, but it will hurt constituents who could benefit from having access to Medicaid or coverage through a health exchange.  And because Congress can’t agree on improvements to the law, the only way to get changes is when the Obama administration on its own makes changes,  as it just did by delaying the requirement that large employers provide coverage.  

Today’s question:  Do you agree that extreme partisanship and ideology is not only undermining efforts to improve Obamacare and make its implementation go smoother, but poisoning our democracy itself?

Monday, July 1, 2013

“There’s too much confusion, I can’t get no relief”

"There must be some way out of here," said the joker to the thief, "There's too much confusion, I can't get no relief.”

Whether it is ICD-10 or PQRS or meaningful use, physicians can surely identify with this refrain from Bob Dylan’s classic 1967 anthem: there is too much confusion over what is expected of them, they can’t find a way out, and they surely aren’t getting any relief from government.

But what if there was someone out there who was willing to keep track of all of the deadlines and associated deliverables affecting them and their practices?  So that doctors could spend more time with patients instead of tracking what form the government needs and when?  Someone who not only told them what was required of them by what date, but also suggested steps that they could take, weeks, months and even years in advance to make things easier?  Someone who was able to cut through the confusion by providing simple, understandable, and practical resources to help them successfully meet the demands that have been imposed on them? Someone who not only kept a timeline and resources on the annoying regulatory deadlines that government imposes on them, but also kept track of opportunities to be better paid for their services, along with what specific steps they need to take to qualify?

Well, the American College of Physicians is that someone.  Earlier this month, the College released a new tool, the Physician and Practice Timeline, “a helpful at-a-glance summary of important, upcoming dates related to a variety of regulatory, payment, educational, and delivery system changes and requirements” according to the ACP website.  But it is more than a summary: on a quarterly basis, physicians and their staff can access a drop-down menu of  key dates/deadlines relating to each of the six regulatory/reimbursement programs currently being tracked in the tool, as well as suggested states and action steps that they can take to prepare for a subsequent deadline or requirement.  On the right hand border of the tool’s landing page, they can see a list of  “ongoing items” with “guidance on what you should be working on, collecting, and thinking about right now.”

The timeline currently tracks six programs: Medicare’s e-prescribing, Physicians Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs;   Meaningful Use requirements for electronic health records, ICD-10; the Sunshine Act, and Transitional Care Management Codes.   Looking today at the tool’s main landing page, for instance, and you’ll find that July 1 (today)  is the start date of the data collection period for Medicare’s Physician Quality Reporting Program, “The six-month PQRS data collection period for .5% bonus is from July 1, 2013 to December 31, 2013” the site explains. “The six-month period only applies to reporting measure groups via registry. Physicians must begin reporting 2013 PQRS to avoid the (-) 1.5% penalty in 2015 to their Medicare reimbursements.” 

On meaningful use, it explains that “Eligible Professionals beginning their first year of Meaningful Use must report data for any 90-day period during the calendar year. Reporting period runs from July 1, 2013 to September 30, 2013.”   August 1 is the date when “applicable manufacturers and GPOs must begin tracking covered payments and transfers of value to physicians and teaching hospitals. Industry will be reporting all 2013 exchanges from this date to the Centers of Medicare and Medicaid Services (CMS) in the first quarter of 2014.”

Want more information? Click on the drop down menu for each program, and the tool gives the user access to practical information that has been developed or approved by ACP to help physicians successfully satisfy the requirements for each program, or to qualify for higher reimbursement as is the case for the transitional care management codes.

ACP plans to add more programs to the tool over the next several months, will constantly update (and retire information that is no longer relevant), and make the tool even more interactive.  Currently, the tool is available and free to anyone, member or non-member of the College, although ACP plans to make it a benefit that is offered free of charge only to members later on in the year.

Another line in Dylan’s “All Along the Watchtower” continues “So let us not talk falsely now, the hour is getting late.”  The hour is getting late for physicians to qualify for higher PQRS, e-RX, and
Meaningful Use payments and avoid penalties, to comply with the ICD-10 mandate, or earn higher payments for their transition of care management services.   ACP’s new timeline tool can help reduce the “too much confusion” that exists about these and other programs, help lead physicians to a way out, and provide them with much needed relief from the byzantine world of Medicare payments and regulations.

Today’s question: What do you think of ACP’s Physician Practice and Timeline tool?