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.

But,
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!
And they'd FEAST! FEAST! FEAST! 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!
THE House GOP
GOT A WONDERFUL, 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!
IT CAME!
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

...WE OURSELVES ...!
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 www.politifact.org 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?

Wednesday, September 11, 2013

How Physicians Can Counter Obstructivism over Obamacare

In less than three weeks from now, millions of uninsured Americans will be able to enroll in qualified private health insurance plans offered through the state marketplaces, with federal dollars to help them afford it.  The state marketplaces, created by the Affordable Care Act (Obamacare) will begin enrolling eligible people on October 1, and eligible persons will have until March 31 to sign up.   The coverage and subsidies for those who sign up will start on January 1, 2014.  As a result, an estimated 7 million uninsured people are expected to get health insurance next year. 

Yet instead of this being a cause for celebration by Obamacare’s supporters, and perhaps grudging acceptance (if not acquiesce) by its foes, the political fight over the law’s future continues to rage.  The fight is fueled by opponents’ unrelenting crusade to do anything and everything they can think of to try to stop it.   Some members of Congress have threatened to shut down the federal government on September 30 if President Obama and Senate Democrats refuse to go along with their demand to defund the ACA.  Some interest groups are actively discouraging uninsured people from signing up for health insurance offered by the marketplaces. 

Worst of all is the effort by some states to sabotage and even nullify Obamacare by enacting legal barriers to its implementation.  Several states have passed laws to try to make it impossible for federally-certified trained navigators to help people sign up for coverage.  At least one state has made it illegal for state and local employees to help people sign up for Obamacare.  Others have proposed arresting federal employees who try to implement it in their states, and several states have said they will refuse to enforce Obamacare provisions that make it illegal for insurance companies to turn down people with pre-existing conditions.

How crazy and wrong is this? The idea of state nullification of federal law was commonly used in Southern states in the 1960s to resist federal civil rights law.  Since then, the idea that states can nullify federal laws they disagree with had been soundly discredited, as a matter of both law and justice.  Until now, that is. 

The reality is that neither the efforts in Congress to defund Obamacare, nor state laws to impede its implementation, will succeed.  The ACA is here to stay.  But such efforts will make it harder for people to sign up.   They will be the real victims of the efforts to defund, delay, obstruct and even nullify Obamacare.

What can be done?  I hope that physicians will stand up to the obstructivism over Obamacare by telling federal and state lawmakers that it is wrong and unjust to enact barriers on people signing up for coverage.  But there is something even more important that you can do, which is to help your patients sign up.  Reach out to your uninsured patients.  Explain to them that they may be able to get affordable coverage through the state marketplaces created by the ACA.  Point them in the right direction for help. 

To make it as easy as possible for physicians to help their patients enroll, ACP this week launched a new web resource center on the ACA’s marketplaces, which includes  state-specific guides for physicians and patients on how to sign up for coverage.   By making such information available to your patients, physicians will not only do the right thing by their patients by helping them get affordable coverage, but they can also become the most effective counterweights to the agents of Obamacare obstructivism.

Today’s questions:  Will you help your patients sign up for coverage in the marketplace created by Obamacare?  And what do you think of the efforts to defund, delay or even nullify the law?