Monday, December 22, 2014

How the Grinch Stole Obamacare (2014 version)

On December 23, 2009, the day before the United States Senate passed its version of what later became known as Obamacare,  I posted a rhyme comparing the debate to Dr. Seuss’ famous tale about the Grinch who (tried) to steal Christmas, with the GOP in the role of the “Grinch” and Obamacare playing the part of Christmas.  Here’s my updated version—all intended to be in good (non-partisan) fun!

Every Dem
In the Congress
Liked Obamacare, a lot ...

But the GOP
Who sat to their right,
Did NOT!

The GOP hated ObamaCare! (Some called it treason)!
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 like their government, small.

But,
Whatever the reason,
Their base or their views,
They stood there on Christmas Eve, hating it all,
Staring down with a sour, disapproving frown
They vowed that next year, they’d bring it all down.

"We’ll control the House, and the Senate!" they snarled with a sneer.
"Our chance for repeal is coming! It's practically here!"
Then they growled, with their fingers nervously drumming,
And said, “Obamacare’s demise is finally coming!"
For, in 2015, they knew...

...They would finally be freed
Of having to get things past old Harry Reid,
With Mitch in charge, they’d slay the Obamacare beast.
And then they'd feast! And they'd feast!
And they'd FEAST! FEAST! FEAST! FEAST!
Because “socialized” medicine, you know, they can’t stand in the least!

And the more they thought of finally prevailing,
They started to worry, about possibly failing.
Obama can veto our plans, strike them all down
We can’t let him let him stop repeal from coming!
... But HOW?"

Then they got an idea!
An awful idea!
THE GOP
GOT A WONDERFUL, AWFUL IDEA!

"We know just what to do!" They laughed in their throat.
“We just need the Supremes to strike it down, on a 5 to 4 vote!"
And they chuckled, and clucked, "What a great GOP fix!
We'll sue Obama and let the court do the trick!

"We’ll say that Congress never planned for the subsidies to apply,
In the GOP states that want Obamacare defied,
Who cares about the facts, or legislative intent?
As long as we can persuade five judges to relent
And strike the subsidies down, for better or worse,
We can get it tossed out, chapter and verse.

"Pooh-pooh to Obama!" they were heard to be humming.
"By June he’ll find that the end is finally coming!
When the court rules against him! We know just what he’ll do!
His mouth will stay open a minute or two
And Barack Obama will 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 over DC town.
It started out low, and then got quite loud,
But the sound they heard from the White House wasn't sad!
Why, this sound sounded merry!
It couldn't be so!
But it WAS merry! VERY!

They stared down at the Washington Post headline
And the GOP popped their eyes!
Then they shook! And they shook,
What it said was such a surprise!

On a five to 4 vote, the Roberts Court
Again upheld Obamacare, made their case naught,
They HADN’T stopped ObamaCare from coming!
IT CAME!
Somehow or other, it came just the same!

And the GOP, even with all of the Koch brothers’ dough,
Kept puzzling and puzzling: How could it be so?
Obamacare came despite our winning the midterm election!
It came though the pundits said it was an Obamacare rejection!
It came even despite the demands of Senator Cruz,
It came despite the ranting by our friends at Fox News,
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 really is about getting healthcare to the millions of 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 the law, if we just do it right,
We’ll do it in through reconciliation, we’ll continue this fight
As we promised the Tea Party, who like Obama the least
…WE OURSELVES …!
Won’t rest until we carve up the ObamaCare beast!”

Of course, one part of my rhyme--the Supreme Court upholding Obamacare’s premium subsidies--assumes that this will be the outcome of case that the court has agreed to hear, challenging the legality of the subsidies in the 36 states that opted to let the federal government run their health insurance exchange.  In fact, we really won’t know the outcome until the Court issues its ruling (likely in June, 2015).  Let’s hope that the Supreme Court upholds the subsidies—because if they don’t, millions of Americans would lose their health insurance coverage.  And that would truly be a reason to cry Boo-Hoo!

Today’s question:  No question, just my best wishes to you for a happy holiday season and prosperous and healthy New Year.  (P.S., This will be my final blog post of 2014, will be back in early 2015).

Wednesday, December 17, 2014

Because of you, we have now reached 2 million page views, and counting

As of 11 a.m. this morning, because of readers like you, this blog has received 2,001,555 lifetime page views! (A page view represents each time a visitor views a page on a website). The lifetime of this blog began on October 29, 2008, when I asked, 'Is healthcare a privilege, a right, or a responsibility?' This inaugural post generated a spirited debate among the 11 people who posted comments in response. (We as a society are still debating this question, although the Affordable Care Act clearly shifted public policy toward establishing healthcare as a right, over the continuing fierce objections of its conservative critics). This is my 465th post; collectively, the posts to date have received 2178 published comments.

I accompanied this first post with a description of myself and what I hoped to achieve through the ACP Advocate blog:

This blog will reflect my work with ACP, but will not be a mouthpiece for ACP's positions. Instead, I hope to invite commentary on the most provocative and intriguing health policy discussions I come across in my daily work.

This continues to be my goal.

Which of my posts generated the greatest interest, as measured by page views, from you, the readers? Here are the top 5:

1. My April 25, 2014, post, Yes, times are tough, but don’t compare doctors to janitors, in which I challenged a comparison made by blogger Daniela Drake, received the most page views, by far.

2. Next was my November 5, 2014 post, What does the 2014 election mean for Obamacare?

3. My March 28, 2012 post, Don’t Ask, Don’t Tell, in which I criticized laws that restrict physicians’ ability to discuss firearms and other medically-appropriate health issues with their patients, was next.

4. On January 15, 2014, in What my auto accident taught me about Obamacare, I wrote about my own very personal experience of a car crash. I  wrote that I was fortunate: my injuries were limited to a fractured sternum and my pride (I inexplicably drove my car into a tree). But the accident also taught me that we are all vulnerable and how important having health insurance is; What might have been the outcome for someone in the same circumstances as me, but without health insurance and with a much more modest income? And I was reminded of how government regulation (in this case, air bags) helped keep me from suffering worse injuries. This post topped the all-time list with the number of comments (25) posted in reply.

5. Next was my December 17, 2013 post, What Physicians Should Expect When the ACA goes live on January 1.

Interestingly, although the vast majority of page views for the ACP Advocate blog are from within the United States, there is a significant international audience for it:

United States: 1,843,144
China: 28,913
Ukraine: 14,518
Germany: 12,209
France: 12,143
Russia: 6,855
Canada: 5,033
United Kingdom: 4,860
India: 2,816
Brazil: 2,122

Because of the visibility created by this blog, I have also become a periodic guest blogger for the Philadelphia Inquirer, where on Monday of this week I posted The Collapse of the Case Against Obamacare, citing data that most of the critics’ dire predictions have not come to pass.  And the www.KevinMD.com blog often reposts my ACP Advocate blogs, most recently Obamacare, The Anti-Death Panel Law.

 I realize that this post might come across as self-promotional (although this is inherent in social media, which measures its relevance by page views, hits, retweets, mentions, and a whole host of other statistics that try to measure, 'Who is paying attention to what I have to say?').

But my real point in writing this is to thank you, the readers of this blog; whether you post comments or not, you are helping to stimulate a conversation “about the most provocative and intriguing health policy discussions I come across in my daily work,” as I promised on October 29, 2008. But I especially want to thank those of you who do take the time to post your comments. Now you know that your views may be reaching the numerous visitors to the ACP Advocate blog!

Today’s question:  What would you recommend to make the ACP Advocate blog more relevant to you, and others, and to increase the number of views and comments?

Friday, December 12, 2014

Same old, same old

The 113th Congress will be wrapping up its two year session within the next few days—and good riddance!  Measured by how many laws it is has passed, this Congress is likely to turn out to be the least productive in modern U.S. history.

Now, some might say that passing laws isn't necessarily a good thing, if it results in bad laws.  The problem, though, is that because this Congress was unable to reach agreement on just about everything and anything, many important issues where legislation is needed were neglected.

Take two of the medical profession’s highest priorities: repeal of the Medicare SGR formula, and continuation of a program that raised Medicaid payments to primary care physicians (and related subspecialists) to no less than the Medicare rates.  Despite the best effort made by ACP, and many others, Congress failed to complete action on either.  This is how I explained the situation in an email I sent yesterday to the 12,000-plus internists who participate in the College’s grassroots ACP Advocates network:

Dear ACP Advocates,

I am writing to thank you for all of the work you have done to help ACP advance its advocacy agenda with the 113th Congress, and to update you on where things stand on two of our highest priorities: (1) reform of the Medicare physician payment system and repeal of the SGR formula, and (2) continuation of the Medicaid primary care pay parity program.  I also write to share with you our current thinking about priorities for the new 114th Congress, which will take office in January.

Historians are likely to label the 113th Congress as perhaps the least productive ever, as it has compiled an unprecedented record of failing to address the key challenges facing our country. Regrettably, improving healthcare will be among the many issues where Congress has failed to act.

Specifically, it is now evident that Congress will, within a few days, adjourn without enacting legislation to repeal the Medicare SGR formula or to reauthorize the Medicaid primary care pay parity program.

This is not the first time that Congress has failed to enact legislation to repeal the Medicare SGR formula, of course, but it is particularly frustrating this time around, because Congress was so close to enacting a bipartisan and bicameral (House and Senate) bill to permanently repeal the SGR and make other improvements in Medicare payment policies. You may recall that both parties had agreed to such a bill earlier this year, but they couldn’t agree on how to pay for it. So, instead, they passed another temporary “patch” to prevent an SGR payment cut that would have gone into effect on April 1—their 17th patch over the past 11 years!  This patch will expire on March 31, 2015, at which time the SGR is scheduled to cut physician payments by another 21 percent.

Even so, despite the patch, ACP did not give up on getting full SGR repeal in the 113th Congress. With your support, ACP has continued to press Congress to enact the bicameral and bipartisan SGR repeal bill in the current post-election “lame duck” session. We now know, though, that they will end the year without doing so, to our great disappointment.

This does not mean, though, that your and our advocacy on SGR repeal has been for naught. Because of our efforts, ACP was able to influence this bipartisan, bicameral SGR repeal bill to include positive payment incentives for physicians who practice in a Patient-Centered Medical Home; to simplify and harmonize Medicare reporting programs (including removing scheduled penalties under those programs); and to make many other improvements. We fully expect that this bill will be the starting point for the new 114th Congress next year, and we will redouble our efforts to get Congress to act upon it before the current patch expires on March 31.

Similarly, this Congress’s failure to reauthorize the Medicaid primary care pay parity program is not the end of the story. Because Congress did not reauthorize this program--which pays internists (including our subspecialists) no less than the Medicare rates for designated services to Medicaid enrollees--most of you will see deep cuts in your Medicaid primary care payments on January 1. ACP will continue its efforts to inform the new 114th Congress of the devastating impact such cuts will have on Medicaid patients’ access to primary care, and to seek to get Medicaid pay parity renewed early in the new Congress. We also will work with our chapters to explore opportunities to get the program funded by the states.

I am sure you are disappointed, even angered, by Congress failing to complete action on these two top ACP priorities, as we are.  Earlier today, ACP issued a public statement expressing “profound” disappointment with Congress’ inaction on the SGR and Medicaid pay parity. But this is not the time for us to throw in the towel.  Next year, ACP’s congressional advocacy agenda will include not only SGR repeal and reauthorization of Medicaid pay parity, but also, reauthorization of the current Medicare 10 percent primary care bonus program, which expires at the end of 2015; reform of Graduate Medical Education financing; medical liability reform; regulatory relief from meaningful use requirements, and much, much more.  You, as a member of our over 12,000-strong ACP Advocate grass roots network, will be critical to our efforts in the new 114th Congress.

Thank you for your efforts and continued support.

Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy

There is not much more that I can say in this space, other than to say how Congress’s inability to agree on policies to improve Medicare and Medicaid payments is simply maddening to me, my colleagues on the ACP advocacy staff, and the ACP leadership, as I expect it is for most readers of this blog.

Yet we remain fully determined to try to move both issues, and other ACP priorities, forward in the new 114th Congress.

Today’s questions: What do you think of the record of the “least productive Congress ever” on healthcare, including the SGR and Medicaid primary care pay parity?  Do you expect things to be better with the new Congress?

Thursday, December 11, 2014

Health Professionals and Torture (revisited)

What ever happened to “first, do no harm?”

One of the findings included in a Senate investigative committee’s report on the US government’s post-9/11 torture program was that it was designed by two psychologists.  They were paid “$80 million to develop torture tactics that were used against suspected terrorists in the wake of the September 11 attacks on the Pentagon and the World Trade Center”—including “waterboarding and mock burial on some of the CIA’s most significant detainees.”  (This isn’t the first time that the involvement of these two psychologists has been made public, but the new report provides more detail on their role—and the methods used).

The idea that a healthcare professional designed—and reportedly, personally helped administer—the torture of detainees would appear to me to be an appalling violation of professional ethics.

In 2009, I wrote in this blog about the ACP’s efforts to pressure the U.S. government to prohibit torture of detainees.  I noted then that the College’s ethics manual clearly states that:

"Physicians must not be a party to and must speak out against torture or other abuses of human rights ... Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners ... Interrogation is defined as a systematic effort to procure information useful to the purposes of the interrogator by direct questioning of a person under the control of the questioner. Interrogation is distinct from questioning to assess the medical condition or mental status of an individual."

I also reported that, in 2003, ACP wrote to then-President George W. Bush to urge his administration to investigate allegations that the U.S. may have engaged in unlawful interrogations including torture, and again, in a follow up letter dated May 17, 2004.  This is what the White House told us in response:

“As the President has said, Americans stand against and will not tolerate torture. American personnel are required to comply with all applicable United States laws, including the Constitution, Federal Statutes, and our treaty obligations with respect to treatment of detainees ... The United States will continue to take seriously the need to question terrorists who have information that can save lives, but will not compromise the rule of law or the value and principles that make our country strong. Torture is wrong no matter where it occurs, and under President Bush's leadership, the United States will continue to lead the fight to eliminate it everywhere."

We now know from the Senate report that the White House response to us does not square with the facts.

I am proud of the ACP’s role in speaking out against torture, which also included introducing a resolution to the AMA House of Delegates, and supporting an amendment by Senator John McCain to codify a ban on torture.  And, on March 3 of 2009, we joined with the American Psychiatric Association to support President Obama’s executive order banning torture.

But it is disheartening to find that despite our efforts, torture was used against prisoners detained by the U.S. government, and that the program itself was designed by mental health professionals. Yes, it is true that they were psychologists, not MDs or DOs, so arguably, they are not governed by the ACP’s code of ethics, or that of the American Psychiatric Association.

But they should have been expected to honor the American Psychological Association’s standards of ethics, which clearly states that “Any direct or indirect participation in any act of torture or other forms of cruel, degrading or inhuman treatment or punishment by psychologists is strictly prohibited. There are no exceptions. Such acts as waterboarding, sexual humiliation, stress positions and exploitation of phobias are clear violations of APA's no torture/no abuse policy.”  

Moreover, the psychologists’ association has just released a statement on the Senate report, in which it states that “two psychologists mentioned prominently in the report under pseudonyms, but identified in media reports as James Mitchell and Bruce Jessen, are not members of the American Psychological Association. Jessen was never a member; Mitchell resigned in 2006. Therefore, they are outside the reach of the association’s ethics adjudication process. Regardless of their membership status with APA, if the descriptions of their actions are accurate, they should be held fully accountable for violations of human rights and U.S. and international law.”

Good for them!  The question is, will these psychologists be able to keep their licenses? Will they be held accountable for violations of human rights and U.S. and international law?

Today’s questions:  What is your reaction to the report on the U.S. torture program?  Are physicians and other health professionals doing enough to speak out against torture?  And what do you think should be done to hold the two psychologists involved accountable for their actions?

Thursday, December 4, 2014

Obamacare, The Anti-Death Panel Law

One of the most pernicious lies about Obamacare is that it establishes “death panels” to ration needed care, especially care of seniors.  Although thoroughly discredited by independent fact checking sites, the death panel falsehood remains a staple of attacks on the Affordable Care Act.

But it isn’t just that Obamacare doesn’t have death panels or anything remotely like them (the law actually prohibits denying benefits based on cost); we now have strong evidence that the law is actually saving lives, and particularly, the lives of seniors.

Earlier this week, the Department of Health and Human Services released a report that shows “an estimated 50,000 fewer patients died in hospitals and approximately $12 billion in health care costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013” and another 15,000 lives may have been saved by preventing unnecessary hospital readmissions.

 These life-saving improvements didn’t just magically happen of their own accord, but are directly associated with two Obamacare programs:

The Partnership with Patients is a collaboration of federal agencies, hospitals, physicians, patients and families to design and implement best practices to reduce health facility acquired infections.  The Partnership with Patients, notes Sarah Kliff, a former Washington Post reporter who is now with Vox Media, is “a government project that's part of the Affordable Care Act, aiming to reduce the number of hospital-acquired conditions by 40 percent between 2010 and 2014. That program has enrolled more than 3,700 hospitals — who account for four in every five hospital patients — in a learning collaborative to share best practices for increasing patient safety.”

The Readmissions Reduction Program, created by Section 3025 of the Affordable Care, requires CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.  Following implementation of this program, “The readmission rate for patients who receive care under the traditional Medicare fee-for-service program, “which held steady at 19 percent from 2007 to 2011 — fell to 18.5 percent in 2012 and 17.5 percent in 2013” writes Sarah Kliff.  “The 1.5-percentage-point decrease in readmissions accounts for 150,000 fewer patients readmitted to a hospital when they didn't need to be.”

So instead of allowing the critics to scare seniors about non-existent death panels, we need to spread the word that Obamacare is really the anti-death panel law, helping to make health care better and safer for millions.

Today’s question: What do you think about the reductions in hospital infections and readmissions attributable to Obamacare?

Wednesday, November 26, 2014

How to Prepare for a Thanksgiving Day “Obamacare” Rant

You might as well be ready for it, especially if you, like me, support the Affordable Care Act and work in a field related to healthcare: Obamacare will be brought up over Thanksgiving Dinner by one of your relatives, particularly if they are convinced by watching Fox News that it is the worst thing ever.

You can hope, of course, that they won’t, because it will probably just lead to mutual bad feelings and indigestion. You could try to shift the conversation away from Obamacare to something less controversial, like whether the Washington Redskins football team should change its name (okay, not a good alternative topic!), or immigration (okay, another bad alternative—maybe there just aren’t any topical subjects out there that won’t make someone mad).  You could try to ignore their Obamacare rants, but I haven’t found that to be terribly effective in my own Irish-American extended family. (Irish-Americans are drawn to a good argument like a moth is drawn to flame, often with similarly calamitous results).  

Or you could try to answer with a reasoned discussion of why you support Obamacare—while recognizing that some of your relative’s objections to the law may be supported by their own personal experiences and personal philosophy.

You are almost certainly going to hear about Jonathan Gruber, the MIT economist and so-called Obamacare “architect” who was recorded on video as implying that Obamacare was passed by taking advantage of the “stupidity” of the American voter.  I personally wouldn’t try to rise to Mr. Gruber’s defense about these particular remarks—calling the voters stupid was, well, stupid.  But it might be helpful for you to know that although Mr. Gruber provided advice to the administration, mainly by creating a statistical model to simulate its impact, he was not the “architect” of the Affordable Care Act in any real sense of the word, as Politico documents in a well-researched story.

The substantive point that Mr. Gruber was evidently trying to make, as a private citizen to an academic audience, is that Obamacare works by transferring money—through higher health insurance premiums and taxes, from the well-off and the well, to help pay for health insurance for the less well-off and the less well, and that the administration wasn’t particularly transparent about it. (Medicare, which is highly popular, does the same—those who are younger, healthier and working subsidize care for older and sicker retirees). It is probably true that many Americans do not understand that Obamacare, and Medicare for that matter, transfer dollars from those who are healthier and wealthier to those who are less healthy and wealthy, but that hardly makes them stupid. And it is also true that the Obama administration and congressional Democrats downplayed the redistributive aspects of the ACA when trying to sell it to the voters—although in my near 36 years of experience in the political process, I have found that all politicians, of all political stripes, promote their ideas by emphasizing the things the voters want to hear, not the parts that will upset them.

And Gruber’s remarks were hardly a smoking gun revelation about Obamacare’s redistributive impact. Conservative critics of Obamacare have been well aware that the subsidies the law offers to sicker and poorer people to help them afford insurance comes from healthier and wealthier persons—which is precisely the reason that many have been philosophically opposed all along! For instance, The Wall Street Journal made exactly this point in an editorial published just a few months after the law’s enactment).

Now, if you try to explain all of the above about Jonathan Gruber to your upset relative, you probably won’t have a particularly pleasant Thanksgiving dinner. So it might be best just to acknowledge that whatever Mr. Gruber meant to say, and no matter what his role in Obamacare was and was not, his “stupidity” remarks were offensive and wrong.

But what is worthy of philosophical debate, independent of Gruber’s controversial comments, is the fundamental question of whether every American should have access to health insurance coverage, no matter how sick they are, where they work and live, or how much or how little they earn. If your answer is yes, then you would have to acknowledge, and be willing to try to persuade others, that the only way that this can be accomplished is by redistributing dollars, through higher premiums and taxes, from those who are fortunate enough to be healthier and wealthier and have insurance, to those who are less healthy, less wealthy, and can’t afford to buy health insurance on their own.

If you philosophically oppose such redistribution, maybe at least in part because you are in the category of people who are paying more under Obamacare to help the less fortunate afford health insurance, then you have to be willing to acknowledge if the Affordable Care Act were to be repealed, the result will be millions more people will have to go without health insurance coverage. (Studies show that many of them will be sicker and die younger as a consequence). Is that an acceptable outcome to you? If not, what would you propose instead?

This is a debate worth having, because it is the fundamental dividing line between those of us who support the Affordable Care Act as a just and moral way to help those who are less fortunate have access to health care, even if some of us who are more fortunate have to pay more, and those who believe it is unjust and immoral for the government to collect money from some to subsidize healthcare for others.

This is a worthy debate to have, although having it over Thanksgiving dinner might still not be the best idea. Not if you don’t want to have mashed potatoes hurled in your general direction, that is!

Happy Thanksgiving!

Today’s question: What will you say if Obamacare is brought up by a relative or guest at your Thanksgiving dinner?

Thursday, November 6, 2014

The Self-Destructive Power of Cynicism

Cynicism appears to have replaced idealism as America’s defining characteristic.  So many of us just don’t trust the government, scientists, the clergy, journalists, business CEOs, labor unions, lawyers, or just about anyone for that matter, to say or do the right thing.

Two years ago, the National Journal reported that as a consequence of the Great Recession, “Americans are losing faith in the institutions that made this country great.”  The Pew Research Center finds that public trust in government has “reached an all time low;” in 1958, a whopping 73% of Americans expressed trust in the federal government; by 2013, only 24%, said they  trusted it much of the time.

The Gallup organization has surveyed the public over the past four decades about how much trust they place in various institutions and professions.  The Economix blog has converted Gallup’s data into an interactive graph that tracks changes in opinion over the decades.  “Click on almost any category charted in the graph,” Catherine Rampell wrote for Economix, “and you’ll see that confidence has generally been falling.”

Even the medical profession, which has relatively enjoyed higher “confidence” ratings and hasn’t suffered as steep declines as other sectors, does not fare so well when compared to other countries. Harvard researchers found that “based on data from an international health care survey, the United States is near the bottom of the list when it comes to public trust in the medical establishment”—ranked 24th in the world, on par with Croatia.

The public’s lack of trust in science and scientists is particularly alarming.

Take the Ebola controversy.  The National Journal’s Ron Fournier says that “the scariest thing about Ebola” is what it says about trust in U.S. government and institutions.

“Once again,” he observed, “Americans are reminded of the limits of U.S. social institutions—in this case various state, local, and federal government agencies and private-sector health systems that responded to the Ebola crisis slowly, inefficiently, and with a lack of candor that Americans, unfortunately, have come to expect.”  Such lack of faith in leadership, he noted in a follow up commentary, has led to “outrageous” policy outcomes, like mandatory quarantines of nurses and doctors.  Why is this so?

“The governors don't trust the scientists who oppose a mandatory quarantine for health care professionals exposed to Ebola,” writes Fournier. “The White House doesn't trust the governors. The governors don't trust the White House. Doctors don't trust nurses. Nurses don't trust hospital administrators. Hospital administrators don't trust federal officials, and the Feds don't trust them. Nobody trusts the media. The public trusts nothing. This rampant lack of faith in each other and in our institutions is how we got to a place where the state of New Jersey is holding a courageous 33-year-old nurse hostage.”

As ACP noted in its own statement, “mandatory quarantines for asymptomatic physicians, nurses and other clinicians, who have been involved in the treatment of Ebola patients, whether in the United States or abroad, are not supported by accepted evidence on the most effective means to control spread of this infectious disease. Instead, such mandatory quarantines may do more harm than good by creating additional barriers to effective treatment of patients with Ebola and impede global efforts to contain and ultimately prevent further spread of the disease.”  The CDC, the Infectious Diseases Society of America, and Dr. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, are all in agreement with us.

The problem is that Americans don’t trust what the experts tell them: 71 percent of them back mandatory quarantines of health professionals that treated Ebola patients in West Africa.

Or take the growing numbers of Americans who refuse to vaccinate themselves or their children. A recent study found that “In some areas, nearly one out of five children has not received their recommended vaccines. The consequences are serious not only for those unprotected children, but for the rest of society as well. ‘Herd immunity’ is threatened as more and more parents free ride off of the community's dwindling immunity, and outbreaks of diseases thought to have been conquered have already occurred.”

Opposition to vaccinations actually increased when anti-vaccine parents were given accurate scientific information about them, another study found.  “Researchers focused on the now-debunked idea that the vaccine for measles, mumps and rubella (or MMR) caused autism. Surveying 1,759 parents, researchers found that while they were able to teach parents that the vaccine and autism were not linked, parents who were surveyed who had initial reservations about vaccines said they were actually less likely to vaccinate their children after hearing the researchers messages.”

Or take climate change.  The Washington Post reports on a study that confirms that 97% of scientists agree that human activities are causing the planet to warm.  A new report from the United Nation’s Intergovernmental Panel on Climate Change concludes that "If left unchecked, climate change will increase the likelihood of severe, pervasive and irreversible impacts for people and ecosystems.”  The World Health Organization concludes that global warming will affect “the social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter.  Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhea and heat stress.  The direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture and water and sanitation), is estimated to be between US $2-4 billion/year by 2030.  Areas with weak health infrastructure – mostly in developing countries – will be the least able to cope without assistance to prepare and respond.”

Yet too many Americans are disbelieving of the scientific consensus: Gallup reports that more than four out of ten say that the seriousness of global warming is exaggerated.

If we allow the cynics to carry the day, we will all pay a steep—and perhaps lethal—price.

If we don’t trust the scientists, doctors, and public health agencies on Ebola, then what will happen if we have a flu pandemic that threatens millions?  Will we tune out the recommendations from the experts about what science tells us needs to be done to limit spread of the disease? How many will die as a result?

If we don’t trust scientists, doctors, and government agencies on the safety and effectiveness of childhood vaccinations, won’t we be condemning thousands of kids to die from diseases that could have been prevented?

 If we don’t trust the scientific consensus on health consequences of global warming, aren't we putting millions of lives around the world at risk of harm and even death from diseases, unsafe water, poor air, insufficient food, and insecure shelter?

British historian and author Kenneth Clark once said that “We can destroy ourselves with by cynicism and disillusion, just as effectively as by bombs.”  I fear that the rising tide of American cynicism may be bringing us closer to that day.

Today’s questions: Why are Americans so cynical? Are you one of them?  Do you agree that cynicism, and especially distrust of science and scientists, are putting us at risk?

Wednesday, November 5, 2014

What does the 2014 election mean for Obamacare?

By decisively taking control of the U.S. Senate and increasing their majority in the House of Representative, the Republicans now have a chance to force some modest changes in the Affordable Care Act, but they will not be able to repeal or reverse it.  But Republican gains in state legislatures and governorships may put the brakes on Medicaid expansion, leaving millions without coverage.

First, let’s start by acknowledging that although the mid-term election may have been a referendum on  President Obama, it wasn’t a referendum on Obamacare. Exit polls show that only 25 percent of voters named Obamacare as the top issue for them compared to 45 percent who named the economy.  47 percent of those who cast ballots in the mid-term elections said that Obamacare went too far, but another 48 percent said that the law was just about right or did not go far enough.

Second, even though Republicans will have sizeable majorities in both chambers of Congress, they will not be able to repeal Obamacare, because they don’t have the 60 votes required to overcome a Democratic filibuster, and if they were somehow able to get a repeal bill to the president, they don’t have the two-thirds super-majority in both chambers needed to override a veto by President Obama.

Third, the Republican-controlled Congress may be able to advance legislation to alter parts of Obamacare that are peripheral, but not essential, to getting people covered, like the taxes on medical devices and insurance companies, and repeal of the Independent Advisory Board, potentially with enough Democratic votes to get a bill to the president.  (Practically speaking, IPAB is probably dead in the water anyway, since IPAB appointees would have to be confirmed by the Senate, and there is no realistic prospect that a majority of Republican senators would agree to confirm appointments to a body that they oppose in the first place).  One problem for Republicans is that repealing the medical device and insurance taxes, and eliminating IPAB, would be scored by the Congressional Budget Office as increasing the budget deficit, unless Republicans find alternative savings or revenues to make up the difference, whether they're from the ACA itself or from somewhere else.

Other Obamacare changes that Republicans can be expected to pursue would include cutting off funding for the subsidies to insurers that are available if insurers experience adverse selection in the ACA’s exchanges, which most Republicans view as a taxpayer “bailout” to insurers.  They will also try to eliminate the requirement that large employers provide coverage for full-time employees, and if they can’t repeal the mandate altogether, they will try to modify how many hours count as full-time employment for the purposes of the mandate.  (Health policy experts disagree on how essential the employer mandate is to the success of the Affordable Care Act).  While the GOP will try to pass a bill to repeal the tax penalty on people who do not buy ACA-qualified coverage—the so-called individual insurance requirement—President Obama would veto it.  Republicans may also seek to make it easier for people whose insurance is “cancelled” to keep their policies, but this would be difficult to achieve without driving up premiums for everyone else.

The GOP may also try to block administration efforts to do a work-around on the Supreme Court’s Hobby Lobby ruling that the federal government cannot force “closely held” companies to provide coverage for certain types of contraceptives.  They could also try to overturn the administration’s ruling that members of Congress and their staffs, who are required to buy insurance coverage through the ACA’s exchanges, can continue to get the premium contribution that the federal government usually makes to its employees as part of their compensation package, which some Republicans have [mis]characterized as a “special subsidy” or exemption. They could also try to cut funding to federal agencies for ACA implementation.

Republicans likely will try to attach the changes they are seeking in the ACA to “must pass” bills like the debt ceiling, repeal of the Medicare SGR formula, and appropriations bills to fund the federal government.  They may also try to get changes in budget reconciliation, which requires only a simple majority. But no matter what vehicle they use to pass the bills, the only changes that Republicans will be able to make in the ACA are ones that the President agrees to, which means that the most important parts of the ACA will remain intact.

Fourth, Republicans will use their control of Congress to exercise more oversight over the administration’s implementation of the ACA.  Expect more adversarial hearings on www.healthcare.gov, especially if there are problems with the next enrollment period that starts on November 15, or if people start getting new cancellation notices, or if premiums go up.  Expect Congress to exercise more oversight over Medicare’s Center on Medicare and Medicaid Innovation and the ACA’s Prevention and Public Health Fund, which some Republicans view as unaccountable “slush” funds that are outside of Congress’s budget control.

Fifth, two programs important to primary care physicians may face tough sledding in the new Congress, because they were created by the ACA.  One is Medicaid primary care pay parity, which is set to expire at the end of this year, unless Congress authorizes an extension of it during the upcoming “lame duck” session.  Otherwise, it will fall to the new 114th Congress to decide whether to reestablish it.  The other is the Medicare 10 percent primary care bonus program, which sunsets at the end of 2015.  Because both of these programs were created by “Obamacare” and because they cost money, many Republicans will be disinclined to support their continuation.  Physicians will have their work cut out in trying to  persuade Republican lawmakers to support both programs on their own merits—as programs crucial to ensuring access to primary care doctors—rather than viewing them as extensions of Obamacare.

Sixth, with more states having Republican governors and legislatures, continued progress in expanding Medicaid may be slowed, leaving millions of poor Americans in the “coverage gap” (ineligible for Medicaid, ineligible for Obamacare’s premium subsidies).  The New York Times reports that:

“Republicans in Florida, Wisconsin, Maine and Kansas won their bids for re-election. Three of them — Scott Walker in Wisconsin, Sam Brownback in Kansas and Mr. LePage in Maine— oppose expansion of the program. Rick Scott, the Republican governor of Florida, has endorsed the expansion, which would extend coverage to an estimated 848,000 people, but has never advocated for it forcefully, and he is not expected to now. And one state that has expanded its program might reverse course. In Arkansas, the legislature has to reauthorize the program every year with a three-quarters majority, leaving the expansion vulnerable to political shifts. Asa Hutchinson, a Republican who appears to be unenthusiastic about the expansion, was elected governor. And opponents of expansion picked up two critical votes in the state Senate.” 

In other states, GOP gains in state legislatures may make their states even more resistant to expanding Medicaid, even if the governor supports it.  Wisconsin may be one of the few remaining big-state wildcards on Medicaid expansion: although the voters re-elected Republican governor Scott Walker, an ardent opponent of Medicaid expansion, they also overwhelmingly passed a non-binding referendum calling on the state to accept federal dollars to expand Medicaid.  Whether the referendum will soften Governor Walker’s opposition remains to be seen.

So the bottom line of the 2014 election is this: Obamacare is here to stay, the Republican-controlled Congress will likely be able to get some peripheral elements of it changed but will not be able to repeal or reverse it, and recent progress on Medicaid expansion may be slowed, leaving millions without coverage.

Today’s question: what is your take on the impact of the 2014 elections on Obamacare?

Thursday, October 9, 2014

Is assimilation inevitable for independent physician practices?

Fans of Star Trek: The Next Generation will recall that the most disturbing aliens encountered by the Federation were The Borg, a part-cyber, part human collective race that functioned as an integrated and cyber-connected whole that existed only for the good of the collective, rather than as distinct individuals with their own thoughts and personalities—much like honey bees work together as a collective for the protection of the queen and the survival of the colony.  When the Borg encountered a humanoid species, they would forcefully assimilate them and their technologies into the collective, or destroy them, preceded by only one warning:

“WE ARE THE BORG. LOWER YOUR SHIELDS AND SURRENDER YOUR SHIPS. WE WILL ADD YOUR BIOLOGICAL AND TECHNOLOGICAL DISTINCTIVENESS TO OUR OWN. YOUR CULTURE WILL ADAPT TO SERVICE US. RESISTANCE IS FUTILE.”

The Borg did not consider themselves to be evil though, explains the www.Startrek.com data base, because “the Borg only want to ‘raise the quality of life’ of the species they ‘assimilate.’"

I expect that many physicians in independent practices feel the same way as the unfortunate humans that encountered the Borg: they are under unrelenting pressure to be assimilated into hospital-owned or other large group practices, giving up their independence in the process, with the promise (of course!) that assimilation will  “raise their quality of life”!

But is assimilation the only option for independent practices?  Is resistance futile?

My answer: No to the first, and yes to the second.

Let me explain.  I believe that independent physician practices can survive, and even thrive, because they offer something valued by most patients: an ongoing relationship with a physician who lives in the community, and who knows them and their families.  A practice where, like Cheers, everyone knows your name - from the front office receptionist to the practice’s physician assistant or RN to the physicians themselves.

 I don’t believe that patients want these practices and their physicians to be forcefully assimilated into large groups that may be located some distance from their homes, where when they arrive for an appointment they are forced to wait for a long time in an overcrowded waiting room, just take a number please, to be seen by someone—a nurse, or a PA, or maybe if they are lucky, a physician—who they never met before and won’t be around next time they need to be seen.  (Now, before I get angry comments about this characterization from ACP members in large group practices, I am not saying that this is how all or even most large groups operate—most provide excellent and personalized and attentive care, often in community-based practices—even though the individual physicians and have chosen to be part of a larger group.  And there are small practices where patients are treated brusquely by inattentive staff and physicians.  My point is that if assimilation into a larger group means the loss of a personal relationship with a physician they know and trust, many patients will be opposed).

But I also think that for independent practices, resistance is futile—if this means resisting making the changes that may be required of them to survive in an increasingly competitive economic environment. It is futile to reject participation in all performance measurement programs; physicians in independent practices should, however, insist on measures that measure the right things for them and their patients.  It is futile to reject the move to electronic health records, but physicians in independent practices should demand that government and private payers facilitate the creation of EHRs that are functional, interoperable, and useful.  It is futile for physicians in independent practices to try to hold onto FFS and summarily reject bundled payments, risk-adjusted capitation, and physician-directed models like Patient-Centered Medical Homes and Accountable Care Organizations. Instead, they should see how their practices can embrace these changes.  (Many independent practices have done quite well, for instance, by becoming PCMHs).   It is futile for independent physician practices to reject being accountable for their cost of care—especially when they may find, as one recent study concluded, that hospital owned physician practices have higher prices and higher levels of spending than physician-owned independent practices!  Armed with such data, independent practices can demonstrate to  payers that they are the best value in healthcare.

And while big is not always better, smaller independent physician practices should explore ways to share information systems, data, and even risk with other independent practices, achieving economies of scale without losing their independence.

Independent physician practices do not have to be assimilated, then, but they have to have to be willing to embrace changes that will better position them to be successful without losing their values, their relationships with their patients, and their independence.

For the unfortunate victims of the Borg, assimilation meant losing everything they valued—their independence, their creativity, their individualism, their personal relationships, their values.  But Star Trek’s Federation learns how to prevail against the Borg, not by becoming part of them, or defeating them militarily, but by showing that an independent Federation of free people, voluntarily working together for the public good, is a better model of survival then a cyborg collective that snuffs out innovation and creativity.  With the right support, I believe that independent physician practices, provided that they are willing to embrace innovation on their own terms, will be able to show that they offer something of extraordinary value to patients and payers, allowing them to survive and even thrive without losing their independence.

Today’s questions: Do you think independent physician practices will be assimilated?  Is resistance futile for them?

Thursday, October 2, 2014

Who’s to blame for unexpected doctor bills?

Patients are being stuck with huge and unexpected medical care bills in circumstances where they have no say in selecting the physician who is billing them, and no way for them to know in advance which services the physicians would render or what it would cost them, says the New York Times.
Mr. Peter Drier received a “surprise $117,000 medical bill from a doctor he didn’t know” for services relating to a 3-hour surgery for herniated disks, the Times reported.  “A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee,” the Times writes. “He was blindsided, though, by a bill of about $117,000 from an ‘assistant surgeon,’ a Queens-based neurosurgeon whom Mr. Drier did not recall meeting. ‘I thought I understood the risks,’ Mr. Drier, who lives in New York City, said later. ‘But this was just so wrong — I had no choice and no negotiating power.’"

And, it appears, Mr. Drier’s experience is just one example of what the Times calls “an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.”

Then, earlier this week, the New York Times reported on patients being stuck with unanticipated out-of-pocket costs for services provided by emergency room doctors who do not accept insurance.  “Patients have no choice about which physician they see when they go to an emergency room,” reports the Times, “even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network. But even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.”

Some physicians will be inclined to blame insurance companies for these situations, arguing that low payments leave them no choice but to opt-out of taking insurance and to charge patients directly the full amount of what they consider to be a fair fee for their services.

But here is the problem with the “blame the insurer” mindset: insurance payments may or may not be too low (does anyone really think that any physician is worth $117,000 for assisting in a three hour procedure!), but even so, it’s no excuse for physicians to take advantage of vulnerable patients.

Advocates for “private contracting” with patients, balance billing (charging more than the insurer allows), and direct cash practices (physicians completely opting out of insurance and their negotiated rates) argue that these will bring free market competition to health care while making it possible for physicians to stay in business.  Fine—except in the cases profiled by the New York Times, there was no choice and no free market.

These were situations in which patients had no say in selecting the physician, and no say in what services the physicians provided.  They had no say in who their surgeon decided to bring into the operating room for assistance.  They had no say in what the doctors charged them or in what the insurance company paid.  They had no ability to “negotiate” rates in advance, and especially for the emergency room visits, no chance to shop around for a better deal.

No, these arrangements don’t sound to me like free market competition, but rather as exploitation of vulnerable patients.  Sticking the patient with the bill for services by a physician they did not choose, and had no way of knowing what the physician would charge, is the antithesis of patient empowerment and patient-centered care.  And quite likely, a violation of professional ethics—ACP’s ethics manual states that:

"An individual patient–physician relationship is formed on the basis of mutual agreement."

"Financial arrangements and expectations should be clearly established. Fees for physician services should accurately reflect the services provided."

AMA’s Council on Judicial and Ethical Affairs states that:

"…the term "surgical co-management" refers to the practice of allotting specific responsibilities of patient care to designated caregivers...The treating physicians are responsible for ensuring that the patient has consented not only to take part in the surgical co-management arrangement but also to the services that will be provided within the arrangement. In addition to disclosing medical facts to the patient, the patient should also be informed of other significant aspects of the surgical co-management arrangement such as the credentials of the other caregivers, the specific services each will provide, and the billing arrangement." 

ACP’s policy on “private contracting” legislation—a bill that would allow physicians to bill patients directly for more than the fee allowed by Medicare—states that physicians must disclose their professional fee for professional services covered by the private contract in advance of rendering such services, with beneficiaries being held harmless for any subsequent charge per service in excess of the agreed upon amount. Further, we state that:

“Since patients in emergency or urgent care situations are not in any position to shop around for another physician, we believe that the bill should clarify that private contracting arrangements should not apply at a time when emergency or urgent care is being rendered, even if the treating physician and patient had previously entered into a private contract.

“The legislation should include a prohibition on private contracting in cases where a physician is the ‘sole community provider’ for those professional services that would be covered by a private contract. This protection is critical, especially in under-served areas of the country, because patients should not be obligated to enter into a private contract with a physician for health care services if there are no other physicians in their community to provide such care…In addition to emergency and urgent care and sole community provider situations, there will be other instances where a patient has no reasonable choice of physician, such as when a physician is assigned to them in a hospital or other institutional setting. We recommend that the bill state that no private contract can be entered into in any situations in which the patient cannot exercise free choice of physician.”

While the situations described by the New York Times mainly involved surgeons, primary care physicians and internal medicine subspecialists must also consider at what point balance billing and private contracting cease to be an understandable and appropriate response to unacceptably low insurance company rates and instead become exploitative of patients who cannot afford to pay more.  The key considerations governing such private contracting arrangements must be that financial arrangements and expectations must be clearly established in advance of services being rendered,  that patients and physicians must mutually agree to the rates and the relationships involved, that patients accordingly must have a real choice of physician and must be informed in advance what they will be charged and agree to it, and that balance billing (charging more than the payer’s approved rates) should not apply in emergency or other situations where there is no real opportunity for such choice and mutual agreement.

As Mr. Drier told the Times "…this was just so wrong — I had no choice and no negotiating power” when stuck with the $117,000 bill from a physician he had not chosen.  It is shameful for some physicians to exploit patients when they had no choice and no negotiating power—and it is up to the medical profession to say so, clearly and forthrightly.

Today’s questions: what do you think of patients being stuck with big bills when they had no choice of doctor?  What should be the medical profession’s response? The government’s?

Monday, September 8, 2014

Imagine if your mechanic couldn’t fix your car before consulting an “electronic car record”

In my guest blog post for today’s Philadelphia Inquirer, I imagine what it would be like if auto mechanics were required to go through the same kinds of hassles that physicians experience in using electronic health records.  I encourage readers of this blog to read the entire post; here are excerpts:

“Imagine you are a car mechanic, and the government offers to help you buy a new computerized tool to make it easier to fix cars.  The tool improves automobile safety, it says, by giving you the latest evidence on the most effective repairs and immediate access to all prior work that has been done on the car. If you buy a tool that meets government standards, you will get a government subsidy to help pay for it, but if you don’t, you’ll be fined.

"Imagine you buy the tool, and discover it that makes it harder for you to do your job. The tool requires that you review a digitalized record of everything that was done on the car in the past, relevant or not, before you are allowed to pop open the hood to take a look at it.  Before you can, say, replace a failing fuel pump, you have to document that you reviewed the last time the car’s tires were replaced . . .  The tool then takes you through a series of “decision support” questions before you are allowed to order the replacement pump.  Do you know that you are replacing the current pump sooner than the accepted standard of car repair? Have you considered less expensive repairs? Only after you say yes again and again, does it allow you to order the part. . . 

". . . Now, imagine that you have become so fed up with using the tool that you decide to quit.  Many other mechanics in your town are doing the same, resulting in consumers having to wait weeks to get their cars repaired by the diminishing pool of mechanics who remain in business.”

My conversations with physicians suggest that this scenario describes how most feel about today’s electronic health records, with two big differences:

For doctors, this isn’t imaginary; it’s what they experience every day in trying to use today’s EHR systems. And because doctors aren’t mechanics, and people aren’t cars, the stakes are much, much higher.

Researchers at the Rand Corporation say EHRs are the biggest contributor to physician burn-out,observing that “no other industry [to their knowledge] has been under a universal mandate to adopt a new technology before its effects are fully understood, and before the technology has reached a level of usability that is acceptable to its core users.”

Yet it is clear that the United States is not going back to paper records.  What we need now is a commitment by everyone involved in the current EHR debacle—government, EHR designers/vendors, standard-setters, certifiers, and the medical profession itself—to get behind an effort to reinvent EHRs so they actually do what they are supposed to do: make it easier for doctors to provide good care to their patients.  Is that too much to ask?

Today’s questions: What do you feel about your EHRs? What needs to be done to make them better?

Friday, August 29, 2014

Get ready for the “Uberization” of Medicine

Even if you don’t live in a city yet that offers Uber’s rideshare app, you probably have heard about it, because the media has widely reported on job actions by taxi cab drivers—and the gridlocked traffic that resulted—that have taken place in Washington DC and in other major cities across the world including London, Berlin, Paris and Madrid. Uber is an “on demand” smart phone app that allows users to summon private drivers to pick them up from wherever they happen to be, usually within minutes; the independent drivers that contract with Uber own their own cars and pass background checks but do not have to meet the numerous regulations (and in some cities, medallion fees) applicable to licensed taxi drivers. By  generally offering more convenient, and sometimes lower cost access to rides than those available from licensed taxi drivers, Uber is displacing many established taxi drivers and companies—a classic case of a disruptive innovation, “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”

What does this have to do with medicine? Well, there are now a number of Uber-type apps that promise to do to medicine what Uber has done to taxis—bring consultations by physicians to patients via their smart phones, on demand, wherever and whenever they request them. You can see a sampling of the services and what they claim to offer here.

One big difference between these services and Uber’s ride sharing app is that they provide access to virtual consultations by fully licensed (and in many cases, the apps claim, board certified) physicians, so the competition is potentially between licensed physicians in traditional brick-and-mortar practices, and licensed physicians who contract with the app companies to provide consultations via smart phone. (They could also be physicians in traditional practices who contract to do smart phone consultations on the side). Yet I can see the potential for these services to be another disruptive innovation if a growing number of patients decide they would prefer to get an on-demand access to a physician, and get their symptoms “diagnosed” and their prescriptions filled immediately, via a few minutes on a smart phone, without having to wait for an appointment and then having to schlep to the doctor’s office. All for about $40 per smart phone consult.

One has to ask, though, what do these apps do to quality?  Continuity of care and the patient-physician relationship?  I perused one such company’s site, American Well, which promises that “Your conversation with your doctor will last about 10 minutes. That’s how long it takes to handle most problems, but of course you can add time if you need to. Doctors can review your history, answer questions, diagnose, treat and even prescribe medication. And your prescriptions will be sent straight to your pharmacy.” (By providing their link, I am by no means endorsing or reviewing their services, just offering the link so that you can also see what I found).

I put in my zip code, and found several board certified family physicians who said they were available for an immediate consultation—at 5:05 p.m. on a Thursday evening! I looked at the credentials of the listed physicians, and all were board certified. I didn't ask for a consultation, but it appears that I could have gotten one right away.

I then checked on the reviews in the App Store from people who claim to have actually used the app. There were 26 reviews, and the overall user rating was just a hair off of five stars, the highest. Yet some of the reviewers’ comments gave me pause:

“The only place where you can see an amazing, friendly helpful doctor in a matter of minutes-right from your phone! I used it for cold/respiratory symptoms and was able to see the doctor and get treatment recommendations in less than 2 minutes.”

“Near me, there are a few urgent care places...but I usually have to wait at least an hour.  This time, I used this app, talked to a doctor, and had a prescription sent to my pharmacy within like 20 minutes. Saved me a ton of time.”

“In less than a minute, I was talking to a live and knowledgeable doctor, in the comfort of my home. The doctor truly cared about my health and my prescriptions were sent to my regular pharmacy!”

“I had developed a cold and was placed on antibiotics. A few weeks later my cold returned with an unbearable sore throat, rash on my forehead, and yeast infection as a result of antibiotics I had been on. It was a Saturday night...I was able to use this app to have a video consult with a doctor at 11:30 p.m. The Dr. I spoke to wanted me to start something before I went to bed. She e-prescribed 4 RXs directly to my 24 hour pharmacy. I picked up everything that night and woke up feeling so much better."

Now, as readers of this blog know, I am not a clinician, and so cannot comment on the appropriateness of the care described in these reviews (and the reviews themselves may not be accurate). But I have to ask those of you who are clinicians whether you believe that it is truly possible to diagnose a patient’s condition, via a few minutes on a smart phone’s video screen, without a history and physical, and without knowing the patient, and prescribe the right medications if medications are even needed? Can these smart phone encounters replace the traditional patient-physician relationship and continuity of care? The hands-on physical exam? The tests and blood work often required before a diagnosis is given? Can they? Should they?

The experience with Uber shows that fighting technological innovation and competition from services like these in all probability won’t work. Just ask the cab drivers. If there are physicians willing to sign up for them, and patients willing to get their care from them, then these services will likely grow, and maybe begin to displace some traditional brick-and-mortar physician practices.

We live in an age when people want what they think they need now, without delay, whenever and wherever they want them. And such innovations could provide opportunities for physicians in more traditional practice arrangements to also get in the business of offering smart phone consultations with both new and established patients. Competition might also result in traditional practices offering more timely visits and after-hours access, in person or by emails and by phone—and they may have to, if they want to stay competitive.

We don’t know how the Uberization of Medicine will affect medical care, but you better get ready for it, because it is coming. And unlike Uber’s car sharing app, which is mainly available in large cities where there is huge demand for taxis, doctor consultations via a smart phone app could potentially be offered anywhere, to anyone, from the biggest cities to the most rural of areas—perhaps making it an even more disruptive innovation for medicine than Uber has been for taxis.

Today’s question: What is your reaction to the Uberization of Medicine?

Thursday, August 7, 2014

“Obamacare” is a lifeline, not a train wreck

For years, critics of Obamacare (Affordable Care Act), have predicted that it would turn out to be a “train wreck”—or something worse.  But now we know that by every objective measure, the ACA is working out pretty darn well.  Let’s run through the “train wreck” predictions, and what we now know to actually be the case:

Train wreck prediction #1:

“Obamacare will lead to skyrocketing health care cost increases and explode the deficit.”

Typical was the claim by Obamacare opponent Avik Roy that “healthcare spending will explode under Obamacare.”

But now we know that:

In 2012, total health care spending increased by 3.7%, the “lowest rate since 1960.” Most recently, the CBO substantially reduced its forecast of projected deficit spending, largely because of the slowdown in healthcare spending.  And the CBO’s director confirmed his agency’s long-standing view that the ACA will lower the deficit.

The ACA may not be totally responsible for the healthcare spending slow down—the same thing is happening in other wealthier countries reports the New York Times.

But the facts to date show that Obamacare surely has not caused health care cost increases to skyrocket, or the deficit to explode; rather, health care spending has slowed and deficits are going down.

Train wreck prediction #2:

“More people will lose coverage under Obamacare than gain it.”

Speaker of the House John Boehner was one of many ACA critics who made this claim.

But now we know that:

Far more people gained coverage than lost it.

The Washington Post’s independent fact-checker wrote in March that there’s “more than enough to demonstrate that no matter how you count it, there has been no net loss in insurance coverage.”

In fact, today we now know for sure that Obamacare has allowed far more previously uninsured people to gain health insurance coverage than lose it.  It’s not even close.  Kaiser Health News reports that three independent studies found that the ACA “reduced the number of uninsured adults by 8 to 11 million people”.  Politico, a highly respected, independent and non-partisan news source for DC policy wonks and politicians, concludes that “by now, the trend is unmistakable: Millions of people who didn’t have health insurance before the Affordable Care Act have gained it since last fall. The law is not just covering people who already had health coverage, but adding new people to the ranks of the insured — which was the point of the law all along.”

To recap, these are the plain and simple facts:

Opponents of Obamacare predicted that Obamacare would become a “train wreck” because health care spending would skyrocket and the deficit would explode as a result.  The fact is you’d have to go back over half a century to find a time when health care spending has  grown so slowly;  the CBO says that federal deficit spending is declining (largely due to the slowdown in healthcare spending), and that the ACA will continue to lower the deficit in the future.

Opponents of Obamacare predicted that it would become a “train wreck” because  millions more would lose coverage than gain it.  But the fact is that under Obamacare, the uninsured rate is the lowest it’s been since at least 2008, according to Gallup, with the rate dropping across nearly every subgroup—extending coverage to some 8 to 11 million previously uninsured adults.

For the millions who have gained coverage, Obamacare today is looking a lot more like a lifeline than a train wreck.

But it’s not only the uninsured who benefit.  Don’t we all share in the benefit of having  lower healthcare spending, lower deficits, and from seeing fewer of our neighbors delay getting needed health care because they couldn't afford health insurance?

Today’s questions:  Is Obamacare a train wreck or a lifeline?  And if you still think it is (or will become) a train wreck, what facts do you have to back that up?

Friday, August 1, 2014

Four Things You Need to Know about the IOM’s Call for GME Reform

On Tuesday, the Institute of Medicine issued a report that calls for major restructuring of Graduate Medical Education (GME) financing “to allow a transition to an accountable, performance-based system” to fund graduate medical education over the next ten years.  The report, coming from a prestigious and highly influential 21-person committee of experts, has created a firestorm of reaction—ranging from the American Association of Medical College’s dire warning that the IOM would “destabilize a system that has produced high-quality doctors and other health professionals for more than 50 years and is widely regarded as the best in the world” to the American Academy of Family Physicians (AAFP) applauding the IOM for its recommended overhaul even though  “AAFP has advocated for quicker change on a larger scale.”   ACP, in a statement issued today, found elements of the IOM report that it likes—and elements of concern.
This is what the fuss is all about:

1. The IOM would keep the aggregate amount of GME financing flat for a decade (with only adjustments for inflation).  Physician organizations (including ACP and AMA), the AAMC, and many outside experts believe that GME funding needs to be increased, across the board (AAMC and AMA) or selectively and strategically (ACP), to fund more residency positions in fields where there is a documented shortage, especially in primary care.

2. The IOM’s call for flat funding reflects its views that:

a. Current GME dollars are not being spent wisely or effectively: “Advocating for increased federal GME funding would be irresponsible without evidence that the public’s current level of investment is helping to produce the workforce needed in the 21st century. At the same time, Medicare GME funding should not be reduced from current levels if it can be leveraged for greater public benefit.”

b. There is “no credible data” that there will be a physician shortage, especially in primary care.  The IOM suggests that increased use of telemedicine, relying more on non-physicians including NPs and PAs, and changing primary care physicians’ roles “from being central to a more consultative role” could eliminate the shortage projected by other studies of anticipated supply and demand.

While ACP and many others in medicine would agree that current GME dollars could be spent more effectively and strategically, we strongly disagree with the IOM’s surprising conclusion that there is “no credible data” of a shortage of primary care physicians, or in other specialties.  From ACP’s statement on the IOM report:

“ACP is very concerned, however, that the IOM did not make recommendations that address the nation’s looming physician workforce crisis. We are particularly concerned that the IOM stated that it ‘did not find credible evidence’ to support claims that the nation is facing a looming physician shortage, particularly in primary care specialties. Paradoxically, the IOM also suggested that ‘GME funds might be used to finance new incentives for choosing a primary care career,’ even as it questioned whether a primary care shortage exists. Although we concur with the IOM that more research is needed to guide physician workforce policies and that incentives, including payment reform, are needed to encourage careers in primary care, we believe there is credible evidence of a real and growing shortage of primary care physicians for adults warranting immediate action. It is estimated by highly credible analyses that the nation will need 44,000 – 46,000 additional primary care physicians by 2025. This figure does not take into account the increasing demand for primary care services as an estimated 25 million uninsured Americans will obtain coverage through the reforms in the Affordable Care Act.”

3. The IOM would divide the flat aggregate dollar amount of GME funding into two pools, the Operational Fund, which would fund traditional GME programs, and a new Transformation Fund, which would “finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.”   Because overall GME funding would be budget neutral, money would be taken away from traditional GME programs funded by the Operational Fund to pay for the new Transformation Fund.

The result would be a redistribution from traditional teaching programs and affiliated hospitals, paid out of the Operational Fund, to grant-funded “innovative programs” paid out of the Transformation Fund.

(The Operational Fund allocations begin at 90 percent of the total Medicare GME fund, decrease to 70 percent over roughly 3 years and remain at that level for several years, and then return to 90 percent by the 10th year. The Transformation Fund would be allocated the balance of the funds - thus starting at 10 percent of the total, moving up to 30 percent as GME pilots and activities gear up and then returning to the 10 percent allocation as successful pilots and research establish the basis for broad application of GME improvement initiatives, including additional slots.)

It is this redistribution that has AAMC warning about  “destabilization” of a GME system that is “widely regarded as the best in the world.”  ACP, for its part, stated that it “joins with the IOM in its call for innovation and transformation in GME, including a greater emphasis on training in community-based settings, but we are very concerned that reducing GME payments to existing programs to fund innovation and transformation could do great harm to the educational mission of many teaching hospitals and the patients they serve.”

4. The IOM states that GME is a public good— it benefits all of society, not just those who directly purchase or receive it.  Yet the IOM rejected the idea of establishing an all-payer fund to finance GME,  arguing that Medicare funding provided more stability.  Advocates for all-payer funding, ACP included, argue that because GME is a public good, all payers should pay into it—and that spreading the pool of financing to include public and private payers would be less risky than relying mostly on Medicare.

Still, much of what the IOM recommends resonates with the ACP policy that “Payment of Medicare GME funds to hospitals and training programs should be tied to the nation’s health care workforce needs. Payments should be used to meet policy goals to ensure an adequate supply, specialty mix, and site of training.”  Going forward, ACP plans to analyze the IOM report further, “offering our suggestions in the spirit of building upon the many imaginative reforms recommended in the report. We will also continue to advocate for policies to ensure an adequate supply of physicians to meet the nation’s health care needs, including strategic increases in the number of Medicare-funded GME positions in primary care and other specialties facing shortages.”

Today’s question: What is your reaction to the IOM report?

Friday, July 11, 2014

Will American conservatives lead the U.S. to a single payer system?

The unrelenting opposition by American conservatives to Obamacare may have the unintended consequence of leading the United States to a single payer system like Canada’s.

How’s that, you say? Isn’t the whole point of conservative opposition to Obamacare to drive home the point that the government is incapable of managing people’s health care?  Yes.  And aren’t conservatives effective in driving home that point? Yes, polls show that confidence in government is at an all-time low, no doubt related in some degree to the attacks on the Affordable Care Act and its chaotic launch.  (The VA scandals undoubtedly will also undermine trust in government, as I noted   in a recent guest blog post for the Philadelphia inquirer).

Yet when future historians write the history of health care reform in the United States, they may very well report that Obamacare was a stepping stone to single payer—not because liberals persuaded voters that we’d be better off with the government fully in charge (they’ve been trying to make that case for decades, with little evidence of success), but because conservative opposition to Obamacare ended up destroying employer-based private insurance, leaving the government as the only remaining payer.

Consider the following:

The Supreme Court ruling in the Hobby Lobby case is widely viewed as a victory for conservatives, since it reins in the ability of government to impose mandates on for-profit companies that violate their owners’ religious beliefs.  But Don Munro, a contributor at Forbes, provocatively asks if Hobby Lobby will “signal the end of employer-sponsored health insurance.” Fred Rotondaro and Christopher Hale from Catholics in Alliance for the Public Good persuasively argue that the Hobby Lobby decision:

“…brings to the forefront something we’ve all known for sometime: that Obamacare—for all the good it’s done in increasing access to quality and affordable healthcare—is a messy law. It asks employees to be at the whim of its employers’ objectives and mission for what health care benefits they receive. It also asks employers to at times reject its deepest convictions in order to provide certain benefits to its employees.

This isn’t sustainable. A person’s access to quality healthcare shouldn’t depend on who their boss is. And an employer shouldn’t be heavily fined if they don’t compromise their religious convictions in providing healthcare for their staff. . . A single-payer public health care option eliminates such complications. No matter who your boss is or what business you work for, you get access to the healthcare you need. And employers will not be forced to compromise their religious beliefs while providing the public good of healthcare.

And let’s be clear, if you have something that is both supported by the United States Conference of Catholic Bishops and Planned Parenthood, you might be onto a plan that proves the angel Gabriel right: nothing is impossible with God.”

Renowned health economist Uwe Reinhardt also believes that the Hobby Lobby rule may lead Americans to re-examine employer-based health insurance:

“The ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance. For many smaller firms, that choice is narrowed to one or two alternatives – not much more choice than that afforded citizens under a single-payer health insurance system. . .

. . . the Supreme Court’s ruling may prompt Americans to re-examine whether the traditional, employment-based health insurance that they have become accustomed to is really the ideal platform for health insurance coverage in the 21st century. The public health insurance exchanges established under the Affordable Care Act are likely to nibble away at this system for small and medium-size business firms, especially those with a mainly low-wage work force. In the meantime, the case should help puncture the illusion that employer-provided health insurance is an unearned gift bestowed on them by the owners and paid with the owners’ money, giving those owners the moral right to dictate the nature of that gift.”

But it isn’t just Hobby Lobby where conservative opposition to Obamacare may help bring about single payer.  CNBC reports that another pending court case against Obamacare’s insurance subsidies, instigated by conservative critics of the law, makes the claim that:

“those often-valuable subsidies are illegal because the Affordable Care Act only authorized such tax credits for people who bought insurance through one of the exchanges originally set up by an individual state or the District of Columbia—not the federal exchange. Nearly 90 percent of the people who enrolled in plans via the federal exchange qualified for those subsidies because they had low or moderate incomes. Take away those subsidies and many, if not most, of the enrollees on HealthCare.gov might not buy insurance next year because they will find it unaffordable at the full premium price. That, in turn, could create a much-feared ‘death spiral,’ where insurance pools have too many sick enrollees and not enough young healthy ones, and premium rates skyrocket. And if those subsidies are not available to individuals in the states served by HealthCare.gov, it would also mean that businesses in those states could not be mandated starting next year to offer affordable health insurance to their workers or pay a fine. That's because the so-called employer mandate is linked to the availability of those subsidies for workers who opt to buy individual insurance.”

A court ruling for the plaintiffs in this case (although considered unlikely) would be another huge blow to relying on private health insurance to make affordable coverage available to most Americans, because it would keep all Obamacare’s benefit mandates on the books, while making the private insurance offered through the exchanges unaffordable to the millions of people it was supposed to help.  But the “public option” part of Obamacare—Medicaid—would remain intact. 

And let’s not forget that conservatives are stoking public opposition to Obamacare’s mandate that people buy private insurance—even though they once championed an individual insurance requirement as an alternative to either single payer health insurance or requiring employers to provide coverage.

Now, I don’t see the United States rushing head-long into a single payer system (although just about all Americans regardless of their political leanings love Medicare), because the country is deeply polarized, and people have little trust in government, and even less in politicians. But it’s plausible that over time the unrelenting conservative attacks on Obamacare will end up showing Americans that it is just too difficult to provide affordable coverage through a system of regulated and subsidized private insurance and by counting on employers to continue to offer coverage, especially when employers can opt out if they have religious objections.   Conservatives then will not just have destroyed Obamacare—they will have opened the door to single payer as the only feasible way to provide affordable health insurance coverage to all.

Today’s question: Will conservative attacks on Obamacare lead the United States to a single payer system?