Tuesday, December 22, 2015

How the Grinch Stole Obamacare (2015 update)

Last year at this time—in keeping with this blog’s holiday tradition—I wrote about how the GOP, cast in the role of the Grinch, tried again to stop Obamacare from coming, counting on the Supreme Court to overturn the law.  I predicted then, maybe with more hope than confidence, that the Supreme Court would disappoint the Grinch, by upholding the Obamacare subsidies on a 5-4 vote.

 It turns out I was wrong—the Court, as we now all know, upheld the subsidies and the law on a 6-3 vote!  That doesn’t of course mean that the anti-Obamacare forces will desist in their efforts.  So here’s the 2015 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.

Whatever the reason,
Their base or their views,
They stood there on Christmas Eve, hating it all,
Staring down with a sour, disapproving frown
Because they’d been so sure that in 2015, they’d bring it all down.

"We control the House, and the Senate!" they had said with a sneer.
“Our chance for repeal is coming! It's practically here!"
They growled, with their fingers nervously drumming,
And told the Tea Party, “Obamacare’s demise is finally coming!"

For, in 2015, they knew...

...They were finally 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!
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 stop repeal from coming!
... But HOW?"

Then they got an idea!
An 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.
"Soon 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 in June 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 6-3 vote, the Roberts Court
had again upheld Obamacare, made their case naught,
In 2015, they HADN’T stopped ObamaCare from coming!
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 win the White House
Obamacare’s rejection
Will come from the 2016 election!
…and then, WE OURSELVES …!
Will feast, feast and feast!
As we finally carve up the Obamacare beast.”

Happy holidays to all, and my best wishes to you and your loved ones for a healthy, safe, and prosperous New Year!

Monday, December 14, 2015

“When logic, and proportion, have fallen sloppy dead”

These lyrics are from Jefferson’s Airplane’s White Rabbit, the classic 1967 psychedelic song based on Lewis Carroll’s Alice in Wonderland (and a thinly veiled reference to the rampant drug use of the times).

But I think the lyrics also describe today’s political discourse: on so many issues, “logic, and proportion, have fallen sloppy dead.”  We live in a time when evidence is disregarded, fact checkers ignored.  When confrontation is favored over conversation.  When moderation, in tone and substance, is considered to be weakness; and over-the-top rhetoric, strength.  When you don’t just disagree with someone, you hate them, or at least, you hate what they stand for.  When social media allows people to rant and rail, and shame and bully others, hiding their identities behind anonymous Twitter handles.

Take the issue of preventing injuries and deaths from firearms.  Logic tells us that when a typical day, more than 90 Americans are killed by firearms, we have a problem and the status quo of firearms policy isn’t working.  Logic tells us that when more than 20,000 people each year kill themselves with a gun, we have a problem and the status quo of firearms policy isn’t working.   Logic tells us that when hundreds of children each year get shot or shoot others because of unsecured and loaded guns in their homes, we have a problem and the status quo of firearms policy isn’t working.  Logic tells us that when our own workplaces, malls, city streets, colleges and elementary schools are not safe from firearms-related violence, we have a problem and the status quo of firearms policy isn’t working.

Yet even the most modest of efforts to address the problem of firearms-related injuries and deaths—by allowing the scientists at the NIH and CDC to research its causes and effects, just like they research the impact of smoking on health—has attracted a storm of opposition from the NRA and politicians aligned with the organization.  In fact, at the NRA’s urging, Congress since 1996 has flatly prohibited the agencies from using any funds to conduct research on gun violence.  On December 1, ACP joined with dozens of other health-advocacy organizations to urge Congress to lift the gun violence research ban.  On December 9, we sent our own letter to House and Senate appropriators on our funding priorities that included a request that they end the research ban, and on Thursday, we issued an advocacy alert asking our members to call their representative and Senators to urge the same.  At the time this blog was posted, the fate of the ban was the subject of negotiations between House Republicans and Democrats, with the outcome still to be determined.

But what I do know is this:  all of the logic, and all of the evidence we have for allowing government scientists to research how to prevent gun violence, won’t sway those who are opposed to any and all efforts that, in their minds, might lead to restrictions on guns.  Just like all of the logic and evidence that ACP has marshaled on the broader issue of reducing injuries and deaths from firearms, and the modest and sensible and, according to the American Bar Association, constitutional solutions to gun violence that we and 59 other health advocacy groups have put forward (like closing the  private sale loophole in the federal background check system), won’t sway those who view any limits on guns, no matter how modest and sensible, to be an unacceptable assault on their freedom.

Rather, our efforts to apply logic and evidence to reducing firearms-related injuries and deaths often are greeted with vitriol.   Typical was an email we received after we sent out our  call to action on the gun research ban: “You people are pathetic. The last 3 terrorist (can I use the term) attacks were in GUN FREE ZONES. More people die in Chicago every weekend another gun free zone. What weapons are worse AR 15’s or AK 47’s. By the way ,by definition) neither one is an assault weapon. Stick to medicine you morons!”  Similarly, when I tweeted about the need for evidence based policies to address gun violence through my @bobdohertyACP twitter account, I got many mentions and retweets, but also dozens of anonymous posts that ranged from dismissive to insulting to threatening.

I have a thick skin and I am well aware that anonymous Twitter posts are not representative and can bring out the worst in people; what is more concerning to me is that our elected representatives also seem impervious to the logic and evidence on the need to reduce gun violence, just like they are on so many issues.  I am also concerned about the seeming lack of proportionality in the reaction of many of those who oppose even the most modest of gun restrictions: universal background checks to keep guns out of the hands of convicted felons, folks, is not Nazi-style tyranny.

The United States is facing huge problems that need to be addressed through calm, reasoned discourse, informed by evidence and analysis.  Sure, we can and should have a healthy debate over how best to prevent firearms violence—each side should put their facts, their evidence, and their supporting rationales out there, let’s respectfully dissect and challenge each other, and then, let’s decide on a sensible and informed course of action.

But if in the debate over guns we allow logic and proportion to fall sloppy dead, then the status quo will prevail and tens of thousands will die as a result.

Today’s question:  Can’t we at least agree that allowing the CDC and NIH scientists to conduct research on the causes and effects of gun violence would be a good starting point?

Wednesday, November 25, 2015

Here’s a way for primary care doctors to earn a lot more. (If only they would use it)

The fact that primary care is undervalued by Medicare and other payers has been long-understood to be driving the precipitous decline in the numbers of new physicians choosing  primary care internal medicine or family practice, and a growing exodus of established primary care physicians.  Efforts to address this undervaluation have traditionally been to (1) bump up the payments (relative value units) for the office visit codes traditionally billed by primary care physicians, (2) explicitly fund, usually on a temporary basis,  higher payments  for primary care that do not require offsets from others, like was the case with the two-year Medicaid primary care pay parity program, which expired on January 1 of last year, and the five year 10% Medicare primary care bonus program, which is set to expire at the end of this year if Congress doesn’t continue it, (3) offer higher payments contingent on primary care physicians meeting performance measures (pay-for-performance), and/or (4) develop  and promote alternative payments models, like Patient-Centered Medical Homes and Accountable Care Organizations, which offer higher payments in delivery models that require more accountability and risk for quality outcomes and savings.

Each of these approaches are important, and can potentially make a big difference, but each also has its  limitations.  Under Medicare’s “budget neutrality” rules, bumping up the RVUs for office visits results in across-the-board cuts in all RVUs, which intensifies resistance by other specialties.  (Think of it like a pie: a bigger slice for primary care results in a smaller slice for everyone else) . And even the primary care services that are supposed to benefit from the bump end up having to absorb part of the budget-neutrality adjustment. And, because office visits are the most frequently billed services, even a small bump up can result in large across-the-board budget neutrality offsets.  Programs to temporarily fund increased payments for primary care are all well and good, but because they are expensive, they also tend to be time-limited, depending on the willingness of Congress to keep open the funding spigot going past their expiration date.  (Good luck with that!).  Pay-for-performance  programs can potentially increase payments to some primary care physicians but they are a hassle, usually include both penalties and rewards, require a lot of physicians to perform poorly in order for the better performing physicians to get more (another variation of budget neutrality), and physicians don’t have a lot of confidence in the measures being applied.  New payment models may ultimately prove to be the best option to systematically improve payment for primary care,  but there is an uncertain track record with them, and the investment in the practice that is required makes for an uncertain and uneasy cost-benefit for primary care physicians.

What if I told you there was another way, already available to primary care physicians, to potentially earn tens of thousands of dollars more from Medicare and other payers, while improving patient care?  That is already built into Medicare’s budget neutrality adjustments, so there isn’t any resistance from other specialties? That doesn’t tie pay to performance measures?  That isn’t time-limited and temporary, that doesn’t depend on Congress’s “generosity”?  That is available within the traditional fee-for-service payment system, not linked to alternative payment models?

What if I told you that there is another way, one that takes a page out of the surgeons’ book?  One of the way that surgical specialties have been able to earn higher payments is to constantly create new CPT codes and RVUs for their services, slicing and dicing what they do (pun intended) to create more billable opportunities.  Why can’t primary care do the same, creating more codes and RVUs (and with them, more billable revenue opportunities), instead of being stuck with the same old 10 codes for office visits for new and established patients?

Well, this is exactly what has happened over the past few years in primary care.  Largely because of ACP advocacy, Medicare has approved at least 7 new codes that create very substantial billable revenue opportunity for primary care physicians.  Practices that bill for all of them can potentially increase their revenue by six figures, or more.  (One company has developed a spreadsheet that physicians can use to estimate the potential revenue gains, as well as costs associates with the codes).

What are the new codes?  Medicare’s wellness examination, which in 2016 will pay $172.69 for an initial visit, and $116.80 for a subsequent one. Transitions of care management, 14 day discharge, pays $164.81;  7 day discharge pays $232.52.  Chronic care management,  20 minutes, pays $40.84.  And, brand new, for the first time starting on January 1, Medicare will pay $85.99 for 30 minutes of advance care planning!  (These payment amounts are before application of Medicare’s geographic adjustments, and apply to services provided in a non-facility setting).

ACP’s regulatory affairs department has prepared a nice spreadsheet that shows the available payments for these services in both the non-facility and facility settings.

Yet many primary care physicians are not routinely billing for these codes, leaving tens of thousands of dollars at the door.  Many say that the documentation requirements are too much, or they might have to hire more staff, so it’s not worth the effort. There is no question that Medicare could make it easier and simpler for physicians to document these services, as ACP has recommended.

At the same time, though, I expect a cost-benefit analysis would show that many primary care physicians and their practices would come out way ahead if they began to bill for these codes, while improving patient care in the process—a real win-win.

So how about it, primary care doctors?  Isn’t it time for you to consider taking advantage of the new codes and revenue opportunities available to you, even as ACP and others continue to advocate for more fundamental reforms to improve payment for primary care?

Today’s questions:  Do you bill for these new codes?  Why or why not?

Thursday, November 12, 2015

How does concierge and direct primary care affect access and cost?

We don’t really know, according to an ACP policy paper, written by me on behalf of our Medical Practice and Quality Committee and Board of Regents published in the Annals earlier this week.  What we do know that the numbers of such practices are relatively low but there is growing interest in them, and judging from a live twitter session I just concluded, considerable passion from those who have embraced direct primary care.

Why did ACP decide to take on this issue? A few years ago, the ACP Board of Governors adopted a resolution from our Florida chapter asking us to look into developing policy on concierge practices. This resulted in a general statement of College policy encouraging physician choice of practice arrangements that best meet their patients’ needs in an ethical and accessible way.   As time went on, though, it became apparent to us that a more detailed policy analysis and recommendations were needed, for several reasons.

It is now evident that increasing numbers of internists and other physicians are considering becoming part of a concierge, direct primary care, or some other practice arrangement that includes one or more of the following elements:  (1) downsizing of patient panels (2) charging a retainer or concierge fee and/or (3) not participating in patients’ insurance.  (Collectively, we define such practices in the new paper as direct patient contracting practices, or DPCPs.)  The Affordable Care Act allows the insurance exchanges to offer direct primary care with a wrap-around high-deductible insurance policy.   We also have had ACP members ask us whether the College has any policy or guidance on concierge or direct primary care practices.  The growth of such practices can have a significant impact on quality, access and cost of care, as well as patient and physician satisfaction, yet little has been published in the available research literature on their impact.

For these reasons, our Medical Practice and Quality Committee accordingly decided that the College could make a positive contribution by doing an evidence-based analysis of the reasons why a growing number of physicians are interested in such models, what we know and don’t know about their impact on quality and access, what issues require further study, and ethical considerations that apply to physicians regardless of their practice mode.  The members of our Medical Practice and Quality Committee who developed this paper included an internist in a direct primary care practice as well internists in more traditional independent practices.  The Committee was unanimous in supporting the paper and its recommendations.

If you have not done so already, I encourage you to read the entire paper included as an appendix to the summary version published in the Annals of Internal Medicine.  I think you will find that the paper is a balanced, objective, and evidence-based analysis of the implications of DPCPs as we intended.  Several highlights:

The paper clearly recognizes why many physicians are moving to DPCPs because of their frustrations with paperwork and insurance interactions, EHRs, and not being able to spend enough time with patients, and other external constraints on their ability to provide their patient with the best possible care.  We call on policymakers to address such frustrations.
We call on physicians in all types of practice to strive to provide care to all types of patients, including the poor and those on Medicaid, reflecting guidance from our Center on Ethics and Professionalism, Committee on Ethics and Professionalism, and ACP’s Ethics Manual on the obligation of all physicians to provide non-discriminatory care, regardless of their practice arrangement.
We observe that there are examples in the literature of DPCPs that have structured their practices to ensure access to low-income patients, including Medicaid enrollees.  Yet we also observe that there are concerns in the literature, supported by studies in our review of the evidence and input from our Committee on Ethics and Professionalism, which suggest that some practices that charge retainer fees and/or do not accept insurance could potentially create barriers to poorer patients who cannot afford to pay a retainer fee or pay out-of-pocket at the time the service is rendered.
We address concerns about the potential for patient abandonment associated with downsizing of patient panels, which can create legal and ethical issues that physicians should be aware of.
We provide practical suggestions for physicians who are in, or considering, a DPCP, to consider taking on their own to mitigate any adverse impact on poorer patients, such as waiving or lowering retainer fees, waiving requirements that payments be made at the time of service, and helping patients file claims.
We call on all practice arrangements to be transparent with patients.
We call for continued consideration of Patient-Centered Medical Homes
We call for more research on the impact of DPCPs.

The paper neither endorses nor opposes direct primary care, concierge practices, or other DPCPs; rather, it just tries to provide a balanced assessment of their potential advantages and disadvantages and issues that merit further consideration by physicians, policymakers and researchers.  Without more research, it would be premature for ACP to take a position on encouraging or discouraging them.

In summary, ACP affirmed our support for physician and patient choice of practices that are ethical and accessible and that best meet the needs of patients in a non-discriminatory way, whether in a more traditional independent practice, a large group practice, an academic practice, or a concierge practice, direct primary care, or other DPCP.  And we call for more research on the impact of DPCPs on quality, cost and access to care.

Today’s question: What do you think of concierge and direct primary care practices, and ACP’s recommendations?

Thursday, October 22, 2015

The Growing Affordability Crisis

Record numbers of Americans have health insurance, largely because of the Affordable Care Act.  Yet there is growing concern that even with insurance, many people are not able to afford the care they need:

- For over a decade now, employers have been shifting more costs onto employees.  The Commonwealth Fund reports that in 2003, only 1 percent of privately insured persons had deductibles of $3000 or more; in 2014, it was 11 percent, a greater than 10-fold increase.  In 2014, 27% were enrolled in plans with deductibles between $1000 and $3000 compared to 7% enrolled in such plans in 2003.

- The increasing amount that people have to pay out-of-pocket has resulted in millions of Americans becoming underinsured—they have insurance, but have to pay so much out-of-pocket that it creates a barrier to obtaining needed care.  The same Commonwealth Fund analysis finds that 31 million privately insured persons in 2014 were underinsured compared to 16 million in 2003.  (Underinsurance was defined by Commonwealth as out-of-pocket costs being 10% or more of income, 5% for lower-income persons; or the deductible is greater than 5% of income).

- The fund also found underinsured persons were less likely to get needed care: “insured adults with coverage all year who had health plans with high deductibles were more likely than those with low or no deductibles to report cost-related problems getting health care. More than two of five (44%) privately insured adults with a deductible of $3,000 or more reported not getting needed care because of cost compared with 16 percent of adults who did not have a deductible. Many underinsured adults with health problems reported difficulty caring for their conditions. Among adults with at least one chronic health condition, a quarter (24%) of those who were underinsured said they had not filled a prescription for their condition or had skipped a dose of their medication because of cost, compared with 7 percent of those insured all year and not underinsured. . .  Similarly, underinsured adults with chronic health conditions were more likely to say they had gone to the emergency room or stayed overnight in the hospital for their condition than were insured adults with health problems who were not underinsured.”

- The rising cost of prescriptions and generic drugs is also creating an affordability crisis for many.  A report by Express Scripts found that 15.7% of people enrolled in Medicare, Medicaid or commercial insurance had annual drug costs of $50,000 or more. Nearly two-thirds of those with annual drug costs of $100,000 was for hepatitis C, cancer, or compounded treatments.

For people enrolled in the marketplace plans offered through the Affordable Care Act, cost-sharing subsidies are available for those who earn less than 250% of the federal poverty level.  Such subsidies, however, are not available to those enrolled in commercial insurance plans.  And while most people enrolled in the ACA’s marketplace plans are satisfied or very satisfied with their deductibles and co-pays, the number one reason cited by eligible uninsured persons who have not enrolled is that the plans were too expensive.

The bottom line is that the high deductibles that are increasingly common in the commercial and employer-based insurance sectors, combined with the rising cost of medications, may be contributing to a new healthcare affordability crisis.  Getting more people covered, as the ACA clearly has done, is a worthy and essential reform.  But so is making sure that out-of-pocket costs and medication prices aren’t so high that even insured people can’t afford the care they need.

Today’s question:  What should be done about the growing affordability crisis?

Friday, September 11, 2015

September 11 reflections

Today is a day for remembering and reflecting on what happened on that terrible day, 14 years ago, when terrorists killed and injured thousands of Americans.   As time goes on, memories will fade, witnesses will pass away,  and there will be fewer first-hand accounts, not just of what happened, but how it felt—just like there are so few left that remember the “date that will live in infamy” when the Japanese attacked Pearl Harbor.  I think  this explains why so many of us who remember 9/11, especially who were in New York City and Washington DC when the attacks took place, feel it is necessary to document what we saw and felt, adding our own small piece to the historical record while we can.  A few years ago, I posted an account in this blog on what I saw and felt on that terrible day, excerpted below:

 I remember Washington the way it was on the day that our nation was attacked. I remember listening to my car radio on the way to work, and hearing that a “small” plane had collided with the Twin Towers in my home city of New York. I remember gathering with my co-workers to watch the event unfold on TV. I remember going to the roof of our office building to watch the smoke rising from the Pentagon. I remember hearing that another hijacked plane was heading to Washington, maybe to the White House, only four blocks from our office, an intended missile that never came to us because we later learned that it was brought down by courageous passengers in rural Pennsylvania.

I remember hearing rumors of more attacks—bombings at the State Department, in Metro subway stations, rumors that were not true, but we didn’t know that then. I remember not knowing what to tell our employees to do—go home, stay in the office until we got further word? Nothing in my training had prepared me for my city being under possible attack. I remember the traffic gridlock as millions tried to flee. I remember the eerily empty streets of DC, many hours after the traffic finally cleared and people hid in their homes.

I remember the helicopters endlessly circling the city. I remember days later, when we were able to return to work, seeing the intersections of the nation’s capital patrolled by tanks and National Guards troops with automatic weapons, something I never expected to see in my life. And I remember a few days later, taking Amtrak to an ACP chapter meeting in Connecticut, looking out the window as we passed Manhattan, and seeing through my tears the smoking, gaping hole where the World Trade Center once stood.

And I remember trying to make sense of the senseless to my young children, trying to reassure them that they were safe when in my heart I was never sure we’d ever feel safe again.

Much has changed in the years since, but in a world where terrorism remains a threat here and abroad, and where mass shootings have become an almost weekly event in the United States, I must still question if we’ll ever truly feel safe again.

Today’s question: What are your reflections on September 11, 2001?

Wednesday, September 9, 2015

ACP to Medicare: Pay internists better!

This is, in a nutshell, what ACP told the Center for Medicare and Medicaid Services (CMS) in a 47-page comment letter on the agency’s proposed rule for the 2016 Medicare Physician Fee Schedule.  Of course, it wouldn’t be effective for ACP to just say that its members should be paid more; we would have to show the agency why (the value to patients) and how (what changes specifically need to be made) to improve Medicare payment policies.

Among its many recommendations, ACP:

- Called on CMS to expand the Comprehensive Primary Care (CPC) Initiative both to additional geographic regions, as well as in existing CPC initiative areas.  The CPC initiative, a Medicare-funded pilot test of the impact of advanced Patient-Centered Medical Homes on quality and cost of care, is currently limited to approximately 500 practices in 7 market areas.  These practices are receiving a risk-adjusted average of $20 per Medicare patient per month, in addition to their usual Medicare fee-for-service payments, and they have the opportunity to share in savings to the program if they can reduce costs while maintaining or improving quality. The College believes that there is sufficient evidence of its effectiveness in improving quality and/or achieving savings to support making it widely available to beneficiaries and practices across the country.  ACP recommended that CMS seek out agreements with other payers in additional regions of the country to join with Medicare to support practices that wish to participate in the CPC initiative, and to open up participation to more practices in the current CPC initiative regions.

- Supported CMS’s proposal to allow Medicare reimbursement for advance care planning services. While this proposal is an important step to improve care for Medicare patients with serious illness, ACP urged that reimbursement for advance care planning be made uniformly available to all physicians and their Medicare patients through a national coverage determination, rather than leaving it to each regional Medicare carrier to decide whether to cover the service.

- Urged CMS to reduce barriers to physicians getting reimbursed for the Chronic Care Management (CCM) Code and allow reimbursement for CCM services that require additional time.  ACP recommended that CMS develop add-on codes for time increments greater than 20 minutes such as 21-40 min; 41-60 min; and greater than 1 hour.  ACP also recommends that the electronic care plan sharing requirement for providing the CCM service be suspended until the time that EHRs have the ability to support such capabilities.

- Encouraged CMS to use payment approaches that are aligned with the goal of moving payments away from volume to value-based care such as by exploring bundling of codes for certain chronic diseases. More specifically, ACP recommended that a code bundle for Diabetic Care Management (DCM) be developed to emphasize better care coordination, communication, and integration of the care team aimed at a better overall outcome cost of care for the Medicare beneficiary.

- Supported CMS’ recognition of the need to value the delivery of behavioral health services within the Physician Fee Schedule.  ACP recommended that the “collaborative care” model described in the proposed rule be implemented through a Center for Medicare and Medicaid Innovation (CMMI) demonstration and be rapidly expanded within Medicare through the Secretary’s authority based upon the results of this demonstration.

- Recommended that CMS investigate the adequacy of payment for physician services that typically take place outside of a face-to-face patient encounter. The College urged CMS to recognize non-face-to-face services-- such as telephone and email consultations-- that facilitate care coordination by internists and other primary care physicians.

ACP ‘s letter also offered comments on:

- Additional specific coding issues, such as Practice Expense (PE) determination, moderate sedation valuation, and surgical global periods.
- Physician Quality Reporting System (PQRS)
- The Value-Based Payment Modifier and Physician Feedback Program
- Physician Compare
- The Medicare Shared Savings Program (MSSP)
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
- CMS’s request for comments on issues relating to the  Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation

ACP’s comments were the result of countless hours of analysis by the College’s regulatory affairs staff, and from the volunteer physician leadership on its Coding and Payment Policy Subcommittee, Medical Practice and Quality Committee, Subspecialty Advisory Group on Socioeconomic Affairs, and the ACP representatives to the RVS Update Committee (RUC).

So when someone says the College doesn’t do anything to advocate for its members, or that we care “only” about the big and controversial policy issues like immigration and health, reducing harm from firearms, and LGBT healthcare disparities, it just isn’t so.  While we do care deeply about -- and are proud of our advocacy on -- issues that directly affect individual and population health, we devote at least as much of our advocacy resources and staff to improving the economic and regulatory environment for our members—proudly and justifiably so!

Today’s questions: What do you think of ACP’s recommendations to improve Medicare payments for internists’ services?  What would you recommend?

Wednesday, August 26, 2015

Why physicians must speak out against mass deportation of undocumented immigrants

Mass deportation, as proposed by Donald Trump, and echoed to varying degrees by other politicians, would have a catastrophic effect on the health of the approximately 12 million undocumented residents of the United States.  Physicians accordingly have an ethical responsibility to speak out, individually and collectively, for the health of these people, and against mass deportation.

That the medical profession is obliged to advocate for the health of all persons, without regard to their legal residency status, is well-established.  ACP’s Ethics Manual, Sixth Edition, affirms that “All physicians must fulfill the profession's collective responsibility to advocate for the health, human rights, and well-being of the public.”  “Health and human rights are interrelated,” it continues. “When human rights are promoted, health is promoted. Violation of human rights has harmful consequences for the individual and the community. Physicians have an important role to play in promoting health and human rights and addressing social inequities. This includes caring for vulnerable populations, such as the uninsured and victims of violence or human rights abuses. Physicians have an opportunity and duty to advocate for the needs of individual patients as well as society.”

It is indisputable that people who are undocumented, and at risk of deportation, are especially vulnerable to adverse and inequitable health consequences:

- “Worries about their legal status and preoccupation with disclosure and deportation can heighten the risk for emotional distress and impaired quality of health.”
- “Restricted mobility; marginalization/isolation; stigma/blame and guilt/shame; vulnerability/ exploitability; fear and fear-based behaviors; and stress and depression are specific to undocumented immigrants and have health and mental health implications.”
- The psychosocial impact of deportation include “the trauma of sudden and imposed family separation” . . . “drug use and less interaction with medical or treatment services (including HIV testing, medical care, and substance abuse treatment” . . .adverse “changes in family structure and stability. ”
- “The aftermath of deportation impacts entire communities as it instills fear of family separation and distrust of anyone assumed to be associated with the government, including local police, school personnel, health professionals and social service professionals.”

Such adverse health impacts would be exponentially higher if the United States were to attempt to remove by force every person who is in the country unlawfully.

Recognizing this danger, the American College of Physicians asserted in a 2011 position paper on immigrant access to health care that:

 “Any policy intended to force the millions of persons who now reside unlawfully in the U.S. to return to their countries of origin through arrest, detention, and mass deportation could result in severe health care consequences for affected persons and their family members (including those who are lawful residents but who reside in a household with unlawful residents— such as U.S.-born children whose parents are not legal residents), creates a public health emergency, results in enormous costs to the health care system of treating such persons (including the costs associated with correctional health care during periods of detention), and is likely to lead to racial and ethnic profiling and discrimination.”

Instead of mass deportation, ACP advocated “for a national immigration policy on health care that balances the needs of the country to control its borders, provides access to health care equitably and appropriately, and protects the public’s health.”

In the same paper, the College also cautioned that a policy of mass deportation could compromise the patient-physician relationship, if it required that physicians report on the legal status of their patients:

 “Any law that might require physicians to share confidential information, such as citizenship status to the authorities, that was gained through the patient–physician relationship conflicts with the ethical and professional duties of physicians. National immigration policy should respect the boundaries of this relationship and the ethical obligations of physicians and not require physicians to reveal confidential information. Therefore, federal policies should not intrude upon a physician’s obligation to treat patients, regardless of legal status, and physicians should not be required to report on the immigration status of patients.”

Finally, ACP advocated that:

“U.S.-born children of parents who lack legal residency should have the same access to health coverage and government-subsidized health care as any other U.S. citizen” noting that “as outlined by the 14th Amendment to the U.S. Constitution, all persons born or naturalized in the U.S. and subject to the jurisdiction thereof are citizens of the U.S. and of the state wherein they reside. This means that a child born in the U.S. to immigrant parents automatically becomes a citizen . . . U.S.-born children should not be at a disadvantage from receiving the benefits of U.S. citizenship because of their parents’ immigrant status and fear of deportation.”

ACP clearly was prescient in anticipating the current debate over mass deportation and the citizenship of U.S. born children of undocumented persons, addressing the issue solely from the standpoint of advocating for the individual and collective health of the all persons, without regard to legal residency status.  But given that the direction of the debate has taken a decidedly wrong turn in the four years since ACP released its recommendations, it is high time for physicians, and their professional associations, to raise their voices now, individually and collectively, against mass deportation of undocumented persons, for the constitutionally-guaranteed right of their U.S. born children to have the same access to health coverage and government-subsidized health care as any other U.S. citizen,  and against any policy would require that physicians report on the on the immigration status of their patients or otherwise compromise their ethical obligation to provide care for all.

Today’s question:  Will you take up the call to speak out against mass deportation and for policies to ensure access to healthcare for all U.S. residents, regardless of legal residency status?

Monday, August 17, 2015

Escaping the echo chamber

Humans have a tendency to seek confirmation of our own beliefs, choosing to surround ourselves with like-minded people and information sources—a phenomenon that social scientists call the “echo chamber” effect.

For instance, if I asked my neighbors in my upscale Washington DC community about their views on a range of issues, they almost uniformly would tilt liberal: support for Obamacare (although some would have a preference for single payer), pro-gun control, belief in global warming and support for policies to mitigate it, and pro-gay marriage. If my neighbors only get their news and opinions from sources like the New York Times and MSNBC’s Rachel Maddow, they likely would conclude that their liberal views are held by most Americans, except for a “misguided” minority of people who have been “duped” into holding unscientific, illogical and contrary conservative views.

On the other hand, if people who live in “red state” communities were to ask their neighbors about their views on a range of issues, they almost uniformly would tilt conservative: opposition to Obamacare, anti-gun control, disbelief in global warming and opposition to policies to mitigate it, concern about gay marriage. If they only get their news and opinions from sources like the Wall Street Journal and Fox News’ Sean Hannity, they likely would conclude that their conservative views are held by most Americans, except for a misguided minority of people who have been “duped” into holding unreligious, illogical and contrary liberal views.

This is nothing new:  long before Fox News and MSNBC, Americans turned to highly partisan sources for news that reinforced their own views.  The University of Wisconsin’s Center for Journalism Ethics observes that in the 19th century, “‘The power of the press,’ one journalist candidly explained, ‘consists not in its logic or eloquence, but in its ability to manufacture facts, or to give coloring to facts that have occurred.’ Party newspapers gave one-sided versions of the news.  Papers in opposition to Andrew Jackson in 1828 attacked him for marrying a woman before her divorce had been finalized.  He was the violator of marital virtue, a seducer.  Jackson, one paper declared, ‘tore from a husband the wife of his bosom.’  Pro-Jackson newspapers insisted on the general’s innocence, and accused his critics of violating his privacy.  There was no objective, middle ground.”  (Donald Trump might have felt right at home!). Yet the extent of the echo chamber effect has ebbed and flowed.   By the early 20th century “most newspapers ceased to be party organs.”

Today, we seem to be in an era where the echo chamber effect is back in full force.   The Pew Research Center reports that “Republicans and Democrats are more divided along ideological lines – and partisan antipathy is deeper and more extensive – than at any point in the last two decades. These trends manifest themselves in myriad ways, both in politics and in everyday life. And a new survey of 10,000 adults nationwide finds that these divisions are greatest among those who are the most engaged and active in the political process.”  “’Ideological silos’” are now common on both the left and right” Pew continues:

“People with down-the-line ideological positions – especially conservatives – are more likely than others to say that most of their close friends share their political views. Liberals and conservatives disagree over where they want to live, the kind of people they want to live around and even whom they would welcome into their families.”  63% of “consistently conservative” people say that “most of my friends share my political views”; 44% of “mostly conservative” people say the same.  Twenty-five percent of “mostly liberal” people, and 49% of “consistently liberal” people, report that most of their friends share their political beliefs.

Such ideological silos, reinforced by our own respective echo chambers, have contributed to an antipathy to the kinds of political compromises that are necessary for government to work, breeding self-reinforcing cynicism and anger about our political system and our politics.

(On a more positive note, Pew finds that “the majority [of Americans) do not have uniformly conservative or liberal views. Most do not see either party as a threat to the nation. And more believe their representatives in government should meet halfway to resolve contentious disputes rather than hold out for more of what they want.  Yet many of those in the center remain on the edges of the political playing field, relatively distant and disengaged, while the most ideologically oriented and politically rancorous Americans make their voices heard through greater participation in every stage of the political process.”)

So what will it take to turn around the polarization that is dividing the country between uncompromising ideologues, paralyzing the political process, and poisoning our politics?

Well, the obvious answer is to seek out people who don’t think like ourselves, and diversify our sources of news and opinion to seek a range of opinions.  This, of course, is easier said than done, when many Americans say they want to be surrounded only by people who think the same way, when the news media and social media feeds on and fans such divisions.  Yet each of us can make the choice, on our own, to take a step outside of our own echo chambers, and encourage others to do the same.

In my own case, in my role as a spokesperson for the politically-diverse 143,000 members of the American College of Physicians, I make it a point to step outside the Washington DC echo chamber and travel to ACP chapters throughout the country, red state, blue state, and everything in between, to converse with physicians who represent the full spectrum of political persuasions.  This fall, for instance, I will be traveling to chapter meetings in Omaha, Nebraska; Wichita, Kansas; and Osage Beach, Missouri, all red state chapters; and Monterey, California and Seattle, Washington, blue state chapters.  I know from experience I will get an earful from internists whose political views span the spectrum from right to left (just like the comments I get on my blog posts)!

Nicholas DiFonzo, a psychologist who has studied the echo chamber effect, found that “when Republicans and Democrats were put in separate groups and each group was asked to discuss a derogatory rumor about the other party (e.g., ‘Republicans are uneducated;’ ‘Democrats give less to charity’) beliefs in these rumors polarized in predictable directions. When the discussion groups were mixed, this did not happen.”

Advocacy organizations that want to step outside their echo chambers must therefore ensure that the decision groups where policies are discussed and debated are inclusive of people who hold different policy and political perspectives.

To illustrate, ACP’s Health and Public Policy Committee (HPPC), the committee that developed recent policy papers on firearms, the Affordable Care Act, vaccine exemptions, LGBT persons’ access to care, and other controversial issues, currently has a membership of 13 physicians and one medical student.  HPPC’s members hail from Pennsylvania, New York (upstate), Texas, Wyoming, Kentucky, Washington (state), Minnesota, Tennessee, Arizona, Nebraska, and Wisconsin, a true mix of red, blue and swing states.  From what I know of their views as expressed by their comments at committee meetings, HPPC’s membership is just about evenly divided between conservative- and liberal-leaning physicians, Republicans and Democrats. HPPC’s members include physicians who own guns for hunting and personal protection and physicians who would never consider owning a gun.  It includes internists who live in small rural towns and internists who live in big cities; academic physicians and private practice doctors; young medical students through more senior physicians; physicians who own their own practices and physicians who are employed by large systems, men and women, the whole wonderful diversity found in ACP’s 143,000 members!  In addition, HPPC conducts an evidence-based review of the research literature before recommending policies to the Board of Regents, ensuring that ACP’s policies are not based just on the personal opinions of its members, but the evidence of what is effective in improving healthcare.

I believe that ACP’s approach to policymaking is a model that can and should be embraced by other physician advocacy organizations.  Before adopting policy, make an effort to visit physicians around the country to find out their concerns.  Make sure that the physicians who are elected or appointed to the governing bodies that develop your organization’s policies have a good mix of political perspectives, types of practice, age, gender, race, ethnicity, career stage, and age.  Put their opinions to the test by reviewing the evidence from research studies, some of which may uphold their initial views, others may cause them to reconsider them. Seek broader input from your membership and outside parties, continue to debate the issues, as informed by the evidence and the diverse views provided, and then reach a consensus. Once your organization adopts its policy recommendations, continue to welcome dissenting views.

Call it the anti-echo chamber approach to developing policy!

Today’s question: what will you do to step outside your echo chamber?

Thursday, July 30, 2015

Medicare and physicians, 50 years together: it’s complicated

Fifty years ago today, President Lyndon Baines Johnson signed Medicare (and Medicaid) into law.   Medicare’s relationship with physicians since then can best be described as a complicated one.

First, recall that Medicare became law notwithstanding the American Medical Association’s fierce opposition to it. Three years prior to its enactment, AMA President Ed Annis warned that "We doctors fear that the American public is in danger of being blitzed, brainwashed, and bandwagoned" by the Kennedy administration’s proposal to provide compulsory health insurance to the elderly.  The AMA continued to fight tooth-and-nail against Medicare, even after the Johnson administration took up the cause following President Kennedy’s assassination.   After Medicare was enacted, however, the AMA came to the table to negotiate with the administration on its implementation. The ACP, for its part, did not participate in the debate over Medicare’s enactment, but once it became law, the College “began to realize that it could no longer limit its mission to education, professional standards, and fellowship: it had to became an advocate in policy and political arenas” as Dr. Lynne Kirk and I recount in the chapter "The American College of Physicians and Public Policy" in the recently-published Serving Our Patients and Profession: A Centennial History of the American College of Physicians, 1915-2015 (available for purchase in the ACP Catalog).

Second, despite the AMA’s forebodings, physicians and their patients have flourished under Medicare.  Before Medicare, seniors were often uninsured and many lived in poverty.  “While 48 percent of the elderly lacked health coverage in 1962, today just 2 percent do. And while the 15-year increase in life expectancy at age 65 achieved between 1965 and 1984 cannot be wholly attributed to Medicare, without its coverage many elderly Americans would simply not have had access to the medical advances that also have contributed to rising longevity” observes the Commonwealth Fund.  “In the early 1960s, the choices for uninsured elderly patients needing hospital service were to spend their savings, rely on funding from their children, seek welfare (and the social stigma this carried), hope for charity from the hospitals or avoid care altogether” wrote Rosemary Stevens, a sociologist at the University of Pennsylvania, quoted in the Politifact discussion of 'Were the early 1960s a golden age for health care?'  Before Medicare, much of the care that physicians provided to seniors was on a charitable or uncompensated care basis.  After Medicare, demand for medical care grew, pumping hundreds of billions of dollars into care provide by physicians.  It should be no surprise to anyone, then, that physicians saw huge gains in payments and their incomes: between 1967 and 1993 physician payments from Medicare grew at an average annual rate of 13.7 percent.  And despite price controls and spending caps, like the recently repealed Medicare SGR formula, Medicare per capita payments to physicians have continued to increase to the present day, although payments and incomes for primary care physicians have lagged behind other specialists.  In addition, U.S.-trained physicians who entered practice after 1965 have benefited from Medicare paying for their post-graduate education.

Yet my sense is that many physicians today look at Medicare with a complicated set of emotions: appreciation for all of the good it has done for their patients, acknowledgement that physicians themselves have greatly benefited from the infusion of public dollars, yet concern that Medicare has begat greater government intervention in the patient-physician relationship, as evidenced by a never-ending cascade of rules,  mandates, and performance measures imposed on harried doctors and their patients.

 Looking forward, most physicians are probably aware that Medicare will become an even bigger part of their daily lives, with more than 10,000 baby-boomers becoming Medicare-eligible each day for the next 20 years, yet they likely view this development with uncertainty and some trepidation.  Can the country afford it?  Who will pay for it?  Will greater government spending lead to even greater government controls, regulations and paperwork?  Will payments be fair and adequate?  Will Medicare really begin to do something meaningful to reduce the disparities in payments between primary care and other physician specialties?  Will pay-for-performance really improve patient care, or just be another hassle with unintended adverse consequences for patients?

These are all good questions, with no clear answers.  But on the most important question-- have physicians and their patients benefited over the past half century from Medicare?--the answer has to be an unequivocal yes.  The challenge going forward is to continue to sustain, support and fund the Medicare in a fiscally-responsible way, for the next 50 years and longer, while empowering physicians to improve care to patients without tying their hands with more unnecessary and counterproductive mandates.

Today’s question: How would you characterize the past, present and future relationship between Medicare with physicians on the program’s 50th birthday?

Tuesday, July 21, 2015

Putting to Rest the “Death Panel” Lie

Earlier this month, Medicare issued a proposal to begin paying physicians for the time and work involved in engaging their patients in advance care planning.  If finalized by the agency, the new benefit will be available to physicians and their Medicare patients starting in 2016.

It’s about time!  For many years now, ACP has championed advance care planning and has urged Medicare and other insurers to cover it.  As articulated in our Ethics Manual, “Advance care planning allows a person with decision-making capacity to develop and indicate preferences for care and choose a surrogate to act on his or her behalf in the event that he or she cannot make health care decisions. It allows the patient's values and circumstances to shape the plan with specific arrangements to ensure implementation of the plan. Physicians should routinely raise advance planning with adult patients with decision-making capacity and encourage them to review their values and preferences with their surrogates and family members. This is often best done in the outpatient setting before an acute crisis.”

Yet when Medicare in 2010 offered to include voluntary advance care planning in the new Medicare wellness exam, it unleashed a fury of criticism that if the government reimbursed doctors for discussing advance care planning with their patients, physicians would then pressure patients to give up on treatment and end their lives—the notorious “death panel” lie about Obamacare.  Because of the partisan backlash, Medicare ended up withdrawing the proposal.

That was then, this is now.  Today, the idea that Medicare should reimburse doctors for advance care planning has bipartisan support.  Even before Medicare issued its new proposed rule, U.S Senators Johnny Isakson, R-Ga., and Mark R. Warner, D-Va., had introduced legislation designed “to give people with serious illness the freedom to make more informed choices about their care, and the power to have those choices honored” by “creating a Medicare benefit for patient-centered care planning for people with serious illness.”

Now that members of both political parties agree on the wisdom of empowering patients to take control of their own healthcare, perhaps this will also mark the time when the notorious “death panel” falsehood is put to rest, once and for all.

Today’s question: what do you think of Medicare’s proposal to pay for advance care planning?

Wednesday, July 8, 2015

ACP and the “LGBT Agenda”

When ACP came out with its position paper on access to healthcare for Lesbian, gay, bisexual, and transgender (LGBT) persons, published online by the Annals of Internal Medicine on May 12, we knew that some of our recommendations would be controversial.  Our call for civil marriage rights for same-sex couples, our opposition to conversion,” “reorientation,” or “reparative” therapy for the “treatment” of LGBT persons, our advocacy for health insurance coverage of comprehensive transgender healthcare services, and our view that the definition of “family” should be inclusive of those who maintain an ongoing emotional relationship with a person, regardless of their legal or biological relationship, were among the recommendations that we anticipated would generate objections, including from some segments of the ACP membership.

And, as we expected, we have since heard from a dozen or so ACP members who have taken issue with the paper.  (We have also heard from many members who applauded it).  Some of those who objected said that ACP shouldn’t be involved in “political” issues.  Some said they knew of patients, friends and colleagues who benefited from “reparative” or “conversion” therapies. Some cited their own religious beliefs in explaining why they object to same-sex civil marriage and the College’s support for it.  And although the Supreme Court just a few weeks later validated our view that same-sex couples should have the same civil marriage rights as heterosexual couples, a decision we applauded, the ruling has hardly settled the controversy, with many conservative states now considering laws to exempt people with religious or personal objections from providing services to same sex married couples.

ACP respects the sincerity of those who differ with us on religious or other grounds.  Yet at the same time, we remain firmly committed to our advocacy for policies that the evidence shows are necessary and appropriate for reducing healthcare disparities for LGBT persons, as we have done for other patient populations that have been discriminated against because of race, ethnicity, or gender. Our paper references studies and other  evidence-based sources that support the recommendations made in our paper, including that denial of same-sex marriage rights can result in “ongoing physical and psychological health issues” for LGBT persons, that  same-sex marriage bans (now found to be unconstitutional) result in “increases in general anxiety, mood disorders, and alcohol abuse”, that “the denial of marriage rights to LGBT persons has also been found to reinforce stigmas of the LGBT population that may undermine health and social factors, which can affect young adults,” that  “all major medical and mental health organizations do not consider homosexuality as an illness but as a variation of human sexuality, and they denounce the practice of reparative therapy for treatment of LGBT persons” and that reparative therapies “may actually cause emotional or physical harm to LGBT individuals, particularly adolescents or young persons.”

Several of the ACP members who object to our recommendations said that we were promoting what they called “the LGBT agenda.”  I’ve been thinking a lot about that, because I am not sure what the “LGBT agenda” even means.  But if it means that ACP is advocating for public policies to ensure that lesbian, gay, bisexual and transgender persons have the same civil marriage rights and legal protections as everyone else, that they can visit the hospital and make decisions for an incapacitated spouse, that they are not pressured into “therapies” that are premised on the wholly disproven idea that their sexuality and gender identity is “abnormal” and in need of treatment, that they should not be harassed or discriminated against and denied healthcare services and insurance benefits because of who they are, well then, we are guilty as charged, and proud of it.

Today’s question:  What do you think of the concerns expressed by some ACP members about the College’s recommendations on LGBT access to healthcare, and specifically, the idea that we are promoting an “LGBT agenda”?

Thursday, June 25, 2015

Supreme Court: “Congress passed the ACA to improve health insurance markets, not to destroy them."

This was the key finding  made by the Supreme Court, in its landmark decision this morning upholding  that the ACA requires that premium subsidies apply in all 50 states.  The 6-3 decision, written by Chief Justice Roberts, ensures that the Affordable Care Act is here to stay for the duration of President Obama’s term in office.  Even more importantly, it ties the hands of any future administration from re-interpreting the statute to deny the subsidies in states that have let the federal government run their exchanges.

The Supreme Court could have ruled more narrowly, upholding the subsidies as a reasonable exercise of the IRS’s administrative authority to implement a statute when the wording it unclear.  Had it gone that way, a new President and his or her administration could have reinterpreted the statute so that the subsidies would no longer apply in states with federally-facilitated marketplaces.  Instead, it issued a definite ruling that the law requires that the premium subsidies apply everywhere.

 “This is not a case for the IRS,” wrote Justice Roberts on behalf of the court. “It is instead our task to determine the correct reading of [the statute].”  And the statute, the justices found, “compels the Court to reject petitioners’ interpretation because it would destabilize the individual insurance and likely create the very ‘death spirals’ that Congress designed the Act to avoid.”

The court’s concern about the impact on patients, if it had overturned the subsidies, is evident from this paragraph in the ruling:

“So without the tax credits, the coverage requirement would apply to fewer individuals. And it would be a lot fewer. In 2014, approximately 87 percent of people who bought insurance on a Federal Exchange did so with tax credits, and virtually all of those people would become exempt . . .  If petitioners are right, therefore, only one of the Act’s three major reforms would apply in States with a Federal Exchange.  The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral. One study predicts that premiums would increase by 47 percent and enroll­ment would decrease by 70 percent. E. Saltzman & C. Eibner, The Effect of Eliminating the Affordable CareAct’s Tax Credits in Federally Facilitated Marketplaces (2015). Another study predicts that premiums would increase by 35 percent and enrollment would decrease by 69 percent. L. Blumberg, M. Buettgens, & J. Holahan,The Implications of a Supreme Court Finding for thePlaintiff in King vs. Burwell: 8.2 Million More Uninsured and 35% Higher Premiums (2015). And those effects would not be limited to individuals who purchase insur­ance on the Exchanges. Because the Act requires insurers to treat the entire individual market as a single risk pool . . .premiums outside the Exchange would rise along with those inside the Exchange.  It is implausible that Congress meant the Act to operate in this manner.”

Touche!  This is precisely what ACP argued, in an amicus brief we submitted to the court along with 17 other health advocacy organizations.  Our brief noted that tax credits (premium subsidies) established in the ACA as well as the insurance market reforms have enabled millions of Americans to purchase health insurance. If the Court decides in favor of the plaintiffs, millions will lose their health insurance subsidies. This will likely lead many to drop coverage or elect to go uninsured, driving up health insurance premiums for those that remain covered. If health insurance subsidies for federally-facilitated marketplace (FFM) plans were eliminated, enrollment in ACA-compliant individual market plans would drop by 9.6 million, according to the RAND Corporation. The Urban Institute/Robert Wood Johnson Foundation estimates the number of uninsured would increase by 8.3 million.”

So the Supreme Court ruling is a big win for patients and their physicians, and for ACP advocacy on their behalf.  ACP President Dr. Wayne Riley, in a statement issued this morning, said that “we are thrilled and gratified by the Court’s ruling, which affirms that the citizens of all 50 states will have the opportunity to access either a state or federal exchange to obtain subsidies to purchase health insurance policies which benefits themselves, their families and loved ones.”

The Supreme Court decision doesn’t mean the end of the Obamacare wars, of course.  Congressional Republicans will still try to get changes, although the court’s decision takes away their leverage to try to force President Obama to agree to repeal of major provisions of the law in order to keep the subsidies going.  I now predict that there will be no major legislative changes in the ACA until President Obama leaves office.

The voters could elect a president in 2016 that is committed to changing or repealing Obamacare, but because the Supreme Court took away the next President’s option to reinterpret the statute to discontinue the subsidies, they would need Congress to amend or repeal the law, no easy task.  And by then, millions more Americans will have coverage from the ACA.

“The Patient Protection & Affordable Care Act of 2010 is now more than ever, the law of the land and we urge the Congress to work with this and future administrations to improve it in the years ahead” said Dr. Riley in his statement on the court’s ruling.

Let’s hope that there comes a time when this reality sets in, and the debate shifts to improving the law, not destroying it.

Today’s question: what do you think of the Supreme Court ruling?

Thursday, June 18, 2015

What do doctors really think of Obamacare? (It’s not what critics have told you).

Anti-Obamacare critics often claim that “every” physician they know hates Obamacare. For instance, Pediatric neurosurgeon and GOP Presidential candidate Dr. Ben Carson told Fox News that “he's spoken to hundreds of doctors throughout the country about the Affordable Care Act, and not one of them ‘liked’ President Barack Obama's signature healthcare law.”
Doctors hate Obamacare, it’s alleged, because it authorizes government to “control” the practice of medicine and impose “rationing” of care, thereby harming patients.  The conservative Examiner website quotes a New Jersey family physician, Dr. John Tedeschi as saying, “Just as a guitar string has to be tuned, so does a person’s health to get the right tone. The government has taken away, or refocused the intelligence part of the tuning, and has just about destroyed the creative, or compassion component. Now, with Obamacare, we are left with an incompetent mechanism that does not have the best interest of the patient in mind.”  An ER physician quoted in the articles said that the “storm of patients [created by Obamacare] means when they can't get in to see a primary care physician, even more people will end up with me in the emergency room."

There is no question that some doctors (mainly conservatives) hate Obamacare, and if they were the only ones you talked to (like the ones who apparently talked to Dr. Carson), you might think that all doctors feel the same way. But the reality is that—surprise, surprise!—primary care physicians’ views are just like the rest of us, split by their partisan leanings.
A new survey by the respected Kaiser Family Foundation found that 87% of Democratic-leaning physicians view Obamacare favorably, while the exact same percentage of GOP-leaning physicians view it unfavorably. Independent doctors split 58% unfavorable to 42% favorable.  Because there were more GOP and independent physicians among the survey respondents, the overall breakdown of primary care physicians’ views on the ACA is  52% unfavorable to 48% favorable.  Yet only 26% of all primary care physicians viewed the law “very unfavorably. “  So it might be said that just one out of four primary care physicians “hate” Obamacare.

And a deeper dive into the survey results directly refutes the contention of anti-Obamacare doctors that the law is leading to poorer quality, physicians turning away patients, or longer waits for appointments:  

- Most primary care physicians say that quality has stayed the same: 59% said that their ability to provide high quality care to their patients has stayed about the same, while 20% said it has improved and 20% said it has gotten worse.
- More primary care physicians report that Medicaid expansion has had a more positive impact on quality than a negative one. “When asked more specifically about the expansion of Medicaid under the ACA, nearly four of 10 providers (36% of physicians and 39% of nurse practitioners and physician assistants) said the expansion has had a positive impact on providers’ ability to provide quality care to their patients (Table 7). About two of 10 said it has had a negative impact and the remainder said it has not made a difference or they are not sure.”
- Ease of getting same-day appointments is about the same as before the ACA. “Overall, about four of 10 primary care providers said almost all their patients who request a same- or next-day appointment can get one; another quarter said most of their patients can get such appointments” which is largely unchanged from 2009 and 2012.
- Most continue to accept new patients. “A large majority of primary care providers (83% of physicians, 93% of midlevel clinicians) said they are currently accepting new patients . . . A survey conducted in late 2011 through early 2012 found that 89 percent of primary care physicians were accepting new patients and 52 percent were accepting new Medicaid patients.  This indicates that while physicians’ rates of accepting new patients overall may have declined slightly since the ACA coverage expansions went into effect, acceptance rates for Medicaid have remained about the same.”

When asked specifically about their views on the impact of the Affordable Care Act on five dimensions, the ACA fared well, with one exception (costs to patients).

- Access to health care and insurance in the country overall: 48% positive, 12% no impact,  24% negative, and 14% not sure.
- Overall impact on practice: 31% reported no impact, 23% a positive  impact, 36% negative  and 9% not sure.
- Quality of care their patients receive: 50% reported no impact, 18% positive, 25% negative, and 6% not sure.
- Ability of the practice to meet patient demand: 44% no impact, 18% positive, 25% negative, and 10% not sure.
- Cost of health care for their patients: 17% no impact, 21% positive, 44% negative, and 16% not sure.

However, “physicians’ responses to questions that mention the ACA by name are deeply divided along party lines. For example, by a three-to-one margin, physicians who identify as Democrats are more likely to say the ACA has had a positive (44%) rather than a negative (15%) impact on their medical practice overall (Table 8). Republican physicians break in the opposite direction by about seven-to-one (57% negative, 8% positive).”

The survey also does not support the contention that the ACA is contributing to primary care physician dissatisfaction with practice and burn-out:

“Even though providers with different political affiliations do not share views about the Affordable Care Act, a large majority of primary care providers (83% of physicians and 93% of nurse practitioners and physician assistants)—both Republicans and Democrats—reported they are very or somewhat satisfied with their medical practice overall. The changing environment does not appear to be affecting overall provider satisfaction even among providers who see a larger share of Medicaid patients or work in Medicaid expansion states. Indeed, current satisfaction levels are slightly higher than what was reported by primary care physicians before the ACA. In 2012, 68 percent of primary care physicians reported they were very satisfied or satisfied with practicing medicine.”

Interestingly, Democratic physicians (56%) are more likely to recommend a career in primary care than Republicans (39%)  or Independents (40%).

I know that many conservative primary care doctors have a strong and principled objection to Obamacare, believing  passionately that it gives the government too much power and the physicians and their patients will be hurt as a result.  I (and ACP) may not agree with them, but I respect their views, and their right to make their case to their colleagues and to the public.

But the Kaiser Family Foundation survey shows us that the anti-Obamacare doctors do not represent the views and experience of most primary care doctors on the front lines, never mind “all” of them.  Doctors (at least those in primary care, who knows about surgeons?) clearly don’t “hate” Obamacare.  Rather, more of them see Obamacare as doing some good things, like improving access; and doing not as well on other things, like lowering costs to patients.  Much of what they do and see in their practices remains unchanged by it, for good or bad.

 And that strikes me about right, Obamacare is making many things better, but there is a lot more that needs to be done to improve quality and access, lower costs to patients, and sustain and support primary care.  Of course, such nuances do not make for as good a headline or political talking point as “Doctors Hate Obamacare.”

Today’s question: What is your reaction to the survey results on primary care physicians views on Obamacare?

Tuesday, June 16, 2015

How the Supreme Court is Reshaping American Health Care

As long-time readers of this blog know, I have worked in Washington DC as an advocate for internal medicine for more than 36 years now (yes, since Jimmy Carter was President!), first for the American Society of Internal Medicine from 1979 to 1998 and since the merger of ACP and ASIM in 1998, for ACP.  For 33 of those years, the third branch of government, the Supreme Court, rarely engaged in the major debates over healthcare policy, leaving  those decisions to Congress and the Executive Branch.

No more.  Under Chief Justice Roberts, this Supreme Court has already done more to drive healthcare policy than any other, at least in my memory.  First, it ruled in 2012 that the Affordable Care Act’s individual insurance mandate was constitutional; the same ruling found that the federal government couldn’t require states to expand Medicaid.  Last year, it ruled that some for-profit corporations could opt-out of the ACA’s contraceptive mandate because their owners’ religious objections.

It is now poised, as early as next week, to issue two momentous opinions that could affect healthcare for generations.   It will decide whether the ACA’s premium subsidies are legal in the 34 states that have opted to let the federal government run their exchanges.  And it will decide whether same sex couples have a constitutional right to civil marriage, and, with it, the same rights to access healthcare as other married couples.

First, let’s recap what the Roberts court has already done.  When the Supreme Court decided in 2012 to uphold the ACA’s individual insurance requirement, the decision was widely regarded as settling the argument over whether the law’s constitutionality, which it did, but only to a point.  The same 5-4 opinion found that it was unconstitutionally coercive for the federal government to punish that states that refused to expand the Medicaid program.  By making it voluntary, the court opened the door for states to walk away from expanding Medicaid, even though almost all of the cost is paid for by the federal government.  So, as of March 2015, there are 22 states that have chosen not to expand Medicaid, with the result that “nearly four million poor uninsured adults fall into the ‘coverage gap’ that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits” reports the Kaiser Family Foundation.  In other words, in these 22 states, the very poor (those at or below the federal poverty level) are simply out of luck when it comes to getting help from their states in getting covered, while people who make more than the poverty level can get generous ACA subsidies to afford coverage.

Then, last year, the Supreme Court ruled in the Hobby Lobby case that the ACA’s mandate that health plans cover contraception imposed an unacceptably high burden on the religious beliefs of the company’s owners, for the first time establishing that the religious beliefs of some types of for-profit companies were protected by the Religious Freedom and Restoration Act.  The immediate impact of this ruling so far appears to be fairly limited, mainly to Hobby Lobby and its employees and to other “closely held” companies that also have religious objections to the contraception mandate.  But the concern all along of critics of the Hobby Lobby decision is that it could open the door to other companies seeking relief from other mandates that conflict with their owners’ religious beliefs.  “Once the contraceptive mandate issues have been resolved by courts, the next wave of disputes is likely to involve employers who object on religious grounds to paying benefits to the same-sex spouses of employees. Unlike with the contraceptive mandate, however, these businesses may have a tougher time prevailing . . .” observes Robert Tuttle, a Professor of Law and Religion at The George Washington University.  Apparently emboldened by Hobby Lobby, laws have been introduced this year alone in 16 states exempting some businesses from having to provide services to gay couples.

Within days, and no later than June 30, the Supreme Court will rule on same-sex marriage and on the challenge to the ACA’s insurance subsidies.  A ruling establishing that same sex partners have a constitutional right to marry would help improve their health and break down barriers to them getting appropriate medical care.  As ACP wrote in its recent position paper supporting same-sex civil marriage, “The health and financial benefits of marriage for different-sex couples are widely reported, and contemporary research supports similar benefits in same-sex marriage. On the other hand, denial of marriage rights for LGBT persons may lead to mental and physical health problems. Health benefits associated with same-sex marriage result from improved psychological health and a reinforced social environment with community support.”  A Supreme Court decision ensuring a constitutional right to marriage for same sex couples would also presumably give them the same legal protections as other married persons when it relates to hospital visitation rights and decision making.  “If LGBT spouses or partners are not legally considered a family member, they are at risk for reduced access to health care and restrictions on caregiving and decision making; further, they are at increased risk for health disparities, and their children may not be eligible for health coverage,” ACP noted in its paper.  On the other hand,  a Supreme Court ruling that same sex couples do not have a constitutional right to marriage would be a devastating setback in ensuring that same sex couples have equal access to healthcare, and to other legal protections, as other married couples.

Finally, the Supreme Court will rule in the King versus Burwell case, which challenges the legality of the ACA’s premium support subsidies in the 34 states operated by the federal exchanges.  If the court rules that the subsidies are illegal, consumer premium contributions will increase by an average of $3300 in those states, according to a new study by the Alvalere consulting firm.  Enrollment in ACA-compliant individual market plans would drop by 9.6 million, according to the RAND Corporation and the Urban Institute/Robert Wood Johnson Foundation estimates the number of uninsured would increase by 8.2 million.  According to a Commonwealth Fund report, physicians, hospitals, and other providers may lose more than $9 billion in revenue a year and potential closures or reduced services for rural hospitals, community health centers, and non-profit hospitals that serve a disproportionate number of low-income individuals.  “If the challengers win, it would throw the health-care law into chaos” writes Vox’s Sarah Kliff.  “But if the White House prevails, something equally momentous will have occurred: President Obama's signature legislative accomplishment will actually, really, definitely be here to stay.”

How you feel about the recent Supreme Court rulings on upholding the ACA’s individual mandate,  making Medicaid voluntary, and allowing for-profit companies to opt-out of benefit requirements that are contrary to their owner’s religious beliefs, or how you will feel about  its upcoming decisions on same sex marriage and the ACA’s premium subsidies,  probably depends on your own underlying political leanings.  We all pick and choose, applauding court decisions we like while objecting to those we don’t.

Yet what is clear to me is that the Roberts court will have done more to shape the future of American healthcare than any other in decades, and the consequences  of its decisions will be debated for generations.  If that doesn’t define an activist court, than I don’t know what does.

Today’s questions: What do you think about the Roberts Court’s activism on healthcare?  How will future historians judge it?

Thursday, June 4, 2015

For physicians, is money all that matters in deciding where to practice?

I would think that when physicians decide where to set up practice, there are things that they would want to think about other than how much money they’ll make.  Yet if one reads Medscape’s current list of the best and worst places to practice, it would appear that money trumps everything else (although Medscape said it also considered factors like “cultural attractions”). What Medscape apparently did not consider at all are factors like the percent of the population that is uninsured, mortality and morbidity rates, rates of chronic disease, per capita healthcare spending, that is, anything having to do with patients.

As a result, the locations that Medscape rated as best for practice are, with only a few exceptions , the states with higher physician earnings, lower taxes, and fewer malpractice lawsuits-- but that also have the largest numbers of uninsured people.  The locations that Medscape rated as the worst for practice are, with only a few exceptions, the states with lower physician earnings, higher taxes, and more malpractice lawsuits—but that also have the fewest numbers of uninsured patients.

And I think this is a problem, because it suggests to its mostly physician readership (and to the broader public that may hear about it and get the wrong impression) that all physicians should care about is the money coming in and going out of their practices—without regard to the social, economic, and policy environment affecting the health of their patients.
Here is Medscape’s list of the top 10 best places to practice, and why, ranked in order:

1. Tennessee: low cost of living, good pay for physicians, progressive communities, music and attractions.
2. Mississippi: low taxes, low malpractice payouts, cultural activities.
3. Oklahoma: high physician income, arts and cultural community.
4. Texas: no state income tax, choice of cities and geographies, fewer malpractice lawsuits, excellent medical community.
5. Wyoming: many cultural activities, natural beauty, no state income tax, demand for physicians.
6. Idaho: outdoor recreational activities, reasonable home prices, average tax burden.
7. South Carolina: warm climate and warm people, several museums, good practice environment.
8. New Hampshire: good physician compensation, low taxes, educated populace, proximity to Boston.
9. Nebraska: below average cost of living, wealthy state, strong industry, good schools and low crime.
10. Alaska: no income tax, adventurous lifestyle, wide scope of practice, tight knit community.

Here is their list of Medscape’s 5 worst places to practice, and why:

1. New York: with a special warning “to avoid New York City” because, “At $249,000, average physician compensation is more than $22,000 below the national average. New Yorkers know they pay a premium to live in the city, but they may not be aware of just how hefty it can be.”
2. Rhode Island: “RI physicians responding to the 2015 Medscape Physician Compensation Survey reported lower pay than any other doctors in the country.”
3. Maryland: “a high cost of living and too many doctors”
4. Massachusetts: “high taxes, a high cost of living, exorbitant housing costs, and average physician compensation that is $23,000 below the national average”
5. Connecticut: “It costs a lot to live there, and doctors don't make a lot to compensate”

What if practice locations were instead ranked by the fewest and the most numbers of uninsured patients?  You end up with a very different ranking than Medscape’s:

The top 10 best states based on fewest uninsured (as % of population)

1. Massachusetts (4%)
2. Hawaii (5%)
3. Minnesota (7%)
4. Delaware (7%)
5. Vermont (8%)
6. District of Columbia (8%)
7. South Dakota (9%)
8. Rhode Island (9%)
9. Wisconsin (9%)
10. Iowa (9%)
11. Connecticut (9%)
12. New York (9%)
13. Kansas 10%)
14. Maine (10%)
15. Pennsylvania (10%)

(Nebraska and Maryland also have 10% of their population uninsured).

The bottom 10 worst states based on greatest number of uninsured (as % of population):

1. Texas (20%)
2. Nevada (20%)
3. Arizona (19%)
4. Florida (19%)
5. Wyoming (17%)
6. North Carolina (16%)
7. Georgia (16%)
8. New Mexico (16%)
9. Alabama (16%)
10. Alaska (16%)
11. South Carolina (15%)
12. Montana (15%)
13. California (15%)
14. Arkansas (15%)
15. Idaho (14%)

(Oklahoma and Mississippi are also tied with 14% of their populations uninsured).

Why should the uninsured rate matter to physicians when considering the best and worst places to practice?  Because “people without health insurance live sicker and die younger than those with insurance.”

What if one were to rank the states based on their overall performance on composite measures of accessibility and availability, prevention and treatment, avoidable hospital use and cost, healthy lives, and equity?  The Commonwealth Fund did this, and also came up with a much different ranking than Medscape’s:

The top 10 best states based on overall healthcare performance are:

1. Minnesota
2. Massachusetts
3. New Hampshire
4. Vermont
5. Hawaii
6. Connecticut
7. Maine
8. Wisconsin
9. Rhode Island
10. Delaware and Iowa (tied)

The bottom 10 worst states based on overall healthcare performance are:

1. Mississippi
2. Arkansas
3. Oklahoma
4. Louisiana
5. Nevada
6. Alabama
7. Georgia
8. Texas
9. Indiana
10. Kentucky

(The next in order of worst to best are Florida, Tennessee, North and South Carolina).

Now, to be clear, I have no beef with where physicians choose to live and practice: the choice of where one decides to live and work is a highly personal one, weighing a variety of factors that are unique to each physician and his or her loved ones.  Who am I to judge?

Nor do I have a beef with any of the states listed above, no matter where they rank on the respective lists.  I have been fortunate to have traveled to all 50 states, plus Puerto Rico and of course my home in the District of Columbia, many repeated times, and I love the wonderful diversity of this country, the breathtaking beauty, and the hospitality and kindliness of the people I’ve met.  One of the highlights of my job at ACP is to visit physicians at our chapter meetings throughout the country: over the past year I have visited physicians in Rhode Island, Nebraska, Virginia, South Dakota, Kansas, Delaware, Nevada, and California, and I have trips coming up to Missouri, Washington state, and California and Nebraska again.  Universally, I have found that physicians in every state I’ve visited are committed to giving their patients the best possible care.

No, my beef is only with Medscape, and the sources (recruiters, interviews, surveys) they used that looked mostly at the economics of practice, not the environment affecting the care of patients.  As a result, there is an inherently conservative bias built into Medscape’s analysis, because by emphasizing higher physician earnings,  lower cost of living, fewer malpractice suits and lower taxes over health outcomes and the percentage uninsured, its rates more favorably the states that are hostile to government programs to help cover people and reduce healthcare disparities, and less favorably the states that have more activist governmental programs to reduce the ranks of the uninsured and healthcare disparities, often requiring higher taxes to pay for such programs.

And by focusing mostly on the money, isn’t Medscape doing a disservice to the many physicians who have chosen to practice in their so-called “worst” states—even though they may earn less on average?  One Rhode Island internist, a personal  friend of mine, when I told him his state was ranked by Medscape as one of the top 5 worst places to practice,  responded, "No one asked me. While [our] economy took a big hit, we have a great medical community and collaboration with hospitals, insurance companies, government.”

And aren’t they doing a disservice even to physicians in their “best places to practice," who love their states but would like to see them do better on things like covering the uninsured?  I know many Texas physicians, for instance, who for good reason love their state and the favorable practice environment it offers, but are working hard to try to persuade a hostile legislature and governor to expand Medicaid coverage to the poor.  Expanding Medicaid would, in their mind, make Texas an even better place to practice—and even more importantly, a better place for patients to get the healthcare they need.  And to be sure, many physicians have told me they would even be willing to pay higher taxes if it meant that fewer of their patients would be uninsured.

So how about this, Medscape?  Next time you rank the best and worst places to practice, how about looking not only at the economics of practice, but at how well each states does in providing health insurance coverage, in tackling healthcare disparities, and in improving the health of their populations?

Today’s question: What is your opinion of Medscape’s “best and worst places to practice” list and my objections to it?