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”?