Thursday, December 15, 2016

There must be 50 ways to lose your health insurance (if Obamacare is repealed)

The Republican congressional leadership appears to be determined to move forward with a high-risk “repeal, delay and replace” plan, very early in the new 115th Congress to repeal (at least on paper) the Affordable Care Act’s key coverage provisions—Medicaid expansion, subsidies to make private insurance sold through the exchanges affordable, the individual and employer mandates, and the taxes to pay for coverage—by a simple majority vote, while delaying when the repeal would go into effect to give them time to come up with a replacement. 

The problem is that this isn’t likely to work, not without disrupting care for millions.   As I point out in a commentary The Demise of the Affordable Care Act?  Not So Fast, published online on Tuesday in the Annals of Internal Medicine, I think it is magical thinking to believe that one can repeal the ACA, delay the repeal from going into effect, avoid loss of coverage, and then replace the ACA with something that keeps the popular parts while jettisoning the unpopular ones.

Much more likely, according to many independent and non-partisan studies, the result of “repeal, delay and replace” will be that many millions of Americans will lose their coverage as early as 2017, and many more if the ACA is full repealed without an alternative that offers comparable coverage. 

So many, in fact, that I found from the studies that there must be at least 50 ways you could lose your health insurance if the ACA is repealed (my apologies to songwriter Paul Simon).  Under ACA repeal, you could lose coverage if:

  1. You are the one of nearly 59 million who would lose coverage if the ACA is fully repealed.
  2. You are one of the 7.1 million who would lose coverage because of an expected “near collapse”  of the individual insurance market while Congress tries to come up with a replacement.
  3. You are one of the 4.3 million who would lose coverage as early as 2017, because “if Congress eliminates the individual and employer mandates immediately, in the midst of an already established plan year, significant market disruption would occur.”
  4. You are one of the 52 million people, 1 out of every 4, with a pre-existing medical condition, because insurers may once again be allowed to turn you down or charge you more for coverage.
  5.  You have a specific “declinable” medical conditionlike asthma, diabetes, cancer, or hepatitis C—that could become ineligible for coverage in the individual insurance market.
  6. You live in one of 11 states, most of them red (Republican-leaning) states in the South, where at least 3 in 10 non-elderly adults have a pre-existing “declinable” medical condition.
  7. You have a “declinable” pre-existing condition and lose your employer-based coverage, say because of a lay-off, and then find that no insurer in the individual market will cover it.
  8. You are a miner, baggage handler, EMT first-responder, off-shore oil driller, or one of dozens of other occupations that places you at risk of suffering job-related injuries needing medical attention.  Before the ACA, many people in such higher-risk occupations could be turned down for coverage.
  9. You are a woman, because insurers would again be allowed to treat being female as a pre-existing condition, allowing them to charge you higher premiums.
  10. You are a woman having a baby, because insurers could again begin to deny coverage for maternity care and breastfeeding support, supplies, and counseling.
  11. You are a woman using contraceptives, because insurers would again be allowed to deny coverage for contraception.
  12. You are a survivor of domestic or sexual violence, which often was counted as a pre-existing condition before the ACA, making you ineligible for coverage. You could also lose the ACA-mandated coverage for interpersonal domestic violence screening and counseling.
  13. You are a pregnant woman who has a medical need for gestational diabetes screening, an ACA-required benefit that could be taken away.
  14. You are a sexually active woman who benefits from the ACA-required coverage of STI counseling on sexually transmitted infections (STIs), which can reduce risk behaviors in patients; for high-risk human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results; for HIV screening and counseling; and for contraceptive counseling.
  15. You are a sexually active man who benefits from HIV screening and counseling and STD screening, benefits which may no longer be offered if the ACA is repealed.
  16. You are or have a child who gained coverage from the ACA and now might lose it, doubling  the number without health insurance, like the 67,000 children in New York state alone who would are at risk of being dropped. 
  17. You are one of the 12.3 million people who live in a state that has expanded Medicaid under the ACA and could be dropped from coverage if it is repealed.
  18. You are a low-wage person who lives in a red state that was considering expanding Medicaid, and are now likely to put the brakes on expanding eligibility.
  19. You are one of the 14 million who would lose their Medicaid coverage, or no longer gain coverage in the future, if the ACA’s Medicaid expansion is replaced with block grants to the states.
  20. You are in a red state that has expanded Medicaid because ACA repeal could cut off funding for the “more than 2.5 million people in GOP-represented states [who were] were enrolled in Medicaid through the expanded eligibility” created by the ACA.
  21. You are one of the 60 million people suffering from a mental or behavioral health condition or substance use disorder who could lose your coverage because “full repeal  of the health law would gut major benefits and protections . . .”
  22. You are one of the 1.4 million young adults who get coverage from their parents’ plan but could lose it.
  23. You are an entrepreneur with a pre-existing condition who may have to give up your start-up to get a regular job that offers coverage.
  24. You have a pre-existing condition and end up being stuck with a job you don’t like—job lock—because you might not be covered if insurers in the individual market can again turn you down or charge more for coverage. 
  25. You are one of the 10.7 million seniors or disabled persons under Medicare who to date have saved $10.8 billion on prescription drugs because the ACA phases-out the “doughnut hole” in Part D coverage.
  26. You are one of the over 39 million seniors who have received no-cost preventive services  guaranteed by the ACA, like “flu shots, tobacco cessation counseling, as well as no-cost screenings for cancer, diabetes and other chronic diseases” and “annual wellness visits wellness visit so they can talk to their doctor about any health concerns” at no out-of-pocket cost to you.
  27. You are a senior enrolled in Medicare who would likely see higher premiums, deductibles, and cost sharing for Medicare-covered services.
  28. You are white working class person because 56 percent of those at risk of losing coverage from ACA repeal are white, most of who are from the working class.
  29. You are Latino or Hispanic because 22% of those who could become uninsured from repeal are Hispanic, a disproportionately large share of those at risk.
  30. You are African-American because 12% of those who have gained coverage under the ACA are black, and now are at risk of losing it if the law is repealed.
  31. You are one of the 7 million people who are eligible for cost-sharing subsidies under the ACA; if these subsidies are repealed, your maximum out-of-pocket costs will increase substantially.
  32. You are one of the 9 million people who make between 100 and 400% of the Federal Poverty level who receive ACA’s premium subsidies to make insurance affordable.
  33. You are older but not yet Medicare age, because if insurers are again allowed to charge older people 5 or 6 times more than younger ones (the ACA limits it to no more than 3 times more), your premiums in the individual market will go up.
  34. You are one of the 133 million people with at least one chronic health condition who could find yourself again turned down for coverage or charged more.
  35. You are one of the millions of patients who are, or will sometime in the future, be diagnosed with cancer and who now benefit from the ACA’s prohibition against excluding or charging more to patients with pre-existing conditions, no-cost coverage of preventive and screening tests, and a ban on annual and lifetime limits on coverage, leaving many cancer patients “frantic and scared” about loss of coverage.
  36. You are one of the 137 million people (55.6 million women, 53.5 million men, and 28.5 million children) who have received no-cost coverage for preventive services from private insurers since the ACA’s required coverage of such services went into effect.
  37. You are one of the millions of Americans who received combined $2.4 billion in refunds from your insurers because they spent too much on administration and too little on direct patient care; protections that would go away if the ACA was repealed.
  38. You are a gun violence victim, because the ACA “has brought coverage to tens of thousands of previously uninsured shooting victims, often young African-American men, who, once stabilized in emergency rooms, missed out on crucial follow-up care and have endured unremitting effects of nerve injuries, fractured bones, intestinal damage and post-traumatic stress disorder.”
  39. You are one of the 105 Million Americans, many of whom are middle class, who could again be subjected to lifetime limits on coverage under ACA repeal.
  40. You are LGBT, because the ACA protects you from discrimination in coverage.
  41. You live in a “red” (Republican leaning) state because you are more likely to be at risk of losing coverage under the ACA and your state will have fewer state resources to help you keep it, compared with “blue” [Democratic-leaning] states that have fewer people at risk, and more resources to maintain coverage for those who are.
  42. You don’t have a college degree, since an estimated 80 percent of adults at risk of becoming uninsured if the ACA is repealed do not have at least an associate degree.
  43. You are one of the millions of non-elderly veterans who have gained coverage since the ACA was enacted, reducing the uninsured rate among veterans from 12% in 2011 to 8.6% as of 2015.
  44. You are one of the approximately 15 million people with incomes below 200% of the federal poverty level, approximately 48,000 for a family of four in 2016, who would lose coverage under full ACA repeal.
  45. You are one of the 700,000 who would lose coverage from your employer.
  46. You are insured and end up paying more for your hospital care, because hospitals are forced to cost-shift to you the $166 billion in losses that would result from ACA repeal.
  47. You are one of the 1.7 million non-seniors who live in Florida and have signed up for Obamacare coverage sold by private insurers, the most of any state, and would stand to lose it if the law is repealed.
  48. You live in California, the state that “has the most to lose” if the ACA is repealed.
  49. You live in any of the 50 states or the District of Columbia, all of which would see big losses in coverage; it’s just a matter of degree.
  50. You one of the 36,000 Americans who could die each year if the ACA is repealed.
To be clear, you can’t add up all of the numbers above, because people at risk of losing coverage could fall in multiple categories.  But no matter how you slice and dice it, ACA repeal, particularly without an alternative that would cover as many with comparable benefits and protections, will lead to massive losses in coverage, touching just about everyone in some way, in some fashion.  Yes, there are at least 50 ways you could lose your health insurance if the ACA is repealed, and probably, many more.

Today’s question: What is your reaction to the data on how many could lose coverage and benefits, and in what way, if the ACA is repealed?

Wednesday, December 7, 2016

Preparing ACP for the post-election political environment

It’s often said that elections have consequences, and this is especially true of the 2016 election. The election of Donald S. Trump, combined with continued GOP control of Congress, will rock the health care world, starting with the GOP pledge to begin to repeal and replace the Affordable Care Act early in the new Congress. 

But it’s not just the ACA: the Trump administration may try to privatize the VA, end U.S. commitments to reduce emissions contributing to climate change, reverse Obama’s executive actions on firearms violence prevention, convert Medicare into a defined contribution (voucher) program rather than an open-ended entitlement, and much, much more.  While these are highly concerning to ACP, we believe that there will be many opportunities to find common ground on improving access to mental health, healing the opioids epidemic, reducing barriers to chronic care management, reforming the medical liability system, and especially, reducing regulatory burdens on physicians and their patients.

In order for ACP to be effective, we have to start by stepping back and assessing what the impact of the elections will likely be on our priorities, recalibrating as needed to achieve our objectives.  To be clear, this does not mean stepping back on our commitment to issues like universal coverage, mitigating the public health impacts of climate change, reducing gun violence, and ensuring access to care for all persons without regard to race, religion, ethnicity, gender and gender identity, and sexual orientation; these are overarching core principles and policy commitments the College has made to the public, they can’t be negotiated away.  But we can and will assess how best to advance or defend them given the changed political circumstances.

Here is what your ACP advocacy team in Washington has been doing to help ACP prepare for the new administration and Congress:
  • We provided suggestions to ACP President Dr. Nitin S. Damle on his November 17 email to all ACP members, U.S. and international, on the implications of the 2016 election.
  • We are working with Dr. Damle on responding to several dozen e-mails from members in response to his letter.
  • We are doing a comprehensive staff assessment of all of our key public policy priorities; for each of them, we are evaluating whether there is a threat or opportunity or threat and opportunity, whether it’s from Congress, the Executive Branch, or both; and whether we need new or revised policy direction from the ACP policy committees, regents and governors.
  • In particular, we are examining how the GOP may use a “repeal, delay, and replace” legislative strategy to undo as much of the ACA as possible through budget reconciliation, which requires a simple majority vote, while delaying for a couple of years the date(s) when those provisions would expire, which in theory gives them a time to develop a replacement plan (which is much easier said than done, which I will address in a future post).
  • For some of our priorities, we are doing a much deeper policy dive; for instance, examining possible GOP alternatives to the ACA overall and specific elements of it; the impact of possible efforts to privatize the VA system; implications of turning Medicaid into a block grant program; potential threats to Graduate Medical Education funding; and policies affecting women’s health access, among others.
  • Our regulatory affairs team is preparing specific recommendations to the new administration and Congress on changes in federal regulations, quality measurement, EHRs and “meaningful use” requirements, documentation guidelines, and on other ways to ease administrative burdens on physicians.
  • We are reaching out to other health-advocacy organizations, not just within the medical profession, but with business leaders, hospitals, insurers, and consumer groups, to see where our interest may align and where we may differ; and how we might work together when we are in agreement.
  • We are continuing to encourage members to sign up to participate in our grass roots Advocates for Internal Medicine (AIMn) program while making enhancements to it.  The strength of this program will to a large extent determine how effective we can be advocating with the new Congress.

Even as we are devoting so much of our time to prepare for the new administration and Congress, we are ensuring that ACP’s voice is heard now, as the lame-duck 114th Congress completes work on several outstanding health care bills, including the CURES Act and a temporary resolution to fund the federal government into early next year.  We are also providing extensive comments to the outgoing Obama administration on the 2017 Medicare physician fee schedule final rule and the MACRA final rule.  Oh, and we are developing new and updated resources and tools to help members be successful as Medicare’s new Quality Payment Program (created by MACRA) begins to be rolled out on January 1. 

In my view, ACP advocacy is more important now than ever before.  On issues ranging from ensuring  that internists’ patients don’t lose their health insurance coverage, easing the regulatory burden on physicians,  protecting GME from budget cuts, ensuring that women don’t lose access to care, supporting the many ACP members in the VA system and the veterans they serve from ill-advised “reforms’,  advocating for medical liability reforms,  opposing policies that would be discriminatory against LGBTQ persons, and continuing to advocate for policies to reduce the health consequences of climate change,  ACP will be there, ensuring that internists’ voices are heard in this tumultuous time for American (and global) health care. 

Today’s question: What policies do you think are most important for ACP to advocate with the new Trump administration and Congress?

Thursday, November 3, 2016

Fear and Loathing on the Campaign Trail, 2016 Edition

Many regard Hunter S. Thompson’s book, Fear and Loathing on the Campaign Trail, which covered the 1972 Nixon versus McGovern campaign, as the best account yet of a modern U.S. presidential campaign.  Hunter’s reporting was based on his own conversations, often over copious amounts of alcoholic beverages (and sometimes, other illicit recreational substances) with the people involved in both campaigns, from George McGovern himself to the front-line worker bees whose job it was to get out the votes. In an introduction to the 40th anniversary edition of the book, re-issued in 2012, journalist Matt Taibbi observed that, “What makes the story so painful, and so painfully funny, is that Hunter chooses the presidential campaign, of all places, to conduct this hopeless search for truth and justice. It’s probably worse now than it was in Hunter’s day, but the American presidential campaign is the last place in the world a sane man would go in search of anything like honesty.  It may be the most fake place on earth.”

I think we would agree that the 2016 American presidential campaign is far worse than it was in Hunter’s day.  Polls show that for many voters, this election is viewed as a choice between two evils, or as Hunter put it in Fear and Loathing,  “How many more of these stinking, double-downer sideshows will we have to go through before we can get ourselves straight enough to put together some kind of national election that will give me and the at least 20 million people I tend to agree with a chance to vote FOR something, instead of always being faced with that old familiar choice between the lesser of two evils?”  (I know that many supporters of Mr. Trump or Mrs. Clinton would strongly disagree with the “lesser evil” description of their own preferred candidate, yet polls consistently show that both of them have historically high disapproval/approval ratios).

Framing the election as a “lesser of two evils” choice can’t obscure the fact that there are very real differences between Mr. Trump’s and Mrs. Clinton’s views on just about everything—including health care policy.  They disagree on climate change (Mrs. Clinton is for expanding on Obama’s policies to limit emissions; Mr. Trump has said the climate change is a hoax and pledges to increase production of fossil fuels), on firearms injury prevention (she wants to expand background checks and limit access to assault weapons; he opposes any intrusion on an individual’s “Second Amendment” rights to own guns, supports  greater enforcement of existing laws but opposes any new restrictions, and advocates a national “right to carry” law). 

Mr. Trump promises to repeal the Affordable Care Act (Obamacare) and replace it with a plan that would allow people to enroll in tax-free Health Savings Accounts to pay for their out-of-pocket costs, make premium payments by individuals tax deductible, create state pools to insure “high risk” patients who have not maintained continuous coverage, allow insurers to sell insurance across state lines, and convert Medicaid to a block grant program, where the states would get a fixed amount of federal funding per beneficiary to redesign the program as they see fit.  Mrs. Clinton pledges to preserve, build upon and improve on the ACA by increasing tax credit subsidies so families pay no more than 8.5% of income; working with states to establish a public option to compete with private plans in the marketplaces; allowing individuals aged 55-64 to buy into Medicare; create fallback for HHS to block unreasonable rate increases; repealing the “Cadillac Tax” on high premium employer-sponsored plans;  requiring plans to cover 3 “sick” visits per year without deductibles; creating a new tax credit of up to $2500/$5000 per individual/family for out-of-pocket expenses in excess of 5% of income; ensuring consumers pay no more than in-network cost-sharing for care received in a hospital in their plan’s network (surprise bills); providing 100% federal match for first 3 years if states adopt expansion, regardless of when they start; and allowing undocumented immigrants to buy coverage from exchange plans at their own cost.

The Rand Corporation conducted an analysis of the candidate’s proposals, and concluded that Mr. Trump’s proposals would add tens of millions of people to the ranks of the uninsured, while Mrs. Clinton’s plan would expand coverage to tens of millions.

No matter who the voters elect next week,  however, the new President will have great difficulty translating their plans into policies that have a chance to be enacted into law.  Should we have a President-elect Hilary Clinton, and even if Democrats narrowly take control of the Senate, she likely will have to deal with a Congress where  the House of Representatives will still be controlled by Republicans who have no interest in strengthening Obamacare, and where Senate Republicans can still use the filibuster to thwart her initiatives.  And she would still have to deal with dozens of states that will continue to be controlled by GOP governors and legislators who are not likely to jump on the Obamacare bandwagon.

Should Mr. Trump get elected, he likely will benefit from a Republican-controlled House and  continued GOP control of the Senate.  Expected Democratic gains in the Senate though likely will make it easier for Democrats to use the filibuster to thwart efforts to repeal Obamacare.  And, practically speaking, repealing Obamacare would mean kicking 20 million people off of the health insurance coverage they have gained from it, pulling the plug on federal funding of Medicaid expansion, and taking away some very popular consumer protections, like the guarantee that insurers can’t deny coverage or charge more to people with pre-existing conditions.

For sure, there are many things a Clinton administration could do to strengthen the ACA through regulations should legislation become impossible.  There are things that a Trump administration could do to ease Obamacare’s requirements on insurers and states through regulations should legislative repeal become impossible. 

Yet, unless we see a marked change in our political culture as a reaction to the 2016 election, the current toxic stew of partisanship, polarization, and gridlock likely will get worse before it gets better. “The American electorate has grown increasingly divided along party lines in recent decades, by political attitudes, social values, basic demography, and even beliefs about reality,” observed political scientist Gary Jacobson in an analysis published late last year in the Annals of Political and Social Science.  “Deepening partisan divisions have inspired high levels of party-line voting and low levels of ticket splitting, resulting in thoroughly nationalized, president- and party-centered federal elections. Because of the way the electoral system aggregates votes, however, historically high levels of electoral coherence have delivered incoherent, divided government and policy stalemate.”
The question is whether the 2016 election will lead to continuation and even intensification of the “incoherent, divided government and policy stalemate” that has engendered growing voter rage and historic declines in trust in government, and even in our democratic system of government itself?  Or act as a catharsis for voters and politicians to begin pulling us back from the brink?

As Abraham Lincoln said in his first address to Congress in December 1862, when our nation’s politics had grown so toxic that the country was in the first year of a bloody civil war, “We can succeed only by concert.  It is not ‘can any of us imagine  better?’ but, ‘can we all do better?’ The dogmas of the quiet past, are inadequate to the stormy present. The occasion is piled high with  difficulty, and we must rise – with  the occasion. As our case is new, so  we must  think anew, and act anew. We must disenthrall ourselves, and then we shall save our country?”

Now, to be clear, I don’t believe that the stakes in this election are anywhere near what President Lincoln confronted, we aren’t going to fall apart at the seams and start taking up arms against each other.  But if we the voters don’t begin to “save our country” by embracing politicians who believe that compromise to achieve a common good—so “we can all do better”—is a virtue, instead of voting for those who put their own partisan and political interests and ideological purity above what is best for all, then we will continue to weaken and undermine our great American democracy.  This, I believe, is what we should fear and loath most long after the ballots are counted next Tuesday.

Today’s question: What do you think is at stake in the 2016 election, and afterwards, for healthcare, and our democracy itself?

Friday, October 7, 2016

My answer to direct primary care evangelists

One thing I’ve  learned is that physicians who have gone into direct primary care (DPC) practices are passionate about their decision: they not only believe that DPC is better for their patients and their own professional and career satisfaction; many  assert it is the answer to just about everything ailing primary care.  There is an evangelical fervor among some DPC advocates to spread the word and convert other primary care physicians to their cause.

It’s no surprise to me, then, that many of them have expressed frustration—to put it mildly—that ACP has decided not to endorse or promote DPCs. Instead, our 2015 position paper, for which I was the lead author on behalf of the College’s Medical Practice and Quality Committee, aims to provide a balanced and evidence-based assessment of the potential impact on patients of practices that have one or more of the following 3 features:

They charge monthly per patient retainer or subscription fees.

They do not participate in insurance contracts.

They have reduced their patient panel sizes well below the norm. 

The American Academy of Family Physicians says that “Generally, DPC physicians have a panel of between 600 and 800 patients. In typical FFS settings, the patient panels tend to range from between 2,000 and 2,500 per family physician.”

One of the challenges ACP found in assessing the impact of direct primary care is that it is only one variation of practices that charge retainer fees, do not participate in insurance, and/or have smaller patient panels.  For example, practices often described as “concierge” practices often charge much higher monthly per patient retainer fees than most DPCs say they charge.  (Many DPC proponents fiercely object to being labeled as concierge practices). 

Yet ACP found little in the literature that defines the accepted range of monthly fees charged by DPC compared to “concierge” practices—Medical Economics magazine says they typically range from $50 t0 $150 per month, citing AAFP.   A study in the Journal of the Board of Family Medicine (JBFM), which was published after ACP had completed the literature search for our paper, reported that “Practices that used the phrase DPC on average charged a lower fee than practices that used the term concierge to describe their model: $77.38 compared with $182.76, respectively. Of 116 practices with available price information, 28 (24%) charged a per-visit fee, and the average per visit charge among this group was $15.59 (range, $5 to $35). Thirty-six of these 116 practices charged a one-time initial enrollment fee, and the average enrollment fee among this group was $78.39 (range, $29 to $300).” 

The wide variations in the monthly fees charged begs the question:  at what point, does the monthly fees charged by DPC practices make them concierge? 

Our paper found examples of DPCs that provide low cost and accessible services to all types of patients, including Medicaid patients.  Yet we also observed that there is a potential that less well-off patients, who can’t afford to go without insurance or pay a monthly fee, might be disadvantaged.  Guided by our Committee on Ethics and Professionalism, we accordingly urged physicians who are considering DPC, concierge or other practice arrangements that have one or more of the features described above to consider steps, like waiving or lowering monthly fees for patients who can’t afford them, to mitigate any potential impact on undeserved patients.  Perhaps most importantly, we called for more research on the potential impacts of such models. 

This reasoned position, neither endorsing nor opposing DPCs,  instead calling for more research and consideration by physicians who enter into such practices of steps that could mitigate any adverse impact on poorer patients, has been misinterpreted by some DPC advocates as ACP being opposed to  DPCs.  This is not the case.  Our paper clearly states that physicians should have a choice of entering into practice arrangements that provide ethical and accessible care to their patients, which can include DPCs that meet the ethical considerations laid out in paper.

In a recent letter published in the Annals of Internal Medicine, I responded to a letter from Dr. Martin Donahoe that was highly critical of what he called “luxury care clinics,” especially in academic medicine.  I cautioned against painting too broad a brush in characterizing the motivations of physicians who charge monthly retainer fees and have downsized their patient panels:

“I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients.  Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient's income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.” 

I am heartened that Dr. Bob Centor, chair-emeriti of the ACP Board of Regents and a long-standing proponent of direct primary care, blogged that my Annals letter was “a very thoughtful rebuttal” to Dr. Donahoe’s broad condemnation, noting that “ACP has an excellent position paper on direct primary care,” referring to our 2015 paper.

Yet some DPC evangelists remain unsatisfied with the College’s position that we need more research on the impact of DPCs  on quality, access and cost, especially for underserved populations.  One DPC evangelist—a DPC physician himself, and one of the co-authors of the AJFM study cited above—called the analysis by ACP, our Medical Practice and Quality Committee and our Ethics, Professionalism and Human Rights Committee “ignorant”—even though his own ABFM study concluded that “Most DPC practices are young and small and thus lack sufficient quality and cost data to assess outcomes thus lack sufficient quality and cost data to assess outcomes.”  Calling one’s colleagues in another primary care field “ignorant” is a sure fire way to win people over!

Finally, it needs to be acknowledged that there is a significant crossover between DPC advocates and anti-Obamacare physicians.  Just do a Google search of “direct primary care as an alternative to Obamacare” and you’ll find dozens of commentary about why DPC is a “free market” alternative to the Affordable Care Act’s insurance regulations, alternative payment models, and other features.  ACP, which strongly supports the ACA’s benefit requirements, subsidies, and consumer protections, would have difficulty embracing a movement that many of its own advocates assert is intentionally designed to subvert the ACA.  DPC, on the other hand, could be a reasonable option that exists as already permitted by the ACA, as long as it doesn’t weaken the law’s consumer protections.

So this is how I see things.  It is fine for DPC advocates to promote the benefits of this model.  It is fine that many physicians are considering going into a DPC, motivated by their desire to  desire to spend more time with their patients, although I would encourage them to consider the steps recommended in our paper to mitigate any adverse impact on poorer patients.   It is fine—in fact, imperative—that there be more research on the impact of DPCs on quality, cost, and access.  However, the evangelical strain of the DCP movement that seeks to convert ACP, and everyone else, to endorsing the movement—you're either for or against them—is not going to result in the respectful, evidence-based dialogue that is needed. 

Today’s question: what is your opinion of Direct Primary Care?

Wednesday, August 17, 2016

Patient-centered care? Not for this patient . . . and not for how many more?

Although I didn’t know Jess Jacobs, a young woman who tragically died on Monday after suffering for years from two rare diseases, I have learned much about her from her blogs  detailing her encounters with the healthcare system.

I have learned that she suffered greatly from her conditions, postural orthostatic tachycardia syndrome (POTS), an autonomic disorder, and from Ehlers-Danlos Syndrome (EDS), a rare hereditary disease of connective tissue. 

I learned that her suffering was unnecessarily compounded by a health care system that, by her own detailed reports, failed her at every point.

On February 14, 2014, she wrote of her frustrations over receiving the following letter from her primary care physician:

Hi Jess,

POTS is a rare diagnosis, and I am by no means a specialist in the treatment of it. I cannot comment on whether treatment with opioids is the best route or not. My only suggestion was that it might be prudent to see another POTS specialist for an opinion. It might also turn out to be helpful to see the Rheumatologist and Neurologist to see if they have any thoughts or ideas.

I know this is beyond frustrating for you, feeling poorly and not having any therapies pan-out with respect to making you feel better. There are no clear answers when it comes to POTS.

Best wishes,

Primary Care Physician

Jess’s reply, excerpted below, takes the doctor on for “surrendering” rather than trying to coordinate her care:

The majority of my friends are allied with the healthcare field – doctors, health lawyers, nurses, health administrators – and all ask “who’s coordinating all of this?” to which I say I am and then they all stress about who is going to take over when I start puking and can’t get off the floor on my own.

I’m not sure where they got the notion that my primary care physician should coordinate my care, maybe they were looking at NCQA’s patient centered medical homes model, or found a copy of the Accountable Care Organization regulations from CMS, or listened to people discuss Obamacare on Late Night with Jimmy Fallon. All I know is that they all say that a PCP is the person to coordinate care.

In my search to figure out what this actually means, a physician friend turned me onto Vernon Wilson’s 1969 article entitled “Prototype of a Doctor.” Wilson postulates that as a continuing medical advocate for their patient, a PCP’s job is to evaluate and coordinate patient care and “accept responsibility not merely pass it along – utiliz[ing] specialists rather than surrendering to them.”

By telling me that my condition is complex and stating that I should just see additional specialists, you are surrendering. . . So, this leads me to ask: If you are not willing and able to help me, who in your practice is?



On November 15, 2014, she added up all of the encounters she had with the health care system to date--“56 outpatient doctor visits, 20 emergency room visits, and spent 54 days inpatient”--and how many of these visits were actually useful to her.  I encourage readers of this blog to read her detailed tables. She particularly felt that her visits with her primary care physician were the least valuable:

The only reason Primary Care received any value attribution is because I need someone to renew prescriptions for anti-nausea drugs, letters for FMLA, and send records to hematology. I feel bad that their years of medical school and residency are being wasted on purely administrative procedures.

Some of these specialties were overly impacted by the amount of time it takes to schedule visits. For instance, hematology took six months and over four hours of my life to schedule one visit; however, the time spent with the doctor herself is quite valuable. Conversely, Ophthalmology and Endocrinology were scheduled using a third party platform so the scheduling process was very smooth, but using the third party platform led to billing issues. If I accounted for the time-value of money, the numbers would shift a bit.

On May 31 of last year, she wrote about a hospital stay that she called  “the most profoundly heartbreaking experience of my life”—not just for her, but for the patient that shared the room with her, excerpted below:

. . . when I answer people asking ‘What is the worst healthcare experience of your life?’ - that honor belongs to the 48 hours I spent housed in an on-call room last November.
November’s stay made me appreciate my cellphone in ways that you should not have to appreciate your phone while inpatient at a hospital. Here my phone wasn’t my connection to the outside world - it was how I connected the dots within. It enabled me to contact five of my physicians, all of whom are attending physicians at your institution, when my resident was unable to do so. When the resident insinuated I had not established care with hematology, I was able to call the hematology department and connect my hematologist to the resident in under 15 minutes. At the time of admission, I had given this resident a typed list of my specialists which included the same contact information I used successfully; as such I find it difficult to believe the resident attempted to verify I was an existing patient.

When the nurses couldn't hear the physical bells my roommate and I were given, I resorted to calling the nursing station on my cellphone (Ironically, courtesy of the speaker in the wall of our on-call room, we heard nurse requests from all the other patients on the floor). My roommate did not have a cellphone and I ended up relaying her requests by calling the nurses station each time my roommate rang her physical bell. As such, I didn't sleep the entire time we were in this closet.

However, these communications issues are simply annoyances in comparison to the emotional torture of a fellow human experiencing unrelenting pain.

My roommate, admitted for a Sickle Cell crisis, cried hysterically for over 12 hours while her pain remained unmanaged. During this time I called and emailed the patient advocate several times on my roommate’s behalf and ‘rang’ the nurse countless times.  Eventually my roommate’s attending came to see her. Unfortunately her physician was “Dr. Feelgood.” I had the misfortune of being this physician’s patient in July. I nicknamed him “Dr. Feelgood” for stopping my pain regimen (developed by a pain specialist) and insisting yoga (contraindicated with my joint condition) would magically fix all my problems. True to form, Dr. Feelgood insisted my roommate's issues related to positive thinking and refused to revert to a pain regimen that had apparently worked before. I’m not a physician and have no idea what pain medications this girl should have been on. But as a human I know that “Tears = Bad” and anyone that cries for twelve hours while begging someone, anyone, to call their physician of record isn't faking it. She didn’t stop crying until a doctor with some humanity sedated her following shift change. The complete disregard for her pain stripped her of her dignity and brought me to tears.”

Reading Jess’ posts brings me to tears. How can anyone who has empathy not be?
But feeling bad for Jess, her roommate, and the many other patients who are failed by our health care system is not enough.  We who make our livings as advocates for primary care and Patient-Centered Medical Homes must acknowledge the chasm between the principles  we articulate, and Jess’ experience. 

Where in Jess's experience was the “ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” ?

Where was the “personal physician [who] leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients” ?  

Where was the “Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care”? 

Where was the “Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community based services)”? 

Where was the advocacy “for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care-planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family”?

Federal policymakers must also acknowledge and address the gap between Jess’ experience and the kind of care they would want for themselves and their families, and how their own regulations and flawed policies may contribute, as Acting CMS Administrator Andy Slavitt did in tweeting about Jess.  Hospital administrators need to acknowledge and address how their institutions are failing patients like Jess. 

And physicians, nurses, pharmacists and other health care professionals must acknowledge and address the fact that Jess, like so many other patients including those with more common diseases—have been failed by a system that doesn’t put patients first.  While I believe that most health professionals care deeply about their patients, and try to do the best they can, many of them would say that they are stymied by a “system” that devalues patients’ experiences with the care received.  But blaming the system isn’t enough: the medical profession has an obligation to do everything it can not to surrender their patients to a system that doesn’t seem to care about them, and to advocate for reforms to truly put patients at the center of the health care system.

Most importantly, we need to listen to patients, including those like Jess who now speak to us from the grave.

Today’s question: What do you think of Jess’ experience, and what should be done about it?

Thursday, August 11, 2016

Make it go away!

We all want this sometimes, don’t we?  We want the things in our daily lives that bug us the most, like long lines at the DMV, to just go away.  But how often does that really happen?

As the senior staff person for ACP’s governmental affairs team in Washington, D.C., I hear often from exasperated physicians who want ACP to just make things they don’t like go away, whether it's MACRA or EHRs or Obamacare. The problem is that “make it all go away” is mostly about wishful thinking; it’s not a winning strategy. I respond by trying to explain while it may not be possible to make “it” go away (and probably not a good idea even if we could), ACP is striving to make things better.   As much as some physicians might want, and some pandering politicians and membership associations may  tell them, here are 3 things in healthcare that are not going to  go away, yet much can be done to make them better.

1. “Government-run” health care isn’t going away.  The fact is that millions of Americans already get their health insurance from government programs, and the number will continue to grow. More than 55 million people are enrolled in Medicare;  more than 72 million in Medicaid and the Children’s Health Insurance Program; 12.6 million in qualified health plans offered by the Affordable Care Act.  Comparing 1997 to 2014, the number of persons under age 65 with public health plan coverage increased from 13.6 million to 24.5 million while the number with private health insurance declined from 70.8 million to 63.6 million.   Enrollment in both Medicare and Medicaid, driven by demographics and, in the case of Medicaid, by the Affordable Care Act, will continue to grow: by 2022, an estimated 66.4 million people will be enrolled in Medicare, another 77.9 million in Medicaid. 

And as more people are enrolled, federal spending will increase: for 2015 through 2022, projected Medicare spending growth of 7.4 percent annually “reflects the net effect of faster growth in enrollment and utilization, increased severity of illness and treatment intensity, and faster growth in input prices, partially offset by ACA-mandated adjustments to payments for certain providers, lower payments to private plans, and reducing scheduled spending when spending exceeds formula-driven targets” according to the latest government estimates.  The same report says that Medicaid spending will grow by about 6.6% annually from 2016 to 2022, mainly driven by spending on the aged and disabled.

There a lot of things about “government-run” healthcare that doctors don’t like, and for good reason -- things like excessive regulations and price controls.  Much can be done to streamline, simplify, and improve Medicare, Medicaid, and Obamacare while making them more fiscally responsible.  But “government-run” healthcare has also improved the lives of many millions of seniors, children, and previously uninsured persons who otherwise would not have access to coverage and affordable care.  It is mainly because of government programs that the uninsured rate is at an historic low. 

2. Obamacare isn’t going away.  Related to the above, the Affordable Care Act, or Obamacare if you prefer, is not going to be repealed.  There is no plausible scenario where the voters will elect a Congress that will have the votes needed to repeal the ACA, even if Mr. Trump was elected to the White House.  And even if somehow they did, they would have to figure out a plan to replace it without kicking off the 20 million plus Americans who now get coverage because of the ACA.  This is why independent experts, including ones that have been highly critical of Obamacare, believe that a more likely course of action is that Obamacare will be reformed to address unpopular things like the Cadillac tax (which Mrs. Clinton has also proposed to repeal).  Steps might also be taken to shore up the health insurance marketplaces so they are not as subject to disruptions as insurers raise premiums or pull out of markets because they are losing money.  As the Washington Post editorial board recently wrote, there are some modest Obamacare fixes to the marketplace instability that could be implemented by a new President, if Congress was inclined to be part of the solution.

3MACRA isn’t going away.  The Medicare Access and CHIP Reauthorization Act (MACRA), which was passed last year with overwhelming bipartisan support, is not going to be stopped or repealed, nor should it.  The law makes needed changes in Medicare physician payment to align payments with value and to promote innovative delivery models like Patient-Centered Medical Homes.  As I wrote in previous posts, MACRA is a big improvement over the existing Medicare Physician Quality Reporting System (PQRS) and EHR Meaningful Use programs; the “sky-is falling, end of small practice” narrative is not supported by the facts.  Yet MACRA implementation is a work-in-progress—CMS has only issued proposed rules for 2017, not final ones—and there is much that needs to be done to ensure that Congress’ intent of simplifying quality reporting is met.  As I also wrote in this blog, what we need are practical solutions -- as ACP has provided in its comments on the proposed rule—not anti-MACRA rants. 

Now, I know that some conservative readers of this blog will say, there Bob goes again, defending big government health care.  Yes, I do believe—as does ACP—that programs like Medicare, Medicaid, and the Affordable Care Act have made American healthcare better (and the facts are on our side).  I do believe, as does ACP, that MACRA has the potential to bring about needed improvements in how Medicare pays physicians while achieving greater value for patients in the process.  But I also know that there is much that can and needs to be done to make these, and other programs, better for doctors and patients.  I believe, as does ACP, that there is merit to many conservative ideas that would introduce more competition, transparency and fiscal responsibility into them while easing regulatory over-reach.  I believe, as does ACP, that there is also merit to many liberal ideas to improve these programs, like allowing patients over the age of 55 to buy into Medicare and having a “public option” to compete with private insurers in the marketplaces.

There is a place for ACP members, conservatives and liberals alike, to work through the College to come up with practical improvements that draw on the best ideas from both camps—as they do, every day, by serving on ACP policy committees, the Board of Governors, the Board of Regents, and in leadership positions in our state chapters. They don’t engage in wishful thinking, they help us develop practical solutions.

Yes, we can make government-run health care programs more efficient, less costly, more accountable and less burdensome to doctors and patients.  But make them go away?  As we would say in my home city of New York, fuggedaboutit!

Today’s question:  Do you think “government-run” health care can or should go away?

Wednesday, July 27, 2016

Doctors and nurses are battling (again), but does it have to be this way?

The Department of Veterans’ Affairs proposal to allow Advanced Practice Registered Nurses (APRNs) to have full and independent practice authority, preempting state laws that hold them back, has triggered another ugly fight between the medical and nursing professions.  The American Nurses Association supports it, the AMA opposes it.

The fight over the VA’s proposal continues a long-standing battle that plays out regularly in state legislatures, as nurses have sought to expand their “scope of practice” and eliminate existing “physician supervision” requirements, while state medical societies have battled back. 

Both sides, of course, frame the issue as being about quality and access, not about who is in control.  Physicians argue that being licensed as an MD or DO requires a higher level of education and patient care experience (four years of medical school and at least 3 years of supervised direct patient care training in residency and fellowship positions) that makes them uniquely qualified to take care of patients, especially those with more advanced conditions, while nurses argue that their different but unique  training and skills—especially those that have been trained as Advanced Practice Registered Nurses—make them at least as qualified to treat most patients, with equal or better outcomes.  Both cite conflicting studies to support their positions. 

I have personal experience in how hard it is to find common ground between the two professions or, for that matter, within the medical profession itself.   Three years ago, the American College of Physicians published a position paper in the Annals of Internal Medicine, Principles Supporting Dynamic Clinical Care Teams: A Position Paper of the American College of Physicians, which I co-wrote with my colleague Ryan Crowley on behalf of ACP’s Health and Public Policy Committee.  I know Ryan would agree with me that it was one of the more challenging papers we have written.  Throughout the two years of research and writing the document, we struggled to find positions that would enjoy the support of ACP’s own membership, which were themselves not entirely on the same page on how hard to push back against efforts to expand nurses’ scope of practice, but also to move closer to finding common ground with the nursing profession.

There was almost universal agreement among ACP’s leadership that physicians have unique training and skills that make them especially qualified to exercise advanced clinical leadership responsibilities for team-based care.  But there was also recognition that APRNs, NPs, and other non-physician professionals are essential members of the team, and, in some cases, they may have been held back from practicing to the full extent of their training and skills by overly restrictive internal supervision requirements and overly restrictive state laws.  Some of ACP’s members favored a more hard-line, physicians-should-always-be-in-charge stance, while others were open to a more nuanced approach that emphasized collaboration and sharing of clinical responsibilities within teams, putting less emphasis on who should run the show.  During the process of writing the paper, we engaged in a constructive dialogue with respected members of the nursing profession, seeking to find common ground where possible or, at least, to avoid using words (like physician “supervision”) that we learned from them were viewed as offensive, creating rhetorical barriers to achieving agreement. 

In the end, I think the paper struck exactly the right balance, affirming that physicians do have unique and more advanced training and skills that make them especially  qualified to exercise clinical leadership responsibilities for a team, while supporting the important and essential contributions of highly trained APRNs, NPs, PAs, clinical pharmacists and others in sharing patient care responsibilities, with all members of the team being allowed to practice to the full extent of their training.  In other words, we came up with a nuanced approach to the issues of clinical leadership responsibilities within a team rather than defining the issue as being about who is in charge.

The problem is that the VA’s proposal is anything but nuanced, because it frames the issue as a binary choice: are you for or are you against allowing APRNs to practice independently, pre-empting any state law licensure laws that hold them back? Presented this way, is it any surprise that it has led to another divisive fight between the medical and nursing professionals?

ACP, for its part, thinks there is a better way.  In our comments on the VA proposal, submitted Monday, we offered an alternative to the VA’s proposal that tries to move the discussion away from considerations of “independence” and “hierarchy” to how to organize high-functioning, patient-centered clinical care teams that use everyone’s skills to the maximum extent of their clinical training and skills, based on the principles in our 2013 paper.  Our alternative offered the following key points:

  •  While ACP does not support the VA's proposal to broadly preempt state licensing laws to grant full independent practice authority to APRNs, we propose an alternative that matches patients with the health care professionals on the team who have the training and skills needed to meet their care needs, modeled on the recommendations in ACP’s 2013 position paper.
  • We express support for veterans being able to have access to a personal physician who accepts clinical responsibilities for care of the “whole person,” consistent with the Patient-Centered Medical Home model.  In a press release that summarizes our recommendations to the VA, ACP’s President, Dr. Nitin S. Damle observed that “While internal medicine physicians have unique training to exercise clinical leadership responsibilities for the team and to care for adults with complex illnesses and diagnostic challenges, patients might appropriately be seen by other members of the clinical care team -- including nurses -- depending on their specific clinical needs and circumstances with physicians being available for referral or consultation as needed."
  • Because primary care encompasses various activities and responsibilities, it is simplistic to view primary care as a single type of care that is uniformly best provided by a particular health care professional.  To illustrate, our letter observes that an advanced practice registered nurse providing primary care commensurate with his or her training may consult with or make a referral to an internal medicine physician, a family physician, or another physician specialist when presented with a patient with significantly complex medical conditions.
  • Effective clinical care teams allow each member of the team to practice to the full extent of their training and experience, ACP observed.  While ACP does not support pre-emption of state licensing laws, it strongly encourages states to examine their laws to ensure that all clinicians are able to practice the full extent of their training and skill while practicing within a dynamic clinical care team.
  • Our letter notes that especially in physician shortage areas, it may be infeasible for patients to have “an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.  They may also be unable to have immediate on-site access to other team members who may be located some distance from where the patient lives and accesses medical care. In such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient's health care needs are imperative. We suggested the even if a physician and APRN are not physically co-located, the patient should have access to a 'virtual' clinical care team through use of telemedicine, electronic health records, regular telephone consultations, and other technology to enable the on-site primary care clinician and all members of the health care team to effectively collaborate and share patient information. Telemedicine and telehealth technologies can help virtual clinical care teams provide clinical consultation and decision support as well as patient education, remote monitoring, and other services.”

I am under no illusion that ACP’s approach will be the basis for a truce between the medical and nursing professions on the VA’s proposal or, more broadly, over the other raging battles over preserving, changing, or superseding state laws that set limits on what nurses can do independently.  These fights will go on, precisely because they present the issue as “either/or” choices.  I am hopeful that ACP’s nuanced approach of trying to move the discussion towards how both professions can work together, rather than fighting against each other, will eventually bridge some of the differences over leadership, supervision, and scope, especially at the level where care is actually delivered, when teams of clinicians, highly trained in their own disciplines, work closely and collaboratively together while focused solely on what is best for their patients.

Today’s question: What do you think of the VA proposal and ACP’s alternative?