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?

6 comments :

Robert J. Sobel, M.D. said...

Dear Bob,

I've had trouble reading through some of the recent posts. The details I can forego for now, as the arrival of the quality bureaucracies comes after I've already been made uncompetitive by the forces of both public and private payors. I'm well aware that things don't go away. That is why we rely on you not to keep recommending solutions that are worse than the disease, or don't address it.

The shaming of fee for service is a shame itself. Sylvia Burrell interview I read in the paper today was just scary. The excitement of thinking measuring my quality will help my patients, me, or society is really hard for me to buy into. It is why I've never trusted the home, though I respect the efforts of those who are trying to do things at different scales than my now solo practice.

The lack of a fee schedule on drugs and new technology is the only missing bureaucracy. The creation of new quality bureaucracies should be halted. Period. End of discussion. The counterargument just doesn't hold any water. Our professionalism is really at stake with this displacement of health care energy into measurement distractions that will at best, require another consultant to pay, and, at worst, get manipulated in unforeseen ways because the stakeholders have to self-preserve.

The current structure has failed to allow me to sustain within the system. Concierge is my only survival mechanism, as distressing as it is to lose patients on a financial basis. Of course, it is a trend that has come as our standing with insurance has been gradually degraded over my twenty years of practice.

You allow the drug prices and new technologies to be astronomical. You have not analyzed the situation in a way that stopped the corporate impositions. You have asked me to be a steward, but I am lost in manipulations if I try to enter cost effectiveness into clinical effectiveness calculations. Leave me to focus on the latter. That is the support I need from the ACP.

Did you not mention price controls as an argument against government? Now you say it. Are you telling me MACRA is not even beyond that pale? On the other hand, God forbid price controls on the commodities of health care. I've been ignored and now I can't be helped by anyone other my patients, on whom I clearly plead guilty of piling on.

I have no problem with the insurance mandate. Let it stand. Reform the structure of the private health care industry, or change it to public if you really want. At this point, they appear to be one and the same and unable to respect individual, small practice providers in the sea of entities who make up the other 90% of the health care pie. Yeah, you have a hard job fighting off the rants.

All the best.

Haroon Hameed said...

I've been involved in our AMA for about 9 yrs.......for the last year or so CPT and RUC too. I can't agree with more regulation in healthcare, and I'm sincerely opposed to the changes in healthcare that are making the best intentioned of this country slaves to socialism. These policies will lead to 'brain-drain' and subsequent losses in quality care of the people of our country,.....if the people have spoken, so be it. But no one can say that we that didn't try to fight the death of old American-values in our profession al the way. Good luck with these newer policies,......lets see what happens to you when you need help most

Haroon Hameed said...

I've been involved in our AMA for about 9 yrs.......for the last year or so CPT and RUC too. I can't agree with more regulation in healthcare, and I'm sincerely opposed to the changes in healthcare that are making the best intentioned of this country slaves to socialism. These policies will lead to 'brain-drain' and subsequent losses in quality care of the people of our country,.....if the people have spoken, so be it. But no one can say that we that didn't try to fight the death of old American-values in our profession al the way. Good luck with these newer policies,......lets see what happens to you when you need help most

Toby W said...

Perhaps we need to examine the entire system by a measure of time spent by non-patients and time recieved by patients. Then observe: is this number reasonable? How many hours of face time with a HC provider do I get annually? How many dollars do I pay? And incidentally, how much of MY time is spent in achieving this?

Perhaps drugs, etc., need a different system, but in a complex system of this magnitude simplification is needed, i.e. one thing at a time.

Toby W said...

Byzantine in Technology
jargon, architecture
A term describing any system that has so many labyrinthine internal interconnections that it would be impossible to simplify by separation into loosely coupled or linked components.
The city of Byzantium, later renamed Constantinople and then Istanbul, and the Byzantine Empire were vitiated by a bureaucratic overelaboration bordering on lunacy: quadruple banked agencies, dozens or even scores of superfluous levels and officials with high flown titles unrelated to their actual function, if any.
Access to the Emperor and his council was controlled by powerful and inscrutable eunuchs and by rival sports factions.
[Edward Gibbon, "Decline and Fall of the Roman Empire"].
(1999-01-15)

The Free On-line Dictionary of Computing, © Denis Howe 2010

Toby W said...

Perhaps we need to examine the entire system by a measure of time spent by non-patients and time recieved by patients. Then observe: is this number reasonable? How many hours of face time with a HC provider do I get annually? How many dollars do I pay? And incidentally, how much of MY time is spent in achieving this?

Perhaps drugs, etc., need a different system, but in a complex system of this magnitude simplification is needed, i.e. one thing at a time.