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.
3. MACRA 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 :
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.
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
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
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.
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
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.
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