Friday, September 13, 2019

Trump’s health care plan is hiding in plain sight

As the Democratic candidates for president continue to beat up each other on how best to achieve universal coverage (Medicare-for-All, a public option, closing the ACA’s coverage gaps), health care journalists keep wondering when President Trump will release his long promised “phenomenal” plan to position the GOP as “the party of health care” for the 2020 election.

Skepticism is warranted over when or even if the administration will actually offer such plan (never mind whether it will be “phenomenal”) since it never did during the two years when the White House and then GOP-controlled Congress unsuccessfully sought to “repeal and replace” the ACA. The Trump administration currently is urging a federal appeals court to uphold a ruling by a Texas judge that the entire ACA is unconstitutional, without explaining what should replace it—repeal without a replacement. Polling also shows that President Trump starts with a very substantial disadvantage on health care: a recent ABC/Washington Post poll found that “Americans, by a 17-point margin, say his handling of health care makes them more likely to oppose than support him for a second term.” 
Yet even without a formal plan, the administration’s approach is readily discernible from the things it has announced and is implementing. Democrats and their progressive allies might discover to their surprise that it may have more appeal to voters than they now anticipate. A Trump health care plan likely would look like this:

1. A promise to let individual Americans decide for themselves what kind of health care coverage they need and how much they want to spend on it, instead of “government bureaucrats” imposing an expensive plan on them. The administration can point to the changes it has made to offer people so-called short-term duration and association health plans, both of which are exempted from the “Obamacare’s” benefit mandates—which it will spin as Washington no longer forcing you to pay for coverage you don’t want or need.

2. It will promise that no one will be turned down for coverage for a pre-existing condition. But unlike the ACA, or Medicare for All, the administration will argue that government won’t dictate what the plans available to people with pre-existing conditions will cover—a 60 year man with Type 2 diabetes won’t be required to buy coverage for maternity care, for instance.

3. It will say that the Trump administration is doing more to reduce paperwork burdens on physicians and patients, through its Patients Over Paperwork initiative.

4. It will say that the President is leading the effort to drive down prescription drug prices and require hospitals to be transparent in their pricing of health care services.

5. It will point to its commitment to protect patients from the harms of tobacco and e-cigarettes, calling for much greater regulation than is usual for Republican administrations.

6. It will contrast its approach of trusting Americans to make their own choices over what it will say is the Democrat’s support for a complete government take-over. It will argue that whether the Democratic nominee supports Medicare for All plan with no private insurance, or a Medicare Choice/public option approach that keeps a role for private insurance, the result will be a government “take-over” of health care, higher taxes, fewer choices, longer waits, and poorer outcomes. (No matter that countries with publicly-funded care generally have better outcomes and lower costs than in the United States). Health insurers, drug manufacturers, and hospitals will eagerly reinforce such misleading scare tactics.

Critics will argue, correctly in my view, that the administration’s weakening of essential benefit and pre-existing protections, efforts to get a federal court to overturn the entire ACA, “conscience protections” that allow employers to opt-out of offering contraception and other needed services, treatment of immigrants, and it’s wholesale assault on women’s reproductive rights and health, denial of climate change, and unwillingness to confront the epidemic of gun violence, are anti-health and anti-patient. At the same time, the administration deserves credit for addressing the administrative burden on physicians, increasing regulation of tobacco, addressing high prescription drug costs, and increasing price transparency. Progressives and Democrats will make the case that Medicare for All, or a public option, will make care more affordable and accessible for most Americans, and they have plenty of evidence on their side.

Yet they would be foolish to underestimate the potential appeal of a “Trump Health Plan” that is framed, accurately or not, as a choice between you deciding what’s best for your health, or the government deciding for you.

Wednesday, July 3, 2019

How does U.S. health care measure up to the Declaration of Independence?

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

If there is a single sentence defining what the United States was founded upon and still aspires to become, this from the Declaration of Independence would be it.

While written in a very different context—a justification for U.S. independence from British tyranny—Thomas Jefferson’s words might be applied to contemporary discussions of U.S. health care policy:

Does U.S. health care treat all men--and women--equally?  Does it deliver on each person’s unalienable right to life, liberty, and the pursuit of Happiness?

The answer, sadly, is that it often does not.


Equality: While U.S. health care excels in some areas, it consistently ranks last or near-last in access, administrative efficiency, equity and health care outcomes.  Many U.S. residents face systematic barriers to care and discrimination because of personal characteristics, including sex and sexual orientation, gender and gender identity, race, ethnicity, religion, language and country of origin.

Life: While helping people live longer and healthier is the very purpose of health care, the U.S. fares poorly on this as well.  Life expectancy is lower and chronic disease rates are higher than those of similar countries. The U.S. has a higher mortality rate for amenable deaths (medical conditions for which there are recognized health care interventions) than countries like Germany, the Netherlands, Japan, France, and Australia. The U.S. also has much higher rates of injuries and deaths from gun violence than other wealthy countries.

Liberty: U.S. health care policy infringes on personal liberty in many respects: many state governments have passed draconian laws to limit women’s reproductive rights and dictate to physicians what they can or must say to patients, even when it goes against science and the physician’s clinical judgment and ethical obligations.  The U.S. micromanages nearly every aspect of clinical care, requiring that patients and doctors alike jump through hoops to get needed care authorized and covered, a characteristic that launched ACP’s Patients Before Paperwork initiative.  Physicians face a barrage of administrative tasks, including activities related to billing, electronic health records, and performance measures. Administrative tasks can contribute to physician burnout. By comparison, physicians in many other countries with universal coverage have far fewer administrative tasks to comply with: U.S. physician practices spend $61,000 more per physician per year on costs related to dealing with health insurers than their counterparts in the single-payer Canadian system.

Pursuit of Happiness:  it is hard to be happy if one is sick, uninsured, and unable to afford medications and hospital bills.  Yet that is the reality for tens of millions of Americans. The U.S. is the lone wealthy industrialized country without universal coverage.  More than two-thirds of bankruptcies in the U.S. are because of health care costs.  And, thousands of children seeking to immigrate to the United States are being held in horrifying conditions in U.S. border control facilities, denied access to basic health care services and personal hygiene, a direct consequence of government policy.

Many of us will be with family members on Thursday celebrating Independence Day, and the politics of U.S. health care, Medicare for All, limits on reproductive rights, guns, and immigration may very well come up.  It might be a good time to reflect that when it comes to living up to the Declaration of Independence’ founding principle, “We hold these truths to be self-evident, that all men [and women] are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” U.S. health care and U.S. government policy fails to measure up in so many ways.

Tuesday, April 23, 2019

If they build it, will they come?

On April 22, the Department of Health and Human Services (HHS) unveiled new alternative payment models that it hopes will “transform” primary care to support high-value care. Released at a briefing hosted by the American Medical Association and attended by me and other ACP officials and members (and hundreds of other “stakeholder” groups, plus the news media), the proposals would create more voluntary options for primary care physicians and their practices to be paid for keeping patients healthy and out of the hospital.

One of the new models, called Primary Care First, “will focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments.  The other, called the Direct Contracting (DC), is directed at large systems that have the experience and capabilities to take on substantial financial risk for large numbers of patients.
In today’s post, I am only going to summarize the key elements of the Primary Care First (PCF) model, taken mostly from CMS’s fact sheet, because it’s expected to be available to far more internists than the Direct Contracting model.

Practice Eligibility: To be eligible to participate in the PCF model, a practice must include “primary care practitioners, (MD, DO, CNS, NP and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine and hospice and palliative medicine.”  It must have 125 attributed Medicare beneficiaries at a particular location, have primary care services account for at least 70% of the practices’ collective billing based on revenue, and in the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services. It must also “have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.” 

Geographic locale: The practice must be in one of the 26 regions selected for the program: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

Simplified payment structure: Each practice accepted into the program will be paid what CMS calls a “simplified payment structure” consisting of risk-adjusted per beneficiary per month (PBPM) payments, plus a flat set amount for each office visit. It will get a “performance based adjustment providing an upside of up to 50% of revenue as well as a small downside (10% of revenue) incentive to reduce costs and improve quality, assessed and paid quarterly.”  A different [and higher] payment structure will apply to PCF practices that agree to treat seriously ill patients that are currently lacking a primary care practitioner.

Quality Assessment: CMS will assess quality of care based on “a focused set of measures that are clinically meaningful for patients with complex, chronic needs and the serious illness population.”

Predictable revenue and reduced administrative burdens: CMS believes that PCF will appeal to a wide range of primary care physicians and their practices, including those in small and solo practices, because the risk-adjusted PBPM payments will provide them will predictable revenue each month, with limited downside risk (maximum 10% reduction) and substantial upside potential gains (50% of revenue). Administrative burdens will be also less, because the flat office visit fee eliminates the need to document different levels of office visits. Administrative burdens might also be reduced if PCP practices only have to report on a more focused set of quality measures.

By building the PCF program as described above, CMS believes that primary care physicians will come to it, like the baseball fans drawn to the cornfield baseball diamond in Field of Dreams. CMS needs them to come, because as a completely voluntary program, there has to be enough physicians, practices, and patients participating to assess the model’s effectiveness and reproducibility.  But will they?

It’s too soon to tell.  

 As ACP observed in a generally supportive statement issued today, there are elements of the PCF model that suggest that CMS is on the right track: there are a variety of payment and delivery models offered that support internal medicine and primary care practices, from smaller and independent practices to larger integrated ones; there is a range of risk options available to practices, and the new models aim to reduce administrative burdens—potentially allowing physicians to spend more time with their patients.

However, a lot of details are still missing that may determine how many physicians and practices will seek to participate, including basic things like how the PBPM payments will be adjusted by risk, the amount of those payments, and how they are to be calculated. Also, unless other payers join Medicare in supporting PCF practices with a simplified payment structure and more focused measures, practices may not experience the reduction in administrative burdens and predictable revenue that CMS anticipates. Presumably, CMS will be releasing such information soon, prior to the enrollment period it intends to begin this summer.

ACP concluded its statement with a note of caution: “The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things. ACP will continue to evaluate the new payment and delivery models based on such considerations, and we look forward to working with CMS and to continue advocating for ways to support the value of primary care for physicians and for all patients across the health care system.”

If CMS really wants primary care physicians to come to the models they've built, these - and other practical considerations - need to be included in their design. We'll soon find out if they will.

Wednesday, January 23, 2019

Reflections on 40 Years of Advocacy for Internists

Yesterday was the 40th anniversary of my career in representing internal medicine doctors, first with the American Society of Internal Medicine, and then with the American College of Physicians after the ASIM-ACP merger in 1998.   My first day on the job for ASIM was January 22, 1979.

To understand how long ago it was when I started working for ASIM, in the month of January 1979:

Jimmy Carter was President. He proposed on 1/14 that Martin Luther King’s birthday become a national holiday.

The Village People's Y.M.C.A became their only UK No.1 single.

The Shah of Iran fled Iran during the cultural revolution. 1 million marched in Tehran in a show of support for the exiled Ayatollah Khomeini.

In Super Bowl XIII, the Pittsburgh Steelers beat Dallas Cowboys, 35-31; MVP: Terry Bradshaw, Pittsburgh, QB.

Tom Brady was only 17 months old.  Really.                               

The Dukes of Hazzards premiered on CBS.

The “Wiz" closed at Majestic Theater NYC after 1672 performances.

Pope John Paul II embarked on his first overseas trip.

Midnight Express, starring Jane Fonda and John Voight, won the Golden Gloves award for Best Picture.

I was 22, a few months out of college; my hair was brownish (not white), quite a bit longer, and parted in the middle; and I weighed quite a “few” pounds less than now.  Had you asked me then if I would still be advocating for internists four decades later, I’d have said you were crazy.

So how is it that I am still here 40 years later?

I work for internists—a special breed of doctor that almost without exception, has been caring, thoughtful, engaging, creative, supportive of me and others on the [ASIM, ACP] staff, and fun!  There is no better group of physicians to work with, or for, than internists.  Many of them are my friends.

I’ve had great mentors and supporters of my career, from every one of the bosses that I reported to, from Bill Ramsey (ASIM), Mark Leasure (ASIM), Joe Boyle, MD (ASIM), Alan Nelson, MD (ASIM, and ACP), Walt McDonald, MD (ACP), John Tooker, MD (ACP), John Mitas, MD (ACP), Steve Weinberger, MD (ACP), and now Darilyn Moyer, MD (ACP).  Their management styles couldn’t have been more different, yet I’ve learned so much from them, and I’m still learning.

I was able to contribute to the successful merger of ACP and ASIM in 1998, working with Alan Nelson, Mark Leasure, John Tooker, and Walt McDonald to bring together the staff from the then-ACP and then-ASIM Washington offices into a team of equals, after years of being rivals.  The result has been the most effective physician advocacy organization on the planet (IMHO).

I am privileged to work in an organization where there is mutual respect between our internist-members/leaders and their staff, recognizing that we each bring different skills to the organization. This organizational culture of staff and physicians being on the same team is rare in American medicine.

I’ve been to all 50 states on business trips, and seen the beauty and diversity of our country in ways few are able to experience.  I’ve talked to many thousands of internists in my travels, learning from them what can be done to make things better for them and their patients.

I’ve been able to write often about health care, feeding my inner journalist.

I’ve been invited to author/co-author some of ACP’s most influential policy papers, many published in the Annals of Internal Medicine, addressing topics from universal coverage to gun violence to reducing administrative burdens to improving payments for internists’ services, and many more.

I’ve had the best staff colleagues, and still do; many are among my closest friends.

And, at the top of my list, my career has allowed me to make a difference, improving health care for patients and improving the professional lives of internists.  Is there anything more defining than that for a successful career?

It’s been a great 40 years of being an advocate for internists and patients.  I plan to keep on doing it, until . . . well, I’ll know when it’s time.   But not yet, not too soon; there is still too much to accomplish and still too many good times ahead!

Thanks to all of you for your support and friendships over the past 4 decades.