The ACP Advocate Blog by Bob Doherty

A health reform wish list

noreply@blogger.com (BDoherty) — Wed, 09 May 2012 20:05:00 +0000

Remember as a kid tossing a coin into a fountain, closing your eyes, and silently mouthing your deepest wish (a puppy, a bike, a BB gun?). Didn't work, of course, unless your parents or Santa (coincidentally?) had the same wish for you.

Nowadays, I wish there was a magical Wishing Well that would deliver on my wish for a more civil, more informed, less ideological, more evidence-based, more compassionate, and less polarizing debate over health care reform and the Affordable Care Act. More specifically, I wish:

--That fiscal conservatives who say we can't afford the ACA because it doesn't do enough to control costs would not in the next breath label as "rationing" the programs it creates to reduce costs and even improve patient outcomes. Advance care planning, Accountable Care Organizations, evidence-based benefit packages, medical homes, Comparative Effectiveness Research, regulation of insurance companies' underwriting and administrative expenses, preventive care, and even the beleaguered Independent Payment Advisory Board may save money, or maybe they won't, and maybe there is a better way (let's hear it!), but they won't ration care, period. And while we are at it, how about acknowledging that no society can spend unlimited resources on health care alone, so decisions have to be made on what we can afford, and what we can't? It is just a question of how, and by whom.

--That liberals would not automatically dismiss the concerns of conservatives about the ACA's cost. The law will cost a ton of money—a trillion dollars over the next decade, according to the CBO. Both sides should admit that even though the CBO says that the law (barely) pays for itself, long-term cost estimating is an imprecise business and it could cost more, it might cost less. One can still argue that the ACA is worth it—my view, and ACP's view—for the good it can do in expanding health insurance and eliminating other barriers to care, while still acknowledging that it is legitimate to worry about the cost of a big new entitlement program.

--Speaking of CBO, I wish that all sides (and yes, I have done this myself, mea culpa!) would stop selectively citing the CBO or the Medicare actuary when it helps their case and then dismiss the same when it doesn't. The CBO and actuaries do the best they can, but as far as know they are not soothsayers and can't see the future. And let's face it, their methodologies are rather opaque. So yes, their forecasts should be considered in context, but we should all be a bit more humble about citing them to "prove'' our own biases.

--That conservatives would stop calling the law socialism. Only in America would subsidizing the purchase of private, often for-profit, health insurance be labeled socialism! (We do have socialized medicine in the U.S—it is called the VA and the health care system for men and women in uniform administered by the Department of Defense—but even Tea Party types aren't calling for their repeal!).

--That liberals would acknowledge that the government isn't the source of all good and business and markets the source of all evil. The government does some important and good things, like regulating the safety of food and drugs, funding medical research and providing programs to help people who are falling behind—like the uninsured who will be helped by the ACA. But the government also often does things inefficiently, bureaucratically, indifferently, and expensively, and at its worst, it can stifle innovation and distort markets. And corporations—yes, even drug companies and health insurers, for heaven's sake—can simultaneously contribute to the public good and generate profits for their shareholders, like producing a new cure (drug companies) and helping millions of people afford health care (insurers).

--That conservatives would acknowledge that the government isn't the source of all evil and business and markets the source of all good. An elected government "of the people, by the people, for the people" (as Lincoln called our American democracy in his Gettysburg address) is the way that Americans make decisions together on how to "promote the public welfare" (per the constitution). Government regulation and funding can help keep us safe, find cures to diseases, and provide economic help to people (see above list) when companies and markets are unable or unwilling to. The ACA was created precisely because business and markets alone have not been able to provide tens of millions of Americans with access to affordable health insurance.

--That liberals would listen to the concerns of conservatives about government getting too involved in their health care, the most personal of personal concerns. It is not irrational or unreasonable for people to worry that if the government can define what services will be covered, how and what their physicians would be paid, what insurance companies can cover, and even require people to buy health insurance, the government will over-reach and limit personal choices and freedom.

--That conservatives would acknowledge that lack of health insurance is a matter of life and death, and that liberals would admit that having health insurance doesn't guarantee access to care. It used to be that Republicans and Democrats alike agreed that the government has a role in ensuring that all Americans have access to health insurance, but disagreed on the means, but now many on the right argue that health insurance really isn't all that important, that the uninsured get care anyway. But an Urban Institute update of a groundbreaking Institute of Medicine report from several years back found that tens of thousands of Americans die each year because of lack of health insurance. But the left needs to understand that many of the uninsured get compassionate care from selfless physicians, and that health insurance won't guarantee access if, say, there aren't enough doctors to take care of them.

In other words, my wish is that all sides of the health reform debate would be more humble, more willing to consider the other sides' views, more informed about what the law actually does and doesn't do, less inclined to use polarizing and absolutist words to make their points, that is, to be more willing to listen to each other and try to find the right balance on how much the government should be involved in health care. But getting that wish fulfilled is about as likely as the BB gun I wanted as a child and that my (rightly) protective parents would never give me.

Today's question: What do you think of my wish list? Do you have your own?

Is family medicine the only “pure” primary care specialty?

noreply@blogger.com (BDoherty) — Tue, 01 May 2012 16:19:00 +0000

Brian Keppler writes that family physicians are the only "pure" primary care specialty, in a Kevin MD post railing against the decision by the American Academy of Family Physicians (AAFP) to remain in the RUC (RVS Update Committee). So what does that make internal medicine, an impure primary care specialty? (Brings back memories to me of the nuns in my Catholic parochial school, warning us to guard against impure thoughts—even when we were only eight years old!)

Keppler's point seems to be that because ACP represents internists who provide primary and comprehensive care, as well as IM subspecialists like endocrinologists and rheumatologists, we can't be expected or trusted to advocate for primary care. Apparently, in his view, unlike AAFP, which represents only primary care physicians, because family medicine doesn’t have subspecialties. Not only that, he makes the unsubstantiated claim that ACP (and AOA and AAP) are "dominated by sub-specialists, and so have been content with the RUC’s approaches."

(Well, if he was privy to the communications that I get from IM subspecialists who claim that ACP is too oriented to primary care and not doing enough for subspecialists, he might have a different view. I also hear from IM specialists in primary care who say that ACP is too focused on its subspecialist members! C'est la vie!)

The fact is that it was ACP that warned about the collapse of primary care in 2006, and it has been steadfast in advocating for policies to improve the lot of primary care physicians—internists, family physicians, and pediatricians. At the same time, ACP tries to effectively represent all of internal medicine, which requires consensus and most importantly, balance, something that is in short supply in today's polarized political environment.

ACP has also worked diligently to reform the RUC, and we have achieved a large measure of success, with the RUC's decision to add another seat for primary care and another seat for geriatrics, which will add to the existing seats for AAFP, ACP, AOA, AAP and a rotating seat for IM subspecialties. We also have advocated for establishing an independent panel, outside the RUC, to identify potentially misvalued services.

ACP’s record on the RUC and primary care isn’t the only thing that Keppler got wrong in his post: he called AAFP "the nation’s largest medical society" when actually ACP is the largest specialty society and AMA the largest physician society.

Keppler isn't the first one to refer to family medicine as the only "pure" primary care specialty. Consider this AAFP video that encourages medical students to consider family medicine this "versatile, pure primary care specialty."

Really, folks? Internal medicine and family medicine, along with pediatrics and osteopathic medicine, have had a long history of working effectively together to help our members in primary care. Do we really want to have a purity test about which specialty is the purest? Or to assume that organizations like ACP that have both primary care specialists and subspecialists can’t advocate for the interests of both? No primary care specialty can be effective if it goes its own way, jettisoning its alliances with its colleagues in other primary care fields.

Plus, it isn't just primary care that is undervalued or in shortage. The evaluation and management services of many IM subspecialists also are undervalued. And with demand increasing, we need an "all hands on deck" approach to help all physicians who are involved in care coordination and who will be needed to take care of an aging population with more chronic diseases. Not the divisive effort by Keppler and others to split primary care into "pure" primary care and, I guess, "impure" primary care specialties, like internal medicine.

Today’s post: What do you think about efforts to define family medicine as the only pure primary care specialty?

Walking the Walk

noreply@blogger.com (BDoherty) — Fri, 20 Apr 2012 19:55:00 +0000

Talking the talk about lowering health care costs is easy, walking the walk—not so much. But today the nation’s largest physician specialty organization—the American College of Physicians—released a plan to achieve big savings in Medicare while also improving outcomes for patients. The plan, released at a press conference held in conjunction with ACP’s annual scientific meeting in New Orleans, proposed major restructuring in Medicare pricing, payments, benefits and delivery systems to achieve better value for patients and taxpayers. ACP hopes to set an example for politicians and other advocacy organizations who talk about controlling costs, but aren’t willing to walk the walk by putting any serious proposals on the table.

How does ACP propose to reduce spending while achieving better outcomes?

Allow Medicare to consider the comparative clinical effectiveness and cost of different treatments and diagnostic tests in deciding what it will pay for.

Give beneficiaries some skin in the game by allowing cost-sharing contributions to vary based on evidence of clinical effectiveness and cost, so that they would pay little or nothing out-of-pocket for services of high value, and more for services of lower value.

Cover and pay for advanced care planning and palliative care.

Allow Medicare to get the best prices for drugs by acting as a prudent buyer, just like the VA does for its programs, but Medicare is prohibited by law from doing.

Begin to pilot test ways to adjust the pricing of physician services based on evidence of clinical effectiveness, so that doctors might be paid more for services that have more value to their patients and less for ones of lesser value.

Reward and strengthen primary care, which studies show is associated with better outcomes at lower cost. Pay for models, like Patient-Centered Medical Homes, where internal medicine specialists and other primary care physicians would work with teams of other health professionals to improve care coordination and achieve better outcomes for their patients—with accountability for achieving the desired results.

In other words, allow Medicare to do what any good business or government purchaser of services would do: purchase care that has been shown to deliver the best bang for the buck.

Common sense, you would think, but ACP’s proposals will invite controversy because much of the health care industry benefits from the status quo. If you are a physician who is doing just fine because Medicare pays you more than its services might be worth to the patient, you won’t want change. If you are medical device manufacturer that is doing just fine because you can get Medicare to cover the fanciest and newest diagnostic test without having to show that it offers any real value over existing and less costly alternatives, you won’t want change. If you are a drug manufacturer that is doing just fine by charging the federal government and patients a lot more than you would get if you had to competitively bid for Medicare’s business, you won’t want change.

But for internal medicine specialists and their patients, change is needed because the status quo is not working. You are not being paid commensurate with your value. You are not paid for things that can improve outcomes and save money, like advanced care planning and care coordination of high-risk, high-cost patients. You and your patients are not benefiting when hundreds of billions of dollars are wasted each year on things that have little or no clinical value or are overpriced, money that could be used to shore up support for primary care internal medicine and cut the deficit.

Some controversial ideas to save Medicare money have not earned ACP’s support, because they would shift more costs onto the backs of seniors who can’t afford to pay more. So in the position paper released this morning, ACP reaffirmed its opposition to a Medicare premium support model, unless and until well-designed pilot tests are done to determine the impact of premium support on patients’ access and out-of-pocket costs, adverse selection, and other factors.

Making seniors wait until age 67 instead of 65 to qualify for Medicare also didn’t make ACP’s cut, because this will just lead to more uninsured seniors—although some of them would end up on underfunded Medicaid programs—unless they are provided other affordable coverage options during the two more years they would have to wait for Medicare. For instance, ACP suggested that advancing the age of Medicare eligibility could be accompanied by allowing anyone over the age of 55 to buy into Medicare, with subsidies for lower-income persons, bringing more younger and lower-risk, lower-spending persons into the program while providing a coverage bridge until they reach age 67.

By walking the walk on proposing ways to lower Medicare costs while improving outcomes, ACP will get its share of abuse. I have no doubt that someone will try to pin the "rationing" label on us, even though there is a huge difference between spending money rationally by taking into account value to the patient—ACP’s approach—and denying access to services that actually have been shown to have value because the government doesn’t want to pay for them, the true definition of rationing.

But someone had to take the issue of unsustainable Medicare spending head on, and I am glad it is an organization of internal medicine specialists, because doctors more than anyone else have the credibility with the public, and the understanding of where our health care dollars are going, to make a real contribution to enlightening the debate on health care costs.

Today’s question: What do you think of ACP’s proposals to reform Medicare in an age of deficit reduction?

"You say you want a revolution, well you know, we’d all like to see the plan"

noreply@blogger.com (BDoherty) — Fri, 13 Apr 2012 16:22:00 +0000

Many skeptical doctors react to the mantra about revolutionizing health care delivery the same way John Lennon did when he wrote these lyrics for the 1968 Beatles anthem. Well you know, they’d all like to see the plan.

Well, you know, this week Medicare released two critical pieces of its plan to revolutionize health care delivery, naming the 27 medical organizations/groups selected for Medicare’s Shared Savings (Accountable Care Organization) program, and the geographic sites chosen for the Comprehensive Primary Care Initiative. (As I blogged in September, the Comprehensive Primary Care Initiative could be a game-changer for primary care, because it will provide sustained financial support and revenue opportunities from Medicare and private payers for participating practices.)

The Innovation Center’s announcements this week effectively counter two pernicious myths about the Affordable Care Act and physicians:

Myth # 1: That the government is trying to put independent physician practices out of business.

Myth # 2: That the government wants to put hospitals in control of physicians.

Actually, a majority of the organizations selected for the Shared Savings Program are "physician-led," as the AMA noted in praising the CMS announcement. But you don’t have to take the AMA’s (or my) word for it: just look at the descriptions from CMS and the physicians themselves of several of the 27 organizations who voluntarily agreed to join the Shared Savings Program:

The Atlantic Integrated Health Network "is one of the oldest self-sustaining physician-led networks in North Carolina."

The Coalition of Athens Area Physicians "represents 300 independent physicians from Athens, Georgia and surrounding counties."

Mississippi Coast Physicians "was founded by community physicians to offer accessible, cost effective and high quality healthcare services to employers and healthcare consumers along the Mississippi Gulf Coast."

North Country Physicians Organization "is a physician organization of 160 physicians" in upstate New York.

The Independent Physicians Network is "a Physician managed and controlled medical delivery network established in 1984" in the Milwaukee, WI community.

Accountable Care Coalition of Texas, Inc. is "an ACO created through a partnership between an affiliation of Independent Physician Associations, medical groups and health systems in the Houston/Beaumont area of Texas and Collaborative Health Systems."

"Owned and managed by physicians, AppleCare Medical ACO partners with more than 800 physicians in the region, as well as major hospitals and medical centers across Southern California to provide access to a full spectrum of facilities for receiving whatever care a patient may require."

"Located in Buffalo, NY, Catholic Medical Partners is a network of more than 900 independent practicing physicians."

"Coastal Carolina Health Care, the ACO’s sole participant, is a physician-owned and operated medical practice with over 50 providers."

There’s many more physician organizations in the 27 ACOs selected by CMS, but I think you get the point: physicians are the ones who will be leading the ACO revolution, through physician-controlled and owned organizations, ranging from tightly integrated group practices to looser coalitions and networks of independent smaller practices. The Comprehensive Primary Care Initiative will soon provide an opportunity for another 500 or so physician practices to lead the transition to the Patient-Centered Medical Home model, supported but not controlled by Medicare and other payers.

Well, you know, this is the way it should be: ACP has long argued that physicians are uniquely qualified to achieve the triple aim of better individual patient health outcomes, better population health, and lower per capita costs—not the government, not the hospitals, and not insurance companies. It is good to see this is Medicare’s plan as well.

Today’s question: What do you think CMS’s announcements say about its view of the role of independent, physician-owned organizations in revolutionizing health care delivery?

Overturn the ACA, and chaos will follow

noreply@blogger.com (BDoherty) — Fri, 06 Apr 2012 18:32:00 +0000

Imagine you’re a physician, and you have a full schedule of patients to see the day after the Supreme Court has thrown out the entire Affordable Care Act. Imagine you never liked “Obamacare” in the first place, so you are feeling pretty good about the Supreme Court decision.

Your first patient, an elderly retiree named Mrs. Jones, comes in for her annual Medicare wellness visit—one of the new Medicare preventive benefits offered at no cost to the patient. But this new preventive service benefit was created by the ACA, so presumably with the ACA overturned, Medicare no longer is allowed to pay for wellness visits. Do you tell Mrs. Jones that Medicare might not cover the visit? Provide the visit anyway, hoping that somehow Medicare will find a way around the Supreme Court ruling and pay for it? Offer it at no charge, or try to collect the 20% you would collect for a normal (non-preventive) office visit?

Your second patient, Mr. Jones, another senior, comes in for a follow-up visit for an ongoing chronic condition. You decide to renew his expensive brand-name prescription drug, knowing that he is eligible for a 50% discount because he has fallen into the Medicare Part D “doughnut hole.” Oh wait ... the Medicare Part D drug discount was part of the now-defunct ACA. So does that mean he now has to pay full price? Do you prescribe the drug anyway, knowing he can’t afford to pay the regular retail price? Prescribe a lower cost no-name brand drug that he doesn’t tolerate as well?

Your billing person prepares to submit the claim for Mr. Jones’ office visit. It ordinarily would have been eligible for the 10% bonus that Medicare pays for all office visits, nursing home and custodial care visits provided by primary care physicians. But that was before the Supreme Court overturned the ACA, and with it, wiped out the primary care bonus created by the law. With the bonus gone, your practice will lose about $4,000 over the next six months. Does the bonus disappear immediately—with this visit? What happens to bonus payments that were already paid out? Who knows?

Next up is Ms. Wilkins, a single mother of three who is seeing you for her diabetes and congestive heart failure. She is fortunate enough to be among the 50,000 Americans enrolled in the low-cost Pre-existing Condition Insurance Plan created by the Affordable Care Act and administered by the state. Oh wait, that was until the Supreme Court decision. With the ACA gone, the authority and funding for the Pre-existing Condition Insurance Plan disappears. Will she still be covered for this visit and any tests or medications she needs? And if so, for how long before the program is forced to shut down? Where else will she find affordable insurance? Will she go without it? Who knows?

A text message comes into you from your 22 year old son, a recent college graduate who hasn’t found a job. He has a doctor’s appointment for the knee he hurt playing rugby, and wants to know if he still will be covered by your health insurance plan. But the requirement that young adults up to age 26 be covered by their parents’ plans was part of the ACA, so presumably, your health plan no longer is obligated to keep him. Will it drop him? If it keeps him on, for how long, and for what extra premium?

You start thinking about your oldest daughter, a fourth year medical student who plans to apply for a loan repayment program from the National Health Services Corps in exchange for providing primary care in an underserved community. But the funding for NHSC in 2012 comes entirely from dollars mandated by the ACA. Will the NHSC now have to cut back on its award amounts and recipients? When, and by how much? Will she no longer be able to get a NHSC slot?

Your practice has joined with other primary care physicians in the community to become an accountable care organization (ACO) under the Medicare Shared Savings Program. It has spent tens of thousands of dollars and countless hours to do the planning and set up the infrastructure to qualify. But the federal money to pay for the Shared Savings Program comes from funds obligated by the ACA, so with the ACA gone, the ACO program may be suspended as well. Does that mean your practice wasted all of that money preparing to become an ACO?

Your local medical school has applied for Title VII primary care grants for faculty and scholarships for low-income students—the only federal program specifically designated to support primary care training. But the Title VII grant program was part of the ACA. Does that mean that the grants will be suspended? Who knows?

Your hospital expanded its internal medicine residency program because of a provision in the ACA that redistributes unused residency slots in other specialties to primary care. Who will pay for them if Medicare can’t? Will the slots have to be eliminated?

I could write pages and pages more of programs created by the ACA that would be invalidated if the Supreme Court overturns the whole law. What I can’t tell you—what no one can tell you—is how the federal government will deal with the absolute chaos that will follow.

Rules will have to be withdrawn and re-written, contracts suspended, agencies closed down or downsized, agreements renegotiated, delivery reform pilots terminated or scaled back, and mandated insurance protections suspended—with little guidance from the Supreme Court or Congress on what to do next. And there’s almost no chance that Congress will step in to repair the wreckage.

In the meantime, physicians and patients will be left reeling by the resulting chaos and confusion created by the court’s decision.

I haven’t even mentioned the 32 million Americans who would have gotten coverage in 2014 if the law was sustained—but will lose the most if the court overturns it.

Henry Aaron, a renowned health care expert at the Brookings Institution, also predicts chaos if the Supreme Court overrules the law:

“And what if the Supreme Court throws out the whole bill?

That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.

Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.

It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.

Is that the future we want?”

Today’s questions: What are you going to do to prepare for the chaos that will happen if the Supreme Court overturns the entire Affordable Care Act? Is that the future we want?

Don’t Ask, Don’t Tell

noreply@blogger.com (BDoherty) — Wed, 28 Mar 2012 18:57:00 +0000

Don’t Ask, Don’t Tell is making a comeback—directed now at doctors, not the military, but this version has nothing to do with sexual orientation and everything to do with the doctor-patient relationship.

Lawmakers across the country are involved in a feeding frenzy to see who can pass the most obnoxious, offensive and intrusive laws to prohibit physicians from asking or telling patients about clinical information that is relevant to their health. They also are going at the physician-patient relationship from the opposite direction, mandating what physicians must ask or tell patients about their medical care—and even what tests and procedures they have to impose on them. Without regard to a physician’s clinical judgment, patient preferences, informed consent, clinical effectiveness, medical necessity, or cost!

To illustrate how ridiculous this has gotten, last June I posted a satirical description of a new Florida law to prohibit doctors from discussing alcohol consumption with their patients. Actually, the real Florida law prohibits doctors from asking or telling patients about firearms safety—but to make my point, I substituted references to alcohol whenever firearms were referenced in the actual statute, such as:

“An act relating to the privacy of consumers of alcoholic beverages; providing that a licensed medical care practitioner or health care facility may not record information regarding ownership or consumption of alcoholic beverages in a patient's medical record . . .”

I asked “If Florida’s ban [on doctors asking patients about firearms] stands up in court, is it really out of the question that manufacturers and sellers of whiskey, or red meat, or even marijuana, might want to do the same?”

Well, I didn’t think to include fracking (high-pressure chemicals, sand, and water that is blasted into rock to tap into natural gas). Pennsylvania has passed a law so that doctors can get information from mining companies about a patient’s potential exposure to hazardous chemicals related to fracking, but they can’t disclose the information to anyone, including the patient they are treating! Here is the offending section of the PA law:

“If a health professional determines that a medical emergency exists and the specific identity and amount of any chemicals claimed to be a trade secret or confidential proprietary information are necessary for emergency treatment, the vendor, service provider or operator shall immediately disclose the information to the health professional upon a verbal acknowledgment by the health professional that the information may not be used for purposes other than the health needs asserted and that the health professional shall maintain the information as confidential. The vendor, service provider or operator may request, and the health professional shall provide upon request, a written statement of need and a confidentiality agreement from the health professional as soon as circumstances permit, in conformance with regulations promulgated under this chapter.”

Excuse me, but doesn’t this seem fracking ridiculous to you? If I were a patient, and my doctor found out that I had been exposed to specific chemicals that might have harmed my health, shouldn’t I have the right to know about them—and shouldn’t my doctor be obligated to tell me?

To be clear, the American College of Physicians has no policies on fracking. We don’t have policies on access to abortion services, or the right to bear arms (although we do support gun safety screening as part of a preventive risk assessment). On a few occasions, we or our state chapters have taken positions on state laws based on broad policies on the doctor-patient relationship and informed consent. With the national ACP’s support, our Florida chapter has objected to and joined in a lawsuit to successfully block the Florida gun safety gag rule. And ACP’s Virginia chapter recently wrote to its legislature to urge opposition to Virginia’s ultrasound before abortion bill, on the basis that “this legislation represents a dangerous and unprecedented intrusion by the Commonwealth of Virginia into patient privacy and that it encroaches on the doctor-patient relationship . . .” The chapter pointed out that it has no position, individually or collectively, on abortion itself. (An amended version of the bill passed and was signed into law by the governor.)

State lawmakers will offer all kinds of reasons for intruding into the doctor-patient relationship, from protecting business interests, to their ideology, to constitutional rights, to seemingly sincere and principled views on the morality and need for different medical interventions. But to me, the issue comes down to one thing: the government not telling my doctor what he can say or do or the decisions we make together about my health.

You would think that at least some of the people who are parading with their “Keep government out of health care” signs today outside the Supreme Court today would be even more concerned about their own states’ efforts to insert government, in the most fundamental and intrusive ways possible, into the relationship between doctors and their patients. They may discover that the real government takeover of medicine is happening in their own state capitols, not Washington.

Today’s questions: What do you think of state laws to tell doctors what they can and can’t ask or tell patients or what tests they must perform on them? And why do you think that there is not more of an outcry about such laws from the public, and from many physicians?

What now for health reform?

noreply@blogger.com (BDoherty) — Mon, 26 Mar 2012 15:56:00 +0000

Today, the American College of Physicians, the nation's second largest physician membership organization and largest specialty society, reminded the public why it is essential that the country not turn its back on reforms to provide all Americans with access to affordable health coverage. The statement, issued the day that the Supreme Court will begin to hear oral arguments about the Affordable Care Act's constitutionality and three days after the second anniversary of it being signed into law, points to the millions of Americans who already have been helped by the law. These include: young adults who are now on their parents' plans, children who can't be turned down because they have a pre-existing condition, seniors who have access to no-cost preventive services and reduced prices on prescription drugs, and fourth year medical students who are getting loan forgiveness or scholarships to practice primary care in underserved areas.

But the biggest changes are yet to come: affordable health insurance for nearly all Americans and 32 million fewer uninsured, to be achieved by offering sliding scale subsidies to help people with incomes up to 400 percent of the poverty level buy competitive private insurance offered through state-run exchanges, expanding Medicaid to pay for the poorest families (paid for almost entirely by the federal government—100 percent in 2014, going down to 90 percent of the cost by 2020—so that it isn't an unfunded mandate on the states), and a ban on insurance companies turning down or overcharging anyone who has a pre-existing condition. Oh, and the requirement that people pay a small (but unenforceable) penalty—the law doesn't allow the government to file charges or liens against people who refuse to pay—if they can afford health insurance but refuse to buy it.

These changes are hardly radical, and they are not "socialized medicine." (Only in the weird world of American partisan politics could subsidizing someone to buy for-profit private insurance be called socialism.)

And they used to have bipartisan support. ACP first proposed a similar set of policies in 2002 with no objections from our more conservative members—in fact, the only objections I recall came from liberal doctors who favored a single payer system! ACP's ideas were then incorporated into a bipartisan bill, the HealthCARE Act, introduced in two consecutive Congresses. Conservative think tanks including the Heritage Foundation until recently advocated a similar set of policies, including the individual insurance requirement that it now says is unconstitutional.

It was only when these policies became the Affordable Care Act, or "Obamacare," that bipartisan consensus broke down.

Now, the question is: will the Supreme Court, and the U.S. political process, allow these reforms to remain, or will we go back to the days when the country tolerated 50 million or more uninsured persons and allowed insurance companies to cherry-pick who they choose to insure?

I don't know what the Supreme Court will rule, and ACP's statement stayed away from the constitutional arguments because the organization's expertise is in evidence-based development of health policy, not constitutional law. But based on its assessment of the most effective ways to expand access to health care, ACP concluded that the key reforms created by the ACA—subsidies, exchanges, Medicaid expansion, and the individual insurance requirement—should be maintained.

I see no other viable political pathway to achieve ACP's decades-long vision that every American, no matter where they live or work or how rich or poor they are, should have access to affordable coverage for essential health benefits. If the ACA goes, there will not be a "replacement" plan offered by the law's opponents that will come anywhere close to providing coverage to nearly all Americans. (The GOP plans offered to date—health savings accounts, buying insurance across state lines, and medical liability reforms—would not materially reduce the percentage of uninsured Americans, according to the Congressional Budget Office.)

People will disagree on whether universal health insurance coverage is a right, but there didn't use to be much disagreement that it is the right thing to do. As we hear arguments over the next few days about the Commerce Clause, states’ rights, the anti-injunction act, broccoli, and rationing, I hope we don't forget the millions who have been helped by the ACA, and the millions more who will be if it is allowed to stand.

Dissecting the Ryan Budget

noreply@blogger.com (BDoherty) — Wed, 21 Mar 2012 19:12:00 +0000

Try your hand at today’s multiple choice quiz about the budget blueprint released yesterday by Rep. Paul Ryan (R-WI), House Budget Committee chair. The plan:

1.    Dramatically reduces the public debt over the next decade.
2.    Relies on unrealistic and vague assumptions.
3.    Drastically reduces health spending on the poor.
4.    All of the above.

The answer is all of the above—even though the first two statements seem to contradict each other. How can they both be true? Well, the Congressional Budget Office says this about the Ryan budget:

“At the end of fiscal year 2011, federal debt held by the public was 68 percent of GDP. The paths for revenues and spending specified by Chairman Ryan and his staff would lead to debt equal to 61 percent of GDP in 2023, 53 percent in 2030, and 10 percent in 2050. That debt would be a much smaller share of GDP . . .”

But here is the kicker: the CBO was relying on the “paths for revenues and spending specified by Chairman Ryan and his staff” in coming up with these estimates—that is, it is taking their word that Congress will come up with the required revenue and spending cuts, and that the policies proposed in the document will work as Rep. Ryan says they will. Or, as CBO itself puts it, “Those calculations do not represent a cost estimate for legislation or an analysis of the effects of any given policies. In particular, CBO has not considered whether the specified paths are consistent with the policy proposals or budget figures released today by Chairman Ryan as part of his proposed budget resolution.”

And, as the Washington Post points out in its editorial today, the Ryan budget is “intentionally vague” on how it would achieve the revenue and savings numbers that the CBO was working from:

“THERE IS NO credible path to deficit reduction without a combination of spending cuts and revenue increases. This is the fundamental conclusion of every responsible group that has examined the issue, most prominently the Simpson-Bowles commission, and it is the fundamental failure of the budget blueprint released Tuesday by House Budget Committee Chairman Paul Ryan (R-Wis.). Instead, and unfortunately, Mr. Ryan’s plan lunges in the opposite direction. He dangles the carrots of lower income and corporate tax rates. He says he would maintain tax revenue and in fact have it grow to 19 percent of the gross domestic product by 2025. Yet he fails to do the hard, and politically treacherous, work of specifying what deductions and credits he would eliminate in order to make all that happen. Does Mr. Ryan propose to eliminate the mortgage interest deduction? The preferential tax treatment of employer-sponsored health insurance? The deduction for charitable donations? Mr. Ryan says he’d leave those pesky details to the tax-writing House Ways and Means Committee, and no wonder: The nonpartisan Tax Policy Center said Mr. Ryan’s plan would reduce revenues by an eye-popping $4.6 trilllion — and that’s on top of the $5.4 trillion cost of making the Bush tax cuts permanent.”

What is much clearer is that the Ryan budget would cut so much out of Medicaid (the program that funds medical care for most of the poor) that it would result in millions more uninsured and underinsured poor Americans, according to an analysis by the Center for Budget and Policy Priorities. (The CBO agrees: “the magnitude of the reduction in spending . . . means that states would need to increase their spending [on Medicaid and the Children’s Health Insurance Program], . . . make considerable cutbacks in them, or both. Cutbacks might involve reduced eligibility, . . . coverage of fewer services, lower payments to providers, or increased cost-sharing by beneficiaries — all of which would reduce access to care.”)

The Washington Post’s Ezra Klein observes that the reduction in spending on the poor isn’t due to any intent on Rep. Ryan’s part to hurt the poor, but because the GOP’s “overlapping fiscal commitments . . . leave them few other choices”:

“I don't think Paul Ryan intended to write a budget that concentrated its cuts on the poorest Americans. But there's a reason their budgets turned out so similar: The Republican Party has settled on four overlapping fiscal commitments that leave them with few other choices. The Republican plans we've seen share a few basic premises. First, taxes are too high, and must be cut. Second, defense spending is too low, and should be raised. Third, major changes to entitlement programs should be passed now, but they shouldn't affect the current generation of retirees. That would all be fine, except for the fourth premise, which is that short-term deficits are a serious threat to the country and they need to be swiftly cut. The first three budget premises means that taxes and defense will contribute more to the deficit, and Medicare and Social Security aren't available for quick savings. That leaves programs for the poor as the only major programs available to bear cuts. But now cuts to those programs have to pay for the deficit reduction, the increased defense spending, and the tax cuts. That means the cuts to those programs have to be really, really, really deep. The authors have no other choice.”

The Ryan budget also includes a new version of last year’s Medicare premium support program, but this time, he would allow beneficiaries the option of enrolling in a public Medicare program in addition to the choice of using the government’s allowed contribution to buy private insurance. Under either option, most seniors would pay more for their care, because the government’s allowance would not likely keep pace with the costs of medical care.

Rep. Ryan deserves credit for laying out the fiscal choices facing the country (but not for his vagueness in how he would achieve the revenue and savings estimates). On that score, he has done much more to focus the debate on how to reduce the debt and the choices involved than President Obama and Senate Democrats, who have been quick to criticize while failing to offer their own detailed plans.

But physicians especially should be concerned about the impact of the Ryan budget on health care for the poorest Americans. The American College of Physicians has long advocated that every American, regardless of where they live or work or how much they earn, should have access to affordable health coverage. The Ryan plan, regrettably, violates this concept by taking health care away from those who can least afford it. There are better ways to reduce the public debt than going after health care for the most vulnerable.

Today’s question: What is your reaction to the Ryan budget?

Health care limericks

noreply@blogger.com (BDoherty) — Fri, 16 Mar 2012 16:07:00 +0000

As long-time followers of this blog know, I hail from a decidedly Irish background. My beloved late Dad, Jack Doherty, was born and raised in Drumshanbo, Ireland, emigrating to the United States with my grandmother at the age of 10. He owned, operated and tended bar at the establishment originally opened by my grandfather, Thomas, for more than 30 years, until he sold the bar in 1978. When I was in college, I worked behind the bar—the third generation of Doherty’s “behind the stick,” as the old-timers would remind me. The bar—then called Doherty’s Bar and Grill (located in Woodside, Queens, New York)—is still there and operating as a drinking establishment, but under a different name and ethnic clientele, serving a largely Latino population.

So as you can imagine, Saint Patrick’s Day is a big occasion in my family. One of my traditions is to write limericks to honor the occasion. Limericks are a “humorous, witty or nonsensical” poem named after the Irish city, following a prescribed AABBA rhyme scheme.

In honor of the great Saint Patrick, my Dad, Ireland, and Doherty’s Bar, I offer the following limericks to mark the occasion:

The SGR is like Groundhog Day
Something that just won’t go away.
Congress dithers,
Medical care withers,
As doctors turn patients away.

Doctors don’t always agree
With the positions of the A-C-P
My blog posts stir the pot
And make some downright hot
As they write, “You aren’t speaking for ME!”

(Okay, these aren’t going to win any poetry awards, but I hope they introduce a bit of levity into your day.)

Today’s question: How about taking a turn at writing a health care or political limerick for posting here?

Will health information technology make medical care MORE expensive?

noreply@blogger.com (BDoherty) — Thu, 15 Mar 2012 20:26:00 +0000

“Doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records,” reports the New York Times on the findings of a controversial new Health Affairs study.

The study’s authors write that “physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered,” suggesting to them that “electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering.” From this, they go on to make the sweeping conclusion that:

“Use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests.”

Not so fast, says Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, who issued a response to the Health Affairs article, taking issue with its methodologies and conclusions, which in turn invited a response to his response from the study’s authors. You can read an excellent account of the back-and-forth on this in an American EHR blog post by my ACP colleague, Dr. Michael Barr.

I don’t claim to be an expert on health information technology or on the methodological debate over the Health Affairs research, but my sense is that the study raises an important question—do health information technologies that make it easier to order and then read the results electronically also make it more likely that an unnecessary test will be ordered? I don’t think we definitively know.

But at the same time, there are enough questions about the study and its limitations to reach any sweeping conclusion on the value of health information technologies in reducing costs. Plus, as Dr. Barr points out in his blog post, the world of health information technology is changing rapidly, including the new stage 2 “meaningful use” proposed rules that will encourage adoption of clinical decision support tools, based on evidence-based guidelines on appropriateness, in computerized order entry systems.

Of greater significance than this one study alone is that it adds to a growing body of research and opinion (exaggerated and magnified by news reports and the blogosphere) that suggest that some of the most popular remedies offered to bring down rising health care costs won’t work. Last week, I blogged about the limitations of price competition, transparency, high deductible HSAs, and private contracting in bringing down costs; today, it is heath information technology that at least this one study says won’t deliver the bang for the buck. And my next post will be about studies that raise questions about the value of care coordination in lowering overall spending.

My concern is that the message that could be received by the public and policymakers is that nothing being contemplated today will be effective in bringing down health care costs. So why bother trying? Or let’s just pull the plug on the ones that aren’t working?

Healthy skepticism about the cost control idea of the day is good. More research is good. But at some point, showing the limitations of current cost control interventions and suggesting more studies won’t be enough. Instead, we will have to come up with an American way that will actually work to lower health care costs, or policymakers will end up on the tried and true cost control measures used in other countries: explicit rationing of services, and even more price and capacity controls.

Today’s question: What do you think about the research questioning the value of health information technology in lowering costs?

“Feeling much like a cow on a milking machine”

noreply@blogger.com (BDoherty) — Fri, 09 Mar 2012 18:24:00 +0000

A reason getting a handle on rising health care costs is so hard is that many of the approaches people hope will work to lower costs turn out to be not terribly effective, and those we know from evidence will work usually involve unpopular trade-offs.

Today’s blog will examine several new analyses that call into question the effectiveness of price competition and transparency in lowering health care costs. (Future posts will examine new studies on the impact on costs of health information technology and care coordination.)

The argument for price competition and transparency is straightforward. Markets do better than government in setting a fair and competitive price for health care services. For price competition to work, there needs to be more transparency in the price of health care services, so that patients can anticipate in advance what they would have to pay and can shop around for the best deal. And patients need to have more “skin in the game”—for instance, through high deductible conventional health plans and health savings accounts.

This all sounds great—in theory. Market-based competition works great for cell phones and tablet computers, driving down costs while steadily increasing capabilities and performance, so it should work for health care, right?

But what if health care is different, and price competition and transparency ends up driving up health care costs?

National Journal's Maggie Fox reports on a new Health Affairs study that found that if consumers are given information only on the cost of treatments, they prefer the more costly medical care. The study involved 1,400 workers, who were offered different doctors and care options. “If they were given details on price alone, the volunteers chose the most expensive choice,” presumably because they associated more expensive care with better care. Providing patients with quality and cost information “moderated” their choices—but the U.S. is a long way from developing a reliable “quality score” for patients to use in selecting a physician or hospital.

High deductible plans in theory should counter the bias for more expensive care, because patients would have a more direct economic interest in selecting a less costly source of care.

But a patient’s first-hand account, posted in ABIM’s Medical Professionalism Blog, shows how difficult it is for patients in high deductible plans to get physicians to reveal their prices or find less expensive care options. The patient, Court Nederveld of Florida, writes

“Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with my rise in blood pressure, it would be prudent to prescribe a blood pressure medication and order a nuclear stress test. With only a catastrophic insurance policy and a $5,000 deductible, it was imperative for my financial health to know the cost of both the drugs and the procedure up front.”

But he found this was much easier said than done.

Mr. Nederveld researched and sought out a less expensive hypertension drug than the Lotrel recommended by his doctor. He encountered resistance when he tried to get his doctor to reveal in advance the cost of a nuclear stress test or to consider a less expensive conventional stress test. Only after Mr. Nederveld’s persistence did his physician agree to a modest discount in the fee for the nuclear stress test, but even then, it was more than he could afford. He continues:

“Feeling much like a cow on a milking machine, I began to test the theory that medical procedures should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, and would willingly and promptly forward the results to my primary care physician. To verify that all was understood, I informed them that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11.” [Compared to his own physician’s “discounted” fee of $1,900 for the test plus an initial $250 consultation fee.]

You might say that Mr. Nederveld’s experience shows that high deductible plans and price competition can work in driving down costs, since he was able to get his nuclear stress test for less. But the enormous obstacles he encountered raise doubts in my mind about how realistic it is to expect that most patients, especially the elderly and those facing life-threatening conditions, will have the time, skills, and persistence needed to get a better deal, when the system is skewed against them and time may be of the essence.

Finally, another study has found that the United States spends more on health care than other countries because U.S. residents pay higher prices for common procedures. The Washington Post’s Ezra Klein blogs about a new Health Affairs study, which found that “in 22 of 23 cases, Americans are paying higher prices [for common procedures] than residents of other developed countries . . .Usually, we’re paying quite a bit more.”

And the reason we pay higher prices, Mr. Klein argues, is that in most countries the government controls or negotiates prices with physicians and other providers, whereas in the U.S. “it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured”—except for Medicare and Medicaid, which regulate the prices charged by physicians and hospitals.

So let’s connect the dots. When patients are given information about the cost of treatments by different doctors, they choose the most expensive ones. When they have more skin in the game because of a high deductible plan, they encounter huge barriers to getting advance information about the cost of care and finding less costly alternatives. And a main reason health care in the United States is more costly than in other countries is that there is less government involvement in setting prices, not too much.

People who argue that getting government out of health care and unleashing the market will lower health care costs start from a good, principled position that seems as American as apple pie. (ACP, for its part, supports greater price and quality transparency, and the option for physicians to privately contract with patients to charge a higher fee than Medicare allows, as long as there are safeguards to protect patients when they have no real choice.) But free-market advocates don’t get to simply ignore evidence that health care is so different from other markets that competition, price transparency and less government regulation might have the opposite effect of driving up prices and costs.

I think that there is a better way of looking at the question of market competition in health care than posing it as an either-or choice of more government or less. Instead, we could acknowledge that government works best when it uses its regulatory authority to make free markets work better (the reason our Founding Fathers gave Congress the constitutional authority to regulate interstate commerce), not to replace free markets.

So, instead of using its regulatory authority to directly set prices, the government could establish the rules of the game: require clinicians to provide accurate pricing, cost and quality data before care is rendered, mandate safeguards to protect patients from being over-charged when they have no real choice of physician, and break up insurance monopsonies that hinder competition. In theory, such regulated competition should work to lower costs, but even so, we can’t rely on theory and blind faith alone. We need solid evidence.

Today’s questions: What is your reaction to the studies that show that price transparency, competition and less government price regulation may increase health care costs? And what does Mr. Nederveld’s experience tell you about the barriers to market competition, even for a patient who knew “it was imperative for my financial health to know the cost of both the drugs and the procedure up front”?

Note: the original post of this blog incorrectly cited the author and source of the article on the study that people prefer more expensive care. This version has the correct reference.

Much ado about IPAB

noreply@blogger.com (BDoherty) — Wed, 29 Feb 2012 21:51:00 +0000

Congressional Republicans and some Democrats have set their sights on eliminating the Independent Payment Advisory Board (IPAB) authorized by the Affordable Care Act.

Today, the House Energy and Commerce Committee voted 17-5 to repeal IPAB, with the support of Frank Pallone (D-NJ), the ranking Democrat on the committee. The House likely will take up and pass the IPAB repeal bill later this year. Prospects for IPAB repeal in the Senate are far less certain, but even if repeal were to pass the Senate, President Obama could veto it. So IPAB likely will remain on the books for now.

Even if IPAB survives, it is unlikely to do much of anything for at least another six years. The members of IPAB won’t even be named by the President until 2014—and they would have to first be confirmed by the Senate (where their nominations likely would be subject to a filibuster by IPAB opponents). Then, assuming the President is able to get IPAB members confirmed, the board will submit recommendations to Congress to reduce costs only if spending exceeds a target rate of growth set by the statute. That likely won’t happen until 2018, at the earliest, according to HHS Secretary Kathleen Sebelius. IPAB’s recommendations would then automatically go into effect unless a “Super Majority” of Congress voted to override it. Even so, IPAB is prohibited from making any recommendations to ration health care, raise revenues or Medicare beneficiary premiums, increase Medicare beneficiary cost sharing, or otherwise restrict benefits or modify eligibility criteria.

(You can learn more about how IPAB is supposed to work in “The Internist's Practical Guide to Health System Reform,” published by ACP’s governmental affairs division.)

So IPAB hardly is a clear and present danger to anyone, if it ever will be.

Yet you wouldn’t know that from the rhetoric being hurled at it—with some calling IPAB a “death panel” or “rationing board.”

And, as Don Taylor explains in the Incidental Economist blog, some prominent Republicans—who today are ardent foes of IPAB—proposed similar unelected cost control boards. The Patients’ Choice Act, introduced in 2009 by Rep. Paul Ryan (R-WI), now chair of the House Budget Committee, would have created an unelected quality commission with authority “to make recommendations to the Secretary to enforce compliance of health care providers with the guidelines, standards, performance measures, and review criteria adopted [by the commission]. Such recommendations may include the following, with respect to a health care provider who is not in compliance with such guidelines, standards, measures, and criteria: (1) Exclusion from participation in Federal health care programs . . . and (2) Imposition of a civil money penalty on such provider.”

The point is that many Republicans and Democrats used to agree that an independent board of health care experts and clinicians could help the country decide on the difficult tradeoffs involved in controlling health care costs, outside of the usual political process where powerful health care industry lobbies can effectively block any legislation that hurts their economic interests.

For its part, ACP “believes that an independent board of physicians and other healthcare experts would be more likely to achieve needed Medicare changes, and be less affected by undue special-interest influence,” than Congress. The College believes that the IPAB has the potential to serve this role, but requires some significant modification—including amending the law to allow Congress to reject IPAB’s recommendations with a simple majority vote.

Maybe a future Congress will be able to demonstrate that it can make tough cost control decisions on its own, even if this means going against the special health care interests that fund the lawmakers’ campaigns. Maybe it doesn’t need an independent group of experts who really understand health care to help it figure out the most effective policies—and provide political cover for the unpopular tradeoffs involved. Maybe…but why in the world would anyone believe that Congress is up to the task?

Today’s questions: Do you think an independent board of health care experts is needed to help Congress make decisions on controlling health care costs? What do you think about the argument that IPAB will lead to rationing and “death panels”?

The Candidates offer up a budget fantasyland

noreply@blogger.com (BDoherty) — Fri, 24 Feb 2012 21:39:00 +0000

“If I had a world of my own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn't. And contrary wise, what is, it wouldn't be. And what it wouldn't be, it would. You see?”
- Alice, from Lewis Carroll’s Alice's Adventures in Wonderland & Through the Looking-Glass, 1865

Alice could have been talking about the budget fantasyland conjured up by the 2012 presidential candidates.

Recall that in his Republican response to President Obama’s State of the Union address, Governor Mitch Daniels (R-IN) promised that if the GOP prevails in the election, 2012 will be “the year we strike out boldly not merely to avert national bankruptcy but to say to a new generation that America is still the world's premier land of opportunity.”

So you might assume then that the Republican presidential candidates have plans to reduce the debt, right?

You might, but you would be wrong.

“The national debt would balloon under tax policies championed by three of the four major Republican candidates for president,” according to an independent study by the bipartisan Committee for a Responsible Federal Budget (CRFB), reported in yesterday’s Washington Post. Former Pennsylvania Senator Santorum would add $4.5 trillion and former House speaker Newt Gingrich would add $7 trillion to the debt by 2021, “pushing the portion of the debt held by outside investors to well over 100 percent of the overall economy,” writes the Post. Former Massachusetts Governor Mitt Romney's plan would add about $2.6 trillion.

The only Republican with a plan to lower the debt is Congressman Ron Paul, who proposes even bigger cuts in government programs than the revenue that would be lost from lower taxes, bringing down the debt by $2 trillion over the next decade. But Paul assumes a wholesale dismantling of most federal agencies and an end to entitlements—cuts that are not likely to be accepted by a majority of voters or ever be enacted by Congress.

The fact that three of the four GOP candidates would add trillions to the debt doesn’t let President Obama off the hook. In a separate analysis, CRFB finds that the under the President’s proposed FY 2013 budget request, “deficits would total $6.7 trillion (3.3 percent of GDP), with debt reaching $19.5 trillion (76 percent of GDP)” by 2022.

This, from a president who said that “if we don’t act, the growing debt will eventually crowd out everything else, preventing us from investing in things like education, or sustaining programs like Medicare.”

To recap, this is the year when:

the country will elect a new President from a Republican party that promises to “avert national bankruptcy”

or

we will re-elect a President from the Democratic party who said “if we don’t act, the growing debt will eventually crowd out everything else”

and this is how much more their tax and spending plans would add to the public debt:

Romney: +$2.6 trillion

Santorum: +$4.5 trillion

Obama: +$6.7 trillion

Gingrich: +$7 trillion

“If [they] had a world of [their] own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn't. And contrary wise, what is, it wouldn't be. And what it wouldn't be, it would. You see?

Today’s question: Will the voters see through the candidate’s budget fantasyland and demand real answers on taxes and spending?

“We are playing a silly little game with doctors and Medicare patients.”

noreply@blogger.com (BDoherty) — Fri, 17 Feb 2012 19:43:00 +0000

This is the best description I’ve heard of the short-term Medicare SGR “patch” that passed the House and Senate today. It didn’t come from a press release from organized medicine, but from someone directly involved in the process, House Minority Whip Steny Hoyer (D-MD). Here is the full quote from his speech today on the floor of the House, minutes before it voted to extend Medicare payments to doctors for another 10 months:

“We are playing a silly little game with the doctors and with Medicare patients, and this silly little game pretends we are going to extend SGR for 10 months. That's baloney and everybody knows it. We are going to extend SGR over and over and over again. We should have done it permanently in this bill. We should have done it permanently last year in the Congress which I was the Majority Leader. We should have done that. So with respect to SGR, ladies and gentlemen, we are playing a game, and the doctors all over this country and the Medicare recipients all over this country know we're playing a game. We're giving them no certainty, no confidence that come this September, October, November, we won't have another one of these silly little debates.”

Now, a cynic would point out that Congressman Hoyer is a Democrat in a Republican-controlled House, so it is easy for him to take pot shots now. But at least he was honest in saying that getting rid of the SGR should have been done permanently last year when his party controlled the House and when he was the Majority Leader.

So maybe we should all stop referring to the Sustainable Growth Rate as the SGR, and start calling it the SLG—Silly Little Game—that has been played by Washington politicians from both political parties on doctors and patients for a decade now. But it won’t seem so silly, or much like a game, when patients no longer can find a doctor.

Today’s question: Are you going to tell your members of Congress to stop playing this silly little game with you and your patients?

A surgeon, an internist and a family physician walk into . . .

noreply@blogger.com (BDoherty) — Thu, 16 Feb 2012 21:39:00 +0000

. . . a congressional office (sorry, not a bar!), and actually speak with one voice on an important health care issue. No joke! Despite the reputation that doctors (deservedly so) have for not being able to agree on much of anything when it comes to health care policy, the American College of Surgeons, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association recently joined forces to lobby Congress on repeal of the Medicare Sustainable Growth Rate (SGR) formula.

And, when it became clear last night that Congress would not go along with repeal, the groups today collectively told Congress that the announced deal to extend the current Medicare rates for 10 months “neither solves, nor moves us closer to solving, the Medicare physician payment crisis.” The doctors noted that after the extension expires, the next cut will be steeper—an estimated 32 percent cut on January 1, 2013—and that “as a result, the threat to access will be greater, the budget price tag to eliminate the cut will be even higher, and the barriers to comprehensive payment reform will be even steeper.”

The four organizations represent a combined membership of nearly 400,000 physician and medical student members, which if they were one organization, would make them by far the largest single physician membership organization in the United States, representing almost 65% of all active U.S physicians! The AMA remains the largest single physician membership organization, with about 215,000 members in 2010, the most recent information I can find. ACP is second, with 132,000 members. (This is not to say that the loose coalition formed by the four specialty membership groups can or should replace the AMA—there remains a need for a national membership organization whose membership includes all physicians, without regard to their specialty, and includes strong representation from geographic (state) societies. The AMA is the only organization that fits the bill.)

But if ACP, ACS, AOA, and AAFP can continue to find common ground, just think about how much influence they could carry—and how much good it could do for the public! Even the idea that surgeons and primary care physicians can agree defies the usual expectation that their economic interests inevitably will collide with each other.

Now, I am not being Pollyannaish about the possibilities of cross-specialty collaboration. The potential for conflict remains, especially if the issue is one of redistributing dollars from one group of specialties to another. But as I look at the big issues facing medicine, I sense that there are wonderful opportunities for surgeons, internists, and family physicians, both MDs and DOs, to find common ground on such things as:

· Promoting high-value, cost-conscious care
· Ensuring that there are enough physicians in all fields to meet the demand for health care services
· Improving coordination and transitions of care
· Reducing red tape and regulatory hassles
· Reducing the costs of defensive medicine
· Influencing new models of health care payment and delivery, from ACOs to patient-centered medical homes
· Ensuring that health information technology works to the benefit of both physicians and patients
· Establishing team-based models of care that recognize each specialty’s contributions, and the contributions of non-physicians (including nurse practitioners and physician assistants)

Collaboration on such issues for the purposes of health care advocacy would parallel the movement at the practice level away from “siloed” physician practices to team-based and collaborative models.

It may take some time for the four biggest specialty organizations, and the specialties they represent, to put aside decades of suspicion and distrust, resulting mainly from battles over redistribution of money under the RBRVS, but the potential is there. This initial collaboration of ACP, ACS, AAFP and AOA may not have won the day (yet) on the SGR, but it was an important step forward to bringing the largest and most influential specialty organizations together. And that may have been the best thing to come out so far from what otherwise is another huge disappointment from Congress’ ongoing failure to fix the SGR.

Today’s question: Do you think surgeons, family physicians, and internists, DOs and MDs, can speak with one voice on critical health care policy issues? On which issues? And what should the next step be in the emerging relationship between ACP, ACS, AOA, and AAFP?

Here they go again

noreply@blogger.com (BDoherty) — Wed, 15 Feb 2012 22:03:00 +0000

Congress is expected to reach final agreement tonight on another "patch" to the Sustainable Growth Rate (SGR) cuts: 10 month continuation of current (2011) rates, followed by a 32% cut on January 1, 2013. In other words, the same old thing that Congress has been doing year-after-year, month-after-month: enact a patch that puts off a long-term solution. Even worse, the patch, like the others before it, will only make the next cut bigger (from 24.7% now to 32% on January 1). And, as the cut gets bigger, the cost to the budget of preventing it--and all future scheduled cuts--grows by tens of billions of dollars.

What is particularly difficult to understand is that Congress had an exit ramp this year from the whole SGR debacle. It could have used unspent money from overseas military operations that will never take place to prevent cuts from the SGR that Congress will never allow to happen. This would have produced more than enough money for Congress to fully repeal the SGR, without having to offset the cuts by goring someone else's ox. Just about every physician, hospital and seniors group had urged Congress to take this exit ramp but in the end, it decided to stay on the same familiar path of putting off the solution (and finding the money for it) to another day, another time.

To be fair, there were some members of Congress, Republicans and Democrats, who urged their colleagues to use the unspent operations money to get rid of the SGR, once and for all, but unfortunately, they didn't carry the day.

Where does this leave organized medicine? I expect it will fall to a post-election, lame-duck session of Congress to come up with a plan to eliminate the January 1, 2013 SGR cut, as well determining the future of the Bush tax cuts (also expires at the end of the year) and across-the-board budget sequestration cuts scheduled for 2013. ACP will continue to push for a permanent solution as the only right thing to do--but I wouldn't bet on it.

Some of you will no doubt want to blame one political party or the other. But the fact is that an institutional failure to enact a permanent solution to the SGR has been the legacy Congress' and administrations stretching back to 2002, the first time an SGR cut went into effect, no matter which party was in control at the time.

And some of you no doubt will blame your professional organizations for Congress not enacting a permanent solution. Criticism is fair game, and I would welcome ideas on what we might do differently next time. But other than taking steps that violate physicians' own professional ethics, like organizing strikes and boycotts, I can't think of what we might have done or do differently.

Today's question: What will you say to your members of Congress about the latest SGR patch?

“My love for you is like health care cost growth: out of control”

noreply@blogger.com (BDoherty) — Tue, 14 Feb 2012 17:12:00 +0000

Policy wonks have a reputation as being rather serious folks who can talk incessantly about things like medical loss ratios, CBO scoring, and risk pools – not exactly fodder for a knee-slapping good time or a romantic night on the town.

But many of us do have a sense of humor, as evidenced by the Health Policy Valentines shared on a new Twitter hash tag. The hash tag, started by a federal government staffer to share with her friends, has gone viral, getting thousands of responses and inviting attention from the Washington Post and New York Times, among other “mainstream” media. (For those of you who are not Twitter savvy, a hash tag is a way of organizing Twitter discussions around a central theme. So the #happyvalentinesday hash tag allows Twitter subscribers to create and share their own health policy-related Valentines.)

But you don’t need to be on Twitter to enjoy the Health Policy Valentines. The headline for this post is one of my favorites, written by Sara Kliff, a health reporter for the Washington Post. I wrote and Tweeted several myself (my Twitter “handle” is @bobdohertyACP if you want to follow me):

Will our love have a sustainable growth rate? Or will our hearts be broken, year after year after year?

Hey, sweetheart, the CBO isn't the only one who knows how to score!

My love, I'll define my contribution if you'll define my benefit.

Sweetheart, I've paid into this relationship for all these years, so I'm entitled to be your Valentine.

My love, please don't repeal and replace me!

I'll show you my medical loss ratio if you'll show me yours!

If love was like health reform, does that mean that people could shop around for a better deal through an exchange?

If love was like health reform, it would be universal and portable. Kind of like San Fran in the Summer of Love.

If love was like health reform, everyone would have to have a partner, or pay a penalty.

Is a broken heart a pre-existing condition? If so, will you mend mine or exclude me?

I promise to be true to you in good times and bad, with guaranteed renewability and no life-time limit on my love.

Some of my favorites (not penned by me):

No court would ever strike down this love!

You are my statistically significant other.

Roses are red, violets are blue, I could never ration my love for you!

How about trying your hand and posting your own Health Policy Valentine as a comment to this blog? And Happy Valentine’s Day!

Today’s question: Can you write and post a Health Policy Valentine, in 140 characters or less?

The Myth of the Well-heeled Senior

noreply@blogger.com (BDoherty) — Wed, 08 Feb 2012 15:07:00 +0000

One constant public policy challenge is that some things that people fervently believe to be true—often based on their personal observations—just aren’t so. Take the myth that most senior citizens are well-off—and can afford to pay more for their health care.

If you believe this to be true, then it makes eminently good sense to raise Medicare co-payments. Or to lift the restrictions on doctors charging more than Medicare’s approved amounts. Or to give seniors a voucher so they can shop around for coverage, even if though this might mean they would have to pay the difference between the voucher amount and the actual premium. They can afford it, right?

Not really. Most seniors are less Warren Buffet and more all-you-can-eat buffet types, searching for ways to stretch their limited fixed incomes. The Census Bureau’s data on household income by age shows that the median income for households whose occupants are 65 and older is only $31,354, the lowest of all groups except those aged 15-24. For all households, all ages, the median is $49,177.

There’s more. Crunch the Census Bureau numbers, and you’ll find that 47% of senior households have incomes of less than $25,000. Twice as many senior households reported incomes below $15,000 (19%) as those with more than $100,000 (9%). Some 12% of senior households have incomes between $50,000 and $75,000. Thirty percent of senior households have incomes between $25,000 and $50,000.

[Note that the above figures are from 2009 Census data, the most recent I could locate. Given the deep and abiding economic slowdown since then, there is no reason to expect that things are much different today.]

And the Census Bureau data probably overstates individual seniors’ incomes. A study by the Urban Institute for the Kaiser Family Foundation reports much lower median incomes for Medicare beneficiaries, most likely because the Census Bureau data cited above is for households with occupants age 65 or older, which may include more than one senior in the household. The 2010 median income for individual seniors, according to the Urban Institute study, was only $22,000, and less than 1% had incomes above $250,000. Most also had very limited assets and savings.

Also, most seniors depend on Social Security for their incomes. “For more than half (55%) of elderly beneficiaries, Social Security provides the majority of their cash income. For one-quarter (26%), it provides nearly all (more than 90%) of their income. For 15% of elderly beneficiaries, Social Security is the sole source of retirement income,” reports the Center for Budget and Policy Priorities.

And seniors on Medicare already pay a lot for their health care. Another study for the Kaiser Family Foundation finds that “median out-of-pocket health spending as a share of income increased from 12% in 1997 to 16% in 2006,” and “1 in 4 Medicare beneficiaries spent 30% or more of their income on health expenses in 2006; while 1 in 10 beneficiaries spent more than half their income on health expenses.”

So here’s the rub: many of the proposals to reform Medicare essentially shift more costs to seniors, or at least to some of them—through vouchers, higher deductibles, higher co-insurance, or raising the age of eligibility—yet most seniors don’t have the means to pay more. Some surely could, of course—and from a fairness point of view, plus bringing in some more revenue, it might make sense to ask them to pay more. But it won’t bring in enough revenue to solve the fiscal crisis facing Medicare, and it could put many seniors at risk of not being able to afford their health care. Is that what we really want to do?

There also are strong arguments—like the right of patients and physicians to privately contract for services—that can be made for lifting the restriction on doctors charging seniors more than Medicare’s approved amount, especially as long as the government continues to threaten them with double-digit cuts because of the Medicare SGR formula. But let’s not kid ourselves: relatively few seniors have the financial resources to make up the difference between what Medicare pays and what their doctor considers a fair fee. And can physicians really know which of their patients can afford to pay more and which ones should be charged less? Even seemingly well-off patients may not be doing as well as they seem, and many might not want to discuss their personal financial circumstances with their doctor. Appearances, after all, can be deceiving.

It is undeniable that the financing structure for Medicare will need to be changed, and some recipients will have to pay more for it. But we need to proceed with caution, and not allow the myth of the well-heeled senior to drive public policy decisions, when most seniors are just getting by.

Today’s question: What is your reaction to the data that most seniors are not well-off, and what do you think it means for proposals to require them to pay more?

A tip of my hat to ACP’s physician leadership

noreply@blogger.com (BDoherty) — Wed, 01 Feb 2012 18:53:00 +0000

One of the things that I like most about my job is engaging with ACP’s physician leadership—the internal medicine doctors who dedicate enormous amounts of time, at great personal sacrifice, to represent the interests of our members and their patients.

One of the things that I like least is when an ACP member (or non-member physician) caustically dismisses their efforts, usually because they disagree with some aspects of ACP policy. It is one thing to disagree with ACP’s policies and priorities or to be frustrated with the pace of change, but it is another thing altogether to label your colleagues (whom you probably don’t even know) as being “out of touch” or “Ivory Tower” doctors! I can’t think of anything that is more insulting to physicians than a colleague implying that they aren’t “real” doctors taking care of real patients.

Why am I worked up about this today? Because yesterday I witnessed what ACP’s physician leadership do for ACP’s members and the enormous challenges and sacrifices involved. Yesterday, ACP’s president, Dr. Virginia Hood, and ACP’s chair of the Board of Regents, Dr. Yul Ejnes, came to Washington to join with the leaders of the other three largest national specialty societies to lobby Congress to end the cycle of Medicare payment cuts, once and for all. Along with the leaders of the American College of Surgeons, the American Osteopathic Association, and the American Academy of Family Physicians, they spent a grueling day meeting with 22 members of the House and Senate and their staffs to urge SGR repeal, paid for by money that has been budgeted—but will never be spent—on military operations in Iraq and Afghanistan.

What did this involve? Drs. Hood and Ejnes had to come in on Monday night, after a full day at their real jobs—being internal medicine physicians. To be here, they had to reschedule all of their Tuesday appointments, when I know that inconveniencing patients is the last thing they want to do. On their flights to DC and late in their hotel rooms, they had to read arcane explanations of how the Congressional Budget Office “scores” federal spending (not exactly what they learned in medical school!) They had to be at a 7:30 a.m. breakfast on Tuesday to meet their counterparts from the other participating societies and to be briefed in advance of the Hill meetings. Then, they spent the rest of the day being directed around Capitol Hill to their respective meetings, one after another, all day long.

And the Hill meetings themselves were hardly a walk in the park. Yes, some of the members of Congress and their staff welcomed them enthusiastically and indicated support for their request. Others listened politely but didn’t commit. Others were at best skeptical. Some lectured the doctors and tried to get them to choose sides in the partisan fight over health reform. A few were even dismissive or hostile.

What did they accomplish? Lobbying is a slog, and we won’t know for a few more weeks what Congress is going to do about the SGR. But we know that the good doctors accomplished one very big thing: they showed Congress that the four largest national physician specialty organizations, representing more than half a million doctors, speak with one voice on the need to repeal the SGR. And by taking the time to come to Washington, they showed Congress how deeply they care about patients and their profession—as only real doctors who take care of real patients could do.

So I hope that next time you know of someone who is tempted to blast ACP’s leadership as being out of touch, remind them of this: ACP’s leaders are just like them, except that they have chosen to dedicate a substantial portion of their professional lives to organizational efforts to make things better for their colleagues and their patients.

And by doing so, they are living up to Alexis de Tocqueville’s famous 1831 observation that:

“Americans of all ages, all conditions, all minds constantly unite. Not only do they have commercial and industrial associations in which all take part, but they also have a thousand other kinds: religious, moral, grave, futile, very general and very particular, immense and very small; Americans use associations to give fêtes, to found seminaries, to build inns, to raise churches, to distribute books, to send missionaries to the antipodes; in this manner they create hospitals, prisons, schools. Finally, if it is a question of bringing to light a truth or developing a sentiment with the support of a great example, they associate.”

Yesterday, Drs. Hood and Ejnes came to Washington to unite with other physicians to bring light to a truth and develop a sentiment in Congress to end Medicare cuts, using their own great example as internal medicine physician specialists who care deeply about their patients. I tip my hat to them. They would have made de Tocqueville proud.

Today’s question: What do you think of my view that it is simply wrong for physicians to dismissively label the leaders of ACP (and other professional associations) as being “out of touch” and “Ivory Tower” doctors (no matter what you think of the organizations’ policies)—when in fact they are real doctors, taking care of real patients, who have chosen to live up to de Tocqueville’s perhaps idealized view of America?

How Bad Budgets and Broken Politics Undermine Health (and what can be done about it)

noreply@blogger.com (BDoherty) — Thu, 26 Jan 2012 21:21:00 +0000

Earlier today, the American College of Physicians released a report on the State of the Nation’s Health Care in 2012. The report makes the case that unwise budget choices and broken politics are undermining progress in reducing health care costs, improving health and expanding access. It calls on Congress to reverse across-the-board budget cuts (sequestration) that will have a devastating impact on programs to ensure public health and safety, conduct medical research, provide access to care for vulnerable populations, and address a growing shortage of physicians.

This was NOT a case, though, of ACP being another “special interest” complaining about budget cuts to favored programs. For one thing, we don’t believe that government programs to protect the public from natural and manmade health disasters and pandemics, ensure their food and drugs are safe, and help find cures for cancer and diabetes qualify as special interest “pork.” For another, ACP proposed an alternative plan to achieve hundreds of billions in budget savings that focus on the real cost-drivers: fixing a dysfunctional physician payment system, reducing the costs of defensive medicine, enacting structural reforms in Medicare and Medicaid, and reforming the tax system to encourage people to consider costs when choosing health benefits.

Many of ACP’s recommendations to reduce costs in a fiscally and socially responsible way have been endorsed by bipartisan commissions that have come up with plans to reduce the federal budget deficit. But the report notes that a broken political system that favors confrontation over compromise has made it nearly impossible to move forward on such common-ground solutions.

Rather than allowing politicians to continue to hide behind divisive rhetoric while ducking the real issues, ACP challenges them to answer three questions each about how they would improve health care quality and access and reduce costs. For Republican candidates, the questions focus on the unanswered “replace” part of “repeal and replace.” For President Obama and Democrats, the questions focus on possible changes to the ACA and their views on entitlement reform.

(You can find the report and all of its supporting materials here, including a slide deck that summarizes the key findings and recommendations.)

Realistically, ACP’s report is not going to lead to a “Hallelujah” moment when the politicians decide to deal responsibly with health and to seek bipartisan agreement of common-ground reforms. But through today’s report, ACP at least hopes to show them that there is a way forward.

Today’s question: What do you think of ACP’s assessment of the state of the nation’s health care, our proposals for a better way to reduce costs, and our challenge to the candidates?

Health Care Reform Barely Mentioned in SOTU???

noreply@blogger.com (BDoherty) — Wed, 25 Jan 2012 21:27:00 +0000

Last night’s State of the Union address was many things, but one thing it wasn’t was a clarion call by the President for the public to support his health care reform law. Instead, he confined his comments to a pledge “not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage, or charge women differently than men.”

You would think that the President would have spoken out more passionately on what he clearly considers to be his signature domestic accomplishment. Just as surprising, the Republican response by Governor Mitch Daniels (R-IN) didn’t even mention the party’s promise to repeal “ObamaCare.” His only implicit reference was in the context of distinguishing the GOP’s approach from his characterization of the President’s:

“In word and deed, the president and his allies tell us that we just cannot handle ourselves in this complex, perilous world without their benevolent protection. Left to ourselves, we might pick the wrong health insurance, the wrong mortgage, the wrong school for our kids; why, unless they stop us, we might pick the wrong light bulb.”

And that’s too bad. I would have liked to see President Obama make a clear case as to why the country is better off under the Affordable Care Act—and especially, I would have liked him to make the moral argument that it is simply wrong to deny millions of people access to health insurance simply because they can’t afford it, or work for an employer that doesn’t offer coverage, or live in an area where coverage is not accessible, or have a pre-existing health condition. I would have liked to have heard Governor Daniels explain what the GOP would offer instead of the ACA—and for that matter, whether the party even believes, as it has for almost its entire history, that a goal of public policy should be for everyone to have access to affordable health insurance coverage. After all, universal health insurance coverage was first proposed by a Republican president, Teddy Roosevelt, almost 100 years ago!

Just because the President and Governor Daniels didn’t have much to say about health care reform, though, doesn’t mean that there isn’t much to say. Tomorrow, ACP will be releasing its annual State of the Nation’s Health Care report. The report will provide an assessment of progress and challenges in U.S. health care, discuss the danger to health created by unwise budget cuts, offer an alternative framework to achieve hundreds of billions in savings by addressing the real cost drivers in health care, discuss the obstacles to achieving bipartisan common ground consensus created by the country's broken politics, and conclude with a challenge to the candidates, Republicans and Democrats alike, to provide clear answers about their plans for health care. (I will have more to say about ACP’s report in my next blog.) Last night, neither President Obama nor Governor Daniels were willing to reveal much, which is too bad, because voters have a right to know.

Today’s question: What did you think of health care reform getting only a passing reference in the President’s remarks and the GOP response?

Politicians won’t admit it, but repeal means taking real benefits away from real people

noreply@blogger.com (BDoherty) — Thu, 19 Jan 2012 15:34:00 +0000

Politicians who favor repeal of the ACA like to talk in general terms about getting rid of the two thousand pages of law (“monstrosity” is their preferred description) that it created, ignoring the fact that those same pieces of paper extend or improve benefits for hundreds of millions. It is easier to make rhetorical points about “government-run” health care than to explain what you are willing to take away, and from whom, or what you would offer to replace it.

The reason for this, I think, is mainly political: if the politicians really leveled with the people about what they and their families will lose if the ACA is taken away—and without a realistic alternative—many voters would think twice about repeal.

Consider this. Imagine that it is a week from now, and Mitt Romney is in St. Petersburg, Florida, campaigning to wrap up the GOP nomination. Imagine if he gave the following speech to a group of mostly senior citizens:

“Dear friends. As you know, I am opposed to ObamaCare. I am opposed to government-run health care, and my first item of business when I am President will be to repeal it. But you have a right to know what this might mean for you.

Say you are a senior citizen who is receiving a 50% discount on brand-name drugs filled through Medicare’s donut hole—I see there are quite a few of you in the room! After repeal, the discount will disappear. So if you are now paying $100 a month for a prescription, you will pay $200 monthly after ObamaCare is repealed. This means that after repeal, a typical senior enrolled in traditional Medicare will pay $3500 more for their drugs over the next decade.

Also, if you are a senior on Medicare, you now get routine preventive exams, like screening tests for cancer and an annual wellness exam at no cost to you. But after repeal, you will have to pay out of your own pocket for the deductible and co-payments. Yes, the 1,348,087 Florida seniors who now get these services for free will have to start paying for them.

Your internist will get paid less to take care of you. Right now, primary care doctors get a 10 percent Medicare bonus on their office and nursing home visits. After repeal, they won’t get the bonus. What this means is that a typical internist will end up being paid $8000 less from Medicare after repeal. Also, starting in 2013, primary care doctors were supposed to get a big raise from Medicaid, so that the program would pay no less than Medicare. In Florida, this would have meant that Medicaid payments to your primary care doctor would have gone up about 45 percent. But after repeal, Florida Medicaid will go back to paying primary care doctors only a little over half of what Medicare pays them.

Some of you may have granddaughters and grandsons who just graduated from college—congratulations!—and are out looking for a job. In the past, they probably would have lost their health insurance after graduation and until they got employed. Not now, though: the health reform law allows them to be covered under their parents’ plans—some 2.5 million young adults nationwide in 2011 got health insurance as a result. But after repeal, their parents’ plans no longer will have to offer them coverage, and they probably will have to find an affordable plan on their own, if they can.

Some of you may have a grandchild with a pre-existing condition, like asthma. Today, insurance companies can’t turn them away. After repeal, though, nothing will stop an insurance company from turning away or dropping kids who are unfortunate enough to be sick and need health insurance.

Right now, insurance companies must spend at least 80 percent of the premiums they collect from working people on patient care, not profit and administration. After repeal, there are no limits on how much they would be allowed to take out of premiums to pay their CEOs eight-figure salaries and hand out big profits to their shareholders.

Finally, starting in 2014, most of the nearly 4 million people in Florida who don’t have health insurance will get coverage, either through Medicaid or a private health insurance plan that the government will help pay for. After repeal, most of them likely will still be without coverage.

These are the facts, folks. I want to be honest with you, repeal means taking real benefits away from real people. But I favor repeal, because I don’t think the federal government should be involved in your health care. I don’t think we can afford it. I don’t think people should be required to buy health insurance. I don’t think we should tell insurance companies how to run their businesses. And if you need help from the government, I think you should ask Governor Rick Scott for help, because the states can always do it better than the federal government, right? Don’t you agree?”

Mr. Romney saw that the room was strangely silent, many in the audience seemed visibly upset, and few even had their calculators out. Funny, he thought to himself, the polls say that a majority of Americans favor the ACA’s repeal. I guess they weren’t really ready for straight talk about what is really in the law and what they could lose. Next time, I think, I will stick to the tried-and-true railing about government-run health care, and leave out the details about what benefits the voters will lose. They can always find that out after I get ObamaCare repealed.

Obviously, no politician in his right mind would give a speech like this. And I understand that Republicans like Mr. Romney have strong philosophical and pragmatic reasons for opposing the Affordable Care Act, notwithstanding the benefits that it offers to millions. I also understand that President Obama and the Democrats aren’t leveling either with the American people on the fact that Medicare and Medicaid can’t be sustained as they currently exist, and that pretending otherwise and demagoguing solutions does a disservice to the public. But I do think the public has a right to know that “repeal ObamaCare” means that they and their families will get less in benefits and pay more for their health care, and if the politicians won’t tell them, then someone else must.

Today’s question: Do you think politicians who favor repeal should level with the American people about the benefits they will lose if the law goes away?

Historic declines in health spending growth? Healthier people? Who knew?

noreply@blogger.com (BDoherty) — Fri, 13 Jan 2012 15:33:00 +0000

Blogging about health care can be a downer. Exploding health care costs, too many uninsured, Medicare pay cuts, a dysfunctional political culture . . . and so it goes. But I came across a couple of new reports that suggest that there may be some rays of sunshine among all of the clouds.

For one thing, did you know that health care cost increases have hit a 50-year low? That’s right: health care costs in 2009 and 2010, the most recent years for which data are available, had the smallest increase since the days when Elvis Presley was topping the charts. According to the government’s most recent analysis:

“In 2010 extraordinarily slow growth in the use and intensity of services led to slower growth in spending for personal health care. The rates of growth in overall US gross domestic product (GDP) and in health spending began to converge in 2010. As a result, the health spending share of GDP stabilized at 17.9 percent. . . Continued slow growth in private health insurance and out-of-pocket spending (which grew just 2.4 percent and 1.8 percent, respectively) and decelerations in Medicare and Medicaid spending growth (which slowed to 5.0 percent and 7.2 percent, respectively) contributed to overall low growth in 2010.”

Oh, and another piece of good news in the report. You know the allegation that “ObamaCare” has caused a big spike in health care spending? Not so . . . the Affordable Care Act added a statistically insignificant amount to the nation’s health care bill, even as millions of seniors got discounts on their brand name drugs and no-cost preventive services, 2.5 million young adults were able to keep their coverage through their parents’ plans, and children with pre-existing conditions could no longer be dropped from coverage.

It is true that the last two years’ decline in health spending growth might not be entirely good news, since the researchers suggest that some of it may be because people put off needed care during the recession. Some might be luck, like the fact that we had a relatively uneventful flu season.

But another analysis found that annual health care cost increases have been slowing for the past eight years, so neither bad luck (the recession) nor good luck (not a lot of flu) can explain it all.

This doesn’t mean we are out of the woods on health care spending: even though it is increasing at a historically low rate, it is still growing faster than the overall economy. The Congressional Budget Office (CBO) still projects that “spending on the major mandatory health care programs alone would grow from less than 6 percent of GDP today to about 9 percent in 2035 and would continue to increase thereafter. Altogether, the aging of the population and the rising cost of health care would cause spending on the major mandatory health care programs and Social Security to grow from roughly 10 percent of GDP today to about 15 percent of GDP twenty-five years from now. (By comparison, spending on all of the federal government's programs and activities, excluding interest payments on debt, has averaged about 18.5 percent of GDP over the past 40 years.)”

Still, the fact that health care spending growth has been slowing for almost a decade now is good news. Maybe we are starting to figure out a way to deliver care more effectively and efficiently.

People also are healthier, according to another new government report. In 2010, life expectancy increased, the death rates fell for all five leading causes of death, and the death rate from homicide was as low as it’s been in half a century, according to the National Center for Health Statistics.

Policymakers frankly aren’t sure why homicides and health spending growth have dropped so much. As Buffalo Springfield sang in the 1960s, “There's something happening here, What it is ain't exactly clear.” But still, it is good to reflect that despite all of the challenges facing American health care, it isn’t all gloom and doom.

Today’s question: Why do you think health care spending growth has reached historic lows, even as the population is healthier?

Emptying the Cost Control Tool Kit (Revisited)

noreply@blogger.com (BDoherty) — Mon, 09 Jan 2012 19:58:00 +0000

“Imagine that it is 2013, and a new President is sitting in the Oval Office... Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs... To make things even more interesting, let's imagine that [although]... expansion of health insurance coverage [was] enacted into law... most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.

What is a new President to do?

Because the most promising approaches to gradually ‘bend the cost curve’ - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out of the health reform law... the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke?”

The above comes from a post I wrote in November, 2009, four months prior to the Affordable Care Act becoming law. I bring it up again because here we are, less than a year from the presidential election, and in my view, things are turning out just as I had feared. Critics of the ACA, mostly from the right, are doing everything they can to discredit even the most modest programs to lower health care costs, while at the same time deriding “ObamaCare” for not controlling costs! The result may be that a new President—are you listening, President Romney, Santorum, Gingrich, Huntsman or Perry?—may have nothing left in the tool kit to tackle health care spending, other than shifting costs onto patients and cutting their benefits. Let’s say that President Obama is re-elected; he too may find that the most effective tools to lower health care spending have been damaged by the political effort to turn the public against them.

Case in point: Grace-Marie Turner’s breathtaking distortion that Washington is funding research on the effectiveness of different medical treatments for the purpose of “setting up the systems to direct doctors to practice Washington-approved medicine.” (Turner is the Executive Director of the Galen Institute, which describes itself as “a non-profit public policy research organization devoted exclusively to advancing free-market ideas in health policy.”)

Independent fact-check organizations long ago discredited the idea that CER “is being used to build a ‘scientific’ case for government rationing of health care” as Turner claims. In August 2009, the Pulitzer Prize winning “PolitiFact” said that a similar claim by [now Speaker of the House] Rep. John Boehner was false, pointing out that “it's a stretch to call giving patients better information about which treatments and drugs are most effective ‘rationing.’ In fact, given specific language in the bill to the contrary, we think it’s outright wrong... to claim the research findings would be used by the government to ration care.” (The law says that “Nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer.”) Factcheck.org, a project of the Annenberg Public Policy Center, also said that it is “false” to say that CER will allow government to “decide what care I get (a.k.a. they won’t give grandma a hip replacement).” Yet this doesn’t stop the Grace-Marie Turners of the world from repeating this discredited claim over and over again, probably because they know that scaring people into believing that the government will ration their care is the most effective way to undermine support for health reform, facts be damned.

It is this type of shamelessly cynical attack that former CMS administrator Don Berwick decried in uncensored remarks delivered a few days after leaving government:

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels”– the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas…

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

The fact is that the next president, whether it is in 2013 or 2017, will have to deal with the fact that health care costs are rising at an unsustainable rate—and this will be true, regardless of whether the Affordable Care Act survives or not. Empowering doctors and patients by giving them information about what treatments work well, and what doesn’t, is the kind of program that conservatives should embrace, because “markets” don’t work if people do not have the information needed to make a comparative choice. Helping patients make their own decisions about how they want to be treated when their life is coming to an end is good and compassionate care, not a government death panel. But the unrelentingly cynical attacks on such common sense ideas to help improve care and reduce costs may actually work in persuading the public to reject them, leaving the new president with nothing in the tool box other than cutting benefits and raising taxes.

Today’s questions: What is your take on the continuing claims that comparative effectiveness research equals government rationing? And what will this mean for the ability of the next president to lead a discussion on controlling health care costs?

Physician strikes can’t be justified to make a political point, ever.

noreply@blogger.com (BDoherty) — Fri, 06 Jan 2012 21:37:00 +0000

With Congress’ continued failure to enact a solution to the Medicare SGR problem, more and more physicians may decide that it is time organize a strike or boycott to send a message to Congress. Or something akin to a strike, like a single day when doctors collectively close their offices except for emergency care.

Earlier this year, the ACP Internist published a letter from a member who argued exactly that. He wrote that “it is time for the ACP, AMA, AAFP, and other groups to call for and lead a Medicare strike, whereby physicians refuse to see Medicare patients, except for urgent/emergent problems, for a period of, say, three days. By the way, don’t call Grandma by phone and tell her that her appointment is cancelled. Let her struggle across town and up to the office with her walker, then tell her why she won’t be seen that day, then hand her a piece of paper with the office phone numbers of her senators and representative on it. Maybe then we will see real change. If that doesn’t work, strike for a week. Then two weeks. Then a month. It is obvious that only such action will get rid of the SGR.”

There is precedence for a physician strike to put pressure on legislators. In 2003, the New York Times reported that almost all of the 30,000 physicians in New Jersey “canceled routine checkups and rescheduled elective surgery during the week of Feb. 4 in one of the nation's largest walkouts ever by doctors” to protest the state legislature’s unwillingness to curb malpractice premiums.

It is refreshing, then, that the brand new version of ACP’s code of ethics, published in the current issue of the Annals of Internal Medicine, reaffirms the College's position that strikes, boycotts, and other collective actions to deny care to patients or to inconvenience them are flat out unethical:

“Changes in the practice environment sometimes adversely affect the ability of physicians to provide patients with high-quality care and can challenge the physician's autonomy to exercise independent clinical judgment and even the ability to sustain a practice. However, physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available. In general, physicians should individually and collectively find advocacy alternatives, such as lobbying lawmakers and working to educate the public, patient groups, and policymakers about their concerns. Protests and marches that constitute protected free speech and political activity can be a legitimate means to seek redress, provided that they do not involve joint decisions to engage in actions that may harm patients.”

Yes, it is frustrating that Congress hasn’t ended the endless cycle of scheduled Medicare payment cuts. Physicians have a right to be angry. Traditional lobbying—persuading our democratically elected lawmakers to do the right thing—is a slog, difficult, time-consuming, and doesn’t always deliver the desired results, especially in today’s broken political system. But professionalism says that “the physician's primary commitment must always be to the patient's welfare and best interests.” [ACP Ethics Manual]. Accordingly, Congress’ failure to do its job cannot be an excuse for physicians not to do theirs. Collective actions to deny care to patients, in order to make a political point, can never be justified.

Today’s question: Do you agree with ACP that physician strikes or boycotts can never be ethically justified?