The ACP Advocate Blog

If having health insurance doesn’t matter . . .

noreply@blogger.com (B Doherty) — Thu, 16 May 2013 16:36:00 +0000

Would you give your health insurance up and become uninsured? And cancel your loved ones’ policies?

Why do I ask? Because one of the principal argument made against ObamaCare—and specifically, the option for states to expand Medicaid to the poor and near-poor—is that having health insurance coverage really doesn’t matter very much. The argument pretty much goes along the following lines. The uninsured already have good access to care through free charitable clinics.   Hospitals aren’t allowed to turn them away. Health insurance just gets inbetween doctors and patients. Health insurance really doesn’t ensure access and good outcomes. Offering the uinsured coverage will cost a lot of money. So it isn’t a good use of taxpayer dollars to extend coverage to the uninsured, they are doing okay without it.

Funny thing is, the people who argue that health insurance doesn’t matter are for the most part well-off people who have generous health insurance coverage for themselves and their families, usually through their employers. It is a big part of their compensation package and employee benefits. My guess is that they value having the peace of mind that health insurance gives them and their families. They and their employers have made a cost-benefit calculation that health insurance is worth it. But for the poor and near-poor (most of the uninsured), the same peace-of-mind and cost-benefit calculation apparently doesn’t apply.

Now, before someone accuses me of making a straw man argument—that is, my premise that many critics of ObamaCare believe that providing health insurance to the uninsured really isn’t that important—let me back it up.   A new study that compares the experience of previously uninsured persons who won a lottery to be covered by Oregon’s Medicaid plan, to those who remain uninsured, has been seized upon by ObamaCare critics to argue not only against expanding Medicaid—but against the very idea that having health insurance really matters that much when it comes to better health outcomes.

The Washington Post’s Sarah Kliff posted an excellent (as she always does) blog explaining how the study’s principal finding—that the Oregon expansion didn’t result in better health outcomes on cholesterol, blood pressure and blood sugar levels for the new Medicaid enrollees (after two years) compared to the uninsured—has been seized upon by opponents of ObamaCare’s Medicaid expansion. But although it is true the study didn’t find any improvements in these three common measures of outcomes, it did show one huge benefit—the people who were able to join Medicaid no longer had to worry that getting sick would result in a financial calamity, as Jonathan Cohn explains in his New Republic post:

“The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.”

The same study also found a substantial reduction in reported incidents of depression—which (I am just speculating) might have had something to do with recipients no longer having to choose between paying rent or getting health care!

So on one side, you have conservative critics of ObamaCare’s Medicaid expansion concluding that the new study validates their view that it is a big waste of money because putting people on Medicaid won’t improve health outcomes. On the other side, you have liberals who argue that the study shows that putting people in Medicaid protects them from financial catastrophe and is well worth the cost, even if it doesn’t result in immediate gains in health outcomes.

If the argument was just about Medicaid, that would be one thing—surely one can make a credible argument that there are better ways to provide coverage to the poor than expanding Medicaid (although I have yet to see a plausible conservative alternative), but some conservatives are citing the study to argue against the very idea of providing health insurance coverage (not just Medicaid) to the poor.

The Washington Post’s Robert Samuelson opens his latest column, Why ObamaCare is Oversold, with this provocative statement (citing the Oregon Medicaid study):

“It’s the great moral imperative behind the Affordable Care Act (“Obamacare”): People should not be denied health care because they can’t afford insurance. Health status and insurance are assumed to be connected, and opponents have often been cast as moral midgets, willing to condemn the uninsured to unnecessary illness or death. The trouble is that health status and insurance are only loosely connected. This suggests that Obamacare may result in more spending and health services but few gains in the public’s health.”

He continues:

“The most overlooked finding [from the Oregon study] is that the uninsured already receive considerable health care. On average, the uninsured annually had 5.5 office visits, used 1.8 prescription drugs and visited an emergency room once. Almost half (46 percent) said that they ‘had a usual place of care,’ and 61 percent said that they had ‘received all needed care’ in the past year. About three-quarters (78 percent) who received care judged it ‘of high quality.’ Health spending for them averaged $3,257. Much of this was known — or could have been surmised — during the debate over Obamacare. The Congressional Budget Office reported that the uninsured typically received 50 to 70 percent of the care of the insured. A study in 2007 of the 1965 creation of Medicare — insurance for the elderly — concluded that it had ‘no discernible impact on elderly mortality’ in the first 10 years but improved recipients’ financial security by limiting out-of-pocket expenses.”

And then this:

“ ‘Health insurance is a financial product that is aimed at providing financial security,’ the study says. On that ground, the expansion succeeded; by most clinical measures, it didn’t. Perhaps it is too early. The expanded Medicaid coverage was only two years old at the time of the study. Maybe greater health improvements will emerge. But maybe they won’t, and not only because the uninsured already receive care. Many uninsured are relatively healthy; insurance won’t make them healthier. For others, modern medicine can’t cure every health problem. Still for others, bad luck or bad habits are hard to change. About two-fifths of Oregon’s uninsured were obese or smoked; Medicaid didn’t alter that.”

And Samuelson concludes with this stunning attack on the motivations of those, like me and ACP, who support ObamaCare, arguing that is our sense of moral superiority (rather than concern for the poor) that motivates our support for universal coverage:

“Obamacare’s advocates ignored these ambiguities. They were too busy flaunting their moral superiority. Universal health insurance is a legitimate goal, but 2009 — in the midst of a major economic crisis — was the wrong time to pursue it. Predictably, it polarized public opinion and subverted confidence for what seem to have been, based on the available evidence, likely modest public health improvements. The crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.”

Wow . . . “the crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.”    Really?

I would say that extending health insurance coverage to everyone, so that no one has to worry about a financial catastrophe because they get sick, is in itself enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare.

If protecting the uninsured from health related financial catastrophe wasn’t enough, I would say that the preponderance of evidence shows having health insurance will reduce tens of thousands of preventable deaths, notwithstanding the Oregon study—which by itself would be enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare. The esteemed Institute of Medicine in 2009 looked at all of the evidence on being uninsured, and found that there is a “chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death.”

I don’t support ObamaCare because of my own self-worth, but because I believe that the evidence shows that it will provide enormous economic benefit (for sure) and health benefits (most likely) to the 30 million or so uninsured (and mostly) poor who now have no access to coverage.

But don’t take my word for it. Listen to this interview with a real person who explains to Kaiser Health News reporter what being brought under Oregon’s Medicaid plan has meant for her:

Q: How did lacking insurance affect your medical care?

A: “At one point I needed some cortisone for my asthma and they wanted to do a complete heart work-up to make sure that my troubled breathing wasn’t congestive heart failure. You're always telling them, ‘No, no, no, this is the only thing I want.’ It's like trying to buy the burger with no fries at McDonald's. You have this resistance all the time, because doctors and nurses look at you with these big soft eyes and say, "But it would be so important to know your level of cardiac health, I'm really concerned. I'm sure the doctor there will work out something and make payment arrangements." And it sounds so good and you do it and it never works out. The discount isn't there or you fill out something wrong and all of a sudden you have a $300 bill in collections. So you have to make sure none of that happens to you.”

Q: How has your health changed since you went on Medicaid?

A: “Over the course of nine months or a year I was able to drop two different blood pressure medicines, which is nice because they had side effects I didn’t like. So I'm down to half a pill of one of the medicines and my blood pressure is still stable. For about a five-year period I thought my thyroid medicine was too low and I couldn’t afford the doctor visit to have the lab slip to get a new prescription. That whole procedure is about $300 so I just stayed with the same medicine. With Oregon Health Plan I was able to go back to the doctor and when she said wanted to check my thyroid levels I could say, ‘Yes, I'll go to the lab and get that done.’ They were low again. I was able to get that increased and that made a big difference in how much energy I had and how much better I felt.”

Q: If you had hadn't won the Medicaid lottery, where do you think you'd be financially and medically?

A: “Financially, I'd be maybe $100 a month poorer. I would not be monitoring my blood sugar. I would not be paying as much attention to my cholesterol. I probably would have lost some weight but I don't think I would have lost so much, and I don't know if I would have been so good at keeping it off. I'd be much more anxious about what could go wrong. One of the things you get in Oregon is you get your teeth cleaned and X-rayed once a year. I hadn't been to the dentist in six or eight years except to have a tooth pulled. So it was really nice to have my teeth cleaned and find out I don't have cavities and don't need my teeth pulled. My father died of melanoma and there's a lot of melanoma in my family—one of my sons had skin cancer when was he was 15—and so that's a worry. Being able to go to the doctor and have my moles checked was a big weight off my mind. I'm a lot surer I'm going to be able to make it to 70 without being crippled or in a wheelchair and not being able to take care of myself.

And there's something about just feeling like you're part of regular life. There's a lot of emphasis on how everyone should be healthy and everyone should live longer, and you don't want to be a burden on society. If you don’t have medical insurance, you're kind of not part of that. It's hard to explain, but there's an element of participating in society that being able to go to the doctor gives you. Everybody always asks everyone how you're doing, and to be able say ‘My doctor says I’m doing really well,’ that's nice, instead of being in a group of people and saying, ‘Well, I don't really go to doctors.’”

Q: The Oregon study did not find significant health improvements for those who won the Medicaid lottery versus those who did not, with the exception of improvements in self-reported depression. Some commentators have seized on these findings to argue that having Medicaid does not lead to better health. Do you agree with that?

A: “ Some people have completely lost track of what health insurance is supposed to be. We're talking about somebody being able to get their broken arm fixed if they fall out of a tree. My blood pressure is still not perfect, but over the last two years I have stopped taking two different blood pressure medicines and am only taking half of a third. That is a health improvement but it doesn't necessarily show up in the study. My blood sugar is not perfect, but it's more consistently in the right zone. But according to the study, I haven't improved. Most of the people who are going to be on Medicaid are going to be working. What are you supposed to do if you're working at McDonald's 30 hours a week? You're working all the hours they give you. Why shouldn't they be able to go to the doctor? Why should they have to lose everything they own if they break their arm and have to go to the emergency room? Everybody can't go to college and get a good job. Somebody is always going to work in the nursing home. Somebody is always going to work part-time at JC Penney even though they want to work full time, because the store only wants them there on Saturday and Sunday. Those people need to make enough money to live on, they need to have enough food to eat and they need to be able to go to the doctor when they're sick.” [Emphasis added by me in italics]

So yes, I admit that I feel that it is a great moral imperative to extend coverage to people like this woman. Medicaid is by no means perfect, but expanding it to her and others who are “working at McDonald's 30 hours a week” will give them financial protection. Why shouldn’t they be able to go to the doctor? Why should they have to lose everything if they break their arm and have to go to the emergency room? Why shouldn’t they have enough money to live on, enough food to eat, and be able to go to the doctor when they get sick. Why shouldn’t they be able to feel like they are just part of regular life—like you and me who are fortunate to have health insurance for ourselves and our families?

So if you really feel that this woman, and the millions like her, don’t need health insurance, how about canceling your own insurance (and your family coverage, to boot) and see what it is like to depend on free clinics for your medical care? And to make it a truly comparable experience, try to go without health insurance while living on a minimum wage.

If you aren’t willing to make the choice of going uninsured for you and your family members, then is it too much to ask that you support extending health insurance coverage to everyone, and especially, the poor and near poor? (And if you don’t like Medicaid and ObamaCare, explain how else you would make coverage available to everyone?). If having health insurance matters to you, it matters to them, it matters to everyone, it is the right policy to pursue, and yes, it is a great moral imperative that we try.

Today’s question: If you oppose expanding health insurance coverage to everyone because health insurance “doesn’t matter” or it is too expensive, would you give up your own health insurance? Why or why not?

Does measurement improve performance?

noreply@blogger.com (B Doherty) — Mon, 29 Apr 2013 19:51:00 +0000

Like it or not, measuring physician performance is now a key part of the conventional wisdom on improving our health care system. Borrowing from management guru Peter Drucker’s mantra “You can’t manage what you can’t measure” health care policy makers have embraced performance measurement as being central to managing our heretofore unmanageable health care system. But there is a small but seemingly growing group of Don Quixote-like dissenters who are tilting at the performance measurement windmill, arguing that these measures will not achieve the ends of improving quality and saving money and may instead do considerable harm.

Dr. Bob Centor, author of DB’s Medical Rant blog, is one of them.   (Disclosure: Dr. Centor is chair-elect of ACP’s Board of Regents, although the views he expresses in his blog are his own, not ACP policy). One of his posts, titled “What has performance measurement wraught?” calls them madness:

“Most readers know that I am obsessed with performance measurement and why it not only rarely works but often causes negative unintended consequences. As I have pondered this question recently, computers cannot replace physicians as diagnosticians. And the same misunderstanding of medicine that would advocate such a position drives the performance measure movement.

Physician decision making requires a complex weighing of disease severity, number of diseases, social situation, cost of medications, the patient's desires and willingness to address issues and more that you can imagine. To think that we can apply simple rules to such decision making represents an unjustifiable conceit that patient care is simple and can therefore be broken down into RULES.

The unintended consequences of this movement are many. We now have nonsensical report cards and, here the author gasps, public reporting. If we could define excellence, then public reporting would make sense. But we cannot define excellence through rules that cover only selected diseases and only one aspect of doctoring.

How do we stop this madness???"

In an earlier post, he cites a commentary in the Journal of the American Medical Association (JAMA) which suggests that poorly-designed performance measures can cause harm to patient care. “Too often we have measures based on a religious belief (e.g. lowering HgbA1c is always the proper goal) and not based upon good prospective data,” he writes.   “Whenever we have to struggle to meet a performance goal, we run the risk of unexpected consequences. This irresponsible process likely harmed patients. Let me repeat that sentence. This irresponsible process likely harmed patients. The reasons now are clear. Some, including the authors of this commentary complained bitterly back in 2006. We allow organizations to establish performance measures without expecting the same rigorous testing that any other intervention must have prior to approval. We would not approve a new drug without careful testing for both efficacy and safety. Should we not hold performance measurement to the same standard?”

But is it possible to improve clinical performance without measuring it? The Institute for Healthcare Improvement, formerly headed by ex-CMS administrator Don Berwick, MD, says that “Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement.”    In 2008, Dr. Berwick co-authored an article published in Health Affairs that presented the Institute’s now widely accepted Triple Aim of improving individual patient outcomes, improving population outcomes, and lower per capita costs. He writes that “in general, opacity of performance is not a major obstacle to the Triple Aim. Many tools are in hand to construct part of a balanced portfolio of measures to track the experience of a population on all three components. At the Institute for Healthcare Improvement (IHI), for example, we have developed and are using a balanced set of systemwide measures closely related to the Triple Aim. A more complete set of system metrics would include ways to track the experience of care in ambulatory settings, including patient engagement, continuity, and clinical preventive practices.”

Measurement for the purpose of helping groups of physicians assess how well they are doing in achieving the triple aim may be challenging enough, paying based on performance measures raises a whole host of other issues. All payment systems create a mix of potentially good and potentially bad results. Fee-for-service achieves the potentially good outcomes of creating incentives for physicians to actually see their patients and not undertreat them, because FFS pays them on how many patients they see and how many procedures they do, but it can also have the undesirable outcomes of “rushed” assembly line visits and over-testing and over-treatment. Capitation achieves the potentially good outcomes of encouraging physicians to be more efficient and not over-treat their patients, since they are paid the same amount per patient no matter how many procedures or visits provided, but it can also have the undesirable outcome of incentivizing physicians to not see patients enough, not treat sicker patients, or undertreat them. Payment systems linked to performance measures can have the desirable outcomes of creating incentives for physicians to organize their care to achieve better outcomes for their patients, better care of the patient population they see, and maybe, lower costs (the Triple Aim), but also the undesirable outcomes of “treating to the measure” (paying attention only to things being measured, and less to things not being measured), and creating disincentives for physicians to take care of sicker patients and those with lower socioeconomic status because such patients may adversely affect their performance “score.”

Performance measures though could help level out the potentially undesirable incentives existing in FFS or capitation: FFS tied to performance measures could help counter the incentives for over-treatment because physicians who over-treat with no improvement in outcomes wouldn’t score as well on measures of individual, population or per capita cost outcomes. Capitation tied to performance measures—if accompanied with appropriate risk adjustment-- could help counter incentives for physicians to under-treat patients, since under-treatment would result in poorer “scores” on individual and population-based health outcomes and patient experience with the care provided.

My sense is that the performance measurement genie is out of the bottle and isn’t going away. We live in an era where just about everything and everybody is being measured and held accountable for getting better results as efficiently as possible. Health care is so damn expensive that the public (through government) and insurance company shareholders will want to know if physicians are achieving the best possible results and the lowest possible cost—how can they know what results they are getting without measuring it?

But as measurement becomes increasingly imbedded in our health care system, we should pay attention to potential unintended consequences. We should insist on meaningful measures that are based on the best available science through a transparent process, not measurement for the sake of measurement. We should test measures whenever possible before they are widely adopted, just as we do for new drugs, and withdraw measures that turn out to be harmful, just as the FDA withdraws newly approved drugs if they are found to have unforeseen harmful side effects. We need to be very careful as we design payment models that incorporate performance measure so that what is best for the patient, not what is best for the measure, always comes first. All of these, and more, safeguards are called for in ACP policy on performance measurement.

And rather than starting with measurement as the be-all and end-all goal, we should begin by defining how best to organize care to achieve the best possible results for patients, through models like Patient-Centered Medical Homes, then determine a payment model that best supports those models, and then build and incorporate measures that actually help the physicians in these systems monitor and achieve the best possible outcomes for their patients—not the other way around.

If we really believe, as ACP does, that a well-trained internist, in a system of care designed to achieve the best outcomes for patients, will be shown to be the best bargain in American medicine, then performance measures can be our friends—but only if they are the right measures, measuring the right things, for the right reasons, and with the right oversight.    And we should always keep in mind the cautionary note from sociologist William Bruce Cameron, sometimes misattributed to Albert Einstein, “That not everything that can be counted counts, and not everything that counts can be counted.”

Today’s question: do you think performance measures will improve or harm health care outcomes?

What the Senate Gun Vote Says About Washington . . . and About Us

noreply@blogger.com (B Doherty) — Thu, 18 Apr 2013 21:15:00 +0000

Many experts predicted that the unspeakable murder of dozens of children and adults at Sandy Hook elementary school would be a “game-changer” that would cause Congress to enact meaningful controls over firearms.   How wrong they were.

Yesterday, the United States Senate rejected every single legislative proposal to make it harder for people—including convicted felons-- to obtain and use firearms to inflict harm on themselves and others.    Because of Senate rules requiring 60 votes to get just about anything passed, a minority of U.S. Senators were able to block a bipartisan plan for universal background checks offered by two Senators with “A” ratings from the NRA, despite the fact that 90% of the public supports expanded background checks.

Proposed bans on the future manufacturing and sale of military style weapons and high capacity ammunition magazines didn’t even get a majority of Senators to vote for them. These are the weapons of choice of mass murderers, used to gun down children and adults at Sandy Hook; college students at Virginia Tech; a member of Congress and others standing near her (including the murder of a young child) outside a grocery store in Tucson; movie theater patrons in Aurora, Colorado, and so many more people who have been killed or injured, in so many places, by assault weapons loaded with high capacity magazines. But banning such weapons and ammunition was too big a political lift for most U.S. Senators.

The background check proposal had a much more modest purpose, closing existing loopholes to keep guns out-of-the hands of convicted felons, persons with domestic violence restraining orders, and violent, mentally-disturbed persons under court order (while exempting most sales among family members), but that was also too much of a lift for politicians cowed by the NRA’s opposition and a passionate but small minority of gun owners who oppose expanded background checks. Support for background checks among gun owners is about the same as the general public, with 88% of them supporting background checks for all gun owners according to recent polls.

I am deeply disappointed that Senate rules allowed a minority to again block the will of the majority of the Senate and the will of an overwhelming majority of the public. I am deeply disappointed by the effectiveness of the NRA’s deceptive, cynical “slippery slope” argument that universal background checks would create a federal registry of gun purchases that later could be used by the government to take legal guns away from law-abiding owners, when such a registry is expressly prohibited by the background check bill as well as by current law barring the FBI from retaining records of persons passing background checks.

I am also disappointed that organized medicine didn’t do more to support the Senate bill. ACP did its part: we wrote letters of support for the background check bill and asked our 8,000 plus ACP Advocates Network members to urge their own Senators to vote for it. The American Academy of Pediatrics did at least as much as we did. But from what I can tell, most of the other national physician membership organizations and state medical societies sat this one out. They either didn’t engage at all prior to the Senate vote, or limited their engagement to a letter of support, without backing it up with grass roots lobbying, direct lobbying on Capitol Hill, and the other elements one would associate with a high priority campaign.   In my blog post immediately after the Sandy Hook massacre, I asked “Is the Medical Profession Doing Enough About Gun Violence?”   Regrettably, the answer for much of organized medicine, appears to be no.

But my disappointment over the Senate’s failure on guns pales to that of Gabby Giffords, the member of Congress who was grievously injured in the Tucson shooting.   Read what she said in today’s New York Times:

“Senators say they fear the N.R.A. and the gun lobby. But I think that fear must be nothing compared to the fear the first graders in Sandy Hook Elementary School felt as their lives ended in a hail of bullets. The fear that those children who survived the massacre must feel every time they remember their teachers stacking them into closets and bathrooms, whispering that they loved them, so that love would be the last thing the students heard if the gunman found them.

On Wednesday, a minority of senators gave into fear and blocked common-sense legislation that would have made it harder for criminals and people with dangerous mental illnesses to get hold of deadly firearms — a bill that could prevent future tragedies like those in Newtown, Conn., Aurora, Colo., Blacksburg, Va., and too many communities to count.”

She continues:

“I watch TV and read the papers like everyone else. We know what we’re going to hear: vague platitudes like ‘tough vote’ and ‘complicated issue.’ I was elected six times to represent southern Arizona, in the State Legislature and then in Congress. I know what a complicated issue is; I know what it feels like to take a tough vote. This was neither. These senators made their decision based on political fear and on cold calculations about the money of special interests like the National Rifle Association, which in the last election cycle spent around $25 million on contributions, lobbying and outside spending.

Speaking is physically difficult for me. But my feelings are clear: I’m furious. I will not rest until we have righted the wrong these senators have done, and until we have changed our laws so we can look parents in the face and say: We are trying to keep your children safe. We cannot allow the status quo — desperately protected by the gun lobby so that they can make more money by spreading fear and misinformation — to go on.”

My deep disappointment with the Senate’s failure on guns can’t come close to that expressed by the heartbroken father of his beloved seven year old son murdered in Sandy Hook. Mr. Barden spoke last night at the White House of his anguish at the loss of his son, his disappointment with the Senate vote, and his determination to press forward:

“We'll return home now, disappointed but not defeated. We return home with the determination that change will happen -- maybe not today, but it will happen. It will happen soon. We've always known this would be a long road, and we don't have the luxury of turning back. We will keep moving forward and build public support for common-sense solutions in the areas of mental health, school safety, and gun safety.”

(Click on this link to watch his remarks followed by President Obama’s statement).

I know that some readers of this blog argue that background checks and bans on assault weapons and high capacity magazine’s won’t work in preventing all or even most firearms injuries and deaths, and that may be true, although the best available studies and simple logic suggest that they would help.

Despite gaping loopholes, the current background check system resulted in some 1.5 million persons with criminal records being turned down when they try to buy guns. Logic tells us that a system that closes the loopholes would keep guns out of the hands of even more convicted felons.   Logic tells us that limiting access to certain guns that are designed to kill as many people as possible would result in fewer people being killed when someone tries to obtain them to inflict harm on us and others.

Some of you may also point out that the issue is more complicated than simply regulating firearms purchases—that mental health, culture, substance and alcohol abuse, and other societal factors also play a role—and with that I would agree. But the need to examine other factors contributing to firearms-related injuries and deaths isn’t a valid argument for not doing what we can now to keep guns out of the wrong hands and to limit their killing capacity.

Listen to more of what Gabby Giffords had to say about the Senators who voted against background checks:

“They will try to hide their decision behind grand talk, behind willfully false accounts of what the bill might have done — trust me, I know how politicians talk when they want to distract you — but their decision was based on a misplaced sense of self-interest. I say misplaced, because to preserve their dignity and their legacy, they should have heeded the voices of their constituents. They should have honored the legacy of the thousands of victims of gun violence and their families, who have begged for action, not because it would bring their loved ones back, but so that others might be spared their agony.

The should have, but they didn’t.

Today’s question: What is your reaction to the Senate’s rejecting of expanded background checks and a ban on assault weapons and high capacity magazines?

What does ACP have to say about . . .

noreply@blogger.com (B Doherty) — Wed, 03 Apr 2013 19:54:00 +0000

Medicare physician payment reform? Medical liability reform? Performance measures? Electronic Health Records?   Medicaid expansion? GME? Or any of the many other public policy decisions that affect internal medicine and patient care?

Until now, you might have had a hard time finding out.   For years now, ACP has routinely posted all of its position papers, letters to Congress, comments on federal regulations, testimony and other health policy documents on our web site, but you would have had a hard time finding out what we had to say on any specific issue.   Because the College is involved in so many issues, providing policy input in so many different ways, it was very hard to locate any particular document or topic—there were just too many, and the ability to effectively search by topic was limited, at best.

Not anymore.   Earlier this week, ACP launched a total redesign of our site, organizing the content by issue topics and making it easily searchable. And, we have created a new policy library that allows searches of public policy documents, as well as clinical and ethical guidelines. Here are some of the features of the advocacy site redesign that I think will make it particularly useful:

--Three topical, timely and high priority advocacy activities that we think are of greatest interest to members are featured on the landing page and updated regularly to ensure their timeliness and importance. For instance, the current “spotlight” highlights ACP’s State of the Nation’s Healthcare paper, released late February, and our newly updated Internists’ Practical Guide to Understanding Health System Reform.

--On the advocacy landing page, you can click on any one of four tabs to get more information:

Where We Stand, which provides an inclusive link to ACP’s advocacy communications (letters to Congress, testimony, comments on regulations, and policy papers), sorted by eight topics: Affordable Care Act/Access to Care, Medical Liability Reform, Workforce, Medicare reform, Medicaid reform, Physician Payment/Delivery System Reform, Health Information Technology, and Federal Budget /Appropriations. Click on any of those topics, and you will see a comprehensive (and constantly updated) list of documents relating to ACP advocacy on that topic.

Advocates for Internal Medicine Network, which provides a link to information about ACP’s grass roots advocacy program (including how to sign up) and our latest Legislative Action Center alert on what members can do to influence an upcoming action in Congress.

State Health Policy, which provides links to resources on public policy issues arising in the states, especially relating to state implementation of the ACA.

Advocacy in Action, which provides links to advocacy events organized by ACP, such as our Leadership Day on Capitol Hill and our policy-related press briefings.

Current Public Policy Papers, also organized by issue. These are the official policy papers approved by ACP’s Board of Regents, the basis for all of our other advocacy communications and activities. Think of them as representing our Bible of Internal Medicine public policy.

If clicking on these four tables doesn’t get you exactly what you are looking for, you can search for a document by clicking on the ACP Policy and Recommendations library. The library enables you to search for documents by key words and search terms, similar to how you would do a regular Google search. You can use filter settings to limit your search by date and type of document (e.g. clinical guideline, policies, testimony, letters to officials). For instance, if you entered “SGR” as a search word, 118 documents show up; if you limit your search only to ACP “policies” relating to the SGR, 24 documents show up.

The site has other cool features: a policy compendium that summarizes ALL of ACP’s current policies, by topic (just the policies, without the background information, analysis, and references that are included in the actual position papers themselves). And, this blog is prominently featured on the main advocacy landing page!

If you spend even a few minutes on the redesigned advocacy site, I think you will be amazed at the breadth and depth of the issues that the College has addressed. (If there is an issue an ACP member is concerned about, it almost certainly has been addressed by the College!). But the site isn’t just for ACP members: journalists, health policy analysts, members of Congress and their staff, and federal agency officials will now find it much easier to know what the ACP has to say.

So next time, someone asks you “What does ACP have to say about Nurse Practitioners and Primary Care” or any other issue that is on their mind. . . you will know where to get the answer.

Give the new site and policy library a test drive and let us know what you think.

Today’s question: what do you think about ACP’s redesigned advocacy page and policy library?

An Honest Assessment of Obamacare at Age 3

noreply@blogger.com (B Doherty) — Thu, 28 Mar 2013 19:00:00 +0000

Saturday was the Affordable Care Act’s third birthday, but you might have missed it for all of the (lack of) attention it received. Sure, there was the usual back and forth from the law’s supporters and opponents, but almost nothing that provided any new insights.

Supporters, such as the liberal New York Times editorial page, marked the ACA’s anniversary by touting the tens of millions already being helped by the law, from seniors on Medicare getting preventive services at no cost to them, to children with pre-existing conditions being able to get affordable coverage—the first steps on the road to expanding coverage next year to as many as 30 million uninsured persons (including 535,000 uninsured veterans according to a new study) while providing new benefits and consumer protections to everyone.

Opponents such as the conservative Heritage foundation, marked ObamaCare’s anniversary by charging that it is causing higher premiums, putting more people out of work, leading to a loss of employer coverage, and making it more difficult for seniors to access Medicare-covered services.

Because the charges and counter charges were mostly a repeat of the same old tired talking points we have been hearing for three years, is it any wonder that much the public tuned the whole thing out?
Meanwhile, a new poll shows that the public remains ambivalent about the law and perhaps even more confused than ever. According to the Kaiser Family Foundation’s well-respected health tracking poll, “a majority of Americans are unsure how the law will impact them, and few are paying attention to the details of state‐level decisions about implementation. Though opinion on the law overall remains nearly evenly divided, opponents’ attacks seem to have taken a toll on the public’s expectations, and Americans are now more likely to think the law will make things worse rather than better for their own families. While most of the law’s individual provisions remain popular, many of the most well‐liked elements are the least well‐known among the public. Public knowledge of the ACA’s provisions has not increased since 2010, and awareness of some key provisions has declined somewhat since the law’s passage when media attention was at its height.”

As Mick Jagger sang, “it’s enough to make a grown man cry!”

But let’s put aside the political talking points for a moment, and instead look at some hard truths about ObamaCare’s present and future:

1. The law already is helping many millions of people—that’s a fact, not a talking point. For the most part, the people being helped so far are mostly those who already had health insurance coverage (no-cost preventive services for seniors, rebates if your insurance company spends too much on profit and administration rather than patient care, elimination of life-time limits on coverage) while helping relatively small pockets of people who in the past had trouble getting coverage (e.g. children and some adults with pre-existing conditions, and young adults).   The law also has increased Medicare and Medicaid payments to primary care physicians, provided scholarships and loan forgiveness for thousands of them and increased access to underserved communities through the National Health Services Corps. The Kaiser Family Foundation has an excellent three-year anniversary summary of who has benefited so far and the progress being made in preparing for the next steps. These gains are nothing to sneeze about, but they are just the opening acts to the huge changes that are supposed to take place in a little over nine months, when the ACA’s biggest coverage expansions and full gamut of health insurance regulations are scheduled to take place.

2. The next act—expanding coverage to up to 30 million uninsured persons and mandating minimum levels of health insurance benefits and new consumer protections for everyone-- will be highly disruptive to the current system, and as a result some things will go right, some things will go wrong, some will pay more, some will pay less. But why should this surprise anyone?

Did anyone really think we could transition from the current system, where tens of millions are uninsured, where many millions more have inadequate insurance and consumer protections from insurance practices that put them at risk of losing coverage, to one where almost all legal residents will have access to guaranteed, subsidized minimum benefits that can’t be taken away when you get sick, without it being highly disruptive? Changing the status quo is supposed to be disruptive.

Did anyone think you can provide coverage to people who don’t have health insurance, especially those who are older and sicker, without some people (mainly the healthy young and wealthy of all ages) paying more through higher taxes and premiums? This is the way risk-sharing and pooling is supposed to work!

(About those premium increases for some people, by the way: keep in mind that this isn’t a case of premiums going up for the same old insurance you had before, it is premiums going up for new and improved insurance offered on the individual insurance market. An analogy: when the federal government required all new cars to have seat belts, air bags, and safer crash protection, these increased costs were passed on to consumers through higher prices, but most of us would agree it was worth it, because with these features, we are less likely to die or become hurt in car crash! The same is true for health insurance: the insurance we will buy next year will have standardized benefits and consumer protections that will help ensure that we all have better access to health coverage with the benefits we need to help keep us alive and well, so of course we may have to pay a bit more for it. But also keep in mind that under the ACA, the premium charged isn’t the same as what the insurance will actually cost you, because anyone with an income up to 400% of the federal poverty level--about $94,000 for a family of four--will be eligible for subsidies to help keep the cost down).

The social contract underlying all of this, of course, is that someday it will be me, someday it will be you, who will become older and sicker, and we all benefit from having a system that spreads risks and costs more equally over our lifetimes so that health insurance and healthcare are there for us when we need it most, at a price we can afford at that time.

3. The biggest practical challenge facing Obamacare is that the federal government has too little control over what happens next.   Yeah, I know it is a staple of conservative critiques of the law that it is a big (federal) government take-over of healthcare, but from the very beginning, the ACA was classic example of U.S. federalism—the federal government would provide most of the money and establish the ground rules, while the states would create the structures to implement most of it.   So, as the law was written, the states were supposed to be the ones who would set up the marketplaces (exchanges) by which eligible persons would be able to buy a qualified and federally-subsidized health insurance coverage. The states were supposed to be the ones to expand Medicaid to the poor- and near- poor, paid for almost entirely by the federal government. (Originally, the Medicaid expansion was for all intents mandatory, because states could have lost their current Medicaid funds if they didn’t go along—but the Supreme Court decided in 2011 that punishing states for not going along was unconstitutional, making the Medicaid expansion a totally voluntary one for the states).   Because Republican governors and legislatures in most states are continuing to resist Obamacare, both for political (ideological opposition and a desire to see it fail, see below) and practical reasons (uncertainty about how much it will cost them), most states have opted-out of setting up the health insurance exchanges and only half have agreed to the Medicaid expansion.

In the immediate future, the federal government may (on paper, at least) actually have some more control over the health insurance industry than originally anticipated by the ACA’s framers, because it will run the health insurance marketplaces (exchanges) for the dozens of states that opted-out.   This raises another concern though: will the federal government really be able to carry it out, especially since Congress has not given the administration any additional money to help pay the increased costs it will incur for the federal exchange and the agency responsible for the program has lost billions of dollars in funding because of sequestration?   The administration says it will be ready to operate an exchange in every state that has opted-out—but this is hardly a sure thing.

The key point though is that under the ACA, the federal government does not have the power turn a switch to make the program work the way it wants it to (like it can with Medicare); instead, it must rely on the states, including GOP-led states that in many cases are going to do everything they can to make sure it doesn’t succeed.

4.    This brings me to the greatest political challenge facing the ACA, which is the unrelenting effort by GOP opponents to try to make sure it fails.   It is no secret that Republicans will continue to try to limit funding for Obamacare’s implementation. They will push for votes to remove the tax revenue that the government needs to fund it. They will point to any problems that can be pinned on the law (e.g. higher premiums for some people, the confusion that will take place as new insurance options are rolled out next year) as evidence that the law isn’t working. They and their allies will continue to go to court to try to get it overturned. Most importantly, they will count on state resistance to the law (see #3 above) to make the law’s “failure” become a self-fulfilling reality. This, they hope, will lead to an “I told you so moment” and widespread public disaffection with Obamacare.

As the Washington Post’s Ezra Klein notes, “ceaseless efforts Republicans have made to attack the law publicly, impede it procedurally and defund it legislatively. Implementation of a law of this size would always be difficult. But it will be far harder with Republican governors refusing to help and Republican legislators viewing each and every tough problem as an opportunity to chip away at the legislation.”   But this will not result in repeal, he believes. “Obamacare can have a hard implementation in 2014, but President Obama isn’t going to repeal it or even lose reelection over it (though congressional Democrats might). And by 2015, it will be insuring tens of millions of people, the health-care industry will have adapted and many businesses and ordinary Americans will be using the exchanges. At that point, no one is going to repeal it.”

So to summarize, an honest assessment of Obamacare on its third anniversary would acknowledge that it already is helping tens of millions of people. It would also acknowledge that the next steps—expanding coverage to up to 30 million uninsured persons and providing better benefits and consumer protections to everyone —will be highly disruptive, but that this shouldn’t surprise anyone, it was supposed to be disruptive. It would acknowledge that some things will go right and some things will go wrong as a result. It would note that the states have a critically important role in making all of this work but acknowledge that many GOP-led states will be doing everything possible to make Obamacare fail. It would acknowledge the political reality is that congressional Republicans have no intention of calling a ceasefire in their efforts to make sure that Obamacare’s implementation does not go well, hoping that if the implementation is messy they can decisively turn public opinion against it.

It would also acknowledge that in the end, Obamacare is not likely to go away, and somehow or another, bumps and all, it likely will get us to a better place than today, a health care system where nearly all will have access to better and more affordable health insurance coverage. But getting from here to there isn’t necessarily going to be pretty.

Today’s question: What do you think of my analysis of the “hard truths” about Obamacare on its third anniversary?

Casting Aspersions

noreply@blogger.com (B Doherty) — Tue, 19 Mar 2013 18:20:00 +0000

“Physicians care more about their pocketbooks than taking care of patients. They are self-interested and overpaid. They want to control everything. They don’t know what life is like in the real world of patients.”

By now, I am sure that physician readers of this blog can feel their blood boiling, for good reason. Why would I, as the principal staff advocate for internal medicine physicians, put such pernicious, unfair, inaccurate quotes in my blog?

You would be right to be angry at me—if I believed any of the above, but I don’t. I work for doctors because I believe in doctors. I believe that with very few exceptions, physicians are motivated by a compassionate commitment to applying their skills and training to improve the health of their patients and the American people. And when it comes to physician advocacy in public policy arena, I believe that the vast majority of them take stances that they believe to be in the best interests of patient care, even though they may not agree among themselves on the best course of action.
So why would I start this article with made-up quotes (although you can find many people who say the same) that cast aspersions on the medical profession? To make the point that broadly labeling a profession or occupation as consisting of people who are unethical, self-interested, controlling, over-paid, and out-of-touch is simply wrong—on the facts, but also by any sense of objectivity and fairness. Casting aspersions, after all, means making “a false or misleading charge meant to harm someone's reputation, cast aspersions on her integrity” or “the act of making such a charge: defamation.”

But there is one group of our fellow Americans—almost two million of them, by the way—that are regularly defamed in the political arena: people who work for the federal government. People I know, people who are my friends, people who I interact with every day on behalf of the American College of Physicians, people that many of you know—most of whom live and work outside of Washington, DC. (Very early in my career, I was one of them, employed by a federal agency that dispensed higher education grants, and before then, as an unpaid intern for a member of Congress).

Here is what I know about them, and maybe you don’t, or maybe you do. Most of them work extraordinarily long hours, longer than many I know in the private sector. They haven’t had a raise in three years yet their productivity would put many private sector employees to shame.

Most are motivated by a desire to serve the public—that is why they chose careers in public service, rather than Wall Street. Many are highly educated, but many are also working class people who are doing the unseen work of keeping things running. Many have advanced degrees and years of experience that would have allowed them to cash in long ago to make more money in the private sector, but they don’t, because they have a higher calling than that.   Many of them have chosen careers that potentially put them in harm’s way—Soldiers, Sailors, Airmen, Marines; and people like my sister, a foreign service officer who represents U.S. interests in other countries; and FBI agents, Capitol Hill and Park Service police, federal marshals, and many more who work in law enforcement.

Most federal employees are crammed into small offices and cubicles that from all appearances haven’t been upgraded since the 1950s. Instead of state-of-the art technologies, most are stuck with out-of-date computers and cell phones (past generation Blackberries, no IPhones for them!). They are at the whim of whatever Congress decides to do, or not do, to enact a federal budget, with the seemingly constant risk of government shut-downs (read, lay-offs), and now, sequestration pay cuts. They expected to do their jobs even as travel budgets are slashed, hiring freezes imposed, and technology upgrades cancelled because of funding cuts.

They are people like my friends in the Government Accountability Office, whose jobs are to investigate federal spending programs (on behalf of Congress) to ensure that the money is spent wisely and effectively.   They are people who make sure all of those millions of Medicare and Social Security checks go out every week.   They are people like my friend at Treasury who tracks money laundering by terrorists and drug kingpins. They are the federal agency employees whose jobs are to turn laws passed by Congress into workable regulations and policies—just think of all the employees of the Center for Medicare and Medicaid Services who are working over-time to try to implement the Affordable Care Act on time and effectively, to ensure that it meets its goal of expanding access to affordable coverage. They didn’t write the law, but they have to make it work.

They are people like my brother-in-law, who works for probably the most loathed agency, the IRS—but without which, we wouldn’t have the resources required to do everything the federal government does, from keeping the elderly out of poverty to keeping us safe to providing financial assistance to the poor to paying for physicians’ graduate medical education, whatever we the public have asked the federal government to do through laws duly enacted by the Congress we elect.   They are people like a former ACP colleague of mine and long-term friend who now works as a Republican staffer on Capitol Hill, assigned with such seemingly insurmountable jobs as figuring out a way to eliminate Medicare’s SGR formula and create new and more effective payment systems!

They are people like the ACP physician members who work in CMS and other federal agencies, guiding research on health care disparities and access (Carolyn Clancy, MD who is the outgoing director, Agency for Healthcare Research and Quality) and federal funding to improve health care payment and delivery systems (Rich Baron, MD, who left private practice to work in CMS’s Center for Medicare and Medicaid Innovation and is now leaving to become CEO of the American Board of Internal Medicine). People like former CMS administrator (and pediatrician) Don Berwick, who brought a refreshing and passionate voice to the agency on always putting patients first. This is how Dr. Berwick describes his CMS colleagues:

“The time at CMS has been a privilege. I got the chance to work with thousands of career public servants, and to learn how much these people do for us all, unsung and too often unappreciated. These are the people who translate laws into regulations and regulations into deeds. In CMS these are the people who keep the lights on – they see that providers get paid, they protect the public trust, they help the most vulnerable people in America, and make sure that they get the care they need.”

Yet as a class, federal employers are castigated, repeatedly, inaccurately, and unfairly, often by politicians (who themselves are federal employees)!   Politicians who call federal employees “faceless bureaucrats” even though they know that federal employees have names and faces--and by law are held to very high levels of accountability and transparency for their work.

But it is not just the politicians who castigate federal employees: polls show that much of the public views them as being "lazy, overpaid, and incompetent, among other adjectives.” A recent poll even found that a majority consider federal employees to be “corrupt” even though objective studies show that the public sector in the United States is rated as among the “cleanest” (least corrupt) in the world. And, to the extent that there is a risk of public sector corruption in the U.S, it is more likely to be in state governments than the federal government.

And now, because of Congress’ failure to reach a thoughtful deficit reduction package, we are stuck with across-the-board cuts that will furlough (mandatory unpaid time off) as many as a million federal employees—the equivalent of a 20% pay cut for those affected. Physicians rightly   are crying foul over a scheduled 20% cut in Medicare doctor pay, but where is their sympathy for federal employees taking a comparable hit?

It is one thing to criticize federal government policies that you don’t agree with, to try to get those policies changed, and to elect different people to office—this is the essence of democracy. And for sure, the partisan gridlock in Washington is a sound reason to feel disconnected, even disgusted by the state of politics and governance today. But it is another thing to defame the hard-working, conscientious, honest, and public-spirited federal employees who, after all, are working for us.

Yes, there are a few bad actors in any line of work, whether it is an indifferent public employee or an unethical physician. But it is wrong to cast aspersions on dedicated and public-spirited physicians because of the ethical failings of a few, just as it is wrong to cast aspersions on dedicated and public-spirited federal employees because you might have had a bad experience with a few of them. The fact is that physicians and public sector employees have one important thing in common: they have chosen public service careers, and are doing the best they can in exceedingly difficult circumstances. But physicians, unlike federal employees, at least have the comfort of extremely high ratings from the public.

Today’s question: Do you agree with me that it is wrong to cast aspersions on all federal employees?

In Honor of my Irish Heritage

noreply@blogger.com (B Doherty) — Fri, 15 Mar 2013 15:38:00 +0000

Veteran readers of this blog know that I descend from a decidedly Irish heritage. My dear departed father, Jack Doherty, was born in a primitive thatched cottage in Drumshambo, Ireland, in County Leitrim, historically one of the poorest counties in Ireland. He emigrated to the United States at the age of 10 with my grandmother, Eliza (Elsie) Doherty, joining his father, who had emigrated several years earlier. He later made his living working behind (and owning) Doherty’s Bar in Woodside, Queens, New York, an establishment opened by his father Tom Doherty. When I was in college, I worked behind Doherty’s Bar, the third generation of Doherty’s “behind the stick” as the old-timer patrons put it. (This is one thing I have in common with Speaker of the House John Boehner—we are both SOB’s, or sons of bartenders.) Later on, my Dad went back to school to get his B.A and then a Masters in education, sold the bar, and became a high school teacher at an inner-city school in Brooklyn, New York.

So you can imagine that Saint Patrick’s Day is an important day on my calendar. Like all good Irish (Americans), it is a day for story-telling, enjoying “fine” Irish cuisine, and um . . . imbibing in some of the other pleasures associated with being Irish. One tradition I particularly enjoy is the distinct form of humorous poetry known as limericks, named after the famous city in Ireland, although some engage in the heresy of saying that the English invented it!

In honor of Saint Patrick’s Day weekend, I have penned a few political limericks for your enjoyment (I hope). (Advice, they may read better after you’ve had a few!)

I am so sick of the Medicare SGR,
Makes me want to escape to a bar
I'd prefer to drink
Rather than think
About how Congress has denied care to Grandma.

It really isn't fair
How critics attack Obamacare
Death panels are a lie
They won't send grandma to die
Scaring seniors is more than I can bear

Do you share my sense of frustration?
At Congress sticking us with sequestration?
Closing White House tours is cheap,
Long lines at airports make me weep
This is no way to run a great nation.

When it comes to predicting snow
DC weathermen really don’t know
Yet we close schools anyway
Shut the government for a day
We're just cold weather wimps, don't you know?

Sláinte, and Happy Saint Patrick’s Day!

Today’s question: Care to try your hand at writing and posting a limerick here?

The Privatization of ObamaCare’s (Only) Public Option

noreply@blogger.com (B Doherty) — Fri, 08 Mar 2013 14:30:00 +0000

Liberals lost the fight to include a new Medicare-type public option in the Affordable Care Act, but they took some solace in the fact that about half of the people expected to get coverage under ObamaCare would get it through the publically-run Medicaid program.   Even though many didn’t like the fact that the other half would get coverage through regulated private insurance sold through exchanges.

But as it is has turned out, even Medicaid—ObamaCare’s last and only true public option--will be replaced in some states with private health insurance, blessed by the Obama administration.

The result will be “a larger, but more conservative” Medicaid program, blogs the Washington Post’s Sarah Kliff.   “Emerging deals show [Republican] governors exploring approaches that would significantly reshape the program, such as moving beneficiaries into privately managed health coverage or giving enrollees a greater financial stake in their health care” she writes. And the Obama administration has gone along. For instance, Florida governor Rick Scott was able to get a waiver to move almost all of Florida’s Medicaid enrollees into private health insurance plans, right before announcing his change of heart in favor of expanding the program.

It isn’t just Republican governors, though, pushing for Medicaid privatization. Mike Bebee, the Democratic governor of Arkansas, reached a “super expensive, legally dubious” agreement with the administration to allow the state to “enroll new patients in the same private health plans that will be available for residents with higher incomes, “writes the National Journal’s Margot Sanger-Katz. “If the state Legislature approves the plan, all Arkansans earning below 133 percent of the federal poverty limit—or about $15,000 for a single person—will be able to get [private] health insurance. Other states are watching closely.”   (Among them being Texas, where Republican lawmakers recently decided that they opposed expansion—for now—“but left the door open to doing so if the Obama administration grants Texas enough flexibility” reports the Texas Tribune.

On one hand, if you believe in federalism and states as the laboratories of innovation, the willingness of the Obama administration to allow states to privatize Medicaid could be viewed as a good thing, enabling states to achieve ObamaCare’s goal of covering all of the poor and near-poor using customized approaches that may be more suitable to a particular state’s culture and politics. It belies the argument that the Obama administration is trying to impose a one-size-fits-all federal program on states. And if it achieves the goal of getting poor people covered, why should anyone care if a state does it through private insurance instead of the traditional public Medicaid?

Well, you might care if it ends up costing federal taxpayers a lot more. The same National Journal article cited above reports that “Estimates suggest that a plan such as the one proposed in Arkansas may cost in excess of 50 percent more than the Medicaid expansion described by the Affordable Care Act. The cost would increase because private plans that will be sold on state insurance exchanges, or marketplaces, will be much more expensive than government-run insurance and won’t cover all of Medicaid’s required benefits.” And you might care if you believe that private health insurance plans are more likely to skimp on care or take advantage of poor people, and because you are worried that they will divert some of taxpayers’ money to insurance company profit rather than patient care. Yet liberals have for the most part been quiet about Obama administration’s willingness to let states privatize Medicaid, “even though Medicaid is now central to the progressive vision of a universal health care system” writes the Progressive Policy Institute’s Ed Kilgore in this month’s Washington Monthly. “This provides Republicans at the federal and state levels with a dual motive for sabotaging the Medicaid expansion, even if that means that federally run health care exchanges must pick up the slack.”

So here we have it: conservatives have consistently blasted the law and the Obama administration for imposing federally-run health care on the states, yet in fact the Obama administration is allowing conservative states to privatize Medicaid, as long as they agree to expand it to the poor and near-poor. Liberals fought and lost the battle to include a new public option in the Affordable Care Act, yet almost all got behind it in the end because they viewed it as a step toward achieving universal coverage. But how many liberals anticipated that the price they’d pay for getting more people covered would be increasing privatization of Medicaid, the ACA’s only true public option? Yet we are heading to result where more of the poor will end up in private insurance and fewer of them in public Medicaid, leading to “a larger and more conservative Medicaid ”--with relatively little public debate on whether that is the best result for patients.

Today’s questions: What do you think about the growing number of conservative states agreeing to expand Medicaid as long as they can turn it over to private insurance companies? Is this a good or bad thing for patients? And how do you feel about the Obama administration’s willingness to let them?

Dumb and Dumber

noreply@blogger.com (B Doherty) — Wed, 27 Feb 2013 20:52:00 +0000

Sequestration is a dumb idea—plain and simple.   It is a dumb idea if you are a Democrat. It is a dumb idea if you are a Republican. It is a dumb idea if you are an independent. Even dumber is that fact that Congress and the President inflicted this dumb (and totally unnecessary) crisis on us and are wasting time now by blaming each other for who came up with the dumb idea in the first place—rather than solving it.

(For the record, sequestration—across the board budget cuts that will go into effect on March 1--is the handiwork of both parties. The President proposed it to break the impasse on re-authorizing the debt ceiling in the summer of 2011, a fiscal crisis brought on by House Republicans who refused to pass a routine bill to increase the ceiling without an agreement to cut spending. To overcome this impasse, majorities of Republicans and Democrats in the House and Senate then voted for the Budget Control Act of 2011, which included sequestration as a back-up plan to reduce the deficit that was intended to go into effect only if a congressional “Super-committee” couldn’t come up with an agreement on a better way to achieve savings. The “Super-committee”—made up evenly of Republicans and Democrats, House and Senate—deadlocked and couldn’t produce a plan, and as a result, the Act required that sequestration be instituted on January 1 of this year. On January 1, 2013, both the House and Senate reached a last-minute bipartisan agreement, signed into law by President Obama, to postpone sequestration until March 1. And here it is now, with fewer than 48 hours left, and there has been no serious effort by either party, by the House and Senate, or by the White House, to come up with a bipartisan plan to stop sequestration.)

How dumb is sequestration? Well, let’s say you were the mayor of a mid-size city, your budget is deeply in the hole, creditors are at the door, and you realized you have no choice but to reduce your debt. Would you:

1.    Cut all of your expenses by the same percentage amount—the money set aside to stop an unsafe bridge from collapsing; the money allocated to pay the salaries of teachers, police and firefighters; the taxpayer money you asked for to buy nicer furniture for your own office; the money for that all-expense-paid trip to Palm Springs (golf included) that you and the city council want to take to “network” with other mayors (including attending that cool symposium on how to control your city’s spending), and the budget for medical care and shelter for the homeless?

2.    Prioritize your spending, cutting some categories by more, some by less, and some not at all—protecting the money set aside to stop an unsafe bridge from collapsing, the money allocated to pay the salaries of teachers, police and firefighters and the budget for medical care and shelter for the homeless, over new furniture for your office and the trip to Palm Springs?

3.    If prioritizing your spending isn’t enough to close the gap, ask your wealthiest residents to pay a little bit more to help preserve funding for the most essential and effective programs that benefit everyone, but especially, the least well-off in your city?

Most of us, I think, would agree that #2 and #3 are pretty smart, and #1 is just plain dumb. Yet #1 is exactly what sequestration is all about--it cuts federal programs by the same amount, no matter how good or bad, how essential or non-essential, how effective or ineffective, how important or unimportant, how many are helped by the program cut.

And although there are some in and outside of Washington who argue that sequestration will do no harm, the sequestration cuts to healthcare will have a real impact on access, quality and public health and safety, maybe not all at once, but before too long, and the longer they are allowed to remain in effect, the greater the damage. ACP’s State of the Nation’s Health Care report, released last week, documented the impact, including:

1.    Medical research to prevent and cure diseases will be curtailed. The cuts would result in 2,100-2,300 fewer NIH research grants, and Research Proposal Grant (RPG) success rates would drop from 18 percent in FY2011 to 14 percent in FY2013.

2.    Funding for programs to train more physicians, especially primary care physicians in under-served areas, will be slashed: 295 fewer scholarships for minority and disadvantaged health profession students, a loss of funding midway through their training for 14 primary care residents; 2,315 primary care physician and physician assistant trainees adversely affected by reduced funding for the Title VII Primary Care Training and Enhancement Program, and 14,760 fewer public health professionals trained through the Title VII Public Health Training Center Program.

3.    Patient access will suffer and jobs will be lost as Medicare payments to hospitals, physicians, and physician residency programs are cut. Altogether, Medicare will be cut by $11 billion in 2013 under sequestration resulting in a loss of nearly 500,000 U.S. jobs. But the biggest impact will be on seniors and disabled persons who rely be on Medicare coverage to enable them to access quality health care. Although guaranteed benefits will not be directly reduced by sequestration, cuts in payments to physicians and hospitals will force many of them to lay-off staff, curtail services, and limit how many Medicare patients they can see. Physicians and other clinicians may have to lay off as many as 62,000 employees if sequestration goes into effect. In the case of physicians, the sequestration cut is a prelude to a much larger scheduled cut on January 1, 2014 as the result of Medicare’s flawed Sustainable Growth Rate formula.

4.    The federal government’s ability to prevent and control diseases and to ensure the safety of food and drugs will be compromised. Funding for the Food and Drug Administration will be slashed by $191 million and for-the Centers for Diseases Control and Prevention by $444 million over 10 years starting in 2013.

How dumb it that—to train fewer primary care physicians when we know that the country is facing a massive shortage, to lose our edge in medical research, to make it harder for Medicare patients to find doctors, to make our food and drugs less safe, to make it harder to detect and prevent the next flu outbreak or pandemic? When there are far better ways to reduce unnecessary health care spending?

But before we just blame the politicians for their cognitive impairment when it comes to the federal budget, we should look in the mirror. Polls show that a majority of Americans want the focus of deficit reduction to be mostly on spending reductions rather than tax increases, but this general support for spending cuts doesn’t translate into support for cutting any specific category of spending. Rather, a recent poll shows that the public rejects spending cuts for 18 out of 19 categories of spending; the “only exception is assistance for needy people around the world. Nonetheless, as many say that funding for aid to the needy overseas should either be increased (21%), or kept the same (28%), as decreased (48%).” (Only 22% favored cuts in health care spending, and only 15% supported cuts in Medicare).

So we Americans want to cut the deficit, we want deficit reduction to focus mainly on spending cuts rather than higher taxes, but we reject cutting anything other than the miniscule amount of federal money spent on foreign aid? That is, no cuts in any program that benefits us directly. Now, how dumb is that?

Today’s questions: What is your take on the budget sequestration mess? How should the country get out of it?

Time is on My Side

noreply@blogger.com (B Doherty) — Thu, 21 Feb 2013 17:01:00 +0000

Time very well may be on your side if you are Mick Jagger and Keith Richards (they‘re still rockin’ after all these years!) but not for doctors and patients. The pressure on physicians to spend less time with patients is part of an unrelenting assault on the patient-physician relationship, declared the American College of Physicians in a report released yesterday on the state of the U.S. health care. ACP President David Bronson, MD, FACP described it this way at a press briefing announcing the reports, “System-wide efforts to improve the healthcare system won’t succeed on their own in improving access and quality if the physicians that the system is counting on to deliver care are over-hassled, over-stressed, harried, hushed and rushed.”

Or, as I put it in my remarks at the same briefing, “None of us want our doctors to spend more time on paperwork than listening to us, yet we have a system that buries physicians in administrative tasks to the exclusion of patient care. None of us want our physicians to be rushed from patient-to-patient, from task-to-task, but that often is the only kind of medicine that the system allows.”

Lack of time with patients was one of seven barriers to the patient-physician relationship identified by ACP:

“Lack of time with patients. Current payment, coding and relative value systems discourage physicians from spending time with patients. Also, as physicians spend more and more time each day complying with unnecessary administrative tasks and mandates (see below) imposed by payers and government, they have even less time to spend with their patients.

Excessive, Unnecessary and Unproductive Administrative Tasks. A recent study found that U.S. physicians spend $31 billion annually on interactions with health plans. More specifically, physicians reported spending almost a half-hour each day, three hours each week, and three weeks per year, interacting with health plans. Primary care physicians spend significantly more time (3.5 hours weekly) than other medical specialists (2.6 hours) or surgical specialists (2.1 hours).

Electronic Health Records that Do Not Meet Clinicians’ and Patients’ Needs. Electronic health records were intended to improve care but many physicians are frustrated that they lack the capabilities needed while adding more inefficiency to their daily workflow, compounded by well-intended government “meaningful use” standards that might make things even worse.

Performance measures that can result in unintended adverse patient care consequences. Performance measures can be difficult to report on, may measure the wrong things, and they do not always agree with each other. Physicians appropriately ask: who is measuring the value and effectiveness of the measures themselves?

Growing and excessive number of mandates on physicians enforced by penalties. Payers and government keep imposing more penalties on physicians: for not e-prescribing, for not converting to a complex ICD-10 diagnosis coding system, for not meaningfully using electronic health records, and for not successfully reporting on measures. Physicians wonder how they can even find the time to track all of these mandates, incentives, rules, and penalties, while keeping their practices open.

The adverse consequences of a dysfunctional medical liability system. Physicians feel continually exposed to the risk of medical liability lawsuits, and feel pressured to perform “defensive medicine” to reduce the risk of being sued. At the same time, patients who are truly harmed by medical errors often wait years for a court to decide on their compensation, if they receive compensation at all.

Direct government intrusion into the patient-physician relationship. The patient-physician relationship is undermined by laws that tell physicians what they can and cannot say to their patients or what tests or procedures they must compel their patients to obtain, without regard to the physician’s clinical judgment or the patient’s interests.

What can be done about it? ACP offered the following nine proposals to reduce such intrusions:

1. Public and private policymakers and payers must ensure that any payment reforms have, as an explicit goal, allowing physicians to spend more appropriate clinical time with their patients.

2. Payment and delivery reforms that hold physicians accountable for the outcomes of care (measurable performance on quality, cost, satisfaction and experience with care) should concurrently eliminate the layers of review and second-guessing of the clinical decisions made by physicians.

3. CMS should harmonize (and reduce to the extent possible) the measures used in the different reporting programs, work toward overall composite outcomes measures rather than a laundry-list of process measures.

4. CMS should provide more clinically relevant ways to satisfy the requirement that physicians must transition to using ICD-10 codes for billing and reporting purposes.

5. Congress and CMS should consider working with physicians to encourage participation in quality reporting programs by reducing administrative barriers, improving bonuses to incentivize ongoing quality improvements for all physicians, and broadening hardship exemptions. If necessary, Congress and CMS should consider delaying the penalties for not successfully participating in quality reporting programs, if it appears that the vast majority of physicians will be subject to penalties due to limitations in the programs themselves.

6. The government, the medical profession, and standard-setting organizations should work with EHR vendors to improve the functional capabilities of their systems, to improve the ability of those systems to report on quality measures and to ensure that those systems improve rather than adding to workflow inefficiency.

7. Medicare and private insurers should move toward standardizing claims administration requirements, pre-authorization, and other administrative simplification requirements even in advance of, and in addition to, the simplification rules included in the ACA.

8. Congress should enact meaningful medical liability reforms including health courts, early disclosure errors, and caps on non-economic damages.

9. State and federal authorities should avoid enactment of mandates that interfere with physician free speech and the patient-physician relationship.

ACP’s report didn’t just focus on policies to reduce intrusions on the patient-physician relationship; it also proposed ways to improve the health care system overall—by building on the progress in expanding coverage and lower costs, by creating incentives for primary care, but putting a stop to across-the-board budget cuts to vital health programs, by eliminating the Medicare SGR, and by preventing deaths and injuries from firearms. ACP doesn’t buy into the argument that one has to choose between expanding coverage to the uninsured and reducing hassles for physicians and patients—we need to do both.

Dr. Bob Centor, chair-elect of the ACP Board of Regents, puts it this way in his DB’s Medical Rants post on ACP’s proposals:

“Often readers of this [DB’s Medical Rants] blog impugn the ACP and other national organizations. They charge that we are not in sync with practicing physicians. I challenge you to read these positions and say that here. You may disagree with parts of the ACA, but most of you do want to see broader coverage for patients. I know that you care about payment and making primary care a more desirable option. You have told me often that government is intruding into our practices, and I contend that the ACP's positions should be most agreeable.

We are proud of our agenda. We believe that most internists will agree with the majority of our positions. We wish the Congress and their staffs, the White House and state legislatures would pay attention. We can improve health care AND spend less money. We can decrease physician burnout without harming quality. And please note my favorite point – one that readers of this blog will recognize: Payment reforms must allow physicians to spend more appropriate clinical time with their patients.”

The need to change the things that drive physicians and patients crazy is a theme I blogged about last fall, and it is good to see ACP give such prominent attention to the issue in its new report (Disclosure: I was the principal staff author of the report).

Putting time back on the side of patients and their physicians won’t be easy—harried and rushed medicine is deeply engrained in our system---but it is essential if we are to have the kind of health care that patients want and deserve. Let’s rock n’ roll to make it happen.

Today’s questions: What do you think about ACP’s description of the “unrelenting assault on the patient-physician relationship”, and its policy proposal to end it?

Not in My Lifetime

noreply@blogger.com (B Doherty) — Fri, 15 Feb 2013 17:21:00 +0000

An elderly doctor passes away, and he find himself standing before the Pearly Gates. The Almighty greets him and says, “In recognition of your stellar life of service to your patients, family and community, I welcome you to paradise. And because I know that doctors have a great sense of curiosity about all things, you can now ask me any question—any—and I will answer it.”   The doctor ponders for a moment or two, thinking about all of the mysteries of the world, and comes up with the one question that has troubled him the most. “Can you tell me, your greatness, whether Congress will ever get around to repealing the Medicare SGR?”   God hesitates for a moment, and responds, “Yes . . . but not in my lifetime.”

(A version of this joke has been around for years, only the question asked was whether Congress would ever enact universal health insurance coverage. With the ACA getting us close to universal coverage, I thought that substituting the SGR would make for a more timely question for the good doctor to ask the Almighty!)

And after more than a decade of botched efforts, who can blame doctors if they begin to think that it will take an eternity—or longer, if that is possible!—for Congress to finally get around to repealing the SGR.   Year after year, they have seen the same tired script replayed. CMS announces that the SGR will cut physician payments (by an escalating amount each year). Members of Congress pledge that it won’t happen and that this will be the year when the SGR will be repealed. You can believe us for sure, this time will be different, we promise you, wink, nod.   They then ask physicians not only for ideas on replacing the SGR but also commitments (like agreeing to be measured on their performance). Physicians dutifully offer serious proposals and commitments, Congress thanks them, then dithers for months, gets itself into a partisan spat about how to pay for SGR repeal, waits to the very last minute before the cut is supposed to go into effect ( and in some instances past the last minute, requiring a retroactive fix) and then finally—hallelujah!—passes something that averts the cut for a few months, or maybe a year or two (at best).

And then we start the whole darn thing all over again. If that isn’t the earthly equivalent of eternity, it is pretty darn close.

But maybe, just maybe, there is now cause for hope that this year could be different.

First, the Congressional Budget Office cut in half its estimate of the cost of repealing the SGR, down from $244 billion to $138 billion (over ten years).   Yesterday, Glenn Hackburth, chair of the Medicare Payment Advisory Commission, told the House Energy and Commerce Committee that “In effect, SGR repeal is now on sale. But the sale may not last forever.” (Still a lot of money, but with the new CBO numbers, it makes it easier for Congress to find a way to pay for SGR repeal.)

Second, for the first time in a very long time, there actually is a draft plan on paper to eliminate the SGR that has the support of congressional leadership.   The plan, offered by the Republican leadership of the two House committees with jurisdiction over Medicare, would eliminate the SGR in three phases and begin to link future updates to physicians’ participation in quality improvement efforts or new payment models.

Third, Congress actually is talking about putting partisanship aside—imagine that, what an idea!—to come up with an SGR repeal plan.   Rep. Fred Upton (R-MI), chair of the House Energy and Commerce Committee, said his hope is to get a bill on the floor of the House by August, and that he would seek support from Democrats on a bill that could pass the Senate. Related, a bipartisan bill, the Medicare Physician Payment Innovation Act, to repeal the SGR, stabilize payments, provide higher updates for undervalued evaluation and management services, and transition to new models was re-introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck (R-NV).   The bill, which is strongly supported by ACP, is in many respects similar to the one proposed by the House committee leadership.

Finally, Congress is actually listening to the doctors! The plans being floated directly reflect ideas offered by ACP, AMA, and more than 100 physician organizations—demonstrating an unprecedented degree of unity.

It still may require divine intervention for Congress to enact legislation to repeal the SGR, and I wouldn’t bet on it. But at least for the first time in a decade there is at least a prayer of making some progress.

Today’s question: What do you think of the latest developments on the SGR?

Blaming the Patient

noreply@blogger.com (B Doherty) — Tue, 29 Jan 2013 21:26:00 +0000

"Discrimination against heavy people, by the general public and medical professionals, might be a greater health and social problem than any extra pounds they may be carrying" argues UCLA Professor Abigal Saguy, PhD, in a provocative essay in the Washington Post. "Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have" she writes, comparing such "size profiling" to "racial profiling."

"Both types of profiling" she continues "lead to false positives (people wrongfully accused or medically overtreated) and false negatives (people who get away or are medically undertreated)."

I think comparing "size profiling" to the horrible continued legacy of racism is a stretch, but Dr. Saguy has a point--some clinicians seem quick to blame their patients for being overweight. And also for smoking, for abusing drugs and alcohol, for eating unhealthful diets, for not exercising enough, for not taking their prescribed medications and for not following their physician's advice. I have heard some internists rail against patients who are "not taking responsibility" for their own health, demanding to know what the ACP is doing to make people accept more responsibility.

I can sympathize with physicians who are doing everything they can to help their patients improve their health, only to encounter patients who continue to do bad things to their health. Especially, if the physician is subjected to performance measures that penalize them when their patients don't have the desired outcomes. No one wants to be blamed for things outside of their own control!

But this is true of patients as well.

The "blame the patient" attitude assumes that how much we weigh or how sick or well we are is mostly a matter of will power. Sure, there are things that each of us can do (and don't do) that can help make us less or more healthy. But many of these things--eating better, exercising more, not smoking, not drinking to excess--may be very difficult or even impossible for some people to achieve because of genetics (family history of alcoholism and other substance abuse), culture and community (the diet your grew up with, the food choices available to you in your community, exposure to crime and violence), stress, literacy, physical and emotional abuse, how you were raised by your parents, the quality of your schools--the list goes on and on. And even if you do everything right, it may not work--eating well and exercising does not guarantee that someone won't be overweight. And being overweight doesn't guarantee you will get sick.

The "blame the patient" philosophy also shows up in public policy proposals: high deductible health plans that by definition mean that the sick will pay more out-of-pocket (because they need and use more health services) than the well (because they need and use fewer health care services); higher co-payments for receiving non-emergency care in emergency rooms (which disproportionately affect poor people in poor health who may not have good access to community-based primary care); and proposed regulations that allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status.

Yesterday, House Democrats sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish "health-contingent wellness programs" that "allow differential rewards based on health status factors, including a person's cholesterol, blood pressure, weight or body mass index." The lawmakers argued that such programs would undermine the ACA's prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm "certain population groups, including racial and ethnic minorities, such as Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels."

ACP, in a comment letter on the same proposed rule, similarly stated "that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals."

And ACP's ethics policy, developed by its Committee on Ethics, Professionalism and Human Rights, states that "Incentives to promote behavior change should be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control. Incentives to encourage healthy behaviors should be appropriate for the target population. The American College of Physicians supports the use of positive incentives for patients such as programs and services that effectively and justly promote physical and mental health and well-being."

Objecting to stigmatizing and punishing patients because of their body weight, health status, genetics, and personal choices is not the same as arguing that patients shouldn't be engaged in, and responsible for, making contributions to their own health. Physicians can and should engage patients in shared decision-making about their health. They should engage patients in helping them understand their risk factors and how they might help reduce their risks. They should help them succeed and also support them if they fail.

Physicians can also advocate for public policies to engage and empower patients in healthcare decision-making--such as for reimbursement changes to allow physicians to spend the time required for effective shared decision-making and creating positive incentives to help people access effective weight-loss or other wellness programs. While advocating against policies to stigmatize and punish people for their health status.

As my mother might say, no one likes a scold. Let's stop scolding people for supposedly not doing enough to stay healthy. And instead, lets start helping them be as healthy as they can and make sure they are cared for when they are sick, no matter what they did or didn't do when it comes to taking care of their own health or the genes they inherited from their parents.

Today's questions: Do you agree with Dr. Saguy that many in the medical profession stigmatize patients for being overweight and other aspects of their health? How do you feel about programs that would penalize people for not achieving measurable improvements in their health?

Is Global Capitation a Better Way to Pay Primary Care Physicians?

noreply@blogger.com (B Doherty) — Thu, 24 Jan 2013 22:04:00 +0000

Despite the clamor about new ways of paying physicians, the reality is that most continue to be paid under a fee-for-service basis, and likely will be for some time. Even under the ballyhooed “new models”, like Medicare’s Accountable Care Organizations and Comprehensive Primary care Initiative (which is based on the Patient-Centered Medical Home concept), most physicians will continue to be paid principally on a fee per-visit and procedure basis. In the case of ACOs, it is fee-for-service plus/minus shared savings, and in the case of Comprehensive Primary Care Initiative, it’s fee-for-service plus monthly risk-adjusted care coordination payments for each patient seen by the practice, linked to measures of performance.

Might it not be better to drop fee-for-service altogether, and instead pay primary care physicians on a global capitation basis? Under global capitation, primary care physicians would get a set amount of money each month for each of their patients, with the monthly amount per patient being adjusted upward or downward based on the relative complexity/risk of each patient in the physicians’ panel.

ACP members Drs. Allan Goroll and Bob Berenson, and two other co-authors, proposed such a fundamental change in how primary care physicians are paid, in an article published five years ago in the Journal of General internal Medicine. They studiously avoided calling their proposal capitation, because “proposing a comprehensive, aggregate payment is likely to evoke memories of primary care capitation with its pejorative connotations; however, there are important differences, which lead us to avoid using the term ‘capitation’ to describe our system. The most important differences are risk/needs-adjustment, paying for performance to guard against underservice, and budgeting sufficient monies to support teams and infrastructures. These features are essential to avoiding the withholding of necessary care and the shunning of complex patients that too often occurred under the capitation initiatives of the past decade."

From a payer’s perspective, the advantage of primary care capitation, or comprehensive aggregate primary care payment if you prefer, is that it makes spending much more predictable and controllable—the payer gives the primary care physician a set amount of money, and the physician is then responsible for keeping spending within that amount. It also eliminates most of the cost to the payer of claims processing, billing, and utilization review systems and personnel, since the only “bill” that has to be processed is a monthly check to the physician, and with no health insurance claims being submitted, no claims to review. Since the physician would have to live within the budget set by the monthly capitation payment, there would be no need to review the physicians’ utilization of tests, procedures and visits.

The idea of providing care within a monthly global budget, though, is precisely what many physicians fear. They worry that the monthly payments won’t be adequate to cover their costs. They worry that they will have to skimp on care in order to come out ahead. They worry that even if the initial monthly payment is sufficient, payers would have an incentive to ratchet it down over time to save more money. They worry that the payments won’t adequately adjust for the complexity and risk of the patients that they have in their practice. They worry that the budget will put them at risk for things they can’t control, such as services provided by non-primary care physicians that the patient is also seeing. They remember that under the primary care capitation schemes popular in the mid-90s, the best patients were the healthy ones who never needed much care and the worst were the sick ones who needed more services, because the physician was paid the same amount no matter how sick the patient was.

Dr. Goroll and his co-authors recognize and try to allay these concerns, by differentiating their model from the discredited transfer of insurance risk on the back of doctors form of primary care capitations that physicians (rightly) object to. They propose that the monthly payments “be directed to cover all practice expenses and salaries related to operating a robust, modern primary care practice, one that would qualify as an ‘advanced medical home’ for adults, a practice structure that enables efficient provision of comprehensive, coordinated, patient-centered care” so that “total practice revenue would markedly increase compared to that under RBRVS.”

Also, “Payment for hospital and specialist services and ancillaries such as medications, laboratory tests, and imaging studies would remain the responsibility of payers and not the practice” and “a validated risk-adjustment framework that incorporates the full spectrum of important risk determinants, including those accounting for patient behaviors will be needed.”

Finally, the authors note that “in a cost-conscious society, it is unlikely that the new payment model will be adopted widely if it is viewed as a give-away to primary care physicians/practices. Conversely, primary care physicians are likely to reject the model if it appears to be yet another attempt to use them as gatekeepers or insurance companies. Our model tries to avoid both pitfalls by assigning most of the financial/actuarial risk to insurers while recognizing the responsibility of primary care practices to be financially and clinically accountable.”

I think it is time for primary care physicians to balance their legitimate reservations about anything that smells like capitation with an openness to consider the potentially big advantages, to them and their patients, of a model like that proposed by Dr. Goroll and his colleagues.

The three things that I hear primary care physicians complain the most about is that they are under-paid, over-hassled, and overly-controlled by payers who feel compelled to second-guess everything that they do. A Comprehensive Primary Care Monthly Global Capitation model, if it offers sufficient revenue in exchange for practice transformation with adequate risk adjustment, could result in primary care physicians getting paid more for their services, remove the hassle of having to submit bills and associated documentation requirements, and put the primary care physicians--not the payers!--in control of managing costs and quality within a budget—all while making health care spending more predictable and potentially, saving money for the system. That sounds like a win-win to me. What about you?

Today’s question: What do you think about replacing fee-for-service and RBRVS with paying primary care physicians on a monthly, risk adjusted global payment basis, with the aggregate payments being “sufficient to cover all practice expenses and salaries related to operating a robust, modern primary care practice”?

Curiouser and curiouser!

noreply@blogger.com (B Doherty) — Thu, 17 Jan 2013 15:43:00 +0000

Trying to figure out what is going on with health care costs is like Alice’s adventures in Wonderland, things are just getting curiouser and curiouser. To illustrate: which of the following statements do you think are correct?

1.    It’s been 50 years since health care costs increased this slowly.
2.    The U.S. spends more on healthcare than any other country but our health is much worse.
3.    Last year continued a three year trend of historically low Medicare cost increases.
4.    Looking ahead, Medicare spending is projected to climb at a rate the country can’t afford.
5.    ObamaCare is driving up premium costs.
6.    ObamaCare is keeping healthcare cost increases down to historically low levels.

A credible case, based on the evidence, can be made for every one of the above statements, including the ones that appear to be in contradiction to each other! Let’s boil down each one, in order.

#1: “It’s been 50 years since health care costs increased this slowly.” True! In 2011, health care spending grew only 4.4%, the lowest in fifty years, and that trend continued into 2012.

#2: The U.S. spends more on healthcare than any other country but our health is much worse.” True! NPR reports on a new Institute of Medicine study that found “Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations” and “the gap is steadily widening” despite the fact we spend much more on health. (So much for American Exceptionalism!)

#3: “Last year continued a three year trend of historically low Medicare cost increases.” True! According to official government numbers, Medicare per capita costs went up by only a fraction of a percent In 2012 (0.4%), much less than the rate of growth in the economy (3.4% growth per capita). Over the three year period from 2010-2012, Medicare spending per beneficiary grew an average of 1.9% annually, or more than 1 percentage point slower than the average annual growth of 3.2% in per capita GDP (that is, at GDP-1.3).

#4: “Looking ahead, Medicare spending is projected climb at a rate the country can’t afford.” Probably true, but maybe the trajectory isn’t quite as worrisome as it used to be—or is it? On one hand, the government report cited earlier, projects that, “The slow growth in spending per beneficiary from 2010 to 2012 combined with the projections of spending growth at GDP+0 for 2012-2022 is unprecedented in the history of the Medicare program. If sustained, the slower growth would improve Medicare’s ability to meet its commitments to seniors and persons with disabilities in future generations.”   But the qualifier “if sustained” leaves a lot of room for doubt. The Fiscal Times notes that, “ ‘Even though spending per beneficiary is projected to grow at or below the rate of per capita GDP, the number of Medicare beneficiaries is projected to grow at approximately 3 percent a year,’ the HHS report says. The 50 million beneficiaries today will grow to more than 85 million in 2035. ‘As a result, aggregate Medicare spending will account for a growing share of GDP over the next decade.’”

Okay. Let’s move onto #5: “ObamaCare is driving up premium costs.” It is true that many insurers are raising premiums in the small and individual insurance market, but experts disagree on how much of that is due to ObamaCare, and how much of it is due to loosely-regulated insurance companies gouging the consumer. The conservative Wall Street Journal editorial page predictably pins the premium increases on Obamacare, arguing that the reason insurance companies are raising premiums is because of the law’s “newly imposed mandates” and taxes. The liberal New York Times editorial page predictably pins the blame on insurance companies, noting that the “jarring discrepancy [between double-digit premium increases and unusually low rates of national health care spending increases] suggests that both the federal government and the states need more power to reject premium increases that can’t be justified.”

(I agree with those who say it is counter-intuitive for health insurance premiums to be going up by double-digits when health spending increases are the lowest in half a century. A small part of the increase might legitimately be due to ObamaCare’s mandates and taxes, although the law’s critics forget that people are getting better benefits and protections as well, but shouldn’t premiums be at least somewhat related to the costs of care, so that as health care spending slows, premium growth should slow as well?   If they aren’t, then insurance companies sure got some explainin’ to do, and regulators shouldn’t just accept the excuse that it is all ObamaCare’s fault).

And now for # 6 (drum roll): “ObamaCare is keeping healthcare cost increases down to historically low levels.” Critics point to the premium increases to say “absolutely not” and supporters to the three year spending slowdown to say “absolutely yes.” The rest of us aren’t so sure. Maggie Mahar shifts through the competing claims and concludes that “one thing is certain: medical spending trends are headed in the right direction. At last, we seem to be breaking the back of healthcare inflation.”

I wish I could be as certain as she is—we are heading in the right direction, but I don’t know that it can be sustained. And we still have that “little” problem of demographics: more older and sicker people needing health care benefits, fewer healthy and younger workers being around to pay for them.

Maybe we should all just take a deep breath and admit we don’t really know what is going on with health care spending.   Liberal supporters of ObamaCare shouldn’t rush to the judgment that it has “broken the back” of health care inflation, especially since most of its supposedly cost-saving delivery system reforms are just getting started. Conservative critics of ObamaCare shouldn’t rush to the judgment that it is causing premiums to explode, especially since most of its coverage mandates and taxes won’t fully go into effect until next year, and its supposedly cost-saving delivery system reforms are just getting started.

Let’s all acknowledge that it is good news for everyone if the three-year slowdown in health spending can be sustained, no matter who or what is responsible, since that would make it a whole lot easier to reduce the federal budget deficit and keep care affordable for individuals, families and employers.
Let’s admit we don’t know why health care costs aren’t increasing as fast as they used to, and we don’t know if the trend can be sustained.

Let’s face up to the fact that we still as a country spend more on healthcare than anyone else (even if the rate of increase has slowed) and our health is worse in most respects, and that can’t be good news.
As I said, it’s getting curiouser and curiouser.

Today’s question: What do you make of the data on health care spending?

Can Team-based Medical Homes Eliminate the Primary Care Physician Shortage?

noreply@blogger.com (B Doherty) — Fri, 11 Jan 2013 15:24:00 +0000

It’s a rare thing when a single study has the potential to rock the health policy world by directly challenging conventional wisdom, but that’s the case with one published on Sunday in Health Affairs, the go-to journal for policy wonks. It offers the prospect that the much ballyhooed shortage of primary care physicians may not happen after all, because team-based models—the Patient-Centered Medical Home (PCMH) in particular—have found a way to provide good access to primary care for more patients, using fewer clinicians. (The full article is available only to Health Affairs subscribers).

The article specifically found that primary care workforce capacity can be stretched to take care of more patients when primary care physicians work as a team with nurse-practitioners (NP) and physician assistants (PA) in a patient-centered medical home. In which, the non-physicians take care of the majority of patients with routine presenting problems while the physicians take care of patients with more complex diagnostic and treatment challenges.   This, by itself, is not a new concept—there is a broad consensus that an “all-hands-on-deck” approach will be needed to meet the current and future demand for primary care. There also is a broad consensus that collaborative teams of physicians, NPs, and PAs can deliver care more effectively and productively than individual clinicians working in their own disconnected silos.

This study, though, goes so far as to say that multi-disciplinary clinical teams in a PCMH, supported by health information technology, have the potential of eliminating primary care physician shortages.   How so?

“We show that by implementing partial pooling of patients by two or three physicians and diverting as little as 20 percent of patient demand to nonphysician professionals or using electronic health record–enabled electronic communication, or both, most if not all of the projected primary care physician shortage could be eliminated.”

In other words: the authors believe that electronic communications can substitute for many primary care visits; NPs and PAs working with physician can handle a good proportion of primary care visits, and primary care physicians can handle the rest. They also suggest that PCMHs could make primary care more attractive to physicians, helping to increase supply:

“In addition, the use of nonphysician professionals to deal with more routine problems and the decreased need to respond to urgent requests for care that comes with shared practice can increase the attractiveness of primary care careers for new physicians, adding to the forecast supply. In fact, recent data suggest that this trend may have already begun.”

If you accept their analysis, you would need fewer primary care physicians to meet demand, far fewer than the studies projecting shortages of tens of thousands of primary care physicians.
It is important to note that the authors did NOT say that NPs can replace primary care physicians, nor do their findings support the call for more “independent” NP-run practices.

There are obvious limitations to the study. For one thing, it principally is based on modeling and simulating how models like the PCMH could help meet the demand for primary care more effectively, and then comparing those simulations to accepted studies of primary care physician workforce studies.   The authors acknowledge that there are “barriers” to team-based PCMHs that need to be accounted for, but my sense is that the barriers are much greater than they think. For one thing, they may have more confidence in the ability of electronic health records and current electronic communications to substitute for primary care visits than is merited, given the dissatisfaction many physicians have with the current information systems available to them and patient skepticism about them.

They also didn’t address the reality that for the numbers of PCMHs to increase to the point where they could have a major impact on projected workforce demands, there needs to be a sustainable payment model to support such practices.

Nor did they address the reality that many primary care physicians are so frustrated that they are looking for a way to get out of practice altogether, or at least to drastically reduce their patient volume by converting to “concierge” practices.   While it is true that more physician practices are making the transition to PCMHs, we are losing more and more, good primary care physicians even as we try to re-invent the system.

It is one thing to model an ideal team-based, technology-enabled multi-disciplinary medical home and how this model might affect the number of patients that can be effectively seen by a practice, and another for policymakers to conclude that PCMHs can “eliminate” the primary care shortage.
At the same time, the study makes an important contribution in illustrating that how we organize and deliver primary care in the United States can make a big difference in the number of physicians and other clinicians we will need. Turning out more primary care physicians just to increase the numbers of them will not be as effective as determining the most effective ways to organize primary care to meet demand, including how to best to combine the skills of all primary care clinicians (physicians, nurses and physician assistants) in accord with patients’ needs and demands, and then build workforce and payment policies to support the most effective models.   This is how other parts of the economy have dealt with mismatches between supply and demand. That is, they increase productivity by determining the requisite number of people, with the right combination of skills and technologies needed to meet increased demand using fewer resources. They don’t just produce more of the same.

Bottom-line: I believe that this one study is not enough to throw about the much larger body of research that shows that the United States is facing a growing shortage of primary care physicians. But they are onto something: PCMHs and multi-disciplinary clinical care teams can be a big part of the solution. And we need to begin to integrate analysis of workforce supply and demand with determining how best to organize the delivery of primary care in the United States.

Today’s question: What do you think of the authors’ premise that team-based models that pool primary care physicians with NPs, and that use electronic communications to substitute for some visits, can eliminate the projected primary care physician shortage?

The Good, the Bad, the Ugly, and the Really, Really Ugly

noreply@blogger.com (B Doherty) — Wed, 02 Jan 2013 21:23:00 +0000

Are you uncorking the champagne to toast Washington for not going over the fiscal cliff? I didn’t think so . . . me neither.

How could anyone toast a Congress that took the country (again) to the brink of economic chaos? Who waited until the 11th hour (literally) to clear a bill that prevents huge tax increases on just about everyone and huge cuts in just about everything? That wasn’t able to assure Medicare patients and their physicians that there wouldn’t be a 27 percent cut in payments the very next day? That waited until 11 p.m. on January 1 to come to an agreement, even though it has known for more than a decade that the Bush tax cuts would expire after 10 years, has known for more than a year that across-the-board budget sequestration cuts would automatically go into effect and that Medicare physician payments would be cut by nearly 30 percent on the first of the year, and that has known since at least 2002 that the Medicare SGR formula is fundamentally unworkable and need to go? That in the end, could only agree to prevent the SGR cuts for another year, but with no plan or timetable to advance a permanent solution? (Read what ACP had to say about the fiscal cliff deal and the lack of an SGR solution).

Sure, there is (some) good in the fiscal cliff deal, some that is bad, and a lot that is ugly, really ugly, especially when it comes to the sad state of policy discourse and decision-making in the United States. Let’s run it down.

The good: Congress didn’t take us into another recession by allowing the country to go over the fiscal cliff. Medicare payments to doctors won’t be cut by nearly 30 percent. Most Americans won’t see their federal income taxes go up, except for higher income individuals and families.   Defense and domestic programs won’t be cut across-the-board—yet.   Congress rejected a proposal to cancel an increase in Medicaid payments to primary care physicians (went into effect yesterday) to offset the cost of preventing the Medicare physician payment cut.

The bad: The one-year extension of current Medicare rates to physicians was a repeat of the same old, enact a temporary patch now to stop the immediate cut and put off until later a permanent solution, failed approach to the Medicare SGR Congress has taken every year since 2003. This was the best they could do? Even though ACP offered Congress an achievable and realistic framework to repeal the SGR and move to better payment framework? Even though organized medicine collectively offered Congress a similar set of payment reform principles?   Also bad: Congress also couldn’t come to an agreement on an alternative to across-the-board budget sequestration cuts, deciding instead only to postpone them until March 1.

The ugly: Congress did nothing to address the rising costs of health care, except for further ratcheting down Medicare payments to hospitals, ambulances, Medicare Advantage plans, and physicians who provide imaging services. The plan it passed does not make a meaningful contribution to reducing the federal budget deficit, although it will bring in somewhat more tax revenue (from higher income persons) than if the Bush tax cuts were renewed in their entirety. Congress and President Obama again missed an opportunity to agree on a Grand Bargain to increase revenue, reform the tax code, and reduce spending on entitlement programs, although they reportedly weren’t that far apart on the numbers.

The really, really ugly: The political process—and the flawed outcome it produced—was so embarrassing and unworthy of a great country that it led National Journal writer Ron Fournier to ask “Can we fire Washington over the fiscal cliff fiasco?”   He writes that “the ‘fiscal cliff’ process was secretive and sloppy, and the nation’s so-called leadership lacked the political courage to address our root problems: joblessness and debt. Instead, the White House and congressional leaders set the stage for another maddening confrontation two months from now, when the nation’s credit will be held hostage again to Washington’s incompetence.”   It was so ugly that the Speaker of the House of Representative, John Boehner, reportedly gave the finger and issued the F-bomb to Senate Majority Leader Harry Reid!

And that is the really, really ugly thing to think about.   Less than two months from now, the across-the-board sequestration cuts go into effect, unless Congress and the President can agree on an alternative. Just two months from now, Congress will need to enact legislation to authorize the Treasury department to borrow more money to honor existing obligations (the debt ceiling), and Republicans already are saying that they will demand more spending cuts in exchange while President Obama says he won’t negotiate with them on it, not this time, not again. Remember, it was the debt ceiling debacle of the summer of 2011 that led to the failed “Super Committee” and the across-the-board sequestration cuts that were delayed for two months, but not canceled, by the new law. The consequences of defaulting on the country’s debt obligations would be far more serious and detrimental to the U.S. economy than going over the fiscal cliff. And that’s not all: a temporary measure to fund the federal government expires at the end of March, leading to the prospect of another tussle over spending and the possibility of a government shut-down.
Good bye and good riddance to the 112th Congress, arguably the worst since members of Congress were caning each other before the Civil War!

Personally, I have been involved in observing and influencing government for more than three decades now, and I have never seen Washington so polarized, never seen supposedly responsible people in Congress being willing to gamble (again and again) with the country’s economic health to make an ideological point, never seen so many who think compromise is a dirty word, and never seen a Congress so unable to pass legislation until the clock has run out and the wolf is at the door.
The deal that was passed was better than the alternative of going over the cliff, but the politics that has produced it was so divided and so dysfunctional and so ugly that maybe the best we can hope is that it can’t get any worse—or can it?

Today’s question: What do you think of the fiscal cliff legislation and what it says about our country’s capacity to govern?

The Fiscal Cliff is Coming to Town

noreply@blogger.com (BDoherty) — Fri, 21 Dec 2012 15:36:00 +0000

If you had to describe the current state of affairs in Washington, which of the following famous quotes would you use?

Ronald Reagan: “There they [he] goes again”

Yogi Berra: “Déjà vu all Over Again” or

Mark Twain: “Suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself.”

How about all of the above? Congress once again is going home for the holidays, without agreeing on a bill to prevent massive cuts in Medicare payments to physicians. We went through this last year—but this time is different, and worse. The physician payment cut is steeper—nearly 30%. The impasse is not only on Medicare payments, but hundreds of billions of dollars of across the board “sequestration” cuts in federal programs and tax cuts that are set to expire on the first of the year.

The latest non-development was when Speaker Boehner found last night he didn’t have enough votes in his own GOP caucus to pass his “Plan B” (renewing tax cuts for people who earn less than a million dollars—nothing about stopping the Medicare SGR cut), greatly weakening his leverage in any renewed negotiations with President Obama, should they occur. The Senate will recess today. This will leave Congress with only 6 days at most—yes, SIX days—to reach an agreement with President Obama after it returns to Washington on December 26.

Sure, a Christmas miracle could happen, but I wouldn’t bet on it. Right now, it looks more likely that the impasse will not be resolved until after that automatic cuts and tax increases go into effect on January 1. Yes, that means physicians should plan for the likelihood that the Medicare physician payment cut will happen, and may not be reversed for several weeks. ACP members can keep up the latest news about how the cut will affect them and what they can do to prepare at ACP’s Running Your Practice resource page. And please keep the up the pressure on your own members of Congress.

Eventually, there will be a deal. Once the physician payment cut happens, and Medicare patients can’t find doctors, and taxes go up on just about everyone, and agencies have to start laying off the federal employees who keep our food and drugs safe, and the Pentagon’s ability to defend our country is weakened, a deal will be reached. But a lot of folks will be hurt in the meantime.

ACP is doing everything it can to get Congress and the President to reach an agreement to stop the cuts and enact a fiscally responsible alternative, offering them this week our own three-step plan to eliminate the SGR by the end of next year. Last week, incoming Board of Regents chair, Chuck Cutler, MD, FACP, traveled to Capitol Hill to lobby Congress with his counterparts at the AMA, American Academy of Family Physicians, American College of Surgeons, and American Osteopathic Association.

I know the situation isn’t funny. But this is the time of year that is supposed to be joyous, and I have a tradition of having my last post before Christmas being a humorous (I hope) adaption of a Christmas Classic to reflect the latest in Washington. So here’s my latest, sang to the tune of Santa Claus is Coming to Town:

The Fiscal Cliff Is Comin' To Town"

You better watch out
You’ll want to cry
You’ll want to pout
I'm telling you why
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

Congress is making a list,
Checking it twice;
Gonna cut programs, it ain’t gonna be nice.
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

It will cut your pay while you're sleeping
It will raise your taxes when awake
It will cut programs, both bad and good
Even Medicare, for goodness sake!
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

You better watch out
You’ll want to cry
You’ll want to pout
I'm telling you why
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town
The Fiscal Cliff is coming to town

The Fiscal Cliff is coming
The Fiscal Cliff is coming to town

(Coming to town)
Congress is a busy place, they have no time to play
But they’re putting coal in your stocking this Christmas day
(The Fiscal Cliff is coming to town)
(Coming to town)
(The Fiscal Cliff is coming to town)
(Coming to town)!

Today’s question: No question today, just my best wishes to you and your loved ones for a peaceful holiday, notwithstanding the mess Washington has created.

Is the medical profession doing enough about gun violence?

noreply@blogger.com (BDoherty) — Mon, 17 Dec 2012 21:48:00 +0000

Are any of us? This is the question that we all must ask ourselves, in the wake of the incalculably sad massacre of little school children in Newtown, Connecticut.

I have struggled for days now to find the right words—how can I, or anyone else for that matter, find the words to describe the indescribable shared grief we have about the indescribable horror of that day and its aftermath? But I have to say something, we have to say something. Something about what this says about our country, and its repeated inability to rise to the occasion to address the causes and consequences of gun violence. Silent reflection in the face of tragedy is a necessity for most of us. But silence in the public policy arena means acquiescence to the cynical and powerless view that there is nothing that can be done to prevent the next Sandy Hook, or Virginia Tech, or Aurora, or Columbine.

Yesterday, President Obama found a way to speak truth to the people of Newtown, and to the country. He said that “This is our first task — caring for our children. It’s our first job. If we don’t get that right, we don’t get anything right. That’s how, as a society, we will be judged. And by that measure, can we truly say, as a nation, that we are meeting our obligations? Can we honestly say that we’re doing enough to keep our children — all of them — safe from harm? Can we claim, as a nation, that we’re all together there, letting them know that they are loved, and teaching them to love in return? Can we say that we’re truly doing enough to give all the children of this country the chance they deserve to live out their lives in happiness and with purpose? I’ve been reflecting on this the last few days, and if we’re honest with ourselves, the answer is no. We’re not doing enough. And we will have to change.”

We are not doing enough. We will have to change.

So, those of us who work for, or are members of health professional societies that are dedicated to improving health and well-being of the American people, must ask ourselves, are we doing enough? Is the medical profession, the healing profession, doing enough? How will we be judged?

My employer, the American College of Physicians, has been on record since 1996 (policy reaffirmed in 2006) calling for policies to prevent firearm injuries, including a ban on assault weapons, like the one used in Sandy Hook. Banning assault weapons and high capacity ammunition may not prevent tragedies like Sandy Hook, but simple logic tells us that there would be fewer casualties resulting from them.   Most recently, ACP has called for “best practices” to reduce injuries and deaths from firearms, as well as the right of physicians to ask patients about firearms in the home.

Some members of Congress, who previously had the highest ratings from the National Rifle Association, agree that the time has come for “rational gun control” and “meaningful action” on guns including even a ban on assault weapons. But many others remain opposed to any new restrictions on gun ownership.

We also have to acknowledge that even if future sales of assault weapons were banned tomorrow, there are millions of them that would legally remain in persons’ hands, because they were acquired before the ban. Some will end up in the hands of people who want to inflict the maximum harm to others, but most won’t. We have to acknowledge that most gun owners, including owners of assault weapons who use them only for recreational target-practicing, would never harm anyone or wish harm on anyone. They too care about their children and they care about ours.

An evidence-based analysis would have to acknowledge that the deaths from homicides reached a 50 year low in 2010, even as restrictions on gun ownership have been loosened across the country and even without a ban on assault weapons. An evidence-based analysis would also acknowledge that a good part of that decline may be due to better emergency care for trauma—large numbers of people are still getting shot, but not as many of them are dying from it. An evidence-based analysis would acknowledge that it isn’t just the massacres we need to care about, it is the men, women and children who are murdered or injured everyday on city streets and buses and workplaces and in their own homes.

An evidence-based analysis would also acknowledge that many disturbed and potentially dangerous people don’t have access to mental health services in the United States. It would acknowledge that the vast majority of those with mental illness pose no threat to others.   An evidence-based analysis would acknowledge that people with mental illness benefit from having the loving support of their families. But it would also acknowledge that being in a loving family, and having access to mental health services, does not guarantee that very distributed persons will be able to control their violent impulses. Just read this heartbreaking account from a loving Mom about her challenges in controlling her sometimes violent son, despite having access to mental health services.

To be clear, I believe, and ACP believes, that limiting access to assault weapons and high capacity ammunition can help reduce the death toll.   But it is just one piece of the puzzle. We will need to carefully examine all of the evidence that we can find on the most effective strategies to minimize deaths and injuries from firearms, and strive to seek a national consensus to implement them.

But the complexity of the problem and possible solutions should not be used as an excuse to delay action or to accept the status quo. “No single law — no set of laws can eliminate evil from the world, or prevent every senseless act of violence in our society, “observed President Obama yesterday. “ But that can’t be an excuse for inaction. Surely, we can do better than this. If there is even one step we can take to save another child, or another parent, or another town, from the grief that has visited Tucson, and Aurora, and Oak Creek, and Newtown, and communities from Columbine to Blacksburg before that — then surely we have an obligation to try.”

We have an obligation to try, including asking whether the healing professions are doing enough about to curb gun violence in the United States.

Today’s questions: Is the medical profession doing enough to advocate for policies to reduce injuries and deaths from firearms? Are any of us?

Cliff Notes

noreply@blogger.com (B Doherty) — Tue, 11 Dec 2012 14:28:00 +0000

Many in Washington are worried that the U.S. will soon do a real life imitation of Thelma and Louise, driving the U.S. treasury off the fiscal cliff created by hundreds of billions of expiring tax breaks (mainly, the Bush tax cuts) and across-the-board spending cuts (sequestration).

But I think a better cliff metaphor comes from a different movie: the scene when Butch Cassidy and the Sundance Kid, pursued to the edge of a cliff by a relentless Pinkerton man, must decide whether to jump to near certain death or be captured and hung for their crimes. Here's how their conversation went:

Butch Cassidy: Alright. I'll jump first.
Sundance Kid: No.
Butch Cassidy: Then you jump first.
Sundance Kid: No, I said.
Butch Cassidy: What's the matter with you?
Sundance Kid: I can't swim.
Butch Cassidy: Are you crazy? The fall will probably kill you.
Sundance Kid: Oh, sh . . .

Well, imagine House Speaker John Boehner and President Obama having the same type of conversation in their one-on-one meeting yesterday at the White House.

For a deal to be struck, Obama has to jump off the cliff of accepting hundreds of billions in cuts in entitlement programs--with Medicare topping the list--knowing that this will probably kill his support from unions, AARP and liberal members of Congress.

For a deal to be struck, Boehner has to accept hundreds of billions in tax increases, including raising the marginal tax rate on higher income earners, knowing that this will probably kill his support among his Tea Party allies and wealthy GOP donors.

If they don't jump together, taxes will go up on just about everyone and spending will be cut on just about everything, taking hundreds of billions out of the economy and likely plunging it back into recession.

Of the two, Boehner has the toughest challenge, kind of like the Sundance Kid not being able to swim.

He and his members have to face re-election and potentially primary challenges from the right if they "sell out" on taxes. Some say even his speakership could be at risk. There is no guarantee that if he strikes a deal with the President, he can deliver the votes in his restive and very conservative caucus.

Obama, of course, doesn't have to face re-election, polls show that the public is on his side and that they will blame failure to get a deal on the GOP, not the President.

We know what Butch and Sundance ended up doing--they jumped over the cliff, and miraculously lived to fight another day. Whether President Obama and Speaker Boehner can do the same, with only a few legislative days left before the Christmas break, is anyone's guess.

If they do hold hands and jump together on a plan to raise taxes and reduce entitlement spending, this is what the deal will look like:

1.    The Bush tax cuts will be renewed for people below an agreed upon income level, allowing it to rise automatically for higher income earners on January 1.
2.    The congressional committees with responsibility for tax policy will be instructed to develop legislation to reform and simplify the tax code to achieve hundreds of billions more in increased revenue (how much more still needs to be decided), with details to be worked out next year.
3.    Congressional committees with jurisdiction over Medicare and Medicaid will be instructed to find hundreds of billions in savings to those programs, details to be worked out next year.
4.    The near-30% scheduled Medicare physician payment cut will be put off for another six months or year, perhaps with instructions to the committees to develop legislation to permanently eliminate the Medicare SGR formula and transition to value-based payment models, details to be worked out next year.
5.    The devastating, across-the-board budget "sequestration" cuts to health to defense, Medicare, and other programs will be replaced with instructions to Congress' appropriators to find the same or greater savings through targeted policy changes, again--guess what!--with details to be worked out next year.

Those are a whole lot of details to be worked out next year!

But a broad framework agreement is probably about as much as can be realistically accomplished before the end of the year. And to be clear, the "details" to be worked out next year likely will include consideration of painful cuts that could directly affect physicians--cuts in payments to Graduate Medical Education programs, canceling scheduled increases in Medicaid payments to primary care physicians, reducing payments for so-called "over-priced" procedures, and tightening or eliminating the Stark in-office ancillary services exception have all been discussed as ways to trim entitlement spending. ACP, for its part, won't go along with cuts that threaten GME and other key priorities--for instance, ACP helped organize a massive effort by organized medicine to persuade Congress to not take money out of Medicaid primary care payments to pay for the fiscal cliff. At the same time, ACP will continue to press Congress to come up with a fiscally and socially responsible alternative to the fiscal cliff, sequestration and the SGR cuts, focusing on the true cost drivers in American medicine, like over-use of marginal and ineffective medical tests and treatments driven in part by defensive medicine.

So if the country has to go over a cliff, wouldn't you rather it happen the way Butch Cassidy and the Sundance Kid did it, risking everything to take the plunge together and miraculously surviving to fight another day, over how Thelma and Louise did it, accelerating over the edge, roll the credits, the end?

Today's question: Do you think President Obama and Speaker Boehner will channel Butch and Sundance and go over the cliff together, risking it all to agree to tax increases and entitlement cuts?

Why Competition May be the Wrong RX for Lowering Health Care Costs

noreply@blogger.com (B Doherty) — Tue, 04 Dec 2012 18:54:00 +0000

A staple of conservative political ideology is that free market competition is the answer to controlling health care spending, not government mandates. The theory, of course, is that if “consumers” (patients) are given accurate information about the price and benefits of available health care services, they will choose the option that offers them the most bang for their buck.   It works in other parts of the economy, it is said, so why not health care?

But what if competition actually works to increase costs?

Health care is unlike most other market choices that we make.   How many other choices do we make that potentially are life-and-death situations? (Choose an incompetent barber, you get a bad hair cut. Choose an incompetent doctor, and you die. Although I do recall a bad hair cut in 9th grade that made me want to die!).

How many of us have the knowledge to select the medical alternative that gives us the best value? Can we trust the information being delivered to us, much of it from drug companies, hospitals, and device manufacturers that want us to order more care that is more expensive, not less care that is less expensive?

We don’t need to look to academic literature to understand why competition might actually increase costs by stoking demand for unnecessary care. Just look at your own daily newspaper and favorite TV shows.

Yesterday, as I flipped through the Washington Post over my morning cup of coffee, I came across a full-page advertisement on page A-14, touting a “Limited Time Offer” by INOVA hospital (Northern Virginia’s largest hospital system) and its partner HealthFair, to get a battery of ultrasound tests for your heart and arteries. For only $139 I could get a stroke/carotid artery ultrasound test, plus an abdominal aortic aneurysm ultrasound, plus an EKG, plus an Peripheral Arterial Disease Test, plus a Hardening of the Arteries (ASI) test—ordinarily valued at $1800! For another 60 bucks, I could get an EKG ultrasound test, regularly priced at $150! And a 5 year disease risk and lipid panel—Results While You Wait!—for $99! And if combined both packages, I would get another $20 off!

What a deal! And, to make it convenient for me, the HealthFair screening trucks would be coming to 17 sites throughout the region over the next month! Happy Holidays!

Maybe I don’t need all of these tests, I thought to myself. After all, I saw my internist for a physical only five months ago, and he ordered some (but not all) of these tests for me. But wait a minute . .. what if I die because I don’t get the tests? The ad included two testimonials from individuals who say their lives were saved by getting the same tests. Mr. Maurer was quoted as saying that “The ultrasound revealed that my right carotid artery was 75% blocked. . . Within a few days, a vascular surgeon confirmed the health screening’s findings and I was told that I needed surgery on my carotid artery or I would not be around much longer. The surgery solved the problem . . . I now have new outlook on life and cherish every moment.”    Linda Covey recounted how the screening for her husband found “something that needed to be checked. We made an appointment right away at the hospital and found out that he had an ascending aorta aneurism. Surgery took place shortly after that and he is a new man again . . .Go get checked, it may save your life too.” (Interesting that these examples led to the patient’s getting surgery in the hospital, which I am sure benefits Inova’s bottom-line).

To be clear, I have no reason to doubt that the screening tests benefited Mr. Maurer and Mr. Covey. And I’m not a clinician, and maybe it is the standard of care for me to get all of these tests. But if so, why didn’t my internist order them for me? Maybe it isn’t the standard of care, but how would I know? Can I really afford to risk my life by not getting them, especially with such a great “Limited Time Offer”!??

Then, last night, I watched Monday Night Football. (Great win, Redskins over Giants). Along with trying to get me to drink more beer and eat more pizza than would be good for me, there were the usual ED and “you gotta go” Direct-to-Consumer drug advertisements.   No further comment needed, other than it is pretty clear that the advertising was intended to increase demand for health care, not decrease it. (I am not questioning that the advertised drugs have benefit—only that the millions being spent to hawk them on national TV clearly has one purpose, which is to increase demand for them).

A few nights ago, I was watching CNN, and I saw repeated ads for motorized scooters (tells you something about CNN’s viewer demographics) with a promise by the company that they’d even help get them covered by Medicare at “no cost”! Too bad for them, but I am bit too young for that, and can get around just fine on my own, thank you very much. But what about my elderly mother?
This is what health care competition looks like: millions spent to get people to spend health care dollars, either out of their own pocket or from someone else’s through insurance, to buy tests, devices and treatments that may benefit them, or may not, but that surely make money for the companies pitching them.   We can decide not to get the advertised products, but what do we know? Especially since if we go without them, might we end up “not being around much longer?”

There is a role for competition—provided that it is regulated and accompanied by consumer protection safeguards. For instance, the Affordable Care Act will give millions of people a choice of health plans sold through a state—or federal exchange—but strict rules will apply to how the health plans can market themselves.

But the idea that poorly-regulated competition alone will result in people making wiser choices on health care expenditures is belied by the best evidence of all: the unrelenting newspaper and television advertisements that play on our emotions and take advantage of our lack of clinical knowledge to convince us that when it comes to health, more is always better than less. Especially when it is 20% off the regular price!

Today’s question: What do you think the millions spent to get people to buy more health care says about the idea that market competition is the best way to lower costs?

"Honest Abe" and ObamaCare

noreply@blogger.com (B Doherty) — Thu, 29 Nov 2012 21:32:00 +0000

“Passed by corruption, aided and abetted by the purest man in America” is how anti-slavery Congressman Thaddeus Stevens described President Lincoln’s successful effort to enact the 13th amendment, banning slavery.   This historically accurate quote, which runs counter to the public image of “Honest Abe” Lincoln, is among the many fascinating stories recounted in the Steven Spielberg’s masterpiece “Lincoln” playing now in movie theaters nationwide.

The movie doesn’t claim to get every fact right, but its description of Lincoln’s single-minded determination to get the 13th amendment passed by Congress in the final months of the Civil War-- over the objections of his own advisors and knowing he initially was at least 20 votes short-- is spot on. And to get the votes he needed, Lincoln did whatever he thought was necessary, including offering jobs to lame-duck members of Congress who had lost re-election. (This practice was not illegal at the time, although undoubtedly ethically suspect).   Today, offering jobs for votes would be against the law and grounds for impeachment.

But the movie depicts Lincoln’s commitment to banning slavery in an extraordinarily favorable light. Human bondage was such a moral wrong, the source of misery for enslaved millions, and the cause of heart-breaking bloodshed for the entire country, that if there ever was a case of the ends justifying the means, this surely was it.

The film depicts “politics as hand-to-hand combat, and it portrays Lincoln not as idealist or moralist but as pragmatist and realist. Doing so does not diminish him but elevates him.”   For his efforts, though, Lincoln was called a tyrant by his critics.

There are lessons from Lincoln that we might keep in mind as we consider our current political divisions.   As much as the fight over taxes and spending cuts seem like a big deal to us, and seemingly outside the reach of compromise in an ideologically polarized Congress, it is not even close to the stakes and divisions Lincoln faced over the 13th amendment.   The movie shows the unseemly side of politics but also shows members of Congress acting in an extraordinarily honorable ways: voting their consciences, voting against the position of their own (in this case, Democratic) political party, and putting their careers at risk for voting for the amendment. It shows abolitionist Thaddeus Stevens tempering his rhetoric in favor of full equal rights for African-Americans in order to win votes for the amendment.

Wouldn’t it be something if there were more members of Congress today who would vote their consciences and buck their parties? Who would be willing to hold their tongues and compromise when needed to advance long-term priorities?

The lesson we can learn from Lincoln is that politics can be both high-minded and unprincipled. The process of getting legislators to vote your way always has, and always will, involve some degree of wheeling and dealing. So it was in Lincoln’s time, so it is today.

To be clear, I am not arguing in favor of offering jobs or money for votes, or selling out to the highest bidder, or even bending the rules by flying members of Congress around in corporate jets to elite golf outings. Those things today are for the most part illegal, and we are better for it.

But let’s stop looking at politics through Rose Colored glasses. ObamaCare’s critics got themselves into high dudgeon over the “backroom deals” the Obama administration made to win support from interest groups and individual Senators (The Democrats were equally indigent when House Republicans kept the vote on Medicare prescription drug coverage open for four hours in 2005 to arm-twist the final votes they needed for passage).

The promises made to get interest groups and lawmakers on board with Obamacare (all legal, by the way) don’t come close to the “do what every is necessary” Realpolitik exercised by Lincoln.   But as the National Journal’s Jill Lawrence writes “If Lincoln were operating now, though, Americans would be following all the wheeling, dealing, and good-government lamentations in real time on Twitter and cable TV. I’m guessing there would be plenty of cynicism, and certainly no halo — at least until decades later.”

I am not equating ObamaCare to ending slavery, by the way. For all of the good that health care reform may do in my opinion, it doesn’t rise to ending slavery. Nor am I saying that Obama is the measure of Lincoln: no one today can say how Obama’s presidency will be viewed by historians, and Lincoln sets such a high bar that it unlikely that any contemporary politician will come close.
But I am saying that sometimes achieving a principled end—like covering the uninsured—requires a certain degree of arm-twisting and deal-making. Sometimes, the end (within reason) does justify the means. Jill Lawrence concludes that the film “exalts ends without sugar-coating means, and holds out the promise of vindication — in history, if not their lifetimes — for leaders who wield their ‘immense power’ to perfect the nation as they see it.”   Just take it from Honest Abe.

Today’s question: What lessons do you draw from the account of Lincoln’s deal-making to pass the 13th amendment?

Thanksgiving

noreply@blogger.com (B Doherty) — Wed, 21 Nov 2012 15:31:00 +0000

In the spirit of tomorrow’s celebration, here is a list of ten things, related to health care, for which I give thanks:

1.    I am thankful that my immediate family and I are in good health, to the best of my knowledge.

2.    I am thankful that when my family members and I get sick, as we all will someday, we have good health insurance and won’t have to worry about being bankrupted because of high health care costs or having to go without care because we can’t afford it.

3.    I am thankful that a little over a year from now, when the Affordable Care Act becomes law, as many as 32 million uninsured Americans, and many millions more of us with pre-existing conditions, will be able to say the same.

4.    II am thankful that I have the privilege of working for an association of internal medicine physicians—the American College of Physicians—that has have shown remarkable prescience, leadership, determination and commitment to advocate for what they believe to be best for patient care, taking on the really tough issues of universal coverage, cost, payment and delivery system reforms.

5.    I am thankful that I was able to play a role in helping ACP develop its policy positions on universal health insurance coverage, the rational allocation of health care resources, and many other challenging issues--and subsequently seeing so many of them accepted into law and regulation.

6.    I am especially thankful for my contributions to getting coverage to nearly all Americans through ACP’s advocacy on behalf of the ACA.

7.    I am thankful to have gotten to know so many physicians through my work that are everything one could ask for from the medical profession: smart, dedicated, and compassionate women and men who spend their days and nights making health care better, by taking care of patients, by teaching the next generation of physicians, and by helping ACA develop and advocate for responsible patient-centered policies.

8.    I am thankful that I have the opportunity to work with so many other people—my friends colleagues on the ACP staff, the people I know who work for other health advocacy organizations, and the many dedicated and unfairly maligned public servants who work in government—who also have dedicated their careers to improving American health care.

9.    I am thankful that I live in a country where public policy decisions on controversial issues, like the ACA, can be debated freely and with decent respect for each other’s views.

10.    I am thankful for those of you who put up with my musings In this blog, whether your just read or take the extra time to post comments on it, even and especially when you disagree with me (as I am sure some of you will about my expressions of gratitude for the ACA!).

I wish each of you a peaceful and restful day of Thanksgiving with your loved ones!
Today’s question: If you made your own list of ten things related to health care for which you would give thanks, what would they be?

Rooting for the ACA’s Failure?

noreply@blogger.com (BDoherty) — Tue, 13 Nov 2012 17:55:00 +0000

Beyond stating what now should be quite obvious—that ObamaCare is here to stay—what does the 2012 election mean for health care reform? On one hand, the voters have spoken, re-electing a Democratic president who is committed to full implementation of the law over a Republican candidate who promised to repeal it on “Day One”—while expanding Democratic control over the Senate and reducing the Republican majority in the House.   As a result, there is no realistic scenario where there will be the votes in Congress to roll back the law. Also, exit polling suggests that just one-quarter of voters favor complete repeal of the Affordable Care Act. On the other hand, it would be a gross misreading of the election to say that voters have enthusiastically embraced ObamaCare. The same exit polling shows that voters are split nearly down the middle on the law’s future, with slightly more (47%) being in favor of keeping or expanding it compared to the 45% who said they thought it should be fully or partially repealed.

In other words, complete repeal is off the table, at least for the next four years. But the proponents of ObamaCare haven’t yet won the hearts and minds of a solid majority of voters. That likely will only happen if the law is successfully implemented at the federal and state levels, and voters find from their own actual experience that it is a good thing. But if its implementation is messy, confusing, uneven, unsatisfying, and/or too costly, then the public could yet render a judgment against it.

What worries me is that the ACA’s opponents, having failed in their “three year war against ObamaCare”, will decide that their best remaining option is to do their darndest to make implementation confusing, uneven, unsatisfying, and/or too costly for the public. Then they can say “we told you so” and hope that the public agrees.

So, for instance, a large number of conservative states might decide not to set up the state health exchanges through which federally-subsidized insurance will be sold to qualified residents, hoping that it simply is too much work for the federal government to effectively set the exchanges up and run efficiently for millions of persons in (potentially) dozens of states. They might decide not to accept federal dollars to expand Medicaid to their poorest residents, as at least a half dozen states are threatening to do, thereby ensuring that implementation will be at best uneven, leaving behind many of the most vulnerable people who were supposed to get coverage under ObamaCare. Also, under the ACA, hospitals and other safety-net clinics will get fewer federal dollars to offset the costs of treating indigent patients because they were supposed to be fewer of them as Medicaid is expanded. But if their state doesn’t agree to the expansion, those same safety net institutions still have to treat the indigent patients that will be denied access to Medicaid, but with a lot less funding—potentially forcing them to close or at the very least resulting in cost-shifting to those with insurance. And then the politicians in those states could say, see, it is all ObamaCare’s fault, even though it was their own opposition to the Medicaid expansion that made the law untenable for their safety net clinics!

And setting up the law to fail in the states that oppose it is precisely the advice being offered by some ObamaCare critics.    Arguing that the federal government can’t “competently operate dozens of exchanges. . . Republican governors should allow the feds to live with the mess they created rather than clean up for them” writes Philip Klein in the Washington Examiner.   And, at the federal level, the House GOP could again try to use its leverage over spending to try to deny the administration the funds it needs to implement the law, although this wasn’t very successful in the outgoing 112th Congress, and will likely be even less so in the new one.

If the critics of ObamaCare decide to do everything they can to undermine its implementation, they are essentially putting patients at risk to make a political point. States that refuse to set up the exchanges or agree to the Medicaid expansion will be making it harder for their residents to get access to health insurance. By refusing to lending a hand to the federal government’s effort to make the law work in their states, they may succeed in making it more confusing for the public and less likely to achieve the law’s goal of facilitating enrollment in qualified health plans, but how can it be good public policy to make it harder for people sign up for coverage?

There is a better way, which is to get over the polarized, ideological and hyper-partisan political debate over ObamaCare, accept that it is here to say, to acknowledge that a majority of voters could have elected a President and Senate committed to its repeal but didn’t, and instead seek bipartisan avenues to improve it. USA Today reports that some Republicans and Democrats are beginning to talk about ways to “come together and fix it” rather than continuing the fight over killing it on one hand or keeping it exactly as is on the other.   History reminds us that this is what happened when Medicare and Medicaid were enacted in 1965: after initially being fiercely opposed by conservatives, and after several election cycles where voters chose the candidates that favored continuing those programs rather than the ones promising to repeal it, the cries for repeal faded, the efforts to disrupt implementation ceased, and repeated Congresses and administrations found a way to enact bipartisan legislation to make them work better.

Isn't it time for the country to come together to try to make the Affordable Care Act work, including fixing things that are wrong with it, rather than rooting for (and even trying to facilitate) its failure in delivering on the promise of accessible, affordable health insurance for all?

Today’s question: How would you answer the above question?

ObamaCare is here to stay

noreply@blogger.com (BDoherty) — Wed, 07 Nov 2012 07:37:00 +0000

With the re-election of Barack Obama and Democrats retaining control of the Senate, the debate over the future of ObamaCare is over: it is the law, will remain the law, and will be fully implemented in 2014. To the extent that there is still a question about its future, it is whether the states will agree to expanding Medicaid to all of the poor and near poor and to set up marketplaces to buy subsidized private insurance. Every state that says no to either or both will take away from the law's promise of taking of covering nearly all Americans. And the fact remains that the public remains deeply divided about the law. Still . . . there is a chance, a hope, a promise, a potential, that the country can move past the polarized, ideological debate over repealing ObamaCare on one hand (won't happen) to making it better (could happen). The election doesn't settle which choice the country will make, except that it will not be repealed. But I hope that when realization sets in among the public that ObamaCare won't be repeated, there will be a renewed willingness to take what is good about the law, especially coverage of the uninsured, and make changes where needed (how about real medical liability reform as a start?) to make it better Today's question: What do you think the election mean for ObamaCare?

The Election

noreply@blogger.com (BDoherty) — Mon, 05 Nov 2012 14:52:00 +0000

So it all comes down to this: tomorrow voters will be deciding not only on who they want in the White House and in control of Congress, but also on two fundamentally different views on the role of government in health care. President Obama proposes to continue to expand the federal government’s role in financing, funding and regulating health care and continue Medicare and Medicaid as defined benefit programs; Governor Romney wants to turn more responsibility over to the states, cut federal healthcare spending, and convert Medicare and Medicaid from defined benefit programs to defined contribution programs, limiting the federal government’s contribution to each.

I expect that most readers of this blog have decided which approach you favor and who you will vote for, based not only on their positions on healthcare but on the economy, national security and other issues that matter to you. It would be presumptive of me to evaluate the candidates for you and, as a matter of policy, law and good sense, ACP does not endorse candidates for political office. We have and will always be strictly non-partisan, taking positions on the issues based on ACP policy, not positions on the candidates themselves.

As a resource for those of you who want to learn more about the issues at stake, here are links to content that I hope you will find to be of interest, some from previous posts to this blog, some from the ACP and Annals website, others from respected advocates, commentators, and journalists:

ACP’s comparison of President Obama’s views compared with College policies

ACP’s comparison of Governor Romney’s views compared with College policies

NEJM article from President Obama on how he “would secure the ACA’s future”

NEJM article from Governor Romney on how he would “replace ObamaCare with real reform”

My article from this week’s ACP Internist publication on how the election may decide four critical health policy issues

Annals perspectives from health policy experts David Blumental, Gail Wilensky and Bob Berenson on what the elections mean for healthcare

Article from the ACP Advocate Newsletter discussing how healthcare was addressed in the presidential debates

Medical Economics magazine article that quotes me, AAFP’s President, and others on how the election might affect primary care

NPR report on the prospects for ACA repeal should Governor Romney be elected

Blog post from the Washington Post’s Ezra Klein on why healthcare is the most important issue in the 2012 elections

My blog post on the ten things that bother doctors the most that are being overlooked by the candidates

Analysis from NPR’s Julie Rovner on how Governor Romney would reform healthcare and how his approach differs from President Obama

My Annals of Internal Medicine article on the Supreme Court, the elections, and the ACA’s future

My recent blog posts on the leadership deficit of both candidates and who is to blame, the secret truth behind Medicare vouchers and their unpredictable risk and benefits, and how the candidates’ positions on Medicare are a triumph of nonsense over substance.

No matter what your views are on the candidate’s and their positions on healthcare, I hope that my blog posts and links to others’ expert analysis have helped inform you about the issues at stake. And, once the dust settles and we know who won the election, I will post my own post-election thoughts and share insights from other experts, and like always, seek your thoughts as well.

Today’s question: How are the candidates’ views on healthcare influencing your vote?