ACP American College of Physicians - Internal Medicine - Doctors for Adults

Obama uses regulatory authority to give raise to primary care doctors

Yesterday, the Obama administration began to deliver on its promise to improve payments to general internists and other primary care physicians.

A proposed rule released yesterday by the Centers for Medicare and Medicaid Services would make major revisions in Medicare payment policies that "Taken together ... would increase [total Medicare] payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule)," according to the agency's press release. This shift occurs because the administration proposes changes in the Medicare relative values units (RVUs) for physician work, practice expenses, and medical liability expenses that generally are favorable to primary care, although some surgical and medical specialties also would benefit from the changes. CMS proposes to update the practice expense relative values to use the latest data on physician practice costs from a new AMA survey; this survey, which was co-sponsored by ACP and other specialty societies, show that internists' practice expenses are much higher than CMS previously had assumed.

This change alone would increase total Medicare allowed payments to general internists by 4 percent. Internists would also benefit from changes in the physician work RVUs (another 1 percent) and malpractice RVUs (another 1 percent) for a 6 percent total gain. In aggregate, total allowed Medicare payments to general internal medicine would increase by an estimated $10,061,000, according to CMS, more than any other specialty. (On a percentage basis, some specialties come out higher than general IM, but IM does the best in total dollars because the specialty starts with more Medicare allowed charges than others.)

Not all physicians will be cheering CMS's moves -- by law, changes in RVUs are budget neutral. The agency proposes a big cut in payments for imaging procedures, which would result in deep cuts to cardiologists and radiologists. It also proposes to eliminate the policy of paying for consultations at a higher rate than other initial hospital visits; these dollars would be redistributed to non-consultation visit codes. Many internal medicine subspecialists will likely object to eliminating the distinction between the work involved in consultations and the usual initial hospital visit.

Another change will win the applause of all doctors. The administration proposes to remove physician-administered drugs, like chemotherapy, from the definition of physician services under the Sustainable Growth Rate (SGR) formula. This would have the effect of reducing the negative updates (cuts) to physicians that are triggered whenever spending on physician services (which will no longer include the costs associated with physician-administered drugs) comes in higher than the allowable SGR target. It will also reduce the budget cost to Congress of enacting a long-term solution to the SGR problem by incorporating these costs into the Medicare baseline. ACP, the AMA, and other physician groups had long argued for removal of drugs from the SGR formula.

Public comments on the proposed rule will be accepted through August 31. The Medicare payment changes proposed by CMS, if included in the final rule following public comment, would go into effect on January 1, 2010. ACP will be analyzing the proposed rule, and will seek input from internists, generalists and subspecialists alike.

While ACP may not end up agreeing with every aspect of the proposed rule, it is a very positive sign that the Obama administration has decided not to wait for Congress to begin re-aligning Medicare payment policies toward primary care. Any changes that Congress may subsequently enact, such as providing a primary care bonus payment, would be on top of the new payment scale proposed by CMS.

Another indication of the administration's interest in primary care is that Dr. Fred Ralston, ACP's President-elect and a practicing general internist from Fayettsville, TN, and I will be participating in a primary care roundtable, hosted today by Nancy Ann Deparle, director of the White House Office of Health Care reform, at the White House. You can watch the proceeding via streaming video http://www.whitehouse.gov/ from 2 p.m. to 3:30 today, EDT.

Today's question: Do you agree that these proposed new policies show that the Obama administration is serious about improving payment for primary care?

posted by BDoherty at 12:31 PM   0 Comments

No we can't! No we can't!

The defining symbol of Obama's campaign was thousands of people joining together to chant "Yes we can! Yes we can!"

The defining symbol of health care reform, at this critical juncture, could be the growing chorus of "No we can't!" to health care reform - or, at least to the parts of reform not to a particular group's liking.

Hospitals are saying "No we can't!" to Medicare pay cuts to fund health care reform.

Labor unions are saying "No we can't" to taxing health benefits (above a certain premium cost) to pay for health coverage for the uninsured. They also are saying "No we can't!" to health reform that doesn't include a public plan option like Medicare - and some unions are even attacking Democrats who disagree.

Insurance companies are saying "No we can't!" to health reform that includes a public plan option like Medicare.

Employers, for the most part, are saying "No we can't" to mandates that they provide coverage to employers or pay into an insurance pool. Today's announcement that Walmart supports an employer mandate is one welcome, and highly notable, exception.

To be fair to the groups mentioned above, most of them say they want health care reform to happen this year. Some have shown a great deal of leadership in promoting positive reforms in the health care system. They would tell you that their objections to specific elements are in the spirit of getting a "good" bill passed.

What about physicians? My sense is that there is a broad range of opinions on issues like the public plan. Most physicians still believe reform is necessary, but some are focusing on the things they don't like (like expanded roles for nurses), and there is a vocal minority of doctors who are hoping that the whole thing "tanks" (as one physician commented yesterday in response to my blog post on Obama's views on primary care).

For its part, ACP believes that health care reform is imperative, and we support the broad outlines of the draft proposal being considered in the House of Representatives: sliding scale subsidies for people to buy affordable coverage through a health exchange, insurance market reforms, and payment reforms and funding for primary care.

It is one thing to express concern about particular elements of reform, but it is another thing to issue non-negotiable, take-it-or-leave it, line-in-the-sand, my-way-or-the highway statements that leave no room for consensus or compromise. There will come a point where the chorus of "No we can't" on particular elements will begin to drown out the more compelling reasons why we need health care reform, and undermine public support in the process.

Health care reform is about making sure that each and every American has access to coverage at a price they can afford, that no one is turned down because they have a pre-existing condition, and that they have access to a personal primary care doctor. It is also about creating a health care system that won't bankrupt American families, businesses, and taxpayers. In my mind, we can't afford not to achieve those goals.

Today's question: Do you think that those who are laying down firm markers on what they can't support will ultimately derail health care reform?

posted by BDoherty at 4:23 PM   2 Comments

Does President Obama have the right Rx for primary care?

Last week, President Obama made his most extensive comments yet on the crisis in primary care. In his responses to two questions - one from a nursing student and the other from a medical student - during a town hall meeting hosted by ABC News, Obama had this to say:

"Well, first of all, we need more people ... who are going to school and committed to the kind of primary care that's going to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously training physicians, training nurse practitioners, that takes years of work. But what we can do immediately is start changing some of the incentives around what it takes to become a family physician.

Right now, if you want to go into medicine, it is much more lucrative for you to go into a specialty. Now, we want terrific specialists, and one of the great things about the American medical system is we have wonderful specialists and they do extraordinary work. But, increasingly, medical students are having to make decisions based on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are going to make substantially less money, and it's going to be much harder for them to repay their loans.

... But what we're also going to have to do is start looking at Medicare reimbursements, Medicaid reimbursements, working with doctors, working with nurses, to figure out how can we incentivize quality of care, a team approach to care, that will help raise and elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money if they're getting paid fee-for-service.

... And one of the things that I'd like to explore -- and I've been working with the administration and with Congress -- are their loan forgiveness programs where people commit to a certain number of years of primary care. That reduces the costs for their medical education. That would make a significant difference.

If we provide the right incentives I think we're going to start seeing more young people say that going into medicine is a satisfying, fulfilling profession -- especially if we can eliminate some of the paperwork and bureaucracy that they have to deal with right now ...

But I also think that one of the big potential areas where we can make progress is ... how can we get nurses involved in more effective ways. If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system -- and they haven't quite gotten there yet -- they have had a problem with an overload of patients.

... One of the areas where we can potentially see some saving is a lot of those patients are being seen in the emergency room anyway, and if we are increasing prevention, if we are increasing wellness programs, we're reducing the amount of emergency room care, then that frees up doctors and resources to provide the kind of primary care that will keep people healthier, but also allow them to see more patients and hopefully give more time to patients, as well."

It is good to hear the President describe primary care as "critical" to improving quality and bringing down costs. He also seems to have a good grasp of the reasons that young people aren't going into primary care, including high student debt, poor pay, and excessive paperwork.

Obama doesn't believe, though, that the answer is to just train more primary care physicians and pay them more. Instead, he wants reforms to "raise and elevate" the roles of both primary care physicians and advanced practice nurses under a "team approach" that "incentivizes" quality of care. And he wants to help reduce the debt of both doctors and nurses that go into primary care.

Today's question: Do you agree with Obama's prescription for the primary care workforce crisis and the roles of both physicians and nurses?

posted by BDoherty at 5:02 PM   4 Comments

House proposal moves policies in the right direction

Yesterday, the House Committee on Energy and Commerce wrapped up three days of hearings on a draft bill to provide health coverage to all Americans, to establish policies to ensure an adequate physician workforce, and to revamp payment and delivery systems to get more value for each dollar of health care spending.

In a statement submitted for the hearing record ACP expressed broad support for the goals of many of the specific policies proposed in the bill. Like ACP's own plan, the bill expands Medicaid to cover everyone at or modestly above the Federal Poverty Level; provides individuals and small businesses a choice of health plans offered through an exchange (similar to that offered to federal employees); provides sliding scale subsidies for individuals to purchase coverage through such an exchange; requires that that all health plans, both within and outside the exchange, abide by rules relating to acceptance of all individuals without regard to pre-existing conditions or health status, guaranteed renewability, modified community rating; and requires that they offer essential benefits, including preventive and primary care services, as recommended by an expert commission. Employers would have to contribute to coverage or face a penalty and individuals would be required to obtain coverage once it is available and affordable, with appropriate hardship exemptions.

On workforce, the bill would create a national advisory group to recommend national health workforce goals, greatly expand funding for primary care training programs and create new ones to provide scholarships and loan forgiveness to primary care physicians who serve in areas of need, allocate more graduate medical education slots to general internal medicine and family medicine residency programs, allow residents to defer their debt through completion of their residencies, provide grants for primary care training and enhancement, eliminate barriers to teaching in non-hospital based primary care practices, and provide grants to address health care disparities and education on team-based models of care. Many of these provisions were taken directly from the bipartisan Preserving Patient Access to Primary Care Act, introduced by Representative Allyson Schwartz (D-PA) and Senator Maria Cantwell (D-WA), which is based principally on ACP policies and has received the College's strong endorsement.

The legislation also advances payment and delivery reforms aligned with patient-centered primary care. It would eliminate the pending 21 percent Medicare payment cut from the Sustainable Growth Rate and completely wipe out all of the accumulated costs resulting from the failure of past Congresses to enact a long-term SGR solution. (This accumulated cost -- running running into hundreds of billions of dollars -- has been a principal barrier to getting rid of the annual cycle of Medicare doctor pay cuts). The current SGR formula would be replaced with two separate spending targets for physician services, one for primary care and prevention (GDP plus 2 percent) and the other for all other physician services (GDP plus 1 percent). ACP has expressed concern, though, that continuing to benchmark physician updates on growth in the U.S economy, as measured by GDP (even with the additional percentage allowances for each category), could result in future payment cuts to physicians.

The draft bill provides more than $1 billion to fund two national Medicare pilots of the patient-centered medical home, one of which would pay qualified practices directly for prevention and care coordination of high risk patients and another that would pay community-based organizations for providing care coordination services to physician practices and provide payment to the practices themselves that use such services.

Primary care physicians would also receive a bonus payment for designated services. The amount of the bonus, 5 percent for most primary care physicians and 10 percent for those who practice in health professional shortage areas, is considerably less than ACP has requested. The College will continue to press for a more substantial primary care bonus. Primary care physicians would also see their Medicaid payments increased in every state until they are equal to Medicare.

Finally, the bill proposes new rules to streamline and standardize the administrative costs of health plan interactions, which impose a disproportionate burden on primary care physicians.
Although it is certainly true that "You can't always get what you want" from legislation (although I don't think Mick Jagger was thinking about health reform when he coined this refrain), the House proposal goes a long way toward advancing our goals on coverage, workforce, payment and delivery reform and administrative simplification.

Today's question: what do you think about the House proposal, and particularly, its impact on health coverage and primary care?

posted by BDoherty at 10:59 AM   0 Comments

The end of the road for health care reform? (Hardly)

Today, I am blogging from the end of the road - literally.

I write from the beautiful shores of Homer, Alaska, famously described by former resident and "All Things Considered" commentator Tom Bodett as being the "end of road." I am here because later this week I will be meeting with internists attending the annual ACP Alaska chapter meeting in Anchorage, and Homer, a little over 200 miles away on the Kenai Peninsula, is a nice side trip. (Each year, I try to attend as many as a dozen ACP chapter meetings across the country. This allows ACP members to hear my perspectives on what is going on in Washington, and in turn, I get an earful on what's on their minds, especially from notoriously independent Alaskan physicians!)

The end of the road might be an apt description of how some commentators now view President Obama's prospects to achieve lasting health care reform.

The Congressional Budget Office's report on the cost of health care reform, followed by the decision by the Senate Finance Committee to delay release of its draft plan, have led some to conclude that President Obama's push for health care reform is in deep trouble. Roll Call reports that the price tag and partisan bickering could "derail" Senate passage of health care reform.

After months of mostly upbeat reports, it's as if the press suddenly awakened to the fact that reforming health care won't be easy. But why? - all of the negatives from the past week were entirely predictable.

Health care reform will cost a lot of money? Well, yeah.

Republicans and Democrats will bicker? Duh.

Democrats will have difficulty reaching agreement amongst themselves? What else would you expect from a party that has made internal dissension a celebrated art form?

But amidst all of the gloomy reports, there actually was quite a bit of positive news for President Obama and his congressional allies.

First, the drug industry reached an agreement to reduce the costs of drugs paid for under the Medicare Part D program. This is important because the White House and Congress need savings and offsets that will not be fought by the affected stakeholders.

Second, House Democrats produced a draft bill that includes measures designed to win broad support among key constituencies - including doctors. It not only eliminates next year's 21 percent cut in Medicare's payment to doctors, but would also get rid of hundreds of billions of dollars in accumulated doctor pay cuts - a top priority of the medical profession. The bill includes scholarships, loan forgiveness, and payment reforms to support physicians in primary care. I will write more about the House proposal later this week, but I believe that there are enough positives in it to keep physicians at the table in a way that help move things forward.

Finally, despite all of the hand-wringing in Washington, a new poll shows that the public remains strongly in favor of health care reform. 85 percent of respondents said that health care must be completely rebuilt or fundamentally changed - with a strong majority favoring a greater government role in health care. The poll also showed strong support among Democrats, Independents, and even a majority of Republicans for a "public plan" option, one of the most controversial issues in Washington.

Instead of reaching an end of the road, health care reform continues to move forward - as it does, it will run into speed bumps, pot holes, and perilous turns along the way. The whole effort could yet crash and burn, but from where I sit, at the end of a road overlooking Kachemak Bay, the finish line remains very much in sight.

Today's question: Do you think health care reform is in deep trouble - or will it continue to move forward to enactment?

posted by BDoherty at 1:05 PM   1 Comments

CBO score slows down drive to health care reform

Maybe because I have two teenage daughters who dream about a big wedding with all of the bells and whistles (way, way in the future . . . of course!), the Congressional Budget Office reminds me of the frugal father who adds up the tab and is forced to put the brakes on a beloved daughter's plans for the "perfect" wedding.

The Congressional Budget Office told the Senate that the cost of their health reform legislation could be about 2.6 trillion dollars over the next decade - and still leave tens of millions without health insurance. The CBO also told Congress that plans to expand coverage to more Americans could cause an unsustainable increase in the federal deficit - unless offset by enforceable cuts in spending - and expressed skepticism that investments in prevention would achieve substantial savings. It acknowledged that primary care is associated with lower costs, but suggested that increasing the numbers of primary care physicians would help only if linked to policies to curb the numbers of non-primary care specialists:

"One study of the relationship between Medicare spending and the composition of the workforce of physicians found that, with the total number of physicians held constant, states with more general practitioners had lower spending. Achieving that outcome, however, involves reducing the number of specialists in line with increasing the number of primary care physicians, and the mechanism for accomplishing that change (for example, the appropriate adjustments in payment policies) is unclear. Savings would be less likely if the number of specialists remained the same while the number of primary care physicians increased."

The CBO report is causing Congress to hedge on its plans to have legislation passed before the August recess. The Democratic majority also is looking for ways to scale back how many would be covered, to find more revenue (tax) increases, and to find other measures that to save money - such as more cuts in payments to hospitals and other providers. The problem, though, is that tax increases and provider cuts will increase the level of opposition.

As Congress looks for ways to trim the cost, I worry that it will look in the wrong places. For instance, plans to spend more money to increase payments to primary care physicians and to train more of them could be at risk. One can anticipate the "we wanted to do more, but we couldn't find the money" excuse.

On Thursday, the leaders of the American College of Physicians, American Academy of Family Physicians, and the American Osteopathic Association are coming to Washington to make the case to Congress that failure to fund primary care will inevitably cost the country far more in the longer run . . . even if the CBO won't "count" such savings in the budget.

Today's questions: do you think Congress should scale back its plans because of the cost? How?

posted by BDoherty at 5:14 PM   3 Comments

Obama's homecoming wows AMA

Who would have thought that an organization, whose legacy includes opposition to the creation of Medicare, would be brought to its feet (repeatedly) by a Democratic president who has vowed to remake American health care? Yet this is precisely what happened today in Chicago when Barack Obama took his case to the AMA House of Delegates.

I was one of those present to witness Obama's speech. It was, in my opinion, a masterful exercise of political persuasion. One very sage observer of the AMA, who has been active in the organization for decades and has himself served in one of AMA's top elected positions, told me after the speech that Obama's political skills are akin to Franklin Delano Roosevelt and Ronald Reagan at the height of their power.

Why did Obama get such a positive response from a group of doctors whose political views can generously be described as leaning right of center?

First, he made the case, as he has done to so many other audiences, that the status quo is not sustainable. He analogized U.S. health care to General Motors - that rising health care costs will ultimately bankrupt the country. He told the AMA that "the alternative to ... reform is a world where health care costs grow at an unsustainable rate. And if you don't think that's going to threaten your reimbursements and the stability of our health care system, you haven't been paying attention." In other words, work with me now to make it better, or allow the system to collapse, with dire consequences for physicians and patients.

Second, Obama acknowledged the reasons why many physicians have reservations about health care reform saying, "There's a sense out there among some, and perhaps some members who are gathered here today of the AMA, that as bad as our current system may be -- and it's pretty bad -- the devil we know is better than the devil we don't." To reassure physicians, he promised that no one would be forced to give up their doctor or their own health plan. He skillfully took on the arguments that he knows will be made against health care reform - that it will lead to "socialized medicine" and "rationing" of care or that a public plan would be a "Trojan Horse" for a single payer system.

Third, he clearly laid out his vision for health care reform: health coverage for all, subsidies for individuals to buy coverage from health insurance offered through an exchange, a ban on pre-existing condition exclusion, and paying doctors based on the quality - not just the quantity - of care provided.

Fourth, he was honest about issues where he knew there would be disagreement. He expressed a willingness to work with the AMA on reducing the costs of defensive medicine but told them he would not support a cap on damages. He explained why he supported including a public plan option "to keep insurers honest" but also said he wanted to design a plan that physicians could support.

Fifth, he spoke to issues that physicians care deeply about. He credited the AMA for getting Congress to enact sweeping legislation to allow the FDA to regulate tobacco. He emphasized prevention and the need "to do more to reward medical students who choose a career as a primary care physician." He received a standing ovation when he articulated the frustrations physicians have with health insurance paperwork.

He did two other very important things. He appealed directly to physicians' tradition of professionalism. When describing the incentives created under current payment systems for doctors to order unnecessary tests, Obama said, "That's not why you put in all those hours in the Anatomy Suite or the O.R. That's not what brings you back to a patient's bedside to check in, or makes you call a loved one of a patient to say it will be fine. You didn't enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers. And that's what our health care system should let you be. That's what this health care system should let you be."

And he acknowledged their power and influence of the medical profession and the AMA itself, making an unabashed appeal for their support: "We need your help, doctors, because to most Americans you are the health care system. The fact is Americans -- and I include myself and Michelle and our kids in this -- we just do what you tell us to do. That's what we do. We listen to you, we trust you. And that's why I will listen to you and work with you to pursue reform that works for you."

This had to be music to the ears of a group of physicians whose voices had become increasingly marginalized.

Today's question: Do you think most doctors will rally behind Obama's call for help in reforming the health care system?

posted by BDoherty at 4:31 PM   5 Comments

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