The ACP Advocate Blog by Bob Doherty

A good (and not so good) day for health reform

2009-11-19T16:29:00.003-05:00

Yesterday's unveiling of the revised Senate bill on health reform ordinarily would have constituted a good day for health reform, moving the ball yet another few yards closer to the goalposts. The Washington Post reports that Senate Democrats were "jubilant" that the CBO estimates that the new bill will reduce the deficit by $130 billion over the next decade while providing coverage to 94% of uninsured legal residents. Majority Leader Harry Reid (D-NV) plans to bring the bill to the Senate floor on Saturday for a procedural vote, requiring 60 votes, to halt a GOP filibuster and to allow debate on the bill itself. A final vote, which would require getting 60 votes to overcome more procedural hurdles, likely will not take place until December. ACP is in the process of analyzing the bill compared to policy, so I will have more to say about it in a future blog post, and we also will post updated information on www.acponline.org/advocacy.

At the same time as Democrats were celebrating the release of the Senate bill, the flap over the new mammography guidelines from the U.S. Preventive Services Task Force (USPSTF), published in ACP's own Annals of Internal Medicine threatened to undermine public support for health reform. Now, I am a health policy wonk, not a clinician, and have absolutely no opinion on the guidelines themselves, but I can comment on the political fallout from the guidelines.

In one sense, the mammography guidelines have absolutely nothing to do with health reform. They were in the works long before the current administration took office, they would have come out even if health reform was not on the national agenda, and the guidelines themselves are purely advisory.

But in another sense, they have everything to do with health reform. The House and Senate health reform bills would require that health insurers provide coverage for preventive services recommended by the USPSTF - although insurers would be allowed to offer additional benefits. The Chicago Tribune notes that research on comparative effectiveness is a "central idea in the push to improve American medical care and control its cost: experts studying the effectiveness of treatments and procedures to determine which work best."

KevinMD opines that health reformers should be very worried about what the backlash to the guidelines means for the future of comparative effectiveness research: "If recommendations from an entity like the USPSTF - as non-partisan and robust as it gets - gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."

NPR reports that Republican opponents of the Democratic bills have used the controversy over the guidelines to argue that it will lead to rationing and "the insidious encroachment of government between the patient and their doctor" according to Rep. David Camp (R-MI). (Notwithstanding the fact that under the bills, the USPSTF's recommendations would still be advisory, or that the independent scientists on the USPSTF are hardly government bureaucrats.) Seeing the threat being created by the backlash, and fearing that the GOP criticisms will resonate with votes, the Obama administration distanced itself from the USPSTF guidelines in a statement attributed to HHS Secretary Kathleen Sebelius.

All of this goes to show why reforming the health care system is so difficult. Scientists would like to believe that we people can rationally make health care decisions based purely on science and evidence. But health care is very personal and emotional, and even the best science will be rejected if people sense that it will take decision-making away from them or limit their choices. And if taxpayers are going to subsidize coverage, decisions will have to be made on what services will be covered, and as this incident shows, such decisions will not come without generating intense debate and opposition.

Today's question: What do you think the flap over the mammography guidelines means for health reform?

How important is it really to provide health coverage to all?

2009-11-18T16:49:00.005-05:00

Many issues relating to health reform are creating deep divisions among Americans, including taxes, mandates, and the public plan option. Yet I had assumed that there was a general consensus that everyone should have access to affordable coverage, and the disagreement was mostly over how to achieve it, not whether this should be a major objective.

I was wrong: many critics of the current effort believe that covering everyone is not all that important, at least when compared to other priorities.

For instance, the House GOP's health reform proposal, according to the Congressional Budget Office, would reduce "the number of nonelderly people without health insurance by about 3 million in 2019 and leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019 - 83 percent - would be roughly in line with the current share." Instead, the GOP plan focuses more on providing more (and less costly) coverage options for people who already have health insurance.

In a recent Washington Post column, Robert Samuelson makes the case why providing health insurance to everyone is less important than keeping government spending under control:

" . . almost everyone thinks that people in need of essential medical care should get it; ideally, everyone would have health insurance. The pursuit of these worthy goals can easily be projected as a high-minded exercise for the public good. It's false for two reasons. First, the country has other goals - including preventing financial crises and minimizing the crushing effects of high deficits or taxes on the economy and younger Americans -- that 'health-care reform' would jeopardize. And second, the benefits of 'reform' are exaggerated. Sure, many Americans would feel less fearful about losing insurance; but there are cheaper ways to limit insecurity."

Is Samuelson right that the issue is mostly about reducing "insecurity?" For many of the uninsured, it is much more than that. According to a new Harvard study, people without health insurance are 40 percent higher risk of death than those with health insurance, and 45,000 Americans of them die each year as a consequence. Similarly, in 2002, the Institute of Medicine found people without health insurance are more likely to suffer poor health and die prematurely. And in 2008, the Urban Institute updated the IOM report and estimated that 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.

Providing all Americans with access to affordable health insurance coverage is a top priority for the American College of Physicians, and one of the many reasons why the College has expressed support for many of the key policies in H.R. 3962.

I am ambivalent about the question of whether health care is a right, but I firmly believe, as does the ACP, that covering everyone is the right thing to do. I don't disagree that the country has other important goals, as Samuelson argues, like minimizing crushing deficits. But if the annual death toll of not having coverage is akin to the total U.S. deaths suffered during the Vietnam War, how can preventing such deaths not be an essential purpose of health reform?

Today's questions: Do you believe that uninsured people are more likely to die prematurely? Do you believe that providing all Americans with health coverage should be an essential purpose of health reform?

How the critics' lies are making it harder to control health care costs

2009-11-16T15:01:00.004-05:00

An op-ed by Rep. Earl Blumenauer (D-OR) in yesterday's New York Times is a "must read" account for anyone who wants to understand why the health care reform bills don't do more to control health care costs. He writes about how an eminently sensible, modest (and bipartisan!) provision to reimburse physicians for discussing advance directives with their patients became fodder for critics who willfully distorted the proposal as creating "death panels" that would pull the plug on grandma.

One of the principal villains in Rep. Blumenauer's story is Betsy McCaughey, former Lieutenant Governor of New York, now with the Hudson Institute, who first made the claim that "would make it mandatory, absolutely require, that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." Her statement was immediately disproven by respected and independent fact-checking organizations, including the Pulitzer-prize winning PolitiFact.com and Factcheck.org, but this didn't stop her lie from becoming a staple of the attacks on the bill.

McCaughey is at it again: in a November 7 Wall Street Journal op-ed she makes so many false or misleading claims about H.R. 3962 that it is almost impossible to keep up with them all, but one is of particular concern to ACP. Citing a provision that would fund Medicare pilots of the patient-centered medical home, she opines that "the medical home is this decade's version of HMO-restrictions on care." She never bothered to check with ACP, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association - the four organizations who authored the joint principles on the medical home, and who have called for the health reform bills to include expanded testing of the model - before making this ill-informed and misleading claim.

Blumenauer's account explains why the willingness of some critics to say anything to scare the public - what is more scary than putting old people to death? - is denying the American people a serious debate about how best to control health care costs. Many of the critics like to have it both ways: decry the lack of cost controls in the bill, and then do everything possible to undermine public backing when ideas are proposed to lower costs. Even ideas that the medical profession itself has championed and that have had strong bipartisan support in Congress - advance directives, care coordination in a medical home, and research on comparative effectiveness - become branded as government rationing.

It shouldn't be surprising then that the health reform bills don't do enough to control costs, but that they do so much, despite the attacks and falsehoods. John Iglehart writes in the New England Journal of Medicine that "the bills contain no shortage of ideas for reforming the delivery system, enhancing the quality of care, and slowing spending. Pretty much every proposed innovation found in the health policy literature these days is encapsulated in the measures."

Could the bills do more to control costs? Sure, but I don't see that happening as long as the Betsy McCaughey's of the world - and politicians who echo them - are willing to make truth a casualty in their battle to stop the health reform bills from becoming law.

Today's question: What is your reaction to Rep. Blumenauer's story and what it bodes for health reform?

AMA reaffirms support for health reform -- with caveats

2009-11-10T15:07:00.009-05:00

Late Monday, the AMA House of Delegates rejected, by an overwhelming majority of 350-167, efforts by dissident delegates to put the organization on record as not endorsing H.R. 3962. (The Associated Press/Washington Post has a good story on the organization's deliberations).

The House of Delegates did, however, pass a number of policies that require that the AMA Board of Trustees "oppose inclusion" of cost controls in the Senate Finance Committee bill that would result in redistribution of payments among physicians. With these actions, and the AMA's previous letter of support for H.R. 3926, the AMA effectively (and perhaps ironically) has allied itself with the House-passed bill, which some analysts label as the more "liberal" of the bills because it spends substantially more money than the Senate Finance bill. Among the policies opposed by the AMA are redistributing payments to physicians based on their outcomes and efficiency, redistributing payments from some specialties to increase payments for other (read primary care) specialties, penalizing physicians who do not successfully report on quality measures, and creation of a Medicare commission that would recommend and implement changes in payment and delivery systems to achieve specific savings unless Congress enacted an alternative. Many of the policies opposed by the AMA are the same as those opposed by a coalition of surgical specialty societies. Unlike the surgeons' letter, though, the AMA House action doesn't commit the AMA to opposing a Senate bill that includes such policies, only to advocate that they not be included. It will be interesting to see what the AMA will do, though, if the Senate bill ends up including many of the policies that the House of Delegates has directed it to oppose.

ACP shares some of the concerns about the provisions in the Senate Finance bill, but we have also noted the many policies we support and proposed alternatives -- such as more safeguards over the Medicare Commission -- rather than flatly opposing it.

Whether health reform legislation gets passed or not (and I still think it has a better chance of getting passed), it seems to me that policymakers, both within and outside of government, will insist on changes in payment systems to align incentives with the value of care being provided, which means that there will be redistribution among physicians and specialties depending on the value of the care provided. Just opposing such changes will not be effective if physicians want to influence their design.

Today's questions: Do you believe that organized medicine should oppose efforts to redistribute payments among physicians based on quality, outcomes, and efficiency? Or from other specialists to primary care?

Tap-dancing through a minefield

2009-11-09T16:42:00.004-05:00

I write today's blog from the back row of the American Medical Association's House of Delegates meeting, where the main topic of debate is whether the House will back its own elected Board of Trustees' decision to support H.R. 3962, the Affordable Health Care for America Act of 2009. The House of Delegates is considering resolutions that would either force the AMA to withdraw support for the bill and/or set a list of non-negotiable set of pre-conditions for the AMA to continue to support health reform. Yesterday, I sat through over eight hours of debate in front of a "reference committee" of House of Delegates members charged with hearing testimony and then drafting recommendations on the resolutions introduced by state and national medical specialty societies. The vote on the reference committee recommendations will take place this afternoon or evening.

As I've listened to the debate here, and also Saturday's debate in the U.S. House of Representatives, the image of tap-dancing through a minefield keeps popping into my head. To get a narrow majority to vote to pass H.R. 3962, Speaker Nancy Pelosi had to step around a series of political minefields, any one of which could have blown the bill apart. As reported in the Washington Post, the decision by Pelosi to allow a vote on an amendment to preclude federally-subsidized health plans from offering coverage of abortion was necessary to win the support of "pro-life" Democrats, but "pro-choice" advocates in both the House and Senate are vowing to block a final bill if it includes the same prohibition. Abortion, like it so often is in American politics, may end up being the single biggest minefield, because it is not suitable for "split the differences" compromises used to overcome other divisions.

The AMA is tap-dancing through its own minefields. If the delegates vote to overturn the organization's support for H.R. 3962, it could well paralyze the ability of its own Board of Trustees to continue to negotiate for its members, since the administration and Congress will lose confidence in the AMA's leadership to deliver. Yet there is a very vocal group of conservatives within the AMA House of Delegates who oppose H.R. 3962 on deeply held philosophical, political and ideological grounds, and they argue that the AMA will lose members if it does not change course.

There are many other delegates who believe with equal fervor that the AMA Board of Trustees did the right thing, and that the AMA stands to lose members if it reverses course. There are delegates who believe it is unwise for the AMA to reconsider its support for H.R. 3962, even if some of them have their own misgivings about the bill. They want the House of Delegates to set pre-conditions, or at the very least a list of top priorities and concerns, to guide future decisions by the Board of Trustees. The reference committee attempts to tip-toe through the minefield by affirming the House of Delegate's support for health reform in accord with established policies, even as it expresses "strong concerns about inclusion of" several provisions in health care reform legislation that would reduce payments to physicians who do not report on quality measures, reduce payments to higher resource use physicians, redistribute Medicare payments among physicians based on outcomes, quality, and risk-adjustment factors "that currently do not exist," and Medicare payment cuts for all physician services to partially offset bonuses for primary care services. (Interestingly, these provisions come from the Senate Finance Committee's version of the bill, not H.R. 3962.) I expect though, that efforts will be made today by conservative members of the House to turn these concerns and other issues into non-negotiable pre-conditions for continued support by the AMA and/or to substitute the original resolutions to reverse support for H.R. 3962.

The ACP, for its part, believes that H.R. 3962 advances important long-held policy objectives. (Our website has just been updated to provide a detailed list of answers to frequent questions about the ACP's views.) Our delegation to the AMA believes it would be a huge mistake for the House of Delegates to force the AMA to either withdraw support for H.R. 3962 or set "my way or the highway" pre-conditions, some of which are neither desirable nor achievable, which effectively would result in the AMA coming out against the current health reform effort.

No matter how the vote goes today in the House of Delegates, the AMA's slogan of "Together, we are stronger" does not reflect today's reality. Organized medicine will continue to be divided on health reform, reflecting the deep divisions among physicians on the role of government in health care, just as the close vote in the House of Representatives reflects the deep divisions on the same among the American people.

Today's question: What would you do if you were the AMA?

Will the House reform bill reduce health care costs?

2009-11-05T15:06:00.002-05:00

The House of Representatives is poised to vote, as early as Saturday, on H.R. 3962, the Affordable Health Care for America Act. Passage of the bill would be a historic milestone. At no other time in American history, has either the House or Senate passed legislation to extend health insurance coverage to (almost) all Americans.

Of course, like other milestones, there are many more miles to travel before health care reform legislation becomes law. The Senate leadership has yet to figure out how to combine and modify the Senate Finance Committee and Health, Education and Labor and Pensions Committee into a single bill that can get 60 votes. And then the House and Senate would have to reach agreement on what likely will be very major differences between the two versions, and when they do, another vote would have to take place in both chambers before it becomes law.

H.R. 3962 is closely aligned with ACP policies on coverage, workforce, and payment and delivery system. On November 2, ACP sent a letter of support to the House leadership that details the dozens of provisions in the bill that merit ACP's support.

Of course, critics are doing what they can to derail the bill. One unfortunate tactic is the resurfacing of a chain email, about the earlier H.R. 3200, that has been discredited by two independent fact-check organizations. A new partisan critique of the bill repeats several of the same false claims, according to a new analysis from Politifact.com.

On a more substantive basis, the bill is getting criticized for not doing enough to control costs.

But as Timothy Jost blogs in Health Affairs, H.R. 3962 actually includes many policies that "will in fact work important changes in the American health care system" to improve health care delivery and lower costs. Among them: accelerated pilot tests of medical homes and accountable care organizations, increased payments for primary care, quality and efficiency incentives for Medicare Advantage plans, comparative effectiveness research, promotion of shared decision-making, gainsharing, reporting on infections acquired in hospitals and ambulatory surgical centers, and workforce initiatives to increase the numbers of primary care physicians

I keep hoping that we can get to the point where there is a substantive debate on whether the bills do too much or too little to control costs; have too much or too little regulation; or spend too much or too little to make coverage affordable. The critics can surely do better than relying on discredited falsehoods, like the one that claims that H.R. 3962 would prohibit people from buying private insurance, to make their case.

Today's question: Do you think the House bill begins to put in place the right policies to expand coverage and control costs?

My rockin' the U.S.A tour

2009-11-03T16:00:00.003-05:00

Twenty-one days on the road and 17,200 miles travelled since Labor Day.

Stops in Wichita, Kansas; Lead, South Dakota; Osage Beach, Missouri; Charleston, South Carolina, Phoenix, Arizona; Winston-Salem, North Carolina; Stowe, Vermont; and Rochester, Minnesota. Coming up next: 4000 miles and four days in Houston, Texas, followed shortly by a return to the Lone Star state, and then Sacramento, California. Upcoming early next year: Las Vegas, Nevada; Tyson's Corner, Virginia; and Hattiesburg, Mississippi.

No, this isn't the itinerary for Bruce Springsteen and the E Street Band. It is what I have been doing since Labor Day, meeting with physicians, mainly at ACP chapter meetings, to talk about health care reform.

Keeping in mind Will Roger's truism that "This country has come to feel the same when Congress is in session as when the baby gets hold of a hammer" shouldn't I instead remain in Washington, keeping an eye on Congress? Well, no. Although my job is to represent the interests of internists in Washington, D.C., I feel that I can't do that effectively if I don't spend time meeting with internists. We have a top-notch advocacy staff in D.C. that keeps me informed about everything, and modern technology allows me to be a mouse click from being (virtually) on the scene.

I mention all of this because some commentators on this blog have taken me and ACP to task for not listening to its members. I don't take it personally or defensively, but I doubt that there is anyone else who has listened to as many internists, in as many different places, as I have in the past three months.

What have I learned? First, I have not encountered a single instance of an ACP member reacting with "town hall" style hostility to my explanations of the ACP's views on health reform. This is not to say I found uniformity; internists, like the American people generally, have a wide and diverse range of views.

Like the young Med-Ped physician who I met with in South Dakota, who believes with all of his heart and soul that the current bills will lead to a loss of liberty, crushing taxes and debt, and government rationing of services. Like the ACP member in Vermont, who believes with all of his heart and soul that only a government-financed, not-for-profit, single payer system can provide Americans with equitable and affordable care. These ACP members, and many like them, are at polar opposites on the political spectrum, yet they expressed their views to me with civility and with a high degree respect for the ACP.

Internists' views also differ depending on where they live, but not as much as one might expect. Physicians in "red states" like Kansas and South Carolina are more likely to be concerned about the plans being developed in Washington, and those in "blue" states like Minnesota and Vermont are more likely to support them. But you find a range in all regions. In Charleston, SC, for instance, the first question to me came from a conservative doctor who was concerned that ACP was in favor of "government-run" health care, while the very next question was from a single payer proponent.

The most common sentiments I've encountered are confusion about what is in the bills; general agreement with ACP's views; hopefulness that the reforms will improve things; and anxiety that they could make things worse. To address the confusion, ACP continues to update its resources for ACP members, including a new snapshot tool that compares the new House health reform bill with ACP policies.

I have come away from my travels encouraged that most internists want health care reform, and that they place a high degree of confidence and trust in the ACP to do the right thing, an obligation I take very seriously. I am committed to continuing my efforts to listen to as many internists as possible, but even though I am listening, it doesn't mean I will always agree with you.

Today's question: Do you feel that there is "common ground" in internists' views on health care reform and of ACP?

Who wins from the House reform bill? Follow the money and find out.

2009-10-30T16:57:00.008-04:00

Estimates by the Congressional Budget Office of how legislation affects the federal budget can tell a lot about Congress' priorities. Provisions in bills relating to specific health care sectors (e.g. physicians, hospitals, drug manufacturers, insurers) that the CBO scores as producing "savings" means that that particular sector is going to be hit with payment reductions or tax increases to fund other priorities in the bill. Provisions scored by the CBO as adding to federal budget expenditures means that the bill's sponsors have decided that the affected sector is a priority deserving of more federal dollars.

What does the CBO's preliminary estimate of the new House health reform bill tell us about Congress' priorities? That primary care and prevention are the sectors that Congress has identified as deserving as more federal spending, above all others, and that insurance companies in the Medicare Advantage program is the sector that will take the biggest hit. Other sectors facing steep reductions are hospitals (reduction in their market basket increase and disproportionate share payments), drug companies and home health agencies.

In fact, primary care physicians get the single largest bump in spending of any sector in the entire bill. Here is how:
$ 57 billion more will be spent over the next 10 years to increase Medicaid payments to primary care physicians so that they equal the Medicare rates. This is more than any other sector of providers, suppliers and health professionals will get, bar none.
$ 4.7 billion more will be spent to increase Medicare payments to primary care physicians for office, hospital, nursing home, home and emergency room visits.
$ 2.3 billion more will be spent to fund two Medicare and Medicaid pilots to reimburse primary care physicians for care coordination in a Patient-Centered Medical Home.
$ 1.5 billion more will be spent on Medicare GME, much of it directed at increasing primary care training.

Prevention and wellness programs will also get tens of billions in additional federal spending. The bill creates a $34 billion trust to fund public health investments in wellness and prevention, and another $10.7 billion to fund coverage of preventive services under Medicaid.

Now, I know that many of the regular commentators for this blog will respond with a shrug to the increased spending on primary and preventive care, because they will say that it is not enough to prevent a catastrophic shortage of primary care physicians. And they will have a point: I don't think the policies in this bill, by themselves, will suddenly result in thousands of more medical students choosing primary care, or necessarily persuade those in practice that there is a brighter future ahead, but I do believe that they begin to put in place programs that will help. Still, it is undeniable that the Congress has decided that primary care and prevention are priorities that deserve a lot more money: the combined $100 billion that the House proposes to spend directly on primary care, prevention and wellness over the next decade represents more than 10% of the bill's total net cost of $894 billion. The fact that primary care is now viewed as a top priority also is evidenced by introduction today of a bill, supported by the House leadership, that would repeal the Medicare sustainable growth rate and replace it with a new update system that will allow payments for primary care and preventive services to grow at a faster rate than all other services.

By any standard, a combined expenditure of almost $100 billion on primary care, prevention and wellness represents a huge shift in the priorities of the federal government, and one that I think deserves our recognition and support.

Today's question: What do you think the increased spending on primary care and prevention could mean to internists and their patients?

Revised House bill would expand Medicaid, offer public option, cover 96%, and lower the deficit

2009-10-29T16:35:00.001-04:00

Today, Speaker of the House Nancy Pelosi (D-CA) released a new version of the health care reform legislation that is derived from an earlier bill (H.R. 3200) approved by the House's three health committees. I am still making my way through the bill, so will have more to say about it in future posts. As reported in The Washington Post, the bill is likely to attract broad support among Democrats but no Republican votes.

The biggest difference with H.R. 3200 is that the bill expands Medicaid to all persons up to 150 percent of the federal poverty level, instead of 133% in the earlier bill. Medicaid, once the poor sister of the popular Medicare program, would now be the single largest source of health insurance in the United States. To increase physician participation in Medicaid, the bill would increase Medicaid payments to primary care physicians over several years until they at least equal Medicare pay rates in all states.

It is also substantially less expensive than H.R. 3200, with an estimated cost of less than $900 billion over 10 years, according to the CBO, and would reduce the deficit by $104 billion over the same ten years. One reason that the cost has gone down is that it is cheaper to enroll people in Medicaid than to offer them subsidies to buy private health insurance coverage. It also removes the cost of repealing the Medicare SGR physician pay formula from the legislation; instead, the House leadership has introduced a separate bill that would repeal the SGR and create two separate spending targets, a higher one for evaluation and management and preventives services, and a lower one for all other services, although both categories would be allowed to grow faster than under the current SGR. How the House plans to move the SGR bill outside of health reform legislation remains to be seen.

The bill includes a permanent 5% Medicare bonus for office and hospital visits provided by primary care physicians, 10% in health professional shortage areas. There would be a modest expansion of graduate medical education (GME) training positions for primary care, and new and expanded loan repayment for primary care clinicians who satisfy a service obligation.

And, on the public plan, the new bill would offer individuals who qualify for subsidized coverage the ability to enroll in a government-administered plan that would negotiate its payment rates with physicians and hospitals instead of using the Medicare rates.

Today's question: What is your initial reaction to the new health reform bill?

The Public Plan Rorschach Test

2009-10-28T16:18:00.004-04:00

The idea of offering people the option of enrolling in a public plan, similar to Medicare, has become the Rorschach test for health reform. Many conservatives see it as a foot-in-the-door that will lead to government-run, socialized medicine. Many liberals see it the same way, as the first step to achieving a single payer system, although fewer will admit to it.

If you distrust and dislike insurance companies, you like the public plan. If you distrust and dislike government, you despise it.

Then there are the deal-makers, the people in Congress who have to find a way to bridge these differences so that they can get a majority in the House and a 60 vote super-majority in the Senate. For them, the policy is less important than the votes they need to pass a bill. They are the ones who dream up things like "triggers", so the public plan would only go into effect if private insurers don't cover enough people and keep costs under control, or state opt-out or opt-ins, so each state could decide whether or not to participate. The deal-makers also have to decide if they will get more votes by having a "robust" public option (meaning that it would pay doctors or hospitals based on the Medicare rates), as the liberals insist, or whether it would use negotiated rates, as many of the "centrists" prefer.

The Hill newspaper is reporting that Speaker Nancy Pelosi (D-CA) will be unveiling an agreement tomorrow to have a public plan option that would use negotiated rates instead of Medicare. Last week Senator Majority Leader Harry Reid (D-NV) announced that the Senate bill will have a public plan with a state opt-out.

But one way or another, the public plan has come back from the dead, as captured in this Halloween illustration brought to us by The Washington Post cartoonist Tom Toles.

The scary thing about the public plan though, may be what it doesn't do, as Fred Hiatt, writes in The Washington Post. He argues that the public plan allows the politicians to pretend they are controlling health care costs while for the most part ducking the issue. Robert Samuelson, also writing for The Post, makes a similar argument, that the debate of the public plan allows Congress to "fake it" when it comes to controlling costs.

I see the public plan in the similar fashion as they do. Although the public plan has become the defining issue for many, I think there is a lot less to it than meets the eye. Depending on how it is structured, it could do some good in introducing some needed competition to the insurance industry, but I hardly believe that its inclusion or not is going to make or break health care reform. Especially since the deal-makers likely will water it down so much it won't have that much negotiating clout in the market.

Today's question: How important do you believe the public option is to health care reform?

Coming soon! Medicare Part E!

2009-10-22T13:29:00.003-04:00

The Hill reports that the House Democratic leadership has decided to rebrand the "public option" as Medicare Part E, that is, Medicare for everyone. But are they really proposing that everyone should be able to enroll in Medicare, fulfilling the wildest hopes of single payer advocates?

Not likely. The House's version of Medicare Part E could more aptly be labeled as the Medicare Part UPWDNHATAEHCAWDNQFMOS program , standing for Uninsured Persons Who Do Not Have Access To Affordable Employer Based Health Coverage And Who Do Not Qualify For Medicaid Or SCHIP. Barring a complete re-write of the House bill, the re-branded public plan option would be available only to the 30 million or so people who fall in the UPWDNHATAEHCAWDNQFMOS category and are eligible to receive federal subsidies to buy coverage through a health alliance. Calling it Medicare for Everyone doesn't make it so.

Still, it might be a very good political move. People like Medicare and don't associate it with "government run" health care (remember the reports of seniors at the August town hall meetings screaming "keep government out of my Medicare?").

The Hill also reports that the plan will be "the 'robust' option or 'Medicare Plus 5' in the jargon that has emerged on Capitol Hill, [which] ties provider reimbursement rates to Medicare, adding 5 percent."

The American College of Physicians has said that it could be appropriate for people eligible for the health exchanges to have the option of choosing either a qualified private insurance plan or a public health plan, provided that the public option is funded through premiums and is not tied to Medicare physician participation agreements or Medicare rates. ACP wrote:

"Proposals to use the current Medicare reimbursement structure as a basis for reimbursement under the public plan option raise significant concerns. In particular, payment levels for physicians participating in the public plan would amount to price controls that insufficiently compensate physicians for their work. It is widely believed that the current Medicare fee schedule is ineffective in promoting quality care and incentivizes volume-based rather than value based health care. In its March 2009 report to Congress, MedPAC stated that it was dissatisfied with the current fee schedule updating mechanism for physician payments. Further, the Medicare fee schedule has resulted in improper utilization of services rather than cost containment. Proponents of the public plan option have cautioned that hospital closures, stifled innovation of new technology, and limited access to physician services could result if a government-run health plan strictly limits payments to providers under a public plan ... To be successful, a public health plan would not have to control prices to maintain access, promote quality care, and limit cost efficiencies ... Instead, the government (or the plan's administrator) should negotiate with providers in a manner similar to the private market."

Especially given the Senate's failure yesterday to repeal the Medicare Sustainable Growth Rate (SGR) formula, it doesn't make sense to build the new Medicare E program on a payment structure that Congress itself knows doesn't work and would require that they close a $240 billion budget shortfall to stop the scheduled physician pay cuts. The same payment structure that Congress acknowledges undervalues primary care and rewards volume over value. Yet Speaker Pelosi wants the flawed Medicare fee schedule to be the foundation for the new public option?

My guess is that the decision to base the public plan on the Medicare rates is principally a negotiating tactic in anticipation of a conference committee with the Senate, which is not likely to include a "robust" public option in its bill. A compromise might be to accept the House's proposal for public plan option, but to divorce it from the Medicare rates and instead allow the public plan to negotiate rates with physicians, hospitals and other providers. Yet in one form or another, it seems more likely than ever that some kind of public option will end up in the final bill. Call it Medicare E if you want, even though most of us will not have access to it.

Today's questions: What do you think about re-branding the public option as Medicare Part E? Should it pay physicians and hospitals based on the Medicare rates (plus 5%) or should the rates be negotiated?

Congress again fails to end the SGR lunacy

2009-10-21T16:51:00.003-04:00

Just a few days ago, it looked like Congress might actually do the right thing and end the annual cycle of enacting short-term measures to stop Medicare payment cuts caused by the Sustainable Growth Rate (SGR) formula, only making the problem harder and more expensive to fix the next time around.

But today by a 47-53 vote, the Senate - including 13 Democrats - voted against a motion to end a filibuster against S. 1776, the Physician Payment Fairness Act of 2009, even though the bill had the support of the White House, Senator Finance Committee Chair Max Baucus (D-MT), and Senator Chris Dodd (D-CT), acting chair of the Senate HELP committee during the (late) Senator Ted Kennedy's illness. S. 1776 would have repealed the SGR and eliminated all of the accumulated cuts caused by the formula.

S. 1776 failed despite a huge grass roots push by the ACP, American Medical Association, and other physician organizations, and despite the fact that AARP, the voice of America's seniors, supported the bill.

The bill was victim to the dysfunctional political environment today that makes consensus so difficult. Many Republicans viewed the bill largely as a Democratic effort to "buy" physicians support for health care reform (a cynical and unsupported allegation - more on this later) and they wanted to deny the Democrats a victory on anything having to do with health care reform. They also wanted the cost of the SGR repeal to be counted against the cost of the health reform bill, so that the bill would be seen as blowing a hole in the deficit. (Never mind that the SGR, which has led to all of the accumulated cuts and costs we are now facing today, was created by the Congress in 1997, when the GOP was in control, and that past Congresses, Republican and Democratic alike, have failed to take the steps needed to fix it. The SGR problem and its cost would be with us today, even if there was no health reform bill.)

It also seems many Democrats have had the equivalent of a death-bed conversion to fiscal responsibility, or at least a make-believe version of fiscal responsibility that says that pretending to save taxpayer's money is the same as saving them money. The Senators know that the $245 billion price tag for SGR repeal is itself a budget fiction, because it requires that we suspend disbelief and assume that Congress will actually allow double-digit cuts in physician payments to go into effect. They won't and they know it. Medicare will end up spending the $245 billion anyway, but that doesn't matter, as long as the Senators can tell voters that they didn't vote for a bill that would add to the deficit.

ACP has released a statement that is harshly critical of the Senate vote and vowing to continue to push for SGR repeal. The statement takes on the charge that S. 1776 was offered in exchange for physician support of health reform:

"The American College of Physicians rejects the cynical charge made by some that physicians' support for health care reform is conditioned on repeal of the SGR. Instead, ACP supports health care reform because we believe that all Americans should have access to affordable care. Our positions on the pending health reform proposals will continue to be based on how they align with ACP's long-standing policies on ensuring coverage, reversing a catastrophic shortage of primary care physicians, and testing and implementing new models of payment and delivery to align positive incentives with the value of care provided. At the same time, we believe that repeal of the SGR is necessary to provide the stability needed to achieve real and lasting physician payment reform, to implement payment reforms to support the value of care provided by primary care physicians, and to assure seniors' access to care."

Where does this leave us on the SGR? Right where we were in . . . 2008, 2007, 2006, 2005, 2004, 2003, 2002, and 2001 . . . with Congress saying that they know the SGR has to go, that they won't allow the cuts to go into effect, that they know that have to find a permanent solution, but not now, some other time. Like the Chicago Cubs and a World Series appearance, it seems it is always "wait til next year" when it comes to repeal of the SGR.

Today's question: What is your opinion on the Senate's rejection of SGR repeal?

Finally, a plan to end the lunacy of the Medicare SGR

2009-10-15T14:12:00.001-04:00

Yesterday, I joined representatives from the AMA and other physician organizations in a meeting with the Senate Majority Leader Harry Reid (D-NV), Senator Max Baucus (D-MT), Senator Chris Dodd (D-CT) and Nancy Ann Deparle, the head of the White House Office for Health Reform, to discuss a plan to get rid of the Medicare SGR formula, once and for all. We learned that Senator Reid will ask the Senate to vote next week on a bill to repeal the SGR and all its accumulated scheduled cuts to physicians for the next 10 years.

It's about time. I can't think of a single other issue that has so bedeviled physicians and Congress alike as much as the SGR.

Under the Medicare sustainable growth rate (SGR) formula, physicians have faced deep annual cuts in payments since 2002. Congress has stepped in all but one year to enact a temporary "patch" to stop the next year's cut. But rather than accounting for the difference between the lower payments mandated by the SGR, and the higher payments under the patch, Congress has assumed that the higher spending will be made up with even an even deeper SGR pay cut the following year. This is why the "patch" for an estimated 5 percent SGR cut in 2008 resulted in a scheduled 10.5 percent SGR cut in 2009. And why the patch for the 10.5 percent SGR cut in 2009 balloons to a scheduled 21 percent cut in 2010.

To illustrate how crazy all of this is, imagine you worked for a small business, and imagine that your boss told you that your wages would be cut by 10 percent this year. Later, your boss announces that your company will not cut your wages, but that the only way the company can afford to stop the 10 percent cut will be to pretend to reduce your wages by 20 percent the following year. She tells you not to worry, though: they will just do the same thing next year - prevent the 20 percent cut by pretending that the cost will be made up by cutting your wages by 40 percent the following year. She adds, though, that the company has no intention of ever allowing the 40 percent cut to happen. They just have to pretend they will so their accountants will allow them to stop the immediate pay cut.

No small business would actual run its payroll budget this way. Yet this is the budget lunacy that Washington has employed to hide the true costs of stopping Medicare physician payment cuts.

On Monday, Senator Reid will bring S. 1776, the Medicare Physician Payment Fairness Act, to the Senate for a vote. The bill, introduced by Senator Debbie Stabenow, simply sunsets the SGR and eliminates all of the scheduled cuts in 2010 and subsequent years. Instead of using gimmicks to hide the cost of SGR repeal, as Congress has done in the past, the costs would be reflected in the estimates going forward of Medicare spending. Following Senate action, the House of Representatives is expected to take up the issue.

Once the SGR is repealed, Congress would have to design a new system for updating physician services with the input of the medical profession.

I applaud Senators Reid, Baucus, Dodd and the White House for making this commitment to end the lunacy created by the SGR, including the smoke and mirrors budget accounting designed to make the costs look lower than they really are. Getting the bill approved by the Senate is no sure thing, though. Senator Reid will need at least 60 votes to overcome procedural obstacles to its consideration. You can help him and ACP get the votes needed to get rid of the SGR, once and for all, by making a call to your Senators today. Click here for more information.

Today's question: What will you be doing to get your Senators to vote for S. 1776 and permanent repeal of the SGR?

A Snowe (flake) does not a GOP blizzard make

2009-10-13T16:58:00.003-04:00

The decision by Senator Olympia Snow (R-ME) to vote "yes" today on the Senate Finance Committee (SFC) package does not mean that there suddenly will be a blizzard of Republican support for the pending health care reform legislation. She was the only Republican to vote for the bill, which was approved by the committee this afternoon on a 14 - 9 vote, with all of the Democrats voting in favor. It may be that she will end up being the only Republican, House or Senate, who votes in favor when the final tally on health care reform legislation is taken later this year. Still, in Washington it just takes a single vote from a member of each party to get the highly "coveted" bipartisan label.

By reporting out its bill, the Finance Committee has joined the Senate Health, Education, Labor and Pensions Committee (HELP) and three House committees in moving President Obama's signature domestic priority a step closer toward a debate on the House and Senate floors, and possibly, enactment. At no other time in U.S. history, going as far back as to 1912 when President Teddy Roosevelt first called for universal coverage, have health care reforms designed to cover (almost) all Americans made it to the House and Senate chambers for a vote.

This doesn't mean, though, that the road ahead is an easy one. The House and Senate leadership and the White House will have to reach agreement on such contentious issues as a public plan option, employer and individual mandates, taxes and fees, offsets/cuts to different stakeholders, the level of subsidies and benefits, and a myriad of other issues, all of which are far from being resolved. The Senate HELP bill and H.R. 3200 would provide higher levels of spending on a host of programs than the SFC bill, which will pose a challenge to Congress in coming up with a common approach that doesn't break the budget.

One of the budget issues that still has to be resolved is how to fund a solution to Medicare physician payment cuts. The House includes a long-term physician payment fix - at a budget cost $250 billion. To keep the price tag down, the SFC bill offers only a one year reprieve from the SGR cuts, with a much lower budget price tag. (The different approach to the SGR is the single biggest reason why the CBO found that the Senate bill pays for itself while H.R. 3200 does not.) The House reportedly is considering taking the SGR fix out of the health reform bill to keep the price tag down and, get a favorable CBO "score," so that it meets Obama's requirement that the bill not add "one dime" to the federal deficit. Even if taken out of H.R. 3200 itself, the House leadership and the White House continue to be committed to getting a long-term solution to the SGR physician pay cuts enacted this year, even if the cost ends up showing up somewhere else in the federal budget and not in the health reform bills. How to do this - in a way that will get the fiscal conservatives in both the House and Senate on board - remains unresolved. But the physician community - including ACP - will insist that Congress find a way to put an end to the cycle of SGR cuts, once and for all.

Finally, I expect we will see more and more interest groups sharpening their knives to kill parts of health care reform that they don't like, which could still result in health care suffering a death of a thousand cuts.

The SFC is far from perfect - ACP has its own list of major concerns about it - but the vote today was historic, in that it moves the United States closer than ever toward the goal of providing all Americans with access to affordable coverage. I hope we all keep our eye on the prize even as we try to change the things we don't like.

Today's question: What do you think of today's Senate Finance Committee vote?

The return of Harry and Louise?

2009-10-12T16:21:00.003-04:00

It was only a matter of time, I suppose, before the interest groups that stand to make or lose billions of dollars would come out swinging against the pending health reform bills.

It wasn't supposed to be this way, of course. President Obama reached out early and often to different interest groups to try to keep them at the table, and for the most part, he succeeded in getting the most powerful among them - health insurers, labor unions, physicians, hospitals, and drug manufacturers - to hold their fire. Until now, that is.

With Congress inching toward a consensus on health reform legislation, the health insurance industry decided that now was the time to make its opposition known to the bill being considered by the Senate Finance Committee. America's Health Insurance Plans (AHIP), the successor trade association to the group that funded the "Harry and Louise" ads that helped kill Clinton's health reform plan, today released a report which claims that most Americans will pay thousands of dollars more in health insurance premiums if the Senate bill becomes law. Calling it a "blistering new attack" by the insurance industry, the AHIP-funded study by PricewaterhouseCoopers will provide "ammunition to Republicans attacking the legislation and might intensify the concerns of some Democrats who worry that the bill does not provide enough help to low- and middle-income people to enable them to buy insurance," writes Robert Pear in today's New York Times.

The timing of AHIP's report appears to be designed to undermine and potentially delay approval of the bill tomorrow by the Senate Finance Committee, the last of the congressional committees to complete action on health reform legislation.

Politics aside, is AHIP correct that the Senate Finance Committee bill will raise premiums? Ezra Klein, blogs in the Washington Post that "seriously engaging with its methodology probably gives it more credit than it deserves, making this seem like an argument between two opposing sides as opposed to a predictable industry hit job. But totally ignoring its claims means some of them might live unchallenged." He then proceeds to take apart most of the key assumptions behind the PricewaterhouseCoopers analysis.

I don't think AHIP will be the last stakeholder to try to mount public opposition to key elements in the bills. There is a sense among interest groups that time is running out on them, and if they want to make the bills more to their liking, they will have to go public with their opposition. Some of the grounds for their opposition, I am sure, will have merit and should be considered by Congress in crafting a final bill.

The problem is that we may be approaching a period where powerful interest groups that up until now have been saying "yes . . . but" to health reform will switch to "hell no . . . unless" each of their own particular objections are met, which of course is not possible. This in turn could cause public support to collapse, costing us the best chance in a generation to extend coverage to millions of Americans. Just ask Harry and Louise.

Today's question: What do you think of the insurance industry's decision to release a report, on the eve of the Senate Finance vote, claiming that most of us will see higher premiums if the plan passes?

CBO says Senate bill will reduce the deficit, expand coverage to 29 million

2009-10-08T15:16:00.003-04:00

Yesterday, the Congressional Budget Office (CBO) released its preliminary estimates on the impact of the Senate Finance Committee bill on the federal budget and providing coverage to the uninsured. The CBO estimates that the bill will reduce the federal deficit by $81 billion over the next ten years, and will likely continue to reduce the deficit in subsequent years. It would increase federal spending by $829 billion over ten years, but the higher spending would be more than covered by savings and revenue increases (taxes and fees) in the bill.

What would this spending buy? According to the CBO director's blog "The number of nonelderly people who are uninsured would be reduced by about 29 million, leaving about 25 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the proposal, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent. Roughly 23 million people would purchase their own coverage through the new insurance exchanges, and there would be roughly 14 million more enrollees in Medicaid and CHIP than is projected under current law. Relative to currently projected levels, the number of people either purchasing individual coverage outside the exchanges or obtaining coverage through employers would decline by several million."

Who will pay? CBO says that the costs "would be partly offset by receipts or savings, totaling $311 billion over the 10-year budget window, from four sources: net revenues from the excise tax on high premium insurance plans, totaling $201 billion; penalty payments by uninsured individuals, which would amount to $4 billion; penalty payments by employers whose workers received subsidies via the exchanges, which would total $23 billion; and other budgetary effects, mostly on tax revenues, associated with the expansion of federally subsidized insurance, which would reduce deficits by $83 billion." Additional savings come from reductions in spending on Medicare in the following areas: "Permanent reductions in the annual updates to Medicare's payment rates for most services in the fee-for-service sector (other than physicians' services), yielding budgetary savings of $162 billion over 10 years (emphasis added italics), setting payment rates in the Medicare Advantage program on the basis of the average of the bids submitted by Medicare Advantage plans in each market, yielding savings of an estimated $117 billion (before interactions) over the 2010-2019 period, reducing Medicare and Medicaid payments to hospitals that serve a large number of low-income patients, known as disproportionate share (DSH) hospitals, by almost $45 billion." Another $22 billion would come as a result of recommendations from a Medicare Commission that would have the authority to bring proposals to Congress to reduce spending, which automatically would go into effect unless Congress passed an alternative with equivalent savings.

What happens next? The Senate Finance Committee is expected to vote on the bill next Tuesday, after which Senate Majority Leader Harry Reid will work to blend it with another version passed by the Senate's HELP committee. The merged bill would then have to be voted upon by the full Senate, and if it passes, reconciled with the version reported out of three House committees also making its way towards a vote.

ACP has prepared a preliminary analysis of how the SFC, HELP and House bill's compare to College policy in critical areas. The Senate Finance Committee, like the HELP and House bills, has many provisions that are consistent with ACP policies on coverage, workforce, and payment reform. At the same time, the SFC bill does not include a permanent solution to the Medicare SGR physician payment cuts, gives the Medicare Commission too much authority to propose and implement cuts without sufficient congressional oversight, would impose penalties on physicians who do not successful report on quality measures after several years of positive incentives, and reduce payments to physicians with the highest resource use - all areas of major concern to ACP.

The SFC bill and the favorable "score" by the CBO advance the prospects for health reform, but some of its provisions will be opposed by key constituencies. In addition to the concerns that physicians will have about the above provisions affecting physician payments, labor unions and insurance companies will likely howl about the excise tax on high cost plans, Republicans will say that the excise tax and individual mandates will raise taxes on the middle class, Medicare Advantage HMOs will object to the cuts in their payments, governors will object to shifting more Medicaid costs onto their states' budgets with insufficient federal funding, and progressives will object to the lack of a strong public plan option. President Obama will have his work cut out to negotiate a final bill with the Congress and not lose the support of key constituencies - especially doctors, health plans, hospitals, and labor unions - needed to push health reform over the finish line.

Today's questions: Do you think the Senate Finance bill advances the chances for health reform?

The Wall Street Journal tries to ignite a Civil War among physicians

2009-10-07T16:50:00.004-04:00

Yesterday, the Wall Street Journal's editorial page launched an extraordinarily deceptive attack on "Obamacare" for waging a "war" on specialists to benefit primary care.

Let's start with the WSJ's dismissive attitude about primary care. "Compared to bread-and-butter primary care doctors, specialists cost more to train and make more use of expensive procedures and technology - and therefore cost the government more money. Even so, the quiet war Democrats are waging on specialists is astonishing," says the WSJ. Yet, as ACP has documented, these same "bread and butter" primary care physicians save taxpayers a lot of "bread" by improving outcomes for diseases like cancer and diabetes and preventing avoidable hospital admissions. You would think that a newspaper that likes to think of itself as a champion of fiscal responsibility would support the importance of primary care in saving taxpayers' money, instead of dismissing them as being less valuable than other specialists.

And what's with the WSJ's implication that general internists, pediatricians, and family physicians aren't specialists in their own right? In a recent policy paper ACP describes, the highly specialized skills required to be a primary care physician: "The IOM defines primary care as 'the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.' Primary care physicians provide not only the first contact for a person with an undiagnosed health concern but also continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis . . . General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health."

Now, what about the Obama administration's alleged "war" on other specialists? The WSJ mixes up, confuses, connects, and distorts several different policy initiatives: provisions in pending health reform bills, supported by President Obama, to improve the accuracy and appropriateness of physician payments; and a completely unrelated regulatory initiative (which began long before the current administration came into office) to update Medicare's relative value units. The health reform bills being considered by Congress provide a relatively modest Medicare payment increase (5% in the House bill, 10% in the Senate Finance version) for designated services by primary care physicians. In the Senate version only, one half of this increase would be funded through 0.5% offsets to other physicians. Otherwise, the proposed primary care increases are funded with additional federal dollars at no cost to other physicians. The bills also would pilot test new payment models to increase payments to primary care physicians and other medical specialists alike for working together to achieve better outcomes, and create an expert panel to identify potentially mis-valued services under the Medicare fee schedule. Yet instead of applauding these efforts to improve the accuracy and value of Medicare payments so that tax payers are getting more value for the money they spend on Medicare, the WSJ condemns them. Go figure.

Finally, the editorial directs most of its ire at a proposed rule that would increase Medicare practice payments for primary care physicians and some other specialties, but lower them for cardiologists and oncologists. The origins of this proposal go back to 2006, when over 70 specialties urged Medicare to conduct an updated survey of physician practice expenses. Medicare subsequently contracted with the AMA to conduct a new survey, and in June of this year, it asked for comments on a proposal to use the new survey to update how much it pays physicians for their overhead costs. In ACP's comments to CMS , the College urged the agency to address, in an open and transparent manner, the concerns from cardiology and oncology about the application of the survey to their specialties, as it also expressed support for updating the practice expense payments for all specialties. But the essential point that the WSJ misses is that this whole regulatory process is part of Medicare's statutory responsibility to update physician payments on an annual basis, is independent of the health reform legislation being debated by Congress, and its origins pre-date the current administration. Sure, there can be legitimate differences of opinion on whether Medicare should proceed with the proposal as announced in June, but to label it as Obama launching a war on specialists, to benefit primary care, is absurd.

The WSJ may not like the fact that there is a broad and civil consensus within medicine, primary care and other specialties alike, on the need for more primary care physicians, including reforming physician payments to support primary care. It's true that no specialty wants to take a pay cut to increase pay to another, but medicine has, for the most part, been able to engage in a respectful discussion of such issues without making this a "primary care versus [other] specialists" issue. I hope that physicians will not allow the WSJ's to turn this civil discussion into a civil war.

Today's question: What is your opinion of the WSJ editorial?

The interconnectedness of health reform

2009-10-05T15:33:00.002-04:00

One of the problems with reforming the health care system is it's so darn complicated. Critics have made a point of the House bill being over 1000 pages in length, and polls show that the public continues to be confused about key details.

It would be nice if there was a simple way of fixing the health care system that would take only a few pages of legislation and could readily be explained to the public. The reality, though, is that health care itself is so complicated that there are no simple fixes or easy explanations, and any effort to fix one part of the system will create multiple connections to other issues.

Remember the children's rhyme - "the toe bone connected to the foot bone, and the foot bone connected to the ankle bone, and the ankle bone connected to the leg bone ..." - well, the health care system is something like that. A policy that deals with one particular aspect will almost always be linked to another.

Take the popular idea of prohibiting insurance companies from excluding people with pre-existing conditions. It is hard to see such a requirement working though, without a requirement that people buy coverage (otherwise known as an insurance mandate). Otherwise, some people would just decide to go without insurance coverage until they get sick, knowing that insurance companies could no longer turn them down. This would screw up the whole concept of pooling risk. If you are in favor of requiring insurance companies to accept people with pre-existing conditions, you pretty much have to support a requirement that people buy coverage, because one won't work without the other. Yet many of those who support a ban on pre-existing condition exclusion are opposed to an individual mandate.

Similarly, take the idea of requiring large employers to provide coverage to their employees. Many of conservative critics who object to an employer mandate oppose expansion of government-funded health care. But when a company that can afford to provide coverage, but chooses not to, their employees will likely end up getting coverage from ... you guessed it ... Medicare, the SCHIP program, or private coverage subsidized by taxpayers. So the best way to limit the number of people covered under taxpayer-funded public or private plans, if that is your goal, is to link it to a requirement that large employers provide coverage to their employees.

Or, take the idea of expanding Medicaid to the poor. The Washington Post reports today that the governors of many states are concerned that the federal government will not provide them with enough money to pay for enrolling up to 11 million people in Medicaid. Also, the article notes that any expansion of Medicaid may not ensure access to care if the payment rates are so low that physicians refuse to treat Medicaid enrollees. The House bill has a provision to raise Medicaid rates for primary care until they equal the applicable Medicare rates but the Senate Finance bill lacks such a provision. Unless Congress provides states with the money needed to increase payments to physicians at the same time as it demands expanded coverage, the likely result will be that many of the newly covered won't be able to find a physician.

It is because of these many linkages that ACP has taken the view that incremental reforms that deal with only one part of the puzzle won't be effective. If we are going to subsidize coverage for the poor through Medicaid, then we will need to increase Medicaid payments to physicians. If we are going to prohibit insurers from excluding people with pre-existing conditions, then we will need to require people to buy coverage. If taxpayers are going to subsidize coverage for those who can't otherwise afford it, then we need to require that large employers - if they can afford it - provide coverage to their employees, or pay back taxpayers for shifting the cost onto the rest of us. And if we are going to provide everyone with access to an affordable health insurance plan, then we also need policies to ensure that there are enough physicians, particularly primary care doctors, to take care of them.

Today's questions: Do you agree that a ban on pre-existing condition exclusions needs to be linked to an individual mandate to buy coverage? That subsidies to help people afford coverage need to be linked to a requirement that large employers provide coverage? That expansion of Medicaid and other health insurance programs needs to be linked to increased payments to primary care physicians?

Will health reform help a Missouri bartender?

2009-10-02T10:52:00.005-04:00

Early this morning, the Senate Finance Committee finished its work on amending the bill drafted by Chairman Max Baucus (D-MT). A final vote within the committee is expected next week. Baucus says he has the votes to get it out of committee although it remains unclear if Senator Olympia Snowe (R-ME) will vote in the affirmative, in which case she would be the sole Republican, Senate or House, to vote for the health reform overhaul. Assuming approval by the SFC, Majority Leader Harry Reid (D-NV) will work on melding the SFC bill with the version approved by the Health, Education, Labor and Pensions Committee, with a floor debate and vote in mid-October.

As the Washington Post reports, approval by the SFC and HELP committee and the three committees of jurisdiction in the House of Representatives, will take health reform farther along the road to enactment than any other time in American history. It is looking more and more likely that there is a consensus among Democrats to get a bill sent to President Obama for his signature. Nothing is assured, though, until the final votes are cast.

Although all of the attention is on Washington, I am reminded of a recent conversation with a woman in Missouri that reminds me of what health care reform is all about. I was in Missouri attending the ACP chapter meeting. Over several beers at the hotel bar, Dave Fleming, the ACP Missouri chapter governor, and I were debating whether health care is a right, privilege or societal responsibility. Our bartender overheard our conversation and asked if health care reform would help her and her family.

She said she has some serious health problems that require expensive medications, which are only partly covered by the health insurance plan offered by her employer. Her company plan also covers her 19 year old dependent daughter with a serious mental health condition. Her husband, an independent contractor who can't find coverage on his own, also relies on his wife's plan for coverage. She said that even with the insurance, her premiums and out-of-pocket health care bills are so high that "I don't know how we'll make it". She was planning to take a day off from work to plead with state Medicaid office to cover her daughter, even though she had already been advised over the phone that her daughter wouldn't qualify.

Dr. Fleming and I explained that health care reform might make her daughter eligible for Medicaid, because the pending bills would require the program to cover anyone up to 133% of the poverty level (we didn't ask her how much she and her husband earned). We also told her that she might be able to get subsidized coverage through a health exchange, and that insurers wouldn't be allowed to turn down her daughter or charge higher premiums because of her pre-existing mental health condition. She wistfully responded, "I hope so" but sounded unconvinced that the politicians in Washington would do these things for her.

As the politicians continue to debate the intricacies of such things as excise taxes, budget offsets, health exchanges, subsidies, mandates, and public options, I hope we don't lose sight of this Missouri bartender, and the millions of working American families, who can't afford health care and are looking to Washington for help. None of the bills making their way through Congress are perfect - far from it. But I believe the litmus test of whether the results are worth it is whether our Missouri bartender and her family can get good coverage at a price that they can afford.

Today's question: Do you have confidence that the politicians in Washington are going to produce a bill that provides help to this Missouri family and the millions like her?

Is it morally objectionable for physicians to consider cost in treatment decisions?

2009-09-29T16:07:00.003-04:00

Yes, according to a majority of physicians in a recent poll. The survey, which was reported in the September 14 edition of the New England Journal of Medicine, found that 54% of surveyed physicians said that they had "moderate" (40%) to "strong" (14%) moral objections to using cost-effectiveness data to determine which treatments to offer to patients. 45% said they had no such moral objections.

A third of physicians had moderate to strong disagreement with limiting reimbursement for high cost procedures or drugs in order to help expand access to basic coverage to those who do not have it, while 67% favored such limitations to expand access for others. Primary care physicians were more likely than surgeons or procedural specialists to support limits on payments to help fund basic care for others.

The survey has some other surprising findings. While a large majority of physicians agreed that physicians are ethically obligated to care for the uninsured and underinsured, 27% moderately or strongly disagreed. Slightly more than one out of five physicians agreed that addressing societal health policy issues, as important as that might be, falls outside their professional obligations as physicians.

Like any poll, how a question is worded can produce a quite different result. I wonder, for instance, if fewer physicians would have moral objections to cost-effectiveness data if it was to "guide" or "inform" patient care decisions rather than "determine which treatments will be offered to patients" as stated in the survey. I can see why the notion that a treatment might not be even offered to patients, if it was determined not to be cost-effective, would raise moral objections. Comparative effectiveness research, at least the way ACP has envisioned it, should be used to engage patients in shared decision-making with their physicians on which course of treatment might work best for them, not to deny them this choice by taking the more expensive treatments off the table.

At the same time, the survey suggest to me that many physicians do not agree with concepts of social justice and fair allocation of resources as described the Physician's Charter on Professionalism, which has been endorsed by the ACP, the American Medical Association, the American Board of Internal Medicine, among others. The Charter's principle of social justice states that "The medical profession must promote justice in the health care system, including the fair distribution of health care resources." It also states that physicians must have a commitment to a just distribution of finite resources:

"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Today's questions: Do you personally have a moral objection to using cost-effectiveness data to determine the treatments offered to patients? What about to guide and inform such treatments? Do you agree or disagree with the Charter's view that physicians must be committed to social justice and a fair distribution of finite resources?

"You can't always get what you want . . .

2009-09-24T17:12:00.004-04:00

. . .But if you try sometimes, well you might find,
You get what you need."

So sings Mick Jagger in this rousing refrain from the hit song on the Rolling Stone's 1969 "Let it Bleed" album.

Most people wouldn't look to Mick Jagger and Keith Richards as a source of child-raising advice. But I have quoted this phrase many, many times to my kids. Like when my 17 year old daughter recently insisted that she needed a "cool" new cell phone, when she already had a perfectly good phone. Of course, telling her that "you can't always get what you want" didn't help my approval rating that night.

The advocates of health care reform are dealing with something similar. What people want is unlimited health care, paid for by someone else, at no cost to them. What they need is access to care that is reasonably affordable, with some limits to ensure that the total price tag doesn't bankrupt the country.

It is the "limits" part that has people upset. They instinctively understand that health care reform will involve some limits on their own care, even as heath reform advocates try to sugar-coat things by saying it can all be paid for by reducing waste and fraud and promoting "value" and "efficiency" in health care. We can deny all we want that health care reform will lead to rationing, yet much of the public believes that in the end, the government will put limits on the care they want.

I think this explains the ambivalence about health reform in recent polls. The Kaiser Family Foundation's August tracking poll found that 45% of voters felt that health care reform would make "the country as a whole" better off but only 36% felt it would do the same about them and their families. Only 29% thought it would make the quality of care better for them personally, but 37% thought it would make quality "in America" better. 42% thought that it would make wait times for non-emergency treatments personally worse for them. 51% were more worried that Congress would pass a bill that won't be good for them and their family, compared to the 39% that were more worried that Congress wouldn't pass a health care reform bill this year.

The public's concern about the impact of health care reform on them personally is appropriate and understandable. President Obama has tried to blunt this by emphasizing how people with health insurance will benefit from reform, and some other recent polls suggest that he is making progress.

I think the President has not squared with the American people that it isn't possible for everyone to get everything they want. But the critics of his efforts have also done a disservice by screaming "rationing" every time the discussion turns to controlling costs.

The issue, in my mind, is not whether there will be limits - call it rationing if you must, although it is such a loaded term. Instead, the question is who will do the rationing and how. Should we continue to leave it to insurance companies to limit services by denying coverage for people with pre-existing conditions, cancelling coverage when they get ill, and finding every possible reason to deny claims for services?

Should we do it based on who has access to health insurance and who doesn't? By how rich your benefits package is? By whether you work for an employer who can provide coverage, or whether you work for a small company that cannot? By giving everyone a high deductible plan so they are more responsible for the cost of their own care? By making smokers and others who have so-called "lifestyle" illnesses pay more? By having the government fund research on the clinical effectiveness of different treatments and then designing benefits, coverage, and payment policies around such research?

Good arguments can be made for, and against, almost all of these approaches, but at least they recognize the simple fact that when it comes to health care, you can't always get what you want, but if you try sometimes, well you might find, you get what you need.

Today's question: Do you think it is possible to engage the public in a rational discussion about rationing?

Let the sausage-making commence!

2009-09-22T17:12:00.004-04:00

Senator Max Baucus today released a revised draft of his health reform bill, which will be marked up (amended) by his Senate Finance Committee beginning today. As many as 600 amendments have been drafted. The amendments generally fall into the following categories:

1. Amendments by Republicans who will not vote for the bill, no matter what, and that have little possibility of being accepted by the committee. Most of the GOP amendments would eliminate the cost controls in the bill (striking Baucus' proposals to create a Medicare advisory commission, or fund comparative effectiveness research, for instance), eliminate mandates on individuals and employers, strike proposed cuts in payments to providers, and eliminate any and all tax increases to fund coverage expansions.

2. Amendments by liberal Democrats to replace the bill's health plan co-operatives with a strong public plan option.

3. Amendments by Democrats to increase the subsidies so as to make coverage more affordable when an individual mandate takes effect. Olympia Snowe (R-ME), the one Republican who seems open to voting for the bill, also supports increasing the subsidies.

4. Amendments offered by Republicans and Democrats alike to promote specific policies they favor. For instance, a number of amendments were offered to increase support for primary care training programs.

My favorite amendment, apparently offered tongue-in-cheek by Senator Orrin Hatch (R-UT), would exempt any state beginning with the letter "U" from the excise tax on high cost insurance plans.

The overall direction of the revisions made today by Senator Baucus, and the amendments most likely to pass, will be to broaden federal assistance to those who need help buying coverage (which will drive up the cost of the bill) while at the same time reducing the tax increases and budget offsets (cuts) that he hopes to use to pay for the legislation. The risk is that this will end up increasing the price tag to the point that it will test his, and the Senate's, commitment to passing a bill that won't add to the deficit.

ACP, for its part, sent a letter to Senator Baucus with our views on what we like and don't like about his proposal.

The legislative process is not for the faint of heart. It is messy and contentious and sometimes produces an unpalatable product that no one will swallow. Other times, though, it produces something worthy of consumption - just like the sausage-makers to which Congress is often compared. We'll see soon which will be the case this time around.

Today's question: How many states begin with the letter U? Or, more seriously, what do you expect this process to produce?

A Tale of Two Presidents

2009-09-21T12:59:00.002-04:00

The media is abuzz about President Obama's "unprecedented" presence yesterday on five network and cable interviews to make his case for health reform, to be followed tonight with an interview on the David Letterman show. As President Obama continues to make his case to the American people, might I be so bold as to suggest that he take note of an op-ed that appears today in the Atlanta Journal Constitution, written by ACP's own President, Joe Stubbs, MD? I am biased, but I think Joe makes as good a case as anyone, on why reform is imperative. He writes:

"I take care of patients in a general internal medicine practice in Albany, as I have done for the past 27 years. I take enormous professional pride and satisfaction in keeping my patients healthy, helping to heal them and providing comfort and relief when they are nearing the end of their life. I also share their frustrations with a health care system that is stacked against us both; a system that is unacceptable and unsustainable. Examples readily come to mind to support this point. By 2017, an average middle-income family will spend $4 out of every $10 they earn on health care alone, putting it out of reach for most. Just three years later, the number of uninsured is expected to climb from today's 46 million to 60 million, which is about one in five of our population. And, those with insurance will not be able to find a primary care doctor because of a growing primary care physician shortage of tens of thousands ...

Within our grasp is the achievement of health reform legislation that makes coverage affordable by building upon and improving our current employer-based system, providing incentives for young doctors to go into primary care, reforming and improving Medicare physician payments, and reducing the costs associated with our broken medical liability system. Let's not let the opportunity slip away."

If Joe is right that rising costs will exceed the ability of families to afford coverage - and I have no doubt that he is - then why does the public not seem to have the same sense of urgency? Ezra Klein writes in yesterday's Washington Post that the cost of health care to individuals and families is masked by the fact that employers pick up (most) of the tab. But when employers pay more for health care, they pay their employees less in wages. Health care costs arguably may be the biggest cause of decades of wage stagnation for middle and lower class families.

The political dilemma is that since the public doesn't readily see the impact of rising health care costs on their livelihood - unless they are among the unfortunate millions who have no health insurance coverage or have experienced personal bankruptcy because of a personal health care catastrophe - they don't want to hear about the need to control costs. When even relatively mild ideas to control costs are proposed - like funding research on the comparative effectiveness of different treatments, or reimbursing doctors and patients to sit down together to discuss advance directives - they are demagogued as "rationing" by some politicians.

This is why the political debate is shifting to things that are relatively popular with the public - like prohibiting insurers from turning them down if they have a pre-existing condition or cancelling their insurance if they get sick - instead of controlling costs. The idea seems to be to sell the public on the gain from insurance that can't be taken away, while postponing a discussion of the pain involved in controlling costs. Even though, as Joe Stubbs wrote, the cost of the current system is not sustainable for his patients and their families.

Today's questions: What do you think of the views expressed by Dr. Stubbs? How would you recommend engaging the public in a discussion of the cost of health care?

Baucus offers plan to extend coverage, cut deficit, and increase primary care fees

2009-09-16T16:56:00.003-04:00

Today, Senator Max Baucus (D-MT), chair of the Senate Finance Committee, released his version of health reform. ACP is analyzing the bill, so I'll have more to say about it in subsequent blogs. A few highlights, or lowlights, depending on your point of view:

The CBO projects that the bill will reduce the deficit by $49 billion over ten years, and that likely it would to continue to reduce the deficit in subsequent years.

It is financed principally by a tax on insurers who sell high cost health plans and by savings in Medicare and Medicaid. There is no direct tax increase on higher income persons, as in the House bill, although the insurance tax on high cost health plans likely would be passed onto to people enrolled in such plans.

The bill bans most insurers from excluding or cancelling insurance based on a person's health status or pre-existing condition, and limits the factors that can be used in setting premiums.

It provides subsidies for people up to 400% of the federal poverty level to buy coverage through an exchange (purchasing pool), but the subsidies are much lower than in the House bill. With the result that out of pocket costs will be much higher, especially for younger persons.

Individuals seeking subsidies or coverage through an alliance would have to submit documentation that they are in the United States lawfully.

The bill provides additional funding for states to expand Medicaid to 133% of the federal poverty level.

It does not include an employer mandate. Instead, large employers who do not cover their workers will be required to pay the costs of any federal subsidies extended to those workers.

No public option; instead, regional non-profit cooperatives are proposed to compete with private insurers.

Everyone, with only a few hardship exceptions, would be required to buy coverage.

On physician payment, it would provide only one year of relief from the Medicare SGR physician pay cuts (0.5% increase instead of a 21% cut in 2010), paid for in a way that will cause an even bigger cut the following years. Congress would then need to pass legislation next year to halt the subsequent years' cuts, at an even bigger budget price tag.

Senator Baucus proposes to give general internists, family physicians, pediatricians, and geriatricians a 10% bonus payment for designated office visits and other evaluation and management services. Half of this would be paid for with additional federal spending, the remaining by a small (half percent) across-the-board reduction in Medicare physician fee schedule payments. The House version, H.R. 3200, proposed a 5% primary care bonus paid for entirely with new federal dollars (no budget neutrality offset to other physician services).

Oh, and despite months of working to get GOP support, Chairman Baucus had to admit that as of now, not a single Republican has signed onto the bill, although he expressed confidence (hope?) that he'd have some level of bipartisan support by the time that the Senate Finance Committee takes up the bill next week.

I expect that ACP will find some things we like in the Baucus bill, but other things - especially the fact that it just kicks a solution to the Medicare SGR pay cuts down the road - are likely to be of real concern. I am interested though in readers' initial reaction to the proposal, and especially to the idea of giving primary care physicians a bigger raise, paid for in part by a modest reduction to other physicians.

Today's questions: What is your initial reaction to the Baucus plan? Is it reasonable to ask all physicians to chip in a half percent of their Medicare fees to help fund a 10% increase in designated services by primary care physicians?

New poll shows physician support for expanded government role in coverage

2009-09-15T16:51:00.006-04:00

I have received quite a few comments from ACP members who say that the College's positions on health reform are not representative of most internists' views. For instance, on Friday an internist posted the following comment in response to my blog about Obama's speech to Congress:

"You will be hard-pressed to find a physician outside of a university setting that supports this ridiculous bill . . ."

Lately, such criticisms have come mostly from the right of the political spectrum. Over the years, though, I have heard from many ACP members who support a single payer system; they also claim most internists agree with them and that ACP is out-of-step with its membership.

A new poll, funded by the non-partisan Robert Wood Johnson Foundation, found that a large majority of physicians - almost 63% - "support proposals to expand health care coverage that include both public and private insurance options - where people under the age of 65 would have the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans government." Fewer than one in ten of the physicians surveyed support a single government plan (Medicare for all) that replaces private insurance. Large majorities of physicians also support a Medicare buy-in option for people between the ages of 55 and 65. Primary care physicians - internists, pediatricians, and family physicians - were the most supportive of providing a public and private option, with 65.2% being in favor.

Physicians in all regions of the country supported a public-private option, with support ranging from a low of 58.9% in the south to a high of 69.7% in the northeast. 63.3% of physicians in urban areas and 59.6% in rural ones supported the public-private option. It wasn't just academic or salaried doctors who said they support a public plan option. Solid levels of support were found from physicians in private practices (59.7%), those who are involved in patient care more than 20 hours per week (62%), and those who get most of their income from direct billing rather than salary (58.9%). More than six out of ten AMA members expressed support for a public-private option.

Now, I have learned from experience that people tend to dismiss as being "biased" polls that do not agree with their own views. I also recognize that polls have their limitations, and some are more accurate than others. Some polls, especially those funded by advocacy organizations or political parties, should rightly be suspected of carrying bias. But there are a lot of highly respected researchers who are doing their best to capture accurate information about physicians' and the public's views, and I think this polls meets any reasonable standard of credibility.

Polls are snapshots of opinion, and opinions can change rapidly as circumstances change. Plus, complex issues like health reform aren't easily captured in a single poll. This poll did not ask the physicians about their specific views on President Obama's plan or the bills pending in Congress. Nor did it ask their views on financing health reform through higher taxes, or requiring that individuals buy insurance. Still, the poll suggests that there is broad and deep physician support for a larger federal government role in health care.

Now, just because physicians seem to agree on the need to provide the public with a choice of public and private plans doesn't make it the right policy prescription for America. A principled argument can be made against giving the government a bigger role in health care, just as a principled argument can be made for a single payer system. Still, physicians making such arguments should be aware that they seem to be at odds with where most of their colleagues stand.

Today's question: Do you agree with the poll's finding that most physicians support giving people the option of enrolling in a Medicare type program, along with private insurance? If you don't agree, are there alternative surveys or data on physicians' opinions that this blog's readers should know about?