Wednesday, July 15, 2009

A battle for physicians' hearts and minds

Yesterday, the chairmen of the three House committees with jurisdiction over health released America's Affordable Health Choices Act of 2009, H.R. 3200, a comprehensive bill to reform U.S. health care. With release of the bill, we can expect to see an intensification of the battle that is underway already to sway physician opinion.

ACP has concluded that the bill goes a long way in addressing the College's priorities for health reform.

On coverage, it creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage. It reforms the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. It provides for sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.

On workforce, it would create an advisory process to set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians, and includes polices to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need.

On payment and delivery system reform, the bill would eliminate the accumulated Medicare SGR payment cuts, provide a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and create a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care. It increases Medicare payments for designated services provided by primary care physicians - not as much as we would like, but it is a start. It raises Medicaid payments for primary care until they are equivalent to Medicare. It provides funding that is provided to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home.

H.R. 3200 also would fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making, as called for by ACP. It also include provisions in the bill to simplify and reduce the costs associated with interactions with health plans.

So what's not to like? These are the principal arguments that critics are using to sway doctors to oppose the bill:

The say that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.

The idea that the public plan would destroy private insurance is not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many of 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons - 164 million, an increase of two million persons compared to current law - would be covered by employers.

Opponents also argue that Comparative Effectiveness Research would lead to rationing of care by government bureaucrats. Actually, there is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.

I understand that died-in-the-wool conservatives aren't likely to support H.R. 3200, because of the cost and the expanded role for government. Just as I wouldn't expect support from died-in-the-denim liberals who believes that Canadian-style health care is the only answer. But on the policies that matter most to ACP, I believe that the bill moves things in the right direction and deserves internists' support.

Today's questions: Who do you think will win the battle for physicians' hearts and minds? Health reform advocates who support expanded government regulation of insurance and subsidies to help people buy it - and a strong public plan? Or critics who argue that Congress' approach to health reform will lead to a government take-over of medicine and rationing of care?


Anonymous said...

It seems to me that the closer we get to health care reform, the worse it looks for primary care physicians. The latest news is that we will now get a 6% pay increase on "certain E & M" codes, not the overall 10% increase originally discussed. This is in exchange for more red tape from both private insurance companies and the federal government. Bob Doherty says this is a start. Does he really think that more pay raises are likely to occur in the next few years given the state of the economy? Does he think that this pay raise is enough to make any difference?

I really don't see how primary care is better off. Internists will continue to be angry, new physicians will not take the place of those who retire or leave, and more physicians will continue to drop out of Medicare(now happening quickly in LA) and private insurance companies networks as a matter of survival.

Yet organized medicine tells us to take whatever deal that is offered, as the results of not taking it would be worse. I really don't see how things can be much worse. It seems to me that the "back room" deals continue to be made at our expense. When do we stop? When do we say enough? We need to demand changes that will ensure the future of both our specialty and the American health care system!!!! It is ludacris to expect internists to continue to function under these circumstances.

Jay Larson MD said...

5% increase in primary care payment in 2011. Pretty lame. I hope the Senate can convince the House that primary care needs more support.

jfddoc said...

Investor's Business Daily reports the following on page 16 of HR 3200:


In other words, you can keep your current insurance, or switch to the public option. You just can't switch from United Healthcare to Blue Cross if the Blues offer a better deal. What happens to HSAs under this scenario? Isn't this at odds with the concept of "portability" as espoused by the College?

While I understand the desire to get on board with the general concepts of reform, I'm concerned that these sorts of devilish details will be overlooked.

Unknown said...

Disclosure: I left primary care after 8 years because it was too much work for me to do well and have any time for myself and family. I am now employed as a hospitalist with a 50% increase over my primary care salary.

I'm going to talk out loud so much of this this may be disjointed. If health care reform works and we now know that 97% of our patients will be insured can this really be bad? If a large percentage of our patients are insured by a plan with well published uniform rules like medicare won't this make our lives easier? No prior auth for x-ray exams or non-formulary drugs or surgical procedures. We will know up front what the new plan will and won't pay for and then decisions will be up to us instead of bargaining with a private insurance administrator. It may even be possible to cut down on office staff used to field insurance phone calls, pharmacy precerts and other precerts. Now that's progress. If 97% of our pts are insured might we not have to deal with the guilt of turning a patient away because they don't have insurance? Isn't that a particularly difficult and stressful part of the horrible working conditions most primary care physicians endure? Won't any of us walk a little taller knowing that we work in a health care system where there are no longer 50milion uninsured and underinsured? (It's always increasing like the number of burgers served at McDonalds) Hopefully the US can rise to the ranks of other industrialized nations in our statistics for immunizations and other core quality indicators. I may be off by a few points but I believe that the US is 17th in overall health care quality in the world. That hurts. No matter how hard all of us work we will not be able to change that number because it is based on the number of people who are not getting ANY care rather than our patients who are for the most part getting excellent care. I am always embarassed when a doc from another country brings up this issue.

Doctors' salaries are decreasing and will continue to decrease until they level off significantly lower than previous. Should we be frustrated that the change in reimbursements is totally changing our life planning and our ability to afford the lifestyle we could previously afford. OF COURSE!! Should we let this reality get in the way of a plan which will improve the health of America. NO WAY!! If we step back and look at what's happening to other jobs in the US we might think of ourselves as somewhat fortunate. Our job cannot be outsourced to another country. We are not auto workers in a crumbling industry. Few of us are losing our jobs. There will be employment as a physician into the distant future. We are not financial professionals subject to the whims of an ever changing stock market. Things are not great. In some instances they really suck. But the majority of Americans are dealing with the reality of increasing cost of living relative to their income. We have job security even though our income security is changing. I truly believe our incomes will stabilize. Was there any course in medical school that said we would be rich as physicians? I never had a professor who told me that medicine was a gold mine and practice was an excellent return on investment. We are rightfully pissed off that we are at the mercy of economic and political forces beyond our control. Let's not let that get in the way of supporting an insurance plan that will allow more Americans access to the excellent care American physicians have to offer.