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A great deal remains to be done before any of the parts of the new health reform law, the Patient Protection and Affordable Care Act (PL 111-148), begins to affect people. Regulations have to be written, appropriations (in many cases, where they are not included in the law) need to be made (or not). There are a number of lawsuits pending, including several by states’ attorneys general. While these suits probably have little constitutional basis, nothing is certain when it comes in front of a Supreme Court that has recently declared (in Citizens United) that corporations have the same rights as people, at least in terms of giving money to political campaigns. However, it is a good time to look at this bill – at least parts of the massive 2,600 pages – and consider the impact on health, medicine, and social justice.
I indicated in a guest blog piece on Health Strong, “Why we need health reform”, before the bill became law, that the three key problems that exist, and need to be the touchstones to examine for the new law’s effectiveness, are:
1) Access – does it increase access for the 45+ million uninsured, tens of millions of underinsured, and tens of millions more whose premiums, co-pays and deductibles are becoming more and more prohibitive while the extent of their coverage drops?
2) Cost containment – as medical care costs approach 20% of GDP they threaten to choke off other, key social programs. Is there a viable method for cost control?
3) Health -- medical care, and even health care, are not health (Health is more than Medical Care, Jan 10, 2010). The goal must be to improve people’s health, of which medical care contributes only 15 % at best. In addition to genetics, individual behaviors and the socioeconomic environment are better predictors of health than medical care. At a population level, it is arguably true that improving educational opportunity for all children would provide greater increases in health status than all medical care.
The new health reform law will certainly increase financial access to health care for many people, an estimated 32,000,000. To the extent that this improves actual access will depend upon elimination of other barriers including geographic, transportation, co-pays and deductibles for those who are not fully subsidized, the existence of enough providers (especially in primary care) and the ability of people to get to the place where they can be seen (e.g., many people lose a day’s pay if they go to the doctor). The law will also (provided insurance companies can be prevented from “gaming” the system) prohibit denial of coverage for pre-existing conditions (for children this year; for everyone in 2014) and prevent rescissions – canceling your policy when you get sick.
In addition, as I have previous noted (Primary Care and the Medical Home, Today and Tomorrow, Primary Care and Residency Expansion), there need to be doctors or other providers; in particular there need to be primary care doctors. In rural areas, health care means essentially only primary care, and as has been noted by many of these blog pieces by Robert Bowman (Ten Biggest Myths Regarding Primary Care in the Future, Top Ten Reasons for Future Subspecialist Physicians To Be Concerned) and myself, this means family doctors, because this is the only “form” of primary care that “distributes” to where the population is – 20% of Americans live in rural areas and 23% of family doctors practice in such setting; no other primary care form (physician, NP, PA) come close. However, the need for primary care providers is not only in rural areas; in suburban and urban areas people still need a physician who is “their” doctor, not the doctor for only a piece of their body or a particular condition, someone who can coordinate and manage all their preventive, chronic, and acute care. And there are not, as we have also demonstrated, enough of them. Massachusetts discovered this when its statewide health reform dramatically increased the number of state residents with financial coverage; there were not enough primary care doctors to see all these people. We have also discussed the fact that medical students are not choosing family medicine and other primary care specialties in adequate numbers. (Note that our physician workforce is less than 30% primary care and dropping; to get to 50-60%, the ideal ratio in all international studies, in less than a generation, will require more than 50% entering true primary care training.)
What does the health reform law do for these issues, particularly in producing primary care doctors and related issues? Here are some of its components, with page numbers in the law in parentheses for anyone who wants to read the law in more detail:
· Primary care physicians (defined in a reasonable way) will received a 10% increase in reimbursement from Medicare for 5 years, as will general surgeons practicing in rural areas.
· The annual threat to all physicians from Medicare cuts will be addressed.
· Medicaid will reimburse primary care physicians at the higher Medicare rate for 2 years (2013-14).
These changes (pp 1413ff) will help primary care providers survive, but are not likely in themselves to reverse the trend of students entering subspecialties. (The American Academy of Family Physicians, AAFP’s, Robert Graham Center (“Does graduate medical education also follow green?”, ref below) estimates that a 35% increase in primary care reimbursement would be needed for students interested in family medicine to feel that they would earn enough to be able to pay off their medical school debts). In addition, residency training is addressed in several ways:
· Unused residency “slots” (positions Medicare would pay for) are to be distributed with a preference for primary care and rural training (pp 1421ff),
· Medicare GME money would pay for training in non-hospital settings, addressing the problem of hospitals wanting to keep residents in-house and thus limiting their training in community settings (pp 1431ff),
· Teaching Health Centers, especially in federally-funded Community Health Centers, would be encouraged with grant money (pp 1457ff).
· Training grants for primary care (“Title VII”) will be re-funded, and there will also be new grants, both with specific funding priorities rewarding schools and residencies that send graduates into underserved and rural areas (pp 1315ff, pp 2343ff), as well as grants to fund Preventive Medicine residencies (pp 2349ff).
Access to care will also be enhanced by large increases in funding for Community Health Centers (CHCs) (pp1479ff) and for loan repayment for doctors who work in underserved areas through the National Health Service Corps (NHSC). It will also provide funding for the creation of Primary Care Extension Services, which I have previously advocated (pp1404ff). The Medical Home concept, which identifies a multi-disciplinary “home” for each patient, requires advanced management techniques like electronic medical records and easy patient access, and pays for prevention and care coordination, is supported through an “Innovations Center” and the law requires payment for these services from insurers (p 2048). Funding is also provided for national and state health care workforce planning. In addition several new programs, including one that creates US Public Health Service “scholars” who will receive tuition and stipends (pp. 1372ff), and a major initiative to train dental therapists to provide basic dental care in areas where there are no dentists or even dental hygienists, are included, as are demonstration projects to reduce fees for underserved people (pp. 2357ff), and training Community Health Workers (pp. 1346ff).
On the downside, more than 23 million people, including all undocumented residents will remain uninsured. Clearly, covering the undocumented is a “hot button” political issue, but not allowing it is a classic example of “head in the sand”; these people are here, they work, they pay taxes – and they get sick and use expensive emergency rooms for care of conditions that could have been treated much earlier and better. The law is also a windfall for both insurance companies (who will get paid at their outrageous rates for all these new customers) and pharmaceutical companies. There are no structural systems for really controlling costs.
In summary, the good parts of the new law are that it is good for primary care practice, probably good for providers in general, expands funding for primary care education, provides more funding for CHCs and the NHSC, creates funding for Medical Homes, Primary Care Extensions, and other innovative programs. More people will be covered, it will prohibit denying coverage for pre-existing conditions and prevent rescissions, and will create restrictions on “medical loss ratio” – that is, insurers will have to pay at least 85% of the premiums they collect on actually paying for health care (imagine that!).
On the negative side, it leaves lots of people uninsured, is very complicated (it phases in over many years and it is still not clear how – or even whether – all the components will be implemented), there is no real mechanism for cost control, and it is good for insurance companies and good for drug companies (a bad thing – e.g., Insurance company greed: To know them is to not trust them). It also creates incredible complexity in coverage, with different members of families likely being eligible for coverage through different programs.
We will see how this plays out, but it would have been (and still remains) a much better idea to simply include everyone into Medicare, creating a single payer for everyone, a simpler and much less costly administrative mechanism, and a real opportunity to control costs. Those, including most (or all) Republicans who are critical of this bill because of the cost are neither advocating (in fact, they desperately oppose) a single-payer system that would really save money, nor even recognizing that continuing the way we were going was about the worst choice. Maybe it is too much to ask them for logical consistency. But those of us who are committed to social justice must continue the struggle. Re-read Dr. Ferrer’s blog piece The Sharp End of Ideology.
References:
· The bill – HR 3590 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590eas.txt.pdf
· MEFS summary www.medicaleducationfutures.org
· Community Catalyst summary http://www.communitycatalyst.org
· Kaiser Family Foundation summary http://www.kff.org/healthreform/8023.cfm
· STFM Summary & implementation timeline http://www.stfm.org/advocacy/news.cfm
· Implementation timeline (AAFP)
· Aaron HJ, Reischauer RS, “The war isn’t over” NEJM, 8Apr10;362(14):1259-61
· Himmelstein DU, Woolhandler S, “Obama’s reform: no cure for what ails us”, BMJ 3April2010, 340:742
· Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010 Feb 22;170(4):389-90
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Showing posts with label Medicine: Health Reform Law. Show all posts
Showing posts with label Medicine: Health Reform Law. Show all posts
Thursday, April 22, 2010
Sunday, April 11, 2010
Doctors and Health Reform: How should a physician's politics affect their patient care?
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President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.
Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?
On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)
More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?
I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.
Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.
The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.
.
President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.
Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?
On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)
More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?
I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.
Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.
The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.
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