Thursday, January 28, 2010

Mary Landrieu Blasts Obama Over Health Care

"I think the president should have been more clear about a way forward on health care last night," Sen. Mary Landrieu told reporters on Capitol Hill Thursday. "I'm hoping in the next week or two he will be, because that's what it's going to take if it's at all possible to get this done." [from CNN]

I agree with her in this much: Until the White House steps up and says what it wants from the House bill and what it wants from the Senate Bill AND WHY and clearly elucidates its reasoning and priorities, they are doing us all a disservice.

I have heard they are negotiating behind the scenes, in the vernacular. Man up and say what it is you want to do.

Bill Clinton was right when he said better to be strong and wrong than weak and right. Last night was a start trowards strong, but until they say what they are willing to go to the mat for, they are not being strong enough!

A lot of us out here in the fields (I'm with Doctors for America) are waiting for some forceful language and commitment from this group. If they learned nothing this year it should be this: The anti-HillaryCare approach of not getting involved AT ALL has been a failure. Get in the trenches and fight!
Read the Article at HuffingtonPost

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My notes for Testimony for GOP doctors caucus January 21, 2010

[I know, I know,State of the Union! I did want to get this up, however, for the record. My opening statement is here.]

As I do not have a transcript, and the video posted by the Caucus only contains the opening statements of the Congressman and not the panel (imagine that!), these comments reflect what I recall based on my note taking on the fly during the hearing.

The committee was co-chaired by Congressman Tim Murphy and Rep. Phil Gingrey.
Rep. Murphy started hearings and made some comments about the congressional process, the election in Massachusetts, and then outlined his specific ideas for healthcare reform: these included purchasing insurance across state lines; focus on cost, outcomes and transparency;health insurance should be personal portable and should not lose insurance with job. He also in passing mentioned that Medicare has not been overhauled since it was passed.

Gingrey also opened with observations about Massachusetts election. He then quoted Jefferson, "Whenever the people are well-informed, they can be trusted with their own government;... whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights." He postulated that people don't like the House or Senate bills, and that deals or cut behind closed doors were bad, and finally that the GOP stands opposition to health care reform is currently constituted

Congressman Roe stated that the process should be open and transparent and that simple ideas will increase access. He is opposed to special interests deals that were made, and quoted a survey that said that 91% of people surveyed like what they had in regards to health insurance, and something along the lines of "when you take this much money out of the system..." bad things will happen.

Congressman Broun had a very simple message that can be summed up as the market will fix all. He has introduced HR 3889 along these lines . He referenced the original intent of the Constitution. He spent a few minutes complaining about CLIA regulations that shutdown labs and he thought this was inappropriate and was bad for healthcare.

Congressman Fleming said that we agree on the need for increased access and decrease costs.

Congressman Boozman: transparency is critical.

Before I move on to the testimony, I do want to say a few words about the opening statements. I do not doubt that all of the Congressman would like to achieve universal access to health care in some sense of the word. I do not believe that their sense of universal access to health care comes anywhere near my concept of universal access to health care. They are perfectly comfortable, I believe, with a multitiered system, with poor receiving charity care when it is available, the less poor receiving Medicaid rationed as it is by its fee structure, and then others with very poor insurance policies which limits their access to care, and so on. It is fairly striking to me, that Medicare really is the Cadillac plan in the United States. Private health insurers may pay more for procedures or office visits or what have you, but Medicare provides care to everyone in the level that ensures the basic dignity of every patient. Is dignity important? To some, it is not. But I think, as someone who advocates for a traditional view of social justice and basic dignity of human beings, that the ability to seek medical care and not beg for it is important not only to the individual, but to us as a society.

All of the Congressman at some point during the day reference how important they felt it was to have the ability to purchase insurance across state lines. My view, and the view of many economists and health policy experts, is that this will lead to a race to the bottom. In one of my meetings with Congressman Murphy, he expressed great skepticism in the ability of a government program to do anything properly. He argued that he'd seen some government programs go so wrong as to make him supremely cautious about allowing any new government programs to be enacted. I understand the skepticism. But my skepticism of the ability of state governments to avoid the corrupting influences of money and corporate power far, far outweigh any concern that I have about a federal government program going out of control. And I say this as someone who believes that the privatization of our defense efforts in the forms of Blackwater and other extra governmental agencies has become extremely dangerous for this country. But, looking out across states, and seeing how easy it is for corporations to drastically influence state elections including those for judges and Supreme Court justices, the ability to pressure insurance commissioners, the ability to influence elections for state representatives, and also seeing how poorly some states manage and fund their Medicaid programs, I worry about the states.

I certainly think all the sentiments expressed about transparency in the process and the avoidance of sweetheart deals and backroom deals are very true. However, to hear this from the party of Medicare Part D, and Billy Tauzin, energy policy by Exxon and Enron, the party that by and large believes the BS of Ayn Rand, I find this concern, well, inconsistent. But, I will echo all of those sentiments.. FDR would have gone out and challenged all those special interests that the Democrats made deals with. I, too, am disappointed in my party's leadership.

Regarding the comment about Medicare not been changed since its inception, I guess one could argue that the general concept of Medicare hasn't changed since its inception, but obviously, many parts of the program have changed. Some of the biggest changes included the massive increases in spending in the 60s and 70s allow for growth hospitals expansions of a residency programs in medical schools and so on. Other big changes have come in the forms of DRGs in order to contain costs, this remains a mainstay of financing of health care by both public and private insurers around the world. Payments to physicians and the structure of these payments has changed drastically since the inception of Medicare. Another interesting one is, the addition of the end-stage renal disease benefit program. Because of the sympathy engendered by patients who cannot afford dialysis and were driven to destitution and death, a benefit was added to pay for people with end-stage renal disease. This is now also an untouchable program. But consider that even this program with such good intentions has the same fatal flaw as much of the rest of American medicine, in that it focuses on taking care of the patient after the disease has progressed beyond retrieval. Very telling, indeed.

I was quite surprised by Congressman Roe's comment about the ill effects of taking large amounts of money out of the system. If American medicine were anything close to lean mean machine, there might be some validity to that comment. But the massive amounts of bureaucratic waste, the massive amounts of over testing, under testing, over treating, under treating, the perverse incentive system of rewarding procedures over prevention and high-tech healthcare often with marginal benefit, over coordinating the care of complex patients, the abysmal end-of-life care, the "sweetheart deal" of Medicare part D., the excess subsidies in Medicare advantage plans, and on and on make this comment ludicrous.

Briefly, regarding the Thomas Jefferson quote, all I could think at the time was, that's why the Democrats have overwhelming majorities in both houses and the White House. They'd finally had enough. I do not claim to be an expert in the Massachusetts election, but the only sound clip I saw of the victor was a short sound bite in which he made proclamations about health care reform that were, to be kind, misleading. This dovetails with Congressman Roe's notation that most Americans are happy with the insurance they have, if they have it. I think doctors and nurses will back me up on this: most of them are only happy because they haven't had to try using their insurance. It's that sticky part about when you actually have to use your benefits and become sick and miss work and possibly lose your job and so on and so on so many become unhappy with their insurance and stunned to find out how poorly it sometimes functions. Monty Python said it best with their "never pay" insurance companies sketch.
Panel testimony then followed. Besides myself, the panel concluded Paul Fronstin, Ph.D. of the Employee Benefit Research Institute testified on how the excise tax in the Senate bill will force companies to limit employee coverage, and The Lewin Group’s John Sheils told the Caucus that if these bills passed, wages will decrease as employers pay more in healthcare benefits. Other witnesses included Jim Martin of 60 Plus Association and Dr. Karen Nichols with the American Osteopathic Association.

Fronstin of the EBRI: I will admit that my mind wandered here and I did not critically analyze his testimony on excise tax. A couple of points he did make were that 20% of the population accounts for 80% of the cost of health care, and that chronic conditions are the bulk of the cost.

Jim Martin of the 60+ organization, the conservative alternative to the AARP and, he did not disappoint. It was, unfortunately, like listening to a mash up of Limbaugh/Hannity/Beck/Coulter/Malkin quotes. They believe in healthcare reform but incremental and he emphasized first do no harm. He argued to not take a wrecking ball to the current system, that cuts to Medicare will hurt seniors "whether you're for Medicare or against it" (an interesting quote, eh?), that seniors are scared, that they "paid their due" and expect their due, and he also perseverated on the size of the bill in pages, and also that that "bureaucrats are asking seniors to sacrifice more." You know, I'm not even going to bother.

Dr. Nichols of the AOA: one of five medical students is osteopathic; there is a physician work force shortage; graduate medical education funding needs to be expanded not just reapportioned; Medicare pays for graduate medical education the hospitals and so training incentivize to stay within the hospital and out of community areas and underserved outpatient settings; international medical graduates-the US imports doctors and this creates an international brain drain; primary care physicians are disincentive on by income; only 55% of the work of a primary care physician is actually taking care of patients; payment system values procedures and not coordination of care or cognitive services; emphasized the need to repeal the SGR; threefold difference in income in primary versus specialist; national health service Corps deferments need reinstated.

Shiels of the Lewin Group (he had lots of charts and graphs but we did not get copies, so I missed a lot): the House bill creates a $372 billion increase in employer costs; talked about the change in after-tax income which I didn't follow; changes in average family health spending; if under 50,000 they get a net savings, if over 100,000 there was a modest increase in cost and if greater than 150,000 there is a $443 increase in the House bill and hundred $47 and the Senate bill.

Question-and-answer period. I'm going to have to free flow this because i don't have many notes because - can you believe it- I was paying attention.

Medicare advantage, why is it being cut?
Mr. Martin said it's because the AARP wants market share
We disagree, as does the AMA, and other organizations, and the White House explanation is here.

Gingrey Massachusetts hates the Massachusetts health care reform plan. Except that 68% like their own plan. And 70% of physicians like it, too. And among Obama voters who voted for Brown, only 23% thought Health Reform went too far, with 41% not knowing why they opposed it and 36% didn't think it went far enough! He is worried about the work force adequacy
Nichols reiterated the need to fix the SGR.

Mr. Martin voiced his disgust at people at the Townhall meetings August being called un-American clearly did not get the point. I almost grabbed the microphone next to me to shout him down so he would get the point. Really. I almost did it.

Martin also mentioned that we should scrap all the bills and the Medicare is going bankrupt. I find this magical thinking by the Right about medicare truly amazing. Medicare is going bankrupt, but taking money out of Medicare, even overspending on Medicare Advantage, reducing practice variation, increasing preventive care and improving care coordination and all the things we talk about to improve quality and decrease cost, are off the table. It reflects the schizophrenia of having a popular government program that they would love to vilify and gut if they could, but they can't because seniors will have their heads. And seniors like Martin want it all and more in terms of spending on them, the rest of the economy and the country be damned.

Mr. Broun tried to get us all agree that market reforms that solve the system's problems
I was wondering if Medicare was unsustainable for Part D, as it is now...I will try to find out.

Broun reiterated his idea of four things he considered "critical:" 1. being able sell insurance across state lines is critical, 2. association pools were critical, 3. high risk pools were critical, and 4. health insurance costs be 100% deductible. Dr. Brown also made the amazing statement that he went to Canada and only found one Canadian happy with Canadian healthcare. Just one table for now, because this is just so terminally stupid: 34% of Americans think we need to completely rebuild our system compared to only 12% of Canadians. And only 28% of Republicans still believe that we have the best system in the world.

There was more, but this is enough for now.

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Tuesday, January 26, 2010

Uwe on Reform :Hits Nails on Head

"President Obama's plan to overhaul the nation's health care system hangs in the balance. Uwe Reinhardt, professor of economics and public affairs at Princeton University, says it won't make much difference to most Americans if the legislation dies. But Gail Wilensky, a health care economist who served in the administration of President George H.W. Bush, says she believes there needs to be an overhaul of the system because the soaring costs are unsustainable."

Uwe Reinhardt nails it again. You can click away when Wilensky atarts.

Lose Valerie Jarret, bring in Uwe. (And bring in Krugman for Geithner while we're at it!)

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Monday, January 25, 2010

Beware: Cut Medicare Fees to Doctors and Watch the System Die

(Trying to cross post this at Huffington Post for this piece: )
Sorry, nice try.

1. The projected cost of Medicare will bankrupt the United States.
Only if we do nothing to bend the curve and reduce unnecessary procedures and increase preventive care and care coordination. I suggest you read some Gawande and then come on back here. And "This American Life":

2. There remains tens of millions of US citizens that do not have adequate policies or means to pay for health care coverage.
Yet none of them are over 65.

3. The cost of adequate health care coverage for those citizens still fortunate enough to be able to pay is rising at an unsustainable rate.
See number 1.

4. Systemic waste remains.
See number 1 again.

5.Doctors are compelled to practice expensive defensive medicine due to fears of almost infinite liability and costs associated with litigation.

Really? When was the last time you saw a physician bankrupted by medical liability? That is why we have insurance. Patients, on the other hand are bankrupted routinely by health care costs.Defensive medicine varies inversely with the time you are willing to put in with the patient explaining what you are doing. The big problem with defensive medicine is that we are reimbursed well, in many cases to practice it, and rewarded very poorly for explaining why a patient does not need a CT scan or antibiotics or whatever.

I will acknowledge a frightening trend against science, however:

Yes, we're all against fraud and we all SAY we are for universal access to prevent pain and suffering, but there are different views of that. For example, is going to a Remote Access Medical clinic good enough? Some would say that, yes, as long as there is a free clinic somewhere, that's good enough. I disagree.

At the risk of starting a food fight, I think if we totally revamped what Medicare pays for (quality, not quantity; counseling over procedures), we could absorb that 20% OVER THE LONG TERM without too much trouble. When specialists make 3 or more times what a PCP makes, something is wrong with the paymenty system (I'm an intensivist, BTW).

I'll stop there, and not take the bait on teachers. I hope you have some in your life and they read this!

Read the Article at HuffingtonPost

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Wednesday, January 20, 2010

Testimony to GOP Doctors Caucus

I am giving testimony on Health Care Reform to the GOP Doctors Caucus on Thursday morning, Jan. 21, 2010.

UPDATE: My notes on the back and forth are posted here.

I am representing myself for sure, and, if I do well, will claim to be representing Doctors for America, as well (just kidding).

Here is my opening statement:

Thank you for this opportunity to speak to you today.

A study published recently in the New England Journal of Medicine[i] indicated that 78% of physicians “agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%).”

I was greatly encouraged by this study. But also, sometimes being a glass-half-empty kind of guy, I also was disappointed that 22% of physicians do NOT think they have a duty beyond their individual practice or owe a duty only to the patients in patients in front of them.

In 2004, the American College of Physicians and the American Board of Internal Medicine Foundation published the Charter on Medical Professionalism,[ii] which included language that very pointedly noted that physicians have a duty to social justice in health care:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

It also states that we have a duty to improve access to care and to a just distribution of finite resources. The ACP reports that more than 50 professional organizations in America and around the world have signed on to this Charter.

I am pleased to say that the leadership of most of our medical professional organizations are now not only talking the talk, but walking the walk, and in an unprecedented manner, the 10 largest physician organizations are supporting health care reform that coincides with their stated goals of universal access to health care in America.

But it is not only organized medicine in favor or reform, as most physicians support reform as well. Another survey from the New England Journal showed overwhelming support (63%) for either reform with a public option or straight up single payer health care.[iii]

It is estimated that 45,000 people die in America every single year due to lack of access to health care.[iv] Whether this is twice as high or half as high as the “true” number is almost immaterial, as it is unacceptable in any case. My experiences, and the experiences of my colleagues, convince me that this number is true, and perhaps even a gross underestimate. Every physician I know has stories of patients who ignored some illness or deferred seeking treatment due to lack of health insurance. I had a patient who was literally coughing up blood for months and had a severe cough for many more months before that before he finally came into the hospital with respiratory failure and advanced cancer.

And, just as in war there are multiples of wounded for every casualty, so too, in our struggle with illness, we see much more suffering that does not get counted. The cab driver supporting a family of five who ignores his diabetes (he knows that is what it is), because he is trying to get health insurance and knows this diagnosis will doom his chances. So he ends up in my ICU with severe diabetic ketoacidosis. The construction worker with a seizure disorder who cannot see a neurologist to adjust his medications because of lack of money to pay for his last visit. He develops uncontrolled seizures for the second time in a few months and ends up in the ICU on life support.

Every physician you know can tell you stories like this. And there are more than 800,000 of us in the US, so the 45,000 number strikes me as not only low for preventable deaths, but only the tip of the iceberg in terms of the human cost in physical suffering and anguish. Remember, all these patients had families who loved them.

I know you hear from many disgruntled physicians who are concerned and even fearful of change. It is unfortunate that this fear prevents many from listening to the “better angels of our nature,” and, instead of striving to improve reform as proposed, simply attack and reject any and all proposals on the table.

It is also worth noting that the changes Congress makes now will certainly affect me and my peers with gray hair, but these bills are really about physicians just starting practice, still in medical school or still just thinking about medical school. And, if you have kids, you know this: they don’t think like us. In medicine, in particular, surveys have shown that they view medicine as a chance to help people and serve society, and don’t have that “calling” to medicine as older generations did. They don’t expect to make a small fortune, but they do expect fair compensation for all they have had to go through to get through medical school and residency, financially and in opportunity cost. So, remember when you hear grumbling about reform, consider the source, and, to channel Yogi Berra, remember the future.

In this final minute, I do want to run through some particulars of what we like in the current House and Senate Bills and would like to see in the final reform bill:

  1. Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
  2. Provide substantial subsidies to help make coverage more affordable for our patients.
  3. Implement insurance market reforms to prevent individuals from being denied coverage because of pre-existing conditions, and to limit premium differentials based on age, gender and other factors.
  4. Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
  5. Provide a 10% bonus payment for all primary care providers and a 10% bonus payment for general surgeons and PCPs practicing in underserved areas to ensure a strong physician workforce.
  6. Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
  7. Expand the National Health Services Corp and Title VII health professions training programs.
  8. Expand the medical home pilots and other health care delivery improvement models in addition to creating the Innovation Center to focus on improving the health care delivery system
  9. Invest billions to strengthen our public health system and focus on prevention and wellness.
  10. Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
  11. Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
  12. Create an Independent Medicare Advisory Board, isolated from the political process to ensure patients get the care they need, to make recommendations on cost containment and improvements.
  13. Focus on prevention and wellness including reimbursement for an annual Medicare wellness visits, advance care planning, and eliminating the cost burden on patients for preventive services

So, in conclusion, I would ask all of you to strive for health care reform where our bottom line is quality affordable health care for everyone. Because ultimately, our goal is to reduce the number of deaths and needless suffering due to lack of access to care as close to zero as possible, and to leave our children with a better system than we inherited.

Thank you.

Christopher M. Hughes, MD, FCCP, FACP, FCCM
State Director, Pennsylvania, Doctors for America
Board of Trustees, Pennsylvania Medical Society

[i] Antiel, Ryan M., Curlin, Farr A., James, Katherine M., Tilburt, Jon C.Physicians' Beliefs and U.S. Health Care Reform -- A National SurveyN Engl J Med 2009 361: e23

[ii] Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine Ann Intern Med February 5, 2002 136:243-246

[iii] Keyhani, Salomeh, Federman, AlexDoctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med 2009 361: e24

[iv] Health Insurance and Mortality in US Adults.Wilper et al. Am J Public Health.2009; 99: 2289-2295

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