After the ACA Ruling: Next Urgent Steps for Cardiologists

After the ACA Ruling: Next Urgent Steps for Cardiologists

Medscape: What was the reaction from the ACC to the Supreme Court ruling on the ACA?

Dr. Zoghbi: We are pleased with the ruling, particularly from the angle that we are not setting back the clock on healthcare reform. However, we have a lot of work ahead. All the stakeholders -- professional societies, payers, healthcare professionals, hospitals, device and pharmaceutical companies -- have to work together to develop a sustainable healthcare system. The ACA doesn't necessarily give us all the solutions. It is a step in the right direction that would need adjustment and refinement. We need to work on payment reform that rewards quality rather than volume, with the ultimate goal of having a sustainable system that provides win-win situations and aligns incentives of all involved, eliminating waste and rewarding quality and value. I think you won't see too many people disagreeing with that. Where I see the need to focus is spreading the message that we need to work together; we cannot target one or the other segment of the stakeholders involved in healthcare.

Medscape: What are the ACC's specific goals in the coming year in regard to the ACA? What is particularly important to focus on?

Dr. Zoghbi: The immediate urgent matter, which Congress keeps kicking down the line, is the flawed sustainable growth rate (SGR) formula. It is not part of the ACA directly, but it will impact it. The growth of the debt is always in the background and it gets worse and worse over time. We need a solution, paired with good payment reform, that would emphasize quality, integration of care, and, importantly, elimination of waste. Administrative costs and hassles to provide care have to decrease significantly.

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After ACA Ruling: Next Urgent Steps for Internal Medicine

After ACA Ruling: Next Urgent Steps for Internal Medicine

Medscape: We're very interested to hear what the ACP thought about the Supreme Court ruling on the ACA.

Dr. Bronson: I think the decision is highly supported by our organization and we can now move forward.

Medscape: Will the ruling have any impact on internists or internal medicine?

Dr. Bronson: I think it will be positive for internal medicine, broadly speaking, because it gives more patients access to care through insurance. It will increase demand for services, but that's a positive thing.

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After the ACA Ruling: Next Urgent Steps for Family Medicine

After the ACA Ruling: Next Urgent Steps for Family Medicine

Medscape: What was your initial impression when you learned of the Supreme Court ruling on the ACA?

Dr. Stream: I didn't know what to expect. I had a difficult time separating what I wanted the outcome to be from what I could intellectually predict it would be. I'm pleasantly surprised.

Medscape: Will this ruling change any of the AAFP's expectations about the impact of the ACA on family physicians?

Dr. Stream: I don't believe so. We've been working for over 2 years under a strategy that the ACA was the law of the land, and we wanted to focus on those areas important to family medicine and patients and to make those areas as successful as possible. We also wanted to work on provisions that weren't part of the ACA or were not fully addressed by it, particularly replacing the sustainable growth rate (SGR) formula and achieving meaningful medical liability reform.

Having the mandate upheld is consistent with what has been AAFP policy for over 20 years. We have advocated for healthcare coverage for everyone and access to at least basic health services, including good primary care with prevention and chronic illness care. You can argue whether the mandate is the only means to get there, but at least in the analyses that I've seen, it was one of the best identified ways to get everyone covered.

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Next Steps in Healthcare Reform: Repealing IPAB and SGR

Next Steps in Healthcare Reform: Repealing IPAB and SGR

Medscape: When Medscape interviewed AMA CEO Dr. James Madara in April, he reiterated the AMA's support of the ACA, but he stressed that like all things, it's a work in progress. Now that the law has been upheld, what are the next steps to improving the healthcare system? What areas of healthcare are in most need of improvement?

Dr. Lazarus: We think the things in the act that we'd like to get rid of, like IPAB, would help. We would like to see comprehensive medical liability reform, which we think would help on the cost side and bring down the cost of care. We would like to see a repeal of the SGR in Medicare. And we, in our own strategic planning, are looking at new delivery and payment models that will work better, both for physicians and patients. We think this will give physicians more satisfaction in whatever kind of practice situation they're in, and it will enable them to deliver better care to patients at a reduced cost. We need to have time to do that. It's a 5-year plan, and we're excited about that part of our strategic plan.

Medscape: Do you have any parting thoughts on the future of medicine and the ACA?

Dr. Lazarus: This is something that we had been working on for a long time. We had been advocating for health insurance coverage for all Americans for many years, and we were pleased with the outcome. It gives us at least a roadmap to where we're going. It eliminates the uncertainly about where things were going. As the law is implemented, we'll see what other changes need to take place. But we were pleased at the outcome.

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Error Correction Physicians organizations on HCR from 2009/2010

In 2009, I had tracked down the largest medical organizations to determine their position on the then current Health Care Reform Bill, HB 3200. At the time, I reported that 8 of the 10 largest physicians organizations supported HB 3200. I noted at the time: 

For completeness, #8, the American Society of Anesthesiology and #10, the American College of Radiology are still against reform until they get reimbursement "fixes." 

 

Then, on Nov. 11, 2009,  I wrote:

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

That, apparently is incorrect, and my colleagues Vivek Murthy and Harold Pollack linked to my post from Feb. 9, 2010, indicating that the ten largest organizations supported health reform with a public option. That last part, I believe, is/was true in that all of those organizations were supportive of the public option (the ASA when reimbursement was delinked from Medicare rates). As my blog post states, 

SO, actually, the BIG NEWS is that 10 of the 10 largest physician organizations support health reform with a public option.

I must have inferred or confused the ASA support with the public option with overall support, and I suspect that this was due to the massive focus on the public option issue at that point in time.

As I look back at the other posts I wrote since then, including the one Vivek and Harold cited, I have an exclamation point beside the ASA, as it surprised me so much. 

 

But I have spent over an hour looking, and although I found press releases indicating qualified support by the ASA, I cannot find anything indicating unqualified support. And, as they pointed out to Harold and Vivek, they did issue a formal statement against the FINAL reform bill in March, 2010.

BUT, ASA correction noted, nearly all of the major physicians organizations supported the House Bill (which included the Public Option and the SGR fix), and continued to support the final bill, warts and all.

So, my apologies to the ASA and to Harold Pollack and Vivek Murthy. I will go back and note this correction in the old posts.

Sincerely,

Christopher M. Hughes, MD

 

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Doctors Soften Their Stance on Obama’s Health Overhaul - NYTimes.com

Doctors Soften Their Stance on Obama’s Health Overhaul - NYTimes.com:

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

That change could have a profound effect on the nation’s health care debate. Indeed, after opposing almost every major health overhaul proposal for nearly a century, the American Medical Association supported President Obama’s legislation last year because the new law would provide health insurance to the vast majority of the nation’s uninsured, improve competition and choice in insurance, and promote prevention and wellness, the group said.

As I pointed out here many times over the past couple years, doctors support health reform.

Follow the tags with this to find out more.

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NEJM -- Have Physicians Stepped Up for Reform?

NEJM -- Medicine's Ethical Responsibility for Health Care Reform -- The Top Five List

The medical profession's reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians' income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Dr. Brody makes some interesting points about physicians' role in health care reform, including the general unwillingness of organized medicine to step up and make concessions on income or to vigorously work on the problem of practice variation.

He is only partially correct in his assessment of organized medicine's advocacy role this time around. I think it is a real accomplishment, an unprecedented consensus, that the ten largest physician organizations have come out in support of the House Bill, which includes many very important reforms including the public option.

What amazes me is that this has NO currency in the media. Does anyone know this fact? Does anyone realize how monumental this should be? So regardless of whether organized medicine has made the right offers or concessions in this current debate, the fact that they have stood up, in many cases with much pushback from conservative members and advocated for health reform is a big deal.

Secondly, even if organized medicine's endorsement of reform has not taken the form some of us would like (single payer, Bismarkian insurance), individual physicians, in surveys published in the NEJM have indicated overwhelming willingness to make a deal (i.e., accept a public option) and accept concessions.

a large majority of respondents (78%) 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%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data "to determine which treatments will be offered to patients.

...the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

So i would differ with Dr. Brody's assessment that physicians and organized medicine have not stepped up adequately.

The problem, as I see it, is that the media and the pro-reform contingent in Congress, have done an abysmal job of letting the public know that the people whose opinions they value most in this debate - physicians - are overwhelmingly in favor of reform.

What we see in the media are the conservative physicians in congress (Sens. Coburn and Barrasso, Congressman Boustany) who are ridiculously out of touch with mainstream physicians. Though in touch with the angry tea partiers and the admittedly sizable contingent of conservative American physicians (not accidentally all of these physicians practicing in high income specialties - ob/gyn, orthopedics and surgical subspecialties ), they do not represent the thinking of most physicians.

Furthermore, as Dr. Brody rightly points out, physicians have a higher duty to our patients than to our own narrow self interest. But here, again, physicians have acknowledged this in a formal way in the Charter on Medical Professionalism, published in 2004 by the American College of Physicians and endorsed by more than 50 major national and international medical organizations:

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 seems pretty clear that physicians have answered the call, but somehow, in spite of opinion polling showing how highly the public values our opinion, nobody has noticed.

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Organized Medicine on HCR Updated Again

Update: the ASA, No. 7 below did not support the HCR Bill, just a Public Option. See the full correction here. My apologies.


Not an earth shattering update, but a membership update on one of the organizations courtesy Alice C. of Doctors for America

Below are the largest physicians organization, in order, with estimated membership numbers based on their own websites (or other sources when the Web Site didn't have them). Previously we had the AOA, American Osteopathic Association, as number 5 because their web site had previously said they "represent" 67,000 Osteopaths. Alice sent me actual numbers indicating they have about 40,000 members, still keeping them in the top ten, just not as high up.

All are YES on reform with Public Option and supporting the House Bill, with some points of contention, but generally have endorsed it.

1. AMA 240,000
2. ACP 126,ooo (Internists and many medical subspecialists)
3. AAFP 94,000 (Family Practice)
4. ACS 76,000 (surgeons)
5. AAP 60,000 (pediatricians)
6. ACOG 52,000 (ob-gyn)
7. ASA 43,000 (Anesthesiology!)
8. AOA 40,000 (osteopaths)
9. APA 38,000 (psychiatry)
10. ACC 37,000 (cardiology)

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Physicians on Health Reform, UPDATE!

Update 1/23/12 : the ASA, No. 7 below did not support the HCR Bill, just a Public Option. See the full correction here. My apologies. 

Below are the largest physicians organization, in order, with estimated membership numbers based on their own websites (or other sources when the Web Site didn't have them).

All are YES on reform with Public Option except 11 and 12 as noted below.

1. AMA 240,000
2. ACP 126,ooo (Internists and many medical subspecialists)
3. AAFP 94,000 (Family Practice)
4. ACS 76,000 (surgeons)
5. AOA 67,000 (osteopaths)
6. AAP 60,000 (pediatricians)
7. ACOG 52,000 (ob-gyn)
8. ASA 43,000 (Anesthesiology!)
9. APA 38,000 (psychiatry)
10. ACC 37,000 (cardiology)*

NO: 11. ACR 32,000 (Radiology - Not on Board)*
NO: 12. ACEP 27,000 (Emergency Medicine - Has policy statements, no stand on bills)

13. AGA 17,000 (gastroenterology)

14. It gets a little fuzzy from here on. I think Dermatolgy with 14K is next (they are against a public option), but there are probably organizations that I'm not thinking of that belong in here. Please fill me in and I will update accordingly.

SO, actually, the BIG NEWS is that 10 of the 10 largest physician organizations support health reform with a public option.

[*I had mistakenly put Radiology above Cardiology. But I checked the numbers again today, and these, I think are accurate as they are from the society's websites. PLEASE correct me if you think I've erred.]

State Medical Societies (these are rough estimates):

1. Texas 43,000 Against Senate Bill, member survey: more worried about govt than private insurer interference in medicine.
2. California 35,000. Sent letter of support to AMA
3. NY 30,000. Sent letter of support to AMA
4. PA 20,000. Sent letter of support to AMA on principals, not specifics
5. Florida 19,000. Has set of principles, no specifics
6. Illinois xx,000. For reform, worried about Medicaid expansion (low reimbursement) and no fix for SGR in Senate)

If you'd like to add your state to the list or correct what I have, please do and I will put it up on my blog.

And, of course, don't forget the recent NEJM published surveys of physicians' opinions on reform.

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An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I'll bullet here, but you can go read on your own.

• Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
  Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
• First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
  There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
• Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
  Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
• We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
  In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
• For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs- cmhmd]
• Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
• Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
  Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

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AMA - AMA votes to continue commitment to health system reform

AMA - AMA votes to continue commitment to health system reform:

AMA votes to continue commitment to health system reform
Outlines details to guide efforts toward making the health system better for patients and physicians
For immediate release:
Nov. 9, 2009
HOUSTON – The American Medical Association (AMA) House of Delegates today voted on health system reform policies, reaffirming the AMA’s commitment to health system reform. The AMA's House of Delegates is the nation's broadest, most inclusive assembly of physicians and medical students. Delegates representing every state and medical specialty debate and vote on behalf of their physician peers.
“Now is a defining moment in the history of the AMA,” said AMA President J. James Rohack, M.D. “In a democratic process, the AMA House of Delegates today voted to continue AMA’s commitment to health system reform for patients and physicians. The time to make health system reform a reality is now.”
The AMA reaffirmed its support for health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of physician practice and universal access for patients. It also outlined specific elements it will actively and publicly support and oppose as the health system debate continues.
The AMA’s support for H.R. 3962 and H.R. 3961 remains in place.
“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” Dr. Rohack said."

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

Even if you take out the AMA and AOA as a friend suggested because they are multispecialty groups, we have 8 of the ten largest physician specialty organizations supporting reform. The American College of Radiology is still against it, the American College of Emergency Physicians (# 9) has still not committed and the American College of Cardiology ( which I'm pretty sure is # 10) is on board.

That's about as close as you can get to running the table with physicians groups.

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House Bill Effects on Physician Income

I had a piece in the Pittsburgh Post-Gazette today on physician support of health reform.

A sadistic friend posted it on Sermo. Weee!

The subject of the effect on physician income came up on our Doctors for America and I said:

I often ask my colleagues who 1.) complain about Medicare rates and 2) say all care for the uninsured should be via charity by physicians , "Wouldn't you rather get paid a bit less and have everyone covered so you have more paying patients?"

I doubt anyone has done an analysis of what the net effect of this would be, but perhaps the net effect would be neutral or positive, I don't know. BUT as the NEJM survey said, most of us find it acceptable to take lower reimbursements if everyone is covered.

Our terrific Media Mogul, Mandy Krauthammer-Cohen, MD, of course, had a great bit of information:

Some additional food for thought. If you look at the Lewin group analysis....which does have a conservative bias given it is owned by United Health...physicians will actually make more money under health reform with a public option.

Testimony by Lewin states: "In the first year of the program (when public option is only opened to small businesses with less than 10 employees), physician income would increase by $10.9 billion. This reflects the reduction in uncompensated care for uninsured people as well as increased health services utilization for newly insured people. It also reflects the House bill provisions that would increase Medicaid reimbursement for primary care services to Medicare payment levels. Thus, the reductions in payment for people who shift to the public plan are outweighed by increases in reimbursement for Medicaid, reductions in uncompensated care and revenues from increased service use for newly insured people. Average net-income per physician wouldincrease by $15,237 in 2010 under this scenario."

Read the whole testimony here.

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Physician's Perspective on Health Reform Slides

I updated my slides on physicians' opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.

Cheers,

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Eight of Ten Largest Physician Groups Back HR 3200

(Original Title) "American Psychiatric Association voted unanimously to support H.R. 3200"

Medical News Today News Article - Printer Friendly:

The Board of Trustees of the American Psychiatric Association voted unanimously to support H.R. 3200, America's Affordable Health Choices Act, as the basis for health reform.

'In doing so, the APA is pleased to stand with the American Medical Association,' said a letter presenting the board's decision to the American Medical Association. 'The APA Board of Trustees also voted to support the concept of a public plan option based upon the voluntary participation of physicians and other healthcare professionals in the ongoing dialogue of health care reform.'

'While H.R. 3200 - like any bill - is not perfect, we recognize that it offers many positive benefits for psychiatrists and other physicians, and most importantly for our patients,' the letter said.

This now adds the 9th largest physician organization to be on board for HB 3200, including the AMA, ACP, AAFP, AAP, AOA, ACS, and ACOG.

For completeness, #8, the American Society of Anesthesiology and #10, the Amercian College of Radiology are still against reform until they get reimbursement "fixes."

#11, the American College of Emergency Physicians is still waiting for final form bills to commit.

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Hospitalists' Take on Baucus Bill

From The Hospitalist Web site

Addition of a hospital value-based purchasing (VBP) program to Medicare beginning in 2012. The program would tie incentive payments to performance on quality measures related to such conditions as heart failure, pneumonia, surgical care, and patient perceptions of care. So far, the program’s rough outlines have been well received. “We fundamentally support hospital value-based purchasing,” Dr. Siegal says. “We think it’s a necessary step in the evolution to higher-value health care in general.”

Expansion of the Physician’s Quality Reporting Initiative, with a 1% payment penalty by 2012 for nonparticipants. The bill also would direct the Centers for Medicare and Medicaid Services (CMS) to improve the appeals process and feedback mechanism. Although the Baucus plan’s “mark” doesn’t discuss transitioning to pay-for-performance, Dr. Siegal says the shift likely is inevitable. In the meantime, pay-for-reporting can encourage better outcomes through a public reporting mechanism and “grease the skids” for a pay-for-performance initiative.

Creation of a CMS Payment Innovation Center “authorized to test, evaluate, and expand different payment structures and methodologies,” with a goal of improving quality and reducing Medicare costs. Dr. Siegal says the proposal is consistent with SHM’s aims. “We have for a long time advocated for a robust capability to test new payment models and to figure out what works better than what we have right now,” he says.

Establishment of a three-year Medicare pilot called the Community Care Transitions Program. The program would spend $500 million over 10years on efforts to reduce preventable rehospitalizations. SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify. “We’re very positive about that,” Dr. Siegal says. “I think there is a huge amount of scrutiny now on avoidable rehospitalizations. We think BOOST is a step in the right direction, and we’d love to see greater funding to roll this out on a much larger basis.”

For more information on the current healthcare reform debate, visit SHM’s advocacy portal.

Bryn Nelson wrote the piece for The Hospitalist, and Eric Siegal, MD, is chair of the Society of Hospital Medicine's Public Policy Committee.

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Organized Medicine on Reform

***Update: Now 8 of the 10 largest organizations are on board!***

Welcome to the blog. To make this a bit easier for everyone, here are the physician organizations FOR either HB 3200 or something close to it: AMA, AOA, ACP, AAFP, ACOG, ACS, AAP, ACC, AGA, ASCO, and SHM.

Squishy middle: AAO, AAOS, ACEP

Mo' money, then we'll talk: ASA, ACR.

Details below...

The American Medical Association, ~240K members:

[After passage of HB 3200 out of committee -cmhmd]... the American Medical Association sent a letter to House leaders supporting H.R. 3200, "America's Affordable Health Choices Act of 2009." "This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform," said J. James Rohack, MD, AMA president. "We urge the House committees of jurisdiction to pass the bill for consideration by the full House." H.R. 3200 includes provisions key to effective, comprehensive health reform, including:

• Coverage to all Americans through health insurance market reforms
• A choice of plans through a health insurance exchange
• An end to coverage denials based on pre-existing conditions
• Fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula
• Additional funding for primary care services, without reductions on specialty care
• Individual responsibility for health insurance, including premium assistance to those who need it
• Prevention and wellness initiatives to help keep Americans healthy
• Initiatives to address physician workforce concerns

"The status quo is unacceptable," Dr. Rohack said. "We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues."

The American Osteopathic Association ("represents" 67K, per their website; not clear if this is actual membership)

Why is the AOA supporting H.R. 3200?
The “America’s Affordable Health Choices Act” (H.R. 3200) contains several provisions that reflect AOA priorities forhealth system reform. These priorities include: expanding the availability of affordable health care coverage to the uninsured, increased support for prevention and wellness services, investments in the physician workforce, increased Medicare payments for primary care services without cutting payments for other services and, importantly, it represents our best hope for eliminating the current sustainable growth rate (SGR) formula for updating Medicare physician payments. The AOA continues to work with members of the House of Representatives to improve the bill by seeking additions and changes in the legislation. Specifically, we are working to include expanded graduate medical education provisions, medical liability reform, and student loan financing reforms. Favorable action on a House bill is necessary to move the process to the end game negotiations that will determine the specifics of a final bill.

American College of Physicians (ACP, represents 126 K internal medicine physicians including primary care and medical subspecialists like me):

H.R. 3200 does much of what ACP asked Congress to do in terms of coverage, support for the primary care workforce, payment and delivery system reform, based on long-standing policies that have been adopted by this organization. No bill is perfect, but H.R. 3200 delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College's leadership over many years and always guide how ACP’s leadership, Key Contacts and staff advocate for internal medicine physicians and their patients.

American Academy of Family Physicians, 94K members:

On behalf of the 94,600 members of the American Academy of Family Physicians, thank you for the positive steps you have taken toward broader, affordable coverage that will mean improved health care based on primary care. We believe that the America’s Affordable Health Choices Act (H.R. 3200) will make significant progress toward payment and delivery system reforms and contribute to building a primary care workforce for the future. AAFP supports this legislation and we will be pleased to work with your committees to improve it further.
......
The public plan option developed by your committees reflects most of these principles very well.

American Academy of Pediatrics, 60 K members:

“The American Academy of Pediatrics (AAP), which represents 60,000 pediatricians, pediatric medical subspecialists, and surgical specialists, praises the U.S. House Energy and Commerce Committee for its vote today on H.R. 3200, America’s Affordable Health Choices Act, and applauds all three House Committees for their continued and steadfast work in the effort to pass significant health care reform.
“The Academy continues to support the process of bringing comprehensive health care reform to America’s children. While there is still work to be done, H.R. 3200 makes significant progress in achieving the Academy’s priorities of covering all children in the United States, providing children with age-appropriate benefits in a medical home, and establishing appropriate payment rates to guarantee children have access to covered services.

American College of Surgeons, 76 K members:

They have a letter of support for HR 3200, but you can't copy and paste... maybe a little gun-shy about letting the membership see it!

American College of Obstetrics and Gynecology, 52 K members:

"ACOG President Gerald F. Joseph, Jr. MD provides ACOG endorsement of HR3200 (proposed America's Affordable Health Choices Act of 2009)."

[The rest is behind a password protected section.]

American Academy of Ophthalmology, 7 K members:

Have not yet taken a position on any specific bill, but:

Meanwhile, the Academy, AMA and the American College of Surgeons have been up on the Hill pushing medicine and ophthalmology’s agenda. The Senate bill is expected to contain a rate-setting commission proposal that the Academy helped defeat in the House bill and other troublesome provisions affecting medicine and surgery.

and...

Acknowledging that the status quo in health care is unsustainable and that issues of access to coverage, quality of care and cost control must be addressed, and given legislative momentum in Congress, the Academy is advancing components for bills that protect patients and physicians. While reform discussions are still ongoing and no pending legislation is perfect, we are committed to continue collaborating with health leaders in Congress to improve bills being considered. The Academy is actively engaged with other physician organizations as key House and Senate committees debate legislation that puts a long-term sustainable growth rate (SGR) fix in play, in addition to other top issues.

American Association of Orthopedic Surgeons, ~17 K members:

The AAOS is committed to ensuring that the final bill be as beneficial as possible to the Orthopaedic community, including our patients. We will not make any decisions in support or opposition until something closer to a final bill is available.

Ooops! Perhaps phrased poorly!

American College of Cardiology, 37 K members:

On behalf of the American College of Cardiology (ACC), representing 37,000 cardiovascular members, I am writing to commend you for H.R. 3200, the "America’s Affordable Health Choices Act of 2009.” This legislation makes a significant financial commitment to comprehensive health system reform and we are committed to working with you on this effort.
ACC is especially pleased that H.R. 3200 takes extraordinary measures to extend coverage to every American and takes positive steps to strengthen Medicare. Among the Medicare provisions the College supports include:
• Funding to eliminate the accumulated debt from the flawed Sustainable Growth Rate (SGR);
• Establishment of a positive Medicare physician payment update (MEI) for 2010
and favorable spending targets for updates in the future;
• Significant payment and delivery reform models such as incentives for physicians to participate in Accountable Care Organizations; and
• Expansion and improvements to the Physician Quality Reporting Initiative (PQRI) to encourage successful participation;

American Society of Clinical Oncology:
Can't find anything on their website. The American Cancer Society, on the other hand, has made access to health care via serious reform their top priority. And, by the way, on palliative care? They're for it.

American Gastroenterological Association, 17 K members:

On behalf of the American Gastroenterological Association (AGA), representing over 17,000 physicians and scientists who research, diagnose and treat disorders of the gastrointestinal tract and liver, I am writing to express our appreciation and support for several provisions in H.R. 3200, America’s Affordable Health Choices Act. The AGA appreciates your leadership and shares in your goal to expand health care coverage to the uninsured, improve coordination of care, and enhance quality.

American College of Emergency Physicians, 27 K members:

"It is important to note, however, that a common theme supported by members of the House and Senate (Democrats and Republicans), as well as the White House, is to extend coverage to nearly all Americans, although there are differences of opinion as to how this objective is best achieved. ACEP supports this endeavor to provide universal health care as a benefit for patients and its outcome of drastically reducing the burden of uncompensated care provided by emergency physicians.
ACEP encourages you to discuss and promote these issues with your members of Congress during the August recess. Your message to lawmakers:
These provisions will improve your constituents' access to vital emergency medical care services and they must be part of the final health care reform package that is sent to President Obama.
Due to the fragmented, unpredictable nature of the process, and the lack of a final product in the House or Senate, ACEP has refrained from taking a public position on the overall legislative proposals. This has been, and remains, a very fluid process and we want to assure you that ACEP will continue to monitor these plans and advocate
for the needs of emergency physicians and your patients."

American Society of Anesthesiology, 43 K members:

"ASA members may be confused by a request for support of H.R. 3200 by other medical associations, including most recently the AMA. ASA CANNOT AND WILL NOT SUPPORT THE BILL IN ITS CURRENT FORM. Members are strongly encouraged NOT to respond to AMA’s request to support H.R. 3200. The bill, the ‘America’s Affordable Health Choices Act,’ includes a public plan option based upon Medicare payment rates for anesthesia services. A Medicare rate-based public plan would be detrimental to the medical specialty of anesthesiology.

“ASA has consistently urged lawmakers to address anesthesiology’s ‘33 percent problem’: the fact that Medicare pays 33 percent of what private insurers pay for anesthesia services (while Medicare pays an average of 80 percent of what private insurers pay for most other medical specialties). This 33 percent payment level simply does not reflect the costs of providing anesthesiology medical care. As such, Congress must not use this payment level as a model for any health care plan.

“We acknowledge that there are many laudable provisions included in H.R. 3200. Still, many issues remain unresolved, and questions linger about how various provisions would impact anesthesiology. We must remember that there is no other organization involved in the reform debate that is speaking for anesthesiology. In fact, some groups are actively lobbying for provisions that would harm our specialty. Anesthesiologists’ shared voice is the only way to ensure that the important and unique concerns of our specialty, our practices and our patients are heard in the halls of Congress. "

American College of Radiology, 32 K members:

Best I could find on their website:

Unfortunately, it seems ACRs position regarding the House version of healthcare reform, HR 3200, has been incorrectly characterized. As many of the details of overall health care legislation remain fluid, the College has not taken a position, for
or against, any of the current overall congressional proposals, including HR 3200.
Regarding HR 3200, we continue to educate congressional leaders that the imaging and radiation therapy provisions, including a raise in the equipment utilization rate assumption to 75 percent and a further 25 percent cut to contiguous imaging, are flawed ideas that will ultimately harm patient access to care particularly in rural areas.
Until negotiations regarding such provisions are complete or are clearly at an impasse, ACR will not take an official position on the entire House bill. Any information that ACR has offered its support or opposition to HR 3200 is incorrect.

Update: I almost forgot to include some rather contrarian sentiments from the South Carolina Medical Association, as well as some "Old School" conservative physicians to round out the round up. They are not alone, as some other deeply red states' Medical Societies have expressed similar dire warnings. But for them, this is really about ideology, not solutions.

Update II:

Society of Hospital Medicine ( ~6 K members, represents hospital based physicians):

On behalf of the Society of Hospital Medicine (SHM), I am writing to express our support for provisions in H.R. 3200, the “America’s Affordable Health Choices Act of 2009” regarding delivery system reform. SHM represents the nation’s hospitalists—physicians whose primary professional focus is the general medical care and management of hospitalized patients. We agree that the time has come for comprehensive health reform and appreciate your leadership and commitment in pursuit of this worthy goal.

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From our friends at the South Carolina Medical Association

Dear Colleague, [This was sent to the members of the SCMA - my comments are in italics below.]

The momentum that has been building in support of a nationalized health care system appears to be overwhelming. With health care overhaul bills on the fast-track in Congress, and with a new and powerful administration determined to pass legislation this year, the deck is stacked against us. We’ve been told to sit in the corner and watch while the “experts” figure out how to fix health care. The problem is that the “experts” who are fixing health care are the same people who have run Medicare into insolvency and created a Medicaid system that is inefficient and ineffective.

The federal government is kicking us down the road toward indentured servitude. Envision a world where each decision you make for every patient has to be approved through the laborious channels of government bureaucracy. Imagine the federal government dictating to you which patients yo can and cannot see and which treatments you can and cannot provide—not just for Medicare patients but for all of your patients. Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare.

Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. Dutiful compliance and inaction are no longer options. The muzzle that the Feds placed on us must be removed and the decibel level of our voices must be raised so that we are unmistakably heard. We’re not suggesting a strike, but anything short of that is the kind of bold and thunderous statement we need to be making right now.

The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing. Our commitment to channeling these strong feelings into action is strong and will not lessen. W will not stand silent and watch while the federal government destroys our health care system. In the next few weeks, we will be laying out a course of action to ensure that our voice is heard. Be ready to act quickly, speak loudly, and fight for your career and the health care freedoms your patients deserve.

[Signed by the President and Chair of the Board of the SCMA]

Wow. They must be practicing in paradise down there in South Carolina. No problems, everybody's insured, getting great preventive and chronic care, nobody goes bankrupt from health care expenses, etc. Maybe we all should move there. Because, you know, in the rest of the country we have ridiculous bureaucracies, rules, and non-physicians telling us what we can do and who we can see and what we can charge already, only they are our private health insurance companies.

But here is the money quote, "Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare. " And that' really what it boils down to for so many, doesn't it? And besides, the answer to this question is that, if I don't have to hire a team of staff to fight with PRIVATE insurers to get reimbursed, to get prior approval, to jump through all of their hoops, maybe that reimbursement would result in a higher net reimbursement. And at least Medicare doesn't tell my patients whether they can see a physician because he's not on the right panel.

SCMA, what is the solution? Or aren't there any problems with the health care system in South Carolina.

Maybe they're still all practicing in Mayberry in the 1950's, but for the rest of us, we need to fix this broken system!

I ranted further over at dailykos...

Wow. This is not about healthcare reform with these people. These are like the Japanese soldiers found on islands 20 years after WW II, still fighting against the Yankees. They are opposing a Soviet medical gulag, entirely a figment of their imaginations and deep paranoia. Lively debate, eh?

But, to the letter's substance, and frankly, its' ignorance.

Nationalized, or singe payer, if that's what they mean, is pretty much off the table according to the guys in charge of the process like Baucus. It would be nice to have the momentum for that, but although there are vocal supporters at the grass roots level, the powers that be will not hear of it. But sadly, I doubt they even know what they mean when they say "nationalized." I am sure they have some conceptual bogey man system hybrid of the UK, Canada, and the old Soviet Union in their heads, but I am equally certain they have not spent more than 10 minutes actually learning any comparative health care, even bothered to investigate the systems in Germany, France, Australia and elsewhere.

"The deck is stacked against us." Is that against patients, physicians, insurance companies, who? Who is the deck stacked against?

"We've been told to sit in the corner..." Really? The message I've heard from Congress and the White House is that they value and want physician input. Maybe they don't want bat-shit crazy input, but they want input.

"The same people who have run Medicare into insolvency..." Um, that would fall quite largely on the shoulders of physicians. We have abdicated our role in shaping health care policy and controlling spending and reducing unwarranted and dangereous practice variation and having realistic end-of-life discussions with our patients and so on. We have also not called BS on the private insurers who steal health care dollars in the name of private enterprise and we have taken the money of Pharma for ou meetings and lunches and pretended they were spending all that money on R & D and not on recruiting cheerleaders. Literally recruiting cheerleaders.
But I'm with them on the Medicaid thing.

"The federal government is kicking us down the road toward indentured servitude." Seriously? Don't you guys have private health insurance companies in South Carolina? But really, this letter is not about health care, this is a stale ideology in its last throes.

"Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. "
Again, one has to have reasonable views to expect to be listened to seriously Foaming at the mouth like Zell Miller and Sean Hannity does not invite reasoned discussion. But listen, all of the physician supporters of single payer have much more to gripe about than the SCMA. At least organized medicine is participating in discussions, while PNHP has to have a major grass roots insurrection just to get invited to the White House photo-op. If anybody has the right to gripe about exclusion, it's the progressives, not the conservatives.

"The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing." I expect this is true. SC represents a far more conservative population than most states (it's in the top 10 most red states), and so their phsyicains likely are more conservative as well. So, fine, make your case, but we will not sit quietly by and let you screw up the best chance for health care reform we've had in this country's history.

The final line about fighting "for your career and the health care freedoms your patients deserve." Again, maybe I'm practicing in a dark dystopic bit of America, but around here, that ship has sailed. Our patients, even the insured ones, have little choice in doctors or hospitals. They only go to whom and where their plan allows. No "freedom" there. And our careers? Whose careers? Your primary care physicians careers? Really? I'll let my colleagues decide who you're really looking out for. My bet is that you're looking out for your failed ideology, not for physicians or patients.

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"Doctors, too, are ready for CHANGE" | The Register-Guard | Eugene, Oregon

"Doctors, too, are ready for CHANGE" The Register-Guard Eugene, Oregon:

"For most of the last century, no single group was a bigger obstacle to universal health care than organized medicine. Today, perhaps no single group stands more united in support of some form of universal coverage.

"Before their lost battle against President Lyndon Johnson and Medicare, the opposition of major medical organizations and individual physicians guaranteed doom for various state and presidential efforts to establish either a national health plan or other means to achieve universal health insurance.

"Now, surveys reveal that overwhelming numbers of physicians resent the current crazy patchwork health care system, which fixes their reimbursements, regulates and too often denies patient care, and piles physicians with paperwork so unending and from so many directions that the average doctor has little time left over to challenge the status quo.

"Add to all this the frustration arising from working for no pay to coordinate care and provide care after hours, from struggling with the cost of health care insurance for their own employees, and from seeing their uninsured and underinsured patients go without recommended care, and what emerges is widespread physician support of radical reform.

"More than four-fifths of physicians now agree that our health care system either needs fundamental changes or should be rebuilt completely."

Keep reading, this is a nice summary of where the specialty societies are coming down on health care reform, and it is encouraging...

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Medical Professional Organizations' Views on Legislative, Regulatory, and Other Issues: Health System Reform

ACS Views on Legislative, Regulatory, and Other Issues: Health System Reform:

Since November 1, 2004, representatives (one elected leader and one staff person) from 11 physician organizations have held three health reform summits, with the goal of developing consensus on approaches that might lead to health care coverage for all, control of exploding health care costs, and sensible adjustments to America’s medical justice system.

Participating organizations included:

• American Academy of Family Physicians
• American Academy of Orthopaedic Surgeons
• American Academy of Pediatrics
• American College of Cardiology
• American College of Emergency Physicians
• American College of Obstetricians and Gynecologists
• American College of Osteopathic Family Physicians
• American College of Physicians
• American College of Surgeons
• American Medical Associatio
• American Osteopathic Association
  
  The Board of Directors of 10 of the 11 participating organizations approved the final set of “Principles for Reform of the U.S. Health Care System”; the AAP did not sign on.
  
  The goal when signing on to the principles was for each organization to be able to say: “These principles are consistent with our organization’s policy, and therefore we support them.”

Now is the time for the organizations to begin discussions about how we might wish to introduce these important principles to various external audiences — key decision makers, policy makers, the media — and to consider any other "next steps" that we might consider regarding this important issue.
................
1.Health care coverage for all is needed to ensure quality of care and to improve the health status of Americans.
2.The health care system in the U.S. must provide appropriate health care to all people within the U.S. borders, without unreasonable financial barriers to care.
3.Individuals and families must have catastrophic health coverage to provide protection from financial ruin.

.............

6. Access to and financing for appropriate health services must be a shared public/private cooperative effort, and a system which will allow individuals/employers to purchase additional services or insurance.

...
11.Comprehensive medical liability reform is essential to ensure access to quality health care.

This was news to me, and it is something to build on...

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