Internal Medicine by liaoqinmei

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									Health Care Reform: Is it for real this
           time around?
                         Bob Doherty
 Senior Vice President, Governmental Affairs and Public Policy
               American College of Physicians
                        Alaska Chapter
                        June 25 , 2009
Questions
 What do the voters want?
 Why has Obama made it a priority?
 How is health care reform occurring?
 What are the key issues for ACP?
                 Voters express a strong desire for change in our health
                 care system, with over two-thirds saying we need a
                 complete overhaul or major reform.


Does our health care system need complete overhaul, major reform, minor reform or no reform at all?



        90%
        80%                 69%

        70%
        60%
                                       44%
        50%
        40%
                      25%
        30%                                             20%
        20%
                                                                         8%
        10%
          0%
                 Complete       Major Reform Minor Reform          No Reform
                 Overhaul                                                                             3
                       Voters’ greatest dissatisfaction is with the rising cost of
                       health care and the lack of coverage for everyone. While
                       they trust their doctors’ training and the quality of care,
                       over one-third are dissatisfied with prevention of medical
                       errors.
Now I am going to read you some different aspects of the health care system in the U.S. For each one, tell me how
SATISFIED you are with that aspect of our health care system – VERY satisfied, SOMEWHAT satisfied, SOMEWHAT
unsatisfied, or VERY unsatisfied.



                                           81%                                          29%


                                                 62%                                           33%



                                                           38%                                         52%


                                                                                                                72%


                                                                    16%                                             78%




                                                                                                                          4
              Support for reform is strong across all the important
              political groups, with the strongest support among
              Democrats and Independents, and with over half of
              Republican voters on board.
                              Initial Reform Ballot                 Republican Support by Gender

                                                             90%

                                                             70%
90%                                                                                     54%
                                                                      49%
                                                             50%                              44%
                                                                            38%
80%                                                          30%
                                                                                  13%
70%   67%                                                    10%                                    2%

                        59%                                  -10%   Republican Women    Republican Men
60%
                                            52%
50%
                                                  42%
40%

30%                           27%
            21%                                                       Favor Health System
                                                                      Reforms
20%                                 15%
                  12%                                                 Oppose Reforms
10%                                                     7%
                                                                      Both/Neither/Don't
                                                                      Know/Refused
0%
      Democrats         Independents        Republicans
                    While opposition messages raise some doubts for voters,
                    they are much weaker than supporting messages.
                    Interfering with the doctor is the strongest concept in
                    opposition messages.
Now I am going to read you a series of statements people have made in opposition to some of these
health system changes. Please tell me whether each raises serious doubts, some doubts, minor doubts,
or no real doubts in your own mind about reforms to the health care system. If you are not sure how you
feel about a particular item, please say so.
                                                                         In a head-to-head
                                                                         contest, even after
                                                                         hearing opposition
                                                                         arguments, support for
                                                                         health system reform
                                                                         remains strong, with a
                                                                         +29 point margin
                                                                         favoring reform (56%
                                                                         support, 27% oppose).
The broad consensus in support of health system reforms
remains robust – even after hearing opposition arguments.


             Final Reform Ballot
Health care reform is top Obama priority

    “Health care reform cannot
    wait, it must not wait, and it
    will not wait another year.”
    President Obama, WH Summit on Health
    Reform, March 5, 2009
Why? Because Obama believes
current system is not sustainable

For individuals and families
For the economy
For the federal budget
Not sustainable for individuals
   “Wages earned by American households will become
    too small a donkey to carry the load of the family’s
    spending on health care.”
    •   A family who today has a gross wage base of $60,000 might see it grow
        by 3 percent per year over the next decade, to $80,600 by 2017
    •   For the same family, total health spending might grow by 8 percent
        per year over the same time frame, to $33,700 by 2017.
    •    For this worker, 41 percent of the family’s gross wage base would be
        taken up by health care alone, before any deductions for taxes or
        fringe benefits.
    Economist Uwe Reinhardt, accessed November 10 at http://economix.blogs.nytimes.com/2008/11/07/the-
       health-care-challenge-sailing-into-a-perfect-storm
Not sustainable for the federal budget

   “Slowing the growth rate of health care costs will
    prevent disastrous increases in the Federal budget
    deficit.”
   “Medicare and Medicaid expenditures are projected to
    rise from the current 6 percent of GDP to 15 percent in
    2040. Only about one-quarter of this rise is due to the
    projected demographic shifts in the population …
    remaining three-quarters is due to the fact that health
    care costs are projected to increase faster than GDP.”
    The Economic Case for Health Reform, Council of Economic Advisors, accessed June 2 2009 at
    www.whitehouse.gov/assets/documents/CEA_Health_Care_Report.pdf
                    Not sustainable for government and taxpayers:

                           Projected Medicare Outlays, 2008-2018
         $1,000
                                     Total outlays in billions                                          $887
                                                                                       $814 $850
           $800                                                               $729
                                                                     $681
                                                             $636
                                            $567 $568
                          $486 $514
           $600
                  $454
           $400


           $200


             $0

                  2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

 Share of:
 Federal
 Budget    16%          16%       16%      17%        17%      18%       18%       19%       20%       20%      20%
 Gross
 Domestic 3%              3%       3%        3%        3%       3%        4%        4%        4%       4%        4%
 Product
NOTE: Numbers have been rounded to nearest whole number.
SOURCE: Kaiser Family Foundation, based on Congressional Budget Office, The Budget and Economic Outlook: An Update,
January 2008.
           Medicare Beneficiaries and The Number of
                   Workers Per Beneficiary

             Millions of beneficiaries                                          Number of workers per
                                                                79
                                                                                    beneficiary

                                                     62                          4.0
                                                                                           3.7

                                            47
                                                                                                     2.9
                                   40
                                                                                                               2.4
                         34


      19       20




    1966      1970     1990      2000     2010      2020      2030              2000      2010      2020      2030



SOURCE: Kaiser Family Foundation, based on 2001 and 2008 Annual Reports of the Boards of Trustees of the Federal
Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
How will health care reform occur?
 First stages:
  • Re-authorization of SCHIP
  • Stimulus legislation (“down payment” on
    health reform)
  • Budget
 Now:
  • Comprehensive health care reform legislation
    in both chambers before August recess
ACP priorities for health reform

 Affordable coverage for all
 Reverse shortage of primary
 care physicians
  • Medical education and financing
  • Payment reform
                                        ALT AR U M IN ST I TU TE P R ES E NT A TI O N 2 0 0
                                                                9




Reason for Concern: USMD PC Preferences and Practice

Our analysis shows that declining interest in primary care is leading to a decline
                                    in supply


                                                                                              Practice following
                                                                                              preferences




                                                                                                Preferences
                                                                                                equal to the
                                                                                                all-time low




Sources: AAMC Graduation Questionnaire (preferences), AMA Masterfile (practice), Altarum analysis (forecast)
                                                                                                                   16
Why does it matter?

 Demand for primary care is
 increasing
 Primary care is associated
 with better outcomes and
 lower costs
ACP review of impact of primary care
on outcomes and costs
   States with higher ratios of primary care
    physicians to population have better health
    outcomes, including mortality from cancer,
    heart disease or stroke
   An increase of just one primary care physician
    is associated with 1.44 fewer deaths per 10,000
    persons
    How is a Shortage of Primary Care Physicians Affecting the Cost and Quality of
    Medical Care: A Comprehensive Literature Review, ACP, 2008
ACP review of impact of primary care
on outcomes and costs
 During the year 2000, an estimated 5 million
    admissions to U.S. hospitals may have been
    preventable with high quality primary and
    preventive care treatment; the resulting cost was
    more than $26.5 billion.
   A 5 percent decrease in the rate of potentially
    avoidable hospitalizations alone could reduce
    inpatient costs by more than $1.3 billion
     How is a Shortage of Primary Care Physicians Affecting the Cost and Quality of MedicalCare: A
    Comprehensive Literature Review, ACP, 2008
Solving the problem requires a multi-faceted
approach
 How influential were the following factors in determining
 your specialty choice?
 *2008 AAMC Graduation Questionnaire
                    100
                             90

                             80                                                    Moderate Influence
       Percent of Students




                             70                                                    Strong Influence
                             60

                             50
                             40

                             30
                             20
                             10
                             0
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Create a national workforce policy
 Problem:
  • Workforce based on institutional needs, not
   national priorities

 Solution:
  • Commission to establish goals including
   primary care physicians, policies to achieve
   them, and benchmarks for success
         Improve primary care training
 Problem:
  • Students and residents not exposed to well-functioning
      primary care practices

 Solution:
  •   Eliminate barriers to training in ambulatory settings
  •   Increase funding for primary care training programs
  •   Grants for primary care mentorship programs and faculty
      and curricula development
  Eliminate student debt

 Problem:
  •   Average debt burden of public school graduates was over
      $145,000
  •   High debt = less likely to choose primary care

 Solution:
  • Scholarship and loan repayment awards
  • Allow deferment of educational loans
  Increase Primary Care GME Capacity
 Problem:
  • GME slots are capped so that we cannot produce
    enough primary care physicians to meet demand

 Solution:
  • Lift GME caps but require residency programs to
    give priority to general IM, family medicine, and
    pediatrics
                Reduce administrative costs

 Problem:
   •   Primary care physicians spend more time (3.5 hours weekly) than other
       medical specialists (2.6 hours) or surgical specialists (2.1 hours) on
       interactions with health plans
   •   $64,859 annually per primary care physician - "nearly one-third of the income
       plus benefits of the average primary care physician.“

 Solution:
   • Reduce hassles associated with formularies
   • Uniform billing, credentialing, and eligibility

       Casalino, et al, What Does it Cost Physician to Interact with Health Plans, Health Affairs, May 14, 2009
       http://www.healthaffairs.org/press/mayjun0903.htm
Reform a dysfunctional payment system
 Problem:
  • Current system rewards volume not quality or value
  •   No incentive to collaborate across settings
  •   Primary care not competitive with other fields

 Solution:
  •   New payment models to align incentives with patient-
      centered primary care
  •   Increase FFS to make primary care ompetitive
  New payment models are needed!

 Federal government should fund pilot tests of
  new models to align incentives with value
 Then expand successful ones nationwide into
  Medicare and other public programs
 Criteria should be used to evaluate and
  prioritize selection of new models
Traditional FFS
Medical Care: Version 1965
   Based on the way that care was provided forty
    years ago—not the way it is delivered today
    • patients treated only when sick (acute condition)
    • little or no emphasis on prevention and coordination
    • care based on doctor’s best judgment as informed by
        CME and journals but not on evidence-based
        guidelines
    •   specific visit or procedure code
    •   individuals not teams
    •   “usual, customary, reasonable” (UCR)
Wanted! New pay models for
Medical Care: Version 2009
   Medical care today:
    •   prevention/management of illness rather than just
        treating disease
    •   care rendered by coordinated teams of health
        professionals
    •   clinical judgment informed by evidence-based
        clinical decision support
    • results matter (not just service rendered)
    • systems and processes of care to support better
        outcomes
New payment models should:

   Support patient-centered primary care
   Create incentives to work across settings
   Consider challenges faced by smaller practices
   Be administrative feasible—practice level and
    administration by government
New payment models should:
   Support chronic disease prevention and
    management
   Recognize quality and efficiency and reward
    appropriate stewardship of resources while
    promoting and maintaining high quality
   Transition to a unit of payment that diminishes
    the incentive to increase volume, ensures
    appropriateness, and promotes greater
    accountability
    Improve FFS


   Average primary care income is 55% of the average of
    the medians all non-primary care specialties
   AAFP Graham Center determined that the average
    non-primary care physician earns $3.5 million more
    over a 35-40 years
   Specialty preferences among USMGs is correlated
    with PCP income as percentage of specialty income
    Robert Graham Center. Specialty and Geographic Distribution of the Physician Workforce: What Influences
        Medical Student & Resident Choices? March 2009.
    Ebell MH. Future salary and US residency fill rate revisited. JAMA. 2008;300(10):1131-1132
         Primary Care Income Less Than Most Other Specialties
         Median Salary by Specialty in thousands of dollars, 2006

                                 Cardiology-Invasive
                                Diagnostic Radiology
                                 Orthopedic Surgery
                                    Gastroenterology
                                      Anesthesiology
                               Hem atology/Oncology
                                               Urology
                                         Derm atology
                                 Otorhinolaryngology
                                     General Surgery
                                        Opthalm ology
                                               OB/GYN
                                Em ergency Medicine
                                            Psychiatry
                           General Internal Medicine
                                   General Pediatrics
                  Fam ily Medicine/General Practice


                                                       $50             $150              $250              $350   $450

                     Source: MGMA Physician Compensation and Production Survey, 2007; slide from AAMC Physician
                     Workforce Research Conference, IM Subspecialty Meeting, April 29, 2009
Source: MGMA Physician Compensation and Production Survey, 2007
                                                                             ALT AR U M IN ST I TU TE P R ES E NT A TI O N 2 0 0
                                                                                                     9




                                     Relationship Between Income and Preferences

                USMD preferences move with relative incomes but relationship varies
                                     90%

                                     80%
PC Income as Percent of NPC Income




                                     70%

                                     60%

                                     50%
                                                                                                                                                        PC incomes as a % of
                                                                                                                                                        NPC income
                                     40%

                                     30%
                                                                                                                                                         %graduates interested
                                                                                                                                                         in primary care
                                     20%

                                     10%

                                     0%
                                           1982   1984   1986     1988   1990     1992         1994        1996        1998        2000   2002   2004     2006

                                                                Year of Graduation from US Medical School


Sources: AAMC Graduation Questionnaire for preferences, MGMA data on incomes
                                                                                                                                                                                 34
    Improve FFS
   Medicare and other payers should increase primary care
    compensation to be competitive with other specialties
   Replace the Sustainable Growth Rate (SGR) and cycle of
    ongoing Medicare cuts
   Establish a mechanism to assess impact of primary care on
    other aspects of the Medicare program, e.g. Part A, and
    apply such anticipated savings to increase payments to
    primary care
   Improve accuracy of relative values
Growing Support for Primary Care

 We're not producing enough
 primary care physicians.”
   President Obama, White House
   Summit on Health Reform, March 5,
   2009
Growing Support for Primary Care

 “Primary care is the keystone of a high-
  performing health care system. Increasing
  the supply and availability of primary care
  practitioners by improving the value
  placed on their work is a necessary step
  toward meaningful reform.”
    Senator Max Baucus, D-MT, Chair, Senate Finance Committee, White
    Paper on Health Reform
Growing Support for Primary Care
 "We've upset the whole practice of
 medicine to such a point that we don't
 have many primary care givers. That has
 driven up the cost of medicine itself with
 emphasis on specialists, and it has
 reduced the quality of delivery,
 particularly in rural areas."
 Senator Charles Grassley, R-IO, March 19, 2009
 Kaiser Family Foundation, Health Reform Newsmaker Series, Senator
 Grassley’s full remarks are available at:
 http://www.kaisernetwork.org/health_cast/player_kff.cfm?id=60#clip_1
 Figure 7. Promoting the growth of integrated delivery systems
 and increasing supply of PCPs though payment reform seen as
    most effective in reducing growth of health care costs.
         “How effective do you think each of these proposals for structural change
     in health services markets would be in reducing the growth of health care costs?”
                                                                                                      NET


                    Promote the growth of integrated delivery systems        25%        37%           62%

  Increase the supply of primary care providers by raising payments for
primary care services, providing additional payments for providers who
 serve as a patient-centered medical home accountable for quality and         29%                     61%
                                                                                        32%
  efficiency, rewarding providers for high-quality and coordinated care,
and offer incentives that encourage patients to enroll in medical homes

        Establish a public/private center for comparative effectiveness
             to produce and disseminate information on effectiveness,        22%      32%             54%
                      guide clinical practice, and inform benefit design

       Provide funding to accelerate the adoption of health information
            technology, promote uniform standards for interoperability,      19%      31%             50%
                  and establish health information exchange networks


                      Increase the supply of primary care providers and
          public health practitioners through loan repayment programs,       23%      27%             49%
                              training grants, and infrastructure support



                                Reform the malpractice liability system     12% 19%                   31%
                                                                                                                    THE
                                                                                                               COMMONWEALTH

                                                                   Extremely effective        Very effective
                                                                                                                   FUND


Source: Commonwealth Fund Health Care Opinion Leaders Survey, April 2009.
Preserving Patient Access to Primary
Care Act of 2009, H.R. 2350/S. 1174

 Introduced by Representative Allyson
 Schwartz on May 12, 2009 and on June 3
 by Sen. Maria Cantwell (D-WA), Sheldon
 Whitehouse (D-RI), and Susan Collins
 (R-ME)
 Comprehensive approach to primary care
 workforce crisis
Preserving Patient Access to Primary
Care Act of 2009
  •   Primary care mentorship and curricula development
  •   Scholarships and loan forgiveness, expanded GME
      and more ambulatory training
  •   Increase Medicare FFS payments, apply savings in
      Part A to primary care, and pay for care coordination
  •   Patient-Centered Medical Homes
  •   Reduce hassles of Part D formularies and test “real
      time” claims adjudication
What about tort reform?

   ACP believes that medical liability reform is
    essential
   But caps on non-economic damages will not
    pass a Democratic Congress or be signed into
    law by Obama
   Obama told AMA he was open to other ideas:
    health courts? Alternative dispute resolution?
    Safe harbors if following guidelines?
House draft health reform bill

Coverage                            Consistent with ACP?
   Medicaid expanded to               Yes
    cover the poor (133% of
    FPL)
   Sliding scale tax credits for      Yes
    people above poverty
    level, up to 400% of FPL
 People can keep own
    insurance or buy coverage          Yes
    through an exchange
House draft reform proposal

Coverage                     Consistent with ACP?
 Health plans must cover       Yes
  people with pre-existing
  conditions, guarantee
  renewability, not vary
  premiums except for age,
  gender and location
House draft reform proposal

Coverage                        Consistent with ACP?
   Commission to                  Yes
    recommend covered
    benefits
   Plans must provide             Yes
    essential benefits,
    including preventive
    services; no cost-sharing
    for preventive services
House draft reform proposal

Workforce                         Consistent with ACP?
   Advisory council to              Yes
    recommend workforce
    goals
   Increased funding for            Yes
    NHSC and Title VII
    primary care programs
 New scholarships/loan
    repayment for primary care       Yes
    physicians in areas of need
House draft reform proposal

Payment reform                   Consistent with ACP?
   Eliminates current SGR        Yes
    formula and accumulated
    cost
                                    Yes, but does not complete
   Higher updates for               eliminate GDP. Provides
    primary care (separate and       GDP plus two for primary
    higher spending target for       care, GDP plus one for
    primary care)                    other services.
   Medicaid pay for primary      Yes
    care increased to Medicare
House draft reform proposal

Payment reform                    Consistent with ACP?
   Bonus payments for               Yes, but ACP is pushing
    primary care: 5% for              for a higher bonus
    designated services by
    primary care physicians,
    increased to 10% in health
    professional shortage areas
                                     Yes, provides over $1
 Patient-centered medical            billion to fund pilot to pay
    home to be tested on a            qualified practices for care
    national scale                    coordination
House draft reform proposal

Administrative simplification         Consistent with ACP?
 Standardize language and forms         Yes
 Establish operating rules and          Yes
   companion guides for using and
   processing health care
   transactions
 Increase consistency of claims         Yes
   edits and code corrections
 Increase electronic exchange of
   administrative and clinical data      Yes
House draft reform proposal

Administrative simplification   Consistent with ACP?
   Standardize quality            Yes
    reporting requirements
 Development of “smart
    card” technology               Yes

   Plans must spend at least
    85% of premiums on           Yes
    patient care instead of
    administration
House draft reform proposal

Public plan                      Consistent with ACP?
   Offers a public plan to         Yes and no—only some of
    compete with private             ACP’s criteria for support
    insurers                         were met:
   Physician participation         Yes
    voluntary--not mandated if
    you also accept Medicare
House draft reform proposal

Public plan                        Consistent with ACP?
   Medicare rates (plus 5%           No, ACP believes that
    for physicians who                 Medicare rates are not
    participate in both                adequate; safeguards need
    Medicare and public plan)          to be in place including
    used for first 3 years, then       independent assessment of
    plan would create own              plan’s payments compared
    rates                              to private sector and
                                       ensuring sufficient
                                       participation by physician
                                       specialty and locale
House draft reform proposal

Public plan                    Consistent with ACP?
   Must offer essential          Yes
    benefits including
    prevention
   Administered by separate      Yes
    entity than the federal
    agencies running the
    exchange
   Financed by premiums not      Yes
    federal treasury
What is missing from the House plan?

 How much will it cost?
 Who will pay?
What about the Senate?
   HELP committee is working on legislation that
    includes many of the primary care workforce
    and coverage proposals supported by ACP,
    similar to House bill
   But SFC is working on a “scaled back” bill to
    cut the total cost; co-op idea being considered
    instead of a public plan
Next few weeks will tell us . . .

 If there is a governing consensus in
  Congress (disagreements among the
  Democrats and the House and Senate are
  the biggest challenge)
 Whether the public will continue to
  support it
New NY Times Poll
    72% support a public plan option, including
     overwhelming majority of Democrats and
     Independents and majority of Republicans
    85% believe that health care must be completely
     rebuilt or fundamentally changed, but 77% are
     “somewhat” satisfied with own care
    Majority would pay higher taxes and most have
     more confidence in government to control costs
    NY Times, June 22, 2009
“Stars are aligned” (Obama) but now
comes the hard part
1.    Mandates on employers, individuals
      • Pay or play
      •   Minimum benefit packages/ERISA exemption
      •   Penalties on individuals for non-compliance
 2.   “Rationing” and “taking decisions from your doctor”
      •   This argument raises biggest doubts
      • Physicians will be key in how the public responds
“Stars are aligned” but now comes the hard
part
  3. “Public plan” option (both sides suggest that it could
    lead to a “single payer” plan)
     −   But what do they mean by a public plan?
     −   Current dysfunctional Medicare rates? Or
         improved payments?
     −   “Playing field” with other health plans?
  4. Where does the money come from?      Taxes on wealthy,
    taxes on health premiums?
  5. The budget deficit
Conclusion
 “The stars are aligned” for comprehensive
    health care reform
    •   Public wants it
    •   Popular president had made it his top priority
    •   Democrats have the votes—if they stay together
    •   Current system is not sustainable

   Obama will need to overcome deep divisions on
    public plan option, mandates, and taxes
Conclusion

 Policies on primary care must reflect
  urgency, be multi-faceted, and
  implemented concurrently
 Payment reform to support patient-
  centered primary care is essential
Conclusion
   ACP priorities on workforce, primary care,
    coverage and payment reform are being
    addressed, but “you can’t always get what you
    want” *
   There will be pain with the gain
   But the alternative is a health care system that
    will collapse under the weight of rising costs
*Source: Mick Jagger, Rolling Stones
What can you do?
   Politics is not a spectator support:
    • Physicians have more influence over the outcome than anyone
      else
    • Why? Because the public trusts physicians!
    • Requires that each of you participate in the political process—
      starting with joining and supporting your physician advocacy
      organizations
    • Internists: sign up to become involved in ACP advocacy!
    • But don’t wait—next 8 weeks may define health care for
      generations
A Marxist definition of politics

 “Politics is the art of looking for trouble, finding
 it everywhere, diagnosing it incorrectly, and
 applying the wrong remedies”
  Groucho (not Karl)
 Our task: help find the real problems, diagnose
 them correctly, and get Congress to apply the
 right remedies

								
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