At the Thanksgiving dinner table, we all consider what we all have to be thankful for. During these trying 10 years, many good and bad things have happened to our health care system. I am thankful that the GOP Replace and Repeal health care bill never passed and maybe Congress and yes, both the Republicans and the Democrats will work together to improve what we have had for the last nine years since the Affordable Care Act was passed.
As we remember the Senate Republicans introduced a new version of their tax bill that would eliminate the Affordable Care Act’s (ACA) penalty for not enrolling in qualified health plans.
The Congressional Budget Office (CBO) estimated last week that repealing the individual mandate would raise the number of insured Americans by 4 million by 2019, and by 13 million in 2027 — but also reduce the deficit by $338 billion.
That was a small boon to Republican leaders whose tax bill would otherwise balloon the deficit by $1.5 trillion from 2018-2027.
The CBO report estimated that payments to so-called Disproportionate Share Hospitals costs would rise by more than $40 billion.
Robert “Bob” Laszewski, president of Health Policy and Strategy Associates, in a recent blog post wrote that “killing the mandate while simultaneously opening up the market to cheaper stripped-down alternatives would combine to create unintended consequences the Republicans haven’t appeared to comprehend.” He was referring to President Trump’s recent moves to allow partial-coverage health plans with low premiums but that leave enrollees on the hook for potentially huge bills.
Laszewski said these two factors would create a bifurcated market with a “very expensive Obamacare compliant risk pool” and another “very cheap ‘short-term’ policy risk pool” for healthy people.
“In other words, this scheme works much better than what we have today — until you get sick,” and he noted that everyone at some point does get sick.
“A health insurance system that works only while you are healthy is not a health insurance system,” he concluded.
The mandate — really more of an incentive, as the penalty is considerably lower than the cost of insurance — was meant to incentivize healthier individuals to buy policies, which would help smooth out risk pools and keep premiums reasonable for the less healthy.
Numbers are Cloudy
David Howard, Ph.D., of Emory University in Atlanta, said everyone he’s spoken with and everything he’s read suggests that the fiscal impact of scrapping the mandate has been overestimated. He called the $338 billion in estimated deficit reduction “fictitious.”
The projected reduction seems “way too high,” echoed Tim Jost, JD, professor emeritus at the Washington and Lee University School of Law in Lexington, Virginia. “The people who are going to drop coverage are going to be predominately those who aren’t subsidized,” he said, meaning the government doesn’t save if they become uninsured.
It doesn’t make sense that people who are “heavily subsidized” would drop their insurance, noted Gail Wilensky, PhD, who served as administrator of what is now the Centers for Medicare & Medicaid Services under President George H.W. Bush, who was skeptical of the coverage numbers, calling them “a little excessive.”
Joe Antos Ph.D., of the American Enterprise Institute, speculated that because the CBO numbers were released “relatively quickly” the office likely ignored an important factor in its calculation: how individual states and insurers resolved the issue of not receiving the cost-sharing reduction (CSR) payments.
These are subsidies the government paid to the insurance companies to help them defray out-of-pocket expenses, such as co-pays for low-income beneficiaries, which President Trump withdrew in mid-October. “To sort all that out would have taken more time,” he said.
But what bothers Antos most is senators’ reliance on the numbers. “CBO is advisory and they are working in the dark like everybody else,” he said.
It’s unclear how many votes will be needed to pass the bill in the Senate. Republicans have talked of using the reconciliation process, under which only 51 votes are needed, but the so-called Byrd rule puts that out of reach for bills that would still add to the deficit more than 10 years out — in which case 60 votes would be needed to overcome a filibuster.
If reconciliation becomes possible, then head-counting among Republicans, of whom there are 52, becomes critical.
Why force the issue of health care by combining or attaching it to the tax reform bill? Luckily even the President is now willing to forgo this step for health care reform on a tax reform bill in order to get the tax reform passed.
Robert Pearl, a physician, wrote about the “doctor-patient” relationship is tightly woven into the culture and history of medicine. But that special bond is under enormous pressure today. And to keep it from fraying, we need periodically to examine the fabric. Last month, the Council of Accountable Physician Practices (CAPP), representing 28 of the nation’s largest and best medical groups in the U.S., did just that.
Annually, CAPP sponsors a meeting in Washington D.C. where it invites patients, elected officials, healthcare leaders and policy experts. The day focuses on amplifying the voice of the patient and the physician. This year’s gathering, co-sponsored by the American Cancer Society, showed videos of courageous patients fighting and overcoming cancer and offered talks by members of Congress, the Administration, and physicians on what is ailing the health of the nation and what can be done to address it.
To prepare for the event, CAPP sponsored focus groups across the country to compare the perceptions of patients with those of physicians about what is most valuable in healthcare delivery. This research was a follow-up to a survey commissioned in 2016 by CAPP through Nielsen Interactive. That survey of 30,000 patients and 700 doctors measured the degree to which physicians communicated to patients the importance of avoiding and better managing chronic illness through diet, exercise, and preventive services. The results were discouraging.
The study found that fewer than one-third of those surveyed reported receiving advice from their doctors encouraging them to increase their levels of activity, eat better and undergo the preventive screenings needed. When patients failed to make appointments or fill prescriptions, most reported never being contacted by the physician–or anyone in the doctors’ office. And 40% of primary care doctors said they could not access their patients’ electronic records when they were hospitalized or visited the emergency room, making continuity of care problematic.
A question that arose from the first survey was why these shortcomings were so pervasive. Did they reflect doctor and patient preference, or were they failures in the current healthcare system? To answer it, CAPP this year sponsored focus groups of consumers and physicians to ascertain what each wanted from the healthcare system. The data gave us a snapshot of the situation today, providing a comparison to information from a similar study done in 2007.
New Research Yields Surprising Similarities In Attitude in physicians as well as our patients.
Focus group participants were asked to rank 22 healthcare delivery attributes, including coordinated care, evidence-based medicine, access, preventive services, value-based care and technology, and categorize each as either most important, of moderate value or of minimal value.
And guess what? At the top of their list were the doctor-patient relationship, evidence-based medical treatment, and care coordination. Access and facilities were seen as offering moderate value, with the least importance assigned to technology and preventive services.
Physicians were asked to do the same ranking. Unexpectedly, they chose the same highest priorities as the patients–the doctor-patient relationship, evidence-based medicine, and care coordination. They likewise saw access as moderately important, adding preventive services to the category. Physicians, too, relegated technology to least important, but along with facilities.
Surprisingly, patients and physicians alike highly valued evidence-based medicine, a term frequently derided in the past. And neither patients nor doctors saw technology, including the electronic health record and online tools for patient engagement, as particularly important.
Of course, for both groups, the explanations for these survey responses likely go beyond personal preference. For physicians, the cost of office-based information technology influences their attitudes toward it, as does the unwillingness of most insurance companies to pay for virtual visits. And most patients have never experienced the value modern technology can deliver in terms of quality outcomes and convenience of care, because their doctors don’t utilize these computerized systems or offer these services.
What was also surprising was the dramatic change in perception between the members of the current focus groups and the ones who participated 10 years ago. Compared to the first survey, terms like coordinated care, pay for value, team-based care and evidence-based medicine were all rated far more positively by the recent participants. And the words “accountable care,” a very negative term only a decade ago and associated with bureaucratic processes and defensive medicine, were now linked with responsible medical care promoting improved patient health.
The Big Takeaways from the Survey
Patients no longer see themselves as only patients. They also see themselves as healthcare consumers. As a result, they have an increasingly sophisticated understanding of the healthcare delivery system and the approaches that lead to the highest-quality outcomes. And for this reason, they identify the doctor-patient relationship as essential. And in parallel, they value other system-wide features as important to getting the right care. They value effective communication among physicians, the availability of a comprehensive electronic health record accessible to all clinicians and medical treatment based on the best available evidence, not anecdotes.
Compared to a decade ago, consumers today are more knowledgeable about and comfortable with terms like “evidence-based medicine,” “team-based care,” and “accountable care.” And rather than seeing those concepts and services as negative, they recognize the value they deliver. That patients and physicians alike were nearly identical in ranking the 22-item list of attributes was both unexpected and reassuring. Exactly why both groups undervalued technology in healthcare, accepting less functionality from these tools and applications than they do in banking, travel, and retail, remains to be determined.
Dr. Pearl left Washington freshly encouraged about the future of American healthcare. As I have been encouraging by my writing, the American healthcare system is unlikely to change until the patient in all of us demands it. The upshot of this research is that patients and doctors increasingly agree on what is most valuable in medical care today and recognize the importance of both the doctor-patient relationship and the best approach to healthcare delivery. And when patients and physicians share the same perspectives, anything and everything is possible.
The only thing that I am concerned about is that there is a large group of patients who want it all and believe that the government should pay for it all. The problem they haven’t figured how the government pays for it or where the government gets the funding to pay for a health care for all.
It is also time for physicians to fight back. Now!
Dr. Matthew Hahn suggested that the American health care system is broken, but it is not really “health care” that is the problem.
The science of medicine, the tests, and the treatments available are better than ever. It is health care bureaucracy that is the problem. But doctors, nurses, and patients bear the brunt of the dysfunction. Medical professionals are unable to practice, and patients are denied the care they need, even though it is readily available. Careers are being ruined, and lives lost along the way. It is time to fight back.
Instead of focusing on ways to improve patient care, medical professionals today have to wade all day through a jungle of red tape just to get paid, order tests, and deliver treatments. Cumbersome government rules control the details of how we write notes, use a computer, calculate a bill, how much we can charge, who we can admit to the hospital, how long we can treat them, and much, much more.
And for everything we do, there must now be data. The bureaucracy is obsessed with data, to the detriment of everything else. It is tyranny through data. We spend so much time collecting data and running after all of these things that it is a challenge to find the time to actually care for patients!
On top of that, newer health insurance policies with high premiums, high deductibles, prior authorizations, and narrow, inscrutable coverage block us from delivering the care patients need. It is health care by government and insurance company fiat. Medical professionals and patients have few choices and little control.
And now, on top of everything else, we face Medicare’s complicated new MACRA “value-based payment” program, which collects data across four categories: quality measures, advancing care information, performance improvement activities, and cost. A physician’s annual score will be compared to the scores of other physicians to determine future Medicare pay increases or penalties. There is a huge effort being made to explain the intricacies of the new program, the first sign that it is too complicated to be of benefit.
Has American health care improved under this rule-bound and data-crazed regime? No! These approaches have demonstrated little of their intended effect. What is the bureaucracy’s answer to this? More rules and more data collection, and now, even penalties! They are trying to box us in like lab rats, and with rewards and punishments, make us perform tricks in our cages.
What has been the medical profession’s response? Adjust, learn the rules, and do it again, and again. We grumble. We retire early. We hide in bigger organizations that are supposed to protect us from it all. We look to our professional organizations for leadership. But this is not working. We lose more and more ground. We are now on a tiny island — but many of us are falling into the water and drowning.
When we begin our careers in the medical profession, we take an oath to do no harm. But today we practice in a system that is harmful by design. To honor our oath, we must find ways to fight back.
I think the answer is to better organize — even to form unions (though they are legal for physicians only in certain circumstances) — to find ways to actively fight against this out-of-control bureaucracy. We must bring balance to a system where today we have absolutely no control. What we must demand is a system that works for us rather than against us at every turn, that helps us to deliver better care rather than blocks us and then penalizes us when we fail.
I am sick and tired of worrying about the system, and not my patients. We must organize to turn things around. We can have the best healthcare in the world. It starts by organizing the system around those it affects most, patients and their healthcare teams.
I take it one step further. We need the physicians as well as our patients to get involved in the choices as well as the influencing our Congress what we want and what is needed to care for us all.
I think this discussion is a good lead into a discussion of the Single-Payer health care system that the Democrats will probably run on during the midterm election or if not then, the next presidential election.
I hope that you all survived Black Friday where we act like animals to save a few bucks. Where are our ethics and respect for our friends and other human beings? It doesn’t seem right in a season of Joy and Happiness!