Healthcare Professionals for Healthcare Reform

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My trip to Capitol Hill

I am writing this on the train heading back from Washington DC but will post it tomorrow (May 22nd). I took the Accela first thing this morning in time to make a noon appointment with Chris Murphy. Unfortunately, Murphy was at a vote (or actually a series of votes that included Cap & Trade, moves to censure Pelosi and even motions to adjourn), and I was not able to meet him until 12:45. While waiting in the office I got to talk to the receptionist who mentioned that the Congressman had had a slew of groups over the past couple of months coming through to discuss healthcare reform. She said she thought ¾ of all the visits in the past month have been for HCR. This set the tone for the rest of the day…

Chris Murphy and his legislative aide (Paul Kidwell) met me in an office next to the Energy and Commerce committee (of which he is a member) Conference room and had to get up a couple of times to vote. Despite all the distractions and very limited time, we did have a very detailed discussion on EMBRACE and healthcare reform in general.  Although he admitted that he had not read the paper, he claimed he understood the gist of our plan and felt that it was in essence a single payer system. I attempted to explain the differences (and that we had actually created it as a “not a single payer plan with the advantages of a single payer plan”) but in the end he felt that “it would still be perceived as a single payer system”.  I spent some time with Mr. Kidwell, when Murphy was voting, discussing some of the other features and he seemed genuinely interested in how we handled several political and financial issues. Then Murphy seemed to imply that for all intents-and-purposes the healthcare bill is mostly written, and from the gist of how he stated it, I suspect it will have a component of a privately subsidized public plan to compete with the private insurance companies.  Although they claim that there will be some provision to keep re-imbursement high for providers, we didn’t really have time to discuss any details.

It was what Murphy said when we ended our meeting that I think was most disturbing to me. He said that with the exception of the delegation from the ACP that came the day before, none of the doctors’ groups that have come by have actually wanted to discuss healthcare reform!!! They were more concerned with petty battles with other doctors/medical specialties than with reform!

All I could think was: we (doctors) blew it again: The ACP and I got here too late to influence the drafting of the legislation that seems to be all but written. I truly got the feeling, as we ended our session, that Murphy would have liked to have helped us, but it seems that other groups have been more consistent in their advocacy and united in their points.

John Larson was not available to meet with me but I did meet with his Legislative assistant, David Sitcovsky. He had read the EMBRACE article in the Annals (I sent all of the aides a copy before going down), and seemed to understand the gist of the plan. After listening to me explain the advantages of EMBRACE and taking down careful notes, he proceeded to tell me, in essence, that we are too late: he explained that “there will be a healthcare reform bill by July.” He seemed to confirm that it will contain the insurance reform that Murphy described. When I asked what kind of provisions there were to improve outcomes and reduce bureaucracy for the provider he mentioned the “Medical Home” model advocated by the ACP the day before. When I asked him how the primary care doctors, who would have to direct the Medical Home, would get reliable guidelines, he mentioned that there would be a department in HHS that would be responsible for developing guidelines. What mechanism this department/committee would use to develop the guidelines though is not clear.  

My final meeting was with Dodd’s staff. I was already informed that neither Dodd nor his healthcare aide, Jeremy Sharp, would be able to meet with me, but that I would be able to meet with Monica Feit and Rebecca Davidson. Ms. Feit is a PHD and a Public Health Fellow in Dodd’s office and Ms. Davidson is a Legislative Correspondent a year out of GW. They were both quite happy that two key pieces of legislations that Dodd held near and dear (the Credit card bill and tobacco regulation) had just been passed/promoted and it was clear that they were swamped with work. Neither had had the chance to read the material I sent so I spent a few minutes explaining EMBRACE. Unfortunately, before I could even finish explaining the plan (let alone discuss its assets), Ms. Feit was called away by Mr. Sharp for an important meeting. However, before she left, Ms. Feit told me that I would be happy to know that the Senate already has a bill being developed “that has many of the features of your plan”, but did not have time to go into the details. I spent the remaining time with Ms. Davidson discussing the advantages of EMBRACE.

With all of these meetings, seeing that we missed the boat with EMBRACE, I pleaded that whatever legislation is passed must reduce the financial and bureaucratic burden on the healthcare provider and put in measures to improve the health of our patients.

Now as I sit on the train going back home, I have a feeling of regret that I/we did not make the trip earlier and a feeling of foreboding that what will be passed in Congress will not be healthcare reform as much as health-insurance reform; and that we providers (and our patients) will get screwed again. Unfortunately all we can do now is just sit back and see what we get!

Gil

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May 22, 2009 Posted by | Uncategorized | Leave a comment

EMBRACE versus the Oregon Plan

Q: I agree with your approach.  There are hard ethical decisions to be made and that frightens many, especially politicians.  I understand that the Oregon Plan for Medicaid patients shortened a few political lives.  It was the right approach since it defined necessary from elective medical care.

May 6, 2009 Posted by | Uncategorized | Leave a comment

EMBRACE and Single Payer

Recently I had the opportunity to meet John Larson, a Representative from Connecticut who was recently elected as the Chairman of the Democratic caucus. He talked about what he was looking for in healthcare reform, and many of his stipulations sounded like they were right out of EMBRACE.
I met a few other people there including some physicians who seemed interested in learning more about the plan. They emailed me back and it seems had some issues with EMBRACE versus single payer plans. Below is my answer to them:

It was great to meet the two of you and I am honored that you took the time to read EMBRACE.
I will try to answer all the points that you both raised.
First a general statement: Setting aside the question/issue of healthcare being a right or a privilege, I do believe that in a perfect world any doctor that has taken the Hippocratic oath should be in favor of universal coverage for all services. In fact, many of the members of our group and even the members of the writing group of EMBRACE were (and some still are) members of PNHP. Many of us have been interested in healthcare reform even from before the Clinton debacle and have seen many plans come and go. The main problem is, as you point out, that the politicians tend to usurp healthcare policy away from those who tend to have patient and physician interests in mind, toward one that has a more fiscal based ideology. The problems, as I (and many of our group) have come to realize, is that we healthcare professionals have not been politically active (or savvy) enough and that we don’t live in a perfect world.
What we have attempted to do with EMBRACE (which was created in response to the above concerns) was to develop a plan that satisfied the basic tenets that all Americans should have free basic healthcare coverage, that the user (patient AND physician) friendly aspects of the current system (for those with insurance) be preserved, keep the practice of medicine in the hands of doctors and other healthcare professionals (rather than politicians and insurance companies) BUT also make it politically palatable/viable.
Your discussion on rationing and different types of healthcare systems is very much a discussion that we at HPfHR have had for most of our existence. What we have come to understand is that ALL healthcare systems have rationing; because there is no country (except maybe in the Persian Gulf) that can afford to cover all their countrymen for all medical care. In the US we have “irrational rationing” based on age, employment status, economic status and pre-existing conditions. In many European countries and even Canada, the rationing is much more rational, often based on medical evidence for effectiveness and cost (including cost to society). The problem for all these systems is that there are always going to be certain services, tests, medications and/or devices that can not be provided within the system. This means that there is ALWAYS at least a 2 tier system (as long as one does not outlaw the provision of these services outside the main system as occurs in Cuba). The existence of a tier that is not covered by the national insurance, invariably then creates opportunities for entrepreneurial creation of “private” insurance plans and even parallel medical delivery systems. Instead of helping the overall delivery of healthcare, this phenomenon almost always creates an unhealthy form of competition for resources and, worse, creates a system where a patient cannot go to the same provider for the different therapies and may even be dropped from the national plan (as happens in England). What is more, there are usually different physicians for different “tiers”, making the system more frustrating for the provider and more dangerous for the patient.

Now for the specifics:
1) Q: Whether continuing the for-profit health insurance industry should be part of the new plan:
A: Although I agree with the sentiment, there is no way that we can outlaw private insurance in the US. Even with HR 676 (which is the PNHP plan that has been sitting in committee in Congress for 3 years), one can ban private insurance in the main system, but the insurance companies WILL have a presence for those who are not covered, and I suspect, that they will draw away many of the more healthy patients and put them in “for profit” clinics that will compete with the single payer providers. EMBRACE acknowledges this and allows private insurance to work WITHIN the system with only 2 stipulations: they cannot compete for Tier 1 patients (which we believe will not be an issue, since Tier 1 represents the greatest risk to profits for the insurance companies) and they must provide plans from a pre-determined (independently created) menu. By keeping the insurance companies within the system in this way we can a) regulate them b) make them compliment Tier 1 rather than compete against it, c) reduce the price of private insurance (because we reduce the risk to the insurance company and we increase competition -with the menu- that allows the costumer to compare prices), and d) make it more politically palatable and viable.
2) Q:The fatal flaw of the EMRACE proposal is that establishment of a so-called Tier 2 that funds “quality of life” care is a serious ethical problem for me. Health care is not like buying a car. Patients should not have to choose between a “Chevy or Cadillac.” Your future health care needs are unpredictable. You do not know if tomorrow you may be in an auto crash or develop diabetes. How does a Board decide what is “life-sustaining” versus “organ-sustaining” in this system? Does Tier 1 cover cataract surgery to restore vision only for those people who need to see well to perform their job, or a knee operation for a construction worker to continue his profession, or angioplasty for active people but not covered for non-active people?
A: First I should explain that the Board will decide what is covered by the different Tiers depending on best evidence (medical, ethical and economic). I also want to clarify that Tier 1 would include most chronic conditions such as diabetes, hypertension, high cholesterol and even obesity and smoking addiction. These are conditions that are life threatening and their treatment would be preventative so they would almost definitely be covered by Tier 1. Also, Tier 2 would be MUCH more affordable than private insurance is now (this is one thing that many in the US find hard to understand, but as in Germany and France -which you mentioned- the price is low because of less risk and more competition). A worker would almost definitely be able to have Tier 2 insurance that covers knee surgery, that is purchased by the employer (as a “perk”), the union or even the individual him/herself. Even if the individual is not insured, usually the price of Tier 2 operations are relatively low compared to treatment through Tier 1 and are almost always elective, allowing the patient to make a decision of whether he/she wants the procedure or to keep their money (or find a physician who may do it for less). There is NO moral problem here because there is never any denial of essential services or even for these “quality of life” services.
3) Q: By eliminating the for-profit health care insurance industry, money immediately flows into the health care delivery system. All economists agree that Medicare has a 4% overhead cost v. an average of 19% for the for-profit health care insurance industry. If, instead, we create a public funding option for people to purchase, this keeps the overhead costs down and eliminates the need for the for-profit industry.
A: EMBRACE eliminates all this overhead AND makes the system more streamlined. Almost all the overhead that private insurance has has to do with its interactions with the provider (and BTW, most of the statistics do not include the overhead for the providers for hiring billers and pre-certifiers and for the time spent on the phone…). EMBRACE removes all this for all concerned.
4) Q: One alternative is to adopt a system such as in France or Germany , whereby they do have a tightly regulated minimally for-profit insurance system that exists along with public-financed health care. The difference is that these insurance companies do not waste money on marketing, obscene salaries, and layers of patient denials. The entire ludicrous notion of a “medical loss ratio” exists only in the warped delivery system in America .
B: This almost exactly describes the EMBRACE Tier 2 system but keeps it in one streamlined system. The insurance companies can still give their execs obscene salaries (if they choose), but at least the competition will make sure that these may be less.
5) Q: Congressman John Larson and the Democratic leadership are cowards. They know that a single-payer system is the morally right solution. By dismissing the PNHP proposal, he acknowledges that the Democrats are as much in the pockets of the insurance industry as the Republicans. To say that this is politically unworkable is untrue. Without even any fanfare or public awareness, John Conyers’ Hr 676 already has 72 co-sponsors in the 111th Congress. The 110th Congress had 93 co-sponsors before it died. By all physicians advocating for a single-payer system or creation of a minimally for-profit insurance entity to compete with the existing insurance industry, we can make it happen.
A: Without the name-calling, I would agree. HOWEVER, this is America and American politics. We physicians (and all in the healthcare delivery profession) should take great notice of what has happened and is still happening with HR 676 so that we don’t get screwed again!
HR 676 was first introduced by Conyers in February 2007 and quickly ignored in committee. It did, as you say get 72 co-sponsors by the end of the two-year session and has picked up some this session BUT there are 435 seats in the House. And, when I had the opportunity to ask the healthcare aides for Kennedy and Pulosi about the chances for the bill the Pulosi aide said “One degree north of zero”. When I asked them why, they both agreed that it is because of the insurance issue. When I talked to other Congressmen and politicos I was essentially told that it will be hard enough for the Democrats to convince the public (their constituency) that there should be some government control of health insurance (like expanded Medicare and/or Medicaid) that they cannot even begin to want to think about a single payer system. You can argue that that is because they have no guts but it won’t help OUR cause, namely to get meaningful healthcare reform that will be good for our patients and help us healthcare professionals provide that service to them.
Listening to Larson (who is now the Chair of the Democratic caucus!) I felt that EMBRACE pretty much fits in with his desires in healthcare reform. Because of this I think that EMBRACE has a much better chance of passing than HR 676 as long as we can show Congress there is support for this from healthcare professionals AND their constituency. So we must not only petition our Congressmen, we need to talk to our patients and have them urge their Congressmen to embrace EMBRACE.
6) Q: The key ingredient is to ensure that physicians remain in the system. The “Board” that sets reimbursement rates for physicians must set a reasonable fee schedule. As we all know, this is the greatest concern (and rightfully so) for physicians in crafting any new system.
A: I completely agree. In fact one of the upsides of the EMBRACE system is that providers will be in control of deciding reimbursement and will be able to manipulate these payments to push more important services like preventative care, and reduce the financial incentive to do more tests and/or procedures. With the increase in the number of “paying patients” with EMBRACE, all providers, no matter if they are primary care providers or sub-specialists will have enough “business” and there will be a significant reduction in overhead and bureaucracy in the system, which should also make life easier (and help retain providers in the profession and the system).

Thanks again for your interest. Please let me know if you have any more concerns.

Gil

May 5, 2009 Posted by | Uncategorized | Leave a comment