Independent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”. In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain. Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor. The seeds were planted for the Revolutionary War.
Above the Fold
Is the ACA Merely a Step Towards Single-Payer “Medicare-for-All?”
A recent commentary in the Wall Street Journal announced, “Obamacare’s meltdown has arrived.” Over the years I’ve heard conspiracy theories that the Affordable Care Act was designed to fail, as a means to nudge a reluctant nation one step closer to a single-payer, Medicare-for-All health care system.
Bernie Sanders famously advocated for single-payer during his campaign. In 2011, the Vermont legislature passed a bill to create a single-payer initiative. Green Mountain Care was abandoned in 2014 by Vermont’s governor — a Democrat — as being too costly. Despite an 11.5 percent payroll and a sliding-scale income tax of up to 9.5 percent, Green Mountain Care was projected to run deficits by 2020.
A similar single-payer initiative is now taking place in Colorado. Amendment 69, known as ColoradoCare, would create a taxpayer-funded health insurer. ColoradoCare would be available to nearly all Colorado residents, including Medicaid enrollees. Federal programs, such as Medicare, TRICARE and the VA would remain in place, however.
A Letter from CMS to Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening
Today, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).
After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.
We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.
The ACA: We Got Quantity but What About Quality?
One of the main goals of the Affordable Care Act (ACA), perhaps second only to improving access, was to improve the quality of care in our health system. Now several years out, we are at a point where we can ask some difficult questions as they relate to value and equity. Did the ACA improve quality of care in the ways it intended to? Did it do so for some people, or hospitals, more than others?
How did the ACA Attempt to Improve Quality?
Three particular programs created by the ACA are worthy to note in this regard. The Hospital Acquired Condition Reduction Program (HACRP) took effect on October 1, 2014 and was created to penalize hospitals scoring in the worst quartile for rates of hospital-acquired conditions outlined by the CMS. The Hospital Readmissions Reduction Program (HRRP), which began for patients discharged on October 1, 2012, required CMS to reduce payments to short-term, acute-care hospitals for readmissions within 30 days for specific conditions, including acute myocardial infarction, pneumonia, and heart failure. The Medicare Hospital Value-Based Purchasing Program (HVBP) started in FY2013, was built to improve quality of care for Medicare patients by rewarding acute-care hospitals with incentive payments for improvements on a number of established quality measures related to clinical processes and outcomes, efficiency, safety, and patient experience.
Open Enrollment 2016… Can the Exchanges Be Saved? And Other Trending Questions
It’s open enrollment season—the annual period in which tens of millions of consumers wallow in the misery of health insurance choices and costs. So, let’s pause to reflect on the status of things—enrollment-wise—with employer coverage, Medicare, and the exchanges.
In particular, do consumers have better tools these days to help them choose insurance plans?
For people with employer-based coverage—about 150 million Americans—things are okay and stable, but not great. The latest report from the Kaiser Family Foundation, released last month and based on a detailed survey of 1,900 employers (small, mid-size and large), indicates that premiums rose on average a modest 3% in 2016—to just over $18,000 for family coverage. Workers paid 29% of that.
A similarly small increase in premiums has prevailed for several years and is expected again for 2017.
Almost all firms with 50 or more employees offer health benefits and the vast majority claim their coverage meets the ACA’s requirements for value and affordability. Overall, 56% of employers offer health benefits because hundreds of thousands of small firms either choose not to offer it or can’t afford it—especially the smallest Mom and Pop shops.
Peter Orszag’s Obsession with Overuse
In May 2009 the New Yorker published an article about Peter Orszag, President Obama’s director of the Office of Management and Budget and his chief health policy advisor. The article said Orszag was “obsessed” with the claim by Elliot Fisher and his colleagues at Dartmouth that unnecessary medical care accounts for 30 percent of all US health care spending. Based on these claims, said the article, Orszag had come to the conclusion “that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient …, thus saving billions of dollars.” The article then observed: “Obama is in effect betting his Presidency on Orszag’s thesis.”
If you have read the first four installments in this series on President Obama’s article in the August 2 edition of the Journal of the American Medical Association (the first installment is here you will readily understand why I begin this essay on Orszag with that quote from the New Yorker. The New Yorker got it dead right. Because the Affordable Care Act would be regarded as Obama’s main legacy, and because Obama assumed that Orszag’s diagnosis of and solution to the health care crisis was accurate, it is reasonable to say Obama “bet his Presidency on Orszag’s thesis.”
The Impatient Patient Advocates
At the 10th Annual Health 2.0 conference in San Diego I had the honor of moderating a session celebrating a group of outstanding patient advocates and activists for their contributions to the field of digital health. They were chosen through a public voting process. The group was inspiring—their stories, sprit, and impact on the crowd was palpable.
In addition to these individuals’ contributions, it’s important to acknowledge the growing impact of patient advocates in aggregate. Thanks in part to the Internet, smartphones, and social media, patients increasingly exchange ideas for diagnosing and managing their health conditions, analyze and contribute data and research, provide social support to each other, and advocate to improve the healthcare system.
I’m an Ex-Health Plan CEO. I Used to be a VA Critic. Then I Became a Patient.
In early 1970, I was on reconnaissance in I Corps in Viet Nam as a 1st Lieutenant Team Leader with the 101st Airborne Division Pathfinder Team. No, we did not bite off the heads of ducks to impress the indigenous, but we were in “the bush” and were considered in harm’s way.
On a rather ordinary insertion to inspect potential landing zones, I was moving my team from one area to another when we encountered heavy booby trapping. I stepped on one myself without it exploding. But as I moved up from my usual third spot to my slack man to get us off the trail, he stepped on a rocket propelled grenade booby trap that killed him instantly, and knocked me badly about. Only slightly wounded but with profound hearing loss, I literally picked up the pieces, got us extracted, made my way to the Da Nang 95th Medevac, and was evac’d stateside. I was extremely embarrassed to receive a Purple Heart given my slight impairments.
American Medicine’s Toxic Workplace
I’ve attended medical Grand Rounds most weeks for the past 50 years. I consider the exercise one of the grander traditions of my profession. I trace it back to the amphitheater at the University of Montpelier where the 15th C cleric, humanist, author and physician, François Rabelais, first studied and then held forth. By mid-20th C, Grand Rounds had become a focal point of training and continuing medical education in academic medical centers. A patient was presented whose illness was puzzling, informative, and/or daunting. A member of the faculty considered the clinical challenges in a fashion designed to be illuminating. The front rows of the audience were populated by silverback physicians behind whom various levels of novitiate were seated. It was incumbent on the discussant to engage the interest of all in the audience regardless of their degree of specialization and incumbent on the audience to participate in a lively exchange. By lively, I mean disagreements on points of substance were valued. There was always an element of showmanship. The result was a durable transfer of information and an hour that was memorable more often than not.
Report: Pet Care Is As Dysfunctional As Human Health Care
A new report from the National Bureau of Economic Research looked at veterinary medicine. Veterinary medicine is different than human medicine in important ways. The rate of pet insurance among pet owners is thought to be less than 1 percent. There are no government programs to provide veterinary care to poor pets or elderly pets. Indigent pets can be turned away from emergency veterinary hospitals. Health policy analysts have long blamed the inefficiencies that befall the U.S. health care system on our over-reliance of third party payment. A logical extension of that argument would assume pet care should function very different from human medical markets. Yet, despite this theory, the authors found many characteristics of vet care matched human medical care:
1) Spending on care for pets rose faster as a share of GDP than medical care during the past 20 years. 2) Spending is correlated with income. 3) There has been rapid employment growth in the veterinary sector. 4) Pet care also experiences significant spending on end-of-life care.
