Organized Medicine – The Moral Healthcare Blog

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.

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.

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.

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.

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

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.

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.

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)

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.

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.