But Barbara McAneny, MD, applauds the recently signed legislative ban on pharmacy gag clauses.
This article first appeared October 17, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- A single-payer healthcare system in the U.S. would break her practice, said the president of the American Medical Association (AMA), who argued that Medicare and other government programs as currently structured simply don't pay enough.
"We need a payment system that the country can afford," said Barbara McAneny, MD, AMA president, and a practicing oncologist/hematologist in New Mexico.
McAneny pointed out that in the portion of her practice that serves the Navajo Nation, 70% of payments are from governmental payers, and "I have struggled for the last 10 years to keep that practice breaking even."
Medicare payments are designed to cover about 80% of the cost of doing business, McAneny said. If all her commercial patients were to pay Medicare rates, there would be no other place from which to shift coasts, she explained. "My doors would be closed. I would no longer be able to make payroll."
Moving to a single-payer healthcare system won't fix what's broken, she said during a meeting with reporters Tuesday to discuss a variety of issues, including drug pricing, value-based payments, and turf battles.
While she said she strongly supported Medicaid expansion in New Mexico, McAneny expressed skepticism about the possibility of a Medicaid "buy-in," which would allow people to purchase Medicaid-based public insurance plans.
She pointed out that only about a quarter of the population in New Mexico has commercial insurance, and "Medicaid and Medicare do not cover the expenses of providing care." With fewer patients to cost-shift from, independent practices and small rural practices "would not be able to keep the lights on."
AMA policy supports patients buying "individually selected health insurance," subsidized with advanced or refundable tax credits, that corresponds inversely to income, McAneny said.
McAneny also discussed the Trump administration's recent efforts to curb drug prices, and to the challenge of transitioning from fee-for-service to value-based care.
She called the latest bill banning pharmacy gag clauses "really important. When patients discover that they can pay less than the co-pay to buy the drug, they need to know that because patients are going broke out there, trying to buy their drugs."
Gag clauses prevent pharmacists from telling customers whether paying for their prescription might be cheaper if they paid the cash price instead of using their insurance.
Earlier this week, the Department of Health and Human Services (HHS) announced that drug makers would need to include the list price of any drug paid for by Medicare or Medicaid in their TV advertisements. In an AMA press release, McAneny stated that the HHS move seemed like "a step in the right direction," although the AMA is opposed to direct-to-consumer advertising in general.
McAneny said greater transparency was a "first step" toward addressing such high drug costs.
"There's so much the public doesn't understand about the market, including the true costs of research and development and the role of middlemen, like pharmacy benefit managers and insurance mark-ups , she said.
"Before we suggest any sort of treatment, we think it' s a good idea to make the diagnosis, and that means really understanding that entire process, which means they're going to have to pull back the curtain and let us, the healthcare community, really take a look at that and figure out what adds value and what doesn't," she said.
McAneny was less supportive of changing the way Part B drugs are bought and paid for. In May, HHS Secretary Alex Azar suggested moving some Part B drugs administered in a physician's office into the Part D program, in an attempt to negotiate more competitive prices.
"People cannot afford a 20% co-insurance on a drug that costs $5,000 a month," she said.
In terms of value-based payment, McAneny said she's excited about the work the physician-focused Payment Model Technical Advisory Committee (PTAC) is doing. Doctors are well-positioned to help design alternative payment models, she noted.
"We see all the time places where healthcare dollars get wasted, and patients don't get what they want," she said, so allowing doctors to come up with new methods of care delivery, which incorporate things they've always wanted to do for their patients, has "tremendous potential."
McAneny said she hopes Azar will test as many pilots projects as possible, and see what works, but not penalize groups who fail. "If you're trying something innovative ... sometimes you're going to be wrong, and those people shouldn't have to lose their practices... they should be allowed to fail quickly, and move on to something else," she stated.
McAneny said she will present an alternative model to the PTAC in December.
Another challenge in healthcare is scope of practice, with some physicians expressing concern that nurse practitioners and physicians assistants (PAs) are encroaching on their territory.
McAneny acknowledged that concern, noting that primary care physicians must be "incredible diagnosticians," she said. "They need to know when a sore throat is a sore throat and when it's really cancer."
"In my own practice, where we have everyone working to the top of their license, I value my nurse practitioners and I value my PAs immensely, but I don't expect them to be oncologists, and I don't really expect them to be primary care doctors," she added.
"Everybody has a place in healthcare," McAneny stressed, "but I do not feel that a nurse practitioner who has gone to nursing school and done one extra year... and has not practiced in that post-doc process, has the same level of expertise to be that diagnostician."