The American Medical Association has garnered most of the attention in recent weeks about its healthcare reform views--especially in regards to its chilly response toward a public plan option.
But while the AMA is the largest physician organization in the U.S., other groups representing physicians--particularly primary care physicians--have been vocal about what they would and would not like to see in healthcare reform legislation.
In the past two weeks, hearings on both the House and Senate side of healthcare reform legislation have given many of these physician groups—who represent the majority of physicians who care for Medicare patients—a chance to be heard on issues, including insurance exchanges, comparative effectiveness research, Medicare and Medicaid improvements, and public plan options.
American Academy of Family Physicians President Ted Epperly, MD, recently told two House panels, which were holding hearings onthe tri-committee draft healthcare reform bill, that his organization was "highly supportive of many of sections" of the draft measure.
In the AAFP's view, he said, "a reformed system should provide health coverage for all, promote primary care, support coordination and reduce fragmentation of care, minimize administrative complexity, prohibit denial of insurance on the basis of a preexisting condition, require an affordable basic benefit package that includes prevention and wellness, and protect against catastrophic costs."
AAFP said it would support a public plan option that is "consistent" with a list of principles including:
The value of primary care is acknowledged though creation of such things as patient-centered medical homes.
The new public plan must be actuarially sound.
Public and private insurers should be required to adhere to the same rules regarding reserve funds.
The public plan should not be required to use Medicare-like payment methods permanently.
"We are pleased that the [House] bill takes a comprehensive approach to reforming healthcare," said Joseph Stubbs, MD, president of the American College of Physicians (ACP), the second largest physician group in the country.
Stubbs said that ACP supported the overall approach to providing affordable coverage including:
Expanding Medicaid to cover everyone at or modestly above the federal poverty level.
Providing individuals and small businesses with a choice of health plans offered through an exchange.
Providing sliding scale subsidies for individuals to purchase coverage through such an exchange.
Eliminating cost-sharing requirements for preventive services.
Requiring that all health plans, inside and outside an insurance exchange, abide by rules relating to acceptance of all individuals--without regard to pre-existing conditions or health status--plus guaranteed renewability and modified community rating.
ACP also told the Energy and Commerce Health Subcommittee last week that it thought that a public plan could "appropriately" be included among the options made available to individuals and employers. However, the group was concerned that building such a plan on Medicare rates--even though limited to the first three years from inception as proposed in the House draft legislation--would have a negative impact on physician participation, particularly primary care physicians, because Medicare pays PCPs far less than private payers in many markets.
ACP also told the subcommittee that it will provide recommendations to help ensure that payment rates under a public plan are sufficient to support primary care and to ensure adequate participation by physicians by specialty and by their locations of practice. It also wants to support making physician participation in the public plan voluntary—or not linked to an agreement to participate in Medicare.
Larry Wickless, DO, president elect of the American Osteopathic Association, said, "Congress must make a concerted effort to restore the patient physician relationship." This should be done by making shifts in how healthcare is delivered: by moving from "the current episodic based payment system toward payment models that promote the patient physician relationship."
Physician payment is an area that all the groups representing primary care physicians found important. They called on Congress to enact a five part plan to reform physician payments that would:
Provide a substantial increase in Medicare payments to primary care physicians, beginning in 2010.
Eliminate the Medicare Sustained Growth Rate (SGR) and replace it with a system that provides "predictable and stable updates" to all physicians.
Improve the accuracy of relative values for services paid under the Medicare physician fee schedule.
Pilot test other new payment models to align incentives with the value of services provided by primary care physicians.
"Unless Congress takes action very soon to stop this precipitous drain on the numbers of primary care physicians in the United States, healthcare costs will continue to skyrocket while the quality of overall care will decrease," Epperly said.
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The Agency for Health Research and Quality recently expanded its "State Snapshots" to illustrate with colorful graphics the wide variation in care provided from state to state across the country.
"Every state has areas where it does well, as well as opportunities for improvement. We generally think this is a good 'get people going' kind of tool," says Ernest Moy, MD, medical officer for the Agency for Health Research and Quality, which produced the Web-based application.
Hospitals, state health officials and other providers can now see both how their states are performing relative to data collected in previous years as well as how they compare with other states. "From our perspective, comparison with other states has the greatest potential for the use of this data," Moy said.
Here are a handful of the findings:
Maryland had the worst hospital post surgical sepsis infection rate of any other state, but Oregon had the best.
Texas and California had the worst track records in giving surgical patients antibiotics at appropriate times, while South Dakota and Maine had the best performance rates in this category.
Utah had among the lowest rates of death per 1,000 adults admitted with conditions or diseases associated with low-mortality, but Iowa had among the highest.
Minnesota had the lowest rates of "iatrogenic pneumothorax," or incidents in which hospital procedures provoked air accumulation in the pleura of the lung, but Vermont had the highest.
The agency does not speculate on why such great variations in quality measures vary so much.
The state snapshots Web site shows data that ranks each participating state in more than 100 quality measures based on the place of care (preventive, acute, or chronic care) setting, such as a hospital, ambulatory, nursing home, or home health care setting, and by type of condition, such as cancer, diabetes, heart disease, maternal and child health, and respiratory disease.
Included are several new scoring areas, such as the prevalence in each state of adult asthma rates and the numbers of potentially preventable hospitalizations for children, adults, and the elderly.
Each participating state's performance is marked with a pink, yellow, and green performance meter, which illustrates state scoring with two needles, one that shows how the state is doing compared to a prior year, and the other shows how it compares with other states.
AHRQ collects but does not publish data from about eight states–depending on the category–because it's not statistically significant or because of concerns that small numbers may identify a patient or provider, Moy says.
But some states have declined to participate in some categories, he adds. "They just never thought about doing it, or they're too small, or they have other bizarre kinds of restrictions. A couple of states have rules that prohibit collecting such information or if it does collect it, prohibits the state from sending it to us." In the case of one state, a movement is afoot in the state Legislature to change that rule.
Such ranking tools will doubtless become more important as the federal government looks more seriously at finding ways to measure care with an emphasis on comparative effectiveness as a way of determine best outcomes and quality.
Each measure was rated on a bell curve, so that some states did well while others did poorly. Massachusetts, Moy says, is in the top 10 for more than half the quality measures that were tracked, but did not do well in home health or nursing home measures.
"On the flip side, we highlight Nevada, which is at the bottom 10 for a big chunk of the quality measures, but does fairly well in home health care," Moy says. "New England states tend to do well, but southwest and south central states tend to be the worst."
This is the first year AHRQ has published information on rates of sepsis among patients admitted to hospitals for elective surgery. Moy says some hospitals and states may be worried about the kind of feedback they might get, and are concerned about how these rankings may reflect on the quality of care delivered in hospitals in that state.
Other measurements ranked by this Web site include the percentage of heart attack patients for whom medication was given within 30 minutes, the percentage of hospitalized patients with pneumonia who had blood cultures collected before antibiotics were administered, and the percentage of nursing home patients who spent all or most of their time in a bed or a chair.
The data also filters general information on state performance by disease category. For example, for each state, one can see rankings on cancer, diabetes, end stage renal disease, heart attack care, maternal and child health, mental health, respiratory diseases, HIV and AIDS, surgical care, nursing home care, patients' ability to get timely appointments, and patient experience of care.
The expansive data file is available in Excel under the heading "All state data tables for all measures."
Imagine a Web site that allows consumers to compare health insurance plans and select one that best suits their needs.
That just may become a reality if lawmakers include an insurance exchange as part of the larger healthcare reform package. There are a number of different insurance exchange proposals in Washington and they vary in a number of areas.
Supporters of the various insurance exchange programs agree that the program would provide one-stop shopping for individuals to compare available plans. The program would also allow for portability so a person wouldn't lose health insurance because of job loss. After those two highlights, however, there is a lot of disagreement as to the actual makeup of the exchanges.
Here are five tough questions lawmakers will have to answer if the insurance exchange remains part of a larger health reform package.
1. Does it include a public plan?
The most hotly contested healthcare reform topic in Washington has been a public insurance plan. Supporters say a public option is one key way to reduce health costs because private insurers would need to cut costs in order to compete against a public plan with lower overhead.
Public plan foes, however, say the government should not create a public plan that would pay doctors and hospitals less and potentially hurt private insurers. They argue that a public plan, paying at rates similar to Medicare, would actually cause doctors and hospitals to transfer more costs onto private insurers.
Robert E. Moffit, PhD, director of the Center for Health Policy Studies at The Heritage Foundation, wrote in 2006 after about 15 state legislatures introduced statewide health insurance exchanges. Moffit supports an exchange that would make health insurance portable by having employers pay tax-free contributions to the exchange for their employees' healthcare.
He says creating a health insurance exchange to work in concert with a public insurance plan, on the other hand, will mean the end of private insurance.
"In my view, we're talking about something that looks like the Roman Coliseum where all the private plans are the Christians and the public plan is the lion. So the national health insurance exchange becomes a giant killing field for private health insurance, which is what I think they want to do," he says.
2. Is it a federal or a state program?
An insurance exchange could be a federal program or a state-run program that would launch with federal seed money.
Most experts agree that the exchange would need to be run at the state level because there are so many variations in mandates, laws, and insurers by state that a national exchange would be impossible.
Janet Trautwein, executive vice president and CEO of the National Association of Health Underwriters, says most of the insurance exchange proposals would create an exchange that would not preempt state law. Another option is to let individuals choose between policies with state-mandated policies and ones without those mandates.
Trautwein says lawmakers must make sure that insurers are treated the same whether outside or inside an exchange, such as offering the same subsidies to each. A level playing field is needed or people could flee their employer-based plans to take advantage of subsidies in the exchange.
"It is very important if we have an exchange that the rules be the same whether people purchase inside or outside the exchange—otherwise it could really upset the market," she says.
3. Will it include an individual coverage mandate?
An individual coverage mandate has been the cornerstone of Massachusetts' health reform and state officials say they wouldn't enjoy such low uninsured numbers without the mandate.
But others think federal lawmakers should not require all Americans to have health insurance. They instead would rather a health insurance exchange that is similar to eHealthInsurance, which is a Web site that allows consumers to compare health plans. Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy at American Enterprise Institute for Public Policy Research, says lawmakers don't need to mandate insurance to accomplish that kind of system.
"There are enough people who understand that they ought to have coverage and are interested in having some choices and this is a viable business model," says Antos, who recently wrote The Case for Real Health Care Reform.
He says creating a program heavy with regulations and mandates would price young people out of the insurance market. Antos adds young people want basic health insurance and not a plan that is designed for a middle-aged family man. Those types of plans are too expensive for recent college graduates, he says.
"If you set the bar very high, and that might be the direction that some Democrats want to go and certainly the direction Massachusetts went, then you will basically eliminate the economic incentive for insurers to try to come up with a better combination that reflects reasonable coverage at a reasonable price," says Antos.
Rather than federal lawmakers creating mandates for insurers to follow, Antos thinks private insurers should be allowed to design benefit programs that interest their various members.
"What you really want to do is enlist the smart people in insurance companies who design insurance plans and give them an economic reason to design a plan that would actually be attractive to a wide range of Americans, which implies balancing the benefits with a cost," he adds.
4. Is the exchange a way to compare plans or something more?
An insurance exchange could be merely a Web site that allows people to compare prices and benefit packages or it could take a more regulatory role (such as Massachusetts) and negotiate with plans. An exchange could also mandate types of coverage and plans that it allows in the program.
The argument for setting a floor for benefits and coverage is that prospective members could compare apples to apples. Those who oppose the idea, however, say that coverage mandates will add costs and price out people, particularly younger people who are needed to fund health insurance.
One benefit for the exchange idea is that a Web site could go beyond providing price and benefit information, but could help people learn more about health and how to become better healthcare consumers.
5. Who will have access?
Federal lawmakers can open the exchange to the individual market, small employers, or everyone.
Opening the exchange to only the uninsured to join individual plans would not help small employers who are struggling with health costs, but other experts are worried that opening the exchange to too many people initially will cause a stampede out of employer-based insurance and could flood the exchange in its infancy.
Trautwein says she would like an exchange to start with the individual market to work out the bugs before expanding to employers with as many as 50 workers.
Trautwein adds that the exchange must provide low-cost plans in order to woo younger people into the plans. "You have to really be careful about how you set up your rating model so it's still affordable for young people to come in. Those are the groups you really want in. They are a big part of the group that's not in today," says Trautwein.
Regardless of the specifics of the insurance exchange, supporters in both parties believe it could become a part of a bipartisan reform package that gives Americans a place to become better health insurance consumers.
"Virtually all economists agree that if you provide more information to consumers and more choices that they're likely to pick something that is closer to the combination of benefits and cost that appeal to them personally," says Antos.
President Obama is trying to enlist the nation's governors and his own army of grass-roots supporters in a bid to increase pressure on lawmakers that are divided in regards to healthcare legislation. In a meeting with five governors, Obama privately urged them to serve as his emissaries to Congress. He even coached them on the language they should use with lawmakers, two of the governors said, advising them to avoid terms like "rationing" and "managed care," which evoke memories of the Clintons' failed health initiative.
Doctors call them frequent fliers: Patients who leave the hospital, only to boomerang back days or weeks later. They have become a challenge not only for hospitals and doctors but also for those trying to rein in rising healthcare costs. Typically elderly and suffering from the chronic diseases that account for 75% of healthcare spending, their experiences of being readmitted time and again reflect many of the deficiencies in a fragmented, poorly coordinated health system geared toward acute care, according to this article from the Washington Post.
