The Obama presidency and ACP’s public policy agenda

The Obama presidency and ACP’s public policy agenda Bob Doherty Presentation to PA Chapter Council March 7, 2009

Messages: • President Obama has the best opportunity to reform health care • ACP has the best opportunity ever to achieve our principal policy objectives • Reform will involve tremendous challenges, risks and rewards for the College

Do the voters want health care reform? • Yes. • Large majorities in polls support fundamental reform—over 80% want “fundamental reform” or complete rebuilding” (Commonwealth Fund, August, 2008) • The candidate that promised reform (Obama) got the most votes • Voters want health care reform despite (or because of?) economic challenges

ABC-Washington Post Poll, January 16, 2008 • For each issue, please tell me what kind of priority you think Obama and the Congress should give it - the highest priority, a high priority but not the highest, or a lower priority than that? • Health care responses: Highest: 41% High: 49% Lower: 10%

Is health reform an Obama priority? Yes! “Our health care is too costly . . . The question we ask today is not whether our government is too big or too small, but whether it works, whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified.We will restore science to its rightful place and wield technology's wonders to raise health care's quality and lower its costs ... All this we can do. And all this we will do." President Obama, Inaugural Address to the Nation, January 20, 2009

Is health reform an Obama priority? Yes! • White House health reform summit, March 5, 2009 • 140 stakeholders, members of Congress, experts, and top administration officials • ACP one of select group of invitees, represented by ACP President Jeff Harris, MD, FACP

Is health reform an Obama priority? Yes! “Health care reform cannot wait, it must not wait, and it will not wait another year.” President Obama, WH Summit on Health Reform, March 5, 2009

Why is health care an Obama priority? • The President believes that costs of current health care system are not sustainable • Not affordable to individuals, families and businesses • Not affordable to government and taxpayers

Not affordable to individuals “Wages earned by American households will become too small a donkey to carry the load of the family’s spending on health care.” A family who today has a gross wage base of $60,000 might see it grow by 3 percent per year over the next decade, to $80,600 by 2017 For the same family, total health spending might grow by 8 percent per year over the same time frame, to $33,700 by 2017. For this worker, 41 percent of the family’s gross wage base would be taken up by health care alone, before any deductions for taxes or fringe benefits. Economist Uwe Reinhardt, accessed November 10 at http://economix.blogs.nytimes.com/2008/11/07/the-health-care-challenge-sailing-into-a-perfect-storm

Not affordable to individuals “The economic slowdown, according to analysts, is making it more difficult for many employers to subsidize health care costs at previous levels. On average, experts say, benefit packages contain the biggest increases for workers since the recession of 2001. Workers' health costs are rising much faster than wages.” “A Premium Sucker Punch”, Washington Post, January 24, 2009

Not affordable to government • Social Security, we can solve," he said, waving his left hand. "The big problem is Medicare, which is unsustainable. . . . We can't solve Medicare in isolation from the broader problems of the health-care system." “Obama Pledges Entitlement Reform”, Washington Post, Interview with President-Elect Obama, January 16, 2009

Medicare Beneficiaries and The Number of Workers Per Beneficiary Number of workers per beneficiary Millions of beneficiaries SOURCE: Kaiser Family Foundation, based on 2001 and 2008 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

Is there are governing majority for health care reform? Yes, but . . . • Major reforms involving more government role occur when Democrats controlled White House and Congress . . . • . . . and at times of crisis • Large Democratic majority in House, but “Blue Dog” Democrats could join with GOP to block unfunded entitlements • Democrats are one or two votes short of filibuster-proof majority in Senate, but Obama will need GOP votes

Has the new President learned from Clinton’s failures? • Health reform must be: • Transparent • Inclusive of stakeholders • Involve member s of Congress from “get go” • Reassure voters about trade-offs • Accept compromise as needed

What a difference 15 years make! • Instead of a plan developed in secret by an elite task force, Obama has: • Organized town hall meetings in December, several hosted by ACP members • Results of the meetings summarized at new www.healthreform.gov website • Involved Congress, key stakeholders from the beginning • White House Summit on HR, March 5, 2009

What a difference 15 years make! • Willingness to compromise: “If there is a way of getting this done where we’re driving down costs and people are getting health insurance at an affordable rate and have choice of doctor, have flexibility in terms of their plans, and we could do that entirely through the market, I’d be happy to do it that way. If there was a way of doing it that involved more government regulation and involvement, I’m happy to do it that way as well.” President Obama, White House Summit on Health Reform, March 5, 2009

How will health care reform occur? • Stages, not all at once • First stages: • Re-authorization of SCHIP • Stimulus legislation • President’s budget • Next: • Comprehensive health care reform (with aggressive timetable)

ACP supported S-CHIP legislation • Expands coverage to an additional 4 million children • Funded principally by raising the cigarette tax from 39 cents to $1 a pack.

Stimulus legislation included ACP top priorities • HIT • Primary care • Comparative Effectiveness • Coverage • ACP took positions only on the health-related provisions, not entire stimulus package

Stimulus: HIT incentives • $19 billion for electronic health records • Starting in 2011 and 2012, physicians who purchase a certified electronic health record (EHR) and use it for “meaningful purposes,” like e-RX or reporting on quality measures, could qualify for higher Medicare payments • Paid out in annual increments over five years

Stimulus: HIT incentives • Longer a physician waits to adopt a certified EHR, the less Medicare pays • A physician who acquires and uses a certified EHR in 2011 or 2012 would get up to $44,000 • A physician who waits until 2013 would get up to $39,000 • A physician who waits until 2014 would get up to $24,000 • A physician who waits until 2015 would get no any additional Medicare payments • Starting in 2016, physicians who still have not adopted a certified EHR would be subject to Medicare payment cuts.

Stimulus: primary care • $500 million to train physicians, nurses, and dentists through the National Health Services Corps and the scholarship and loan repayment programs funded under Title VII and Title VIII of the Public Health Service Act

Stimulus: prevention and wellness • $1.1 billion for a Wellness and Prevention Fund to support programs to increase immunization rates, promote clinical and community-based wellness and prevention strategies, and achieve measurable improvements in treatment and prevention of chronic illnesses

Stimulus: comparative effectiveness research (CER) • $1.1 billion for the National Institutes of Health and the Agency for Healthcare Research and Quality to “conduct or support research to evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition.”

Addressing the CER controversy • Critics of CER and HIT funding spread misinformation, claiming they would lead to rationing, denial of care to the elderly, even Nazi-style forced euthanasia • In fact, legislation states that CER may not be used to mandate coverage, reimbursement or other policies by public and private payers • ACP supports CER to provide clinicians and their patients with evidence-based, unbiased information on the relative effectiveness of different treatments

Stimulus: health insurance coverage • Subsidizes and extend COBRA coverage for people who are temporarily out-of-work • Help states offset the costs of Medicaid

Obama proposes dedicated fund for health care reform • $634 billion fund paid for by: • raising taxes on persons earning more than $250,000 per year • reducing payments to Medicare Advantage insurers ($174 billion saved over 10 years) • reducing drug prices ($29 billion saved) • lower payments to hospitals with high rates of readmissions ($26 billion saved) • and reduced home health expenditures ($37 billion saved).

Obama’s budget paves way for permanent SGR fix • “Our Budget includes the Administration's best estimate of future SGR relief . . . As a result, projected deficits are about $400 billion higher over the next ten years than they would otherwise be. In contrast, past budgets accounted for no SGR relief in any years.” Peter Orszag, Director, Office of Management and Budget, Testimony to House Budget Committee, March 4, 2009

Obama’s budget paves way for permanent SGR fix • Obama’s willingness to acknowledge costs of SGR fix is a marked departure • In past, Congress used budgetary slight-of-hand to fund the temporary "patches" • Rather than honestly acknowledging that each annual "patch" would increase Medicare baseline spending, it pretended that higher spending will be made up with even an even deeper SGR pay cuts • This is why "patch" for 5% SGR cut in 2008 resulted in a scheduled 10.5% SGR cut in 2009. • And why the patch for the 10.5% SGR cut in 2009 balloons to a scheduled 21% cut in 2010

How is ACP influencing the debate? • Developing and prioritizing policies • Being at the table • Building coalitions • Engaging and informing ACP members

ACP’s Report on the State of the Nation’s Health Care, 2009 • Released February 2 at National Press Club • Paper is based on current ACP policy, but proposes measurable objectives and policies to achieve them

State of the Nation’s Health Care • Documents the growing shortage of primary care physicians • Links need to expand the primary care workforce with coverage expansions • Makes case that primary care is the best medicine for better care and lower cost (new tag line)

State of the Nation’s Health Care • Raise payments to primary care physicians to create “market competitiveness” • Primary care compensation 55% of other specialists • Set target rate of increase to close the gap • For example, increasing primary care to 80% of other specialists would require annual pay increase of 7.5-8% per year over five years • Identifies methods for paying for primary care without requiring cuts to other specialists

State of the Nation’s Health Care • Proposes executive order requiring so all federal agencies develop plans to set measurable goals to increase primary care physician workforce capacity, including metrics of success

State of the Nation’s Health Care • Expand Patient-Centered Medical Home model • SGR repeal, HIT, reduction in hassles, more accurate pricing for Medicare fee schedule, revamping the PQRI • Help people keep coverage during the recession, followed by comprehensive reforms leading to universal coverage

ACP: new policy to influence health reform • New papers under development on: • Evidence-based solutions to primary care “collapse” • Transparency • New payment reform framework • Cost-drivers and potential solutions • Nurse practitioners in primary care

Why this paper? Why now? • Existing ACP policy was outdated (2000) • Policymakers considering expanded roles for nurse practitioners (NPs) • Patient-centered Medical Home projects • Nursing profession policies and advocacy • Productive discussions with Nurse Practitioner leaders opened ongoing and helpful dialogue

ACP’s positions: • Different skills, not equivalent, but complimentary • Both share commitment to high quality care. • Physicians are often the most appropriate health care professional • Needs and preferences of every patient should be met by professional with the most appropriate skills and training • Patients with complex problems will typically be best served by physicians • Patients have the right to be informed of the credentials • ACP recognizes role played by NPs in meeting the current and growing demand for primary care, especially in underserved areas • Research needed on effective systems of consultation

ACP’s positions: • Collaboration is defined as ongoing interdisciplinary communication regarding the care of individuals and populations of patients in order to promote quality and cost-effective care. Recognizing the importance of coordinated care to improving health outcomes, we offer . . . principles on collaboration between physicians and nurse practitioners.

Licensing and certification exams for nurse practitioners should be developed by the discipline of nursing, based on standardized training involved in graduating from advanced practice nursing programs and scope of practice statutes and regulations. ACP therefore opposes use of Step 3 of the U.S. Medical Licensing Exam and certification by the National Board for Medical Education (NBME) for the DNP. ACP’s positions:

In the PCMH model, care for patients is best served by a multidisciplinary team where the clinical team is led by a physician. However, given the call for testing different models of the PCMH, ACP believes that PCMH demonstration projects that include evaluation of physician-led PCMHs could also test the effectiveness of nurse practitioner-led PCMH practices in accord with existing state practice acts and consistent with the following: ACP’s positions:

NP participation in PCMH demos • NP-led PCMH practices should meet the same eligibility requirements as those for physician-led practices. • NP-led PCMH practices should be subject to the same recognition standards to participate in the demonstration project as physician-led practices. • NP-led PCMH practices should be subject to the same standards of evaluation as physician-led PCMH practices. Position 4 Sub-points

Patients who are selecting a PCMH as their source of regular care should be informed in advance if it is a physician-led or nurse-practitioner led practice and the credentials of the persons providing care within each practice. All clinicians within the PCMH are operating within existing state practice acts. Payments and evaluation metrics for both physician and nurse-practitioner led PCMH practices must take into account differences in the case-mix of patients seen in the practice. NP participation in PCMH demos Position 4 Sub-points

ACP advocates for research efforts to identify and disseminate effective models of collaboration, referral, and co-management of patients between and among nurse practitioners and physicians. Opportunities for professional multidisciplinary training and team development should be incorporated into the education and training of all health professionals. Workforce policies should ensure adequate supplies of primary care physicians and nurse practitioners to improve access to quality care and to avert anticipated shortages of primary care clinicians for adults. Workforce policies should recognize that training more nurse practitioners does not eliminate the need nor substitute for increasing the numbers of general internists and family physicians trained to provide primary care. ACP’s positions:

Being at the table and building coalitions • ACP and AMA are only two physician groups invited to join a multi-stakeholder effort to develop a consensus statement on health care reform • ACP was one of only a handful of physician organizations invited to White House summit • ACP participates in Senator Kennedy’s (HELP committee) drafting sessions • ACP asked by Senator Baucus to participate in Senate Finance Committee stakeholder meetings

ACP’s views are being heard! • Our priorities are included in: • SCHIP re-authorization • Health reform “down payment” in stimulus • Concept of health reform fund in President’s budget • Budget $ for SGR fix • Baucus white paper • White House Summit

ACP’s views are being heard! “The plan strengthens the role of primary care and chronic care management. Primary care is the keystone of a high-performing health care system. Increasing the supply and availability of primary care practitioners by improving the value placed on their work is a necessary step toward meaningful reform.” Senator Max Baucus, D-MT, Chair, Senate Finance Committee, White Paper on Health Reform

ACP’s views are being heard! • We're not producing enough primary care physicians.” President Obama, White House Summit on Health Reform, March 5, 2009

Opportunities • ACP has the best opportunity ever to achieve reforms to provide health insurance coverage for all and to make general internal medicine and primary care a viable and attractive career path for internists • Our policies have broad support in the Obama administration, Congress, and other stakeholders • If we don’t do everything possible to see our objectives adopted now in law, we may not get another chance

Risks and challenges • Risk of over-reaching or under-reaching • Public, Congress, Obama administration may react negatively to increasing primary care doctors’ incomes at a time when many Americans are losing their jobs • But if we don’t say what we think is really needed, the results will not likely be up to the task

The Obama presidency and ACP’s public policy agenda