Employed Physicians and Their Political Leanings

Reporting for work!

Read this "Doctor's Inc" article in the New York Times, and it's easy to get the impression that the absence of employed physician support for the Republican Party translates into their active support for the Democratic Party.  Times reporter Gardiner Harris implies this shift is somehow responsible for waning doc interest in liability reform, greater support for public health issues such as consumer safety and the American Medical Association's decision to back President Obama's health reform agenda.

Don't be so sure, says the Disease Management Care Blog.  While it has opined on the  generational "Millennial" shift and what it means for population health management and the practice of medicine, it's not convinced that that means that the physicians will experience a meaningful political shift.  There's little reason to believe that they'll trade their country club memberships, tasseled shoes and Fox News habits and for professional soccer season tickets, pinot grigo at a Sheryl Crow concerts and Pelosi twitter feeds. In fact, midway through the article, Mr. Harris points out that there are no surveys that objectively track physicians' political leanings or can correlate it with employment status.

There are several reasons why the DMCB doubts that things are so simple:

1.  During its multi-decade career as an employed doc, the spectrum of opinion among its employed colleagues spanned the political spectrum  This was not a granola crowd. 

2. There are many instances of mutual support between organized private practice physician groups and large employed physician groups.  This is a good example.  There are others.  

3. It's not unusual for large employed physician groups to cover the dues of membership in County and State medical societies, as well as the AMA.  This is one example.  That's because 1) some docs want to join organized medicine 2) these professional organizations do much of the "political heavy lifting" in areas such as provider reimbursement, 3) at a local level, they've generated a lot of community good will, and 4) can they aid in physicians' professional development.

The DMCB also thinks its unfair to assert that the AMA changed its stance or that the liability reform is no longer a hot button issue.  The AMA had long established principles for national health reform, and it arguably attempted to make a reasonable compromise over what they regarded as an "imperfect" Democratic proposal.  Many of the States have instituted liability reform (here's a good example) precisely because organized physician groups, employed physicians and their employers were unanimous in their agreement that the current tort system is broken.

While there may be something to the notion that being an employed physician makes it easier to be politically unengaged, the DMCB agrees with Health Affairs' John Iglehart that it's too early to tell. It's possible that after a few years, a significant number of employed physicians will have second thoughts.

President Clinton Listens To The Other Side On Health Reform

Blasting away?

According to Kaiser Health News, President Bill Clinton "blasted" the Ryan health reform proposal because it is wrong, will saddle seniors with unaffordable costs and do little to blunt medical inflation.  Questioning KHN's portrayal of a centrist Democrat known for co-opting Republican ideas, the Disease Management Care Blog accessed Peter G. Peter Foundation video library and viewed the next to the last 2:17 Clinton video for itself.

What Mr. Clinton really said is that Mr. Ryan is "wrong" to to believe that taxes shouldn't be touched and that his Medicare proposal is "wrong" "on the merits" because there is no reason to believe it will restrain health care costs.  If costs continue to rise, said Mr. Clinton, people will avoid care and be at risk for premature death.  The President also stated that Medicare is part of a health system with a "toxic" inflation rate that is blunting pay raises and harming America's global competitiveness. He also said he "applauds" Mr. Ryan for the suggestion -  even though "it doesn't work."

Hardly a "blast," scoffs the DMCB.  At least President Clinton, unlike many of his colleagues in his party and the liberal media, is actually listening.

And speaking of listening, the DMCB, thanks to a specially chosen vintage, endured a broadcast of Lady Gaga's "Monster Ball" HBO Concert Event.  While it was mystified by much of the spectacle, the music prompted the DMCB to adapt an old adage about tequila.  Lady Gaga's music, Federal efforts to control health care pricing and tequila all share some key attributes: they're all only suitable when they're really dressed up, or when it's late and there are no other options.

in translation

The cancer centre has implemented something new. When patients check in for treatment, we're asked to fill out a questionnaire related to our well-being (it has some acronym but I can't remember it). We're given the option of filling it in on a central computer but I'm really squeamish about germy public terminals. I always ask to fill the thing in manually (furthering my feeling that I am more of a Luddite than some of my seniors).

Filling out the form involves reading statements such as "I am in pain" and then circling a number between 1 (no pain) and 7 (excruciating pain - or something like that). Most of my numbers were very low except for the ones about my emotional well being and sleep habits. My answers resulted in the following conversation with the well-meaning nurse who checked me in for treatment:

Nurse: 

"You're depressed. Why?"

Me: 

"I'm just a little blue. Five years of doing this is a long time." (Translation: "I'm pissed off and fed up and I have survivors' guilt.") 

"I'm seeing someone at the psychosocial oncology centre." (Translation: "I don't want to talk about it with you, in front of the all the strangers in the room"). 

"The crisis is over and now it's all hitting me." (Translation: "I think I have PTSD. Did I mention that I'm pissed off and fed up?")

Next time, I'm stuffing the damn form into the bottom of my purse.

kitchen conversation (he's so, so right)

My spouse (after listening to lengthy rant #342 yesterday): "Not to excuse that person's bad behaviour, but a lot of things piss you off these days."

Me: "True."

Spouse: "Oh! We forgot to put the compost out!"

Me: (String of expletives, unprintable in a blog my children might read).

Spouse (Meaningful silence)

Then we both burst out laughing.

I need to get some perspective.

But at least I can still laugh at myself.

A Defense of the Current Accountable Care Organization (ACO) Proposed Rule Takes Things From Bad to Worse

The future of standard FFS Medicare?

From time to time, well-meaning attempts to help just make things worse.  One telling example is when Republican Governors, Congressmen and Senators extol the virtues of marital fidelity.  Another is when the Disease Management Care Blog tells the spouse that mini-gargoyle statues could enhance the living room decor. 

And in the same vein,  Paul Ginsburg, writing in the latest New England Journal, ineptly praises the first rendition of the controversial CMS Accountable Care Organization (ACO) regulations.  Despite some political signals that CMS will show some flexibility and change the proposed rule, he hopes they stick to their guns in four key areas. That's because he believes that, when it comes to health care reform, this time the Feds really really mean it.  He thinks that's a good thing. Yet, while extolling the proposed rule, he is simultaneously alerting the DMCB and its readers to some troubling aspects about ACOs and Medicare's payment reforms.

1. Retrospective attribution?  Cost savings will be calculated by looking back at the Medicare claims for the population at the end of the contract instead of the beginning.  This has the advantage of ensuring that all beneficiaries are treated equally.  Dr. Ginsburg says its not a problem because CMS will "provide extensive data on beneficiaries on the beneficiaries who could have been attributed to an ACO."

In other words, the success of the retrospective approach will strongly depend on CMS' ability to provide timely data to the participating ACOs.  Anyone paying attention, especially regular DMCB readers, knows that CMS' track record of data support has been decidedly spotty (here and here).  This is an ACO vulnerability that is bigger than was appreciated by the DMCB.

2. Shared savings?  Benchmarks will be locally based, meaning that historically inefficient organizations will have an easier baseline to beat, giving them an out-of-the-gate advantage in their pursuit of shared savings.  Dr. Ginsburg says that's good, because those inefficient organizations need to change and should be recruited as ACOs anyway. 

What alarms the DMCB, however, is Dr. Ginsberg's carrying this logic forward to what could turn out to be an ultimate zero-sum game.  He notes that if ACOs succeed, "evolution toward national or regional benchmarks is inevitable, and already efficient ACO providers will then get larger rewards."  The DMCB believes it's far more likely that a fiscally strapped Washington DC will ratchet down the national or regional benchmarks, ultimately assuring that all ACO providers get smaller rewards.  In other words, ACOs give the Feds one more tool to squeeze the docs.

3. Quality of care?  Dr. Ginsburg notes that CMS's quality measures will evolve over time.  He correctly notes that ACOs would benefit from some stability in the quality measures. 

The DMCB didn't realize that organizations that commit to ACOs may be forced to shift measurement gears during the life of the contracts.  Egads.

4. Mission over margin or... no margin?  Yes, the up-front investments and the high bar on gainsharing make it possible that the return on investment for participating organizations will be too small to make it worthwhile.  Too bad, says Dr. Ginsburg, because the ACOs are in the vanguard of a transition to value-driven payment and that it is inevitable that fee-for-service payments will go away.

So, in other words, some ACOs will succeed and others may go belly up but all the other providers will watch their Medicare incomes vanish as the Feds innovate their way to value-based purchasing.  This is not changing Medicare as we know it?

generation gap

On Tuesday, as I waited at the Heart Institute for my regular echocardiogram, I had the following brief conversation with the older gentleman sitting beside me.

Me: Is that a Playbook?

Him: I don't play! This is an ipad!

Me: Oh. I was just curious about the Blackberry version of the tablet.

Him  (scornfully): Do you have a Blackberry?

Me: I do.

I didn't bother explaining that I don't find touch screens to be intuitive and that I prefer an actual keyboard for sending emails and texting. Instead, I pulled out my knitting, thus eradicating all doubt that I was the Luddite in our conversation.

The Latest Health Wonk Review Is Up!

If the folks at Health Affairs Blog ran the latest HWR, would you expect anything less than a superbly written summary with links to the best that the health care policy blogs have to offer?  Well, readers will not be disappointed and it's well worth the time to check it out.