By NIRAN AL AGBA, MD
The narrative goes like this:
The Democrats are the party of healthcare. The Republicans are the party that wants to take healthcare away from people. Dismantle the Affordable Care Act and we’ll have a disaster on our hands, millions will lose their healthcare coverage, middle class Americans will go bankrupt, the World will end
All this political propaganda ignores a fact that physicians have understood for some time now: For doctors and millions of Americans, Obamacare already is a *total and unmitigated disaster*. From opening day when the administration’s Healthcare.gov web site symbolically blew up, it was clear that things weren’t going to be going according to plan.
Giving millions of people access to healthcare was a great thing and long overdue. But kowtowing to health insurers and pharmaceutical companies, obsessing about centralization, and endless digital paperwork all but guaranteed an epic fail.
In retrospect, it is quite clear one of the primary causes of the Affordable Care Act’s crash and burn was the fact that nobody talked to the people who understand the healthcare system. Instead academicians, health policy wonks, and other “experts” led the way, blustering about how much they know when in fact, they didn’t know much.
For more than a generation, the Powers that Be have done everything possible to drown out the voices of doctors and other healthcare professionals with frontline experience. In that time, costs have skyrocketed and Democrats continue selling themselves –successfully– to voters as the party of healthcare ideas.
The reality? Democrats have been the party of one or two good ideas and a lot of very bad ones.
Can Republicans do better? I think they can.
If Republicans want to become the “party of healthcare,” they must start with good ideas. The last place they should be looking is the policy swamp that produced one bad healthcare policy after another.
And there is nobody better positioned to fix this mess than doctors.
This may be the single greatest lesson from Obamacare’s demise. By ignoring and marginalizing doctors, the Affordable Care Act alienated and politicized an entire generation of physicians, many of whom probably would have been Democratic voters for life.
Believe me, I know. I’m one of them.
If the Republicans want to become the “party of healthcare”, here is a task list from the desk of a doctor on the frontlines. It is getting handed to them on a silver platter.
First, a Preamble, without which all of this isn’t going to work:
Healthcare reform must begin and end with a commitment to lowering cost. Period. This phrase should be shouted at every legislator in Congress repeatedly until they begin to understand this is the only – and I mean the only – lens through which to look. While Democrats are clamoring for “Medicare for All”, and Republicans cling to dreams of a “free market”, they both keep overlooking how to pay for any health system overhaul.
Ready? Here goes:
1. Repeal the Medicare Anti-Kickback Safe Harbor Statute, which affords protection to group purchasing organizations and pharmacy benefit managers, who receive millions in kickbacks for supplying pharmaceuticals to hospitals. In a complicated construct where capitalism and conflict of interest meet is where the development of a “safe harbor” facilitated the pharmaceutical industry to grow ripe with corruption, unnecessary drug shortages, and a ‘pay-to-play’ scheme that would be illegal in any other business sector.
2. Repeal the HITECH act. The Health Information Technology for Economic and Clinical Health (HITECH) Act, included in the American Recovery and Reinvestment Act of 2009, was signed into law to promote the adoption and utilization of health information technology. Under the HITECH Act of 2009, the federal government invested $30 billion in incentives for health care providers to purchase health information technology (HIT), yet these different systems can’t “talk” to each other.
3. Exempt small private medical practices from Electronic Health Record (EHR) and Merit-Based Incentive Payment System (MIPS) for practices with fewer than 20 doctors. A recent expose by Kaiser and Forbes reveals that despite ten years and $36 billion dollars, the US healthcare system has little to show for their pipedream of health record portability for patients. Instead of reducing cost, healthcare costs have climbed sharply, physicians are leaving medicine in droves, and investigations have uncovered countless unacknowledged patient safety risks, including wrongful death of patients associated with the use of technology.
4. Support transparency in our healthcare system. Representative Larry Bucshon (R-IN) introduced the “Truth in Healthcare Marketing Act,” H.R. 3928, 115th Congress, and it should be enacted. Requiring transparency ensures patients receive accurate health care information by prohibiting misleading and deceptive advertising or misrepresentation in the provision of health care services. This legislation mandates that licensed health care professionals properly identify themselves. Consumers are smart. Put decision making in the hands of people.
5. Address the impending physician shortage with legislation. Senators Menendez (D-NJ), Boozman (R-AR), and Schumer (D-NY) recently introduced the “Resident Physician Shortage Reduction Act of 2019.” This legislation addresses the impending physician shortage and will strengthen the nation’s health care system. To address this critical issue, the Resident Physician Shortage Reduction Act of 2019 would increase the number of medical resident training positions by 15,000 over five years. That means the US will train 3,000 more physicians (hopefully in primary care) annually.
6. Medicare and Medicaid payments for medical goods and services must be site-neutral. Currently, if a patient sees a physician at a hospital-based clinic, known as a hospital outpatient department (HOPD), then the physician is reimbursed $116 and the patient coughs up $23. if you see a physician at a private clinic, Medicare pays them $86 and the patient pays $16. Site neutrality means no matter where you see a physician, the out-of-pocket payment remains the same. While $7 may not seem like much, this policy will result in lower copayments for beneficiaries and generate an astounding savings of $380 million for the Medicare program in one year. Furthermore, this change encourages physicians to remain in independent practice – which is best for patients and their pocketbooks.
7. Expand the Hospital Price Transparency and Disclosure Act of 2018 — H.R.6508 – legislation which took effect January 1, 2019. American hospitals are required to post prices of their services, but that is only half the battle. When feasible, these prices should be provided to patients prior to receiving care and those prices should be accompanied by quality outcomes to provide context. That will allow patients to make informed choices.
8. Repeal the ban on physician-owned hospitals (POH). Since the ACA was enacted, hospital consolidation increased by 70 percent. Since employed physicians have been forced to refer to specialists within these large, corporatized systems, costs have increased substantially without improving outcomes for patients. Senator James Lankford (R-OK) introduced a Senate bill in 2017 to repeal ACA- ban on construction of physician-owned hospitals, yet this common sense solution has been largely ignored. Studies have since demonstrated POH’s have higher patient satisfaction, lower mortality rates, and lower costs compared to hospitals owned by corporations.
These are just a few ideas discussed amongst physicians practicing on the front lines of medicine. There are literally dozens more like them. Most are common sense, something that’s been sorely lacking in Washington in recent years.
Of course, there are plenty of health reform ideas floating around out there, most of them being sold by snake oil salesman with slick powerpoint presentations, who have never set foot in a hospital or cared for a real live patient. After all, those same people once touted other ‘amazing innovations’ like accountable care organizations, “value-based healthcare,” quality measurement and big data to name a few, so I encourage you to listen to what they have to say.
A good rule of thumb? The more complicated it is and the more moving parts it has, the less likely it is to work and the more expensive it will be when the bill comes due.
To legislators, I say, when you’re done listening to the charlatans, please take a walk down the street and chat with your constituents. Then find a yourself some real doctors who actually practice medicine –instead of just pretending like they do– and ask them what they think. We are likely to have a different view of the way the real world works, if only because we live in it. Many of us have great ideas. Most of us are eager to help.
We’ve just been ignored for years.
You know where to find us. Right where you left us. Hard at work in doctors offices, clinics and hospitals around the country.
Niran Al-Agba is a pediatrician based in Washington State.