Colorado Medical Society

http://www.cms.org/articles/may-june-perspectives/

Member perspectives

Monday, May 01, 2017 12:14 PM

Colorado Medicine asked a group of members who had previously self-identified interest in health care reform to provide their perspective on how federal reform should be approached and managed, and how it will affect their practice of medicine now and in the future. The physicians briefly answered five open-ended questions. Below is a selection of the wide range of responses we received, followed by all responses.

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Question 1: Given that the House effort to “repeal and replace” has failed for now, Health and Human Services Secretary Tom Price, MD, will be managing regulatory control of the ACA. He is on record supporting repeal and replace of the ACA and supported the American Health Care Act. What would your advice to him be now that Congress failed to act on new legislation and Dr. Price has control of ACA regulatory levers?

Paul Hsieh, MD (PH): Minimize the regulatory burden on doctors, hospitals, and insurers as much as possible, while a genuine free-market health care reform plan gets hammered out.

Brian Joondeph, MD, MPS, FACS (BJ): Until Congress acts on its every-two-year campaign promise to repeal and replace Obamacare, HHS Secretary Price has at his disposal an Obamacare kill switch. Appearing over 1,000 times in the ACA legislation, the secretary “shall” or “may” “determine” how the law is implemented. He could essentially “determine” that Obamacare “shall” be null and void. Alas only as a temporary fix as there will someday be a new administration that “may” feel otherwise.

Lucy Loomis, MD (LL): The ACA is not a perfect bill. It is complex, and with many interweaving sections that can make it hard to separate what is working well from what is not, and to identify unintended consequences. While there are clearly significant problems with the individual market, many of those existed before the ACA, and those affected are a relatively small portion of the total number of people whose access to health care has been greatly improved. I think the responsible thing for Dr. Price to do is support the current law until it has been repaired or replaced.

Thomas Billroth Gottlieb, MD (TG): The mission of HHS (Dr. Price) is to enhance the health and well-being of Americans. Delivery systems are not the problem. People/patients are not the problem. The problem is financing of health care by multiple commercial insurance companies. Solution: Socialized insurance, Medicare-for-All.

Adam Tsai, MD (AT): My advice to Secretary Price is to listen to the American people. Public opinion polls are very clear that a majority of Americans want to keep the coverage gains made under the ACA. Secretary Price and Congress should examine what could be done to cover more people and lower costs, rather than replacing the ACA with a system of tax credits that is projected to cause tens of millions of Americans to lose coverage. Improving access and lowering costs will require both parties to address the underlying drivers of high health care spending, such as high prices for services.

Question 2: What should Congress do next? President Trump?

PH: Congress and the White House should rally behind a genuine free-market reform. A good start would be Sen. Paul’s plan. Another would be the “Whole Foods Plan” proposed back in 2009 by John Mackey: www.wsj.com/articles/SB10001424052970204251404574342170072865070.

BJ: Congress needs to align their disparate factions and follow through on their campaign promise to “repeal and replace” Obamacare. President Trump, in keeping with “The Art of the Deal,” must mediate, negotiate, cajole and convince Congress into crafting and passing legislation consistent with their campaign promise to the American people. This is called leadership and is a reasonable expectation of our elected leaders.

LL: Despite some of the rhetoric, there is not a crisis and no evidence of impending implosion. Congress and Trump should take the time to understand what is working and what is not, and try to fix what is not. He should resist extracting tax revenue from a program that is improving access to health care for lower-income Americans in order to reduce taxes for those who are better off.

TG: Congress: Propose a health reform plan that supports people, not profits. Preservation of a democracy requires that people guide our congressional leaders. People support a “single insurer” such as Medicare-for-All. Trump: Trump promises universal health care, higher quality, lower cost, no one loses coverage, and all with pre-existing conditions will have access. Trump should not replace the ACA (Obamacare) until he offers a better plan.

AT: Congress should work across the aisle as much as possible to advance policies that cover more people and lower costs. Both parties have ideas that could potentially lower insurance costs for people purchasing insurance on the health care exchanges. For example, Democrats favor adding a public insurance option, which would create more competition for private insurers. Republicans favor selling insurance across state lines; regional rather than state-based insurance exchanges might offer greater economies of scale to lower insurance costs.

Question 3: Given the vacuum created by lack of action on the American Health Care Act, what should organized medicine (AMA, state, county and national specialty societies) do right now to ensure optimal coverage and timely access to medical care?

PH: Physicians should lobby their lawmakers to support market-based reforms that respect physician freedom to practice free from onerous government rules and practice guidelines. We’ve seen repeatedly that robust service markets thrive best under freedom, not when hampered by a large regulatory state.

BJ: Organized medicine, while an important voice, is not Congress and cannot alone pass legislation. But they can make their voice heard through advocacy, just as they are now doing. Make sure legislators know our priorities for health care reform, for our patients and for the sustainability of our profession.

LL: Organized medicine should continue to support what is best for the health of the entire population. Lack of insurance and access to health care creates problems that ripple through a community and the health care delivery system. Access to quality health care should not be a partisan issue, a message we can effectively deliver when working with our legislative colleagues. However, organized medicine also needs to take the lead in promoting efforts to deliver the right care at the right time and increase the value, not just volume of care provided, providing good stewardship for the taxpayer dollars that are invested in expanding health care access. This should not be considered a blank check to the health care delivery system. We should continue to endorse reducing overall costs of care (as well as administrative burden and overhead).

TG: Use the reform guidelines of affordability, equitable timely access, and cost savings in health care. Merging state medical assistance programs and acquiring private health insurers to reform Medicare programs would be the most effective method (Medicare-for-All). Refer to www.hcacfoundation.org.

AT: Organized medicine should continue its advocacy to maintain and improve access to care. The AMA’s recent public opposition to the American Health Care Act is a good example. State medical societies should advocate for their states to continue running insurance exchanges and to maintain expanded Medicaid coverage.

Question 4: Given all that you observed and read about the strongly held positions on all sides of this contentious debate, are you more or less inclined to be politically active in the future and why?

PH: More active. This is our best chance to avoid the dangers of European-style “single payer” system.

BJ: I will continue to make my voice heard, through my writing and radio appearances. While a lone voice, if I don’t make the effort, who will? If physicians sit in the back of the bus, we abdicate driving the bus to lobbyists and industry: Hospitals, insurance companies, pharma and politicians, all of whom have different priorities than practicing physicians.

LL: As a safety net provider, I have seen first-hand the benefits of improved access to health care for the patients we serve. As a community health center, we have worked successfully with both parties by emphasizing the importance of CHCs in providing access to quality cost-effective health care for underserved populations. Providing good health care should not be partisan issue. I think it is our duty as leaders in organized medicine to emphasize this point, and try to guide conversations around how best to provide health care, and be accountable for the outcomes. We can also be very effective in sharing stories of our own and our patients’ experiences in gaining (or not) access to health care.

TG: More! Sadly, health care reform is not a scientific evidence-based movement, but a political movement. If we are serious regarding medical ethics and democracy, then only a grassroots political movement will be effective.

AT: I am more inclined to be politically active. Despite the many great things about the United States, we remain very much an outlier compared to the rest of the developed world when it comes to providing health care for our people.

Question 5: What are the three most important things about health care delivery and the practice of medicine you would tell your member of Congress to keep in mind, whichever way this debate finally goes?

PH: Make insurers compete across state lines, reduce regulatory burdens on hospitals/doctors/insurers, and allow widespread use of HSAs.

BJ: 1) Health care is a right. Or at least an entitlement. Founding documents aside, we have become an entitlement society. Completely privatizing health care, leaving it to the free market, is politically impossible and a nonstarter. 2) Health care is a privilege. Taxpayers and businesses cannot afford to pay for top-of-the-line medical care for everyone, without limit and on demand. Some form of rationing is an economic necessity. Create a sensible scheme to acknowledge and implement this reality. 3) Health care can be both a right and a privilege. A two-tiered approach works in many countries, a parallel public and private system. Then the thorny political question of “right versus privilege” doesn’t need an answer. It can be both. While not perfect, it is politically feasible, accommodating both sides of the partisan debate.

LL: 1) There continue to be problems with the U.S. health care system. It is not equitable; there are still many examples of health disparities.  We overvalue expensive interventions, and undervalue primary and preventive care. We tend to treat social problems with an expensive medical model, when what may be more effective is addressing the underlying social determinants of health. Congress needs to invest in primary care and prevention. 2) As we continue to strive to improve systems, we need to work together with payers and Congress to increase the value of the health care. 3) Don’t forget the Quadruple Aim! 4) Reduce the administrative burden on our providers.

TG: 1) The major problem is the multiple payer commercial insurance business. Physicians/providers and people/patients are not the major problem. 2) Financing of health care is the problem that can be fixed by socialized insurance, not socialized medicine. 3) A business plan is needed to accomplish these “important things” and is available as: U.S. Healthcare Financing Reform, Consolidation of the Health Insurance Industry, www.hcacfoundation.org.

AT: 1) A pure free market approach to health care is not a feasible option, as much as some policy makers would like it to be. Health care is complex. It is not pejorative to say that many people are not capable of being sophisticated “consumers” of care; it is reality. Health care is not selling cars. 2) Every other wealthy country in the world guarantees health care to its citizens in some form. It is way overdue for us to join the rest of the developed world. 3) To the politicians who think that individual responsibility can cure all our health care problems, I invite you to spend a day in the exam room with me treating chronic medical illness.


Laird Cagan, MD

  1. I would recommend to Dr/Secretary Price that he not work to repeal the ACA nor weaken its existing statutes, as for now it is the will of Congress to continue it.
  2. Ideally Congress should work for universal, affordable coverage, particularly in light of the strong public opposition to repeal and replace. President Trump promised good health for all Americans and should also support this.
  3. The CMS should take active leadership in advocating for better health care in Colorado starting with continued education of its members on the personal, ethical, and economic advantages of health care for all. Then educate the people of Colorado as well.
  4. I am fiercely supportive of affordable, quality health care for all. I will be politically active.
  5. For physicians, prevent insurance companies from imposing administrative burdens and push them to allow physicians to make clinical decisions, if market based financing is continued. For patients, support transparency in health care costs and give them free choice of physician. For all, support universal coverage.

Gary D. VanderArk, MD

Health care reform must address two key issues: access and cost.  The Patient Protection and Affordable Care Act (ACA) produced a dramatic improvement in the number of covered people but also produced a large increase in the number of underinsured people because of cost. The ACA also initiated the shift from volume to value with MACRA.

Dr. Price should use his regulatory powers to immediately ease the burden caused by Essential Health Benefits. He could significantly decrease the overconsumption of medical care. Then Dr Price could lead the way in expanding our commitment to value by expanding MACRA to the insurance industry

The federal government must stabilize the insurance market. There needs to be a cost-sharing subsidy to help those with incomes below 3Xs the federal poverty level. Insurance companies offering insurance in a state must be required to participate in the state’s health insurance exchange program. The individual mandate could be replaced by penalties for signing up for insurance late. Young and healthy people must be encouraged to enroll in insurance programs. The Alaskan reinsurance program that helps insurers pay for extremely high cost patients should be implemented in all states. Costs can dramatically be reduced by challenging the local hospital or health system monopolies. We need to return to managed competition. Hospital charges bear no relationship to cost.

Organized medicine must fight to decrease the 30 percent of health care costs that are of no benefit. Every county medical society must have a Doctors Care program for assuring access for poor people. Yes, I will continue to tilt at windmills and be politically active.

On April 14 I met with U.S. Rep. Mike Coffman (a Republican) and asked for his commitment to 1) access for everyone, 2) requirements to decrease cost, and 3) to seek the advice of physicians in all things. After visiting Doctors Care last year and discovering that we have 1,000 physicians and six hospitals volunteering to take care of the poor, he said, “I think you have found the answer to Republican health care reform.”


Floyd Russak, MD

  1. Give up and let it continue, but take away some entitlements.  Reduce the deductible for primary care visits that have been shown to reduce ER utilization and costs.
  2. Expand Medicare to everyone over 50.
  3. Encourage Medicare expansion.
  4. Yes. Our future and that of our kids depends on it.
  5. Health care is like education. It needs to be readily available at low cost.

Gary Alan Mohr, MD

  1. Dr. Price and I both belong to the Association of American Physicians and Surgeons, a free market alternative to the AMA. I have heard him speak, and I think that his emphasis will and should be on free market reforms to restore a more natural physician-patient relationship. Strengthen HSAs. Allow medical insurance to be sold across state lines. Reduce onerous regulations so that physicians are less reluctant to participate in the programs that already exist.
  2. Try to keep the newly-covered Obamacare patients covered, but with a less expensive, less onerous program. Keep Jonathan Gruber out of it. Allow balance billing for government programs.
  3. Ask Dr. Price how we can help him achieve our common goals of high quality affordable medical care for everyone.
  4. I am very excited about the near future of medical care in the United States. I have emailed both President Trump and Dr. Price and offered to participate in any way possible.
  5. 1) High quality medical for our patients has to come first, before politics. 2) Ask us, organized medicine and practicing physicians, what we need to do our best work for our patients. 3) Acknowledge that the need for medical care is infinite and resources are limited. Cosmetic surgery, for example, cannot be a benefit of publicly funded plans.  Limits to coverage should be made apparent prior to enrollment.

Alan Kimura, MD

  1. a. Dr. Price must create an environment that fosters clinical care with a lighter burden of reporting by doctors. Wasteful of precious doctor-patient time, it is also a major source of physician burnout. The health care system’s need for process and outcomes data should occur through automated data acquisition from Qualified Clinical Data Registries (QCDR) created by physician specialties. QCDRs should be approved to satisfy MIPS reporting requirements. Well-run QCDRs will serve patients and doctors better, while providing meaningful data feeds for quality improvement – all consistent with the drive toward value-based care. b. Dr. Price should properly weigh the potential harm to patients, as well as the potential waste when paying for drugs that may be ineffective.  There is movement toward FDA excluding efficacy data from the drug approval process, which would be a grave mistake.
  2. a. Congress is moving further away from being an effective governing body for Americans.  Enduring legislation must involve compromise – the major pieces of legislation affecting health have historically passed in a bipartisan manner. But over the recent decades, increasing hyper-partisanship makes this branch of government dysfunctional. It would be amazing to see a reversal of gerrymandering, to make truly competitive House of Representatives races. b. POTUS: Yes, health care is complicated.
  3. a. Organized medicine must maintain its outreach efforts, aiming to build ever more effective advocacy at every level of government.  There is so much at stake now. b. The Quadruple Aim addresses the critical importance of clinical practices and practitioners in hitting three targets with one arrow – the Triple Aim of cost control, population health, and the patient experience of care.  If I had to pick a promising program to promote, it would be the Transforming Clinical Practice Initiative (TCPi).  The TCPi is the outside intermediary helping individual practices transition from often wasteful, inefficient volume-based care to value-based care. Value-based care will endure as the driving force likely regardless of which party occupies the White House; it is a matter of economic competitiveness in a global economy.
  4. More inclined. But will put more energy into the regulatory side of the executive branch, and pay more attention to the judicial branch as the final check of power. However, the hyper-partisanship and conflict-of-interest in government makes governing our society very challenging.
  5. a. Continue operations and funding of the Centers for Medicare and Medicaid Innovation (CMMI) to pilot effective experiments on the health care system. b. Continue operations and funding of the Transforming Clinical Practice Initiative (TCPi) and Practice Transformation Networks (PTN). The path forward into value-based care will require education and practice “hand-holding” to ensure a successful practice transition.

W. Ben Vernon, MD

What just happened? Still blind with rage over the PPACA enactment and giddy from unexpected electoral success, our federal majority leadership failed spectacularly to “repeal and replace” the ACA for want of public support. Even health insurance companies were initially opposed until the deal sweetened with $705 billion in investment tax relief. Twenty-five years ago the Clinton attempt to “fix” health care failed principally because erudite policy crafted in secret by “policy experts” failed to recruit key political support for the process and proposal.

Even broken systems continue to work. It matters not who fixes this, President Trump, Congress, HHS, Colorado, CMS or physicians. What matters is that the dysfunctional elements be honestly identified, critically analyzed and intelligently corrected. Analyzed from inside the patient-physician alliance concentrically outward, the desired and dysfunctional aspects of our system must be prioritized and corrected.

We first discover that some patients delay and do not seek care for want of financial coverage. And when care is ultimately received its cost can bankrupt the patient and shift expense to others. Our professional ethics ensure universal access to care. We just have an accounting failure causing inefficient resource utilization.

Next we find that our care is impaired, not facilitated, by digital records. Many patients perceive our practices as inconvenient. Our team performance is impaired, not facilitated, by archaic communication platforms and failed connectivity. And then we wait for payment authorization (still not an approval for payment) for what is clinically indicated!

Enter dystopian commercial health insurance. Seventy percent is provided through “Administrative Services Only” arrangements, which means Insurer X, with no risk at all, writes the checks from Employer Y’s account, and provides the network of hospitals and physicians the insureds can see, with the audacity of determining which care will be “authorized.” How is it the physician collects the “patient responsibility” rather than the insurer or employer? Why do insured patients have first dollar responsibility, not last? If you have or sell health insurance in Colorado, you already cover the uninsured through cost shifting!

Physicians are especially sensitive to our patients’ health needs and the barriers faced together to deliver care. The lesson to be learned from the Clintons’ failed proposal, the SGR implementation, PPACA, MACRA and the failure of ACA repeal is that this time, NOW, physicians must be organized and politically forceful together to get this system, nearly a fifth of our national economy, back on track. Universal Coverage, Insurance Overhaul and Technical/Infrastructure Support are no longer negotiable.


Health Care Reform: Is it achievable or even needed?
Mark K Matthews, MD FACP

In 1927 Francis Peabody, MD, at Harvard Medical School stated, “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it.” This was at a time when he witnessed students and residents focusing more on X-rays and lab tests then on the patient. For me, and I suspect all of you, the joy of medicine is in the personal relationships we develop with our patients. Yet, since 1927 health care has become dominated by administrators resulting in the devaluation of this all-important relationship as evidenced by the following situations:

The medical community has the ability and indeed the responsibility to take a leadership role in developing a health care system that is socially just, fiscally responsible, and reaffirms the primacy of the physician-patient relationship.