We gratefully acknowledge the sponsorship of the Sparrow Hospital/Michigan State University Family Medicine Residency Program of Lansing, Michigan for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:
Dr Mark Clasen, Wright State University, Dayton, Ohio (moderator): Thank you, David. Following the family physician from Utah is Dean Richard Clover from the University of Louisville School of Public Health and Information Sciences, continuing the presentation “How Will it Work: the Path to Implementation or Deconstruction of PPACA”.
Richard Clover, MD, University of Louisville (Kentucky): I’m going to make some comments. I’ve always been amazed for us that have been here a long time that in the early conferences the best equipment we had was an overhead projector and today Bill Burnett has embraced technology where we have two projectors for PowerPoints to run in two locations. So we’ve evolved over time.
I believe that Dr Sundwall made a lot of the points I was going to make. I do think the law will stay the court challenge and will be implemented as it is.
What influence to we have as a group or as individuals to influence those issues? One common example I used earlier this morning in the breakout discussion is there is a real push to move all immunizations out of part D of Medicare into Part B, because a lot of people don’t have Part D and there’s still a huge co-pay that relates to Part D. There is an attempt to make some of those preventive services more friendly to the Medicare/Medicaid population.
There is a lot of money in the public health infrastructure. It’s not clear to me how it will be spent (or if it will be appropriated).
I think the overarching issue about this law is how there is going to be enough doctors, enough nurse practitioners, enough physician assistants to give primary care services to the entire nation. The last workforce report I saw, the answer to that was that there aren’t enought. So, I think we have a challenge in how these populations get their insurance, and how the healthcare team will take care of the population.
The a final comment. The interface between what we do as family physicians to the community-based interventions that are in place. I think that’s why the public health/preventive money was in the law, but it’s also one of the things that was first attacked by the Congress. It’s going to be an issue, a continual struggle. I think the only concern, at least from my perspective, that would be if the Supreme Court overturns part of the law. But I think that’s a low possibility.
Now, I suggest we open it up to questions and discussion.
Dr Clasen: The lead question will be from Dr Charles North.
Charles Q. North, MD, MS, University of New Mexico (Lead Questioner): I think that the point of this session is to have some discussion about what PPACA is. I’m constantly reminded of it. I followed the debates. I read parts of the bill. I had just heard a talk on Friday at another conference on what PPACA has in it. It’s just amazing. It’s sort of like a holy scripture. You go back and you find new things and interpret the in new ways. It’s almost overwhelming in its detail.
Of course, if it’s repealed by the Supreme Court or it’s not funded by Congress, it’s not going to have much impact. The impact will be slow over several years and so far, I think, the impact has been relatively minimal.
I’m going to ask a lead question to Dr Sundwall because he mentioned the politics of PPACA. I want you to imagine that you’re advising President Obama. You want him to implement a part of PPACA immediately, earlier than is scheduled in the bill and to fund it.
What do you think in PPACA would have the most impact on measurable aspects of population health if it were implemented sooner? If you were advising him to use his bully pulpit and maybe work with legislators to implement part of this and move up the agenda – what’s the part that would have the biggest impact on population health?
Dr Sundwall: Honestly, I would think the best thing to improve population health would be to get the expanded insurance coverages. You know all of the prevention programs are fine. We have a track record that they make a difference. But probably the core, closest corollary between improved health is having health insurance coverage. It’s healthy for you.
Now that is, unfortunately, the most politically difficult. The law allows states to move forward quicker with Medicaid expansion than was scheduled in the law. So, if they chose, they could already go up to 133 or 138% and get the federal match the law would allow them to do that.
I don’t know of any state that has the resources to do so. Even though states get a more handsome federal match, there’s still some required state match and most states are really struggling. So fundamental to one’s health is having health insurance coverage. Beyond that, I would like to see those CDC provisions funded and implemented.
I think that would be helpful. I spend a lot of time in Washington now and I can tell you that everything’s dominated by the budget. We’re afraid that most aspects of MEDPAC and MACPAC won’t continue to be funded. They’re looking at every penny to reduce this awful deficit, so there’a a pall over everything. Consequently, we don’t think a lot of the provisions will be appropriated, even if they’re authorized.
Dr North: In the interest of fairness, I’ll ask another lead question to Dr Clover. If you were advising Representative Ryan (who is not only the most physically fit member of Congress, but has taken on the role of provocateur, if you will, on the budget), what would you recommend that he put in the legislation to improve the health of the American public through means that would be acceptable to his Republican base?
Dr Clover: I would suggest a more systems approach to the problem. I don’t think we as individual practitioners can make a significant change to the population we serve unless we have a partner in creating that change. So, I would like to see wording to the nature of how insurance companies would address, whether it’s case management or it’s integrating new docs, or whether it’s home visits, whether it’s prenatal care – whatever the topic you want to look at how you coordinate that.
Last year we talked about how the life expectancy increased by about 30 years from 1900 to the year 2000. Eighty-five percent of that increase was due to public health, not medical care. The common cause of death previously was infectious disease. Through water treatment and immunizations, we’ve eliminated most of that risk.
But the challenge today is that our population is different. Now, we’re a population with chronic diseases. What kinds of interventions will we need to improve the health status of persons with chronic disease? That’s the biggest challenge for the CDC and the biggest challenge for government today.
Donald Frey, MD, Creighton University School of Medicine, Omaha, Nebraska: This may sound like kind of a smart aleck question, but I think it speaks to the issue of politics and the role it plays in this entire process. This is a question that has puzzled me, about whether or not PPACA is unconstitutional, particularly the individual mandate.
One of the individuals who’s spoken out quite openly against PPACA is Orrin Hatch, the Senator from Utah. He has argued against its constitutionality. In fact, he wrote a piece in the Omaha newspaper speaking of this fact.
If you look back to the Republican plan, called the Health Care Access Reform Act of 1993 that was proposed as the response to the Clinton health plan, it is actually an individual mandate. One of the co-sponsors of the bill was Senator Orrin Hatch. Has anyone ever asked him why it was a good idea when he proposed the bill in 1993, but now, is not only is a bad idea, is actually unconstitutional when it was passed in 2009? Has anyone ever addressed that?
Dr Sundwall: Haven’t you heard the phrase consistency is the hobgoblin of little minds? I don’t mean to be too facetious, but let me tell you how awful the political environment is now. I worked for Senator Orrin Hatch from 1981 through 1986. I know and love him. He’s not behaving like himself. He’s behaving like someone who’s running scared to get reelected. You probably know that Senator Robert Bennett of Utah was the first high profile senator to get dumped by the Tea Party.
In fact, I was in Taiwan at the time with a group of public health experts from what was a Duke University sponsored exchange. It was headlined in the international English speaking papers that Senator Bennett lost the primary in Utah. My thought was, how can that be newsworthy in Taiwan? But it was – for reasons we now know – that there’d been a shift in politics in the United States of America. So Senator Hatch is up for reelection. Why he wants to be elected again, I’ll never know, because he ought to kick back and enjoy his senior years. But he of course wants to be, in my opinion, the Strom Thurmond of this generation, so he’ll be there as long as he can.
It’s a legitimate question, but trust me the politics are changed, and his public position has changed.
Hector Flores, MD, White Memorial Medical Center, Las Angeles: Good morning. Thank you for your thoughtful presentations. My question is about accountable care organizations (ACOs). To me these are a “genie out of the bottle” because the fact is they were promoted by the Republican administration of George W, Bush, they are in the PPACA, and there’s a lot to like in the concept.
I’m also forewarned about the fact that ACOs are like the unicorn. You know everyone can describe it but no one’s ever seen one. The question is, what shape it will take? We have seen bits and pieces of the unicorn from the demonstration projects themselves. There are other excellent systems like the Kaiser Foundation Model. Those are really accountable care organizations, except they use the capitation payment method.
Here’s the concern I have. Everybody, including my hospital, is moving towards accountable care around Medicare and commercial plans, around Medicare bundled payments, around Medicare saving sharings and around what the commercial health plans are already doing in our State of California.
It’ll be easy for all those organizations to say: “We’ve saturated our capacity with Medicare and commercial patients; let someone else worry about the Medicaid patients; let someone else worry about the uninsured”. So what kind of caveats or recommendations would you make about preventing that from happening?
Dr Sundwall: I think that someone will do it if your hospital won’t. I think there will be other organizations (in fact, there is a push for it) that will do managed care for Medicaid. I didn’t mention that in our next MACPAC report in June, we’re focusing on the challenge of the “duals”, meaning those qualified for both Medicaid and Medicare, who are the most costly of all the Medicaid clientele. The push from both the Obama Administration and from MACPAC will be for all of those people to be in a managed care process, because there are demonstration projects that have been done around the country that show that it really works.
I’m not too concerned about who does it, but I think you’ll find that Intermountain Healthcare is already positioned to do the managed care for Medicaid under the Lindquist waiver. They’re scrambling, They want that business. I don’t know why your hospital doesn’t. With the number of uninsured in our country, a covered life is a covered life is a covered life. You may not like the level of reimbursement, but it beats the heck out of having to eat it for the uninsured. So I think there’ll be a market for people to manage the care for Medicaid beneficiaries.
Dr Flores: The concern here is that in California, the money coming in for Medicaid is 49th in the nation. It’s very low. And the dollars that are coming in are fought over by the cartels. You have a hospital cartel that says we’re serving this proportion of insured, this number of uninsured and this number of Medicaid patients. Therefore, we need those monies. My hospital is a DSH [disproportionate share] hospital. The FQHC’s get cost-based reimbursement, yet there’s an infrastructure that both the DSH hospital and FQHC are dependent upon: specialty care physicians out in the community, as well as supplementary services, such as hospitalist work and moonlighting, from primary care physicians in private practice. These private practice physicians are chronically underpaid and our governor is threatening and additional 10% reduction!
Finally, I don’t think there’d be enough money in Medicaid managed care here in California, especially since the enrollment of Seniors and Persons with Disabilities is part of our MediCal Waiver. I don’t think there’s enough money there to really support the upfront costs of ramping up new care coordination, or case management services for the patient as they’re mandated to join an HMO. Because we’re mandating our sickest patients – the seniors and persons with disabilities – to join managed care, we are at risk of a collapse of the infrastructue that provides those services.
So the answer is that somebody will pick it up, maybe. I think the health plans have picked it up because they pass the risk onto the providers; to the hospitals and the IPAs and to the physicians. But I don’t think we have the answers of how to achieve savings yet. I’m curious why Intermountain would be interested in this. Is it that their capitation payments are so much higher than California’s that they see a business opportunity?
Dr Sundwall: Intermountain will do it because they’re the big 800 pound gorilla in my state and they are exceptionally profitable for a not-for-profit organization. Whether or not they can make it even, they’ll get political points. It’s not the landscape of California. I acknowledge it’s very, very different. But, they could do this feasibly. By the way, you mentioned the word implode. Fasten your seat belts, I think we’re going to see pockets of implosion all over the country, because we’re not going to be able to sustain what we’ve become accustomed to in our country.
The biggest challenge to your question is the large state variability and our response doesn’t address that. We as a community started seeing this as a means of cutting costs in Medicaid. The state put out an RFP, basically for a managed care company to come in and manage the Medicaid population. So we as a university and we as the healthcare system responded to the RFP and created the managed Medicaid company. We found a management firm to run it. It is now one of the most sought after patient populations, especially for the “pharmacare” docs; because we incentivize the docs to do the preventive healthcare services and the HEDIS reporting requirements that we want to see done.
Could other states could copy what Utah does? I don’t know. The Utah Legislature increased the revenues to the docs for doing a lot of case management, but whether every state can model a plan like Utah’s, that’s up for discussion. But I do think some large healthcare systems are going to pick this up.
Gary Leroy, MD, Wright State University, Dayton, Ohio: Our topic here today is the path to “implementation or deconstruction” of the Accountable Healthcare Act. I want you both to look into your crystal ball a moment and see it would work if we somehow found it was unconstitutional and then we had to deconstruct this act. So how do we would get “out of the frying pan and into the fire” if this thing were to implode as a nation?
This is just a thought experiment. Go ahead. That’s the easy question.
Dr Sundwall: Looking at the crystal ball, ok. For reasons that I’m not sure I understand I don’t think the U. S. Supreme Court can find the Act unconstitutional. There have been too many things that have been implemented that have been successful. To now tell a parent that their 22 year-old son can’t have insurance is going to be difficult to do for either Congress or the Supreme Court.
What I would be hopeful for in that discussion is that we look at what may not have been designed correctly, and deconstruct those but reconstruct where it makes sense. Whether that’s even a dream, I don’t know. But I do know it’s been interesting watching, especially as to how the Secretary is interpreting the regulations and instructing the Department of Health and Human Services on what they need to do.
Dr Clover: Gary, I don’t think it will, but I honestly don’t know what the Supreme Court is going to do, because we’ve been surprised with two other challenges that have been in favor of overturning the law. That’s why it’s going to go to the Supreme Court. Maybe someone knows if the entire law is in challenge or is it only the mandate and can you consider parts of the law unconstitutional but the rest of it ok?
Dr LeRoy: We do have one lawyer in the audience. Can you say the mandate isn’t constitutional, but the rest of the law remains in effect? Is it the entire act that is considered unconstitutional or just the mandate?
William J. Burnett, JD: The law did not contain a severability clause and because of that, Judge Roger Vinson has declared the entire law unconstitutional. If his ruling prevails, then the other parts of the legislation would have to be re-enacted. [The summary conclusion of Judge Vinson’s ruling may be accessed at: Judge Roger Vinson’s January 2011 Declaration of PPACA as Unconstitutional.]
Dr LeRoy: So, if they got rid of the mandate, they would have to go back and reconstruct the law because you take the mandate out, then the law implodes upon itself, especially since the mandate was part of how to pay for it. So you’d have to go back and reconstruct the whole law itself. So what do we do as a country when all of that basic features of the bill cease to be law? Well it’s a great example of how you better watch out what you wish for. The Republicans may find themselves really scrambling then to figure out what’s an alternative to the coverage that was expanding through this legislation.
Jimmy Hara, MD, Kaiser Permanente, Los Angeles: In California, we’ve got a special problem in that under the Patient Protection and Affordable Healthcare Act, undocumented individuals are not covered. They’re not part of the act. And in fact, in California we’ve got another issue: that the only individuals who are guaranteed coverage are prisoners – whether you’re a citizen or not, and the cost of prison care in California is really astronomical. So the issue we have here in California is that the number of undocumented is more than the population of many states in the union.
Dr North: So you’re recommending – just to clarify – that those of us who don’t have insurance, should commit a felony in California.
Dr Hara: Short of reform what should we do? Three strikes you’re out, and then you’ll have universal coverage for your sentence at least.
Dr North: Ok good, good. Does anybody want to respond to that? The panel is politically astute and they’ll choose what they respond to carefully.
Dr Sundwall: This will sound parochial but I would call your attention to the Utah compact which was just signed by the Catholic, the Mormons, the business community, everybody. It’s a progressive, fair, sensible way to deal with immigration which those at the federal level are apparently ignoring, which is a shame because they ought to follow up on that and federalize it, because we all think there ought to be a national solution to immigration, not a state by state approach. I’s a humane concept that I’d call your attention. It’s called the Utah compact.
Miki Paul, Ph.D. I’m Miki Paul from the great state of Arizona. Is there much discussion about treating patients in groups in all the policies that you’re hearing going on?
Dr Sundwall: When you say groups, you don’t mean like accountable care organizations where they’re enrolled in a panel of patients? What do you mean by groups?
Dr Paul: No, I mean having all the patients, treating them in a group; rather than individual treatment with patients.
Dr Sundwall: You mean group visits?
Dr Paul: Yes, group visits. Are group visits covered in PPACA?
Dr Sundwall: There’s a big new home care visitation program for $1.4 billion, which again is subject to not being funded, but it’s a really good idea if you believe in traditional public health and frontline medical care, but I’m sorry I don’t know if there’s any such thing as direct funding for group visits.
Dr Clover, do you know of anything?
Dr Clover: No, I do not, no.
Marc E. Babitz, MD: Utah Department of Health: In 1994 when President Clinton came out with his big health care reform plan, it was defeated, because everyone claimed the public was absolutely against it. People were frightened by the Harry and Louise ads and they were afraid of it. What we learned, of course, after the fact, was that those ads were sponsorered by the Health Insurance Association of America.
My question is that the same rhetoric comes from the Tea Party which says that Americans are up in arms against PPACA. The Democrats say Americans are for this act. I wonder, what’s your sense of who’s really behind all this controversy? Who are the players who are pushing for defeating this act?
Dr Sundwall: I will tell you if you read this book, you will find this startling fact. Do you know what PPACA means for people currently insured? Not much. In other words for the average American this law doesn’t do much at all except possibly change their taxes. That’s what was one of the most revealing things about this book is what the PPACA doesn’t do, and it doesn’t do much for anybody currently insured. How many is that? About 80% of the population has some kind of insurance. Anyway, most people don’t really care, Mark. I don’t think they have strong feelings one way or another.
Just one final comment, the Kaiser Family Foundation on their website has a great timeline for progression, for when parts of this act are going to be implemented. So I encourage you all to look at that with your leisure time.
Dr Clasen: It does strikes me that many of us have managed budgets and large budgets and smaller budgets and fixing the budget is easy. You either raise revenues or cut expenses, right? And no problem. If you’ve noticed that our discussion is all on managing expenses and politically I think that at least has me thinking. Is the revenue side of the equation off the table? Apparently it is. So we will have no revenue enhancement and will slice up the expenses.