Shifting alliances

the american medical Association, the venerable lobby organization for doctors, was for years a reliable Republican-leaning voice on big health care issues. For much of the past decade, however, the organization seemed to be on a drift to the left. First, it endorsed the Patients’ Bill of Rights guaranteeing patient protections against insurance companies. Then the AMA really turned heads by endorsing President Obama’s health care law. The leftward lurch, however, may prove to be short-lived, as the organization is now joining the Repub­lican chorus complaining about burdensome government regulation—some of it brought about by the 2010 health care overhaul the AMA embraced.

The group says doctors are overwhelmed with pending deadlines to implement updated coding for their diagnoses and inpatient procedures and to adopt electronic health records systems and e-prescribing programs, as well as deadlines to change how they report their work for Medicare patients.

Massachusetts figures prominently in the dispute. Nearly 5,500 Massachusetts doctors are members of the AMA, making the Bay State delegation bigger than all but 10 other states. And the man who until recently drew doctors’ wrath was Donald Berwick, who headed the Centers for Medicare and Medicaid Services (CMS) until he resigned in November to take a job with a left-leaning think tank in Washington. Berwick, a former Harvard School of Public Health professor, previously ran the Institute for Healthcare Improvement, a Cam­bridge think tank that has championed the quick implementation of new health care information technology practices that the AMA is now fighting.

Berwick is “certainly a pioneer in all of this,” says Lynda Young, who recently finished her term as president of the Massachusetts Medical Society, which represents doctors in Massachu­setts.

The AMA hasn’t sugarcoated its displeasure. Last year, it sent Berwick a lengthy letter outlining doctors’ need for relief from regulations ranging from the requirement that they hire translators for hearing-impaired Medicaid patients to new documentation they have to provide on treatments given to Medicare patients.

In April, the group wrote to Berwick’s successor, Marilyn Tavenner, to express its “profound concern about the imminent storm that is about to occur due to simultaneous implementation of multiple programs that will create extraordinary financial and administrative burden as well as mass confusion for physicians.” Doctors, the AMA explained, are under pressure to adopt electronic health records systems and electronic prescribing over the next two years at the same time they are required to use new reporting systems for Medicare aimed at tracking the quality of care.

“Facing all of these deadlines at once is overwhelming to physicians, whose top priority is patients,” says AMA President Jeremy Lazarus. “We have asked CMS to develop solutions for implementing these regulations in a way that reduces the burden on physicians and allows them to keep their focus where it should be: caring for patients.”

Berwick declined to comment about the hard line he took, but one of his new colleagues at the Center for American Progress, Topher Spiro, says all of the initiatives Berwick supported are crucial to making health care more efficient, reducing medical errors, and driving down health care costs. “These types of changes can’t be done quickly enough,” says Spiro, who leads the health care policy team at the center and is a former aide to the late Sen. Edward Kennedy. “They will save billions in health care costs over the long term.”

So doctors’ reluctance to move on them quickly, despite more than $1 billion in subsidies provided in the 2009 economic stimulus law, has put them at odds with both advocates of health care reform and with health care information technology providers.

At primary issue are three programs that Congress has mandated to require doctors to prescribe medicine by computer, to keep track of patient information electronically, and to report to Medicare on the results of procedures they perform.

Congress first ordered doctors to computerize their prescriptions in 2008, then added the requirement for electronic health records in the 2009 stimulus law.

Those mandates won’t go away even if the Supreme Court this summer overturns the 2010 health care law. Still, it’s ironic that doctors would get some of the relief they want if the court does strike down the law the AMA endorsed. That’s because the health care law added requirements for doctors to report on their treatment of Medi­care patients as a means of gauging whether patient care is adhering to best practices. The health care law also mandates that, as of 2015, the government pay doctors who treat Medicare patients based on their performance rather than the number of treatments they provide. Doctors who keep costs down and whose patients do well will receive bonuses; those deemed to be spending too much on poor care will see their reimbursements drop.

Right now, however, the government is paying doctors to adopt the new systems. This year, for example, doctors can receive incentive payments of $18,000 if they move to electronic health records. If doctors are prescribing medicine by computer or reporting under the new quality control system, they can tack on an additional 1 percent to their Medicare bills.

The electronic prescribing payments totaled $420 million in 2009 and 2010, according to the Centers for Medicaid and Medicare Services, while the agency says it has spent $653 million to help doctors adopt electronic health records.

Janet Marchibroda, who leads the health care information technology research team at the Bipartisan Policy Center, a Washington think tank, says the incentives have been generous. “All of these initiatives started with incentives first, with the penalties pretty far down the road in the hope that they could get the lion’s share of clinicians in before the penalties hit,” she says.

Doctors say the money has helped, but that the payments have only covered a fraction of the costs of e-prescribing systems, which can run around $2,500, and electronic health record programs, which cost about $20,000. And Young, the Massachusetts Medical Society president, notes that many small practices didn’t qualify for the money because too few of their patients are on Medicare, or Medicaid in the case of pediatricians and other doctors who don’t see older patients.

Soon the incentives will give way to penalties that will cut doctors’ Medicare payments by 1 or 2 percent a year, depending on how long they are delinquent. The AMA is particularly irked that the Medicare and Medicaid agency is basing the penalties on physicians’ actions in years prior to the penalty phase. For example, this year doctors who don’t move to electronic prescribing will face a 1.5 percent reduction in all their Medicare claims next year. Likewise, doctors who aren’t using electronic health records by next year will pay penalties on Medicare claims in 2015. The same is true for the Medicare quality reporting.

Doctors’ complaints have started to resonate. In April, the federal government pushed back by a year another initiative, the roll-out of new codes to better describe diagnoses and procedures, from 2013 to 2014, to the great dismay of the companies that make health care computer software.

Such matters may seem arcane, but they will delay better quality care, says Dan Rode, the vice president of policy and government relations for the American Health Information Management Association, a trade association for people in the health care technology business. The old coding system, he notes, provides no information about the severity of injuries or diseases or how they were in­curred. “The system now doesn’t say whether a person with a puncture wound was stabbed in a gang fight or cut themselves peeling potatoes,” he says.

The lack of specificity in current coding procedures means specialists have to spend more time with patients getting up to speed. The code problem also prevents public health researchers from having access to reliable data about the spread of disease.

None of the AMA’s recent positions is much of a surprise to students of the organization’s history. The AMA was for years an unyielding opponent of government interference in medicine. It famously fought the creation of Medicare in 1965, and its political action committee for decades favored Republican candidates.

That seemed to be changing, though, in the late 1990s when Democrats pushed for a Patients’ Bill of Rights to regulate health insurance companies and to give doctors back some of the control over patient care that they’d lost to insurers. Though Republicans eventually killed off that bill, the AMA’s new bond with the Democratic Party seemed to grow when it endorsed President Obama’s health care law. In 2008, the AMA gave 55 percent of its political action committee contributions to Democratic congressional candidates. And in 2010, it gave 57 percent to Democrats.

The shift coincided with a continuing decline in the AMA’s membership, as doctors moved increasingly into specialty societies, many of them more conservative than the AMA. Two generations ago, three in four US doctors were members of the AMA. Today only a bit more than one in five are, or 215,854 out of 985,375 doctors practicing in 2010.

Soon after the AMA endorsed President Obama’s health care law that year, the group’s anger over its implementation began to grow. In addition to the deadlines for Medi­care reporting imposed in the law, doctors also fought to eliminate perhaps the most important provision aimed at better controlling health care costs, the creation of a new Independent Payment Advisory Board, which was charged with finding ways to slow Medicare’s growth. In March, the AMA endorsed a House Republican bill to eliminate the board.

The payment board “puts important health care payment and policy decisions in the hands of an independent body that has far too little accountability,” says?James Madara, chief executive of the medical association. “Major changes in the Medicare program should be decided by elected officials.”

The doctors say they fear the board would order further cuts akin to the existing Medicare “sustainable growth rate” formula that Congress enacted in 1997. Each year, the formula calls for a large reduction in the fees paid to doctors serving Medicare patients and each year Congress suspends the cuts under pressure from the AMA.

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Shawn Zeller

Washington Correspondent
But supporters say the advisory board is the only way to get around the difficult politics of containing Medicare spending. The board would reach decisions without being influenced by outside interest groups—including the?AMA—and Congress would have to vote on its proposals without the opportunity to amend them. A similar system has enabled the Pentagon to close military bases despite local opposition.

The AMA is doing more than just complaining. The group is again reversing course with its campaign giving. So far during this election cycle, Republican candidates are getting 60 percent of its contributions.