American College of Physicians: Internal Medicine — Doctors for Adults ®

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Positions on health care reform aren't all black and white

From the July/August ACP Internist, copyright 2012 by the American College of Physicians

By Robert B. Doherty

People often ask me to describe how ACP approaches health policy issues, because the College's positions often don't fit naturally into the binary liberal-or-conservative, Democratic-or-Republican, for-or-against way of looking at things. Instead, ACP has a Kodachrome vision of health policy. (For those of you raised only on digital cameras, Kodachrome was the film of choice for many generations of photographers because of its brilliant colors, until Kodak accepted the digital reality and ceased production in 2009.) The College doesn't see most issues as being black or white, but as needing to reflect a wide spectrum of views that together make for a more complete picture.

ACP's position on the Affordable Care Act (ACA) has been to support the parts of the law that will help achieve the College's decades-long support for universal health insurance coverage and advance other important policy goals, while asking Congress to improve on it by, for example, enacting more meaningful medical liability reforms.

Much of the rest of the world looks at this as an either-or choice: Are you for the ACA or against it? But isn't it more reasonable to say that there are things about the law that are good and should be kept, and others that are not so good and should be changed or dropped?

Especially in the wake of the Supreme Court decision (which hadn't been announced at press time), the United States will have to reach some degree of closure on the ACA. The issues of access to health insurance, increasing costs, and a physician workforce that is too small to meet rising demand will continue to be with us.

We need an informed debate that leads to consensus about what the government's role should be in helping people buy health insurance, in training more doctors and in driving down costs. The choices won't be as simple as keeping government out of health care on one hand or letting it run everything on the other.

I suspect that some of the ACA's fiercest Republican critics aren't really against the parts of the law that improve Medicare and Medicaid reimbursement to primary care physicians, or prohibit insurance companies from putting lifetime and annual limits on coverage, or allow young adults to stay on their parents' plans. Yet they can't even hint at wanting to keep any part of “Obamacare” without risking a revolt by ideological purists.

I suspect that President Obama and most Democrats privately wish they had done some things differently in the law and would be open to constructive revisions, but they can't say so because that risks opening the ACA up to wholesale changes and even repeal.

The Relative Value Update Committee (RUC), which provides expert advice to Medicare on the relative values of physician services, is another example of how a complex issue has become unproductively polarized. On one side are people who view the RUC as the source of all evil and who want to get rid of it, lock, stock and barrel. On the other side, some people are so protective of the RUC that they reflexively resist any effort to reform it.

ACP doesn't fit into either camp. The College believes a fair and evidence-based evaluation of the RUC would show that it has done some good and done some harm.

On the positive side, the RUC has supported substantial increases in the relative values for many evaluation and management services done principally by primary care physicians. On the other hand, primary care has been consistently underrepresented in the RUC's membership, the relative values for many primary care visits are still too low, some of its methodologies are suspect, and it hasn't done a great job at recommending reductions in overvalued procedures.

But instead of issuing ultimatums or trying to blow the RUC up, ACP has worked to improve it, both within the RUC itself and by applying pressure externally through Congress and CMS. There has been progress. The RUC recently agreed to add two more seats, one for geriatrics and one for primary care, in addition to the current seats for ACP, the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, and a rotating seat for internal medicine subspecialties. ACP's constructive engagement with the RUC was likely a factor in the RUC's subsequent decision to elect ACP's nominee to the new primary care seat.

Other improvements in the way that the RUC and CMS establish relative values are needed, but the new primary care and geriatrics seats are a good start. Yet the anti-RUC purists argue that ACP and AAFP are “selling out” primary care by not walking away from the RUC altogether.

Unfortunately, like Kodachrome, open-mindedness to a wide range of perspectives and principled compromise is now out of fashion.

In 1973, singer-songwriter Paul Simon's hit song “Kodachrome” extolled the film's “nice bright colors” because “everything looks worse in black and white.” Framing health policy issues as a black-or-white choice gets people riled up, but it makes everything worse by closing off dialogue, to the point where it has become almost impossible to achieve consensus on needed reforms.

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