#FullRepeal Daily Digest

Forbes: How American Doctors Lost Their Professional Autonomy

• About the same time that the Centers for Medicare and Medicaid Services was botching the rollout of healthcare.gov, the agency also announced its successful creation of two mobile apps designed to help doctors keep track the stuff they get from drug makers. It lets doctors electronically tabulate (and report to the Feds) each consulting fee, pen, and jelly doughnut that they receive, right on their I-Phone. The aim of this de rigueur is to help doctors comply with a new federal law passed as part of the Affordable Care Act. Starting this year, drug and medical device companies must report to CMS nearly every transaction they have with individual doctors and how much the physicians received. CMS will post the data on a searchable, public website that goes live September 2014.
• The “Physician Sunshine Act” is as much a response to the past marketing excesses of the drug and device makers as a reflection of the retreating stature of the American doctor. Aspects of medical practice that were once firmly the domain of professional bodies are now subject to federal tinkering. This has profound implications for doctors and patients alike who have firmly ceded vital autonomy. The Sunshine Act mandates that medical product companies report to the Federal government any payment or “items of value” that total $10 or more and are provided to an individual physician over the course of one year. The law also applies to “indirect transfers.” For example, when a drug company pays money to a marketing firm and then expects the group to provide something of value to doctors.
• One of the central tenets of professional autonomy and responsibility is the act of self-regulation. There’s a historical expectation that prestige professions like law, medicine, and accounting weren’t just afforded certain privileges merely by virtue of their specialized knowledge. It’s also their commitment to certain principles of impartial service that prompted society to entrust these professions. There was a time when the Hippocratic oath meant something tangible. Now the only professional currency that counts is what gets codified into federal regulation.
• Underneath the imposition of the Sunshine Act is a far more troubling revelation: Washington has little faith in American physicians, and sees a need and a license to regulate just about every aspect of medical practice, even trinkets doctors receive. There’s a clear view that doctors can’t be trusted to have any financial interactions with drug and device makers, no matter how small or simple these transactions. A free mug is as likely to influence a physician’s judgment as a $50,000 consulting fee.
• As full implementation of the Sunshine Act begins, the law’s provisions are already having some predictable but regrettable consequences to the broader enterprise of medicine and science. Because monetary and criminal penalties attach to lapses in compliance, drug and device companies are interpreting the provisions with no frills. They are often lumping valuable scientific consulting work with sales and marketing activities (like paid speeches given to other doctors) that the law’s architects always viewed with more suspicion. I have seen my own scientific consulting relationships constrained or curtailed as a result of this law.
• Companies are ending a lot of very useful dealings. For example, the number of investigator-sponsored studies (where drug companies pay doctors to do small scale, exploratory clinical studies) has plummeted. Barred from recognizing the full economic value of their expertise through consulting work, some providers will seek other endeavors where their skills will be put to less useful purposes.

Washington Post: Federal health-care subsidies may be too high or too low for more than 1 million Americans

• The government may be paying incorrect subsidies to more than 1 million Americans for their health plans in the new federal insurance marketplace and has been unable so far to fix the errors, according to internal documents and three people familiar with the situation.
• The problem means that potentially hundreds of thousands of people are receiving bigger subsidies than they deserve. They are part of a large group of Americans who listed incomes on their insurance applications that differ significantly — either too low or too high — from those on file with the Internal Revenue Service, documents show.
• The income information is significant because the government for the first time is providing subsidies to help working-class and middle-class Americans buy private health plans. Under the federal rules, an application is “flagged” for special checking if the income someone says that they expect this year is at least 10 percent above or below the most recent income in their IRS tax returns.
• According to various recent internal documents, income discrepancies are the most frequent kind of inconsistencies among insurance applicants, and they exist on 1.1 million to 1.5 million out of nearly 4 million inconsistencies overall. Of the total inconsistencies, the documents show, consumers have uploaded or mailed in about 650,000 pieces of “proof” — or for about one inconsistency in six.

Politico: Politico poll shows mounting danger for Dems

• Among these critical voters, Obama’s job approval is a perilous 40 percent, and nearly half say they favor outright repeal of the Affordable Care Act. Sixty percent say they believe the debate over the law is not over, compared with 39 percent who echo the president’s position and say the ACA debate has effectively concluded.
• But none of those issues comes close to approaching health care as a major concern for midterm voters. Nearly nine in 10 respondents said that the health care law would be important to determining their vote, including 49 percent who said it would be very important. By comparison, only 28 percent said that immigration reform was “very important” to determining their vote, and 16 percent who said the same of male-female income disparity.
• Among voters who had an opinion of the ACA, the electorate was almost exactly split between those who want to repeal the law entirely and those who favor either leaving it alone or keeping it in place with modifications.
• Forty-eight percent of respondents endorsed repeal, versus 35 percent who wanted to modify the law without repealing it and just 16 percent who said it should be left unchanged.

New York Times: Poorer Health of Surgery Patients on Medicaid May Alter Law's Bottom Line

• Surgery patients covered by Medicaid arrive at the hospital in worse health, experience more complications, stay longer and cost more than patients with private insurance, a new study has found. The study, by researchers at the University of Michigan, may offer a preview of what to expect as millions of uninsured people qualify for Medicaid under the Affordable Care Act…[the study found]:
  • In the month after their operations, the Medicaid patients had two-thirds more complications and were more than twice as likely to die, compared with those on private insurance.
  • Medicaid patients typically needed extra time in the hospital — three days, on average, rather than two — and were more likely to return after going home from surgery.
  • Medicaid patients “had more emergency operations and used 50 percent more hospital resources than patients with other kinds of insurance.”

New York Times: Medicine's Top Earners Are Not the M.D.s

• THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.
• That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.
• The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.
• And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.