COMMENTARY

What Obama Didn't Say -- The Supportive Position

Robert W. Morrow, MD

Disclosures

January 26, 2011

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The State of the Union Address From the Liberal Viewpoint

Hi. This is Dr. Bob Morrow. I'm a family physician in the Bronx. I am part of the faculty of the Department of Family and Social Medicine at the Albert Einstein College of Medicine. I have been asked by Medscape to make some comments from the liberal point of view, if you will, about President Obama's State of the Union Address. Thank you for coming.

What Wasn't Said Was More Interesting

On the whole, what the president said was interesting, but what he didn't say was even more interesting. The first thing that was obvious was his sense that "Yes, we've passed this. Some people don't like it, but we're going to go ahead and implement this." In fact as he said that, it became clear that the major portions of the implementation (the start) are already in place, making it possible for tens of millions to get health insurance, extending funds to states for Medicaid support so it doesn't collapse, and in general setting up institutes, which are going to advance the interests of those of us who care for patients, and for our patients.

The Patient-Centered Outcome Research Institute: Home to CER

Let me start with some of the earlier events that he didn't even have to bother mentioning. One was the establishment of clear comparative effectiveness structures. This has been in the hands of the Agency for Healthcare Research and Quality and is going to be transferred to an organization, which is a separate institute called the "Patient-Centered Outcome Research Institute." This is already in place. The board has been chosen and they have started to meet. They will hand out fairly large sums of research money to look at what works and what doesn't work, and 12% of that money has been set aside for implementation. By implementation we mean how do you apply these effective strategies for therapy in our patient population? This is money that is largely for research in educational methods.

The National Institutes of Health have also been authorized to put 12% of their budgets towards implementation science. How do you make these things work? This is wonderful for primary care because now we can talk to our patients and our specialist colleagues about what is effective and what is not, and have a solid, neutral research base to lean on. As I've been saying over the last few months, clearly primary care has seized the moral high ground in healthcare, and it's time for us to seize the intellectual high ground. What is effective? How can we do it? This brings us to the issue of primary care.

Seed Money for Developing New Pharmaceuticals Based on Need

Before I leave the institutes, I should also mention that our pharmaceutical industry has been unable to come up with any good new drugs lately, and so an institute and seed money for the development of new pharmaceuticals, based on need and not on profit, has been set up by the Obama administration. This is something that will not be stopped, and it's something that will enable us to develop new medications so that we can have things like the new $5 meningitis vaccine for Africa and those developments available to everybody.

Funding for Primary Care: Recognition at Last

Just as the Obama administration prevented the collapse of research institutes and research establishments during our recent massive recession by adding funds for extra projects, monies are now being funneled into primary care, showing recognition that primary care makes up the base of an efficient and effective healthcare system. I like to say "Behold, it's a great mystery that if you invest more money in primary care, the cost of everything else goes down." We have plenty of experience of this in the United States and massive experience from abroad. Investing in primary care makes it possible for the neighborhood health centers and the federally qualified health centers to do better and to become educational centers. Hundreds of millions of dollars will be invested in more residency slots, and more training for nurse practitioners and physician's assistants. These funds have been allocated and are being put to active use at this time. President Obama didn't have to mention it, because it's going to happen. It was wise of him to not harp on this victory, because everybody likes it. Why make it a political football?

Of course perhaps some of our specialist friends don't like it, because for many years, they have been encouraging their organizations to get them pay at 5, 6, or 7 times that of primary care. Although none of us would object to them being paid at 1.5- 2 times what primary care receives, our current disparities, which are new over the last 15 years, are really dragging down the interest of students in primary care.

The Numbers of Primary Care Doctors Are Increasing!

Lo and behold, this year not only do we have more residents from the United States applying for our family medicine residencies -- and wherever I speak, the people who are doing the interviews are saying they're getting great students to apply -- but in addition I am told that, after a small decline, the American Academy of Family Physicians now has more members than ever in its history. This is at a time when doctors are busy; doctors don't have money in their pockets to pay for dues, and yet the importance of primary care being promulgated not only by our health researchers but by the federal government has led to a tremendous resurgence and interest in the base of the healthcare of this country being the primary care physicians. It's really easy to underestimate this. I've watched the number of medical students interested in primary care go up and down in waves over the years, but the truth of the matter is that we are going to be doing a great deal better because of this administration.

What's Wrong About the Accountable Care Act?

So, are there things we didn't like about the new Accountable Care Act? Absolutely, it was a political mess getting it through. We lost single payor. We lost the ability to have a government-funded health service like Medicare. However, if we look objectively at the circumstances, Medicare and Medicaid and the Veteran's system and the military system make up a huge swath of healthcare in the United States, certainly the majority, and our commercial sectors are going to be shrinking. They have been limited again by this act to 85% loss ratios, and this means that their profits can't be in the 30% range. They're going to be pushed down to a much lower range. This will mean much less interest in investors in for-profit healthcare and much more interest in the public health sector taking over how the monies are spent in the public sector.

What Obama Did Say: Liability Reform

This brings us to the issue that came as a surprise to many of us in President Obama's State of the Union address, which is the issue of liability reform. This has been one of the major issues of the Republicans, who beat up on health reform by saying, "We don't need health reform; we just need liability reform." Well, he seems to have taken that prop out from under them by saying "Sure, let's do that." I must say, that although everybody has the right to redress for their injuries, it's clear that most people who are injured in health services are not paid for their injuries. On the other hand, I'm paying $5 a visit for my $19,000-a-year liability policy as a family physician. This is not a good use of resources. It seems to me that we could spend that $19,000 dollars on better education for our healthcare provider base, and maybe use a little bit of that money to design programs for those who are performing poorly and making mistakes to correct those mistakes. We don't make airplane pilots pay a huge insurance fee if one of them crashes a plane. We make them all learn how to not crash the plane. Liability reform would be a wonderful thing, and that's now being offered to Congress by President Obama.

Summary

All in all, what was not mentioned were the things that are going to happen, and these are marvelous things: the increase in the research base, the emphasis on primary care, the setting up of institutes, which will fund implementation science, and the taking over to some degree of changes in the liability system. These are all wonderful things. Could we have had more? Of course we could have had more, but I'm really interested in your comments. Give us a line so that we can all respond to each other, and let's see where this is all going. Thank you very much. This is Bob Morrow, a family physician in the Bronx.

I should mention I have a small grant to implement comparative effectiveness research and to disseminate that out through networks of peer educators, and that I am on the faculty of the Albert Einstein College of Medicine and part of the Center of Continuing Medical Education as the Associate Director of Interventional CME. Thanks very much for your time.

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