Questions That Expert Docs Want to Ask the White House

George Bakris, MD; Jeffrey S. Berns, MD; Robert M. Centor, MD; Jeptha P. Curtis, MD; David C. Dale, MD; Murray Epstein, MD; Desiree Lie, MD, MSE; David J. Maron, MD; Ileana L. Piña, MD; Daniel Z. Sands, MD, MPH; Mark E. Williams, MD; Charles P. Vega, MD; Howard Weintraub, MD


January 27, 2011

Medscape was invited by the White House to participate in a roundtable 2 days following the January 25th State of the Union Address. We were allowed 3 questions, so we decided to poll some of our advisors to find out what questions they would ask. Surprisingly, no one had the same questions and we thought they were thoughtful and might be of interest to our readers.

George Bakris, MD (Nephrologist)
Most hypertensive patients have never been talked to about salt restriction. Nobody asks about family history or kidney disease. This needs to change. We need to educate all patients about risk factor management. We need more research on the difference that risk management and risk reduction makes in all communities -- not just initiatives in high-risk urban areas, where some funding is currently being spent. Are there plans for doing this?

Jeffrey S. Berns, MD (Nephrologist)
The 3-year results of the Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Prospective Payment System were recently released.[1] How does the administration interpret these results, and what are the implications for improving care and constraining costs related to the care for ESRD patients?

Robert M. Centor, MD (Internist)
Does the administration recognize the different levels of primary care? Especially, does it understand the role of internists in providing complex, comprehensive care with continuity?

Will they consider a drastic revision of the payment system. See Uwe Reinhardt's excellent blogs in The New York Times about the irrationality of the resource-based relative value scale and the Relative Value Update Committee.[2,3]

Jeptha P. Curtis, MD (Cardiologist)
I think the assumptions about methods to reduce healthcare costs are overly optimistic. Given that the plan is touted as budget neutral or positive, I would like to understand what the administration plans to do if costs cannot be contained.

David C. Dale, MD (Internal Medicine)
Given the tension between access to care and the cost of healthcare in the United States, somehow we have to rein in costs without sacrificing access or choice. How can we do this?

We are not training enough primary care physicians to meet the nation's need and probably not enough nurse clinicians either. We are draining less developed countries to support this national need. It is getting worse. What are we going to do?

We are requiring residents to work less, and we are graduating more medical students. The proposed federal budgets call for reduced expenditures on graduate medical education (GME). How do we assure the public that new doctors will be truly well-trained and that enough will be trained if we cut GME budgets?

Murray Epstein, MD (Nephrologist)
How would the administration incentivize organ donation? For example, some have proposed that we legalize financial "incentives" for unrelated kidney transplants. Rather I would propose that the states create "insurance" incentives. For example, 2 years free insurance for those who donate an organ and life-long insurance for those who become permanently disabled as a result of donation.

What do you think about the proposed bundling of dialysis services and the "unstated" reality that it confers a negative impact on patient care? In order to prevent their income from dwindling, most dialysis providers will resort to low quality and cheap (and often less efficacious) drugs, medical products and dialysis materials.

Since the Accountable Care Organization concept is new to most participants in American medicine, how does the administration see CMS assisting organizations to prepare and implement this delivery system?

Desiree Lie, MD, MSE (Family Medicine)
What are the administration's concrete plans for expanding the manpower base for health professionals in terms of training more physicians and physician extenders?

What is the current state of the pay-for-performance, outcomes-oriented approach for health reform? What more can be expected?

Give us 3 major changes out of CMS in the next 1 year that you expect will affect healthcare providers?

Ileana L. Piña, MD (Cardiology)
How can we change of the culture of 1 patient-1 doctor to 1 patient and a team that works together and cares?

How can we get insurers to understand that hospitalization is really one long office visit from admission to follow-up in the office after discharge?

Daniel Z. Sands, MD, MPH (Internal Medicine)
While we understand how the future world of reimbursement is supposed to work, with payment for quality and not quantity, this seems a very long way off. The Patient Protection and Affordable Care Act (PPACA) only discusses this in nonspecific terms, referring to Accountable Care Organizations (ACOs) and bundled services in the future. However, even within the scope of the legislation, it seems as if not all (and perhaps very few) patients will be cared for under these arrangements -- especially since we don't care for only Medicare patients. For most patients this means that for the foreseeable future, we will still be in a fee-for-service world with the same incentives for overuse of healthcare resources. Worse than that, we will be trying to manage heterogeneous panels of patients, some of whom are in capitated arrangements and some fee-for-service. So how are we going to ever achieve the goals of paying for value rather than quantity for all patients?

Face-to-face care, while necessary in some situations, is quite expensive and not always practical. How will physicians be reimbursed for nonvisit-based care, such as that delivered through e-messaging, telemedicine, and other care-at-a-distance technologies?

Do you think that, through cultural shift or legislation, we will ever get to the point at which patients are viewed and treated as full partners in their care, which includes permitting them full online access to their medical records?

David J. Maron, MD (Cardiologist)
I would like to know how incentives will be changed from the current predominantly fee-for-service reward system to encourage physicians to provide cost-effective, evidence-based, patient-centered care.

Charles P. Vega, MD (Family Medicine)
Defunding of the Affordable Care Act would be a complicated process. What does the Obama administration health team foresee in terms of active opposition to the law, and what measures are they taking to counteract these challenges?

Howard Weintraub, MD (Cardiologist)
Our president said that he believes in prevention and characterizes these efforts as making sure that people get flu shots and have mammographies. I think that we must look beyond those steps and consider what we are going to do about cardiovascular disease, which is going to claim the lives of nearly 40% of the adults in this country. There has to be greater emphasis on promoting measures that can reduce mortality and the incidence of nonfatal myocardial infarction and stroke.

Mark E. Williams, MD (Internal Medicine)
The new healthcare program greatly expands access to care for most Americans (which in my opinion is terrific). However, given this expansion, in what ways will it reduce the costs of healthcare?


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