Shutdown Imperils Public Health and Doc Fix, Societies Say

October 03, 2013

The partial government shutdown of 2013, now in its third day, has not yet affected the everyday practice of medicine, but it has begun to gnaw away at the nation's public health infrastructure, and that's worrisome, say leaders of organized medicine.

Case in point: Right at the onset of the 2013–2014 influenza season, the shutdown caused the Centers for Disease Control and Prevention (CDC) to furlough employees who run its seasonal flu program, which detects outbreaks, identifies virus strains, and tracks flu-related illness and mortality. As a result, physicians will battle influenza without the program's intelligence, at least for now.

"It's a shame," said Charles Cutler, MD, who chairs the Board of Regents of the American College of Physicians (ACP). "It's worse than a shame. It's a disgrace.

"This is the public health of the country. We need to know where the outbreaks are, what it's doing in our community."

These concerns appear to be lost in the din of political acrimony as a new fiscal year for the federal government arrived on October 1 without any cash. The Republican-controlled House has repeatedly passed appropriation bills with crippling provisions for the Affordable Care Act (ACA) only to meet granite resistance from the Democrat-controlled Senate and President Barack Obama, who say government funding should not be held hostage to ACA animus. Congressional leaders met with Obama last night to discuss how to break the stalemate, but nobody budged.

"There's such partisanship," said a frustrated Reid Blackwelder, MD, president of the American Academy of Family Physicians (AAFP) in an interview with Medscape Medical News. "I don't know what happens to the art of compromise."

Skeleton Crews Protecting the Nation's Health

In the meantime, the federal government is executing its playbook for a partial shutdown. It has spared what are deemed essential services, such as mail delivery and Social Security and Medicare benefits — Medicare reimbursement for physicians, too — while closing national parks, halting routine Environmental Protection Agency inspections of drinking water systems, and holding up permits for transportation projects.

Ironically, one part of the federal government that continues to operate unscathed is the collection of state-by-state online marketplaces, or exchanges, where Americans can buy subsidized health insurance under the ACA. Those exchanges debuted October 1 only to malfunction frequently owing to high traffic and software glitches. Obama promises that with some fine-tuning, the exchanges will work better in the future.

The ACA aside, the government's healthcare operations took a big hit on Tuesday. The Department of Health and Human Services (HHS) furloughed almost 41,000 employees — 52% of its workforce — with far-reaching consequences for a panoply of agencies, as explained in the department's shutdown plan:

National Institutes of Health (NIH): Patients enrolled in existing NIH clinical trials will continue to receive care, but NIH will not admit new patients, initiate new trials, or act on grant applications or awards. The American Society of Clinical Oncology (ASCO) is alarmed about what this means to patients with cancer looking for a cure. "We are deeply concerned that as a result of the government shutdown, roughly 200 patients with cancer per week, including children, will not be able to participate in clinical trials at the National Institutes of Health Clinical Center in Bethesda, MD," said ASCO president Clifford Hudis, MD, in a news release.

House Republicans passed a measure yesterday that would restore NIH funding, but Senate Democrats today blocked it, objecting to what they call a piecemeal approach to funding the government. The White House took the same position.

Food and Drug Administration (FDA): The agency is staffed for emergencies and "high-risk recalls," but not for most of its food safety, nutrition, and cosmetics activities, or the majority of its laboratory research. The AAFP's Dr. Blackwelder wonders whether a skeleton-crew FDA can adequately respond to a crisis, such as last year's outbreak of fungal meningitis that was traced back to contaminated steroid injections from a Massachusetts compounding pharmacy.

"Who's to say something like this won't happen during the shutdown?" Dr. Blackwelder told Medscape Medical News.

Health Resources and Services Administration (HRSA): The sprawling agency has halted payments to residency programs at children's hospitals. Thomas McInerney, MD, president of the American Academy of Pediatrics, said in a news release that this and other healthcare cutbacks put kids and families at risk. "Our children deserve better than this," Dr. McInerney said.

HRSA will continue to operate the National Practitioner Data Bank, which collects information on jury awards and settlements in malpractice cases.

The Office of the National Coordinator for Health Information Technology (ONC): Furloughs here could jeopardize physicians qualifying for bonuses or avoiding penalties in an HHS program that promotes "meaningful use" of electronic health record (EHR) systems. To satisfying meaningful-use requirements, physicians must deploy an EHR system certified by ONC. That vetting has been suspended at a time when vendors are trying to get their products approved for a second stage of meaningful-use requirements that takes effect next year.

CDC: The effects of the shutdown on this healthcare watchdog perhaps are the most unsettling to clinicians — after all, viruses and bacteria do not belong to political parties. According to the HHS shutdown plan, the CDC will have "significantly reduced capacity to respond to outbreak investigations, processing of lab samples, and maintaining the agency's 24/7 operations center."

The suspension of the seasonal influenza program exemplifies this retrenchment. The CDC was scheduled to post its first weekly "FluView" report about the 2013–2014 influenza season on its Web site on October 11. However, agency spokesperson Barbara Reynolds, PhD, told Medscape Medical News that FluView data aren't being compiled as a result of furloughs.

"Expect delays," said Dr. Reynolds. "So sorry to have to tell you that."

Dr. Blackwelder said that physicians depend on FluView reports to guide patient care and make a more compelling case to get vaccinated. He pointed to his own practice in Kingsport, Tennessee, in the eastern part of the state.

"It's one thing to say, 'Did you get your flu shot?' It's another to say, 'We're noticing that in Tennessee, the western part of the state has already started seeing a dramatic increase [in flu-related illness]. It means we're likely to see it soon. Now is the time to get your flu shot.' "

Will the Doc Fix Go Off the Radar of Congress?

While the behind-the-scenes work of the CDC and other agencies suffers, the shutdown has caused nary a ripple so far for the average physician, by all accounts.

"I'm unaware of any problems," said Dr. Cutler. "Doctors are seeing their patients."

Practice management consultant Judy Capko in San Francisco, California, told Medscape Medical News that she was at an orthopedic practice yesterday, and "they were totally unfazed."

"We're not hearing anything from our members except anxiety," said Dr. Blackwelder at the AAFP.

The anxiety, he said, has been first and foremost about getting paid by Medicare and Medicaid. His medical association has attempted to reassure members with the facts.

Medicaid is safe. Jointly funded by the federal government and states and administered on the state level, it will keep chugging along during the shutdown. State Medicaid programs received their federal payments for the new fiscal year before October 1, according to HHS.

And Medicare continues to cut checks to physicians, just as it did during the last government shutdown in December 1995 and January 1996. The Centers for Medicare & Medicaid Services (CMS) doesn't depend on Congress to appropriate money to reimburse providers because those funds come from Medicare trust funds.

In contrast, the private companies called Medicare administrative contractors (MACs) that process and pay claims on behalf of CMS are paid from the agency's operational budget, which Congress controls. Interrupted cash flow for MACs in the last shutdown did not keep physicians from getting paid, however, because the companies did their work on a credit basis for CMS, expecting the agency to catch up later.

Perhaps not surprisingly, CMS announced on Tuesday that the MACs would continue processing and paying claims during the duration of the current shutdown.

That announcement provided short-term comfort, but organized medicine is worried about the shutdown's long-term impact on Medicare reimbursement. After all, physicians face a 24.7% pay cut on January 1 dictated by the program's sustainable growth rate (SGR) formula unless Congress acts to avert it. Similar cuts in the past have been merely postponed. A bill with rare bipartisan support in the House would repeal the 16-year-old SGR formula, provide 0.5% annual raises from 2014 to 2018, and then introduce pay-for-performance requirements.

Physicians have high hopes for Congress to enact this "doc fix," but Dr. Cutler and Dr. Blackwelder both warn that the legislation could languish from inattention, not only during the shutdown crisis but also because of the expected battle over raising the federal debt ceiling later this month. The result could be just another 1-year delay of a massive Medicare rate reduction, and more angst for physicians.

"We're now extremely concerned," said Dr. Blackwelder. "Discussions have been diverted from that critical issue. All of a sudden, the SGR fix as a repeal-and-replace option is much less likely." The odds decrease, he said, as the congressional civil war continues.

Dr. Cutler agrees.

"The last few days have jeopardized a solution to the SGR impasse," he said. "The longer the shutdown goes on, the less focused Congress is in solving the problem."

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