DOs adopt wait-and-see attitude toward stimulus act

Days before President Barack Obama signed the American Recovery and Reinvestment Act of 2009, several health care-related provisions of the legislation provoked a wave of disapproval, even outrage, from physicians and other health care professionals across the country.

The reaction was swift, fueled by political punditry on talk radio, impassioned commentaries splashed across the editorial pages of major newspapers and a deafening roar of criticism that echoed across the blogosphere.

Signed into law on Feb. 17, the $787 billion stimulus act earmarks roughly $19 billion to promote the development and adoption of health information technology and another $500 million for primary care training programs. But it is the act's $1.1 billion for comparative effectiveness research that has provoked fears that Big Brother is knocking at the door.

In a Feb. 9 commentary on Bloomberg.com headlined "Ruin Your Health With the Obama Stimulus Plan," former New York lieutenant governor Betsy McCaughey warned that the legislation will lead to federal monitoring "to make sure your doctor is doing what the federal government deems appropriate and cost effective."

During his Feb. 10 radio show, Rush Limbaugh fumed, "[Y]our doctor is going to have to consult either a book, a computer program, or maybe even make a phone call to find out what kind of treatment you can get and how much to charge for it based on how much the government's going to reimburse for it."

An op-ed published in the Feb. 5 issue of the Washington Times cautioned readers that the plan will "hand over decisions about your care to a group of bureaucrats."

So far, such dread is unfounded, says former AOA president Marcelino Oliva, DO.

"Many physicians are concerned that the government is going to build a huge data warehouse where it mines everyone's health information," says Dr. Oliva, who chairs the AOA Bureau of Federal Health Programs. "Physicians are going to continue to submit electronic claims just as they have for the past 15 years, and information will be collected from those claim forms just as it has been for the past 15 years. This is nothing new."

Advocating for DOs

Although the AOA did not take any formal position on the legislation, the association weighed in on provisions of the bill related to training for primary care physicians, prevention and wellness, health information technology and comparative effectiveness research.

"On each of these issues, the AOA has extensive long-standing policy established by our House of Delegates. Our comments were based on these policies, not on political views or ideology," explains AOA Executive Director John B. Crosby, JD. (To hear more from Crosby about the stimulus package, visit the AOA's YouTube channel, found at www.youtube.com/americanosteopathic.)

"Regardless of whether you agree with the provisions set forth in the act, it is great to see our federal government make such a huge investment in the health care system," says Paul A. Martin, DO, who serves on the AOA Bureau of Federal Health Programs the AOA Joint Committee on Quality and Reimbursement. "Normally, health care doesn't get such big play on Capitol Hill other than at the end of the year, when lawmakers are forced to step in before Medicare reimbursements are slashed."

The American Recovery and Reinvestment Act is only the first step in what is sure to be a long journey on the road to health care reform, points out Dr. Oliva. "This is the beginning of a long process, and no particular bill is going to be the endpoint," he says. "During the coming months and years, the AOA will continue to work with lawmakers in Washington to protect the interests of our physicians and their patients."

Regulating research

In one of its most controversial provisions, the American Recovery and Reinvestment Act allocates $1.1 billion to establish a federal council to coordinate comparative effectiveness and related health research across several federal agencies and departments.

Theoretically, by comparing the clinical outcomes of treatments, physicians can improve efficiency and patient care. However, some physicians worry that compiling such research could ultimately limit the medical treatments available to patients.

"Even though the research will have no direct impact on payment and reimbursement, there are concerns that it could pose a threat for physicians and patients down the road," says Dr. Juhasz, who serves as the AOA's liaison to the U.S. Preventive Service Task Force. "If a government body decides that treatment X is not effective, insurers might decide not to pay for the treatment anymore."

The federal government, Dr. Martin says, "is going to need to establish clear guidelines about how this information is compiled and how it will be used."

Responding to concerns that the bill would allow research to be used for insurance coverage and benefit design, the AOA urged lawmakers to stipulate that the data can only be used to educate physicians on the efficacy and efficiency of treatment modalities.

"The strengthening language that was added ensures that the coordinating council will not be able to make recommendations on benefits and coverage based on the research," explains Dr. Oliva. "The council can only provide data, and the data must be unbiased."

Dr. Juhasz points out that comparative effectiveness research presents a unique opportunity for the osteopathic medical profession to assess the efficacy of osteopathic manipulative treatment. "This is an opportunity for us to take some of the treatments we have used for years in our practices and document their effectiveness," he says.

Driving technology

The stimulus act will provide individual physicians up to $44,000 to offset the cost of implementing electronic medical records (EMR). The incentives will be dispersed through Medicare and Medicaid reimbursements beginning in 2011.

Although some physicians are disappointed that funding will not be provided up front through grants or other government programs, the AOA believes this provision is "a huge step in the right direction," Dr. Oliva says.

To qualify for reimbursements, physicians must be considered "meaningful" EMR users, which means they meet such criteria as tracking and reporting clinical quality measures, prescribing electronically and coordinating care. If eligible physicians do not become meaningful users by 2015, their reimbursements from Medicare and Medicaid will be reduced as a penalty.

To ease the transition, the U.S. Department of Health and Human Services will establish a set of interoperable standards for EMR systems no later than Dec. 31, 2009.

"DOs need to keep in mind that all EMR systems should be certified by the Certification Commission for Health Care Technology (CCHIT), should be interoperable and should be in operation by 2015," Dr. Martin says. "It does no good to have each physician operating on an island, so the systems need to be able to communicate with each other."

Less than 20% of the nation's physicians are using EMR systems, according to a survey published in the July 3, 2008, issue of The New England Journal of Medicine. "Many DOs, particularly primary care physicians, are in solo or small practices. As a result, they are less likely to have converted their offices," says AOA Trustee Robert S. Juhasz, DO, the medical director at the Cleveland Clinic's Willoughby Hills (Ohio) Family Health Center. "This funding will help many of those physicians make that transition."

The stimulus act's EMR spending provisions could give a boost to the patient-centered medical home model, which is strongly backed by the AOA and several other national health care associations. Part of the model's success will depend on physician adoption of EMR systems, according to AOA 3rd Vice President Joseph A. Giaimo, DO. "For primary care physicians to coordinate care with specialists, hospitals, pharmacies and other health care providers, they will need immediate access to all medical information for each of their patients," he says.

However, some DOs are hesitant to convert their paper-based offices to electronic systems just yet, acknowledges Dr. Giaimo. "I have a lot of concerns about how the government is going to decide what kind of systems will be eligible for the incentives and what makes someone a 'meaningful' user," says Dr. Giaimo, who converted to an EMR system a little more than a year ago. "Choosing an EMR system is a huge commitment. It's something most physicians can only afford to do once."

Focus on primary care

A study published in the Sept. 10, 2008, issue of JAMA: The Journal of the American Medical Association indicated that only 2% of allopathic medical students surveyed planned to practice general internal medicine. To address such shortages in the primary care physician workforce, the stimulus act provides $500 million for primary care education and training programs through the National Health Service Corps and other pathways.

"By including this funding in the stimulus package, lawmakers are responding to the call for more primary care physicians," says Dr. Oliva, a retired family physician from Dade City, Fla. "This is a great first step toward heading off a physician shortage in coming years."

Although he would have liked to see more money set aside, Dr. Juhasz calls the investment "a great opportunity for our physicians and osteopathic medical students."

Moreover, this provision will build support for the patient-centered medical home, Dr. Juhasz says. Taking a team approach to providing care, the medical home designates primary care physicians as team leaders who arrange, coordinate and monitor all treatments provided by medical specialists, nonphysician clinicians and other health care professionals.

"Of course, primary care physicians are going to play an integral role in the medical homes, so we need to make sure we have the funding and programs in place to train them," Dr. Juhasz says.

Looking ahead

While additional guidelines are being developed for several of the health care-related provisions of the stimulus bill, Dr. Giamo says he will keep an open mind about how the legislation will ultimately impact his practice.

"We are still waiting to hear many of the details," he says. "Only time will tell how this bill will affect physicians and patients."