Policies and legislation passed on Capitol Hill directly affect physicians around the country in their practices and their ability to care for patients. OPAC supports those candidates who support osteopathic physicians by taking a stand on important issues.
Below are a few key issues physicians face everyday.
Medical Liability Reform
Medicare Physician Payment
Graduate Medical Education
Scope of Practice
Student Loan Interest Deduction
For more detailed information on key issues affecting osteopathic physicians click here.
Medical Liability Reform
The medical liability crisis represents the greatest challenge to our nation’s health care delivery system and must be addressed through comprehensive medical liability reform. Over the past thirty years physicians have experienced a steady increase in liability premiums. According to the National Association of Insurance Commissioners, between 1975 and 2002 medical liability premiums for physicians increased, on average, 750 percent. These premium increases are related directly to an explosion in medical liability lawsuits filed against physicians and hospitals and the rapid increase in awards paid out. The Government Accountability Office (GAO) confirms this. In a 2003 report, the GAO stated that losses on medical liability claims are the primary driver of increases in medical liability insurance premiums. Other studies have shown that on any given day there are 125,000 active lawsuits against physicians. The challenges presented by the medical liability crisis are threefold:
Limits patient access to health care services
As a result of the decreased availability and increased costs of professional liability insurance, our members are confronted by decisions that impact adversely their professional careers and patient access to care. Many are forced to limit the services they offer their patients in an attempt to secure affordable medical liability coverage. Others are forced to relocate to states with more favorable medical liability laws or simply retire from the practice of medicine altogether. Regardless of the decision, patients face decreased access to health care services. Additionally, since hospitals rely upon physicians to provide services within their institutions, a loss of physicians or decrease in physician services limits their ability to provide care to patients.
Economic impact upon the health care system
The economic impact is well documented and growing worse. In a 2002 report, the Department of Health and Human Services estimated that medical liability adds $60 billion to $100 billion to the cost of health care each year. The Congressional Budget Office (CBO) estimates that the enactment of comprehensive medical liability reforms would save the Federal government $14.9 billion over ten years. The trends in medical liability cases, in states without meaningful reforms, show no sign of improving. The average jury award, according to Jury Verdict Research, has increased 176 percent since 1994. The average jury award is now $3.9 million. Fifty-four percent of all awards are for $1 million or more.
Influence upon physician workforce
The influence of the medical liability crisis upon future generations of physicians is an area of great concern. In March 2004, the AOA surveyed osteopathic medical students to determine the impact of the crisis upon their career decisions. The results are startling. 82 percent told us that the cost and availability of medical liability insurance would influence their future specialty, while 86 percent stated that it would influence their decision on where to establish a practice once their training is complete. Additionally, 98 percent told us that medical liability would influence their future career decisions, 73 percent stated that it would have a significant influence. These statistics demonstrate the significant negative impact the crisis has upon medical students.
Reforms Work
Texas was once one of the worst states for medical liability lawsuit abuse, with physicians facing limited availability in the insurance market. In 2002, only 4 companies were writing policies for physicians and hospitals in the state. Since the enactment of comprehensive medical liability reforms, over 30 companies have begun writing policies in Texas and physicians across the state have seen actual decreases in their insurance premiums. As a result, over 3,000 physicians have established practices in Texas and patients across the state have improved access to physician services. Texas and states with similar laws are proof that comprehensive medical liability reforms work.
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Medicare Physican Payment
The use of the flawed and inequitable sustainable growth rate (SGR) in the Medicare physician payment formula should be eliminated and replaced with a payment formula that accurately compensates physicians for their services, reflects the costs of providing care, and is adjusted annually based upon inflation.
The current Medicare physician payment formula poses a long-term threat to patient access to physician services. According to the Medicare Trustees, physicians will see their reimbursements reduced by 4 percent to 5 percent per year through 2012—potentially resulting in cuts of 20 percent or greater over the next six years. The continued use of the unstable and unpredictable SGR formula may lead to decreased participation in the Medicare program by physicians.
Additional cuts in Medicare physician payments potentially threaten beneficiary access to care as a result of physicians limiting the number of Medicare beneficiaries in their practice or physicians refusing to participate in the Medicare program all together. It is widely agreed that cuts of this severity will decrease the ability of Medicare beneficiaries to access physician services. A MedPAC survey conducted earlier this year found that 22 percent of Medicare beneficiaries reported having difficulties obtaining an appointment with a primary care physician. Access problems are not limited to primary care specialties. Other studies demonstrate that beneficiaries face decreased access to surgeons of all types. Access problem such as this will only increase if additional cuts are implemented.
Additionally, reduced payments hamper the ability of physicians to purchase and implement new technologies in their practices. According to a 2005 study published in Health Affairs, the average costs of implementing electronic health records was $44,000 per full-time equivalent provider, with ongoing costs of $8,500 per provider per year for maintenance of the system. This is not an insignificant investment. When facing deep reductions in reimbursements, it is safe to project that physicians will be prohibited financially from adopting and implementing new technologies.
Physicians are the only Medicare providers subjected to the flawed SGR formula. The SGR, which is tied to the gross domestic product (GDP) and other flawed methodologies, produces negative updates based upon economic factors unrelated to the health care needs of beneficiaries or physicians’ costs of providing care. Physicians are the only Medicare providers that do not receive positive updates based upon a formula that reflects increases in practice costs. In 2006, other Medicare providers received positive payment updates ranging from 2.5 percent to 4.8 percent.
It should be recognized that the average physician practice is a small business. According to a 2004 Health Affairs study, more than half of all practicing physicians are in practices of three or fewer physicians. Three-quarters are in practices of eight or fewer. These are small businesses. They face the same economic barriers as every other small business in America—increased overhead, rising health insurance costs, rising liability insurance costs, and rising costs for support staff. When facing deep reductions in reimbursements at the same time that their operational costs are increasing, it is safe to project that most businesses will not be able to continue operation.
Physician payments should reflect increases in practice costs. In its 2006 March Report to Congress, MedPAC stated that payments for physicians in 2007 should be increased 2.8 percent. Since 2001, MedPAC has recommended that the flawed SGR formula be replaced by a formula based upon increases in physician practice costs minus a productivity adjustment, which would produce annual updates equal to the Medicare Medical Economic Index (MEI).
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Graduate Medical Education
Supervising physicians should be allowed to volunteer their teaching time and any teaching costs associated with supervising physicians who are not volunteers should be based on negotiations between the hospital and the non-hospital setting, rather than a complicated formula requiring unreasonable administrative burdens on both the teaching programs and non-hospital training settings.
Recent rule-making and guidance by the Centers for Medicare and Medicaid Services (CMS) are creating a chilling effect on residency training programs in non-hospital settings where most ambulatory training occurs. These sites include physician offices, nursing homes, and community health centers – cornerstones of ambulatory training for graduate medical education programs.
Since 2002, CMS intermediaries have begun denying, retroactively through audits, the time residents spend in non-hospital settings where faculty are volunteering their services or are receiving nominal payments. This has the effect of reducing, by large amounts, the Medicare Indirect Medical Education (IME) and Direct Graduate Medical Education (DGME) payments a hospital or teaching program receives for residents training in non-hospital settings. This is particularly a concern for osteopathic and allopathic family medicine residency programs that utilize a large proportion of ambulatory training in their educational programs. Other specialties that promote community ambulatory training, such as internal medicine, pediatrics, OB/GYN, surgery, and others also are affected.
CMS’s actions are in direct conflict with Congressional intent expressed in provisions of the 1997 and 1999 balanced budget acts, which were designed to encourage rural and out-of-hospital experiences. If CMS current policy is not halted, resident physicians will have less opportunity to train in diverse community settings. In fact, some programs, particularly in rural and underserved areas may close. Allowing hospitals to receive payments for the time residents’ train in a non-hospital setting is sound educational policy and a worthwhile public policy goal that Congress clearly mandated in 1997.
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Scope of Practice
Nurse practitioners, physician assistants, certified nurse midwives, certified registered nurse anesthetists, chiropractors, naturopaths, acupuncturists, homeopaths, optometrists, podiatrists, psychologists, pharmacists, physical therapists, occupational therapists and numerous other non-physician clinicians have unique and valid roles in providing healthcare. In recent years, the growth of these non-physician clinicians has been significant. This growth is due in part to public demand, an expanded healthcare market, changes in state laws regarding these professions, and an increase in the number of non-physician clinicians being trained.
Today, non-physician clinicians are seeking expanded scopes of practice and other increased rights - into areas traditionally reserved for physicians. Many non-physician clinicians have succeeded in attaining new rights in a number of these areas. Specifically, non-physician clinicians have succeeded in increasing their autonomy, scopes of practice, prescriptive rights, and direct reimbursement from third party payors. However, there are disturbing inconsistencies in the manner in which these rights have been expanded.
Patient Care and Safety
The practice of medicine and the quality of medical care are the responsibility of properly licensed physicians. As the DO/MD medical model has proven its ability to provide professionals with complete medical education and training, their leadership in such an approach is logical and most appropriate. Further, the states' medical boards confirm the appropriateness of the medical model by utilizing it for medical licensure requirements.
Non-physicians are currently seeking roles that increasingly overlap with the activities of a physician. Too often at the state level, expanded rights of non-physician clinicians become "turf battles" with other professions - including physicians - where political maneuvering and other personal biases lead to decisions on non-physician clinician practice rights that directly affect patients' lives. Such a formula for making these decisions is not based on empirical evidence proving patient safety, but rather the professional aspirations of non-physician clinicians and their ability to persuade state and federal legislatures and regulatory authorities. Public policy dictates patient safety and proper patient care should be foremost in mind when the issues encompassing expanded practice rights for non-physician clinicians - autonomy, scopes of practice, prescriptive rights, liability and reimbursement, among others - are addressed.
In the healthcare marketplace, a physician's board certification may be considered one of the highest standards an individual physician can achieve in a particular specialty or subspecialty. Today, many hospitals and managed care organizations are requiring board certification for employment of physicians. In addition, state medical boards are likewise beginning to look at increasing the number of postgraduate training years required for physician licensure. While these higher standards are being placed on physicians, the same scrutiny is not faced by non-physician clinicians, in spite of the fact that at the same time they are asking for and receiving increased scopes of practice.
However, many non-physician clinician professions themselves are beginning to recognize the need for proper instruction and training levels in the education of their professionals. For example, many of these professions are moving towards master's level requirements for accreditation purposes, and some are requiring continuing education for licensure purposes. As professions seek expanded roles in the delivery of healthcare, these professions' educational curricula, training, examination, and licensure should likewise expand to match the level of care they wish to provide patients within the "team" framework.
Independent Practice
Certain non-physician clinician professional groups, including some groups who traditionally have worked under the supervision of physicians, such as nurses, are currently seeking roles in the delivery of healthcare without any physician involvement. These individuals and groups seek to completely separate their role from that of a physician, with little to no supervision, referral, collaboration or contact whatsoever. Many of these roles sought increasingly overlap with the traditional activity of physicians. This lack of physician involvement, again, does not appropriately attend to patient safety or proper patient care.
As patient safety and proper patient care must be the foremost concern of any healthcare professional, all non-physician clinicians should recognize and refer those patient cases that require knowledge beyond their training. Just as a family practice physician will refer a patient to a specialist when his or her illness or injury is beyond the physician's scope of expertise, so too must any non-physician clinician call upon a physician when a patient's condition warrants such action. To ignore the physician's role as the leader of the "team" approach in the delivery of healthcare is to compromise the patient's safety.
Liability
Patient safety mandates that those physicians who act as supervisors must exercise due care within this "team" approach to healthcare delivery. It is crucial to understand the delegation of duties by a physician to a non-physician clinician does not equate with the delegation of liability. Physicians, as leaders of the "team," should be held liable for the acts of those they supervise or work in collaboration with, if they fail to provide adequate and reasonable supervision.
Conversely, in the "team" model to healthcare, holding a supervising physician liable does not exonerate the non-physician clinician from liability. Non-physician clinicians are accountable for the adverse treatment decisions they make. In legal terms, both the non-physician clinician (for the adverse medical treatment) and the physician (for failure to provide adequate supervision) would be named defendants to a malpractice suit. Because these non-physician clinicians can‘t shield themselves from liability, those working under the supervision of or in collaboration with physicians should obtain their own individual malpractice insurance.
For those non-physician clinicians who desire to practice autonomously without any form of physician supervision or collaboration, there should be a corresponding exclusive, personal liability. This is because the physician would no longer operate in a supervisory capacity and therefore should not be held accountable for the acts of the independent provider. Liability for treatment decisions should be placed on the individual or institution responsible for providing the treatment, and not default onto the physician.
Educational Standards
As the osteopathic profession has continually proven its ability to meet and exceed standards necessary for the unlimited practice of medicine, non-physician clinician professions should also meet educational, training, examination, and regulation standards for the roles they seek. Current standards may not exist and may need to be formulated.
Non-physician clinician professional standards should be implemented, reviewed, and validated for the roles they currently fill as well as for the roles being sought. Once education, training, examination, and regulation are all proven effective, either through documented studies or other empirical means, expanded roles may be granted within the "team" framework.
The review and validation of non-physician clinician standards may need to come from an objective, independent body. Possible sources of this review may be the U.S. Department of Education, an accrediting agency that it recognizes, or CHEA. Alternatively, a national advisory board on health profession issues could be utilized, as is suggested in the Pew Commission Taskforce on Health Care Workforce Regulation's 1998 report, Strengthening Consumer Protection: Priorities for Health Care Workforce Regulation. The taskforce recommends the creation of a national advisory body to study existing scopes of practice, competency requirements, and other professional matters for all health professions and establish clear guidelines in each of these areas. However, this board would strictly serve an advisory function and its guidelines would not be binding. That is, the individual state licensing boards would still possess the exclusive authority to license and discipline its medical personnel. The individual states could choose to incorporate the guidelines into state law, but this decision would be within the sole discretion of the states.
As DOs/MDs have proven and continue to prove the efficacy of their education, training, examinations, and regulation for the unlimited practice of medicine, only holders of DO and MD degrees should be licensed for medicine's unlimited practice. The education, training, examination and regulation necessary and proven effective for the unlimited practice of medicine validate the physician's role the leader of the "team" approach for the delivery of medical care. As non-physician clinicians seek wider roles, standards of education, training, examination, and regulation must all be adopted to protect the patient and ensure that proper patient care is being given. Liability considerations for non-physician clinicians should appropriately be shared between those parties making treatment decisions, and those non-physician clinicians who act autonomously of physicians should be held completely liable for the outcomes of those decisions. Further, Roles within the "team" framework must be clearly defined, through established protocols and signed agreements, so physician involvement in patient care is sought when a patient's case dictates. Only proper attention to each of these considerations will ensure that the care being provided by non-physician clinicians is safe, effective, and of the highest quality.
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Student Loan Interest Deduction
Raising the income eligibility limit for the student loan interest deduction, elevating the amount at which the deduction is phased out, and by making permanent the elimination of the tax penalty placed on recipients of awards from the National Health Service Corps Scholarship Program and Armed Forces Scholarship Program, provides osteopathic medical students a better opportunity to pursue higher education.
Currently, the average osteopathic physician graduates from medical school with over $130,000 in student loan debt. The mere expectation of accumulating substantial student loan debt dissuades some of the most qualified individuals from seeking a degree in osteopathic medicine. Furthermore, educational debt plays a significant role in the future career choices of osteopathic and allopathic medical students. Students facing large amounts of debt often are less likely to pursue primary care specialties or practice in a rural or underserved community. Due to financial pressures, many medical students will pursue medical specialties with higher earning potential. Many base their decisions not on their interest in a particular field of medicine, but instead on the debt they must repay.
Recognizing the escalating cost of higher education, on June 7, 2003, the President signed into law the “Economic Growth and Tax Relief Reconciliation Act” (EGTRRA). The law modified the loan interest deduction and eliminated the tax penalty placed on recipients of awards from the National Health Service Corps (NHSC) and Armed Forces Scholarship Program, among other things. Following is a summary of the current educational tax provisions.
Student Loan Interest Deduction
Under current law, individual filers earning less than $65,000 and joint filers earning less than $130,000 are eligible to deduct up to $2,500 of student loan interest per year for the life of the loan. The amount of the interest deduction is reduced gradually for individuals whose modified adjusted gross income is between $50,000 and $65,000 and for joint returns with modified adjusted gross income is between $100,000 and $130,000.
Higher Education Expenses
Current law allows a taxpayer an above-the-line deduction for expenses paid by the taxpayer during a taxable year for qualified higher education expenses. Specifically, taxpayers with adjusted gross incomes not exceeding $65,000 for individuals or $130,000 for individuals filing jointly are entitled to a maximum deduction of $4,000. Taxpayers with adjusted gross incomes not exceeding $80,000, or $160,000 for individuals filing jointly are entitled to a maximum deduction of $2,000.
Hope Scholarship Tax Credit and Other Provisions
Currently, the Hope Scholarship Tax Credit only applies to tuition expenses. Furthermore, the value and availability of the tax credit may be impacted adversely by the receipt of Federal Pell Grants and Supplemental Educational Opportunity Grants. In addition, EGTRAA eliminated the tax penalty placed on recipients of awards from the NHSC and Armed Forces Scholarship Program. This provision is slated to expire December 31, 2010.
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