Repeal the Medicare Sustainable Growth Rate (SGR)

Decreasing Medicare reimbursement has made it increasingly difficult for Medicare patients to find a doctor who will see them. For many people, this can be a major barrier to attaining care, especially when transportation becomes an issue. One of the reasons for this problem is that the payment formula is flawed. Since 1992, Medicare has reimbursed physicians on a fee-for-service basis. In 1997, Congress implemented the SustainableGrowth Rate (SGR) to control Medicare spending and make sure that growth in physician reimbursement does not exceed the growth in GDP. This has not worked because the cost of medical care has increased faster than GDP; health careexpenses currently make up 18% of GDP, while in 1998 it was 13.4%. Congress has had to continually override the SGR because of concerns that reduced payments to physicians would limit patients’ access to care.

Each year, the Centers for Medicare and Medicaid Services (CMS) sends a report to Congress about the previous year’s costs as well as a conversion factor that will change the payments for physician services for the next year in order to match the target SGR. For example, if 2013 expenditures exceeded the target (which they did), then the conversion factor will decrease payments for 2014. If the expenditures were less than expected (guess how many times that has happened), the opposite would happen. These changes take place on March 1 every year. As it stands, without congressional action Medicare physician services face a 23.7% cut on April 1 of this year. Furthermore, if the trend continues, it is projected that average 2021 Medicare payments will be just half of what they were in 2001 (adjusted for inflation).

There is currently joint legislation to repeal the SGR (H.R. 4015/S. 2000). The SGR Repeal and Medicare Provider Payment Modernization Act will allow for a more stable Medicare physician payment policy that better serves Medicare patients. The current system with SGR is flawed and unsustainable. Tell your members of Congress to vote as soon as possible in support of repealing the SGR formula and reforming the Medicare physician payment system.

Save GME and Alleviate the Physician Shortage!

I’m sure that most have heard of the massive physician shortage this country faces, especially the shortage of primary care physicians. Under the sequestration, Congress has cut funding to Medicare by 2%, and Graduate Medical Education (GME) is part of Medicare. This is unfortunate, but just about everything funded by the government has taken a cut. Now more importantly, President Obama's 2014 budget includes an $11 billion cut to GME over the next decade! Pediatric residencies are funded separately, and Obama's budget includes a reduction from $265 million to $88 million in 2014! GME has already been cut 2% due to the sequestration, which equates to about 2000 residency positions out of the current 100,000 funded residency slots (a cap set by Congress in 1997). GME provides medical school graduates, or residents, the opportunity to complete the required years of clinical training necessary to obtain a medical license and become a practicing physician.

This year 528 U.S. MD medical graduates did not match into a residency, which is more than double the number from last year. Including DO (osteopathic) and foreign medical graduates, there were about 1700 that did not match into a residency. With a current physician shortage of about 16,000 and about 25 million Americans entering the health care system in the next few years under the Affordable Care Act, cuts to federal funding for residency programs will only worsen physician shortages. Workforce experts predict a shortage of 62,900 physicians by as soon as 2015.

Congress can help remedy this problem by doing two things: (1) retaining federal funding for GME, and (2) raising or eliminating the annual cap on the number of residents each year (currently 100,000). We need these changes in order to protect our most vulnerable Americans. I need you to submit letters to your Senators and Representatives to tell them to do these things. You can find your Senators here and your Representative here. You can basically copy much of this post for use in your letter. Thanks for your help!

High Quality Research Act

Earlier this year, Lamar Smith, the new chair of the House of Representatives Committee on Science, Space, and Technology, drafted a bill that would require that the National Science Foundation (NSF) director certify that projects funded by the NSF are groundbreaking and in the interests of national health and welfare. Additionally, it would also set in motion a process to determine whether the same criteria should be adopted by every other federal science agency. This could potentially politicize decisions made by the NSF. The bill is called the High Quality Research Act, and it has not yet been formally introduced in Congress.

Specifically, the draft would require the NSF director to post on the NSF website, prior to any award, a declaration that certifies the research is:

1) “… in the interests of the United States to advance the national health, prosperity, or welfare, and to secure the national defense by promoting the progress of science;

2) “… the finest quality, is groundbreaking, and answers questions or solves problems that are of utmost importance to society at large; and

3) “… not duplicative of other research projects being funded by the Foundation or other Federal science agencies.”

At face value to a lay audience, this may not seem like such a bad thing; after all, don’t we want our tax dollars to fund innovative research that has the potential to cure diseases? However, it is concerning that bill could potentially undermine the peer review process, which has always been at the crux of scientific research. The best feedback and criticism comes from other researchers in the same field, and this needs to continue. However, this is probably the worst-case scenario. In reality, it seems to me that this bill would not have the power to replace the peer review process, and it says nothing about doing so.

I can understand the motivation for writing such a bill. The government is appropriating less money for research, especially after the sequestration cuts, so with its limited resources it should fund projects that are of greatest interest to the American people. However, I really do not see this bill having much effect because the NSF and our country’s scientists use these promises (i.e. their work is groundbreaking and of interest to the American people) to justify their grant recipients and research, respectively. Nevertheless, it is important to be mindful that this bill could potentially undermine the peer review process.

Gun Policy Ideas

I have previously discussed the gun crisis we have in this country. So how are we going to deal with it? First, Senator Manchin announced on April 29 that he would reintroduce a bill requiring universal background checks. This is something we all need to get behind, as it is sound policy for our health and is supported by about 90% of Americans. Under current federal law, people who buy weapons from federally-licensed gun dealers have to undergo a background check. The name is submitted to the National Instant Criminal Background Check System (NICS), which is a computerized background check system designed to respond within 30 seconds on most inquiries. Private transactions are not covered by federal law, so no background checks are required.

Second, the NICS database needs to be strengthened because 28 states do not report inpatients with mental illness, and 17 have reported fewer than 10 mental health records since database’s creation. Furthermore, the U.S. General Accounting Office(GAO) estimates that NICS’s mental illness data falls short by 2 million individuals. New York made a step in the righ direction when it recently passed the New YorkSecure Ammunition and Firearms Act of 2013, requiring mental health professionals (psychiatrists, psychologists, social workers, nurses, etc.) to report patients deemed likely to seriously harm themselves or others, check the gun license database, suspend the individual’s gun license, and send a police officer to remove the firearm. I am curious to see the gun violence data in New York following this law.

Third, we need to get rid of high capacity weapons. The problem is that there are so many of them in circulation, and guns are durable goods and will not dissolve or expire. A solution might be to offer payouts for returning your guns, but obviously this will require government funding.

Fourth, we need to do more research on smart gun technology. A smart gun is a gun that will only fire in the hands of its lawful owner and can use technologies such as fingerprint recognition, magnetic rings, and other. Eventually it might be possible to require gun companies to include this technology in their products. New Jersey jumped on this and passed the Childproof Handgun Bill in 2002 that requires new handguns to contain a mechanism that only allows their owners to use them.

Fifth, we need to strengthen policies concerning gun shows, because approximately 40%of guns sales occur at gun shows. A possible option is requiring background checks before anyone enters a gun show. This would prevent the large number of gun sales that occur without background checks at gun shows.

These ideas for policy change are not going to fix all our gun problems, but they will make steps in the right direction.

Support Biomedical Research!

Time to hold on for dear life: we have reached the fiscal cliff! Being a physician scientist in training, one of my biggest concerns is the 8.4% cut to National Institutes of Health (NIH) funding of biomedical research. Every single time a doctor evaluates a patient or prescribes a therapy for a serious illness, federally funded biomedical research plays a key role in the process. We need to continue to make progress in learning about and treating incurable diseases, and this cut in NIH funding severely undermines such progress. Currently, about 90% of research proposals made by scientists and physicians are rejected for funding by the NIH due to resource limitations. This is an unhealthy rate and will only worsen if the NIH budget is further reduced.

I’m probably preaching to the choir; I would hope that everyone knows how detrimental this is for research. However, what people may not realize is what it can do for young people in training to become scientists or physician scientists. We need to be concerned with how this funding drop will affect our future, not just the present research. Looking down the road, this low level of funding and insanely competitive grant applications will inhibit young people from entering careers in biomedical research.

Another possible ramification of decreased biomedical research funding is that it accidental discoveries may become less likely. Some of our greatest advancements have been made by accident, namely Alexander Fleming’s discovery of penicillin. Only grants that are extremely well thought out and have very clear, logical hypotheses get funded. This leaves little/no room for riskier experiments where there is no clear hypothesis.

So what do we do about it? Well we cannot just sit back and wait for it to happen. You can write letters to your Senators and Representatives. You can write letters to the editor of newspapers or magazines. We must let our voice be heard so that America’s future biomedical research is not jeopardized.

Organ Donation: To Opt In or Opt Out, That is the Question

Organ shortage is a serious problem in the United States. About 20,000 organ transplants occur every year in the U.S., and 116,689 Americans are currently on a waiting list for an organ, with kidneys being the most needed organs. Furthermore, the obesity epidemic is also contributing to the shortage; a quarter of prospective donors are too obese to donate their kidneys. People typically wait 3-5 years for an organ, and thousands die every year (an average of 18 people per day) because they do not get the organs they need. Research is being done using embryonic stem cells and engineered scaffolds to try to regrow organs, but the complexity of these organs and the number of different cells and tissues comprising each organ tell me that this is not a possibility in the near future. However, there is something that can be done right now. Here I will present my case for the U.S. switching from our current opt-in program (i.e. the default is non-donor, and you must physically give consent for your organs to be donated when you die) to opt-out or presumed consent (i.e. the default is donor, and you must request to be taken off the list if this is what you want).

One of the major problems with organ donation is that people don’t want to acknowledge their mortality. It’s difficult to think about what will happen when you are dead, and it may seem weird for someone to take your organs. Other people are indifferent, apathetic, or don't want to take the time to opt-in when they get their license.

Consider Germany and Austria, which are very similar countries. Germany has an opt-in system and a 12% donor rate, while Austria has an opt-out system and a 99% donor rate! Here’s another comparison: Spain, with an opt-out system, currently leads the world with 34.4 deceased donors per million people, while the U.S., with an opt-in system, has 21.9. Clearly the default matters in this situation. The government is taking a stance and telling people what it recommends, and this greatly affects how people respond. In opt-out programs where the default is being an organ donor, there are higher donor rates.

Illinois has an interesting system called “mandated choice,” in which people are required indicate their preference. As a result, they have a 60% donor rate compared with the national rate of 38%. This program is a step in the right direction, as it at least solves the problem of people being indifferent or not taking the time to consider organ donation.

One of the major criticisms of the opt-out program is that freedom and liberty are being compromised. However, this is not the case because you still give each person the opportunity to opt out, and it is ultimately his or her responsibility to make this choice. Another potential problem is that an opt-out program may not actually increase organ donation rates, as Johns Hopkins researchers suggest. They say that physicians always approach the family members of the deceased and ask whether they would still like to donate their loved one’s organs. The family gets to make the final decision, regardless of the deceased’s intentions. I can see where they are coming from because you want to be respectful of the grieving family. However, people don’t always think the most clearly when they are emotional and grieving. Further, this limits the autonomy of the deceased, as they may have wished to have their organs donated. If this were followed more strictly, perhaps we would have more organs donated, especially if we switched to an opt-out program.

Adopting an opt-out program in the U.S. would definitely increase the donor rate, which is a step in the right direction. More stringent enforcement of people’s wishes by doctors would enable this to be carried out, decrease the organ shortage, and save thousands of lives.

Gun Control

As a student at a school of medicine and public health, I felt compelled to write about gun control, especially in light of recent events. The lack of strict gun control in the United States is a public health crisis.

In a recent Time article, Fareed Zakaria eloquently argued for gun control. He reports that the gun homicide rate per capita in the United States is 30 times higher than in Britain and Australia, 10 times higher than in India, and four times higher than in Switzerland! Why is this? Is it possible that the United States has more people that are psychologically debilitated? This seems unlikely. The answer appears to be the number of guns. In the United States there are 88.8 firearms per 100 people compared to 54.8 in Yemen, 45.7 in Switzerland, 45.3 in Finland, and all other countries have fewer than 40. Zakaria also reports that crime in America has significantly decreased in the past few decades with the exception of one category of crime: firearm homicides, whose rate has not changed in the past few decades.

Critics claim that gun control is unconstitutional, namely because it violates the 2^nd Amendment’s right to bear firearms. To that, I urge you to consider the initial motivation behind the 2^nd Amendment and the ruling by the Supreme Court in United States v. Miller. The actual text of the 2^nd Amendment is as follows: “A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed.” Note the word “militia,” which the Supreme Court explained to mean a group of people enrolled for military discipline, and that when they were called for service they would appear bearing arms supplied by themselves. Therefore, the 2^nd Amendment refers to bearing arms in the military intended for the protection of the country, not bearing arms for private purposes. The Supreme Court seriously overstepped when they declared in District of Columbia v. Heller that the 2^nd Amendment protects an individual’s right to bear a gun.

Critics also claim that gun control will not decrease gun violence or even violence in general. People will still be able to obtain guns on the black market. Also, there will still be just as much crime, but the only difference is that people will use weapons other than guns. However, this argument is not cogent. Having a gun in the home allows you to act on impulse and to complete an act that you might not have otherwise done. An article in the Journal of Epidemiology reported that people with guns in the home were at a greater risk than those without guns of dying from a homicide in the home. Furthermore, according to an article in the American Journal of Psychiatry, most people who commit suicide are ambivalent about doing so. Having a gun makes it so much easier for people to commit suicide if they are ambivalent.

For the health and safety of our country, our leaders would be wise to enact stricter gun control laws. The risks gun control are very minimal, or perhaps nonexistent, because doing so will only decrease gun violence. The only downside of gun control is that our freedom is slightly limited, to which I respond by saying that sometimes we have to make sacrifices for the greater good.