Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!
On this Giving Tuesday, I thought I would share what DFA means to me and what it means for patients across the country.
We have had our time to grieve and now we must act.
President-elect Donald Trump and the new Congress have threatened to repeal the Affordable Care Act on day one. And, day one is just around the corner in January. That means we need to make our voices heard right now with Senators who will be crucial in this fight.
We need to send a clear message that doctors, medical students and those who care about the health of the nation won’t go backward to a time when Americans struggled to get the care they needed.
Tell them to protect the gains we have made under the Affordable Care Act and protect the health coverage of millions of Americans.
Our patients need us now more than ever. I hope you will join us.
Over the last eight years, we have given so much of ourselves to improve the health of our nation. Together, we have celebrated many victories and wept over defeats. During this time of great uncertainty for our country and our patients, let us spend this Thanksgiving with our loved ones resting and rejuvenating ourselves. There will be tremendous work ahead, but whatever the future holds we will surmount it together.
On behalf of the entire leadership team, thank you to the Doctors for America community. Your love for your patients and our shared value of health care and justice for all sustains us throughout the year. I know that together we will work to protect and expand our vision of a healthier America.
Thanks for all you do,
Scott Poppen, MD MPA - Vice Chair
Today marks the start of the Open Enrollment period for the health insurance marketplace. While millions of Americans have gained coverage since the first enrollment period, there are still many patients who remain unaware or confused about their coverage options and the financial assistancethat could help them lower their monthly costs. In fact, it is easier than ever to navigate plans and enroll in coverage this year.
Together, we will keep spreading the facts as we seek to build upon the successes of the ACA and improve the health of our patients and communities.
Yours in service,
Mona Mangat, MD
Board of Directors - Chair, DFA
Carol Duh-Leong, MD, MPP and Laura Marcus, MD
This past summer in our primary care clinic in the South Bronx, the most important anticipatory guidance we gave was not to take a vitamin or to eat a new vegetable, but rather to read a new book. Studies show that achievement gaps in high school between students of high socioeconomic status and students of low socioeconomic status can be traced back to differential summer learning over the elementary school years.1 While this knowledge is discouraging, it also creates a potential point of intervention for pediatricians. Summer plans for our patients are often fraught with anxiety, due to the prohibitively expensive nature of camps, travel, or additional structured activities. However, reading year round, with the help of a library card and the encouragement of your pediatrician, has always been free. Books are the cheapest form of international travel, the easiest way to meet presidents and heroes, and the greatest innovation we have engineered for time travel. If Yeats is correct and learning is not the filling of a pail, but the lighting of a fire, books are the kindling. The value of reading and independent learning cannot be underestimated in a school system fraught with overcrowding and lack of resources.
The impact of literacy and education on health outcomes cannot be understated, nor can the effects of health on education. Asthma is the leading cause of absenteeism among elementary school children, and accounts for more than 14.7 million days of school missed in 2002 nationally.2 Additionally, a study undertaken in our state’s schools revealed that 51% of school nurses feel that asthma is more disruptive to school routines than any other chronic condition.2 However, in a family in which more basic needs, like food and security, are at stake, remembering to give your child a controller medication for asthma is often a much lower priority, and lower health literacy often compounds this problem. As doctors we see every day that insufficient education and poor health are intimately and inextricably linked, and that both are a symptom, as well as exacerbating factor, of poverty.
In the Bronx only 54.7% of students who started high school in the year 2010 graduated within 4 years, as compared to 64% in Brooklyn and 67% in Queens and Manhattan.3 In our clinic, there exists a harsh discrepancy between the answers to, “What do you want to be when you grow up?” and the actual outcomes we see. Every day we hear our patients say that they want to be doctors, nurses, social workers, teachers, criminologists, police officers, and business people. Many adolescents express interest in going to college. As pediatricians, we push our adolescents to dream. However, in order to land among the stars, rockets require the forethought, training, and focus, often extinguished by the crushing weight of scarcity. It is our job to utilize what resources we do have, one of which being public libraries filled with books, to help put our children on the path to success.
Alexander, Karl L., Doris R. Entwisle, and Linda Steffel Olson. 2007. “Lasting Consequences of the Summer Learning Gap.” American Sociological Review 72 (2): 167–80. doi:10.1177/000312240707200202.
“Asthma and the School Environment in New York State.” 2008. Center for Environmental Health at the New York State Department of Health. http://www.health.ny.gov/diseases/asthma/docs/asthma_in_schools.pdf.
"Graduation Results: Cohorts of 2001 through 2011 (Classes of 2005 through 2015) Graduation Outcomes." NYC Department of Education. NYC Department of Education, n.d. http://schools.nyc.gov/accountability/data/graduationdropoutreports/default.htm
This piece also appeared in the AAP FACE Poverty newsletter.
Thank you. I want to thank Representatives Doggett and Welch for their leadership on this issue and for the invitation. I also want to thank my colleague Bruce Rector from DFA, my co-chair and the energy behind much of the work we do.
To introduce myself, I currently serve as the Co-Chair for Doctors for America’s Drug Price, Value, and Affordability Working Group, and serve as the State Director for DFA in Maryland. I am currently a medical student in the joint MD/PhD program at the Johns Hopkins University School of Medicine, and was previously trained as a bioethics fellow in the Department of Bioethics at the National Institutes of Health.
I am here today representing Doctors for America, a nonpartisan nonprofit organization, with the combined voices of more than 18,000 physicians and medical trainees as well as others involved in providing health care to millions of Americans. Our members span the spectrum from rural primary care and family medicine physicians to those in tertiary care oncology and surgical subspecialty practices. We are all united in our mission to fight on behalf of the patients we serve, advocating for policy positions based on what we see and what we hear on the ground from our patients each and every day. This is why DFA was formed: to be a group of health care providers who advocate for their patients first.
It is because of our motivation to improve the quality, affordability, efficiency, and compassion of the health care systems our patients experience that we support the Part B Demonstration. This past spring, DFA leadership voted overwhelmingly to support the Demonstration because we have seen too often how meaningful and well-intentioned efforts at reforming our completely irrational drug pricing systems get derailed by theoretical concerns.
Meanwhile, there are hundreds of thousands of patients – by some estimates, up to 24% of Medicare beneficiaries – who at this very moment are having difficulty accessing the medications they need because of high and ever-rising drug prices. The current Part B reimbursement formula has unintended incentives that forces some physicians to sustain their practices through reimbursement for these higher-price medications rather than through fees that better reflect the care they give to patients. And the pharmaceutical industry retains the ability to utilize the perverse incentives that are currently embedded in the Part B reimbursement scheme to their advantage, using the high price of a drug as a tactic to encourage physicians to use their products.
Increasing prices for medications cause a spiral of unintended consequences where higher-priced medications are prescribed frequently - even when a comparable, cheaper alternative is available - leading to barriers being placed to reduce their use. With no restraints in place, drug companies raise prices further in order to increase profits. Such a system is unsustainable for the country. It is also actively harming real people – people like Heather Block - in that it often prevents those suffering from devastating cancers and disabling autoimmune conditions from accessing the very care that these systems are set up to support.
You may have heard of Heather Block’s story; if not, she is a patient with metastatic stage 4 breast cancer who is fast going through her savings trying to pay for her medications, which are billed through Part B and require her to pay 20% with no out-of-pocket-maximum. She has written and spoken out in support of this demonstration. And there are many more in the same situation.
We recognize the concerns raised by our colleagues in oncology, rheumatology, and elsewhere that these reforms risk adversely impacting their practices. Our membership includes many providers in these specialties and our goal is to enable our patients to access and be able to afford the care that they need and for physicians to maintain adequate financing for their practices. However, we feel strongly that the prudent path forward is to collaborate with CMS to strengthen the Demonstration before and during its implementation, NOT to prevent it from happening. In this vein, we are part of the previously-mentioned coalition who has proposed several modifications to the demonstration, and support the ideas of Dr. Bach and others regarding increasing the flat fee, for example.
It is possible to simultaneously focus on the needs of all our patients, while also making sure specialty patients maintain access and that physicians are protected. To say otherwise is a false choice. We have past experience with formula changes where there were dire warnings of patients not having access and physicians going bankrupt – both when the system transitioned to ASP as the reimbursement standard, and during the sequester. These warnings did not pan out, yet these threats continue to be raised, most often by those with a stake in the status quo. More than anything, our physicians want to be adequately paid for doing what they do best – doctoring – and do not want to worry about balancing their practice finances based on reimbursements from drugs.
We are confident that CMS can monitor the Demonstration to ensure that physician practices are not being unduly harmed by these reimbursement adjustments. We need to make sure specialty drugs are priced at reasonable levels, and that patients do not face unthinkable trade-offs between medications and other essentials. By changing reimbursement incentives, focusing on concepts of value, testing models such as reference-based pricing, and providing clinical decision-support tools – all of which, as you’ve heard, this Demonstration proposes to do – we can allow physicians to focus on providing the best care possible for their patients and limit the ability of drug companies to raise prices.
This demonstration could have real positive impact on patients like Heather Block, patients like those on expensive infusions for autoimmune diseases like Multiple Sclerosis, patients like the approximately 1 in 5 Medicare patients without supplemental coverage facing co-pays that are as much as 20% of the total Medicare payment amount for the drug, patients whose stories have been shared with us by dozens of our members (stories which I am happy to share with you). It is THESE patients that illustrate why the ideas embedded in the Part B demonstration must be implemented.
We know that several other physician groups have come out against this proposal, and those in oncology are particularly concerned. Thus, I want to share the perspective of a prominent practicing oncologist-hematologist, Dr. Vincent Rajkumar of the Mayo Clinic, who in August 2015 brought together a large coalition of oncologists in calling for efforts to lower the prices of cancer drugs. He shared with DFA his opinion on the CMS Part B Demonstration, writing: “I express my strong support for the proposed Medicare Part B changes. The current system rewards physicians for dispensing the more expensive drug when two equally good options are available. The push back against the proposals are coming from those who stand to lose revenue. This is to be expected. Thus, it is best to get feedback from those who don't have conflicts of interest. It is sad that what is good for patients does not have the support it deserves."
We believe the CMS Part B Demonstration Project represents an important step, and it is because of the thousands of patients that we see each day that we strongly support moving forward. We urge all of you to do the same. Please – please – be the ones who take a stand in support of the patients that are suffering now, the patients that we see each day. Give them the support they deserve. Thank you.
Justin Lowenthal an MD/PhD student at Johns Hopkins, a biomedical engineer, and a bioethicist with expertise in ethical issues at the intersection of emerging therapeutic technologies and health care systems.
Each of us knows that mental health is vitally important to the overall health of our patients. Yet, too many Americans do not have access to the mental healthcare they need. Many of us know how it feels when we are unable to find adequate help for those who are suffering from anxiety, depression, addictions or a serious mental illness. It's heartbreaking.
We know that change is needed to better address the complete emotional and physical well-being of our patients.
In our most recent membership survey you rated mental health as a top priority for our movement. We need your input to build a healthcare system that fully addresses the needs of our patients.
We will use this information to build Doctors for America's mental health platform, then submit these recommendations to the next Administration.
Together, we will help improve our healthcare system to ensure it works better for everyone.
Dora is the leader of DFA's new Mental Health Task Force. Dora is a telepsychiatrist with a specialty in anxiety and mood disorders. She is based in New Mexico, where she is Historian for the University of New Mexico School of Medicine and a Penguin Books author.
Did you know the price of the EpiPen skyrocketed 400% while Mylan executives gave themselves huge pay raises? Now millions of patients are scrambling to figure out how they can pay for this vital drug.
As doctors and medical students, we know access to an EpiPen can mean the difference between life and death.
Mylan is now saying it will offer an expanded coupon for commercially insured patients to help make the EpiPen more affordable. This move is nothing more than a bandaid that does nothing to help uninsured, Medicare or TriCare patients. That is why we are calling on Mylan to take robust action by lowering it's actual retail price to help truly remedy these exorbitant, cruel hikes.
How much longer must our patients suffer while pharmaceutical companies get rich?
Let's tell big pharma that doctors and medical students won't be silent while they price-gouge Americans. Join us in demanding patients over profits.
Yours in service,
Dennis Deruelle, MD - Justin Lowenthal - Bruce Rector, MD - Mark Rood, MD
Co-Leaders of the DFA Drug Price & Value Campaign