ObamaCare rollout faces physician shortage

Excerpted from "Get ObamaCare, while supplies last," USA Today, column by Paul Howard, July 11, 2013 - On Oct. 1, the uninsured can start signing up for coverage under ObamaCare. But should every policy be sold with an asterisk: Guaranteed access to care ... while supplies last?
Maybe. The unpleasant truth is that we don't have enough doctors to offer quality care to a growing number of Americans, never mind the nearly 30 million uninsured who'll begin to gain coverage under ObamaCare starting in 2014.

Changing demographics and perverse reimbursements are the main culprits. But ObamaCare didn't do much to address the underlying problems. Estimates vary, but the Association of American Medical Colleges predicts the U.S. will be short 130,000 doctors across all specialties by 2025. In fact, about one-third of all doctors plan to retire in the next decade.

Today, nearly 20 percent of Americans lack adequate access to primary care because there aren't enough physicians. About 30 percent of doctors won't accept new Medicaid patients. About one-third of ObamaCare's insurance expansion will come through expanding Medicaid.

ObamaCare relies on primary care providers to coordinate care in the hopes of lowering costs and improving outcomes. After adjusting for population growth, aging and demand for care created by the newly insured, we estimate that by 2025, the U.S. will face a shortage of 30,000 primary care physicians, nearly 5,000 of which are attributable to the expansion of insurance under ObamaCare.

Medicare grossly underpays primary care doctors compared with specialists and pays nurse practitioners 85 percent of what it pays doctors for the same services. And medical students are leaving school with crushing debt.

ObamaCare's focus on expanding health insurance left many of our biggest access-to-care challenges untouched. Get ready for Health Care Reform 2.0, starting next year, when many of America's newly insured realize that they have to get in line to see a doctor when they need one.

Commentary

CMDA CEO David Stevens, MD, MA (Ethics):"Why go to school for seven or eight years to become a primary physician when you can make 85 percent of a physicians salary as a nurse practitioner by adding just a couple more years of schooling to your undergraduate degree? You also will come out with a lot less debt. The median debt for a public medical school in 2012 was $160,000 and for a private $190,000.¹ It is no surprise that only 25 percent of allopathic school graduates are going into primary care, but even that statistic may be misleading since 75 percent of students matching to internal medicine programs go into specialties.² That is one of the reasons that osteopathic schools are prospering. Their number has grown from 19 campuses in 2000 to 37 in 2013.³ More than half their graduates go into primary care.⁴ Unfortunately, their debt load average on graduation is higher than allopathic schools by almost 25 percent.

"Economic disincentives have seriously damaged primary care and, if surveys are right, it will be worsened by the large number of physicians planning to retire early due to their concerns about Obamacare.⁵ Ultimately, patients will pay the price with decreased accessibility and poorer health.

"The ranks of mid-level professionals are increasing dramatically to fill in the gaps, but we should be concerned that a significant drop in primary care physicians will leave a dangerous knowledge and experience void between what mid-levels can provide and what specialists should handle.

"This cloud does have a silver lining! With the need for more physicians, it has opened the door for two Christian osteopathic schools to be up and running by this fall and two more are in the planning stages. I’ve also noted that there seems to be a higher percentage of Christian students on secular osteopathic campuses than allopathic ones and they seem to maintain a more balanced life."

1.https://www.aamc.org/download/152968/data
2.http://sphhs.gwu.edu/abouttheschool/news/?d=12544
3.http://www.aacom.org/about/colleges/Pages/default.aspx
4.http://www.princetonreview.com/medical/osteopathic-medicine.aspx
5.NewsMax “Sixty percent of the doctors responding to the Deloitte Center for Health Solutions survey are likely to will retire sooner than planned in the next one to three years, irrespective of age, gender or medical specialty.”

Conscience, liberty and duty

Excerpted from "What ‘Conscience’ Really Means," National Review Online interview, July 12, 2013 - "Respect for the dignity of the human being requires more than formally sound institutions; it also requires a cultural ethos in which people act from conviction to treat one another as human beings should be treated: with respect, civility, justice, compassion," Robert P. George writes in his new book, Conscience and Its Enemies: Confronting the Dogmas of Liberal Secularism.

KATHRYN JEAN LOPEZ: Can conscience have enemies if we don’t even agree on what conscience is?

ROBERT P. GEORGE: Sure. But one’s identification of the enemies of conscience will depend on one’s view of what conscience is. Today, many on the Left and even some on the Right imagine that “conscience” is a matter of sorting through one’s feelings to see whether one would feel badly about doing something — badly enough, that is, that one would prefer the option of not doing it. Where one strongly desires to do something, and especially where one sees some advantage to oneself in doing it, “conscience,” understood in this way, tends to be reliably permissive. If one wants to do something badly enough, “conscience” can pretty much be counted on to produce a “permission slip” — especially if one can manage to conceptualize the conduct in question as purely “self-regarding.”

The distinction between liberty and license — a distinction critical to the thought of the founders of our nation and the architects of our Constitution — loses its intelligibility, and those who defend traditional notions of morality, virtue and the common good come to be perceived and derided as reactionaries, and even “bigots” and “haters.”

Authentic conscience is not a writer of permission slips to act on feelings or desires. It is one’s last best judgment — an unsentimentally self-critical judgment — informed by critical reason and reflective faith of one’s strict duties, one’s feelings or desires to the contrary notwithstanding. Authentic conscience governs — passes judgment on — feelings and desires; it is not reducible to them, and it is not in the business of licensing us to act on them.

Today, the enemies of conscience trample on those sacred rights in a wide variety of ways — everything from the odious Department of Health and Human Services abortion-drug and contraception mandates to the abuse of anti-discrimination laws to drive religiously affiliated adoption services out of business or to harass caterers, florists and others who cannot, in conscience, provide their services for ceremonies they judge to be immoral. Another way that they assault conscience is by stigmatizing as a bigot anyone who dissents from their views on morally divisive issues.

Commentary

CMDA Senior Vice President Gene Rudd, MD: "Notice George’s comment, 'If one wants to do something badly enough, "conscience" can pretty much be counted on to produce a "permission slip."' Of course he is speaking of the dangers of a poorly formed conscience.

"C.S. Lewis addresses this well in The Abolition of Man. Lewis rejects the view that all judgments are subjective. He explains how moral truth and values are supported objectively. He goes on to show how moral values (conscience) must be taught to each generation lest society slip into anarchy. Lewis illustrates using the body. The head provides reasoning. The stomach represents our passions (the carnal man). But something is needed between them for proper stature – the chest. The chest represents the moral values instilled in us by a rightly structured family, church and society. 'Men without chests' are dangerous.

"George is right, 'Authentic conscience is not a writer of permission slips to act on feelings or desires.' An authentic, God-honoring conscience must be formed within each of us. While we can still learn this as adults, it best occurs at the formative time of our lives, in the home. Are we training our families to have such a conscience? We cannot depend on society, or even the church, to do that for us."

CMA lobbies senators to protect charitable gift tax deduction

Excerpted from "Religious Charities Ask Congress To Save Charitable Deduction in Tax Overhaul," The Chronicle of Philanthropy, July 22, 2013 -- Members of a newly formed coalition of religious charities visited Capitol Hill last week to persuade members of the Senate to back the charitable deduction as they draft recommendations for a massive federal tax overhaul that must be submitted by Friday. In a face-to-face meeting, members of the new Faith and Giving Coalition told lawmakers—including Sen. Orrin Hatch, a Utah Republican, and Sen. John Thune, a South Dakota Republican—that the charitable deduction meets that three-pronged standard.

“We feel it’s important that [Congressional] members hear from the faith-based community because of the importance of private giving to what we do,” said Steven Woolf, senior tax policy counsel at the Jewish Federations of North America.

The coalition was formed two months ago by John Ashmen, president of the Association of Gospel Rescue Missions, and the National Christian Foundation. Its members include such groups as the National Association of Evangelicals, Salvation Army and World Vision. Jonathan Imbody, vice president for government relations with the Christian Medical Association, said his organization had not previously lobbied to protect the charitable deduction. But the approach taken by Sen. Max Baucus and Mr. Hatch spurred his group to join the coalition.

“When you read the letter that says they’re starting with a blank slate,” Mr. Imbody said, “that’s enough to get you going. If you want something included you’d better speak up.”

President Obama has failed in repeated efforts since 2009 to impose a 28 percent limit on the value of itemized deductions for such expenses as mortgage interest, state and local taxes and gifts to charities as a way to help tame the federal budget deficit. Non-profit advocates say the proposal could reduce donations by as much as $9 billion annually.

Obama administration officials have said that the change would affect single people with incomes of more than $200,000 and married couples with incomes above $250,000. Taxpayers with incomes below those levels who do not itemize deductions would not be affected.

Commentary

CMA Vice President for Government Relations Jonathan Imbody: "Behind closed doors, Members of Congress have been proposing charitable gift deduction cuts that would severely harm giving, charities and those they serve. That's why I joined several colleagues from leading nonprofit organizations last week to meet at the Capitol with four U.S. senators and staff, to urge them not to kill tax breaks for donations to charities--a move that would hurt donors, cripple faith-based charities and deprive those they serve of desperately needed services.

"A person gives from the heart, of course, but tax policies can significantly influence how much donors feel able to give. The charity deduction is unique in that it simply acknowledges that a person is giving away income to help others in need. The charitable gift deduction is not a loophole--it's a lifeline.

"With the self-imposed deadline for Congressional action--i.e., a draft bill by the end of the month--fast approaching, we need to explain clearly and quickly why the proposed cuts to charitable giving would harm millions of Americans. Please visit CMDA's Freedom2Care website now to learn more and take action on this issue that impacts your charitable tax deductions, ministries like CMDA and, most importantly, the millions of individuals served at home and abroad through American charities."

Take Action

Use the easy form at CMDA's Freedom2Care legislative action web page to tell your legislators to protect charitable giving

AAP encourages fighting 'homophobia'

Excerpted from “Pediatricians have a new mission: Fight ‘homophobia’,” The Washington Times. June 24, 2013 -- In its first sexual-orientation policy update in nearly a decade, the nation’s largest pediatricians group said its members should do more to fight “heterosexism” and “homophobia,” as well as step up their care of teens with same-sex attractions. “Sexual-minority youth should not be considered abnormal,” the American Academy of Pediatrics (AAP) said in its new materials on lesbian, gay, bisexual, transgender and questioning (LGBTQ) youths. The policy statement and technical report is nonbinding but recommends that pediatricians create offices that are “teen-friendly and welcoming to all adolescents, regardless of sexual orientation and behavior.”ⁱ

Doctors can signal their openness to LGBTQ youths by putting out brochures with pictures of “both same- and opposite-gender couples” or posting a “rainbow” decal on an office door or bulletin board. The report also suggests that medical questionnaires be changed to be gender-neutral, and that staff be trained to not ask a boy about his girlfriend, but to ask him to “tell me about your partner” instead.

AAP’s new guidelines are not filled with “gloom and doom” about LGBTQ youths, said Dr. David A. Levine, lead author and member of the AAP's Committee on Adolescence. “There is an emerging literature about resiliency [in these populations], and about the fact that parental acceptance and parental love, family connectiveness, religious connectiveness and school connectiveness are all very protective against risk behaviors,” said Dr. Levine.

Leaders of smaller pediatricians groups said they agree that all patients should be treated with compassion, respect and quality care, but they do not believe that non-heterosexual orientations should be normalized. “That’s where we would disagree. Major, major disagreement,” said Dr. Den Trumbull, president of the American College of Pediatricians.

“It’s wrong for anyone to be bullied or mocked or stigmatized. At the same time—and I know this is heresy to the lesbian and gay community—I do not think we should normalize these kinds of behaviors and orientations,” said Dr. Jerry A. Miller Jr., a pediatrician in Augusta, Georgia who is chairman of CMDA’s pediatric section. Teens can get involved in so many risky behaviors, especially regarding drugs, alcohol and sex, said Dr. Miller. As caring physicians, “we want our patients to thrive, and we just don’t think that is going to occur in that [LGBTQ] lifestyle.”

Commentary

CMDA Member and Chairman of CMDA’s Pediatric Section Jerry A. Miller, Jr., MD: “The technical report makes some statements that we can all agree with. Of course, physicians, and especially Christian physicians, should provide compassionate care for all of our patients. Of course, Christian physicians would not want any child bullied, stigmatized or mocked. Jesus is the most welcoming and accepting person in the universe, and His followers should welcome and receive all others. There is no room for ‘homophobia.’ In addition, we are all concerned that LGBTQ children ‘have higher rates of depression and suicidal ideation, higher rates of substance abuse and more risky sexual behaviors.’ⁱ

“I strongly disagree, however, with some of the report’s key conclusions and implications:

"I object to the report’s attempt to normalize these sexual orientations. The Bible is explicit in the Genesis account (and Jesus later affirms and strengthens the idea) that marriage is between a man and a woman for life. Some elements of this marriage model are transparency, permanency, exclusivity, complementarity and oneness. Normative human sexuality is rooted and defined in the Bible, and is to be expressed only within a marriage between husband and wife. Therefore, polygamy, adultery, promiscuity, homosexuality, etc. are precluded.

1. My role as a pediatrician is to recommend what is best for my patients and warn them of what is destructive. I want my patients to thrive. LGBTQ lifestyles are harmful and do not lead to human flourishing and thriving; biblical sexuality and marriage do. Therefore, accepting the person without affirming abnormal sexual orientation is the proper approach. Being nonjudgmental does not equal withholding the truth. Acting as if all sexual orientations and lifestyles are equivalent is not being truthful with our patients. Merely embracing these LBGTQ youth is not enough. Christian physicians must gently and lovingly guide them to a vision of biblical sexuality, and then help them see that deep and meaningful transformation for anyone occurs only through Jesus Christ. Though same-sex attraction may be a part of a person’s make-up for his/her entire life, transformation is possible (for all of us) through Jesus.
   
2. I object to the idea that the significant problems of LGBTQ youth are due only to the rejection by others of their sexual orientation, i.e. ‘heterosexism.’ This may be a contributing factor, but we must take into account how much the lifestyle itself contributes. Prevention or early intervention seems to be key in helping these patients.
   
3. The terms ‘sexual minority youth’ and ‘heterosexism’ used in the report seem to place the LGBTQ issue squarely in the realm of racial, sexual and ethnic discrimination, as if there were equivalence. The implication: unless you agree with the report that all forms of sexual expression are fine, then you are a heterosexist persecuting a minority. I disagree with this argument.”
   

ⁱFergusson DM, Horwood L, Beautrais AL. Is Sexual Orientation Related to Mental Health Problems and Suicidality in Young People?. Arch Gen Psychiatry. 1999;56(10):876-880. doi:10.1001/archpsyc.56.10.876.
CMDA Ethics Statement on Homosexuality
Annotated References on Homosexuality Statement
CMDA Ethics Statement on Human Sexuality
Is Sexual Orientation Related to Mental Health Problems and Suicidality in Young People? Arch Gen Psychiatry

Outcry in America over prohibitive cost of birth

Excerpted from “Outcry in America over prohibitive cost of birth,” BioEdge. July 6, 2013 -- A report by data analytics company Truven has revealed that the cost of giving birth in the U.S. is the highest of any industrialized nation. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying an average of $18,329 and $27,866.


One factor contributing to the high birth cost is the “charge for service” policy of U.S. hospitals, whereby patients are charged for each service they receive during their stay.

There have also been claims of a lack of transparency and regulation in the pricing of services provided by hospitals. Hospitals are able to set prices extremely high with little fear of retribution. Charges for delivery have nearly tripled since 1996 and out of pocket costs are four times higher. Some women have reported that they are very reluctant to have a caesarean due to the hefty price attached.

American commentators have reacted strongly to the report. "It's a truly sad state of affairs," wrote Sasha Brown-Worsham of The Stir. “There is something so damaged about a country that claims to support families and wants people to procreate and then does absolutely nothing to support them once they do.”

Commentary

CMDA Executive Vice President Gene Rudd, MD: “The cost of healthcare has become a plague in and of itself. The burden of paying for healthcare is the leading cause of bankruptcy with childbirth-related costs, resulting in seven percent of those bankruptcies. Too many young families face lifelong economic marginalization due to these excessive costs.


“Why is U.S. healthcare so costly? There are many reasons: overutilization, for example. The threat of malpractice adds many ‘routine’ but unhelpful tests and procedures. There are too many cooks in the kitchen—business entities waiting in line to make profits. And the uninsured are most severely affected. They are expected to pay the chargemaster costs while those with third-party payers pay discounted rates often at one-third of the chargemaster.

“It is further disturbing to know that we are not getting a good return on our healthcare investmentⁱ. Shameful, in fact. We pay a higher amount of our social and family budgets than any other developed country, but rank well below in outcomesⁱⁱ.

“Personally, I oppose the current healthcare reform plan, but not because I oppose reform. Reform must occur. I oppose the current plan because it does not adequately address our economic burden of health care as reflected in the cost of childbirth. Starting with already unacceptably high costs, the planned reforms only exasperate the problem, likely collapsing the system. Was this intended by social engineers as a means of getting what they ultimately want, a single-payer, universal system? I do not know, but I am growing suspicious.”

ⁱHealth care spending, delivery, and outcome in developed countries: a cross-national comparison. American Journal of Medical Quality
ⁱⁱ For Americans Under 50, Stark Findings on HealthThe New York Times

Texas' abortion bill may face next battle in the courts

Excerpted from “Texas’ abortion bill may face next battle in the courts,” DallasNews.com. July 13, 2013 -- Sweeping abortion restrictions were passed by Texas’ lawmakers on Friday, July 12, but a slew of court injunctions and blocks of similar laws in other states may mean the contentious measure is ready for its next battleground: the courts. The Republican-controlled Legislature passed the bill just before midnight, with all but one Democrat voting against it. The bill, which was derailed in last month’s special session by a Democratic filibuster, would give Texas some of the nation’s most restrictive abortion laws.


It includes four major elements: a ban on abortions after 20 weeks of pregnancy, a requirement that abortion physicians have admitting privileges at local hospitals, a requirement that abortion facilities meet the same standards as surgical centers and restrictions on abortion-inducing medication. The regulations are similar to laws enacted in recent years by other states, many of which have met court challenges.

Gov. Rick Perry, who will sign the bill into law in the next few days, said Saturday that the measure will withstand court challenges by those who oppose it, adding “we wouldn’t have passed it if we didn’t think it was constitutional.”

The bill’s author, Rep. Jodie Laubenberg, R-Parker, argued that the bill is about protecting women’s health. Critics, however, say the measure’s intent is to close abortion clinics and block doctors from performing the procedure. Laubenberg acknowledged that opponents will challenge the bill. “It will probably go to the Supreme Court,” she said.

Texas’ measure, which would restrict abortions after 20 weeks of pregnancy, uses an underlying argument for the timeframe. Some studies show a fetus can experience pain after that point. Under current law, abortions in Texas are prohibited after 24 weeks. Ten other states have passed identical restrictions based on the moral argument over fetal pain.

Commentary

CMDA Member and Member of the Board of the Texas Institute of Health Care Quality and Efficiency Beverly Nuckols, MD, FAAFP: “At what point do humans become human enough to have the right not to be killed? How should society balance protection for women who choose to abort their children with the burden imposed by that protection?

"While 62 percent of Texasⁱ and 59 percent of U.S. votersⁱⁱ support a ban after 20 weeks, opponents of the bill stormed the Capitol, disrupted hearings and threatened lawsuits that will likely decide whether the law is enforced. In the middle of the noise, both sides told legislators painful stories about the effect of abortion on their lives.

"Texas’ new law bans abortion after 20 weeks, based on the possibility that the fetus can feel pain at the lower limit of viability since the lower brain structures are in place, the thalamo-cortical connections are developing and primitive memory and learning have begun.ⁱⁱⁱ There are exceptions for life and permanent injury for the mother and severe fetal anomalies. The law also requires that abortion facilities meet guidelines required of facilities that do similar procedures like D&Cs. Doctors performing abortions must obtain hospital privileges within 30 miles of the facility and follow FDA guidelines for medical abortions.

"Christian doctors are in a unique position to guide the public conversation toward one of ethics, rather than popular opinion, science or law. We must also demonstrate Christ’s healing love and forgiveness to those who are in pain because of abortion."

ⁱUniversity of Texas / Texas Tribune “Texas Statewide Survey Field Dates: May 31 to June 9, 2013.” http://s3.amazonaws.com/static.texastribune.org/media/documents/ut.tt-jun2013-summary-full.pdf (Accessed July 2, 2013)
ⁱⁱhttp://big.assets.huffingtonpost.com/toplines_abortion_0627282013.pdf (Accessed July 16,2013)
ⁱⁱⁱAnand, KS. “A scientific appraisal of Fetal Pain and Conscious Sensory Perception” Testimony before Congress, November 1, 2005. (http://www.cmda.org/WCM/source/Testimony_KJS_Anand.pdf Accessed online July 1, 2013)

Testimony of Jean A. Wright, MD, MBA
CMDA Ethics Statement on Abortion
CMDA Supports Unborn Child Pain Awareness Act