Grading the Trump administration's healthcare initiatives

March 12, 2018

One doc's perspective on how the White House has done when it comes to fixing healthcare.

It has been more than a year since Donald Trump ascended to the presidency, promising the very best of everything. I was among a small minority in healthcare that cheered the arrival of a different administration because it brought with it the hope of a new direction. Suffice it to say, my problems with the direction the prior administration took were legion.

 

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Without re-litigating the myriad issues that arose in the last eight years, most can comfortably agree that at the end of the era of enlightened planning from the center, healthcare is more expensive, more regulated, and more inefficient.

It is the fashion of late to not just disagree with Trump, his cabinet, and his policies, but to find them all immoral people who hate (in no particular order): children, poor people, women, and any persons of color. I find it striking that most of these characters were relative unknowns toiling away in their former lives who garnered no special attention prior to joining the Trump team, and finally being outed as Voldemort-worshiping death eaters. The members of the #RESISTANCE need not, therefore, have to worry their heads about actual policy positions, but
I will attempt to summarize the stance of these apostles of Satan.

Next: Tom Price

 

Tom Price: C

Tom Price, a former orthopedic surgeon, was brought in as head of the Department of Health and Human Services. The move was applauded by most rank-and-file physicians because he spoke the language of physicians suffering under the weight of the prior administrations good intentions. In his Senate confirmation hearing, he bemoaned the rules and regulations related to Meaningful Use that had pushed physicians into retirement, but did nothing to increase value to patients. He signaled a lighter touch may be on the horizon when it came to EHRs by noting that the major role of the federal government was to ensure interoperability rather than micromanaging the collection of useless data points from data entry clerks formerly known as doctors.

 

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Unfortunately, the former Senator was gone before he could affect any change, felled by the stellar journalists at Politico who uncovered evidence of travel via a charter plane for personal matters. I must profess to being incredibly annoyed at the development. The penalty seemed entirely too great given how hopeful I was at having a physician voice speaking to physician concerns at the head of the policy making table. Regardless, the reign of Price was an ineffectual one.

Seema Verma: B-

Appointing Seema Verma to head the Center for Medicare and Medicaid Service was another move applauded by many in the trenches. Little known to most, she had garnered attention locally in Indiana with an innovative approach to the state’s Medicaid program. She seemed to understand that poor access in Medicaid patients was driven in large part by inordinately poor reimbursement for a population that can be very complex to manage.  A key component to Indiana Medicaid was using tobacco tax dollars to raise Medicaid rates to at least be equal to Medicare rates-a move that made her popular among physicians whose charge it was to take care of these patients.

Unfortunately, it is the charge of the director of CMS to administer, rather than make, new laws. There has been little of substance to report from Verma other than some nice words about putting patients before paperwork. She has also been remarkably ineffective in making a case for what she believes in publicly.   Those of us who believe that the solutions in healthcare lie with physician-patient partnerships that take a wide berth around third party payers, need an effective and vocal salesperson. While there are glimmers of what could be as a recent fiery address at the HIMSS conference attests to, Verma, has unfortunately mostly relegated herself to staid positions that inch the ball forward.

Evidence of this can be seen in her approach to the framework of value-based care that is mostly indistinguishable from its predecessors. There are some more exclusions for low-volume providers, but the meaningless system that transfers healthcare dollars from those unable to comply with regulations to those that can comply with regulations, is largely in place.  It is still early, but a lack of bold action has marked the Verma reign so far.

Next: Scott Gottlieb

 

Scott Gottlieb: A

The man appointed as commissioner of the FDA has been a bright spot that has drawn applause from many corners of the political spectrum. A conservative approach to the high price of drugs dictates using markets to lower prices, and in that vein, the FDA commissioner approved a record number of generics in 2017. The FDA also announced an expedited review of generic drugs for which there are fewer than three existing generic competitors.

In an attempt to allow the market to push drug prices lower, the FDA approved numerous generics in 2017, and announced an expedited review of generic drugs for which there are fewer than three existing generic competitors. Gottlieb also launched a pilot program for orphan drug requests to ensure the world would create no more Martin Shkrelis.

 

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Gottlieb also maintains an active and mature presence on Twitter, in stark contrast to the other members of the healthcare team. If he could only manage the President's Twitter account as
well, world peace may well be within our reach.

Healthcare Policy: B

Health care turned out to be very complicated. Who knew? The solutions to what ails us remains comfortably far from reach after one year. There are those like me who believe the path to the best healthcare system courses through physician-led practices beholden to patients rather than systems.  A mostly non-practicing class of healthcare busybodies made up of administrators, economists, public health officials, and MBAs think the opposite. To this group, the physician is an interchangeable widget. Pushing back against this monolith is a slow process that began with the election of an outsider. The people appointed by Trump have not disappointed in changing the overall conversation in healthcare. The individual mandate is a good example. What was a good idea to ensure everyone paid their fair share turned into a $300 to $500 per month boondoggle for a 40-year-old who just wanted financial protection from a catastrophic event. Little surprise that there were few tears shed here when this non-working mandate was repealed with the recent tax bill.

The administration has also hearteningly attempted to rein in spending for a Medicaid program that has largely been working poorly for patients because low reimbursement rates have meant poor access to primary care physicians. The reimbursement rates are particularly befuddling given the fact that the United States gave ~$500 billion to insurance companies in 2015 alone to manage Medicaid patients. One hopes that the nation’s vast wealth may be deployed in a manner that serves patients, rather than their insurance companies.

Overall, there is ample evidence that new management has brought a different approach
Change, though, continues to be frustratingly slow. Value-based pay-for-performance care that doesn't actually relate to value remains the law of the land, and its implementation continues to leave much to be desired. Vertically integrated networks, once formed, seem difficult to displace.

A word of advice for the appointees facing some very tall tasks in the three years to come: Fly economy.

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