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Maryland Physician Magazine - Supreme Court Ruling Should Spur Physician Leadership

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By Linda Harder

In Maryland Physician's recent interview with Maryland Congressman John Sarbanes, he offers his take on the Supreme Court's ruling June 28th on the Affordable Care Act (ACA) and describes his efforts to increase physician availability. His recent reinstatement to the Energy and Commerce Committee, which has legislative oversight on many health-related matters, puts him in a position to advocate for physicians.

How will the ACA affect the insurance industry?

If you want to enforce new rules and regulations on the commercial insurance industry, the individual mandate was important because having everyone opt in is the best insurance pool design you can have. Without the mandate, insurers would reject many of the important measures put into place by ACA, such as ending discrimination against individuals with pre-existing conditions or covering preventive care services at no additional charge. By increasing the risk pool, ACA provides insurance companies with an incentive to offer comprehensive health coverage to all individuals.

How effective will the Republican challenge to the ACA be and what role should physicians play in implementing it?

Their efforts to impede the legislation started at the beginning of this legislative session. They'll continue to make runs at it, but as the healthcare industry begins to invest in making the changes required by the reform law, it will become more difficult to pull it apart.

Physicians have a tremendous leadership role to play now that the Supreme Court has ruled the law is constitutional. Physicians can explain the new benefits of ACA to their patients and also address some of the myths. They can also explain that we are trying to turn the system towards prevention and better management of patient care.

For example, ACA closes the prescription drug "donut hole," which will directly impact the health of millions of America's seniors. Currently, physicians see patients who cannot afford the drug regimen they've been prescribed to keep them healthy. By closing this gap in coverage and providing a 50 percent discount on brand name drugs, physicians can have more confidence in the care they provide.

At the same time, working with their colleagues, physicians are in a position to embrace those components of the ACA that create more efficiencies and better care management, and help their colleagues explore the potential for electronic medical records and the use of online resources and data. Within the ACA, there are meaningful, structural opportunities to better manage care going forward, such as with Accountable Care Organizations (ACOs). Physicians can now have a higher level of confidence, and as a result, they can play a leadership role to help us move toward a more rational healthcare system that leans in the direction of prevention.

How will your legislation, the Physician Re-Entry Demonstration Program, help increase physicians in the workforce?

Primary care physicians, in particular, have a critical role to play in keeping people healthy and the shortages in this field are alarming -- the shortage will reach 40,000 in the next ten years and is expected to grow to nearly 160,000 by 2025. We have to think about how to bolster the supply of physicians. We can do that in the traditional fashion, but we also have to think out of the box about where to find new physicians. We've looked at all kinds of ways of doing that -- more quickly assimilating returning army medics and things of that nature.

I found that one topic that kept coming up was physician re-entry. There are a fair number of physicians who leave medicine for early retirement or family obligations, such as caring for a young child or an aging parent. When they want to return, they encounter a variety of financial and logistical obstacles.

I looked at some of the physician re-entry programs around the country. My proposal, which I've introduced and the American Medical Association supports, sets up a demonstration project with 10 sites across the country. The sites would train physicians and provide financial assistance for

stipends, salaries, and so on and it wouldn't be limited to those previously in primary care. There are some specialty areas where you would have been certified as an internist as part of the process, so the universe of potential candidates is actually quite large. Physicians who complete the process would be placed in a public health environment - community health centers, VA medical centers or school-based health centers -- places where we have the most shortages.

It's designed to address some of the most significant inhibitors to returning to practice, such as providing malpractice insurance through the Federal Tort Claims Act, and the costs associated with the program aren't significant when you consider what the return would be. We'll also have a streamlined, customized training program and financial support. I think that will be very inviting to physicians. I'm hopeful I'll get support from both sides of the aisle on this because it's the first time these ideas have been put together into one piece of legislation.

What's the future of Medicare reimbursement and the waiver in Maryland?

We have this continuing frustration around the sustainable growth rate (SGR). I experienced that when I was chair of the health care practice at Venable [a Baltimore-based law firm] representing non-profit hospitals and senior living providers, so I remember this period of time in December every year -- everyone's running around in a panic because you didn't know whether the reimbursement was coming through -- even when the cuts were only 6 or 7%. Now the stakes are even higher. Physicians are facing double-digit cuts and the cost to repeal the SGR is over $300 billion, but it's critical that we find a long-term or, preferably, a permanent solution.

In terms of the waiver, I'm hopeful that Maryland can find a new way to morph the waiver that allows the Rate Setting Commission to be on the cutting edge and be compatible with the ACA. Joshua Sharfstein, John Colmers (Secretary and former Secretary, respectively, of the Maryland Department of Health and Mental Hygiene), and others are wrestling with what the next generation of the waiver will look like. It's allowed Maryland to do some creative things; if we can find a way to sustain that innovation with CMS and HHS through a waiver approach, we ought to fully explore that.

What Role will the Energy and Commerce Committee play as the ACA moves forward?

Even if the ACA and all its components remain in place as we now expect, we will need to monitor various parts of the law. Any reform of that magnitude needs constant attention to make sure it's doing well and the committee will have a very active role in evaluating the implementation of the law as well as potential improvements or changes that may need to be made.

Please discuss the Public Service Loan Forgiveness (PSLF) Program

I worked hard to pass this legislation and I'm proud we've done something to address the huge financial burden students face when they finish their degrees. Often times these students owe loan payments that could never be covered by public-sector salaries. This federal program provides critical loan reduction for people who pursue careers in public service and forgives the balance of their debt after 10 years.

I've spoken to medical students who are anticipating $100,000 or more in student loans and want to go work at a non-profit health clinic. With the loan forgiveness option, if you work for 10 years at that clinic, then your loans are completely forgiven. We've got to get the word out about this program because it will be especially helpful for medical students.

All of the information and forms you need are now on the web at It's another way to get people into positions they might not otherwise be able to afford to do and is very relevant to an aspiring group of young physicians.

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