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Peck, Peggy


NASCAR dads have replaced soccer moms, the electoral darlings of the 1990s, in this year's hotly contested presidential election. Neurologists – even those who are moms or dads – are not even a blip on the radar screens of campaign strategists, yet the election results could have a major effect on neurology as a profession as well as on the day-to-day life of practicing neurologists.

Like many Americans, many neurologists are outspoken about their choice for president. “As a physician I think it is imperative that we speak out on political issues surrounding the elections like the race between President Bush and Senator Kerry,” David Charles, MD, Associate Professor of Neurology at Vanderbilt University Medical Center in Nashville, TN, wrote in an e-mail to Neurology Today.

“As AAN members, we need to think about our patients and our practices as we vote. With that in mind, it seems to me that no issue is more important to physicians and patients than medical malpractice liability reform.”

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Dr. Charles, a member of the AAN Legislative Affairs Committee (LAC), added that when he polled AAN members at CME sessions, medical liability reform consistently was the number one concern while other issues such as stem cell research, privacy for genetic tests, and even Medicare received varying levels of response.

“President Bush has consistently pushed for a wide package of reforms that will work to end the lawsuit lottery, lower insurance rates, and keep physicians in the practice of medicine treating patients,” Dr. Charles wrote. ''On the other hand, Senator John Kerry has a long history of opposing any liability reforms that have been opposed by the trial attorney's bar, the group that really profits from our country's skewed malpractice system. Now he has chosen Senator John Edwards to be his running mate.





“Sen. Edwards made a fortune as a trial attorney suing physicians who were unlucky enough to deliver children born with cerebral palsy. The Kerry/Edwards ticket has made it quite clear that the lawsuit lottery will continue if they are elected and that the physician crisis in America will not be addressed.”

But Mark S. Yerby, MD, MPH, Chairman of the LAC, does not place the same emphasis on liability reform. “This is a phony issue because it is a state issue, not a federal issue,” he said.

Moreover, while Dr. Yerby agreed about the appeal of a cap on non-economic damages, which is the centerpiece of the Bush-backed federal tort reform proposal, he said that “a cap is not useful because it does nothing to provide relief for physicians who are paying skyrocketing premiums. Certainly, the current administration offers no respite for this problem.”

Dr. Yerby added that the only way that neurologists could be assured of real relief from premium increases would be “if the Academy were to self-insure. That is what we really have to do because we can't rely on insurance companies to help us.” Another option, said Dr. Yerby, would be mandatory arbitration – a position that comes close to the Kerry proposal for mandatory mediation before trial.

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Thomas Swift, MD, President-elect of the AAN and Professor Emeritus at Medical College of Georgia in Augusta, said the number one problem facing neurology as a field is that the current payment system does not adequately reimburse for cognitive services. “If I see a new Alzheimer disease patient, it is going to take me at least an hour – maybe an hour and half – to review the case, go over diagnostic studies, talk with the family and, for that, I will be paid $62.50,” he said. But if he sends the patient for an MR scan, the ''radiologist will spend seven minutes reviewing the scan and will be paid $250 to $500 – for seven minutes of work.

“The lack of payment for cognitive services is driving neurologists to procedures. They're doing Botox injections, sleep studies, and EEGs, but they are devoting less time to the real work of neurology: the management of patients with chronic conditions such as Parkinson disease and Alzheimer disease,” he said.

Dr. Swift predicted that this imbalance in payment is leading to a crisis in health care. “But no one is talking about that,” he said. “Of course we need a single payer. Of course, it's obvious. But no one is talking about that,” he said. Dr. Swift speculated that one reason that neither candidate supports a single-payer system is that “both Kerry and Bush are taking money from the health care industry.”

Dr. Yerby echoed this concern. He noted that “neither camp wants to offer a substantive fix for Medicare payment.” He noted that Medicare calculates payments using a formula called the Statistical Growth Factor – a formula that the health economists, regulators, and Congress all agree is “flawed, but no one is willing to do anything about it other than quick fixes every few years.”

Their point is confirmed by a quick review of the literature supplied by the Bush and Kerry campaigns: no one is suggesting an overhaul of physician payment.

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“The biggest agenda item for the American Neurological Association (ANA) is the funding of academic neurology – research, basic and clinical,” explained Walter Koroshetz, MD, Chair of the ANA Public Policy Committee. “We are facing an uphill battle over funding,” he said, noting that a research-friendly presence in the White House could be helpful to the “uphill battle.” But Dr. Koroshetz, who is Professor of Neurology at Harvard Medical School in Boston, MA, said that neither Bush nor Kerry is making research funding a top priority.

John Gates, MD, President of the Minnesota Epilepsy Foundation and Professor of Neurology at the University of Minnesota in St. Paul, agreed that research funding is a critical issue. “I was just at a meeting where NIH funding was discussed. During the ‘Decade of the Brain’ we were funding grants at the 28th percentile level, now we dropped down to about 16th percentile. That is horrible. It means that one in six applications is actually being funded even though what sets this country apart and makes us successful and competitive as a technological entity is our medical science; if we allow it to deteriorate, we are doing a terrible disservice to the scientific infrastructure that makes us the leader.”

Once more, neither candidate is on record with a specific proposal on research funding, but one research issue is making campaign headlines: stem cell research.

The Bush campaign is on record supporting only limited research using established stem cell lines, while Kerry has pledged to back federal funding for stem cell research.



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“The stem cell issue is a point against Bush and a point in favor of Kerry,” said Dr. Swift.



Dr. Charles maintains, however, that the issue is not that simple. “Even in an area as controversial as stem cell research, the difference is not whether to move forward, but rather how and with what types of funding,” he wrote.

But Dr. Yerby said the issue is fairly straightforward: “A blanket ban [on stem cell research] and the manner in which this research has been limited by the administration does create some problems for neurologists.” Dr. Yerby noted that Academy is in the process of formulating a new policy on stem cell research, and he indicated that the new policy is likely to support such research.

Moreover, Dr. Yerby said that there has been ongoing concern among neurologists about the Bush administration's approach to research. “Neurologists have been concerned about the kinds of appointees that the administration places on scientific review panels. This has had a chilling effect on research, and there is a real concern in neurology about the use of political or ideological litmus tests rather than scientific expertise when making appointments. We've heard these reports over and over again, and there is a sense that this practice would change with a new administration.”

Gary M. Franklin, MD, MPH, Adjunct Professor at the University of Washington in Seattle and Medical Director of Seattle Worker's Compensation Plan, said stem cell research is “a hot button issue and I could not disagree more strongly with Bush. Most physicians think of ourselves a scientists and we want the best research that will offer our patients the best chance. I can't think of anything worse to do than to inhibit research because of a right-wing agenda,” he said.

While stem cell research is a clearly dividing issue for the candidates, when it comes to cost savings Bush and Kerry are on the same bandwagon. Both contend in campaign documents that large-scale cost savings could be achieved by an infusion of information technology in the form of electronic medical records and electronic prescribing systems.

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Dr. Franklin said this is the type of campaign promise that sounds good but means little.

“You can achieve huge savings with electronic systems if you have a single-payer system, but you cannot achieve savings when you have to work across several systems of payers,” said Dr. Franklin.

Likewise, Dr. Franklin is critical of both candidates' plans for expanding coverage to the uninsured. President Bush favors Health Savings Accounts, but “if people earning the median salary of $42,000 can't even afford to buy healthy food, I don't think they can afford to fund a medical savings account,” he said.

Senator Kerry's proposals, on the other hand, “do go farther than President Bush's, but they would cost much more. With 45 million people uncovered, how can you solve the problem of finding the money to cover them?” The only real solution, said Dr. Franklin, is to stop paying for expensive treatments with limited benefit such as lung reduction surgery or bariatric surgery. But that approach, which is likely to be considered rationing, is not on the drawing board of either candidate.



Finally, while the neurologists in the article are each voicing their personal beliefs, the Academy may become more politically active in the near future. The AAN's leadership is considering a proposal to fund a political action committee. That proposal, according to AAN staff, will not be formally considered until sometime in the first few months of 2005.

The AAN has four identified legislative priorities, said Michael Amery, AAN Federal Affairs Manager. Those four items are: medical liability reform – AAN supports federal tort reform that would include a cap on non-economic damages; reform of the Medicare physician payment formula; an increase in NIH funding; and a campaign to assure that the Medicare prescription formulary now being created includes coverage for appropriate neurological agents.

At press time, the AAN, in conjunction with the ANA, was reviewing a new policy on stem cell research. Before the action of the Bush administration, the AAN was on record supporting responsible stem cell research and Rod Larson, Director of Public Policy at AAN, told Neurology Today that the new policy is likely to reflect the same position.

Meanwhile – as they say in the election ads – neurologists will do well to remember that every vote counts.

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  • Health Care: Establish tax-free health savings accounts (HSA), expand community and rural health centers, an active state waiver program to encourage expanded access to Medicaid as well as the State Children's Health Insurance Program (SCHIP), and the Medicare prescription drug benefit included in the Medicare Modernization Act. Plan would cost $90.5 billion over 10 years and would extend health coverage to an estimated 2.1 million US residents.
  • Children: Combine federal and state resources as well as community organization, including faith-based organizations, to cover all SCHIP-eligible children within the next two years.
  • Small Businesses/Working Uninsured: Establish tax credits of up to $2,000 for low-income families to help pay for health premiums and $1,000 cash grants to deposit in HSAs (for individuals, the tax credit would be scaled down to $700 for premiums and the cash grant would be $300).
  • Small businesses would be aided with tax rebates to promote the use of HSAs and employed uninsured persons would be offered an above-the-line tax deduction to help pay for insurance premiums. Additionally, small business would be encouraged to form alliances, association-based health plans would be expanded, and President Bush would promote health insurance shopping across state lines.
  • Medicare/Seniors: No new Medicare legislation is proposed, with implementation of the prescription drug benefit included in the Medicare Modernization Act in effect in January 2006. Tax deductions for long-term care insurance premiums and a tax exemption for caregivers who care for an ill family member at home are proposed.
  • Medical Liability Reform/Cost Saving Proposals: Federal tort reform would include a cap on non-economic damages – legislation that annually passes the House of Representatives but has been tied up in the Senate. Additional savings achieved by promoting health information technology.
  • Stem Cell Research: Opposes federal funding for stem cell research except in the case of 60 stem cell lines identified by the President on August 9, 2001.
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  • Health Care: Spread catastrophic costs across a public-private partnership that will create a premium rebate pool that will reimburse “private and public employer and group health insurance plans” for catastrophic costs that fall above a pre-defined threshold. Eligibility for this “pool” would abe limited to companies that provide health care for workers, insurance plans that utilize disease management and care coordination programs, and employers that share health care savings with employees.
  • Plan would cost about $653 billion over 10 years and would expand health coverage to an estimated 26.7 million – financed by repeal of tax cuts for families whose annual incomes exceed $200,000, as well as tax incentives, and savings from a mix of disease prevention and information technology strategies.
  • Children & Adult Uninsured: Federal government to cover the full cost of 20 million children now covered by Medicaid in a quid pro quo deal with the states that would require states to expand Medicaid coverage to 200 percent of the federal poverty level. States would also be required to offer Medicaid coverage to all childless adults below the poverty level. Additionally, all adults would be permitted to join the Federal Employees Health Benefits Program – the plan that insures Federal employees as well as members of Congress – by the addition of a “new pool for small and large businesses, as well as individuals and families who need affordable health insurance.”
  • Prescription Drug Costs: Full disclosure required from pharmacy benefit managers of any bulk purchase savings or rebates from pharmaceutical companies; prevent pharmaceutical companies from blocking generic alternatives; and allow insurers to negotiate lower prices with drug companies. Campaign alleges that President Bush would not allow the government to negotiate with drug companies, and that the Bush plan would allow imports from Canada.
  • Medical Malpractice: Opposes capping non-economic damages and suggest a series of “steps” to reduce meritless litigation including requiring nonbinding mediation before allowing plaintiffs to proceed to trial and “mandatory sanctions for claims and defenses that are presented for improper purposes.”
  • Stem Cell Research: Opposes the Bush ban on stem cell research and said he will sign an executive order that removes the limits placed by President Bush.
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✓ Neurologists – like the nation at large – are divided about whom to vote for in November. They don't agree, as well, on the impact that the candidates' positions will have on neurology.

©2004 American Academy of Neurology