U.S. Rep. Phil Roe, MD: Healthcare issues the new Congress needs to address

Republican Congressman Phil Roe, MD, represents Tennessee’s 1^stCongressional District in the U.S. House of Representatives and co-chairs the 16-member House GOP Doctors Caucus. Before being elected to Congress in 2008, he practiced for 31 years as an OB/GYN in Johnson City. Roe chaired the House Committee on Veterans Affairs from 2017-2018.

Roe spoke recently with Medical Economics about healthcare issues he thinks the new Congress needs to address, including price transparency and the shortage of primary care physicians. A transcript of the interview, edited for length and clarity, follows.  

Medical Economics: What are some of the healthcare-related issues you think the House of Representatives is going to tackle in 2019?

Roe: I can’t say for sure what they will tackle. I can tell you what the Doctors Caucus is looking at. What we have been doing with the Doctors Caucus and what I’ve heard traveling around the country from patients is very much a concern about prescription drug pricing.  And so we set up a series of meetings with [HHS] Secretary Azar and CMS Director Seema Verma about this and I am pleased to say that our Senate colleagues are joining us. So this has been a bicameral approach.

We’ve met with pharma and we’d like to also bring in the PBMs [Pharmacy Benefit Managers] and then maybe host a roundtable a little later to see how we can begin to get our arms around this very complicated issue of drug pricing. Everybody has a hand in it and the people I think that are being the least served by this system we have now are our patients.

If you’ve got great health insurance and you don’t feel much of the cost it’s working fine for you, but if you’re a small business person and you have a $6,000 deductible or you’re a senior and you drop into the [Medicare Part D] donut hole, all of a sudden you realize those rebates that are going to the PBM sector are not going to you. That you don’t see any of the benefit. And something as simple as insulin, where a person who’s not in a prescription drug plan is actually paying for it, is terribly expensive now.

So we’re looking at that. Also, we may come up with some legislation that will involve one of the things we hear about all the time, price transparency. 

ME: Does transparency matter if you can’t afford the drug?

Roe: Knowing what something costs matters. And knowing how you arrived at that price absolutely matters big-time. Sunshine is a great disinfectant.

ME: It sounds like you’re saying the really important thing is not the price itself but knowing how the drug companies arrived at that price?

Roe: No, the price is important too. But finding out how that’s arrived at and allowing market forces, and we know the more generic alternatives you have-now in Medicare Part D, as I understand it, about 90 percent of the drugs that are prescribed are generics-the more generic prescription drugs we have, the lower the cost. So that does matter a lot.

ME: It’s been nearly four years now since Congress passed MACRA and I’m wondering what you and the other members of Doctors Caucus are hearing from your physician constituents about it. Has it worked out the way you thought it would? Do you see any major modifications coming down the road?

Roe: I don’t see major ones. Let’s put it this way: I’ve heard a lot less with MACRA implementation than I did with SGR every year.

One of the concerns that I have-and this will be something we’ll be talking about in the Caucus-is the cost of medical education and the staffing shortages that we have. If you look at what the AAMC [American Association of Medical Colleges] says, by about 2030 we’ll be as many as 100,000 doctors short. And if you look at the demographics of physicians, in this country it’s like 25 percent of practicing doctors are over 65. That is a huge problem and these are very productive physicians who are at the tail ends of their careers. 

Then there’s the cost of medical education. I’ve been a proponent of educating our doctors less expensively. Let me use myself as an example. My dad worked in a factory and never made $10,000 a year in his life. I stayed at home and went to college and medical school and I graduated with no debt. 

Now, admittedly I worked through college, and during medical school. That’s impossible now. And these young people are coming out with hundreds of thousands of dollars of debt and I’m afraid it’s discouraging bright young people from going in to medicine.

So we’re going to need to work this term on how we pay for medical education. And think about this: If we’re a hundred thousand doctors short in 2030, that means we’re into the 2040’s before we educate enough young doctors even to begin to fill that deficit. So we need to get started right now and one of the things that I’m going to look at and will bring up with the Doctors Caucus is how Medicare funds residency slots.

I say this as a joke but when I talk to medical students I say, “Look, everybody can’t be a dermatologist or radiologist. Somebody actually has to see patients and has to put their hands on people.” And we’ve got a huge problem in rural America of getting anybody to go into these areas and practice medicine. And we need to see if we can address it by helping students pay off debt or give them some incentives to go into underserved areas.

ME: What about the paperwork and all the hoops that doctors have to jump through to care for their patients. Can Congress do anything about that?

Roe: I think so, and when we meet with Azar and Verma, we fuss about that all the time. I call it polyboxia. If you don’t check all the boxes you don’t get paid.

So we’re trying to get them to think about, and get more comments on, of all those things  we have to check off on our [EHRs], what really matters about patient outcomes? Because what really matters at the end of the day is: Do we get better patient outcomes? So if we could lessen that load and make it easier for our doctors when they see their patients to click just two, three or four things that really actually matter that would make their jobs much more satisfying.

I can remember installing our practice’s electronic health record in 2007. We spent a million dollars putting it in. It made my job a lot less fulfilling because I’m sitting there at night entering data into a computer. That’s not what I signed up for. I said, “if I’m here at 8:00 at night in my office, I should be seeing patients.”

So the Secretary is very well aware of the need to lessen that load and so is the CMS director. And I think they’re both committed to try to make things simpler. 

ME: There have been studies showing that the number of people with healthcare coverage has been leveling off in the last couple years and maybe even declining. Does that concern you? What are some ways that we could extend coverage to more people?

Roe: One of the things we’re seeing is more and more people employed. So I think you’re actually going to see the actual number of people without coverage go down, because to attract good employees you have to offer benefits.  

I do think we need to sit down with our Democratic colleagues and take a hard look at the ACA [Affordable Care Act]. The idea of expanding coverage and lowering cost, I absolutely agree with that. I just think the ACA was the wrong formula for it. You see it with these Christian Sharing Ministries, you see it with a lot of different things, the larger pool of patients you can get the more you can spread the risk, the more you can lower the cost.

I’ll give you a perfect example of that. A company in my district that has about 15,000 employees. And the owner hired a preventive healthcare nurse and said, “I want you to set up systems that help lower my healthcare costs.” So they’ve done programs addressing cholesterol, blood pressure, diabetes, smoking cessation, weight management. With all those things he’s been able to hold their healthcare cost increases to 1% per year.

And this is in rural east Tennessee, which is not exactly Nashville or San Francisco. So why wouldn’t you want a system that allows you to group in large groups association health plans to provide those things we already know that work?

And then being able to buy insurance across state lines. Health insurance is the only insurance I know of you cannot buy across state lines. That makes no sense to me. So those are things we need to start thinking about. How can we make insurance less expensive for people and don’t let it be a political issue.

ME: Do you see any possibility of the public option coming back? Might that be a way to lower costs?

Roe: I didn’t support the public option, but I think you will see a debate on Medicare for all.  And I think we need to have that debate. I think we need to see what the benefits of that would be, what the cost would be and what the downside of it would be. 

The only problem with it is that, even to make Medicare come into balance, at an absolute minimum you have to double the rates that we’re charging now [for the Medicare payroll tax]. You’d have to go from 1.45 percent to about 3 percent that the individual would pay and 3 percent the employer would pay right now to even make that plan come into balance. 

So I think we have to be honest with the American people and say, what is the cost, what are you willing to give up, is care going to be rationed, how is it going to look? And I think, for physicians, many of them are saying, “Give me anything, just make it simpler for my practice.” I hear it all the time.

ME: So it sounds like you’re at least open to discussing it?

Roe: I think it should be debated. I don’t know that the country is ready for it when they find out what the implications are. Look, you have to have some very serious discussions about where money is being spent in Medicare right now, what percent is being spent in the last six months of life, all of those things. But those are debates that the American people deserve to have, and not in a demagogic way, but in a very open and transparent way.

ME: What do you think the implications will be now that Democrats control the House of Representatives?

Roe: I’ve been in the minority before, in 2009-10, and basically what happens when you’re in the majority is you determine what the theme of the day is. For example, as chairman of the Veterans Affairs committee now I laid out a vision for where I wanted to go. And I brought the Democrats in because without their support I couldn’t get it passed in the Senate. And so if the entire Congress would work a little bit more like the Veterans Affairs Committee I think you’d have a lot better legislation but it is politics at the end of the day.