Home Forums Discussions General Discussion Affordable Care Act/Obama Care

I found a good, simplified summary of the upcoming changes in case anyone is interested:
HealthCare Bill Main Points - Extremely Simplified


This particularly caught my interest. If the patient doesn't want to take his medicine, it's now the doctor's fault and his reimbursements will be decreased.
January 2015 - Reimbursement for Physicians

So doctors will stop seeing uncooperative patients to keep their numbers up? What are your thoughts?

Some will for sure, depending on the bonuses or sanctions imposed by CMS. This type of "gaming the system" is characteristic of top-down bureaucratically controlled systems (see Pay for Performance: Is Medicare a good candidate? , by Michael Cannon in the Yale Journal of Health Policy, Law & Ethics, page 12). Doctors who are monitored by such limited criteria as medication compliance have a powerful incentive to deselect (dismiss or refuse to accept) patients whose outcome measures fall below the quality standard and therefore worsen the doctor's "rating". You can see that people are thinking of this already in the link that Sandeep provided.

There is already a large scale example of how poorly these physician rating systems work. In the United Kingdom, the NHS began a pay for performance initiative in 2004, known as the Quality and Outcomes Framework (QOF). General practitioners received bonuses for meeting 146 quality indicators for 10 chronic diseases and patient experience. The program was a financial shock for NHS. The 8,000 family practitioners included in the study earned an average of ?28,000 more by collecting nearly 97% of the points available. The new GP contract as a whole cost ?1.76 billion more than the Government had expected. Moreover, the QOF has been criticized for not meeting quality goals: "concerned that the QOF has diverted attention to what it targets and set GPs up in a 'game' to get points that can damage professional integrity and the GP/patient relationship."

A review done 2 years after the QOF was implemented concluded that the initiative had failed to meet 2 of its 3 overall goals and commented: "Radical change to payment systems will always risk perverse and unintended consequences, but at least some of these can and should be avoided ... by more rigorous testing before implementation."

But here in America the only testing so far for the ACA has been in the courts. Sorry about this rant, but I am passionate about my practice being experimented on by politicians and the medical elite that advises them in Washington.

Maybe we need a "rant" board section for David and I.

Lol I would be pretty mad. You're being forced to practice bad medicine. Bad for patients and doctors.

I can do rants!
Oh... I forgot.. You already knew that...

Seriously, this whole healthcare mess is like one of those movies where the hero has 15 seconds to defuse the atom bomb and has to choose between cutting the green wire or the blue wire. If you do something it's liable to be bad. If you do nothing, it's certain to be bad. And I don't see myself getting the girl at the end.

Lol I think the typical SWAT procedure is pour liquid nitrogen on the bomb. Newer bombs are pretty complex and the wiring is usually hidden.

Thanks, Sandeep. Sounds like a valuable tip

Either way, you needed to be dressed appropriately:




Now if it came in white, I could wear it to the office.

The result is going to be polarization of practices that make their profit by quality versus quantity.

There are compliant patients, some very highly motivated, which will gravitate to the quality doctors and be referred to other quality doctors.

Other patients will get less attention at the practices oriented to quantity.

What we have now will just get worse, and the quality doctors will have a disincentive to see poor and unsuccessful people in the community.

According to what I read either I will be fine or I am toast and should sell out to the hospital immediately.

And yes there will be pressure on doctors not to treat non-compliant patients.

Playing devil's advocate here:

Who wants to treat a non-compliant patient, anyway? If you tell a patient to quit drinking because half his liver is gone and that patient continues to down a 5th of Crown Royal every weekend, then what are you supposed to do? Keep taking the patient's or government's money until they die from liver failure?

Doctors are doctors, not magicians. Sooner or later, the patient has to do his/her part.

I remind you, I am playing devil's advocate.

JamesNT

James, the new trick is that, since that alcoholic has a bad outcome, that is poor quality work on your (well, the doctor's ) part so they pay him/her less. if at all.

Yeah, I say dump the non-compliant so-and-so.

I actually like some of my noncompliant patients, smokers and all, and I want to help them in whatever way they permit me to. There's always the chance that they will turn around with my help, or some life-changing experience. Just had a lady finally accept cholesterol meds after her sister had a devastating stroke.

And there are people who, for want of a scientific explanation, just have bad genes. We all have very smart, motivated and compliant folks with a bad BP or HbA1c, despite multiple meds and lifestyle changes. We used to call them "outliers", and keep trying aggressively and reduce other risks to compensate. Now they are just "liabilities".

I recall reading an elegant study of hospital readmission rates, done by Cleveland Clinic a few years ago, which emphasized the foolishness of using broad criteria to determine quality. Hospitals were (and still are) graded on 30 day readmission rates. Cleveland Clinic was looking bad, based on readmissions for their cardiac patients. The study disclosed that the type of patient being readmitted to Cleveland Clinic was not surviving to be discharged in comparable hospitals. So the high readmission rate was actually a quality indicator in this instance.

Which points out a very important background issue in all these "value-based" criteria -- they are all about saving money. Raising quality is just a smoke screen. Does anyone want to bet that, if something more expensive though safer for patients would increase quality, such as breast MRI instead of x-ray mammography, it sure won't show up in any of these guidelines.

"Figures often beguile me," he wrote, "particularly when I have the arranging of them myself; in which case the remark attributed to Disraeli would often apply with justice and force: 'There are three kinds of lies: lies, damned lies, and statistics.'"

Mark Twain

Allow me to tell a story...

Back in the 1950's, my Dad was a doctor in Tucson. This was way before Medicare, and even health insurance was a fairly novel idea. Part of the deal was, the physicians in town all took turns rotating taking care of indigent patients at the County hospital, as I recall a month at a time. There was no reimbursement as I remember it... it was just expected. For certain, County was a pretty bleak place, but the care given was not significantly different from other hospitals, just less comfortable. I remember as a little boy riding with him in the car as he made his rounds.

Then Medicare and Medicaid came along. Now, the expectation on every physician's part became that they were going to get paid by every patient. And, in turn, every patient came to expect the same level of creature comfort whenever hospitalized, no matter their means.

I think the old system was cleaner. He was a doctor. He took care of some people for free. Some got "nicer" care than others, but no one really had to go without. And there was no other agency, governmental or insurer, that told him his services were only worth 25% of what he was accustomed to charging.

If I am going to work for free or next to free, I want it to be my choice. I want to feel good about it, not "taken."

The AHCA is now the law of the land, so we can stop pretending we can do something to stop it.

Inasmuch as the law was written by, and for the insurance "industry", it stands to reason that the purpose of all this is to generate profits for the insurance companies, not serve patients, and certainly not for the comfort of physicians.

The fundamental realities are that they (the insurance companies) are much more clever and politically savvy than doctors. They have arranged to collect and be in charge of ALL the money, then they get to decide how to dole it out. And now they have even more power: it is a crime (a violation of tax law) to fail to participate and give them whatever they demand!

Not only that, the health insurance companies enjoy almost total immunity from anti-trust law, so they have enormous financial leverage that organized medicine (let alone individual doctors) can't even imagine.

sic transit gloria mundi. The profession of medicine is toast, but there will of course still be sick people, and doctors to take care of them. So I suppose nothing will really change much in the trenches.

Tom

I do not think physicians have any choice in the matter, according to the supreme court ruling.
It is every citizens' right to health care, and you, David, are going to provide that service to each and every citizen patient.
Choice, there is no choice and every good citizen needs to burn Erasmus' De Libero Arbitrio and get those thoughts of free will out of their conscious state.

The whole point of Obamacare is the destruction of that choice. Only if you are a good citizen will you work for free or next to free, and you will feel good about it.

I am being a bit cynical, but we have to look after our own liberties to keep this a sacred profession.

I don't think this makes doctors into slaves.
It does limit our options, and we will be forced to game the system if we want to survive.
That's life in an autocracy.
But life goes on, life is good.
I am trying not to sweat the small things.

Thanks, David. You just gave a succinct explanation of why we needed the ACA.

It may play out to be better than the inexorable downhill course we were on.

So let's try being optimistic.

There is going to be a lot more demand for our less valuable services.

Now is the time to start finding bottlenecks in our efficiency. How do you maximize patient contact time while minimizing paper work? How do you work smarter? How do you get better at following guidelines? Who are the staff that need to change? How do I need to change?

Now is the time to do the strategery about increasing your office production. Is your office big enough to hire a/another physician extender? Do you need a larger office, more parking, a real server?

Come on! We're going to be rich!

Don't hire another physician, get an extender, or 3, or a dozen! We'll run 'em through like burgers. It's the new model of US medicine, the "McACO" -- 23 million new covered lives served!

John,
Will you or your physician extender(s) be performing annual wellness visits while exercising at the local fitness center with your patients to promulgate good health? And do you envision McACO (I love the term by the way) playing well with McPCMH (patient centered medical home)? Now that we are no longer suppose to be doing mammograms on women 50 and younger or PSA's but screening for spousal abuse, I will have lots of free time. I don't know about you, but with all the needless positive PSA/abnormal mammogram letters I won't have to write, I will now have time to exercise with a portion of that new 23 million lives you mentioned.

And to Jon--I am currently thinking of having my lawyer interpret the new guidelines for when to order a colonoscopy after finding a polyp, it may be easier just to do away with that screening modality to avoid all the unnecessary confusion.javascript:void(0)

Truly some forward-thinking concepts there jimmie!

But I don't see any reason why we need exam tables any more, lets just have exercise equipment. I'll establish Doc John's McPCMH & Spa. I can imagine it now, my nurse reports, "Rash in room 4 on the elliptical, and rectal bleed in 2 on the recumbent bike." All the while, in the waiting room physician extender # 11 leads a Zumba class, while the big screen TV shows a carefully selected series of antismoking and Cialis ads.

I'll just relax on my tanning bed in the back, watching Amazing Charts version 8 and SuperUpdox complete hundreds of preauthorizations and superbills with lightening speed. Yes, with Obamacare, the PCP is king!

So... Dan Watrous from CA, I used to focus on efficiency. Cut people off to stay on time. Made them come back multiple visits. I always ran behind, stayed late, and still made some patients unhappy and myself unhappy. What I did was to make all my appointments 30 min (unheard of for lowly FP docs) and women Px appts 50 min. I discovered I had time to take care of most all the problems, got my notes done, even had time to chat. My providers and I are all much happier, patients love it, and reimbursement stayed about the same (we meet time requirements for charging high levels - if appropriate). I think what people want is time - which nobody can make more of. I imagine it's different in specialty clinics. Supply and demand will impact all of us. I wonder what's going to happen re number of providers. When socialized med was implemented in Canada and GB, 20-30% of providers "retired". In Anchorage up to 60% have stated they will consider this if ObamaCare passed.
I assume you hail back from ORU - Hi John & Miriam

Yes, John.... Good on 'ya for figuring out what patients need is to be heard.

Long term, there will be new doctors to take the place of those who quit; they will start their training and careers with different expectations than we. I have a friend, completing second year WWAMI at University of Washington. He just wants to be a doctor, primary care in Alaska,actually, and figures he will take the economics that exist when he gets there. I think very few of us had a specific economic model in mind when we started. At least I know I didn't. I was in my last year of residency when I learned not all medical specialties paid the same.

John-ryanjo--I can't recall which throw away journal but actually read where the exercise/annual exam at the fitness center is being recommended as part of the patient centered medical home--
John Nolte--a breath of fresh air to read your thoughts--my wife has been helping out at the office this week and we were just talking about extending patient time slots--I agree listening/spending time is often the best medicine
David--I was the same as you and did not have an economic model in mind and did not have any role models who ran their own small business growing up, but was extremely fortunate 19 years ago when I got my first job to have joined a small group of like minded docs, with one in particular that was a small business genius (he still is but just retired) and I was able to pattern my business model after his--basically the lichen principle I have mentioned before. But feel extremely grateful to chance or fate or both to have been given the privilege of learning from him these past 19 years on how to run an office-something I will always cherish.

Hi, John

Great to hear that you and Miriam are thriving in Alaska. We've been thru Anchorage several times in the last few years, and love it. Will look you up next time.

Dan