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Hi everyone,

Anyone have a good feel for what Obamacare really means to a practicing physician? Not the effect on us as employers, but the effect on us as health care providers?

I do not ask this to get opinions as to the good or the bad of Obamacare. It looks like it is going to come to pass, so the only relevant question is, how will it affect us?

Thanks.

Gene

In 2015, reimbursements will be based on "performance." E.g. having a larger percentage of patients who comply with treatments will result in a larger reimbursement.

Gene,

My brother in law from Illinois sent me this, but I think one of the concerns with Obamacare is with the expansion of Medicaid we will need more providers to handle the volume of patients.

"Cook County Medicaid expansion approved by federal government
Late last week, the Obama Administration approved a controversial federal waiver that will allow Cook County to begin enrolling persons early in the expanded Medicaid program under the Affordable Health Care Act (Obamacare).

The early implementation of the Medicaid expansion was authorized by House Bill 5007, which passed the Illinois General Assembly on a largely partisan roll call in May. Most Republicans voted against the expansion, which is expected to add between 100,000 and 250,000 adults to Medicaid.

Opponents argued that, given the soaring costs of the existing program and the decision to reduce benefits for many seniors, children and chronically ill individuals already on Medicaid, it was wrong to add thousands of childless adults to the Medicaid rolls. Cook County sought the expansion, saying that the affected individuals were already receiving medical care though emergency rooms and free clinics and that the waiver would save the county as much as $100 million by forcing the federal government to help pick up the tab."

Interesting article. You have to understand that Cook County contains 1/3 of the people in the State of Illinois. Another 1/3 are in the surrounding counties, whose poor often seek services at the Cook County Health systems.

I did not read this article, and I am actually not aware of it. On googling it, I came across this, from the Cook County Government website (NOTE THAT THE UNDERLINING IS MY EMPHASIS):
"Illinois General Assembly passed House Bill 5007. This initiative will allow the federal government to consider the Cook County Medicaid Waiver that, if approved, will permit current patients of the Cook County Health and Hospitals System who will be eligible for Medicaid coverage in 2014 to enroll early in a Cook County Medicaid Network with absolutely no cost to the state of Illinois.

These are patients that our health system treats today. By allowing them to enroll in a county Medicaid network prior to 2014, our health system will be able to access federal reimbursement for the costs of their care while transforming our health system into one that provides appropriate, coordinated and preventive care for their medical needs."

Currently the County health system has a budget of almost a BILLION dollars. By moving these patients to quasi Medicaid, some of this would be offset to the federal government. This is a cost shifting measure. THESE PEOPLE ARE ALREADY COVERED BY "GOVERNMENT" healthcare (albeit the county, not the federal government.) Also note it will only take place IFF the federal government accepts the plan.

Technically, it is NOT Obamacare, since these provisions would not take effect until 2014. Obamacare does increase eligibility for people 133% BELOW the poverty level in 2014.

Obamacare also includes provisions that:
1)Insurances cannot use prior existing conditions in making rates. Also it eliminated a cap of lifetime payments.
2)Children under 26 can stay on their parents health insurance (not sure if they are required to be in school
3)Capped raising premiums on insurance companies for increasing profits.
4)Created insurance exchanges to theoretically lower rates (yeah, right...)

In short it increases the number of patients covered by insurance. Although they tout it will save money, I seriously doubt how covering more people without restricting prices will save money.

Some want to put the Medicare cuts into Obamacare, but those predated these provisions.

I have issues with Obamacare, but have no issues with increasing availability of health care, which are the main provisions of the plan.

(This message was NOT approved by Obamacare nor paid by any Federal funds )

Wendell here is what my B-N-Law sent me,
I just assumed it was true but did not dig any deeper to find out if it was true.

I just posted the info near the bottom of the article since most of the stuff didn't have to do with the topic at hand--but maybe this helps.

Senator John Jones, State Senate - 54th District


The state released its annual School Report Card on Oct. 31 said Sen. Jones, which showed that despite increased per pupil spending, Illinois schools continue to fail to meet federal standards for ?Adequate Yearly Progress? designated in the No Child Left Behind Act.

Also this week, the federal government announced its approval of a controversial Cook County Medicaid expansion, and despite an arbitrator?s ruling on the contentious state facility closures pushed by Gov. Pat Quinn the facility closure struggle continues.

State School Report Card released, shows schools fall short of federal standards
Sen. Jones said that although the state continues to increase per student spending, many Illinois schools once again to failed to meet federal standards for "Adequate Yearly Progress" set out in the No Child Left Behind Act. However, the reasons behind the statistics are complex say education experts and may say more about the challenges of educating some students than about the overall state of education in Illinois.

The Illinois State Board of Education released its annual School Report Card Oct. 31 and the results provide ammunition for all sides in the education debate.

In the latest report, 66 percent of Illinois primary and secondary schools failed to make adequate yearly progress. However, looking only at Illinois High Schools that number climbed to 98 percent. In addition, about half of all high school juniors in the state failed the Prairie State Achievement Examination. On the other hand, more than 80 percent of grade school students passed the Illinois Standards Achievement Test.

At the same time, per pupil spending averaged $11,664 statewide for the 2010-2011 school year, an increase of more than $2,000 since 2007. Average teacher salaries were $66,616, while the average administrator was paid $110,870.

Some critics point to the apparent disconnect between the cost of education and the results. Even education officials have said there is no clear link between spending and student success.

"There is really not a direct correlation between spending and achievement," former State School Superintendent Glenn "Max" McGee told the Chicago Tribune.

The ongoing debate over test scores and school evaluations has led the state to move toward new standards. Beginning next year, the Illinois State Report Cards will be revised with new standards. The state is also seeking a federal waiver from some of the requirements of the No Child Left Behind Act.

For information on how school districts performed, the School Report Cards are available on the Illinois State Board of Education website. Additionally, both the Chicago Tribune and the Chicago Sun-Times have created special sites with tools to review local school districts.

Arbitrator's ruling gives the go-ahead for closures
Recently, Gov. Pat Quinn?s fight to close a number of state facilities was bolstered by an arbitrator?s ruling which found that the Quinn administration has taken reasonable steps to work with union workers on closing the facilities, and should be allowed to proceed with shuttering the facilities. In addition, a state board charged with reviewing healthcare facilities, gave the green light to the Governor's plan to close the Jacksonville Development Center, which houses developmentally disabled persons.

Though the arbitrator noted that ?the ideal solution? would be to keep the facilities open, he ruled the prison closures would not present a ?clear and present danger? to facility employees. However, the American Federation of State, County and Municipal Employees (AFSCME) questioned the arbitrator?s determination; the union has long contended that the state?s correctional system is vastly over-crowded, arguing that closing and consolidating facilities will make circumstances more dangerous for prison employees.

In response, AFSCME has asked an Alexander County judge to retain the current injunction prohibiting closures. AFSCME is also asking the judge to vacate the arbitrator?s opinion, contending state law requires employers to provide a safe work environment. A recent Associated Press investigation revealed that the state had eased security rules for prison transfers, despite promises from the administration that no changes in procedures or policies would take place.

Spurred by the ruling, the Quinn administration also turned to the courts, requesting a Cook County judge lift the order to allow the state to move forward with the long-sought closures. It is not known how quickly the judges will respond to these requests.

In a separate action, the Illinois Health Facilities and Services Review Board, which is appointed by the Governor, voted 6-1 to allow the Quinn administration to proceed with closing the Jacksonville Developmental Center as early as Nov. 21. The board ruling came despite testimony against the closure from Jacksonville's mayor, State Senator Sam McCann and State Representative Jim Watson.

Cook County Medicaid expansion approved by federal government
Late last week, the Obama Administration approved a controversial federal waiver that will allow Cook County to begin enrolling persons early in the expanded Medicaid program under the Affordable Health Care Act (Obamacare).

The early implementation of the Medicaid expansion was authorized by House Bill 5007, which passed the Illinois General Assembly on a largely partisan roll call in May. Most Republicans voted against the expansion, which is expected to add between 100,000 and 250,000 adults to Medicaid.

Opponents argued that, given the soaring costs of the existing program and the decision to reduce benefits for many seniors, children and chronically ill individuals already on Medicaid, it was wrong to add thousands of childless adults to the Medicaid rolls. Cook County sought the expansion, saying that the affected individuals were already receiving medical care though emergency rooms and free clinics and that the waiver would save the county as much as $100 million by forcing the federal government to help pick up the tab.



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Senator John O. Jones
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Update My

For those who think "universal care" will substantially improve the quality of health in the US, as measured by WHO, you may want to check out the editorial in latest edition of Pharos (page 3). Therein lies the lesson of the Saudi prince and the Amish

Pharos

They are closing most of the public psychiatric hospitals in the state and there is a prison that is not being used that is up for sale.

As I said before, our state is nearly bankrupt. We have not had fiscally responsible governors for some time. Now they are living the life of luxury in our penitentiaries (Blagojevich and Ryan are currently behind bars).

The schools have a lot of issues. I cannot begin to address them here.

I am on board with us needing to help people get better health care however, I don't think Obamacare will do it. IN short, I think people may have some insurance but not sure how it would affect private practice if we don't take the insurance (unless government forces us to). I think that it hurts a lot of our patients that chose to be cash pay. I have a lot of 21-35 year olds who don't have insurance if they are single because it is cheaper for them to pay cash for random visits they need. In that case it hurts me as the provider because we all know cash is king.

I am not sure yet the ramifications of which insurance policy people would have out. It may bring down our payments if everyone starts following medicare and other payment plans. I haven't been affected by the medicare reduced rate because I only have about 15 medicare patients on my load.

Our state as Wendell said is out of money so as it is anything that the having to be paid by the state we aren't getting paid on. Right now for example Cigna (some of it) was taken over by the state and I am getting random checks every month of $5.24 or $9.36 or $2.13 (you get the point) and it is just paying me some type of "interest rate" on the money they owe me ..some of it from freaking 9 months ago. So if the govt insurance plan if they make it work is gonna be paid by the states..then those of us in IL are screwed....not sure about other states.

I guess I am happy that where I am at, I don't see a lot of people jumping onto that insurance plan...Most of my patietns are UHC and BCBS and Humana...I am hoping it stays that way and it just sits well for me...I think I should have opened my practice 10 years ago instead of 3 and I would have been doing much better...oh yeah..10 years ago I was still in med school (well just leaving)

The young people can be on their parents' insurance to age 26 even if not in school. This helps lots of my patients get their care.

The biggest change we are seeing is the coverage for preventive services. All qualified health plans must now cover, with no cost-sharing, the recommendations of the USPSTF for preventive services, including immunizations and screenings.
Now I see a lot of patients who come for 'annual and Pap' but actually have significant problems that they've been saving to discuss. If it's a strictly preventive service, there's no copay, no deductible. If we discuss, evaluate, treat issues, then that's a problem visit and they do have to 'cost-share' the visit.
This is taking a lot of education of patients and staff (and me!)

THe documents are so freaking long. i don't understand all of it yet. I have been to meetings and such but wish there was a local group or hell a national meeting to talk about this stuff. If someone broke it all down to explain it, it would be awesome!

Ketan, The State of Illinois had a policy through Cigna for some state employees. It was self funded, but Cigna did the administration. Because it WAS NOT funded and the bills have not been paid, Cigna must pay interest on those claims ( and probably bill the state which has probably not paid for that. ) That's why you're getting the small checks.

Government insurance is exempt from paying interest if they are late in paying That's why Medicaid traditionally could be slow in paying.

The biggest issues with healthcare, and these are also issues that the majority of people utterly FAIL to understand are as follows:

* Many think going to a single payor government sponsored system such as that in Canada or the U.K. will solve many problems and reduce cost. It doesn't matter what kind of system the country has be it single payor or a hybrid like ours is now, you must have more money coming in than going out. In the United States, we have far more demand than supply. Furthermore, and yes we have heard this a million times, there are just way too many people not paying in. We have a gigantic baby-boomer population that retires and stops paying many taxes when they do, we have a gigantic single-parent population that gets tax credits out the whazoo (kids are currently $1000 each). We have a gigantic population dependant on manufacturing jobs that are all going overseas and their vote to grant them more welfare is winning out over the vote to get them re-trained for different jobs.

* We are a country of sick people. Diabetes is rampant in this country. Thanks to our pitiful excuse of a media, we have huge rallies for breast cancer and things like that but not one person says anything to the fat chick who honestly thinks she looks awesome in those hip-hugger shorts. Men guzzle huge cups of sugary soft drinks and think they look cool doing it. Our dogfood and catfood is insanely nutritious yet we insist on eating fast food with that pink slime. If you were the CEO of Aetna, what would you do if you read a government statistic that stated 30% of all graduating highschool students were 20lbs or more overweight?

The issues could go on and on. But the bottom line is simple: We have too many sick people, too few doctors, and too many too stupid to realize the answer isn't more healthcare, it's more Gold's Gym memberships.

JamesNT

I agree with James somewhat. The bottom line is incentivizing patient healthful behavior, like exercising, stopping smoking (over 20% still do), losing weight, going for preventive care, taking meds that work and not vitamins and other crap that doesn't. Oh -- and learning at least as much about your body as you know about your cellphone or TV remote.

But instead Obamacare will start paying docs on a differential depending on the way patients behave. After all, don't we pay politicians on how much they improve life for their constituents? (Yeah, right)

We Americans are irresponsible and mostly ignorant about our health. When we get benefits for cleaning up our act, then costs will go down and America will be healthier. But nothing in the ACA is going to change that.

I'd like to know the parts you do not agree with. I'm curious.

JamesNT

Single payor will eliminate duplicative administrative costs. Having 400 different entities all duplicating the same administrative functions, some better and worse is a waste of health care dollars.

There may be advantages with preventive duplicate testing and such since it would be easier to query what was done by another provider. This would depend on how the system was set up.

We do have more demand than supply. That is because you get what you pay for. Specialists have traditionally been paid more than PCPs and thus more physicians have gone that route. Procedures were more valued than prevention. The inequity will need to be addressed regardless of the system.

Often many of the services done by specialists could be done by PCPs but are referred by habit or by reimbursement issues. Again, this is not related to the type of system but another issue that would need to be corrected.

People often confuse single payor with government. It need not be the case. Any nonprofit could fit the bill. It could be regional - somewhat like the Blue Cross model. If you are out of area, the Blues work it out among themselves. It probably averages out in the long run.

(Of course BCBS of IL built a 1 billion dollar building downdown and 10 years later added a 2 Billion dollar addition on top - all paid in cash depends on what you call nonprofit...)

So I wonder who is going to look after my non-compliant diabetics, smokers, obese patients? I will have to ask these patients to leave since they will affect my"numbers"!

I misspoke -- I don't disagree with you James. Your statements on the financial aspects of single payor systems and American lifestyle choices are right on target. I think we need to incentivize behavior to change the dynamics you describe.

Franc,


That's part of the idea. Those people are to be pushed out so they will stop costing the rest of us.

JamesNT

Actually most for profit health care is designed on the same premise. Confuse and avoid paying. Eventually either they give up or transfer to another plan. Keep the change. This is true both for patients and physicians.

Is is REALLY necessary to change to ICD 10 with 3 times the codes? Does it REALLY matter if the ear infection was Left or Right?

While I understand the need to do population based actuarial analysis, the idea that "we won't pay unless you give us the untra-fine details" that are not really going to be used for a useful purpose only supports my assertion.

You get what you pay for... more detail, more money IFF it is really that important. (IFF = if and ONLY if). 3 digits we pay blah, 4 digits we pay blahhh, 5 digits we pay blahhhhhhhh (based on ICD 9.) Any other scheme is purely to avoid payment. It's the same on the patient side as well.

Wendell, my friend, duplication of services is a government specialty. One of the few things done well. As for putative administrative savings......
The government?s own projections say the cost of health-care administration will soar from $29 billion in 2008 to $71 billion by 2020, a $40
billion increase in bureaucratic expenses to administer health care. Some have pointed out that?s enough money to buy private health plans
for half of all Americans who are now uninsured because they can?t afford it.

Yes, but does it have to be done by the feds.

Again, regional Blues could be expanded for one model. Or Kaiser of the US

Well call me paranoid or, more kindly, a suspicious soul but it appears to
me Obamacare is not really about saving money or providing care. It's all
about ultimately achieving government control. Any screw-ups and roadkill
along the way helps the cause; the means that justifies the end.

You are not paranoid if they are really out to get you. Think of the SGR monster lurking on Jan 1, 2013. Our government needs to subjugate us, then it will be much easier to convince patients that all is well.

SGR????

SGR definition.

SGR imminent disaster.

Does it still qualify as an imminent disaster when it happens every year, like clockwork, for 10 years in a row?

Really makes you wonder what would happen if someone in the government decided that "Docs don't need a fix" this year. That is the disaster that remains imminent. A 27.5% cut? That might be the point at which enough Doctors say no, or even HELL NO, and start dropping Medicare en masse.

Alternatives exist. We are on-boarding a multi-location practice that serves a more rural, 'working poor' part of the US, and focuses on preventative care. They don't take insurers - direct payment only.

We look forward to analyzing their data with them to see how they are doing measured by treatment goals - A1C, smoking cessation, cholestrerol/lipids, etc.

Perennial disaster?

It would be ironic if, simultaneous with ACA providing health insurance for 30 million more people, that doctors would face the option of bankruptcy or cash only.

So true!

I don't know if those will be the only options, and this group of Doctors and Providers are an interesting sub-set, but there is going to be a mathematical point at which refusing certain payers will make sense.

A certain practice recently told me that they have to see 3-4 government payer patients to match what they make from their other payers. Based on current market rates, it is 2 government payer patients to one cash patient. We came up with a spreadsheet model based on their active patient population so that they can play with numbers and see if they are better off dropping the government payers, offer those patients a variable visit fee instead.

This may become an more important calculation for independent practices.