Tag Archives: ACA

Election 2020: What Exactly Is Joe Biden’s Healthcare Plan? And Really, Telehealth to Care for Our Patients?

So, first I wanted to relate an experience, which exemplifies the failure of telehealth, or maybe the failure of healthcare workers who are taking advantage of the “new” health care system of patient care.

Consider the case a two weeks ago. As I was about to operate on a cancer surgery patient, I was asked to evaluate a patient healthcare conundrum. One of our nurse teammate’s husband was sick and no one knew what was the problem. He had lost 23 pounds over 3 ½ weeks, was dehydrated, appetite, sore throat, weak and needed to go to the emergency room multiple times for intravenous fluids. Each time he was told that they were very sorry but they had no idea what the problem was.

His Primary care physician would not see him in person, and he had another telehealth visit, which he was charged for and was prescribed an antibiotic with no improvement.

I asked if he had a COVID test which he did and it was negative.

I then asked if I could examine him or if she had any pictures. She had pictures, with no skin rashes except I noticed something interesting on the intraoral pictures, which showed left sided ulcers on his cheeks, left lateral posterior tongue and palate, again-only on the left side.

I asked if this was true in that the ulcers were only on one side of his mouth? When his wife responded with a yes to the question I then responded that he had intraoral shingles involving the nerve to the tongue, cheek, palate ( glossophyngeal nerve ) and sometimes also affected additional nearby cranial nerve, which is probably why he was having some of his stomach problem. She thought that was interesting and wanted to know what to do since he was about to have some gallbladder studies.

I outlined a treatment plan and low and behold he is getting better. My question is why didn’t anyone in the doc’s office or ER never complete a thorough physical exam? Oh, wait- how does one do a complete physical exam through the telehealth system? What about heart or lung disease patients, how does a nurse or physician listen to their heart or lungs, etc?? Are we physicians forgetting our teachings and training regarding the proper approach to physical diagnosis?

And now what about Biden’s proposal for health care?

Leigh Page pointed out that physicians — like all Americans — are trying to size up Joe Biden’s healthcare agenda, which the Democratic presidential nominee has outlined in speeches and on his official website.

Many healthcare professionals, patients, and voters of all political stripes think our current healthcare system is broken and in need of change, but they don’t agree on how it should change. In Part I of this article, we take a look at Biden’s proposals for changing the US healthcare system. Then, we include comments and analysis from physicians on both sides of the fence regarding the pros and cons of these proposed healthcare measures.

Part 1: An Overview of Biden’s Proposed Healthcare Plan

Biden’s proposed healthcare plan has many features. The main thrust is to expand access to healthcare and increase federal subsidies for health coverage.

If elected, “I’ll put your family first,” he said in a speech in June. “That will begin the dramatic expansion of health coverage and bold steps to lower healthcare costs.” He said he favored a plan that “lowers healthcare costs, gets us universal coverage quickly, when Americans desperately need it now.”

Below are Biden’s major proposals. They are followed by Part 2, which assesses the proposals on the basis of comments by doctors from across the political spectrum.

Biden Says We Should Restore the ACA

At a debate of the Democrat presidential candidates in June 2019, Biden argued that the best way to expand coverage is “to build on what we did during the Obama administration,” rather than create a whole new healthcare system, as many other Democratic candidates for president were proposing.

“I’m proud of the Affordable Care Act,” he said a year later in his June 2020 speech. “In addition to helping people with preexisting conditions, this is the law that delivered vital coverage for 20 million Americans who did not have health insurance.”

At the heart of the ACA are the health insurance marketplaces, where people can buy individual insurance that is often federally subsidized. Buyers select coverage at different levels ― Gold, Silver, and Bronze. Those willing to pay higher premiums for a Gold plan don’t have high deductibles, as they would with the Silver and Bronze plans.

Currently, federal subsidies are based on premiums on the Silver level, where premiums are lower but deductibles are higher than with the Gold plan. Biden would shift the subsidies to the Gold plan, where they would be more generous, because subsidies are pegged to the premiums.

In addition, Biden would remove the current limit on subsidies, under which only people with incomes less than 400% of the federal poverty level qualify for them. “Many families making more than 400% of the federal poverty level (about $50,000 for a single person and $100,000 for a family of four), and thus not qualifying for financial assistance, still struggle to afford health insurance,” the Biden for President website states.

Under the Biden plan, there would still be a limit on insurance payments as a percentage of income, but that percentage would drop, meaning that more people would qualify. Currently, the level is 9.86% or more of a person’s income; Biden would lower that level to 8.5%.

“We’re going to lower premiums for people buying coverage on their own by guaranteeing that no American ever has to spend more than 8.5% of their income on health insurance, and that number would be lower for lower-income people,” Biden said in the June speech.

Add a Public Option, but Not Medicare for All

In the primary, Biden parted company from rivals who backed Medicare for All, a single-payer health system that would make the government pay for everyone’s healthcare. “I understand the appeal of Medicare for All,” he said in a video released by his campaign. “But folks supporting it should be clear that it means getting rid of Obamacare, and I’m not for that.” But he nor anyone else who supported Obamacare has come up with a way to finance this type of healthcare system.

However, Biden embraced a “public option” that would allow people to buy into or be subsidized into “a Medicare-like” plan. It is unclear how similar the public option would be to regular Medicare coverage, but the Biden campaign has made it clear that it would not take funds from the Medicare trust fund, which is expected to start losing funds by 2026.

The more than 150 million Americans who have employer-sponsored insurance could keep it, but they could still buy into the public option if they wanted to. In addition, the public option would automatically enroll ― at no cost to them ― some 4.8 million low-income Americans who were excluded from the ACA’s Medicaid expansion when many states chose to opt out of the Medicaid expansion.

In addition, the 37 states that participate in expanded Medicaid could switch coverage to the new public option, provided that they continue to pay their current share of the costs. (In June, Oklahoma became the 37th state to allow the expansion, following the results of a ballot measure.)

“We need a public option now more than ever, especially when more than 20 million people are unemployed,” Biden said in the June speech. “That public option will allow every American, regardless of their employment status, the choice to get a Medicare-like plan.”

Lower the Medicare Age

In spring 2020, Biden proposed lowering the age to qualify for Medicare from 65 to 60. This provision is not included among the official policies listed on the Biden for President website, but it has been cited by many, including the Biden-Sanders Unity Task Force.

This provision would bring almost 23 million people into Medicare, including 13.4 million from employer-sponsored coverage, according to one analysis. It’s not clear whether these people would buy into Medicare or simply be covered. Their care would not be paid for by the Medicare Trust Fund but would use tax dollars instead. Oh, finally, we find out that our taxes would go up. How much is the problem as we consider all the other programs that Biden and Harris have promoted.

Provide Relief in the Covid-19 Pandemic

Biden would cover the cost of COVID-19 testing and the cost of health coverage for people laid off during the pandemic.

“Testing unequivocally saves lives, and widespread testing is the key to opening our economy again,” Biden said in his June speech. “To fix the economy, we have to get control over the virus.”

Prescription Drug Reform

Biden would repeal a Bush-era exception that bars the Medicare program from negotiating prescription drug prices for the Part D prescription drug benefit. “There’s no justification for this except the power of prescription drug lobbying,” the Biden for President website states.

In addition, Biden’s prescription drug reform plan would do the following:

• Limit launch prices for drugs. The administration would establish an independent review board that would assess the value of new drugs and would have the power to set limits on their prices. Such drugs are “being abusively priced by manufacturers,” the Biden for President site says.

• Limit price increases to inflation. As a condition of participation in government programs, drug prices could not rise more than the general inflation rate. Biden would impose a tax penalty on drug makers whose prices surpassed inflation.

• Allow consumers to buy prescription drugs from other countries. Biden would allow consumers to import prescription drugs from other countries, provided the US Department of Health and Human Services certifies that those drugs are safe.

• Stop tax breaks for pharma ads: Biden would drop drug makers’ tax breaks for advertising, which amounted to $6 billion in 2016.

Stop Surprise Billing

Biden proposes to stop surprise billing, which occurs when patients receive care from a doctor or hospital that is not in their insurer’s network. In these situations, patients can be surprised with very high bills because no payment limit has been negotiated by the insurer.

Twenty-eight states have enacted consumer protections to address surprise medical billing, but Congress has not passed such a measure. One proposed solution is to require payers to pay for out-of-network services on the basis of a benchmark, such as the average Medicare rate for that service in a specific geographic area.

Closely Monitor Healthcare Mergers

Biden would take a more active stance in enforcing antitrust laws against mergers in the healthcare industry.

“The concentration of market power in the hands of a few corporations is occurring throughout our health care system, and this lack of competition is driving up prices for consumers,” the Biden for President website states.

Overhaul Long-term Care

Biden’s latest plan calls for a $775 billion overhaul of the nation’s caregiving infrastructure. Biden says he would help create new jobs, improve working conditions, and invest in new models of long-term care outside of traditional nursing homes.

Restore Funding for Planned Parenthood

Biden would reissue guidance barring states from refusing Medicaid funding for Planned Parenthood and other providers that refer for abortions or that provide related information, according to the Biden for President website. This action would reverse a Trump administration rule.

Boost Community Health Centers

Biden promises to double federal funding for community health centers, such as federally qualified health centers, that provide care to underserved populations.

Support Mental Health Parity

Biden says he supports mental health parity and would enforce the federal mental health parity law and expand funding for mental health services.

Part 2: Physicians’ Opinions on Biden’s Healthcare Plans: Pro and Con

Biden’s plans to expand coverage are at the heart of his healthcare platform, and many see these as the most controversial part of his legislative agenda.

Biden’s Medicare expansion is not Medicare for All, but it can be seen as “Medicare for all who want it.” Potentially, millions of people could enter Medicare or something like Medicare. If the Medicare eligibility age is dropped to 60, people could switch from their employer-sponsored plans, many of which have high deductibles. In addition, poor people who have no coverage because their states opted out of the Medicaid expansion would be included.

The possibility of such a mass movement to government-run healthcare alarms many people. “Biden’s proposals look moderate, but it is basically Medicare for All in sheep’s clothing,” said Cesar De Leon, DO, a family physician in Naples, Florida, and past president of the county’s medical society.

Reimbursements for Doctors Could Fall- No, Will Fall!

A shift of millions of people into Medicare would likely mean lower reimbursements for doctors. For example, the 13.4 million people aged 60 to 65 who would switch from employer-sponsored coverage to Medicare would be leaving some of the best-paying insurance plans, and their physicians would then be reimbursed at Medicare rates.

“Biden’s plan would lower payments to already cash-strapped doctors and hospitals, who have already seen a significant decrease in reimbursement over the past decade,” De Leon said. “He is trying to win the support of low-income voters by giving them lower healthcare prices, which doctors and hospitals would have to absorb.

“Yes, the US healthcare system is dysfunctional,” De Leon added, “but the basic system needs to be fixed before it is expanded to new groups of people.”

The American Association of Neurological Surgeons/Congress of Neurological Surgeons warns against Biden’s proposed government-run system. “We support expanding health insurance coverage, but the expansion should build on the existing employer-based system,” said Katie O. Orrico, director of the group’s Washington office. “We have consistently opposed a public option or Medicare for All.

“Shifting more Americans into government-sponsored healthcare will inevitably result in lower payments for physicians’ services,” Orrico added. “Reimbursement rates from Medicare, Medicaid, and many ACA exchange plans already do not adequately cover the costs of running a medical practice.”

Prospect of Higher Taxes- Absolutely, grab your wallets and your retirement funds!!

Paying for ambitious reforms means raising taxes. Biden’s plan would not make the Medicare trust fund pay for the expansions and would to some extent rely on payments from new beneficiaries. However, many new beneficiaries, such as people older than 60 and the poor, would be covered by tax dollars.

Altogether, Biden’s plan is expected to cost the federal government $800 billion over the next 10 years. To pay for it, Biden proposes reversing President Trump’s tax cuts, which disproportionately helped high earners, and eliminating capital gains tax loopholes for the wealthy.

“Rather than tax the average American, the Democrats will try to redistribute wealth,” De Leon said.

“The elephant in the room is that taxes would have to be raised to pay for all these programs,” said Gary Price, MD, president of the Physicians Foundation. Because no one likes higher taxes, he says, architects of the Biden plan would try to find ways to save money, such as tamping down reimbursements for physicians, to try to avoid a public backlash against the reforms.

“Physicians’ great fear is that efforts to keep taxes from getting too high will result in cutting physician reimbursement,” he said.

Impact of COVID-19

Perhaps an even larger barrier to Biden’s health reforms comes from the COVID-19 crisis, which didn’t exist last year, when health reform was the central issue in the presidential primary that pitted Biden against Vermont Senator Bernie Sanders, the chief proponent of Medicare for All.

“The top two issues on voters’ minds right now are the pandemic and the economy,” said Daniel Derksen, MD, a family physician who is professor of public health policy at the University of Arizona in Tucson. “Any other concerns are pushed down the list.”

The COVID-19 crisis is forcing the federal government to spend trillions of dollars to help businesses and individuals who have lost income because of the crisis. Will there be enough money left over to fund an ambitious set of health reforms?

“It’s not a good time to start reforms,” warned Kevin Campbell, MD, a cardiologist in Raleigh, North Carolina. “Given the current pressures that COVID-19 has placed on physicians, healthcare systems, and hospitals, I don’t believe that we can achieve meaningful change in the near term.”

However, supporters of Biden’s reforms think that now, during the COVID-19 crisis, is precisely the right time to enact healthcare reform. When millions of Americans lost their jobs because of the pandemic, they also lost their insurance coverage.

“COVID-19 has made Biden’s healthcare agenda all the more relevant and necessary,” said Don Berwick, MD, who led the Center for Medicare & Medicaid Services (CMS) under President Obama. “The COVID-19 recession has made people more aware of how vulnerable their coverage is.”

Orrico at the neurosurgeons group acknowledges this point. “The COVID-19 pandemic has exposed some cracks in the US healthcare system,” she said. “Whether this will lead to new reforms is hard to say, but policymakers will likely take a closer look at issues related to unemployment, health insurance coverage, and healthcare costs due to the COVID-19 emergency.”

Many Physicians Want Major Reform

Although many doctors are skeptical of reform, others are impatient for reform to come and support Biden’s agenda ― especially its goal to expand coverage.

“Joe Biden’s goal is to get everyone covered,” said Alice Chen, MD, an internist who is a leader of Doctors for Biden, an independent group that is not part of the Biden campaign. “What brings Democrats together is that they are united in the belief that healthcare is a right.”

In January, the American College of Physicians (ACP) endorsed both Medicare for All and the public option. The US healthcare system “is ill and needs a bold new prescription,” the ACP stated.

The medical profession, once mostly Republican, now has more Democrats. In 2016, 35% of physicians identified themselves as Democrats, 27% as Republicans, and 36% as independents.

Many of the doctors behind reform appear to be younger physicians who are employed by large organizations. They are passionate about reforming the healthcare system, and as employees of large organizations, they would not be directly affected if reimbursements fell to Medicare levels ― although their institutions might subsequently have to adjust their salaries downward.

Chen, for example, is a young physician who says she has taken leave from her work as adjunct assistant clinical professor of medicine at the University of California, Los Angeles, to raise her young children.

She is the former executive director of Doctors for America, a movement of thousands of physicians and medical students “to bring their patients’ experiences to policymakers.”

“Doctors feel that they are unseen and unheard, that they often feel frankly used by large health systems and by insurance companies,” Chen said. “Biden wants to hear from them.”

Many idealistic young physicians look to health system leaders like Berwick. “I believe this nation needs to get universal coverage as fast as we can, and Biden’s policies present a path to get there,” the former CMS director said. “This would be done chiefly through Biden’s public option and his plans to expand coverage in states that have not adopted the ACA Medicaid expansion.”

But what about the potential effect of lowering reimbursement rates for doctors? “The exact rates will have to be worked out,” Berwick said, “but it’s not just about who pays physicians, it’s about how physicians get paid.” He thinks the current fee-for-service system needs to be replaced by a value-based payment system such as capitation, shared savings, and bundled payments.

The Biden-Sanders Task Force

Berwick was a member of the Biden-Sanders Unity Task Force, which brings together supporters of Biden and Sanders to create a shared platform for the Biden campaign.

The task force issued a report in early July that recommended a variety of healthcare reforms in addition to expanding access to care. One of them was to find ways to address the social determinants of health, such as housing, hunger, transportation, and pollution, which can harm health outcomes.

Chen specifically cites this provision. “We need to focus on the social determinants of heath and try to encourage better health,” she said. “I remember as a doctor advising a patient who was a young mother with several small children that she needed to exercise more. She asked me, ‘When am I supposed to exercise, and who will watch my kids?’ I realized the predicament that she was in.”

Price is also glad to see the provision in Biden’s plan. “Social determinants of health has been a key focus of the Physicians Foundation,” he said. “To my knowledge, this is the first time that a political candidate’s healthcare policy has included this point.

“Physicians are not in control of the social determinants of health, even though they affect their reimbursements,” he said. Under Medicare’s Merit-based Incentive Payment System, for example, doctors are penalized when their patients don’t meet certain health standards, such as when diabetes patients can’t get their A1C levels under control, he says.

However, Price fears that Biden, in his efforts to make peace with Sanders supporters, may have to some degree abandoned his moderate stance on health reform.

Is the Nation Ready for Another Health Reform Battle?

Clearly, many Democrats are ready to reform the system, but is the nation ready? “Are American voters ready for another major, Democratic-led health reform initiative?” asked Patricia Salber, MD, an internist and healthcare consultant who runs a blog called The Doctor Weighs In.

“I’ve been around long enough to remember the fight over President Clinton’s health plan and then President Obama’s plan,” she said. Each time, she says, there seemed to be a great deal of momentum, and then there was a backlash. “If Biden is elected, I hope we don’t have to go through the same thing all over again,” Salber said.

Derksen believes Biden’s proposed healthcare reforms could come close to rivaling President Obama’s Affordable Care Act in ambition, cost, and controversy.

He shares Biden’s goal of extending coverage to all ― including paying the cost of covering low-income people. But the result is that “Biden’s agenda is going to be a ‘heavy lift,’ as they say in Washington,” he said. “He has some very ambitious plans to expand access to care.”

Derksen speaks from experience. He helped draft part of the ACA as a health policy fellow in Capitol Hill in 2009. Then in 2011, he was in charge of setting up the ACA’s insurance marketplace for the state of New Mexico.

Now Biden wants to begin a second wave of health reform. But Derksen thinks this second wave of reform could encounter opposition as formidable as those Obama faced.

“Assuming that Biden is elected, it would be tough to get this agenda passed ― even if he had solid Democratic majorities in both the House and Senate,” said Derksen,

According to polls by the Kaiser Family Foundation (KFF), 53% of Americans like the ACA, while 37% dislike it ― a split that has been relatively stable for the past 2 years, since the failed GOP effort to repeal the law.

In that KFF poll, the public option fared better ― 68% of Americans support the public option, including 42% of Republicans. These numbers help explain why the Biden campaign moved beyond its support of the ACA to embrace the public option as well.

Even when Democrats gain control of all the levers of power, as they did in 2009, they still have a very difficult time passing an ambitious healthcare reform bill. Derksen remembers how tough it was to get that massive bill through Congress.

The House bill’s public option might have prevailed in a reconciliation process between the two bills, but that process was cut short when Sen. Ted Kennedy died and Senate Democrats lost their filibuster-proof majority. The bill squeaked through as the Senate version, without the public option.

The ACA Has Survived-But at What Cost?

The ACA is much more complex piece of legislation than the public option.

“The ACA has survived for a decade, despite all efforts to dismantle it,” Salber said. “Biden wants to restore a law that the Republicans have been chipping away at. The Republicans eliminated the penalty for not having coverage. Think about it, a penalty of zero is not much of a deterrent.”

It was the loss of the ACA penalty in tax year 2019 that, paradoxically, formed the legal basis for the latest challenge of the ACA before the Supreme Court, in a suit brought by the Trump administration and 18 Republican state attorneys general.

The Supreme Court will make its ruling after the election, but Salber thinks the suit itself will boost both Biden and the ACA in the campaign. “I think most people are tired of all the attempts to repeal the ACA,” she said.

“The public now thinks of the US healthcare system as pathetically broken,” she added. “It used to be that Americans would say we have the best healthcare system in the world. I don’t hear that much anymore.”

Physicians who oppose the ACA hold exactly the opposite view. “Our healthcare system is in shambles after the Obamacare fiasco,” Campbell said. “Even if Biden has a Democrat-controlled House and Senate, I still don’t think that there would be enough votes to pass sweeping changes to healthcare.”

Biden Could Choose Issues Other Than Expanding Access

There are plenty of proposals in the Biden healthcare plan that don’t involve remaking the healthcare system.

These include making COVID-19 testing free, providing extra funding for community health centers, and stopping surprise billing. Proposals such as stepping up antitrust enforcement against mergers would involve administrative rather than Congressional action.

Some of these other proposals could be quite expensive, such as overhauling long-term care and paying for health insurance for laid-off workers. And another proposal ― limiting the prices of pharmaceuticals ― could be almost as contentious as expanding coverage.

“This proposal has been talked about for many years, but it has always met with strong resistance from drug makers,” said Robert Pearl, MD, former CEO of the Permanente Medical Group and now a faculty member at Stanford School of Medicine and Graduate School of Business.

Pearl thinks the first item in Biden’s drug plan ― to repeal a ban against Medicare negotiating drug prices with drug makers ― would meet with Congressional resistance, owing to heavy lobbying and campaign contributions by the drug companies.

In addition, Pearl thinks Biden’s plans to limit drug prices ― barring drug makers from raising their prices above the general inflation rate and limiting the launch prices for many drugs ― enter uncharted legal waters and could end up in the courts.

Even Without Reform, Expect Lower Reimbursements

Although many doctors are concerned that Biden’s healthcare reforms would reduce reimbursements, Pearl thinks reimbursements will decline even without reforms, owing in part to the COVID-19 pandemic.

Employer-based health insurance has been the bedrock of the US healthcare system, but Pearl says many employers have long wanted to get rid of this obligation. Increasingly, they are pushing costs onto the employee by raising deductibles and through premium sharing.

Now, with the pandemic, employers are struggling just to stay in business, and health insurance has truly become a financial burden, he says. In addition, states will be unable to balance their budgets and will try to reduce their Medicaid obligations.

“Before COVID-19 hit, healthcare spending was supposed to grow by 5% a year, but that won’t happen for some time into the future,” Pearl said. “The COVID economic crisis is likely to continue for quite some time, forcing physicians to either accept much lower payments or find better ways to provide care.”

Like Berwick, Pearl believes healthcare will have to move to value-based payments. “Instead of producing more services, doctors will have to preserve resources, which is value-based healthcare,” he said. The primary form of value-based reimbursement, Pearl thinks, will be capitation, in which physicians agree to quality and service guarantees.

Even steadfast opponents of many of Biden’s reforms foresee value-based payments taking off. “Certainly, there are ways to improve the current healthcare system, such as moving to value-based care,” said Orrico at the neurosurgeons’ group.

In short, a wide swath of observers agree that doctors are facing major changes in the payment and delivery of healthcare, regardless of whether Biden is elected and succeeds with his health agenda.

Notice that no one has mentioned tort reform in healthcare. Why Not???????

From the Patient’s Point of View-Why will they be Miserable?

 The 15-minute visits also take a toll on the relationship of the patient-doctor relationship. The patient who sits patiently in the exam rooms waiting patiently for the doctors to arrive for their visit and to finally speak with their physician. They have already seen the administrative secretary and the nurse, but they came here to see their physician. So, now the physician presents his or herself. Based on my complaint he or she looks in my mouth, throat and up my nose, said that my throat was inflamed and told me to see the nurse for a prescription and that I was suffering from a sinus infection with inflammation of my throat from posterior pharyngeal drip.

When I protested the drug that he wanted to prescribe he cut me short and told me to see the nurse……and he was out of the exam room. It must have been a visit that lasted for a total of 9-11 minutes, if that.

This story is becoming increasingly common. The patients as well as the physicians are feeling the time crunch as never before. The doctors and nurses feel like “running” office hours on rollerblades. Doctors have to see more patients and perform more procedures to make up for the discounted, flat or declining reimbursements.

This problem will worsen with the Affordable Care Act (ACA). Remember, millions of consumers who are gaining healthcare through the ACA begin to seek care, many of whom have never, or very rarely, have seen a doctor and therefore this patient population presents with a list of untreated problems. Often in the primary care as well as in other specialties, the patient is seen for only one diagnosis per visit. This is very inconvenient for the diagnostically/multiple disease patient. They then don’t get the comprehensive care with continuity associated with the individual patient. This is happening today as evidence by one of my patients with complex endocrine disease (diabetes and thyroid disease) who has been frustrated by these short visits with the results that her complex disease is out of control. I quickly referred her to an endocrine specialist.

In today’s world it seems that the doctors have one eye on the clock and the other on their laptop computers, typing away to capture the correct amount of “points” for the highest reimbursement for the visit.

As Roni Caryn Rabin stated in her article in WebMD, short visits take a toll on the whole relationship of the doctor –patient, which I have already stated in an important part of the good care equation. As I presented last week, we have to have a change in behavior in both the doctor as well as the patient. The office visit and the physician-patient relationship represents missed opportunities for getting patients more actively involved in their own health care. Research and the surveys show that there is less of a dialogue between the patients and their doctors, which increases the odds that patients will leave the office frustrated. Also, the shorter visits also increase the likelihood that patients will leave the office with a prescription, instead of discussion about behavioral changes like trying to lose a few pounds by going to the gym/exercise.

The physicians also don’t like to be rushed either, but for the primary care physicians and now even with specialists, time is is, quite literally money. Primary care doctors are paid mostly per visits with only minor adjustments for those that go longer than the time allocated for the diagnostic codes. Specialists who do procedures also need to see an increasing number of patients to generate a proportion of patients an increased number of procedures to compensate for the decreasing/discounted reimbursements for those procedures. The struggle is getting worse and worse with doctors thinking about meeting the bottom line, paying the overhead, having to pay staff and keep the doors open.

The pressure becomes even worse between both physician and patient when the patient has waited 9 months for his or her appointment and when the doctor comes in the exam room the patient pulls out a long list of complaints. Remember, the patient is thinking that they have waited sometimes a few months for the appointment and I’m going to try to get the most of my time that I have taken off from my work or have had to get paid childcare so that they could get to the appointment.

The situation became worse when doctors started participating in managed care networks where the doctors gave the insurers discounts on their rates in exchange for the promises to steer more patients to their office. Therefore, to avoid a cut in income the doctors had to see more patients.

In medical school the students are drilled in the art of taking a careful medical history, but studies have found that the doctors are falling short and that they have a bad habit of interrupting. A 1999 study of 29 family care practices found that doctors let patients speak for only 23 seconds before redirecting them and that only four patients got to finish their statements. Today the technical doctor of the present is often, and the interview is interrupted by the physician’s beeper, their cell phone or an email notification as their typing in the patient information on their laptops.

Communication between the physicians and their patients is important and making the patient feel they have been heard may be one of the most important elements of the healthcare equation. People are feeling dissatisfied when they don’t get a chance to say what they have to say, when they don’t get their questions answered, that they got their monies worth.

What happens when the patient doctor relationship suffers? Well, the patients lose trust in their caregivers and don’t fully engage in their care. How then do you change the patient’s behavior leading to better care, a healthy patient that leads to a more sustainable health care system?

It is predicted by this writer and physician, that with the increased numbers of patients forced into a system with less and less physicians that this relationship between the physician and their patient will get worse and worse. So, the middle class will get poorer healthcare and have to pay more for it.

Looking at the Question-Why Are Physicians So Unhappy?

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With the Affordable Care Act(ACA) you would think that physicians would be ecstatic. They will have more covered patients; that is less, patients without insurance coverage. So, why are they “miserable”?

Daniela Drake in her article in The Week magazine stated that “Being a doctor has become a miserable and humiliating undertaking.” Caring for the sick used to be prestigious and everyone admired the profession. That is except for the doctors themselves, who started seeing the changes. Today the physicians, and especially the primary care doctors, have more work to do then ever before. They work extra hours in a hectic, thankless, unsatisfying profession, which is now dominated by insurers and with the ACA, more government control, government bureaucrats, and as usual the malpractice lawyers. She further states that “many doctors feel that America has declared war on physicians,” and her research shows that nine out of ten doctors say that they would discourage others from entering their profession. In fact of my five children and their friends, I have discouraged then from considering the practice of medicine.

I know that many people have very little empathy for the doctors, since most of the non-physicians believe that all physicians enjoy the sky-high incomes of the Hollywood plastic surgeons and Medicare-mill ophthalmologists. But research shows that the life of the primary-care physician is neither “privileged” nor especially lucrative. In fact, it is not only the primary-care physicians who are “suffering” from the discounted pay scale and denial of payment, with an increase in their workload. We see the general surgeons, cardiologists, ENT, pediatricians, etc. all suffering in the new health care model.

Physicians must now cram in 24-30 or more patients a day to pay the overhead due to regulated fees and cost of filling out insurance forms, which averages $58 per patient. The addition of the Electronic Medical Record software and hardware adds, on average, $30,000 per practitioner per practice. Also, don’t forget the high malpractice premiums that physicians must pay out just to see even one patient.

If you look at the average primary care physician patient visit, the visit lasts about 11-12 minutes per patient. The ACA is now adding even more bureaucracy and pressure to cut costs. With the new pay for performance, physicians will be penalized if they don’t improve the health of their patients or see their patients more than the allotted visits without showing improvement in the care of the patient.

How then do we attract the best minds to choose medicine as a profession and to convince the good physicians to stay in practice? As Ms. Drake summarizes, “the well-being of America’s caretakers is going to have to start mattering to someone.”

We will continue this discussion as we look at both sides of the picture-the perspective of the physician as well as the patient. The shorter visits create a toll on the doctor-patient relationship, which is considered a key ingredient of good care and may actually represent a missed opportunity for getting patients more actively involved in the own health, including preventative care. This goes back to our discussion regarding changing patient as well as doctor behavior.

The question is America, are you starting to see how complex the problem is and that with poor planning the system is already broken. We must all consider the future options and how we will all force our politicians to modify the health care system to benefit all.

Good Behavior and Bad Behavior-How do we reward or penalize behaviors?

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As I suggested weeks ago, that in order for the Accountable Care Act(ACA) to work or become sustainable as a health care system for the USA, we need to have behavioral changes take place.

These behavioral changes need to come from both the patient as well as from the physician and the health care delivery system. We can reward the physician as well as the health care delivery system by increasing reimbursements or payments for the patient interaction, i.e. patient visits, patient care, surgical procedures. We negatively affect the physician and health care system by assessing penalties or decreasing what the ACA pays out for patient interactions or surgical procedures. We can also penalize health care providers by denying them licensing to practice or increasing their malpractice premiums. This way we weed out the bad players in health care, as well as bad behavior.

But how do we encourage good behavior for patients involved in their care, improving their health? How do we penalize the patient who does not want to participate in their care, persisting in their bad behavior, with no improvement in their health? In fact these patients get sicker and the demands financially and the man/woman-power investment become unrealistic.

The patients that pay their insurance premiums, we can increase the premiums, increase their deductibles, penalize them on their taxes, whether federal of state taxes. But what will the results be? Increasing their deductibles discourages the patient from seeking medical care because the majority of cost is now out of pocket. So, how does this encourage good behavior?

Increasing the premiums for patient’s bad behavior and decreasing their premiums and deductibles for good involved compliant behavior makes a lot of sense. But increasing their premiums or assessing tax penalties will not work, especially in the fully subsidized person or persons who will not feel the true effect.

In fact, will any of these ACA health care strategies work if we can’t change the overall behavior of the patients who are going to still delay their care, resulting in the continued use of the most expensive form of health care….. the emergency room (ER) for their routine care. This is a problem because using the ER sets the system up for failure due to the increase expense and the level of care needed for the patients who wait until it is often too late to for preventive care and then often result in the need for interventional costly procedures.

In a survey that I completed I had a number of participants want to deny coverage altogether for these noncompliant patients. Really? How does this contribute to a system, which is designed to provide health care for all potential patients blinded to their financial status?

Unfortunately, we are truly stuck in that we can not really penalize bad behavior in the portion of the demographic segment of patients who are completely subsidized by the government health care system or those who pay no taxes.

But we can reward good behavior. Here is the answer, I believe, to this dilemma. If they already have subsides like SNAP cards, can we increase or bonus them for good behavior? I think this is a workable solution. We may have to put on our thinking caps and design creative rewards so that these “bad behavior” patients are converted to patients who participate in their care lowering their blood sugars, their weight and who will stop smoking.

I love the idea of the British system, utilizing consumer taxing to subsidize their system, i.e. the Value Added Tax (VAT), which is being increased from 17% to 27%. Heck, raise the tax on cigarettes to 50-75% as well as increasing the tax on alcohol as well as on “bad” non-nutritious foods.

We need to be very careful in that we don’t proceed down the murky path of true social engineering. Do we deny hip and knee replacements for the obese noncompliant diabetics? Why not? They are the patients who will have the highest complication rates, costing the system a true financial burden.

Do we extend this thinking to the noncompliant patients who don’t take their blood thinners, medications for high blood pressure and heart medicines? Why not? Here we will eventual see these patients dying out and therefore decreasing the “bad” patient population. Wow, should we really conceive these strategies? Think about it. In the European system where the necessary surgery waiting times are often weeks to months, aren’t they also culling out the “bad” behavior patients? Sure, the high-risk patients and noncompliant patients then die from their underlying premorbid diseases or go elsewhere for their care. I truly cringe when I just mention these potential strategies. But what options do we have?

So, what are your solutions to these difficult problems? We have to consider these problems and come up with solutions otherwise the system will eventually fail or result in a multi-tiered health care delivery system.

Myth of Health Care Charity

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First, before I initiate a discussion regarding charitable health care, let me question the intelligence of voters in the State of Maryland. I already discussed weeks ago regarding the horrendous roll out of the Maryland healthcare system under the Affordable Care Act (ACA). Who was responsible? The Lieutenant Governor of the State of Maryland, Anthony Brown was responsible and he botched up the roll out eventually costing the taxpayers of Maryland about $200 million. However, the campaigning lies are promoting the wonderful job that he did regarding the ACA. The latest TV ad suggests that he did so much, especially for the aged/seniors. Those that know anything and have minimal intelligence, probably the minority of voters, realize that the seniors/aged are covered by Medicare and have very little to do with the roll out of the ACA. So, as I have said multiple times, wake up America, wake up Marylanders!!

Now on to our Sunday evening discussion.

Anne Zieger reported that in an effort to force patients to buy policies through the ACA health insurance exchanges, hospital systems around the country have started cutting back on financial help for lower- and middle-income people who don’t have health insurance. They are assuming that these families can afford the health insurance plans offered on the exchange, but have declined to make the investment.

While the number of systems that are taking this tack seems limited so far, many hospitals and health systems are considering a “get tough” approach to charity care, and experts predict that that more restrictive policies will become increasingly common, according to the piece in The New York Times. The State of Maryland is different because has waivers for uncompensated care as well as a TPR or total payment system.

One example that stood out in the Times piece comes from St. Louis, where Barnes-Jewish Hospital has started charging copayments to uninsured patients, no matter how little money they’ve got. Another example comes from the Southern New Hampshire Medical Center in Nashua, which no longer provides free care for most uninsured patients above the federal poverty line of $11,670 for an individual. Yet another hospital taking a stricter approach to the uninsured is Burlington, VT-based Fletcher Allen Health Care, which has cut back on financial aid for uninsured patients who earn between twice and four times the poverty level, the Times piece notes.

Unfortunately, these providers’ assumptions about patients’ ability to pay are incorrect. Those at or near the poverty line may not be able to afford even heavily-subsidized policies, and the middle class — who get little or no subsidies — often find that the hundreds of dollars a month they are expected to pay is far beyond their reach

The open but little-discussed secret to the health exchanges is that they really haven’t made health care that affordable after all. In Virginia, for example, the cheapest policies are approximately $350 per person with a $4,000 deductible and a 20% coinsurance requirement. Not only is that a sizable premium level even for middle-class family, the deductibles and coinsurance requirements reduce the value of such a policy dramatically, as low- and middle-income families are seldom equipped to meet such deductibles and coinsurance requirements. Here in Maryland we are seeing deductible as large as $5,000-$7,500 with insurance premiums rising by 42-50 percent. Therefore, they now have catastrophic care insurance policies. Who is winning in this scenario? Not the insurance companies! No, once again, as I have previously pointed out, it is the middle class working tax paying person who is footing the bill for the ACA and who suffer the most.

Health systems are continuing under this assumption as though this were a reasonable option, and that the less prosperous patients are simply being intransigent. “Do we allow our charity care programs to kick in if people are unwilling to sign up?” Nancy Schlichting, chief executive of the Henry Ford Health System in Detroit, asked the Times. “Our inclination is to say we will not, because it just seems that that defeats the purpose of what the Affordable Care Act has put in place.” 

Another hospital, Southern New Hampshire Medical Center, had previously provided free or discounted care for patients who were at or below 225% of the poverty level, or about $26,260 for an individual. Now, however, patients who “refuse to purchase federally mandated health insurance when they are eligible to do so will not be awarded charitable care,” the hospital’s new policy states. Notice the use of the word “refuse” — it implies a lot that’s simply not true about the uninsured.

Ultimately, all of this posturing is in vain, and merely punishes lower-income patients to no avail. If hospitals hope to save money by cutting back on charity care, they’re probably out of luck. If a family can’t afford premiums on the health exchange, they aren’t going to be able to pay massive hospital bills either.  Depriving them of charity care won’t magically force them to take on a larger percentage of their hospital bill, it will simply increase the level of bad debt a hospital must account for, and what’s more, makes it more likely that frightened consumers won’t come in to the hospital for help when it’s needed.

It’s understandable that hospitals want to see the health exchanges work, and want to see as many lower income people buying policies on the exchanges as possible. After all, that does give them a shot at reducing their bad debt.  But if they really want to deal only with insured patients, it’s time they gear up campaigns to subsidize health exchange premiums through thirdparty payers, a strategy that actually has a chance of working. Taking a position that tries to force the poor to produce premium funds out of thin air is just plain wrong.

But also, expecting the middle class to shoulder the high premiums as well as having to deal with extreme deductibles makes no sense. We, as physicians, are already seeing patients cancel their office visits, surgery and routine diagnostic tests, which can and will lead to poor care and delayed diagnosis of diseases. Therefore, they delay treatment leading to more extensive surgical procedures, additional chemotherapy and or radiation with threat of recurrence of disease, cancers and additional treatment.

A recent “edict” was passed in Europe, which we should all pay attention. In discussing affordable health care, socialized medicine or what ever you want to call it in the European countries we want to evaluate how these countries pay for health care. The British Isles depends on the Value Added Tax or VAT tax. Up until this recent change the tax was 17%. However, change is coming in two phases. Number one is the use of co-payments, which haven’t been part of the system since the 1940’s. Number two is the raising of the VAT tax to 27%. Yes, a tax elevation of 10%.

We will spend more time reviewing and evaluating the ACA, other comparative systems and hopefully will strategize modifications to the ACA, if possible.

The Biggest Losers

I ended the last blog hinting about the losers in this new health care program and was encouraged to pursue this discussion while reviewing two articles.

But let me first set things straight, as a strategic planner, the reason we are where we are is due to the lack of real research and planning. As much as I am not a President Obama fan, I really believe he and years before, Hillary Clinton, really believed what they were proposing was a good thing for the American people. I only object to the method that was chosen and the politicization, the lack of real research and planning with people in the know.

I comments in this last paragraph were further strengthened when I read the comments by the Speaker of the House discussing the Republicans mistakes and the lack of ability to overturn the health care law and the need to modify it and make it work. It was interesting to read that House Speaker John Boehner inadvertently revealed that repealing Obamacare “isn’t the answer,” and that “Republicans also need to offer a replacement.”

I also object to Harry Reed and Nancy Pelosi being so arrogant and closed minded in not allowing a non partisan discussion and resolution of difficulties to result in a bill which can “get the job done” efficiently and effectively for all the American people.

This has become a political ping-pong ball and shows that our elected officials really don’t care about Middle America especially and also points to the necessity for term limits.

Jonathan Bernstein wrote that“ The challenge is that Obamacare is the law of the land. It is there and it has driven all types of changes on our health care delivery system. You can’t recreate an insurance market overnight…. So the biggest challenge we are going to have is—I do think at some point we’ll get there—is the transition of Obamacare back to a system that empowers patients and doctors to make choices that are good for their own health as opposed to doing what the government is dictating they should do.”

This is interesting to me due to one of my previous blogs and the strategy that needs to be embraced- getting over the repeal idea and instead find ways to make the law work.

Think about the question that I posed at the end of my last blog-Who are the Biggest Losers? Byron York in his latest Op-Ed piece notes that Obamacare losers are harder to discern. I think not! He finally noted that “The plans being offered through the exchanges in 2014 appear to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than employment-based plans do.” The Congressional Budget Office (CBO) said “These features allow insurers that offer plans through the exchanges to charge lower premiums (although they also make plans somewhat less attractive to potential enrollees).”

The health care analyst, Bob Laszewski, questions who is harmed and points out that “when carriers converted their old policies to Obamacare-compliant policies, it was typical for the insurance company to increase costs about 35%” and “That increase could come in the form of higher premiums, more co-pays and deductibles and narrower networks.” This is what we are seeing in that enrollees are facing higher premiums and higher deductibles, which add up to a total higher cost, as well as a narrower choice of hospitals, doctors and prescription drugs than they had before. Therefore, what we are finding is that health care is becoming a more expensive and troublesome system.

Rick Newman in his article in The Exchange (April 25, 2014) points out that there are three subsets of people whose policies were canceled and then are the posers under the Affordable Care Act (ACA): people who are self-employed, those over 35, those who are white, or some combination of all of these three.

The biggest losers to ACA are the people who lost their insurance coverage but are unlikely to qualify for subsidies through one of the exchanges, which require an income of less than $47,000 for an individual or $95,000 for a family of four. Some of these people who lost insurance coverage report paying twice as much with deductibles of $4,500-$7,500 or more. It was interesting that Mr. Newman pointed out that it so happens that these groups so impacted negatively tend to be Obama’s political opponents.

Do the insurance companies lose? In a previous blog I pointed out that WellPoint was planning to increase their premiums and now I read that CEO of Aetna, Mark Bertolini, stated that their premium increases would range from low single digit to double digits, based on its first quarter earnings. So the insurance companies never lose. The have to make a profit and usually the profit is much larger than the proposed profit margins that the committees and government departments are demanding for health care facilities.

Ethan Rome (The Truth About Health Insurance Company Profits: They’re Excessive) reviewed health insurance company profits and went on to further review the American trade group American Health Insurance Plan’s (AHIP) focus on profit margins which he thought was misleading when they quoted 4.4%, and designed to protect their massive income by shifting attention away from their return on equity — a key measure of profits as a percentage of the amount invested. “That return is a phenomenal 16.1% as of today. By that measure, health insurers are ranked fourth highest of the 16 industries in the health care sector. They also deliver a higher return for investors than cellphone companies, beer companies, mortgage companies, life insurance companies, TV broadcasters, drug store companies or grocery stores.”

In May 2011, the New York Times reported “the health insurance industry is enjoying record earnings while millions of Americans get less medical care. Wall Street investors are delighted with the industry’s profits, and to health insurance executives, that’s all that counts. Insurance CEOs want investors to buy their stock and keep share prices marching higher, and that’s exactly what has happened. To achieve excessive profits, insurers are happy to gouge consumers and small businesses, do little to rein in medical costs and spend billions of our premium dollars on lobbying, secret political activities, bloated executive pay and stock buybacks.”

How about the greedy doctors? Are they losers? In the beginning and for quite a while they will lose as they have for years as their reimbursements (what they are paid by the insurance companies and the government, i.e. Medicare and Medicaid) are further discounted. But they will not be able to keep their offices open unless they become employees of the hospitals, universities or convert to boutique type practices. The boutique practices will charge patient fees to become practice members and or start to do procedures that they are not trained for and for which the complication rate will be high. But the added income will be necessary to maintain their overhead expenses.

Having insurance policies that include $5,000- $7,500 deductibles means that almost all health care needs, office visits, tests and surgery will be out of pocket expenses. How does the new plan then encourage good health care behavior and encourage preventative care?

Yes, the uninsured, if they fulfill the requirements for the government subsidies, will get coverage, but who will take care of these patients and cane you change their “bad” behavior? Will we have enough doctors to provide care and what type of care will be provided? I will discuss these topics further in future blogs.

Let us also consider who is in control of the ACA and what their history predicts. These are the same government systems that have control of the problematic Medicare, Medicaid and Veteran health systems. Remember what we have been hearing about concerning the Veteran Administration Health Care problems in the last few weeks. Long waiting times, poor care, lack of care, deaths, suicides, etc. What then can we expect for the future control and management of the ACA?

Let’s Look at the Equation Again

This past week I was interested in a front-page article in our local paper-Rural healthcare lags behind. What does that mean and how does the Affordable Care Act (ACA) affect areas like the Eastern Shore of Maryland as well as other rural areas of this State and around the country?

There are other areas in similar to the Eastern Shore of Maryland where the rural population consists of a large Medicare and Medicaid patient population needing health care.

Isn’t this why ACA was designed? The article describes these areas as challenges of providing health care where the patients are very sick and the resources, which are very scarce. These areas are lacking health care providers contributing to health disparities that include higher rates of heart disease and obesity and lower life expectancy. The author, Megan Brockett, compares the situation is akin to a “Third World country.”

Maryland is especially problematic in that in the national 2014 County Health Rankings released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, found that five of the 10 least healthy jurisdictions in Maryland are considered partially or completely rural by federal standards and three others in the bottom 10 fall under the state’s broader definition of rural. The article further points to the lower rankings in health care outcomes.

The experts and advocates link the disparities to the scarcity of health care providers in these rural areas and the decreased access to care. The ratio of primary care providers to residents is horrible from a best-case scenario of 1 in 1,056 – to the worst case of 1 to 2,915.

“As a result, people living in rural areas often have to travel long distances for health care, a disincentive to getting even the basic preventative care they should be receiving.” Now add the additional burden of high deductibles, where the patient has a higher out of pocket expense in their health care.

Ms. Brockett goes on to point out that the rate of specialty care providers is worse in the rural areas through out the state. And the effects are seen regularly in the clinics around the state.

Much of the campaign to improve the situation centers on efforts to recruit and retain health care providers to practice in these rural communities and the workforce shortage in rural areas is the biggest barrier to care.

This article is so interesting to me, a specialist practitioner, who practices in one of the state’s rural areas. I have had my billing agency beg me to move my practice out of the rural area to increase my reimbursements by 17-20 %. This is true in a state, which is so backward in that they have demographic areas that pay the physicians at a lower rate than a county/ areas 30 to 45 minutes away. Why would any new physician graduating with a debt in loans of on average of $325, 000 want to practice here where they may never be able to pay back their debts?

Do we get a break in malpractice premiums or practice overhead in the rural areas? No and No.

So, why would any new practitioner want to come to one of the rural areas in Maryland or in any rural area in the US?

Nothing will change regarding the practitioner to patient ratio to acre for the additional enrollees until the educational costs and tort reform is reality.

Another article appeared in The Week magazine, April25, 2014, Page 12 by Daniela Drake-Why doctors are so unhappy. It is a summary of her review in The Daily Beast, starting with the quote “Being a doctor has become a miserable and humiliating under taking.” She states something those of us who went into medicine 20-30 years ago, that “caring for the sick used to be the country’s most prestigious and admired professions.” However, today an emotion that I feel almost daily, that America has declared war on physicians and yes I continuously attempt to discourage others from entering the practice of medicine.

Not only primary care physicians, but also all physicians toil thanklessly in a hectic, unsatisfying profession, which is dominated by the insurers, politicians and their agencies, and malpractice attorneys. We physicians work long hours cramming in more patients than reasonable, 20-30 per day because of regulated fees and the cost of filling out insurance forms, which averages $58 per patient. Right now without all the added enrollees secondary to the ACA the average patient visit lasts 12 minutes. What information, what type of diagnosis can be made in that short period of time?

It is amazing to me that no one challenges the “salaries” that actors or professional athletes make, however they try to make doctors feel guilty when they make money. Do you think that it costs nothing to run a practice with electronic medical records. computers, specialized staff of nurses, billing personnel, etc.?

Patients question and try to make doctors feel guilty about changing their practices to boutique or concierge type of practices. However, more and more physicians will need to convert their practices to this type of practice as the government further discounts physician’s reimbursements and deductibles rise or face bankruptcy or early retirement.

Affordable health care will add more bureaucracy and pressure to cut costs and make it more expensive to maintain their practices. Health care providers, doctors, nurses, nurse practitioners, physicians and the hospitals will be losers in the future of the new system. Who are the other losers? I will delve deeper in the “losers” of ACA or Obamacare. Can you think who will be the “Biggest Losers?”

Doesn’t anybody care except the perceived “rich” doctors?

Again I say, wake up America! We need to have a system that understands what it takes to have a truly affordable health care system that is sustainable and fair to all.