The Unintended Consequences of Good Intentions!

Another guest blog from Dr. Donald Kamens on the health-care exchanges- a personal experience.

Sometimes the symptoms of a disorder are the best clues about etiology.  In the case of healthcare insurance 2016, we have a disorder that is a horse, but not a zebra.  Why? Some would have you believe that rising costs are secondary to the high cost of emergency room care (zebra, or baloney, whichever seems more appropriate).  However, any individual not provided insurance by an employer, can try to buy coverage independently (or for a family member). Thereupon, the horse comes out of the barn.

So what is the breed of that horse?  Is it a Quarter-horse, an Andalusia, an Arabian?  No indeed.  That horse, is a Complexity-horse.  A tough breed, difficult to train. In fact the complexity here is so intense, that a new specialty has arisen:  the CAC (Certified Application Counselor).  Why?  Because applying for coverage is so complex that guidance, or counseling, is needed.  Well, it does not take a rocket scientist to figure out that if a system requires that it spend money for advisors to help hold the hands of applicants, something deeply internal is wrong.  The complexity is just too costly, in and of itself, regardless of the costs of care! What a conundrum!

Now, here’s a live example.  I have been trying to buy healthcare insurance for my wife. She left a teaching position several years ago to pursue other dreams, and that meant finding our own insurance plan.  In November 2016, that is so complex that the neighbors, many miles away, may well hear me screaming.  My years of working in this milieu, as a physician, as an administrator, and as a group principal, do not impact the sense of swimming through spaghetti.  Here are just some of the issues I ran into:

1.     The “marketplace” is impossible to discern.  Every state has its own pallet of availabilities, and within those, each company there is a bewildering spectrum of plans.  The website pages are impossible to read.  Even with page expansion on 36 inch screens, my wife even took pictures of me pouring over them with a magnifying reader.

2.     There is a proliferation of acronyms, incomprehensible terms, and head-scratcher delineations.  IF (and that is a big IF) one gets to see them, one has to do considerable deciphering.  DED means deductible; yes.  But then, you have to figure out and research many (many) others (e.g. PCY  ...per calendar year.  Something wrong with /yr.?). There are tons more.  And then, do you know what $1/$5/$15 means?  In some places (but not all) it means tier 1/tier 2/tier 3 drug costs. 

3.     The plan listings are in disorder.  For one company I was examining, there are bronze, silver, and gold plans. Fine, the idea is clear that gold is best, and so on.  But not so fast.  In this one, they are listed with bronze at the top, gold in the middle (though the costliest), and silver at the bottom being the only one with no drug deductible. What?

4.     The websites do not work very well.   Not uncommonly one gets bounced and has to start over, or some button does not work. Or worse, as on one site, things start acting crazy.  Here, it asked me the number applying for coverage [=1]. Then the number of people living under the same roof, including those not applying for coverage [=3]. Then it said “Sorry the number in your household does not correspond with the application number.” Seriously. Really.

5.     This is a mess!  Did I say that before?  The intentions of those who have set such things up, we have to believe, were good, even if modified by legitimate business concerns.  However, the outcome of this complexity is going to shoot the whole system in the foot. Or the head.

Worse than being a mess in just one state, think about setting up all these complex plans for 50 states! It has been no easy task. Nor was it free.  How much chemotherapy for a patient who could not afford treatment could this baloney have paid for?  I would estimate that if the amount spent on the complexity of the system were actually put into delivery of healthcare itself, the benefits to people would be immense.  This insurance mechanism is a waste of money, a waste of time.  And the real benefits to people are, I would venture to say, going to cause more problems than anyone needs.

Finally, here is my suggestion for an insurance application having five parts:

1.       Do I need health care coverage?  [  ] yes   [  ] no

2.       What is my income:  _____________

3.       How much can I afford per month per individual or per family for coverage?

[  ] $0 [  ] $10 [  ] $50 [  ] $100 [  ] $200 [  ] $500 [  ] $800 [  ] $_______

4.       Do I have any known illnesses requiring care? [list] _______________

5.       When do I want it to start? ____________________

Done!

In the past, when colleagues said they were leaving medicine because it was becoming more and more difficult to practice, I tended to think “wimp!”  Now I am myself thinking of leaving the country and finding a more rational solution to just being a citizen who might, or whose family might, need care someday.

 

 

Have You Lost That Burning Desire?

Professional, occupational or job burnout is short-term exhaustion, lack of enthusiasm/motivation, feeling drained and most times there is negative emotions and cynical behavior that result in reduced professional efficacy within the workplace. 

The article Is Technology to Blame for Physician Burnout analyzes the Medscape Physician Lifestyle Report, which states the electronic health record is a factor in physician burnout.  The data identifies three key factors: insufficient income due to reimbursement cuts, extended hours to maintain the status quo, and the negative impact of technology (time, money, and more staff).  When is the last time you had someone smile when the acronym EHR is mentioned??

It is no secret that physicians, as well as all other health-care providers, have been endlessly bombarded with massive political, economic, and social change.  Simply for survival, most every physician and provider has had to rethink priorities just to keep afloat. 

The EHR was once touted as a solution to the chaos in health-care. Instead of being an answer, it has become an added burden for providers'.  Why?  One thing, lack of standardization has created an additional unknown in a providers' environment.  What problems is this thing going to give  me today?  Even physicians who practice every day in the same location, are face with technological impediments.  Those who work at different sites, often have to readjust to a different interface on the fly.  Such impediments include surprise updates, new facility and regulatory requirements, restructured workflows, unpredictable interfaces, and software that is anything but friendly. Add to all that the failed pledge of interoperability- my system will talk with your system- and it is easy to see why the EHR simply has not lived up to its promise--Not even close!  These studies show that a majority of physicians have felt that the presence of EHR technology decreased face-to-face time and the ability to see patients, while only a minority felt that the quality of their practice was improved.

Burnout is a major potential problem for the health-care system, for patient care as well as for the individual provider that may fall prey.  In this environment, the EHR is a natural scapegoat for the deeply entrenched ills of the system.  With the rapidly aging physician population, once can understand that doctors are expressing a desire to get out of the click race.  Hopefully, the next generation EHR will be better than the current one.  Maybe the psychological and emotional contribution to the specter of burnout will perhaps lessen, if not disappear.

Is It Time to Start Downsizing?

The author of 12 Changes That Will Affect Doctors' income in 2015 lists major changes that should have a net negative effect on providers’ incomes due to the Affordable Care Act. I suggest you read this article.

 

1.      High deductibles is the new self-pay in disguise with many patients not aware of this serious issue.

2.      Decrease in malpractice premiums which will probably be a transient benefit. Caps are being overturned or litigated in most states.

3.      ICD-10 will begin in October and the true cost is not yet known. Most experts think practices should have a 90 day reserve fund to make payroll.

4.      Practices involved in Medicare Accountable Care Organizations will be losing their guaranteed contracts to avoid losing money. There is a bill in congress to keep the contracts viable for 3 more years. Not sure what will happen in new congress.

5.      The emergence of Telemedicine is affecting the growth of certain practices. The reimbursement for these services are still be battled over. The legal liability is also in flux.

6.      Retail clinic pharmacy driven practices are direct competition to the standard practitioner.

7.      Primary Care Physicians will lose their enhanced Medicaid payments. These payments will lower back to approximately 40 cents on the dollar.

8.      Meaningful use become more “mean” and will now penalize rather than reward the practitioner.  The government wants its money back.

9.      PQRS will no longer give maintenance of certification monies for meeting quality measures. Penalties will ensue.

10.   Medicare payments to specific providers are now available without context on new websites.  Bad publicity is the net effect.

11.   Medicare will start paying for chronic care outreach to providers who deal with patients with 2 or more chronic conditions. The downside is the necessary documentation to avoid future audit.

12.   New CPT modifiers to replace the 59 modifier for procedures. Make sure your billing team is ready to change. Failure to act will lead to another excuse to deny or delay
CLAIMS MADE.

 

Welcome to the electronic age to save Medicare money. These trends are just the beginning to try to save Medicare. Cost shifting to the provider is an easy route because they are all “rich doctors” anyway.

Rethinking Office Personnal

Rapid change is occurring to the world of medicine and its varied practitioners.  These practitioners run varied practices, but all have the similar goal of providing quality health care.  The trick is figuring out how to change your processes to reflect the new nature of health care.

Traditional practices have office managers, receptionists, medical assistants, nurses, technicians, and the various providers.  As technology and new rules come into play, these various roles will need to be adjusted.

All the employees of the business will have to be able to multitask, be cross-trained, and most of all pleasant.

The receptionist will be a self-logging user-friendly computer terminal similar to the airlines where the consumer logs in with drivers license, credit card, insurance card and eventually their own personal barcode.  The computer will access eligibility, account balances, and create a spread sheet of what the patient is covered for, their referral list (specialists, lab, x-ray, and needed age-appropriate wellness screens.  The computer will ask pertinent information of the patient pertaining to the chief complaint and motivation for visit.

The intake specialist will review the data, while the vital. sign machine records the blood pressure, etc.  They will order obvious tests (blood, ekg etc. per protocol) and queue the patient to the appropriate provider according to triage protocols.


The provider (Physician, Nurse Practitioner, Physician Assistant) will assess the patient, determine a plan, institute a protocol if needed, and/or make a disposition.  Their personal data technician will create a document that reflects the transaction and document the orders.  The provider may want to input some data through voice-activated technology.  The nurse, medical assistant, and technicians process the orders.  The data technician advises the providers about alerts, core measures, etc. that the Electronic Health Record has given a notification for.

After the patient is given their instructions and medical education by the provider or their surrogate, the social worker interviews the patient.  They deal with the most difficult part of the transaction.  They advise the patient within their social situation how to access their prescriptions, follow-up care, and devise a real-time follow-up plan to keep the patient from floundering in confusion.

The billing specialist analyzes the visit and informs the patient of the costs and options.  With modern billing technology, most practices will be able to do their own billing.

With the social worker monitoring the care in real-time, this should lead to consistent, cost efficient outcomes.  The provider with this type of cross-trained medical staff can hopefully concentrate on practicing "Medicine" and not business, liability, and endless outside pressures.  This environment will lead to success and job satisfaction for all parts of the team.

10 Reasons Doctros Are Pulling Their Hair Out

In the 2013-2014 era, doctors and providers are being asked to adapt to massive changes in their practices, businesses, and their modus operandi.  The stress from all these changes will be felt in the doctor-patient relationship.

Why are doctors unhappy?

1. Conversion of ICD-9 to ICD-10.  Nobody is sure of its value, but are painfully aware of the costs.  Having a code for a crash landing in a space craft would be relevant only for Sandra Bullock in Gravity!
2. Confusion created by the Affordable Care Act roll-out.  Not sure who's on first?  Who's covered? What's the fee schedule?  What are the new, complex rules?
3. High deductible insurance plans making payments at time of service mandatory.  Creating a new class of de-facto self-pay patients who formally were covered.
4. Acute or chronic reimbursement issues as? Fee for service will be replaced by outcome measurements.  What outcome measurements?  Who's measuring?
5. No relief from malpractice liability in most states.
6. Dealing with the Electronic Health record.  Did I purchase the right one?  The continuous moving target of getting meaningful use money. The accompaniment of possible claw backs if the data is not filled out correctly.
7. Hiring more help (scribes, medical assistants, Nurse Practitioners, and Physician Assistants) to see potentially less patients.
8. Hiring more consultants to see potentially less patients.
9. Becoming the most expensive data technician in the room.
10. Fill in the blank __________________ yourself.

 

Practicing medicine is rapidly changing and providers will have to adjust to the new realities.  At what cost to the provider and patient will be determined in the future.

High Deductible Insurance Angst

In Popeye cartoons, the hamburger-loving character Wimpy would always say "I'll gladly pay you Tuesday for a hamburger today".  This sort of entreaty will become the new medical office mantra for poor patients with high deductible insurance plans.  The underlying problem is that these individuals will continue to have no available funds through Tuesday, and beyond.  Those who cannot afford high deductibles will likely seek care elsewhere (or no where), once the door to the doctor's office becomes shuttered by these huge tolls.

Let's look at some definitions of a high deductible health plan, a co-pay, and a health savings account.

• High-deductible Health Plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan.  Being covered by a HDHP is also a requirement for having a health savings account.  Some HDHP plans also offer additional "wellness" benefits provided before a deductible is paid.  High-deductible health plans are a form of catastrophic coverage, intended to cover for catastrophic illnesses.
• Co-pay is a payment made by a beneficiary (esp. for health services ) in addition to that made by an insurer.
• Health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP).  The funds contributed to an account are not subject to federal income tax at the time of deposit.  Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.  HSAs are owned by the individual.

When the HDHP was introduced, it included a significant ability to save money through an HSA where the  individual could theoretically manage their own healthcare expenses through a tax-deductible vehicle.  any money not spent can remain in personal interest bearing account and spent, if needed, at a later date.

However, as of 2015, the HSA permissible maximum contribution is being diminished from $6,500 to $2,500 annually.  this leaves the individual with a minimal tax advantage. 

How does the Affordable Care Act fit in?

 

The ACA intends to provide subsidized coverage with high deductibles with no tax benefits.  One might initially think that people selecting this coverage would expect to pay a reasonable monthly payment.  However, when huge deductibles and required co-pays are added to the total cost of insurance, the cost of a policy becomes unaffordable.

 

Think of it this way:  the ACA "insured" now becomes a de facto self-pay patient until the deductible is met.  Hence, there will be many defaults on what would otherwise have appeared to be reasonable and manageable monthly premiums.  Patients are simply not going to be able to pay huge deductibles, monthly premiums, AND continue to get care.  Something is going to have to give.  Over the coming year, we will see this play out, and likely CMS will create some adjustments and workarounds to counteract this present course.

 





Meaningless Disuse!

Guest blogger Dr. Donald Kamens, MD FACEP gives his take on Meaningful Use and where we are today.

It seems that Uncle Sam, healthcare, and technology mix about as well as oil and water; maybe worse.  The problem is not only the ObamaCare tech debacle, actually. Ever since 2004, when the government thought it had to protect its interests (read Medicare) by assuring that data acquired in health care delivery was accessible, parse-able, and otherwise capable of supporting arguments to decrease reimbursement, it has tried to become a techie agency.  And O, how it has tried. 

At first there was a fledgling effort to create an office in DC to oversee healthcare IT, the ONC (Office of the National Coordinator).  In the near-decade since its instatement, there have been five (5) chiefs, only one of whom lasted for a full two years.  There is currently an acting chief, and likely, he can’t wait to get out of there either.

In its beginning the budget numbers were in the neighborhood of about $24M (thirteenth letter of the alphabet).  Since the advent of incentive programs based on the demonstration by vendors of EHR products of Meaningful Use, the bill is more like $70B+ (that’s the 2^nd letter of the alphabet).  What gives?

It is the result of an extreme paranoia.  Clearly a total mental distortion that says:  “if we don’t know what is going on (in there), then we cannot come down on them enough to cut payments.” “So, we gotta know.” “And because we gotta know, we have to bribe the physician population to use devices to record what is going on.” $70B+ is a pretty big bribe.

What baloney.  Recording of medical record information has its historical basis on two needs:  to remind the physician what was done, last time; and to inform anyone covering in case the patient shows up unexpectedly.  Well….you give ‘em an inch…..and what happens… the legal world gets in on it and begins to use these notes to claim malpractice.  And then the insurance companies get in on the deal to determine what the will refuse to pay.

It’s just not needed.  Most all medical encounters can be summarized in just a few words.  If a study is being done on some clinical entity, then a bit more data would surely be of value.  But really, does anyone need 13 pages for an ED visit?  Or 8 for an urgent care stop? 

It’s time to get rid of this Meaningless Disuse program, and its huge expenditures that could otherwise fund significant helpful programs, and perhaps institute a Meaningful Pen/Tablet program. Or even a Meaningful Interface program that works like an ATM, or even as well as iTunes.  Give each doctor a new pen, or an iPad, and let him keep it if he can fill out an accurate chart, or template, in under 2 minutes.

Many physicians like EHRs; most don’t.  Those on the “no” side usually recognize MU is a severe piece of government overkill, that is doing few people any good, while creating long waits in many places as the staff struggles with machines.