[Editor's Note: This is a guest post from Bill Pacquin, who describes himself as a patient care advocate and the CEO of a healthcare publisher called Vertical Health which produces Spine Universe and Diabetic Lifestyle. He supports the “creative destruction of our current healthcare system.” We have no financial relationship.]
While surveys suggest that the Patient Protection and Affordable Care Act (PPACA), or “Obamacare,” is generally unpopular among the American public, there is still uncertainty regarding its impact on the majority of our nation's physicians. The congressional proponents of the PPACA claim that the law will transform the American healthcare system to provide quality service for individuals who otherwise would have no access to medical care.
Although some of the effects of the PPACA are already apparent, physicians should educate themselves on how the law might affect their career. The information below outlines some of the most basic ways the PPACA intends to improve healthcare in the U.S., while also addressing some doctors' concerns that it could also transform the medical profession in a less than desirable way.
How does Obamacare affect New Physicians and New Patients alike?
In recent times, this nation has experienced what some may call a shortage of physicians, particularly in the primary care or internal medicine field. In fact, the Association of American Medical Colleges estimates that we will be short by 160,000 doctors by 2025.
At the same time, although there may be fewer doctors, there will most certainly be more patients. Congress claims the PPACA will provide healthcare to those who would otherwise go untreated.
The truth of the matter is that emergent care is, and always has been, available to any human being in this country: whether legal or illegal, if you are a person experiencing a medical emergency, you will be treated. [And billed – ed] However, you might not have previously qualified for ongoing treatment and routine care from a general practitioner – now you will.
What's the Deal with Electronic Medical Records?
The PPACA aims to create a uniform national system of maintaining electronic health records to allow different practitioners and medical facilities to track patients and their healthcare needs. Sounds great, right? While in theory the effort sounds commendable, the system is not without its flaws.
Creating this sort of system will require a tremendous financial investment on the part of doctors and hospitals who must convert to new technology. And some doctors feel that using a computer or a tablet to document information about a patient's health drastically reduces the quality of the information in the patient's file (but it does eliminate the issue of doctors with notoriously bad handwriting!).
Clicking various options on a list of symptoms may not tell the full story, whereas a physician's hand-written notes can capture details that aren't possible with computerized medical record keeping. Doctors are already consumed with complying with thousands of diagnosis and billing codes to please the insurance industry, and further regulation in this area can be an overwhelming burden to physicians.
Along the lines of insurance company difficulties, one concern is that by having one centralized repository for a person's entire medical history, insurance companies may have more fuel to avoid repayment for certain courses of treatment. Indeed, if an insurance company is facing an enormous bill for one patient, all it needs to do is sift through the patient's medical history, which is now conveniently located in one spot – online – to find the one doctor 15 years ago who didn't do something “by the book” which gives them the justification to avoid payment now. Clearly, there are still issues to work out. [Life, health, and disability insurance companies would also love having access to this database when doing underwriting- ed]
Increased Costs for Doctors and their Families
On a more personal level, like all Americans, physicians will join in paying the huge ticket to implement the PPACA through higher taxes. For example, in 2013, individual doctors earning $200,000 or more and married doctors who, with their spouse, earn 250,000 or more must pay 2.35% toward Medicare (as compared to the previous 1.45% rate). In addition, the same target group (individuals earning $200,000.00 or more and married couples earning $250,000) must pay an additional 3.8% Medicare tax on either (1) their net investment income or (2) their modified adjusted gross income (less the $200,000 for individuals or $250,000 for married couples), whichever is less. Further, medical practices employing fifty or more employees will now be subject to a fine if they fail to adequately insure their employees.
Chief Concerns
Although many aspects of “Obamacare” are intended to benefit an oft-overlooked segment of the population, some doctors worry that the net effect may be that patient care on the whole falls into the background. As a result of efforts to bridge the gap between the top and bottom of society, many in the middle could end up suffering.
There are only so many hours in a day, and that means that dealing with a whole host of new requirements, new regulations, and new forms could take doctors away from their patients. The bottom line? Doctors who haven't already started figuring out how to address these issues in their own practices should immediately educate themselves and start planning for the future.
So, what do you think? How has the PPACA impacted your practice and your lifestyle thus far? What do you worry about in the next few years as the implementation continues? Comment below!
Here are some of my concerns.
1. Look at the table on page 2 of this report from CMS in 2010 that shows the estimated decrease in Medicare spending in billions under the bill. Doctors are clearly going to make less money. http://www.cms.gov/ActuarialStudies/Downloads/S_PPACA_2010-01-08.pdf
2. The government should not be influencing which field of medicine people want to go into. Sec 1202 of the Amendment will increase Medicaid payments to 100% of Medicare for 2013 and 2014 for PCPs only (family medicine, general internal medicine, pediatrics). They are trying to push more people into these lower paying specialties strictly to try and contain costs but this has nothing at all to do with improving the quality of care.
3. Sec. 3023 of the Original Bill – National Pilot Program on Payment Bundling. The government defines “an episode of care” as 3 days prior to hospital admission to 30 days after discharge. This program will give the healthcare system one lump sum of money and essentially say “here you go, you guys figure it out.” This one sum will pay for acute care inpatient services, post-acute care services as well as any outpatient service. If they say that an MI is worth $50,000, all care surrounding the treatment of this patient will need to be divided among this $50,000 between all healthcare providers.
4. Sec. 10320 of the Original Bill.
By 2015 the government is mandated to establish a “Payment Advisory Board” which will submit recommendations every 2 years on how to slow growth in national health expenditures (aka how to decrease reimbursements to healthcare providers).
5. Sec. 3025 of the Original Bill1.
Reduce Medicare payments to hospitals to account for excess “preventable readmissions.”
6. Sec. 2702 of the Original Bill.
Prohibit payments for health care-acquired conditions. The list of included conditions include things such as Stage 3 and 4 pressure ulcers, trauma from falls, catheter-associated UTIs but there are many others. To think that these can all be somehow “prevented” is ridiculous.
7. Sec. 10904 of the Original Bill.
2.3% tax on sale of medical devices. I have a good friend whose uncle is a dentist and has to charge his patients more for implants because they are now considered a “medical device.” In the end, any increase in costs only gets passed on to the consumer so this does nothing but increase the cost of care.
8. Sec. 1406 of the Amendment.
Annual fee on health insurance providers
2014…$8 billion
2015…$11.3 billion
2016…$11.3 billion
2017…$13.9 billion
2018…$14.3 billion
2019 and thereafter–previous year + rate of premium growth
Do you think that pharma will somehow find a way to pass this fee onto the consumer? I think so.
This bill was supposed to bring down the cost of care right? Anyone that owns a business will tell you that premiums have gone up in the last few years and will continue to go up as insurance companies will just charge more for fees.
In addition, there will be 10,000 new government agencies created to oversee the implementation of this bill. That is a lot of red tape and overhead.
In my opinion, the practice of medicine is going to become more expensive and less efficient while at the same time cause doctors to make less money.
Felix
Felix,
You should have been the one to write the actual blog post as the fluff piece by Bill Pacquin added about as much useful information about the PPACA as does sucralose to one’s caloric intake. I’ve generally been accepting of the guest posts, but this one was such as waste of my time that I’m now motivated to waste more of my time commenting on it. Your comments (which were far more informative than the actual blog post by Bill) were, however, worth spending time reading. Thank you.
David
Felix makes some good points, but dodges the real problem- US healthcare already was inefficient and too expensive. The PPACA is easy to criticize, but it is an attempt to deal with a broken system. Just harping on its failures as if the status quo is better is missing the point. And maybe intentionally misleading. Felix’s comments at the end are surprisingly devoid of any factual basis. 10,000 new goverment agencies? Really? The bill was designed by insurance companies and hospitals for insurance companies and hospitals. The comment about anyone owning a business telling about rising premiums is decidedly wrong as misleading. First of all the bill has yet to be implemented. Second in case no one was paying attention premiums were rising rapidly BEFORE the bill ever even passed. since passage premiums have risen slower but that is not necessarily a nothing to do with the bill, it is a fact not a matter of opinion. Finally the first batch of rates truly influenced by the PPACA In California have LOWERED premiums for most. That is at least some I dictation that the Chicken Littles who predicted only disaster from the bill were wrong (so far).
To be clear, I suspect cost control will come at the expense of physicians as they were not the ones writing the bill, the insurance companies wrote it. Doctors will have to practice differntly and maybe ir will be better. There is room for that. Much of what practitioners do is wasteful, duplicative, defensive and sometimes not only of questionable benefit, but even harmful. . Other countries get as good or better outcomes at a fraction of our costs. Within our own country the Mayo clinic can provide excellent care at a fraction of the cost in another part of the USA. Again, these are demonstrable facts. I am NOT arguing that the PPACA addresses these aspects of care adequately or well. But it is the only plan that even tried. Unfortunately iit seemed the only alternative offered was the word, NO. If the Republicans had actually engaged in the give and take of the legislative process maybe we could have gotten tort reform, incentive sharing by consumers, and other sensible reforms. Personally I was impressed by the book Total Cure by Harold Luft. It had plenty for both sides of this issue. As a soon to be retired MD I will have a different perspective going forward. I am glad the PPACA will make getting insurance easier for those of us without a job. I doubt early retirement would be as easy without that.
[Inappropriate comment removed. Please focus comments on ideas and not people.]
Paul,
Your comments read like the Obama talking points press release that continues to be repeated ad nauseam. I would respectfully suggest you do your own independent research into this topic.
The PPACA was designed (and continues to be fleshed-out) by bureaucrats, not insurance companies.
Premiums have risen FASTER than expected in CA.
The USA provides the best health care in the world. “Other countries” provide sub-par care and skew their data to manipulate their outcomes data.
While both Democrats and Republicans are to blame for this mess, not a single I would suggest you read the book “2 Days That Ruined Your Healthcare” by Dr. Waters.
Enjoy your retirement. I will be working as a physician in this rapidly disintegrating system for the next 20 years.
Wouldnt early retirement be possible without the unaffordable care act?
Could you not save into an HSA?
If the ACA had not passed wouldnt there be bipartisan support for increased insurance competition by being able to buy across state lines? There was bipartisan support for covering pre existing conditions as well. To act like it was obamacare or bust is not based in fact.
Rand Paul had an innovative plan. One could buy a long term policy likened to a 30 year life insurance premium. If you buy a 30 year health insurance premium when you are young (and presumably healthy) it would be cheap, it would be portable as well. You could tell your job to shove it and take you health insurance with you.
Tort reform from the left – [that’s unlikely.]
Keep comments focused on ideas, not people please- ed.
Oh, I am sorry-
The US has the best healthcare system in the world which is why every other country is rushing to copy our system.
Health care premiums were not rising faster and faster than any other segment of the economy before 2009. I must have dreamed that.
And the Insurance Lobby had NOTHING AT ALL to do with the design of a law that MANDATES every single citizen MUST buy their product or be fined for not doing so.
And tort reform and other improvement to the PPACA is impossible unless we eliminate every single liberal politician because never before in history have the different sides of a question been able to compromise and give and take to craft solutions to problems. One side must always get absolutely everything their way for anything to ever get done…
I guess I was drunk. Silly me.
Little story – 4 years old bought a health insurance policy for my nanny- nothing crazy – she was 54 at the time and i just wanted her to have basic coverage – a 5k deductible policy (with an HSA) with some basic stuff- screening, annuals etc set me back $212 a month, seemed pretty reasonable and I was shocked that you could get such a plan for a reasonable price. Then your favorite law started – first it was no life time limits – policy went to 300 something a month – then came the dead beat kids on daddy insurance – policy went up again. Other portions of her plan were now illegal- premium goes up again. Just got notice that her/my new rate is 480 a month. Keep in mind she never went to the doc and this was a just “in case” policy.
Tort reform should have been first- that is a major driver of cost and any doc who says otherwise has practiced defensive medicine so much that don’t know the difference. It was a democratic congress and a democratic president – one can only assume that law law we got is what they wanted – “this is a big f***ing deal” is what the VP said.
Her increase in cost likely had nothing to do with the ACA. Especially considering most aspects of the ACA actually haven’t been implemented yet. Health insurance rises on average 6-7% a year or twice the level of inflation. That is AVERAGE. Meaning for the young it barely rises and for the old it rises much more (maybe as high as 10%). Further don’t you think its possible that they sold you a low policy on day 1 with the intention of raising the rates every year to what they wanted you to pay? Insurance companies do that all the time. But like most Americans you didn’t use the “capitalism” available to you to shop around because you either didn’t want to, couldn’t, or didn’t know how to compare. Which is exactly the problem.
“In 2012, U.S. companies and their employees saw the lowest health care premium rate increases in six years, according to an analysis by consultancy Aon Hewitt. The average health care premium rate increase for large employers in 2012 was 4.9 percent, down from 8.5 percent in 2011 and 6.2 percent in 2010. In 2013, however, average health care premium increases are projected to jump up to 6.3 percent.”
Correlation is not causation. I don’t think you can prove that the introduction of some of the provisions of PPACA was responsible for that slowing of the premium increases. In fact, I would argue that it is because insured people are consuming less health care due to higher deductibles, higher co-insurance, and slightly increasing transparency of costs.
Every ascept of the ACA that I mentioned is in fact already implemented. So while you can guess what happened – I am telling you. If the policy changes from a million-dollar lifetime cap to no lifetime it does not take a PhD to figure out that is the reason. For fun I called blue cross and asked them and guess what they said – i know it is the evil insurance company – it cant have anything to do with the fact that there is no limit to what they have to insure.
And keeping 25 year olds on their parents insurance – just happens – no one has to pay for that- same for pre- existing conditions – (i wrecked my car – i would like a car insurance policy now) -again – when it went into effect – I asked and again the evil insurance company told me what I wanted to hear. It had nothing to do with the fact that they now had more people to cover.
I have bought individual health insurance for myself and three childcare providers over a decade and rates never doubled in four years. And of course I compared and shopped for insurance. But to be clear, due to the ACA the policies were different – I would argue not better – but still. When her rates jumped no one could sell a million dollar lifetime cap, no deadbeat kids on the policy and no pre-existing conditions- they were outlawed- all the rates went up.
The fact that you quote what large companies pay for insurance demonstrates that you don’t get it. Most large companies provide fat policies that few people need. I may have a large family but I am not a large employer- my group has about 100 employees and I can tell you are rates (which the group pays 100%) have increased with each ACA “improvement”. I find it very interesting that our reimbursement rates have decreased- I know the evil insurance company.
While I am not a doctor I expect that doctors will adjust their practices for the various laws and insurance companies. If you include all the spending by various governments I bet the cost of our healthcare system will increase. I would expect doctors to not accept or get rid of Medicaid and Medicare patients. I expect long lines and waits for care as the system is overwhelmed by more individuals demanding a lot of care, tests etc. I also expect to pay a retainer for my doctor to serve me. These things may occur in a “single payer” system as well so I reject “single payer” as an improvement. Rates for year one are generally created to take market share and after you are “hooked” go up in year two and three, this somewhat explains the experience in CA where the rates are lower than expected, but are apples to apples higher than now.
A very complex issue – with too many political implications.
Electronic Records – Yes, the age of the hand written notes on paper are gone. And good riddance. I realize that there are limitations, but technology will adapt – how else do you share the information in today’s age? Imagine dealing with a bank who still used a paper ledger. And, there is no central repository in the US. Many of your patients already think that the records are digitized and available electronically – not aware that you are still using fax machines to transfer notes.
Insurance costs – the rates have gone up for the young – so that they can be capped for the older people. It is a fairer system, so that people pay into the system all their lives, not just when they need insurance. Who needs insurance? One does not know they need it until they do. And no, you will not be able to call the insurance company on the way into the operating room, as there is a waiting period.
Mandate – how about some personal responsibility? An idea that was supported by many before it became the other guys idea – then they want to fight against there own idea. How about this – repeal the EMTALA, and more people would be on board to get insurance, instead of taking the risk – with me and you paying the bill for them taking the risk.
The day of requesting another test for convenience will soon be over. The insurance company will soon stop paying for duplicate services.
The plans have become more comprehensive, because there are too many mickey mouse plans out there that do not pay for real healthcare – they are just a marketing money maker. Why are there state mandated minimums on car insurance – so that one is properly insured. Too comprehensive – have a dialog and fix it, not throw the baby out with the bath water.
Sharing risk – what is the incentive for a Provider to cut costs and reduce testing – none – as the insurance company benefits and has done nothing. Paying out a lump sum, and moving the risk to the provider will give them an incentive to provide better care at a cheaper cost – the non payment for readmits will insure the better care. Perfect – no, but change is needed.
10,000 new agencies (Felix) – please cite where you see that figure.
Is ACA perfect – far from it, but the status quo – rising rates, less insured, etc are/were not a valid option either. Too bad our political parties do not seem to be able get to a middle ground and do something – and the middle ground was each other’s position before getting so polarized into corners.
Healthcare is not something one is able to shop around for – try to find out how much an MRI or CT will cost you, never mind the emergency situation. One would think walking into the ED for services would relate to one getting a single bill – likening it to hiring a home builder where you get one bill for the home – not having to deal with each contractor on an individual basis.
I agree it is a complex situation, one that needs to be addressed, and that there will be lots of unforeseen consequences. PPACA is huge and complex, and not all of it is necessarily bad. I disagree with a couple of ideas of yours. First, repealing EMTALA. Are you going to come down to the ED and be the guy who does the wallet biopsies? If not, then quit advocating the repeal of EMTALA. It’s a good law, as the situation previous to EMTALA was unconscionable. The problem with it is that it is unfunded. If the government is going to mandate something like that, it (we) need to find a way to pay for it.
Second, this whole idea of not paying for complications/readmissions is stupid. Advocates for it seem to believe that people get readmitted to the hospital and/or have complications because someone screwed up, which is not the case in the majority of situations. Guess what? People get sicker. Complications happen a certain percentage of the time. A certain percentage of patients who get an LP, no matter how perfectly I do it (despite their whale-like size, arthritis or scoliosis), are going to get a post-LP headache. So when they come back for a blood patch, it has to be done free? The other issue is that it often isn’t the same doc (or even hospital) taking care of the readmission/complication. Just cause Doc Smith down the street caused a complication that I’m taking care of I don’t get paid? Think about the unforeseen consequences of that one. Now I don’t want to take care of you, so I’m sending you back to the guy who screwed you up the first time. How’s that going to make you feel? Or how about a cardiologist who perfs a coronary during a cath and you require a CABG? You want the cardiologist doing it instead of a CT surgeon? I’m sure the CT surgeon doesn’t want to take care of you for free. The only way that kind of a system is going to work is if all the docs are salaried employees of a hospital system, which has its own unforeseen consequences. And if the law says that only the same hospital doesn’t get paid for the readmission, then we’ll just find a reason to transfer them to another hospital. We’ll take their complications/readmissions and they’ll take ours. Or how about when complications/readmissions are due to the patient being non-compliant? It’s just a bad idea. People aren’t automobiles or appliances.
WCI – I agree with you (mostly). Yes, EMTALA is unfunded – the government mandated that private enterprise provide services without verifying the ability of the individual to pay for those services. The mandate puts a balance in place, that the expectation is that people will be insured, ie, be able to pay.
As far as the readmits – I believe it (right now) only pertains to AMI, CHF and Pneumonia (hospital charges). There needs to be a balance (and a penalty) between quality care and the desire to cut costs. I believe the hospital will be reimbursed for the procedure, but will have reduced reimbursements for the following year – ie, the second hospital should not be the one adsorbing the cost, as it will not show as their readmit. Perfect – hardly so, but doing nothing is not an option that will solve anything. Status quo is not acceptable.
You LP example, while valid, is not impacted at the moment (please correct me if I am wrong on this). Your example of the CT surgeon is not valid – ie, he will not be performing services for free.
I understand it’s only CHF, PNA, and AMI admits (so far) but expect that to expand and don’t see why it should apply to those any more than anything else. So one hospitalist admits the PNA and he comes back on the second visit and is seen by a second hospitalist, who now doesn’t get paid. Or a second hospital, who now doesn’t get paid. Or if he does, then we just start transferring people around so we all get paid etc. It’s just a bad idea.
If the problem we were trying to fix were too many readmits, that would be one way to try to slow it. If the problem is that we’re spending too much on health care, I don’t think this is part of the solution.
I don’t have a problem with a health insurance mandate. I see it as no different from a car insurance mandate. I understand the arguments against it, but disagree with them.
As I said, the law is not all bad nor all good. I agree the status quo is untenable. I wish the law had addressed what I see as bigger issues- over consumption of health care, lack of cost sharing, and lack of transparency of prices.