How to Rate the New Health Care Changes

The Affordable Care Act contains a series of provisions that are phasing in, as scheduled, until the final period of complete implementation in 2014. Now, with the advent of 2011, several provisions take effect which start to change things for all of us. I give each change a "thumbs up" or "thumbs down" rating below.

• New rule for tax-free savings accounts. If you have an HSA, like I do, so called non-prescription "over-the-counter drugs" that are not actually prescribed by a doctor are no longer eligible to be paid from that account. This is the kind of rule that might look good to a bureaucrat, but to me it is ridiculous. People now will be calling for prescriptions for their Tylenol, resulting in wasted time and money by all of us. Instead of saving money, this will be a fiasco.  Thumbs down!

• Health-insurance companies “medical loss ratio”. Plans will now be required to spend at least 80 to 85 percent of the premium for actual medical care and quality improvements for patients, instead of administrative costs. Those that fail to do so will be required to issue a rebate to their customers beginning in 2012. The US Department of Health and Human Services says on www.HealthCare.gov that this will protect up to 74.8 million insured Americans from unreasonable rate increases. Last year, in 2010, we saw large increases from insurance companies who were attempting to pad their revenue before this provision took place. Thumbs up!

• Closing the Medicare drug coverage “doughnut hole.” Drug companies are now required to provide a 50 percent discount on brand-name prescription drugs to Medicare recipients who fall into the coverage gap in the Part D drug plans. Also, federal subsidies will be phased in for generic prescriptions in the Part D coverage gap. This gap will be progressively be closed over the next 10 years. It would be better to require competitive bidding by these companies, but this is a step in the right direction. Thumbs up!

• Medicare bonus for Primary-care physicians and general surgeons. These doctors will receive a 10 percent bonus payment for treating Medicare patients, which should help to encourage better access, although it is not enough, in my opinion to make much of a difference. Thumbs up!

• Preventive care for Medicare recipients. In a big change of philosophy, seniors will now be able to get free preventive services that include annual checkups and personalized prevention plans. No more waivers! Thumbs up!

• Medicare Advantage changes. Medicare recipients are eligible each year to choose private insurance companies for their care, a system called Medicare Advantage. We have all seen the adds! In the past, these plans were eligible for payments that were higher than ordinary Medicare, and these costs were born by increased premiums for all Medicare beneficiaries. Now, Medicare Advantage payments will be tapered down over the next few years to eliminate this subsidy. The new law has already resulted in higher premiums for many Medicare Advantage plans, but it prohibits these plans  from raising cost-sharing requirements higher than what is required under traditional Medicare. Thumbs up!
 
• Center for Medicare and Medicaid Innovation. This center is already up and running and has launched multiple initiatives to test new ways of delivering care to patients that reduce costs and maintain or improve quality. One idea is an Accountable Care Organization (ACO), which is a new entity in which health-care providers can work together to contract for and manage care. Work is already under way here in Whatcom County to try and build such a system! Thumbs up!

• Community Based Care Transitions Program. One of the most expensive problems in health care, that also is a sign of poor quality is the readmission of discharged patients to the hospital right after they are sent home. This program seeks to improve care for seniors after they leave the hospital, by coordinating care and connecting patients back to services in their communities. Thumbs up!

• Medicaid incentives for prevention of chronic disease. The plan includes grants for states to help begin support services for Medicaid (low-income) recipients to cope with chronic problems, such as tobacco use, weight control, and various health conditions. Thumbs up!

All in all, things are slowly moving in the right direction. More details here:  http://www.healthcare.gov/law/timeline/index.html 

A Sad Irony

Senate Democrats lost a key vote October 21st on a $247 billion dollar measure to avoid decreased Medicare reimbursement payments to doctors over the next 10 years. This would not have been an increase, but would have simply kept them at the same level they are now. The proposal was blocked in a 47-to-53 vote and thirteen Democrats broke with their party's leadership to join a unanimous Republican opposition.

Why is this a big deal? Well, the irony of this vote is that is that we may be passing health care reform to expand care availability to the general public, while decreasing access for Medicare patients to needed primary care if this vote stands.

This measure had been separated from broader proposals to overhaul the nation's health care system, because it is a separate problem that predates health care reform proposals. Under the current formula, Congress balances the Medicare budget by decreasing doctors payments to compensate for increased utilization by the public. Primary care is hit particularly hard, since those doctors have high office overhead costs that must be paid. A 21% cut is planned for January 1st, and 10% cuts are foreseen every year thereafter. Since doctors are already limiting access for Medicare patients due to existing low payments, it does not take a genius to understand that this payment decrease will be a catastrophe for Medicare patients. How sad that 53 members of the United States Senate either do not to understand that, or cynically do not care.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

Is there a Health Plan proposal that stands out in the Presidential Race? I think so!

On October 23, 2007 , Democratic Presidential Candidate Sen. Joseph R. Biden Jr. of Delaware unveiled a health care plan that would provide health insurance for all children, provide more coverage options for adults, and focus on disease prevention and modernizing the nation's health care system.

Biden's plan would permit uninsured Americans to buy into an insurance program similar to the one that provides health care benefits to federal employees and members of Congress. People would pay on a sliding scale based on income. Biden's proposal would continue the Medicare program, and inaddition, allow people between the ages of 55 and 64 to buy into the Medicare program, with the federal government providing a subsidy to low-income individuals.

The State Children's Health Insurance Program (SCHIP) would be expanded to children in families with incomes of 300 percent of the federal poverty level or below. This equates to $61,950 for a family of four, and coverage to children in the family would be extended to at least age 21. Biden's plan also would have the federal government "reinsure" 75 percent of the cost of catastrophic health costs for cases exceeding $50,000 per individual, in order to help keep the cost of the commercial plans low.

Senator Biden has said that if he is elected, he would convene a meeting, within the first 90 days of his administration, with all players involved in health care, in hopes of making coverage both universal and affordable. "Getting this done will require the kind of experience and leadership that comes from years of success corralling bipartisan support for numerous issues," he said. "I have that experience and it will prove invaluable when I am president."

Here are some other important elements of Biden's plan:

• Eliminate co-payments for physicals, vaccinations, vision and hearing screenings, and preventative dental checkups for children of all income levels.
• Prohibit employers and insurers from collecting or using genetic discrimination when making decisions about hiring or providing health care coverage, including the cost of a policy.
• Invest at least $1 billion yearly to help hospitals, physicians, and other health care providers move to electronic health records systems.
• Add 100,000 new nurses to the workforce in the next five years and establish scholarship and loan repayment programs to encourage people to join the public health workforce.

After reviewing all of the plan proposals from the Democratic and Republican candidates for president that have so far been released, this plan seems like the best to me! It combines the strengths of our private insurance system with intelligent government subsidy for those who need it. It also encourages access to needed types of primary care in order to improve quality and decrease cost. It addresses a growing problem of older adults not yet able to join Medicare, ensures treatment for children, and covers the large group of younger adults who are ignored by most other proposals. Most importantly, this plan avoids the "false choice" between pouring more money into our dysfunctional current system, or going to a government take over of health care. It is an intelligent middle way, that includes important reforms along with intelligent funding.

One of my adult daughters has given money to the Biden campaign based on her support of this proposal, and I hope this plan receives a great deal of attention and debate!

Click here to read more from the Biden Campaign

The Medicare Crisis, National in Scope, Local in Impact

Medicare was founded in 1965 to help cover the costs associated with health care for older Americans and those with certain disabilities. Since that time it has evolved into one of the most needed and important programs in U.S. Government history. Unforunately, however, as our nation’s health care system now braces for a Medicare Population explosion, caused by the Baby Boom Generation aging into Medicare, primary care medicine finds itself on the verge of collapse due to drastically insufficient Medicare reimbursement.

Some Medicare beneficiaries have already felt this on a personal level, as they have had difficulty finding a family doctor for their primary care needs. This is due to the fact that Medicare funding for the services provided by family physicians often does not cover the actual cost to the doctor of providing that care! In fact, according to a 2006 report from the American College of Physicians, "Primary care is on the verge of collapse. Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy". The report further notes that the key contributor to the problem they describe is the "inadequate and dysfunctional payment policies" of the government and insurance companies. "Unless immediate and comprehensive reforms are implemented by Congress and CMS (Medicare), primary care - the backbone of the U.S. healthcare system - will collapse," concludes the report. "The consequences will be higher costs and lower quality as patients find themselves in a confusing, fragmented, over-specialized system in which no one physician accepts responsibility for their care, and no one physician is accountable to them for the quality of care provided."

The problem described in this report is very familiar to your family doctor, and all of us here in my practice at Family Care Network (FCN). A Family Medicine practice is really a small business which simply cannot remain viable if revenue does not exceed expense. If the current inadequate and dysfunctional Medicare payment policies continue, and with the Medicare population about to increase dramatically, doctors will have no choice but to close their practice to Medicare patients. It is simply not possible for physicians to subsidize the care of so many without becoming economically non-viable. This is a terrible prospect, at the very time when the need will be the greatest! I believe that this is unacceptable, and that is why I am sharing this information about steps we are taking in my medical group, The Family Care Network Solution.

Family Care Network (FCN) has been working diligently to bring this crisis to the attention of our elected officials. While we sincerely hope that our State and Federal Governments will eventually address this crisis on both a national and local level, we have taken a position that FCN must seek out a more immediate solution to ensure our long term viability for survival.

FCN has developed a long term strategic plan for Medicare which we believe will enable us to:

1. Remain in Practice.
2. Continue practicing family medicine according to the Personal Medical Home model of health care as advocated by the American Academy of Family Physicians (AAFP) (see next page).
3. Continue providing care for our existing Medicare Patients.
4. Care for existing patients who become Medicare eligible.
5. Accept new Medicare patients into our practice (beginning in 2007).

The central component to the FCN Medicare Strategy is partnering ONLY with Medicare insurance companies that recognize the critical role played by family medicine in the overall health care system, and choosing ONLY insurance partners that financially support the "Personal Medical Home" as advocated by the AAFP and ACP.

We realize that patients have different needs and preferences when it comes to their Medicare health insurance. As such, FCN will provide our patients with access to multiple Medicare insurance plan options. We also recognize how confusing Medicare insurance has become and therefore FCN will provide insurance counseling services at no cost to our patients. Licensed insurance professionals well versed in all of the various Medicare insurance plans accepted by FCN, will be on-hand to help you understand your options and enroll in the Medicare insurance plan that is best suited to your personal needs.

Finally, FCN believes that healthy communication correlates directly to healthy patients. FCN requires that all Medicare insurance company partners provide internet connectivity between patient and provider via the DocInTouch web messaging program, at no cost to the patient. DocInTouch is a secure internet-based service that enables patients and physicians to communicate efficiently and effectively, and this type of functionality is part of the personal medical home concept.

The Personal Medical Home

All physicians and staff at FCN firmly embrace and support the Personal Medical Home model of health care advocated by the American Academy of Family Physicians (AAFP). FCN supports the Personal Medical Home in the following ways:

1. The physician makes a commitment to the patient to know them as a person, and to provide ongoing, continuity of care for illness and injury, as well as medical planning and advice for screening for illnesses and maintenance of good health.
2. Our office team shares this commitment, assisting the physician in providing hospital care, home care and consultation when needed.
3. Maintain accurate medical records for the care delivered and provide patient education using current technology.
4. Maintain patient registries for certain chronic diseases (Diabetes, Congestive Heart Failure) in order to study, monitor and improve the adequacy of their care, as well as to seek out patients who have not received needed care.
5. Provide planned chronic care visits for diabetes and other appropriate conditions, so that needed information is present for treatment and education at the time of the visit.
6. Integrate patient feedback to improve the performance of the practice.
7. Implement the “New Model of Family Medicine” described in the Future of Family Medicine Report, including secure web messaging.

As we communicate with our patients about these changes, we are letting them know that we greatly appreciate their continued support and patronage. Providing their Personal Medical Home is something that we take very seriously and we remain fully committed to providing the absolute best primary care medicine possible. We recognize that re-evaluating Medicare insurance needs involves significant effort, time and stress. We hope that they understand the challenge we are currently facing, but with stheir support we are confident that we will overcome this challenge, together.