Abbott posted this new topic:
“Medicare is not a good analogy for the ACA. Medicare is funded through payroll taxes (all pay the same tax rate). Individuals are not required to participate in Medicare. Medicare does not seek to massively subsidize one part of the population at the expense of another (although they have started down that road with premiums adjusted for income to a limited degree). Medicare does not have restrictive networks of hospitals and physicians.
“Said another way, the reason the majority of Americans are opposed to the ACA is that it forces people to buy something the may not want, it forces them (in many ways) to subsidize other Americans to buy something, and it is disrupting a healthcare system that works well for a majority of Americans.
“Let’s face it — probably the only people who really support the ACA are the folks who want to be subsidized (financially and/or by spreading their bad risk).”
Blogfinger Medical Commentary: By Paul Goldfinger, MD, FACC
Prior to the passage of the ACA, 80% of Americans said that they were satisfied with their health insurance and their doctors. The ACA bill was sold to the public as being about providing coverage for the other 20% .
Some parts of the plan were intentionally not revealed, leaving most Americans to believe that the ACA would not impact them. This is lying by omission. Some believe that the ACA was passed under false pretenses.
Abbott also mentions doctor and hospital networks . Prior to the ACA, most insurance plans that were considered to be good plans allowed the policy holders to see any doctor and to go to any hospital. That was the norm and was true for Medicare and Medicaid as well. This was one reason why many seniors preferred regular Medicare compared to the more restrictive Medicare Advantage plans. Most people still prefer freedom of choice.
But ACA-approved insurance plans all seem to include networks of hospitals and doctors. This will produce a big change in how medicine will be practiced, and there wasn’t a mention of it when the ACA was explained to the public before it was passed. If any of you have found Obamacare plans that give free choice, please let us know.
Interestingly, Dr. Ezekiel Emmanuel, an architect of the ACA, said on TV last Sunday that you can have your usual doctor, but you may need to buy a more expensive plan that has your doctor in-network. To his way of thinking, there was no lie when we were told that we could retain our doctor.
Also, every ACA plan seems to have significant deductibles and copays, and the lower the premiums, the larger the out of pocket costs. Many current pre-ACA plans do not have copays or deductibles. Some, however, may have caps on spending, which the ACA plans do not, and policy holders can be balance billed by providers unless the doctors are “in-network.”
Abbott makes another point when she says that Obamacare will “disrupt” our current healthcare system. Some say that Obamacare is not about the delivery of healthcare, but rather is about insurance reform. However, there is no doubt but that the ACA will change the way medicine is practiced in a multiple ways including enforceable practice guidelines, rationing of care, restricted physician networks, etc. The actual enforcers of practice changes will often be the insurance companies who will be trying to lower costs and follow ACA rules.
Ken: This question, “What is the Republican plan” keeps coming up. I would say that GW Bush should have tried to fix the situation, but he didn’t. Obama came into office and got this law passed. Since it is the law of the land, it will be attacked. If someone wants to defund or repeal Obamacare, they are entitled to their opinions, although, given the preponderance of Democrats in the Senate and the oval office, it won’t happen. Some of that is disingenuous and represents political strategies.
Republicans in Congress (and elsewhere) do have proposals ready that are based on their conservative views. The Republicans will need to stop merely attacking Obamacare. They will have to put their ideas together into a coherent proposed healthcare plan and have it ready to run on for the next election. It is not ready now, but it will be.
Joe, I recall the AHRA did not propose to “fix’ ACA, rather it was to REPEAL it.
All these comments have been more informative and more easily understood than what any publication or newspaper or TV news show has been.
@ Ken, re: “If problems with Obamacare “can be fixed”, why did the Repubs not propose any?”
If you are going to defend ACA, go look up the “American Healthcare Reform Act”—- the Republican proposed alternative you didn’t know existed.
Paul, the plans are not mandating that you pay for any specific service, just that all plans must cover these services. It’s the new minimum and it sets the bar higher to assure that everyone gets access to these necessary services. It’s this combination of services that health economists and experts agree will reduce costs by improving overall health and reducing the number of chronic cases the healthcare system deals with due to the lack of preventative services.
And while a man may not need a mammogram, he will need a colonoscopy and a prostate exams. They tell me it all evens out over the years. And we all are getting older and we all are more likely to need these services. And by the way, we are paying for the costs of people not having access to preventative services and then using the emergencies services when things become acute.
Again this about overall economics and public policy. I may not use public schools or the transit system, but I pay my share of them regardless. This is the same thing in my opinion.
Abbott:
Our current health care system is too costly, only moderately good quality and completely unsustainable. Health care costs are rising at 12% per year. That’s not just Medicare, it’s all care. In fact CMS has done a better job at holding the line on costs than the insurance industry and it’s only going to get worse with hospitals buying each other up and buying private practices. They will have the power to negotiate pricing whether we like it or not!
And by the way, most non profit hospitals are making outsized profits that don’t get shared with their employees or most physicians.
Take a look at what the CEO of Partners ($3.1m) or Meridian ($2.2m) or Kaiser ($7.7m) makes. http://www.njspotlight.com/stories/13/10/27/the-list-best-compensated-nonprofit-hospital-executives/
And because the majority of large corporations self fund their health insurance benefit, it makes American businesses uncompetitive in the global economy. Several times through varying trade agreements the US government has tried to get other countries who have socialized medicine to take that into account and have even suggesting that they abandon it to put US businesses on an equal footing. We can’t continue to burden American business and stifle innovation by having employers responsible for assuring that people have health care.
The problem is that costs are not transparent and we need to gain a more cost effective way of delivering care. Its time to take a look and ask ourselves what can we do differently.
Carol
Paul,
First many plans are not apples to apples. Policies must cover certain essential services that they did not before or that they may have charged extra for like the prescription plan.
If your insurance was previously a plan the State referred to as Basic and Essential, (as opposed to HMO, EPO, PPO) your rates were pretty low. But this is not a catastrophic care plan. Below is what it covered.
Basic and Essential Plans do not provide comprehensive benefits like the Standard IHC plans, but instead provide:
1 90 days/year for hospitalization
2. $600/year for wellness services
3. $700/year for office visits for illness or injury
4. $500/year for out-of-hospital testing
5. Limited benefits for mental health services, substance abuse treatment and physical therapy. ”
For someone my age that plan was $444 per month or $5,328 per year and that was the cheapest plan you could buy. But I would be spending a fortune after I hit the limits. That same plan for a 30 year old was $296 per month.
BUT these plans were cancelled by the ACA because they do not provide the minimum 10 essential health services; ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Now carriers who wish to sell health plans must provide some of the above services with NO copay or out of pocket. Those services as I mentioned before include well baby visits, annual checkups, and preventative care tests including colonoscopies, mammograms, pap smears, flu shots, and so on.
And because the insurer cannot decline insuring a person for preexisting conditions, they can’t price for them either. (Pricing for a pre-existing condition could have the same effect as declining to insure)
Further there are no lifetime limits so the insurer has to have a significant pool size to spread risk. Also, as I mentioned before, if your insurer charges you too high a rate, and they don’t spend 85% of the premium on you, you are entitled to a refund. If you are part of a group plan from your employer, the employer gets it.
An HMO plan for me with $30 copays from Amerihealth under the old regime would have cost me $1,064. or $12,768 per year (This is because I am at an age where I go to the doctor more) A Gold EPO plan from Amerihealth plan from the Health Exchange was $8,882 with a $1,250 deductible and a $20 copay for physicians and a 20% coinsurance to a maximum of $2,00 out of pocket is between $ 11,834 minimum and $14,334 at a max!
For me the difference is that there is no maximum per year or lifetime maximum, and all my wellness visits and preventative care tests are included.
Is the difference worth it? For me it is but here’s the thing: If I fell at 400% of the poverty line… that same plan would only cost me $569 per month or between $8078 and $10578.per year (subsidy of $312 per month)
If you are making $47,000 a year gross, that premium is still a lot of money, so I would probably move down to a Bronze plan at $338 per month (subsidy of $312 per month).
Is this helpful?
Carol
Editor’s Note: Carol. Thank you for spelling out these details. But don’t these new plans mandate that people buy services that they may not care about (such as maternity or well baby visits) or would rather have the choice, for example, to pay privately for, such as preventive services like
checkups and flu shots?
Also, don’t many people have excellent private plans that are comparable to what you describe above (i.e. Cadillac plans), so how do they compare price wise (apples and apples?)
—Paul
Paul, As for your 1, 2, 3.
Re 1. Be real, they want ACA to work in their favor. Their lobbying efforts to influence the ACA be more to their liking were largely successful . Nothing illegal there; I only wish the citizenry had someone equally effectively looking out for their interests. Please do not suggest those elected to Congress do that. The money poured into their reelections speaks volumes about that.
Re 2. First,….reread my ‘Re 1.’ above, then consider If problems with Obamacare “can be fixed”, why did the Repubs not propose any?
Re 3.To expect the party that flat out demanded nothing short of outright ACA repeal would “win and change course”…defies logic.
Where sarcasm fails make the point maybe the facts will.
ken.
Carol: Please explain to us why the premiums for so many ACA policies have gone up so much? Thanks, Paul
Oh! Poor insurance companies whining all the way to the bank to deposit their loot. Reminds me of how little sympathy I have for a bad acting child being held to task by responsible adults.
I also recall that the insurance Co. restrictions on MY healthcare options were not in MY best medical interests but rather for their best interests.
AND to read, “Or the Repubs, will take over Congress in 2014, and the ship of health will begin to change course.” What can I say? Sounds like a Rush Limbaugh statement.
Again I raise the question: which to trust LESS..government or insurance companies?
ken
Let’s not feel too badly for the insurance companies just yet. If you look at where their profits come from premiums from individuals is minuscule compared to revenues and profitability from plan and claims administration and in some cases, the ancillary research data business
The CEO for Aetna got up at a HIMSS meeting 2 years ago and said they are transitioning into the data analytics business, which is to say, they can make more money from selling the data found in claims and outcomes than they can from health insurance. And it’s been this way for a long time.
United Healthcare couldn’t care less about selling policies, they care about the data which helps drive their more profitability. They are a leader in developing tools for healthcare and their Ingenix division is a gold mine. You might think of health insurance as the loss leader that gets them the data for the more profitable business, Ingenix.
By the way, the ACA limits the profitability of health insurers by mandating that they must spend 85% of the premium on the individual or rebate the difference. So basically there’s no money in selling and administering individual policies. The money is in the data. And believe me, pharma pays handsomely for good data.
The insurance companies are in a regulatory stranglehold administered by the ACA (i.e. the federal government.) They made a deal and rolled over and accepted this situation in order to get access to 30 million new customers. You’ve seen nothing yet until you see how your personal healthcare is affected by all this.
But, yes, the insurance companies do have to worry about profits.They are private businesses. I remember how the insurance companies (HMO’s) were fighting with patients and doctors in the 1980’s as the companies tried to restrict care and lower doctor fees to bring costs down. In the end, they gave up fighting, drew their enforcers back, and simply raised their premium prices.
If the quality of our healthcare system gets damaged, it will be the fault of the government—-insurance companies are accomplices.
But now the government will tell insurance companies what to do in terms of “better and affordable healthcare” and the companies will be the bad guys and then they will turn blue and die. Then we will have socialized single payer medicine as the government comes in to save us. Or, the Repubs. will take over Congress in 2014, and the ship of health will begin to change course.
Do the very profitable healthcare insurance companies have any responsibility in all this other than to their stockholders? The government (us taxpayers) pay….for what? Dividend checks to share holders? How about some better healthcare also.
So I am an “11 percenter” then (80% less the 2/3 (67%); satisfied, really?.
That would be the healthcare system that >2/3 of Americans are satisfied with.
http://washington.cbslocal.com/2013/11/25/poll-69-percent-of-americans-satisfied-with-personal-health-care-plan/
OldTimer: What “current excellent system”?
An 80 percenter.
Interesting conversation. I bet American healthcare under the ACA quickly moves us to a UK-like rationing system that we will all hate. It has to go there because what’s the government going to do when the costs of ACA+Medicare explode? We’ve sold our souls to help the 20% of the population that was underserved by the current, excellent system.
Bythesea: I am in favor of tools that help improve productivity for doctors and quality care for patients, so that includes electronic medical records, practice guidelines, and evidence based medicine. But those “tools” can be misused and counterproductive in the wrong hands.
I want patients to have freedom of choice as they consider where to go for their care. Doctors need to be in charge of practice guidelines, and those guidelines need to be flexible so that doctors can individualize care for each patient. Funding for research is essential in order to bring scientific evidence to the practice of medicine.
Paul — to put you on the spot — can you offer your observations regarding the two (opposing) views of the new healthcare practice environment for physicians: EBM, EMR, restrictive networks, treatment protocols as tools of enlightenment and higher quality medicine OR as tools of restricting physicians, rationing, and cookbook medicine. These are two very different takes on what the future holds.
Many thanks to Carol (and PG, MD) for their clarifying information on today’s practice of “healthcare”. I consider this thread has been invaluable for those of us “not in the know”.
Dear Grounded in Reality
The EMR does not dictate what the physician must do; it does suggest a best practice but the physician is free to do what he or she believes is best for the patient. It’s all recorded and if it works out for the patient, all well and good. I joined Kaiser in 2007 and I can’t say I ever heard of a physician being punished or censured for doing what they thought best unless it ended up in a problem. Then there was a formal review by their peers. ( but if you tell me that it happened in California, I will ask the CMIOs I still keep in touch with and ask about it.)
In this day and age, there are so many new findings, information and issues and these can be presented to all physicians thru the EMR. This is the amplification of knowledge!
You know the number 1 request I would get from KP physicians? The ability to quickly find the information or material the patient walked in with!
Patients are so much better informed and they are constantly asking about new protocols or for drugs that they see advertised or hear about on other social media sites like Patients Like Me. It’s frustrating to be an MD in this day and age! With tools like the EMR and drug information libraries, they have a better chance of keeping up but it ain’t easy.
Everyone pays the same payroll tax into Medicare and everyone gets the same benefit out (although, again, they have started to charge a slightly higher premium to “wealthy” enrollees). While contributions are not voluntary, actual enrollment in Medicare is. Like Social Security, Medicare is not a means tested program and benefits are not being tilted to favor less affluent parts of the population. I believe that this notion that all pay the same and get the same is what makes both of these programs politically popular. However, to be clear, they are both socialist programs that have unsustainable economics.
I wonder: how many massive social welfare programs with unsustainable economics does the government want to create?
As to the disruption of the existing healthcare system, just wait.
I write in response to Abbott’s statement that “Medicare does not seek to massively subsidize one part of the population at the expense of another” and her or his assertion that “individuals are not required to participate in Medicare”.
Both assertions, of course, wrong. I have been subsidizing Medicare with every pay check I have received since my teenage years. And my participation in this subsidy was most certainly required. .
Now I am not complaining about that, and I certainly don’t begrudge senior citizens whose Social Security and Medicare benefits I have been funding for decades. Indeed, I consider it a privilege to live in a society where elderly persons do not have to fear being left to die or go bankrupt when they become ill — and also receive the lifeline of a guaranteed income stream funded by all working persons in the country..
But I have long been embarrassed to live in a country where persons who have worked all their lives — but have yet to reach 65 — can end up indigent because they suffer a grave health reverse, .That is the grave problem the ACA addresses,
As for the supposed massive disruption to the “healthcare system” arising from this important effort to address an undeniable crisis in that system, well I have not seen it.
The challenge to what is said above, is that EMRs (as a tool of measurement and enforcement) and treatment protocols “validated” by evidence based medicine (as a tool of practice control) are being forced upon physicians. At best, these protocols, if informed by an EBM study, take the perspective of what works best for an “average” patient, and should therefore be taken as nothing more than one input into physician decision making (not gospel).
The problem is that most patients are not “average”, they are unique. The physician is in the best position to judge what is best for a particular patient, what that patient’s preferences are, etc. However, when the physician deviates from what the managed care corporation/government says is the “correct” way to treat a patient, as measured through the EMR (and increasingly the protocols are explicitly loaded into the EMR or there is other interface bias built into the EMR to make it hard to go “off protocol”), then the physicians is judged to be providing “low quality” care and is punished via reduced bonus or excommunication from the provider network — when, in fact, higher quality care may be being provided. This is how it works at Kaiser — non-compliant physicians get hammered (know that from a physician who works at my company who practiced medicine there until 2006).
I would challenge any physician to say they have more autonomy and control today than they had 5 years ago. They should, because they have never had more data/info more easily available. But sadly, medicine is being dumbed down to what works OK for an “average” patient to cut costs instead of being juiced up to maximize the quality of care for each patient.
The tools and processes to enforce rationing of care are being laid down. Wake up sheeple and rise up against government and manage cared hegemony over your health!
Thanks Carol for an excellent discussion on electronic medical records and evidence based medicine.
From a clinicians point of view, evidence based medicine provided a huge advantage for me in making decisions which could be backed up by science. It is not a new discovery; it began to emerge in the early 1990’s. The large trials which provide the evidence are usually funded by the Federal government or by big drug companies. They usually cost multiple millions of dollars and involve thousands of subjects.
But these studies are always imperfect because the more questions they answer, the more questions are asked.That is why it is never “cookbook medicine.” Physicians are always blending the results of research trials with the art of medicine which includes experience and knowledge at “the bedside.”
For example, after the 1994 4S trial (Scandinavia) was published that showed, in over 4,000 patients with coronary disease, a 42% reduction in risk of dying from that disease simply by taking a statin drug (to lower blood cholesterol) called simvastatin (Zocor,) doctors were afforded proof that they can place patients on those drugs knowing that the decision was justified and could really save lives. But since then, studies of statin drugs continue now as many questions remain unanswered such as: what ages benefit, do healthy people benefit, how low should the blood cholesterol go, which drugs are better, what are the safety issues, etc. etc. As Carol says, this approach to medical care has saved lives and has improved the quality of care delivery.
As for electronic medical records, we knew back in the 1960’s that medical records were an extremely important tool for patient care. We followed the “Weed Problem Oriented Medical Record” model of keeping carefully documented MR’s which was used around the world up to present time. Of course, paper records had considerable shortcomings, but good doctors tried as best as possible to have accurate and detailed medical records.
Larry Weed, a physician from Maine, said “We need to better organize our records, better utilize paramedical personnel and appropriately use computers” But he also didn’t want to overemphasize the reliance on charts, so he said, “We’re not taking care of records, we’re taking care of patients.”
That’s all coming true now, becoming perfected in the form of EMR’s. I have watched my cardiologist in action with his computer in the examination room, and I have seen the process getting better and better as time goes by, and this advance is justified across the entire system, and the ACA will do that, but it will painful, expensive and awkward.
I could not possibly leave Devo’s comments unanswered. I am not a physician but I am a patient and I am also a healthcare technology consultant and was responsible for the implementation of the single biggest private health system rollout of Electronic Medical Records (EMR) system in the US (Kaiser Permanente has over 16,000 physicians, 40 hospitals and over 1,000 outpatient facilities serving close to 9 million members).
Let’s first start with the statement that evidence based medicine is a cookbook forcing all doctors to practice to a standard of care.
Evidence based medicine simply means that the medical community has solid science behind a practice or treatment protocol and knows what to expect. That means your doctor can tell you what should happen and tell you that if the treatment isn’t working, or if you get some other reactions, you need to come back.
Evidence based practice has advanced the standard of care, not detracted from it. It assures that protocols are followed by the care team and it alone has been responsible for saving millions of lives not to mention $. It assures that consumers are provided with safe drugs and treatments and that we are not subject to voodoo medicine. It is based on the principle of “Do no harm” It is no different than the standards of practice used by the legal profession, airline pilots, financial services or other high impact professions.
ICD 10 is an insurance billing code system already in place in Europe that provides more specificity to the coding of diagnoses, procedures, medications, diagnostic orders, etc. It adds nothing to the care delivery process but will make the cost of care far more transparent. And we can not begin to reduce costs till we understand what is being charged.
The problem for physicians in particular and hospitals, is that it is exceedingly, almost painfully detailed, more so than the SNOmed coding used in EMRs. Thankfully, the EMRs all have billing modules so they provide the ICD 10 codes that will go to insurance and CMS (Medicare). The deadline for ICD 10 adoption is Oct 2014. Facilities that do not send their bills in this format, may find themselves penalized.
EMRs have already proven to have improved workflow, reduced medication error, reduced legal challenges to doctors and hospitals, almost a secondary tort reform as it were, because everything the doctors know at the time they make a decision is reflected in that record. Yes it is that detailed. It encapsulates all the data that comes out of monitoring devices, second by second, including the anesthesia systems, all the drugs a patient has taken and provides an unprecedented knowledge base to the physician. It is often supplemented by other external systems for that.
EMR workflows as I said in an earlier post are designed by doctors, and the training and implementation is difficult because people don’t like to do things differently. Even with an order set (workflow) that is provided, a physician can override it. The override is recorded and reviewed by the quality committees in order to improve practice. We saw this most often in pediatrics where drugs in the formulary were at times only adult strength or in pill form and the doctor wanted a syrup.
When I went to work at Kaiser after 25 years in financial services, I saw a business practice that was over 20 years behind in the use of technology to benefit patients. It was a cottage industry where only your doctor had access to your records and it was in a drawer in the office. But the past five years, we have been catching up. And it’s messy and it’s hard, but everyday, the nation and the patients and their families benefit.
Carol
ICD 10, EMRs, evidence-based medicine, comparative cost effectiveness, ACOs, treatment protocols, restrictive physician networks — these are all tools designed to decrease physician autonomy and force cook-book medicine on an unsuspecting public. While advocates of the physician-as-checklist-follower model will say that some physicians practice medicine below the standard of care, I believe that the distribution is skewed such that a vast majority of physicians are now practicing at or above the standard of care [Paul, what do you believe?]
And how does the standard of care get advanced? Where does innovation come from in medicine? It comes from physicians who try something different, who go beyond conventional approaches. The Australian physician who started treating stomach ulcer patients with antibiotics rather than surgery (now the standard approach) would undoubtedly be kicked out the managed care network for not following treatment protocols if he had been in the US in 2014.
Hey government and managed care — stay out of the doctors’ way please [believe it or not, doctors know more about medicine than bean counters and/or their conflict-of-interest-tinged salaried physician “justifiers”].