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Archive for the ‘Obamacare issues’ Category

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By Paul Goldfinger, MD, FACC. Editor @Blogfinger

Since the Affordable Care Act was passed three years ago, I’ve been floundering around trying to latch onto any snippet of information which would give us advance notice about how the new law would affect quality of care. In the absence of transparency, we have been left to speculate and wait for the law to take effect.

Lately we have experienced the flawed rollout and we have seen all sorts of fiddling with the law by the administration, a process which has been questioned as being unconstitutional.  We have heard about canceled insurance policies and inaccurate information such as “you can keep your doctor.’

Finally we can begin to get to the clinical aspects, so we have discussed practice guidelines and physician networks. Then, from Oregon, we learned that people given new Medicaid policies use the ER’s even more than those with no insurance—another surprise.

But getting into the weeds without some overall understanding of what is going to happen has been frustrating.  Carol Rizzo told us that the ACA was mostly about insurance reform, and the clinical aspects would be found elsewhere.  I was skeptical, so I was pleased to see two major figures in healthcare appear on Sunday at Meet the Press.  Both are MD’s and both are CEO’s of major health systems.  Great!  These guys should be able to explain the overall scenario.

Dr. Toby Cosgrove is from the Cleveland Clinic and Dr. John Noseworthy is from Mayo.  When asked if they really know what to expect from the ACA, Dr. Cosgrove said, “We really don’t understand this.”

Dr. Noseworthy said that the current healthcare system is a “bunch of cottage industries” which need to be turned into an integrated “system.”  He said, “We don’t understand the implications of the ACA for hospitals and doctors.”

They both seemed to agree that only time will reveal what the ACA will bring and if it will be successful.  They said, “The ACA will take its own path.” As for the changes being made in the ACA as we speak, they agreed that many more changes will have to  be made if the “entire healthcare system” is to be reformed .

They pointed out that Medicare is involved in 50 %  of healthcare and that its “insolvency is looming.”  The payment systems need to be modernized, and the way that providers are paid must be changed.  Dr. Noseworthy said that everyone in the system will be paid less if the ACA is to work.

They also had something to say about the patients, “Something has to be done with incentives to encourage patients to take better care of themselves.”  They offered the “epidemic of obesity” as an example.

So I was sort of relieved by this conversation. Now we know:  the chaos and murkiness of the ACA rollout seems that way because this freight train is heading into a fog of unanswered questions.

We can keep going into the weeds and looking at what is emerging, but let’s stop seeking the holy grail of completely understanding the ACA, because full understanding now is just impossible. Even if you read every page, you will still be left like the two doctors above who “really don’t understand this.”

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By Paul Goldfinger, MD, FACC    Editor@Blogfinger

As many of you know, my main concern regarding Obamacare relates to how it will affect quality of care. But all we hear is about insurance and economics. But even with that, we can begin to see the effects on quality, because some people will be left naked on Jan 1 when they no longer have coverage. Obviously, if you don’t have health insurance, the quality of your care will be reduced.  But I am certain, as you know, that quality will be negatively impacted in many ways and I recently reported on the situation with practice guidelines potentially  interfering with the doctor-patient relationship.

However, on Jan 1, as people actually seek care under the ACA, I suspect we will hear many horror stories having to do with the deterioration of quality care. In today’s Wall Street Journal we find an opinion piece by Marc Siegel, MD, and Professor of Medicine  at the NYU School of Medicine. Dr. Siegel says he has awakened “to the harsh realities of our medical future.”  His piece rambles a bit, but you can see from his observations that you don’t need a weatherman to tell you which way the wind is blowing.  Here is Dr. Siegel’s “The Death of the Bedside Manner”     *Wall Street Journal, Dec. 27, 2013.

WSJ on Obamacare

BOB DYLAN:

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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.

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This topic is suggested by David Lurie of Ocean Grove who has included a link to the New York Times, December 9, 2013 issue. The paragraph below is written by him:

“Worth reading. Here are some examples of the actual people who are being helped, and who have been paying huge prices for our current system of providing (or not providing) care.  I  found telling the example of immigrants from China who – as children – had to return there for medical treatment and pharmaceuticals.  The cancer patient who was skimping on his chemo was more than a bit disturbing as well.  These realities, it seems to me, need to be reckoned with by anyone who want to nullify the ACA.”

Here is the link from today’s NY Times.

Amid the Uproar Over the Health Law, Voices of Quiet Optimism and Relief 

Blogfinger Medical Commentary:   By Paul Goldfinger, MD, FACC

We already know about some positive results that have occurred with Obamacare, including  the elimination of pre-existing illness restrictions by insurance companies, allowing young people to stay on their parents’ plan and the removal of dollar caps from health insurance plans.

But besides that, at this point, we have mostly promises which include providing coverage to over 30 million people. However we know that promises don’t count—only results–because of the broken promises regarding keeping your insurance and your doctors.

The New York Times article linked below by David Lurie is inspiring, and we all welcome relief for those in need, but putting out anecdotes like this will convince only the naive that the new healthcare system will make our country healthier.

We need to wait until  at least 2014 to learn how well the ACA is working in terms of the practice of medicine. I have been repeating that mantra and I will look forward to seeing documentation of success in the form of numbers and not anecdotes. If Obamacare delivers on its promises, then we all can jump on board and be happy.  But if it fails, then we will need to reinvent healthcare in the US.

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By Paul Goldfinger, MD

As predicted, the ACA’s problems will multiply as we get past the website disaster.     To keep you informed of the concerns regarding quality as they evolve, we will periodically do the Obamacare Hotline.

1. It is expected that about 107 million people   (80 million from the business community)  will eventually lose their existing policies so that they will be forced to look for other health insurance, preferably on the ACA exchanges.   But most will find higher premiums and higher deductibles and perhaps crummier policies than before.  Contrast these “losers” with the “winners” who get insurance that they didn’t have before, but they number about 14 million according to current projections.

2. Because of the huge increases  (“explosion”) in Medicaid enrollment, we will evolve a two tiered system, not a system equal for all.  Those at the bottom of the ladder will be on Medicaid and they may have major problems in getting access to care for a variety of reasons, not the least of which has to do with doctors not wanting to participate in Medicaid due to extremely low fees. Clinics will have to be organized to deal with the huge rush and demand for services.  Note that New Jersey has the lowest rate of Medicaid doctor participation in the country.  Then comes California.

California is a model for dealing with the Medicaid  problem. The link below discusses how California is doing it:

NY Times on California Medicaid

3. The mechanisms for passing new customer dollars (premiums)  to insurance companies  are flawed. As a result, patients with ACA acquired policies may find themselves rejected by providers in their networks because the providers are not being paid.  This could leave covered individuals at risk for medical problems. This problem should be fixed quickly.

4.  Doctor networks in ACA policies are smaller than customers would like. In many cases,  doctors have not been contacted to sign up with insurance companies. Or the doctors have refused to sign contracts with some companies.

5.  Applicants have until Dec 23 to buy insurance  on an exchange if they hope to have coverage by Jan. 1.

6. The sign up forms  (called 834 EDI transmission  forms) on the exchanges have been causing confusion. These are the forms that everyone who wants to buy insurance needs to fill out.  They contain all the information that insurance companies need to enroll a customer.  But this “back end” function, which provides data to the ACA website has proven to be difficult for shoppers and prone to errors.

The insurance companies are finding all sorts of errors on those data sheets which cause problems getting people enrolled.  The NY Times says, “This is what everyone’s worried about”   Some people who think they have acquired insurance on their exchange  may find out that they don’t when they check in January.

Sign up for Medicaid has been the most successful part of the process, but that program is free, and the government is pretty good at offering free benefits.

7.  Here is a website called “ObamaCare Facts:  Dispelling the Myths.”   ObamaCare facts web site.   This site is supportive of the plan and tried to provide encouragement and information to those who want to sign up.

But don’t be bamboozled by double talk.  Here is a quote from page one of that website:

“ObamaCare doesn’t regulate your healthcare, it regulates health insurance and some of the worst practices of the for-profit health care industry.”

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