Showing posts with label concierge medicine. Show all posts
Showing posts with label concierge medicine. Show all posts

Monday, February 10, 2014

Affordable Care Act.......The Missing Link....It is not Australopithecus


Houston, we  have a problem  "Failure to Launch"

Despite a goal of access to health care for all, however the hinge on the door for acccess is squeaking. News such as this are appearing in medical news.


Millions Trapped in Health-Law Coverage Gap
Wall Street Journal - February 9, 2014
They quit their jobs, thanks to health-care law
Washington Post - February 9, 2014

Enrolling in Covered California is not for the weak of heart, or spirit.  For those who were previously uninsured for a variety of reasons the affordable care act raise spirits with the elimination of the fear of not being able to pay for health care. The current system was not sustainable financially, however health care is available taking away the financial morass of insurance companies, bureaucracy and government.  Neither government, nor insurance companies provide health care. Physiciains, nurses, hospitals and many other providers care for patients.

A consequence of the change will be the marked reduction in 'free care'. The old model of those fortunate enough to pay for their own care, and providers and hospitals having deep pockets to finance care for the less priveleged of our society.

In order to assure health care and security for all the down side is forfeiting freedom. The tyranny of absolute security is freedom. Some of  us understand the concept and the reason for opposition to the affordable care act.  Others see it as an opportunity   for free health care.   Those whol will receive this generosity are often not only uninsured, but also un-empowered, and have little impact, are passive and do not have resources, nor influence to make changes.

The U.S. Constitution (    )  guarrantees the pursuit of life, liberty and the pursuit of happiness.  That statement places us in a conundrum.  Does that mean care to avoid illness, or treatment to keep one alive?

This is not some ephemeral abstract thought embodied in our founding document. Other constitutional guarrantees in the past have been manipulated to make change


The Affordable Care Act in Californa is known as  'Covered California'.  Patients who sign up are screened for eligibilty based on income and household size. Those who's income is greater than........are required to purchase a subsidized health insurance policy or face a fine.  Some of these policies look nice, offered by stable companies, such as Blue Shield, Healthnet, Anthem and their providers are listed under providers for Covered California.  However with a more in depth search you will find they did not receive contracts and are not providers.  (small details).....this will reduce access to providers (and some hospitals). None of this has been adequatly explained 

Some who look forward to using Covered California should call their chosen provider and ask if they are a provider for Covered California.   Many of them are not, and some may not even know if they are signed up for it.





Saturday, December 21, 2013

WHY AREN'T DOCTORS INVOLVED IN HEALTH REFORM--ACTUALLY WE ARE, BUT NO ONE LISTENS TO US

Dear lawmakers: 


As I was watching CNN news recently, I noted in the headlines different ways Obamacare is failing.  Current problems discussed were the customers’ sticker shock of high deductible plans (up to $12,700 for families), the president blaming the insurance companies for having substandard plans, and the people blaming the president for losing their current insurance.
One patient even complained, “My new health care plan tripled in price, and now, it is like having a third loan to deal with, including my car and home loan.”  A vicious cycle of blame between Washington, health insurance companies, and the patients is quickly demoralizing this nation and simply increasing costs with more administrative regulations.
And we need answers.
Surprisingly, in all of this, doctors were not even mentioned.  As if doctors do not know the intricacies of how the health care system works.  As if doctors are not there for their patients 24 hours per day, ordering tests or doing procedures that can benefit a patient’s well-being.  As if doctors are not dealing with denials from the insurance companies on a daily basis, losing valuable hours to menial paperwork that could be spent caring for our country’s sick.
Doctors have a duty to care for their patients and are the engines that put health care into motion. They yearn to maintain that physician-patient relationship that is important to the care of our patients.  Unfortunately, doctors are not being directly involved in the health care reform debate despite being on the front lines of care.  They have an opportunity to provide valuable insight into the day-to-day operations of this health care machine.
Would you want to fly in a plane with no input from a pilot? Or design a curriculum without a teacher’s input?  These “insider” insights are essential to health care in order to exact true change and improve health care for everyone to enjoy. Unless we embrace this idea and look to doctors to help solve these dilemmas, we will be doomed with increasing prices, more talking heads on TV blaming others, and dysfunctional insurance companies, all who have never spent a minute shadowing a doctor, yet claiming to know all the answers.
The current law and regulations being implemented under Obamacare will ultimately lead to sicker patients and low quality care for three reasons:
First, older doctors will retire early fed up with the system. These older doctors feel that the loss of a patient-physician relationship and the burdensome regulations (ie. paperwork) will choke off their ability to provide good care.  In addition, their expenses are increasing with these new regulations.  Add in the projected cuts in reimbursement up to 26%, and their livelihood will be threatened. These cuts could force these doctors out of practice or force them to stop seeing Medicare patients simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already.
Second, young smart minds will no longer enter the field due to rising debt (average $250,000 after medical school) and severe cuts in reimbursement (yearly threats of 26% cuts to reimbursement).  If young college students realize that they cannot provide for a family despite going to school and training for 14 years, deferring income for all those years, and then being slapped with a $250,000 medical school bill, they will turn to different professions.
Third, current younger doctors will become more demoralized with administration and lawmakers dictating how they provide care.  They will feel as if they are increasingly being treated as machines, expecting to provide great care such as answering patient calls at 2am, working 24 hours shifts, doing more procedures for less, and filling out more and more paperwork, all with the threat of getting sued if they don’t perform without making a mistake.  This will produce a high burnout rate and poorer care.
These doctors went into medicine to feel a healthy bond between themselves and their patients.  They enjoy talking and spending time with them in the office.  Unfortunately, with all the unnecessary documentation regulations and time restraints, doctors are losing the bond that is so critical for care. For those doctors who choose to stay in the field of medicine, many of them will instead elect to practice concierge medicine, taking the insurance company out of the equation and attempting to maintain the physician-patient relationship.
There are numerous articles out there that show concierge medicine is growing.  With current doctors feeling demoralized and younger students afraid to enter the field, this will create a massive shortage of doctors and threaten the health of our citizens.
Having said all this, I as a doctor do not want this to happen.  I went into medicine as a calling to help others and take this role seriously.  I longed for the idea of sitting down and talking with my patients, sharing stories with them, not on the clock, and without cumbersome, slow computers and administrators documenting every move I make.  I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this.
Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws.
I would now like to outline below a few of these ideas that would lead to better and more affordable care.
The first idea involves making costs and reimbursement more simplified and transparent.  These changes would help clarify misconceptions about doctor’s pay.  Leaders need to stop attacking doctors for how much they earn because they do not really know how it works.  In all other professions, one gets paid what the bill says.  If a handyman comes in to fix your sink and charges $80, you pay him $80.  If you seek a lawyer, and he says he charges $250/hour and he works 4 hours for you, you owe him $1000.
Unfortunately, the medical billing is unique, confusing, and wrong.  The charges (bills) that patients see in the mail are not what doctors get paid.  These are inflated numbers derived from contracts between hospitals or groups and insurance companies.  A recent New York Times article headlines read “As Hospital Prices Soar, a Stitch Costs $500.”  Sadly, these inflated numbers have nothing to do with what the doctor gets paid. In fact, those bills do not go to the doctor at all, but rather to the hospital.
When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid, depending on the patient’s insurance, utilize a fee schedule.  This schedule consists of thousands of codes that give dollar amounts for individual procedures or clinic visits.  Each code has a dollar figure to determine how much to reimburse that doctor.  This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare.  This can range from 80% to 180% of Medicare depending on the insurance carrier.
If a patient has Medicare, however, one can see exactly what that doctor will get paid based on the code for that procedure, test, or office visit (CPT code) by using the fee schedule.  This is often called the “allowable charge” in patient’s bills.   The revenue the doctor receives is in fact this fee and is set no matter how much the hospital or doctor chooses to charge.
To complicate matters, there are usually two different charges in a patient’s bill: a “professional” charge from the doctor, and a “facility or hospital” charge.
First, the doctor only collects a fraction of the “professional charge.”   This is the charge for the doctors’ services (e.g. office visit vs. procedure vs. MRI interpretation).   The doctor only receives a fraction of this “professional charge” because this is reduced by the fee schedule to the appropriate amount.  Remember, charges and what the doctor actually gets paid are very different in medicine.   The doctor does not collect any of the hospital charge as this charge goes to the hospital.  After all of this, a doctor gets paid only a small fraction of this “professional charge” because these allowable charges do not include overhead expenses the practice incurs (which can range from 30 to 60%).
This situation I describe above is not understood by our leaders as verified in this video of President Obama discussing foot amputations in diabetics.   President Obama claimed that surgeons get paid “30, 40, 50 thousand dollars” for a foot amputation.  Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his expenses are considered.  This $738.90 needs to cover his office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation.  Thus, the doctor actually gets paid 1.4% ($738.90/$50,000) of what President Obama claimed he got paid. Our leaders are clearly confused and have no right attacking physicians’ reimbursement.
Another example of confusing costs of medical treatment hits closer to home as my own mother presented to the ER with sudden blurry vision a few weeks ago.  Concerned for serious causes for this symptom, several tests were run to rule out causes such as stroke or tumor.  Thankfully, her diagnosis was nothing life threatening and is recovering.  She then received the following bill two weeks later in the mail explaining her charges.  I have attached a copy of the bill.
She was shocked at how high the charges were and could not decipher this bill.  Referring to my explanations above, under “professional/physician charges,” it “appears” a physician gets paid $450.00 to interpret a CT head and $580.00 to interpret a MRI of the brain.  As I described above, this is far from the truth.  Looking at the fee schedule, code 70450, a CT head would pay a doctor $29 for a Medicare patient.  This is far different than the $450 shown on the bill.  In fact, it is only 6% of what the bill states!  Likewise, an MRI brain, code 70558, would pay a radiologist $109.  Way off from the charge of $580.   There are other inflated fees for the hospital as you can see in this bill totaling over $11,000, but these are not related to a doctor’s compensation.
This clearly illustrates that doctors payment systems are confusing for patients and creates much anxiety when trying to decipher a bill in the mail.  It is apparently even confusing to lawmakers and the president who are trying to modify reimbursement yet do not know how doctors get paid.   Even though a stitch may cost $500, the doctor got paid $28 dollars to read a complex CT scan of the brain.  We need real costs to health care, not inflated charges from hospitals.  This needs to be addressed so patients and lawmakers can understand where doctors are coming from and realize that doctors are getting paid much less than meets the eye.
In addition to the above explanation, doctors do not get paid for talking on the phone to patients or other doctors, writing prescriptions, or ordering lab work or radiology tests. This is simply work we do to allow patients to get the best care and do not charge hourly fees for this work.  We do this work in between seeing patients in the office.
Further, if we drive to the hospital in the middle of the night to perform a procedure, we get paid the same and we do not charge extra.  Doctors do not collect whatever they want for clinic visits or procedures; this is all determined by the fee schedule explained above.  In addition, if one procedure takes longer than average or is more complex, a doctor does not collect more for that procedure unlike other professions that are paid hourly.  The fee is pre-determined by the Medicare fee schedule no matter how sick the patient is.  This is clearly different among other professions which charge an hourly rate.
In addition, if there is a follow up call or letter after the procedure, this is all part of the one fee and no additional fees are billed.  If that patient calls at 9pm that night with a health complaint or the patient arrives 30 minutes late to an appointment, there is not an increased charge (ie. we do not get paid more).  I am not stating that hourly rate work like how lawyers get paid is flawed or wrong; I am simply stating it is very different and sometimes this contrast is not noticed.  Do I speak with patients at 9pm and do I spend the extra 30 minutes helping patients get the quality care they deserve?
Of course, I willingly do this because I went into medicine to help those in need and I get satisfaction from this. I do worry, however, that this may not continue to be the case for all doctors if reimbursement models are not modified and doctors’ fees are not corrected for inflation and practice expenses.  They simply will not bring in enough revenue to cover their expenses. Again, doctors’ fees have been declining, are not secure (please read about the SGR formula), and do not adjust for inflation.  Solutions involve making costs and charges more transparent and realizing the true (not inflated) costs and benefits of medical devices, services, and materials.  With actual costs (not inflated charges) being available and transparent, patients would be given choices and autonomy about their health.
The vehicle for this would be health savings accounts (which I will describe in more detail below), which would allow patients to use their own money with their doctor’s advice to decide on what care is best for them.  This would increase competition amongst providers, lower prices, and offer more choice and involvement in their care.
The second idea involves tort reform.  We as doctors have a calling to help patients.  But, as we all are human, mistakes can happen. It is very important that patients who are injured by mistakes be compensated in a way that the law is supposed to provide.  However, the point of law is to provide reliable decision-making that can sort good health care from bad health care.  Instead, currently, it is run ad hoc jury by jury with no set standards. The system currently favors a doctor if in fact something was done wrongly or it may favor a patient even if no mistake was made.  This unreliability leads to defensive medicine, ordering tests and procedures just to prove that you did something, or excessively documenting trivial facts to prove you looked at everything.  The estimates for defensive medicine has been estimated up to $200 billion per year.  The current laws neglect both the patient and the doctor and drives up costs with administrative and attorney fees.
Here is an example of the evolution of defensive medicine. If a family physician determines a patient’s headache is likely due to tension and there are no warning signs for something serious, the doctor may choose not to order a CT scan and have the patient follow up if symptoms do not improve. Rarely, a tumor or bleeding in the brain could present in such a way despite a normal clinical evaluation by the doctor.  If that patient ends up having a tumor or bleeding, they can sue the doctor for not ordering the CT scan earlier.  In turn, that doctor doesn’t want that to ever happen again, even though he did everything right by using his clinical knowledge to determine nothing serious was likely going on.
Thus, he will order CTs on everyone simply to avoid a frivolous lawsuit even though he knows that the CT will be normal.  This exponentially increases costs as doctors across the thousands of hospitals in America follow suit not only for headaches but for other common ailments. No, doctors cannot play God and know every outcome with the thousands of patients they see yearly.  But they are very good at using their knowledge and training to determine if someone is sick and likely needs further immediate attention or not.
Having said that, if the doctor did do something wrong, the patient is still taken advantage of with the current tort system.  Thirty-nine percent of cases take three years to settle and 60 cents on the dollar are used for lawyer fees and administrative costs.  Patients definitely deserve to be compensated for poor health care and this current system fails them.
The answer to this rests in health care courts described by Common Good Chair Philip K. Howard.  He states that expert judges without juries would determine what is good versus bad care.  This would provide consistent standards of what is required in certain health care situations.  It would benefit patients because they would not spend three years dealing with the jury system nor pay trial lawyers 60 cents on the dollar for a case they may not even win.  And it would benefit physicians because they could act on their best professional judgment without being scared of being liable when they did nothing wrong.  It would let us do our jobs without being smothered by lawyers looking over our shoulder, yet provide patients with fair consistent rulings in cases of being wronged.
By creating clear standards of care, health care courts will allow judges to dispose of weak and invalid claims quickly after filing, while also disincentivizing doctors and insurers from defending cases in which they are clearly at fault.
The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs.  This could be accomplished with health savings accounts.  These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status.   With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services.   This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones.
In order for these accounts to work well though, hospitals’ and doctors’ prices need to be more transparent and reflect true costs so patients know what they are buying.   Currently, that is impossible.  Hospital and doctor bills make little sense, are falsely inflated (as described above), and do not reflect true costs, leaving patients confused about real costs to their health.  When a patient hurts his or her knee, goes to the doctor, and the doctor orders an expensive MRI, there is no mention of costs.  The patient’s insurance “covers” the MRI, making the costs a non-issue for that patient.  There is no incentive to try ice, physical therapy, and rest before delving into an expensive MRI.
If the actual price was known for that MRI, patients could know what they are “buying.”  This price would be significantly less than the inflated charges because prices would be required to be transparent.  True prices would be published and patients could shop for MRI scanners just as they would for any other service.  This would thus allow patients control over how they spend their health care dollars.
In the same light, during the last six months of our lives, we spend up to 50% of our own total lifetime health care dollars.   In America, when patients are extremely sick and brought into the hospital, everything in our medical repertoire is used to keep them alive.  Costs can be up to $10,000 per day of ICU care not including other aggressive measures.
Unfortunately, patients may not know these costs.  With patient funded health savings accounts, patients would have more of a role in their own care, and could decide based on a doctor’s recommendation the best course of action, considering the patient’s prognosis, benefits, risks, and costs.   Of course, families always have input into their loved ones health near the end of his or her life and can decide how aggressive they wish to be while talking with their team of doctors.
However, the way it is being done is likely wrong.  Doctors are not bringing up hospice to patients early enough. Instead, many families with their loved ones are faced spending their last months in an ICU, hooked up to breathing tubes, only prolonging the inevitable.  Patients’ and their families are being deprived of spending that time at home in a more comfortable setting.  Quality of life is not being brought up, only quantity.  An article in the Washington Postaddresses these end of life issues extremely well, entitled “An unrealistic view of death, through a doctor’s eyes.”
It states that modern medicine may be doing more to complicate end of life issues, rather than improve it.  The article also states that people think death is a failure of modern medicine rather than simply life’s natural conclusion.  I am not saying that every patient in an ICU needs hospice brought up.  Each patient in unique and families should decide based on their values and wishes.  A previously healthy 28 year old involved in a car wreck who remains in an ICU may need months in an ICU to recover and would benefit from this long hospitalization.
However, a 90-year-old patient with other medical problems such as heart failure and kidney disease in the ICU with a new diagnosis of a terminal cancer may benefit from a talk with hospice.  Every human being is unique in their health needs and I feel families and doctors need to be more open about goals of care at the end of life   An interesting article details some of these issues, entitled “How Doctors Die.”
It basically points out that most doctors choose less, not more, care at the end of their life because they personally witness the limits to human medicine action.  It illustrates that there is not always an answer or a cure and that doing nothing is sometimes the best care available.  All in all, more patient ownership of end of life costs utilizing their health savings accounts combined with frank discussions with their doctors about these end of life issues would definitely lower health care costs and even help families cope with difficult illnesses.
The final suggestion involves preventing chronic illnesses that end up costing Americans a lot as they age.  We are very good at treating complex medical problems with patients who are very sick, but not very good at reducing medical costs through preventative medicine.  We are very good at bringing a new state of the art drug used to thin the blood to the market, but bad at actually preventing the reason for needing that drug in the first place!
In fact, 50% of our health care dollars ($623 billion) are spent on the sickest 5% of patients (30 million) in America.   Interestingly, the top 1% of health care “spenders” accounted for 20% of the total health care expenditures in America.   These are usually patients with multiple chronic medical conditions such as obesity, diabetes, kidney and heart disease. Studies often quote Americans as spending a lot on health care, yet being ranked lower than most other countries on health care outcomes.  This is the reason these stats make sense.  We spend a lot on patients who are very sick and can prolong their life, but do little to prevent them from getting sick.
Recently, Sanjay Gupta summed up the solution to this paradox very well in a CNN article.  He basically states that increased access to health care with Obamacare would not improve our health outcomes.  Rather, patients taking ownership of their own health and holding themselves accountable will promote a healthier America.  Eating better, exercising more, and reducing stress can go a long way.  It would also reduce the likelihood of developing these expensive chronic medical conditions, which drive costs higher.
In conclusion, I feel that Capitol Hill needs input from doctors working in the front lines to discuss our issues so that the best reform possible can be made.  Doctors experience all of the above issues on a daily basis and have insight that politicians cannot observe since they do not spend time in doctor’s offices or hospitals.  These are a few issues that would help our deserving patients get the best care and restore that critical relationship we need with our patients.
I believe that by empowering patients more in the health care system through health savings accounts, reforming our tort laws, making costs more transparent, being more realistic about end of life issues, and living healthier, we can come a long way. I hope we can work together with lawmakers to create a system that can benefit everyone.
Matthew Moeller is a gastroenteroloigst.

Thursday, December 19, 2013

Health Benefit Exchange

Has health care improved since the ACO went into effect??  We have been told that already the ACA has saved millions and perhaps billions of dollars. How is that so?  Where are the details?

I have an open mind and I am willing to consider the facts....so just show me the numbers. How is it that the government has infused billions of dollars into health IT and providers must now support it operationally ? Given the lifetime of IT hardware and software obsolescence in five years at the most it will all have to be upgraded and/or replaced with a second generation of sofware that has real meaningful usability, not the garbage that HHS is insisting we use to accomodate the "quants" at HHS who massage the information spewing out of their machines.

Health care now supports an industry of high tech that has nothing to do with patient care. Vendors of hardware, software, consultants, IT consultants, a stream of auditors, review firms, outcome studies. What idiots think we are saving money?  The money in health care no longer is going to patient care......it is going to many parasitic organizations.  The only good thing about it is that unemployment would be much worse than it is already.

How long will  health benefit exchanges  be useful after the initial period of signing up the uninsured. Surely it will cost a great deal to fix it, and maintain it.

If the affordable care act continues to roll out the next five years will be a financial and health disaster.

For all the details on Health Benefit Exchanges and which insurance companies have signed up here is the list. It does not mean your doctor will accept these plans since the reimbursement rates in the Affordable Care Act will be very low compared to the current rates.

Stay tuned.




Wednesday, December 11, 2013

WHY YOUR DOCTOR WON'T (CAN'T) SEE YOU NOW , AND HOW TO GET AROUND IT



October, November and December 2013 have been rough months for all Americans. The effects of the Affordable Care Act are having some predictable effects on our health system.  In addition to what has happened, unknown secondary effects are still boiling below the surface of health reform.

Many Americans are concerned about the viability and even the enrollment process for the Affordable Care Act.

Some of these patients will seek out alternative methods to obtain acute or even routine necessary health care.  Cash will become a new source for paying your doctor.

In the midst of the Obamacare fiasco, direct payment and concierge practices are an alternative, and perhaps a necessity to obtain health covereage, even for the short term.

For every great challenge there are also great opportunities, such as direct payment practice. However caution is a necessity.

CALIFORNIA: 70 percent of California doctors plan to boycott Obamacare exchanges




Many reputable neutral sources have reported, " About 70 percent of California’s 104,000 doctors are reportedly planning to stay out of the state’s health insurance exchange, a move that could have significant impact on implementation of the Affordable Care Act.  

This is not a 'willful" arbitrary decision on the part of these physicians.  It is a logical and sound business decision to remain fiscally viable and avoid insolvency. As states across the country work to enroll Americans in the ACA, one question that remains is exactly what kind of doctor access patients will have when their coverage kicks in. According to the president of the California Medical Association, Dr. Richard Thorp, residents there could find limited options at the start of the new year.
Thorp told the Washington Examiner the primary reason that seven-out-of-10 California doctors are boycotting the Obamacare exchange is due to the state’s low Medicare/Medicaid reimbursement rates, which typically land 30 percent below those in other parts of the country.
For example, Medicare typically pays doctors $76 for return-office visits, but in California doctors only receive $24. A tonsillectomy, meanwhile, pays out between $500 and $700, whereas doctors in California receive $160 for the procedure.
“We need some recognition that we’re doing a service to the community,” Thorp said. “But we can’t do it for free. And we can’t do it at a loss. No other business would do that.”
“This is so poorly designed that a lot of doctors are afraid to participate,” said Dr. Sam Unterricht, president of the 29,000-member medical society, to the New York Post.“There’s a lot of resistance. Doctors don’t know what they’re going to get paid.”  California’s Medi-Cal reimbursement rates have long been a sticking point for doctors, but when insurance companies revealed their rates would be tied to the state’s Medicaid program, many physicians balked.
This sign indicates the extreme distress the Medi-cal system will endure from ObamaCare in California.

To make matters more confusing, multiple medical association leaders told the Examiner that many of the doctors listed as participants in Covered California, the state’s insurance marketplace, have not stated they’d accept patients from the exchange.
“They may be listed as actually participating, but not of their own volition,” said Donald Waters, executive director of the Alameda-Contra Costa Medical Association.
“Enrollment doesn’t mean access, because there aren’t enough doctors to take the low rates of Medicaid,” Alex Briscoe, health director for Alameda County Health Care Services Agency in California, said to the Examiner. “There aren’t enough primary care physicians, period.”

If you want to know more about direct payment programs, and models consider reading Concierge Medicine Today
The content of this post offer opinions on both sides of the issues, patients and providers.