ACA and the Three I s

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

PPACA AND OUTPATIENT PROCEDURES

HealthCare LeadersMedia expects the Affordable Care Act to cause the number of outpatien proceures to increase for those opted-in for Medicaid expansion in the PPACA. And according to figures there is a spread seen as examined by state.   By 2015 California stands to perform 46 million outpatient procedures, while a state such as Texas (opted-out for Medicaid expansion) will decrease by 53 million cases.  (reported by Truven Health Analytics)   

These figures are further broken down by specialty. Two specialties which create a significant number of ambulatory surgeries, and among the top tier of expense are cardiology and orthopedics.  Medicaid opt-in vs opt-out produces some signifcant differences in reimbursement that outweigh numbers of cases.  The split per  specialty mirrors that of the total number gained or lost in 2016.  

Mental health services (Psychiatry) are already in short supply and  have previously been throttled by the lack of reimbursement by insurers.  PPACA has mandated an increase in these services as a covered benefit. For those states who are opted out the medicaid eligible population will suffer relative to states opted-in. Those who live in states opted-out of Medicaid expansion will not have access to insured  care for outpatient psychiatry services.

As expected the variance is greatest for California and Texas which are outliers in the data. In 2016 the volume of Cardiology cases in Califonia will increase by 672,000, while Texas will forgo 840,000 cases.  These figures also reflect population differences and the number of medicaid eligible patients in each state.

For orthopedic surgery California (opted-in) will benefit from over 299,000 outpaitent orthopedic cases, while states such as Florida and Texas (opted-out) stand to lose near 300,000 orthopedic cases.

The choice to opt-in vs opting out not only effects who will receive benefits in the eligible  population but will have significant effects on the hospital industry.  The number of outpatient surgerie outweighs the number of inpatient surgeries.  Using the present fee for service reimbursement rates under FFS hospitals have been advantaged by higher reimbursement reflected by higher cost.  The loss of coverage for medicaid eligible patients not only places them in jeopardy, it also creates significant differences in the infrastructure necessary to deliver these services.

Outpatient services in states who have opted-in will need a business plan to expand capacity which includes not only physical plant, but skilled workers, such as surgical techs, surgeons, expendables as well as revising operating schedules, reducing turn-a-round times and the like.

DME suppliers will reap these benefits in opt-in states.

The figures represent the number of cases gained vs the loss of gain by opting out. The opt-out numbers are a speculation, and do not represent an actual decrease in cases.  The number of procedure in any case will not decrease in states that have opted-out.

Increased demand for services always encourages efficiency and technical breakthroughs, to decrease loses and encourage profitability, much as occured with small incison cataract surgery and the development of small incision surgery in cardiology,general surgery and orthopedic surgery.

While ‘futurists’ attempt to predict the effects of the new law, serendipity and the butterfly effect should be expected.

This article also appears in Health Train Express, February 22, 2014. http://healthtrain.blogpot.com

The author also publishes at Digital Health Space http://digitalhealthspace.blogspot.com

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The Sad State of HHS and CMS

Many ask, "Has HHS and CMS bitten off more than it could chew?"

The Failed Whale

Perhaps health.gov should have used the 'Fail Whale' icon for it's failed website. Those of you who were on twitter when it first began would see the 'fail whale' when twitter was overloaded. We don't see this very much anymore.....HHS has inherited the 'Moby Dick" of the Affordable Care Act.  Has anyone seen Ishmael ?

Medicaid & Medicare  Pharmacies Braced for Cuts to Their Medi-Cal Payments LawMakers Reach Deal on Doctor Payments Health Reform News  U.S. lawmakers reach accord on paying doctors for Medicare Los Angeles Times - February 7, 2014 Exchange Mum on Premium Payments California Healthline - February 6, 2014 Aetna Expects to Lose Money on Health-Law Marketplaces Wall Street Journal - February 7, 2014 Obamacare Thrives In San Francisco's Chinatown Kaiser Health News and NPR - February 7, 2014 An interesting evaluation of an ethnic community health plan Ex Microsoft Exec Brings Lists and Whiteboard to Overhaul Obama Website How he wound up with this job...His road to this job was a long one. It began in July -- about 12 weeks before the launch of healthcare.gov -- when Microsoft CEO Steve Ballmer announced a massive reorganization  (their loss, our gain).  DelBene’s process is collaborative and open, his colleagues say -- which is important in his new role. “You can see him evolve his positions as he gets more data. It’s not like he’s established his positions and [listening] is just a formality -- just Kabuki ritual theatre,” says U.S. Chief Technology Officer Todd Park. Todd Park, the U.S. chief technology officer, praises DelBene for listening and being open to new ideas (Photo by Karl Eisenhower/KHN). After finishing up his part of the presentation, he felt a “tingle” at the back of his throat, as though he was going to start coughing. He didn’t want to disturb anyone, so he headed for the door to the hallway -- or so he thought. “I started opening the door to the closet!” he recalls, and there was laughter all around.  “Oh! The new guy!” the president said. The Health Benefit Exchange is a product of how government works. DelBene would never have released a product from Microsoft without assurances it did not have many "bugs.  Perhaps part of our government should be 'privatized' and failures should be penalized........just as it is in the real world.  How long will voters and taxpayers tolerate incompetence while paying the bill ?

Ideologues and Unrealistic Expectations

Comments from Gary Levin MD are underlined and italicized:

Today I am amazed at an enthusiastic article about the Affordable Care Act by Eugene Robinson from Tallahassee.com.

His unbridled enthusiasm in the face of many difficulties that have nothing to do with health care exemplifies those who designed this law and passed it without reading it.

Here are some of his unsubtantiated claims and perhaps 'wishful thinking'

Eugene Robinson:  Washington Post

"Now that the fight over Obamacare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.

The fight is history, you realize. Done. Finito. Yesterday’s news.

Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the new year arrived. That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges. Obamacare is now a fait accompli; nobody is going to take this coverage away."

1. The fight is not history, we are barely through round one and all the points go to the opponents of the ACA.

2. Six million Americans have not received coverage from the ACA. Registering is only the first step. It took me over ten hours of fumbling on the web site, and on hold via telephone. How many will be able to pay premiums by deadlines, or negotiate the difficult process of acquiring a provider. 

"There may be more huffing, puffing and symbolic attempts at repeal by Republicans in Congress. There may be continued resistance and sabotage by Republican governors and GOP-controlled state legislatures. But the whole context has changed."

The upside of the ACA is that all previously uninsurable patients now are enrolled no matter what pre-existing condition they have A+++++.

Can the ACA be improved?  Most definitely. The argument should not be Republican against Democrat.  Political party does not immunize one against illness.

I wholly agree with Mr. Robinson's analysis regarding the eventual goal of a uniform health system.  To call it universal care is a misnomer.

"The real problem with the ACA, and let’s be honest, is that it doesn’t go far enough. The decision to work within the existing framework of private, for-profit insurance companies meant building a tremendously complicated new system that still doesn’t quite get the job done: Even if all the states were fully participating, only about 30 million of the 48 million uninsured would be covered.

Yes Obamacare does not go far enough, however that is not the principle flaw. There is no one principle flaw, if there are any that is the poor analysis  and proposed implementation of a major expenditure that will effect most businesses,  all patients, and our national budget, and come up short.  If we are intent, committed and dedicated to these goals then let's get it right (or mostly right the first time)

Obamacare does establish the principle that health care is a right, not a privilege — and that this is true not just for children, the elderly and the poor but for all Americans.

Throughout the nation’s history, it has taken long, hard work to win universal recognition of what we consider our basic rights

This is a political and philosophical statement, not about health care. We need to keep these issues separate.  I agree with him about the tenet that all people should have health care financing.

Our first step should be to put on hold further mandates while the act is re-evaluated. Repeal is not an option, however amendment is a reality and not an 'existential' argument.

Mr Robinson's  article is not objective, nor unbiased. He totally neglects the weaknesses of the law which will require amendments.  Placing the issue in terms of a 'battle' between political parties does disservice to dedicated professionals who have  been in the system,  and who were neglected during the planning process.

To ignored the flaws would be a fatal mistake, health care costs will soar and there will still be large gaps in the insured population

Contact Eugene Robinson ateugenerobinson@washpost.com.

Contact Gary Levin MD at gmlevinmd@digitalhealthspace.com

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.”

Rob Lamberts M.D. a DPC physician offers his experience and advice to other physicians

RT, a popular online Russian news source reports the same information

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.