Respite from the ACA

It’ Time for a new Hot Topic for the Media

The Ukraine and Vladimir Putin now will share the stage with Tax Reform.

Policy makers will shift from health reform to Tax Reform.  Media is already filling up column space with articles about the American  tax  system.

“To Tax the Community for the advantage of a class is not protection, it is plunder” -Benjamin Disraeli

“People who complain about taxes can be divided into two classes: men and women”-unknown

“The hardest thing in the world to understand is the income tax”-Albert Einstein,physicist

What comes next?  My best bet is reforming the tax code, and restructuring the IRS.  Not much will occur until President Obama is out of office. There have been many Congressional committees examining the code, that have made recommendations, including one by G.W.H.Bush that  quietly disappeared

The Healthcare portion of the GDP is said to be about 16-18%, prior to the ACA. In 12 months or at the calculation of GDP what will the healthcare GDP look like. Will it go up, stay the same, or decrease.?

The Federal and State tax portions of the GDP is It differs from state to state, however it hovers at about 15-16% of the GDP, an amazingly similar number as the Healthcare GDP. Tax reform following the affordable care act may be the perfect storm to reduce costs.

Any consideration of a repeal or major amendments to the code are overshadowed by pervasiveness of taxes, deductions, credits designed to stimulate business growth, and stimulate mortgages and home-ownership.  An entire industry feeds on the complexities of tax law.

“Income tax has made more liars out of the American people than golf” -Will Rogers, humorist

What's New in The News after ACA ? TAXES

It’ Time for a new Hot Topic for the Media

The Ukraine and Vladimir Putin now will share the stage with Tax Reform.

Policy makers will shift from health reform to Tax Reform.  Media is already filling up column space with articles about the American  tax  system.

“To Tax the Community for the advantage of a class is not protection, it is plunder” -Benjamin Disraeli

“People who complain about taxes can be divided into two classes: men and women”-unknown

“The hardest thing in the world to understand is the income tax”-Albert Einstein,physicist

What comes next?  My best bet is reforming the tax code, and restructuring the IRS.  Not much will occur until President Obama is out of office. There have been many Congressional committees examining the code, that have made recommendations, including one by G.W.H.Bush that  quietly disappeared

The Healthcare portion of the GDP is said to be about 16-18%, prior to the ACA. In 12 months or at the calculation of GDP what will the healthcare GDP look like. Will it go up, stay the same, or decrease.?

The Federal and State tax portions of the GDP is It differs from state to state, however it hovers at about 15-16% of the GDP, an amazingly similar number as the Healthcare GDP. Tax reform following the affordable care act may be the perfect storm to reduce costs.

Any consideration of a repeal or major amendments to the code are overshadowed by pervasiveness of taxes, deductions, credits designed to stimulate business growth, and stimulate mortgages and home-ownership.  An entire industry feeds on the complexities of tax law.

“Income tax has made more liars out of the American people than golf” -Will Rogers, humorist

HEALTH LEADERS MEDIA

HealthLeadersMedia is a less known publication to physicians. The April print edition arrived on my desk, Monday.  The cover story is titled, “Physicians at the Crossroads”

Doctors face critical decisions that will affect their future role in healthcare delivery,especially when it comes to developing care and payment models.  What remains critical is the continuing engagement of clinicians in the process, which has become more difficult with increasing regulations, incentives and penalties driving change for the sake of change rather than applying proven models for increasing quality of care.

What people have underestimated is the complexitiy of workflow in healthcare in general and particularly in outpatient and primary care. The patient flow and variability of work require extreme flexibility for an outpatient clinic. This frankly is not assembly line production. Assembly line production is very modlable; you can calculate changes. The workflow that comes into doctor’s offies is a lot more complicated.

As health care administration has become more complex, more physicians seek and gain hospital or integrated health system employment.  Hospitals and providers alike now recognize that employment does not guarrantee effective integrated care, nor coordinated care.  Typically each hospital environment has had it’s own medical-politic of referrral relationships and services to it’s community.  This is often based upon decades of community involvement, and development.  This trend colors the new relationship between providers and inpatient facilities.

Integrated health systems, although growing. develop a silo mentality and are competitive, some times in the same or surrounding location.  While they are individual business and medical entities, the Health Information Exchange serves to bind them together overcoming regional competitive issues. At the same time the HIX also serves to strengthen the internal workings of the integrated health system.

THE MEDICARE DUMP

No I don’t mean the claims that are denied or returned due to an error in a code, ,or a mismatched diagnosis and procedure code…

The dump of which I speak is the release of 2012 CMS payments to individual providers according to CPT  code.

The reactions are as predicted, whether true or false,

CMA-“MDs upset by Medicare’s release of payments”

U.S. CTO Todd Park puts it an “unprecedented” opportunity for transparency. But what will researchers--and ultimately seniors and taxpayers--be able to actually learn from it?

Consumer’s Watchdog- “Doctors fighting physician accountability to Public get paid millions by Public via Medicare: Most dangerous docs lead pack

And down to the ridiculous from MDigital Life- “Doctors who tweet aren’t ones who bill Medicare for millions”.

In case you had not heard HHS Secretary Kathleen Sebelius resigned. Her parting words were; “ And I thought being a Governor was tough Try being an administrator”. Sebelius served as the sounding board and magnet for opposition even before the health benefit exchange suffered it’s startup meltdown.

Can Doctors speak their minds without getting into trouble?

Will the new Secretary of HHS, Sylvia Matthews Burwell, the President’s pick to head HHS be able to carry out the implementation of the ACA, in the face of intense opposition which continues as when the ACA was first passed.

Health Train Express opines that the release of this data is good, very good for providers, especially those in the top 5% of payments. Further information may reveal high costs for drugs, and  equipment for specialty practices such as neurosurgery, ophthalmology, cardiology, radiology and others.  Contrary to many opinions someone making a lot of money is not necessarily a felon, greedy, or lumped in with terrorists or pediophiles.  Chances are Obama will use this information to ‘spread the wealth’ by decreasing payments to the most productive MDs and give it to those most deserving...and needed...pediatricians, psychiatrists and some primary care providers.

Patients (taxpayers) now will be informed where their tax money goes, besides defense, and other branches of the government. Ir might even turn out to one-up-manship. (My doctor makes more money than yours, so he must be better)

As most charts and tables that are published there is much to be seen in the footnotes, which this document does not include.  

It gives me a warm feeling to know that we are supporting more algos to analyze this ‘BIG  DATA”

Whatever happened to that Federal law designed to reduce paper?

Proponents of an initiative seeking more public accountability for California physicians said the federal government's posting online of Medicare payments to specific physicians puts California Medical Association leaders in an uncomfortable position.

And finally--In other news John Lynn asks, “Are you optimistic or pessimistic about healthcare?”

Answer- “About the same as for the general state of America”

#medicare #health #healhcare #data #hhs #sebelius #cmsdata

What MDs should know about Security on the Internet and using the cloud for your EHR

Heartbleed 'top of food chain' forhealth care industry, says CISO Although providers are not information technology experts, it is essential that they understand some aspects of security on the internet. We already know it is a complex process involving multple layers of privacy beginning with passwords, and encryption. In additon to these layers the operating systems for the internet include built in safe guards. When it comes to security threat severity, the Heartbleed bug doesn't miss a beat. That's according to Phil Lerner, chief information security officer at Beth Israel Deaconess Medical Center, who, on a scale from 1 to 10, ranks the bug a solid "high priority" at 7.5. For those of you familiar with the recent discovery of the bug named Heartbeat you know that this affects a major component of web site security allowing unauthorized intrustion into an otherwise secure system.  SSL is the eponym for secure socket layer, which appears in  your internet setting of your browser. It affects all browser.  A patch has been released which is supposed to cure the problem.  The ‘bug’ was in the wild for several weeks before it was discovered. This particular version of SSL is ‘open source’, which means the computer code is open and readily available. Open source is used in many programs for developers to use, as opposed to proprietary source codes such as used by Microsoft, Apple and many others.  Google uses open source in Android and their Chrome browser. Website owners can find if the bug is present on their system. Estimates are that 2/3rds of web sites are effected. The idea of using an open source seems anathema to developing a secure socket layer. However, the internet is designed to be an open network of which SSL is a basic commodity. Proprietary  SSLs would create more isolation of diverse providers and web sites. The original SSL was developed in the late 1990s by a non-profit concern that contracted with the U.S. Government. I plays an essential role for management of domain names such as .com .net and .org.  Many new domains have been issued in the last several years--.med .fr .za .bus .tv and others.  The organization that issues domain names is currently based in California, (ICANN) Internet Commission Assigning Names and Numbers.  The organization was set up as an international non-governmental organization and allow for an agency completely free from government interference.   Many potential changes are forseen, among them the U.S. withdrawing from ICANN.  ICANN will be assigned the task of evaluating and making policy for domain names, and then handing it off to anothe agency to manage the technical aspects.

Medicare-Provider Payment Information

In the past it has been illegal for physicians to collude by comparing their fees in an effort to set fees.

CMS however has unique powers to reveal physician fees and has done so to the general public this week.  Will this be a net positive or negative? How will patients put this info into proper perspective?

Some possible uses for Medicare fee disclosures:

1. Spotting fraud and abuse

2. Educating the public

3. Providing some misleading information

4. Creating fodder for quality ratings.

5. Directing patients to low cost procedures

6. Providing leverage to group physicians

What do you think about this?  

CMS on April 9 did release several very large  spreadsheets reimbursment with the details driling down to each physician.  

The numbers require some analysis, as to demographics, and regions

MEDICARE HAS RELEASED YOUR INCOME FIGURES TO THE PUBLIC

By now most providers know that CMS has released numbers to the general public that were once privileged.  This is a major change in the policy of the past 4 decades.

For me this is equivalent to posting an annual IRS tax return for individual providers. Is this a civil rights violation, or a violation of privacy ? When I submitted my Medicare Enrollment Application I do not remember hearing or reading any small print stating that my medicare reimbursement figures would be made public.  Certainly the figures could have been masked with an identification code.

Is this a form of ‘crowdsourcing” ? Throw out the data and have readers compare notes to find previously hidden patterns to root out fraud and abuse?

When publishing this data CMS should have included several caveats when interpreting this information.  Although those in  health care know that these figures do not reflect operating expenses, or capital outlay.. Regional differences also play a role in big cities, rural areas, regional deficits in provider availabiltiy.  Some areas may have only one cardiologist and others may five cardiologists.  The figures did not distinguish age groups, a serious deficit in trying to interpret what the numbers mean. It also does not take into consideration areas of excellence whereby patients seek out experts in cancer, cardiology, neurosurgery, or referrals to such experts, at Universities.

Medicare equates this with the ongoing increased access to provider rankings and help in choosing a doctor.

Knowledgable experts and authorities have always had access to these important numberes for planning and reducing fraud and abuse.

NPR reported this story and adequately explained the caveats and pitfall with this change.

Reports indicate further reports will be announced, in regard to pharmaceutical use, payments to providers from pharma, durable medical equipment, entertainment lunches during lunch or evening CME activities.

Let’s equalize this process and disclose CMS reimbursements to the thousands of hospitals who receive CMS reimbursements.

It seems providers are the target for reform. If I were a paranoid person I might think this is designed to intimidate providers.  There are already effective means for CMS and insurers to analyze what doctors do and are paid.

C.A.R.E. The Republican Alternative to Obmacare

One of the key criticisms of  Republicans by Democrats and others is a lack of a concrete plan as an alternative to ObamaCare.  The Republicans say they were shut out of meaningful negotiations and discussions about the Affordable Care Act.  This is  hard to believe since Republicans were part of the legislative process, investigating and listening to experts in heath care prior to making informed decisions.  Discussions broke down between opposing parties.  Each side needed to take responsibility and cease the heated rhetoric for the benefit of the American people.

Citizens are rightly fed up with  Congress’s lack of cooperative legislation not only in health care, but in many other areas of legislation. Congress overall has a large disapproval rating by Americans.

Now, after the initial enrollment period has brought a measure of progress Republicans are offering generic improvements to the law;

Republican opponents of the reform law continue to propose alternative solutions to the ACA. For example, The Patient Choice, Affordability, Responsibility, and Empowerment Act (CARE) would revoke the ACA's individual and employer mandates, cancel Medicaid expansion, lower tax credits for buying insurance, and eliminate ACA-related taxes and fees.

''Just talking about repeal is not going to make it with 7 million people getting insurance on the exchange. And it has to be something reasonably credible ... it can't just be repealed. We are beyond that," economist Gail Wilensky, who ran Medicare under President George H.W. Bush, told the AP.

Affordability remains a major issue leading into next year. Insurers must determine the characteristics of new members to set 2015 rates, FierceHealthPayer previously reported. The economic risk insurers made when the law was created remains unknown. If insurers were conservative right from the start, that would take some pressure off next year's premiums, notes the AP.

So far, the average premium increase is 11 percent in the small group market and 12 percent in the individual market, according to a survey of brokers who sell coverage in the individual and small group market, reports Forbes.

Four main factors are driving the rate increases, including commercial underwriting restrictions; the age bands that don't allow insurers to vary premiums between young and old beneficiaries based on the actual costs of providing the coverage; new taxes on insurance plans; and new benefit designs, notes Forbes.

Another affordability concern deals with the cost of deductibles and copayments consumers must pay when they use their insurance benefits. Insurers should be allowed to sell high-deductible plans on all health insurance exchanges, says America's Health Insurance Plans President and CEO Karen Ignagni. To keep premiums low, many plans have high out-of-pocket costs.

One thing for sure, the ACA is a goal in progress.  

HEALTH CARE SPENDING: THE FLATTENING OF THE CURVE IS REVERSED

Health Care Finance Administrators for the past several years have reported that health care spending had leveled off.  During the fourth quarter of last year health care spending rose 5.6% reported by the Bureau of Economic Analysis last week.

The jump triggered a sharp upward revision in the government’s estimate of consumer spending overall and accounted for nearly a  quarter of the economy’s 2.6% annualizd growth in the last three months of 2013.

Despite the number of inpatient days dipping 1% during the fourth quarter hospital revenues increased 8 billion  (more than all the previous four quarters, combined). The dip in admissions mah be during this last period as the unemployed were without health insurance and/or limited their spending during the recession and sluggish recovery.

The 2010 Affordable Care Act incentivized hospitals to become more efficient by decreasing readmissions, and shifting costs to patients through high-deductible plans and other measures, encouraging Americans to limit visits to doctors and hospitals.

For the time being those trends may be levelling off, however there are long term upward pressures on health care costs, such as the growth of expensive high tech treatments  re-emerging.  Many uninsured Americans delayed health care treatment until the Affordable Care Act was passed.  This demographic has bottled up demand and a pool of ‘disease’ awaiting treatment that will be treated in the next several years, which will inflate health care spending. It is very likely we will see a significant increase in health care spending as the result of the ACA. Although some new organizational changes have been designed to limit increases in health spending, the proposed and hoped for results are in doubt.

Insurers now are faced with setting rates for 2015.  The time period is very short with less than 4-6 months remaining until 2015 rates are set.  Insurers (Wellpoint) predict double digit increases in rates. The rates may be different in accordance with different rates of enrollment in each state.

In the next several years the acceptance of the ACA will hinge on consumer satisfaction, and true affordability in the daily budget of family finance. The statistical outline for subsidies may be ‘fantasy”. Premium rates may change, increasing in some states and decreasing in others. If there are large increases some Americans could be once again priced out of the marketplace. Fluctuations in personal income will shift subsidy amounts, from year to year.  Some may even involuntarily be penalized if their premium policy is too much.  The new mantra may be “Do I feed my family or be penalized by the ACA”.

While some what unclear is an IRS statement that penalties will be taken from a tax refund, and if the taxpayer has no refund they will not pay a penalty. And according to the way the wind is blowing politically the White House may make changes accordingly.  

Although some Democrats are waxing enthusiastic about the ‘numbers’ the ultimate success of the ACA is still open to question.  Only 26% of Americans give the ACA a favorable rating.  

C.A.R.E. A PROPOSED ALTERNATIVE SOLUTION TO THE ACA

One of the key criticisms of  Republicans by Democrats and others is a lack of a concrete plan as an alternative to ObamaCare.  The Republicans say they were shut out of meaningful negotiations and discussions about the Affordable Care Act.  This is  hard to believe since Republicans were part of the legislative process, investigating and listening to experts in heath care prior to making informed decisions.  Discussions broke down between opposing parties.  Each side needed to take responsibility and cease the heated rhetoric for the benefit of the American people.

Citizens are rightly fed up with  Congress’s lack of cooperative legislation not only in health care, but in many other areas of legislation. Congress overall has a large disapproval rating by Americans.

Now, after the initial enrollment period has brought a measure of progress Republicans are offering generic improvements to the law;

Republican opponents of the reform law continue to propose alternative solutions to the ACA. For example, The Patient Choice, Affordability, Responsibility, and Empowerment Act (CARE) would revoke the ACA's individual and employer mandates, cancel Medicaid expansion, lower tax credits for buying insurance, and eliminate ACA-related taxes and fees.

''Just talking about repeal is not going to make it with 7 million people getting insurance on the exchange. And it has to be something reasonably credible ... it can't just be repeal. We are beyond that," economist Gail Wilensky, who ran Medicare under President George H.W. Bush, told the AP.

Affordability remains a major issue leading into next year. Insurers must determine the characteristics of new members to set 2015 rates, FierceHealthPayer previously reported. The economic risk insurers made when the law was created remains unknown. If insurers were conservative right from the start, that would take some pressure off next year's premiums, notes the AP.

So far, the average premium increase is 11 percent in the small group market and 12 percent in the individual market, according to a survey of brokers who sell coverage in the individual and small group market, reports Forbes.

Four main factors are driving the rate increases, including commercial underwriting restrictions; the age bands that don't allow insurers to vary premiums between young and old beneficiaries based on the actual costs of providing the coverage; new taxes on insurance plans; and new benefit designs, notes Forbes.

Another affordability concern deals with the cost of deductibles and copayments consumers must pay when they use their insurance benefits. Insurers should be allowed to sell high-deductible plans on all health insurance exchanges, says America's Health Insurance Plans President and CEO Karen Ignagni. To keep premiums low, many plans have high out-of-pocket costs.

PHYSICIAN-ADMINISTRATOR TENSION

The Affordable Care Act and development of Accountable Care Organizations increases the critical need for improving communications between physicians, clinic administrators, and hospital CEOs.

A tension has always been present between clinicians and bureaucrats.  When  you consider the physician mind-set is one of decision making autonomy, and dealing with new events. The concepts are not always congruent with the mind-set of the practice administrator.  In the operating room the surgeon is always thought to be ‘captain of the ship ‘.  The administrator is trained to focus on the complexity of coordinating multiple practice issues inside the office, or the hospital.  This coordination requires a set of skills not taught in undergraduate medical school curriculum.

MDs who desire non clinical responsibilities usually obtain a business degree such as an M.B.A. or M.P.H.  Some develop these skills on the job.

In the new environment of the ACO and ACA, he is just one of the key players. For some MDs this is anathema to  prior education and experience, especially for those who have been practicing for twenty years or more.  New graduates and young clinician are trained with the new paradigm and hierarchy in mind.

Add to this the necessity for change management in reimbursement, quality of outcomes and management of new reporting requirements the stage is set for increasing interaction between  clinician leaders and ‘management’. Without everyone’s cooperation in the practice change results can be compromised.

The principal characters (physicians) belong in several groups .

1. The champions for change who see the goals as beneficial.

2. Those who are neutral to changes, will ignore them and go on about their clinical work

without much thought to change, except to adapt quickly so they can continue their

clinical work with minimal disruption.

3. The saboteurs who will go beyond passivity or ‘foot dragging’ to slow down, delay, or

reverse the change.

In the recent past this third group would accomodate themselves by leaving an institution that was not compliant with their own preferred practice pattern. They would move to private practice either solo or in a group more compatible with their desires.   These opportunities have diminished drastically by the corporatization and more bureaucracy and support structures that are thought to be more efficient . The group mindset prevails since the financial rewards are mandated by the group and ‘political’ pressure on the individual clinician.  In the past clinicians might even leave their community to a region where patterns are different.  Today this is less possible because there are  fewer small practices and physiciains becoming employed to deal with the Affordable Care Act and overwhelming bureaucracy and regulatory functions.