The Physician's Plight Some doctors back away from Obamacare

In the Press Enterprise

BY LAURIE UDESKY  CHCF Center for Health Reporting  December 20, 2013; 

The Affordable Care Act has placed most physicians in a state of conflict. I don't know any physicians who would not want all their patients to have good health and wellness.  Wellness is always a less expensive alternative and pursuing it adds to the quality of life immediately.

While the Affordable Care Act has these components as part of the basic standard many physicians cannot participate in the roster of providers who will accept patients in Covered California, the state exchange.

Surveying other exchanges may reveal the same situation repeated 50 times.  Much of it depends upon the rates for reimbursement set by insurers, and is individualized by each insurer.

The California Health Care Foundation did a survey of physicians in California and found that 70-80% of physicians who studied the reimbursement plans,  (about 70% of the Medicare rates) decided to not participate in Covered California (the Health Benefit Exchange run by the state. 

Medicare rates have already been decreased almost 50% since 1988.  This in spite of inflation and skyrocketing administrative costs for providers due to increased regulatory requirements in order to be an eligible provider for CMS.

Dr. Steven Larson, the CEO of the Riverside Medical Clinic (140 providers), said he was taken aback when he saw what insurance companies were willing to pay. “The rates were 70 percent of Medicare [reimbursement]. It doesn’t leave room for making a living,” he said. “It’s potentially a huge problem,” said Larson, who also is the chairman of the California Medical Association Board of Trustees.

The clinics serve 300,000 patients under a variety of plans, including many Medicare patients who are not affected by the new exchanges. But the patients who want their care covered under a health exchange plan will now to have to look elsewhere for a doctor.

 In some cases they are trying to decide whether to join. In other cases they are finding that they have been dropped from plans. And many are just trying to get information about whether they are listed in an exchange plan or not.

Covered California maintains that the plans offered through the exchanges include 80 percent of the state’s physicians. “We arrived at the 80 percent by comparing our network to the two largest commercial networks,” said Covered California spokeswoman Anne Gonzales.  This reveals the lack of expertise and knowledge that state health agencies have about health care in the market place. A recent survey of California Physicians showed that 70-80% would not participate.

About a year ago numerous insurers (or Covered California ) sent out letters of intent asking providers if they would participate in the exchanges.  At that time there were no  speciffics as to reimbursement or other provisions, which are left to the insurers as long as their policies conformed to the ACA benefits.

This amounted to asking providers to sign a 'blank check'.

Recent analysis of insurer directories reveal they are inaccurate for many reasons. The directories are prepared annually with many months of lead time. California Medical Association President Dr. Richard Thorp. “Many times when we look at their physician directories, they include names of people who have moved out of state, are retired or dead. ”Some physicians have even  been listed in the exchange after they refused to participate because of the low reimbursement rates.
The challenges to participate in Covered California are as great for providers as it is for patients.

The scenario is unbelievable, except that it is fact.

Health Train Express reviewed California Health Care Foundation statements as well as the California Medical Association. The following are some of the examples:

Insurers are required to notify doctors if they’re included, according to Lisa Folberg, vice president of medical and regulatory policy for the California Medical Association.

That hasn’t always happened in Riverside, according to the executive director of the Riverside Medical Society. “Basically doctors don’t know if they’re in or out of the network,” she said. The society has told doctors to call the plans directly.

If the present situation is confusing, unfortunately the future, despite the government's intention to organize health reform, looks even more grim.  Insurance c ontracts are usually an annual renewal. At any time after the first year and later as the system matures it will be in the purvey of these "guardians of Covered California' to alter the rates.  Debt ceilings, national catastrophe, conflicts will all effect health.

The current GDP incorporates the sixteen percent due to health enterprise.  The ACA has added more levels and administration to an already bloated health system.

ObamaCare: We Did Not Know What was In It Until It Passed

It did pass, and we still don't know what  is in it.  Each day we learn of waivers, modifications, amendments to 'fix' fatal flaws in the law.  This is the simple part.....getting people to sign on for health coverage....the doorway to health and wellness.

Dates have been set, mandates have been put on hold, insurance policies were cancelled, no wait..Obama says "Kings X", I take that back. Sebelius smiles and goes before congress, non-plussed.  She must be close to retirement so no problem and undoubtedly she will be through with her public service.  I wonder if she has health coverage?

Many of us have tried to take the high road and plan health reform logically analyzing each step as we proceed.  This is almost a futile endeavour, because the landscape is constantly changing.




Secretary of Health and Human Services Kathleen Sebelius testifies at a Congressional panel last week. The White House has outlined a new exemption under the Affordable Care Act

n a last-minute policy change, the Obama administration waived the so-called individual mandate under the Affordable Care Act for people whose individual health insurance policy is being canceled.

The act requires most Americans to have qualified health insurance starting in 2014 or pay a tax penalty, unless they meet one of myriad exemptions. One is if qualifying coverage would cost more than 8 percent of household income (the affordability exemption). Another is they can prove a hardship such as homelessness, bankruptcy, domestic violence, large medical debts, utility shutoff notice or death in the family.

Under new guidance issued late Thursday, the Centers for Medicare and Medicaid Services (CMS) said that having an individual insurance policy canceled now qualifies for the hardship exemption.

The process is not really that simple:

People who qualify for the cancellation hardship exemption have two options:

-- Don't buy coverage and don't pay a fine.

-- Buy a bare-bones catastrophic policy on an exchange. These catastrophic policies do not meet the requirements of the Affordable Care Act, but people who buy them won't owe a fine. Before Thursday's rule change, to buy this policy a person had to be younger than 30 or meet the affordability exemption.

To qualify for the new policy-cancellation exemption, consumers must complete a hardship application, which will let them purchase a catastrophic plan or receive a penalty waiver, according to Centers for Medicare and Medicaid Services. (For the application, see http://1.usa.gov/19YrBnK.)

To purchase the catastrophic policy, they must submit the form, and evidence of a canceled policy, to a company selling such policies in their area.

The announcement came just days before the Monday deadline for enrolling in coverage to start Jan. 1, and insurance companies are not happy.

When Obama announced another policy reversal in November - saying insurance companies could temporarily renew certain policies that were to be canceled because they did not comply with the act - he gave states the option of allowing that or not.

Covered California did not. As a result, most individual health policies in California that are not grandfathered will be canceled Dec. 31.

Some customers of Anthem Blue Cross and Blue Shield of California will be able to keep their non compliant policies until the end of February or March, respectively, under a settlement with the state insurance commissioner.

People with individual plans that are grandfathered, meaning they had them before the act was signed in March 2010, may keep them until the insurance company decides to cancel them.

It appears that nothing is guaranteed as to the roll out. Insurers, providers, hospitals are all nervously watching and waiting. 

The New Public Health Advertising and Social Media

This post today does not reflect approval or disapproval of the Affordable Care Act.   It does point out the means to which the administration has gone to "sell ObamaCare" to the public by riding on the coattails of famous people.


Celebrities and Public Health.

Whether your  favorite celebrity knows anything about health may be open to question.

However given the visibility of celebs such as Angelina Jolie and the topic of breast cancer; or  type II diabetes (such as Tom Hanks) many want to contribute their celebrity either due to a personal involvement with the disease or for charitable purposes.

Somewhat open to question are those who endorse a specific treatment,rather than elevating the public awareness of the disease or treatments.

Celebrities can use their enormous stage presence and visibility to the general public far more than millions of dollars spent by government in public health advertising or announcements.

Who does not know more about HIV and AIDS due to the Bill and Melinda Gates Foundation, or Michael J. Fox and Parkinsonism.



The list goes on.

Actress Angelina Jolie explained her decision to undergo a prophylactic double mastectomy to significantly reduce her risk of inherited breast cancer,

      The effects of the so-called "Angelina Jolie effect" even have reached across the pond, where breast cancer charities have reported a four-fold surge in women asking about having their breasts removed since Jolie announced she'd had the procedure, according to Daily Mail. And the number of calls Cancer Research UK's helpline received about a family history of breast cancer increased from 13 in April to 88 in May, the article noted. In response to Jolie's breast cancer media bombshell, doctors acknowledged not all women need genetic testing but all women should discuss it with their doctors, FierceHealthcare previously reported.

Kim Kardashian brought to light the importance of privacy and confidentiality in the health space and protected information by HIPAA.Some hospital employees in Los Angeles may have gone too far in their quest to "Keep Up with the Kardashians" and now have to face the consequences.

Five workers and a student research assistant at Cedars-Sinai Medical Center (Calif.) were fired over privacy breaches involving patient medical records--and there is speculation that the patient was Kardashian, who gave birth to her daughter with rapper Kanye West in a birthing suite at the hospital on June 15, the Los Angeles Times reports. This event publicized HIPAA rules for the public and providers.

News correspondent Amy Robach announced that she has breast cancer and would undergo a double mastectomy--after reluctantly agreeing to have a mammogram live on-air for Good Morning America. Had she followed the United States Preventive Services Task Force 2009 guidelines for screening, it's likely she wouldn't have undergone her first mammogram until a decade later. Robach is just 40 years old and has little history of breast cancer. This brought to life the controversy of statistical evidence for screening for many diseases.

     Obama's camp took to popular comedy site Funny or Die to get the word out about the Affordable Care Act, with skits featuring Jennifer Hudson, Amy Poehler and Olivia Wilde.  Parodying TV's Scandal, Jennifer Hudson plays a "fixer" who offers up the simple (well, it should be simple) solution of signing up for coverage on Healthcare.gov to clients presenting their problems.

     The first lady stepped into the public health spotlight with her "Let's Move" campaign, encouraging schoolchildren to eat healthier foods and exercise daily--she even enlisted Sesame Street characters Elmo and Rosita to help her promote eating fruits and vegetables during an official press conference

    In fact the Obama campaign used many celebs to raise awareness of Health.gov the national website to enroll in the Affordable Care Act. As health care professionals we should not take for granted our knowledge base as compared to the public.  The Obama effort has some very funny videos that made even me laugh, and the ACA is no laughing matter.

Katherine Zeta-Jones revealed she had bipolar disorder back in 2011, shortly after husband Michael Douglas was diagnosed with stage 4 cancer. Zeta Jones commented on her struggle with bipolar ll (which is less severe than bipolar l), in 2011,

And then there have been comments from people such as Jenny McCarthy.  McCarthy told Oprah Winfrey she "graduated from the University of Google," to come to this idea, but she's been spreading her view that vaccinating young children for diseases like mumps results in autism in books, newspapers and on TV--much to the dismay of doctors, scientists, researchers and other celebrities.

No matter what popular culture is influenced by the media for better or worse.

The United States of Affordable Care (Act)

Health Care Financing would seem to be a long way off from the patient waiting to see their physician.

In today's world the quantitiy and qualitiy of care depends very much upon the type of health insurance the patient has to use.   The care may be far different according to region, or state.

The term 'public health ' is a misnomer. The public health system is not accessible to all people for a number of reasons.  Many perceive public health as inferior to the 'private system of health care", and only would access a center if there were no other option. Many current users of public health and/or Federally Qualified Health Centers would not even know how to access ' private care'. Learn more about them here and here and  here.  I particularly like the last one. No one home --

The resource cannot be found.

If you are successful, the rules are as long as the Affordable Care Act.

A new term which may be unfamiliar to most providers and/or patients is the "Federally Qualified Health  Centers".  These centers are found more commonly in areas of low economic assets and amongst many people who fall in the range of the Federal Poverly Level (FPL).  And here are the numbers which are both unrealistic at the lower end and even more unbelievable at the top end.

• $11,490 to $45,960 for individuals
• $15,510 to $62,040 for a family of 2
• $19,530 to $78,120 for a family of 3
• $23,550 to $94,200 for a family of 4
• $27,570 to $110,280 for a family of 5
• $31,590 to $126,360 for a family of 6
• $35,610 to $142,440 for a family of 7
• $39,630 to $158,520 for a family of 8

We seem to be an impoverished nation in the world of developed countries.

Many of these centers predominantly serve 'medicaid' beneficiaries. They also serve ( unintentionally) to isolate medicaid and those who are receivng public assistance from the main stream of health care.  Hospitals and providers also treat these patients differently, not so much in terms of the quality of care they receive....rather the accessibility.  Many budgetary decisions by states often effect Medicaid patients first, because large portions of state budgets are allocated to Medicaid.

There is a non-admitted  'caste' system when it comes to medical care.  It largely is secondary to income and location, and in cities there is often a sharp divide between those living in upper middle class neighborhoods and lower class neighborhoods.

The situation is also becoming worse, and there is no sign the Affordable  Care Act will diminish the divide.
Although the ACA specifies preventive medical care  (for free)  Despite being "free", there will be a cost. There are 14 general categories,   22 special categories for women, and 25 categories for children.

A disturbing distinction between public health and private health financing is also more evident with the introduction of health information technology. In order to qualify for Grants for Information systems and operational financing a non-profit status is a requirement, which immediately rules out most entrepenurial systems (ie, private fee for service office and/or clinics, as well as some hospitals.

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.

NIH Leader Calls for Evidence on mHealth

Only about 20 randomized clinical trials involving mHealth tools or services have been conducted in the United States since 2008 under the auspices of the National Institutes for Health. And more than half of them have failed to document clear evidence of improved outcomes.

 Francis Collins, MD, the NIH's director, delivered the message to attendess at the 2012 mHealth Summit in his closing keynote on Dec. 5. Collins pointed out that the lack of trial-based evidence is hindering acceptance of the technology by a healthcare industry that could really use these tools.

Dr. Collins also noted that controlled trials often are diffiicult to design in the real world by saying,

"The mHealth field is evolving so rapidly that oftentimes the technology used in trials is outdated by the time the trials are completed. For that reason, he said, the scientific and healthcare communities have to work together to fine-tune the process, producing viable results in a timely manner.

The alternative? Forge ahead with mHealth without evidence that mHealth is improving healthcare."

This viewpoint may be highly biased as to the cohort and demographics of such a study.  Presently there are thousands of mobile apps in development, most stimulated by public perception and enthusiasm from the HIT community. The feeding frenzy for profit is dynamic with the federal stimulus packages.

Many vendors in mHealth would argue differently. Hopefully some of them will comment here.

[See also: New bill would create FDA mHealth office.]

Health Reform: A Play in Multiple Acts

It is a very exciting and troubling time  for health care in the United States.  The stage is set for multiple acts occurring simultaneously.

For those who have boots on the ground with financial commitments and assets the changing landscape means unknown profits (if any) or losses.  Health institutions and providers charged with improved outcomes and 'less cost' are facing the conundrum of supplying more care with less money.

Leonard Zwelling M.D., a Houston physician who was a congressional staffer during the writing of the affordable care act puts it this way, as he discusses a statement made by

Norman Ornstein, a scholar at the American Enterprise Institute, one of the leading experts on the workings of Congress, summed it up in one sentence during a briefing for the press and politicos in November 2008. He said:

"Every one's idea of health care reform is the same: I pay less."

Where I was trying to get my head around a solution to the three tenets of my idea of health care reform, everyone around me was trying to preserve or increase his piece of the health care payoff pie. I was looking for a legislative solution to assist the country in arriving at the place where the rest of the civilized world was - the provision of some form of universal health care as a right of citizenship. Everyone else was looking to cut a deal that preserved his place at the trough of health care profiteering. Guess who won?

With the full cooperation of the Congress and the White House, health care was not even remotely reformed. The Affordable Care Act is not about health care reform. It is about money, particularly preserving the insurance industry's hold over how health care dollars are spent.

Hospitals and providers had little to do with the Affordable Care Act.

"The Affordable Care Act continued to allow hospitals to jack up prices with no relation to actual costs. Only the doctors gave up something because, unlike the insurance industry and the pharmaceutical industry, medicine did not speak with one voice when lobbying on Capitol Hill and thus could largely be ignored. This is health care reform? I don't think so.

The reason the Affordable Care Act did what it did is because that's what it aimed to do - increase access to insurance for the uninsured, get everyone else to pay for it, and make sure no one currently in the health care business loses a dollar from the amounts they are already extracting from patients and doctors alike.

Complicating Ornstein's comments are the multiple scenes ongoing in the 'reform' efforts

Technological advancements such as

Health information technology which includes electronic health records, health information exchanges, the proposed upgrading of the ICD - 9 to ICD -10, the advances in mobile health, telemedicine and more.......

The increased regulatory arm with meaningful use in 3 steps.  MU is linked with financial  incentives from CMS to offset the expense of providers and hospital acquisition of electronic medical records.

The challenging role of an unproven health benefit exchange system, with an incomplete back end disconnecting the actual payment to insurers.





The details of connecting the dots are only now coming into focus for bureaucrats and congress who badly underestimated the complexity of health care delivery.  The turmoil is clearly more evident among providers, hospitals and the patients who are the "guinea pigs"

During the next 12 to 24 months the 'symphony" will unfold.  Will it be harmonious or an unfinished symphony?