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.

WELCOME TO OBAMACARE

Personally I do not like the term “ObamaCare being used in place of the Affordable Care Act. President Obama’s  name creates an immediate political and sociologic issue for many Americans.  Some may notice I often title my posts “ObamaCare”  Why ? My rational has been  “Obamacare” has a very high rank on search engines, such as Google, Yahoo, or Bing. It makes it easy to find “Health Train Express”.

Even the title of the law is deceptive. It is not affordable, either for patients, employers, or the taxpayer. The subsidy is a hidden tax, and the Supreme Court of the U.S.  recognized this when it determined the issue was not a constitutional conflict. John Robertson, the Chief Justice in his statement stated this in his decision.  It is not designed to ‘care’ for Americans. Caring is an individual matter, and the broad sweeping broad law is an attempt to address many divergent problems such as abortion.   The complexities of health and life are an individual challenge financially. Some Americans use lots of medical care in short mild illnesses and some have catastrophic illness with only one or a few very expensive encounters.

The ACA is inadequate because of short term thinking and a need for a quick “political’ fix.

During the past several months we have been focused on the ‘negative’ about the Affordable Care Act.  The number of articles and discussions criticizing Obamacare are overwhelmingly opposed to the law. Some are written by Democrats but most are written by Republicans. It has nothing to do with the content, nor goals of the law, but is now a purely political tension. Ultimately this problem is the upcoming mid-term election and the eventual Presidential Election in 2016.

In our already complex health system the Affordable Care Act adds further confusion, and bureaucracy and expense. The goal of decreasing health care expense is far outweighed by the added layer of HIT and new agencies designed to control use by limiting benefits and preventing access by high co-pays and deductibles.  The Act flies in the face of it’s stated goals of prevention and early care of potentially serious conditions.

Who was it that said “Nothing Good Comes from …….?  The same can be said to sum up my opinions about a mixture of health and politics.

Backlash already appeared as Hillary Clinton cancelled her planned appearance as the headline speaker at next week’s Western Health Leadership Academy in San Diego due to planned protests over her failed leadership involvement in the Benghazi attacks.  Ironically President Obama was denied coverage by all 3 major networks refusing to grant him airtime for a ‘victory lap’ to announce that Obamacare had reached 7.1 million enrollees.