Tag Archives: healthcare reform

“Veritas”, Ivy and the Affordable Care Act: What’s Good for the Goose May Now NOT be Good for the Gander at Harvard

Prominent academics within the prestigious Harvard University department of Economics have long been vocal supporters of President Obama and his Affordable Care Act legislation.  In fact, many Harvard professors helped develop some of the concepts that were utilized in the drafting of the ACA.  During the debates over the ACA in Congress, these professors were frequently seen (and heard) touting the legislation as a fiscally responsible way to provide affordable care to all Americans.  The current Provost, Dr Alan Garber,  (not to be confused with MITs Gruber), was part of a group of economist who sent letters to the President in the early days of the ACA praising certain aspects of the bill such as “cost sharing” and the Cadillac tax applied to the best plans.

My how things have changed.  This week, as reported in the New York Times, these same Harvard faculty are in an uproar as they have seen their own healthcare plans completely overhauled.  Rather than being allowed to maintain their long time low cost (out of pocket) plans, the university has now implemented healthcare coverage that is consistent with the provisions in the ACA.  Now there are more up front out of pocket expenses for basic insurance plans and the Cadillac plans are much more expensive.

During a faculty meeting the vast majority of Harvard professors voted to oppose the changes in the Harvard health plan that would require them to pay more for their own healthcare—How dare Harvard adjust their own benefits and how dare the University actually expect them to be a part of a new ACA influenced health care plan at Harvard???

This type of attitude is even more prevalent among lawmakers in both the White House and in Congress.  Members of Congress as well as the President and all staffers are EXEMPT from the individual mandate.  This type of paternalistic governance is what is wrong with Washington today.  Many Democrats seem to have taken the attitude that they were elected not to represent the people but rather to do what they think is best for their constituents.    In an era when the ACA is wildly unpopular, many politicians continue to refuse to believe that changes to the legislation should be made.

If the ACA is such a great thing, why then do those who designed it and legislated it refuse to participate?

  1. The President and His Legacy:  The President continues to see the ACA as his legacy.  In spite of plummeting approval numbers and a negative referendum on his failed policies during the 2014 Midterm Elections, Obama refuses to examine the numerous issues associated with the healthcare law and does not appear to have any willingness to compromise on amending the act.  Unfortunately, Obama’s pursuit of his legacy appears to trump sensible bipartisan negotiations and will severely limit Washington’s ability to actually govern.
  2. Paternal Governance:  Currently, Many in power feel as though they know what is “best” for the rest of us.  Rather than represent a constituency, many of our leaders actually believe that the American people are incapable of making sound decisions for themselves and their own healthcare.  The “Big Brother” knows best attitude continues to alienate millions of voting Americans.  Interestingly, when those that helped craft the legislation (i.e. the now disgruntled Harvard economics professors) are subjected to the law that they supported, the outlook quickly changes.
  3. Partisan Politics:  Our country is the more divided politically than ever before.  Relationships in Washington are so polarized that compromise will be difficult to achieve.  Our elected government is divided with the President refusing to even consider bills that are put forward–instead he threatens vetoes in advance on any bills that address issues concerning the reform of the ACA.

So, What’s Next?

As a country we must begin to deal with the issue of healthcare in a more productive and collaborative way.  Politics as usual will result in another two years of decline in both the quality and affordability of the American healthcare system.  We must hold Washington accountable and the Obama administration MUST begin to work with Congressional leaders to find workable, effective solutions to the mountain of problems that has been created by the poorly thought out and recklessly implemented Affordable Care Act legislation.  And, those at Harvard (as well as those in Washington) should have to live with the same healthcare insurance programs that are mandated for the rest of us–No Exemptions.

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Reflecting on Medicine in 2014: Sailing Rough Seas and Finding Uncharted Waters Ahead

As we close out on a tumultuous 2014 in healthcare, many physicians are looking forward to a better and more stable 2015. For most of us, 2014 has been marked by significant change. Many healthcare providers have seen their jobs and their patient care roles transform completely. Physician autonomy has diminished and regulation and mandated electronic paperwork has more than doubled. Many physicians find that they are spending far less time caring for patients and a greater proportion of their available clinical time is now being spent interfacing with a computer—both at work and at home on personal time.

During the last year, we have all been affected by the rollout of the Affordable Care Act (ACA), changes in reimbursement, as well as the implementation of a new billing and coding system (ICD-10). For many of us, it also marked a year of transition to system wide electronic medical record systems such as Epic and the growing pains associated with such a major upheaval in the way in which medicine is practiced.   Many practices have continued the trend of “integration” with larger healthcare systems in order to remain financially viable. The American College of Cardiology estimates that by the end of 2014, nearly 60% of all physician members have integrated with hospital systems and this number is expected to rise even further in 2015—ultimately defining the death of private practice as we know it.

Why have these changes occurred?

Ultimately, I believe that the changes to the way in which healthcare is delivered has come about due to 3 distinct reasons:

 1. Declining Reimbursement

Currently reimbursement continues to fall. Multiple government budgetary “fixes” have led to much uncertainty and instability in medical practices (much like seen in any small business with financial and market instability). In addition, the implementation of the ACA has resulted in the expansion of the Medicaid population in the US—now nearly 1 in 5 Americans is covered under a Medicaid plan. Traditionally, Medicaid plans reimburse at levels 45% less than Medicare (which is already much lower than private insurance payments). While the Obama administration did provide a payment incentive for physicians to accept Medicaid, this incentive expires this week. Many practices are becoming financially non viable as overhead costs are risking to more than 60%. As for the ACA, many exchanges have set prices and negotiated contracts with hospital systems—leaving many practices out of network. Both patients and doctors suffer—longtime relationships are severed due to lack of access to particular physicians.

2. Increasing Administrative/Regulatory Demands

With the implementation of the ICD-10 coding system, now physicians are confronted with more than 85, 000 codes (previously the number of codes was approximately 15,000). In addition, “meaningful use” mandates for payment have resulted in increasing documentation requirements and even more electronic paperwork. In addition, the implementation of new billing and coding systems has required increasing staff (more overhead) as well as intensive physician training. Sadly, the new coding system that has been mandated by the Federal government includes thousands of absurdities such as a code for an “Orca bite” as well as a code for an “injury suffered while water skiing with skis on fire”.

3. Electronic Medical Record Mandates

Federal requirements for the implementation of Electronic Medical Records and electronic prescribing have resulted in several negative impacts on practices. While in theory, the idea of a universal medical record that is portable and accessible to all providers is a noble goal, the current reality in of EMR in the US is troubling. There are several different EMR systems and none of them are standardized—none of them allow for cross talk and communication. Many small practices cannot afford the up front expenditures associated with the purchase and implementation of the EMR (often in the hundreds of thousands of dollars).   In addition, the EMR has slowed productivity for many providers and resulted in more work that must be taken home to complete—not a good thing for physician morale. Finally, and most importantly, the EMR often serves to separate doctor and patient and hinders the development of a doctor-patient relationship. Rather than focusing on the patient and having a conversation during an office visit, many physicians are glued to a computer screen during the encounter.

So, What is next in 2015?

While I have probably painted a bleak picture for Medicine in 2014, it is my hope that we are able to move forward in a more positive way in 2015. I think that there are several very exciting developments that are gaining momentum within medicine and healthcare in general.  Innovation and medical entrepreneurship will be critical in moving healthcare forward in 2015.  Physicians must continue to lobby for the tools and freedoms to provide better patient care experiences for all stakeholders in the healthcare space.

2015 begins with much promise. I am excited to see what we as healthcare professionals will be able to accomplish in the coming year. We must continue to put patients first and strive to provide outstanding care in spite of the obstacles put before us. While 2014 provided challenges, we must rise above the fray and continue to advocate for a better healthcare system in the US today and in the future.

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Should We All Die at 75?: Addressing the “Emanuel Principe” in Obamacare

Ezekiel Emanuel, one of the authors of the Affordable Care Act spoke publicly this week about his own desire to “die at 75” in a article published in the Atlantic.  In his piece, he argues that as he ages, he wishes to stop all preventative medical measures and “let nature take its course” as he approaches the age of 75.  This includes screenings such as colonoscopy as well as taking flu shots for the prevention of communicable illness.  While currently in excellent health, Mr Emanuel believes that while death is a loss–”living too long is also a loss.” He argues that the American obsession with living longer results in a larger number of elderly, disabled citizens.  I take significant issue with this position and fear that this is simply the beginning of a new phase in the ACA debate–the rationing of care. From the outset, many of us in healthcare and scholars of healthcare policy have seen Obamacare as a way to promote the rationing healthcare (particularly for the elderly).  While the administration has vehemently denied these claims throughout the legislative and implementation phases of the new healthcare law, it is particularly revealing that one of the principal architects of the law firmly believes that we should not pay attention to life expectancy statistics beyond the age of 75.  Medical advances have made it increasingly possible for seniors to lead healthy, productive exciting lives well into their 80s.  Now, I certainly am not arguing for providing futile care in the setting of terminal illness but–Why then should government (instead of doctors) now have the right to determine how healthcare resources are utilized and who gets what?  Is it all about age?  Do we value the young more than the more “seasoned” citizens? The US healthcare system, while certainly imperfect, offers some of the greatest technological advances in the world and the most significant thing that has always set US healthcare apart form others has been CHOICE.  With Obamacare in place, we now have less choice in our healthcare and very little improvement in access.  This latest article by Mr Emmanuel is no surprise–he has been clear about his belief in allocating health care dollars away from activities which may extend lifespans for Americans.  While, Mr Emmanuel certainly has the RIGHT to refuse care for himself at a certain age neither he (NOR OBAMA or any GOVERNMENT agent) should be able to determine an “acceptable” life span for each of us. Quality of life and health status can be very subjective and care must remain individualized rather than mandated (or withheld) based on actuarial tables or government rationing of resources. Medicine is all about innovation and the development of new technologies.  Through technology we are able to provide longer, more productive lives for our patients.  Our patients are able to retire from a life of work and enjoy spouses, family and friends–well into their 80s and 90s WITH a quality of life.  In fact one of my favorite “golf buddies” is 80 years old and going strong–He can still shoot in the 80s from time to time and never misses a game. In MEDICINE one size does not fit all.  OBAMACARE wants to force a ONE SIZE FITS ALL healthcare system on all of us and as a physician I find this to be unacceptable.  Just as we must cater therapy to individual patients—when (and how) you die must also be catered to each individual patients needs, desires and beliefs. Chronological age such as 75 may be different for different people AND we must respect individual needs.  Medicine is a clearly a science but in many cases the practice of medicine –particularly when making decisions about end of life issues–makes it more of an ART.  The government has no place in dictating ART.  Government should help to preserve and curate art–not regulate and mandate the way in which medical care is delivered to individual patients based on age. Ultimately, left to its own devices, I believe that the ACA will create rationing of care for Americans and we will have two classes of people–those that are wealthy and can afford private care and can pay cash for it–these can make their own healthcare decisions and decide when enough is enough.  The others–most of us–will be lumped into the disaster that IS obamacare and will have little or no choice in how our healthcare is delivered.  Waiting lists for advanced procedures and denials of advanced care for the elderly will be the standard–Just as Mr Emanuel envisioned it when he crafted the law just a few short years ago.

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What Color is My Pill Doc? Using Technology to Improve Medication Compliance

It is clear that patient compliance with prescribed medications is critical to success in the treatment of any chronic disease process.  In addition, patient engagement and co-management of their disease has been proven to improve outcomes.  This past month a new study from the Annals of Internal Medicine suggests that any changes in the appearance of a medication may result in a decrease in compliance–when a pill looks differently patients often simply stop taking them as prescribed.  In this study, a change in pill color was associated with a 34% increase in medication discontinuation and a change in pill shape was associated with a 66% increase in medication discontinuation.  In cardiovascular patients in particular, the sudden discontinuation of medications can result in increased hospitalizations for chest pain, congestive heart failure and other more serious acute cardiovascular events. For other disease processes such as diabetes, medication non compliance can be devastating and life threatening as well.

The Challenges of Managing Poly-pharmacy

In general, today’s patients are taking more medications for a multitude of ailments and even for the most astute patients keeping track of doses and regimens can be a challenge.  Add in changes in color and appearance of chronic medications and the task can often be overwhelming for elderly patients with cognitive decline.  According to a study published in the Journal of the American Medical Association in 2008, nearly 81% of adults aged 57-85 took at least one pill and 29% took 5 or more drugs.  In addition, nearly 50% took concomitant over the counter drugs and/or supplements as well.  Side effects, drug-drug interactions and other concerns have led many physicians to attempt to streamline medication use and avoid the dreaded “poly-pharmacy” patient.  However, this serious public health problem is further complicated by patient non-compliance issues.  Many regulators argue for more FDA intervention as well as requiring generic drug makers to conform to non generic shapes and colors when manufacturing generic substitutes.  However, I believe that this data argues for a more comprehensive, patient centered approach to increasing medication compliance.

Leveraging Technology in Seniors

Technology today is ubiquitous in nearly all age groups. According to a Pew Research poll, most seniors utilize the internet and a large majority of these users interact via tablets, computer or other mobile devices.  As we age, we tend to live with more chronic illnesses and seem to require more daily medications.  Given the fact that now seniors are actively engaged on the internet, it makes sense for medical professionals to use these powerful tools to assist patients with management of their disease.  Many EMR systems already incorporate “patient portals” which allow for direct patient access to certain parts of their medical record such as test results, appointments, etc.  In addition, there are websites such as Pill Identifier that allow patients and physicians to search a large database of drug images in order to more accurately identify a medication–this is particularly useful when a patient approaches a visit in an Emergency Room or has a consultation with a new physician.

Based on the newly released study in Annals, it is clear that pill identification (and consistency of appearance) is critical in maintaining patient compliance with chronic medical regimens. Regulatory agencies are slow to act–forcing private generic drug makers to keep the size, shape and color of the generic consistent with the brand name is not realistic.  I believe that we can use tablet technology to quickly address this issue.  What if we create an application (downloadable to mobile phone, tablet and laptop) that is able to quickly identify all shapes colors and sizes of a particular drug? Currently there is a pill identifier app on the market but it requires the user to enter color shape and size in order to identify the correct medication–are there better apps yet to come? Ease of use and accuracy will be key components to any new medical applications aimed at older adults.

What Are Potential Solutions?  What Can WE Do Now?

As healthcare providers, we must do a better job encouraging the use of technology to help identify drugs and promote compliance.  The Annals study is a stark reminder that even though we may prescribe the best, most evidence based regimen to treat disease, it takes very little for our patients to become sidetracked–something as simple as a change in shape or color may result in the discontinuation of an effective, potentially life-saving medical treatment.  As physicians, we sometimes forget the “simple things” such as the importance of consistency and routine for our patients.  The culture of healthcare in the US no longer allows for the extended office visit and frequent follow up in order to ensure that patients are compliant with their treatment plans–we are asked to see more patients, in less time and the documentation requirements have become paramount in practice.  We must look for alternative ways to assist our patients with managing their disease while at home–I believe technology is the answer.  We must provide education and resources for our patients and assist them in the identification and use of medical applications.  With technology, we may be able to extend our reach–and support for our patients–well beyond the walls of our office.

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The Electronic Medical Record Mandate and Managing Fraud: More Government Ineptness?

The Obama administration has clearly mandated that Electronic Medical Records (EMR) will be necessary in order to comply with Federal regulations for reimbursement for both hospitals and physicians.  The transition to EMR is an important step towards streamlining patient care–however, the current implementation of EMR is fraught with complications, workflow issues and system wide “bugs”.  At this point in the US there are numerous EMR systems and no absolute standard which continues to make communication between different hospital systems and physicians difficult at times.  I realize that the EMR mandate has spanned more than one administration and let me state at the very outset that I am 100% FOR the implementation of an electronic medical record system–However, I would like to see the transition be done in a stepwise, intelligent way that allows for universal portability within the US.   Moreover, the EMR should be electronically available to all patients via smartphone and tablet download from the mysterious (and hopefully secure) “cloud”.

The EMR when properly managed can provide detailed notes that are easily applied to templates for billing medicare and medicaid documentation (it allows MDs to correctly bill the level of service based on comparison of the patient’s newly created chart note to standards for required components).  However, the time involved in documenting via EMR (especially in the transition phase in a busy practice) can be overwhelming.  Physicians and other providers are already overwhelmed with offices full of patients–longer hours, more appointments and loads of new paperwork. The Affordable Care Act (ACA) promises to add loads of newly insured sick patients to the practice workload.  Add to that a cumbersome computer system and it is likely that errors will occur.

This week in the New York Times, Abelson and Creswell report on the new Department of Justice focus on EMR fraud activities.  The Office of Inspector General (OIG) for HHS released a report on Tuesday (the second in two months) warning of the potential widespread fraud and abuse occurring as a result of EMR implementation.  The warning specifically cites a lack of oversight and safeguards in the Federal government to prevent these from occurring.  The government has already spent nearly $22 Billion dollars on the push for conversion from paper to EMR in the US.  (sound familiar?  rapid roll out of new technology without proper evaluation).

According to the New York Times report, the central issue with the EMR and potential fraud has to do with the lack of regulations surrounding the common practice of “copy and paste” known as “cloning”.  For many physicians, the ability to cut and paste data and information from one place to another in a note or within a patient’s particular chart can significantly improve efficiency and reduce the amount of time that is spent inputting redundant data into a patient’s record.  Critics of this practice, including the OIG, suggest that in many cases the importation of data from note to note or chart to chart results in “overbilling” for services that were not in fact rendered.  For example, if a chart note from a follow-up visit of moderate complexity  is “cloned” with data from a previous visit where the level of service was more extensive than the current visit, then charges may be filed for an level of complexity that was not, in fact, provided.  The OIG statement goes on to warn that their “level of involvement in EMR cases [will] increase” and that dealing with documentation “fraud” via cloning in EMR will become a “top priority”.  In a survey conducted by HHS and released in a previous report, the OIG found that very few hospitals and medical practices have any guidelines or restrictions on “cloning” notes for documentation.

Once again, in my opinion, our government has missed its mark.  Instead of carefully creating a universally acceptable and streamlined EMR that allows for responsible and efficient data entry AND migration of data to subsequent encounters, federal regulators have issued yet another mandate without a clear vision of its implications.  As I stated earlier, I believe EMR is vital for patient information management and will ultimately help us provide more streamlined care that is evidenced based.  Unfortunately, the current EMR systems that are in place do not place a priority on ease of use, efficiency or portability.  Although I am sure that there is some intentional documentation fraud occurring, I would suggest that the majority of physicians and other providers are simply trying to “get the job done” and move on to more important patient care activities.  EMR documentation can be slow and arduous.  During transition phases, many providers report 2-3 extra hours added to their days for documentation activities.  No physician wants to continually take a practice laptop home in order to finish entering EMR notes during family time night after night.  Cloning data is a simple way to carry over information such as medication lists, past medical histories and other information in order to improve efficiency while at the same time providing adequate documentation.  As with most things, this type of data migration is easy to abuse if physicians do not pay special attention to ensure that the migrated data is both accurate and representative of the work that was performed.

As the current administration has clearly demonstrated with the rollout of the  ACA,  as well as with the new ICD-10 coding system and the EMR mandates, sweeping reform that is rushed to completion without a full understanding of its implications is doomed to fail.  Putting politics and power ahead of good sense has resulted in increased cost for these government mandated programs.  As a nation we must certainly work to prevent fraud and abuse as part of our efforts to curtail healthcare costs.  However, as we initiate reforms, we must do a much better job of anticipating issues with new technologies and work to deal with them on the front end–if we do not, we can expect costs to continue to rise.

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The Doctor Shortage of Tomorrow: Fact or Fiction?

This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.  Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur.  The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October).  Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…

How can there NOT be a physician shortage?

Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed.  However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California.  Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA.  (its like comparing apples to oranges).  They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows.  They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”

Really?  We are already doing more every day with much much less than we have had in the past….

As doctors often do in clinical practice,  I respectfully disagree with their assessment.  Obamacare will soon flood the system with millions of newly insured patients.  As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates.  Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates.  Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems.  Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.   The concept of a completely free standing private practice will no longer exist within the next 3 years.  Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage.  Medicine is becoming less attractive for young bright students considering a career in healthcare.  Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn.  Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards.  Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care.  However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future).  Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized.  These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes.  But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless.  Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship.  Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond.  We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care.  In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention.  While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process.  We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Are We Simply Losing Our Way As Medicine Remains in crisis….

Ultimately, time will certainly determine the state of physician supply.  If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage.  Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality.  Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

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Sex, Lies and Healthcare Reform: The Current (Sad) State Of The (Un)Affordable Healthcare Act

This week, the US House of Representatives finally got the opportunity to question Secretary Kathleen Sebelius and examine the debacle that is the Affordable Care Act.  Unfortunately, the Secretary of Health and Human Services spent most of the 3 hour session skirting around the issues and tossing blame to other government agency bureaucrats, government contractors and of course the GOP.  When repeatedly pressed, she did in fact admit responsibility for the failed rollout but stopped short of admitting that the ultimate responsibility falls upon the Commander in Chief, President Barack Obama.  Like any good soldier in a politically appointed job, she protected her boss from the fallout of the TRUTH.  However, in spite of the Secretary’s claims of ignorance during her testimony, Lawmakers on the House committee as well as the American people were able to begin to better understand why the ACA has been such a disaster:

1. A complete lack of leadership on the part of the President and his appointees.

2. A complete lack of understanding of the law by the very people who drafted and now champion the legislation.

3. A complete lack of understanding of process of healthcare delivery in the US today

For example, numerous provisions have already been delayed and many more are likely to be postponed in the future.  The mandates on some businesses, the out of pocket expense caps, and now the individual mandate–just to name a few.  Throughout the process there have been many misleading statements made by the President and his political colleagues both in the White House and on Capitol Hill.  No less than 6 different statements were made by Mr Obama forcefully claiming in 2009 while addressing the American Medical Association:

If you like your doctor, you will be able to keep your doctor, period, If you like your health care plan, you’ll be able to keep your health care plan, period. No one will take it away, no matter what.”

Obviously the hundreds of thousands of insured that are now being dropped by their insurance plans and forced into the exchanges are proof that these statements are in fact not true.  In addition, there is mounting evidence that the White House as well as Secretary Sebelius knew about these issues with potential coverage loss for quite some time.  An IRS document from 2010 (during the time in which the President was making such bold statements about coverage) suggested that this may in fact not be the case.  This document clearly states that an estimated 40-60% of individual policyholders would be dropped from their plans due to the ACA.  An article in yesterday’s Washington Post awards the administration with “Four Pinocchios” for making untrue claims about his cherished ACA.

We are a nation built on certain guaranteed Freedoms–in particular freedom of choice, freedom of religion and freedom of speech–we are slowly losing our way in the healthcare debate.  Those with a particularly stringent religious beliefs concerning premartial sex and birth control practices are now forced to purchase products that supply contraception.  The Catholic Church–whose believers practice natural family planning–are being forced to provide their employees with funding for birth control.  Our government has clearly overstepped its bounds.  Those who are healthy and have little need of expensive insurance policies are now forced to pay for benefits they may not really need.   The entire success of the ACA system requires that those who don’t need medical care pay for those who do–a unique system for transferring wealth.

Ultimately, costs will  continue to rise.  As evidenced by a report filed by Sebelius’s very own HHS in September 2013, most will see a significant premium increase.  The average male in the US today who enters the exchange will see a 99% increase–the average female will see a 67% increase.  In some states such as North Carolina where I reside, the average man will pay a 350% increase in premium.  Rather than closing the wealth gap in the US, the ACA will actually result in the development of two divergent classes of Americans with respect to healthcare–Those with wealth will be able to pay out of pocket for concierge medicine–they will have access to whatever they need, whenever they need it as long as they can continue to pay.  The rest of America will be lumped into the dysfunctional and bureaucratic Obamacare system.

I am sadly disappointed by my government–those in charge have slowly chipped away at my noble profession–Medicine is in jeopardy of no longer being a form of art–soon medical care will be an automated system carried out by a group of mindless lemmings.  The doctor-patient relationship which has been the core of good medical care is in danger of extinction.  I am a firm supporter of providing healthcare to those who cannot afford it–just not at the cost of Freedom.  I can only hope that those in power in Washington will respect the basic tenets of our democracy and, most importantly, put legacy and ego aside and do what we do best as doctors–put patients first.

Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

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Limiting Choices and Destroying Relationships: Early Consequences of the Affordable Care Act

Providing healthcare to all is a noble goal.  Providing choice, however, is an entirely separate issue.  Successful partnerships between doctor and patient are developed over time.  These partnerships do not happen easily and most, just like a long standing marriage, take a great deal of work.  As I have mentioned in previous blogs, when patients are engaged and participate in their care, outcomes are improved.  It is easy to see how costs can be lowered through improved outcomes–the focus is shifted to prevention rather than “salvage”.

Last week in the Wall Street Journal, author Anne Mathews discusses the issues surrounding “choices” in the healthcare marketplaces that begin functioning in October.  Many insurers are making “deals” with hospitals and physicians–they will be included in their plans as preferred providers if they are willing to settle for pre-negotiated lower reimbursement rates.  Many major healthcare systems such as UCLA in California, Rush and Northwestern in Chicago and Vanderbilt in Tennessee are being excluded as preferred providers in many plans due to the fact that they are unwilling to accept the terms dictated by the insurers.   These institutions,  and many others like them,  employ many of medicine’s leaders in patient care and research.  Many patients have developed long standing relationships with physicians at these institutions and are now forced to make a “choice”—either continue with their preferred provider at an increased out  of pocket cost or change physicians and start over in their new healthcare plan.

Starting over with a new physician is a lot like divorce.  Divorce is not easy–it is fraught with uncertainty and can be emotionally painful.  It is difficult to face change when so much time has been invested in building a productive doctor-patient relationship.  However, with the pending implementation of the Affordable Care Act (ACA), patients are now being forced to choose between a doctor they trust and lower insurance premiums.  Physicians and hospital systems are being forced to accept payments at whatever level the insurers choose to dictate–irrespective of the cost of the procedure or the staffing and overhead incurred.  Once again, the reform of healthcare in the US is doing little to assist the patients who need help the most.  Instead of working to build relationships, streamline care and focus on prevention, the ACA is forcing “divorce” proceedings on many doctors and their patients.  Moreover, the “choice” that is supposedly supplied by the pending healthcare exchange marketplaces will be severely limited when they open in October.  The government cites a lack of time to prepare for the healthcare law rollout–Others cite a poorly thought out, complicated and unworkable plan.  More than a dozen ACA “deadlines” have already been missed and there will certainly be more to come.

No one argues that the current healthcare system in the US is on life support and badly in need of reform.  However, the current ACA plan is not the answer.  Based on the basic tenet of coverage for all at affordable prices, the ACA is not living up to its billing.  Now, as the law begins its rollout process, many of the finest academic medical institutions in the country are not going to be accessible to many Americans due to contractual issues with the insurance industry.  Ultimately this will create more of a medical care divide in the US.  Academic teaching hospitals provide cutting edge care and access to new potentially life saving technologies before these are available in the mainstream.  Those with rare diseases or those with disease processes that have failed other treatments often turn to academic institutions such as Vanderbilt, UCLA and Rush for experimental therapies that may provide hope for a cure.  Now, as long as the healthcare exchange plans are able to dictate which physicians and institutions are included in their respective plan, only the wealthy and privately (non government exchange or marketplace) insured will be able to have an opportunity to participate in ground breaking and potentially life saving clinical trials.  Ultimately patients will suffer.  Ultimately human beings will be denied potential life saving therapy–all because of limited choice and the coverage “assigned” by insurance companies hoping to limit cost–but at what price?

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The Future of Medicine: Coding For An Orca Bite

When I was in medical school in the mid-1990s at Wake Forest University, the only thing I knew about “codes” was how to use an ATM machine (which was often linked to a very empty bank account).  As my training progressed through internship, residency and fellowship, the idea of coding provider services never even crossed my mind.  No one taught me anything about the “levels of service” or what an ICD-9 (The International Classification of Diseases) code actually was even though the coding system has existed for more than 30 years.  I remember my teachers and mentors scribbling on a card in the front of the chart whenever they interacted with a patient, but I had no idea what the exercise was about.  Years later, I am all too familiar with coding of patient services.

Billing codes serve as a way for the Center for Medicare and Medicaid Services (CMS) to create a payment schedule for services rendered based on diagnoses.  Each diagnosis is given a particular code and then there are “modifiers” that attempt to make the billing code more specific.  Government bureaucrats created a massive list of poorly contrived codes that have been utilized for the last decade known as ICD-9.  Over the years, those responsible for these codes have realized that in order to accurately document medical conditions and improve billing accuracy (and reduce fraud) that these codes are in need of updates.  Thankfully, our government has been working on this new system tirelessly over the last several years.  In fact, the Wall Street Journal reported on the development of this new brilliant system as early as 2008.  Next year, the new set of billing codes will go into effect–they have been created with the goal of improving the specificity of the diagnosis and improving care (through quality measures).  This brilliant work and expansive list of new codes (approximately 150,000 codes as compared to the current 18,00) includes such ingenious diagnoses as code W5621XA “bitten by an orca, initial encounter”.  Another important code that has been created is the commonly used W6112XA-”struck by a macaw”.  As a practicing physician, I am relieved that when the next patient who visits my office after suffering “a burn due to water skis on fire”–I can quickly and easily document the encounter using the ICD-10 code V9109XA.

As government seeks to continue to regulate healthcare and contain costs, it seems to me that our efforts in reducing costs and improving quality of care are a bit off track.  Instead of working to improve efficiency and reduce redundancy in healthcare, we are now focusing on creating codes for injuries that may only occur to Wile E. Coyote during an epic battle with the RoadRunner.  As a physician, I have been required to complete nearly 20 hours of online training to help me understand the new ICD-10 coding system.  After an endless marathon of computer modules, I still have no idea how or why the ICD-10 system will improve my ability to care for patients or improve either the efficiency or quality of care in my practice.   In fact, I am certain that the new coding system will actually add more hours of documentation to my already burgeoning pile of electronic paperwork.  Eventually something has to give….there are only so many hours in the day.  Personally, I would rather see patients and care for those that need my help rather than coding for an attack by a talking bird or a personal watercraft injury due to burning water skis.

Our healthcare system has lost its way.  The new coding system is just one example of misplaced priorities within regulatory agencies.  Instead of creating codes for ridiculous scenarios, we should be training docs to provide thoughtful efficient care. We should be teaching doctors to communicate with each other about patient care and to avoid unnecessary testing.  Time, money and energy could be much more effective if spent on engaging patients in preventative care strategies and modification of risk factors.  Until then, I can at least sleep well tonight knowing that there is in fact an ICD-10 code for the next patient who walks in my office after being “hurt at the opera” …I will be able to quickly use code Y92253.

Please note:  All of the codes mentioned in this blog are REAL.  They are all part of the 150,000 codes that doctors and billing specialists are supposed to know and implement in the next year.  You can verify all codes by using this ICD-10 code look-up website

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