Tag Archives: insurance

Buyer Beware: How Patients are Negatively Impacted by the Changing Landscape of the Affordable Care Act (ACA)

As the Obamacare machine continues to grind forward, many patients have re enrolled in a second year of coverage. While most have not had to use their insurance (the young and healthy crowd) others have found their newly minted coverage to be far less than promised. High deductibles, and up front out of pocket expenses, forced many covered by the exchanges to avoid seeking regular preventative care—Prevention was one of then tenets of the ACA plan. Many have found choices limited and have been forced into healthcare systems that are not their first choice.

Now, as the second year of enrollment (and re-enrollment) has concluded, many of us are concerned about the likelihood of rate hikes and changes in coverage. The Obama administration continues to tout the fact that enrollment numbers remain high and that there have been no substantial increases in premiums. However, this is not necessarily the case. Many exchange insurers have cleverly disguised rate hikes through changes in other aspects of the plans. While some advertise that there are absolutely no significant premium increases, customers who shopped carefully on the exchange site were able to find higher prices for Emergency Room visits, and higher charges for non generic drugs. For some plans this means that rather than pay a $250 co-pay for an Emergency Room visit, the customer must pay up to the yearly deductible for the same ER visit before the co-pay rules go into affect. For many, this may be a non-starter. ER visits can be very expensive and can amount to thousands of dollars in just a few hours. Many patients will find themselves having to pay a 3-6 thousand dollar deductible early in the insured year before any of the benefits begin to contribute to reduce individual out of pocket costs. In some plans, the co-payment for a routine physician visit will go down by an average of 20 dollars and many generic drugs will be covered for free. However, specialty visit co-pays will increase and the prices for specialty medications will increase by 40-50%

In an effort to promote re-enrollment in 2015, the government implemented an automatic re-enrollment system. However, this has left many patients with increasing out of pocket costs due to the fact that multiple changes have been made—such as those described above. Many patients were unaware of the need to shop around for re enrollment and are now increasingly unhappy with their plans. Ultimately the ACA and its supporters in Washington have placed statistics and politics ahead of the patient. While the delivery of quality care to the patients who need it SHOULD be the goal, it appears that politics remains the top priority. Increasing out of pocket costs and higher deductibles—many requiring payment in the first half of the year—are having the opposite affect. One of the central tenets of the ACA is to focus on prevention through promoting regular access to primary care physicians for prevention of chronic disease and its complications.   However, rather than promoting and environment where patients are engaged and actively seek preventative care, many are using the insurance simply as a “disaster plan” simply due to the overwhelming costs. While out of pocket limits and guaranteed care consume the healthcare reform talking points of the Obama administration, the reality is that the way in which the ACA is structured and implemented has actually increased personal financial burden for many.

What Can Patients Do?

images

Unfortunately, much of the burden of navigating the new healthcare landscape falls to the patient. The Law itself remains a moving target—with changes certain on the horizon. We must remember that insurers are for profit entities and will ultimately find a way to make a profit—often at the taxpayer and patient expense. While many have been encouraged by the Obama administration to continue to offer affordable premiums, most have found other ways to improve their revenue streams. Whether it is thru juggling co-payments and charges, shifting cost, denying procedure approval or limiting choice, all of these changes will–in the end—negatively impact patients. As a healthcare provider, my job is to educate patients about behaviors that may improve their overall health. Now with the implementation of the Affordable Care Act, this responsibility now extends to helping my patients manage their insurance choices. While this is not necessarily a traditional role of a physician, it is important that we make sure that our patients continue to have access to the care they need—without incurring a life altering expense.

There are a few things that I think that patients can do to actively advocate for themselves and others:

  1. Stay Informed: Make sure that you ask questions of your insurer—are their changes to my coverage? How are out of pocket expenses handled? Can I see my doctor and my specialist when I want or need to without incurring a penalty or increased cost?
  2. Shop Around: Just because you have had coverage with a particular company in the past does not mean that you have to remain locked in with them. Make sure you explore all of the options that are available to you through the exchanges. Carefully question insurance company representatives so that you completely understand policies BEFORE you agree to a contract
  3. Demand Transparency: If you are unable to get a clear answer from an insurer about costs and coverage BEFORE you sign up, it is very unlikely that you will get a clear answer once you are a customer. Once you are a customer, make sure that you have a clear idea of the costs involved prior to scheduling a procedure or test. A recent survey sponsored by the Robert Wood Johnson foundation found that nearly 56% of Americans get out of pocket cost information before accessing healthcare services.

As with most things that have occurred with the Affordable Care Act, it is the patient who ultimately suffers. Insurers continue to profit, as do drug makers and hospital systems and administrators. Physicians have seen reimbursement cut to levels that have forced integration with large hospital systems. Most tragically, however, patients tend to be caught in the middle and have seen their healthcare suffer. Surveys indicate that patients are now inquiring as to cost prior to office visits, tests and procedures. Many find that they must put off necessary preventative activities and even more opt not to have needed tests and therapeutic procedures due to cost. It is clear that the ACA has missed its mark. While insuring large numbers of Americans is a noble goal, this insurance must also provide value rather than meaningless statistics to be utilized at a White House press briefing. As my research mentors at Duke University taught me during my training–with any data analysis, it remains that garbage will equal garbage out. WE must find a better way to provide affordable care to our patients. For now, insurers, hospital systems and politicians are using patients as nothing more than a “Profit Center”. As reenrollment continues through this year and the next we must make sure that our patients are armed with the old adage—“Buyer Beware”

images-1

“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.

Unknown

Healthcare Industry CEOs and the Cost of Care: Too Many Men (and Women) in Black (Suits)?

Healthcare reform is a reality.  The ACA and its associated mandates have forever changed the landscape of medicine in the US today.  The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans.  Certainly these are noble and lofty goals–but have we completely missed the mark?  Today, many remain uninsured and the majority that have signed up for the exchanges are simply those who have lost their healthcare coverage from other providers.  Healthcare costs in the US remain above those of all other industrialized countries while physician salaries in the US continue to fall.  Even though the US spends more dollars per capita on healthcare than any other country on earth, our outcomes, when compared to other nations,  remain mediocre at best.

What about cost?  Who is actually delivering care?

Over the last 30 years, hospital administrators and CEOs have grown by 2500% while physicians have grown by only a modest amount.  In fact, according to the American Academy of Family Practice, there must be a 25% increase in primary care doctors over the next 10 years in order to keep pace with demand.  Multiple independent surveys (published by the AAMC) indicate a significant shortfall of all types of physicians nationally by the year 2020.  As administrators and insurance company executives grow, hospital staff and services continue to be cut—nurses and doctors are asked to care for more patients with fewer resources.  Executives continue to tout savings within their organizations and boards award these administrators with enormous financial bonuses.

Screen Shot 2014-05-19 at 7.24.21 AM

Source :  BLS and Hammelstein/Wool handler

Where are the Doctors in all of this?

The short answer is that physicians are caring for patients and managing the piles of paperwork that the government and other healthcare organizations and executives have created for them.  Doctors are now consumed with checking boxes, implementing EMRs and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands.

This week in the New York Times, Elisabeth Rosenthal penned an article that spells out what many physicians have known for a very long time—the administrators and hospitals are the high wage earners–not the doctors.  As the numbers of administrators continues to rise exponentially, many independent physicians and physician groups are being driven to integrate with or leave practice altogether in order to remain fiscally viable.  According the the Times, the salaries of many administrators and CEOs (in both the hospitals and the insurance industry) are outpacing salaries of both general practice physicians, surgeons and even most specialists.  Astronomical wages such as those earned by Aetna’s CEO (total package over 36 million dollars) and others are a big contributing factor to the trillions of dollars that we spend on healthcare each year.  According to the New York Times, healthcare administrative costs make up nearly 30% of the total US healthcare bill.  Obviously, large corporations and CEOs will argue that these wages are necessary to attract the best and brightest executives to the healthcare industry.  What is there to attract the best and brightest scientists to medicine?  Certainly altruism is a big part of what physicians are about but economic realities must still come into play when bright young students are choosing careers (while accumulating graduate and professional school debt at record paces).

Why then does it seem as though physicians are the only target for reform?

That answer is simple–hospital administrators and insurance company CEOs are well trained businessmen (and women) with MBAs from prestigious schools.  They understand politics and how to effectively lobby.  They have been actively involved in reform and have participated in discussions on Capitol Hill rather than watch the change happen around them.  When costs are cut from the healthcare expenditures, they have made erudite moves–they have worked effectively to isolate themselves and their institutions from the cuts that are affecting the rest of the industry.   While reimbursement for office visits and procedures falls to less than 50% through many of the exchanges and other government based programs such as Medicare and Medicaid, CEOs and hospital administrators continue to financially outpace their colleagues in other sectors of business.

As physicians, we must continue to focus on our patients and their well being.  Individually, we must continue to provide outstanding, efficient, quality care to those who depend on us every single day.  As a group, however, doctors must begin to work harder to influence those in Washington for change.  While healthcare reform is essential and must be accomplished in a fiscally responsible way, it is my hope that those in a position to effect change will recognize that we must begin to better regulate and limit those in CEO and administrative positions in both the insurance and hospital industries.  Just as we reduce the numbers of nurses on the floor to care for patients in order to save healthcare dollars, maybe we should eliminate a few VPs with fancy offices on the top floors of our hospitals.  Which one do you think will positively impact patients more–fewer nurses or fewer dark suits?

images

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.

no-doctor