Tag Archives: Obamacare

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 Next Government-Based Healthcare Debacle: Coding for Orca Bites?

Due to the ineptness of the Obamacare team and the debacle that has ensued, the botched rollout of the Affordable Care Act has dominated the political and medical headlines since October.  However, other healthcare changes are on the horizon (and have gone virtually unnoticed by the public) that have the potential to further disrupt our ability to treat patients.  In fact, the technical and time consuming aspects of these new government mandated changes for 2014 may result in even larger scale computer glitches than those seen with the infamous Obamacare website.  (if you can believe that).  This week in the New York Times, author Andrew Pollack describes a new government medical coding system that must be implemented in 2014.

For decades the Center for Medicare and Medicaid Services (CMS) has established billing codes for documentation and reimbursement purposes.  These codes are created by the World Health Organization (WHO) for the purposes of standardizing diagnoses in order to track diseases throughout the world–it allows for comparative study.  However, several governments (such as the US, France, Germany, Canada, and others) have long adopted these codes as a way to standardize billing for medical procedures.  These codes have long fallen short of specifically describing what is actually going on with the patient and have led to difficulties in accurately charging for medical services and procedures.  In brilliant fashion, there is now a new iteration of the coding system known as ICD-10 that will be mandated by the US government effective this fall.   Luckily, there are now codes for injuries that occur while skiing on waterskis that are on fire as well as codes for orca bites.  As you may imagine, these codes will certainly streamline my ability to treat my patients with these very very common ailments.

So why is it that our government and its agencies think that there administrators are well qualified to develop codes for medical diagnoses?  How is it that bizarre codes for humorous and extremely unlikely scenarios are being included and programmed into the system?  

If you ask CMS administrators, they will tell you that these new codes were adopted by the US government after careful consultation with coding experts, CMS administrators and physician advisors.  However, I am not exactly sure which physicians were involved in signing off on codes for “balloon accidents”, “spacecraft crash injuries” and “injuries associated with a prolonged stay in a weightless environment”.  The issue at hand is the fact that government is once again working to regulate situations and concepts that they do not understand.  Moreover, they mandate changes without adequate input from experts in the field in which they plan to regulate (such as physicians…)

What are the ramifications of ICD-10 and how might it affect healthcare delivery?

Certainly, if the healthcare.gov website is any indication, I would expect that the technology side of implementation of the new coding system is likely to be plagued with errors and inefficiencies.  Imagine developing software that will assist in billing and coding of numerous diagnoses for each patient–including “struck by a macaw” and “bitten by a sea lion” (yes, these actually exist).  ICD-10 will increase the number of available codes from 17K to more than 155K.  From a physician/provider standpoint, the coding process will likely bring efficiency and productivity to a slow crawl as the new codes are phased in.  In a survey conducted earlier last year, 90% of physicians expressed significant concern over the transition and nearly 75% anticipate a negative impact on their practice (both operationally and financially).  Practices and hospital systems will now require new employees (at a cost that ultimately will be passed on to the consumer) that are trained and expert in applying the new codes in order to keep up with government mandates.  Over the last year, physicians have been subjected to online courses and training in the new ICD-10 coding system–many leaving the classes more confused than when they began.

Ultimately, physicians will have to change the way in which they document office visits and procedures in order to ensure reimbursement.  Altogether, these changes are likely to make an overloaded system even more cumbersome.  As we have seen with Obamacare and other government related policy changes, more work is created, more inefficiencies are exposed—in the end, the patient will suffer.  Providers will become overwhelmed by even more government related paperwork and documentation requirements.  More time spent on coding Orca bites means less time in the exam room chatting with a patient.  My how medicine has changed….

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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.

Finding Success AND Happiness in Medicine? Where Is The Holy Grail?

Medicine is a very rewarding career.  However, recent changes in the healthcare system have made the practice of business much more cumbersome and job satisfaction rates among physicians is at an all time low.  Fear over the unknown and how Obamacare may affect our ability to effectively and efficiently care for out patients has significantly contributed to the general unease in the medical community.  Most physicians are highly driven, highly successful individuals.  Much of my professional happiness (and I expect other healthcare providers feel the same way) is derived from developing relationships with my patients and achieving excellent clinical outcomes.  However, balancing success and happiness in medicine is now more challenging than ever.  More time is now devoted to additional government mandated paperwork, arguing with insurers and managing escalating overhead costs.  All told, these tasks begin to take away time normally devoted to patient care.

This week, in the online magazine Inc.com, I read an article discussing tips for ensuring BOTH happiness and success.  As I read through the piece, I began to reflect on my own balance of success and happiness–How can these two goals can be readily achieved TOGETHER?  Although primarily directed at the executive/business professional, much of the content is very applicable to medicine.  In today’s medical landscape, the most successful physicians have embraced the concept of the Physician Executive–developing a business skill set that allows one to be fastidious with a spreadsheet while also providing exceptional patient care.  I have addressed this concept in several previous blogs–now more than ever, it is critical for physicians to think like business people in order to navigate the changes that are being implemented on a daily basis.  Although much of our new executive-like tasks certainly take time away from patients, if we are able to find the right balance we can still find happiness and fulfillment in our jobs.  As stated in the Inc.com piece, in order to achieve both goals we must think in unique ways–try to do things differently and find out work works best for YOU.

In the article, author Steve Tobak explores six unique ways that one can develop BOTH a successful career and enjoy a happy life–believe it or not, they do not have to be mutually exclusive.  Here is my take on how each of these suggestions (that were created by Mr Tobak) can apply to those of us who have made our careers in medicine and healthcare:

1. Develop real relationships:  In the end, relationships matter.  In medicine, the most important relationship is that with our patients.  Understanding patients feelings, their families and their preferences improves our ability to care for them.  Celebrating their successes and their family milestones provides me with great happiness.

2. Groom yourself:  No, I don’t mean comb your hair–Try new things.  Engage in other activities as time allows.  Make sure that you make time for family outings and that you try skydiving–or horseback riding–whatever it is that interests you–give it a whirl.  It may change the way you look at your work and your life.  Ultimately, exposure to new things can make us all better leaders and provide more opportunities for success at work.

3. Do Nothing:  Medicine can be incredibly hectic.  Running between hospitals and clinics.  Hustling to see a new consult or dictate another note–all of this “noise” can take away from happiness.  Every single day, just take a few minutes to do nothing.  Sit quietly and listen to your own thoughts…meditate.  Even a brief respite can make you more effective and ultimately improve your mood.

4. Work for a great company:  Whether you own your own practice (a rarity in today’s medical world) or work for a university or hospital, make sure you believe in the mission of the organization.  Be involved and try to influence policy.  If you work in an organization that recognizes and appreciates your efforts, your job satisfaction will improve.  If you do not, you may need to consider taking a risk and making a change.

5. Do one thing at a time:  This seems like an impossibility for physicians today (guilty as charged).  However, if you are able to make a list and prioritize–focus on one or two tasks at a time–you will see the fruits of your labor.  Crossing a task off the list gives us a feeling of accomplishment and completion which can add to overall happiness and satisfaction.  Trying to chip away at several things at once can often result in no task done well.  In medicine, it may be that you spend a half day a week on administrative work–take time to separate yourself from clinical work and catch up on the rest.

6.  Be good to yourself:  As physicians we expect nothing but the best out of ourselves–we are often very critical of our own decisions and clinical outcomes.  In the current healthcare market  (world of Obamacare reform) there is much we cannot control.  We must remember to remain centered and remain “in the present” in order to achieve happiness.  Although providing perfect care is a noble goal–it is not attainable.  Be reasonable with expectations–always provide the very best of yourself to your patients and be satisfied with the fact that you do.

Happiness is critical to a successful and fulfilling career.  With sweeping changes in healthcare, many physicians are finding it more difficult to balance both success and happiness.  By applying these 6 unique principles and looking at the “big picture” it is my hope that all of us can continue to serve our patients, continue productive successful careers and remain satisfied and happy throughout our professional and personal lives.  If we are able to achieve the right balance then everyone–patients, family and YOU–will ultimately reap the benefits of a long and HAPPY career in healthcare.

Big Brother is Watching…And Your Healthcare Privacy Rights May Suffer: More Affordable Care Act Fallout

Data is essential in healthcare delivery and it is often what guides us in improving outcomes.  Utilizing data obtained from large populations helps us better decide what aspects of disease prevention and treatment need more of our attention.  I have shared my concerns about the sanctity and security of these data in a prior blog from July.  These data are important and allow us to evaluate at risk populations and target our interventions.  In the US, participation in surveys is 100% voluntary.  The Centers for Disease Control obtains most of its data from diagnoses reported by healthcare institutions (there are certain disease that are mandated by law to be reported).  However, with the advent of the Affordable Care Act (ACA), some corporations and businesses have taken the acquisition of data a step too far.  In George Orwell’s novel 1984, the author presents a vision of an dystopian society where “Big Brother” watches every move ordinary citizens make in an attempt to maintain order (and advance his own agenda).  We have all seen the recent government abuses within the National Security Administration (NSA) and within the Internal Revenue Service (IRS).  As the ACA is implemented, I am concerned that Big Brother may already be here and working in the US healthcare system today as well.  In medicine, the doctor-patient relationship is sacred–data disclosed for healthcare should be sacred as well.

Although our country has always been based on basic tenets of freedom of choice, right to privacy and other key freedoms, some institutions see Obamacare as a ticket to interfere with the daily lives of American citizens.  For instance as reported in the last several weeks by the New York Times,  Pennsylvania State University now is attempting to require all employees, including senior faculty, to undergo physical exams and answer online health questionnaires that contain very personal and very sensitive health information.  It is obvious that the pressures of the ACA and the need for cost containment is motivating these types of mandates.  From the business standpoint, the university is hoping to reduce risk and liability by modifying at risk behaviors in its insured employees.  However, none of these data will help the faculty do a better job for their employers and I am sure that the Penn State University administration clearly see this as a way to save healthcare dollars.  The next logical step, however, may be to deny or terminate employment based on health risk and potential cost to the system.  Where does the rabbit hole end?  Is this the beginning of health status discrimination in the workplace?

Many senior faculty at Penn State are refusing the mandate based on invasion of privacy–even though the university is planning to levy substantial daily fines for non responders.  Several prominent professors have stated that if they are forced to participate they will simply answer the questionnaires randomly and provide far fetched ridiculous answers–simply play the conscientious objector.  Many other Americans are waiting to see how this pans out–there is concern that this type of activity will begin to spread to other institutions and industries.  Labor unions are already beginning to lobby against these mandates–in the case of Penn State, union employees are exempt.  At what point are our private lives and medical histories private?  What is the separation between workplace and home? Where do we draw the lines and do we allow others (government and employers) to draw the lines for us?

The spirit of risk reduction and working with employees to improve their health status and live better lives makes good sense–however, there are better ways to accomplish this goal.  Health fairs, educational seminars and free health screenings for cholesterol and high blood pressure make good sense–but all of these activities should be voluntary.  Asking highly personal questions such as sexual preference, prior drug or alcohol use and the state of one’s marriage should not be a part of a wellness program at work.  In the case of the Penn State questionnaire there are even questions related to how you get along with others in the workplace–including your boss.  These issues are private and should remain that way. In defense of the institution, the development of these wellness programs are not entirely their fault.  In fact, the ACA provides a 30% discount for the implementation of a comprehensive wellness program–virtually assuring that every business will “voluntarily” submit to these types of invasion of privacy. Although the university administrators claim that the data is secure and is not available to supervisors and those in the administration, it concerns me greatly that this will not be the case– (just ask those Americans who had unlawful wire taps and those that were bullied by the IRS due to their associations with certain political groups).  Big Brother is watching….from your doctors office, from your bedroom and from your back porch.   I am afraid that this particular blog may leave you with far more questions than answers….maybe we should ask Big Brother.

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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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