Three Health Care Trends Patients Will Notice in the New Year

As we enter the New Year, I like to reflect on where we've been and where we're heading in medicine. By far and away, this is the most tumultuous time I have ever experienced in health care.  Doctors and nurses appear stressed and downtrodden, administrators are running scared, desperate to seem "value-added," and patients are scrambling to get seen in these last two days of 2013.

It's strange really.

I thought I'd try to make some realistic predictions of what patients should expect in the year ahead now that the "Patient Protection and Affordable Care Act" (PPACA) begins to sink it's tap root into the American medical system.

Triage

With the sudden expansion of the patient pool without a relative expansion of the physician pool, patients can expect a greater degree of triage to occur in medicine when they need to see a doctor. Triage will occur in many ways, but will fall along two lines: (1) treat the most urgent then (2) the most lucrative. Like it or not, these priorities will drive care for most medical facilities, especially our newly minted Accountable Care Organizations (aka, large hospital systems and care networks).  Specialists will become purely  proceduralists, internists and family practice doctors will see specialty follow-up and manage a team of nurse practitioners and "physician extenders," and these care extenders will become the front line care team for the more common ailments. In effect, follow-up specialty care will shift down the health care "food chain" to those less specialized in the name of improving "efficiencies" in health care. Some will argue this is cherry- picking lucrative patients and procedures, others will see this as a survival necessity for health care systems squeezed for revenue. Call it what you will, but realize it's another unintended consequence of the changes taking place in our health care market today.

Costs

There is no question that out-of-pocket costs (both direct and hidden) for health care will continue to rise for patients.  Given the recent holiday season, most Americans are strapped for cash at the beginning of the year.  But insurer's want their first installment for coverage as early as 10 January 2014.  Hidden in their premium will be a 2% tax added to the every insurance plan's premiums, plus a $2 fee that goes to the Patient Centered Outcomes Research Institute (PCORI) created by our new health care law.  As I've previously pointed out, the costly PCORI replicates functions already performed by the Agency for Health Care Quality and Research (AHRQ). The PCORI's budget is also scheduled to mushroom from $350 million to over $500 million annually in the years 2014-2019 with patients paying directly for this government agency thanks to this added fee.  And what do they get in return from the PCORI?  A wealth redistribution scheme to pay for even more "patient-centered" research redundancy.

Patient's take-home pay will also be reduced for middle-class individual tax filers earning more than $200,000 and families earning more than $250,000.  This is because they will pay an added 0.9 percent Medicare surtax on top of the existing 1.45 percent Medicare payroll tax. They’ll also pay an extra 3.8 percent Medicare tax on unearned income, such as investment dividends, rental income and capital gains.

Finally, patients will quickly begin to understand what the terms "deducitible," "co-pay," and "co-insurance" mean when it hits their pocketbooks.  My bet: they won't be happy about it.

Finally there's the issue of health insurance subsidies actually being tax credits.  As reported in the Wall Street Journal:

The federal subsidies that will help many people pay for their coverage are actually tax credits tied to their income. They will go to people making as much as 400% of the federal poverty rate—in most states, $94,200 for a family of four in 2013. The more you make, the smaller your subsidy. The subsidy process "will all be part of the tax computation," says Judy Solomon, of the Center on Budget and Policy Priorities.

People can choose to receive these credits as monthly payments that flow to their insurers over the course of the year. But if they do this, and the subsidies turn out to be too large—if the consumer's income was higher than expected and she should have received a smaller subsidy than was dispersed—the recipient may need to repay at least part of the overshoot.

To avoid this situation, people should report major changes in income to their exchange website when they occur. Consumers who know in advance that their income may fluctuate can also take "less financial support," meaning a smaller subsidy upfront, or opt for a lump sum at year's end, says Cheryl Fish-Parcham, of the consumer group Families USA. 

The government giveth and the government taketh away.   Hey, someone has to pay for all of this bureaucracy.

Confusion

The difficulties experienced with the government's HealthCare.gov website will have their trickle-down effects felt in 2014.  Given the number of vendors involved in development of the site, and their unwillingness to claim responsibility for the site's shortcomings, patients who registered on the site are likely to have little recourse for their difficulties readily apparent.  Social workers will be saddled with helping these patients, along with their other duties.  As if they don't have enough to do already.

Doctors will be introduced (perhaps "force-fed" is a better verb) to the "new and improved" ICD-10 coding scheme in 2014.  With bureaucracy run amok in medicine, this is another hassle foisted upon physicians and care-givers.  Compliance with the scheme is now a pre-requisite for physicians to be paid properly.  Expect more screen time, cursing,  and less patient-care time from your doctor as a result.

Insurers will be even more aggressive with denials based on insurance industry-developed "coverage decisions."  Doctors and patients alike will continue to find this frustrating as insurers must assure their profit margins.

So as we begin the New Year, strap in, and get ready for Health Care 2014.

We're all going to be taken for quite a ride by the changes ahead.  Rest assured, though, that there are still many doctors and nurses out there who will try to help ease their patients' burdens in such a stressful time for everyone.

-Wes



  

This Christmas, Look Up

I sit before the computer screen this morning, wondering "What should I write?"  Yet as I thought about this, I realized I should really write about why I'm thinking about this.

My journey in this space of social media has been a bumpy one, full of ups and downs, ins and outs, obsession and indifference, all rolled up into one.   Yeah, this sums up health care social media now, at least for me.

I began writing here in November 2005, not really knowing what I was doing.  I thought of this space as a marketing space, then an information-to-patient space, then a social space ("gee, so many interesting people here!) and even an "inside view of medicine" space.  In reflection, I really didn't know what the hell this space should be.

But then came 2006 and 2007, my father became gravely ill, and social media was a wonderful outlet for me to reflect on all of the emotions, memories, and experiences that such an event invokes.  I found I loved writing.  To this day, I use this space as a diary of that time in my life, and even found my eyes blurring a bit this morning as I re-read my earlier Christmas reflection of the events that occurred that year.  Blogs, I've found, are really a good space for remembering certain events, certain times.

Later, I'm not sure where I went with social media.  I signed up for Twitter during the Twitter-craze and learned about "tweets" and "hashtags" and all that stuff.  I was amazed at how "up-to-date" I could be with the latest rage, outrage, sound bite and scandal in medicine.  Heck, it my cell phone would come alive!  Medicine is so, *ping* , i-n-t-e-r-e-s-t-i-n-g again!  *ping* *ping*

As if the latest cell phone vibration, chirp, and flash was really what mattered and dull ol' medical care was just, well, glacially stimulating by comparison.  What's not to like, right?  You could be a teacher, provocateur, and health care social media detective!  You, dear doctor, could make a difference!

But in reflection, reality's been very different than that.

I realize now that I am just one voice, one small individual in a the overcrowded mess that is the internet.  Everyone is trying so hard to be heard.  Entire social media companies are developed just to make sure you pay attention to your cell phone - just look at SnapChat, where if you don't immediately attend to your cell phone, the image, message or 10-second video is gone, never to be seen again.  Pay ATTENTION, people!

This is not to say people's voices aren't important.  In fact, many in this space say incredibly powerful things here.  But I am seeing something very interesting on social media now, especially as it pertains to doctors' participation in this space: propaganda.

There are very savvy, well-organized forces on social media now.  Everyone knows this is where the battleground of public opinion rests.  So forces are marshaled, teams assembled to make sure the party line is towed.

I ask you, dear doctor, who much time do you have?  So it is with social media in health care.

But recently in my evolution in this space, I realize I have matured.  I don't come into health care social media starry-eyed any longer.  It has a purpose.  You can meet some remarkably thoughtful and insightful individuals here.  You can make some pretty amazing friends.  And you can get lost.

But I realize there's a purpose, too.  People can tell a single, quiet, story  here - a small, transcendent one, too.

Nowhere was this more visible than in the recent quiet, painful reflections of a young boy suffering with leukemia and the wonderful stories he and his parents shared in their blogs.  These are not people providing propaganda, these were people with a purpose.  These were people who realized what mattered.  These were people who were an inspiration to us all.

As I reflect on all of this at Christmas time, I find it's more important to spend these short, dwindling, yet cherished moments with real life, not one manufactured by the media companies.

Time is precious.  Family is paramount.  And social media is, well, social media.

This holiday season I hope all of us will take time to pull our heads from our cell phones and computer screens.  There some amazing things going on around us, some amazing stories of hope and courage, and things we really need to appreciate.  Most of those things aren't represented by bits and bytes on an iridescent screen, but rather what we take for granted every day, if we dare to look up.

Merry Christmas.

-Wes

Review: The Strategy That Will Fix Healthcare

Two days ago, I was directed to a piece entitled "The Strategy That Will Fix Healthcare" from the October issue of Harvard Business Review by a reader of this blog who knew I had an interest how we can get our heads around the enormity of lowering costs in health care. The piece was written by Michael E. Porter and Thomas H. Lee. Mr. Porter is a Bishop Lawrence University Professor at Harvard University based at Harvard Business School. Dr. Thomas H. Lee is the chief medical officer at Press Ganey and the former network president of Partners HealthCare and has been a professor at Harvard Medical School and Harvard School of Public Health, as well as an associate editor of the New England Journal of Medicine in his former life. Needless to say, they are perfect fodder for the Harvard Business Review.

In their article, the authors speak of their "fundamentally new strategy" that, "at its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost."

Boy, who wouldn't want that?

In their piece, they then propose six steps to "fix" healthcare:

• 1: Organize into Integrated Practice Units (IPUs)
• 2: Measure Outcomes and Costs for Every Patient
• 3: Move to Bundled Payments for Care Cycles
• 4: Integrate Care Delivery Systems
• 5: Expand Geographic Reach
• 6: Build an Enabling Information Technology Platform

But where, exactly, are the author's going? Is their prescription really a "fundamentally new strategy?"

As nicely written as the article is, I don't think so.

To me, their "Integrated Practice Units" sound strikingly similar to the "Pit Crew model" previously promoted by others. Measuring Outcomes and Costs, while it sounds nice, is enormously difficult as "outcomes" that benefit business might not be "outcomes" that benefit patients and costs (both direct and indirect) are rarely, if ever, disclosed publicly.  "Integrated Care Delivery Systems" with their high through-puts sounds an awful lot like someone else's Cheesecake Factory analogy. And bundled payments are hardly "new," having already been implemented in some health care markets.   When put this way, the authors'  "new strategies" sound like a  rehash of plenty of Harvard "old school."

Here's A Real Idea to Ponder

If these authors were really about value to patients, they need to think like patients.  Here's an example:

Some time ago, I inquired from one of the major medical device companies if they would sell a defibrillator directly to a patient.  That's right: direct-to-consumer with no middle man.  They could name their price for he had the cash to buy it. That's because he is self-insured business owner. Being a business man, he wanted to purchase the device himself and then shop the implant between centers to get a deal in a way not too dissimilar from the way one man recently shopped his hernia repair.

But what I was told was surprising.

I was told they could not sell the defibrillator directly to a patient because "we cannot ship directly to patients due to regulatory requirements around product tracing abilities."

What the...?

Seriously? Our regulatory environment prevents such a deal? Where's patient "value" there? Why do medical device companies sell  "only to doctors and hospitals" and not to patients themselves? Where is the patient "value" opportunity there?

But to Porter and Lee, this form of "value" is ignored.  They're business guys.  In their pro-business environment, "value" is defined as lower overhead, lower expenses, and more volume.  And thanks to prices that are artificially held high by the government's (Medicare) payment rates, they can continue to mark-up prices to cover other expenses which may not be of value to the patient, like lobby facades. After all, they have large indirect costs to support. Insurers, too, must assure their cut for profits as they negotiate what they'll pay for device implants.  And still more layers of bureaucracy exists with complicated coding, billing and collection that also has limited "value" to patients, especially in the case of a patient who is willing to pay cash.

We should ask ourselves if these intermediaries are the reason we are where we are in the meltdown of health care costs.

I think this more transparent model (or a variation of it) will become more common in the years ahead as patients are forced to foot more of their medical care bill.  Certainly, it won't be for everyone.  But as we continue down this health care reform path, patients will turn a keen eye to health care out-of-pocket costs.   To assure value for themselves, patients will demand THEY pay for the device, THEY chose their provider  or treatment facility, THEY decide who receives funds for care delivery, and THEY have access to their medical and device data.

THAT is the novel health care cost model that's coming that will be disruptive, not an overly simplified six-step business school "fix."  Businesses involved in all aspects of health care that provide patient-care materials, be they drugs or devices, would be wise to be an early adopter of the patient-empowerment movement. 

After all, most patients (I believe) will eventually demand real medical value for themselves, not business.

-Wes

Images of Change: The Patient Appointment

Time Discarded

Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes

Images of Change: Charting

Image courtesy Kathy Neider, MD, Staff Physician, Baptist Health

"I'm sitting where my credenza used to be, stacked high with charts. I figured if I was going to be in my office till late at night finishing electronic charting, it might as well be in a comfortable place."

Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes