Sunday, December 29, 2013

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.


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.


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.


The difficulties experienced with the government's 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.




Jay said...

Great piece as usual. I'm impressed you've been able to make sense of this morass.

2014 will be interesting, but from my point of view, the real fireworks are due to begin in 2015 with the Independent Payment Advisory Board (IPAB) kicks in (barring the now commonplace delays).

I'm far from understanding all of this, but the IPAB really scares me because of its enormous power and lack of accountability. I think we're going to see real rationing kick in and folks won't be happy.

I'll be looking forward to hearing your take the IPAB in the months to come.

Happy New Year!


Anonymous said...

But Wes, your "Triage" paragraph is how things work currently...


Bob Fenton said...

"a stressful time for everyone" says it all.

Anonymous said...

Where are these "social workers helping patients" with confusion that you mention? Oh, inpatient only, I suppose. There is no one helping patients who are not hospitalized, which just makes them more invisible. Sigh.

Anonymous said...

What Patients Will Not Notice !
The insidious affect on medicine ! Patients will not notice the devices they would have had (tax on device revenue - big , small and start up incubator innovators) for their condition !
They will not notice the drops in quality med school applicants ,due to 'the word is out' messages about medicine 'not being the career it used to be'.
They will not notice the Green Light given to the ambulance chasers.
Patients may not notice the 'treatment-assessment' decision makers who will decide the drugs,procedures,devices ,imaging,,,,they get,,,or, will not get.
Will some patients ever see an MD, with RNP's & PA's taking over at many clinics??
Will patients notice the pandemic retirements of physicians in the next 60 months ??
No,,, however,these folks who voted this "landmark" legislation in , will be the first to start the largest 'Whining Festival' of our era. And, they still will not know all the great innovative products & services which will never (at least for a decade or two) make it to their care, their family !!! Shame the med societies and political parties did not articulate what obamacare really means to patients !

Anonymous said...

Wes writes:
"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."

C'mon Wes, Middle class is $200K-250K annual income??

US Median family income is ~50K.

Surely, those making over $200K can contribute a bit more. After all, even with all of the tax increases you mentioned, the wealthy are still paying a lower rate than during the booming economy of President Clinton.

Anonymous said...

To add a bit more income perspective, 200k is easily in the top 5% of household incomes.

Otherwise, the analysis in very interesting. I'm waiting to see what happens to the actual middle class when the 5k-11k(family) deductibles hit. As I understand it, those apply even if you get a subsidy.

For lower income people, those who qualify for big subsidies, that deductible is a killer.

Interesting times......

Anonymous said...

And just think, there's probably not a soul on the earth that has even read the whole law. I shudder to think of what will be found and how it will all play itself out.
I don't understand why it is apparently legal for a law to be passed before it is read by every member of Congress.

Anonymous said...

I hate to break it to the envious malcontents reading this post, but 200-250K income IS (upper) middle class. And those folks pay full freight for EVERYTHING. Including your "subsidies". When the parasites finally consume their hosts there will be government guaranteed lousy care for everyone. Anything more, you'll have to pony up extra. And like it or not, physicians aren't stupid. After investing (you do know what that means?) decades and hundreds of thousand of dollars to learn their skills, that is the market to which the brightest, most capable and energetic will be drawn. Capitalism 101. Morality arguments aside, that's the way it is and always will be.

Anonymous said...

God created us equal and Obama is going to keep us that way.

Carl Robinson said...

Just found your Blog Dr Wes! Very interesting to things the other side of the pond. To an NHS employee in the UK, this seems to make our healthcare process back and white.. which of course it isn't!

Anonymous said...

For a broader perspective, some may want to google "UN, Millenium Development Goals, 2015"
Here are just a few from page 49 on the PDF:

-We acknowledge that climate change is a cross-cutting and persistent crisis

-We call for holistic and integrated approaches to sustainable development which will guide humanity to live in harmony with nature and lead to restore the health and integrity of the earth's ecosystem.

-We recognize that promoting universal access to social services can make an important contribution to consolidate and achieve development gains.

-We recognize the importance of Universal Health Coverage to enhancing health, social cohesion and sustainable human and economic development.