Obamacare 2016: Happy Yet?

From Bradley Allen, MD in the opinion section of the Wall Street Journal this morning:

"The forecast shortage of doctors has become a real problem. It started in 2014 when the ACA cut $716 billion from Medicare to accommodate 30 million newly "insured" people through an expansion of Medicaid. More important, the predicted shortage of 42,000 primary-care physicians and that of specialists (such as heart surgeons) was vastly underestimated. It didn't take into account the ACA's effect on doctors retiring early, refusing new patients or going into concierge medicine. These estimates also ignored the millions of immigrants who would be seeking a physician after having been granted legal status.

It is surprising that the doctor shortage was not better anticipated: After all, when Massachusetts mandated health insurance in 2006, the wait to see a physician in some specialties increased considerably, the shortage of primary-care physicians escalated and more doctors stopped accepting new patients. In 2013, the Massachusetts Medical Society noted waiting times from 50 days to 128 days in some areas for new patients to see an internist, for instance.

But doctor shortages are only the beginning.

Even before the ACA cut $716 billion from its budget, Medicare only reimbursed hospitals and doctors for 70%-85% of their costs. Once this cut further reduced reimbursements, and the ACA added stacks of paperwork, more doctors refused to accept Medicare: It just didn't cover expenses.

Then there is the ACA's Medicare (government) board that dictates and rations care, and the board has begun to cut reimbursements. Some physicians now refuse even to take patients over 50 years old, not wanting to be burdened with them when they reach Medicare age. Seniors aren't happy."

Medicaid in 2016 has similar problems. A third of physicians refused to accept new Medicaid patients in 2013, and with Medicaid's expansion and government cuts, the numbers of doctors who don't take Medicaid skyrocketed. The uninsured poor now have insurance, but they can't find a doctor, so essentially the ACA was of no help.

The loss of private practice is another big problem. Because of regulations and other government disincentives to self employment, doctors began working for hospitals in the early 2000s, leaving less than half in private practice by 2013. The ACA rapidly accelerated this trend, so that now very few private practices remain."

Read the whole thing (subscription required, sorry).  Not surprisingly, it's not pretty.

-Wes

Social Media Ethics and the Control of Physician Speech

The position paper from the American College of Physicians and the Federation of State Medical Boards, is a humbling reminder of the challenges that today's physicians face when entering the online space. 

Their recommendations for online medical professionalism, written by ethics committees for the two organizations, "provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies" -- no small amount of territory to summarize.

But given the tenure of their document, I should probably hang up this blog right now.  After all, why risk being vulnerable in the online world?  While well-meaning on one hand, we should appreciate that physicians have officially been put on notice on how to behave online.

To be fair, I agree with most of what they say.   All the things about patient confidentiality are appropriate.  All the things about respect for persons, better still.

But to me, the part of the document that wanders off into the "influence of social media on the patient-physician relationship" and the influence of social media on the "public perception of physician behaviors," is more difficult to gauge in its benefit or detriment to the public discourse.  After all, perception is in the eye of the beholder.  When central health care planners muddle the ethics of patient safety by facilitating the deployment and mandating use of untested electronic medical records, should doctors sit quietly and act "professional" as the age-old ethics of research and study are cast aside in the name of the "public good?"   Taking it a step further: should doctors, in the interest of political correctness, cower in our newly constructed cubicles and tow the corporate party line, even though it harms our patients, lest we run afoul of corporate social media gag clauses?

Yes, dear doctor, according to the guidelines, you should. 

Don't harm the "profession."  Be polite.  Be respectful.  Don't stir the waters, or if you do, stir them very gently.  Stick with medical issues and don't wander into the political or the social mire.  Instruct.  Speak of the many wonders of medicine.  Don't raise red flags for they may affect "public perception" of not just doctors, but the institutions that employ them.  Tread very, very lightly, and if you can't play nice, don't play at all.  To do otherwise, dear doctor, might affect our growth strategy.

This is the challenge that doctors must face online these days.  It's not just about being ethical, for the lines of "ethics" is being blurred by others' perceptions of what we should be now, but rather it is being true to ourselves and our patients.  Doctors increasingly work for large, soon-to-be "accountable care organizations" (ACOs) where ethical standards for an organization's success can conflict with the ethical requirements for the autonomous patient.   With whom should we side, the patient or the organization?

The academic elite with little or no real experience with the nuance and complexities of this online world have little realization of the complexities of behavior online and even less appreciation how their position papers of online professionalism can come back to haunt those who delve into this space to tell our story.  "Doctor, we want to talk to you in the front office about your blog.  Do you remember that ethics document from the American College of Physicians and the Federation of State Medical Boards?"

Yes, perhaps I'm an alarmist, but we should appreciate the gravity of these seemingly well-intentioned documents to online physicians who strive to be patient advocates in an era of ACO employment of physicians. 

This is our new professional calling.

Respectfully and ethically, of course.

-Wes

They Can Build It, But Will They Come?

There's an interesting bet being played out across America right now, one that I'm really not sure how it will play out. It is that of continued consolidation and construction in the hospital industry.

Just at a time when the economy is in the doldrums, unemployment is at a steady nine percent or more, and people are paying more for their health care than ever before, we see large hospital systems growing and building at an unprecedented pace. Like squirrels hoarding their nuts for the winter in a panic before the icy winds of winter descend, big hospital systems are building, building, building.

Winter, of course, comes in 2014 for the hospital industry. That's when, according to our recently passed health care bill, the Patient Protection and Affordable Care Act, kicks in with its employer mandate. As it stands now, in 2014 all large employers with over 50 employees will have to purchase health insurance for their employees, or pay a $2000-per-employee fine.

It doesn't take many Betz cells to know what will happen when employers who presently pay $8000-$9000 per employee for health care benefits suddenly get the opportunity to pay a $2000-per-employee "fine." Do the math: for an employer with 3000 employees, they pay about $65.5 million for the health care benefits they're currently providing compared to a $6 million dollar "fine." Seems like a nearly 10-fold savings to me! Now THAT, ladies in gentleman, is one heck of a beneficial fine!

But just before 1 January 2014, Americans would have had to pick their OWN untested insurance plan from one of those offered by an insurer or the US government. These plans will carry certain prerequisites for coverage mandated by someone really smart on such matters in Washington DC, so be sure to read the fine print. If history is any guide, the govenment will want to make sure people have some "skin in the game" with their health care costs, so a larger portion of people's personal income will go toward paying for that insurance, whether it's constitutional or not to do so. That, you see, is the Grand Plan.

But will people come at the same pace to our great health care empires of the future?

No one knows.

But there sure are lots of things being done to make sure they do. Like "free" preventative health care screenings or free "Welcome to Medicare" physicals touted by policy makers as the new way to save money in health care.

Seems logical to me. (Not really.)

What policy pundits in the health care space don't get is that people don't want to think about being sick. They don't think much about their health care needs at all. They prefer Nascar. This is just human nature. We pay plastic surgeons to stay young. We pay health food stores huge sums of money to eat healthy foods. We exercise until we're blue in the face to keep our weight off. And for goodness sakes, we wear lots of facial products. (For the record, it is good to exercise and eat correctly to improve longevity, but let's be real: this simply delays the inevitable). My point is that people, given their own druthers, would prefer to spend their money on just about anything else besides health care.

And there will sit our Great Empirical Palaces to health care taking care of those who really have no choice but to succumb to the forces of nature: the Expensive Ones. The hospital systems that are located in affluent areas will get cold hard cash above and beyond the mandated insurance coverages to do so and likely survive. Those that cater to the indigent and less fortunate will either have to fold, or become like Cook County hospital in Chicago: a bureaucratically run institution with two separate boards trying to out-manuever the other in a political cat-and-mouse game of who gets to tell the taxpayers of Illinois what they're on the hook for and a shining example of fiscally-strapped public health care if there ever was one.

Which, of course, is what our large non-profit hospital systems are banking on: when the rubber meets the road, you'll want your health care like you want your facial products: nothing but first class for you.

But will people be able to afford such care?

They might not have a choice since the alternative health care option to this conundrum, the independent physician, is rapidly shrinking away in favor of the Grand Plan.

But the big question behind it all, of course, is this:

In the end, when we have no choice, will we really be able to afford all this product?

-Wes

So Much For Paying Me for Keeping You Healthy

Okay, America. Stay healthy. Eat only two thousand calories per day, exercise five times a week, don't smoke, keep your body mass index at an appropriate level and for goodness sakes, don't let me find your hemoglobin A1C over 6.5, ya hear? I demand it.

Okay, Mr. Hospital-Employer, I did my part, now pay me, okay?

What? You won't? What do you mean when you say I haven't DONE anything?

I have just broadcast to the world (via the internet, no less) exactly what I should be doing to keep people healthy. Isn't this payment-for-keeping-people-healthy thing supposed to be our new payment model going forward? We're all in this together, right? You know, one big happy Accountable Care Organization. Accountable for the quality of care we provide and for our ability to keep people out of our doors. What's better than preventing illness for lowering our costs to the health care system?

What's that you say?

What do you mean I have to work nights and weekends now? I've been your stalwart foot-soldier! I've done everything our administrative directors and the government has asked me to do: click questionnaires, completed my charts, looked at patients in the eye when I care for them, even went above and beyond to blast sincere public service announcements on your behalf!

What's that? They're getting sick anyway?

No way. They can't! They've done everything right! They've followed my every message! People don't just get cancer! We can STOP that, darn it. Maybe we can issue a few more sincere press releases and policy ideas...

Yes, sir. Sorry, sir. I'll try to do better. No problem going to another hospital that you bought. Really. No that's fine. What's a few more RVU's, right? Yes, sir, I understand.

* pause * (Reaching for his cell phone)

"Honey, I'm going to be a bit late tonight. Looks like I have to see a few more consults..."

-Wes

Agglutination

Today, another large Chicago hospital joined forces with one of the largest remaining local physician groups:

Naperville-based Edward Hospital said Tuesday it has formed a joint venture with the fourth-largest doctors group in the Chicago area.

The venture, which would treat as many as 100,000 patients, initially will focus on health maintenance organization patients of both the 309-bed hospital and Downers Grove-based DuPage Medical Group, which has 320 doctors and revenue of $363 million in 2010, according to Crain's annual ranking of physicians groups.

As the health care law winds its way through the courts, its effects are already profound. Each day we see the consolidation of the health care "market" as doctors groups are swallowed whole by large hospital systems as part of the "Accountable Care" organizational construct mandated by the Affordable Care Act. Now we see the west side of the Chicago suburbs are fortified.

For patients, there's little to notice at the present time since very little immediate change to care delivery will occur. (This was the intention.) But as payment screws tighten to these newly-agglutinated partners and the newly-insured flood the system in the years ahead, there still will be a woeful lack of physicians to absorb the influx of patients. Access to care for patients with insurance will remain challenging - likely more so.

The shortage of specialists continues, too. Our newly-minted specialists from the current training pool are finding it hard to find jobs because of these consolidations. Newly-formed large groups are reluctant to add new hires as they join forces with large health care systems because of concerns they are already joining many other doctors competing for the same pool of patients already. Since their new employment contracts will likely contain productivity clauses, who in their right mind would want to hire now?

So while many are paying attention to primary care shortages, specialist shortages are likely to be even more severe going forward.

But then, specialists cost a lot of money to our health care system, don't they?

And now you know why they call it the "Affordable Care Act."

-Wes

In Comparing Hospitals, What If They're All the Same?

Quality measures. Patient satisfaction surveys. With our new health care reform law, these "performance measures" are the new black in health care.

Hospitals are currently spending, conservatively, tens of millions of dollars to bolster these "performance measures" in hopes of securing a refund of a mere 1% of payments that CMS will soon withhold from them in the name of "assuring" quality improvement.

But what if, nationwide, there wasn't a big difference in these measures between hospitals? What happens then? Might payments then be made on political grounds?

Performance measures have been collected for some time now in anticipation of this new payment initiative by the government, so data exist to evaluate. In fact, Kaiser Health News was nice enough to aggregate the findings from our government's Hospital Compare website for my review.

So I calculated the mean, median and standard deviation of the results of all of this data collected across 50 states and 2 territories and found very little difference in measures collected between states:

MEASURE	Nurses Always Communicated Well	Docs Always Communicated Well	Always Got Help When Needed	Pain Always Well-controlled	Staff Always Explained Medications
Median	76%	80%	65%	70%	61%
Mean	76.06%	80.31%	64.42%	69.29%	60.71%
Std Dev	2.99%	2.84%	4.85%	2.19%	2.89%

MEASURE	Room & Bathroom Always Clean	Always Quiet at Night	Given Info for Recovery	Hospital Rated 9 or 10	Definitely Recommend Hospital
Median	72%	58%	82%	67%	69%
Mean	71.44%	57.67%	82.00%	66.85%	69.25%
Std Dev	3.86%	6.14%	2.95%	4.38%	3.78%

Perhaps most remarkable is the fact that none of these data are skewed (means are virtually identical to the medians) and that there is very little variability (2-6%) between the data sets.

The fact that these data are so similar across states is a testament to the nationwide health care quality that US citizens can currently expect in America.

But these data also lead to a disturbing question: if the data are so similar across every state or territory, will similar findings hold true between hospitals? How is the average Joe or Sally (or Joe or Sally government worker) going to see a meaningful difference in performance measures between states OR hospitals when they show performance differences of as little as ±3%?

The realistic answer?

They can't.

-Wes

Pradaxa, Your Days are Numbered

It was supposed to be the greatest thing since sliced bread: the first new oral anticoagulant in 50 years that did not require INR testing in the majority of patients. It's time to effective anticoagulation was measured in hours instead of days. There were even some data that suggested a possible propensity to lower intracranial bleeding rates compared its older counterpart, warfarin.

But the world changed for dabigatran (marketed by Boehringer-Ingelheim Pharmaceuticals as Pradaxa®) yesterday. That was the day the new proposed rule for structuring Accountable Care Organizations (ACOs) was proposed by CMS and published online with its addendum of 65 quality measures.

Sadly, dabigatran (and probably most of the other direct thrombin inhibitors being developed) will no longer represent "quality care" for patients with heart failure and atrial fibrillation. Quality measure #51 requires the use of warfarin, not dabigatran, for atrial fibrillation in patients with heart failure.

I am not a dabigatran drug representative, nor economist, but it is clear that innovative medications that have the potential to improve our patients' quality of living by unshackling them from the constant blood testing and phone tag with doctors required by warfarin have been officially deemed expensive and bad medicine.

Sadly, this new ACO rule is already outdated and permits the perpetuation of the status quo. The rule steps backward to tie our patients to warfarin instead of newer anticoagulant agents in the name of an "important quality measure." Once in place, this rule will tie our heart failure patients to our overburdened health care system by requiring all of those with atrial fibrillation to get their at-least-monthly prothrombin times (blood thinning levels) and then contacting their ACO for instructions for warfarin dosage adjustments.

Even more concerning, it will take legislative action (and probably expensive additional "Comparative Effectiveness Research" trials) to change these rules once they become law, and then only after a non-elected body decides it should do so. Never mind that such a study has been done.

This, my friends, is life with an ACO in the years ahead. It is for your own good and the good of our country. I'm sorry I will no longer be able to use my clinical judgment on your behalf soon to select the anticoagulant that's best for you. (Pradaxa, it's been fun.) But rest reassured: my quality scorecard, tied to my salary, will look impeccable. After all, I'll soon be practicing nothing but "quality" and "cost effective" medicine in our new Accoutable Care Organizational structure.

-Wes

Accountable Care Organizations: It's So Sad, It's Funny

Thanks to Scott Hensley over at Shots, NPR's Health blog, for highlighting this sad, but funny, video on where we're going with health care:



Scary what happens when theory meets reality.

-Wes