Category Archives: Rationing

Driving Your Doctor Out Of Business

It began almost as a footnote. 

Five months after Obamacare was passed, members of the Obama administration quietly published an article in The Annals of Internal Medicine describing the law’s planned impact on physicians.  

Shortly thereafter, the piece disappeared and was replaced with a more benign one, with the obvious cooperation of the journal. 

You won’t be able to find the original. It’s been wiped from the internet. 

(And no, not “like with a cloth or something.”)

What was so controversial about the article?

The admission that the law aimed to eliminate private medical practices — and drive physicians into the arms of hospital bureaucrats and huge medical groups. 

From the original:

“The economic forces put in motion by [the ACA] are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups … Physician practices that accept the challenge will be rewarded in the future payment system.”

The article’s authors were Nancy-Ann DeParle, JD, Office of Health Reform director, Robert Kocher, MD, formerly from the Obama National Economic Council — and the now rather infamous Ezekiel Emanuel, MD, Obamacare architect and a really special kind of bad guy.

What’s “vertical organization?”

In Medscape Medical News coverage of the piece, the writer likened “vertical organization” to the military and the federal government.

“This business catchphrase refers to enterprises
with a hierarchal structure and centralized management.
An integrated delivery system that owns hospitals,
medical practices, and other healthcare services is a prime example.”

Wow. Sure sounds like single payer, doesn’t it?

And the Obamacare masterminds have been largely successful in moving the medical community in this direction. Journalist Keith Speight observed in 2013 that:

“While the shift away from private practices was already under way prior to Obamacare, the legislation definitely threw gasoline on the fire.”

In its 2014 survey, the Physician’s Foundation found that “only 35% of physicians describe themselves as independent practice owners, down from 49% in 2012 and 62% in 2008.” In contrast, 53 percent of the survey respondents described themselves as hospital or medical group employees, increasing from 38 percent in 2008 and 44 percent in 2012.

Many of the physicians remaining in small practices have already been heroically laboring to comply with ACA and other federal requirements, spending evenings and weekends transmitting patient data through expensive electronic health record systems. 

The newest iteration of health reform,
MACRA (the Medicare Access and CHIP Reauthorization Act),
will break their backs.

MACRA (previously covered here) restructures physician pay by rewarding more patient data-gathering and obedience to government-dictated clinical and electronic activities.

The Centers for Medicare & Medicaid Services, the agency fleshing out the MACRA regulations, admits that its new rules will penalize 87 percent of solo practitioners  and 69.9 percent of practices with 2 to 9 doctors. Over time, many small practices will lose up to nine percent of their Medicare reimbursements. Meanwhile, only 18.7 percent of clinicians in groups of 100 or more will be penalized.

Tom LaGrelius, MD, president of the American College of Private Physicians, explains that “small organizations cannot possibly comply” with MACRA’s complex data-reporting requirements and will be unable to absorb the MACRA penalties. “Such practices are already running on very narrow margins with 70 percent-plus overheads.” 

The Physician’s Foundation reported that even pre-MACRA Medicare reimbursement has risen only 3.6 percent since 2001, while overhead expenses “have increased well over 20 percent.”

Orthopedic surgeon Tony Francis believes “compliance will be difficult or impossible” for small groups.

“Just reading a 962-page proposed rule would be daunting enough.
Comprehending the meaning of it is something else.
That would take a full team of lawyers and CPAs.
What small practice has that kind of resources?”

Why force independent physicians into hospital jobs? Physician and health policy expert Scott Gottlieb explains:

“It will be easier for Medicare to gain
more direct leverage over their clinical decisions.”

And you know what that means.

RATIONING

The inevitable results of the proposed MACRA regulations are these:

  • We can expect an increase in the “silent exodus” of physicians from clinical care, either through retirement or career change. Even health IT whiz John Halamka, MD, finds the MACRA proposals to be “so overwhelmingly complex that no mere human will be able to understand them… as a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.
  • Some will no doubt surrender their positions as “the knuckle-draggers who just won’t get with the Managed Care 2.0 program,” and join corporate medicine, a move that didn’t turn out well in the 1990’s, and will certainly devalue the medical care Americans have enjoyed in the past. 
  • Others will decide to opt out of the Medicare program and treat Medicare patients through private contracts.
  • Wisely realizing that private insurance companies (the Aetnas and UnitedHealths of the world) will eventually make these very same data-collection demands, many physicians will terminate all insurance contracts, offering private individually-tailored care only through direct-pay or concierge arrangements.

If the MACRA regulations are finalized, not only will independent practices suffer, but so will Medicare beneficiaries. Small physician-owned practices are already known to result in fewer preventable hospital admissions than hospital-owned practices. As the Physicians Foundation points out, while mega-health systems “can handle government rules and regulations,” they simply cannot provide “the personalized care found in the offices of private practices.”

Patients, physicians, and other stakeholders can voice their opinions about the destruction of our physicians’ small businesses at http://bit.ly/macracomment.

Your opportunity to comment will close on June 27, 2016.

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Reprehensible Republicans Ruin Medicare

Do you remember reading this from the Associated Press in mid-April? 

Suddenly, bipartisanship has broken out on Capitol Hill.

We were supposed to feel so proud of our Congress! They worked together, reached across the aisle, and enacted a permanent repeal of Medicare’s reviled SGR Fix (or Doc Fix)! 

Well, the Drive-By Media didn’t tell the rest of the story. What happened is this:

212 House Republicans and 46 Senate Republicans
joined the Democrats in radically changing the way
Medicare providers are paid
— and controlled —
by the federal government.

That’s right. The same GOP leaders vowing to repeal Obamacare just grafted it Big Time onto Medicare.

We expect this from the progressive members of Congress. But weren’t we supposed to expect a Republican Congress to lessen the size and scope of government? Didn’t last November’s election results reflect “a mandate to pass sensible legislation?”

And they wonder why we don’t take them seriously.

So who’s gonna pay for this knucklehead move? Eventually, you. 

Thanks to Congress, it’ll soon be very difficult to find a health care professional who’ll accept your Medicare card, since MACRA (Medicare Access and CHIP Reauthorization Act) applies Obamacare’s experiments to the whole program.

It wasn’t as if Medicare was untouched before MACRA, despite what HuffPo’s Jeffrey Young thinks. Thanks to Obamacare, pay-for-performance schemes like Accountable Care Organizations (ACOs) began in Medicare in 2012, and they’ve produced less than impressive results thus far. That didn’t stop our 2015 Republican “leaders” from expanding them.

What are ACOs? Think of the Health Maintenance Organizations (HMOs) of the 1990s, an idea that proved so wildly unpopular that patients revolted in near-universal protests about limited provider networks and rationed care. 

Still, the Obamacare Congress thought it was wise to apply HMO 2.0 to Medicare patients, but with an additional feature: patient satisfaction scores. That means ACO providers are financially rewarded for limiting care and procedures, but also have to make the patient feel happy about it!

(Never mind that payment for satisfaction is associated with higher health care expenses and a greater likelihood of hospitalization and death. The Obamacare Congress knows best.)

MACRA essentially forces all Medicare providers into Obamacare’s experimental ACOs. This spells the end to private independent healthcare practices, as providers must align themselves with a huge health system to survive.

Well, to be fair, doctors do have a choice. They can continue in traditional fee-for-service care, but anti-Obamacare warrior and ophthalmologist Kris Held explains the dangers of this route:

Government bureaucrats and committees will call the shots for Medicare patients. The law actually creates Alternative Payment Models (APMs) and a Merit-based Incentive Payment System (MIPS) which require physicians to follow a government rubric on which we will be graded in grade school fashion. Physicians, now defined as “eligible providers,” will get grades from 0-100 as determined by the Secretary of Health and Human Services. The grade for doing what the Secretary prescribes is called the Composite Performance Score. The score is publicly posted on the Physician Compare Internet Website of CMS, and the Secretary of HHS assigns each physician a payment adjustment factor based on this score. The payment adjustment factor will be positive, 0, or negative. Based on how well a doctor “performs” for the Secretary, the pay could be adjusted 9% up or 9% down, meaning the Secretary’s most compliant doctors will be paid 18% more than those who don’t perfectly make her wishes our commands. What will doctors put up with, and what will we do or not do for patients in order to be paid 18% more than those government deems “less quality” doctors and to avoid public humiliation on the government website? This is indeed chronic and continued abuse taken to a higher, institutionalized level.

That’s right. In either scenario, doctors will be scrutinized by federal bureaucrats aiming to reduce Medicare expenses by dictating care according to one-size-fits-all treatment protocols.

Since the passage of MACRA, many doctors are considering resignation from Medicare. “Opt out providers” will still treat you, but you’re gonna have to pay privately, outside Medicare’s supervision and reimbursement mechanisms.

This has one obvious disadvantage for the typical Medicare patient, since, depending upon the arrangement negotiated, costs may be higher to see these opt-out doctors. 

But it also means Creepy Uncle Sam won’t be in the exam room, and you’ll have care that is tailored to the individual, not forced onto you by Washington DC bean counters.

And it’s likely to be far more affordable than you may think, since health care professionals who opt out of arrangements with government and private insurance have reduced overhead costs. These doctors can charge less than their hand-cuffed peers, who can’t reduce fees for cash patients without violating government and insurance contracts.

As the Association of American Physicians and Surgeons pointed out when MACRA was passed, “opted-out physicians are able to charge a mutually agreeable fee (sometimes lower than the Medicare copayment), drastically reduce administrative overhead, give their patients the time that they need, keep records confidential, and prescribe according to their best judgment rather than a government-approved protocol.”

It’s reasonable to expect that, due to the “rising misery index” and increasing retirement rates among physicians, there will be far fewer of them in coming years. Among those that remain, a growing number will opt out of The System.

And you’ll know who to blame. This time, Republicans are the ones who apparently didn’t bother to read the bill.

Medicare providers wishing to learn how to opt out can visit here.

Americans wishing to do business with liberty-minded physicians can find them here.

Meet Jeffrey Young, HuffPo’s Medicare Donut Hole

On April 17, Huffington Post’s Jeffrey Young admitted he doesn’t know squat about Obamacare. 

Referring to a Bloomberg article on Obamacare polling, he asked his Twitter followers to enlighten him as to one woman’s claims.

And then he revealed that he has no idea whatsoever as to Obamacare’s impact on Medicare.

“Eventually” deducing that she’s “almost certainly on Medicare,” not Obamacare, he writes off her report as nonsense.

Why, it’s as if Medicare and Obamacare are two distinct and unrelated programs! 

His reasoning? On the one hand, some poor schlubs lost their plans and had to sign up for lousy coverage in the exchanges. On the other, there’s Medicare, the insurance plan for the elderly and disabled. And never the twain shall meet, right?

WRONG, Mr. Young.  And Ms. Stone isn’t a befuddled octogenarian who doesn’t know the difference. 

Ms. Stone was treated at physicians’ offices through Russell Medical Center, which has partnered with the University of Alabama at Birmingham Health System (UAB) since August, 2012. At the time, RMC agreed to a plan of “working together to solve problems in health care delivery.”  In September, 2013, UAB embraced Obamacare’s ambition to reduce health care costs.

Ms. Stone has never had heart problems, but during a routine blood draw, her triglycerides tested at 600, almost 10 times her usual result. Her internist put her on multiple medications and referred her to one of RMC’s cardiologists. 

She then became a cardiac patient. 

With three master’s degrees and two specialty degrees, including one in psychometry, Ms. Stone was no fool. “I knew the lab was wrong.” But she couldn’t convince her doctors to retest her.

“They told me I couldn’t get another test for three months and that I’d need to take all of these medicines in the meantime. They said Obamacare was the reason.”

And they explained how Obamacare is influencing patient care: “The doctors are very dissatisfied, and many of them are not able to give their patients the attention that they feel that they need because they can’t have too many appointments, too many tests.”

The unaware and uninterested Jeffrey Young, HuffPo’s Obamacare expert, admits he’s “puzzled” by this. And this revelation is surprising since he’s written about the donut hole repair, Medicare costs, and the increasing out-of-pocket costs Americans are enduring. He even weighed in on King v. Burwell. One could fairly assume he’s researched the law in its entirety. 

Did he stop reading Obamacare when it came to its reforms of Medicare? Did he get sleepy?

As a national health care reporter, Mr. Young ought to know that no other group is as affected by Obamacare as are seniors on Medicare. The law created a variety of pay-for-performance experiments in Medicare, including the following:

Section 3001: Hospital Value-Based Purchasing Program
Section 3002: Improvements to Medicare’s Physician Quality and Reporting System (PQRS)

Section 3003: Expansion of Medicare’s Physician Feedback Program 
Section 3007: Application of Medicare’s Value-Based Physician Payment Modifier (VBPM) to Physicians Payments 
Section 3022: Medicare’s Shared Savings Program for Accountable Care Organizations
Section 3023: Bundled Payment Pilot 

The goals of these experiments are to reduce costs (in large part by limiting tests and procedures) and to improve the quality of care by “rewarding value” rather than the number of services delivered. 

The problem? Federal government bureaucrats, not health care professionals, are the ones defining quality treatment. And when health care providers don’t attest to their compliance with government-approved standards, they’re penalized.

This is what ophthalmologist and Obamacare rebel Kris Held means when she refers to the law’s perverse incentives that shift focus away from what’s best for the patient to what’s best in the eyes of The System’s cost-cutters.

As physician editor of The Hospitalist Danielle Scheurer cautioned last year, “there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.” 

And lower-value care is just what Dell Stone received, thanks to bureaucratic interference with her treatment. When her triglyceride levels tested alarmingly high, her physician clicked the boxes in his electronic health record and prescribed heart medications, including a potentially dangerous statin drug. And due to the drive to keep testing expenses low, a second lipid panel had to wait.

Thankfully, when Ms. Stone returned to her cardiologist two weeks ago, her three-month wait paid off and she was granted a retest. This time her triglyceride reading was 67.

So, yes, Mr. Young, Obamacare did cause harm to this senior — and is in the process of harming countless others. 

When The System begins experimenting with your grandmother’s care, Mr. Young, will you bother to research Obamacare a bit more?