http://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html?_r=0

The Fallacy of Obamacare - Affordable Care at doctors cost !

https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi%3fid=EFkuVlyEAAFiOsLMzU&tmpl=part_b_viewnews&style=part_ab_viewnews

Marilyn Tavenner RN, CMS acting adminstrator announces enaction of "Affordable Care" by asking physicians to provide care to elderly patients at their homes and get paid (by incentives) only by demonstrating "high" quality care and cost saving to the Medicare/Medicid program. The model expects doctors with their "army" of newly hired PA's ($80-90 K salary) and NP's ($90-100K salary) to go to patients home and provide care and at the same time save money !

At whose cost? 

Obviously at the cost of Medicare patients and the doctors. Getting paid at 28 cents on a dollar, (that is constantly on the chopping board) we need to hire more staff to provide this care and then hope you to get paid for the visits ONLY if we demonstrate savings to the Medicare program and at the same time provide high quality care.

Wow!  The Govt. must think all doctors with 20+ years of schooling must be dumb and never took math!

Harbir Makin, MD

Obamacare, a bad deal for America

If you think it’s hard to get an appointment with a family doctor now, just wait until you’re a little older. By 2025, it’d really be best if you avoided getting sick altogether. That’s when America will have a shortage of about 40,000 primary care physicians, according to the U.S. Department of Health and Human Services. Money is at the root of the problem (specialists earn a lot more than primary care doctors), and there is no cure in sight. Many of us won’t be able to get an appointment at all.

So what’s a patient to do? You may not like the answer, but at least it’s simple: become your own doctor. I don’t mean you should go to medical school, of course. Nor do I mean you should panic-Google your itchy tongue (more on that later). But you do need to take on a new set of tasks.

Let’s look at the three things adult primary care doctors do best. The first is to offer “episodic care,” meaning the sort of medical attention you get when you come down with something and head over to the doctor’s office. The second is to offer preventive care, helping you to head things off before they become a big problem. And the third is to monitor and treat continuing problems like diabetes or high blood pressure.

These are all essential services, and we’ll miss them when they’re gone. But here’s the best way to keep them,sort of,going.

First, when you get sick, use a walk-in clinic. These are usually called “urgent care centers,” and they’re often open 24 hours a day, perhaps located in a mall or pharmacy. So if your stomach is hurting like crazy, go consult your yellow pages or Google “urgent care” services in your city. In fact, do it before you eat that suspicious-looking soufflé and get too compromised to make good decisions. Check out the walk-in clinics nearby, write down the info, and put it on your refrigerator or in your smart phone,  so you have it ready. Here’s what you should not do: go to an emergency room with anything other than a true emergency, like a life-threatening problem. Misusing the ER is an incredible waste of time and money and I mean incredible amount of money. It costs the hospitals lots of money to staff and operate an ER.

Second, start taking the lead in your own preventive care. The good news is that the resources are out there, and this wasn’t the case even as recently as five years ago. The best place to go is the website of the US Preventive Services Task Force. This is an entity that was created precisely to allow patients (and physicians) to have the most up-to-date and scientifically supported information on prevention. The recommendations come from non-governmental, non-biased experts, and there are strict rules in place intended to prevent personal biases—and especially monetary biases—from influencing the advice that’s offered.  Look for evidence based recommendations. Do not fall for the Naturopath’s or Chiropractors advice for “cure”.  Not to say that they do not play a role in medicine, but most of non-MD “healers” go beyond their knowledge of medicine.

Third, if you’ve got chronic problems that require regular attention, start going to specialists for them. Studies show that primary care doctors do neither better nor worse than specialists when it comes to management of long-term problems such as diabetes, so it’s reasonable for you to seek long-term care with specialists, who will still be plentiful, rather than primary care doctors, who may be as rare as giant pandas after the Obama Affordable Care act gets enacted. Why?  Because Obamacare wants us, the primary physicians to be held fiscally responsible if the patient is non-compliant and uses more than average resources. The physicians will not get paid under this plan if the patient is non-compliant and does not follow a treatment plan recommended by the physician.  Go figure!

Now, to be an active participant in your own health and prevention of disease you will need to rely heavily on Internet resources.  That’s perfectly fine. But what’s not fine is frantically Googling your symptoms and coming up with half-cocked diagnoses. Before you know it, you’ll be suffering from smallpox, typhoid, and rabies. Instead, recognize that the worst-case scenario (my sore throat could be cancer!) is not even remotely likely, and stick to sites that offer reputable information. The websites of the American Academy of Family Physicians and the American College of Physicians are excellent and open to the public. Use reliable sources.

Meanwhile, current primary care providers can do a lot to help adjust to the new shortage. Every primary care physician should have a website, even if it just has updates on epidemics, downloadable forms, and basic information about the practice. This would save a lot of time in the office. Also, primary care doctors should eliminate hospital care from their regular work. Traditionally, doctors pay bedside visits to any patients of theirs who are hospitalized, in order to provide continuity in the patient’s care. But the emergence of hospital generalists called “hospitalists”—along with more enhanced communication systems—has largely replaced this need.  While it’s nice for the patient in the hospital, it’s a huge and inefficient drain on a doctor’s time.

Primary care providers should also partner with urgent care centers and send all their same-day, sick patients there. This way, they stay on schedule and their sick patients are seen right away when it’s most convenient for the sick person. However, the urgent care centers need to realize that they are what they are (“urgent” care centers) and do not replace the continuity of care provided by their PCP.

Docs who follow this will have more patients, better informed patients, and restful nights. Certainly, the shortage of family doctors and Internists is going to be a problem, but it also creates opportunities for both patients and physicians to improve existing healthcare outcomes. The shortage of PCP’s is inevitable, and until Obamacare is repealed all primary care physicians will be driven out of business and you can expect care provided by nurse practitioners and physician assistants. Diagnosis of complex diseases will be delayed with higher costs of treatment.

Adios!

Harbir Makin, MD

Healthcare Reform Commission and Anticipated Legislation

Healthcare Reform Commission and Anticipated Legislation

State of Alaska, HSS health commission has been busy over the past year collecting data to comply with the Affordable Care Act critical to the success of Obamacare.  While SCOTUS will render a decision on the individual health insurance mandate next spring, the Gov. Parnell has appointed several citizens to a fact finding commission, two are physicians, a pain specialist and a pediatrician and representatives from the insurance industry including the Blue Cross.

Below are the important points of the Millman Report and the fact finding commission. These findings are expected to play a significant role in payment reform in this State and it is also an integral part of the Affordable Care Act and the Accountable care Organizations.

·         Millman report highlights

Ø  Data is based on payment data from Government Health programs Medicare, Medicaid, Workers Compensation and the Veterans Administration. It does not truly reflect the private sector.

Ø  Payment disparity between Alaska and Washington, Montana, Idaho and North Dakota

Ø  Higher cost of living in Alaska has not been given much consideration in this report

Ø  Tort reform shelved

Ø  Emphasis on the Alaska Legislation that prevents insurance companies from paying less than the 80^th percentile

Ø  Recommendations to change the way providers are paid in this State with emphasis on changing the legislation that prevents insurers to pay less than the 80^th percentile.

For those interested in learning more, please log onto the HSS website and read the reports. HSS has sent final recommendations to Gov. Parnell. It is anticipated that some representatives in Juneau will introduce a bill to change the way insurance companies are required to pay the providers, i.e. reduce the payment threshold from 80^th percentile to a lower unknown number to reduce the payment disparity between the WAMIO states.

http://www.hss.state.ak.us/healthcommission

(Cut and paste to browser if link does not work)

Harbir Makin, MD

Ignorance is bliss !

Health and Human Services has proposed that patients be provided with their test results directly from the lab. that performs the test. 

Proposed changes to federal regulations would override existing laws in 20 states and give patients access to laboratory test results without having first to talk with the physicians who ordered the tests. The Dept. of Health and Human Services said its proposal would give patients more control over their health care information and make them better consumers.

Some physicians think that the changes would come at a cost.  Life-altering test results delivered to the patient without the context of a doctor's explanation may increase patient anxiety and affect the physician-patient relationship, however it does makes them more responsible (not liable) to follow up with their doctors regarding abnormal test results. 

One caveat, most do not know that a normal result does not rule out a disease process. It may in fact be more harmful as the patient may feel comfortable with having a normal test result and decide not to return to the physician for further diagnostic considerations. 

Does this sound familiar?

How many times do we hear a patient getting a self prescribed mammogram without a physician breast exam and later diagnosed with advanced breast cancer as she felt comfortable that the density she felt during SBE was not significant because the mammogram was normal?   How many times do we hear a PA or a NP order an EKG on a patient with chest symptoms and feel comfortable that the normal computer read out rules out an impending heart attack? 

Why not let the patients order their own lab tests at a "consumers lab" and decide if they need to see a doctor ?  If people can log onto WEB MD and make a self diagnosis, why not let them order their own lab studies as well?  

It sure will reduce the cost of health care in the US by eliminating the diagnostician from the equation!

Read the entire article in American Medical News:

www.amednews.com/2011/prl11003

Virginia Ruling Obamacare Lawsuit

In a recent U.S. appeals court ruling in Virginia, President Barack Obama won a victory for his signature healthcare law but Republican critics are emboldened in their efforts to uproot the reforms.

The 4th U.S. Circuit Court of Appeals in Richmond ruled the state of Virginia did not have the right to sue to block the law. However it is important to note that the U.S. Circuit Court of Appeals had ruled on Virginia's standing alone and not on the constitutionality.  The US appeals court in Richmond, Virginia, that voided 2 conflicting lower-court decisions was silent on the power of Congress to require individuals to obtain insurance coverage or else pay a penalty.

With divergent court decisions over the 2010 healthcare reform law, political leaders, the health industry and the states will have a harder time predicting how the U.S. Supreme Court will rule when one of the lawsuits reaches its chamber next year.

The ruling is a win for the Obama administration, which has vigorously defended the individual mandate requiring Americans to buy health insurance.  Democrats who were hurt by the healthcare law in last year’s elections for Congress and state legislatures may find comfort in this ruling and more boldly resist  the moves by Republicans to chip away at the law.

Despite the ruling, the GOP hopefuls vying to become the party's presidential candidate in 2012 have turned up the rhetorical heat on the healthcare law and this decision could turn into a rallying cry against a costly and unnecessary government expansion and intrusion. It may galvanize the voters who believe states should have more independence from the federal government and are tired of the government intrusion in their lives.  Most of the patients I talk to do not support the idea of big government intruding in their healthcare decisions.  Medicare patients are tired of what “Part D” did to their prescription costs and are seeing their primary care doctors shying away from the Medicare program due to paltry reimbursement.

Who stands to benefit from this reform? 

The individual mandate provides the healthcare industry with a large and steady pool of insurance purchasers mostly the young and the healthy whose utilization of the system is low… thus filling the coffers of the insurance executives.

However, last month's ruling in Atlanta bolstered beliefs that the Supreme Court will throw out the individual mandate but keep the rest of the law intact. While the Virginia ruling may dampen the prospect of a compromise decision, it does not make it impossible. The Virginia judges were appointed by Democratic presidents -- and two of the three were assigned by Obama. The U.S. Supreme Court leans conservative, with the chief justice appointed by former President George W. Bush, a Republican.

In its challenge of the individual mandate, Virginia claimed it had been injured, which is a prerequisite for legal standing to sue, because the ACA conflicted with a state law declaring that said no resident shall be required to obtain health insurance. The state passed the law the same day President Barack Obama signed the ACA in 2010.

Hudson concurred with the state's argument about "sovereign injury," but the appeals court disagreed. Its opinion contended that the Virginia law "regulates nothing and provides for the administration of no state program" but only purports to immunize Virginians from federal law, which it cannot do.

"The Constitution itself withholds from Virginia the power to enforce [its law] against the federal government," the opinion declared. It described the law as a nonbinding declaration that "does not create any genuine conflict with the individual mandate" that would cast the state as a truly injured party with a standing to sue.

The court warned that if states were allowed to sue the federal government based on laws passed in opposition to federal law, they could challenge the Social Security program or how the Central Intelligence Agency reports its finances.

"If we were to adopt Virginia's standing theory, each state could become a roving constitutional watchdog of sorts; no issue, no matter how generalized or quintessentially political, would fall beyond a state's power to litigate in federal court," the court stated.   Allowing Challenge to ACA Penalty Could Threaten Nation's Tax System

In yesterday's other appellate decision, 2 of the 3 judges also cited technical grounds in striking down a decision by US District Court Judge Norman Moon in Lynchburg, Virginia, that upheld the individual mandate as constitutional. Their ruling opined on the federal government's power to tax.

Liberty University and several individual plaintiffs in the case claimed that the ACA penalty levied on individuals without insurance coverage amounted to an improper tax. They leveled the same charge against an ACA penalty on large employers whose otherwise uninsured employees buy coverage on their own with government help.

The Obama administration asked Moon to throw out the case because a tax law called the Anti-Injunction Act (AIA) bars lawsuits seeking to restrain the assessment or collection of a tax beforehand (taxes can be contested after they are paid). Moon rejected that argument and stated that the AIA does not apply to the ACA penalties.

Two of the 3 appellate judges took the opposite position and said that the ACA penalties did constitute taxes for AIA purposes, citing Supreme Court precedents. "No tax may be challenged in any pre-enforcement action," the majority opinion stated.

The opinion warned that exempting ACA penalties from the AIA could open the floodgate to preenforcement court challenges to income taxes that could "in the long run, wreak havoc on the [government's] ability to collect revenue."

Curiously, the Obama administration did a about-face at the appellate level and agreed with the plaintiffs that the AIA would not bar the lawsuit against the ACA. The majority opinion held that the government's "newly-minted position" contradicted its earlier interpretation of the AIA.

Harbir Makin, MD
Internal Medicine

Obamacare Lawsuit

Once again, I apologize to the folks who did not wish to receive these blogs and read my ranting. I did make a conscientious effort to delete all the names on the “no call list.”  Also, this topic is not meant to undermine my esteemed and deserving colleagues but is an important topic of National debate that will sweep across the States once the Federal Court renders a decision.

Six family physicians in Georgia have accused the Medicare program, in a federal lawsuit filed two weeks ago in US District Court in Maryland, of illegally relying on a committee (RUC) of the American Medical Association (AMA), which they hold responsible for paltry reimbursement rates for primary care physicians and inflated ones for proceduralists and sub-specialists.

This the latest sign of a long-standing rift between primary care doctors and specialists over Medicare compensation. This difference has been a major cause of difficulty with access to primary care physicians across the Nation.  If Obama Care becomes a reality the access to the proposed “free” preventative services would worsen as the number of new PCP’s opting out or being produced will continue to decline unless this disparity is narrowed urgently.

A recent legislation proposed by Rep. Jim McDermott, MD (D-WA) would require the Medicare and Medicaid Services (CMS) to hire independent analysts to identify overpaid and underpaid services in addition to “listening” to the AMA (RUC) committee's advice.

AMA historically represents more sub-specialists than primary care physicians and has been the proponent of RBRVS and its flawed RVS (relative value scale) that led to wide disparity in the reimbursement for cognitive services typically provided by Internal Medicine doctors and family Practice doctors.

Designed to cover all specialties, including the primary care specialties, the committee is supposed to work with the complicated formula. It has 29 members, 23 of whom are appointed by National Medical Societies. Twenty-six of the 29 have voting rights.

Illegal Advisory Committee? 

This will be decided by the lawsuit filed by the 6 FP doctors in Evans, Georgia. This committee (RUC) is being blamed for contributing to the inequality leading to Medicare underpaying primary care physicians and overpaying the specialists

The suit alleges that:

1. Committee membership is "highly biased" toward procedural specialties and only 2 seats of the 29 total truly represent primary care.
2. Committee’s recommendations are based on practice data collected by medical societies using a survey method that experts describe as inherently biased, arbitrary and capricious.
3. The committee functions for all intents and purposes as a federal advisory committee, yet it does not obey laws requiring such committees to field a balanced membership and conduct public meetings. (For its part, the AMA states on its web site that RUC is not an advisory committee to CMS but an independent group "exercising its First Amendment right to petition the federal government," and final payment decisions rest with the CMS.)

All of these circumstances combine to tilt the scale in favor of specialty care and devastate primary care in the process. Medical students are choosing more lucrative specialties (less hours more rewards), leaving primary care shorthanded. Those who do toil in that field are hard pressed to meet the needs of their current patients, leave alone the millions of new patients to be added in the future as a result of proposed changes in the healthcare reform.

For two decades now, this panel has been dominated by specialists who undervalue the essential, complex diagnostic and cognitive skills of primary care physicians, while often favoring costly procedural services.  The result of this is clear — there is a shortage of PCP’s and the patients are not getting the basic services they need. The medical costs are increasingly driven higher by costly and risky procedures, some with questionable benefit…. as determined by evidence based medicine.

The whole issue of RBRVS and RVS and the committee is bizarre and self-serving.  The two medical societies representing primary care physicians — the American Academy of Family Physicians and the Society of General Internal Medicine — have endorsed the proposed McDermott legislation, whereas a consortium of 47 societies, mostly in the specialty realm, have lined up against it. This opposition group includes the American College of Surgeons, the American College of Cardiology, the American College of Obstetricians and Gynecologists, the American College of Radiology, and the to my surprise American Osteopathic Association (AOA).  As of recent years AOA has been producing more sub-specialists than any other group and it encourages its members to “gain respect” by joining the sub-specialty ranks of medicine.  The reason being primarily the financial support these institutes need…., prospective medical students had looked at schools of Osteopathy only second to the traditional allopathic medical schools.

Missing from the list is the giant American College of Physicians (ACP), presumably representing internists. Not surprisingly ACP has long lost its muscle in representing its ranks in the political arena, unlike other colleges that successfully lobby on their members behalf.

Rep. McDermott cites another fact, “however — since RUC's debut, the income gap between primary care physicians and their specialist colleagues has widened from 61% to 89%”.

This disparity needs to be narrowed and needs to be narrowed soon and…. before our species becomes outmoded….. like the Dinosaurian phenomenon!

Harbir Makin, MD
Internal Medicine, Anchorage Alaska