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

Medicare Cuts

Few Americans would support major cuts to Medicare Program to reduce the federal deficit, but many would like to see the increasingly unpopular health care program to improve the accessibility to quality medical care.

The Medicare program with it's extreme dictatorship style bureaucracy, steadily declining reimbursement and flawed reimbursement formula has become a major issue for physicians, particularly the primary care physicians across the Nation to keep their doors open. This has forced a large number of primary care physicians to either stop accepting new Medicare patients, limit the number of Medicare patients they will see or simply stop seeing Medicare patients to stay afloat.

The fearless few have boldly "OPTED-OUT" of the Medicare Program with the risk of losing a good percentage of their patients to mid-level practitioner's such as the nurse practitioners or the physician assistants who are not trained to make complex diagnosis and provide comprehensive care to this group of patients who by virtue of their age suffer from multi-organ disease.

I was the second physician (the first was an Internist in Fairbanks ) in the State of Alaska to OPT-OUT of Medicare about 10 years ago. Due to large percentage of my practice being Medicare, I was in a situation of either closing down my practice and moving or make changes to my current practice to survive. I sent an open letter to survey all my current Medicare patients (approximately 60% of my practice and those who were close to retirement asking for their opinion about the Medicare program and asked their opinion if they would honor my decision to OPT-OUT.  I was worried about retaliation from the community, the Medicare Program and my colleagues. To my surprise 95% of those responding solemnly supported my decision to "opt-out" and promised to continue as patients. 

Then came the tough decision of  finding that first patient who was willing to sign the first contract before I could opt out.   The Feds. have purposefully made it a difficult process for physicians to opt-out.  It required legalities that were not published and had time constraints and most importantly required one Medicare Patient to sign a "Private Contract" before I could submit my affidavit with Medicare to opt-out.  I sent a random letter to 10 patients asking for a volunteer and to my surprise eight showed up the following week to sign up.  A kind lady, who has since passed away was delighted to sign the first contract and was so happy to see her physician "liberated" from the woes of Medicare and it's bureaucracy. 

After several thousand dollars in legal fees and moral support of my wife, friends, patients, employees and an attorney friend I launched into the era of  "OPT-OUT" medicine to provide the best of care my elderly patients deserved without the fear Medicare bureaucracy and dictatorship. I have always been an advocate for my patients and that is what won my battle against Medicare Bureaucracy.   There has been no turning back, my patients no longer feel like "second class citizens" the Medicare Program made them feel.  On the other hand it has made them better patients and consumers.

I admit some of my "newer" Medicare patients have sporadically left my practice to see another doctor and that percentage is minute. Some have left to check the "greener pasture" in the new Providence Senior Clinic run by one Family Doctor, a Public Health Doctor and a band of mid level practitioners and a handful have migrated to Dr. George Rhyneer's Medicare Clinic run by the Alaska Physicians and Surgeons (APS) where care is provided by one family practice doctor supported by a large ancillary staff of 3 receptionists, 3 nurses, 2 medical assistants, a manager and three billing staff, with financial support from the State and a few foundations.  

The formula to "success" proposed by this clinic is based on  "one problem - one appointment" concept that is supposed to generate revenue by over utilization.   This concept leads to a patient with multiple medical problems to make multiple appointments for medical care that should have been and could have been provided in one visit and one charge.  Patients are required to make an appointment to get medication refills and are required to make an appointment if they have a concern as the clinic "concept" does not allow phone calls or advise over the phone.  The end result is generating revenue by over utilization.  So how is this cost effective for the patient and the entire Medicare Program?  This is just another way of circumventing the flawed reimbursement formula and the whole Medicare Program.

Is there a solution to this problem?

While policing the entire world and spending trillions of dollars fighting global wars, the Federal Government will never have enough money to provide for the health care and social programs for the increasing number of baby boomers who are turning 65 and being FORCED into the Medicare Program.

The health insurance industry with its massive lobbying efforts has always taken advantage of the way Medicare program was designed. The Medicare program is managed by the so called third party adminstrators who profit by "pushing paper" for the Medicare program. 35 % of health care dollars are spent on adminstrative "paper pushing". 

Congratulations to Alaska Senator Lisa Murkowski, for taking the bold step of being the first Senator to introduce the bill for "balance billing". The insurance companies have for decades taken advantage of the "no balance billing" provision in Medicare. The doctors are forced to write off 65% of the billed charges. The secondary insurance does not honor the balance of the bill and pays only (20%) a minute amount left after Medicare has paid 80% of the "allowable" charge. Most think that doctors collect the entire balance from their secondary insurance, but when I explain to the few who have asked, they are surprised or rather shocked to hear how low the actual reimbursement is. Senator Murkowski has been the first Senator to actually listen to our "woes". If her bill goes through (it's a uphill battle against a big insurance industry lobby) the balance of the bill will have to be paid by the secondary insurance that majority of seniors do have from having paid into their employers health palns their entire lives, or the pateints would be empowered to negotiate that with the physician.

 It's time for seniors to step up and tell their employers to honor their contracts of "life long" health benefits that they were promised.  This bill needs a lot of public support and we all need to do our share. Beleive me, It's not all about money, but truth is that the primary care doctors will soon be forced to take the shingle down and care will be provided by mid levels.

Finally comes the million dollar (or a trillion dollar !) question:   Is the American public willing to accept Medicare Cuts proposed by the Obama White House?

The latest tracking survey on healthcarerovide comprehensive care issues by the Kaiser Family Foundation found that the public is more willing to accept Medicare spending cuts if done to shore up the elderly healthcare program rather than for deficit reduction or avoiding tax increases. Congressional Republicans want cuts to Medicare and other health and welfare programs as part of a deficit-reduction package they say is needed to secure their support for an increase in the $14.3 trillion debt limit. Democrats balk at including Medicare cuts as long as Republicans refuse to accept revenue increases. Both parties balk as the 2012 elections fast approach. Does the Tea party have a clue?  

The Kaiser survey found that the public's willingness to accept Medicare spending cuts varied with how the savings would be used. Thirty-two percent of those polled said they would back major cuts if the money was used to prevent Medicare from going bankrupt, 42% said they would accept minor changes to keep the program solvent, while 21% said they would support no program reductions for that purpose.

When asked about Medicare cuts to reduce the federal deficit, 18% said they would back major cuts, while 45% said they would be okay with minor cuts. Thirty-three percent said they oppose any Medicare spending cuts for deficit reduction, the survey said.

A similar number, 32%, said they don't support cutting Medicare to avoid tax increases. Forty-three percent said they would be okay with minor cuts, while 20% said they backed major Medicare cuts to avoid tax increases.

When it came to avoiding tax increases for the wealthy, 40% said they would not back Medicare cuts. Thirty-three percent said they would support minor Medicare spending reductions, while 21% said they were okay with major Medicare spending cuts to avoid raising taxes on the wealthy.

Overall, the survey found that the public prefers spending cuts over tax increases as the main approach to deficit reduction.

Kaiser said the survey of 1,203 adults was conducted June 9 through June 14 and has a sampling error of plus or minus 3 percentage points.

CONCIERGE MEDICINE

Concierge practice has yet to arrive in Alaska. This is primarily due to the “isolation” of our State from the “events” in the lower 48.  Today I am going to discuss a little bit about the growing practice of "concierge" or "boutique" medicine patients are encountering in the Lower 48.  What is concierge medicine?   Basically, in concierge medicine, patients pay an additional fee (usually $1500-$2000 a year), and in return they receive better access and service. It is a promise that if they join the plan, the doctor will answer their phone calls 24-7 and concierge patients have more time available when they come in for an office visit, and they do not have to go through a tedious process to gain access to the appropriate specialists in a timely fashion. In other words, patients are going to get “more” of the doctor for the extra fee paid once a year.

What is fueling this shift towards this practice, particularly in primary care?

Simple, it is the red tape, hassles, bureaucracy, micromanagement, and too much overhead cost that primary care providers are facing in the current healthcare environment combined with inequality in the reimbursement formula that favors procedures over cognitive services. There is just not enough time to see patients, and people feel as though they are on an assembly line. It's understandable that the idea of having patients pay more as a way of getting out of a broken system might come to the fore. A lot of people are doing this. There are probably 6000 primary care physicians alone who have shifted over to a concierge practice. To be honest, concierge medicine for the superrich has always been around. The person who has an addiction who goes off to the Betty Ford Clinic and the executive who takes a jet for an executive physical at the Mayo Clinic or the Virginia Mason Clinic:  These are versions of concierge or boutique medical practice. Now it's expanding into the middle class because of our broken health system.

What is the downside, and what are the ethical worries about this growing type of practice?

First, there aren't enough primary care providers around to begin with. We all know that we have too many specialists, not enough generalists, and not enough primary care providers in the United States. If you take a significant number of them out of the pool available to every patient and make them available only to people who can pay additional fees, it results in a bigger workload for the rest of the providers who are doing primary care. No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don't take the concierge route) with more work and the patients are going to end up getting lower-quality care because they might see more physician extenders, a trend that is rampant in Anchorage with “Primary Care Clinics” and “Senior Medicare Clinics” mushrooming all over the city. 

There are certainly some great physician extenders who can play a role in team work -- but patients don't understand that they may be seeing someone with a lot less training and may be paying the same money or fees for someone with less qualification.  Current trend in Anchorage is appalling as large group of sub-specialty physicians choose to use mid-level practitioners as their first contact with referred patients.  My patients are not happy as they wasted time seeing a mid-level when I referred them to a sub-specialist as the diagnostic and treatment plan required a higher level of training and expertise. How can we justify wasting valuable health care dollars on sub-standard sub-specialty consultation rendered by a mid-level who has less training and experience than a referring Primary Care Doctor?

At the end of the day, we have a justice issue. Concierge practice is a business solution to what is essentially a broken system. We must find different ways of solving the problems with healthcare, other than having people pay a fee to escape the broken system.

Concierge medicine is fundamentally unjust, however until the wide discrepancy in the primary care reimbursement formula is fixed we will see more and more PCP’s migrating to the “Concierge Practice” to keep their doors open. The result is what we have just started seeing: medical clinics run by nurse practitioners and physician assistants. We have to come up with a better answer. It will probably be something along the lines of payment reform for Primary Care Cognitive services that our AMA and other Medical Societies (primarily representing increasing numbers of sub-specialists) choose not to discuss.  Concierge medicine is more a symptom of a broken system than it is a solution.

Harbir Makin, MD

Internal Medicine, Anchorage Alaska

Malpractice Liability with Obamacare

If and only if the "accountable care organizations" (ACO) become a reality, the end product may end up looking far different from what was initially conceived by Obama Care proponents.  Regardless, the goal of healthcare reform will be and should be to encourage providers to become more integrated, reduce waste, prevent needless expenditures, and lead to better healthcare for all Americans. Whether it will reduce the amount we spend on healthcare is debatable and remains to be seen. 

On Aug. 8, CMS reported the findings of its five-year pre-ACO demo. Only four of the 10 participating physician groups received incentive payments. CMS Administrator Donald Berwick, MD, recognized the difficulty in launching ACOs, while remaining positive. “We have learned to invest in sustained improvement over time,” he said, “and [learned] that short-term comparisons between start-up costs and measureable results may fail to realize the long-term value of these efforts.”

Marshfield Clinic, in Wisconsin was one of the top earners in the demo earning $56.2 million in bonus payments – more than half of the total payments in the demonstration project.  Majority of physicians in Wisconsin are already in some sort of HMO type structure designed to reward for performance.  However in this published CMS demonstration the results were sobering. Out of the 10 highly motivated groups only 4 were able to save resources and deliver higher quality care while the balance either sustained the costs and quality or the costs increased without change in quality of care delivered with resulting penalties and reduced payments to the providers. While the Marshfield “phenomenon” like the “Kaiser” model is based on performance incentives, that particular trend had resulted in providers being forced to make decisions based on their pocket books, resulting in higher rates of denial of necessary care and procedures just like it happened in the 1980’s resulting in collapse of the capitated system when the consumers cried foul due to HMO (aka ACO) atrocities and injuries as a result of rationed health care in the name of saving health care dollars. The administration at that time imposed laws like EMTALA and anti-dumping laws.

Threaded throughout the proposed current ACO regulations is certain expectation which may have the unintended consequence of increasing malpractice liability for all physicians deciding to participate in the ACO’s.

Under the proposed ACO model, physicians will necessarily have far greater "duties to the patient." Providers named in a lawsuit may not only need to defend their actions in light of the prevailing standards of care, but also explain the details of an individualized care plan and whether their duties within the care plan were met.  The proposed regulations state, "the ACO and the participants shall demonstrate to the Secretary of CMS that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans."

What's worse is that unless expressly stated otherwise, these individualized care plans may be discoverable by plaintiff attorneys. And assuming that they are relevant to the case, they may also be admissible in a trial.  Plaintiffs will gain a significant advantage if they can demonstrate that a physician did not follow the recommended care plan which will likely be in addition to the current standard of care as physicians become liable for the patient and caregiver assignments. The providers, according to the proposals, are required to make sure the “entire” team is compliant with the treatment plan. This shifts the burden of compliance to the provider rather than the patient who is needs to follow the recommended treatment plan.

How does the CMS propose the providers accomplish this burdensome task, without increasing their overheads,  to supervise the “spoon feeding, hand holding and TLC ” treatment of patients who refuse to follow a treatment plan, are non-compliant or prefer to follow “alternative or un-conventional holistic” therapy?

The CMS proposed regulations does require in “plain and clear language” that the ACO’s and its participants (emphasis added) address the needs of their patient population.  Moreover, "we are proposing that ACOs must have systems in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations."  But the big question is who pays for this process and seemingly the burden will rest of the physicians.

Logically, if a physician participating in the ACO does not provide treatment or care consistent with the expressly stated objectives, liability exposure will increase.

With all of these new and burdensome duties and without a directive to shield all of this information from litigation, defending care in some instances may be difficult for an ACO and its participating physicians.

The healthcare reform needs to be tied to malpractice reform, until that happens we can expect ACO’s and participating providers to continue to practice defensive medicine and resulting wastage of resources.

I propose all patients participating in “ACO” model of care be required to participate in a mandatory malpractice mediation paid for by the CMS and all injuries and expenses of mediation be compensated through a “Federal Medical Injury Fund”.  Mediation panels should include representative from ACO’s local unions, the Bar association, Medical Societies and Legislators appointed by the Governor for a two to five year staggered term.

Harbir Makin, MD

The DOC FIX

As Congress and the White House continue to debate how to reduce federal debt and raise the government's debt ceiling before a doomsday deadline of August 2, organized medicine wonders whether the outcome will include the "doc fix" to the Medicare reimbursement crisis for which it has pled.

At least one deal on the table — the plan from the bipartisan "Gang of Six," composed of 3 Republican and 3 Democratic senators — gives physicians what they want, or does it?  Every year the physicians are threatened with notorious SGR formula (sustained growth rate) for reimbursement under the Medicare Program.  On January 1, 2012 the “chopping board” will trigger a whopping 29.5% pay cut, unless the Congress acts on it now to avert it. The big question is would it be averted?   With our politicians playing “dirty politics” it is likely that this issue will likely get least attention when the country is on the verge of defaulting.  The “gang of six” may have it included in the current debt ceiling negotiations but how likely is it to pass with the provisions of “doc fix”.

How does Medicare (whose chief says Medicare is just another insurance company and the seniors are just its beneficiaries) expect the doctors to continue providing services to its beneficiaries with its HMO tactics and the “chopping block”?   Technology is expensive and quality (that all of us have come to expect) costs money.  While we all want quality health care as our birth rights (just like food, water and shelter) who is willing to pay for such quality?   Medicare cuts and HMO tactics is not the solution to provide cheap and quality care.   While the rest of the Nation is disgusted with HMO’s, Alaska is gearing up for a major HMO style managed care as the Hospitals and some Insurance companies look at this moment (under cover of National Health Care Debate) as a prime opportunity to ratchet down on the Providers in this State that has been long resisted by the independent spirit of the doctors who call this State their home………. Yes, it can happen in Alaska as the older generation of free spirited physicians phase out and the newer X- Generation of physicians look for an easy life style.

I constantly hear from my senior patients the question that why the Government has to force them into a “health insurance” (Medicare) that does not work for them or majority of the seniors.  Why can’t they OPT-OUT of Medicare and keep the health plan that they have contributed into all their lives and the plan that works well for them?   

Why should the Government have a problem with it if Medicare is “just another insurance company” as claimed by the chief of CMS, Dr. Donald Berwick?  The ex- Harvard health care safety and efficiency advocate who now heads Medicare and Medicaid in Washington, told health insurance executives in Washington during his first speech that he does not advocate rationing or major "top down'' government solutions to transform the health care system but on the other hand said he'll  "play tough" with those who resist a change. 

Harbir Makin, MD

MEDICARE CUTS

A contentious Congress finally averted a catastrophic government default but it did not calm the financial markets, undermining the credit worthiness of Uncle Sam.   It is troubling to the physicians and the hospital executives, who could see their Medicare reimbursements trimmed in the process. Those potential cuts would come at a time when providers already face other major Medicare reductions. The bill did not include a "doc fix" to the Medicare reimbursement crisis and physicians have been “double crossed” by our self-centered politicians once again. Physicians are scheduled for a 29.5% decrease on January 1, 2012, unless Congress intervenes and with the current hostilities it is unlikely that it will.

The debt legislation lays out a complex path to additional Medicare pay cuts.  A summary of the bill posted on the White House Web site explains that potential Medicare cuts would be "limited to the provider side” while the providers had sought reimbursement relief.  The end result is disheartening as lower Medicare pay would cause many physicians to limit the number of Medicare patients they treat — thus reducing access to care.

The debt ceiling/deficit reduction plan offers a potentially false promise to the patients, it guarantees benefits but, by ignoring Medicare physician payment issues, it potentially denies the actual medical care Medicare beneficiaries will be able to access.  What dials up the anxiety factor further is that the bill passed by Congress does not specify how automatic cuts would be applied to Medicare, likely it will be applied to Part A and Part B (provider services).

The potential for Medicare provider cuts was not lost on The Wall Street. Stocks for healthcare companies, including those that operate hospitals.  The AHA (American Hospital Association) worries that the reimbursement would be sacrificed for the sake of physicians while the physicians worry that the hospitals (a larger lobby) will take over the division and distribution of Medicare payments to the physicians as proposed by Obama Care advocates. The hospitals are proactive in opening their “own clinics” to control the healthcare “pie”.  We are seeing a greater trend in the hospitals owning sub-specialty clinics to compete for the “Medicare pie.” The hospitals, with the advent of Hospitalists do not see primary care physicians being a threat and most PCP’s are being replaced by mid-level providers such as the ANP’s and the PA’s who feed the business to the hospital by utilizing their lab and radiology services.

Organized medicine has not given up petitioning Congress for the elusive doc fix, which almost became a part of the 2010 healthcare reform law before Democrats erased it because of its high cost.  However AMA has repeatedly proven to be ineffective in lobbying for the profession it represents.  Instead of trying to tame runaway costs through "futile" price-control solutions such as the sustainable growth rate formula we ought to encourage our Senators to introduce reforms to promote and reward quality and efficiency.  Such an indirect approach to cost control would have a better chance of succeeding and would weed out the “high rolling” providers who abuse the system by providing sub-standard care by employing mid-level providers who due to lack of confidence and training over use the system and refer patients for unnecessary sub-specialty care.  

What Congress needs to do is to fix the Medicare reimbursement formula that heavily favors procedures over cognitive evaluation.  In the current reimbursement situation Primary Care specialists will be soon extinct and you can expect more and more healthcare dollars being wasted by mid-levels who lack the training, diagnostic skills and experience of a good Primary Care Physician. 

 Harbir Makin, MD

Medicare Cuts

Few Americans would support major cuts to Medicare Program to reduce the federal deficit, but many would like to see the increasingly unpopular health care program to improve the accessibility to quality medical care.

The Medicare program with it's extreme dictatorship style bureaucracy, steadily declining reimbursement and flawed reimbursement formula has become a major issue for physicians, particularly the primary care physicians across the Nation to keep their doors open.  This has forced a large number of primary care physicians to stop accepting new Medicare patients, limit the number of Medicare patients they see or simply stop seeing Medicare patients to stay afloat. Some have boldly "OPTED-OUT" of the Medicare Program with the risk of losing a good percentage of their patients to mid-level practitioner's such as the nurse practitioners or the physician assistants who are not trained to make complex diagnosis and provide comprehensive care to this group of patients who by virtue of their age suffer from multi-organ disease.

Ten years ago, I was the second physician (the first was an Internist in Fairbanks ) in the State of Alaska to OPT-OUT of Medicare. Due to large percentage of my practice being Medicare, I was in a situation of either closing down my practice and moving or making changes to my current practice and survive. I sent an open letter to survey all my Medicare patients (approximately 60% of my practice)and those who were close to enrolling and asked for their opinion about the Medicare program and their opinion of what they thought about my decision to OPT-OUT of Medicare. To my surprise 95% of those responding supported my decision to "opt-out" and promised to continue as patients.

Then came the difficult decision of finding that "first" patient who was willing to sign the "first contract" before I could legally opt out. The Feds. have purposefully made it a difficult process for physicians to opt-out. It required certain legalities that were not published and had time constraints and most importantly required that first Medicare Patient to sign a "Private Contract" before I could even submit my application and affidavit to opt-out. I sent a letter to 10 randomly selected patients asking for a volunteer and to my surprise eight showed up the following week to sign up. A kind lady, who has since passed was delighted to sign that first contract and was happy to see her physician "liberated" from the woes of Medicare program and it's bureaucracy.

After several thousand dollars in legal fees and much needed moral support of my wife, friends, patients, employees and an attorney friend I launched into the era of "OPT-OUT" medicine to provide the best care my elderly patients deserved and without the fear of Medicare bureaucracy and dictatorship. I have always been an advocate for my patients and that is what won my battle against Medicare Bureaucracy. There has been no turning back, my patients no longer feel like "second class citizens" the Medicare Program made them feel and has made them better patients and consumers who use the system judiously.

Not to say that all were happy, I admit some of my "newer" Medicare patients have left my practice to see another doctor but that percentage is small. Some have left to check out the "greener pastures" in the new Providence Senior Clinic run by Family Practice physician and a Public Health physician and a band of mid level practitioners and a handful have migrated to Dr. George Rhyneer's Medicare Clinic run by the Alaska Physicians and Surgeons (APS).

In Dr. Rhyneers Medicare Clinic care is provided by one family practice doctor supported by an ancillary staff of 3 receptionists, 3 nurses, 2 medical assistants, a manager and three billing staff, with a one time financial grant provided by the State and support from a few non-profit foundations. The formula of "success" proposed by this clinic is based on a "one problem -one appointment" scheme that is supposed to generate revenue by over utilization of Medicare.

This revenue generating scheme forces a patient with multiple medical problems to make multiple appointments to get medical care that should have been provided in one visit with one charge. Patients are required to make an appointment for each medication refill and are required to make an appointment if they have a question or a concern. The clinic's "concept" does not allow phone calls to be made to the providers. The end result is generating revenue by over utilization of the burdened , financially run down Medicare Program.

So how is this cost effective for the patient and the entire Medicare Program? 

Would this not be considered fraud by over-utilization?

Is there a solution to this Mediare problem?

While policing the entire world and spending trillions of dollars fighting global wars, the Federal Government will never have enough money to provide for the health care and the social programs needed for the increasing number of baby boomers turning 65 and being FORCED into the Medicare Program.  The health insurance industry with it's massive lobbying efforts has always taken advantage of the loop holes in Medicare program that is flawed by concept and design. The Medicare program is managed by these insurance companies under the guise of so called third party adminstrators. These TPA's profit by "pushing paper" for the Medicare program and 35 % of health care dollars are spent on adminstrative "paper pushing".

Congratulations to Alaska Senator Lisa Murkowski, for taking the bold step of being the first Senator to introduce the bill for "balance billing". The insurance companies have for decades taken advantage of the "no balance billing" loop hole in Medicare that forces the providers to write off 65% of the billed charges. The secondary insurance does not honor the balance of the bill and pays only (20%) a miniscule amount left after Medicare pays 80% of the "allowable" charge. 

The ill informed public is made to believe that the doctors collect the entire balance from their secondary insurance, but the reality hits home when I explain to the few who have asked, and they are surprised or rather shocked to learn how little the actual reimbursement is.

Senator Murkowski has been the first Senator to actually listen to our "woes" and introduce the bill. If her bill goes through (it's a uphill battle against a big insurance industry lobby) the balance of the bill will have to be paid by the secondary insurance that majority of seniors do have from having paid into their employers health palns their entire lives.

It's time for seniors to step up and demand that their employers and their insurance companies honor their contracts of "life long" health care benefits. This bill needs a lot of public support and we all need to do our share.  Beleive me, It's not about money, but truth is that the primary care doctors will soon become extinct and then care will be provided by mid levels.  Thus over-utilization and unnecessary and expensive referrals to specialists by the mid-levels cause the costs to go up.

Finally comes the million dollar (or a trillion dollar !) question: Is the American public willing to accept Medicare Cuts proposed by the Obama White House?

The latest tracking survey on health care issues by the Kaiser Family Foundation found that the public is more willing to accept Medicare spending cuts if done to shore up the elderly healthcare program rather than for deficit reduction or avoiding tax increases. Congressional Republicans want cuts to Medicare and other health and welfare programs as part of a deficit-reduction package they say is needed to secure their support for an increase in the $14.3 trillion debt limit. Democrats balk at including Medicare cuts as long as Republicans refuse to accept revenue increases. Both parties balk as the 2012 elections fast approach. Does the Tea party have a clue?

The Kaiser survey found that the public's willingness to accept Medicare spending cuts varied with how the savings would be used. Thirty-two percent of those polled said they would back major cuts if the money was used to prevent Medicare from going bankrupt, 42% said they would accept minor changes to keep the program solvent, while 21% said they would support no program reductions for that purpose.

When asked about Medicare cuts to reduce the federal deficit, 18% said they would back major cuts, while 45% said they would be okay with minor cuts. Thirty-three percent said they oppose any Medicare spending cuts for deficit reduction, the survey said.

A similar number, 32%, said they don't support cutting Medicare to avoid tax increases. Forty-three percent said they would be okay with minor cuts, while 20% said they backed major Medicare cuts to avoid tax increases.

When it came to avoiding tax increases for the wealthy, 40% said they would not back Medicare cuts. Thirty-three percent said they would support minor Medicare spending reductions, while 21% said they were okay with major Medicare spending cuts to avoid raising taxes on the wealthy.

Overall, the survey found that the public prefers spending cuts over tax increases as the main approach to deficit reduction.

Kaiser said the survey of 1,203 adults was conducted June 9 through June 14 and has a sampling error of plus or minus 3 percentage points.

Harbir Makin, MD