Affordable Care Act and Neurology

[danielmd06]

I've read simple summaries of this bill and was curious what senior (or informed junior) people thought about the effect this will have on the practices of general neurologists (who are highly dependent on Medicare) and the practice of medicine as a whole. I'm most especially interested in comments regarding the Titles dealing with Medicare reimbursements and performance measures for physicians.

Does anyone here recall the beginnings of Medicaid and Medicare and the changes that our profession underwent when these were passed?

To me these issues seem worrisome. However, I'm open-minded and welcome all opinions based in fact. I am emphatically not looking to stoke political debate.

There are many summaries of this act available online, but I've included one here for simplicity: http://dpc.senate.gov/healthreformbill/healthbill04.pdf

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[danielmd06]

No thoughts?

 

[sarcoid]

The Anesthesiology form has many active threads about this. They love politics over there.

My opinion is mixed. On the surface, I hate that Obama & the office of the POTUS is being allowed to force individual Americans to buy a commercial product or pay a fine/tax. I think the implications of this are treacherous for the future of our nation if we wish to preserve our individual liberties.

Deeper down, however, when applied specifically to this issue (health insurance), I'm happy that finally almost everyone will be covered and the problem of so many patients inability/refusal to pay gets a solution, albeit inadequate, but nevertheless a solution to a large problem.

The crux is in the application of the many facets of the law. The main parts being:

Individual mandate
Guaranteed coverage mandate
Independent Medicare Payment Advisory Board (IPAB)
Medicaid expansion
Health care exchanges

If you are a pessimist, looking at the list above can lead you to see how the # of patients on Medicaid will swell, and the overall payments to providers will shrink. This spells doom for doctors' salaries.

If you are an optimist, the above list means tens of millions more patients with health insurance combined with the probably lower payouts will mean an overall neutral change to doctors salaries.

The speculation over the effects of Obamacare is as vast as it was over how the SCOTUS could possibly rule. If you followed the stories leading up to the ruling you might remember how the "expert" opinion was that the SCOTUS would strike down the individual mandate. It had me believing the same. Oh the ignorance that was displayed.

The new IPAB will have the most power over doctors compensation. Wiki has a good summary over this:

http://en.m.wikipedia.org/wiki/Independent_Payment_Advisory_Board

As for my views, I try to maintain them as pragmatic as possible. I read plenty of hyperbole, and even repeat some of it to try it out, but in the end, those views rarely take shape. As for Obamacare, my personal view is negative, but not extreme. I would have been happier with a less heavy-handed approach to a solution (by both the process of passing the legislation and the verbiage). Obama stretched the limits of the Federal Government to regulate actions & decisions of individual Americans. Some call it good leadership. Some tyranny.

 

[danielmd06]

The new IPAB will have the most power over doctors compensation. Wiki has a good summary over this:

http://en.m.wikipedia.org/wiki/Independent_Payment_Advisory_Board

As for my views, I try to maintain them as pragmatic as possible. I read plenty of hyperbole, and even repeat some of it to try it out, but in the end, those views rarely take shape. As for Obamacare, my personal view is negative, but not extreme. I would have been happier with a less heavy-handed approach to a solution (by both the process of passing the legislation and the verbiage). Obama stretched the limits of the Federal Government to regulate actions & decisions of individual Americans. Some call it good leadership. Some tyranny.

Thank you for an intelligent reply. I'll check the anesthesiology site. Amazingly, there is a tremendous lack of articles in the news from major sites addressing how this act will affect doctors. I suppose I shouldn't be surprised. I personally feel that this issue should have had bi-partisan support rather than Congresspeople telling the American public that "they'll read it after they vote on it," but bi-partisan support is easier mentioned than accomplished.

I know that some claim that more money will come through hospitals due to the simple fact of more people having insurance, but I suspect this will not occur due to timed, progressive slashed overall reimbursement totals (courtesy of the IPAB), slashed reimbursements for failure to meet paperwork hoops/"proper" documentation, and slashed reimbursements if our patients don't demonstrate improvement of overall health through our efforts. Of course, we'll have to wait and see I guess. But, it seems fairly logical to presume that we'll simply be busier, have no relief from malpractice attacks, and get reimbursed less through the measures I mentioned.

I don't know anyone who really argues that it's a Bad Thing for more people to have insurance, and to have defenses from insurance companies put in place. However, logistically speaking, a side effect of this is that there will be too many patients for doctors to see. We already have physician shortages. And we furthermore already have a lack of neurologic care providers relative to the demands of an increasing aging population. So, I think we will certainly have rising mid-level responsibilities in primary care roles, and possibly in specialty care roles (very unlikely to be in neurology, but a discomfitting notion nonetheless - why go to medical school when you could be dermatologist via nursing school?). The ANA has supported this bill quite strongly for this reason (among others). They've supported increasing mid-level autonomy and allowance of mid-level directed referral patterns, too. What all this truly means for patients and quality of care is quite another topic. It's been debated on the FP forum a bit.

The FP docs have cogently argued that less educated providers tend to "shotgun" multiple tests and more frequently refer patients to subspecialists, resulting in paradoxically increased costs and more fractured continuity of care.

As I stated above, a neurology-specific complaint is that with dropping Medicare reimbursements (which is clearly a goal of forming the IPAB) and increased paperwork hoops to jump through for maximal reimbursement of Medicare/Medicaid/ACA (which is seemingly a ploy to drop payments guised under improving documentation), I fear our specialty will suffer quite a bit. We are dependent on elderly populations for our bread and butter practice. We cannot mass produce good neurologic care. Unlike some other physicians, we cannot see six patients an hour all day long in our specialty. And our reimbursements are historically not so high as other medical subspecialties, so we have more to lose - relatively speaking.

I knew of the IPAB, but was unaware that Congress had the ability fo override it's decisions - albeit with a "supermajority" vote (which is obviously not easy to obtain and is not clearly defined in the wiki article). Obviously most of us are very worried about what essentially amounts to the government having free rein to decide how much our work reimburses.

 

[sarcoid]

Thank you for an intelligent reply. I'll check the anesthesiology site. Amazingly, there is a tremendous lack of articles in the news from major sites addressing how this act will affect doctors. I suppose I shouldn't be surprised. I personally feel that this issue should have had bi-partisan support rather than Congresspeople telling the American public that "they'll read it after they vote on it," but bi-partisan support is easier mentioned than accomplished.

I know that some claim that more money will come through hospitals due to the simple fact of more people having insurance, but I suspect this will not occur due to timed, progressive slashed overall reimbursement totals (courtesy of the IPAB), slashed reimbursements for failure to meet paperwork hoops/"proper" documentation, and slashed reimbursements if our patients don't demonstrate improvement of overall health through our efforts. Of course, we'll have to wait and see I guess. But, it seems fairly logical to presume that we'll simply be busier, have no relief from malpractice attacks, and get reimbursed less through the measures I mentioned.

I don't know anyone who really argues that it's a Bad Thing for more people to have insurance, and to have defenses from insurance companies put in place. However, logistically speaking, a side effect of this is that there will be too many patients for doctors to see. We already have physician shortages. And we furthermore already have a lack of neurologic care providers relative to the demands of an increasing aging population. So, I think we will certainly have rising mid-level responsibilities in primary care roles, and possibly in specialty care roles (very unlikely to be in neurology, but a discomfitting notion nonetheless - why go to medical school when you could be dermatologist via nursing school?). The ANA has supported this bill quite strongly for this reason (among others). They've supported increasing mid-level autonomy and allowance of mid-level directed referral patterns, too. What all this truly means for patients and quality of care is quite another topic. It's been debated on the FP forum a bit.

The FP docs have cogently argued that less educated providers tend to "shotgun" multiple tests and more frequently refer patients to subspecialists, resulting in paradoxically increased costs and more fractured continuity of care.

As I stated above, a neurology-specific complaint is that with dropping Medicare reimbursements (which is clearly a goal of forming the IPAB) and increased paperwork hoops to jump through for maximal reimbursement of Medicare/Medicaid/ACA (which is seemingly a ploy to drop payments guised under improving documentation), I fear our specialty will suffer quite a bit. We are dependent on elderly populations for our bread and butter practice. We cannot mass produce good neurologic care. Unlike some other physicians, we cannot see six patients an hour all day long in our specialty. And our reimbursements are historically not so high as other medical subspecialties, so we have more to lose - relatively speaking.

I knew of the IPAB, but was unaware that Congress had the ability fo override it's decisions - albeit with a "supermajority" vote (which is obviously not easy to obtain and is not clearly defined in the wiki article). Obviously most of us are very worried about what essentially amounts to the government having free rein to decide how much our work reimburses.

Thanks for the insight into the effect it will have on Neurology.

Your two main points, increased patient load leading to more midlevel encroachment & decreased compensation overall (specifically for neurology) through a number of means, got me thinking.

Since I'm going into Neurology purely for the love of the field, will I be happy with a financial future below my expectations?

My answer: I will be disappointed with the compensation, but not the field. So my focus would have to be figuring out how to make more from a practice. Aka, wear the CEO mantle in addition to the white coat.

I'm not too worried about mid-levels. Even if Obamacare turns the key and opens their floodgates, their autonomy gives us more value as physicians in the eyes of most patients. Plus, most of them still want to work as an employee of a physician group versus being on their own. As a doctor, I plan on utilizing them in my practice in a way that brings in profit. I still have yet to see this in a Neurology setting, but I believe it's possible.

 

[maw4bc]

Thank you for an intelligent reply. I'll check the anesthesiology site. Amazingly, there is a tremendous lack of articles in the news from major sites addressing how this act will affect doctors. I suppose I shouldn't be surprised. I personally feel that this issue should have had bi-partisan support rather than Congresspeople telling the American public that "they'll read it after they vote on it," but bi-partisan support is easier mentioned than accomplished.

I know that some claim that more money will come through hospitals due to the simple fact of more people having insurance, but I suspect this will not occur due to timed, progressive slashed overall reimbursement totals (courtesy of the IPAB), slashed reimbursements for failure to meet paperwork hoops/"proper" documentation, and slashed reimbursements if our patients don't demonstrate improvement of overall health through our efforts. Of course, we'll have to wait and see I guess. But, it seems fairly logical to presume that we'll simply be busier, have no relief from malpractice attacks, and get reimbursed less through the measures I mentioned.

I don't know anyone who really argues that it's a Bad Thing for more people to have insurance, and to have defenses from insurance companies put in place. However, logistically speaking, a side effect of this is that there will be too many patients for doctors to see. We already have physician shortages. And we furthermore already have a lack of neurologic care providers relative to the demands of an increasing aging population. So, I think we will certainly have rising mid-level responsibilities in primary care roles, and possibly in specialty care roles (very unlikely to be in neurology, but a discomfitting notion nonetheless - why go to medical school when you could be dermatologist via nursing school?). The ANA has supported this bill quite strongly for this reason (among others). They've supported increasing mid-level autonomy and allowance of mid-level directed referral patterns, too. What all this truly means for patients and quality of care is quite another topic. It's been debated on the FP forum a bit.

The FP docs have cogently argued that less educated providers tend to "shotgun" multiple tests and more frequently refer patients to subspecialists, resulting in paradoxically increased costs and more fractured continuity of care.

As I stated above, a neurology-specific complaint is that with dropping Medicare reimbursements (which is clearly a goal of forming the IPAB) and increased paperwork hoops to jump through for maximal reimbursement of Medicare/Medicaid/ACA (which is seemingly a ploy to drop payments guised under improving documentation), I fear our specialty will suffer quite a bit. We are dependent on elderly populations for our bread and butter practice. We cannot mass produce good neurologic care. Unlike some other physicians, we cannot see six patients an hour all day long in our specialty. And our reimbursements are historically not so high as other medical subspecialties, so we have more to lose - relatively speaking.

I knew of the IPAB, but was unaware that Congress had the ability fo override it's decisions - albeit with a "supermajority" vote (which is obviously not easy to obtain and is not clearly defined in the wiki article). Obviously most of us are very worried about what essentially amounts to the government having free rein to decide how much our work reimburses.

Well that didn't take long:
http://www.aan.com/go/practice/coding

With this change coming Jan 1, 2013, a standard CTS would be making 65% less per patient, or $425.

That is an astronomical decrease in NCS reimbursement. I really hope AAN / AANEM / AAPMR can team together to stop this from happening. I don't mind giving a little but 65% and giving us a 2 month heads up? I called 5 different neurologists yesterday and none of them knew about this. Let me know if you have any more info or insight. I have left messages with AAN and AANEM. Have yet to hear back from them.

 

[danielmd06]

For those interested in continuing to read about various viewpoints related to this:

http://www.physicianspractice.com/blog/critical-assessment-affordable-care-act

http://www.healthcare.gov/news/factsheets/2010/07/health-care-providers.html

 

[PathoTurnUp1865]

I'd like an update on this. How much has ACA changed healthcare within neurology? For the better? Most articles I find online are over doctors as a whole and don't really dive into medical specialties. Most I find deal with how primary care doctors will/are being affected and lots of forums on here only talk about encroachment of the midlevels. Is this becoming prevalent in neurology too?

 

[neurolddoc]

Ok, I'll take a stab at summarizing my thoughts on the Medico-politico-economic landscape over the last 3 years.

The Good:
The biggest impact the ACA has had in my state is the expansion of Medicaid. I practice in an area where there was a significant uninsured population. They now have insurance and have swarmed into my practice. Our new patient volume has doubled. I have expanded office hours to start at 7 am and put extra new patient slots in during lunch and at the end of the day. These patients have many unmet medical issues. We have hired new technical staff to deal with the increased testing volume.

Medicaid, by the way way in my state, reimburses at Medicare rates. Ironically, I get higher reimbursements seeing a Medicaid patient than I get seeing a patient with Federal BC/BS. (This is more a testament to the lousy reimbursements from private insurers in my state than to the generosity of Medicare payments.)
Also there has been an increase in volume due to more people insured through the exchange.

Our EHR system has allowed us to track return patients more efficiently. It has also allowed me to better track performance parameters in my practice and to better manage the business aspects of the practice.

The Bad:

Some of the new patients are not used to showing up on time or at all for appointments. No show rates are increased. late patients are a constant headache.

There has indeed been downward pressure on reimbursements.

The whole EHR incentive compensation has been passed through to the EHR vendor.

The EHR vendor has lousy support for all of the arcane things you need to do for MU and PQRS compliance.

CMS is not ready for prime time on the whole quality reporting system. We receive notice that we had not submitted Quality measures in 2014 so we were getting dinged 2% in 2016. After my office manager spent a week trying to get through their dysfunctional web site, they finally said "never mind, we had an issue" and we got the deduction reversed.

The Ugly:

Multiple Docs have gone through the MU compliance audit which turns into a gotcha game by the CMS contractor accounting firm to try to screw you our of your Incentive compensation.

One doc in the practice had a 4 year failed transition to EHR's that nearly destroyed his practice.

 

[MemberX]

So overall net positive or negative (at least with respect to compensation and day to day activities)?

 

[neurolddoc]

Overall, it has been a large net positive. The key has been a large influx of new patients and the fact that Medicaid pays at Medicare rates in my state.