ObamaCare's Threat to Private Practice...

[drusso]

This is what we face:

http://www.wsj.com/articles/scott-gottlieb-obamacares-threat-to-private-practice-1417990367

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[DOctorJay]

can you copy/paste the text here, not a subscriber, can't read full article

 

[Ducttape]

Obama and Obamacare are targetting my practice and trying to ruin me financially, and force me to have to start collecting bottles and cutting coupons yada yada yada

 

[Ligament]

I am in private practice. The writing is on the wall; most of us in private practice will not be in a few more years. The government and Comrade Obama are doing everything in their power to drive us out of business with impossible regulations and increased overhead and simultaneously decreased payments. As we are driven into employment by the hospitals, we are then controllable. We will be forced to follow government dictated treatment algorithms. We will be fired if we do not. We will eventually be replaced by midlevels and then fired or regulated to administrative roles only.

Our pay will be based on how promptly we answer patient emails for which we cannot bill, how we kowtow to our subordinates (MAs, Nurses) lest we be written up and be put on probation, etc. Its already happening to my primary care friends here in the Seattle area. 8% of their pay is directly tied to how quickly they answer patient emails and complete their "inbox." I know 3 of them who have been put on "probation" by the hospital due to complaints by lazy MAs who do not view their physician as their boss but rather an inconvenience. MAs leave promptly at 5pm while the docs are at the office till 8pm calling back patients that the MA should have called. Its ugly.

Eventually we will not be referred to as "Dr. X" but rather "Provider X". Everybody will be a "provider" and on equal standing in the organization.

You know what? Prostitutes call themselves "providers" and are proud of that. Think about it.

My hope is my business can squeeze by over the next few years and pray that the next administration is not as overtly hostile to physicians. If it gets any worse there will not be any private practices any longer other than cash pay vanity practices. Perhaps the pain practices that follow the narcotic/in house drug testing/in house sleep center/in house compounding pharmacy/in house ASC will survive...not sure.

I agree that all recent administrations have been unfavorable toward physicians, but Comrade Obama's has been the worst by far. Obamacare was a huge shot at us physicians, private practice is now hanging by a thread.

 

[lonelobo]

I am in private practice. The writing is on the wall; most of us in private practice will not be in a few more years. The government and Comrade Obama are doing everything in their power to drive us out of business with impossible regulations and increased overhead and simultaneously decreased payments. As we are driven into employment by the hospitals, we are then controllable. We will be forced to follow government dictated treatment algorithms. We will be fired if we do not. We will eventually be replaced by midlevels and then fired or regulated to administrative roles only.

Our pay will be based on how promptly we answer patient emails for which we cannot bill, how we kowtow to our subordinates (MAs, Nurses) lest we be written up and be put on probation, etc. Its already happening to my primary care friends here in the Seattle area. 8% of their pay is directly tied to how quickly they answer patient emails and complete their "inbox." I know 3 of them who have been put on "probation" by the hospital due to complaints by lazy MAs who do not view their physician as their boss but rather an inconvenience. MAs leave promptly at 5pm while the docs are at the office till 8pm calling back patients that the MA should have called. Its ugly.

Eventually we will not be referred to as "Dr. X" but rather "Provider X". Everybody will be a "provider" and on equal standing in the organization.

You know what? Prostitutes call themselves "providers" and are proud of that. Think about it.

My hope is my business can squeeze by over the next few years and pray that the next administration is not as overtly hostile to physicians. If it gets any worse there will not be any private practices any longer other than cash pay vanity practices. Perhaps the pain practices that follow the narcotic/in house drug testing/in house sleep center/in house compounding pharmacy/in house ASC will survive...not sure.

I agree that all recent administrations have been unfavorable toward physicians, but Comrade Obama's has been the worst by far. Obamacare was a huge shot at us physicians, private practice is now hanging by a thread.

Drama Queen

 

[Ligament]

Drama Queen

I don't think anything I discussed has not already happened or is in the process of happening. Are you in private practice? solo or group? Do you review the finances in the practice? Are you telling me your business is not feeling the squeeze?

 

[lonelobo]

I don't think anything I discussed has not already happened or is in the process of happening. Are you in private practice? solo or group? Do you review the finances in the practice? Are you telling me your business is not feeling the squeeze?

Yes I have my own practice, I know the finances very well, Sh't has been going down hill long before Obama and Obamacare

 

[Ligament]

Yes I have my own practice, I know the finances very well, Sh't has been going down hill long before Obama and Obamacare

I agree it's been going downhill before Obama, I said that.

 

[nvrsumr]

I don't think Lig is chicken little. Some areas of the country are worse than others though not specific to obamacare. I am thankful that auto, wc and caid are still reasonable payors in my neck of the woods. If I was fighting over the shrinking "good insurance" pie I would be stressed too.

The comparative effectiveness panel put in by Obamacare will result in decreased reimbursement. The confusing PQRS requirements that will result in a 2% gross cut on top of the previous fiscal cliff Medicare cut are also real decreases signed into law by Obama.

We are the cost that is being curved downward by Obama.

 

[drusso]

This is what we face:

http://www.wsj.com/articles/scott-gottlieb-obamacares-threat-to-private-practice-1417990367

By
SCOTT GOTTLIEB
Dec. 7, 2014 5:12 p.m. ET
698 COMMENTS

Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable.

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACO qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

 

[Ducttape]

where does one find how much a facility - ASC or HOPD - can bill for outpatient follow up visits? its not in proposed or actual fee schedules.

 

[drusso]

where does one find how much a facility - ASC or HOPD - can bill for outpatient follow up visits? its not in proposed or actual fee schedules.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

It's a huge area of fraud investigation by the OIG and DOJ. It's the root of large hospital-owned groups are able to exert monopolizing power in local health care markets, drive up prices, and squeeze out competition. Jon Gruber and other architects of Obamacare were well aware of how the site-of-service pricing differential would affect local markets and independent groups and ignored concerns raised from the American Association of Physicians and Surgeons (AAPS) and others.

http://www.aapsonline.org/

 

[Ducttape]

so how much money does the system get for a facility fee from a 99213 or 99214? what is the exact dollar amount?

how come the ASIPP proposed and actual fee rates do not list the facility fees for 99211-5 codes?

 

[drusso]

so how much money does the system get for a facility fee from a 99213 or 99214? what is the exact dollar amount?

how come the ASIPP proposed and actual fee rates do not list the facility fees for 99211-5 codes?

http://www.painphysicianjournal.com/2013/december/2013;16;419-440.pdf

 

[Ducttape]

Am I to assume that the listed punts in the ASIPP schedule that are posted on their site is wrong?

http://asipp.org/rates/Physicians2015F.pdf
Page 9, fyi. Clearly showing that in all 992xx codes, non facility charges more, but these are not listed in the ASC or HOPD codes.

Doesn't affect me - this office bills office based rates for follow ups and new patient evals (and yes, I've seen the bills personally...)

 

[Ducttape]

Am I to assume that the listed amounts in the ASIPP schedule that are posted on their site are wrong or incomplete?

http://asipp.org/rates/Physicians2015F.pdf
Page 9, fyi. Clearly showing that in all 992xx codes, non facility charges more, but these codes are not listed in the ASC or HOPD PDFs. Kind of a funny thing to omit.

Doesn't affect me - this office bills office based rates for follow ups and new patient evals (and yes, I've seen the bills personally...)

 

[powermd]

I didn't think there was a difference between OB and HOPD based billing for E&M. There certainly isn't an APC relative weight assigned to E&M codes as there is for procedural CPTs. The inflated facility fees for HOPD procedures is based on the APC relative weight. Ultimately that gets multiplied by a hospital conversion factor, which is about $74. That's how you end up with a $700 epidural.

Here are the total non-facility vs facility RVUs for 99201-99215. As you can see in every case the non-facility numbers are higher. I wonder how Lax derived this information.

1.22 0.75
2.09 1.41
3.05 2.17
4.63 3.66
5.81 4.76
0.56 0.26
1.22 0.72
2.04 1.43
3.01 2.20

 

[Ducttape]

not sure, but it fits with the listings on ASIPP, which imply that non-facility (office) based fees for 992xx pay more than facility based fees by roughly 20%...

 

[Seth Joo]

This is what we face:

http://www.wsj.com/articles/scott-gottlieb-obamacares-threat-to-private-practice-1417990367

Well Medicine is not going to become a McJob anytime soon, I hope not.

 

[hyperalgesia]

Am I to assume that the listed amounts in the ASIPP schedule that are posted on their site are wrong or incomplete?

http://asipp.org/rates/Physicians2015F.pdf
Page 9, fyi. Clearly showing that in all 992xx codes, non facility charges more, but these codes are not listed in the ASC or HOPD PDFs. Kind of a funny thing to omit.

Doesn't affect me - this office bills office based rates for follow ups and new patient evals (and yes, I've seen the bills personally...)

Facilities don't use those codes any more.
http://news.aapc.com/cms-adopts-one-code-fits-all-for-hospital-clinic-visits/

The visit is coded as APC 0634 regardless of complexity and the rate is about $96 for the facility to supply the space. In total, the cost for a 99213 by an office-based physician is about $120, compared to the hospital based reimbursement of about $186.