Resident/Medical Student Strike in Opposition to the Affordable Care Act

[Dmizrahi]

Please carefully read the following:

I’m currently an intern in Philadelphia and I’ve been following recent governmental policy healthcare changes. There are a lot of myths and misinformation contained in articles and blogs regarding the Affordable Care Act, however I’ve taken the time to painstakingly review the FTC’s documents regarding the Affordable Care Act as well as portions of the actual Affordable Care Act.

I will clearly state that the main objective of presenting this issue is NOT to ignite a political discussion nor endorse a particular candidate for the upcoming elections.

More so I am attempting to gauge the national and local interests in a medical student and resident strike to attempt to give physicians as a whole a voice in national health care policy, raise awareness regarding physician responsibilities, costs of training, tort reform and most importantly patient care and maintenance of the patient doctor relationship.

Should there be regional and widespread interest in the matter, I present that we form a democratic organization insofar that our mission is to define goals that we would organize and strike for that align with the following themes: our primary goal is not for higher salaries or better reimbursements but our primary initiative is to provide better high quality patient care.

We would object to the following items held within the Affordable Care Act:
1. The statute in affect already that penalizes hospitals by 1% for readmissions.
2. The creation of a model which reimburses or pays for outcomes rather than activity. (I.e. reimbursements ONLY for a patient having a HbA1C < 8.0% in a DM patient, how are noncompliant patients dealt with?)
3. Disproportionate costs of Medical/Undergraduate Education in parallel to resident and physician salaries.
4. Profit sharing from other specialties to primary care. Under new medicare laws radiology and radiation oncology will be allocating 4% and 15% respectively to IM and geriatricians.

Goals:

1. Include some level of tort reform or discussion of malpractice in the affordable care act.
2. Present a model that allows for lower interest loan repayment for medical students and/or lowering the cost of education overall.
3. Present the key idea that individual social irresponsibility regarding ones health and lifestyle choices should not result in penalizing physicians and that physicians cannot account for non-compliance, that every human has the right to being alive, but feeling well is a privilege and we should have a system that enforces this theme.

EDITORIAL PORTION:

Sure, we have the AMA – but they’ve done a poor job representing physicians and they only represent a small percentage of physicians. Not to mention allegations that they have a constant revenue stream from medicare for their coding model. Unfortunately, corporate anti-trust laws prevent physicians from unionizing. Unfortunately, a resident strike on a large scale could lead to a serious social collapse and do the very thing we as physicians have taken an oath to and morally/ethically wish to prevent which are patient deaths or poor outcomes. Thus I’m posting for ideas for enacting social change before resorting to a full blown strike.

Based on statistics we are approaching a physician shortage of ~ 100K doctors by 2020. Couple this to 20 million new medicare patients out of 47 million new patients being pushed into the health system and a campaign to make hospitals more transparent, with a model that pays medicare providers (doctors) and hospitals based on outcomes rather than activity will lead to higher volumes of patients (more work) without an increase in pay. I predict that the volume will be dealt with by employing more nurse practitioners and PA’s, unfortunately this will lead to less interaction between the supervising physicians and the patients ultimately leading to a decrease in the quality of care. By increasing transparency in the medical system we will further stratify patients based on socioeconomic status. For example, if hospital A has a higher mortality rate/complication rate regarding MI and sepsis in relation to hospital B, patients with higher socioeconomic statuses and educational statuses will ultimately choose hospital B – leaving lowering income patients with tougher socioeconomic dispositions to hospital A. This example also applies to surgeons who would ultimately choose to operate on patients with less co-morbities because it would show better outcomes.

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[VneZonyDostupa]

I'm seeing a lot of phrases like "based on statistics" and "models" without any sort of evidence to support them.

 

[Dmizrahi]

Which statistics and models do you want evidence for and I'll cite them.

 

[VneZonyDostupa]

reimbursements ONLY for a patient having a HbA1C < 8.0% in a DM patient

Under new medicare laws radiology and radiation oncology will be allocating 4% and 15% respectively to IM and geriatricians.

we are approaching a physician shortage of ~ 100K doctors by 2020.

47 million new patients being pushed into the health system

this will lead to less interaction between the supervising physicians and the patients ultimately leading to a decrease in the quality of care.

These.

 

[DrAwsome]

These.

reimbursements ONLY for a patient having a HbA1C < 8.0% in a DM patient
-I think OP means that physician salaries/incomes will be determined based on patient outcomes, vs. providing appropriate care. I think this is interesting because in the recent Chicago Teacher strikes, one of the things that was discussed during contract negotiations was teacher salaries being affected by student performance. Same thing is happening with docs-if patients don't get the "desired" outcome, then pay is docked, which seems ridiculous. Pay if anything should be based on appropriate care, not outcome. You cannot control what the patient does.

Quote:

Under new medicare laws radiology and radiation oncology will be allocating 4% and 15% respectively to IM and geriatricians.
-These are the new CMS fee schedules for these 2 specialties, and supposedly this money will be given to primary care docs. There are also specialties also taking a pay cut and this money will be given to PCPs.

Quote:
we are approaching a physician shortage of ~ 100K doctors by 2020.
-This is what AAMC says on their webpage regarding physician shortage predictions

Quote:
47 million new patients being pushed into the health system
-I don't know if this figure is accurate, but there are millons of new patients being pumped for lack of a better word, into the system with the new obamacare law

Quote:
this will lead to less interaction between the supervising physicians and the patients ultimately leading to a decrease in the quality of care.
-Although subjective, will likely happen

 

[VneZonyDostupa]

-I think OP means that physician salaries/incomes will be determined based on patient outcomes, vs. providing appropriate care. I think this is interesting because in the recent Chicago Teacher strikes, one of the things that was discussed during contract negotiations was teacher salaries being affected by student performance. Same thing is happening with docs-if patients don't get the "desired" outcome, then pay is docked, which seems ridiculous. Pay if anything should be based on appropriate care, not outcome. You cannot control what the patient does.

This is drastically different than saying you will receive NO reimbursement if the A1C is over 8.0%. While I do agree that, to some extent, pay-for-performance is bad, I think that hyperbolic statements like "you get no money if your patient's A1C is 8.01%" only detract from any reasonable discussion of the issue.

These are the new CMS fee schedules for these 2 specialties, and supposedly this money will be given to primary care docs. There are also specialties also taking a pay cut and this money will be given to PCPs

This was my point in questioning his statement. There is a new fee schedule which increases reimbursements to primary care, with some measure (not totally equivalent) decrease from a handful of specialties and/or subspecialities. This is VASTLY different than saying rad-oncologists are being forced to "allocate" 15% of their income and give it to primary care docs. It's not income if you aren't getting it in the first place. Not to mention, the large majority of our physician shortage is primary care. Primary care also receives a tiny fraction of the Medicare "pie", by comparison.

This is what AAMC says on their webpage regarding physician shortage predictions

That same article also states that the measure taken in the ACA are likely to close that shortage gap by a decent degree, but that there isn't enough data to state positively yet (just like the data is shakey about the 100k shortage, by their own admission).

-I don't know if this figure is accurate, but there are millons of new patients being pumped for lack of a better word, into the system with the new obamacare law

My point in quoting the 47 million "new patients" figure was that it ISN'T accurate. The opponents of the ACA like to pretend that the 47 million uninsured Americans weren't utilizing the health care system prior to the ACA, ignoring the fact that they were one of the largest per capita users of the nations public and emergency health centers.

this will lead to less interaction between the supervising physicians and the patients ultimately leading to a decrease in the quality of care.
-Although subjective, will likely happen

"Subjective" and "likely" seem like pretty shakey grounds to call for a strike (as laughable as a medical student, and to some degree a resident, strike sound). Of course, you aren't the one who posted the quoted comment, so I can't fault you for it =)

 

[375RGRRGT]

I agree that the AMA has not represented the modern physician well. I am not a member of the AMA and many of my classmates are not either.

The AMA did serve a purpose at one point in time, BUT, you have to remember that the time when AMA membership was high there really was only two types of specialities - Medicine and Surgery. By todays standard there are many many more representative organizations to represent a given physician; ACP, ACOG, AAFP, ACEP, ACS, AAP, etc etc. Point is they represent their interests but not the interests of all physicians in a cohesive manner.

So the question remains, how do you organize a bunch of arrogant, egocentric individuals that pride themselves in being an individual and an era of furthering subspecialization? After all failure to do so may essentially lead to us (physicians) destroying our own specialty, even though supply and demand should have some effect - generally speaking there really is NO free market correlation in medicine today.

I dont think Id join any group in reality and there are some components of the ACA that are important such as pre-existing conditions. However, as it currently stands I also realize that I am just some over educated eager puppy dog trying to convince some insurance company that a patient needs some form of care.


In assessing the goals outlined:
1.) tort reform may help but how do we as physicians convince a group of lawyers that this is the case that will improve care and reduce costs?
2.) low interest loans etc - TOTALLY! in fact, i probably would have gone into a primary care field if this were the case. Currently, schools like to say "Go into primary care but your education will cost the same, interest rates are the same, and you will be paid less meaning you will pay more interest"
3.) I wrote a paper on this concept - A = "Society" but is more so societal factors such as alcohol, tobacco, diet, exercise etc. B=current health system and access to care. C=payers of healthcare (mostly medicare due to their overall responsibility as the largest payer and "He who has the gold sets the price"). Point is that currently we are attempting to solve the health care cost problem by addressing "B" rather than addressing "A" which has been proven to extend lives and reduce utility. But interest groups of the "Sin Industries" are much too powerful of a lobby group in congress for that to ever change because they want money too so the physicians and the healthcare system will take the brunt of things for the benefit of "individual freedoms"

 

[NotAProgDirector]

First, it's just as illegal for residents to strike as it is for physicians in general to strike. It would be totally fine to organize the residents at your program together, and strike. But it's illegal to try to get other residents to organize wth you -- at least that's the way I understand it.

Second, residents striking will cause problems for teaching hospitals, but the majority of hospitals will care less. So striking will be completely ineffective. And, to be effective, you'd need to strike for some prolonged time to cause enough pain -- and that means no salary, loss of all benefits, and perhaps being replaced.

Third, only Congress can actually change the ACA. And how would this strike leverage Congress at all?

Last, I bet many residents (and physicians) actually support the ACA -- they won't be interested in striking at all.

And don't get me started about medical students striking. That's just funny. Show me a medical student who doesn't triple my workload, and I'll kiss her feet. Be my guest and strike, although don't expect a tuition reimbursement for what you missed (and, if you miss enough, your schooling might get extended at additional cost to you).

Now, let's be clear. I'm not necessarily a huge fan of the ACA. There are some parts of the law that most people seem to agree with -- allowing kids to stay on their parent's plans until 26, no lifetime caps, etc. These are the parts that cost more to insurance companies. Whether the rest of the parts of the law are "good" or "bad" depends on what you think is important.

About the points above:

1. Outcomes based payments are an interesting idea. Naysayers state the argument above -- that you can't control what patients do, so it's unfair to pay patients for outcomes. On the other hand, supporters point out that perhaps there are things physicians can do -- given the diabetes example, perhaps we need to think outside the box. What can we do to help diabetics get better control of their diabetes? Studies have shown that many patients don't understand their instructions when they leave a doc's office, or that the doc didn't address issues like affording the medications. Perhaps if we focus on that, we could make patients better. And this now gives us a financial incentive to do so.

One good example is CF care. The CF physician community came together many years ago to compare outcomes. It turned out that some centers were doing much better than others. Those others had simply assumed that there wasn't anything they could do better. When they saw that others were doing better, they went to those centers to see what they did. And, not surprisingly, everyone's outcomes improved.

So, outcomes based assessment is not necessarily a bad thing. Yes, it can lead to cherry picking (which perhaps needs to be addressed in some way). Whether it will be good or bad for medicine remains to be seen.

2. Payment changes -- the question is whether current pay for rads and rad onc is "fair". The medical payment marketplace is not a free market -- no one is price shopping for their CT scan because of insurance, not to mention that you really can't find out how much anything costs. I personally feel that radiologists are overcompensated in the current system. Of course, I'm not a radiologist.

3. The physician shortage is all spin. The AAMC quotes this because it wanted US medical schools to increase enrollment, which they happily did (more tuition for them! Yay!). The AAMC wanted this to push out IMGs and the exploding DO schools. If you want more physicians in the US, you need more residency spots. More med school spots will only change the distribution of AMGs to IMGs (although, to be fair, IMG's who train here and then return to their home country are a "loss" to our physician workforce, so as more AMG's take spots and stay in the US, we get more physicians for the workforce -- but this is a very small number).

I also find that blaming a shortage of physicians on the baby boomers problematic. Assuming that we actually train all of these new physicians, when those baby boomers die off, we'll have a glut of physicians.

4. 47 million new patients from the ACA -- also complicated. These patients are currently consuming healthcare -- either going to free clinics, the ED, etc. So, getting them some insurance coverage doesn't really create 47 million new patients, but may actually help fund some clinics which currently serve those with no insurance.

So, it's not so black and white.

 

[VneZonyDostupa]

Very interesting point about the AAMC, aProg...hadn't thought of it that way for some reason.

And thanks for the other great info )))

 

[smq123]

Moving to Topics in Healthcare.

 

[MOHS_01]

...
1. Outcomes based payments are an interesting idea. Naysayers state the argument above -- that you can't control what patients do, so it's unfair to pay patients for outcomes. On the other hand, supporters point out that perhaps there are things physicians can do -- given the diabetes example, perhaps we need to think outside the box. What can we do to help diabetics get better control of their diabetes? Studies have shown that many patients don't understand their instructions when they leave a doc's office, or that the doc didn't address issues like affording the medications. Perhaps if we focus on that, we could make patients better. And this now gives us a financial incentive to do so.

Lead to cherry picking -- oh yes, most definitely. Brass tacks: what this will do is lead to a two tier system wherein MD's keep compliant patients with easily managed disease and shun those who are non-complaint or have disease that proves refractory to simple interventions in an effort to boost their scores and maximize their pay per unit effort. Not a bad thing in my estimation (well, for the shunning of the non-compliant), but not exactly the desired outcome for the measure either.

2. Payment changes -- the question is whether current pay for rads and rad onc is "fair". The medical payment marketplace is not a free market -- no one is price shopping for their CT scan because of insurance, not to mention that you really can't find out how much anything costs. I personally feel that radiologists are overcompensated in the current system. Of course, I'm not a radiologist.

"Fair" is, by definition, subjective. We cannot expect any agreement on it -- ever. Not with regard to taxes and not with regard to pay. The focus on the end of year pay, however, is not the most valid of methods, though, given the piecemeal reimbursement nature and the variance in productivity between individuals.

3. The physician shortage is all spin. The AAMC quotes this because it wanted US medical schools to increase enrollment, which they happily did (more tuition for them! Yay!). The AAMC wanted this to push out IMGs and the exploding DO schools. If you want more physicians in the US, you need more residency spots. More med school spots will only change the distribution of AMGs to IMGs (although, to be fair, IMG's who train here and then return to their home country are a "loss" to our physician workforce, so as more AMG's take spots and stay in the US, we get more physicians for the workforce -- but this is a very small number).

I also find that blaming a shortage of physicians on the baby boomers problematic. Assuming that we actually train all of these new physicians, when those baby boomers die off, we'll have a glut of physicians.

Preach on, brother!!

4. 47 million new patients from the ACA -- also complicated. These patients are currently consuming healthcare -- either going to free clinics, the ED, etc. So, getting them some insurance coverage doesn't really create 47 million new patients, but may actually help fund some clinics which currently serve those with no insurance.

So, it's not so black and white.

Maybe not quite black and white, but it's pretty damn dark gray / pale gray. It takes existing monies to "pay" for currently uncompensated care. It shifts the cost burden of this care to all providers rather than the a minority providing this indigent care currently. In simple terms, it's a redistribution from private entities to already subsidized (largely) public entities. I sincerely doubt many of these existing subsidies will be cut proportionately, so it will worsen the local balances in areas that have to compete with a university center.

As always, if you want to know who the beneficiaries are of legislative largesse, look no further than the proponents.

 

[Dmizrahi]

Hey Everyone,

Thanks for chipping into the discussion be it positive or negative. Sorry to SDN moderators for all the cross posting but I couldn't imagine a more important topic in medicine now - seeing that our countries leaders spent virtually 45 minutes arguing about the topic.

There are some amazing and introspective viewpoints posted above. Here are some more ideas regarding this possible "movement" that is being discussed among the housestaff at my institution and currently considered.

Ideally, I think the first and possibly only phase of this thing would be with non-essential personnel (i.e. Residents on electives) and use the medical students to bulk up the numbers.

I think philadelphia is the perfect place for the movement to begin, seeing as there as so many medical schools - if a collective of 300 medical students and residents (on elective) or more organized one morning and marched to city hall - I feel that would be just enough to get national media attention. Hopefully that would attract other major cities and other major institutions and students. That would be the idea behind this.

Since, students are the future of medicine and they are the ones with the most debt and will be the ones suffering from decreased reimbursements from a system that is designed to penalize physicians for patient non-compliance, they would be the core of this movement. Think about it, if students missed a morning of classes or one day of a rotation - I don't think it would be that detrimental to their education. Furthermore, I think most attending physicians would support them because we are effectively doing something for them and the field as a whole.

Again, we should operate on a general theme that at the very least physicians should not be financial penalized for non-compliant patients - there should be a system that the patient shares some ownership in their poor lifestyle choices. For example, if the patient doesn't have the desired outcomes that medicare wants to see happen - they should pay more out of pocket in gerenal for their care.

One of the most important aspects: this movement would differ from occupy wallstreet in the sense that we would use the framework of goals and objectives as a starting point that I outlined above.

More food for thought and completely hypothetical but in my opinion likely situation- Under the affordable care act, paying Accountable Care Organizations(hospitals with 5000 + medicare patients) more for meeting their outcomes will certainly lead to higher revenue for the hospital. Undoubtedly, each and every corporate executive of said hospital will see a corporate ratings increase and will be eligible for bonuses. Where do you think that bonus money is going to come from? Likely, the surplus that is earned from exceeding or meeting the medicare patient outcomes, for which the physicians and residents worked hard for. Now the question is, do you think the physicians and /or residents will see any of that bonus money if we are salaried or contracted? If so, in what proportion. If I'm a corporate exec and know that physicians and residents legally can't strike - then why bother sharing any of that increased revenue? What bargaining power do the workhorses have other than to quit?

 

[Dmizrahi]

Just another reason we need to take a stand and make a voice for ourselves, time is running out before we're bricks in a wall with little to no autonomy:



http://www.cnn.com/2012/10/05/health/youn-liability-reform/index.html?hpt=hp_bn12

 

[IMvrach]

This is really an interesting perception of the residents' value to the US healthcare system...

Second, residents striking will cause problems for teaching hospitals, but the majority of hospitals will care less. So striking will be completely ineffective.

 

[Dmizrahi]

This is really an interesting perception of the residents' value to the US healthcare system. In Israel the system is similar to the US but the residents are perceived as the main workhorse in the hospital, not just trainees. In fact, when the residents striked last year, their strike was so effective that the goverment promptly called an emergency session of the Supreme Court who deemed the strike illegal.

Thanks for pointing that out. We should move forward with this.

 

[physasst]

Third, only Congress can actually change the ACA. And how would this strike leverage Congress at all?

Last, I bet many residents (and physicians) actually support the ACA -- they won't be interested in striking at all.

And don't get me started about medical students striking. That's just funny. Show me a medical student who doesn't triple my workload, and I'll kiss her feet. Be my guest and strike, although don't expect a tuition reimbursement for what you missed (and, if you miss enough, your schooling might get extended at additional cost to you).

Now, let's be clear. I'm not necessarily a huge fan of the ACA. There are some parts of the law that most people seem to agree with -- allowing kids to stay on their parent's plans until 26, no lifetime caps, etc. These are the parts that cost more to insurance companies. Whether the rest of the parts of the law are "good" or "bad" depends on what you think is important.

About the points above:

1. Outcomes based payments are an interesting idea. Naysayers state the argument above -- that you can't control what patients do, so it's unfair to pay patients for outcomes. On the other hand, supporters point out that perhaps there are things physicians can do -- given the diabetes example, perhaps we need to think outside the box. What can we do to help diabetics get better control of their diabetes? Studies have shown that many patients don't understand their instructions when they leave a doc's office, or that the doc didn't address issues like affording the medications. Perhaps if we focus on that, we could make patients better. And this now gives us a financial incentive to do so.

One good example is CF care. The CF physician community came together many years ago to compare outcomes. It turned out that some centers were doing much better than others. Those others had simply assumed that there wasn't anything they could do better. When they saw that others were doing better, they went to those centers to see what they did. And, not surprisingly, everyone's outcomes improved.

So, outcomes based assessment is not necessarily a bad thing. Yes, it can lead to cherry picking (which perhaps needs to be addressed in some way). Whether it will be good or bad for medicine remains to be seen.

2. Payment changes -- the question is whether current pay for rads and rad onc is "fair". The medical payment marketplace is not a free market -- no one is price shopping for their CT scan because of insurance, not to mention that you really can't find out how much anything costs. I personally feel that radiologists are overcompensated in the current system. Of course, I'm not a radiologist.

3. The physician shortage is all spin. The AAMC quotes this because it wanted US medical schools to increase enrollment, which they happily did (more tuition for them! Yay!). The AAMC wanted this to push out IMGs and the exploding DO schools. If you want more physicians in the US, you need more residency spots. More med school spots will only change the distribution of AMGs to IMGs (although, to be fair, IMG's who train here and then return to their home country are a "loss" to our physician workforce, so as more AMG's take spots and stay in the US, we get more physicians for the workforce -- but this is a very small number).

I also find that blaming a shortage of physicians on the baby boomers problematic. Assuming that we actually train all of these new physicians, when those baby boomers die off, we'll have a glut of physicians.

4. 47 million new patients from the ACA -- also complicated. These patients are currently consuming healthcare -- either going to free clinics, the ED, etc. So, getting them some insurance coverage doesn't really create 47 million new patients, but may actually help fund some clinics which currently serve those with no insurance.

So, it's not so black and white.

This^^^^^^^. Also, to the OP, good luck convincing your fellow residents to strike, although if you feel strongly about it, then pursue it.

I'm a complete supporter of the accountable care portion.....But you have to understand, this movement is/was occuring independent of the ACA. The Prometheus payment model was created and piloted in Rockford, IL prior to the ACA even being written. Various states have/are trying to implement this. This would be happening irregardless of the ACA.

Personally, I think that accountability is a good thing. Let's say an engineer designs and builds a bridge......let's say one of the foreman mis-reads the plan and the bridge is built, but not to specs and then it collapses killing several people. Do you think the engineer can simply point at the foreman and say..."It's his fault!" No. It's the teams fault including the engineer.

Much of my research is focused on audit and feedback research and the effect of clinical decision rules, and examining how providers change their behavior when their practice is "audited" and they are provided "feedback" on their performance. A Cochrane SR was done not too long ago on audit and feedback research, and it found that cumulatively, physicians only changed their behavior 4.3% of the time. That's abyssmal, and quite frankly, unacceptable.

 

[MOHS_01]

... irregardless...

^^^^^^ This. (is not a word)

Personally, I think that accountability is a good thing. Let's say an engineer designs and builds a bridge......let's say one of the foreman mis-reads the plan and the bridge is built, but not to specs and then it collapses killing several people. Do you think the engineer can simply point at the foreman and say..."It's his fault!" No. It's the teams fault including the engineer.

Are people now somehow subject to the laws of material physics? Homogeneous with respect to their response and behavior? Damn, it would have been helpful if somehow had sent the memo out. It may carry more weight if it comes on official politburo stationary.

Much of my research is focused on audit and feedback research and the effect of clinical decision rules, and examining how providers change their behavior when their practice is "audited" and they are provided "feedback" on their performance. A Cochrane SR was done not too long ago on audit and feedback research, and it found that cumulatively, physicians only changed their behavior 4.3% of the time. That's abyssmal, and quite frankly, unacceptable.

Oh, you assume too much. Perhaps the "feedback" they got was not deemed "helpful". Do you have any specific examples of what was audited and what the feedback may have consisted of?

 

[physasst]

^^^^^^ This. (is not a word)

Are people now somehow subject to the laws of material physics? Homogeneous with respect to their response and behavior? Damn, it would have been helpful if somehow had sent the memo out. It may carry more weight if it comes on official politburo stationary.

Oh, you assume too much. Perhaps the "feedback" they got was not deemed "helpful". Do you have any specific examples of what was audited and what the feedback may have consisted of?

Nice try MOHS, nice to see you here BTW, but my point was not that people represent static materials such as those used in the construction of a bridge, but that responsibility extends to the provider. I'm sorry if that was somehow lost for you. My point was, this is/was happening even prior to the ACA. ACO's are not a panacea, and will not fix all ills. But hopefully, it will begin to help somewhat, along with AF, clinical decision rules, and the new Performance Improvement CME that almost all physicians/PAs, and now, CRNA's are subject to. Other providers will have to do it eventually, but it is still being rolled out. BTW, the PI-CME also predated the ACA. So did AF as part of OPPE, and clinical decision rules, as well as quality based payment models (episode based) like Prometheus. The ACO models are merely the next extension in that process. Or are you opposed to quality review?

As far as the AF stuff, well, you can read it yourself as I won't simply regurgitate it for you.. Keep in mind, as I noted, it is a systematic review.....

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/otherversions

Hope you and your family are well.

 

[MOHS_01]

Nice try MOHS, nice to see you here BTW, but my point was not that people represent static materials such as those used in the construction of a bridge, but that responsibility extends to the provider. I'm sorry if that was somehow lost for you. My point was, this is/was happening even prior to the ACA. ACO's are not a panacea, and will not fix all ills. But hopefully, it will begin to help somewhat, along with AF, clinical decision rules, and the new Performance Improvement CME that almost all physicians/PAs, and now, CRNA's are subject to. Other providers will have to do it eventually, but it is still being rolled out. BTW, the PI-CME also predated the ACA. So did AF as part of OPPE, and clinical decision rules, as well as quality based payment models (episode based) like Prometheus. The ACO models are merely the next extension in that process. Or are you opposed to quality review?

As far as the AF stuff, well, you can read it yourself as I won't simply regurgitate it for you.. Keep in mind, as I noted, it is a systematic review.....

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/otherversions

Hope you and your family are well.

@physasst -- where are you now? Family is hanging in there... they did want me to pass along, however, that they were much better before the ACA came along to destroy the apple cart. SMH