Implications of new health plan for PM&R?

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Annual jury awards and legal settlements involving doctors amounts to “a drop in the bucket” in a country that spends $2.3 trillion annually on health care, Amitabh Chandra, another Harvard University economist, recently told Bloomberg News. Chandra estimated the cost of jury awards at about $12 per person in the U.S., or about $3.6 billion. Insurer WellPoint Inc. has also said that liability awards are not what’s driving premiums.

And a 2004 report by the Congressional Budget Office said medical malpractice makes up only 2 percent of U.S. health spending. Even “significant reductions” would do little to curb health-care expenses, it concluded.

A study by Bloomberg also found that the proportion of medical malpractice verdicts among the top jury awards in the U.S. declined over the last 20 years. “Of the top 25 awards so far this year, only one was a malpractice case.” Moreover, at least 30 states now cap damages in medical lawsuits.

The experience of Texas in capping damage awards is a good example. Contrary to Perry’s claims, a recent analysis by Atul Gawande in the New Yorker found that while Texas tort reforms led to a cap on pain-and-suffering awards at two hundred and fifty thousand dollars, which led to a dramatic decline in lawsuits, McAllen, Texas is one of the most expensive health care markets in the country. In 2006, “Medicare spent fifteen thousand dollars per person enrolled in McAllen, he finds, which is almost twice the national average — although the average town resident earns only $12,000 a year. “Medicare spends three thousand dollars more per person here than the average person earns.”

o.....k. let me rephrase:

economists, the CBO, and Bloomberg cant reliably estimate the impact of malpractice on the practice of defensive medicine. they McAllen, Texas story is enlightening, and I am an avid reader of Gawande, but that doesnt come anywhere close to estimating cost.

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Annual jury awards and legal settlements involving doctors amounts to “a drop in the bucket” in a country that spends $2.3 trillion annually on health care, Amitabh Chandra, another Harvard University economist, recently told Bloomberg News. Chandra estimated the cost of jury awards at about $12 per person in the U.S., or about $3.6 billion. Insurer WellPoint Inc. has also said that liability awards are not what’s driving premiums.

And a 2004 report by the Congressional Budget Office said medical malpractice makes up only 2 percent of U.S. health spending. Even “significant reductions” would do little to curb health-care expenses, it concluded.

A study by Bloomberg also found that the proportion of medical malpractice verdicts among the top jury awards in the U.S. declined over the last 20 years. “Of the top 25 awards so far this year, only one was a malpractice case.” Moreover, at least 30 states now cap damages in medical lawsuits.

The experience of Texas in capping damage awards is a good example. Contrary to Perry’s claims, a recent analysis by Atul Gawande in the New Yorker found that while Texas tort reforms led to a cap on pain-and-suffering awards at two hundred and fifty thousand dollars, which led to a dramatic decline in lawsuits, McAllen, Texas is one of the most expensive health care markets in the country. In 2006, “Medicare spent fifteen thousand dollars per person enrolled in McAllen, he finds, which is almost twice the national average — although the average town resident earns only $12,000 a year. “Medicare spends three thousand dollars more per person here than the average person earns.”

The first paragraph does not appear to take in to consideration CYA testing. I've seen estimates of 20% or more of tests are mainly CYA. It is hypothesized by many that the extra costs of these tests could be averted by more serious tort reform. That is only testable where or if tort reform is enacted.

What is the health of the population of McAllen, Texas? Maybe they are just more unhealthy than the rest of the country. Hey, someone has to be #1!:laugh:
 
The first paragraph does not appear to take in to consideration CYA testing. I've seen estimates of 20% or more of tests are mainly CYA. It is hypothesized by many that the extra costs of these tests could be averted by more serious tort reform. That is only testable where or if tort reform is enacted.

What is the health of the population of McAllen, Texas? Maybe they are just more unhealthy than the rest of the country. Hey, someone has to be #1!:laugh:


http://health.msn.com/fitness/articlepage.aspx?cp-documentid=100104950

it appears that some on this board may not be doing their job all that well...... :rolleyes:
 
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The first paragraph does not appear to take in to consideration CYA testing. I've seen estimates of 20% or more of tests are mainly CYA. It is hypothesized by many that the extra costs of these tests could be averted by more serious tort reform. That is only testable where or if tort reform is enacted.

What is the health of the population of McAllen, Texas? Maybe they are just more unhealthy than the rest of the country. Hey, someone has to be #1!:laugh:

McAllen has a large population of retirees, mostly from other parts of TX, OK, Nebraska, KS etc. It has a low cost of living, good weather, good fishing and hunting. You get the picture. Lots of RVs and 5th wheels. It is VERY unhealthy. It does not make the list cause it it too small population wise.

There was a survey by the American College of Cardiology which was just reported to it's members (I don't know if it was formally published yet) which estimated that over 50% of cardiac testing was done to CYA. The cardiologist who told me this used to practice in Damascus. He said that the cost of treating a patient with CHF in Damascus was 1/10 of what it is here. He said that most CHF there is treated outpt with frequent f/u and labs. Anecdotally, he said that he thought the patients did better there!
He then told me that he would not consider that type of program here for fear of being sued. Again, that is one man's opinion.
 
So the fact that you get paid the global fee in the office as opposed to the professional component does not impact you?

You are being a hypocrit. You work in a facility that has its own MRI/CT and fluoro equiptment. But YOU don't do anything unethical.

You are talking about CHARGES in physician owned hosp. as being different from other types of hospitals (not for profit/for profit private). They are not. Everyone tries to maximize their reimbursement.
I did not attack you directly. You seem to take my characterization personally. If the shoe fits...

Maximize reimbursement = raping the system in my book. Feel free to defend the $30,000 epidural - I don't see how that is ethical - perhaps you do.

Oh, and your info is wrong - our practice does not, in fact, have either an MRI or CT.
 
I did not attack you directly. You seem to take my characterization personally. If the shoe fits...

Maximize reimbursement = raping the system in my book. Feel free to defend the $30,000 epidural - I don't see how that is ethical - perhaps you do.

Oh, and your info is wrong - our practice does not, in fact, have either an MRI or CT.

[SIZE=+1]IMAGING SERVICES[/SIZE]

FLUOROSCOPY

COMPUTED TOMOGRAPHY

MAGNETIC RESONANCE IMAGING

INDEPENDENT REVIEW OF DIAGNOSTIC STUDIES


I do not take any of this personally. I took the above info as cut/paste from your office website. I apologize if I was wrong about who owned the machines. I do know that Dr. April reads and dictates his own imaging reports (at least he used to 10yrs ago when I practiced in NOLA), I assume he billed for that as well.

I don't even do interventional spine, so "the shoe don't fit". I am a strong supporter of Physician owned hospitals since I have personally seen what this type of facility can do to a medical community (at least in a rural setting). The quality of care in my town has drastically improved in the year since our second hospital opened, satisfaction is up (at both hospitals), and COSTS ARE DOWN!--And no, I will not be posting the data on a public forum. That info is propriatary.​

 
Yup, your information is 5 years out of date - and reflects the the services the practice offered pre-Katrina
 
Hmmm - you were offended by my characterization, but yet didn't take it personally - interesting inconsistency.

Physician owned hospitals do not provide emergency medical care, which is typically the biggest cost center of any hospital. So of course costs are down - you no longer have to eat those costs!

Physician owned hospitals take their patients out of network for facility fees, overutilize, and cherry pick profitable procedures and patients, leaving community hospitals far worse off financially. Forgive me if I don't take your word for it when your town's experience runs counter to the vast majority of communities nationally.
 
Hmmm - you were offended by my characterization, but yet didn't take it personally - interesting inconsistency.

Physician owned hospitals do not provide emergency medical care, which is typically the biggest cost center of any hospital. So of course costs are down - you no longer have to eat those costs!

Physician owned hospitals take their patients out of network for facility fees, overutilize, and cherry pick profitable procedures and patients, leaving community hospitals far worse off financially. Forgive me if I don't take your word for it when your town's experience runs counter to the vast majority of communities nationally.

Any physician owned HOSPITAL (not ASC or "specialty hospital") has a fully functional ER. And it is staffed by physicians 24/7. Sorry if I don't take your wealth of experience living and practicing in one city as gospel either.
 
Ok--so I read the back and forth; just a few recent events of note:

1. I got a call from a doc in the medical center ( Houston), saying that a patient from an African Country needed treatment but two hospital systems in the medical center ( with Emergency Rooms), were asking for $100,000 up front and the patient thought it was too much and could I help him and work out something reasonable. I said yes. The total cost of care for the patient was $11,254.
2. One of those hospitals has standing orders for all docs to order daily labs and a number of standing tests, regardless of need. I know this is upsetting to some of my friends that practice at this place, because they weren't trained that way, but they have no choice.

Draw your own conclusions.

Story 2: Radiation Therapy Centers; Lots of money at stake at these places for sure:

1. Private Doctor owned place does the following:

a. gets patient assistance for pts in need.
b. Pays for patient toll tags
c. Walks every patient by the arm while they are in the center moving around, so they are never alone.
d. has a graduation ceremony for the patient when they finish.
e. Assists the patient with any insurance applications etc.
f. Uses the latest equipment that uses the minimal radiation dispersion.

2. Public Hospital - demands money up front. No services. Does not update equipment as frequently and does not have the latest equipment.

3. British Columbia, Canada - has a grand total of four radiation centers; patients must drive up to nine hours to get to a center. treatments are often daily.

Draw your own conclusions.

Government Medical experiments in care;

Tenncare, Maine, Massachusetts, the VA ( here in the US). Read up on all of them draw your own conclusions.

here is my opinion; the belief that the government can run healthcare is foolish. general hospitals drive up costs. private docs can control costs. health care reform will remove money from doc reimbursement because the health care reform act precludes any real reductions from pharma and hospitals until a later date, if ever. while this protects income for certain types of specialties.

Malpractice cases in states without tort reform like Texas drive up costs indirectly, by their effects on test ordering by other docs. McCall en Texas has a very high rate of diabetes and hypertension, much higher than the national average, and Medicare costs reflect this. Docs are moving to Texas in droves, away from other states, because its easier to practice medicine here. The economic impact of a single doc moving to a state has been studied, and is large in dollars. Employees, vendors, everything all come with the package. Texas understands this and is benefiting. Still no state income tax yet!

Government run health care is equivalent to financial failure in every instance - just like the government. Its all about cost at a time when the government has no money. There isn't anything in the Constitution about the government running health care and for good reason. They don't have the expertise and correct motivations.
 
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Yup, your information is 5 years out of date - and reflects the the services the practice offered pre-Katrina

So you stayed while others left. I respect that--but it explains your anger at " the man."
 
Okay - an updated look at the impact on PMR:

1. ACOs (These are accountable care organizations and participation is voluntary). Doc groups and hospitals as well as joint ventures can form organizations that costs and incentives in an attempt to bring value and efficiency and control to medical management.

PMR recommendation: providers should watch how these organizations form and consider the impact on their personal practice situation. A well positioned PMR doc in good with a hospital inpatient service that is also a source of income for outpatient services such as therapy could do fairly well. Be on the right committee in other words that can figure out how to grow a pie by having a PMR presence as opposed to a static pie with smaller slices. Can you help grow the pie with your professional relationships?

2. CMS Innovation Center - 10 Billion to test new innovative payment models within Medicare. CMS has specified 13 models. These models align evidence based guidelines. With incentives and emphasis on follow up care.

PMR recommendation - The national organization needs to participate with CMS in constructing its own model or be a part of one of the others. Perhaps a co-specialty approach to modeling would make sense. The lack of evidence based outcomes in PMR ( relative lack) places the speciality in a compromised position. The specialty is going to have to think through how to handle this very carefully and it really does require some leadership. ( probably not the type seen in this thread so far).

3. generic Incentives - removes incentives for using higher cost drugs - might be some money to be made here, if you feel a generic is a true equivalent for whatever it is you are prescribing. No real PMR impact in particular.

4. Clinical trials - ins co must cover costs of patients in clinical trials for their otherwise routine care. This might increase participation in clinical trials. PMR-Might be useful for some head injury researchers ( as an example only) working as attendings on rehab units.

5. New fees on medical device manufactures- might increase acquisition costs for equipment.

PMR- better charge $30,000 for those epidurals! LOL. Just kidding. A better capitalized entity will have the advantage regardless of specialty. Might drive the hook up with a surgical sub specialty approach in PMR.

6. Payment Advisory Board - their only mission is to reduce spending. They WILL cut procedure code reimbursement and make some way out there recs- such as the mammography debacle.

PMR - very vulnerable to this board. It wont matter if you are on salary or in private practice or whatever. This could really hurt budgets and revenue in a PMR balance sheet.

7. Comparative Effectiveness - non-profit outcomes research center. Compares CE of medical treatments based on outcomes.

PMR - use available literature to justify effectiveness of rehab interventions wherever possible and be visible with this research. We all know how this works. Its just same song different tune, except with higher stakes.

Thats all I have for now. Good Luck guys. ( and gals).
 
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They don't have the expertise and correct motivations.

incorrect. they have the correct motivations. they absolutely do not have the expertise or infrastructure
 
Government doesn't run healthcare now. The health care reform act left the provision of healthcare in the hands of private insurers. Clearly, Medicare can be difficult, but they tend to be far less capricious in their decision making than 3rd party payers.

Clearly on the whole Medicare pays us less. But collection costs are also significantly less. At present, opting out isn't a viable option in my community.
 
Clearly on the whole Medicare pays us less. But collection costs are also significantly less. At present, opting out isn't a viable option in my community.
But what will you do when your FI stops paying for Facets and discograms and there is a 21% across the board cut in all reimbursement?

That is the real question. How will you make your practice survive?

(I am assuming that you are not employed by a hospital, multispecialty group or other umbrella type organization)
 
But what will you do when your FI stops paying for Facets and discograms and there is a 21% across the board cut in all reimbursement?
Those are chicken little the sky is falling scare tactics - there is no reason to believe either of those procedures will not continue to be funded, and fixing the SGR is far more likely than any other option. No physician has ever had their fees cut 21%, despite multiple "crises", and there is no reason to believe that will happen in future.
 
incorrect. they have the correct motivations. they absolutely do not have the expertise or infrastructure

I was hoping someone would inquire on this. Thanks. A process heavily affected by politics defines the wrong motivation. So if we look at the payment advisory board, due to politics the only area they are allowed to look at for decreasing remuneration for a service is providers. Politics protected the other recipients of taxpayer dollars. The hospitals protected themselves for a period of years from this part of the reform bill. Pharma did for ever, and ins cos went along because they expect more premium dollars to manage. Incorrect motivation is an accurate description.
 
Government doesn't run healthcare now. The health care reform act left the provision of healthcare in the hands of private insurers. Clearly, Medicare can be difficult, but they tend to be far less capricious in their decision making than 3rd party payers.

Clearly on the whole Medicare pays us less. But collection costs are also significantly less. At present, opting out isn't a viable option in my community.

If you read it more closely it gradually incentives insurance away from the private side and towards the public side. The mere changes in Medicaid qualifications to 89,000 a year for a family of four is a huge move in the direction of full government control, but that's just the most obvious and egregious tactic among more subtle shifting. The government is broke and wants more sources of funding to allow its survival. I just don't think healthcare should be part of this clear conflict of interest and motivation.
 
Those are chicken little the sky is falling scare tactics - there is no reason to believe either of those procedures will not continue to be funded, and fixing the SGR is far more likely than any other option. No physician has ever had their fees cut 21%, despite multiple "crises", and there is no reason to believe that will happen in future.

I also believe the SGR will get fixed; but procedures without strong literature support and deemed non-essential will likely become a target for the payment advisory board and may be eliminated entirely so we have a basic public health care option for most and the rest will pay for a higher level of service. The middle class loses again. While it exists that is.
 


Okay. So what is your opinion of this article? Is it wrong? I know in New Orleans most of the small oncology groups have had to sell their practices to hospitals; they aren't happy but they had no choice.

If this article is correct, health care restricts insurers in running their own businesses. This is a real shame actually, and distinctly socialistic.
 
Okay. So what is your opinion of this article? Is it wrong? I know in New Orleans most of the small oncology groups have had to sell their practices to hospitals; they aren't happy but they had no choice.

If this article is correct, health care restricts insurers in running their own businesses. This is a real shame actually, and distinctly socialistic.

no, i agree with the article. i dont think its wrong.

of course, everything is affected by politics. big pharma and insurance companies throw more money in the ring, so their interests are protected. nothing new there. as docs, our lobby is what, the AMA? nice work there. id love to see insurers take a hit, it love to see big pharma take a hit.


im no socialist, but wanting quality healthcare for all isnt some uber-radical left wing idea

ive seen estimates where health insurers take 35% of all health care dollars. and what do they do, really? they act as a middle man between health care providers and patients. they true solution is to build infrastructure nationally to eliminate the middle man. docs get paid more, patients pay less. chance of this happening? -- next to zero.

what it inevitably will boil down to is docs will need to turn away or provide poorer quality care if we want to get paid. it is so deeply ingrained in us to avoid this that itll be hard to do for many docs. i suspect we will see some docs playing the martyr, others raping the system, and overall, not that much will change.
 
no, i agree with the article. i dont think its wrong.

of course, everything is affected by politics. big pharma and insurance companies throw more money in the ring, so their interests are protected. nothing new there. as docs, our lobby is what, the AMA? nice work there. id love to see insurers take a hit, it love to see big pharma take a hit.


im no socialist, but wanting quality healthcare for all isnt some uber-radical left wing idea

ive seen estimates where health insurers take 35% of all health care dollars. and what do they do, really? they act as a middle man between health care providers and patients. they true solution is to build infrastructure nationally to eliminate the middle man. docs get paid more, patients pay less. chance of this happening? -- next to zero.

what it inevitably will boil down to is docs will need to turn away or provide poorer quality care if we want to get paid. it is so deeply ingrained in us to avoid this that itll be hard to do for many docs. i suspect we will see some docs playing the martyr, others raping the system, and overall, not that much will change.

reasonable. I don't disagree with anything you say. But here's how I looked at that article. If the article is correctly citing facts - the health care reform act basically will put pressure on insurance companies to cut their reimbursements to doctors. As long as we have the current situation, where private unsurers reimburse at higher levels than medicare and Medicaid in most instances, doctors have a true option to not see federally insured patients.

While this option would remain, the margins will move closer together. I believe that this is what is intended.

I think were I differ from a lot of the posters on this thread is that I really do believe that the federal government's involvement with direct health care delivery should be minimized, and I do not believe that the true motivation is quality. I believe it is cost and trying to figure out how to spend less dollars in a looming budget crisis ( well I should say growing). Regardless of any shortcomings in our system currently, it works well for the vast majority of people who have private health insurance, and I don't think that that should be changed. Specifically. if I have a private policy, I don't want the Feds to interfere with my relationship with my health insurance company in anyway, and certainly not my employer's decision to provide or not provide it. or how it is provided.

I would still raise the age entry level of Medicare a couple of years as a cost saving measure, because it would help preserve the integrity of the program for those who are in it.
 
Okay. So what is your opinion of this article? Is it wrong? I know in New Orleans most of the small oncology groups have had to sell their practices to hospitals; they aren't happy but they had no choice.

If this article is correct, health care restricts insurers in running their own businesses. This is a real shame actually, and distinctly socialistic.
So left to their own devices, insurance companies would be provider and patient friendly? Good for the system?
 
I would still raise the age entry level of Medicare a couple of years as a cost saving measure, because it would help preserve the integrity of the program for those who are in it.
And the next time you came up for re-election, you would be voted out of office. It's a nice hypothetical, but not a viable proposal. Reducing Medicare benefits is one of the third rails of American politics.
 
And the next time you came up for re-election, you would be voted out of office. It's a nice hypothetical, but not a viable proposal. Reducing Medicare benefits is one of the third rails of American politics.

Actually raising the age of entry preserves benefits for those in the program. As it stands, Medicare beneficiaries will lose benefits under revenue distribution in the health care reform bill. I understand what you are saying about politics, but in reality, those already in would be OK with this, and those years from retirement would be as well. Minimal political risk actually.
 
So left to their own devices, insurance companies would be provider and patient friendly? Good for the system?

The current system works well for those with private insurance in the vast majority of instances. I don't think the government should be in a position to affect private industry as much as the health care reform bill does -- its none of the feds business actually and they have no legitimacy whatsoever in health care other than Medicare and Medicaid. The Health Care reform bill increases taxes and gives government way too much discretion over more peoples money, including forcing people to buy insurance- which I also disagree with.

The Government has a budget problem.They don't have enough money. That's whats driving all of this. Nothing else. They want control of more money.
 
Providers are getting squeezed in the current system. Reimbursements are getting capriciously cut in the current system, seemingly at the whim of the insurers. Patient premiums and copays have skyrocketed under the current system.

Portability and coverage for pre-existing conditions are not available under the current system.

Carrier executive pay is in the 8 figure range under the current system.

I don't know where you practice, but virtually every provider I knew pre health care reform was exceedingly unhappy with the current system. Virtually every patient I took care of was incredibly ticked at the lack of coverage for basic services despite escalating premiums and co-pays. I can not think of a single patient, other than those with Medicare, who thought the current system "worked well"

The 500 million dollar talking point the Republicans describe as a reduction in Medicare is the 15% kickback private insurers received through Medicare advantage. No Medicare recipient's Part B benefits are in any way diminished under the health care reform act.
 
Providers are getting squeezed in the current system. Reimbursements are getting capriciously cut in the current system, seemingly at the whim of the insurers. Patient premiums and copays have skyrocketed under the current system.

Portability and coverage for pre-existing conditions are not available under the current system.

Carrier executive pay is in the 8 figure range under the current system.

I don't know where you practice, but virtually every provider I knew pre health care reform was exceedingly unhappy with the current system. Virtually every patient I took care of was incredibly ticked at the lack of coverage for basic services despite escalating premiums and co-pays. I can not think of a single patient, other than those with Medicare, who thought the current system "worked well"

The 500 million dollar talking point the Republicans describe as a reduction in Medicare is the 15% kickback private insurers received through Medicare advantage. No Medicare recipient's Part B benefits are in any way diminished under the health care reform act.

So first you are railing about million dollar a year providers raping the system and now providers are getting squeezed. Which is it?

here's the truth; providers whose offices have good business management practices can do OK and those that don't have that sort of skill set are getting squeezed. So we can agree that health care reform as far as costs ALREADY HAS STARTED based on your post WITHOUT GOVERNMENT INTERFERENCE.

Patients with private health insurance OVERALL have actually had their costs go down in most instances. If you have Medicare Part B and an AARP secondary policy your cost is almost ZERO right now. How can this be any get any better as far as cost? It can't. The current system is optimal for patients.

The problem of cost is solely based on a government with a looming budget crisis in a world where private insurers and private patients are fine. The only real problem is access to care for those who do not have insurance who are US citizens.

The health care reform bill is a huge tax increase and will force young healthy people to spend money they don't have, either by purchasing insurance or by paying a penalty. This does not help the economy. And ratcheting down fee schedules to providers even further ( which will occur) will only decrease wages and create job loss for the middle class. And decrease the number of providers who can exist in private practices. None of this is good in my opinion.
 
The 500 million dollar talking point the Republicans describe as a reduction in Medicare is the 15% kickback private insurers received through Medicare advantage. No Medicare recipient's Part B benefits are in any way diminished under the health care reform act.

Wrong. There is a huge redistribution of Medicare benefits to non medicare age patients in the health care reform bill. I don't disgree that Medicare advantage plans will lose in health care reform as well. But lets all realize that the Medicare advantage plans did transfer risk out of the traditional Medicare system and may have actually contributed to cost control despite the premium you cite, which was not a uniform number by the way ( but 15% is reasonable).

The point I am making is that bringing medicare advantage patients back into the traditional Part B system ( which we know doesn't meet budget) is a financial step backwards because now Part B is again assuming risk it didn't have before in a system that was over budget already.
 
The AAPMR has a fairly lengthy diatribe on its position on health care reform. Its long on words and tends to have something for everyone in it. It does say at one point that the Academy position is that without tort reform and solid plan financing health care reform will likely be ineffective.
 
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