Mister Mxyzptlk

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I wonder how they plan to run their health care system without any doctors.

July 17, 2009
Mass. Panel Backs Radical Shift in Health Payment
By KEVIN SACK

BOSTON — A high-level state commission recommended Thursday that Massachusetts seek to rein in health care costs by radically restructuring the way doctors and hospitals are paid.

The commission’s action kicks off the second phase of a health care overhaul that has succeeded in covering nearly every resident of the state but done little to slow the relentless growth of spending.

The recommendations, if approved by the legislature and Gov. Deval Patrick, would make Massachusetts the first state to end the practice of paying health care providers for each office visit, laboratory test or procedure.

Instead, primary care physicians, specialists and hospitals would group themselves into networks that would be responsible for a patient’s well-being and would be compensated with a flat monthly or annual fee known as a global payment.

The 10-member commission deferred many central decisions to the legislature and to a new authority that would be created to establish and oversee the new payment system. In doing so, it preserved cautious support from the state’s hospital association, medical society and leading insurers for a proposal that resembles guiding principles more than bill language.

Representatives of those groups joined in a unanimous commission vote for the recommendations. But they made clear that their continued support might depend on devilish details, the kind that will determine whether their members are net losers and, if so, by how much.

It was only by keeping those stakeholders at the negotiating table that the state succeeded in 2006 in vastly expanding subsidized coverage for the uninsured. Maintaining that coalition is expected to be more difficult as the state tries to slow the growth of costs, an effort that typically translates into less revenue for providers and insurers.

The existing “fee for service” system has been roundly criticized as offering incentives that encourage doctors to provide more treatment than is necessary, a significant contributor to the high cost of health care.

Global payments, it is thought, would reward health care providers for keeping their patients well rather than for merely treating their ailments. If the cost of treating a patient was less than the global payment, the provider networks, called accountable care organizations, would keep the difference as profit.

Changing the payment system has also been central to the health care debate in Washington. Thus far, those discussions have focused more on providing financial rewards for high-quality preventive care than on demolishing the fee-for-service system.

The Massachusetts commission was created last year by the legislature and was led by Mr. Patrick’s chief finance and health policy advisers. But on Thursday the governor, a first-term Democrat, stopped short of endorsing its recommendations, saying only that they “bring an important focus to cost containment and quality.”

Top state legislators said that they recognized the political challenge in enacting such a plan but that Massachusetts’ circumstances demanded it. Senator Richard T. Moore, co-chairman of a joint legislative committee on health care financing, said he expected to hold hearings on the recommendations this fall.

The committee’s other leader, Representative Harriett L. Stanley, said, “It’s going to be a very long haul, but it’s a trip worth taking.”

The commission stressed the importance of changing the way doctors and hospitals are paid not only by private insurers but also by Medicare and Medicaid. That would require permission from the federal government.

Global payments are hardly a new idea, as the concept closely resembles the capitation model that incited a backlash by consumers who accused health maintenance organizations of skimping on care. But members of the Massachusetts commission said their plan would offer financial incentives for performance that would transform physicians into care coordinators rather than gatekeepers.

“This is not about containing costs by sacrificing quality,” said Mr. Patrick’s finance director, Leslie A. Kirwan, a co-chairwoman of the commission. “That’s been tried and rejected, and rightly so.”

The commission recommended that its plan be carried out over five years. The state would not set rates, which would be negotiated by insurers and the new provider networks. But it would require those payment rates to account for variations in the health condition and socioeconomic status of patients seen by individual doctors and hospitals.

The report left the details of such risk adjustments to the new authority that would be established. It also made no projection of what it would cost to set up the new system.

Interest groups with heavy stakes embraced the proposal, but warily.

“Hospitals want to be part of this historic endeavor,” said Lynn B. Nicholas, president of the Massachusetts Hospital Association. But Ms. Nicholas added that “the success of moving to a global payment system is not a foregone conclusion” and expressed concerns about how risks would be adjusted and how start-up costs would be covered.

The president of the state medical society, Dr. Mario E. Motta, also urged caution. “A big transition like this has never been done on such a broad scale,” Dr. Motta said, “so it must be done very carefully, deliberately and thoughtfully.”

The commission issued its recommendations three years after the state enacted one of the most sweeping restructurings of health care in the country’s history. By requiring nearly all residents to have health insurance, and providing subsidies to those earning no more than $66,150 for a family of four, the state has managed to cover 97 percent of its residents.

That is by far the highest rate of any state, and elements of the plan have been adopted by President Obama and Congressional Democrats in their proposals to revamp the national health care system.

But to maintain political support for expanding coverage, Massachusetts political leaders deliberately deferred any serious discussion then about how to control health care costs. Those costs have continued to rise at what state leaders acknowledge is an unsustainable annual rate of 6 percent to 9 percent. Although the state’s new subsidized insurance program, Commonwealth Care, has kept a lid on premium increases, it is now straining the state’s budget for the second consecutive year.

“We are among the highest-cost states,” said Sarah Iselin, Mr. Patrick’s health policy adviser and the other co-chairwoman of the commission. “Without intervention, our projections are that spending on a per-person basis could double by 2020.”
 

SSdoc33

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Apr 23, 2007
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I wonder how they plan to run their health care system without any doctors.

July 17, 2009
Mass. Panel Backs Radical Shift in Health Payment
By KEVIN SACK

BOSTON — A high-level state commission recommended Thursday that Massachusetts seek to rein in health care costs by radically restructuring the way doctors and hospitals are paid.

The commission’s action kicks off the second phase of a health care overhaul that has succeeded in covering nearly every resident of the state but done little to slow the relentless growth of spending.

The recommendations, if approved by the legislature and Gov. Deval Patrick, would make Massachusetts the first state to end the practice of paying health care providers for each office visit, laboratory test or procedure.

Instead, primary care physicians, specialists and hospitals would group themselves into networks that would be responsible for a patient’s well-being and would be compensated with a flat monthly or annual fee known as a global payment.

The 10-member commission deferred many central decisions to the legislature and to a new authority that would be created to establish and oversee the new payment system. In doing so, it preserved cautious support from the state’s hospital association, medical society and leading insurers for a proposal that resembles guiding principles more than bill language.

Representatives of those groups joined in a unanimous commission vote for the recommendations. But they made clear that their continued support might depend on devilish details, the kind that will determine whether their members are net losers and, if so, by how much.

It was only by keeping those stakeholders at the negotiating table that the state succeeded in 2006 in vastly expanding subsidized coverage for the uninsured. Maintaining that coalition is expected to be more difficult as the state tries to slow the growth of costs, an effort that typically translates into less revenue for providers and insurers.

The existing “fee for service” system has been roundly criticized as offering incentives that encourage doctors to provide more treatment than is necessary, a significant contributor to the high cost of health care.

Global payments, it is thought, would reward health care providers for keeping their patients well rather than for merely treating their ailments. If the cost of treating a patient was less than the global payment, the provider networks, called accountable care organizations, would keep the difference as profit.

Changing the payment system has also been central to the health care debate in Washington. Thus far, those discussions have focused more on providing financial rewards for high-quality preventive care than on demolishing the fee-for-service system.

The Massachusetts commission was created last year by the legislature and was led by Mr. Patrick’s chief finance and health policy advisers. But on Thursday the governor, a first-term Democrat, stopped short of endorsing its recommendations, saying only that they “bring an important focus to cost containment and quality.”

Top state legislators said that they recognized the political challenge in enacting such a plan but that Massachusetts’ circumstances demanded it. Senator Richard T. Moore, co-chairman of a joint legislative committee on health care financing, said he expected to hold hearings on the recommendations this fall.

The committee’s other leader, Representative Harriett L. Stanley, said, “It’s going to be a very long haul, but it’s a trip worth taking.”

The commission stressed the importance of changing the way doctors and hospitals are paid not only by private insurers but also by Medicare and Medicaid. That would require permission from the federal government.

Global payments are hardly a new idea, as the concept closely resembles the capitation model that incited a backlash by consumers who accused health maintenance organizations of skimping on care. But members of the Massachusetts commission said their plan would offer financial incentives for performance that would transform physicians into care coordinators rather than gatekeepers.

“This is not about containing costs by sacrificing quality,” said Mr. Patrick’s finance director, Leslie A. Kirwan, a co-chairwoman of the commission. “That’s been tried and rejected, and rightly so.”

The commission recommended that its plan be carried out over five years. The state would not set rates, which would be negotiated by insurers and the new provider networks. But it would require those payment rates to account for variations in the health condition and socioeconomic status of patients seen by individual doctors and hospitals.

The report left the details of such risk adjustments to the new authority that would be established. It also made no projection of what it would cost to set up the new system.

Interest groups with heavy stakes embraced the proposal, but warily.

“Hospitals want to be part of this historic endeavor,” said Lynn B. Nicholas, president of the Massachusetts Hospital Association. But Ms. Nicholas added that “the success of moving to a global payment system is not a foregone conclusion” and expressed concerns about how risks would be adjusted and how start-up costs would be covered.

The president of the state medical society, Dr. Mario E. Motta, also urged caution. “A big transition like this has never been done on such a broad scale,” Dr. Motta said, “so it must be done very carefully, deliberately and thoughtfully.”

The commission issued its recommendations three years after the state enacted one of the most sweeping restructurings of health care in the country’s history. By requiring nearly all residents to have health insurance, and providing subsidies to those earning no more than $66,150 for a family of four, the state has managed to cover 97 percent of its residents.

That is by far the highest rate of any state, and elements of the plan have been adopted by President Obama and Congressional Democrats in their proposals to revamp the national health care system.

But to maintain political support for expanding coverage, Massachusetts political leaders deliberately deferred any serious discussion then about how to control health care costs. Those costs have continued to rise at what state leaders acknowledge is an unsustainable annual rate of 6 percent to 9 percent. Although the state’s new subsidized insurance program, Commonwealth Care, has kept a lid on premium increases, it is now straining the state’s budget for the second consecutive year.

“We are among the highest-cost states,” said Sarah Iselin, Mr. Patrick’s health policy adviser and the other co-chairwoman of the commission. “Without intervention, our projections are that spending on a per-person basis could double by 2020.”

awful idea. i cant even list how many reasons why this is stupid because my fingertips would fall off from all the typing
 

tchoupdoc

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What is the cheapest, to the current system, treatment for back pain?

There are 2 clinics here that cost insurance companies and medicare/caid NOTHING, because the patients pay cash for visits and meds.

You could argue that there is some cost shifting to the criminal justice system, I guess...
 

2win

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Thanks buddy - I posted your story on anesthesia forum too.
 

Tenesma

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this is capitation re-modeled.... this model would encourage pain doctors to treat pain with the cheapest form of treatment: methadone, advil and soma - neglect therapy, diagnostic or therapeutic injections, surgical interventions, cognitive behavioral therapy.... the only interesting question that would arise out of that last sentence: if the results/outcomes are the same, then why not?

for some weird reason, all the patients on the methadone/advil/soma routine are non-functioning and unproductive in society... wherease the other treatments have allowed patients to go back to work (and pay taxes).
 

Ligament

Interventional Pain Management
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My sister is an MD in a prestigious fellowship at MGH/Harvard. She, herself, could not get a PCP appointment anywhere in the Harvard health system for a month or two because the PCPs are so swamped since everybody has health care now. So, the most useless population of the state is taking away prompt health care from the most useful. Sounds fair to me! :rolleyes::mad:
 

Tenesma

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going to a cash based practice is going to be so easy with the upcoming changes

1) shortage of physicians... most pain docs in my area ALREADY have a 2 month wait for consultations

2) huge influx of insured patients is going to drive that wait to 3 months

3) reimbursements will be cut

4) i will charge cash... my wait list will drop to 1 week, i will see 15 patients a day instead of 40 - make the same amount of money, with less paperwork (and less staff - no more insurance eligibility/pre-cert/pre-auth) and be a happier physician...

done deal

and with all the bad news hitting doctors right now, I can guarantee you that med school applications are going to drop --- and there will be less specialists (why spend another 1-4 years after residency in further training if you can generate the same amount of income with a 3 year IM or Peds residency).... so at some point in time, they will have to change the face of medicine by allowing RNs to practice medicine to cover the gaps OR they will have to admit that they screwed up... i doubt the latter.
 

SSdoc33

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going to a cash based practice is going to be so easy with the upcoming changes

1) shortage of physicians... most pain docs in my area ALREADY have a 2 month wait for consultations

2) huge influx of insured patients is going to drive that wait to 3 months

3) reimbursements will be cut

4) i will charge cash... my wait list will drop to 1 week, i will see 15 patients a day instead of 40 - make the same amount of money, with less paperwork (and less staff - no more insurance eligibility/pre-cert/pre-auth) and be a happier physician...

done deal

and with all the bad news hitting doctors right now, I can guarantee you that med school applications are going to drop --- and there will be less specialists (why spend another 1-4 years after residency in further training if you can generate the same amount of income with a 3 year IM or Peds residency).... so at some point in time, they will have to change the face of medicine by allowing RNs to practice medicine to cover the gaps OR they will have to admit that they screwed up... i doubt the latter.

wow. got any stock tips your might share from your crystal ball? a lot of this may happen, but thats jumping the gun a bit, no?
 

nleeds24

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In regards to your doomsday scenario don't you think its more likely that the govt would allow for more foreign trained docs to come here and cover all the additional work while being satisfied with making a low 6 figures a year? A FP income/lifestyle is awesome to someone who is practicing in the 3rd world treating people with very little money. They would be easy to control and far more qualified than RNs. Only thing is I'm not sure it would work for some specialists as well as it would for internal med, FP, radiology, etc.
 

panetrain

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I predict that PWEB will continue to make huge gains this week!

wow. got any stock tips your might share from your crystal ball? a lot of this may happen, but thats jumping the gun a bit, no?
 
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Jcm800

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1) if you go cash pay, have you figured out what you will charge?

2) will you then drop out of all insurances?

i talk about this all the time, but im not sure patients in my area will pay 500 bucks for an epidural...

the other side is to go for volume, which isnt great patient care, but... add a PA to my existing NP, and i just do procedures...if this is the system they want, it is the system I will give them.

they are crazy if they think i am working twice as hard to make the same amoint of money.

i guess the third option if i cannot increase my volume, is basically scrunch all of my patients into half days, and work 2.5 days a week. Make half as much money, make my NP work twice as hard, and spend the other 2.5 days a week buying Subways and other fast food franchises...unless im told how to charge for a whopper...

going to a cash based practice is going to be so easy with the upcoming changes

1) shortage of physicians... most pain docs in my area ALREADY have a 2 month wait for consultations

2) huge influx of insured patients is going to drive that wait to 3 months

3) reimbursements will be cut

4) i will charge cash... my wait list will drop to 1 week, i will see 15 patients a day instead of 40 - make the same amount of money, with less paperwork (and less staff - no more insurance eligibility/pre-cert/pre-auth) and be a happier physician...

done deal

and with all the bad news hitting doctors right now, I can guarantee you that med school applications are going to drop --- and there will be less specialists (why spend another 1-4 years after residency in further training if you can generate the same amount of income with a 3 year IM or Peds residency).... so at some point in time, they will have to change the face of medicine by allowing RNs to practice medicine to cover the gaps OR they will have to admit that they screwed up... i doubt the latter.
 

Disciple

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i guess the third option if i cannot increase my volume, is basically scrunch all of my patients into half days, and work 2.5 days a week. Make half as much money, make my NP work twice as hard, and spend the other 2.5 days a week buying Subways and other fast food franchises...unless im told how to charge for a whopper...
:laugh:You should do that, it would make a great story for the Wall Street Journal on the state of health care, 5 years from now when we're all suffering.
 

Disciple

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I don't see how you can do cash pay without writing for alot of narcotics. When the expense is all out of pocket, that's what people want.

You'll have to offer basic procedures only, at affordable rates. No RF, no stim.

If the NP sees all the follow-ups, he or she is either going to be lax with prescribing habits (so the patients will be happy) or relatively strict (as it should be), but then the patients are going get upset and are going to want to see you. "I just gave you $100.00, what do you mean you won't refill my Vicodin, give me my effing money back, I'm finding another doctor!".
 
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Kwijibo

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A small portion of my practice is a cash pay practice, and it is not as good as advertised. I charge 1200 for an epidural, and patients will pay. But you have to realize that the patient is not going to come back for another one unless his/her pain is very severe. So I could have done 2 two level transforaminals on a medicare patient and got the same amount of money.

Patients that pay cash are hard to please.
Patients that pay cash want to talk to you for 45 minutes on initial consult.
Try charging someone 1500 dollars for a diagnostic medial branch block that is negative. OR if it is positive, telling them they need another one before RFA.
(I am talking about patients who do not have private insurance with out of network benefits.)

So, overall keep your practice diversified, so you do not depend to readily on one payor type. Keep a good blend of medicare, private pay, private insurance, out of network, auto, work comp, and personal injury so you can shift your practice when the time comes.
 

Doctodd

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I don't see how you can do cash pay without writing for alot of narcotics. When the expense is all out of pocket, that's what people want.

You'll have to offer basic procedures only, at affordable rates. No RF, no stim.

If the NP sees all the follow-ups, he or she is either going to be lax with prescribing habits (so the patients will be happy) or relatively strict (as it should be), but then the patients are going get upset and are going to want to see you. "I just gave you $100.00, what do you mean you won't refill my Vicodin, give me my effing money back, I'm finding another doctor!".
and that's why you should have a sign outside in the waiting room, or have your staff say to all new patient calls that you dont write for narcotics. It will screen alot of those patients out so you can decide who really needs them.
 

Tenesma

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1) narcotics and self-pay.... currently 99% of the patients i see are NOT interested in narcotics or have been weaned off narcotics.... so my assumption of going cash only is based on the same patient population i have right now.

2) prices and procedures: they would have to be simple procedures, and all cortisone based (ie: nobody is going to cough up for 2 diagnostic MBBs only to be told they aren't a candidate for the RF because the 2nd block only gave 10% relief)... the price would have to be better than i what i generate now from private payers.... i'd have to be hospital based, so that the facility fee is covered by their insurance plans....

3) if i can get 200 for consultations, 50 for follow-ups, 500 for injections - i'd be ahead of the game --- however, i suspect my volume would decrease by about 60-80% the first 5-9 months until things solidify...

4) i have a few friends who have cash only pain practices (LA, NY) with minimal narcotics and if you have a good rep, and are connected to the cash-only PCPs and Spine surgeons, then it is quite doable....