Medical Students and the Affordable Care Act: Uninformed and Undecided

[seracus]

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http://archinte.jamanetwork.com/article.aspx?articleid=1362939

As future physicians, do we have a responsibility to be knowledgeable about the ACA?

 

[link2swim06]

http://archinte.jamanetwork.com/article.aspx?articleid=1362939

As future physicians, do we have a responsibility to be knowledgeable about the ACA?

Yes, but there are far more important things. I'd say concentrating on learning medicine should be a priority first.

When you are an attending with free time then it is easier to read up on this stuff.

Nobody should fault med students for concentrating on medicine and using their free time for non-medical related activities.

 

[ChartaBona]

http://archinte.jamanetwork.com/article.aspx?articleid=1362939

As future physicians, do we have a responsibility to be knowledgeable about the ACA?

We won't be attendings for almost a decade. The ACA has been altered a lot already. Who is to say it won't be completely scrapped or overhauled by 2020+?

As US citizens, we should still know the basics of it, since it affects us today. An interviewer may ask you about your thoughts on the ACA as well.

 

[Bangersandmash]

No one has a responsibility to be informed about it, but any American citizen who wants to know what's going on in the country should know the basics.

 

[bengaltiger211]

i actually disagree with some of the comments said, i think that medical students should absolutely be knowledgeable about the ACA. Literacy in these extremely relevant topics to healthcare/medicine doesn't take a enormous amount of time...you can have a good understanding of how healthcare policy and business affects the provider community by reading just an article or two every few days.

take a look at the MD interviews on this very site, a lot of them ask about the most underrated issues that face medicine today. almost invariably they reply that the regulatory and financial climates are the issues that constantly their affect their ability to practice. these are not peripheral issues, they directly affect the way we practice medicine and ultimately the health of our future patients

 

[link2swim06]

i actually disagree with some of the comments said, i think that medical students should absolutely be knowledgeable about the ACA. Literacy in these extremely relevant topics to healthcare/medicine doesn't take a enormous amount of time...you can have a good understanding of how healthcare policy and business affects the provider community by reading just an article or two every few days.

take a look at the MD interviews on this very site, a lot of them ask about the most underrated issues that face medicine today. almost invariably they reply that the regulatory and financial climates are the issues that constantly their affect their ability to practice. these are not peripheral issues, they directly affect the way we practice medicine and ultimately the health of our future patients

It is easy to say this as as a pre-med, but as a med student and resident you will have much less free time.

I think we should encourage students to know about obama care, but it shouldn't be a responsibility.

 

[deleted329605]

It is easy to say this as as a pre-med, but as a med student and resident you will have much less free time.

I think we should encourage students to know about obama care, but it shouldn't be a responsibility.

I think what's even more important than understanding ACA is understanding the underlying problems in providing care in modern times. Obamacare is just one of the many answers to this problem. I think that med students should be held accountable for understanding the environment in which medicine is practiced today, so they aren't hoodwinked when they get out into the real world. I don't believe it would be fair to hold students accountable for understanding in detail the way prices are set, regulated, attempted to be curbed, as well as the overall distribution of risk in healthcare is excessive. Leave that to the actuaries.

 

[mzarrowsmith]

http://archinte.jamanetwork.com/article.aspx?articleid=1362939

As future physicians, do we have a responsibility to be knowledgeable about the ACA?

Yes. Any professional should understand legislation that affects their lives as profoundly as the PPACA will affect physicians in the coming decades. It doesn't affect only attendings, either. Changes to entitlement programs and physician payment certainly will be considered when picking specialties.

The invited commentary correctly argued that medical schools should put the basics in the curriculum. Even if it's a simple lecture series or tacked onto ICM, this would be a good idea.

This article kind of called out medical students, but I'd love to see the results of a similar survey of physicians at large (not just academic medicine attendings). My guess is that there's a lot of practicing docs who haven't the slightest clue what is in the PPACA.

 

[WaterPog]

Should a prospective home buyer be at least passingly familiar with proposed and pending legislation which pertains to buying/owning/financing a home?

I know that if I were about to spend a quarter to a half million dollars on a house I'd want all the information I could get to make sure I'm not doing something foolish out of ignorance....

 

[Gut Shot]

My guess is that there's a lot of practicing docs who haven't the slightest clue what is in the PPACA.

This is true. I have met physicians who don't understand marginal tax rates. That frightens me.

 

[link2swim06]

This is true. I have met physicians who don't understand marginal tax rates. That frightens me.

Speaking of marginal tax rates...earlier this week my attending was explaining to me how "making one dollar above the tax bracket cut off will make you lose tons of money."

I smiled, nodded, and avoided killing my grade by not telling him he is an idiot.

 

[music2doc]

Yes. Any professional should understand legislation that affects their lives as profoundly as the PPACA will affect physicians in the coming decades. It doesn't affect only attendings, either. Changes to entitlement programs and physician payment certainly will be considered when picking specialties.

The invited commentary correctly argued that medical schools should put the basics in the curriculum. Even if it's a simple lecture series or tacked onto ICM, this would be a good idea.

This article kind of called out medical students, but I'd love to see the results of a similar survey of physicians at large (not just academic medicine attendings). My guess is that there's a lot of practicing docs who haven't the slightest clue what is in the PPACA.

Some do put it in there -- I know mine does -- but the view is always biased toward the person giving the lecture. Here, we are in a very poor community where the PPACA will be very helpful to a certain segment of the population. Elsewhere, I suspect it will do far more harm than good. I also have yet to hear anyone answer certain sustainability/provider protections questions satisfactorily. Every time I or anyone else asks a provider-oriented question, the person just gives a smokescreen answer and switches topics. It's clear they have no answer that would be satisfactory which, frankly, scares me because if the providers cannot maintain a sustainable practice under the PPACA, access to care will DROP (like an anvil into an empty pool), not improve!

 

[Frazier]

Speaking of marginal tax rates...earlier this week my attending was explaining to me how "making one dollar above the tax bracket cut off will make you lose tons of money."

I smiled, nodded, and avoided killing my grade by not telling him he is an idiot.

No progressive taxation for you!

 

[HughMyron]

I have some friends who completely abandoned any medical aspirations after seeing the ACA. I didn't, but the more I learn, the more I think I should have.

Oh well, its too late to back out now. Might as well make the best of it.

 

[link2swim06]

I have some friends who completely abandoned any medical aspirations after seeing the ACA. I didn't, but the more I learn, the more I think I should have.

Oh well, its too late to back out now. Might as well make the best of it.

How so? ACA isn't really focused on physician pay or even the way we practice. It is more about insurance policies and required coverage. It is going to affected small to medium sized companies much more.

 

[music2doc]

How so? ACA isn't really focused on physician pay or even the way we practice. It is more about insurance policies and required coverage. It is going to affected small to medium sized companies much more.

While true, I still wonder how it will be sustainable on the provider end. At least in some specialties, Medicare reimburses BELOW the cost to the provider so providers actually LOSE money on each MCR pt. As a result, many providers have to limit MCR slots to ensure a viable payer mix. This may mean min 60% commercial/≤35% MCR/≤5% Medicaid, for instance. Given the proposed increase in MCD pts -- even if we allow for the feds offering MCR-pay for MCD pts (for the first, IIRC, 4 years only) -- this grossly increases the number of underpaying pts. As a result providers are going to have to give preference to "paying customers" (i.e., those pts possessing commercial insurance) and may end up turning away large numbers of MCR/MCD pts as a result (even if by turning away we really mean "scheduling them for an apt 9 months out"). Physician salaries are not even at issue here. The physician group must pay for their own expenses to include a front desk person, MAs, office space, equipment, etc. like any other business. Their own salaries are often a much smaller portion of the expense incurred than might be assumed.

I have yet to have a PPACA advocate answer that issue satisfactorily. Instead, every time it is brought up, they attempt to smokescreen and sidestep the issue. If there is a good solution, I want to hear it. Someone, PLEASE make me look ignorant here! I'd like to hear a viable way this could work without costing providers heavily in terms of finances, bankrupting our government (even further), or limiting access to pts who cannot afford to pay (more).

 

[link2swim06]

While true, I still wonder how it will be sustainable on the provider end. At least in some specialties, Medicare reimburses BELOW the cost to the provider so providers actually LOSE money on each MCR pt. As a result, many providers have to limit MCR slots to ensure a viable payer mix. This may mean min 60% commercial/≤35% MCR/≤5% Medicaid, for instance. Given the proposed increase in MCD pts -- even if we allow for the feds offering MCR-pay for MCD pts (for the first, IIRC, 4 years only) -- this grossly increases the number of underpaying pts. As a result providers are going to have to give preference to "paying customers" (i.e., those pts possessing commercial insurance) and may end up turning away large numbers of MCR/MCD pts as a result (even if by turning away we really mean "scheduling them for an apt 9 months out"). Physician salaries are not even at issue here. The physician group must pay for their own expenses to include a front desk person, MAs, office space, equipment, etc. like any other business. Their own salaries are often a much smaller portion of the expense incurred than might be assumed.

I have yet to have a PPACA advocate answer that issue satisfactorily. Instead, every time it is brought up, they attempt to smokescreen and sidestep the issue. If there is a good solution, I want to hear it. Someone, PLEASE make me look ignorant here! I'd like to hear a viable way this could work without costing providers heavily in terms of finances, bankrupting our government (even further), or limiting access to pts who cannot afford to pay (more).

Right, but also remember medicare raises payouts for primary care every year. I don't know if it will eventually make medicare patients profitable, but it heading in the right direction.

 

[Gut Shot]

While true, I still wonder how it will be sustainable on the provider end. At least in some specialties, Medicare reimburses BELOW the cost to the provider so providers actually LOSE money on each MCR pt. As a result, many providers have to limit MCR slots to ensure a viable payer mix. This may mean min 60% commercial/≤35% MCR/≤5% Medicaid, for instance. Given the proposed increase in MCD pts -- even if we allow for the feds offering MCR-pay for MCD pts (for the first, IIRC, 4 years only) -- this grossly increases the number of underpaying pts. As a result providers are going to have to give preference to "paying customers" (i.e., those pts possessing commercial insurance) and may end up turning away large numbers of MCR/MCD pts as a result (even if by turning away we really mean "scheduling them for an apt 9 months out"). Physician salaries are not even at issue here. The physician group must pay for their own expenses to include a front desk person, MAs, office space, equipment, etc. like any other business. Their own salaries are often a much smaller portion of the expense incurred than might be assumed.

I have yet to have a PPACA advocate answer that issue satisfactorily. Instead, every time it is brought up, they attempt to smokescreen and sidestep the issue. If there is a good solution, I want to hear it. Someone, PLEASE make me look ignorant here! I'd like to hear a viable way this could work without costing providers heavily in terms of finances, bankrupting our government (even further), or limiting access to pts who cannot afford to pay (more).

You are forgetting the "Don't pay a f-ing thing patients", who will hopefully become less common after January 1, 2014.

 

[music2doc]

Right, but also remember medicare raises payouts for primary care every year. I don't know if it will eventually make medicare patients profitable, but it heading in the right direction.

True, if that actually happens but aren't there still ongoing attempts to CUT MCR funding overall or are those no longer with PPACA?

You are forgetting the "Don't pay a f-ing thing patients", who will hopefully become less common after January 1, 2014.

This is true; however, I am not talking about the ED. I am talking about certain out-pt/clinic practices that lose money on these pts. This could be somewhat helpful to the ED since those would be replaced by MCD pts. On the other hand, we all know how much MCD pts seem to care about their own health.... 🙄

 

[Gut Shot]

This is true; however, I am not talking about the ED. I am talking about certain out-pt/clinic practices that lose money on these pts.

I'm a little confused. In your hypothetical clinic:
60% "commerical"
35% Medicare
5% Medicaid

After reform:
60% "commerical"
35% Medicare
5% Medicaid at Medicare rates

How is this clinic going to lose money, again?

 

[chemsmith]

Right, but also remember medicare raises payouts for primary care every year. I don't know if it will eventually make medicare patients profitable, but it heading in the right direction.

I may be mistaken but I believe that the increased payouts require annual congressional renewal, one of the few things AMA keeps up

 

[music2doc]

I'm a little confused. In your hypothetical clinic:
60% "commerical"
35% Medicare
5% Medicaid

After reform:
60% "commerical"
35% Medicare
5% Medicaid at Medicare rates

How is this clinic going to lose money, again?

The clinic won't lose money as long as it maintains that payer mix. The problem is that by maintaining that payer mix, the practice would delay care for a greater number of people. Think about it in terms of numbers...

For our hypothetical clinic...

Patient Capacity: 100 apts/wk
60/35/5 breakdown...
60 commercial/wk
35 MCR/wk
5 MCD/wk

Avg pt seen 1x/mo for 5 mos, so at any given time, we are seeing 400 pts (in high demand as is the case in this part of the country for virtually all specialties) and turnover is 400 pts seen/mo * 1 pt/5 mos = 80 new pts (per mo) = 20 new pts/wk

or... per wk:

12 commercial/wk
7 MCR/wk
1 MCD/wk

Let's also assume that our mix of pts in need is like the national stats (which probably underestimates the number of MCR pts actually needing care in comparison with the number of commercial pts for most specialties, thus resulting in a pretty conservative estimate):

67% Commercial
17% MCR
16% MCD

At first glance, this actually looks pretty good for MCR quite good actually (not great for MCD but hey, it's free right?). Our payer mix policy actually favors MCR pts over Commercial. If we went with what our accountants had figured, we might figure that if we have a waiting list of 50 patients -- how long does it take to get thru that if you are in each category?

Well, for 50 patients:

33 Commercial --> 3 weeks
8 MCR --> 2 1/2 weeks
8 MCD --> 2 months


Now, let's add all of our new MCD patients on and see how long everyone ends up waiting now....

56% Commercial
14% MCR
30% MCD

Now our wait list has also grown by 20% due to the new pts who want care (although in reality, it will likely be far more than this since those 20% are going to come flooding it with much higher volume than the population that was already taking care of itself).

So the WL is now 60 pts:
34 Commercial --> 3 wks
8 MCR --> 1 wk
18 MCD --> 4 1/2 mos


This basically puts us in the same place we already were of having the pts who could not pay still not getting the care they need. Chances are pretty good the pts waiting over a month to be seen are simply going to end up in the ED instead for "walk-in primary care."

 

[Gut Shot]

The clinic won't lose money as long as it maintains that payer mix. The problem is that by maintaining that payer mix, the practice would delay care for a greater number of people.

The problem is you keep redefining the problem.

 

[music2doc]

The problem is you keep redefining the problem.

The problem is multitiered. Either providers lose money or patients don't receive timely service. Let's keep it simplified to that. How do you solve that, first, given our financial restraints?

 

[Gut Shot]

The problem is multitiered. Either providers lose money or patients don't receive timely service. Let's keep it simplified to that. How do you solve that, first, given our financial restraints?

Resource reallocation, which will not happen overnight.

 

[link2swim06]

I may be mistaken but I believe that the increased payouts require annual congressional renewal, one of the few things AMA keeps up

Yes it is commonly know as the 'doc fix' but nevertheless there has been many attempts to make primary care at least break even or be profitable. But who knows how long the raises will continue.

 

[music2doc]

Resource reallocation, which will not happen overnight.

Do you think we cannot reallocate enough resources to make this viable without a change in the responsibility of the public for their own care (i.e., prevention, public health) or in the expectation of "100% success rate" the public (and apparently the gov't) has of medical providers?

 

[Gut Shot]

Do you think we cannot reallocate enough resources to make this viable without a change in the responsibility of the public for their own care (i.e., prevention, public health) or in the expectation of "100% success rate" the public (and apparently the gov't) has of medical providers?

The system can be made more rational irrespective of patient responsibility.

Neither the public nor government expect a 100% "success rate." That is a straw man.