Modern Health Care: Here comes site-neutral payments...

[drusso]

Site-neutral payment proposal sets the stage for battle royale between CMS, hospitals

"The different payment rates were initially set to account for hospital's higher overhead costs, since they must maintain emergency services and invest in unique, expensive equipment. Yet, over time, that premise became distorted, critics of the payment disparities argued. Health systems bought more physicians and physician groups to take advantage of the higher reimbursement rates, which were still doled out even if the hospital-owned clinic didn't look or operate any differently than a community-based doctor's office."

---

Members don't see this ad.

 

[hyperalgesia]

Site-neutral payment proposal sets the stage for battle royale between CMS, hospitals

"The different payment rates were initially set to account for hospital's higher overhead costs, since they must maintain emergency services and invest in unique, expensive equipment. Yet, over time, that premise became distorted, critics of the payment disparities argued. Health systems bought more physicians and physician groups to take advantage of the higher reimbursement rates, which were still doled out even if the hospital-owned clinic didn't look or operate any differently than a community-based doctor's office."

WOW, GAME ON!

For those who don't have access to the article above, search google for "site of service differential".

---
Mostashari gave credit to the current administration for taking site-neutral payment, and other controversial measures, head on.

"The conventional wisdom is that the hospital lobby is too powerful, but this administration may turn that on its head," he said.

 

[Disciple]

2 years after the 2016 election and this is really starting to gain some momentum.

Those who thought they were finished with private practice a couple of years ago should consider giving it one more shot.

Another important case to watch:

California hospital giant Sutter Health faces heavy backlash on prices

"Becerra's suit amounts to a giant test case with the potential for national repercussions. If California prevails and is able to tame prices at Northern California's most powerful, dominant health system, regulators and politicians in other states are likely to follow."

 

[Fpg1245]

Wouldn't get too excited. Forget about site neutral payments. The headline article is more concerning. Guess who will be paying for Medicare for all. Thats right providers!!

Libertarian think tank: Providers would pay for Medicare for All

 

[lobelsteve]

Wouldn't get too excited. Forget about site neutral payments. The headline article is more concerning. Guess who will be paying for Medicare for all. Thats right providers!!

Libertarian think tank: Providers would pay for Medicare for All

Slavery

 

[sunshinefl]

Wouldn't get too excited. Forget about site neutral payments. The headline article is more concerning. Guess who will be paying for Medicare for all. Thats right providers!!

Libertarian think tank: Providers would pay for Medicare for All

Wow. I was silently following this thread. But I am in shock now. I’m a med student on 100% loans that just started 2nd year on Monday, and this makes me want to drop out. (I won’t really, but very scary.)

 

[Fpg1245]

Slavery

Lets not get ahead of ourselves here. We cannot possibly comprehend the suffering of true slavery. But lets be honest, Payers like CMS and other ins will take the closest thing they can get to a slave. Pittance for compensation. No recourse. No private practice. No voice. and best of all No Alternatives so you are forced to continue on the hamster wheel. Its all been arranged for you to work on the cheap.

 

[Fpg1245]

Wow. I was silently following this thread. But I am in shock now. I’m a med student on 100% loans that just started 2nd year on Monday, and this makes me want to drop out. (I won’t really, but very scary.)

Well its not too late! I know that sounds crazy. What else are you good at? Are you a >90%ile standardized test taker? Do you have experience doing anything else? If you take the blinders and the do gooder glasses off and see what is in store for you and take stock of your life at this point is probably the best thing you can do. In my short career, things went from bad to worse financially and professionally. I think you should question what you are doing. "Why am I working so hard so that I can be the object of someone else's contempt?". It makes no sense what we tell residents and medical students today. Things like "Follow your passion", garbage, "Work hard and you will Fill In The Blank (have a job, security, get the residency you want, good pay), non-evidence based chicanery! Med students are being led like cattle to the sacrifice. Take a look at how many med schools have cropped up like a disease in the last 15 years. That is your clueless competition right there and its growing! You're gonna have to wise up to how healthcare is performed and who gets paid for it (Hint: it wont be you) and who doesn't (Almost always you). If you really want a tear jerker check out propublica non profit explorer. Check out the 990 forms on the top hospital admin at major health systems. Ill leave it to you to connect the dots.

 

[emd123]

Wow. I was silently following this thread. But I am in shock now. I’m a med student on 100% loans that just started 2nd year on Monday, and this makes me want to drop out. (I won’t really, but very scary.)

There's no reason to be shocked or depressed. Don't drop out, just don't vote for insane Socialist or Socialist-lite (Democrat) politicians. None of this "medicare for all" crap is going to happen under the current administration. If you vote the crazy socialists in, like Bernie and Ocasio Cortez, or their Democrat sympathizers into office, then it might happen. Then, doctors, plumbers, and ditch diggers will all make the same amount of money, and let me tell you, it won't be at a doctor's salary, but the ditch digger's salary. That's the socialists politicians' end goal: Every earns the same (except them, of course).

 

[Disciple]

Wouldn't get too excited. Forget about site neutral payments. The headline article is more concerning. Guess who will be paying for Medicare for all. Thats right providers!!

Libertarian think tank: Providers would pay for Medicare for All

Obviously, if we elect socialists, that's what they're going to push for. So, let's not do that.

Things are looking up for a change.

Free Markets/Innovation/Site-Neutral Payments.

 

[Extralong]

Get an MBA along the way

 

[lonelobo]

There's no reason to be shocked or depressed. Don't drop out, just don't vote for insane Socialist or Socialist-lite (Democrat) politicians. None of this "medicare for all" crap is going to happen under the current administration. If you vote the crazy socialists in, like Bernie and Ocasio Cortez, or their Democrat sympathizers into office, then it might happen. Then, doctors, plumbers, and ditch diggers will all make the same amount of money, and let me tell you, it won't be at a doctor's salary, but the ditch digger's salary. That's the socialists politicians' end goal: Every earns the same (except them, of course).

So what party is in control now? And what have they done to improve our lives as private practice doctors?

 

[Extralong]

We can join a state and/or national society such as ASIPP, NASS, SIS, etc. and convince congressman of our needs. Or be like Machikanti and start your own society.

 

[244913]

Lets not get ahead of ourselves here. We cannot possibly comprehend the suffering of true slavery. But lets be honest, Payers like CMS and other ins will take the closest thing they can get to a slave. Pittance for compensation. No recourse. No private practice. No voice. and best of all No Alternatives so you are forced to continue on the hamster wheel. Its all been arranged for you to work on the cheap.

Drusso- is this one of your throwaway accounts

 

[Fpg1245]

Drusso- is this one of your throwaway accounts

Nope. No connection. I had to google Drusso just to make sure you weren't implying anything negative.

 

[drusso]

Drusso- is this one of your throwaway accounts

Often imitated...never replicated...

 

[SeniorWrangler]

The paper acknowledged that phasing out employer-sponsored healthcare would translate into a huge increase in taxable wages, as it would free individuals, families and employers from hefty healthcare spending. States would also no longer have to fund Medicaid, consistently their largest budget item.

Good for some, bad for others. It's all hypothetical at this point. I remember the same kind of slavery talk when Obamacare was being debated and yet here we are, still posting on the same forum about the same issues.

 

[Ligament]

Nope. No connection. I had to google Drusso just to make sure you weren't implying anything negative.

Oh he was, he certainly was....

 

[Ligament]

Good for some, bad for others. It's all hypothetical at this point. I remember the same kind of slavery talk when Obamacare was being debated and yet here we are, still posting on the same forum about the same issues.

Obamacare made my business suffer immensely. Reimbursements tanked, pre-auths skyrocketed, denials skyrocketed, co-pays and premiums skyrocketed. Hell, I lost my own private insurance because my insurer had to leave the private pay market, but before that my own personal premiums skyrocketed. Impaired my quality of life significantly. We are still posting on this forum as we survived to this point, but it may not last forever.

 

[Gauss]

None of this "medicare for all" crap is going to happen under the current administration. If you vote the crazy socialists in, like Bernie and Ocasio Cortez, or their Democrat sympathizers into office, then it might happen.

Blue states are likely to enact some version of it, probably medicaid for all. Public pressure is mounting and policymakers like it. It looks inevitable

"Nothing says that the architects of a single-payer program can’t negotiate their way to a program that pays providers better than Medicare while, say, leaving some costs in individual hands or tweaking the program in some other way. The surprise is that Blahous’ analysis, which aimed to show that Medicare for All can’t possibly work, showed the way to make it work."

How a libertarian analyst inadvertently made a good case for Bernie Sanders' Medicare for All

 

[Fpg1245]

Blue states are likely to enact some version of it, probably medicaid for all. Public pressure is mounting and policymakers like it. It looks inevitable

"Nothing says that the architects of a single-payer program can’t negotiate their way to a program that pays providers better than Medicare while, say, leaving some costs in individual hands or tweaking the program in some other way. The surprise is that Blahous’ analysis, which aimed to show that Medicare for All can’t possibly work, showed the way to make it work."

How a libertarian analyst inadvertently made a good case for Bernie Sanders' Medicare for All

So what’s the game plan now? Try to sucker the beleaguered doctor into a sweetheart deal when single payer is ennacted and then in 4-8 years enact massive cuts across the board when the terms are re-negotiated. Sounds great! Only this time, you have won’t have anywhere to go because 99% will be on Medicare and your private payers will barely exist if at all.

 

[Ducttape]

Here comes my question - how does this affect ASC or HOPD procedure fees?

From what I am reading, this is targeting low level fruit of E&M visits, not where the real money is.


If this goes through, it might force all med students to go to purely procedural medicine and not the general specialties... in addition, getting rid of level 4/5 visits might negate any “benefit” of GPs going in to PP due to diminished reimbursements.

It doesn’t help PP as much as hurt HOPD, but we as is our wont, are claiming victory for hurting a segment of our own population.

FWIW, why CUT HOPD reimbursement? Why wasn’t the decision to INCREASE PP reimbursement?

I know you see it as a win, drusso, but unless I am Missing something, its a rhetorical one...

 

[lobelsteve]

Bring it. Im good enough at what i do to excel in the two tiered system. My patients will pay cash, i will treat them well.

 

[Fpg1245]

Here comes my question - how does this affect ASC or HOPD procedure fees?

From what I am reading, this is targeting low level fruit of E&M visits, not where the real money is.


If this goes through, it might force all med students to go to purely procedural medicine and not the general specialties... in addition, getting rid of level 4/5 visits might negate any “benefit” of GPs going in to PP due to diminished reimbursements.

It doesn’t help PP as much as hurt HOPD, but we as is our wont, are claiming victory for hurting a segment of our own population.

FWIW, why CUT HOPD reimbursement? Why wasn’t the decision to INCREASE PP reimbursement?

I know you see it as a win, drusso, but unless I am Missing something, its a rhetorical one...

Not at all surprising. Its actually worse than a zero some game. Somebody wins/Somebody loses but the total just continues to shrink.

 

[Ligament]

Wow. I was silently following this thread. But I am in shock now. I’m a med student on 100% loans that just started 2nd year on Monday, and this makes me want to drop out. (I won’t really, but very scary.)

I'd suggest choosing another profession asap, or get into an MD/MBA program ASAP and go into business after meds school instead of clinical practice. Its not too late to escape, your loans are not insurmountable. You did nothing wrong. The democrats and insurance companies have destroyed your future income potential.

 

[nvrsumr]

Lig. U do great. Don’t scare the poor med student.

 

[Ducttape]

Except... the Republicans are in complete control.


Can’t blame the Dems, sorry.

 

[Fpg1245]

Except... the Republicans are in complete control.


Can’t blame the Dems, sorry.

Don’t worry WSJ hates us too. Check out the headline right now on the website. Repubs hate you just as much if not more than Dems.

www.wsj.com.

 

[Fpg1245]

Except... the Republicans are in complete control.


Can’t blame the Dems, sorry.

I fully expect medicine to become largely a "pathway to citizenship" for the well educated immigrants who want out of their home countries. I believe the number of docs from overseas is around 30% today. That will probably double in the next 20 years. I'd start looking for managerial spots now before the wave MDs that suddenly feel that admin is their ultimate calling start flooding Hospital HR deparments with their resumes.

 

[Disciple]

Except... the Republicans are in complete control.

Can’t blame the Dems, sorry.

A lot of damage has been done the past 8 years.

It's taken about 2 years to put the brakes on and slowly start to turn things around.

Time will tell how much is salvageable.

 

[Disciple]

FWIW, why CUT HOPD reimbursement? Why wasn’t the decision to INCREASE PP reimbursement?

I know you see it as a win, drusso, but unless I am Missing something, its a rhetorical one...

Increase PP reimbursement, with what money exactly?

Medicare is still on track towards insolvency as far as I know.

Most have accepted that more money is not going to be sunk into Medicare, which is why all the experimentation with different practice models, direct pay, etc.

If they're doing nothing more than evening things out, giving independent practices a chance to survive, and even thrive, I'll take it.

 

[Ducttape]

Projected 2026.
But I remember that there was fear Medicare would become insolvent decades before.

How are these changes doing anything to help PP? Are primary care doctors leaving PP because they just want to make more money in HOPD setting? Or are some docs - or most - leaving PP because they cannot afford to keep their practices open with what little reimbursement they currently get?


Worse yet, Here is a thought from the “office of unintended consequences”... hospital CEOs are not going to reduce their salaries to compensate. Rather, they will cut costs... and fire/not rehire doctors, and instead hire lower salary (ie cheaper) NPs to replace all but the top specialists. There will also be no need to hire more specialists because they will just optimize the schedules of the remaining specialists to be in the OR full-time .... Net effect is that many HOPD docs may lose their jobs.

That’s exactly what we want !

 

[lonelobo]

I'd suggest choosing another profession asap, or get into an MD/MBA program ASAP and go into business after meds school instead of clinical practice. Its not too late to escape, your loans are not insurmountable. You did nothing wrong. The democrats and insurance companies have destroyed your future income potential.

Are the Democrats also to blame for you being the last player picked in kickball in 3rd grade?

 

[Orin]

Are the Democrats also to blame for you being the last player picked in kickball in 3rd grade?

No, that was the immigrant's fault with their "futbol" skills. Stealing my spot in the kicking order!

Regardless, back to the OP, this to me has been similar to the pharmaceutical companies different countries/different prices arguments. I understand subsidizing things that are valuable but not reimbursed, but we really should stop subsidizing administration/overhead and start focusing on money moving to patient care or caregivers.

The whole system is just too big to do a full reboot but I'm looking forward to seeing how it evolves over time.

 

[Ducttape]

So... free market economy for pharmaceuticals, right? How did that work for Epi Pen, or Daraprim?

 

[VA Hopeful Dr]

So... free market economy for pharmaceuticals, right? How did that work for Epi Pen, or Daraprim?

How's it working for lisinopril, amlodipine, and metformin?

Free Medication Program

 

[emd123]

Bring it. Im good enough at what i do to excel in the two tiered system. My patients will pay cash, i will treat them well.

I'm good enough at what I do to excel in a three tiered system. So there!

 

[nvrsumr]

So... free market economy for pharmaceuticals, right? How did that work for Epi Pen, or Daraprim?

epi is super cheap. epipen is expensive because of FDA and attorneys. The orphan drug overcharging thing is an issue and I agree with some limits kind like war profiteering etc..

 

[Ducttape]

How's it working for lisinopril, amlodipine, and metformin?

Free Medication Program

I’ve seen low price models for years. In 2011, I remember getting a few patients meloxicam, nortiptyline and flexeril for $5/mo.

Per pharmacists, these meds cost cents to make.

 

[VA Hopeful Dr]

I’ve seen low price models for years. In 2011, I remember getting a few patients meloxicam, nortiptyline and flexeril for $5/mo.

Per pharmacists, these meds cost cents to make.

No kidding. In my old practice I dispensed meds. Some of them are amazingly cheap - literally 1-2 cents/pill.

 

[pastafan]

No kidding. In my old practice I dispensed meds. Some of them are amazingly cheap - literally 1-2 cents/pill.

Like hospitals paying .30 for 2ml fentanyl and charging patients $70-90 for the drug.

 

[Ligament]

Are the Democrats also to blame for you being the last player picked in kickball in 3rd grade?

No.

 

[drusso]

Prediction: Big Hospital is opposing site neutral payment to bring reimbursement in-line with independent doctors and will put tremendous pressure on HOPD-health system MD's to do the same...

Hospitals Urging CMS To Reverse Proposed 40 Percent Cut In Physician Reimbursement.

Congressional Quarterly (8/13, Clason, Subscription Publication) reports that hospitals are urging “the Trump administration to reverse proposed payment cuts to the industry – and experts say it’s unclear whether federal officials will stand firm.” CMS wants to cut “rates for outpatient clinic visits by 40 percent in a bid to pay physicians who work for hospitals the same rate they would be paid as independent doctors.” The article says this “‘site-neutral’ payment policy is already in effect for some facilities, but remains a flashpoint between the industry – which claims hospitals need higher reimbursements to compensate for additional regulations and overhead – and health care experts who claim the policy drives consolidation.” The piece says CMS is expected to unveil a final rule by November 1.

 

[Ducttape]

it will affect PCP offices a lot. interventional offices? not so much.

the disaster of this policy is not the cut in payments, but that it wont change where the main discrepancy is - ASC and HOPD procedures. primary care that relies on the SOS differential for their extremely sick primary care patients will suffer, tho.


drusso, you got what you prayed for, but not what you really want.


fwiw, this will affect me absolutely zero, because this office is "site-neutral".

 

[nvrsumr]

Would love to see some independent PCPs in my area who are free to refer to the best doc for their patients.

 

[drusso]

drusso, you got what you prayed for, but not what you really want.

A journey of a thousand miles begins with one step. This is one step.

Site of differential arbitrage is greedy, evil, and a sin. It distorts locals markets, drains much needed revenue from the local tax base (non-profit health systems buy-out for profit private practices, employ the doctors, absorb the real estate into "non-profit" entities, stop paying local taxes on said property, jack up the cost of care to patients via co-pays, deductibles, co-insurance & insurance companies and government payers). It embarrasses and jeopardizes the professional autonomy of physicians by turning them into employed RVU-****** who traffic patients into ancillary income streams and expensive OR's for services that could be done more cost-effectively in other venues, etc. It is an abomination...

These business practices of nominally non-profit health systems more resemble organized crime than they do charity-work. Good riddance SOS d(f).

 

[Ducttape]

I disagree, particularly with anything that helps those primary care physicians who are not being adequately reimbursed for the level of care they have to provide. hospital clinics oftentimes take care of much sicker patients than private practice offices. this is low lying fruit, to target E&M.

SOS does help with the fact that many people do not have healthcare coverage. your perspective on SOS is not shared universally, and your supposed logic seems tenuous and not all directly related to SOS - more related to hospital practices that may seem uncouth but imo are consistent with "free market").


btw, a lot of PP docs do procedures at ASCs and actually are part owners. what is your position when CMS comes down on these SOS differentials? it will greatly negatively affect many private practices.



but cie la vie. as I said before, this part does not affect me. I will still get the same $50 to see a ASA level 4 patient on 35 different meds with > 8 end stage organ disease that I did before.

 

[drusso]

I disagree, particularly with anything that helps those primary care physicians who are not being adequately reimbursed for the level of care they have to provide. hospital clinics oftentimes take care of much sicker patients than private practice offices. this is low lying fruit, to target E&M.

SOS does help with the fact that many people do not have healthcare coverage. your perspective on SOS is not shared universally, and your supposed logic seems tenuous and not all directly related to SOS - more related to hospital practices that may seem uncouth but imo are consistent with "free market").


btw, a lot of PP docs do procedures at ASCs and actually are part owners. what is your position when CMS comes down on these SOS differentials? it will greatly negatively affect many private practices.



but cie la vie. as I said before, this part does not affect me. I will still get the same $50 to see a ASA level 4 patient on 35 different meds with > 8 end stage organ disease that I did before.

Pay PCP's and doctors for what the cognitive work is really worth on its merits and not via evil, greedy, distorting cross-subsidies from SOS, ancillary streams, etc. All cross-subsidies create "competing commitments."

I don't own an ASC. I think there is probably some room to cut fat there too...

 

[drusso]

Site neutral payment reform is a winning issue for patients – unless Congress rolls it back

"Unfortunately, the powerful hospital lobby is fighting hard to get CMS and Congress to drop these proposals before they are implemented, thereby preserving the unnecessary higher payment rate for hospital outpatient departments grandfathered under the Bipartisan Budget Act. If they get their way, patients will continue to be saddled with higher out-of-pocket costs and fewer provider choices."

 

[hyperalgesia]

Site neutral payment reform is a winning issue for patients – unless Congress rolls it back

"Unfortunately, the powerful hospital lobby is fighting hard to get CMS and Congress to drop these proposals before they are implemented, thereby preserving the unnecessary higher payment rate for hospital outpatient departments grandfathered under the Bipartisan Budget Act. If they get their way, patients will continue to be saddled with higher out-of-pocket costs and fewer provider choices."

I think this is the probable outcome, loss of future SOS but existing are grandfathered. It's not politically feasible to pull the rug out from under hospitals.