Obamacare

[cartoondoc]

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In light of the recent decision by the Supreme Court, how do you think Obamacare will affect PM&R? I've been wondering about how the mandate that doctors be paid for "quality of care" will come into play for us...

 

[physasst]

In light of the recent decision by the Supreme Court, how do you think Obamacare will affect PM&R? I've been wondering about how the mandate that doctors be paid for "quality of care" will come into play for us...

Accountable care is coming irrespective of the ACA. I helped work on the ACO stuff, so of course, I am somewhat biased, but there are a number of payment models that are being experimented with on a national basis.

One of the more prominent is the Prometheus model, developed in Rockford, Illinois. Essentially bundles care, and then uses a complex mathematical model to adjust for severity of illness and complications. Prometheus was being developed and deployed before the ACA was even written (although the Heritage Foundation had a similar plan in 2003).

For PM&R, it shouldn't affect outpatient rates much, but inpatient rates could change depending on some factors. At any rate, fee for service is quickly becoming an anachronism, and would continue to do so irregardless of the ACA....

 

[RUOkie]

We are all going to be bancrupt in 5 yrs.



🙄
😛

 

[cartoondoc]

This topic is being discussed with quite a bit of passion all over the web. Is the fact that nobody here is effusively bashing or praising it a sign that it's already been discussed here or is it a sign that this board is inactive?

 

[DOctorJay]

http://www.zerohedge.com/news/dummy-bears-guide-healthcare

comments?

 

[Gauss]

This topic is being discussed with quite a bit of passion all over the web. Is the fact that nobody here is effusively bashing or praising it a sign that it's already been discussed here or is it a sign that this board is inactive?

ok lemme get out my crystal ball...
magic 8 ball says - less reimbursement, see more patients, incur more liability - just at a faster rate than before

 

[bedrock]

This topic is being discussed with quite a bit of passion all over the web. Is the fact that nobody here is effusively bashing or praising it a sign that it's already been discussed here or is it a sign that this board is inactive?

Unfortunately the PMR board is one of the weaker ones on SDN.

 

[Prof Moriarty]

BTW Cartoondoc, I got your book. All my co-interns loved it. Hilarious stuff.

 

[cartoondoc]

Thanks, Prof 🙂

 

[PMR 4 MSK]

In light of the recent decision by the Supreme Court, how do you think Obamacare will affect PM&R? I've been wondering about how the mandate that doctors be paid for "quality of care" will come into play for us...

You have access to many more patients on Medicaid, for one thing. Woohoo!

 

[ml2001]

Keeping politics aside, can the seniors or those who are familiar with the details of ACA comment on how this will affect Outpt Physiatrists.

Me and my wife both are in PM&R and we both are interested in outpt Physiatry even though we will be diversifying our practice in what we offer (I will be more interventional offering advanced procedures while my spouse will be taking the non-interventional route i.e., u/s guided injections, EMG's, Accupunture, and so on).

I know it is too early to contemplate, but do you guys think, because of ACA, we will be in financial trouble as we are choosing the same career paths with subtle differences in our approaches?

Thank you very much for your responses. Hope you keep the discussion civil and not bring politics.

-ML

 

[SSdoc33]

Keeping politics aside, can the seniors or those who are familiar with the details of ACA comment on how this will affect Outpt Physiatrists.

Me and my wife both are in PM&R and we both are interested in outpt Physiatry even though we will be diversifying our practice in what we offer (I will be more interventional offering advanced procedures while my spouse will be taking the non-interventional route i.e., u/s guided injections, EMG's, Accupunture, and so on).

I know it is too early to contemplate, but do you guys think, because of ACA, we will be in financial trouble as we are choosing the same career paths with subtle differences in our approaches?

Thank you very much for your responses. Hope you keep the discussion civil and not bring politics.

-ML

you will be in no worse shape than other docs. take that comment however you like

 

[PMR 4 MSK]

Keeping politics aside, can the seniors or those who are familiar with the details of ACA comment on how this will affect Outpt Physiatrists.

Me and my wife both are in PM&R and we both are interested in outpt Physiatry even though we will be diversifying our practice in what we offer (I will be more interventional offering advanced procedures while my spouse will be taking the non-interventional route i.e., u/s guided injections, EMG's, Accupunture, and so on).

I know it is too early to contemplate, but do you guys think, because of ACA, we will be in financial trouble as we are choosing the same career paths with subtle differences in our approaches?

Thank you very much for your responses. Hope you keep the discussion civil and not bring politics.

-ML

As above, many more people will be on medicaid. PCPs will get them first. They will turf every issue they can to other doctors to get the pts off their schedule. If you accept Medicaid you will get a lot of them.

Then their will be the Accountable Care Organizations. These are capitated HMOs respun for today. If you contract with them you are either on the prevention side or the consuming side. Prevention side = doctors given financial incentives not to treat, yet unable to collect because then those patients will give lower satisfaction scores and have worse outcomes, both of which will decide your pay. Consumption side = Fee for Service, and they will hate you and deny most everything you try to get authorized.

Many more people will have insurance through their employers, but it will be really, really crappy insurance, with $3-5K deductibles, $50+ co-pays and very limited coverage. This is because employers with more than 50 employees will be forced to buy policies, so they will by the cheapest thing they can.

 

[MOHS_01]

Accountable care is coming irrespective of the ACA. I helped work on the ACO stuff, so of course, I am somewhat biased, but there are a number of payment models that are being experimented with on a national basis.

One of the more prominent is the Prometheus model, developed in Rockford, Illinois. Essentially bundles care, and then uses a complex mathematical model to adjust for severity of illness and complications. Prometheus was being developed and deployed before the ACA was even written (although the Heritage Foundation had a similar plan in 2003).

For PM&R, it shouldn't affect outpatient rates much, but inpatient rates could change depending on some factors. At any rate, fee for service is quickly becoming an anachronism, and would continue to do so irregardless of the ACA....

How exactly is the ACO construct all that different from a repackaged HMO paradigm?*




Despite spending a little time trying to learn more about this Prometheus model the best that I can come away with is that it represents another HMO style shift of the financial risk burden from the third party payer unto the provider. It does not matter how fancy your metrics are or how complicated your algorithms may be -- the distilled version still smells like recycled 1980's and 1990's ****. In sum, this would appear to be not all that dissimilar to Ryan's plan for MC -- it is more of a budgetary model than a payment model.

 

[PMR 4 MSK]

How exactly is the ACO construct all that different from a repackaged HMO paradigm?

My limited understanding of it is that it is not much different from an HMO, other than the docs will be responsible for minimizing expenditures, while making it hard for them to share in the savings.

 

[MOHS_01]

My limited understanding of it is that it is not much different from an HMO, other than the docs will be responsible for minimizing expenditures, while making it hard for them to share in the savings.

Great. So it's an HMO construct wherein the physicians are inevitable losers. Strong work physasst.

 

[MOHS_01]

... At any rate, fee for service is quickly becoming an anachronism, and would continue to do so irregardless of the ACA....

If you're going to be involved in the crafting of legislation that effects each and every American personally and directly the very least you could do is learn the language used in screwing them. 😡

 

[cbest]

What about the difference between effect and affect?

 

[yappy]

I've been reading up on all these ideas: HMO, ACO, etc.

One question: WTF don't physicians [when possible ex: out pt care, etc] just go fee for service/cash/direct credit and deny everything else? Why put up with these contrived models of reimbursement? Imagine firing all of your staff that deal with billing, ask patients to pay a retainer, or just go cash at a rate people could afford yet covers your expenses and generates a profit?

Eventually people would get smart and just get major medical, save for the deductible, and pay out of pocket for most of what physicians do.

 

[MOHS_01]

What about the difference between effect and affect?

Affect is generally used as a verb, effect generally as a noun. Sometimes the roles are reversed -- when one is talking about a person's mood (affect) or when one is speaking of bringing about a change (effect). I tend to think of "affect" as influencing and "effect" as directly causing.... That's the way I learned it, anyway.

 

[MOHS_01]

I've been reading up on all these ideas: HMO, ACO, etc.

One question: WTF don't physicians [when possible ex: out pt care, etc] just go fee for service/cash/direct credit and deny everything else? Why put up with these contrived models of reimbursement? Imagine firing all of your staff that deal with billing, ask patients to pay a retainer, or just go cash at a rate people could afford yet covers your expenses and generates a profit?

Eventually people would get smart and just get major medical, save for the deductible, and pay out of pocket for most of what physicians do.

Because you could not make ends meet, that's why. Patients, somewhat rightfully so, believe that they have paid for their health care need via their premiums; asking them to do so outside of their coverage is redundant cost from their perspective. The number of folks with the disposable income that would allow this arrangement suggested is small, so even if it was to work for a few docs it is not scalable.

 

[cbest]

If you're going to be involved in the crafting of legislation that effects each and every American personally and directly the very least you could do is learn the language used in screwing them. 😡

The use of "effects" in the above post is still incorrect. The legislation would "affect" each and every American.

I understand that the effects of a given situation may, in turn, effect change in another and that along the way one's affect may be affected.

 

[PMR 4 MSK]

I've been reading up on all these ideas: HMO, ACO, etc.

One question: WTF don't physicians [when possible ex: out pt care, etc] just go fee for service/cash/direct credit and deny everything else? Why put up with these contrived models of reimbursement? Imagine firing all of your staff that deal with billing, ask patients to pay a retainer, or just go cash at a rate people could afford yet covers your expenses and generates a profit?

Eventually people would get smart and just get major medical, save for the deductible, and pay out of pocket for most of what physicians do.

We've trained Americans (and pretty much the rest of the world) to believe health care is a right, and therefore, should be free. Most people place value on their doctor's expertise at about $20/visit. When their co-pay rises above that, they stop coming in. If the doctor gets paid more than that via insurance, yippee! If not, who cares?

People don't want to pay for healthcare, they want someone else to foot the bill. A small % recognize the value and are willing to pay out-of-pocket. Most will not.

Many docs cannot go completely cash-only. If you take ER call, you have to accept what the ER sends you, and you cannot refuse to see someone for lack of ability to pay. So let's say you are cash-only and the ER sends you a BCBS pt. You tell the pt you will only see them for $300 and then they can get reimbursed from their insurance. They say they don't have it. You say then come back when you do. They have a complication from delayed care.

There is not a jury anywhere in this country who will be sympathetic to you. As far as the Average Joe is concerned, you should not even consider getting paid. You should just see patients and then drive your Bentley home. You are rich anyway, they reason, so now you can pay this poor sole $5M for your callousness.

The concierge practice with retainers is a nice model, but I'd be willing to be that less than 5% of Americans would pay for it.

 

[MOHS_01]

The use of "effects" in the above post is still incorrect. The legislation would "affect" each and every American.

I understand that the effects of a given situation may, in turn, effect change in another and that along the way one's affect may be affected.

Yeah, you're probably right. I meant it as "result inducing event" rather than an "influencing factor", in which case I believed "effect" was more appropriate. "Effect change" and all that jazz. Poor wording, I admit.

Grammar Geek:
You effect change -- bring it about. It's the verb use of the word effect, although the noun use (meaning result) is far more common.

http://www.englishforums.com/English/EffectVsAffectChange/xrhxv/post.htm

 

[physasst]

If you're going to be involved in the crafting of legislation that effects each and every American personally and directly the very least you could do is learn the language used in screwing them. 😡

Fair enough, I was thinking regardless and irrespective at the same time......poor language for sure.

How are you BTW?

 

[Aegis]

So I'm going to claim ignorance here and say that I've never had a very firm grasp on the business side of medicine. I'm GMO in the military right now, I say Tricare and thats all I need to know. So my question is what direction would you point someone that wants to learn more about everything your basically talking about from the ground up. Maybe think about what advice you would offer a first year med student that is trying to figure out what an HMO is. Any good books? Other websites? I'm sure surfing around wikipedia for a day would clear up a lot, but was wondering if there is something more concrete and concise. Thanks

 

[RUOkie]

We've trained Americans (and pretty much the rest of the world) to believe health care is a right, and therefore, should be free. Most people place value on their doctor's expertise at about $20/visit. When their co-pay rises above that, they stop coming in. If the doctor gets paid more than that via insurance, yippee! If not, who cares?

People don't want to pay for healthcare, they want someone else to foot the bill. A small % recognize the value and are willing to pay out-of-pocket. Most will not.

Many docs cannot go completely cash-only. If you take ER call, you have to accept what the ER sends you, and you cannot refuse to see someone for lack of ability to pay. So let's say you are cash-only and the ER sends you a BCBS pt. You tell the pt you will only see them for $300 and then they can get reimbursed from their insurance. They say they don't have it. You say then come back when you do. They have a complication from delayed care.

There is not a jury anywhere in this country who will be sympathetic to you. As far as the Average Joe is concerned, you should not even consider getting paid. You should just see patients and then drive your Bentley home. You are rich anyway, they reason, so now you can pay this poor sole $5M for your callousness.

The concierge practice with retainers is a nice model, but I'd be willing to be that less than 5% of Americans would pay for it.

your solution to that is to NOT take ER back up. I've been in practice for 17yrs and have never taken ER call.

secondly, you are NOT required to see someone in you office EVER. It doesn't matter what the ER says. If the issue was delaying care, then the ER doc is responsible, or the person who was called by the ER doc. The requirement is to see the person IN THE ER, as defined by your medical staff bylaws.

Our bylaws DO NOT require call. All ER backup is determined through private contract between the hospital and the physician group.

 

[PMR 4 MSK]

your solution to that is to NOT take ER back up.

I agree. Let the hospitals figure that out themselves.

 

[DopaDO]

As a current medical student with a very serious interest in PM&R and Pain, I am somewhat confused as to why some of you believe the cash only model isn't sustainable. I know several docs in my area that run cash only Pain clinics, but I've also recently heard and seen articles of this happening in other fields as well such as FP, even Gen Surgery and Orthopaedics! The articles say that the physicians are not only able to cut costs dramatically, but they are allowed to spend more time with their patients and their patients are much happier. Maybe I live in a part of the country where this just happens to work, but it seems to make sense to me. Any insight is very much appreciated!


PS: I apologize for any stupidity in the above post, I'm still very early in my medical career and still learning the business side of it all.

 

[RUOkie]

As a current medical student with a very serious interest in PM&R and Pain, I am somewhat confused as to why some of you believe the cash only model isn't sustainable. I know several docs in my area that run cash only Pain clinics, but I've also recently heard and seen articles of this happening in other fields as well such as FP, even Gen Surgery and Orthopaedics! The articles say that the physicians are not only able to cut costs dramatically, but they are allowed to spend more time with their patients and their patients are much happier. Maybe I live in a part of the country where this just happens to work, but it seems to make sense to me. Any insight is very much appreciated!


PS: I apologize for any stupidity in the above post, I'm still very early in my medical career and still learning the business side of it all.

Cash only Pain clinic = DEA/local law enforcement investigation. Unless you don't write prescriptions, and then nobody will pay cash. Even if cleared of all charges, a DEA audit is a nightmare. I've been through one, and it was one of the worst days of my life. I would prefer to make far less money and never have to experience that again

Let alone the fact that I live in a part of the country where cash only doctors starve.

 

[Liquidice07]

So I'm going to claim ignorance here and say that I've never had a very firm grasp on the business side of medicine. I'm GMO in the military right now, I say Tricare and thats all I need to know. So my question is what direction would you point someone that wants to learn more about everything your basically talking about from the ground up. Maybe think about what advice you would offer a first year med student that is trying to figure out what an HMO is. Any good books? Other websites? I'm sure surfing around wikipedia for a day would clear up a lot, but was wondering if there is something more concrete and concise. Thanks

This is a great website: http://www.kff.org/
You can spend hours upon hours on it trying to understand it.
I would also recommend the following pdf on this webpage: http://www.kff.org/healthreform/8061.cfm?source=QL
It does the best job of summarizing the ACA. Unfortunately, there are a lot of gray areas that won't be clear until they are played out.