Repeal of the ACA, HCAHPS, Press-ganey, reimbursements.. etc

The cost multiplier for "end of life" care gets high quickly. The ICU bill for all the therapies we use to treat people with acute multi-system organ failure is going to be the same as the bill to treat end-stage chronic multi-system organ failure. As long as the baseline goal of care is understood to be "the heart continued to beat", we are going to spend a lot of money that we are never going to see a return on. Especially when so many families equate the heart continuing to beat with the expectation that their loved one is going to return to the person they remember from 5-10 years ago.

 

Does anyone think that reducing end of life care would ever be able to happen?? As much as I, most of us, would like to see it I feel it's similar to hoping to win the mega lotto.

 

No. Which is why single-payer healthcare would be an unmitigated disaster in this country. We would be be providing free, unlimited care for everyone with no rationing, and no checks on the expenditures.

 

... which is basically what we have now for the uninsured, with the costs tucked into hospital loss statements as "charity care" and passed on to the rest of us indirectly.

The uninsured, illegal immigrant in a farm accident in rural Texas? They get their LifeFlight, emergency surgery, and ICU stay for "free"; no one pulls the plug on daily rounds.

The only example of "rationing" I've seen with respect to financial status has been the placement of BMS instead of drug-eluting in MI patients who couldn't afford to be on clopidogrel for a year afterwards ... and it seems like the evidence suggests they were probably just was well-off, regardless....

 

Which is irritating as plavix is dirt cheap. Its $10/month at Sam's, so $120/year. It does require you sign up for their Plus membership which is another $100/year. So total for 1 year of plavix is $220, or $18.33/month.

 

This. This. This.
This. This. This.
This. And this.

Pay attention, residents.


Good medicine is the expectation. Customer satisfaction is more important. At least to those who have never practiced medicine.

My hatred for suits runs deep. At my first gig out, one of our line docs got cozy with admin, and slid into C-suite. We all figured we had "one of ours in there now"!! They would finally understand!!**!!

We were so wrong. Fat old man rolled right over. Butter on the other side of the bread.

Judas.

 

Potential repeal of the un-Affordable Care Act makes me hopeful.

Having two physicians in the Presidential cabinet, including one running Dept. of Health (and therefore also CMS) makes me hopeful.

That physician taxes will likely go down makes me hopeful.

That a lot of the moonbat-crazy bureaucracy & red tape that's been floated on the world of medicine, makes me hopeful.

There are potential positives to look forward to.


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So you're cool with discharging the uninsured DKA patient with a pH of 7 because... f__ it... your pocket book is worth more than his uninsured life? Mind you, with type 1, he would never be insurable because of a preexisting condition.

Or you're cool with saving his life... but not covering the medications that would have prevented him to need to be admitted to the ICU in the first place? Not to mention the future risk of vascular, cardiac, and renal disease that could be mitigated by providing him with insulin?

 

Isn't COBRA just the full cost of the insurance, where most people have a significant amount of their insurance subsidized by their employer? If you're paying $1k a year for insurance, but your employer is paying an additional $6k a year as a part of your benefits, then COBRA isn't actually expensive. It's just the actual cost of the product you're buying.

 

Yes

 

Insulin is $25 a vial at Wal Mart. Try again.

Every GOP plan that's been discussed has a provision for pre-existing conditions. They all rely on continuous coverage, which said patient should have had from childhood so something of a no issue in this case.

 

That's $125/month assuming a 150 lb person that is actually controlled on 0.3 units/Kg/Day. They'll likely need more. $255 a month for 0.5 units/Kg/day. Furthermore, 70/30 is still a cruddy treatment compared to alternatives (Lantus/regular insulin or an insulin pump).

But I'm sure you'd be happy spending an extra $255/month extra so you don't place a burden on the other people on your insurance plan for your preexisting condition. I mean... unless you developed your type 1 DM after your had your current insurance plan.

As far as GOP plans, to the best of my knowledge none of them has been released for public view yet. "You have to pass it to know what's in it" was BS when it was for the ACA, and it's BS now. Talking points are just that... talking points (I mean.. unless you think that tariffs will #MAGA).

 

I'm not saying its ideal, but it will get the job done (ie. prevent DKA/HHS). I'm also not sure that $100-200/month is asking to much for literally life saving medication; especially if we add on the free metformin/lisinopril/norvasc many grocery stores offer at their pharmacies, or the $4 Amaryl/zocor at Wal-Mart.

Well look at that, 3 diabetes meds, 1 cholesterol med, and 2 HTN meds all for worst case $263/month (potentially less as the Wal-Mart meds are $10 for 3 months, so we actually average $260/month).

Beyond even that, I've had great luck getting drug companies to give my type 1 patients free humalog/levemir if they're uninsured.

As for GOP plans, you're right that we don't have specifics yet - but how about we wait and see what they produce before getting all pissy about it not being in the public sphere just yet.

 

Please tell me you're not prescribing metformin and Glimepiride for type 1 DM (since I've been mentioning type 1 to avoid the moral hazard of "Well, it's they're fault they're fat have have type 2). Also, I'm well aware of the Publix Free Medication list (I'll use them every time without question, but I do wonder sometimes about the ethics of using medications as a loss leader).

Serious question, how long are those free scripts for humalog/levemir?

As far as the GOP "plan?" How long have we been waiting for it? Well, now that they've put the ACA on death row, hopefully we'll actually see some action instead of just talk.

 

Wait, so metformin in type 1 is bad? Man, if only I'd had some type of school to teach me medical things like that...

Generally speaking, they are good for 1 year at a time. When the year is almost up, they send out forms to make sure the patient still qualifies (basically they have to send in that year's tax statements with a new script from me for the med itself).

Rand Paul says his replacement plan is done, I'm guessing it'll be released next week so as not to compete with the inauguration (and make sure that Trump doesn't have a plan ready that his plan will have to compete with). I really hope the GOP doesn't screw this up and not have any replacement ready - goodness knows its a risk.

 

It's not like they haven't had time to write it. We've had the ACA for 6 years - after it took 15 months to "jam it down our throats"
They've managed to vote 50+ times over the past six years to try to defund or repeal it. But not one written plan to even make one iota of change to it yet.
Must be a hard life to campaign for so long on a topic, have so many good ideas (great ideas even) that you just can't find the words for them to make a coherent plan. They all have my sympathies.

 

Curious what will happen once all those Trump supporters with insurance only because they're on ACA plans realize that ACA=Obamacare.

 

https://www.google.com/amp/m.huffpost.com/us/entry/us_587f95e4e4b0c147f0bc277e/amp?client=safari

 

Meh, symbolic votes and we all know it.

Admittedly they have had 2 months since e the election to come up with something better. As I've said several times, I think Rand Paul has something in writing but I guess we'll see.

 

Maybe. The first few were symbolic. After double digits? After 50+? That was obstructionist, giving the finger to Obama, and a sad attempt to tell their constituents "hey, we tried to repeal it, it's all the dems fault (even though we did nothing to actually fix the problem)."

Instead they still had six years to put some ideas on paper, and all they could muster was symbolic but meaningless votes.

All we got during the campaign was promotion of health savings accounts. So you are telling me the people that can barely afford (or can't afford) their premiums or deductibles can instead afford to put money aside into an HSA (with arguably having to pay full price for health services because the ACA will be repealed). Ok, sure.

 

They'll be happy about not being forced to give free money to insurance companies anymore.

 

I grow weary of saying this but have patience to see what/if the GOP comes up with.

 

Like the coal miners with the black lung benefits? :: popcorn::

 

I would have patience, except that they had plenty of time to put pen to paper and the only thing they've written down is to repeal it.

 

Why waste time writing a bill that you know won't get anywhere for 6 years?

 

Cause it is . . . . . . . . . (wait for it, I'm building up the suspense) . . . . . their job.

Yes, as history showed us, a vote for 100% repeal over the past 6 years was worthless. The Dems couldn't stop them from performing a worthless vote. So, if they had an honest attempt to improve on the ACA, they already proved they can hold a vote, I'd like to believe they could sell their position and get some across the aisle support.

Instead they couldn't even muster a half assed bill in 6 years, so now we just have to hurry up and wait.

 

Huh, I guess I should have Googled this earlier... Looks like they did have a replacement ready...

https://www.google.com/amp/www.11alive.com/amp/news/local/gop-replacement-for-obamacare-rooted-in-rep-price-bill/382156033?client=ms-android-verizon

 

Well, I stand corrected. It's a shame the rest of his party doesn't really know about it. They keep talking about how they either need to a) repeal it in writing but not take effect yet so they have time work on a replacement or b) slow down and work on a replacement first. Or Price could send our new POTUS a tweet and let him know of the plan.

 

Right. And yet you were fine with the federal government footing the bill for your residency training.

 

Don't feed the trolls man.


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Real question is why the federal government doesn't subsidize my education as well. Sorry for being a productive member of society I guess.

 

That's like asking "Why train until you get on the Olympic team?" Did you think that the status quo is always going to stay the status quo?

 

So you must've missed the part where Price actually did write a replacement bill...

 

It's only 250 pages I can see how it would be missed when you're busy being obsessed with your talking points

 

Or a 2 page thread where @VA Hopeful Dr linked to the news article only 5 posts before his comment. But who is counting?

 

It was embarrassingly easy for me to find that link (for me anyway, would've saved me a lot of time on this thread). It might serve you well to do the same google search next time before being quite so wrong - instead of complaining that it took me 2 pages to do your homework for you.

 

I already admitted I was wrong. How much more groveling do you want? You were also wrong for many posts until you looked it up. But thanks for the holier than thou attitude. Shame on me for coming into this discussion on page two. And shame on me for listening to the GOP not even know about Price's plan.

I wasn't complaining about you when I quoted you. Just mentioning that we haven't been discussion the intricacies of a 250 page bill, instead you only linked to it a few posts above (in this short 2 page thread). Guess I wasn't very clear. My bad.

 

My apologies for the tone: I'm home alone with 2 sick 15 month olds so I'm grouchy.

I still maintain that having a back up while Obama was president would be a waste of time. It would have been nice, but it doesn't bother me that much that they didn't make one up. I do agree that I would have liked more concrete replacements in the 2.5 months since the election, or a more general awareness of Price's plan but seeing as how the ACA isn't going away tomorrow there is still time to put together something new.

 

Now that a proposal is out from the GOP, any new thoughts on this, if things go through "as is"?

 

The winners: young, healthy, and wealthy.

The losers: everyone else.


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doesnt look like much of a reform besides cutting income and giving tax credits to everyone. from what ive read not sure how premiums wont be sky high. remove required healthcare, remove fee if not in healthcare, remove taxes from healthcare. increase cost if you have elapsed more than 2 months... of course thatll pay for it.(sarcasm)

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What about us as physicians (to be)? Does this bill do anything to forestall the salary and autonomy killing regulations of Obamacare, shift away from fee for service etc?

 

Nope! You're thinking MACRA. The bill does not repeal MACRA.


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This Republican bill is a turkey. Passed or not, it won't end the death spiral.

The fundamental difficulty at the core of Obamacare is the "guaranteed issue" part, which covers pre-existing conditions. Neither party has balls enough to repeal it because it will "hurt people". The problem is that by covering pre-existing conditions at the same rate as the healthy, the private insurance market is essentially destroyed. There is no amount of cost-shifting or subsidies that can be obtained to make this work. The result is that Healthcare exchanges still exist, government has to keep providing medicaid in areas where private insurers have pulled out, and the death spiral continues.

My suggestion would be to remove these people entirely from the insurance market. If for example, your insurance plan is scheduled to cost more than 30% of your gross income, then you would be eligible to be put in a separate high-risk pool subsidized (unfortunately) by a fund in each state. Likely it would only comprised < 10% of people who get private insurance. I would of course remove any mandate or tax penalty for not buying insurance.

 

That's not a bad idea, although it sounds pretty similar for Medicaid for those who can't afford full insurance (with pre-existing conditions making it unaffordable)

I say scrap the whole damn thing:
1) repeal EMTALA,
2) abolish Stark law prohibition of physician-owned hospitals
3) eliminate certificate of need
4) nationwide Medicare-light, which gets seen at nationwide system of teaching hospitals/county hospitals.
--make a new 6 year program from college which makes someone a primary doctor, give free/reduced tuition in exchange for 10 year primary care service (sim. to what military does)
--more subsidies/free tuition if you commit 10 year to work at US-version of NIH (aka British system)
--there will be no malpractice, and there will be rationing of care at the Nationwide US-NIH
--if 2 doctors decide end-of-life, you are on hook for artificially prolonging life of grandma
--in event of malpractice, go to no-fault system

5) Get rid of non-profit hospitals, allow private hospitals which take insurance (or payment) but not bound by CMS regulations (but still subject to intermittent inspections for safety, quality of care)
--full "free-market" hospitals
--Allow malpractice at for-profit centers
--allow multiple hospitals to compete for care of insured patients, including physician owned-centers
--not much different than what we have now w/ insured patients (essentially a two-tier system)
--no govt funding for private hospitals (sim. to Australia)

Let's stop this weird socialized-"free" market hybrid that can't be one or the other b/c of regulations and laws

 

I agree with all of your comments above, however it is impossible to do all that at once. Understand that right now they are stuck doing things through reconciliation that requires only 51 votes. Reconciliation only allows them to repeal portions of the law that affect the budge, like subsidies and taxes. Doing more than that would require 60 votes, which is impossible. Let's start with just doing a clean repeal of Obamacare (as clean as you can do using reconciliation). You can easily get ride of the mandate, medicaid expansion, subsidies, and guaranteed issue, as they all can be argued to directly impact the budget.

Some people will be pissed off, and some will lose their "coverage". It is necessary to do the right thing.

 

I like the first bit, however I'm not sure that hospitals should function as "free market." Life/death is difficult to fit into the commodities market. Hospital competition would be unlikely to be a good thing, especially with uninsured populations. More uninsured patients=more complicated patients=worse outcomes, possibly deterring insured patients. In fact, this is what happens to a variety of hospitals around the country. For profit hospitals have the insured population, until they become too complicated (more risk-prone), in which they are transferred to the county hospital (who is required to take all patients) for further care/expense/morbidity.

Primary care augmentation will certainly be the answer to most problems, in whatever way it is worked out.

 

EMTALA keeps us in business. Get rid of that, you lower patient volumes and your rvus.


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I would keep EMTALA, but let doctors and hospitals write-off unreimbursed care.

 

The "free market" would be optional. If you don't want to use it, you could use the US-NIH, which plenty of people use in England. Essentially, I'd advocate for "private" hospitals which people pay into to use, they can choose patients and vice-versa. Have some strict, government reportable quality measures (eg severity adjusted mortality) and people with the means can "pick/choose" those hospitals. ED docs who choose to work these could, and get paid more, since they could conceivably own the hospitals with other physicians. If you think this is a pipe dream, I basically just described MD-owned FSED's in Texas.

Before anyone cries "unfair", remember everyone would have basic Medicare-light and could get treatment at the US-NIH hospitals. B/c of cost-control measures, you could provide the cheaper healthcare that Canada/France/UK blah blah blah always raves about. Basically, like a disseminated US-VA. Academic EP's could work there (making less, which already happens) as well as staffed by Residents, APP's, etc (with student loan forgiveness for working these hospitals)

I realize this is a pipe dream, but that's how I would rebuild the system from the ground up. At very least, getting rid of Starke-non-sense would help, agree w/ Gen. Veers on write-offs--problem is that non-profits abuse their "non-profit status" currently, and exaggerate their charity care (which they only give if someone asks for it and doesn't have means, otherwise they're quick to send credit collectors after struggling patients.

I'd open up the system like Texas has, lower benefits of Medicare, but expand it to those below a poverty threshold (eg Medicaid plus or medicare lite)