Pissydoc Says…

Since I’ve gotten through half the bill I thought it reasonable to put out a summary of my concerned comments. Note: these are taken straight from the blog without editing so they may be out of context. Review the August and more recent archives if you need clarification. I’ll be posting my positive comments as well. Remember, the biggest issues with the proposals out there are in what they do not address: 1) How such sweeping changes will be paid for, 2) The justification for such sweeping changes, 3) Med-mal/Tort reform initiatives.

• Patients with expensive medical problems may get preferentially herded into the exchange (assuming the treatments are covered) and this could be an overwhelming expense to the program.
• Implies that the public option/exchange programs can impose restrictions related to the clinical appropriateness of care.
• Doctors to still see more and more patients in less and less time so that we can keep our doors open.
• As soon as the bill is passed a committee will be formed to decide what will and what won’t be covered. the president will assign most members of the committee. The committee will decide what is covered and what is not for participating insurance programs.
• Problem with the safety net is that often hospitals and doctors have to absorb the remaining 5-25% costs. We then have to push up other fees to recoup loses.
• The prohibition against discrimination in health care suggests that anyone in the US is enrollable in the program. There are other areas in the bill that fine tune this but I’ve yet to find anything that disqualifies illegals or abusers
• There are provisions that anyone born on us soil may be enrolled in the exchange and then in the future be automatically enrolled in Medicare.
• Reinsurance program for retirees. If you lost your insurance after you retired this gives it back, at least 80% of claims between 15k-90K/year. It’s to be funded up to a TRILLION dollars with money sitting in the treasury that hasn’t been appropriated yet (got any loose change under the sofa cushion?).  The money will go into a trust fund which is NOT subject to “budget enforced processes”. Some have argued, with justifiable reason, that this is a bone to unions to subsidize retirement plans with government money—not cool.
• Outreach programs to recruit the poor and disadvantaged into the program. I guess sending out fliers and letting the people be responsible for signing up is too much to expect. I’ve seen concern that certain organizations such as ACORN might be given this “contract”. I believe it is important that this contract goes out on bid. I’m uncomfortable with ACORN getting anymore national business.
• Automatic enrollment for non-Medicaid eligible individuals. Need a fix? Just hop the border and go to the ER, we’ll have and interpreter waiting, as well as your complimentary insurance.
• If you are born in the US, regardless of the citizenship of the parents, you qualify for coverage AND this in the future will be rolled into Medicaid, even if that child would not otherwise qualify for Medicaid.
• Once a participant in the exchange qualifies for Medicaid he may be automatically changed to Medicaid.
• The government portion of the exchange program will be funded out of a trust fund which itself will be funded by 1) taxes on individuals not obtaining acceptable coverage (what if the public option works and everyone joins, or if these folks don’t pay taxes?) 2) Employment taxes on employers not providing insurance (again, what if they all do?) 3) Excise tax for failure to meet certain health coverage requirements (I don’t even know who this is directed at). 4) Unappropriated money in the treasury (which can only come from cutting other services or increasing other taxes.) I guess this is competing for funds with the Retiree’s reinsurance program. We’ll see in an upcoming section how taxes will be increased for some to try and supplement the fund.
• State run programs need to be managed in a way as to not cost federal dollars (does this mean it might be the state increasing taxes too???)
• Quality (of care) is not defined itself
• This money, as well as the trillion for the Retiree reinsurance program, is coming out of the unappropriated funds gathering dust at the treasury. I want to know how much unappropriated funds do we have now; I thought we were broke.
• Initial payments to hospitals/clinics/doctors will be based on Medicare fee schedules:***This is important***A great many doctors do not accept Medicare because it already pays 15-30% less than what regular insurance pays. Why would doctors sign up for this if they don’t take Medicare?
• The answer (not): during the first 3 years of a physician’s involvement, if he accepts Medicare he will get an extra 5% on reimbursements (which will not likely cover the lost revenue from taking care of Medicare patients). If you don’t take Medicare, you don’t get the extra payment (can you even participate in the exchange??). Smells like a ploy to get more doctors into Medicare.
• The secretary will set and modify reimbursement rates and “THERE SHALL BE NO ADMINISTRATIVE OR JUDICIAL REVIEW (of these rates). So if the secretary changes a rate and physicians don’t like it, we’re hosed??
• Physician payment will be linked to performance, quality, utilization of services (ie xrays, labs, consults) review, bundling of services and capitation (maxing out on billable or reimbursable services.). SO, we’ll reimburse physicians 15-30% less than mainstream insurances (like Medicare) and cut this further if they use services the Secretary feels are unnecessary. Meanwhile, professional risks for the physicians increase followed by their malpractice premiums. Higher overhead and lower reimbursements: I’ll have to think this one over.
• A (insurance) credit eligible individual is someone with a family income 400% of the federal poverty level. FPL this year is about 11000 for an individual, 22000 for a family of 4. So if an individual makes less that 44000 he can get (some) credits to apply towards his insurance costs. For the family of 4 that threshold is at $88000????—really? What if that individual smokes or drinks alcohol in excess? How do we insure that this kind of benefit doesn’t subsidize a person’s bad habits??? I don’t what to subsidize someone’s insurance if they make this much or they use their discretionary funds to support habits that impair health.
• How do you protect the emergency rooms from having to provide care to these individuals. It sounds unethical to turn these folks away however perhaps such an approach would help solve the problem and ensure that costs for legal citizens stay low. Currently, we have people coming to visit relatives here in the states knowing they need surgery (ie open heart). They come into the ER and we take them in fully well knowing that this was a premeditated action to take advantage of our health system. How about something in this legislation to forever discourage this behavior.
• If an employee does not OPT OUT of inclusion in an exchange plan, the employer will give him/her 30 day notice and then enroll the employee in the plan (for which he must pay his portion of the costs). I suspect this is a method for eliminating those employed but choosing not to buy insurance. I see no real harm here other that it takes away choice. I am much more in favor of letting people not insure and then throwing their ass in jail when they fail to pay their medical bills. That lesson would help detour future problems. Thing is, what about the moron who chooses not to insure his family?
• Moneys from these fines go into the general treasury and not into the healthcare trust fund.
• It does not address those who choose to self-insure. I.e. what if I make 2 million per year and choose to self insure, for taking on increased responsibility I get fined and I get increased taxes (see below)?
• What I will cry foul over is this: much of the savings in Medicare or Medicaid (the proposed savings), fines, surcharges…they are not going into the health care fund, they are going into the treasury from which unappropriated funds may be used for health care, but they may be used for all kinds of other things as well, including the Retirees Reinsurance program which appears to benefit only the unions. In effect, as written, this section of the bill is white wash. I will only be comfortable with this if money obtained through the program of from savings within the program—stay in the program.
• The Secretary of HHS will determine what services in Nursing homes will be paid for and which will not. He or she will take into consideration age and functional status of individual patients when making these determinations.
• Budget Neutrality. I really like this term; a shell game by any other name is still a shell game. I would hope that physicians, especially gerontologists, will have the opportunity to review the specific recommendations for services to be covered or cut. There are no specifics provided here. The secretary will of course seek endorsement  of the proposed changes but he/she is not bound by endorsement and can in effect do what ever they want.
• I have no fricken idea what they’re talking about here—and that’s scary. I think this section refers to the use of target growth rates in service utilization to determine correction factors to be applied to standard Evaluation and Management codes (what the physicians use to bill for services) & do away with specific specialty billing codes. I can not tell what the effect on specialty reimbursement will be because of this (I can tell you the specialist physicians I know are pretty worried).
• More bundling of service E&M codes (which will pay the provider less than if the services were billed separately). 252. Again, the Secretary is in total control of this and does not apparently need to answer to anyone.
• Services (physicians, hospitals, nursing homes…) functioning in regions determined to be most efficient in utilization of medical resources will receive quarterly bonus reimbursements as incentive/rewards.
• Much of the next ~20 pages deal with reducing readmissions to the hospitals. This is a difficult subject in so much that punitive measures can actually cause harm to patients.
• There  is a provision to decrease reimbursement of frequently used imaging (xray) tests
• “…promoting the use of bundled payments to promote efficient and high quality delivery of care.” Since when? Bundling usually means less reimbursement and so if a medical provider is looking to preserve revenue he/she/it may choose not to offer some of the care provided in the bundle—the pay is the same. On the other hand, if a provider must bill separately for the services provided he/she/it is more inclined to provide them. The only reason to bundle service is if there are components of that service the government does not wish to pay for. Bundling amounts to reduced services with increased risk to the provider.
• What business does the government have regulating any hospital expansion at all unless that hospital receives non-Medicare, non-Medicaid government funds.
• The caution required here is 1) how is quality defined and 2) Is it a true bonus or are we actually going to be withholding payments from those providers that don’t play. If this is not enacted correctly it could easily be used as a method of decreasing government reimbursements.
• I’m good with this but did I missed the part on what the drug company’s get out of this? Do they get tax breaks that in effect come out of my pocket? Do they incur increased costs that will get passed on to non-Medicare P-D drug prices—in effect a through the back door, up the pants leg, bend over and squeal like a pig tax increase to those with regular insurance.
• I would feel a lot more comfortable if we knew the estimated costs of the administration of this bill. I’m not going to be surprised if it exceeds 25 % of the total costs.
• (Translation services) My question is this, why does this sound like the government is setting up an industry to provide employment instead of funding services already available. This whole section sounds like it should be in the stimulus bill. $500,000 over 3 years isn’t much but you have to wonder what kind of community organizations will be applying for these grants and what kind of vetting will be involved in distributing the funds.
• Government gone HMO? This section will set up incentives for cost-containing primary care physicians. You get paid more for doing less and there will be a cap on the max the gov will pay for—the rest comes out of your (the doctor/clinic/hospital’s) pocket. I was in a HMO that did these things when I first got out of residency. The problem with this was that we were motivated not to test, or exam, or accept certain people as patients. The more you excluded sick people from your practice, the more you made. It wasn’t a good way to practice then, probably still isn’t.
• There are no provisions here for funding these initiatives. This is like me wanting to buy my daughter’s school a new computer but not having a means to make the payments.
• Means of funding this bill are lacking and while medical providers are being asked to take on more medical-legal risk, there are no provisions to protect them. In effect, this bill may increase risk to providers causing increased insurance costs and overhead while continuing to pay providers less that what the market pays. This will not sure up our depleted number of primary care physicians (though it does open up the door to less well trained providers like nurse practitioners and possibly physician assistants).