Pipe dream? Obamacare

[nw30]

NOT from the Rolling Stone, even though some think they are experts on Obamacare, I prefer the opinion from a front line physician.
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A Doctor's Declaration of Independence
It's time to defy health-care mandates issued by bureaucrats not in the healing profession.

By
Daniel F. Craviotto Jr.
Updated April 28, 2014 7:34 p.m. ET

In my 23 years as a practicing physician, I've learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. We strive to do our best even while we sometimes contend with unrealistic expectations. The demands are great, and many of our families pay a huge price for our not being around. We do the things we do because it is right and our patients expect us to.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?

The Centers for Medicare and Medicaid Services dictates that we must use an electronic health record (EHR) or be penalized with lower reimbursements in the future. There are "meaningful use" criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that "Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction."

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don't doctors have control over what they charge for their services? For the most part, no. Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.

I don't know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

We could change the paradigm. We could as a group elect not to take any insurance, not to accept Medicare—many doctors are already taking these steps—and not to roll over time and time again. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table or less? Are we as physicians happier or more disgruntled then two years ago? Five years ago? Ten years ago?

At 58, I'll likely be retired in 10 years along with most physicians of my generation. Once we're gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies? Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.


Dr. Craviotto is an orthopedic surgeon in Santa Barbara, Calif., and a fellow of the American Academy of Orthopedic Surgeons.

http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304279904579518273176775310.html

[swchandler]

Sounds to me that Dr. Craviotto has an issue with electronic health records (EHRs), and as a result, he feels that they are unnecessary. Moreover, apparently in some medical specialties, doctors face board recertifications under the requirement of the ACA, but Craviotto conveniently doesn't delve into the details why.

Why doesn't Craviotto want to step into the 21th century? From what I understand EHRs are being used to improve how Medicare works as a healthcare system, and I'm thinking it's something that health insurance companies support. With the costs of health care skyrocketing, it seems to me to be an area where better documentation and communications make good sense. From what Craviotto has said, to include the findings of the Rand Corp., I'm not convinced the use of EHRs is a pressing problem that is adversely affecting patient care. Sure, documenting what you do can be a pain in the ass, but how can less attention to the details be a better approach. Like it or not, we are all quickly moving into the electronic world.

If there is an argument against board recertifications, I would like to hear it. The medical field is a fast pace scene where it's important to keep up with new research, practices and procedures. I believe that high standards for knowledge and excellence serves the patient's interest.

As far as payments and reimbursements, I'm having a hard time sympathizing with Craviotto. I had shoulder surgery (in Santa Barbara) in November 2013, and the cost for it was astronomical. While it was covered by insurance for the most part, I was amazed that it would cost so much for an outpatient surgery that took under 2 hours. It was significantly more than what my latest heart attack ended up costing, and that included a 4 day stay in the hospital.

From Craviotto's standpoint, it would be convenient to charge whatever he wants, but does that really serve the interests of the patients and the insurance companies that have to pay the bills? Maybe he should blow off Medicare and insurance companies. Yet, I'm thinking that old folks on Medicare are probably a majority of his customers, and that turning them away would spell an end to a good source of his income stream.

[coboardhead]

SWC

Every doctor, for every procedure or visit has to produce an EHR that includes a checklist of multiple items that may have little, or nothing, to do with the specialty of the physician, or the diagnosis of a patient. This means my wife spends more of her time producing a record and less time in face to face with her patients. Many older physicians learned to practice medicine through contemplative interview, rather than the new way of checking off a box on a sheet of paper and are frustrated that documentation has become such an onerous task.

Add to that the inability of the Administration to provide a framework for transferring of these records between providers and this frustration is causing physicians (I know several) to consider bailing out of Medicare. Physicians spend hundreds of hours creating EHRs that are often only used by insurance companies to pay, or deny, claims. (You forget to remind a patient to quit smoking...one of the boxes...and the claim is denied).

[coboardhead]

SWC

Every doctor, for every procedure or visit has to produce an EHR that includes a checklist of multiple items that may have little, or nothing, to do with the specialty of the physician, or the diagnosis of a patient. This means my wife spends more of her time producing a record and less time in face to face with her patients. Many older physicians learned to practice medicine through contemplative interview, rather than the new way of checking off a box on a sheet of paper and are frustrated that documentation has become such an onerous task.

Add to that the inability of the Administration to provide a framework for transferring of these records between providers and this frustration is causing physicians (I know several) to consider bailing out of Medicare. Physicians spend hundreds of hours creating EHRs that are often only used by insurance companies to pay, or deny, claims. (You forget to remind a patient to quit smoking...one of the boxes...and the claim is denied).

[mac]

CB--while this is true, this ship sailed long ago. My wife and I were in a horrific head-on collision over ten years ago in another state. Payments by Kaiser as an insurance entity were broken into over a hundred individual components, with coding standardized, and payments based ultimately on Medicare eligible amounts. It was a nightmare, and it took my attorney to make sure that the hospital and doctors got paid--but ultimately it happened.

The article, and the lack of any connection to the thinking mind when posted by the far right, ignores the fact that many of these problems are a byproduct of the insurance system. At the end of the day, abuses creep into the system to take advantage of loopholes in the insurance policies. Some procedures qualify for payments far in excess of what is paid in other geographic areas, and the system is a game between insurance companies trying to minimize their payments, and doctors who try to heal their patients--and some who try to game the system. The idea that the existing system was efficient, or market based, is the product of a diseased mind.

[isobars]

[swchandler]

coaboardhead, thanks for commenting on details that aren't often mentioned. Seemingly, there are good reasons to streamline the EHR process, and I think that good business practices would dictate that reasonable improvements be made. This is an area where Congress and the Obama Administration can work cooperatively on constructive changes. It could happen if Republicans embraced and accepted healthcare reform, and then they could help fine tune the parts that need improvement.

[coboardhead]

Mac and SWC

I supported the ACA, and still do. The legislation itself. The problem I am seeing with the EHR is that the inefficiencies are not built into the law. They are a byproduct of the inability of the HHS to implement the law. The implementation of the EHR, in particular, has been geared towards claim denial...not efficient medical care. How would you expect a physician to feel when something that is causing so much extra time seems only to be used to reduce his fees?

My wife cannot even access hospital EHR's or provide her EHR to them because they use competing systems. And, the system the hospital uses is not certified for her specialty even if she had the time to redo her entire EHR file system. Yet, Medicare holds reduced reimbursement over her head for not implementing, completely the EHR (One of the requirements is to use EHR for lab reports).

This is not about reducing medical costs. This is, at best, incompetence. At worst, it is special interests, such as EHR managers and large health care providers, manipulating the system.

Isobars...the VA medical record system has NOTHING to do with the EHR process now. EHR systems are developed and managed by independent contractors. Each physician can BUY any system he wants. The VA EHR would be a huge improvement.

[isobars]

[pueno]

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Obamacare stats: Apparently we need a new definition of 'train wreck'

By Michael Hiltzik | The Economy Hub | May 2, 2014

Positive news reports about insurance enrollments under Affordable Care Act have been coming out so steadily that they barely make headlines anymore. Still searching for a way to depict Obamacare as a "train wreck," GOP critics of the law have no option but to make up the bad news.

Before we get to that, let's examine the latest statistics from the Department of Health and Human Services, released Thursday. The HHS report, which updates figures to April 19, toward the end of the extended enrollment period for 2014, reveals that a total of 8.02 million people enrolled in individual health plans through the federal and state ACA marketplaces since Oct. 1. On the face of it, this beats the expectations of 7 million enrollments for the first year of the ACA.

Some of the enrollment trends tracked very closely to what experts anticipated, based on the experience of the Massachusetts healthcare reform ("Romneycare"). One expected trend was that enrollment would surge as the March 31 deadline approached; sure enough, 47% of enrollments came in the final month.

Another was that the share of younger people in the mix would increase sharply toward the end, healthy "young invincibles" being especially likely to procrastinate. Sure enough, the proportion of people aged 18 to 34 increased from 24% during the period between Oct. 1 and Dec. 28, 2013, to 31% during March.

Overall, 28% of private plan enrollees are in this age group, which is close enough to their ratio in the general population (about 40%) to eradicate fears of a risk-based insurance "death spiral." As we reported months ago, the ACA incorporated several provisions to cover disproportionate enrollments by older and sicker customers anyway, but these figures suggest that in general those provisions won't be needed.

The HHS report doesn't help much to answer the question of how many enrollees were previously uninsured, which is one of the obsessions of Obamacare critics on the right. It does offer a curiously positive statistic, though one which HHS officials are treating verrrry cautiously: Of the 5.2 million people who applied for ACA subsidies via the federal enrollment website and therefore were asked about their current insurance status, only 13% said they "had coverage at the time of application."

Simple math would suggest that this means that close to 87% of enrollees were previously uninsured, but that's an extreme interpretation, and the HHS isn't banking on it. The problem is that the individual insurance market is extremely volatile, so the statistic doesn't reveal if these people had been uninsured for one month, 12 months or forever; or if they had simply dropped their coverage in anticipation of signing up for 2014; or if they misunderstood the question.

Other surveys, HHS officials acknowledged during a press briefing Thursday, show the absolute decline in the uninsured to be somewhere in the range of 5 million to 10 million -- from all aspects of the ACA, including expanded Medicaid.

Then there's the question of how many enrollees have paid their initial premiums, which makes their enrollments official. Here's where the GOP has moved into the realm of fiction. Republicans on the House Energy & Commerce Committee released a survey Wednesday claiming that only 67% of enrollees in the federal marketplace have paid.

Compared with other surveys on the topic, this looks like an exceptionally low number. Most other surveys have placed the figure at an average 85%, with some as high as 95%. (California's state exchange, Covered California, says insurance firms are reporting 85% payment.)

Obamacare enrollment tracker Charles Gaba calls the House report "embarrassingly flawed" and, with uncharacteristic bluntness, a "pile of crap." He points out that the report assumed erroneously that premiums on all enrollments were due no later than April 15, whereas only 63% of all enrollment payments were due by then, with the rest due Wednesday (April 30) or even sometime in May. That's a big enough mistake to invalidate the entire study. Gaba adds further that figures from state exchanges in Washington, Massachusetts, Oregon, Minnesota and Connecticut are all coming in at 95% paid or above; there's no reason why enrollments on the federal exchange should vary significantly from those figures.

Here's the takeaway: The GOP's campaign against the Affordable Care Act is still at full cry, but it's becoming more desperate with every passing day.

Source: http://www.latimes.com/business/hiltzik/la-fi-mh-obamacare-train-wreck-20140501,0,5431523.column#ixzz30bjtoTWp
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