The ACA and Small Businesses

[Magox]

Kathleen Sebelius argues that once people get their subsidies from the government the insurance premiums for many of those people won't be higher. Well, that may or may not be true in certain instances, however the projected costs of the subsidies were based off a minimal premium rate of growth that was provided by Congressional Democrats on over to the CBO before the healthcare law was enacted.

 

So if premiums rise faster than anticipated in the individual market, as suggested in this report, then the total cost of subsidies will rise sharper than the original projections, meaning that the total cost of ObamaCare will rise significantly exploding the Federal Budget.

[B-Man]

It’s 4:57 p.m., and the Doctor is not picking up the phone

 

That’s the format of a joke I often told about calling up state regulators when I was in private practice. They go off duty at 5 p.m., so the phone stops being answered at a few minutes before because a conversation started at 4:57 p.m. might go beyond 5 p.m., and they don’t get paid for that.

 

It’s coming to a doctor near you because Obamacare regulations are pushing doctors to become employees rather than owners, as Scott Gottlieb writes in The Wall Street Journal, The Doctor Won’t See You Now. He’s Clocked Out:

Big government likes big providers. That’s why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain….

ObamaCare’s main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned “accountable care organization.”

The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors’ financial incentives to perform extraneous procedures

.)The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.

 

The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology.

 

 

Read the whole thing. It explains how this structure alters physician behaviors, and how the esoteric and complicated billing structure exacerbates the situation.

 

 

 

 

 

 

.

Edited March 27, 2013 by B-Man

[Doc]

It's amazing that anyone can still defend this piece of **** law.

[B-Large]

It’s 4:57 p.m., and the Doctor is not picking up the phone

 

That’s the format of a joke I often told about calling up state regulators when I was in private practice. They go off duty at 5 p.m., so the phone stops being answered at a few minutes before because a conversation started at 4:57 p.m. might go beyond 5 p.m., and they don’t get paid for that.

 

It’s coming to a doctor near you because Obamacare regulations are pushing doctors to become employees rather than owners, as Scott Gottlieb writes in The Wall Street Journal, The Doctor Won’t See You Now. He’s Clocked Out:

 

Big government likes big providers. That’s why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain….

ObamaCare’s main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned “accountable care organization.”

The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors’ financial incentives to perform extraneous procedures

.)The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.

 

The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology.

 

 

Read the whole thing. It explains how this structure alters physician behaviors, and how the esoteric and complicated billing structure exacerbates the situation.

 

 

 

 

 

 

.

 

 

The article has some good points, but I think it off target on a few others:

 

1. Physcian's are not unlike other humans, they work hard only equal the incentive. If they are salaried, and need to produce the RVU's to cover salary and benfits, they will figure out down to the single digit the minimum number they need to see to cover that, and will simple cut clinic time if they meet the benchmark. I personally believe they shoudl be incented to see as many patients as humanly possible, but make sure their reimbursement is conmmensurate with their patient's outcomes... I think that is one thing they are trying to so by getting clinics certfied as PCMH (Patient Centered Medical Homes, or some **** like that)... they want to deliver the best care by collecting and evaluting measureable such as diabetes care.... but it doesn't necessarily incent providers to see more patients if the financial incentive is not there

 

2. We have acquired 3 smaller hospital in Colorado, one in the Springs and two in Fort Collins. Small Medical practices will not be able to compete int he future, unless you open a concierge practice and market to high value individuals and families... however, wealthy pateints are not dumb.... they know when you get sick you need the Medical Center for treatments, especially Cancer... so many of them are making donation to the foundations of Academic Health Systems and establishing care with the internist who handles the VIP's... At least on Colorado, we have 2 players in the Health Care game, one Academic on Private....

 

Good article overall, but the ACA did not all of the sudden bring on these symptoms, they have been in place for decades...

[birdog1960]

The article has some good points, but I think it off target on a few others:

 

1. Physcian's are not unlike other humans, they work hard only equal the incentive. If they are salaried, and need to produce the RVU's to cover salary and benfits, they will figure out down to the single digit the minimum number they need to see to cover that, and will simple cut clinic time if they meet the benchmark. I personally believe they shoudl be incented to see as many patients as humanly possible, but make sure their reimbursement is conmmensurate with their patient's outcomes... I think that is one thing they are trying to so by getting clinics certfied as PCMH (Patient Centered Medical Homes, or some **** like that)... they want to deliver the best care by collecting and evaluting measureable such as diabetes care.... but it doesn't necessarily incent providers to see more patients if the financial incentive is not there

 

2. We have acquired 3 smaller hospital in Colorado, one in the Springs and two in Fort Collins. Small Medical practices will not be able to compete int he future, unless you open a concierge practice and market to high value individuals and families... however, wealthy pateints are not dumb.... they know when you get sick you need the Medical Center for treatments, especially Cancer... so many of them are making donation to the foundations of Academic Health Systems and establishing care with the internist who handles the VIP's... At least on Colorado, we have 2 players in the Health Care game, one Academic on Private....

 

Good article overall, but the ACA did not all of the sudden bring on these symptoms, they have been in place for decades...

as you said, this isn't new and wasn't started by obamacare. private practice has been a dying dinosaur for quite some time. if you're still in it and haven't made the jump you're proabably doing worse financially than your colleagues that have are (excepting concierge practice which has it's own headaches). obamacare will push this faster however. i believe we're moving towards bundled payments for overall care and accountable care organizations. hard to do that and compete in a small practice. probably eventually going to move away slowly from fee for service (via bundled payments and more in line with the kaiser type model). fee for service just doesn't work for cost effectiveness. quality will be compensated and already is. be damn near impossible to get quality bonuses if you can't measure quality with electronic medical records which some small practices still don't have. medical home is an interesting and promising prospect for internists, especially. most of us have been doing this all along (acting as the patient's advocate and "orchestra conductor" for care, if you will. now were going to get paid for it. and that should incentivize more docs to do it. most of these things are good in my opinion. hate to see small practices go away but that's more out of nostalgia than a belief that they are a better mousetrap. all of this would have happened with or without obamacare. it's just happening sooner with it.

[ExiledInIllinois]

It's amazing that anyone can still defend this piece of **** law.

 

This will pump your pistons Doc: LOL...

 

http://www.washingtontimes.com/news/2013/mar/26/magic-johnson-nba-hall-famer-obamacare-working/

 

Just messing with ya...

 

Disclaimer: I know, I know... This must be some sort of twisted joke. Check out the length of the article and the responses... LoL Really Magic? LoL...

[Doc]

This will pump your pistons Doc: LOL...

 

http://www.washingto...macare-working/

 

Just messing with ya...

 

Disclaimer: I know, I know... This must be some sort of twisted joke. Check out the length of the article and the responses... LoL Really Magic? LoL...

Earv also probably thinks his $2B investment in the Dodgers was worth it.

[IDBillzFan]

Earv also probably thinks his $2B investment in the Dodgers was worth it.

 

What is it these days with embarrassing world leaders relying on old basketball stars to get their message out?

[Doc]

What is it these days with embarrassing world leaders relying on old basketball stars to get their message out?

A poor message.

[GG]

 

 

What is it these days with embarrassing world leaders relying on old basketball stars to get their message out?

 

What does this have to do with North Korea

 

[ExiledInIllinois]

What does this have to do with North Korea

 

LA Tea Bag schtick!

 

Kim Jong-un (Supreme Fearless Leader)/Dennis Rodman = Barry Obama (Supreme Fearless Leader)/Magic Johnson

[IDBillzFan]

LA Tea Bag schtick!

 

Kim Jong-un (Supreme Fearless Leader)/Dennis Rodman = Barry Obama (Supreme Fearless Leader)/Magic Johnson

 

Don't be silly. Everyone knows the second to last word anyone would use to describe Barack Obama is "fearless."

[B-Large]

as you said, this isn't new and wasn't started by obamacare. private practice has been a dying dinosaur for quite some time. if you're still in it and haven't made the jump you're proabably doing worse financially than your colleagues that have are (excepting concierge practice which has it's own headaches). obamacare will push this faster however. i believe we're moving towards bundled payments for overall care and accountable care organizations. hard to do that and compete in a small practice. probably eventually going to move away slowly from fee for service (via bundled payments and more in line with the kaiser type model). fee for service just doesn't work for cost effectiveness. quality will be compensated and already is. be damn near impossible to get quality bonuses if you can't measure quality with electronic medical records which some small practices still don't have. medical home is an interesting and promising prospect for internists, especially. most of us have been doing this all along (acting as the patient's advocate and "orchestra conductor" for care, if you will. now were going to get paid for it. and that should incentivize more docs to do it. most of these things are good in my opinion. hate to see small practices go away but that's more out of nostalgia than a belief that they are a better mousetrap. all of this would have happened with or without obamacare. it's just happening sooner with it.

 

I think the Medical Home will be enhanced by innovation is EMR's... the days of having to get records faxed or sent via mail, or home care orders being signed by faxed and sent shou;d become a thing of the past.... its interesting to see my place operate under an all incompasing EMR versus when I got here and it was electronic bilings and registration, but charts and ordering were still hardcopy and shadow charts... tech will be the tool that allows that provider to deliver quality cost effectively to that 2500 patient panel...

 

are you an internist?

[birdog1960]

I think the Medical Home will be enhanced by innovation is EMR's... the days of having to get records faxed or sent via mail, or home care orders being signed by faxed and sent shou;d become a thing of the past.... its interesting to see my place operate under an all incompasing EMR versus when I got here and it was electronic bilings and registration, but charts and ordering were still hardcopy and shadow charts... tech will be the tool that allows that provider to deliver quality cost effectively to that 2500 patient panel...

 

are you an internist?

yes. gave up my small group practice a few years ago to work for a large system. part of the reason was the need to switch to ehr. we had one for years but i never wanted to go through the slow down (and expense) needed to learn and utilize it so we did paper..and, i believe, it served the patients and us well . i do see the advantages of ehr but the systems are far from perfect and it's clear that there were too few clinicians involved in the design of our systems'. why the big players like microsoft or especially apple aren't in the game is beyond me. apple would never put out a buggy product like many of those available. anyway, my perception is that healthcare reformers fully understand the need for a strong primary care base to successfully achieve their goals. they've already thrown a few bones our way and i think there will be more to come. unfortunately, these will likely be at the expense of proceduralists. outpatient primary care is where the growth will be in my opinion..and where it should be if were going to provide more quality care to more people at less cost. some system administrators share this belief. others just seem to see the present ...i think that's a big mistake. systems like geisinger and kaiser have known it for a long time. tech is ok but it's the docs that make (or don't make) the difference. without them, hospitals are just very expensive hotels with bad food.

[Magox]

A fantastic in depth study perfromed by the Manhattan Institute for Policy Research on Obamacare.

 

http://www.manhattan...tm#.UVW1IDeMBpk

 

 

Key Findings:

 

A recent Manhattan Institute study used a report-card format to measure how well the law has reduced costs. "[W]e give Obamacare's cost-cutting efforts a grade C," with the notation: "Weak evidence that reforms will achieve their intended goals or growing evidence of unintended consequences."

 

 

"based on analysis of the available data, we project that Obamacare will increase U.S. health care spending and will not lower health care costs,"

 

 

Obamacare does little to actually stem spending growth, aside from some relatively small pilot projects on reimbursement reform that have had disappointing results thus far, either producing some savings but also some cost increases, or increasing outright health-care spending. For instance, the implementation of electronic health records has, thus far, not only failed to decrease health-care spending but seems to have increased it by making it easier for providers to bill for additional services.

In fact, the largest components of estimated deficit savings in CBO projections related to Obamacare come from revenue increases rather than actual decreases in U.S. health-care spending. As noted earlier, the law shifts health-care costs from individuals to government, with the overarching goal of reducing the share of health-care spending borne by low- and middle-income uninsured consumers. The problem is that evidence strongly suggests that when out-of-pocket spending is lower, health-care spending actually rises.[9] In fact, American consumers spend less on out-of-pocket costs than most of their advanced Organisation for Economic Co-operation and Development (OECD) competitors.

If we examine per-capita health-care spending across a number of OECD countries, we see a significant correlation between out-of-pocket spending as a share of total health-care spending and the level of per-capita health-care spending. This explains about 30 percent of cross-country variation in 2010, suggesting that in order to “bend the cost curve” of health-care spending, more out-of-pocket spending may be needed in the form of deductibles, co-pays, and cost-sharing for routine expenses. In other words, consumers must become more cost-conscious.

 

Something that the Ryan plan looks to address.

 

 

 

As it turns out, since the passage of Obamacare, household premiums have increased by a full 11.3 percent. Moreover, this increase even outpaced the rate of the medical services consumer price index (CPI), which netted a mere 6.8 percent increase over the three years that we measure.[3] The CPI is the commonly used measure of inflation; the medical services CPI measures the growth in prices of medical services.

Independent analysis also suggests that this trend will not slow down anytime soon. In 2012, the CBO and Joint Committee on Taxation estimated that by 2016, employer-based family coverage will cost $20,000, with varying amounts of minimum required contribution based on family size and income.[4] This will be an increase of $4,255 from 2012’s total family premium of roughly $15,745—a 27 percent jump.[5]

Looking further down the road, per-enrollee household private health-insurance premiums are projected to rise steadily through the rest of Obamacare’s implementation (2013–21), with the exception of a brief dip in 2014. (The dip is related to a one-time shift in costs from individuals to the government because people purchasing insurance on insurance exchanges will, on average, pay less of the cost because of federal premium subsidies. This drags down the average premium increase for households, but the costs will be borne by the federal government, i.e., taxpayers.)

Edited March 29, 2013 by Magox

[B-Large]

A fantastic in depth study perfromed by the Manhattan Institute for Policy Research on Obamacare.

 

http://www.manhattan...tm#.UVW1IDeMBpk

 

 

Key Findings:

 

 

 

 

 

 

 

 

Something that the Ryan plan looks to address.

 

Perhaps the underlying assumption of spending going down is false in and of itself in the short run.... there is little reason to believe that with a aging population, people living longer and more inteventions/therapies we can do now to keep people alive, how could spending actually go down?

 

The only way I see spending going down is when A.) People need to pay for a substantial amount of their care before there is any insurance covered benefit B.) People who are really old and sick choose to forgo A and make the decision to skip treatments and have nature take its course...

 

You can have all the competition in the world in healthcare, and while I think that helps alot, the industry still delivers a unique product just about everybody wants (id argue needs), life and health... and we also have a populace tha abhors the thought of a citizens having to forgo those things because of the money hurdle...

[Magox]

Perhaps the underlying assumption of spending going down is false in and of itself in the short run.... there is little reason to believe that with a aging population, people living longer and more inteventions/therapies we can do now to keep people alive, how could spending actually go down?

 

The only way I see spending going down is when A.) People need to pay for a substantial amount of their care before there is any insurance covered benefit B.) People who are really old and sick choose to forgo A and make the decision to skip treatments and have nature take its course...

 

You can have all the competition in the world in healthcare, and while I think that helps alot, the industry still delivers a unique product just about everybody wants (id argue needs), life and health... and we also have a populace tha abhors the thought of a citizens having to forgo those things because of the money hurdle...

 

I don't think you read it to thoroughly.

 

If you had, then you would see that it was advocating much of what you said the other day, which is if people have to spend a little more out of pocket themselves, that it could drive down costs. The assumption, which makes a lot of sense to me is that if the government subsidizes cost, that it could potentially bring down the cost for the end user, but that the rate of growth in health care costs would continue to rise because of there being little pressure on prices to bring them down. If you shift some of the costs to the end user, where funds are more limited, it would provide more competition for those fewer dollars bringing down costs.

 

You basically made the same point the other day, when you said that you believed that higher deductible plans could lead to lower overall costs.

 

I would re read it again.

[birdog1960]

A fantastic in depth study perfromed by the Manhattan Institute for Policy Research on Obamacare.

 

http://www.manhattan...tm#.UVW1IDeMBpk

 

 

Key Findings:

 

 

 

 

 

 

 

 

Something that the Ryan plan looks to address.

i take away something very different from this chart. the czech republic and estonia have nearly the same out of pocket cost as the US but from lowest to highest there's an 8 fold difference in per capita costs. you leave out the linear regression line and it's kinda hard to see the correlation put forth especially with that strange outlier point at the top of the Y axis (US). the better question is why are we such an outlier.

 

as someone, alluded to earlier, healthcare in the us is not a simple free market, supply/demand relationship. people often demand as much as they can get to keep them alive, often for unproven and expensive treatments and tests. and as we've seen from the brill article, the industry can charge even more than the market can bear. sorry to disagree but the path to cheaper healthcare is regulation: of costs, of covered services, of lifetime benefits, of payment for quality, of removal of redundancies and excess capacity, of removal of middlemen. the system is fundamentally unable to self regulate because very sick people will do almost anything to stay alive as we've seen by the number of medical bankruptcies. and the industry is happy to take their money at the highest prices they can get and provide abundant care of questionable value. higher copays won't significantly change these fundamental truths.

Edited March 30, 2013 by birdog1960

[Doc]

i take away something very different from this chart. the czech republic and estonia have nearly the same out of pocket cost as the US but from lowest to highest there's an 8 fold difference in per capita costs. you leave out the linear regression line and it's kinda hard to see the correlation put forth especially with that strange outlier point at the top of the Y axis (US). the better question is why are we such an outlier.

 

as someone, alluded to earlier, healthcare in the us is not a simple free market, supply/demand relationship. people often demand as much as they can get to keep them alive, often for unproven and expensive treatments and tests. and as we've seen from the brill article, the industry can charge even more than the market can bear. sorry to disagree but the path to cheaper healthcare is regulation: of costs, of covered services, of lifetime benefits, of payment for quality, of removal of redundancies and excess capacity, of removal of middlemen. the system is fundamentally unable to self regulate because very sick people will do almost anything to stay alive as we've seen by the number of medical bankruptcies. and the industry is happy to take their money at the highest prices they can get and provide abundant care of questionable value. higher copays won't significantly change these fundamental truths.

Neither will Obamacare. It's ultimate effect will be continued rising health care costs, worsening cancer survival rates, decreased innovation, and driving the best and the brightest away from medicine.

[B-Man]

“Definitive Proof that Obamacare Raises Costs and Kills Jobs.”

 

 

.