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New Health Care Law presentation by Dr. Jason Fodeman

New Health Care Law presentation by Dr. Jason Fodeman


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  • 1. The New Health Law: A Clinical Analysis Jason D. Fodeman, M.D. PGY-2 UCONN IM
  • 2. Introduction
    • Much has already been said about the Patient Protection and Affordable Care Act (PPACA)
      • Expands government control
      • Puts more people on Medicaid
      • Increase taxes
      • Fails to control rising health care costs
  • 3. Introduction
    • How will it influence doctors?
    • How will it impact patients?
  • 4. Introduction
  • 5. Introduction
    • How government already influences the practice of medicine
    • New regulations which will significantly impact patient care
  • 6. Current Role
    • Government is currently a major player in the health care industry
    • Already influences
      • Doctors
      • Patients
  • 7. Medicare Reimbursements
    • Medicare’s physician reimbursement regimen is characterized by
      • Underpayments
      • Perverse incentives
    • This has significant ramifications on patient care
  • 8. Underpayments
    • On average Medicare reimburses
      • Hospitals 71% of private rates
      • Doctors 81% of private rates
    • Medicaid reimbursements are significantly less
  • 9. Underpayments
    • Federal Government payments to health care professionals are so low that on average hospitals lose money caring for Medicare and Medicaid patients
      • In 2008
        • 91 cents for Medicare
        • 89 cents for Medicaid
  • 10. Underpayments
    • On average CMS payments are less than hospitals costs
    • These underpayments have increased
      • 2000 $3.8 billion nationally
      • 2008 $32 billion nationally
  • 11. Underpayments
    • Who’s problem is this?
    • Doctor vs. Patient
  • 12. Underpayments
    • Passed along to patients
      • Diminished access
      • Compromised quality of care
    • Most commonly cited problem:
      • Difficulty that these patients encounter trying to find a physician
    • Problem is increasing
  • 13. Underpayments
    • (district6voter.wordpress.com)
  • 14. Underpayments
    • American Academy of Family Physicians
      • 2009 13% not participating in Medicare
      • 2004 6%
    • American Osteopathic Society
      • 15% don’t accept Medicare
      • 19% don’t take new Medicare patients
    • New York Presbyterian
      • Only 37/93 Internists accept Medicare
  • 15. Underpayments
    • For patients with Medicare this translates into access problems
    • 2008 Medicare Payment Advisory Commission report:
      • 30% of beneficiaries had problems finding a new PCP
  • 16. Underpayments
    • These access problems are more pronounced for Medicaid patients
      • Solo Practitioner and 2 doctor practices
        • 2004-5 35.3% not accepting new Medicaid patients
        • 1996-7 29%
      • Small group practices
        • 16.2% to 24%
  • 17. Underpayments
    • Medicare has a more broad and complicated influence on patient access
  • 18. Underpayments
    • Outpatient setting
      • See more and more patients to stay in business and make a living
        • Shorter visits
        • Less doctor-patient face time
        • Less time to have questions answered
        • Less time to be educated about their illness
        • Less time to understand the treatment course
        • Compromised quality of care
      • Dissatisfying to both patients and their doctor
  • 19. Underpayments
    • Inpatient Setting
      • Pressure towards quick discharge
      • Occasional premature discharge
      • Readmisisons
        • Poor care
        • Demoralizing
        • Lawsuits
  • 20. Expand the Scope
    • PPACA does not reform the government’s flawed reimbursement system
    • Instead it expands its scope to more people
      • Enrolls more into Medicaid
      • People will lose insurance
  • 21. Expand the Scope
    • “ Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out.  Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference.”
  • 22. Expand the Scope
    • As costs soar and promised savings fail to materialize, look for a return to this mantra as the government will very likely try to characterize doctors as greedy to support further pay cuts
    • Just remember who these pay cuts hurt the most!
  • 23. New Regulations
    • 159 agencies, committees, programs
      • Patient-Centered Outcomes Research Institute
      • Affordable Choices of Health Benefit Plans
      • Value-Based Payment Modifier
  • 24. New Regulations
    • (http://2.bp.blogspot.com/_3sT55XdfKD4/Sq27ro9ItoI/AAAAAAAAAPw/_iWhhjwpD70/s400/fat+ambulance.jpg)
  • 25. PCORI
    • Section 6301 establishes the Patient-Centered Outcomes Research Institute (PCORI)
      • Identify research priorities
      • Conduct research comparing the efficacy of medical and surgical interventions (CER)
  • 26. PCORI
    • Supporters of CER
      • Educate patients
      • Help patients make better decisions
    • It could foster patient education and benefit patients and doctors
    • The potential harm depends how it is used
    • It could easily quell medical innovation by centralizing care
  • 27. PCORI
    • Federal regulators could easily use this research to ration care by fiscally punishing physicians prescribing “less effective” treatments
  • 28. PCORI
    • This research coupled with reimbursement changes could easily pave the way for the government telling patients the medicines, tests, and procedures they can and cannot have irrespective of willingness to pay and personal preference
  • 29. PCORI
    • This would replace the professional judgment of physicians with rigid rules set by regulators in Washington DC
  • 30. PCORI
    • A One-Size-Fits-All approach does not benefit real patients
    • After all patients are individuals not robots
  • 31. PCORI
    • The problem is not everybody is the same
    • In medical school future physicians learn the saying “Patients don’t always read the book”
    • This emphasizes that
      • Patients can present differently with the same illness
      • Patients can respond differently to the same treatment
  • 32. PCORI
    • Physicians need flexibility to treat not the “average” patient but the actual patient
    • CER ignores these crucial differences
    • CER also ignores cultural, religious, and life experiences
    • CER will limit choice and stifle medical innovation
  • 33. PCORI
    • President Obama has promised this won’t happen
    • Yet PPACA doesn’t prevent this either
    • “ not be construed as preventing the Secretary from using evidence or findings from such comparative clinical effectiveness research in determining coverage, reimbursement, or incentive program”
  • 34. Exchanges
    • Section 1311 Affordable Choices of Health Plans
      • State exchanges by January 1, 2014
      • Customers can buy “qualified health plans”
  • 35. Exchanges
    • Government control over
      • Insurance companies
      • Doctors
  • 36. Exchanges
    • PPACA states starting January 1, 2015 a qualified health plan can contract with a provider “only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.”
  • 37. Exchanges
    • Depending on the guideline, this gives the federal government unprecedented new authority over physicians
    • Not just those accepting Medicare and Medicaid
    • Over those accepting any third party payer offered through the exchange
  • 38. Exchanges
    • This will coerce physicians to practice medicine not the way they were taught or they way they have seen work
    • But the way the government tells them
  • 39. Exchanges
    • Ultimately, this will lead
      • Poor quality care
      • Restrict choice
  • 40. Value-Based Payment Modifier
    • PPACA also establishes the Value Based Payment Modifier
    • This will adjust doctor reimbursement based on
      • Quality of care as defined by HHS Sec.
      • Cost compared to other physicians
  • 41. Value-Based Payment Modifier
    • Essentially this will create an arbitrary cut-off for acceptable physician costs
    • Those physicians above this threshold will be punished
    • This will disincenitvize physicians across the board
  • 42. Value-Based Payment Modifier
    • The threat of fiscal punishment will further push physicians to practice standardized care and put tremendous pressure on physicians not to order tests, consults, or medicines that their patients may need
  • 43. Value-Based Payment Modifier
    • Ultimately this will result in compromised quality of care
  • 44. Value-Based Payment Modifier
    • New layers of oversight
    • Very costly
    • More time with executives and less time at the bed-side with patients
  • 45. Physician Shortage
    • Severe physician shortage exists in this country
    • Simply are not enough doctors or doctors-in-training
    • November 2008 the Association of American Medical Colleges:
      • Shortage of 124,000 full-time equivalent physicians by 2025
  • 46. Physician Shortage
    • PPACA will exacerbate these harmful trends
      • 1. Increases demand without a comparable increase in supply (likely less than anticipated)
      • 2. Likely decrease the supply of physicians
  • 47. Physician Shortage
    • Push some doctors to retire early or switch careers
  • 48. Physician Shortage
    • September 2009 IBD/TIPP poll of 1,376 practicing physicians
      • 65% opposed
      • 45% consider leaving their practice or retiring early if it passed
    • This would translate into 360,000 physicians who might stop practicing medicine
  • 49. Physician Shortage
    • Medicus survey of 1,195 doctors
      • Reached a similar conclusion
      • Approximately 1/3 of doctors
      • 46% of primary care physicians would want to leave medicine
  • 50. Physician Shortage
    • (saveyourrights.com)
  • 51. Physician Shortage
    • Deterring young people from pursuing medicine in the first place
    • Think very hard if it is worth the investment in both time and money to pursue it
    • The composition of those who do pursue medicine will likely be a stark deviation from the status quo
      • Brightest
      • Best-educated
      • Best-trained
      • Most dedicated
  • 52. Physician Shortage
    • Fewer new physicians
    • Exodus of practicing
    • Access nightmare for patients desperately seeking care
    • Ultimately, this will lead to restricted access, long wait for appointments, and rationed care
  • 53. Physician Shortage
    • (arkansasgopwing.blogspot.com)
  • 54. Solutions
    • World’s premier health care system
    • Of course it can be improved
    • Rather than rolling the dice and starting from scratch
    • A better approach for reform would be to build off the success of the current
  • 55. Solutions
    • Tort reform
    • Expanding HSAs
    • Real national health insurance market
    • Insurance portability
  • 56. More info
    • www.galen.org
  • 57. Bio
    • Visiting Fellow at the Galen Institute
    • Former Graduate Health Policy Fellow at the Heritage Foundation
    • Author of How to Destroy a Village: What the Clintons Taught a Seventeen Year Old
    • Published in National Review Online, Washington Times, TownHall, Daily Caller, Hartford Courant
    • Appeared on Fox News, MSNBC, CSPAN2, the Rush Limbaugh Show