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As Obamacare is winding its way through a hellish bureaucratic labyrinth of its own creation, accompanied by cheers and boos from the blood thirsty spectator crowds, confusion, fear, trepidation, despair and exhilaration, are gripping America’s doctors all at once, because whatever else is accomplished in the next decade, medicine will never be the same. At the confluence of cutting edge technology, great poverty and unimaginable fortunes, a new vision for the practice of medicine is beginning to emerge. Medicine was formed during times when sickness was never far from death. It was devised by old men who went to bed every night thinking that they may never awaken, and it was institutionalized by women who shunned life’s earthly pleasures. They understood the fears of old age, the loneliness of disease, and the comfort and serenity that come with putting your life in the hands of God, when all was said and done. They built houses for the poor and sick and downtrodden, with larger than life Doctors as God’s emissaries, and pious Sisters as angels of mercy.

Over the last century, science and technology changed hospitals from places of suffering, grief and death, to places of hope and new beginnings; from dreary Spartan wards for the dying, to plush private suites for the soon to be healthy; from whispered footsteps in the twilight, to shiny instruments of mechanical shops; from final moaning and groaning, to humming of machines and laughing soundtracks of sitcoms punctuated by shrill alarms and flashing lights. Dying in a hospital is now considered a failure of sorts, a preventable and costly mistake. There is no place for God in a modern hospital, and there is no place for special emissaries or angels. And when God vacates the premises, big business comes in to take His place. Today’s technology driven medicine is shaped by young and invincible entrepreneurs, in search of fame and fortune. Masters of their own fate, bursting with self-quantified health, brilliantly educated in the intricacies of computerized logic, armed with stacks of data points, and carefully clad in black turtlenecks, hoodies, tee shirts and designer jeans, these modern knights of the business round table are engaging in the timeless quest of vanquishing death, or at the very least making it less expensive for the rest of us.

So where does all this leave primary care? Primary care is now considered routine care; routine, like changing oil on an automobile. Sticking a needle in your arm so you never, ever die from a plague is no longer a miracle, just like switching the lights on, or flushing the toilet is no longer deserving of thought. Miracles only happen in hospitals now, and not very often either. Primary care doctors are increasingly banned from hospitals, and asked to stick with routine care and leave the complex stuff to their betters. And primary care doctors agreed to this arrangement, mostly voluntarily, and explained (mostly to themselves) that routine care nowadays is pretty complex on its own, and arguably even more complex than the narrowly specialized interventions occurring in hospital settings. Maybe so, but routine complexity is what technology entrepreneurs eat for breakfast. Terminology is important.

When health care reformers say that primary care is foundational to reform, they mean routine care. They mean vaccines given on schedule, screenings done on time, lifestyles assessed and documented, educational materials handed out, and referrals coordinated to completion. They mean managing populations, stratifying risk, conducting outreach, dotting every BP and crossing every A1c. Welcome to Lake Wobegon primary care where all patients come in correctly diagnosed and ready to be tracked. These things can be automated with the right technology and properly trained teams of workers, supervised by medical professionals providing spot checks and quality assurance. High tech and high deductibles will combine forces to turn routine primary care into the first medical service to become a retail product, with its Med Emporium, Osler 5th Avenue, and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com. The question is no longer how to stop the train; the question is where primary care goes from here.

Let It Go!

When primary care physicians became overworked and underpaid, something had to give. Inpatient care, arguably the high end portion of practicing at the top of one’s medical license, was snatched away by hospitals oblivious to their mission statement, and a good portion of complex care had to be offloaded to secondary care, just so primary care can keep up with demand for routine care.  Primary care became literally broken, and with it, the entire system downstream was broken too. In a fool’s errand type of strategy, routine primary care now includes tasks aimed at gluing primary care together again (e.g. transitions of care management, exchange of clinical information across facilities). Furthermore, routine care is being expanded to include things previously in the purview of public health (e.g. health literacy, physical activity, safe sex), stuff that grandma used to do for us (e.g. eat your string beans, keep your hands out of the cookie jar) and new retail oriented things (e.g. online shopping, consumer experience, values and preferences).

Today, in a plot twist worthy of Beckett himself, tech entrepreneurs in concert with non-physician workers are vying for the business at the low end of primary care. The new routine care will be catalogued, standardized, sterilized, automated, delegated, computerized, transformed and reformed. If you hang on to it, it will drag you down to wherever it’s going. Let it go! Let it go to your “team” (read, staff), or (gasp) let it go to Med Emporium.

Insurers, who could not be made to understand the importance of continuous, comprehensive primary care, seem perfectly willing to support the low skilled, electronic strings and duct tape of the new and expanded routine care. If you have an entrepreneurial gene in your DNA, hire staff, promote your office manager to Chief Quality/Compliance Officer, your receptionist to Care Coordination Manger, the triage nurse to Director of Resource Allocation, and delegate the bejeebers out of your daily work. Become the CEO, and get a secretary (a.k.a. scribe), so you never have to click another box, or type another embarrassingly misspelled sentence. Double your patient population, and let your NPs see the f/u for diaper rash, sports physicals, strains and sprains, the new wave of statin seekers, and everything that your Director of Resource Allocation deems routine.  Grab the fluctuating 25% or so of patients that are most complex and be their Comprehensivist.  Hospitals are routinely inventing specialties, from hospitalists to intensivists to nocturnists, to further fragment continuity of care and increase profits. It’s time to learn from the experts.

Instead of waiting for the System’s other shoe to drop (on your head), proclaim yourself a specialist in the absolutely last remaining piece of what was once primary care. Grab it and hold onto it like dear life, because it will be nibbled on from below and from above incessantly. You will have to compete with the low prices of Med Emporium on one hand and with the natural expansionist tendencies of hospitals on the other. You will have to find a way to get paid for your new specialty services, and just like every other entrepreneur, you will have to take risk; the more complex the patients are, the bigger the risk and the larger the rewards. Fortunately, the new health care law encourages precisely this type of advanced payment models. Go for it! Spend a leisurely hour with each patient needing comprehensive care, while your routine side of the business is humming along on its own.  With proper planning, you can collect the customary and usual fees for your greatly expanded panel, plus the special fees for Comprehensive care, plus any shared savings you can generate from keeping these select folks out of hospitals and emergency rooms. You’ll have to do a bit of marketing and engage in some creative contract negotiations (get a lawyer), but the sky may very well be the limit.

Don’t Let Go!

What if you have no entrepreneurial markers in your DNA? What if the previous few paragraphs made you sick, depressed or really angry? Fortunately, Obamacare is on your side.  For all the docs who argued that health insurance destroyed the doctor-patient relationship because it inserted itself in the payment process, and for all those who argued that insurance should not pay for routine oil changes, this is your lucky day, because it doesn’t anymore. With the exception of the very poor and the very old, people will now need to pay for primary care out of their own pocket. That’s what high deductibles mean. A good portion of these people will become savvy shoppers and choose the technology enabled do-it-yourself method, or go to Med Emporium on an as-needed basis, but there will be more than enough patients (perhaps in higher income brackets), seeking quality over cheapness. The same folks that buy artisan bread and free range eggs from local farmers will bring their family to you, if you promise to provide hand-made wholesome and holistic primary care.

Direct primary care, whether concierge, or ideal or micro, or contracted by employers and even forward thinking insurers, will most likely explode in size during the next decade. There is a huge continuum of service definitions here, and you should be able to find your comfort zone. You can go back to being a country doctor in the midst of a bustling metropolis, and care for multiple generations at home, in clinic, at the hospital, nursing home and eventually hospice. You can dial back a little bit, or a lot, and contract with midsize employers to provide outpatient primary care. You can be a high-tech, electronic-everything doctor, or an old fashioned one, or perhaps a unique combination of both.  Here too, the sky seems to be the limit.

So what’s next for primary care? It seems that for physicians, the door is closing on the treadmill now known as primary care practice, but countless windows are being opened simultaneously. You just have to look up and find yours. Whether you choose to stay in the system, step half way in and half way out, or do it your way all the way, there will always be a need for good doctors. Whether you choose to run the patient mills at Med Emporium, or run your own exquisite Osler 5th Avenue, or start the Hello Kitty Diabetes Company, or care for people slowly and thoroughly, one at a time, from start to finish, primary care may just be the best place to be in right now. You should be thankful this week, because the best is yet to come…

What’s next for Primary Care?

The Sustainable Growth Rate (SGR) formula was enacted into law in 1997 to tie Medicare payment for services to physicians to the overall status of the economy. Basically, if the U.S. Gross Domestic Product (GDP) does well, doctors get more money, and if it does poorly, doctors get less money for the same service. A decade of tinkering with legislation for circumventing the application of the SGR formula, preferably a few days before or after it was due to take effect, resulted in failure to save $150 billion dollars over the last decade. For the next decades, the Congressional Budget Office estimates that avoidance of the SGR formula will fail to save us a mere $139 billion, so this should be a perfect time to let bygones be bygones and come up with a more gentle strategy to cut physicians’ Medicare reimbursement. More gentle, because if we do decide to cash in on our SGR savings on January 1st, doctors are looking at an approximately 24.4% cut in the Medicare fee schedule for 2014.

Building on H.R. 2810, the “Medicare Patient Access and Quality Improvement Act of 2013” approved by the House Committee on Energy and Commerce, the new proposal to fix the SGR comes from the House Ways & Means and Senate Finance Committees with support from both Democrat and Republican members, hence the bipartisan and bicameral labels. It is currently in draft form and it is open for public comment until November 12, 2013. This is a short document, and you should read it before it’s transformed into a 1000 page cleverly titled Act. The idea behind the proposal is very simple, and it is widely used in other service industries, where patrons pay a base price for the service, and discretionary bonuses, gratuity, or tips, are available to service providers based on quality of service. There is a small difference though, since the proposal is supposed to be budget neutral (i.e. a zero sum game). Thus, a sufficient number of physicians will need to be penalized to balance the bonuses awarded to better performers.

Below is a simplified summary of the eight point proposal to repeal the SGR, and replace the straight fee for service payment system with quality adjusted risk-based contracting:
  • The Medicare physician fee schedule will be (sort of) frozen for the next 10 years. After 2023, the fee schedule will be adjusted upwards by 2% annually if you take risk for your patients through an advanced alternative payment model (APM), or just 1% annually if you don’t.
  • The heart of the proposal consists of bundling the multitude of incentives and penalties currently enacted by CMS, into one Value-Based Performance (VBP) Payment Program, beginning in 2017. It’s not that you won’t have to report quality measures or be a meaningful user, you will have to do those things and more, but there will be a single aggregate score to trigger incentives/penalties, calculated as follows:
    • Quality Measures reporting – exactly what you think this is – Weight 30%
    • Resource Use – similar to the CMS Value Based Modifier initiative, with an added requirement for claims self-reporting (subject to payment reduction) – Weight 30%
    • Clinical Practice Improvement Activities – basically patient centered medical home (PCMH) or patient centered specialty practice (PCSP) certification – Weight 15%
    • EHR Meaningful Use – it seems that all that is needed here is the use of a certified EHR – Weight 25%
  • Practices that have very few Medicare patients are exempt and practices that have significant revenues in at-risk contracts (see below) are excluded from the VBP program. This is a budget-neutral item, meaning that high performer bonuses are directly proportional to the number of penalized poor performers. The pool available for bonuses starts at 8% of the total physician payments in 2017 and increases in subsequent years.
  • Since the stated goal of this permanent SGR fix is to eliminate fee for service, an additional 5% bonus will be made available to those who have significant revenues tied to at-risk contracts. The thresholds begin at 50% and go up to 75% revenue. Both Medicare and commercial payer revenues can be counted for this purpose. It is interesting that the thresholds are for revenue, not patients, and it is also interesting that private payers can be counted, although it is not clear if the bonus is 5 percent of Medicare payments, or 5 percent of all payments. A seemingly simpler alternative to obtaining the 5% bonus is to have a “significant share” of revenue in a patient-centered medical home (PCMH) model that has been “certified as maintaining or improving quality without increasing costs”. This will require some explanation in the final bill because PCMH is usually not tied to revenue shares, and because I am not aware of anybody with the ability to certify that a certain PCMH model will increase quality, but not costs.
  • For those practicing in a PCMH, or a comparable specialty model (e.g. PCSP), special care coordination codes will be created. The description here sounds very similar to the new Transitional Care Management CPT Codes following hospital discharge. Note that payment for these codes is also budget neutral within the physician fee schedule, so for each care coordination code paid out, someone or something else will be paid less.
  • Along with ending fee for service, the proposal will also improve the fee for service schedule, by thoroughly evaluating and “identifying and revaluing misvalued services” to facilitate “smooth downward payment adjustments” The yearly downward target is 1% per year, and if not enough misvalued services are identified, the entire fee schedule will be revised downward by the missing amount. If more than 1% reduction is found, the funds will remain in the budget neutral pool to offset bonuses and other changes.
  • The proposal will also ensure that physicians practice medicine correctly. Mechanisms will be put in place to make sure doctors consult appropriate clinical decision tools before ordering “advanced imaging and electrocardiogram services” (no idea why electrocardiogram of all things is specified here). The “tools” will report back to the Secretary of Health and Human Services that such consultation occurred prior to ordering. “Payment would not be made for the advanced imaging or electrocardiogram service if consultation with appropriate use criteria did not occur.” Physicians found to order too many of these services will be required to obtain prior authorization in the future. If things go well, other services will also become subject to appropriate use surveillance.
  • To support all these activities, qualified entities that are receiving Medicare and Medicaid data for public reporting, will be authorized to sell analyses and reports to physicians, as well as commercial insurance companies and employers too.
  • Transparency will be facilitated by publishing physician payment and various performance metrics measured through the program, so the public can search for physicians by name and get all the data they need to select providers.

Bottom Line

Although right now this is just a proposal, it is very likely that sometime around January 15, 2014, this, or something very similar to it, will become the law of the land. For small independent private practice, the increase in bureaucratic burden will be significant and the reach of insurers into your everyday work will become palpable. Noncompliance with the new regulations means that your topline will remain flat for the next 10 years, minus any penalties, rejected claims and downward adjustments, which may or may not be significant depending on your specialty. Initially, this may only affect the Medicare portion of your practice, but it will not remain that way for long.

If you want to continue practicing medicine and remain independent, you have three basic choices: 1) Join a larger entity, such as an accountable care organization, and accept risk for most of your patients in a managed care environment; 2) Adapt to the new paradigm by getting yourself a certified EHR, obtaining PCMH recognition, and learning how to practice under increased supervision; and 3) Stop accepting insurance and switch to a direct pay model. Since the program is slated to begin in 2017, you have 3 years to make an informed decision.

The Upcoming Bipartisan, Bicameral, Doc Fix

If you are a staunch conservative who believes that free markets should solve health care, or that poor people should work harder and have more skin in the game, or that governments should stick to building armies, you don’t need to read this post, unless of course you enjoy being aggravated by clueless liberals.
If you are one of the talking heads posing as a progressive, while repeating the empty slogans of Obamacare (e.g. no one can be denied care any longer, children under the age of 26 can stay on parents’ plans, not perfect but a good a first step, etc.), you should probably not read this either, because you are far beyond the point where independent thinking is an option. If you are none of the above, and have a few minutes between updates on the completely irrelevant status of the Obamacare website, you may want to read on.

Obamacare Strengthens Medicaid

Medicaid is the public health insurance plan for the poor. Medicaid’s continued existence is an affront to human decency. Unlike Medicare, Medicaid is administered by the States. Subject to certain minimums, the States get to decide what medical services are covered, which medications are on formulary, how much money hospitals and doctors are paid, and who is eligible for Medicaid in the State. Some States have the gall to run lottery systems for choosing the lucky poor that are covered by Medicaid, while others have first-come-first-served brief enrollment windows. States are at liberty to decide that they will not cover certain conditions and certain medications, or other therapies, not because these are medically unsound, but just because they can. People on Medicaid have a Medicaid insurance card to let every hospital and every doctor know that they are poor, and that services will be reimbursed with peanuts, if at all. Obviously, many physicians do not accept Medicaid.

Having poor people segregated in a defective insurance plan, separate and hardly equal, should be no more acceptable than any other form of segregation. Medicaid needs to be dismantled and all beneficiaries along with all the funds, including States responsibilities, should be funneled into Medicare, the Federally administered insurance plan, for those who cannot, or will not, purchase private insurance. Instead, Obamacare pours billions of dollars into keeping Medicaid alive on one hand, and privatizing its operations on the other (e.g. managed care, health exchange vouchers, etc.), with a net result of transferring a few more Medicaid cents from health care delivery to private corporations.

Obamacare Voucherizes Health Insurance

The Obamacare health insurance exchange is a marketplace where individuals and small businesses can shop for insurance plans that meet new minimum standards. The plans are sold by private insurance companies, and a formal exchange is needed because Obamacare will pay the private insurance companies a portion of the premiums. The Federal subsidy, or voucher, amount is calculated based on means testing. Those who are poor (but not poor enough for Medicaid) will receive a larger voucher than those who are better off financially. This is in effect a progressively defined contribution. Let’s illustrate this with an example. Say the Jones family, which is not completely destitute, received a $2,000 premium discount. Mrs. Jones goes and uses her brand new insurance to have a mammogram which according to the law carries no cost sharing. Say they find something that should be biopsied. This procedure is subject to the Jones family deductible. If the Joneses have the cash to pay for everything until the out-of-pocket maximum is met, Mrs. Jones will get the treatments she needs. If they don’t have the money, the story will have a different ending. So the benefits are not predefined, but the contribution is. This is the definition of a voucher.

Obviously, if this is good enough for the federal marketplace, it should be good enough for the employer sponsored group market as well. Private exchanges, where employees get a fixed voucher contribution, are already operational and will most likely flourish in the future. I haven’t heard of any pay increases for workers sent to private exchanges to “shop” for a plan that best fits their “needs”. Eventually, as the contributions fail to keep up with costs of care, all health insurance will become just catastrophic insurance. And as middle class wages keep going down the drain, catastrophic insurance premiums will inch up, because those who cannot afford routine care will be experiencing lots of catastrophes. If you want to talk about death spirals, this is a perfect time to do so. 

Obamacare Creates a Tiered Medical System

Much has been said about the transparency of the health insurance marketplace, where for the first time people can get clear information about health plan choices and make apples to apples comparisons. Well, it’s not really the first time, but it helps that plans are labeled by actuarial value, and it helps that there are navigators helping folks make sense of a very complex transaction. However, while you can get information on the costs of insurance, there is no information about the product itself. Health insurance is basically a financial arrangement for paying for health care. Health care is the actual product being bought. Unless we believe that health care is a commodity, then in order to evaluate the product, we need to know who is delivering care. I’m not sure if shoppers on the marketplace are aware of the fact that the financing instruments they are purchasing on the exchange will only work with increasingly narrower networks of health care providers. 

This is similar to buying a new television set, hooking it up and finding out that it can only receive and display channels 501 through 550. You may get lucky and these are the channels you watched anyway, or maybe these are very good channels, but then again you may not be so lucky. Now, there is nothing inherently wrong with selling TV sets that have limited channels, if people want to buy them, but there is plenty wrong with purposely hiding this particular information from buyers. And there is plenty wrong with a government advertising free and discounted TVs that have bigger screens and better picture than your dinky old TV, without telling you that you may not be able to watch premium channels on many of them.

Of course, if this little marketing maneuver works on the federal exchange, it will quickly spread to the private group exchanges, and soon we will have clinics and hospitals for the well-heeled and larger institutions for the shoeless. It’s anybody’s guess where the better doctors will be found. No, not really. Narrow networks are designed by insurance companies to put pressure on physicians and hospital to lower their charges, either for the sheer privilege of being in-network, or for the additional promise of filling out all seats, with plenty stand-by customers, just in case. This is strictly about money, and has nothing to do with excellence or quality. Exclusive networks of high quality delivery systems are usually more expensive (see Kaiser plans in California).

So basically Obamacare is taking another step towards privatization of health care financing, and the inequitable distribution of resources inherent to private markets. Some conservatives became concerned that if Obamacare does not work as expected, the progressives will have a field day instituting single payer in its place. I wouldn’t worry too much, because Obamacare is great for those who extract profits from health care, and they won’t let it fail. Besides, progressives have lost their way long ago, and single payer is not in the cards for the foreseeable future. If it were, the Obamacare bureaucracy nightmare would have been replaced by folding Medicaid into Medicare, and the insurance marketplace would consist of Medicare, and its defined benefits, as the only game in town for all.

So if your beliefs are on the conservative side, you should support Obamacare. You may have to wait a few years, but it’s going where you think it should go, where the Heritage Foundation wanted it to go. If you happen to be a liberal, and feel compelled to support an embattled President, just because he is better than the alternative, remember DOMA, GLBA and PRWORA. Were you cheering for Bill back then too?

3 Reasons Why I Don’t Like Obamacare

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