Tuesday, November 23, 2010

So is there any difference in education between U.S. and foreign trained physicians?

Get Adobe Flash player

If you've ever wondered about the difference in training between foreign medical graduates and those from the U.S., check out this video blog.  Join docdano.com as we discuss the education of physicians both here and abroad with Dr. Caitriona Ryan from Dublin, Ireland who is now a resident in internal medicine in Dallas, Texas.

Friday, November 19, 2010

Disability Insurance: Difficult decision when you're bullet proof and broke

Get Adobe Flash player

An interview with Jim Stevens about the importance of disability insurance.  You insure your car, your house, and life -- but do you ever think about insuring your future income potential.  Check out this discussion about the world of disability coverage and what you need to be on the look out for.

Monday, November 15, 2010

Doctors and Medicare Cuts

Just a quick note on a great article from the Washington Post on the impending Medicare cuts:

"Washington Post Article"

It fits in well with our blog posts this week,


- Posted using BlogPress from my iPad

Location:Dallas, Texas

Friday, November 12, 2010

Is the government telling me if I can see my doctor?

Medicare was touted as the social entitlement program that would forever change health care access for our seniors.

But is it becoming the biggest challenge to seeing the doctor of your choice?

For the first time in the almost 50 years of the program more and more Medicare recipients are facing the challenge of finding a doctor who will take their government sponsored insurance.

Sure, there have recently been problems with the over 65 finding primary care physicians. But these PCP's can be hard for any insurance class of patient to find, though much harder for patients with plans that pay 40 percent of current market rates.

As you have seen from my recent blog posts, we are facing a rapidly approaching meltdown of our Medicare system. With no substantial reimbursement increases since 1997, an expanding older population, and medical costs that are outpacing the rate of growth of GDP, more and more physicians and other health care providers are exiting the market space.

But the current state of affairs is about more than money. A whole lot more.

You see money won't necessarily buy you access to your physician if you are a Medicare patient.

For most capitalist oriented folks this doesn't make sense. This land of milk and honey we call America was built on one's ability to buy anything -- including access. Whether it be to the halls of Congress or the waiting rooms of medical specialists, the rich (or even the middle class) in the United States have always been given the golden ticket for access if they could afford it.

But current Medicare rules don't allow for the normal business relationships that have built the rest of our economy.

This stems from the limited participating agreements that physicians are forced to agree with if they desire to see Medicare patients. And, for laws that restrict the payment of benefits to seniors if they see physicians that aren't a part of the Medicare program.

Physicians are really given only two choices if they want to get paid for seeing a Medicare patient. They can either agree to be "participating" where they are paid directly by the government for delivering care, or "non-participating" where they agree to see an over 65 patient but the payment is paid to the patient and the physician is then responsible for collecting the fee.

If a physician "opts out," that is, decides to not be a part of the program at all ("par" or "non-par"), then they can see a Medicare patient only if a complicated set of constantly renewed contracts are completed.

But here's the catch: the patient cannot receive any reimbursement from the government for the cost of the care.

That's right, as a Medicare patient you lose your benefits from the federal government entitlement program if you enter into a contract with a physician who is not part of the system. You won't even get reimbursed for what Medicare would have paid if the physician was a program provider.

Now honestly this has never been much of a problem: most physicians participated in the program and very few were "non-par", much less opted out. A big impediment to even testing the water of opting out has been the mandatory two year waiting period that physicians must survive before they are allowed to rejoin the system.

That was until the post-Obamacare age we live in now.

Funding the Medicare system has become laughable with a recurrent litany of temporary fixes that now provide only a month-to-month operating budget for the program.

It is this uncertainty combined with the decline in overall revenue that is driving physicians to opt out of the program and into the world of direct contracting.

Is it fair for the federal government to get a free ride on the backs of American seniors by no longer being responsible for providing health care dollars?

If you are an entitled Medicare recipient and you see a physician of your choosing who might not be a part of the system, why shouldn't you at least be able to get reimbursed for your out of pocket costs to the limits of the allowable Medicare charge?

So I guess the answer to the question is, that for now, the government is not "telling patients they can't see the doctor of their choice" but they are telling them that they aren't going to pay for it.

As we move forward into the Republican controlled Congress, and free market capitalism begins to rein supreme, we are almost certain to see challenges to the current status quo. Not only will patients begin to demand the right to see the physician of their choice, Republicans may see changes in the law as a way to limit growth of the program and curb the government's responsibility for cost increases.

Of course, with these rights patients risk a higher amount of out-of-pocket costs.

It's unclear if the political winds will blow to enhance the laws surrounding direct contracting -- loosening the restrictions on physicians from offering these deals and for patients electing to sign up -- but it is almost certain to be a part of the discussion very soon.

Follow this story as we chronicle the debate on www.docdano.com.

- Posted using BlogPress from my iPad

Location:32,000 feet over Virginia, AA Flight 730

Tuesday, November 9, 2010

Should Medicare patients fear creeps

There has been considerable concern recently about the viability of physician's practices as they face a dramatic cut in reimbursement due to the need to slow the growth of health care spending.

No where is that more evident than with Medicare.

This last century era government administered health entitlement program now supplies medical coverage for a growing majority of American citizens. And the cost of this coverage is even exceeding its expected growth rate due to an ever aging and sicker population.

In typical bureaucratic fashion to legislate policy, Congress tied the cap on Medicare expenditures to the sustainable growth rate in an attempt to see that health care costs in the program did not exceed GDP (Gross Domestic Product).

This flawed calculation created in the Balanced Budget Act of 1997 has generally resulted in reimbursement rates to Medicare physicians that have not kept up with the real rate of medical inflation.

Yes, this last measure would have been a better metric to use in the calculation. But who knew in 1997.

Now we get to experience the implementation of this policy decades after the budget sensitive Congress of the 90's have mostly long gone. And the results aren't pretty.

Congress and physicians realized shortly after its passage that the SGR was a flawed system. Rather than solve the problem and change the way the Medicare system is funded, though, they have created temporary "fixes" virtually every year since its inception.

These "fixes" have only served to magnify and put off the eventual point where system implosion is expected to occur.

And that point may be here.

The latest physician hostage crisis of course occurred this year with an impending cut that threatened to throttle the rollout of Obamacare and the new federal health regulation. This fix expires on December 1st.

At that point physician reimbursement will be cut an arbitrary 23.6 percent with another 6.5 percent to follow on January 1.

So will the cut happen? (You can read my prior post: "Dear Santa: I want a Medicare fix")

But more importantly what will physicians do?

That is the question that is becoming more and more the topic of not only surgery lounges where physicians commiserate between cases but also the murmur outside the halls of medical meetings.

Certainly I've seen no organized conspiracy. But it is interesting that many physicians across the country are coming to the same conclusion: is it worth it to stay a part of the system.

Booklets and articles have been written about how physicians can leave the Medicare program. Even more concerning are the materials being produced for patients teaching them how to see non-Medicare participating physicians or even to form "direct contracts" with physicians so they can continue their care outside the system.

Historically and currently there doesn't appear to be a wholesale abandonment of Medicare participation. In my home state of Texas, unofficial numbers put the number of physicians that have resigned their Medicare number at less than 500.

But I don't see this as the real problem. I think more likely we are going to see something I like to call "creep."

Let me give you an example. Recently I was asked to provide some strategic review and planning for a practice in another state -- one with a large retired Medicare population. We prepared a detailed analysis of revenue and expense numbers as part of the consultation service, but the physician seemed to gravitate to one report more than the others.

It was a simple calculation that compared the payer mix of the practice based on the number of patient visits. The physician found that 59% of his office visits were Medicare, but that this group only provided 32% of his total revenue.

He became obsessed with the fact that most of his and his staffs work product was only generating a dwindling minority of his revenue. And without my well deserved consultant-paid-advice he reached his own conclusion that if he only made changes in his schedule and payer mix it could start to minimize his Medicare exposure, decrease his work schedule, and likely either see no change or a slight bump in his practice income.

That is the concern. Creep.

As physician practices get tired of the recurrent uncertainty about the future of Medicare payments, will they begin to find the solution may be to limit Medicare patients within their practice, that is to "creep" their schedules -- and not leave the system altogether?

This would have the effect of exaggerating an already access challenged Medicare population. And since we don't have good data on the clinic slots available to Medicare patients it will be difficult to measure the rate of creep until its too late.

Congress will take up the new fix soon, and conventional wisdom dictates that there will be another temporary solution to stabilize physician payments.

But will it satisfy a physician workforce that is tired of the recurrent stress of practice financial viability on an annual or now, even a monthly basis?

I guess we will get see it play out in the health care access of our Seniors.


- Posted using BlogPress from my iPad

Location:Over El Paso, Texas courtesy of American Airlines

Friday, November 5, 2010

Dear Santa: I want a Medicare fix

Well it's that time of year again.

No, not Thanksgiving or Christmas, or even the venerable Interim Meeting of the AMA. It's the time that physicians nationwide anticipate another mandatory cut in Medicare reimbursement rates.

This time the recurrent temporary fix will result in a cut of 23.6 percent on December 1st. Assuming political gridlock the rate will fall another fraction of 6.5 percent on January 1.

History dictates that there will be lobbying, bluffing, puffing and even some "take my toys and go to my room" childish attitude but in the end Congress will create another "fix". In the past this has been to stabilize payment rates to a Victorian-era fee schedule (ok, 1997 or so) and set up an expiration schedule that again is measured in months.

But this year might be different. Or, at least it threatens to be.

American voters stampeded to the polls to vote out the status quo in favor of a new Republican House and a "lack of cloture" Democratically impotent Senate. Many of these new Republicans campaigned on the promise of fiscal responsibility (read: make the Bush tax cuts permanent and curb spending, including entitlement programs).

The Republicans have as a group pledged to cut $100 billion in January.

Now enter the AMA.

This association is again lobbying for a fix -- though now it is not the "permanent fix" but rather a tempered 13-month patch to give physicians at least a year to worry until the next SGR induced armageddon.

But will this new Congress support the AMA proposal? I don't think so.

Rumors abound to the cost of the AMA idea but it ranges between $17 billion to upwards of $20 billion. I'm certainly not an insider, but a new Republican congressman might find it challenging to explain to those tea party goers about why one of his first actions was to vote to support a double digit entitlement extension.

The other options are also mind stretching.

The lame duck Democratic controlled body could pass a 1 month extension and leave it up to the Republicans to spend the money in 2011. Or, they could use the pout strategy and just grind out the final month with the cut in place with Medicare physicians having to deal with a very arduous Christmas present.

So what will happen? It's anybody's guess but a likely outcome will be a compromise of sorts.

It would be fairly easy to disguise a three or four month fix as part of a January revenue bill to add some permanence to the Bush era tax cuts. This would of course create another type of March Madness, but it also would only cost a minuscule five or six billion. Chump change.

There is the issue of raising the debt ceiling that will have to survive a potential Senate filibuster by one of our new freshman Kentucky senators who will be calling for a balanced federal budget. This ophthalmologist turned tea drinker may not see eye to eye with adding more money to a spending bill -- even if it would be good for patients.

But no one said it would be easy.

- Posted using BlogPress from my iPad

Location:37,000 feet over Arizona