Nice msnbc Video: How patient satisfaction scores in the hospital will be tied to dollars

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So you know that survey you get in the mail after a hospital stay or an outpatient diagnostic test? The one that ask you questions like, "Were you treated politely?" and "Were snacks available without having to ask for them?" Due to requirements in the new Obamacare federal health regulations, Medicare money for hospitals will to some degree be tied to patient satisfaction scores -- most of which will come from those post-encounter surveys. Check out this nice video from msnbc.

Patients feel "Medicare is my benefit!"

TMA President Dr. Bruce Malone tells a patient story describing that "Medicare is my benefit!" His testimony was before a reference committee at the interim meeting of the American Medical Association in New Orleans, Louisiana. Dr. Malone was speaking in favor of direct contracting -- allowing patients a choice to see any physician they want regardless if that physician participates in the Medicare plan or not.

End of Life: What to expect, what it will cost, and what you can do about it

When anyone brings up the idea of end of life care, you are thrown a political football. Yet, the failure to have these discussions with your loved ones creates an expensive and emotional mess.

I can't tell you the number of times I've been sitting at a table with friends and this issue has surfaced with almost unanimous consent: they all want to die with minimal terminal intervention.

Then why do we spend the majority of our Medicare health care expenditures on end of life interventions?

The answer is probably one of political correctness and emotional attachment -- both of which can cloud the decision making process.

This is making the assumption that we could even make the right decision if we wanted to.

Case in point: my father.

Seven years ago when my father was 83 years old he casually asked me to feel a "knot in his belly" on one of my trips to his cattle ranch deep in central Texas.

And, even as a dermatologist, I could tell that he had a pulsatile mass about the size of a navel orange under that cutaneous organ by the same name.

And sure enough, after a trip to the VA medical center, a sonogram and a CT scan, we correctly determined that he had an abdominal aortic aneurysm. And, without intervention, it most certainly would be his death sentence.

So we talked.

I think this is the first of many steps in dealing with elderly parents and end of life decisions. He wanted to know how serious was the surgery, would there be a risk he would end up disabled in the nursing home, or would it change his lifestyle?

As an octogenarian rancher who feeds cows every day, drinks a pot of black coffee, and has smoked at least a half-a-pack of Winston's since WWII, these were certainly concerns.

So we made a decision: no surgery.

If it ruptured and he died an instantaneous death then that would be the way he would leave our world.

We took this opportunity to also discuss asset management of his household possessions, land, cattle, and bank accounts so that my mother would not be a bankrupt widow in the event of an end of life event for either of them.

Time passed and my father lived in constant fear that the rupture could come at any moment.

Fast forward two years: I was attending a medical meeting in Austin, Texas and my father calls at 7 a.m. This is not his normal routine so I was immediately concerned.

He quickly told me that he was having abdominal pain, pain in his legs, and was feeling dizzy. He was rupturing his aneurysm.

I told him to get in the car with my 80 year old mother and drive straight to Providence Hospital in Waco -- 90 miles away.

I was hoping I could temper the dangerous caravan of my mother's driving by calling ahead and warning the emergency room. Within 20 minutes of his arrival we had confirmed that he was dissecting his aneurysm and death or surgery was imminent.

So, we talked.

The doctor suggested surgery and since he had made it to the ER, I encouraged him that he needed to give it a try -- my mother was concerned about the cost. (She is very frugal).

So he had the surgery, was in the ICU for four hours, and checked out back to home in 5 days. That was five years ago.

Now my 90 year old father still feeds and takes care of the ranch, drinks a pot of black coffee every day, and yes, still smokes a half-a-pack of Winstons. Very happy, very productive. No other health complaints.

So did we make the right decision 7 years ago when we agreed not to pursue treatment?

To our family, it was the right decision at the time. So when people make statements that make it sound like end of life care is easy, they are dead wrong. It never is.

But, there are probably some lessons here that we can learn from.

First, you must have the "discussion." It is imperative that you talk to your parents or older loved ones early -- while they still have all of their faculties and can participate in the decision making process.

These discussions are never easy. But it puts the wishes and desires of the parent in concert with those of the siblings. My discussion was easy with my parents, and my sister and I get along so well that there was really no differences of opinion. But it doesn't always work out that way.

You most certainly should formalize a living will. This puts pen to paper and makes the end of life time event easier because there is less opportunity for confusion on what was decided during the "discussion."

And finally, everyone needs to consider the financial impact of any end of life decision. This time is almost always the most expensive health care experience for any patient.

It is not uncommon for spouses to be left bankrupt with years of bills to pay There is also the issue of sitters, home nursing, and medications that also can feed the final costs of someones life.

The government has gotten much stricter on families using their own assets to manage the end of life -- even if it will be detrimental to the surviving spouse. So don't think you can just "transfer assets" into your kids accounts and that will satisfy the requirements to get the nursing home expenses paid for by the state (Medicaid).

You should enlist the help of a knowledgable attorney on all of these end of life decisions. That information can go a long way to making it more understandable for all the parties involved and that the older person's wishes are maintained.

Unfortunately there is no book in the mainstream press on how to deal with elderly parents like we have with pregnancy (such as: What to Expect when You are Expecting).

So, everyone has to write their own conclusion.


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Location:Wolf Island, Galapagos, Ecuador

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,

Dan


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Location:Dallas, Texas

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.


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

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.

Creepy.





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Location:Over El Paso, Texas courtesy of American Airlines

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.

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Location:37,000 feet over Arizona

Mortgage meltdown or medicine meltdown?

As we enter the final phases of the election cycle you can get a good idea of the spoils of big government just by looking at the rhetoric in the campaign.

Clearly, one issue is dominating the election this fall: the economy, and more specifically the lack of jobs.

So I would like to pose a few questions and ideas on just how government actually performs in creating economic growth and in kick starting job growth. I don't necessarily have the answers, but I'm real good at asking questions.

Did government assisted mortgages help the economy? Certainly by artificially lowering mortgage rates and the creation of investor owned, government back sub-prime mortgage equities, the federal system of assistance in home buying has become the norm.

But given the meltdown in the mortgage industry, did we do a service to Americans by putting people in homes they couldn't afford? Flipping houses became the source for a evening cable television show and the folly of many particularly young home buyers.

As liquidity in the mortgage market disappeared so did the dreams and savings of many Americans -- including those that had invested in the "government" back equities of Fannie Mae and Freddie Mac.

Is government funded healthcare going to be beneficial for our country in the long term? Just like mortgages, are we going to put our country into a health system they can't afford?

Out current federal health legislation creates "coverage" for 85% of our citizens, but does nothing to promote access to care or an improvement in health care choices.

The latter is particularly concerning.

Regardless of the life style choices one makes, there is a guarantee of coverage. There certainly needed to be an improvement in health care services for the uninsured, and there needed to be some limitations on the growth in spending, but wouldn't it have been better to put incentives on the user?

The real question becomes: will we be facing a health care meltdown just like the mortgage industry? As the requirements for health care services rise, there being no limitations on cost, and no impediments to limiting health care decisions, can the system continue to function?

The biggest concern here is whether physicians and other health care industry providers (pharmaceutical companies, insurance companies, hospitals) can continue to function in an economic environment of continued declining reimbursement for services.

This is especially true given the proposed 23%+ cut in Medicare rates next month with more to follow in January.

Will there be a decline in health care liquidity?

Physicians and other health care providers may find themselves in a situation much like the mortgage industry: servicing consumers with health care services they and the government really can't afford.

I guess the real question is will there be a foreclosure on your new sub-prime health coverage?



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Obamacare - You want fries with that?

A recent article in the Wall Street Journal and the followup editorial concerning McDonald's decision to consider ending health care coverage for its work force has sparked controversy.

But it is a very compelling message.

Obamacare, or more correctly, the new federal health legislation passed in the spring by the Democratic Congress, promised to "keep your current health coverage intact."

But as the law goes into effect, it is confirming what we pundits have been screaming from the beginning: it will impact everyone in America.

Read: everyone. From the uninsured (which hopefully will see expanded coverage but still be challenged with with limited access) to tax payers to small business and yes, to physicians, everyone will see an impact.

And it will vary from the potential double digit increases on private indemnity insurance for those 25 year old new entrepreneurs to the seemingly bizarre requirement that small business owners will now have to issue thousands of additional 1099 forms to virtually every vendor they purchase products or services from.

So for McDonald's to be considering eliminating health care coverage may not come as a surprise. Now before my faithful readers start sending me emails about "how these were minimum benefit plans" and "these workers deserve better care," let me preempt you.

McDonald's offers ground level employment for thousands of young people -- and many part time workers. So for them to be offering any health care benefits to begin with was extraordinary.

And now to have them being forced to either enrich the plan with added benefits and cost, or abandon their current entry level health benefit structure is an example of how they too will be impacted by the legislation.

But for all the bad that has been said about the federal health regulations, the most chilling concern that I have is that at the end of the day despite the super-sized money and new statues that have been created -- we may not see an improvement in the access and quality of care.

There is no value meal here.

My interview with Dr. Michael Burgess, Congressman from Texas, on some provisions of the new federal health plan