Physicians writing on KevinMD about the rules they practice under: prior authorization and the algorithms now deciding it, gold card laws, scope of practice and who may practice without supervision, Medicare and Medicaid, the Affordable Care Act, drug pricing, rationing that is done and not named, and the policies that decide which patients get care. Four maintained records draw on this archive: Prior authorization: what physicians say, in their own words, Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words, Race and medicine: what physicians say, in their own words, and Medical ethics: what physicians say, in their own words.
Recently, I was among a dozen people who sat privately to talk about the Affordable Care Act (ACA), aka Obamacare, with the embattled Health and Human Services Secretary, Kathleen Sebelius. Dressed in a light green blazer, sitting alongside Memphis Mayor AC Wharton and Congressman Steve Cohen, who had nudged her to visit Memphis, Secretary Sebelius listened to our feedback and shared her insights.
First and foremost, addressing the issue of the …
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A meeting with Kathleen Sebelius about Obamacare
Recently, the chairs and ranking members of the Senate Finance and House Ways and Means committees released a bipartisan, bicameral plan to repeal the Medicare SGR and reform physician payments. And this time, it looks like the effort could actually succeed: never before has there been agreement between the House and Senate, Republicans and Democrats, on a plan to repeal the SGR, never mind on what they would replace it …
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Analyzing the bipartisan plan to repeal the SGR
It is hardly an understatement to characterize the health insurance exchange rollout as a big disappointment. A botched website poses a serious problem and threatens to dampen enthusiasm for the new law — especially among the coveted “young invulnerables” who need to sign up for coverage to keep premiums affordable for all. In the short term, the website troubles put the Obama administration firmly back on the defensive, scrambling to …
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Is it too soon to declare the Affordable Care Act a failure?
If you are a healthcare provider — physician, administrator, or some other leader at a healthcare site — then you know that you face many challenges. Some seem overwhelming and you may be thinking that you may not be able to handle some of them well. Perhaps the transition to ICD-10 coding is your main concern right now.
The solution to difficult challenges begins with the first step. I am taking …
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Use the scientific method in the transition to ICD-10
Providers in all parts of the health care system recognize that troublesome social conditions drive much of their work and costs. Major challenges in people’s social circumstances — layoffs, foreclosures, accidents, violence — can create horrific health care needs, many of which become chronic and carry high price tags. These extreme needs are omnipresent in the nation’s hospitals, which care for about 37 million admissions at a medical expense of …
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Understanding the intersection of health care and social services
My Swedish medical school curriculum was 5 1/2 years, but I remember during a third-year class trip to the Soviet Union hearing that some doctors over there had a much shorter education. My classmates and I were at first surprised to see physicians staffing ill equipped ambulances, riding the streets of Moscow with critically ill patients and no equipment to deliver care. We concluded that physician labor was cheap and …
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Do we really need greater numbers of lesser trained physicians?
Everyone agrees that the US healthcare system is too costly. The challenge of public policy is deliver higher value by improving quality while reducing costs by eliminating waste and increasing efficiency. Historically physician compensation has been tied to productivity, which encourages procedures and over-utilization.
How can we motivate physicians to provide preventive, cost effective and quality care without incentive programs? Alfie Kohn in 1993 published ”Incentive Plans Cannot Work.” Clearly, poorly …
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Financial incentives are the wrong way to compensate physicians
Although you may speak of a “routine” Medicare audit, there is really no such creature. This is like saying you have a “routine IRS audit.” The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.
Having too many claims for level five CPT codes …
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How to respond to a Medicare audit: 17 tips from a lawyer
There are many reasons to be dismayed by the error-filled and managerially incompetent rollout of the federal health insurance exchanges that are in many ways the linchpin of President Obama’s Affordable Care Act. I sympathize with commentators who have called for the resignation of Department of Health and Human Services Secretary Kathleen Sebelius. It’s hard to imagine Franklin Roosevelt not firing someone in his cabinet had social security stumbled this …
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Physicians are the biggest driver of health costs
I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.
He told me how a few months ago, soon after returning to Boston from a trip to China, he …
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How do hospitals build a culture of quality?
There are just a few key reasons why Medicare has become inordinately expensive. There is no end in sight for cost escalation. But there are some obvious solutions and they all begin with chronic illnesses.
Chronic illnesses — diabetes, heart failure, cancer, chronic lung disease, etc. — are increasing at exponential rates; are caused largely by lifestyle behaviors; and consume 70-85% of all claims paid. Medicare enrollees tend to have chronic …
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5 recommendations to achieving a grand bargain in Medicare
For employers, the Affordable Care Act takes two distinct approaches.
First, for small employers (those with 50 or fewer full-time employees), the ACA does not penalize, but rather incentives the purchase of insurance with subsidies available through the Small Business Health Options Program (SHOP). Second, for large employers (those with 51 or more full-time employees), the ACA does very little. Recognizing that the overwhelming majority of these large employers already offer …
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Obamacare’s effect on small business: An unintended consequence?
While the Affordable Care Act ends the era of denying people with pre-existing conditions access to health care, it allows insurance companies to charge tobacco users up to 50% more for their monthly premiums. Tobacco use for this purpose is defined as any self-reported tobacco use four or more times a week within the past six months. There are excellent intentions behind this policy — smoking is the number one …
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Should smokers pay higher health insurance premiums?
Insurance, in its traditional form, is the wrong model for health care financing. It is the wrong commodity to be bought and sold. We don’t need health insurance, and I will tell you why. I will also tell you what we do need.
Insurance is something you buy, and then hope you never have to use. It is a hedging of your bets against bad outcomes. Term life insurance is the …
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Why insurance is the wrong model for health care
If you are like millions of Americans, at some point in your adult life, your doctor will order you to have a CT or MRI scan. Quick, easy, and painless, these invaluable imaging tests provide a vast amount and array of diagnostic information about illnesses, and direct treatment paths.
However, the real pain usually begins when you receive the bill. It is not uncommon for the charges, including radiological interpretation, to …
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Why health insurance for all obstructs lowering health care costs
Some of the criticisms of the Affordable Care Act (ACA), or “Obamacare,” suggest that the federal government will dictate who will get care and how that care will be delivered.
In fact, recent ads funded by a group supported by the Koch brothers show our dear Uncle Sam preparing to administer exams himself. One depicts him with a speculum in hand …
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A more rational concern about the Affordable Care Act
My sense is that the biggest reason Obamacare is now in trouble is because of the top-secret way in which the administration has handled the rollout. If they had developed the computer system in a transparent way, the marketplace would have told them long ago this would not work.
No one outside the inner circle at the Department of Health and Human Services has any idea what’s really going on behind …
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Should the health exchanges be shut down?
On his campaign trails, Harry Truman used to call on citizens to go out and vote for themselves, in their own selfish interests. It may sound shallow and divisive, but Harry Truman believed that the individual interests of the people should trump the special interests of the powerful few, and that’s how Democracy should work. Those were simpler times, but the logic still applies today, although it’s becoming increasingly difficult …
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Why care must conform to patient values and cultural preferences
