ACA - Replacement?

[jmj11]

Okay, there is a lot of talk right now about replacing the ACA. It will cease to exist as we now know it. My question, if you were invited to help write the replacement, what ideas would you have.  Here are some of my first gut reactions:

 

1) Get rid of meaningful use and PQRS. Not that it was not a good idea, but the cost of compliance is hurting a lot of medical practices.

2) Require a co-pay for all insurances, federal and private. So, even if you have Medicaid or Medicare, you pay a minimal $5 co-pay. Also, you must pay a small no-show fee ($15).

3) The pharmaceutical companies are granted a life-time patent on a new medication so they don't have to make back all their R&D money in 5-10 years. Also, to make sure they don't gouge people forever, there will be cost controls on medications like all other countries.

4) Keep the rule that you cannot discriminate based on a pre-existing disease state.

5) All Prior Auths, at all insurances (fed and private) must be reviewed by someone of the same specialty / sub-specialty as the person requesting the treatment. 

6) The specialty of a PA will no longer be defined as "Physician Assistant" but by the specialty in which they practice (eg. orthopedics, dermatology, family medicine).

7) All NPs must be supervised by PAs.

[LKPAC]

why did you cross out #7?

[AMD]

Okay, there is a lot of talk right now about replacing the ACA. It will cease to exist as we now know it. My question, if you were invited to help write the replacement, what ideas would you have. Here are some of my first gut reactions:

 

1) Get rid of meaningful use and PQRS. Not that it was not a good idea, but the cost of compliance is hurting a lot of medical practices.

2) Require a co-pay for all insurances, federal and private. So, even if you have Medicaid or Medicare, you pay a minimal $5 co-pay. Also, you must pay a small no-show fee ($15).

3) The pharmaceutical companies are granted a life-time patent on a new medication so they don't have to make back all their R&D money in 5-10 years. Also, to make sure they don't gouge people forever, there will be cost controls on medications like all other countries.

4) Keep the rule that you cannot discriminate based on a pre-existing disease state.

5) All Prior Auths, at all insurances (fed and private) must be reviewed by someone of the same specialty / sub-specialty as the person requesting the treatment.

6) The specialty of a PA will no longer be defined as "Physician Assistant" but by the specialty in which they practice (eg. orthopedics, dermatology, family medicine).

7) All NPs must be supervised by PAs.

Why should NPs be supervised by PAs?

 

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[Reality Check 2]

It will never happen but I fully support a single payer system. With minimum requirements for patient participation and more penalties for patients based on THEIR choices such as smoking, drinking, etc.

 

Don't penalize me for how people act and what they choose.

 

Pay me a fair wage for fair work and a single payer with reduced or eliminated pre-authorizations and BS to get proper medical care and diagnostics in a timely fashion.

 

No more for profit insurance companies with CEOs making 7 figure salaries AND 7 figure bonuses while denying medical care to premium payers.

 

Just my grouchy 2 cents today.

 

Never going to happen with current administration but I can dream.

[jmj11]

Why should NPs be supervised by PAs?

 

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It was just a joke. Not serious at all.

[UGoLong]

Lifetime patent rights would be a huge mistake, I feel.

 

As a participant in Medicare for the past 2 years, single payer is da bomb!

 

 

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[AMD]

Lifetime patent rights would be a huge mistake, I feel.

 

As a participant in Medicare for the past 2 years, single payer is da bomb!

 

 

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Republicans. They think single payer is the end of the insurance industry. But really it saves so much money!

 

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[jmj11]

I was thinking within reality. Single payor isn't reality in America's present climate. It would be seen by many as "Communism."  I like the European system myself. Maybe some of my ideas are not within reality either.

[mandrew1]

I agree with all; especially the $5 copay for medicaid and no show fees.

[UGoLong]

Medicare involves private insurance companies but has standardization. Not sure why some polititions object to it. But good luck prying it out of my clenched fist!

 

 

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[Guest JMPA]

Republicans. They think single payer is the end of the insurance industry. But really it saves so much money!

 

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demorats, they think goberment should completely control all aspects of peoples lives by elimination of the free market freedom of choice. but really it wastes and costs so much money for bureaucracy with no quality insurance, reimbursement, or timely care.

[HMtoPA]

As a participant in Medicare for the past 2 years, single payer is da bomb!

 

 

 

As a military PA, I agree with you. Not only as a patient, but as a provider knowing that all of my beneficiaries can receive whatever care I prescribe without the obstacle of cost is very refreshing. I literally never think about the financial side of medicine, reimbursement, RVUs, blah blah blah.

[GetMeOuttaThisMess]

This country cannot afford universal healthcare for all, WITHOUT having mandated parameters in place such as USPSTF guidelines, and stopping all the end of life care foolishness (MMG/Pap on someone at end of life, colonoscopies for same, ICU admissions for non-recoverable conditions). I think ethics panels DO need to be put into place to decide on when to terminate aggressive care for patients without a reasonable chance for recovery. Before others go ballistic, bear in mind that this has already existed. It was called frontier and early 20th century medicine where we accepted the normal course of life. It is about quality and not quantity. We do need the ability to negotiate pricing on pharm agents, and go out-of-country if necessary to obtain the best financial deal. I concur with penalizing those with unhealthy habits as I debate on whether or not to have another Skinny Cow ice cream bar.

 

As I noted in a recent dental thread, dentists seem to be surviving without insurance plan participation. How about major medical coverage for all and then folks/employers can choose to purchase "wellness"/sick visit coverage at levels they can afford.

[AMD]

demorats, they think goberment should completely control all aspects of peoples lives by elimination of the free market freedom of choice. but really it wastes and costs so much money for bureaucracy with no quality insurance, reimbursement, or timely care.

Well, I don't think government should control everything, but there's a problem when you've been telling your minimum wage earning diabetic patient to lose weight, and he's been trying but he can't afford healthy food and copay and medication and glucometer supplies. So when he finally loses weight it because gangrene took his foot.

Health insurance is a business where everyone benefits except the consumer. So yeah, IMHO... health insurance and education should be afforded through the gubment. So our consumerist society can earn decent wages and support the economy in the materialistic ways we all know and love.

 

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[Reality Check 2]

I think insurance has to have strict boundaries and limits on premiums.

 

I make a PA wage and my husband moderate union electrician wage and our insurance is $1700 A month for middle coverage through Group Health. We have a really low deductible and 20% coinsurance with decent hospital and a formulary I know how to get around.

 

The Platinum packages offered through his union are over $2600 a month for spouse and family. Some packages now charge per kid.

 

A lot of my patients don't make $2600 a month much less $1700 a month.

 

A married couple with 2 kids where both parents work jobs making average $16 per hour - they go to the marketplace and the cheapest policy they can find through ACA is 1/3 of their take home pay. Benefits offered through their employers are 2/3 of take home pay with heinous deductibles and copays and severe limits.

 

So, it is unaffordable and they take the $600-900 tax penalty instead, put their kids on state insurance which Washington does well for working poor. These patients pay cash for basic appts and come out ahead financially unless they have a tragic event like cancer or trauma.

 

It is a disaster for working poor with multi med problems, polypharmacy and diabetic supplies.

 

Insurance can still TELL ME that a patient on insulin only has to test twice a day..... vials and syringes, not pens unless visually impaired and - oh - why don't you use a sulfonylurea?.....

 

So, no nonmedical mgmt medical interference would be my greatest wish after affordable premiums and some unemployed insurance company CEOs.

 

Then the rest would need to be constructed once someone figures out that the majority of Americans lives on less than $50K a year.

[Marinejiujitsu]

Single payer likely the best option but it will likely come at a cost decreasing md/pa/rn wages. Just like Canada, they became single payer and they rns and Mds fled to the US.

 

I would like to see if a patient that comes to the ER is deamed not an emergency, we are unable to write a prescription for them. My buddy is a county pediatrician, has a full schedule but only see like 7-15 patients a day because they just go to the ER. It's blowing up costs and people don't get it

 

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[overthehorizen]

Lifetime patent rights would be a huge mistake, I feel.

 

As a participant in Medicare for the past 2 years, single payer is da bomb!

 

 

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I don't often hear someone advocate on behalf of Medicare. If you were serious when you said it is "da bomb", would you take a moment to extol its virtues. If not on this thread because it diverts from aca, would you start a new thread or pm me. I read a lot of physicians abandoning Medicare to work in cash only practices. Those physicians see Medicare as a burden to profitability. Appreciate your contrary view on this.

[UGoLong]

In response to overthehorizen:

 

You wanted to know what’s it like being on Medicare? I am not an expert, having only been on it for about 2 years, but I have a story and an opinion.

 

I’ve paid my premiums and been insured all of my life (70+ years) by pretty much every system that exists in America: on my parent’s plan through college, on a college’s group health plan during graduate school, military medical care in the service, group plans in various jobs, individual insurance as an independent consultant (where – before ACA – they tried unsuccessfully to not insure parts of my body), and then on my wife’s plan until she retired. I don’t smoke, I get my routine health screenings, I am not obese, and fortunately I am not diabetic.

 

Now I’m on “traditional” Medicare (free Part A, Part B now deducted from my Social Security check, Part D by monthly check, and a supplemental commercial policy by monthly payment.) Part A covers hospital expenses; Part B provider visits; Part D for drug coverage; and the standardized, affordable, commercial supplemental plan covers most of the shortfalls in Part B. Kind of complicated, right? And definitely not free. Parts B and D are income-adjusted; the more you make, the more you pay. And supplemental policies come in standardized flavors, each for a different monthly payment.

 

And then last year I needed surgery followed by chemo (No: not a body part the earlier policy didn’t want to insure). One drug had a list price of $18,000; I needed six treatments, plus lots of other drugs as well. I also went to a comprehensive cancer center for a second opinion. All of this was essentially covered in full. Medicare didn’t pay the $18,000 for the drug; they approved a bit less than half of that and then Part B and my supplement gobbled that up. The provider by law can’t come after you for anything Medicare doesn’t approve.

 

I know that Medicare carries a big stick when it comes to providers and that many private insurers jump on their bandwagon as far as setting reimbursement rates, etc. And there may be providers who don’t take Medicare, though thankfully not in the large metropolitan area in which I live.

 

All these problems may exist but Medicare literally saved my life. I can keep working my three jobs, loving my wife and family, and going forward for a while longer. Thank you, America! And, like many seniors, you’d have to pry my Medicare card away from me. Hopefully it will be there to save your life one day as well.

 

If anything, I’d like to see everyone -- regardless of age -- have similar access, which is why I like a public option, especially if coupled with something commercial, like my supplemental policy now.

 

When it’s life and death, it’s time for us to pull together – that’s what insurance is all about. A GoFundMe page or appealing for charity should not be the first option. We have to figure out how to pay for it. Other countries have, so I’m betting we could too, if we got together on it.

[HMtoPA]

Single payer likely the best option but it will likely come at a cost decreasing md/pa/rn wages. Just like Canada, they became single payer and they rns and Mds fled to the US.

 

I would like to see if a patient that comes to the ER is deamed not an emergency, we are unable to write a prescription for them. My buddy is a county pediatrician, has a full schedule but only see like 7-15 patients a day because they just go to the ER. It's blowing up costs and people don't get it

 

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The diversion of routine health care to the ED is mind-blowing. Even in my single-payer system with good access (TRICARE, small-ish base, easy to get an appointment same-day many times, definitely within 2-3 days) we have far too many patients presenting to the ED with garden-variety complaints. I get it if you have chest pain in the middle of the night, or severe pain from biliary or renal colic, or stuff of that nature. But why would you go for bronchitis? Or a UTI, which we treat with a nursing protocol (i.e., no provider visit) if uncomplicated? It defies reason. These people must be waiting hours upon hours, and don't get that they are wasting taxpayers $ (TRICARE, remember) and inappropriately accessing a finite community resource (rural community hospital ED). They don't know or they don't care, and we do try to educate them, even working extended hours to try to draw them back, to no avail.

 

Of course, some are drug-seeking frequent flyers and seem pathologically drawn to ED care one or more times per month. To me, these people are hopeless, but they are the minority.

[MedicinePower]

Many friends with chronic health conditions who only have coverage due to the ACA are extremely concerned if they will be alive in a year from now.

[Joelseff]

The diversion of routine health care to the ED is mind-blowing. Even in my single-payer system with good access (TRICARE, small-ish base, easy to get an appointment same-day many times, definitely within 2-3 days) we have far too many patients presenting to the ED with garden-variety complaints. I get it if you have chest pain in the middle of the night, or severe pain from biliary or renal colic, or stuff of that nature. But why would you go for bronchitis? Or a UTI, which we treat with a nursing protocol (i.e., no provider visit) if uncomplicated? It defies reason. These people must be waiting hours upon hours, and don't get that they are wasting taxpayers $ (TRICARE, remember) and inappropriately accessing a finite community resource (rural community hospital ED). They don't know or they don't care, and we do try to educate them, even working extended hours to try to draw them back, to no avail.

 

Of course, some are drug-seeking frequent flyers and seem pathologically drawn to ED care one or more times per month. To me, these people are hopeless, but they are the minority.

I think a lot of it is the notion that they are sicker than they really are. It's not just ED. In PC we get pts filling slots for stuff we just give reassurance for. We have advice nurses and they provide the reassurance for uri, bronchitis etc but pts demand to be seen because they think they need that magic pill to make them better in 24 hours. So they take up a slot in my schedule. I blame the whole green vs clear phlegm crap and a long hx of providers giving abx for everything. Then when you provide appropriate care and deny them an abx they hit you on your Press Ganey, or Yelp, or go to another provider who will cave and write them the med. It's like opiate seeking behavior but with abx lol. I end up ordering CXRs just to prove to them they don't have PNA.

 

Sadly I see this more with my medicaid pts.

 

Other end are the PPO pts. My PPO pts don't tend to come in so much for trivial things because they're share of cost is so high. They also almost always refuse to go to ED when they actually need it though. I had a pt with appy with a 17k white count that refused to go to ED. Ended up going after outpt testing so he had to pay out pt CT, labs my visit and still ended up in ED. Got admitted for 5 days. He should have just listened to his provider.

 

Pts these days "know too much" (I say this tongue in cheek). Don't get me started on my RN and MA pts... ????????

 

Sorry to detract from the ACA topic... To which i will say, I'm waiting to see what they come up with. I do agree, as my rant above kinda shows, that all pts should have co-pays. ????

 

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[jmj11]

I honestly think it would be a good investment to have mental health professionals who have extra training in somatization disorder in every community. When a patient is identified by the provider as a high consumer of healthcare (without objective disease) they would be required to have an somatization evaluation by one of the professionals, and if found to have the disorder, that they start a evidence-based treatment program. In the end that would save a huge amount of money.

 

I had a young lady yesterday arguing with me that she has MS. She has seen two neurologists (one being and MS specialist) say no. BUT her naturopath has now diagnosed her with MS. She has her on a bag full of supplements but also wanted her to find a neurologist who believes her. She wanted me to get a new MRI.  She is 28. I pulled up her radiological exams. Her last MS work up MRIs (brain and spine) were one year ago and normal. But, she has also had about 26 other radiological exams in the past 14 months for various reasons.  This is what I'm talking about. These people consume a huge amount of healthcare dollars.

[Katera]

S.I.N.G.L.E.      P.A.Y.E.R.     NOW

 

 

 

 

After 23 years of practing medicine I can say without a doubt.....Medical insurance companies can burn in hell.

[Reality Check 2]

Some of my Medicaid patients have a tough attitude of - "I have insurance. I don't pay anything. I go where I want when it is convenient."

 

One Washington state insurance, Molina, started charging copays and threatened penalties for inappropriate ER visits - somewhere in my mind I just kept hearing the phrase "blood from a turnip". 

 

No one has really ever taught Primary Care TO PATIENTS or Preventative Medicine. Life is lived through a series of crises and you only go get care when something is wrong.

 

The German NHS REQUIRES twice yearly visits to a PCP or there is a penalty. Their outcomes for Breast Cancer and a whole lot of other chronic conditions are so much better.

 

I get so tired of the whole Government Conspiracy, no one tells me what to do BS from the tin foil crowd. These same folks want EVERYTHING covered when they have that MI or get run over by their farm equipment despite not being willing to pay for insurance. Well, tough. You don't GET covered for crisis unless you CHOOSE coverage for Health and Prevention.

 

We have to change the whole mindset on what medicine is and what it can and cannot do. It will take generations to instill the idea that you get vaccines, you get a physical every year, you go to the dentist, you get an eye exam and you take responsibility for stupidity like tobacco, excess alcohol and illicit drugs. 

 

So, a top down process starting with eradicating for profit insurance. Maybe something like a credit union can help explain the health insurance process. We all contribute, we all benefit, we all help each other.....

 

Oh, and tell Press Ganey to take a hike. 

 

Yep, I am dreaming on Friday the 13th. After a full moon!!

 

Back to my charts........................

[rev ronin]

I'm tempted to delete every post with 'Republicans' or 'Democrats' in it, but the thread seems to have gotten back on track despite incipient label-based blame gaming.  Don't go back there; instead, focus on solutions without dragging political labels into it, please.