Health Policy update....

[physasst]

SO, wanted to drop an update for those interested. I haven't been on here much, but not because I haven't wanted to. I've just been pretty busy. Between AAPA work/committments, clinical work, and institutional leadership work......along with 3 rather complicated studies...(one of which you may receive a survey on), there simply hasn't been time.

 

Today was my birthday...amd while there was no clinical work, I still had 4 meetings, and 2 conference calls...(one with a friend from the Senate Finance Committee).....

 

Anyway, I digress, and no one cares about that anyway...

 

I will be speaking at SEMPA this year on health reform.....and any attendees should plan on coming, it will be a great talk...additionally, I have been asked to be a guest contributor to a top 20 wall street economics blog on health reform....

 

I have 3 articles on malpractice reform, and specifically, will talk about the INCREASED mortality from malpractice liability cost decreases.....(0.2% per 10% saved, or 30,000 deaths per 5% of US population)

 

My research is progressing nicely, I'm also in the process of writing a book....

 

The Affordable Care Act isn't going anywhere, anytime soon. SCOTUS will review, but outside of that, it's here to stay, political theater notwithstanding. BTW, the bill is still fairly divided, last poll showed 51% in favor, 46% opposed...but that has been fairly constant.....and is reflected in the recent federal judge rulings....2 for, 2 against....The SCOTUS doesn't WANT this case, NO HOW, NO WAY...cause no matter how they rule, they're going to be reviled.....My friend with the American Law Institute thinks it will be found constitutional in a 5-4 ruling....

 

Too close to call really......

 

I was at a recent Symposium on Healthcare Reform in DC...(where else..I think I need an apartment there).....It was a great meeting, I was the only PA or NP there, but the leaders of the AMA, CEO's of hospital systems, Congressional Aides, etc. were there.

 

The number one agenda from the meeting....agreed on by EVERYONE:

 

Reform the way medicine is reimbursed....GET rid of Fee for Service....eliminate it entirely....Move to a novel payment system...Prometheus, etc....

 

There were other discussions as well..it was a great symposium, but similar to past meetings as well...

 

On a bright note, I had a 30 minute conversation with Tim Johnson, MD from ABC news about PA' s and our contributions to healthcare...It was a great talk. I actually talked with him for about 3 hours, but only 30 minutes on PA's.....better than nothing....

[marilynpac]

If you're talking about Obamacare, it's going to go down as unconstitutional b/c you can't force people to buy healthcare...5-4.

[physasst]

Dunno..too difficult to tell right now....

 

Kennedy and Roberts will be the key votes....Breyer might surpise as well.

 

And you can force someone to buy something....:) IF you tie the penalty to a tax...which Congress can do. Plus, our Second President John Adams, who likely knows more about Constitutional intent than anyone, actually had a healthcare mandate for merchant seamen, forcing them to contribute wages to a healthcare plan...(ie; insurance)....He recognized that it would be in the Nation's best economic interests back then.

 

Plus the mandate was a republican idea....:) Just ask Stuart Butler (2003 Congressional Testimony for the Heritage Foundation),OR Sen. Grassley, who proposed it in 1993......

 

IT IS NOT a democratic idea, the democrats want a public option at the least, and really want single payor long term....:)

[marilynpac]

Roberts is ultra conservative, and I'm not saying that there aren't misguided republicans(McCain, Graham,Snow). I still say it's going to be proved unconstitutional and if it isn't there is going to be major uproar. I think NPs are going to benefit from this big time and once again, we will be eating their dust...

[treejay]

can you force people to buy car insurance if they have a car?

[BigDuke06]

Dunno..too difficult to tell right now....

 

Kennedy and Roberts will be the key votes....Breyer might surpise as well.

 

And you can force someone to buy something....:) IF you tie the penalty to a tax...which Congress can do. Plus, our Second President John Adams, who likely knows more about Constitutional intent than anyone, actually had a healthcare mandate for merchant seamen, forcing them to contribute wages to a healthcare plan...(ie; insurance)....He recognized that it would be in the Nation's best economic interests back then.

 

Plus the mandate was a republican idea....:) Just ask Stuart Butler (2003 Congressional Testimony for the Heritage Foundation),OR Sen. Grassley, who proposed it in 1993......

 

IT IS NOT a democratic idea, the democrats want a public option at the least, and really want single payor long term....:)

 

 

Is it just me or did I hear Mr Obama insisting that NO taxation would be part of his health plans?????

[BigDuke06]

can you force people to buy car insurance if they have a car?

 

If I don't own a car ,who says I should buy auto insurance? If I don't operate the car I own on public roads or try to register it with the state why should I buy insurance? If I don't eat five servings of vegetables and exercise because it's good for me ,can/should the Federal Government levy a tax on me. Since when does this country tell it's citizens how to spend their own money on personal issues?????

[bradtPA]

Yes, but they can't force you who have no car to buy insurance....

 

And that is state government forcing it anyway, not federal.

[haeriphos]

If I don't own a car ,who says I should buy auto insurance? If I don't operate the car I own on public roads or try to register it with the state why should I buy insurance? If I don't eat five servings of vegetables and exercise because it's good for me ,can/should the Federal Government levy a tax on me. Since when does this country tell it's citizens how to spend their own money on personal issues?????

 

I agree with you in principal. The problem is that your bad habits cost me money in the form of higher healthcare costs. If you don't have insurance and have to go to the hospital to get treatment, the taxpayer or healthcare consumer will end up footing the majority of your bill as providers and facilities increase charges to recoup their losses. The same goes with mandatory seatbelt laws -- I don't care if you get ejected because you just can't stand wearing them. I do care that your ridiculously expensive life-saving care could have been either avoided or reduced had you made an intelligent decision when you got in the car.

 

So I propose allowing anyone who does not want to follow the insurance mandate an exemption as long as they sign a waiver that says EMTALA does not apply to them and declare themselves ineligible for any sort of provider-, hospital-, or taxpayer-funded medical assistance programs.

 

Everyone expects there to be this safety net for them but no one wants to pay for it.

[SocialMedicine]

Even if they declare the mandate of insurance unconst. the remainder of the policy stays in effect. While the policy did not include a specific clause stating this, many health and elgal experts feel the entire legal peice will not be threatened. I applaud physasst for getting involved in this important work. Is there a group of PAs in health policy? Would be an interesting group. Maybe pooling together small money to get some members and ideas out to conferences.

[physasst]

Even if they declare the mandate of insurance unconst. the remainder of the policy stays in effect. While the policy did not include a specific clause stating this, many health and elgal experts feel the entire legal peice will not be threatened. I applaud physasst for getting involved in this important work. Is there a group of PAs in health policy? Would be an interesting group. Maybe pooling together small money to get some members and ideas out to conferences.

 

There's not a specific group, although those that are most active are all well known in a small cadre......

 

I think the administration made a mistake without including a severability clause...I know why they did it, but they're taking a big chance....As Vinson showed.

 

The hardest part with my role in policy, or for any PA really, is to be careful about promotion of PA's....Don't get me wrong, I still promote our profession, but you really need to be seen as promoting, researching, and looking at data from a neutral position. If you come across as 100% gung ho, pro pa...."PA's are the sole answer to healthcare!!", you lose credibility....fast. Rod gave me that advice early, and he was right. You have to be willing to look at positives and negatives, and examine ALL facets of the healthcare system.

 

Rod's paper on the preference of patients in the ED to see an attending physician is one example. We have to look at all data. Even if it isn't favorable....

 

For example, one study I am doing now is examining primary care provision in a care team model....(PA's are scarcely used) It's mostly RN's and MD's. If you are careful, and establish credibility as someone concerned with the whole delivery system....(and in my case, the economics behind healthcare), then when you DO SPEAK about PA's, you will be listened to that much more closely. Additionally, looking at only PA's would be rather shortsighted, and to be honest, while PA's will help address workforce shortages...they won't (and neither will NP's) come close to filling the void, or solving the problem.....

[physasst]

so if the void won't be filled by NP's and PA's, what do you attribute all of the expressed excitement among the PA and NP forums about how they will be at the forefront of filling the gap? just wishful thinking? i get the impression from the NP's that they don't carry similar doubts about what they can accomplish, and that attitude seems to be bearing fruit for them.

 

Two things....For starters, PA's and NP's are NOT physicians....while we can certainly see many of the same patients, we cannot see ALL of them on our own. So you can't look at it is a 1-1 replacement.

 

Secondly, and this is the even BIGGER reason.....we don't produce enough PA's or NP's currently. Bottom line is, there aren't enough graduates every year, that even assuming a 1-1 status (which it isn't), there won't be enough....

 

The NP's think that they can accomplish a lot...but a lot of their workforce data is rough, miscalculated, and it is more of a political bravado/posturing....which is fine, but the empiric evidence isn't there.

 

When we examine using a standard primary care year (defined by the product of years in a career, primary care retention%, % active, and volume contributed):

 

MD-FM=22.44

MD-IM=4.54

MD-Peds=10.94

PA= 4.20

NP=3.47

 

AND,

 

NP with the DNP factored in= 2.93 (loss in years while training, need for higher salaries secondary to greater educational expenses)

 

PAs have gone from 54% in the FP mode in 1984 to only 20% entering FP for the 2008 PA grads But on the plus side, FP PAs have 30 times the rural health clinic rate compared to those not in FP mode, 6 - 7 times the CHC rate, and 2 - 4 times the other rural or underserved rates (using AAPA data)

PA and NP declines in the percentages remaining in primary care (about 33% for both found in FP, IM, PD) have been steady for decades, down from nearly 70% at creation

The PA doubling from 3100 grads in 1998 to 6500 in 2008 did not result in more primary care workforce as the 1998 grads had over 50% enter primary care with all PAs above a majority in primary care. By 2008 the new PAs entered primary care at 28% and all PAs were down to 33%. PA entry to specialty workforce is up 220% from 1998 to 2008 class years and primary care may be up 20%,

 

For NP's....NP is much the same although poor data. Also NP grads are 60% active, deliver 60% of the volume compared to a family physician or pediatrician, only have 27 - 28 years of a career, and have low primary care retention. Also since they did not expand annual grads with still about 7000 new grads a year since 1996, their primary care delivery over the class years is actually declining in new grads and in past grads. since it will take a few years to stabilize at the 7000 per year, they will have primary care, but it will be more and more limited. NP is one of the worst about claiming 32 or 36 hours for full time, overclaiming primary care (using geriatrics, women's health, hospital type care) and not counting missing, part time, and inactive graduates, often those that do NP training but do not use NP degrees and remain in hospital careers (20 - 30%).

Goolsby had 56% of the FTE counted as primary care, but included geriatrics (4%) and women's health (10 - 11%) reducing down to 41% in FP, IM, PD Then this was a 2004 study and this is a 6 percentage point decline at least, likely more. This is where my 33 - 35% estimates are or about the same as PA at 33% in FM, IM, PD.

 

Also, NP also has about 15% in administrative careers - 3 - 4 times other sources.

 

So yes, the futures for both professions look bright, and there will be plenty of employment opportunities, but don't be blinded into thinking that we are the only answer, and that simply changing practice laws will somehow magically solve the workforce shortages...

 

There is simply no empiric data to support that.

[physasst]

so if the void won't be filled by NP's and PA's, what do you attribute all of the expressed excitement among the PA and NP forums about how they will be at the forefront of filling the gap? just wishful thinking? i get the impression from the NP's that they don't carry similar doubts about what they can accomplish, and that attitude seems to be bearing fruit for them.

 

Also, in addition to the other post I just posted. I never said that PA's and NP's won't be HELPING to fill that void....we very, very much will be. But the fact is, that we cannot fill that void by ourselves. We will be at the forefront for HELPING to fill that gap, but it won't be enough....

[physasst]

If I don't own a car ,who says I should buy auto insurance? If I don't operate the car I own on public roads or try to register it with the state why should I buy insurance? If I don't eat five servings of vegetables and exercise because it's good for me ,can/should the Federal Government levy a tax on me. Since when does this country tell it's citizens how to spend their own money on personal issues?????

 

So you enjoy spending an extra 1,000 dollars per year? Or assuming your employer pays 50% of your health premiums, an extra 500 dollars per year? You couldn't use that 500 dollars???

 

The reason I say that, is, that is the premium exacted of every patient with health insurance in the US to cover unpaid medical bills.

 

The uninsured (OR even insured with higher deductibles) who get sick, have an accident et cetera, and then don't pay their bills cost all of us. The total in unpaid medical bills is over 55 billion dollars (2008 numbers...likely HIGHER now)...which equates to an additional 1,000 dollar surcharge on all of us WITH insurance....(again, likely higher, from some crude calculations....IOW, napkin math, probably about 13.6% higher now due to the recession).....

 

I'd personally like my 500 dollars (680)...but hey, that's me..:)

[marilynpac]

Boy PAMAC you obviously haven't read the old political threads of the forums past....esp what I wrote.

[marilynpac]

The DOJ is trying to put a stop on this health care reform going before the Supreme Court. If the administration was so confident that it was constitutional, they wouldn't be trying to stop it at all.

[physasst]

take down the barriers for insurance companies selling across state lines and ad a nominal co pay to most services would make things better.

 

Not really. Interstate health insurance sales won't do much. It will only affect a small percentage of health insurance purchasers, and there are some significant problems with it.

 

1. Health insurance is regulated at the State level, if someone purchases insurance from an insurer OUTSIDE of the state, they may not have any recourse for adverse actions taken against the consumer by the insurer.

 

2. It could potentially increase costs..the reason is, out of state insurers may be able to offer lower rates, and for young, healthy patients (the only ones that this would be offered to [NO insurer wants out of state patients with chronic medical problems..they lose money...there is no risk pool...and see #1])..the problem with this, is it could potentially force some insurance companies in some states (those with higher basic requirements, who won't benefit from this) to have to raise rates secondary to the exodus of younger, healthier patients...it's basically an adverse selection...

 

This is in the ACA anyway, with the call for a federal exchange. Part of what HHS is working on now, is to bring ALL states onto a FEDERAL minimum insurance requirement to help streamline this whole process.

 

This is a great paper on this topic:

 

http://www.allhealth.org/briefingmaterials/HealthInsuranceReportKofmanandPollitz-95.pdf

This was also a good article....it's an NBER article, so it's gated, but I found the non-gated version....Basically, it shows that markets with increased consolidation (DECREASED competition) actually offer lower rates

http://www.cbpp.illinois.edu/pdf/Dafny_paper.pdf

The reason is simple. In markets with multiple insurers, the insurers lose leverage on price negotiations with hospitals and providers....while in markets with 1-2 large, consolidated insurers....prices are lower because of negotiating power.

There are a whole host of economic factors for why healthcare does not behave like a normal commodity, but that's an entirely separate discussion.

Overall, interstate health insurers will slightly lower costs for a small group of patients. young, healthy, independent or small business employees who live in states with higher minimum requirements...

But it won't do much to address healthcare spending overall. At least not based on the evidence we have right now.

[physasst]

you say that competition wouldnt make a dent because the insurers would just not take on older customers, and states are needed to regulate companies and offer recourse, and yet you would argue that putting the federal government at the helm would be a solution. how can you insist that federal control is the answer, and then say that no recourse for customers would be offered if states wouldnt be at the helm? to offer insurance across state lines, the barriers and requirements that various states put up would have to fall. removing those barriers to allow for competition would be beneficial for the consumer. the reason it would be difficult for companies to currently operate state to state is because you have some states with onerous requirements as to what services need to provide.

 

1. Health insurance is regulated at the State level, if someone purchases insurance from an insurer OUTSIDE of the state, they may not have any recourse for adverse actions taken against the consumer by the insurer. why cant congress take care of this.... why not regulate it at the federal level? there are many businesses that operate efficiently across state lines. it happens all the time. you are probably an advocate of more central control anyway, so why would you have a hangup to this and not universal healthcare... the answer is that you dont. you believe in federal control, and only put up the states rights issue to try to hem your opponents in. you say "we need feds in charge", until the point where you want to use that to shoot down alternate voices... then all of a suddend its "im sorry, but states are in charge of that".

 

2. It could potentially increase costs..the reason is, out of state insurers may be able to offer lower rates, and for young, healthy patients (the only ones that this would be offered to [NO insurer wants out of state patients with chronic medical problems..they lose money...there is no risk pool...and see #1])..the problem with this, is it could potentially force some insurance companies in some states (those with higher basic requirements, who won't benefit from this) to have to raise rates secondary to the exodus of younger, healthier patients...it's basically an adverse selection...

you are still insisting that states would operate as an individual entity and convoluting the overall message of total reform across the board. what the fed govt' could to is tell the states to take a hike on insisting on all sorts of requirements as to what insurers provide. TX might see things differently from MA, but if you disolve thier ability to pass all sorts of onerous requirements (as you would be happy to the the fed to on a regular basis), then you solve the problem. you are purposely dragging your feet and saying "well if we allow companies to operate across state lines, then some company states will suffer so we cant do it". what im saying is "get rid of the barriers, and companies in various states (like ones you say would suffer) can try their hand at going for the customers in the states with the companies that are going for thier customers. see.... it would force them all to compete. i see that you are trying to impose your own rules on the debate in order to block out the alternatives, but at its core, im telling you that i want to get rid of ALL the barriers that states have erected that limits interstate commerce in the insurance industry.... and yes, the federal government can certainly bring that to pass for the benefit of the states.

 

as for the point about bargaining in local markets being more of a possibility for certain monopolies... you may have a point about that. i havent thought about it much, but that acually is one of your assertions that passes the smell test, at least in the near term.

 

 

Exactly. I have no opposition to a federal exchange with a standardized minimum criteria. This is exactly what HHS is working on right now. They are drafting the regulations. You do know that there are roughly 50 pages of regulations being written for every page of the bill (and you thought it was big before..LOL)...

 

What you are describing is exactly what is being created by the ACA....

 

It's not about a smell test, it's about what works economically. I don't care about ideologies or the whole big vs small government argument...that's trivial nonsense. I care about data.

[physasst]

states own minimum standards are blocking out competition, not the companies themselves. how can a company be expected to match its offerings to 50 different state requirements? you know that they cant, therefore you want to insist that they try to walk the tightrope. when it all falls down, you then will insist on centrally controlled universal healthcare, which comes with rationing and more limitations to the consumer than they ever dreamed. the debates about treatment of your patients will go away, because they will take place entirely in washington rather than the consult room.

 

I've never insisted on "centrally controlled universal healthcare"....I support single payor, but NOT socialized medicine...and they are two vastly different concepts. France has a single payor system using private health insurance, with 20% co-pays, and means testing. They are also the #1 ranked health system in the world. Canada is socialized....I don't want that....I've never wanted that.

[physasst]

if i lumped you in incorrectly with someone else, then i shouldnt have. but i also dont want to be like france.

 

Out of curiosity, why not? Their health insurance and delivery system encourages responsibility by having co-pays that are not that small, and people still have the choice of who they see and when...

 

Just curious as to your objection...

[marilynpac]

New Rassmussen Poll shows 58% of the American people do not want Obamacare...reason: it's too expensive, quality of care will go down compared to cost.

[physasst]

New Rassmussen Poll shows 58% of the American people do not want Obamacare...reason: it's too expensive, quality of care will go down compared to cost.

 

 

Well, to start with, it's the Affordable Care Act, or ACA, not Obamacare, in fact, it's a republican plan. The Heritage Foundation, or the conservative thinktank, proposed the EXACT same plan in 2003. But of course, not it's not good.

 

Also, your claim of 58% is somewhat misleading. The polling methodology was not great here, as respondents were not given a choice of repealing some parts of the bill, only complete repeal.

 

Here's the questions they asked:

 

http://www.rasmussenreports.com/public_content/politics/questions/pt_survey_questions/february_2011/questions_health_care_update_february_4_5_2011

 

2* A proposal has been made to repeal the health care bill and stop it from going into effect. Do you strongly favor, somewhat favor, somewhat oppose or strongly oppose a proposal to repeal the health care bill?

 

That leaves no other option for voters who may be opposed to only certain parts of the bill. This strongly biases the survey, and makes any results obtained questionable at best. Good polls, will not only ask about repeal, but then drill down farther....Repeal the whole thing? Repeal only certain parts of it? Put a single payor system in place? Put a free market system in place? Eliminate Medicare? Simply asking one question on a complex topic like repeal is sloppy and poor research.

 

BTW, the 58% included ALL voters, many of them who were only opposed "somewhat". Only 44% STRONGLY favor repeal. It's also not consistent with other national polls...

 

When you examine the breakdown, as CBS did a few weeks back, you see:

 

If "Should try to repeal":

"Do you think Congress should try to repeal all of the health care law, or only certain parts of it?"

 

All of itCertain partsUnsure%%%

1/15-19/11

 

50 44 6

 

http://www.pollingreport.com/health.htm

 

It all depends on the questions, and how you ask them.

 

If Rasmussen is consistently getting different numbers than a majority of other polls, than you have to question either the validity of the survey and the survey questions, or their sampling methodology. NOW, if most other national polls were getting similar numbers, than I would concede that you would be right....

 

Polls are tricky. For example, Kevin Drum noted (http://motherjones.com/kevin-drum/2011/01/how-americans-really-feel-about-healthcare-reform)

that 13% of those who opposed the bill did so, because it DID NOT GO FAR ENOUGH.....In other words, they wanted single payor or universal care, or a government option, or whatever....but that changes the numbers then...Per the eminent Mr Drum:

 

I think it's pretty plain that the people who "oppose" healthcare reform because it doesn't go far enough are, in any meaningful sense, in favor of the law but think it doesn't go far enough. In other words, about 58% of respondents support healthcare reform and 37% oppose it. This explains the apparent paradox that 50% of respondents oppose healthcare reform but only 37% want to repeal all or part of the law: it's because only about 37% truly oppose it in the first place.

I'm perfectly willing to concede that polling on this question is quirky and variable. Depending on how the question is asked and what the followups are, you can get a lot of different responses. Still, there's a pretty clear difference between people who genuinely oppose healthcare reform and those who only "oppose" it because they preferred Medicare for All or something like that. What's more, we've now seen this result often enough that there's no real excuse for not presenting it more meaningfully. At the very least, there's no excuse for not asking the question in a way that takes all this into account.

 

So, as you can see, polling is a tricky topic, and I don't put any stock into the Rasmussen numbers at all. Now, if they wanted to do a real survey, I might change my mind.....I'm not close minded, but I need good data to make informed judgements....

 

BTW, when I was working on research in my office today, was watching/listening to the Congressional Hearings on HR3 on CSPAN....Got a little contentious...

[primadonna22274]

Hey Mike,

Thanks for keeping us updated on this. As much as I am fascinated by health policy, I certainly don't have the economic fortitude that you do to sludge through it all line-by-line...but hey, glad you do :)

I've read everything from "primary care is going to the NPs" to "we will never be able to replace PHYSICIANS in primary care". As you know I have a selfish interest in this as a future (probably primary care) physician/PA. I would like to hear your thoughts on how ACA will impact graduating physicians in the next 5 years? Any incentives that you can see?

thanks

Lisa

[physasst]

Hey Mike,

Thanks for keeping us updated on this. As much as I am fascinated by health policy, I certainly don't have the economic fortitude that you do to sludge through it all line-by-line...but hey, glad you do :)

I've read everything from "primary care is going to the NPs" to "we will never be able to replace PHYSICIANS in primary care". As you know I have a selfish interest in this as a future (probably primary care) physician/PA. I would like to hear your thoughts on how ACA will impact graduating physicians in the next 5 years? Any incentives that you can see?

thanks

Lisa

 

 

Hi Lisa, congrats on your entry into LECOM....

 

For starters, we are NEVER going to be able to completely do away with physicians in primary care....that's a ridiculous notion. What I do see, and it is already happening to some degree, is a reorganization of primary care into a pyramid (based on the Naessen's triangle of acuity) with the sickest patients composing typically, 1-2% of a practices population.....the moderately sick composing the next 2-5% in a typical practice, and then the mildly sick....4-10% of a practice, and then everyone else at the bottom. I think you will see a practice organized with a physician caring for the tier one patients primarily.....possibly with telemedicine involvement, and/or care nurses who check on the patient frequently, the next tier will be cared for by either a PA/NP or a physician, but if PA/NP will have regular visits (every 10th or something like that) with the physician as well. Care nurses may also be involved with occasional phone calls and/or home visits. The following lower tiers, will be cared for almost exclusively by PA's and NP's

 

Physician's don't necessarily like this. They point to the old (you don't know what you don't know) argument, but the real reason is that they dread the thought of seeing nothing but REALLY sick patients all day long.

 

Nonetheless, I can see this happening, particularly if the payment reforms I am expecting, will go into effect.

 

As far as primary care within the ACA, its hard to say...there was supposed to be an increase in Medicare payments to primary care, as part of the larger 21% SGR cut that Congress lacked the cajones to actually do...

 

But the outlook for primary care is good. Accountable Care Organizations are all the rage right now, and while a lot of hospitals, groups, practices, and physicians are concerned about ACO's (there's a HUGE upfront investment cost to meet the definition of an ACO), they are definitely a priority in the bill. I helped advocate for them, so I understand the concepts fairly well, there will be incentives for organizations to either become an ACO, or join an existing ACO.....

 

The good news is, the only way an ACO works, is, to say it plainly, if primary care drives the bus. You have to have a STRONG, primary care base that limits referrals to specialists in order for an ACO to really work well. Combined with payment reforms (getting rid of fee for service completely), the future looks bright for primary care. As my doctoral mentor keeps telling me, every society with a strong primary care base, has lower overall healthcare expenditures....

 

So, personally, I think primary care has a bright future. FOR ALL providers.

 

BTW, did you hear our friend Rod has left clinical practice as a PA, and is now a full time researcher for the Lewin Group....

 

Mike

[Moonwalk]

Obviously this is going to have to be decided by the Supreme Court.

 

If the Supreme Court rules the individual mandate to be unconstitutional, then that still leaves a couple of options: 1) change the law so that each person MAY purchase health insurance; those who choose not to do so must pay a mandatory tax to cover a national fund for the uninsured. 2) the status quo (generally thought not the way to go), or 3) a national health insurance plan, or "Medicare for all".

 

Those who oppose the individual mandate likely do not understand how health insurance works. The only way insurance companies can afford to offer health coverage to the sick is if they also provide coverage to large numbers of healthy individuals. Thus the rationale behind "group health insurance" offered by most employers. Employee health insurance covers a diverse group of individuals, but generally excludes the elderly or those too ill or disabled to work.