What does Obamacare, which is here to stay, mean for us?

[KCMA79]

How will jobs decrease if 33 million more people are insured? this is like mitt romney in that the math just doesn't add up.

 

Because you assume that resources will keep up with demand. Patient loads and waiting lists for procedures will also increase as health ins companies etc try to maintain profitability. Some PAs who work for HMOs already are expected to see a pt. every 10min. in FP clinics.

[KCMA79]

I think part of the problem is that too many people get mri's who don't need them, and abx for colds, etc.

some rationing is well, rational. know about this study?:

http://archinte.jamanetwork.com/article.aspx?articleid=1108766

give folks what they want and their health deteriorates, they spend more days in the hospital and die sooner.

bottom line, everyone shouldn't get all the healthcare they want all the time. it's bad for the system and it's bad for their health.

 

I agree with what you said. I'm just not sure the american public is ready for rationed health care. Many of them think they will now be able to get anything they want when they want it.

[Hemegroup]

I'm sure everyone will survive, people, no need to make it into another 'Y2K'. More people insured. Heck, at the Primary Care clinic I'm at now we see everything from Blue Cross PPO to the lowest County MediCal you could imagine. Primarily we see the underserved. I'm making 120K this year. I'm sure we'll be fine. Like was said, people already have to wait for their MRIs. The main point is, they'll be able to get them at a reduced cost than they would if they went to the ER. Open your eyes, the plan pamphlets are already popping up at our office. One actually looked quite good for the cost. We have a LOT of work ahead and are going to be in even more demand.

 

Some nice parts here on his healthcare ideals, at about :50 ...

[68W2PA]

I agree with what you said. I'm just not sure the american public is ready for rationed health care. Many of them think they will now be able to get anything they want when they want it.

 

The America public is already dealing with rationed healthcare. Rationing has always been a part of the system and always will be.

[andersenpa]

The America public is already dealing with rationed healthcare. Rationing has always been a part of the system and always will be.

 

Correct, we currently ration based on the ability to pay.

 

An increase in the number of people purchasing insurance and entering the health care marketplace will raise demand.

How specialists vs generalists are reimbursed will affect how PAs/docs decide which field to enter

But we will all be busy with upstream patient volumes.

[ventana]

I agree with what you said. I'm just not sure the american public is ready for rationed health care. Many of them think they will now be able to get anything they want when they want it.

 

 

we already function under a healthcare system that rations. It is called uninsured or underinsured.

 

I read a lot of comments and laugh at her fear mongering attitude. In no way do I think this is going to cost us jobs. More people with insurance is going to have more people accessing care providing more demand. It may well cut the number of jobs in certain subspecialties as they become more appropriately utilized.

 

Talking to a physician who was trained in Canada and still communicates with a lot of colleagues. They run in entire 2 provider office with 2 office staff. in the United States she probably would need at least 4 office staff just to do with the insurance and overhead. The cost savings from a single pair system, granted that is not ACA, would be huge savings.

 

If not perfect, but it goes a long ways towards correcting a system that does not even exist. It's not a broken system it is a nonexistent system.

 

did you know that all of us are only 1 Maj. illness away from medical bankruptcy. think about it, 18 months or cobra, then you are on your own. If not able to work but have savings he will not qualify for Medicaid , end up spending on all money 2 you qualify for Medicaid. Likely is not getting great care while this goes on as he cannot afford it.

 

 

I do think overall reimbursement to primary care will increase and likely specialties will decrease - but I have to admit this makes sense, brand-new radiologists should not be making $250-$300,000 a year while he brand-new internist makes 150

[68W2PA]

we already function under a healthcare system that rations. It is called uninsured or underinsured.

 

It isn't just that. Even if you have great insurance, there will always be a cost-benefits analysis by the bean-counters. Insurance companies will not spend unlimited resources for minimal gains. If the cost is $5 million to potentially extend the life of a patient for an additional 6 months, you can bet the insurance company will not pay for it. No government or insurance companies is going to be paying for heart transplants for 100 year-old patients. Again... all systems ration. There is no system anywhere in the world that will spend unlimited resources on limited results.

[KCMA79]

Correct, we currently ration based on the ability to pay.

 

Maybe a better way to put it is we will see a higher degree of rationing? Look at the UK NHS, not one of the better systems, with often long waits for appts and even longer waits for procedures. Last time I was in England I spoke with a guy who had been waiting for a yr for an inguinal hernia repair. Other EU countries do a better job than the UK but their care is much more rationed than anything the US is used to. How many women in the US are willing to be seen by a midwife for all of their prenatal care and uncomplicated delivery, which I think is a great idea? I used to work in a snowbird area and each winter our clinic would see many Canadians who came to us to avoid the long wait lists etc in Canada. Is this the end of the world, of course not. But we are in for rough ride and a major change in the way health care is delivered and viewed in this country. And that will come with increased workloads for PAs and lower salaries coupled fewer people wanting to be PAs.

[CAdamsPAC]

To you younglings I suggest you find a practice that DOES NOT accept any form of government reimbursement like a concierge practice. Those that do are going to get hammered with reduced payments, increased administrative burdens, along with real problems getting your patients seen by specialist. The ACA does nothing to increase the numbers of providers at any level, but has provisions create 16K enforcement personnel. Three years and counting..................

[CAdamsPAC]

http://en.wikipedia.org/wiki/Pareto_principle

interesting concept that states that 20% of a population of almost anything is responsible for 80% of the cost or use.

20% of your wardrobe is worn 80% of the time for example or 20% of the population is responsible for 80% of the costs. that means that if you target the 20% you get more bang for your buck but in the u.s. we target the 80% of health care consumers that use only 20% of the resources to garner more political influence. kinda bass awards.

I'm sure Physasst can add to this commentary in a productive way.

 

Stop admitting dying patients into the ICU to be flogged for weeks at a phenomenal cost for the inevitable result!

[EMEDPA]

Stop admitting dying patients into the ICU to be flogged for weeks at a phenomenal cost for the inevitable result!

 

agree. no chemo, liver transplants, etc for 90 yr olds

[CAdamsPAC]

agree. no chemo, liver transplants, etc for 90 yr olds

 

I say set the bar even higher than age >90.........END STAGE diagnosis means just that, it's over !Limit dialysis care by age and to no more than 5 years. Poor surgical risks DM, PVDZ, COPD, ETOH or IVDA excluded from transplant lists, < than 30 preterm deliveries, infertility treatment are all NO-GOs. Physicians need to step up and say just that the patient is dying and all that be done is to extend the process for no good reason.

[ventana]

not to be a downer - but what about anyone over the age of 80 (or some predetermined age) has an automatic DNR - can waive off this by having a conversation with your provider and signing a form to day they want CPR - (exactly opposite of what we do now) ever had those ribs crack under you when CPR on elderly frail? horrible waste... then you get a pulse and they spend a week in between land till they die..... crazy

[CAdamsPAC]

not to be a downer - but what about anyone over the age of 80 (or some predetermined age) has an automatic DNR - can waive off this by having a conversation with your provider and signing a form to day they want CPR - (exactly opposite of what we do now) ever had those ribs crack under you when CPR on elderly frail? horrible waste... then you get a pulse and they spend a week in between land till they die..... crazy

 

Well, medical folks will have to put on their "big boys/girls pants" and man up to the challenge and just say no. This is a conversation that needs to made from the get go of a hospitalization for a condition with a reasonable chance of a poor outcome. The days of "I want everything done" are coming to an end sooner than most people are willing to accept , especially the physician community!!!!!

[Gordon, PA-C]

wouldn't increased demand for services mean more jobs at lower wages? I think erveryone in healthcare from the docs on down will take some kind of pay cut. I don't necessarily think that is a bad thing. primary care folks are underpaid. they should make more. specialists are overpaid. they should make less. in England family medicine docs make more than surgeons because they value prevention over intervention there.

 

Depends on how the employment market is structured.

 

In a system like now where there are tens of thousands of small clinics competing against hospital chains and larger organizations for labor, then yes, salaries would go up in the face of increased demand.

 

However, in Obama's system the tens of thousands of small clinics are going to be squeezed into giant ACO networks. When you have 50 giant ACO networks who control the employment process, then salaries will go down, despite the increased 'demand' for services.

 

It wont happen overnight, but its coming eventually -- in 10 or 15 years, Geisinger, Kaiser Permanente, Intermountain and others are going to be large nationwide ACO networks and will have sufficient market power to bargain down on doc and PA salaries.

[Gordon, PA-C]

How does Obamacare do this? What is the mechanism? This has been the trend for awhile and I am not convinced Obamacare exacerbates it in any way.

 

One thing Obamacare does is automatically insures 33 million more people. That means a lot more jobs for PAs

 

It does this by reimbursement tie ins to ACO status. The government is going to be sending out letters that say somethign like this:

 

"We see that you have not partnered up with an ACO in your area. Please bear in mind that if you join an ACO network, we will give you an extra 5% bonus on reimbursements."

 

Here's what the letter is going to say in 10 years, after the bait and switch has occurred and ACOs have achieved sufficient market clout:

 

"We see that you still have not partnered up with an ACO in your area. To punish your insolence, we are docking 5% on all your reimbursement claims. If you fail to join next year, we'll dock another 5% and the year after that, another 5%"

 

Obamacare ensures that ACOs will dominate because it puts the carrot of increaesd reimbursement into play. That carrot is a bait and switch that will turn into a stick, eventually.

[burnpac]

CAdamsPAC: Actually, the ACA has significant funding to expand the supply of physicians, PAs, and NPs. It is not near enough however!

[VentJock]

http://en.wikipedia.org/wiki/Pareto_principle

interesting concept that states that 20% of a population of almost anything is responsible for 80% of the cost or use.

20% of your wardrobe is worn 80% of the time for example or 20% of the population is responsible for 80% of the costs. that means that if you target the 20% you get more bang for your buck but in the u.s. we target the 80% of health care consumers that use only 20% of the resources to garner more political influence. kinda bass ackwards.

I'm sure Physasst can add to this commentary in a productive way.

 

This is a concept that holds true across a variety of industries. In a study from the Kaiser Family Foundation (not associated with Kaiser Permanente) the top 1% of the population accounted for 22% of healthcare spending, top 5% accounted for 50%, top 10% for 65%, top 15% for 75%, and top 20% for 81%. In fact the bottom 50% of the population only accounted for 3% of healthcare spending.

 

This is why our healthcare system is referred to at times as a "sick care" system because the incentive is to treat sick patients rather than to keep them healthy/out of the hospital.

 

I think more organizations will start to resemble Kaiser Permanente in a few years.

 

My background is in respiratory therapy and I worked in fee-for-service settings. So I was surprised when I started interning at Kaiser that the organization is not in the business of building hospitals. This was so backwards to me as I remember always hearing messages from senior leadership that a high census was always good for a hospital.

 

Once prevention (as it is at Kaiser due to their capitated model) becomes the real "carrot" then will we finally begin to see real changes in the way healthcare is delivered. The ACA helps push towards this direction, but it doesn't change the fundamental flaws of the system.

 

In fact, the "health insurance exchanges" will all be FFS plans, which goes against the whole "ACO" concept.

[physasst]

Okay, well, there's a lot here. First, most agree that the WHO rankings of the US system weren't great, but also, there were assumptions in their model that heavily stacked the deck against us. However, even when you weight the rankings, using the best assumptions possible, the US achieves no higher than 15th.

 

The ACA was a necessary start, but still much to do. ACO models will help, but will force smaller practices to join together which is a good thing over the long run. PA's don't have to worry about paycuts much in the near future. There's simply too much excess capacity and pent up demand. Physician reimbursment on the other hand will likely see some cuts, although that is still probably focusing on the wrong issue. We need to focus on shared decision making models, systems engineering that improves processes, improving patient reported outcomes (as these will be part of reimbursement models going forward) and improved compliance with clinical decision rules. We need more uniform care delivery. It is somewhat disconcerting that a patient with new onset non insulin dependent DM can see 10 different providers and get at least 6-7 different recommendations. We need uniformity where possible. Of course there are cases where this is not possible, but with many things it is. We need better practice conformity by providers. I'm part of an international panel looking at audit and feedback research. It is really unacceptable that the data shows physicians rarely change their practice patterns, even confronted and provided feedback that they are not meeting current goals or aims with the data showing a change only 4.3% of the time (cumulatively).

[physasst]

As far as rationing by the way, I wrote about this in PA Professional back in 2009. Rationing is implicit in any economic system with excess demand and limited supply. As others have noted, we already ration care. But the question remains do we ration effectively?

 

There are ways to do this. The UK has the NICE, and they determine what is covered and what isn't, but that likely would never work in our society and political structure. Germany has a nice alternative in the IQWiG, and I think that this is a model that would likely work well in the US.

[EMEDPA]

I'm studying the german model in a course right now and the main critique of that system I have seen so far is too much choice with the govt required to foot the bill for services which may not be necessary.

[Hemegroup]

alles klar lol i do like snow

[RHC81]

The days of "I want everything done" are coming to an end sooner than most people are willing to accept , especially the physician community!!!!!

 

While I agree with you, I'm wondering how this will interact with the world of medical malpractice/tort law. We all know patients who've been strung along for an extended death by family who are unwilling/unable to let go and a medical team who is covering their butts in case of a malpractice suit...

 

It just seems that the "I want everything done!" culture will have to change before medical professionals can do anything other than say what they say now - "He's dying....we can make him comfortable, but..."

[physasst]

While I agree with you, I'm wondering how this will interact with the world of medical malpractice/tort law. We all know patients who've been strung along for an extended death by family who are unwilling/unable to let go and a medical team who is covering their butts in case of a malpractice suit...

 

It just seems that the "I want everything done!" culture will have to change before medical professionals can do anything other than say what they say now - "He's dying....we can make him comfortable, but..."

 

The threat of lawsuits is not why we order tests. We rationalize it that way (providers are great at rationalizing decisions) but the fact is, providers order tests because they are scared of missing something. In places that have implemented aggresive tort reforms....testing rates went up, spending went up. Not down.

 

However, this is cultural thing that is unique to the US. In other countries, death is more accepted as a natural part of life, but there has been a conditioning here to fight it at all costs. Most of my friends in Europe think this is strange.

[winterallsummer]

I won't mind a drop in wages if it's compensated by better loan repayment programs at some level.

 

Higher patient load sure but I don't really see how this is bad for us... I'm not an economics expert by any means but despite any heavy and technical economic forecast someone cares to make, increased demand for health care tends to be good for us especially considering our versatility.

 

As for health care rationing... whoever posted earlier really hit the nail on the head: we do ration. People who are well off or who have parents with insurance get the good health care early, and those without insurance for whatever reason have to get much sicker before they can rationally receive care and justify risking all their money and going into debt for it.

 

A potential compromise in quality of care (hopefully offset by preventative medicine) IMHO is ethically justified by significantly expanding access. Prevention and early access saves lives and long term care, so don't forget that while it does create problems, Obamacare also addresses many problems with financial roots (such as millions dropped on care for those with deteriorated conditions).