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

[Justeco]

Some good news, I guess.

 

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that providers license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. (B) INDIVIDUALS. The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a96 group health plan or health insurance issuer offering group or individual health insurance coverage.

[user1234556]

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.

 

IMO, the word "rationing" doesn't fit this scenario. But, as far as people who can afford better/more care getting better/more care, people in this country who believe the ACA will change that are delusional. Much like wealthier people in other countries are in a position to go elsewhere for treatment etc, there will always be differences between the economic classes in this regard and anyone who feels like this legislation is equalizing has no clue how things work. There's a reason every rich celebrity in Hollywood could be all about Obamacare since the day they first heard it mentioned, with no clue whatsoever what it even does and no desire to look into it. And that reason is--- it doesn't affect them. It doesn't apply to them. Already they can pay up front for whatever/whoever they want, whenever they want. You think "Brangelina" sits in waiting rooms for hours on end with everyone else at the pediatrician's office? Do you think Kobe Bryant is going on a waiting list for an MRI if he gets injured? As more and more of the better specialists are inclined to move to cash-based practices, this will further divide the quality and timing of care that the different classes receive, but unfortunately it will put the middle class in a position of having to spend significantly more, I'm afraid, to get the efficiency and quality they're used to, or that they know is attainable. For everyone who was already accustomed to government insurance or nothing at all, well.. as the old say goes, ya can't miss what you never had. I personally live in a fairly populated city with a very good medical school and hospital system and you can open up the yellow pages, go down the list in any specialty, and call every decent provider in town, and most of the time you're going to be told that "Dr. X isn't accepting new patients at this time", regardless of whether you have Blue Cross or Medicaid. Physicians in this country are already working at capacity. And for those who ARE taking new patients (and it stands to reason that it isn't coincidental that they aren't as busy), a good number aren't going to take new Medicaid patients.. And the ACA doesn't give much incentive to start, considering it only provides for Medicare-matched reimbursement for the first year or two. So, you can stick half the country on medicaid but that still doesn't mean, from a practical standpoint, that they're going to be able to get an appointment anywhere. Not to mention that many states passed ACA-related amendments last week, none of which were particularly favorable for the Obamacare supporters that live there.

[Gordon, PA-C]

Some good news, I guess.

 

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that providers license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. (B) INDIVIDUALS. The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a96 group health plan or health insurance issuer offering group or individual health insurance coverage.

 

 

This little gem is what will allow naturopaths, homeopaths, and all the other quacks to sue insurance companies when they wont pay for stupid stuff that doesnt work.

[zepoPA]

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.

 

Yes... and No. In primary care I often encounter the patients who (with Medicaid) have access to all the recommended preventive care. While many private insurance policies do NOT cover many of the prevent. checks/studies.

 

Also, I frequently get the s/p E.R. visits. (E.R. last night due to fever 100 and vomited once, otherwise asymptomatic ...! ) Yes, some patients go to Emergency for such reasons. Whereas most patients "who have parents with insurance" usually buy Pepto, take a Tylenol, and see me the next couple days. Why? Because they know the E.R. copay could be $100 or more, so they choose to wait. Copay for Medicaid: Zero.

 

We routinely get the "follow-up E.R." patients and I wonder, time and time again how the E-Med colleagues feel when they encounter these patients. BTW.. we DO instruct patients ALL THE TIME to respect Emergency Dept. for what they are: True Emergencies. (I worked trauma years ago so I know how it is)

 

The disparity is enormous, but do not get fooled. It goes both ways. I have seen patients for the most trivial reasons, such as: "i noticed a wrinkle on my forehead". It is never a "private insured" patient who surprises me with such chief complain.

[68W2PA]

IMO, the word "rationing" doesn't fit this scenario. But, as far as people who can afford better/more care getting better/more care, people in this country who believe the ACA will change that are delusional.

 

Nobody is arguing that the ACA will magically level the playing field and give everybody the exact same level of care. You are arguing a strawman.

[physasst]

IMO, the word "rationing" doesn't fit this scenario. But, as far as people who can afford better/more care getting better/more care, people in this country who believe the ACA will change that are delusional. Much like wealthier people in other countries are in a position to go elsewhere for treatment etc, there will always be differences between the economic classes in this regard and anyone who feels like this legislation is equalizing has no clue how things work. There's a reason every rich celebrity in Hollywood could be all about Obamacare since the day they first heard it mentioned, with no clue whatsoever what it even does and no desire to look into it.

 

Well, this raises the question, do wealthier people get BETTER care, not more care, but BETTER care. We know that they get more care. I see them every day. There was a study done in the early aughts that looked at outcomes in several diseases between the poorest residents in the UK and the wealthiest residents in the US. The wealthiest residents in the US, presumably able to get whatever healthcare they desired had poorer outcomes than the poorest UK residents. More doesn't equal better.....

[rpackelly]

Let me ask then how did Medicare affect PAs when it was first introduced? I'm guessing it would be the same type of impact correct?

 

PAs were not around when Medicare first introduced in mid 1960s

[winterallsummer]

Yes... and No. In primary care I often encounter the patients who (with Medicaid) have access to all the recommended preventive care. While many private insurance policies do NOT cover many of the prevent. checks/studies.

 

Also, I frequently get the s/p E.R. visits. (E.R. last night due to fever 100 and vomited once, otherwise asymptomatic ...! ) Yes, some patients go to Emergency for such reasons. Whereas most patients "who have parents with insurance" usually buy Pepto, take a Tylenol, and see me the next couple days. Why? Because they know the E.R. copay could be $100 or more, so they choose to wait. Copay for Medicaid: Zero.

 

We routinely get the "follow-up E.R." patients and I wonder, time and time again how the E-Med colleagues feel when they encounter these patients. BTW.. we DO instruct patients ALL THE TIME to respect Emergency Dept. for what they are: True Emergencies. (I worked trauma years ago so I know how it is)

 

The disparity is enormous, but do not get fooled. It goes both ways. I have seen patients for the most trivial reasons, such as: "i noticed a wrinkle on my forehead". It is never a "private insured" patient who surprises me with such chief complain.

 

You bring up a very interesting and insightful point and I never thought of it that way. Two quick things to add to the mix:

 

1. Part of Obamacare will enforce all insurance companies to provide preventative care w/o any charge to the patient, covering prev. care recommended by the US Prev Care task force. Now will people opportunize this - hopefully - or will the pattern you observe at work still persist?

 

2. You bring up a good point but IMHO, in the long term, if people are given the opportunity to see a family care PA or doc w/ $25 co-pay the ER will stop getting infiltrated by all these cases.

 

I think your post brings up the large need for PT EDUCATION that is going to be vital for people getting insurance for the first time ever (and hell everyone really).

[winterallsummer]

IMO, the word "rationing" doesn't fit this scenario. But, as far as people who can afford better/more care getting better/more care, people in this country who believe the ACA will change that are delusional. Much like wealthier people in other countries are in a position to go elsewhere for treatment etc, there will always be differences between the economic classes in this regard and anyone who feels like this legislation is equalizing has no clue how things work. There's a reason every rich celebrity in Hollywood could be all about Obamacare since the day they first heard it mentioned, with no clue whatsoever what it even does and no desire to look into it. And that reason is--- it doesn't affect them. It doesn't apply to them. Already they can pay up front for whatever/whoever they want, whenever they want. You think "Brangelina" sits in waiting rooms for hours on end with everyone else at the pediatrician's office? Do you think Kobe Bryant is going on a waiting list for an MRI if he gets injured? As more and more of the better specialists are inclined to move to cash-based practices, this will further divide the quality and timing of care that the different classes receive, but unfortunately it will put the middle class in a position of having to spend significantly more, I'm afraid, to get the efficiency and quality they're used to, or that they know is attainable. For everyone who was already accustomed to government insurance or nothing at all, well.. as the old say goes, ya can't miss what you never had. I personally live in a fairly populated city with a very good medical school and hospital system and you can open up the yellow pages, go down the list in any specialty, and call every decent provider in town, and most of the time you're going to be told that "Dr. X isn't accepting new patients at this time", regardless of whether you have Blue Cross or Medicaid. Physicians in this country are already working at capacity. And for those who ARE taking new patients (and it stands to reason that it isn't coincidental that they aren't as busy), a good number aren't going to take new Medicaid patients.. And the ACA doesn't give much incentive to start, considering it only provides for Medicare-matched reimbursement for the first year or two. So, you can stick half the country on medicaid but that still doesn't mean, from a practical standpoint, that they're going to be able to get an appointment anywhere. Not to mention that many states passed ACA-related amendments last week, none of which were particularly favorable for the Obamacare supporters that live there.

 

Yes you're absolutely right it is disparity not rationing - rationing implies we have some control over the matter.

 

I think you do bring up a good point, 1. yes there is already oversaturation in some HC markets, 2. having insurance does not ensure the same quality of care that people with 'better' insurance get.

 

BUT - it does have to be mentioned that Obamacare is addressing some of the problems that allow these disparities to exist between Rich Man Insurance Co and Crappy Insurance Co.

 

As far as state funded insurance... time will tell how this pans out but you bring out some good points. For the concept of everyone having insurance to work, adjustments need to be made so doc's and PA's are able to profit on all these patients.

 

FYI - I am not really for putting everyone on medicare/aid. I would much rather see the base of pt's insured through their companies. Obviously this is not possible but food for thought - the most successful HC system out there by most people's standards is Japan, where there are 3 big insurers that most people get through their employers. They have the healthiest people as well (obv. a lot is lifestyle, yes) and also the most doctor visits!!! Food for thought again, like I said.

 

What do you all think...

[True Anomaly]

You bring up a very interesting and insightful point and I never thought of it that way. Two quick things to add to the mix:

 

1. Part of Obamacare will enforce all insurance companies to provide preventative care w/o any charge to the patient, covering prev. care recommended by the US Prev Care task force. Now will people opportunize this - hopefully - or will the pattern you observe at work still persist?

 

2. You bring up a good point but IMHO, in the long term, if people are given the opportunity to see a family care PA or doc w/ $25 co-pay the ER will stop getting infiltrated by all these cases.

 

I think your post brings up the large need for PT EDUCATION that is going to be vital for people getting insurance for the first time ever (and hell everyone really).

 

Disagree with point 2- there are patients out there, who are on health assistance, who will do whatever they can to not pay dollar 1 for being seen. I see a population of patients who come to the ER because, due to their medical assistance, it is absolutely free for them to be seen in the ED, and they don't have to wait like they do for an appointment with a PCP. While I have no way to prove this, and I fully admit this is purely anecdotal, I am pretty much convinced that if you made these patients open their wallet and pay 1 dollar to be seen in the ED, they would stay home instead, because it's having to pay some amount of money to be seen, let alone a $25 copay.

 

For the poster above who wonders what the ER people are thinking when a child is brought it because they had a fever and one episode of vomiting, but are fine now, I'll tell you what we're thinking- the first question I ask is why didn't you go see your PCP. One of two answers is usually given- either "I don't know", or "I called them, but they can't see me today, and I don't want to wait". So of course, they get mad when I tell them, "Your child has a virus- it will generally pass- you still need to follow up with your primary care doctor, because if it was serious enough for you to bring your child here, it's serious enough to follow up with your primary care doctor". Not that they're going to, and the blame lies with both parties- since they're medical assistance, there's no financial incentive for a PCP office to squeeze them in, and they also don't want to schedule an appointment to go to the clinic when in their eyes, they're getting the same care in the ED. I've seen patients who have visited the ER more than 20 times in the first two years of life, and they have no congenital or underlying medical disorder- their parents just bring them to the ER for everything- literally​.

[EMEDPA]

Agree with above. I frequently see folks who come to the er for a pregnancy test or a prescription for tylenol....both of which are available at the dollar store...for a dollar.....

[ventana]

Agree with above. I frequently see folks who come to the er for a pregnancy test or a prescription for tylenol....both of which are available at the dollar store...for a dollar.....

 

 

this is one of my pet peeves -

 

why do we have to see them? why does not triage just send them away? course they have a 300 pack yr smoking hx of camels and are carrying the newest Iphone and have bling jewelry on..... but they don't have a dollar for a UCG....

[True Anomaly]

this is one of my pet peeves -

 

why do we have to see them? Why does not triage just send them away? Course they have a 300 pack yr smoking hx of camels and are carrying the newest iphone and have bling jewelry on..... But they don't have a dollar for a ucg....

 

emtala....

[andersenpa]

You bring up a very interesting and insightful point and I never thought of it that way. Two quick things to add to the mix:

 

1. Part of Obamacare will enforce all insurance companies to provide preventative care w/o any charge to the patient, covering prev. care recommended by the US Prev Care task force. Now will people opportunize this - hopefully - or will the pattern you observe at work still persist?

 

2. You bring up a good point but IMHO, in the long term, if people are given the opportunity to see a family care PA or doc w/ $25 co-pay the ER will stop getting infiltrated by all these cases.

 

I think your post brings up the large need for PT EDUCATION that is going to be vital for people getting insurance for the first time ever (and hell everyone really).

 

 

Motivation and education on the part of the health care consumer is the biggest factor

Look at medicaid- a fraction of those eligible acutally apply and get coverage

Preventive care takes knowledge, insight and planning

Not everyone has those skills or effort

Hitting those patients upstream before they become ER/UC cases is a big problem

[andersenpa]

Yes you're absolutely right it is disparity not rationing - rationing implies we have some control over the matter.

 

I think you do bring up a good point, 1. yes there is already oversaturation in some HC markets, 2. having insurance does not ensure the same quality of care that people with 'better' insurance get.

 

BUT - it does have to be mentioned that Obamacare is addressing some of the problems that allow these disparities to exist between Rich Man Insurance Co and Crappy Insurance Co.

 

As far as state funded insurance... time will tell how this pans out but you bring out some good points. For the concept of everyone having insurance to work, adjustments need to be made so doc's and PA's are able to profit on all these patients.

 

FYI - I am not really for putting everyone on medicare/aid. I would much rather see the base of pt's insured through their companies. Obviously this is not possible but food for thought - the most successful HC system out there by most people's standards is Japan, where there are 3 big insurers that most people get through their employers. They have the healthiest people as well (obv. a lot is lifestyle, yes) and also the most doctor visits!!! Food for thought again, like I said.

 

What do you all think...

 

1. More doctor visits doesn't mean better outcomes (proven in UK and canada)

2. Employer based insurance is good in that it increases the pool but it needs to be seemless and portable. In a volatile economy the insurance options for the unemployed are overpriced or shortlived band-aids.

[winterallsummer]

Motivation and education on the part of the health care consumer is the biggest factor

Look at medicaid- a fraction of those eligible acutally apply and get coverage

Preventive care takes knowledge, insight and planning

Not everyone has those skills or effort

Hitting those patients upstream before they become ER/UC cases is a big problem.

 

1. More doctor visits doesn't mean better outcomes (proven in UK and canada)

2. Employer based insurance is good in that it increases the pool but it needs to be seemless and portable. In a volatile economy the insurance options for the unemployed are overpriced or shortlived band-aids.

 

Yep dead on about preventative care. The question of course next is who addresses them and their lack of knowledge? Will it become our responsibility to reach out to the community or will there be more social workers available etc...

 

Yeah not insinuating that more visits means better care or anything, just pointing out that someone having access to medical care without major limitations doesn't necessarily lead to bad outcomes. And yeah not to mention so many jobs that pay under the table and don't offer insurance. I'm not sure how the state insurance will pan out but hopefully in everyone's favor. Right now I pay a ridiculous amount as a student for private insurance that doesn't give me half the coverage my much cheaper one did when I was working and getting it through my employer. I also have had jobs where it wasn't available so there is a lot more to the picture than that of course.

[physasst]

The next question is, do you think that regular checkups save any money......

 

There's a new study that says that preventative visits don't do jack. It's a Cochrane systematic review, which means, that in order to get published in the Cochrane library, it has to be VERY thorough. 182,880 participants...

 

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

 

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract

[EMEDPA]

The next question is, do you think that regular checkups save any money......

 

There's a new study that says that preventative visits don't do jack. It's a Cochrane systematic review, which means, that in order to get published in the Cochrane library, it has to be VERY thorough. 182,880 participants...

 

 

did they stratify by age or complaint? I would argue that well baby checks and vaccinations early on prevent mortality/morbidity later on.

ditto adult vaccinations( shingles, pneumovax, etc) As well as appropriately monitoring/treating cholesterol, bp, etc

If they just looked at the value of a "yearly physical" without current complaint I agree that probably gives a poor return on investment.

[physasst]

did they stratify by age or complaint? I would argue that well baby checks and vaccinations early on prevent mortality/morbidity later on.

ditto adult vaccinations( shingles, pneumovax, etc) As well as appropriately monitoring/treating cholesterol, bp, etc

If they just looked at the value of a "yearly physical" without current complaint I agree that probably gives a poor return on investment.

 

It was limited to adults, unstratified by disease or risk factors. No geriatric trials included. They defined a health check as screening the general population for more than one disease or risk factor in more than one organ system.

 

Here's the main results:

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.

 

We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

[Hemegroup]

Thank you for carrying the torch to light the fire that good men before you had hoped for. Thank you, thank you, thank you.

[andersenpa]

The next question is, do you think that regular checkups save any money......

 

There's a new study that says that preventative visits don't do jack. It's a Cochrane systematic review, which means, that in order to get published in the Cochrane library, it has to be VERY thorough. 182,880 participants...

 

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

 

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract

 

New dx is one thing

Whether the providers followed EBM proven txs for those dxs is another

It's well documented how treatment plans are variable, based on gestalt, and without good science

Again, access and visit numbers do not equal improved health

[andersenpa]

did they stratify by age or complaint? I would argue that well baby checks and vaccinations early on prevent mortality/morbidity later on.

ditto adult vaccinations( shingles, pneumovax, etc) As well as appropriately monitoring/treating cholesterol, bp, etc

If they just looked at the value of a "yearly physical" without current complaint I agree that probably gives a poor return on investment.

 

The immediate rate of return on "well checks" must be low by definition, right?

[zepoPA]

 

Again, access and visit numbers do not equal improved health

 

Many factors should be considered, of course. Let me bring up SPECIFIC examples; some causes for poor outcome: No responsibility and poor accountability.

 

I have seen many patients who have full coverage, they have seen numerous providers in PC (also ED) for PUD sx. We have told them time and time again what foods/additives/ETOH/tobacco etc to avoid to prevent recurrence of Sx. But they refuse to follow instructions, they just want a Rx refills. And so they jump from clinic to clinic, each time receiving prescriptions, and the occasional (or frequent) visit to ED after a couple of days of "indulging", yet the previous UGI and/or endoscopy is crystal clear: behavioral changes are a must. Copay for any of the above: NONE.

 

And what about the Dyslipidemic patient who refuses to exercise and eat healthy. In PC we spent a great amount of time attempting to educate certain patients. Yet, I bet the ED colleagues are very familiar with the "vertigo with dyspnea patient", who receives the entire cardiac work-up (covered by insurance) yet upon returning to PC, patient admits that AGAIN has not followed any of the recommendations of the previous 4 or 5 PC providers. And the cycle repeats itself several times every year. Copay: NONE.

 

I ask these patients if they have any idea of the price of all those tests that I get copies of from the ED visit. Their response leaves ME in need of an EKG : "no idea of the cost, I'm here just for my Rx, and don't tell me again to diet/exercise because I don't like it." (this is why they change PCP several times/yr.)

 

On the other hand, we have the wonderful patients who, by virtue of not having medical insurance, they take excellent care of themselves to prevent CV insult, and also to prevent expensive medical visits. They pay for their own yearly physical and whatever else is recommended as preventive measures. They cook, eat healthy, exercise, and take responsibility for their own health. Very proactive individuals.

[winterallsummer]

I think my point was misinterpreted. I am by no means arguing that there is a solution in getting everyone to pile into the clinic or god forbid the ER in record numbers. I was merely pointing out a fact that Japan exemplifies a HC system with frequent office visits that is still successful.

 

Anyways, I stand by my point that access to care early in MANY CASES saves money long term. I understand many screening tests are not economical or efficient - get rid of them. I understand many people come to the ER without true need for emergency care (seems like people are using this as an opportunity to vent about it, no problem I understand we all need to vent!!).

 

If anything this discussion shows that access to care is not enough. On one hand you have stubborn people. Is there really jack you can do about them??? Then on the other hand you have uneducated - not ignorant, but uninformed - people who do not know how to use HC. These are two separate groups that deserve differentiation. The question is how to best address each of them. If 2014 mimics Europe in the essence of huge waiting lists to seek care, both groups need to be addressed.

 

But let's not miss the forest for the trees here, people!

[gelato]

I've been interested in learning more about the Affordable Care Act, has anybody read any books that give a good overview without too much subjective skew?