SB 863 FALLOUT BEGINS TO SETTLE ON HAPLESS HEADS
It doesn't appear that DWC will have time to consider the comments submitted on DWC Forums and to that extent the request for comments seems to have been a charade. The idea now is to put the newly proposed regulations into effect on an emergency basis and then to consider comments later, weeks or months from now. Our information is that many current liens that are awaiting payment will be held until the Spring of 2013. In the meantime, the $150 IMR lien filing fee will go into effect for the Independent Medical Review system and so will the $325 IBR fee for the Independent Billing Review system.
The presumption is that these onerous requirements will drive many providers out of the system altogether. In due course DWC will adopt the requirements that it wants if the insurance companies don't object too strenuously. Insurance companies will be conveniently enabled to pay providers at 65 to 70% of the fee schedule. Then they'll dare the provoked providers to try to collect the rest. The requirement to pay as much as $475 for the right to challenge a wrongful denial of care and a rejected bill is expected to encourage providers to drop out of the workers' comp system.
In other states where similar reductions took place, so many doctors dropped out that the theorized dearth of physicians became real enough so that fees were restored and even raised (Hawaii is an example). The trouble is that the perpetrators of these adverse changes managed to destroy faith in the system so that many of the doctors didn't return. That created a permanent deficit of access to care. So far that looks to be where SB 863 is going.
Early lien filing may be the PTP's only option. It looks as though injured workers lose again even though Permanent Disability was given an infusion by SB 863. The trouble is that the infusion has been diluted. Our injured workers have been left worse off and now need a transfusion.
Friday, December 14, 2012
Sunday, December 9, 2012
SB 863: A Political Tsunami in California
When Governor Brown declined to accept legislation that would have been a partial fix for workers' compensation at the end of 2011, he said he wanted an overall solution, not a piecemeal adjustment.
Among the politically savvy persons who heeded this admonition was Angie Wei, indefatigable chief lobbyist and legislative director for the California Labor Federation. Wei deftly developed her version of a comprehensive fix. What labor wanted most was an increase in permanent disability. Wei got that, or so it seemed, in the form of $740 million added to permanent disability. Speaking early on about SB 863, Wei said "there is no other path to getting $740 million back in benefits to injured workers. The legislature must pass SB 863." Wei, not exactly a friend of specialty medical doctors, also protested against them when she complained that previous legislation caused medical treatment to be delayed because of "opposition from vendors who profit from the status quo."
SB 863 doesn't appear so far to be as good as its promise. Wei quickly understood that Governor Brown wanted a bipartisan bill, not one crafted only by the labor federation, and not one crafted entirely by insurance companies. Score one for Brown: he forced the two extremes to work together.
Grimmway Farms, Sean McNally, Vice President for corporate and Government Affairs, soon became the chief player for business. No way Big Biz was going to let $740 million slip into Permanent Disability (PD) funding without getting something in return. Pouncing on some of the more abused parts of PD funding, Grimmway et al focussed on out-patient surgery centers, sleep impairments (dyssomnia), and sexual dysfunction (impaired sexual ability even when secondary to spinal injury). The open sesame to the assault on sex-and-sleep was the frequent inclusion of these complaints by applicants' attorneys into their legal pleadings. Deductions emerged:
* Sleep impairment remains open for treatment but not for inclusion in permanent disability claims: this exclusion alone takes $40 million away from the PD pot.
* Sexual impairment remains open for treatment but not for inclusion in permanent disability claims: this exclusion takes $10 million from the PD pot.
* The big slam is the removal of $110 million for out-patient surgery centers.
* All in all, current estimates are that of the $740 million Wei originally sought, about $200 million has already been lost thanks to the maneuvering of Grimmway which in this matter out-maneuvered Wei and Cal Fed.
* Two pro-injured workers bills bit the dust as SB 863 paddled furiously to victory: AB 369 (Huffman) and AB 1867 (Fong). The fun-filled irony in the case of these two bills was that their authors voted in favor of SB 863 the passage of which was then used to tell authors Huffman and Fong that their bills were no longer needed. Huffman's bill was designed to put a stop to step-therapy and was supported by Big Pharmacy, Pfizer, among others. Fong's bill would have required 12-point bold type on the first page of treatment authorization denial letters "so as to be prominently visible to the employee."
So step-therapy which prevents doctors from prescribing medications of choice is still the rule and so is keeping injured workers in the dark. The insurance companies wanted both bills defeated: they got their wish because Brown obliged and used SB 863 as the cudgel to do it. Score another for Brown, in fact, a double-score since he nailed both bills. The workers, ostensibly the constituents that Wei and Cal Fed wanted to serve, lost.
A big time score goes to Governor Brown because one day before passage of SB 863 when it looked as though the bill was going down to defeat Brown went to work in high gear and took up his own lobbying cudgel. Effective lobbying from the California Society of Industrial Medicine and Surgery (CSIMS), directed by Carl Brakensiek and Steve Cattolica of AdvoCal, assisted by the California Society of Physical Medicine and Rehabilitation (CSPMR), the California Neurology Society (CNS), The California Chapter of the International Association of Rehabilitation Professionals, VQ OrthoCare, and the Californa Workers Compensation Services Association, almost defeated the bill despite abandonment of the California Medical Association (CMA) and the American Federation of State, County and Municipal Employees (AFSCME) both of whom voted for passage of SB 863. CMA and AFSCME knuckled under to Brown.
The CMA is credited with getting the Medicare RBRVS modified and once that was done agreed to support the bill. Consultations in workers' comp will be allowed although they're no longer allowed in standard Medicare. AFSCME which represents a few thousand doctors in California wanted to befriend Brown more than it wanted to support its dues-paying doctors and assumed that its doctor members wouldn't protest with too much vigor. AFSCME's political judgment so far has turned out to be correct.
When Brown saw that SB 863 was in trouble, he went to work. He lobbied and asserted the bill would "reduce litigation, claims administration costs, and other frictional costs." He personally lobbied for the bill, actually, furiously in the last two days. His hard work paid off. Score a personal hard-earned political triumph for Governor Brown and chalk up a loss for a medical community that knows how to provide services but not how to persuade anybody that what we do is as worthwhile as we say.
Our opposing position was, and still is, that the bill strips injured workers of their ability to appeal wrongful decisions while also cutting the $740 million for PD by at least $200 million. What Brown calls "frictional costs" are actually the lifeblood costs that injured workers incur in appeals. Appeals for wrongful decisions to the WCAB are eliminated by SB 863 which creates an Independent Medical Review (IMR) process that'll rely on anonymous doctors whose decisions are nearly appeal-proof.
In fact, what Brown was really after all along was Proposition 30 to allow increased taxes. To get it he needed to take down the heat from Big Business. Brown worked to get SB 863 passed to reduce the level of interest against Proposition 30. The strategy worked. The trouble now is the fiscal cliff which, if the country falls off it, will result in widespread financial hardship and will nullify much of what Proposition 30 just won.
Our focus now is on the Independent Medical Review system that has been designed to replace the current Utilization Review system. The IMR system retains the worst aspects of UR, i.e., no need to be licensed to practice medicine in California and no need to interview or examine the patients from whom treatment opportunities may be withdrawn. The IMR method gets an additional advantage, namely, the promise of anonymity so that appeals against even the stupidest of judgments resulting in harmful denial of care will be turned away and will not be eligible for appeal to the WCAB.
Statewide implications
The move is on to restrict access to medical care and shift the blame to doctors, particularly the conveniently convened IMR doctors. The name of the game is cost-reduction while touting improved quality of care. In California, access to the WCAB is being restricted; however, similar wrongful uses of denial-of-care are used by HMOs and in Knox-Keene plans. This accelerating trend deserves to be derailed.
Federal implications
The current IPAB derived from the ACA (Obamacare) also promotes cost conservation at the risk of harming patients. These techniques are being adopted by the ACOs even faster than they were by the HMOs. This trend also begs to be derailed.
When Governor Brown declined to accept legislation that would have been a partial fix for workers' compensation at the end of 2011, he said he wanted an overall solution, not a piecemeal adjustment.
Among the politically savvy persons who heeded this admonition was Angie Wei, indefatigable chief lobbyist and legislative director for the California Labor Federation. Wei deftly developed her version of a comprehensive fix. What labor wanted most was an increase in permanent disability. Wei got that, or so it seemed, in the form of $740 million added to permanent disability. Speaking early on about SB 863, Wei said "there is no other path to getting $740 million back in benefits to injured workers. The legislature must pass SB 863." Wei, not exactly a friend of specialty medical doctors, also protested against them when she complained that previous legislation caused medical treatment to be delayed because of "opposition from vendors who profit from the status quo."
SB 863 doesn't appear so far to be as good as its promise. Wei quickly understood that Governor Brown wanted a bipartisan bill, not one crafted only by the labor federation, and not one crafted entirely by insurance companies. Score one for Brown: he forced the two extremes to work together.
Grimmway Farms, Sean McNally, Vice President for corporate and Government Affairs, soon became the chief player for business. No way Big Biz was going to let $740 million slip into Permanent Disability (PD) funding without getting something in return. Pouncing on some of the more abused parts of PD funding, Grimmway et al focussed on out-patient surgery centers, sleep impairments (dyssomnia), and sexual dysfunction (impaired sexual ability even when secondary to spinal injury). The open sesame to the assault on sex-and-sleep was the frequent inclusion of these complaints by applicants' attorneys into their legal pleadings. Deductions emerged:
* Sleep impairment remains open for treatment but not for inclusion in permanent disability claims: this exclusion alone takes $40 million away from the PD pot.
* Sexual impairment remains open for treatment but not for inclusion in permanent disability claims: this exclusion takes $10 million from the PD pot.
* The big slam is the removal of $110 million for out-patient surgery centers.
* All in all, current estimates are that of the $740 million Wei originally sought, about $200 million has already been lost thanks to the maneuvering of Grimmway which in this matter out-maneuvered Wei and Cal Fed.
* Two pro-injured workers bills bit the dust as SB 863 paddled furiously to victory: AB 369 (Huffman) and AB 1867 (Fong). The fun-filled irony in the case of these two bills was that their authors voted in favor of SB 863 the passage of which was then used to tell authors Huffman and Fong that their bills were no longer needed. Huffman's bill was designed to put a stop to step-therapy and was supported by Big Pharmacy, Pfizer, among others. Fong's bill would have required 12-point bold type on the first page of treatment authorization denial letters "so as to be prominently visible to the employee."
So step-therapy which prevents doctors from prescribing medications of choice is still the rule and so is keeping injured workers in the dark. The insurance companies wanted both bills defeated: they got their wish because Brown obliged and used SB 863 as the cudgel to do it. Score another for Brown, in fact, a double-score since he nailed both bills. The workers, ostensibly the constituents that Wei and Cal Fed wanted to serve, lost.
A big time score goes to Governor Brown because one day before passage of SB 863 when it looked as though the bill was going down to defeat Brown went to work in high gear and took up his own lobbying cudgel. Effective lobbying from the California Society of Industrial Medicine and Surgery (CSIMS), directed by Carl Brakensiek and Steve Cattolica of AdvoCal, assisted by the California Society of Physical Medicine and Rehabilitation (CSPMR), the California Neurology Society (CNS), The California Chapter of the International Association of Rehabilitation Professionals, VQ OrthoCare, and the Californa Workers Compensation Services Association, almost defeated the bill despite abandonment of the California Medical Association (CMA) and the American Federation of State, County and Municipal Employees (AFSCME) both of whom voted for passage of SB 863. CMA and AFSCME knuckled under to Brown.
The CMA is credited with getting the Medicare RBRVS modified and once that was done agreed to support the bill. Consultations in workers' comp will be allowed although they're no longer allowed in standard Medicare. AFSCME which represents a few thousand doctors in California wanted to befriend Brown more than it wanted to support its dues-paying doctors and assumed that its doctor members wouldn't protest with too much vigor. AFSCME's political judgment so far has turned out to be correct.
When Brown saw that SB 863 was in trouble, he went to work. He lobbied and asserted the bill would "reduce litigation, claims administration costs, and other frictional costs." He personally lobbied for the bill, actually, furiously in the last two days. His hard work paid off. Score a personal hard-earned political triumph for Governor Brown and chalk up a loss for a medical community that knows how to provide services but not how to persuade anybody that what we do is as worthwhile as we say.
Our opposing position was, and still is, that the bill strips injured workers of their ability to appeal wrongful decisions while also cutting the $740 million for PD by at least $200 million. What Brown calls "frictional costs" are actually the lifeblood costs that injured workers incur in appeals. Appeals for wrongful decisions to the WCAB are eliminated by SB 863 which creates an Independent Medical Review (IMR) process that'll rely on anonymous doctors whose decisions are nearly appeal-proof.
In fact, what Brown was really after all along was Proposition 30 to allow increased taxes. To get it he needed to take down the heat from Big Business. Brown worked to get SB 863 passed to reduce the level of interest against Proposition 30. The strategy worked. The trouble now is the fiscal cliff which, if the country falls off it, will result in widespread financial hardship and will nullify much of what Proposition 30 just won.
Our focus now is on the Independent Medical Review system that has been designed to replace the current Utilization Review system. The IMR system retains the worst aspects of UR, i.e., no need to be licensed to practice medicine in California and no need to interview or examine the patients from whom treatment opportunities may be withdrawn. The IMR method gets an additional advantage, namely, the promise of anonymity so that appeals against even the stupidest of judgments resulting in harmful denial of care will be turned away and will not be eligible for appeal to the WCAB.
Statewide implications
The move is on to restrict access to medical care and shift the blame to doctors, particularly the conveniently convened IMR doctors. The name of the game is cost-reduction while touting improved quality of care. In California, access to the WCAB is being restricted; however, similar wrongful uses of denial-of-care are used by HMOs and in Knox-Keene plans. This accelerating trend deserves to be derailed.
Federal implications
The current IPAB derived from the ACA (Obamacare) also promotes cost conservation at the risk of harming patients. These techniques are being adopted by the ACOs even faster than they were by the HMOs. This trend also begs to be derailed.
Sunday, November 25, 2012
Accountable Care Organizations: Gag clauses, firing doctors, liability, and profits
Accountable Care Organizations (ACOs), encouraged by the Affordable Care Act (ACA), aka Obamacare, brace for trouble while preparing for profits.
One of the questions we're being asked is whether or not ACOs may impose gag clauses, e.g., if a treating physician wants to prescribe a diagnostic test or treatment, and said diagnostic test or treatment is not authorized or is denied by the ACO, may the treating physician tell that to the patient who has been denied a diagnostic test or treatment? May the cost of the procedure to the ACO be discussed with the employee or patient?
Our initial reaction to reply affirmatively is tempered by our understanding that a recommended study or treatment would have been discussed first with the patient who would presumably already have agreed to it and would know about any non-authorization or denial. But we also observe contract language that physicians are precluded from discussing disagreements about compensation "and other matters" with patients. The treating physician is told in contractual language that where "disagreement cannot be resolved ... under no circumstances shall such disagreement be expressed to the Enrollee."
Contractual language tells the doctors that they may not discuss what the ACO has determined is protected information "to any person ... until such person agrees in writing to be bound by the provisions of this Agreement ..." We take this preclusion to mean that doctors cannot discuss ACO disagreements even with their own lawyers unless the lawyers agree to be gagged!
What lawyer would agree to being gagged before having heard the case?
These gag clauses are reminiscent of the 1990s when HMOs sought to muzzle doctors (see references below). Both the HMOs at that time and the ACOs as currently construed have contract language that allows them to fire doctors at will. Such power is essential to keeping the doctors in their place, compliant, subservient, and dependent.
The ACO agreements we've seen so far carry both "termination without cause" as well as "termination with cause" clauses. The latter are often subsequent to what the ACO may have called a "material breach" which is defined by the ACO itself and generally refers to what the ACO calls information that "that compromises the security or privacy" of information considered proprietary or confidential. Disclosure of this information to patients could be considered a "material breach." That the patient has "right to know" might be a legal defense but it would not preclude ACO management from firing the doctor.
Potential participants, physicians and patients alike, need to understand that ACOs are business organizations selling and dispensing health care services. They are entitled to make profits which they can then distribute to their own business associates as a second source of income in addition to whatever fees have already been paid. One selling point is that ACOs will cut down on unneeded tests and treatment but a countervailing point is that along the way the ACO may deny access to diagnostic tests and treatments with harm coming to patients while participating physicians are not allowed to speak out under penalty of being fired from the ACO.
Questions of medical-legal liability are already being asked: who gets blamed for what if an indicated study or treatment is denied and the patient suffers or dies as a result? Is there liability to physicians who've kept this information under wraps in compliance with ACO non-disclosure policy?
How will profits and payment to providers, including physicians, be determined? One contract we've examined says straight out that the ACO will make that determination, e.g., "Physician agrees that decisions (by the ACO, actual name deleted) ... management and other administrative policies and procedures may be used by (ACO) to deny or reduce payment ..."
In essence this language means that whatever fee schedule the physicians signed may be abrogated, changed, or set aside at the will of the ACO. No bargaining or negotiating is required or encouraged.
All the same "bonus payments" or the prospect thereof will remain in effect. This section of the ACO agreement means that ACOs that actually achieve what they call "savings" will be allowed to allocate a portion of the "savings" to providers as "bonus payments" or additional income, essentially a second source of income, to participating providers. That helps to explain why ACOs will favor primary care physicians as opposed to specialists since it is the latter that usually prescribe expensive tests and the most up-to-date and often most expensive treatment protocols. The "gag clause" will stop timorous physicians from explaining too much to patients about how ACOs work their magic.
ACOs need primary treating physicians to ensure "savings." While specialists with their expensive procedures may be necessary to ensure quality of care, they'll be carefully scrutinized -- call it "economic credentials" (see references below) -- to make sure that they don't have too much impact on profits which the ACOs refer to as "savings." Finally, expect that bonus payments to treating doctors will be limited with the bulk of savings going to the ACO itself and to additional executive compensation.
While the ACO mechanism is more sophisticated than the old HMO methods, they have in common that the goal is financial gain with as much devotion to patient care as can be accommodated.
HMO References
"Why HMOs want to muzzle doctors," San Francisco Examiner, 4 April 96, by Robert L. Weinmann
"Medical Red-Lining, Economic Credentials for Physicians, 12 January 96, by Robert L. Weinmann
The Congressional Record, Vol. 144, # 118, commentary by Hon. Tom Campbell, R-California, 9 September 98
ACO References
"A Hospital War Reflects a Bind for Doctors in the U.S.," New York Times, 11/30/12, by Julie Creswell and Reed Abelson
"Covered California's Plans to Become Self-Sufficient," California Healthline, 11/19/12, by David Gorn
"California's Role In Ensuring That the Potential of Health Reform Becomes Reality," Health Affairs, 30, no. 1 (2011): 71-75
One of the questions we're being asked is whether or not ACOs may impose gag clauses, e.g., if a treating physician wants to prescribe a diagnostic test or treatment, and said diagnostic test or treatment is not authorized or is denied by the ACO, may the treating physician tell that to the patient who has been denied a diagnostic test or treatment? May the cost of the procedure to the ACO be discussed with the employee or patient?
Our initial reaction to reply affirmatively is tempered by our understanding that a recommended study or treatment would have been discussed first with the patient who would presumably already have agreed to it and would know about any non-authorization or denial. But we also observe contract language that physicians are precluded from discussing disagreements about compensation "and other matters" with patients. The treating physician is told in contractual language that where "disagreement cannot be resolved ... under no circumstances shall such disagreement be expressed to the Enrollee."
Contractual language tells the doctors that they may not discuss what the ACO has determined is protected information "to any person ... until such person agrees in writing to be bound by the provisions of this Agreement ..." We take this preclusion to mean that doctors cannot discuss ACO disagreements even with their own lawyers unless the lawyers agree to be gagged!
What lawyer would agree to being gagged before having heard the case?
These gag clauses are reminiscent of the 1990s when HMOs sought to muzzle doctors (see references below). Both the HMOs at that time and the ACOs as currently construed have contract language that allows them to fire doctors at will. Such power is essential to keeping the doctors in their place, compliant, subservient, and dependent.
The ACO agreements we've seen so far carry both "termination without cause" as well as "termination with cause" clauses. The latter are often subsequent to what the ACO may have called a "material breach" which is defined by the ACO itself and generally refers to what the ACO calls information that "that compromises the security or privacy" of information considered proprietary or confidential. Disclosure of this information to patients could be considered a "material breach." That the patient has "right to know" might be a legal defense but it would not preclude ACO management from firing the doctor.
Potential participants, physicians and patients alike, need to understand that ACOs are business organizations selling and dispensing health care services. They are entitled to make profits which they can then distribute to their own business associates as a second source of income in addition to whatever fees have already been paid. One selling point is that ACOs will cut down on unneeded tests and treatment but a countervailing point is that along the way the ACO may deny access to diagnostic tests and treatments with harm coming to patients while participating physicians are not allowed to speak out under penalty of being fired from the ACO.
Questions of medical-legal liability are already being asked: who gets blamed for what if an indicated study or treatment is denied and the patient suffers or dies as a result? Is there liability to physicians who've kept this information under wraps in compliance with ACO non-disclosure policy?
How will profits and payment to providers, including physicians, be determined? One contract we've examined says straight out that the ACO will make that determination, e.g., "Physician agrees that decisions (by the ACO, actual name deleted) ... management and other administrative policies and procedures may be used by (ACO) to deny or reduce payment ..."
In essence this language means that whatever fee schedule the physicians signed may be abrogated, changed, or set aside at the will of the ACO. No bargaining or negotiating is required or encouraged.
All the same "bonus payments" or the prospect thereof will remain in effect. This section of the ACO agreement means that ACOs that actually achieve what they call "savings" will be allowed to allocate a portion of the "savings" to providers as "bonus payments" or additional income, essentially a second source of income, to participating providers. That helps to explain why ACOs will favor primary care physicians as opposed to specialists since it is the latter that usually prescribe expensive tests and the most up-to-date and often most expensive treatment protocols. The "gag clause" will stop timorous physicians from explaining too much to patients about how ACOs work their magic.
ACOs need primary treating physicians to ensure "savings." While specialists with their expensive procedures may be necessary to ensure quality of care, they'll be carefully scrutinized -- call it "economic credentials" (see references below) -- to make sure that they don't have too much impact on profits which the ACOs refer to as "savings." Finally, expect that bonus payments to treating doctors will be limited with the bulk of savings going to the ACO itself and to additional executive compensation.
While the ACO mechanism is more sophisticated than the old HMO methods, they have in common that the goal is financial gain with as much devotion to patient care as can be accommodated.
HMO References
"Why HMOs want to muzzle doctors," San Francisco Examiner, 4 April 96, by Robert L. Weinmann
"Medical Red-Lining, Economic Credentials for Physicians, 12 January 96, by Robert L. Weinmann
The Congressional Record, Vol. 144, # 118, commentary by Hon. Tom Campbell, R-California, 9 September 98
ACO References
"A Hospital War Reflects a Bind for Doctors in the U.S.," New York Times, 11/30/12, by Julie Creswell and Reed Abelson
"Covered California's Plans to Become Self-Sufficient," California Healthline, 11/19/12, by David Gorn
"California's Role In Ensuring That the Potential of Health Reform Becomes Reality," Health Affairs, 30, no. 1 (2011): 71-75
Tuesday, November 20, 2012
ACCOUNTABLE CARE ORGANIZATIONS
The latest hot ticket item in healthcare now that the presidential election is over is the implementation of the most controversial aspects of the Affordable Care Act (ACA), namely, the individual mandate to buy health insurance, or else. Health insurance exchanges are ready to make their move as are specific Accountable Care Organizations (ACOs).
ACOs will be comprised of hospitals, primary care physicians, and specialists who are supposed to accept being held accountable for the cost and quality of the healthcare they provide. Fiscal carrots is the name of the game because providers will continue to be paid on a fee-for-service basis and will share in whatever revenue is brought about by whatever cost-savings techniques the ACOs use, e.g., not accepting doctors who have too many elderly patients or patients with expensive chronic diseases. The days of searching out rare and unusual diseases to care for are over: these unfortunates will be obliged to find whatever comfort is available under the nearest bus. If the ACO is well managed from a fiscal perspective, providing participants will share in the savings as a second source of income. Quietly, with as little fanfare as possible, physicians and hospitals will be encouraged to avoid the sickest, oldest, and most complicated patients. Meanwhile, the ACA calls for expanding Medicaid despite a looming shortage of doctors.
Medicaid is supposedly administered on a state-by-state level. In June of 2012 the Supreme Court (SCOTUS) gave states an option to keep their Medicaid programs as is or expand them. So far, however, only 17 states and the District of Columbia have said they'll develop their own exchanges. Increasingly, therefore, it appears as though the federal government will pick up the exchanges by default and with it increased control of medical care.
Medicare cuts in the amount ot $716 billion are ready. President Obama said he wouldn't cut Medicare itself, just the fees paid to all of the providers. Physicians, already getting only 18 cents on the dollar, will not be overjoyed and many are likely to stop accepting new Medicare patients.
Here's a comment from HHS: "The Department and its partners should be vigilant in identifying ... emerging fraud, waste, and abuse risk areas across all ACA-related programs ... this will require a comprehensive approach to program integrity that integrates effective front-end program gatekeeping (itlaics added)."
In 1998 this writer spoke at the White House in a press conference with then President Clinton. "Gatekeeping" was exposed as a mechanism to reduce patients' access to care. HMOs, seeing the handwriting on the wall, reformed their "gatekeeping" methods. Now, under the ACA, we're seeing new scribbling on the wall that'll enable return of the "gatekeepers."
Beware, patients: your illness may be your ticket to the hoosegow. Not to worry, though, your doctor will be in a near-by cell. The accusations will be "fraud" and "waste."
When your ACO contract arrives, you will need advice about what to do. Your first problem will be where to get that advice. Not to worry. In due course a new legal specialty will emerge.
ACOs will be comprised of hospitals, primary care physicians, and specialists who are supposed to accept being held accountable for the cost and quality of the healthcare they provide. Fiscal carrots is the name of the game because providers will continue to be paid on a fee-for-service basis and will share in whatever revenue is brought about by whatever cost-savings techniques the ACOs use, e.g., not accepting doctors who have too many elderly patients or patients with expensive chronic diseases. The days of searching out rare and unusual diseases to care for are over: these unfortunates will be obliged to find whatever comfort is available under the nearest bus. If the ACO is well managed from a fiscal perspective, providing participants will share in the savings as a second source of income. Quietly, with as little fanfare as possible, physicians and hospitals will be encouraged to avoid the sickest, oldest, and most complicated patients. Meanwhile, the ACA calls for expanding Medicaid despite a looming shortage of doctors.
Medicaid is supposedly administered on a state-by-state level. In June of 2012 the Supreme Court (SCOTUS) gave states an option to keep their Medicaid programs as is or expand them. So far, however, only 17 states and the District of Columbia have said they'll develop their own exchanges. Increasingly, therefore, it appears as though the federal government will pick up the exchanges by default and with it increased control of medical care.
Medicare cuts in the amount ot $716 billion are ready. President Obama said he wouldn't cut Medicare itself, just the fees paid to all of the providers. Physicians, already getting only 18 cents on the dollar, will not be overjoyed and many are likely to stop accepting new Medicare patients.
Here's a comment from HHS: "The Department and its partners should be vigilant in identifying ... emerging fraud, waste, and abuse risk areas across all ACA-related programs ... this will require a comprehensive approach to program integrity that integrates effective front-end program gatekeeping (itlaics added)."
In 1998 this writer spoke at the White House in a press conference with then President Clinton. "Gatekeeping" was exposed as a mechanism to reduce patients' access to care. HMOs, seeing the handwriting on the wall, reformed their "gatekeeping" methods. Now, under the ACA, we're seeing new scribbling on the wall that'll enable return of the "gatekeepers."
Beware, patients: your illness may be your ticket to the hoosegow. Not to worry, though, your doctor will be in a near-by cell. The accusations will be "fraud" and "waste."
When your ACO contract arrives, you will need advice about what to do. Your first problem will be where to get that advice. Not to worry. In due course a new legal specialty will emerge.
Monday, October 29, 2012
The Affordable Care Act (Obamacare) with emphasis on the Independent Payment Advisory Board (IPAB): Memo to Subscribers & Followers of www.politicsofhealthcare.com The hot-button issue in healthcare this week is the Affordable Care Act (ACA), known as Obamacare to some. Within the text of the ACA is an item known as the Independent Payment Advisory Board (IPAB). The IPAB is the section of the law that will allow unelected appointees to overrule treatment decisions made by our personal physicians. The IPAB is empowered by Sections 3403 and 10320 of the ACA. This writer has found large enough fault with the IPAB to have called for its repeal regardless of whatever fate befalls the rest of the ACA. The fate of the ACA is likely to be decided on November 6th -- President Obama wants to keep the ACA as is, Governor Romney wants to repeal the whole thing. Check out our posts on this topic, e.g., January 18, 2011; June 29, 2012; October 4, 2012; and October 20, 2012 (this last one updated on October 29, 2012). When you check out the posts of 1/18/11, 6/29/12, and 10/20/12 you'll see reprints of my comments in POLITICO. Click on the box to enlarge the print to read the comments. Let me know what you think by commenting directly on-line at www.politicsofhealthcare.com (we do not sell, rent, or share your e-mail addresses with others. Your comment will be considered for publication unless you ask us not to publish). -- RLW, Ed.
Saturday, October 20, 2012
OBAMACARE: "DOCTORS ET CETERA" IN THE ACA AND IPAB
DO IT OUR WAY OR DIE
October 29th Update to Politico comment of October 22nd. The above comment is in reference to "Presidential debate: 5 things to watch Monday" by MAGGIE HABERMAN and GLENN THRUSH | 10/22/12 4:23 AM EDT.
Read more: http://www.politico.com/news/
The highwater mark of Obamacare is carried in the bowels of the Independent Payment Advisory Board (IPAB), a level that hasn't yet been reached because the Affordable Care Act (ACA) is still in its infancy. It is the IPAB that will have the authority to declare entire diagnostic and treatment protocols too extravagant not only for Medicare but also for the general public and therefore not covered or payable by the ACA -- that's when Obamacare will become known for its bite.
But that bite won't chomp on President Obama or Congress because both of them are exempt from the ACA. Did you know that? Congress has its own health care plan. The Congressional plan does not include an IPAB to water down care by restricting access to diagnostic testing and treatment. The current ACA does just that. The IPAB portion of the ACA should be repealed even if we continue to debate the rest of it.
Keep in mind that Congress keeps special healthcare benefits handy for itself including access to treatment at military hospitals.
In the autumn of 2009 President Obama stated "I will ensure that no government bureaucrat gets between you and the care you need." It's probably safe to say he wasn't thinking of the IPAB at the time. President Obama has now promised a minimum of 15 brand new bureaucrats.
In the first debate, President Obama said the IPAB would consist of "doctors et cetera." The fact is that there'll be plenty of "et cetera" but there's no obligation under the ACA that any of the 15 appointees to the IPAB must be a physician.
Governor Romney did no better than the president because he didn't seem to realize that President Obama was winging it when he said "doctors et cetera." What else does Governor Romney not know about the ACA except that he prefers his pals in the insurance industry, the blokes who rescind health care contracts once the subscriber has the temerity to get sick?
For a guy known for his financial expertise, we're surprised that the Governor failed to mention that each one of the 15 appointees to the IPAB will be paid $165,000 annually for a total annual budget of $2,475,000 just for the 15 appointees -- staff and resource time will get counted later, right?
The IPAB can be repealed without repealing the entire bill. The mechanism would be to rescind Sections 3403 and 10320. The current stand-off means that one side won't improve what's wrong with the ACA and the other side would repeal all of it to bring back the greed-soaked insurance companies.
See also our October 4th blog; use the glossary to find more articles about the IPAB, the ACA, and related topics.
October 29th Update to Politico comment of October 22nd. The above comment is in reference to "Presidential debate: 5 things to watch Monday" by MAGGIE HABERMAN and GLENN THRUSH | 10/22/12 4:23 AM EDT.
Read more: http://www.politico.com/news/
The highwater mark of Obamacare is carried in the bowels of the Independent Payment Advisory Board (IPAB), a level that hasn't yet been reached because the Affordable Care Act (ACA) is still in its infancy. It is the IPAB that will have the authority to declare entire diagnostic and treatment protocols too extravagant not only for Medicare but also for the general public and therefore not covered or payable by the ACA -- that's when Obamacare will become known for its bite.
But that bite won't chomp on President Obama or Congress because both of them are exempt from the ACA. Did you know that? Congress has its own health care plan. The Congressional plan does not include an IPAB to water down care by restricting access to diagnostic testing and treatment. The current ACA does just that. The IPAB portion of the ACA should be repealed even if we continue to debate the rest of it.
Keep in mind that Congress keeps special healthcare benefits handy for itself including access to treatment at military hospitals.
In the autumn of 2009 President Obama stated "I will ensure that no government bureaucrat gets between you and the care you need." It's probably safe to say he wasn't thinking of the IPAB at the time. President Obama has now promised a minimum of 15 brand new bureaucrats.
In the first debate, President Obama said the IPAB would consist of "doctors et cetera." The fact is that there'll be plenty of "et cetera" but there's no obligation under the ACA that any of the 15 appointees to the IPAB must be a physician.
Governor Romney did no better than the president because he didn't seem to realize that President Obama was winging it when he said "doctors et cetera." What else does Governor Romney not know about the ACA except that he prefers his pals in the insurance industry, the blokes who rescind health care contracts once the subscriber has the temerity to get sick?
For a guy known for his financial expertise, we're surprised that the Governor failed to mention that each one of the 15 appointees to the IPAB will be paid $165,000 annually for a total annual budget of $2,475,000 just for the 15 appointees -- staff and resource time will get counted later, right?
The IPAB can be repealed without repealing the entire bill. The mechanism would be to rescind Sections 3403 and 10320. The current stand-off means that one side won't improve what's wrong with the ACA and the other side would repeal all of it to bring back the greed-soaked insurance companies.
See also our October 4th blog; use the glossary to find more articles about the IPAB, the ACA, and related topics.
Thursday, October 4, 2012
AFFORDABLE CARE ACT LOSES DEBATE
OBAMA and ROMNEY Debate each other but the loser is The Affordable Care Act.
It appears as though President Obama likes the name, Obamacare, for the Affordable Care Act (ACA). It wouldn't hurt if he understood his own legislation better. On other hand, why should he? He and Congress are exempt from it. Romney simply doesn't need it.
Romney said during the debate of 3 October 2012 that Obamacare "puts in place an unelected board that's going to tell people ultimately what kind of treatments they can have." Romney doesn't like that idea. Except he has incorrectly, some would say on purpose, misconstrued the unelected board, named the Independent Payment Advisory Board (IPAB). It will consist of political appointees none of whom need be a physician. Its purpose will be to oversee Medicare costs. The IPAB will have the power to shut down certain costs incurred by Medicare if costs soar out of control and Congress fails to intervene. The IPAB will not be enabled to tell individual physicians what tests to order or what treatment should be used. It will not be allowed to ration care on a patient-by-patient basis. It will not be empowered to raise the Medicare eligibility age or shift costs to retireds. What the IPAB will have will be the power to determine which diagnostic and treatment protocols aren't worth funding anymore and will in that way ration care for the entire Medicare population, the same as when private insurance companies tell hapless patients that they're seeking what they determined in cloaked boardrooms were actually "non-covered benefits," i.e., you pay for it yourself because this or that benefit is not included in your private health care plan. The IPAB method constitutes a form of sophisticated rationing, but it's not on an individual patient-by-patient basis.
Obama said that the IPAB would be composed of "doctors et cetera." Not necessarily. There's no provision in the ACA that requires doctors to be appointed to the IPAB. Obama himself evidently didn't know that when he made his comment, either that or he sought to hoodwink the audience. The 15 or so appointees to the IPAB will be political appointees who will not need to report directly to Congress. They will not be elected so they won't represent the public or an electorate. Their job will be to make economic judgments when they decide which diagnostic and treatment protocols will be covered by Medicare and which won't be covered. In short, your doctor can prescribe whatever he wants. But your doctor can't make Medicare pay for it. And neither can you.
The IPAB is empowered by Sections 3403 and 10320 of the ACA. These sections of the ACA should be repealed. We'll have more to say in due course. So should Obama and Romney. The October 3rd debate showed that both candidates have lots more to learn about the ACA. For instance, they can tell us if it's correct that the members of this board are to be paid $165,000 per year at a total public cost of $2,475,000. Repealing these two sections of the ACA will save taxpayers nearly $2.5 million.
It appears as though President Obama likes the name, Obamacare, for the Affordable Care Act (ACA). It wouldn't hurt if he understood his own legislation better. On other hand, why should he? He and Congress are exempt from it. Romney simply doesn't need it.
Romney said during the debate of 3 October 2012 that Obamacare "puts in place an unelected board that's going to tell people ultimately what kind of treatments they can have." Romney doesn't like that idea. Except he has incorrectly, some would say on purpose, misconstrued the unelected board, named the Independent Payment Advisory Board (IPAB). It will consist of political appointees none of whom need be a physician. Its purpose will be to oversee Medicare costs. The IPAB will have the power to shut down certain costs incurred by Medicare if costs soar out of control and Congress fails to intervene. The IPAB will not be enabled to tell individual physicians what tests to order or what treatment should be used. It will not be allowed to ration care on a patient-by-patient basis. It will not be empowered to raise the Medicare eligibility age or shift costs to retireds. What the IPAB will have will be the power to determine which diagnostic and treatment protocols aren't worth funding anymore and will in that way ration care for the entire Medicare population, the same as when private insurance companies tell hapless patients that they're seeking what they determined in cloaked boardrooms were actually "non-covered benefits," i.e., you pay for it yourself because this or that benefit is not included in your private health care plan. The IPAB method constitutes a form of sophisticated rationing, but it's not on an individual patient-by-patient basis.
Obama said that the IPAB would be composed of "doctors et cetera." Not necessarily. There's no provision in the ACA that requires doctors to be appointed to the IPAB. Obama himself evidently didn't know that when he made his comment, either that or he sought to hoodwink the audience. The 15 or so appointees to the IPAB will be political appointees who will not need to report directly to Congress. They will not be elected so they won't represent the public or an electorate. Their job will be to make economic judgments when they decide which diagnostic and treatment protocols will be covered by Medicare and which won't be covered. In short, your doctor can prescribe whatever he wants. But your doctor can't make Medicare pay for it. And neither can you.
The IPAB is empowered by Sections 3403 and 10320 of the ACA. These sections of the ACA should be repealed. We'll have more to say in due course. So should Obama and Romney. The October 3rd debate showed that both candidates have lots more to learn about the ACA. For instance, they can tell us if it's correct that the members of this board are to be paid $165,000 per year at a total public cost of $2,475,000. Repealing these two sections of the ACA will save taxpayers nearly $2.5 million.
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