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ppaca

The one where I get all soapboxy about the term Obamacare

Tidal Basin

Dear Friends, Pundits, and Politicians,

Can we please stop calling health reform Obamacare?

Opponents began calling the health reform law and its associated components Obamacare as a way to both detract from the law and the President. Those who are not in favor of the PPACA report on Obamacare’s problems and challenges; linking the bill and the President hand in hand with some scary story about how Americans will somehow be less well off if more people have access to healthcare. Let’s defund Obamacare sounds a little to me like taking your toys and going home.

[And, correct me if I’m wrong, I don’t remember calling anything the Bushwar, Clintonbudget or Kennedymoonmission - when did taking liberties with the President’s name become acceptable?]

Those in favor of the the PPACA have co-opted the term; adopting in as a rally cry for the Act’s benefits. Do you like Obamacare, I think it’s a good thing… people will confide in me during meetings and events. Even CMS and policy wonks promoting the Act use the term frequently. Remember the kid in school with an unkind nickname who eventually started referring him-or-herself by the nickname? I bet they didn’t love it, deep down inside.

But here’s the thing…

We’re talking about healthcare. We’re talking about the difference between someone being able to see a doctor or not, to get medications or not, to have better, more fulfilling lives… or not. Making healthcare about politics —and I understand, the two have been an odd couple well before Jack Lemmon and Walter Matthau —does our humanity a disservice.

It’s not Obamacare, it’s the PPACA, health reform, Medicaid expansion, health insurance exchanges, accountable and population health, wellness visits and more.

And besides, spellcheck doesn’t even think Obamacare is a word.

Now, would someone help me down from this soap box, my knees aren’t what they used to be.

From elsewhere: NC hospital closes, but was it really because of politics?

You know you are early for your flight when...

Posting on the Huffington Post, Jeffery Young writes: North Carolina Hospital Closes, Citing No Medicaid Expansion

A small hospital in a coastal North Carolina community will close its doors within months and its parent company says Gov. Pat McCrory’s (R) decision not to expand Medicaid under President Barack Obama’s health care reform law is partly to blame.

But wait, there’s more…

Other considerations, including outdated facilities, also led to the company’s decision to close the hospital but North Carolina foregoing the Medicaid expansion contributed to the decision, Vidant Health CEO David Herman told The Huffington Post.

I’m not surprised we’re seeing smaller community hospitals struggle. Last week the great Mike Sevilla, MD wrote an op-ed for KevinMD questioning: is the end near for small community hospitals?

Without doubt, I think we’ll see more of these closures. But we have to also pay attention to the root cause, particularly in these still early days of PPACA’s implementation.

Note Mr. Herman’s other considerations —outdated facilities. At some point, buying a multimillion dollar scanner or other required life saving equipment for a 49 bed hospital just doesn’t make sense.

It also may not make sense to operate 49 bed hospitals within an hour’s drive of a larger, more sophisticated facility.

We’re seeing the shift away from the shiny hospital on the hill as the only anchor for providers and care delivery for a community.

That story is a lot more interesting than politics and Medicaid expansion.

From Elsewhere: H&R Block using retail locations for insurance exchange enrollment

About to be the least authoritative speaker at Apple's medical event tonight

Writing in Modern Healthcare, Jonathan Block pins: Reform Update: H&R Block, online insurance broker team up to sell health plans

The GoHealth platform will be available through H&R Block both online and over the phone nationwide beginning Oct. 1, said Michael Mahoney, senior vice president of consumer marketing for Chicago-based GoHealth.

Here’s where it gets interesting:

In a separate development, H&R Block on Wednesday said as part of a pilot program, it would have health insurance agents in its tax offices in Arizona to assist with choosing and enrolling in a plan.

Is this really all about the physical footprint of H&R Block’s stores?

It’s not news that funding communication around the rollout of PPACA and health exchanges as been challenge for CMS. What is a problem for the government could be an opportunity for private industry like H&R Block.

In the age of Quicken and TurboTax, its hard to imagine that H&R Block gets as much bang for the buck out of their many physical locations as they once did. By offering in-person health insurance exchange enrollment, they might have found a niche to pull people back in.

What’s next, FedEx and UPS to follow? Maybe Apple could leverage their Genius bar for insurance advice… or, maybe not.

between a Medicare rock and budget hard place

While not originally intended to be a bona fide blog post, the following started life on Google Plus as a reaction to the NPR article below.  So, here we are, between a Medicare rock and budget hard place.

Costs are clearly a problem. Our healthcare system is the most expensive in the world. Take a look at the 2003 figures from the Kaiser Family Foundation. Per capita costs, in 2003, in the US were $3,394 above those of the UK.

We need to work on the costs. That's clear.

But how do we do keep things moving in the mean time? The policy wonks love the airplane analogy: trying to fix healthcare is like trying to work on a jet engine while in flight.

Julie Rovner, reporting for NPR, highlights the challenges doctors are up against as the result of the budget and potential Medicare cuts.

Doctors face an even bigger problem. They're already looking at a 29.5 percent pay cut next Jan. 1 unless Congress acts to change it...But to fix the doctor pay problem will cost more than $300 billion. Industry consultant Laszewski says that just digs the hole deeper for the supercommittee working on the deficit issue.

The question then becomes, where is the $300 billion in excess costs? Without doubt there is waste in our system. Although not all costs are bad. With the high cost of also comes some decent quality. The Commonwealth Fund reports:

Compared with [five other major] countries, the U.S. fares best on provision and receipt of preventive care, a dimension of "right care." However, its low scores on chronic care management and safe, coordinated, and patient-centered care pull its overall quality score down.

Important to note, the Commonwealth Fund report implicates the challenges of access to care as a key contributor to the chronic scores. With nearly 90 million uninsured in the US, its hard to manage acute conditions before they become chronic. There is a lot of that $300 billion in cost right there.

Let's say this pans out as NPR (and many others) predict. Doctors will have a few choices, among them:

1) Take a pay cut. Yeah, its a little more complex than that - they have to downsize practices, maybe lay off staff, its not pretty, but it's an option. The Association of American Medical Colleges says the average debt for medical school graduates is between $150,000 and $180,000. Right out of the gate, many physicians are in the hole. We have this image of doctors as highly paid - largely accurate relative to US median salaries - and very affluent. Some specialties do facilitate affluence, perhaps justifiably (I want my surgeon well paid!). In many cases the take home pay of primary care, internal medicine and family physicians is not quite as high as one might think. For example, the median before tax take home pay for family physicians in the Mid-Atlantic region is $140,000; take out taxes, school loans and cost of living… See what I mean? (source: AAFP http://daws.in/o4mNXo )

2) Stop seeing Medicare patients - Right now, in 2011, Medicare covers 47.6 Million Americans. The average annual spend per enrollee is $303,000. So when some fraction of those 47.6 Million are unable to see a primary care physician or specialist who no longer accepts Medicare, what happens? Do they end up in the hospital where the cost of treatment is considerably higher? Does that drive the per enrollee spend up and in turn push medicare deeper into insolvency? There is a healthy amount of speculation baked into that scenario, but it is well worth consideration. (Sources: Kaiser State Facts http://daws.in/pidNDb ) By the way, the vast majority of hospitals in this country cannot cover costs on Medicare reimbursement and Medicare makes up around 50-60% of business for hospitals. If the same is true of Physicians - I don't have the figures for physicians, but they cannot cover costs, ceasing to see Medicare patients may actually be advantageous to them financially. (I'll research and post a follow up along with my editorial opinion how that's a real failure of the US system which ultimately fails patients. Maybe this parenthetical will suffice.).

3) Doctors can cut some costs - what are these costs? I think we have established I'm no economist. (Have I told you about that 3rd semester of calculus? Yeah, I'm going to stick to reading Children's books). The limited understanding I do have is indirect costs of care are considerably larger than the direct costs of care. Costs to Medicare, in particular have many drivers. According to Kaiser, the largest costs come from Hospital Care - a seriously complex system in its right. How can doctors, constrained by budgets, reduce those costs? They can help reduce medical errors and length of stay - we are seeing those tends now, thankfully. They can use less expensive supplies (IE put the squeeze on suppliers who are making record profits). They have some recourse, to be sure. Still, these are things that have a long time playing out.

And now for the op-ed portion of our show…

I'm not sure what the answer is. The budget crisis is real and Medicare cannot afford to keep spending at the current rate; no arguments there. But, it takes a while to squeeze costs out. Remember the jet engine in flight? What happens when the budget puts the squeeze on the physicians; What will their first reaction be? Is it to cut direct costs and downsize a practice, or take a personal pay cut? The hope is reducing costs will help entice physicians to become more cost conscious. Hey, it may work, but not before a last ditch effort is made to save the jet engine from flaming out first.