healthcare yesterday, today and tomorrow
TRANSCRIPT
HealthCare in America
Yesterday
Today
Tomorrow
A PHYSICIAN’S PERSPECTIVE
Current State of Health Care
Patient Protection and Affordable Care Act (ACA)
Health Care Post ACA
Concierge Medicine or Private Medicine
The Good Old Days
•Patient decides upon the Provider.•Patient pays for service•Payment may be in cash or credit of some sort
Pre Insurance Paradigm
Current System
• Concept of insurance added during Truman’s administration
• Lyndon Johnson-1965-Medicare passed
• 1970’s insurance enters medicine and it becomes oriented more towards business and away from patient care
•Patient chooses insurance (via the exchange, employer, or other).•Insurer tells patient what provider(s) they can see and what is and is not covered.
•Patient waits on the Provider.•Eventually the patient gets a few minutes of “face time” with provider.•Provider reactively treats patient as allowed by insurer, not based on best practices.
•Insurance tells physician what services it can provide for what costs and under what conditions.•Physician bills insurer for payment.
Current Paradigm
“Lost Time is Never Found Again” – Benjamin Franklin
In 2007, Americans 15 years and older collectively spent 1,611 years waiting for medical services.1
The Average Wait Time to see a Physician in 2009 was 22 minutes.2
1. Feb 2009 New York Times Article “A Hidden Cost of Healthcare: Patient Time”2. Oct 2010 Wall Street Journal Article “The Doctor Will See You Eventually”
The current healthcare system is broken.
Average Wait times by City
http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/29/in-cities-the-average-doctor-wait-time-is-18-5-days/
Longest wait times for Family Practice, by city;
• Portland 13 days
• Boston 66 days
• Los Angeles 20 days
• D.C. 14 days
• New York 26 days
Everyone knows…it’s Only Going to Get Worse
1. ObamaCare is adding 30 million more patients to an already overburden system.
2. Fewer Primary Care Physicians are entering the marketplace.
3. Physicians will have to see 30+ patients a day to keep up with demand and carry up to 3,000 patients in their practice.
4. Focus remains on episodic care only.
AFFORDABLE CARE ACT
Biggest effort at social engineering since Medicare and Medicaid in 1965
Requires most individuals to obtain health care coverage
Requires insurance companies and employers to provide consumer protection related to health
http://dailybail.com/home/obamacare-complicated-check-out-the-flow-chart.html
As this graphic shows, the new law creates 68 grant programs, 47 bureaucratic entities, 29 demonstration or pilot programs, 6 regulatory systems, 6 compliance standards and 2 entitlements. What could possibly go wrong with something so-well organized?
AFFORDABLE CARE ACTGoals
1. Increase the quality and affordability of health insurance
2. Lower the uninsured rate
3. Reduce costs of health care
4. Improve health care quality
Affordable Care Act
• Signed into Law-March 23, 2010
• Upheld by the Supreme Court-June, 2012
Provisions of the Affordable Care Act
• In 2010
– Adults with existing conditions are allowed to join high risk pools until health exchanges are opened in 2014
– Council within HHS to develop national prevention and health promotion strategies
– Those caught within donut hole will receive a $250 rebate and donut hole will be eliminated by 2020
Provisions of the Affordable Care Act
• In 2010 cont.
– No more lifetime caps on illness
– Dependents can remain on parent’s insurance until 26
– Insurers cannot consider pre-existing conditions
– Insurers cannot collect copays for certain preventative measures.
Provisions of the Affordable Care Act
• In 2010 cont.
– Insurers ability to enforce spending caps will be restricted and eliminated by 2014
– Insurers cannot drop policy holders when they become ill
– Insurers are required to implement an appeals process
Provisions of the Affordable Care Act
• In 2010 cont.
– Medicare patients with chronic diseases must be reevaluated every 3 months for their medications
Provisions of the Affordable Care Act
• Effective 2011
– HSA’s, FSA’s and Health reimbursement accounts cannot be used to pay for OTC drugs/medical supplies
Provisions of the Affordable Care Act
• Effective 2012
– All new plans must cover preventative benefits including mammograms and colonoscopies without requiring a copay.
Provisions of the Affordable Care Act
• Effective 2013
– Income for self-employed or single individuals earning more that $200,000 will be subject to an additional 0.9% tax. ($250,000 for married couples)
– 3.9% Medicare tax on unearned income
Provisions of the Affordable Care Act
Beginning January 1, 2014, every person must either have health care that meets minimum standards or coverage or pay a penalty when filing tax returns.
Provisions of the Affordable Care Act
How much is the tax penalty?
1st Year-$95/adult and $47.50/child (up $285/family) or 1% of income whichever is greater
2nd Year-$325/adult and $162.50/child (up to $975/family) or 2% of income whichever is greater
3Rd year-$695/adult, $347.50/child (up to $2085/fam. or 2.5% of income
Provisions of the Affordable Care Act
Who is exempt from purchasing insurance.
1. Are uninsured for less than 3 months of the year
2. Have very low income and coverage is considered unaffordable
3. Are a member of a specific excluded group
Provisions of the Affordable Care Act
Effective January 1, 2014
– Insurers cannot charge higher rates or discriminate against individuals based on gender or pre-existing conditions
– No annual spending caps
– 2.3% excise tax on medical devices
Provisions of the Affordable Care Act
Effective January 1, 2014 cont.
– In participating states Medicaid is expanded
– Two year tax credits offered to small businesses
– Max deductible for employer mandated plans established
– Qualifying medical expenses raise to 10% instead of 7.5%
Provisions of the Affordable Care Act
Effective January 1, 2014 cont.
– Penalty of $2000 per employee for employers with 50 or greater employees if employer does not offer health insurance to full time employees (delayed until 2015)
– Establish health insurance exchanges
Healthcare Exchanges
What must be covered in the plans
1. Emergency Services
2. Out patient or ambulatory services
3. Hospitalization
4. Mental Health
5. Care of the newborn and mother
6. Prescription Drugs
Healthcare Exchanges
What must be covered cont.
7. Laboratory services
8. Preventative services
9. Rehab and habilatative services and devices
10. Pediatric services including oral and vision care
Healthcare Exchanges
Open Enrollment
1. Began October 1, 2013
2. Ends March 31, 2014
3. Each year thereafter open enrollment will be from Oct. 15 to Dec. 7
4. Coverage begins January 1, 2014
Who is enrolling in ACA?
Bloomberg: “About 30 percent of new enrollees are under 35. White House officials say that’s an acceptable mix, and they expect more young people to come on board closer to the March 31 deadline. ‘We think that more and more young people are going to sign up as time goes by, based on the experience in Massachusetts,’ Gary Cohen, deputy administrator at the Centers for Medicare and Medicaid, said on a conference call with reporters. ‘We’re actually very pleased with the percentage that we have right now, and we expect that percentage to increase.’
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/
Who is enrolling in ACA?
Bloomberg: “Under Obamacare, insurers can’t charge men and women different rates—or, as Health Secretary Kathleen Sebelius put it, ‘Starting in 2014, being a woman is no longer a preexisting condition.’ That generally resulted in lower prices for women compared with insurance markets where underwriting by gender is allowed, so it’s not surprising women signed up in greater numbers.”
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/
Who is getting a subsidy?
Bloomberg: “Most of the people who bought coverage on the exchanges this fall got subsidies to help them afford the premiums. That’s in contrast to the first month of the program, when less than one-third of buyers were subsidized. People earning up to four times the poverty rate—as much as $96,000 a year for a family of four—can get help buying coverage. …
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/
Provisions of the Affordable Care Act
• Effective January 1, 2015
– Physician reimbursement for Medicare patients based upon quality of care, not quantity
• Effective January 1, 2018
– All health insurance plans must cover approved preventive measures without copays
Provisions of the Affordable Care Act
• Effective 2020
– Donut hole in Medicare Part D prescription coverage is eliminated
http://dailybail.com/home/obamacare-complicated-check-out-the-flow-chart.html
WHAT ARE OUR ALTERNATIVES?
CountryLife
expectancy
Infant mortality
rate
Physicians per 1000 people
Nurses per 1000
people
Per capita $ on health
(USD)
Healthcare costs as a percent of
GDP
% of gov't revenue spent on
health
% of health costs paid by gov't
Canada 81.3 4.5 2.2 9 3,895 10.1 16.7 69.8UK 81 4.8 2.5 10 2,992 8.4 15.8 81.7US 78.1 6.9 2.4 10.6 7,290 16 18.5 45.4
Canadian Healthcare
• Single payor system
• Funded federally/managed by each Province
• Pt can choose provider
• Services typically not covered
– Pharmaceuticals
– PT
– Ancillary services
Canadian Healthcare
• 2006-Gov’t tried to close private clinic
• Supreme Court
“Access to a list does not mean access to health care”
Canadian Healthcare
Negatives
Wait times
Median wait times for specialist-4 weeks
Median wait times for diagnostic services (MRI, CT, etc.)-3 weeks
Median wait times for surgery -4-5 weeks.
English Healthcare
English System
National Health Services (NHS)
July 1948
Single Payor System-British Govt.
Advantages
Cost per patient $2500/pt. vs $6000
Walk in services
NHS
Advantages (cont.)
Greater life expectancy
Fewer surgical/medical complications
Disadvantages
Higher mortality in cardiovascular and Cancer deaths
Average wait time for services requiring Hospitalization-8 weeks
NHS
Disadvantages cont.
Average wait times for outpatient procedure-4 weeks
Average wait time for lab tests-2 weeks
Post ACA
Two Tiered System
Health Care via large corps
Private Medicine
Physicians will begin making choices as to which model they prefer.
Concierge MedicineIn its simplest form, Concierge Medicine is a relationship between the physician and patient in which the patient pays a monthly or annual fee to insure the physician is available to the patient. It is fee for service medicine. Other names include private pay medicine, boutique medicine, retainer-based medicine, innovative medical practice design.
Concierge Medicine
History
Begin in 1996 in Seattle Washington
Developed a national organization in 2003
Most practices are “mom and pop” type operations
On average, one conversion per day from primary care to concierge medicine
Concierge Medicine
Average Practice size of Concierge Medicine Physician
100-1000 patients
Average Practice size of primary care physician
1800-3000 patients
Typical Costs of concierge medicine program
$50/month to $1500/month
Concierge Medicine
Services Offered-General
Same day service
Expanded physician
appointments
Phone Access directly
to physicians
•Patient chooses insurance (via the exchange, employer, or other).•Insurer tells patient what provider(s) they can see and what is and is not covered.
•Patient makes appointment with provider, waits at no more than 2 days to be seen at the practice and no more than 5 minutes in office before being seen.•Patient gets 15-30 minutes of “face time” with provider.•Provider proactively treats patient, with fewer restrictions from insurer, because monthly dues offset financial losses from non-covered items.
• Insurance still tells physician what services it can provide for what costs and under what conditions.• Physician bills insurer for payment.
Basic/Advanced
•Patient still chooses insurance (via the exchange, employer, or other) for when they are not in the Sendant program. ie Hospital stay.
•Patient still chooses insurance (via the exchange, employer, or other) as needed for services outside of the Sendant program, ie Hospital stay.
•The physician/patient balance is restored. Care is provided on best practices and patient needs, not insurance mandates. •Patient makes same day appointments with provider and has no in-office wait time before being seen.•Patient gets all the “face time” they need with provider.•Provider proactively treats patient, with no restrictions from insurer.
New Paradigm, Premium
Concierge Medicine
Services Offered-Higher Levels
Nutritionist on Staff
Personal Trainer on Staff
Preventative Approach
Expanded more inclusive annual exams
Weekly updates on medical issues
Concierge Medicine
Services Offered-Expanded
Specialized in office testing such as ultrasound evaluations
Air Ambulance services
Bill reviews
Concierge Medicine
Current estimates of Concierge Medicine Docs-4,400 vs 200,000+
72% decrease in hospitalizations among patients 35 to 64 who used a concierge medicine physician (Am. Jour. Of Managed Care 2012)
Concierge Medicine
36% of primary care physicians interviewed are planning to cut back on patients, work part-time, or retire in next 3 years (Am. Jour. Of Managed Care 2012)
A PHYSICIAN’S PERSPECTIVE
Review current state of medicine
Look at PPACA (Obama care)
Look at alternative private practice
Provisions of the Affordable Care Act
1. Are uninsured for less than 3 months of the year
2. Have very low income and coverage is considered unaffordable
3. Are not required to file a tax return because their income is too low
• As this graphic shows, the new law creates 68 grant programs, 47 bureaucratic entities, 29 demonstration or pilot programs, 6 regulatory systems, 6 compliance standards and 2 entitlements. What could possibly go wrong with something so-well organized?
• This chart was meticulously compiled over the last four months after perusing the 2,841 pages of Obamacare that no one who voted for the bill bothered to read.
• The HHS czar, Kathleen Sebelius, has 2200 references in the law and 600 new authorities which cannot be challenged. On the chart everything in dark blue to the left are expansions, orange are those empowered with rationing healthcare in the future. In the bottom left hand corner in blue, 150 new bureaucracies and boards have been created between doctor and patient. Those in yellow are specific mandates and there are 17 new mandates on insurance. Rep. Brady stated this law is so complex he couldn’t get the chart to fit on one page, the chart is only actually 1/3 of the size of the law so he shows “bundles of bureaucracy.” For example, one brown bundle hides 59 grant programs. Green diamonds are the taxes this law has created. In the far right corner are 19 special interest provisions, including the “Louisiana Purchase” and special interests for unions.
• Buried deep in the law are 19 special sections that cannot be challenged by the courts or any regulatory system. What the public is being sold and what the law actually has are 2 totally different things.
• And jobs created? Yes. Many. 16,500 new IRS agents to police the law and an explosion of jobs in the HHS Department. Please print out copies of this chart and hand to your friends, families and pass out wherever. The public needs to be educated about the impact of this law and what it will mean for their future.
4. Would qualify under the new income limits of Medicaid but their state as elected not to participate in the expanded Medicaid program
5. Are members of a federally recognized Indian Tribe
6. Member of a religious sect with religious objections to health insurance
7. Participate in a health care sharing ministry.
Provisions of the Affordable Care Act
Beginning January 1, 2014, every person must either have health care that meets minimum standards or coverage or pay a penalty when filing tax returns.
Healthcare Exchanges
What they are suppose to offer
1. A choice of different health plans
2. Certify plans that elect to participate
3. Provide info so that consumers can make an informed decision regarding different plans
Healthcare Exchanges
Who is qualified to purchase insurance thru the HIX
1. A lawful U.S. citizen or resident
2. Not currently in jail
3. Living in an area serviced by the Marketplace
Healthcare Exchanges
What types of plans are available
1. Bronze 60/40
2. Silver 70/30
3. Gold 80/20
4. Platinum 90/10
5. Catastrophic plans will be available for people under 30 and those with very low income
Post ACA
Health Insurance Exchanges (HIX)
Set up in each state
Way to compare insurance costs
Four (4) levels depending upon deductibility 60% to 90%