Posts from 2017

Ten Reasons

Ten Reasons Why Every State Should Welcome the Graham/Cassidy/Heller/Johnson Health Reform Bill

If a state is satisfied with Obamacare, it can keep Obamacare. But here are ten ways a state can improve on the current system if its citizens desire to do so. With the state’s approval, insurers will be able to offer coverage that is:

Affordable. Currently there are close to 30 million people who are uninsured and that number isn’t expected to change much under Obamacare. The reason: millions of people have decided that the products being offered are not worth the premiums being charged. This reform allows insurers to offer a more attractive package of benefits for a lower premium. Judicious use of risk pools and reinsurance will also help – especially with high cost enrollees migrating from group to individual insurance. If a state establishes a dedicated source of funding (outside of its block grant) for this purpose, it should be able to reduce premiums in the non-group market by as much as 50%.

Universal. At least one plan could be offered with a premium that is no more than the subsidy the state provides. Since these plans would require no out-of-pocket payment by the enrollee, people could be automatically enrolled through the Food Stamp program, by H & R Block, at the DMV and in other ways. Universal coverage could be a reality rather than an empty slogan.

Tailored. Currently, low- and moderate-income families are being forced to buy coverage that is completely inappropriate for their financial circumstances and health status. Instead of insurance that has unlimited annual and lifetime limits and a $13,000 deductible, would they rather have less upper bound coverage along with a low deductible and a Health Savings Account. The latter option would give the family easy entry into the system, but would leave some very expensive cases for a safety net (which is a more appropriate way of funding them).

Equitable. One of the worse features of Obamacare is the extremely inequitable treatment of people who are offered insurance at work versus people who purchase their own coverage. Employers of low-wage workers are offering Bronze plans with very high deductibles in return for a premium that is 9.5% of their wage. If employees turn down this offer (which almost all do), neither the employees nor their dependents are eligible for highly subsidized insurance in the exchanges. Under this reform, the employer and individual mandates go away and states can equalize the subsidy offered in the group and individual markets. This will be especially important in states where the non-group market has become completely dysfunctional and group insurance is cheaper and better.

Portable. Because states will have the power to equalize the government subsidy available at work and in the marketplace for low and moderate-income families, they will also be able to allow portable insurance for these same families. For example, a company might buy Blue Cross individual insurance for its employees, instead of Blue Cross group insurance, and the employees could take their insurance with them to the next job.

Private. Virtually every study of the matter has found that private insurance results in better health outcomes than Medicaid. Going forward, states will be able to subsidize private insurance instead of Medicaid enrollment for the poor and the near poor.

Fair. Currently, a large number of people are gaming the system by remaining uninsured while they are healthy and insuring only after they get sick. Because of a 90-day grace period, people are also dropping coverage to avoid paying premiums at year end. Of those who are enrolled in January, roughly 25% have dropped out by September and roughly half of those reenroll for the following year. Additionally, some people buy Bronze plans while they are healthy and then upgrade to Gold or Platinum after they get sick. This type of behavior unfairly shift costs onto other people. Under this reform, states will be able to require individuals to pay the full actuarial cost of any unfair gaming activity.

States will also be able to give their citizens access to:

Personalized care. At $50 per month for an adult and $10 for a child, the cost of direct pay (concierge) medicine has come down to a level that should make it accessible to almost everyone. This reform allows these fees to be paid from a Health Savings Account or by a third-party insurer.

Specialized care. Centers of excellence will be able to specialize in specific diseases – such as cancer care, heart disease and diabetes. They will be able to ask health questions and screen applicants to help get the right patient to the right plan.

A real health insurance marketplace. Obamacare’s risk adjustment is focused on plans, not patients, and there is no realistic way for a plan to know what compensation it will receive for enrolling a patient with a costly medical condition. This is one reason for the race to the bottom – as plans try to attract the healthy and avoid the sick. As an alternative, states will be able to set up a risk adjustment mechanism along the lines suggested by Cochrane, Goodman and Pauly. Risk adjustment will protect patients, not health plans, and centers of excellence will be rewarded for providing efficient, high-quality care to patients with the most serious medical problems.

The Folly of “Population Medicine”

“Take care of the patient,” directed my chief resident. “In the ER—he needs you.” My fifth admission for that 36 hour call cycle, and I was tired. Yet those words are as clear to me now as they were 3 decades ago in that post-call afternoon at Detroit Receiving Hospital. “Take care of the patient” is still my care-style and professional reputation, one patient at a time.

Vexingly, in this week’s version of our overseers’ mandates, they direct us, “Take care of the population.” What exactly does that mean? I think it means that once we all work for large employers, who aggregate our little-guy data, we might get paid if our data looks good enough? Big medicine pays little-guy PCPs in their little medical homes based upon “quality measures.” We should collect our “quality measures,” and are expected to change patients’ bad behaviors and habits, and become accountable for their actions and inactions. Is this what we want to do for a living?

Fortunately, in concierge medicine we work for patients (as opposed to third party payers) and can practice the right kind of medicine for each patient. From a business standpoint, insurance pocket change isn’t worth playing the population game. Realizing the folly of population-care, I sleep fine at night when a patient ignores my advice. He is responsible for his own life. My income does not derive from his decisions. If he makes bad choices and generates bad data I’ll do my best to help, but the real change needs to come from his side of the equation. At a recent EHR-sponsored happy hour, one population-incentivized PCP said it nicely, “Noncompliant patients—I just get rid of them. They (noncompliant patients) can eat what they want to eat and do what they want to do, but I want to get paid—so I get rid of them.” Concierge medicine is a better solution.

Payers have pushed physicians into the “you are responsible for your patients’ actions” trap. In today’s iteration of “best care,” doctors are expected to identify and allocate time and money to identify “at risk patients,” all to improve medical practice outcome data. Make no mistake, insurance work is a fixed-sum game, and individual doctors will ultimately pay to pay this game.

In Concierge Medicine we take care of the patient. In my practice, many of those were cast-off by population-treating doctors and their staff. Once in my practice, do the noncompliant suddenly comply? Usually not, but they appreciate the respect they receive, improve their life’s quality, while receiving much better, individualized care. Some smoke too much, drink too much, and-or eat too much. I don’t take on their life’s burdens and expect their numbers to improve. I do my best for them. In my concierge internal medicine practice, if the outliers’ numbers don’t improve, I will still be paid just as much, as I should. It is a lesson in futility for PCP’s to assume their patients’ risk. Collecting data, checking boxes, and groveling for a better performance bonus—who needs it?

Individual doctors cannot generate a generalizable data set. The n-size is simply too small. Bonus payments based upon doctors generating individual data that betters aggregated data will encourage doctors to lie about the data, cherry-pick patients (an insurance company favorite), and to throw out the outliers, AKA get rid of “bad patients.” As I learned in my research fellowship, “garbage in, garbage out.” Population data can only be as good as its weakest link—and there are plenty weak links! If population data looks valid, it won’t be.

The population health story is yet another Emperor’s New Clothes fable (1). The population idea has gained traction such that we all are expected to believe this idea; Like the emperor’s clothes, we should see how wonderful the nonexistent clothes/worthless ideas are—or we are fools! The concepts and PCP busy-work looks pretty to leadership, just as the emperor’s clothes looked pretty to his admirers and to him. In truth, there really isn’t anything to see. It will take decades for payers to realize individual patients generally cause their own poor outcomes, and that micromanaging doctors will not change patient behavior in the long run. PCP burnout and PCP shortages will be the collateral damage for our leaders’ misguidance.

In Concierge Medicine we take care of each patient, in times of sickness and health, and in times of good data and bad data. In Concierge, we guide our patients, and we let them make their own decisions. We respect our patients for who they are, along with their strengths and weaknesses. At days’ end, we take care of real people, not data sets. Keep up the good work!

1. Andersen, Hans Christian; Tatar, Maria (Ed. and transl.); Allen, Julie K. (Transl.) (2008). The Annotated Hans Christian Andersen. New York and London: W. W. Norton & Company, Inc. ISBN 978-0-393-06081-2.

John T. Kihm, MD, FACP

Director, ACPP

The lesson for us in the Charlie Gard case

There is a lesson to learn somewhere in the debate last month about the unfortunate circumstance of British baby Charlie Gard. Charlie was born with an inherited (yet) incurable disease that left him on a ventilator, blind and deaf. The government wanted to dictate his care in spite of the fact that his parents raised money to pay for his care with cash. The lesson: This is what will happen if the GOP allows the ACA to deteriorate into a single-payer system and choice evaporates from the American lexicon. In the meantime, the Senate debate did not show much promise as a “fix” to the ACA and it doesn’t look like the government is getting out of the way any time soon.

http://www.ocregister.com/2017/08/27/the-lesson-for-us-in-the-charlie-gard-case/

Physicians Convene in Atlanta (October 2017) to Learn About Precision Medicine, Genomics, Concierge Medicine, Direct Pay, Cash-Only and Other Innovative Healthcare Delivery Happenings

2017 Concierge Medicine Forum in Atlanta to Showcase “Precision Medicine” Use, Utility and Innovation Among Other Educational Topics

ATLANTA, GA — Concierge Medicine Today, in partnership with The Direct Primary Care Journal (The DPC Journal), are hosting a 2-day innovative healthcare delivery and precision medicine Forum in Atlanta, GA on Friday, October 27 and Saturday, October 28, 2017 entitled CMT’s 2017 Concierge Medicine Forum. (www.ConciergeMedicineFORUM.com)

Click here to sign up

Concierge Medicine Forum 2017: The Journey to Personalized, Precision Medicine | Concierge Medicine :: Direct Primary Care | ATLANTA, GA

AAPP Board of Directors Votes to Suspend Operations and to evaluate AAPP’s value proposition for 2018 and beyond

AAPP Board of Directors Votes to Suspend Operations and to evaluate AAPP’s value proposition for 2018 and beyond.

https://conciergemedicinetoday.org/2017/08/09/aapp-board-of-directors-votes-to-suspend-operations-and-to-evaluate-aapps-value-proposition-for-2018-and-beyond/

Deregulation in Medicine

We desperately need deregulation in medicine. It is hard to disagree with anything Dr. Hahn in the link below says about our regulatory nightmare, the need for reform and the chaos harmful state and federal regulations, insurance rules and the EMR mess create for all of us, doctors and patients alike. Deregulation is in part what some of us hoped the new Trump administration would do quickly, and it is in part what HHS Secretary Dr. Tom Price is trying to do by himself. His authority is limited however until and unless Congress acts. We should thank and encourage our friend Tom Price in his efforts and hope the Congress gets busy, perhaps in a bipartisan way.

http://www.kevinmd.com/blog/2017/07/health-reform-simplify-health-system-ideas.html

Tom

Ps. Singapore has a functional system that could be adapted here to American values.

https://www.google.com/amp/s/www.vox.com/platform/amp/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained

https://mobile.nytimes.com/2017/03/18/opinion/sunday/make-america-singapore.html?referer=https://www-vox-com.cdn.ampproject.org/v/s/www.vox.com/platform/amp/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained?amp_js_v=0.1&usqp=mq331AQCCAE%3D

Latest actions by HHS

To read about the latest actions by HHS, under Secretary Tom Price, MD, finall helping physicians. Click here

Kaiser Health News

Syndicate – Kaiser Health News

Millions Of Kids Fall Outside Senate Plan To Shield Disabled From Medicaid Cuts

July 11, 2017, 12:41 AM The Republican plan to replace Obamacare would reduce federal funding for Medicaid, but senators want to keep current funding levels for children who are blind or have other disabilities. Their proposal, however, would not apply to the majority of those kids.  

Medicaid Cuts Will Drive Up Cost Of Private Coverage, Montana Insurers Say

July 10, 2017, 2:30 PM Insurance executives in Montana are worried that GOP efforts to repeal and replace the Affordable Care Act could destabilize a market that is working well.  

Senate GOP Bill Aims To Add Psych Beds; Squeeze On Medicaid Signals Their Undoing

July 10, 2017, 2:30 PM The Senate health care bill has a provision to increase hospital beds for psychiatric care, but overall cuts in Medicaid could lead to even fewer beds nationwide.  

Trump’s Surgeon General Pick Built Name Fighting HIV And Opioids In Indiana

July 7, 2017, 2:30 PM Dr. Jerome Adams is the health commissioner in Indiana, the home state of Vice President Mike Pence.  

Do-It-Yourself Detox Can Be ‘Freddy Krueger’ Scary — And Usually Fails

July 7, 2017, 2:30 PM Treatment for opioid addiction can be expensive and difficult to coordinate. That might make some people tempted to think they can overcome the addiction on their own. This rarely works.  

Obamacare Inspires Unlikely Political Action In California’s Red Region

July 7, 2017, 2:30 PM In a county where cows outnumber people and most voters supported Donald Trump, a coalition of health clinics is driven to defend the health law.  

Amount Of Opioids Prescribed In U.S. Has Been Falling Since 2010

July 7, 2017, 5:28 AM Report by CDC researchers finds a steady fall in opioid use in recent years, but the rates are still three times higher than in 1999.  

Half The Time, Nursing Homes Scrutinized On Safety By Medicare Are Still Treacherous

July 6, 2017, 8:08 PM Of the 528 nursing homes that graduated from special focus status before 2014 and are still operating, more than half — 52 percent — have harmed patients or operated in a way that put patients in serious jeopardy within the past three years, a KHN analysis finds.  

Parents Of Ill Children Worry About Return Of ‘Lifetime Limits’ In GOP Health Bill

July 6, 2017, 2:30 PM Current law requires all health insurance sold on the exchanges to cover 10 essential benefits — with no annual or lifetime limits to reimbursement. But the GOP plan might let states reinstate limits.  

As Seniors Get Sicker, They’re More Likely To Drop Medicare Advantage Plans

July 6, 2017, 2:30 PM Medicare Advantage plans offer good value and aim to keep patients healthy but sicker people are far more likely to quit because they can’t get the care they need.  

ACPP Walks the Walk

ACPP Walks the Walk

American College of Private PhysiciansThere’s something to be said for straightforward, honest talk.  There’s something to be said for the ACPP.  The American College of Private Physicians also stands for “All Care by Physicians for Patients.”  We are straightforward.  We are honest.  

In this day of complex arrangements--between payers, accountants and monitors of quality and cost--doctors and patients often seem but an afterthought.   Ergo ACPP.  This organization supports doctors and their patients interacting in real, non-contrived medical business models.

Out of the murky swamp of non-medical stakeholders has evolved a complex gumbo some call “American Medicine,” which in many cases is anything but Medicine or American. The ACPP walks the walk around and outside of that murky swamp, along with its member clinical doctors.  We network, we meet, and we share. We learn how to do things better in our clinics and businesses.  We innovate through new concepts, such as the ACPP Fellowship of Clinical Excellence.  We look back to the future in search of the best.  “How can we take the best care of our patients while taking the best care of ourselves?” we ask.  Clearly, patients need seasoned, well-rested, enthusiastic, accessible doctors, not the burned out, exhausted, discouraged, well-hidden ones found in the murky swamp.  ACPP doctors fill that need.

After so many generations of organizations going along to get along, the ACPP is again strongly supporting the walk of private doctors with their private patients.  This organization will reflect the best in the physician-patient relationship:  Straightforward talk.  Honest relationships.  The ACPP is here for doctors and their patients, promoting professionalism and excellence in business models that reduce or eliminate the wasteful middle layers that cost so much and add so little.  We strive to be honest doctors walking that walk, seeking skillfully to serve our patients’ needs and contracting directly with them.   If you are walking that walk, at long last you again have a professional organization you can call home. 

While the ACPP invites others as auxiliary members, the lifeblood, voting, visible membership is and always will be only doctors on that walk.  All of you around long enough to be called successful in direct, cash or concierge practice know what that means.  Successful private physicians are known for taking the best care of their patients and working only for their patients.  Serving those doctors and helping them serve their patients--that is our mission.

We welcome all of you to celebrate medicine the way it should be practiced.  If you are a doctor in real private practice welcome home!   Please apply for membership.  If you are in another mode of medical practice, are a conversion consultant, or are just a supporter, we welcome you to our auxiliary, to our meetings, and to our family.

Take a walk with the ACPP.  John T. Kihm, MD

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