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Worrisome Trends in Health Care

Philosophically, by now you’ve gathered I was pleased that the Affordable Care Act (ACA) leaped nearly all its hurdles and will be taking effect in a couple years. It was simply wrong that the US has within its borders 40 million citizens with no access to our health care system, and also that insurers could cherry-pick people without “pre-existing conditions” and legally exclude patients who needed care.

But based on my healthcare reading, I’m here to warn you that the next few years are going to be a rough ride. There’s too much money at stake and some very powerful players calling the shots for any patient, physician, or institution to remain unscathed, for anything like the status quo to be maintained.

If your idea of an ideal physician is someone who’s always there for you, who grows older right along with you, who knows your family, your job stresses, and your life, well, forget all that. If you follow the website America’s Health Insurance Plans, the policy and advocacy group for our 1,300 (!) health insurance plans, you’ll see changes afoot. Some new trends are promising, like more emphasis on wellness coverage. Others are downright spooky, and probably illegal in many countries. But, what the heck, we’re used to corporations running our lives. And didn’t the Supreme Court affirm with its Citizens United decision that corporations have a voice equal to the rest of us?

By eliminating the public option (which for simplicity’s sake ought to have been called Medicare for All) from the ACA, our government turned over the health care reins to their friends in the health insurance industry, probably the single largest lobbying group in Washington. Never forget that most health insurance companies are publicly traded, for-profit companies beholden first to their CEOs, second to their Boards of Directors, third to senior management, fourth to stockholders, fifth to middle management, sixth to low-level employees, seventh to whoever pays the premiums (usually your employer), eighth to you, the patient, and last–ninth in line–to me, your health care provider.

Strictly speaking, the Blue Cross franchises are not-for-profit entities, but all this really means is they don’t have to pay corporate taxes or answer to pesky stockholders

The health insurance industry essentially regards hospitals and physicians as a swarm of annoying gnats that interfere with both the bottom line and executive bonuses. The words “benefit,” “authorization,” and “payment” don’t sit easily. To counter the dreaded act of “payment,” the industry has already created obstructions sufficient to stop Attila, Hannibal, and Genghis Kahn in their tracks

And now, with the ACA, we’ve turned over everything to them.

Two concepts you’ll want to grasp
There are two phrases you need to understand if you want to see where US health care is headed. The first is Accountable Care Organizations (ACOs). The second is “evidence- based medicine.” Both have a nice consumer-oriented ring to them. Yes, we want evidence that the pill we just swallowed is going to help. We’ll discuss ACOs now, and evidence-based medicine in a future health tip.

The ACA makes repeated references to ACOs as if they were a panacea to our health woes, like charter schools will solve everything wrong with education. We do all like the word “accountable” as in “held accountable” when it applies to someone other than ourselves, especially if that someone is powerful. We want our politicians, bankers, CEOs, attorneys, and doctors to be accountable. But it also depends on who’s accountable to whom. Certainly all of Eastern Europe bristled at being held accountable to the Soviet bloc. You would definitely not wish to be held accountable to an incompetent supervisor on your job, especially one with a personality disorder.

Thirty years ago, the phrase Health Maintenance Organization (HMO) also had a nice ring to it when first introduced (“Yes, I like the idea of my health being ‘maintained’ by my doctor”), but it turned out to be a disaster for everyone. An ACO is really the same animal with a slightly different financial spin. Although what follows may seem complex, it’s worth reading because you’ll be inextricably involved in it if you need a physician.

In an ACO, doctors (or doctors and hospitals) formalize a group with the intention of reducing costs and improving patient outcomes. If the ACO fails, it’s financially penalized. Obviously there are numerous ways to reach the ACO’s apparently admirable goal of cost reduction and better patient care. As you’d expect, many are sensible, others a bit lame, and still others probably dangerous to your health. In an ACO, health care providers are accountable to two groups: the payor (health insurance company or, in the case of Medicare patients, the government) and to each other. If one physician member appears to be overspending, all members pay the price.

As a physician, signing onto an ACO means loss of control
And this has ramifications for you, the patient. Everything is linked to everything else and the whole kit and caboodle is constantly monitored. Independent thinking is toast, innovation gone forever. It’s the ultimate Big Brother of health care.

A few highlights:

  • The health insurance industry hopes that independent solo physician practitioners and small-group primary care physicians practicing fee-for-service medicine will become history. Under the new scheme, a typical physician won’t be able to afford the demands placed on her practice, most notably the conversion of her office to electronic medical records (EMRs), especially now with declining revenues from health insurers and Medicare. Your doctor will join, or more likely sell her practice to, an ACO because she needs access to the electronic record keeping that she could not otherwise afford on her own. She needs EMRs because she must share her data about you in order to get paid (“outcome reimbursement”).
  • Ironically, medical billing–especially in group practices–has become so complex that the ACOs already in existence (currently in a Medicare setting only) now hire expensive consulting firms to set up efficient reimbursement systems. Among the most successful of these is Optum, a division of United Healthcare, one of the largest of the insurers. That’s right, folks, a group of doctors will hire one division of United in order to successfully get paid by another.
  • Although some ACOs are owned by hospitals, the experience hospitals had in the 1990s owning physician practices was such a financial disaster that these ACOs will probably be bought by a health insurer (there’s simply too much money involved for the insurance industry to relinquish control). Your doctor will be an employee of CIGNA, or United, or any of them. “But,” you say, “isn’t there a conflict if my doctor is an employee of a company that makes money by not spending money on my health care? Seems my best interests aren’t being considered here.” Yes, this has raised eyebrows at the Justice Department regarding violation of anti-trust laws.
  • With health insurers having access to vast amounts of data about you–via your doctor’s practice, your pharmacy, and your hospital–they can monitor some useful activities. Are mammograms being ordered regularly? Are you taking your diabetes medicine? Why didn’t you follow up on that abnormal Pap smear? And yes, as Eastern bloc-ish as this sounds, they can “correct” your physician’s “aberrant” behavior not with thumbscrews, but by reducing her reimbursement or rewarding her if she’s doing well for you by offering preventive services. But there’s little room for independent thinking. She’ll be penalized if she spends “too much time” with you and doesn’t see enough patients per hour or if she takes into account your mammogram phobia and orders the screening test less often than recommended. If she marks “brand only” on your prescription instead of “generic.” A Big Brother will decide what’s necessary and what’s not.
  • And just like the old HMO system, your doc will be financially rewarded for doing less for you–fewer tests, prescriptions, admissions to the hospital, referrals to specialists. She’ll be financially penalized if she does something deemed excessive (brand-name drugs over generics, “unnecessary” tests).
  • Preventive care is always beneficial for you, the patient. The main plus of an ACO is the built-in reminders and fiscal rewards for following the basics of preventive care. The downside is that beyond these basics—wellness counselling, an annual wellness exam, specific annual tests—everything else has the potential to financially work against the doctor. Quick example: I’ve written a lot about vitamin D. Many, though certainly not all, doctors think that maintaining good levels of vitamin D are important for disease prevention. But because checking vitamin D levels regularly is not part of the official wellness guidelines in an ACO setting, a doctor would be financially penalized were she to order this test routinely. Penalizing the doctor for ordering vitamin D teaches her not to order it. If she follows this bit of behavior modification, she’s benefitted the bottom line of the insurer at the expense of her patient’s well-being.
  • The consensus seems to be that creating large ACOs will be the only way to handle the additional 35 million patients who will qualify for care in 2014. Most middle-class patients will have to accept the inevitability of assembly-line medicine, becoming the patient of a group of doctors rather than establishing a relationship with a single physician.

Troubling changes ahead
I’m already seeing troubling signs of the changes ahead. WholeHealth Chicago’s reimbursement rates from insurers are either stagnant or in decline. Tests, procedures, and medications once routinely covered are denied for ambiguous reasons. We’re being asked for more prior authorizations (meaning I have to contact your insurer and verify the treatment I’m recommending will be covered) than ever before on tests, scans, drugs, and procedures. “Coverage denied” is a recurring theme for the vaguest of reasons and often applied with no consistency.

My guess is that this is an attempt to hoard cash just in case the 35 million new patients showing up in 2014 are burdened with 35 million very expensive pre-existing conditions. After years of steadily declining incomes, many of my physician friends in primary care are checking the size of their savings and closing up shop. They’d rather play golf than start struggling with yet another new payment model

The future of health care?
Let me end this lengthy health tip by relating a recent change that to me represents the future of health care in light of these ACOs, performance monitoring, and so forth. It’s what’s happened to the pharmaceutical representatives, the fabled “drug reps.” Like them or not (and they’re all pretty likeable), drug reps have always been a major source of information about new drugs and also free samples for patients. Yes, they’re first and foremost salespeople. Yes, a doctor needs to take their spiel with a grain of salt, but they do let us know what’s new or on the horizon.

During the past couple years many larger medical groups have permanently banned drug reps from their premises. This struck me as odd and seemed like overkill. But the skivvy is this: health insurance companies pay financial incentives to doctors who write cheap generics (just as they do for pharmacists who substitute generics when you get a prescription filled). By deliberately keeping doctors in ignorance about new drugs, the financial managers of the medical group can receive a very hefty financial bonus from the insurer, which they can and do share with the doctors in their groups.

In other words, if you read about a new drug or see it in an ad, there’s a good chance your doctor has deliberately chosen not to learn about it. Keeps costs down. Ups the chance of a performance bonus. Bottom line and all that.

Be well,

David Edelberg, MD


Leave a Comment

  1. David says:

    Do I hear vegan diet and exercise anyone? Getting sucked into this morass as a result of the consumption of rotting animal flesh and dairy products sounds like karma with a capital “K” to me.

  2. Don Schoenbeck says:

    While it’s a scary scenario, I believe you have accurately described the future of medical care. The only minor correction I would offer is the tax status of Blue Cross plans. In 1994, the Blue Cross Blue Shield Association changed to allow its licensees to be for-profit corporations. Some plans (like Illinois) are still considered not-for-profit at the state level. Many of the others have become part of big even multi state for profit corporations.

  3. Mary A Sienkiewicz says:

    No surprise here…this is what happens when the Government gets involved. They work right along the EVIL Health Insurance companies instead of letting the free market do it! Free market competition is the only answer.

  4. John says:

    This is informative and dismaying at the same time. My dismay makes me feel like the Tea Partiers were right all along. What is there to like about ACA, given the situation as Dr. Edelberg describes it? I don’t doubt that he’s right, but I find it profoundly discouraging.

  5. Bonnie Wilkins says:

    As a Masters in Health Information Management recent grad, my study of ACOs views them favorably. Currently our health care system reimburses for the quantity of services provided. ACOs & Patient-centered Medical Home are two payment models that shift the reimbursement focus to OUTCOMES. Providers that join together to participate in an ACO are betting that they can improve patient outcomes, so they opt to share the risk with payers (currently only CMS) in order to benefit from bonuses for improvements. The other goal is for many different providers of a single patient work together as a team to improve health outcomes. EMRs facilitate all a patient’s providers to share information, so primary care physicians know what the cardiologist has ordered and vice-versa, etc. Use of proven “best practices” is encouraged so that every hospital is practicing the proven methods for strokes, heart attacks, pnumonia, asthma, infection, etc. This is to bring hospitals with poor outcomes closer to the par of Cleveland Clinic.

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