Category Archives: Using Health Care

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Something New in Medicare Healthcare Delivery – The ACO

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So, where have I been? Anyone who has written a successful blog will tell you that you need to publish often to attract readers.  It’s been months since my last post.  I apologize for the delay, but I’ve been busy working as the Medical Director for an Accountable Care Organization (ACO) since August and think some of my experiences can offer some insights about new developments in our health care system –  insights that everyone can use.  In this post, I’ll give you a brief overview of Accountable Care Organizations.

What is an ACO?  CMS through regulations found in the Patient Protection and Accountable Care Act is encouraging the formation of ACOs to address some of the problems in our health care delivery system through innovation that moves us from a fee for service to fee for value.  Here’s the definition from the Centers for Medicare & Medicaid Services (CMS):

“ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

Through an application process, ACOs are designated by CMS.  They are focused on achieving the Three-Part Aim of:

  • Improving the experience of care
  • Improving the health of populations
  • Reducing per capita costs of healthcare

To make sure that quality is enhanced, ACOs must report 33 quality measures within the following 4 areas:

  • Care coordination & patient safety
  • Preventive health services
  • Care for at-risk populations
  • Patient & caregiver experience of care

In my next post I’ll talk about some of the opportunities for ACOs to improve how care is delivered for Medicare patients, many of which are applicable to the entire U.S. population.

For Your Health – Dr. Bob

The Affordable Care Act – Have You Read It Yet?

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Well, have you?  With all the furor and debate these past several years I know you’ve heard about the Affordable Care Act (ACA), often called Obamacare.  Its full name is the Patient Protection and Affordable Care Act (PPACA).  What do you know about it?  Just the few sound bites that flood the media?  With the Supreme Court’s decision leaving it intact, the Republican Party is making its repeal the rallying cry for their bid for November’s Presidential Election.  Our country is divided on the issue, and yet, I would bet that the majority of Americans haven’t even read it.  They rely on what they have heard in the news or from their favorite commentator or politician.  The problem is that those messages are designed to be short & emotionally charged, yet ACA is, of necessity, quite broad.

Because your vote this November can be critical to the health of the healthcare system of the United States, I urge you to take the time to read through the law to understand it in more detail.  I have included a copy of the Affordable Care Act and the associated Health Care section of the Health Care and Education Reconciliation Act of 2010.  Just Click Here or the link on the right to open it in a separate window.

A couple of points:

  • The ACA is divided into 10 Titles followed by the Reconciliation section.  Think of the Titles as chapters.
  • The last Title of ACA contains all the amendments that were made to the original draft of the law and is entitled, Title X – Strengthening Quality, Affordable Healthcare For All Americans.
  • Title IX – Revenue Offset Provisions covers the sources of the money that will pay for the components of the law.
  • The Health Care and Education Reconciliation Act of 2010 reconciles the ACA with the Federal budget.
  • The ACA & the Reconciliation Act file available through the link on this blog total 974 pages.  References have been made stating that it is over 2,400 pages long.  This discrepancy is due in part to the fact that certain copies of it as it went through the legislative process were formatted differently and double-spaced.

Suggestions:

  • Rather than reading the law straight through, review the table of contents at the beginning.  This will give you a quick overview of the topics it covers.  Then you can start to read about the aspects of the law that are of interest to you.
  • I urge you to read Title IX that deals with Revenue Offset Provisions.  It includes requirements that health insurance companies, pharmaceutical companies & the makers of medical devices must pay billions of dollars annually based upon their market share.  It also limits the income of health insurance executives.  I think this Title is especially telling because it shows who has the most to lose with this law and may explain why people take the positions they do.

So, take the time to learn about the Affordable Care Act.  You’ll be surprised at what you’ll learn and be better able to judge the accuracy of the many statements about it that fill the media.

For Your Health – Dr. Bob

A Great Video on Hospital Charges

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Shortly after publishing my last post, The $29,000 Appendectomy! (Brought to You by Cost-Shifting), my daughter e-mailed me a link to a video on the CNN website in which Dr. Sanjay Gupta gives some further insight about hospital charges and cost-shifting. As always, he did a terrific job, and I urge you to Click Here to check it out.

I’ve always admired Dr. Gupta’s interviewing skills and ability to clearly explain some complicated medical issues to his audience.

As always, I welcome your comments!

For Your Health – Dr. Bob

The $29,000 Appendectomy! (Brought to You by Cost-Shifting)

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This past May my married daughter suddenly developed abdominal pain.  She was promptly diagnosed as having appendicitis, and within 12 hours after the pain started, she underwent an appendectomy. Twelve hours later she was discharged from the hospital.  Her entire hospital stay, including emergency room evaluation, testing and surgery, lasted less than 24 hours.  She had absolutely great care throughout and was back to her busy schedule within a few days.

Why am I bringing this up on the eve of the Supreme Court’s decisions on several key elements of the Affordable Care Act (ACA)?  Because the hospital charges for less than 24 hours of hospital care were $29,000!!  That’s right, over $1,000 per hour.  Thankfully she has health insurance through her husband, so she only needed to pay $585.  If she didn’t have insurance, she’d be facing that staggering $29,000 bill.  Remember, this does not include the surgeon’s, anesthesiologist’s or emergency room doctor’s charges.

A couple of points:

  • The $29,000 stated cost is the result of cost-shifting.  Remember, my daughter only had to pay $585 which is 20% of the amount that her insurer had negotiated with the hospital.  If you do the math, the negotiated charges to the healthcare insurer were $2,925.  The insurer paid 80% of that which was $2,340 and my daughter paid the $585 balance.  Cost-shifting occurs when one group of individuals pays less than another group for the same service.  Hospitals use this tactic to make up for the loss they incur by providing care to someone without insurance who will not be able to pay the bill or to an insurer whose payment is actually below the cost of that service.
  • The non-insured patient could negotiate with the hospital and probably satisfy their debt at an amount much lower than $29,000.  The hospital would probably be very happy if they received anything over the $2,925 that they get from an insurer.  The trouble is, the non-insured individual doesn’t know how much might be acceptable to the hospital, and the hospital doesn’t have to tell them.

This happens all the time, though the difference isn’t usually this huge.  If you have health insurance and have had medical care recently, you have received an EOB (Explanation of Benefits) notice from your insurer that lists the services you received, how much the negotiated fee is, how much your insurer paid & how much you owe.

While this lack of transparency may hide the true cost of care, there is nothing fraudulent or illegal about it. I guess I prefer not to be playing these number games.  The cost of an appendectomy at a specific hospital should be the same for everyone.  There is a lot to consider about the individual mandate, but if the Supreme Court upholds its constitutionality in the ACA, I believe we’ll move closer to that goal by decreasing the need for cost-shifting.

What do you think?  Have you seen these huge differences between what’s billed by a hospital or doctor and what fee is accepted?

For Your Health – Dr. Bob

Evidence-Based Medicine, Clinical Pathways & Quality

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With all the developments and improved treatments in every area of medicine, it can be difficult for physicians to keep up with the most current and effective therapies in their areas of specialization. So how can a patient know whether they are getting the highest level of quality of care?  After all, patients rely on the expertise of their doctors.  This is one reason why health plans and other healthcare organizations are asking physicians to develop and use Care Pathways, sometimes called Clinical Pathways.

These pathways use evidence-based medical guidelines as their foundation.  With such an approach, appropriate diagnostic testing and treatments for a clinical situation are determined by a team of expert specialists based upon the most recent, scientifically valid medical research that is relevant to the situation.  For example for cancer care, a team of oncologists, usually representing their national specialty board, review the medical studies of the latest cancer research and judge the value of the different tests and treatments for the most common kinds of cancer.  They then make recommendations or guidelines that are published and shared with the rest of the oncology specialists throughout the country to guide them in providing their patients with care that will more likely produce better outcomes.

These evidence-based care recommendations and guidelines sometimes can’t be easily applied in clinical practice as written.  That’s where Care Pathways come in.  Physicians and other clinicians who practice together take these evidence-based recommendations and turn them into a practical approach that they can use where they practice.  These are the Care Pathways that everyone in the practice or hospital follows to make sure that the best care is delivered.  The more innovative and quality-focused practices and healthcare organizations use computer systems to track how well these pathways are followed.  Then they routinely look at these as quality measures to gauge how well they are doing and make improvements to their processes to improve their outcomes.

I think that these Care Pathways hold the promise of increasing quality at the practice level faster than any other quality improvement methodology.  What do you think?  Leave a comment.  After all, it’s your healthcare we’re talking about.

For Your Health – Dr. Bob