(05-25-2015 02:25 PM)dawgitall Wrote:  I've never beaten you up for advocating solutions to the problem, just your constant deflection to it whenever the topic of the ACA comes up. The Thread is for discussion. You should offer lots of insight here and I'm hoping you will!

I have offered insight... repeatedly... and others have as well, including here. I'm really not interested in doing it again and others have clearly articulated a vast number of possible solutions. I'm not married to any single solution... as there are a large number of ways to 'skin this cat'... I'm only against lying to people and claiming that signing people up for insurance means more or better healthcare. The ONLY thing that leads to more or better healthcare is greater supply of healthcare to deliver.... and 'sign up' numbers don't have anything to do with that.

Yes, every time you've brought up the MEANINGLESS number of people complying with the law, I've responded by pointing out that health insurance /= health care. If you want me to stop, then stop trying to claim, as you have, even here... that more insured people = better health care. I haven't started one thread that I recall talking about the PCP shortage. There are numerous that you've started to tout 'sign-ups'.

What I love though is all the solutions from the left aimed somehow at 'forcing' doctors to provide certain types of care.... or act as if those incentives don't already exist.

1) Medical School is Medical School. You don't specialize in medical school.
2) Residency is where you specialize... and while certainly there are subsidies that lots of places (especially rural areas) focus their subsidies on, when the difference in annual compensation between a PCP and the average specialist is almost 100,000 per year, it almost doesn't matter. An ER doc, dermatologist or general surgeon makes over 300k/yr. An OB or Allergist makes 250k. A family med or pediatrician makes less than 200k.

At $50-100k more per yr for the next 30+ years... They'll happily pay back the subsidies.

Now, what it PCPs made more? Then you wouldn't NEED those subsidies to get people to do it, or at least fewer would be willing to do something else. Which explains why I am so bothered that the ACA REDUCES rather than increases what PCPs make. It took a problem it recognized and made things WORSE.... not better.

There are a myriad of ways to solve these problems... and yes, EMR and the like are good... but there are SO MANY ways that the ACA went that are the exact opposite of the way you would go about solving these problems that I can't stand people touting 'compliance with the law' as some sort of success.

maximus, your solutions are well articulated and thought out, but unless I missed something, they leave out some important details..
1) that much of the 'care coordination' that we want PCPs to do is unreimbursable in any setting but an HMO. While arguably they get paid a flat fee to routinely review records as you describe... it is only when that patient actually comes in that they stand a chance of getting paid more. Unfortunately it is the nature of the human beast to try and maximize reimbursement and minimize effort. This is the area where pay should be most greatly increased.
2) even that requires an elimination of one of our biggest healthcare issues, and that is non-compliant patients. Everyone in the world knows that we need to exercise more, drink less, smoke less etc etc... but the people that consume the most healthcare by and large don't follow these simple instructions. Finish your meds... take them as prescribed etc etc... follow up with your PCP... etc etc.

I'm not saying we need to go so far as to pay doctors hourly to review records, but it wouldn't be the worst idea. Expecting them to do more and get paid less (which is how the ACA plans to control costs) is closer to the worst idea.

I'm not saying we need to punish/not treat patients who don't take ownership of their own healthcare, but that wouldn't be the worst idea. Tying physician or hospital reimbursement to 'patient satisfaction' (which is part of the ACA) is closer to the worst idea. It only encourages docs to treat symptoms and prescribe 'magic pills' rather than force patients to move more and smoke, drink, eat or abuse drugs less.

(05-25-2015 04:59 PM)dawgitall Wrote:  I'm still waiting for you to show us that kaiser report that doesn't even exist!

I don't know who you are responding to here. What report/claim is that? There was no 'claim' of a report referenced. If I made the claim, the report exists... I just need to know what you are talking about.

(05-25-2015 09:02 AM)dawgitall Wrote:  I don't think it is all a negative though. I use to have to drive an hour to a cardiologist (still do for my wife) but I just did a stress test three blocks from my home because UNC has set up offices in the small towns all over he area.

Yet when I mention that DMC San Pablo closing will mean that people in that area having heart attacks or strokes will now have to drive 20 minutes further (which means some of them will die), these comments are dismissed.

Buying up a practice is a means of self-defense for a Hospital... It provides alternative sources of revenue and as we go to bundled payments, it will be how they will maximize revenue... but this only works in areas where you have sufficient economies of scale. Rural healthcare isn't even really the problem here... for while they are small, they get 100% of the sick people from the area (there is nowhere else to go). It's mostly urban-inner city hospitals that will struggle... You know, where most of these previously uninsured live... like DMC. San Pablo is a poor area just minutes outside of some of the wealthiest real estate in the country.

The problem is that Hospitals are the money-losers... not the physicians practices. Creating mega-physicians practices like Kelsey Siebold or Kaiser Permanente have all the beauties you talk about, with none of the REQUIREMENT to provide life saving assistance that Hospitals have. I understand why a hospital would want to buy a physicians practice... but why would a physicians practice want to buy/be bought by a hospital? In other words, this only works if the hospital already HAS deep pockets.

The bottom line is, just as i have repeatedly said... that all you are doing is reshuffling the existing chairs... noting the winners and ignoring the losers. If you want to create more winners than losers... then you MUST stop reshuffling the chairs and touting only the areas where people are better off... ignoring the others... and simply create more 'healthcare.' Changing ownership of your local facility doesn't create more healthcare.

(05-26-2015 06:01 PM)Hambone10 Wrote:  

(05-25-2015 02:25 PM)dawgitall Wrote:  I've never beaten you up for advocating solutions to the problem, just your constant deflection to it whenever the topic of the ACA comes up. The Thread is for discussion. You should offer lots of insight here and I'm hoping you will!

I have offered insight... repeatedly... and others have as well, including here. I'm really not interested in doing it again and others have clearly articulated a vast number of possible solutions. I'm not married to any single solution... as there are a large number of ways to 'skin this cat'... I'm only against lying to people and claiming that signing people up for insurance means more or better healthcare. The ONLY thing that leads to more or better healthcare is greater supply of healthcare to deliver.... and 'sign up' numbers don't have anything to do with that.

Yes, every time you've brought up the MEANINGLESS number of people complying with the law, I've responded by pointing out that health insurance /= health care. If you want me to stop, then stop trying to claim, as you have, even here... that more insured people = better health care. I haven't started one thread that I recall talking about the PCP shortage. There are numerous that you've started to tout 'sign-ups'.

What I love though is all the solutions from the left aimed somehow at 'forcing' doctors to provide certain types of care.... or act as if those incentives don't already exist.

1) Medical School is Medical School. You don't specialize in medical school.
2) Residency is where you specialize... and while certainly there are subsidies that lots of places (especially rural areas) focus their subsidies on, when the difference in annual compensation between a PCP and the average specialist is almost 100,000 per year, it almost doesn't matter. An ER doc, dermatologist or general surgeon makes over 300k/yr. An OB or Allergist makes 250k. A family med or pediatrician makes less than 200k.

At $50-100k more per yr for the next 30+ years... They'll happily pay back the subsidies.

Now, what it PCPs made more? Then you wouldn't NEED those subsidies to get people to do it, or at least fewer would be willing to do something else. Which explains why I am so bothered that the ACA REDUCES rather than increases what PCPs make. It took a problem it recognized and made things WORSE.... not better.

There are a myriad of ways to solve these problems... and yes, EMR and the like are good... but there are SO MANY ways that the ACA went that are the exact opposite of the way you would go about solving these problems that I can't stand people touting 'compliance with the law' as some sort of success.

maximus, your solutions are well articulated and thought out, but unless I missed something, they leave out some important details..
1) that much of the 'care coordination' that we want PCPs to do is unreimbursable in any setting but an HMO. While arguably they get paid a flat fee to routinely review records as you describe... it is only when that patient actually comes in that they stand a chance of getting paid more. Unfortunately it is the nature of the human beast to try and maximize reimbursement and minimize effort. This is the area where pay should be most greatly increased.
2) even that requires an elimination of one of our biggest healthcare issues, and that is non-compliant patients. Everyone in the world knows that we need to exercise more, drink less, smoke less etc etc... but the people that consume the most healthcare by and large don't follow these simple instructions. Finish your meds... take them as prescribed etc etc... follow up with your PCP... etc etc.

I'm not saying we need to go so far as to pay doctors hourly to review records, but it wouldn't be the worst idea. Expecting them to do more and get paid less (which is how the ACA plans to control costs) is closer to the worst idea.

I'm not saying we need to punish/not treat patients who don't take ownership of their own healthcare, but that wouldn't be the worst idea. Tying physician or hospital reimbursement to 'patient satisfaction' (which is part of the ACA) is closer to the worst idea. It only encourages docs to treat symptoms and prescribe 'magic pills' rather than force patients to move more and smoke, drink, eat or abuse drugs less.

(05-25-2015 04:59 PM)dawgitall Wrote:  I'm still waiting for you to show us that kaiser report that doesn't even exist!

I don't know who you are responding to here. What report/claim is that? There was no 'claim' of a report referenced. If I made the claim, the report exists... I just need to know what you are talking about.

(05-25-2015 09:02 AM)dawgitall Wrote:  I don't think it is all a negative though. I use to have to drive an hour to a cardiologist (still do for my wife) but I just did a stress test three blocks from my home because UNC has set up offices in the small towns all over he area.

Yet when I mention that DMC San Pablo closing will mean that people in that area having heart attacks or strokes will now have to drive 20 minutes further (which means some of them will die), these comments are dismissed.

Buying up a practice is a means of self-defense for a Hospital... It provides alternative sources of revenue and as we go to bundled payments, it will be how they will maximize revenue... but this only works in areas where you have sufficient economies of scale. Rural healthcare isn't even really the problem here... for while they are small, they get 100% of the sick people from the area (there is nowhere else to go). It's mostly urban-inner city hospitals that will struggle... You know, where most of these previously uninsured live... like DMC. San Pablo is a poor area just minutes outside of some of the wealthiest real estate in the country.

The problem is that Hospitals are the money-losers... not the physicians practices. Creating mega-physicians practices like Kelsey Siebold or Kaiser Permanente have all the beauties you talk about, with none of the REQUIREMENT to provide life saving assistance that Hospitals have. I understand why a hospital would want to buy a physicians practice... but why would a physicians practice want to buy/be bought by a hospital? In other words, this only works if the hospital already HAS deep pockets.

The bottom line is, just as i have repeatedly said... that all you are doing is reshuffling the existing chairs... noting the winners and ignoring the losers. If you want to create more winners than losers... then you MUST stop reshuffling the chairs and touting only the areas where people are better off... ignoring the others... and simply create more 'healthcare.' Changing ownership of your local facility doesn't create more healthcare.

I think you kind of hit on it later in your post. Private insurers are moving away from stricrly fee for service and developing more bundled ACO models that reward a population health model.

And your correct...These models are in direct correlation to why hospital systems are buying practices.

People need to understand that soon enough the only people who are admissions in hospitals are those who are almost dead and or dying. Basically all beds will be ICU beds. Everything else is moving to the ambulatory world.

(05-25-2015 09:14 PM)maximus Wrote:  When talking about the primary care shortage there are really only two things that can be done.

1. Mitigate the problem and use the available resources and tools.
2. Determine the best way to fill in the gaps for the next 5,10,20,50 years.

Number 2 should have been under way years ago but all that has happened is the can has been kicked down the road. It will probably continue that way so let’s focus on number 1.

So when it comes to number one.....there are a few things that can be utilized to accomplish more with less.

1. Population Health / Care Coordination
2. Exchange of Health Information / Data
3. Telemedicine / E-Medicine
4. Patient Engagement / Ownership

There are a few more I could add to the list but let’s go with these for now. There is one thing in common that ties all of these things together.....Electronic Health Data. Like I said in a previous post, I used to be a clinician and when I had to start using EHRs I despised them, it cut my productivity by 50%. I was recruited by my organization to take part in the largest and most costly project in the history of our 100 year old health system. I lead a team of 30 people and I am responsible for around 150 clinics and 80 outpatient hospital departments across 3 states. I am also responsible for our patient portal that allows patients to message providers, request appointments, refills, and advice, along with other tools patients can use in their care. We also offer a web access application to referring providers, nursing homes, insurance companies, DME companies, etc... Where they can log on and access anything done at our organization for a specific patient.

I said all of that to basically say that after having to use several EHRs ...and despised it most of the time......I found out pretty quickly the power of the data I was putting into the record and that it must be leveraged to help care for our patient populations.

Let’s go through a few scenarios on the same patient….

Patient: 52 y/o male with a history of diabetes

Scenario #1

1. Goes to his PCP that he hasn’t seen in over a year with complaints of a fever
2. PCP sees the patient and after review of his chart, notices the patient hasn’t been in for his routine A1C and has not performed a diabetic foot exam in over a year.
3. Patients reports he has been running a low grade fever off and on for 3 weeks and he went to the local Walgreens for the fever twice and received antibiotics. Still running fever.
4. Point of care glucose is 320
5. During a foot exam the provider notices a discolored calloused area on the first metatarsal head. Patient says he noticed it a couple of months ago but it wasn’t hurting. (Obviously because he has peripheral neuropathy) During further examination the provider notices an odor from the foot and is able to express purulence from the location. The patient then admits he has been noticing a foul odor from time to time.
6. Sends patient for diagnostic tests and patient is diagnosed with an acute bone infection.
7. Admits patient to the hospital for surgical debridement, IV antibiotics, and wound care.
8. Patient goes through several cycles and treatments to try and salvage the limb but ultimately has to have a BKA.

Now let’s go through a couple of other scenarios with that same patient.

Scenario #2

1. A care coordinator for the primary care provider runs a few reports on the practices diabetic patients. The data includes recent lab results, last communication, claims data...She also runs the patients through a care risk stratification model that prioritizes the patients at most risk. (Population Health)
2. This patients name comes up in the reports as not having a diabetic foot exam in over a year, has not had his routine A1C, and has not had communication with the office in over 8 months.
3. The care coordinator sends the patient a letter and a communication via the patient portal to proactively reach out to the patient. (Care coordination)
4. The patient sets up an office visit and has the appropriate labs and foot exam. The provider notices the beginnings of a callous and consults an orthotist to mold the patient some new shoe inserts.
5. The provider wants to have the patient track his blood glucose on the patient portal so he can monitor more closely. He sends an electronic tracking tool to the patient that he can complete on his iphone using the portal app. (patient engagement)

Scenario #3

1. Patient goes to the local Walgreens a couple of times over the last few months because it is closer to his home; he has also gone to the local urgent care over the last 12 months.
2. The patient’s provider receives a message each time the patient goes to the Walgreens and Urgent Care because they all have an agreement to exchange the patient’s data electronically. (Health information exchange)
3. The provider reviews the continuity of care document attached to the message and reconciles some data into his record. (Health information exchange)
4. The provider notices an upward trend of the patient’s glucose levels that were checked at both the Walgreens and Urgent Care.
5. The provider has his care coordinator contact the patient to get the patient into the office for a full diabetic exam. (Care Coordination)

Scenario #4

1. The patient lives a good distance from his primary care provider but still wants to see him because he has some questions about his diabetes.
2. The patient notices the provider now provides video visits one afternoon a week. He sends a request for an appointment and the office accepts and schedules. A questionnaire is sent to the patient that he completes prior to the video visit. (Telemedicine)
3. The patient and provider complete a video visit and the provider is able to answer his questions and the patient shows the provider his feet and the provider notices a small callous forming and sends the patient to a podiatrist for a consult and shaving.
4. The provider releases an electronic glucose tracking tool for the patient to complete on his phone so he can track the patients levels real time. (patient engagement)

Obviously scenario 1 is what normally happens and ends up costing the patient (money and wellbeing) and the health care providers and system much more money.

The other scenarios all leverage the EHR data to get the patient the right care at the right time; this in turn relieves the pressure off of the primary care provider. Depending on the payment model it will most likely mean more money for the provider as well.

This is interesting information and in fact hits very close to home for me. We are over an hour away from my wife's doctors and do use the website to communicate. They haven't offered video appointments yet but odds are they aren't too far off. That would be a great help. We do a lot of phone messaging with the cardiology office, usually with a NP regarding things like weight fluctuations.

PCU/Med-Surg beds you mean.

(05-26-2015 09:29 PM)dawgitall Wrote:  

(05-25-2015 09:14 PM)maximus Wrote:  When talking about the primary care shortage there are really only two things that can be done.

1. Mitigate the problem and use the available resources and tools.
2. Determine the best way to fill in the gaps for the next 5,10,20,50 years.

Number 2 should have been under way years ago but all that has happened is the can has been kicked down the road. It will probably continue that way so let’s focus on number 1.

So when it comes to number one.....there are a few things that can be utilized to accomplish more with less.

1. Population Health / Care Coordination
2. Exchange of Health Information / Data
3. Telemedicine / E-Medicine
4. Patient Engagement / Ownership

There are a few more I could add to the list but let’s go with these for now. There is one thing in common that ties all of these things together.....Electronic Health Data. Like I said in a previous post, I used to be a clinician and when I had to start using EHRs I despised them, it cut my productivity by 50%. I was recruited by my organization to take part in the largest and most costly project in the history of our 100 year old health system. I lead a team of 30 people and I am responsible for around 150 clinics and 80 outpatient hospital departments across 3 states. I am also responsible for our patient portal that allows patients to message providers, request appointments, refills, and advice, along with other tools patients can use in their care. We also offer a web access application to referring providers, nursing homes, insurance companies, DME companies, etc... Where they can log on and access anything done at our organization for a specific patient.

I said all of that to basically say that after having to use several EHRs ...and despised it most of the time......I found out pretty quickly the power of the data I was putting into the record and that it must be leveraged to help care for our patient populations.

Let’s go through a few scenarios on the same patient….

Patient: 52 y/o male with a history of diabetes

Scenario #1

1. Goes to his PCP that he hasn’t seen in over a year with complaints of a fever
2. PCP sees the patient and after review of his chart, notices the patient hasn’t been in for his routine A1C and has not performed a diabetic foot exam in over a year.
3. Patients reports he has been running a low grade fever off and on for 3 weeks and he went to the local Walgreens for the fever twice and received antibiotics. Still running fever.
4. Point of care glucose is 320
5. During a foot exam the provider notices a discolored calloused area on the first metatarsal head. Patient says he noticed it a couple of months ago but it wasn’t hurting. (Obviously because he has peripheral neuropathy) During further examination the provider notices an odor from the foot and is able to express purulence from the location. The patient then admits he has been noticing a foul odor from time to time.
6. Sends patient for diagnostic tests and patient is diagnosed with an acute bone infection.
7. Admits patient to the hospital for surgical debridement, IV antibiotics, and wound care.
8. Patient goes through several cycles and treatments to try and salvage the limb but ultimately has to have a BKA.

Now let’s go through a couple of other scenarios with that same patient.

Scenario #2

1. A care coordinator for the primary care provider runs a few reports on the practices diabetic patients. The data includes recent lab results, last communication, claims data...She also runs the patients through a care risk stratification model that prioritizes the patients at most risk. (Population Health)
2. This patients name comes up in the reports as not having a diabetic foot exam in over a year, has not had his routine A1C, and has not had communication with the office in over 8 months.
3. The care coordinator sends the patient a letter and a communication via the patient portal to proactively reach out to the patient. (Care coordination)
4. The patient sets up an office visit and has the appropriate labs and foot exam. The provider notices the beginnings of a callous and consults an orthotist to mold the patient some new shoe inserts.
5. The provider wants to have the patient track his blood glucose on the patient portal so he can monitor more closely. He sends an electronic tracking tool to the patient that he can complete on his iphone using the portal app. (patient engagement)

Scenario #3

1. Patient goes to the local Walgreens a couple of times over the last few months because it is closer to his home; he has also gone to the local urgent care over the last 12 months.
2. The patient’s provider receives a message each time the patient goes to the Walgreens and Urgent Care because they all have an agreement to exchange the patient’s data electronically. (Health information exchange)
3. The provider reviews the continuity of care document attached to the message and reconciles some data into his record. (Health information exchange)
4. The provider notices an upward trend of the patient’s glucose levels that were checked at both the Walgreens and Urgent Care.
5. The provider has his care coordinator contact the patient to get the patient into the office for a full diabetic exam. (Care Coordination)

Scenario #4

1. The patient lives a good distance from his primary care provider but still wants to see him because he has some questions about his diabetes.
2. The patient notices the provider now provides video visits one afternoon a week. He sends a request for an appointment and the office accepts and schedules. A questionnaire is sent to the patient that he completes prior to the video visit. (Telemedicine)
3. The patient and provider complete a video visit and the provider is able to answer his questions and the patient shows the provider his feet and the provider notices a small callous forming and sends the patient to a podiatrist for a consult and shaving.
4. The provider releases an electronic glucose tracking tool for the patient to complete on his phone so he can track the patients levels real time. (patient engagement)

Obviously scenario 1 is what normally happens and ends up costing the patient (money and wellbeing) and the health care providers and system much more money.

The other scenarios all leverage the EHR data to get the patient the right care at the right time; this in turn relieves the pressure off of the primary care provider. Depending on the payment model it will most likely mean more money for the provider as well.

This is interesting information and in fact hits very close to home for me. We are over an hour away from my wife's doctors and do use the website to communicate. They haven't offered video appointments yet but odds are they aren't too far off. That would be a great help. We do a lot of phone messaging with the cardiology office, usually with a NP regarding things like weight fluctuations.

We are working on device integration with our portal. So things like wearables(fitbits/apple health kit), glucometers, scales, BP cuffs, and several other units. That way no phone calls. Just import the data into the portal and it is reconciled into the chart as discrete reportable data.

Almost real time data that can be used to intervene and change medications and therapies sooner to keep the patent in a well state and out of the acute care setting.

(05-26-2015 06:01 PM)Hambone10 Wrote:  

(05-25-2015 02:25 PM)dawgitall Wrote:  I've never beaten you up for advocating solutions to the problem, just your constant deflection to it whenever the topic of the ACA comes up. The Thread is for discussion. You should offer lots of insight here and I'm hoping you will!

I have offered insight... repeatedly... and others have as well, including here. I'm really not interested in doing it again and others have clearly articulated a vast number of possible solutions. I'm not married to any single solution... as there are a large number of ways to 'skin this cat'... I'm only against lying to people and claiming that signing people up for insurance means more or better healthcare. The ONLY thing that leads to more or better healthcare is greater supply of healthcare to deliver.... and 'sign up' numbers don't have anything to do with that.

Yes, every time you've brought up the MEANINGLESS number of people complying with the law, I've responded by pointing out that health insurance /= health care. If you want me to stop, then stop trying to claim, as you have, even here... that more insured people = better health care. I haven't started one thread that I recall talking about the PCP shortage. There are numerous that you've started to tout 'sign-ups'.

What I love though is all the solutions from the left aimed somehow at 'forcing' doctors to provide certain types of care.... or act as if those incentives don't already exist.

1) Medical School is Medical School. You don't specialize in medical school.
2) Residency is where you specialize... and while certainly there are subsidies that lots of places (especially rural areas) focus their subsidies on, when the difference in annual compensation between a PCP and the average specialist is almost 100,000 per year, it almost doesn't matter. An ER doc, dermatologist or general surgeon makes over 300k/yr. An OB or Allergist makes 250k. A family med or pediatrician makes less than 200k.

At $50-100k more per yr for the next 30+ years... They'll happily pay back the subsidies.

Now, what it PCPs made more? Then you wouldn't NEED those subsidies to get people to do it, or at least fewer would be willing to do something else. Which explains why I am so bothered that the ACA REDUCES rather than increases what PCPs make. It took a problem it recognized and made things WORSE.... not better.

There are a myriad of ways to solve these problems... and yes, EMR and the like are good... but there are SO MANY ways that the ACA went that are the exact opposite of the way you would go about solving these problems that I can't stand people touting 'compliance with the law' as some sort of success.

maximus, your solutions are well articulated and thought out, but unless I missed something, they leave out some important details..
1) that much of the 'care coordination' that we want PCPs to do is unreimbursable in any setting but an HMO. While arguably they get paid a flat fee to routinely review records as you describe... it is only when that patient actually comes in that they stand a chance of getting paid more. Unfortunately it is the nature of the human beast to try and maximize reimbursement and minimize effort. This is the area where pay should be most greatly increased.
2) even that requires an elimination of one of our biggest healthcare issues, and that is non-compliant patients. Everyone in the world knows that we need to exercise more, drink less, smoke less etc etc... but the people that consume the most healthcare by and large don't follow these simple instructions. Finish your meds... take them as prescribed etc etc... follow up with your PCP... etc etc.

I'm not saying we need to go so far as to pay doctors hourly to review records, but it wouldn't be the worst idea. Expecting them to do more and get paid less (which is how the ACA plans to control costs) is closer to the worst idea.

I'm not saying we need to punish/not treat patients who don't take ownership of their own healthcare, but that wouldn't be the worst idea. Tying physician or hospital reimbursement to 'patient satisfaction' (which is part of the ACA) is closer to the worst idea. It only encourages docs to treat symptoms and prescribe 'magic pills' rather than force patients to move more and smoke, drink, eat or abuse drugs less.

(05-25-2015 04:59 PM)dawgitall Wrote:  I'm still waiting for you to show us that kaiser report that doesn't even exist!

I don't know who you are responding to here. What report/claim is that? There was no 'claim' of a report referenced. If I made the claim, the report exists... I just need to know what you are talking about.

(05-25-2015 09:02 AM)dawgitall Wrote:  I don't think it is all a negative though. I use to have to drive an hour to a cardiologist (still do for my wife) but I just did a stress test three blocks from my home because UNC has set up offices in the small towns all over he area.

Yet when I mention that DMC San Pablo closing will mean that people in that area having heart attacks or strokes will now have to drive 20 minutes further (which means some of them will die), these comments are dismissed.

Buying up a practice is a means of self-defense for a Hospital... It provides alternative sources of revenue and as we go to bundled payments, it will be how they will maximize revenue... but this only works in areas where you have sufficient economies of scale. Rural healthcare isn't even really the problem here... for while they are small, they get 100% of the sick people from the area (there is nowhere else to go). It's mostly urban-inner city hospitals that will struggle... You know, where most of these previously uninsured live... like DMC. San Pablo is a poor area just minutes outside of some of the wealthiest real estate in the country.

The problem is that Hospitals are the money-losers... not the physicians practices. Creating mega-physicians practices like Kelsey Siebold or Kaiser Permanente have all the beauties you talk about, with none of the REQUIREMENT to provide life saving assistance that Hospitals have. I understand why a hospital would want to buy a physicians practice... but why would a physicians practice want to buy/be bought by a hospital? In other words, this only works if the hospital already HAS deep pockets.

The bottom line is, just as i have repeatedly said... that all you are doing is reshuffling the existing chairs... noting the winners and ignoring the losers. If you want to create more winners than losers... then you MUST stop reshuffling the chairs and touting only the areas where people are better off... ignoring the others... and simply create more 'healthcare.' Changing ownership of your local facility doesn't create more healthcare.

Thanks for posting Ham. I do appreciate your input, even if you view me as some kind of bad guy because I have a few (not bunches) of threads over the last couple of years about ACA signups. The ACA getting off the ground and up and running is something that interests me and that is why I've posted about it. Your criticism of various aspects of the ACA aren't disregarded. I have learned a lot from what you have offered.

The Kaiser report post wasn't directed to you. It was to UofM. He made a false claim about problems people were having because they had high deductible policies. He claimed that there was a Kaiser Foundation report that said that a vast majority of ACA compliant policy holder weren't getting medical attention because they couldn't afford it. In one post he doubled down after I showed the correct Kaiser report figures and claimed it was 75%. I believe it was in the rate hike thread over the last few days.

(05-26-2015 09:30 PM)UCF08 Wrote:  PCU/Med-Surg beds you mean.

I don't think that's what he means. Your 'traditional' bed is a med-surg bed.... and I believe he is saying that there will be decreasing numbers of these. PCU is merely a step-down unit from an ICU.... higher acuity than med/surg. MOST people in med-surg beds are recovering from relatively minor surgery or something that isn't (currently) critical that could arguably be treated in an outpatient setting/telemed.... mostly monitoring vitals and looking for positive and negative reactions to medicines.... and they probably make up 80+% of all inpatient beds.

(05-25-2015 04:59 PM)dawgitall Wrote:  Thanks for posting Ham. I do appreciate your input, even if you view me as some kind of bad guy because I have a few (not bunches) of threads over the last couple of years about ACA signups. The ACA getting off the ground and up and running is something that interests me and that is why I've posted about it. Your criticism of various aspects of the ACA aren't disregarded. I have learned a lot from what you have offered.

The Kaiser report post wasn't directed to you. It was to UofM. He made a false claim about problems people were having because they had high deductible policies. He claimed that there was a Kaiser Foundation report that said that a vast majority of ACA compliant policy holder weren't getting medical attention because they couldn't afford it. In one post he doubled down after I showed the correct Kaiser report figures and claimed it was 75%. I believe it was in the rate hike thread over the last few days.

Fair enough. Thank you. I suspect you think I look for your posts to argue about docs... but I am really only trying to focus on the solutions to our issues as opposed to the hype... which invariably involves addressing the need for more care.

I view the aca completely differently than you do.

To me, the ACA has simply taken medicaid and dozens of other state and federal means to provide 'subsidized' care and turned it into insurance policies... and essentially doubled and re-shuffled the medicare/medicaid taxes to do so. There is nothing wrong with this in general, but I think it is a lot of smoke and mirrors... and that is my REAL problem. I think we are spending a lot of money to make it appear that we are doing far more than we are... or that we aren't doing what we actually are.

Examples are:
1) Is it a tax or isn't it? Obviously the government can collect taxes and spend it on healthcare... and that process already existed both through payroll taxes and income taxes. Rather than simply increase one or more of those rates, we created this cumbersome and convoluted and fraught with new lobbies and 'exceptions for sale' system of mandates and fines.

2) I think the exchanges and medicaid expansion and the like are merely means of taking power (money) away from the states. Now SOME of this is good, like being able to sell insurance across state lines, but much of it is bad in that it creates 'one size fits all' solutions.... which is usually great for high population areas and horrible for less densely populated ones. 'Medicaid expansion' was actually 'medicaid contraction' in a number of states.... and in many states where it wasn't, there were specific reasons why the states made the choices they made... OFTEN because they addressed the needs of those that weren't covered in other ways. We are often told that the feds are paying almost every dime of these expansions, but if the federal government is doing that, why didn't they just make it a Federal plan? It is far more expensive and cumbersome and ripe for issues for the feds to mandate that the states do something some way, and then make exceptions and issue fines and whatever else for non-compliance than it would be for the feds to simply pay for their priorities themselves. Simple example, expand Medicare, not medicaid. Let poor people buy into medicare... subsidize it.

3) The whole health insurance = health care argument.

4) cost controls. Working in a hospital, I find these to be the most cruel lies of all. While absolutely, EMR and data sharing are necessities... and I have LONG supported things like your entire medical record on some sort of a coded chip... MUCH of the direction for payment we are going for is turning doctors and healthcare providers into 'shift workers' at the Post Office. Where the best get paid no more than the worst... and the efficient and thorough are actually punished while the slow and hap-hazard are actually valued. Yes it controls costs... just like Wal-Mart and McDonalds do. Unfortunately, other business models like Saks and Morton's are essentially 'outlawed'. What kind of country would this be if companies weren't allowed to compete with Wal-Mart's low prices by offering more or better service for a higher price?

5) I think the exchanges are an attempt to LOOK like you are providing choices, but because the choices are so controlled, you really aren't offering them. I just see this as more smoke and mirrors. They really need to offer choices... like catastrophic only plans which solve the same 'bankruptcy' issues as all of these ACA policies, but at even lower (and far more straightforward) cost. I mean, the difference between a bronze, silver and gold policy is just math... sort of like how your auto policy with a $100, 500 or $1000 deductible is just math. True CHOICE means the difference between liability only, full coverage, and a variety of choices in between, which doesn't exist in healthcare. I'm fine if the government wants to mandate liability (catastrophic) coverage and provide it to all in some manner of 'free', allowing those who want to pay more to get more to essentially opt out, like they do Social Security. I'm also fine if they want to pay for well-checks for poor people and EMRs. I just want there to be FAR more clarity and direct relationships to what they are doing. THIS is essentially the model that Owl espouses... and there are dozens of highly regarded examples where this works. There doesn't need to be 'choice' in the 'free' government plan... just like their isn't choice in social security.

I believe the ACA is a step towards single payer, single provider. Which I understand that many people want (not me). But it is trying to move us in that direction by misdirection/deception rather than simply extolling/debating the virtues of such a policy and letting well informed people support (or not) that idea. If that is what you mean by 'getting it off the ground', then at least that is honest. (not you, but politicians) Yes, many opponents of the ACA are similarly dishonest.... I simply don't chastise them as much because I still agree with their goals, just not their reasons.

I saw this today. It addresses what we have discussed.

Quote:Millions of people will be able to see a doctor on their smartphones or laptops for everyday ailments once the nation's largest drugstore chain and two major insurers expand a budding push into virtual health care.

Walgreens said Wednesday that it will offer a smartphone application that links doctor and patients virtually in 25 states by the end of the year. That growth comes as UnitedHealth Group and the Blue Cross-Blue Shield insurer Anthem prepare to make their own non-emergency telemedicine services available to about 40 million more people by next year.


Read more at http://www.wral.com/walgreens-insurers-p...gvGcXDg.99

(06-10-2015 06:59 PM)dawgitall Wrote:  I saw this today. It addresses what we have discussed.

Quote:Millions of people will be able to see a doctor on their smartphones or laptops for everyday ailments once the nation's largest drugstore chain and two major insurers expand a budding push into virtual health care.

Walgreens said Wednesday that it will offer a smartphone application that links doctor and patients virtually in 25 states by the end of the year. That growth comes as UnitedHealth Group and the Blue Cross-Blue Shield insurer Anthem prepare to make their own non-emergency telemedicine services available to about 40 million more people by next year.


Read more at http://www.wral.com/walgreens-insurers-p...gvGcXDg.99

I actually have no problem with this...but...there are IMO great risks to the docs. Nothing beats seeing a patient one on one and in person. I can see lawsuits coming right off the bat when someone dies from something that would have easily been detected in an office visit and could not be detected virtually.

(06-10-2015 07:58 PM)Fo Shizzle Wrote:  

(06-10-2015 06:59 PM)dawgitall Wrote:  I saw this today. It addresses what we have discussed.

Quote:Millions of people will be able to see a doctor on their smartphones or laptops for everyday ailments once the nation's largest drugstore chain and two major insurers expand a budding push into virtual health care.

Walgreens said Wednesday that it will offer a smartphone application that links doctor and patients virtually in 25 states by the end of the year. That growth comes as UnitedHealth Group and the Blue Cross-Blue Shield insurer Anthem prepare to make their own non-emergency telemedicine services available to about 40 million more people by next year.


Read more at http://www.wral.com/walgreens-insurers-p...gvGcXDg.99

I actually have no problem with this...but...there are IMO great risks to the docs. Nothing beats seeing a patient one on one and in person. I can see lawsuits coming right off the bat when someone dies from something that would have easily been detected in an office visit and could not be detected virtually.

The number of conditions are limited. Our legal and compliance officers are all over this and a disclaimer has to be signed when logging on.

I'm over the telemedicine project for a whale hospital system.

A pre-visit questionnaire is completed to see if they are a candidate for the requested video visit. During the triage if certain things are answered that are concerning the patient is contacted and told to come into the office.

I will point out we are rolling out to the patients actual primary care providers and not some random doctor. Big advantage doing it our way.

Walgreens policy is to only see a person the max of 3 times if the patient doesn't have a PCP. So this model doesn't fix the PCP shortage, it alleviates some of the minor ailments from reaching them but the patient still needs a PCP.

(06-10-2015 07:58 PM)Fo Shizzle Wrote:  

(06-10-2015 06:59 PM)dawgitall Wrote:  I saw this today. It addresses what we have discussed.

Quote:Millions of people will be able to see a doctor on their smartphones or laptops for everyday ailments once the nation's largest drugstore chain and two major insurers expand a budding push into virtual health care.

Walgreens said Wednesday that it will offer a smartphone application that links doctor and patients virtually in 25 states by the end of the year. That growth comes as UnitedHealth Group and the Blue Cross-Blue Shield insurer Anthem prepare to make their own non-emergency telemedicine services available to about 40 million more people by next year.


Read more at http://www.wral.com/walgreens-insurers-p...gvGcXDg.99

I actually have no problem with this...but...there are IMO great risks to the docs. Nothing beats seeing a patient one on one and in person. I can see lawsuits coming right off the bat when someone dies from something that would have easily been detected in an office visit and could not be detected virtually.

They won't prescribe anything but antibiotics. Saves $100 going to the doc with the sniffles.

Sent from my XT1254 using Tapatalk

(06-10-2015 07:58 PM)Fo Shizzle Wrote:  

(06-10-2015 06:59 PM)dawgitall Wrote:  I saw this today. It addresses what we have discussed.

Quote:Millions of people will be able to see a doctor on their smartphones or laptops for everyday ailments once the nation's largest drugstore chain and two major insurers expand a budding push into virtual health care.

Walgreens said Wednesday that it will offer a smartphone application that links doctor and patients virtually in 25 states by the end of the year. That growth comes as UnitedHealth Group and the Blue Cross-Blue Shield insurer Anthem prepare to make their own non-emergency telemedicine services available to about 40 million more people by next year.


Read more at http://www.wral.com/walgreens-insurers-p...gvGcXDg.99

I actually have no problem with this...but...there are IMO great risks to the docs. Nothing beats seeing a patient one on one and in person. I can see lawsuits coming right off the bat when someone dies from something that would have easily been detected in an office visit and could not be detected virtually.

We're going to telemed as well, but it completely misses the point... All we're addressing is the travel time issues...

Telemed is great in rural or poor areas where it is difficult to staff... because doctors often don't want to live in poor neighborhoods.... but once again, since the doctor can't see a patient in real life while they're seeing a patient by telemed... so once again, since we're short physicians, we're merely swapping one visit for another.

The ONLY area where this can make some difference is in small hospital inpatient settings where you will be able to have one doctor cover two small and low acuity facilities at the same time. The typical physician will see 15 patients/day... and now one physician can cover 2 hospitals with 7-8 patients each. Of course, there aren't THAT many of those, but the number IS far greater than zero.

the biggest advantage is that PCPs will be able to treat you in their lab coat and underwear from their beach house... but they still can't (or won't) see more patients in an hour than before. Once again, it's not as if their waiting rooms are empty....

anywhere

and while it is better than nothing, the swap is actually from a higher value in person visit to a somewhat lower value tele-visit. So it's not MORE medicine... and it's not BETTER medicine... but it IS marginally more convenient... but not by much. You still have an office that the patient has to go to with nurses... but the doctor doesn't have to go there.

I've used online doctor visits several times now. Basically it's good for minor stuff or getting an Rx refilled is you run out but not much more.

I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

(06-10-2015 10:14 PM)dfarr Wrote:  I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

Primary Care
Behavioral Health
Post Op F/U's (some)

We have others, starting there

(06-10-2015 10:55 PM)maximus Wrote:  

(06-10-2015 10:14 PM)dfarr Wrote:  I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

Primary Care
Behavioral Health
Post Op F/U's (some)

We have others, starting there

They might make an apple watch app for that eventually

(06-10-2015 10:14 PM)dfarr Wrote:  I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

It won't have a role for specialists. It does reduce costs for primary care. Common colds and flus, infections, poison ivy, coughs, vomiting, allergies etc can be diagnosed and a prescription written for free (at least my company offers it for free) over the phone as opposed to having to take time off work and spend $100+ (if you have deductibles and no copays) to visit a PCP or doc in the box. Our program started in January and I haven't had to use it yet, but have heard good things from coworkers. The other alternative would be to open up the market a bit and make some of these drugs available OTC.

(06-11-2015 07:33 AM)EverRespect Wrote:  

(06-10-2015 10:14 PM)dfarr Wrote:  I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

It won't have a role for specialists. It does reduce costs for primary care. Common colds and flus, infections, poison ivy, coughs, vomiting, allergies etc can be diagnosed and a prescription written for free (at least my company offers it for free) over the phone as opposed to having to take time off work and spend $100+ (if you have deductibles and no copays) to visit a PCP or doc in the box. Our program started in January and I haven't had to use it yet, but have heard good things from coworkers. The other alternative would be to open up the market a bit and make some of these drugs available OTC.

Some Rxs probably could be handled OTC but not antibiotics. The US already has a problem with an overuse of antibiotics which has fed the current problems with antibiotic resistant illnesses. No way antibiotics could be dispensed OTC. There would be idiots taking them every time they had a virus (those same idiots demand an antibiotic Rx from their doctors now when they go in for a virus). There would also be some people who would probably want to take them daily.

(06-11-2015 07:33 AM)EverRespect Wrote:  

(06-10-2015 10:14 PM)dfarr Wrote:  I don't see how telemedicine has a role in my office and we see patients from roughly a 6 hospital area. Hard to check a prostate via the interwebs.

It won't have a role for specialists. It does reduce costs for primary care. Common colds and flus, infections, poison ivy, coughs, vomiting, allergies etc can be diagnosed and a prescription written for free (at least my company offers it for free) over the phone as opposed to having to take time off work and spend $100+ (if you have deductibles and no copays) to visit a PCP or doc in the box. Our program started in January and I haven't had to use it yet, but have heard good things from coworkers. The other alternative would be to open up the market a bit and make some of these drugs available OTC.

There a few models

The one your employer offers doesn't include specialists but other models do and will.

Curious what vendor your company uses.

Just legalize PCP and there won't be a shortage. End O' Subject. :-)