Author: Stephen Moberg

Physicians & The Rise in Baby Boomers

The Nine Forces Converging On Primary Care: #2 The Baby Boomer Tsunami

Written by Stephen Moberg. Posted in Articles.

On the subject of the Perfect Storm and its metaphoric equivalent that threatens primary care medicine, I wanted to offer the second convergence in a series of nine. And wherever you stand on health reform, there’s no arguing with demographics. Every day in America 10,000 people turn 65. It’s like in just one month, a city the size of Toledo suddenly appears and everyone’s on Medicare.

Add another week and you’ve got a Pittsburgh full of aging Baby Boomers. In four months you’re looking at enough 65-year-olds to fill Dallas. You get the picture.  There are quite a few older adults coming down the road and it’s a road leading straight to the PCP’s office where they’re going to be playing musical chairs with all those newly insured people we met in the last blog.

“Baby Boomers”, and I count myself in their number, are people born between 1946 and 1964. Studies show that the majority of them have at least one chronic illness, and will likely have more as they continue to age. As I discussed in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, managing multiple chronic illnesses takes time and can be costly.

As I referenced in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, the problem is that on average, physicians earn 20% to 30% less from Medicare than they do from private patients. As a result, many doctors are dropping out of the program. In the area of primary medicine, it’s estimated that around 90% of physicians still participate in Medicare. A smaller percentage, however, are accepting new patients so the trend is not good, and it’s likely to get worse.

Along with all those new 65-year-olds, there are quite a few even older Americans around.  In fact, the 85 and over age group is one of the fastest growing among the general population. In 1996 there were about 4 million people in the U.S. over 85 years old. Four years later the number increased to 6.7 million adults over 85 and by 2040 13 million are projected.

This trajectory itself isn’t catastrophic since the rise will be relatively gradual and steady. What may add severe stress to the system, however, are the breakthroughs predicted in genomic science and regenerative medicine that are expected to make significant inroads against cancer, diabetes, heart disease and stroke within the next several decades.

With this increased life expectancy we can only hope that other age-related afflictions, including Alzheimer’s disease, which is predicted to double by mid century, will also be reduced through research breakthroughs and biomedical and technological innovation.

Whatever the future holds in this area, the one thing we can be virtually certain about is that there will be more aging Americans, more chronic conditions, and possibly fewer – but definitely more stressed – primary care physicians.

The ACA hasn’t created the primary care crisis in America, but it will reveal the fractures in the current system.

The Nine Forces Converging On Primary Care: #1 The Affordable Care Act

Written by Stephen Moberg. Posted in Articles.

In the last blog we looked at the Perfect Storm and its metaphoric counterpart, the forces that loom on the near horizon and threaten the current viability and future hope of primary care medicine. The first is the Patient Protection and Affordable Care Act usually shortened to “the ACA” and more commonly called, by opponents and supporters alike, Obamacare. The ACA hasn’t created the primary care crisis in America, but it will reveal the fractures in the current system and contribute to the pressures already directed to the PCP unless it can effectively re-engineer how we care for patients in the exam room.

We’re still in a short holding pattern on exactly what to expect, but we do know that large numbers of newly insured people, estimates range to 30 million plus, will be presenting themselves to primary care doctors. As waiting rooms fill up, many doctors will not be in a position to accept new patients.  As I discussed in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, the Massachusetts experience, probably the closest model we have for comparison, doesn’t offer a lot of hope in that area.

My colleague, Paul Grundy, MD is frank about the broken payment system in America and its affect on the people it’s meant to serve. “The rewards system in health care is so convoluted that people become opportunities to make money. Somewhere in all that we lose the humanity.”

Regardless of your stand on reform (and I still find myself on both sides of specific ACA provisions) the fact is that the United States Supreme Court upheld the constitutionality of most of the reform legislation.  So if you’re waiting on the health train, that one has left the station.

Based on discussions with colleagues I am not alone in my contention that the success of reform and its role in improved health care delivery depend on a robust and expanding primary care workforce. I believe further that reform will be at its most effective if it helps strengthen the doctor-patient relationship as a powerful, quality-producing, cost effective force in medicine. In the meantime I ask people to “imagine health care without the Familiar Physician. “Every time you’re sick, you’re a stranger, enduring long waits for someone to help solve your problem … someone who may have never seen you before.”

Between 2010 and 2011, the number of insured Americans grew by just 3.6 million people, an increase of less than 1.5 percent that was easy to absorb into the existing system.  However, the instantaneous 15-percent increase in the number of insured Americans will shock a system accustomed to much slower growth. The potential for serious gridlock is clear.

So here’s what we’re left with: the ACA, which can be a positive force in improving access to coverage and, ultimately, to care, also carries within it the potential to crush the primary care system unless we make appropriate changes … and quickly.

In a number of ways, the perfect storm is the perfect metaphor for the primary care crisis we are facing.

The Perfect Storm and The Perfect Metaphor

Written by Stephen Moberg. Posted in other.

A meteorological event known as the Halloween Nor’easter of 1991 or far more commonly as the Perfect Storm was popularized by a best-selling book and subsequent film. It’s now part of our language, used to describe situations characterized by powerful converging forces.

The storm developed when the remnants of Hurricane Grace collided with a low-pressure system off Nova Scotia and a high-pressure system that moved up the Appalachians before turning toward Greenland. It caused severe coastal flooding, wind damage and rogue waves up to 100 feet high.

Tragically, the Perfect Storm also took the lives of 13 people including six crewmen on the fishing boat, Andrea Gail, the subject of the book and film. For many, the book cover visual of that boat’s futile attempt to rise up and over a ten-story wave remains the symbol of this once-in-a-century phenomenon.

But the Perfect Storm was not a surprise. The National Oceanic and Atmospheric Administration and the National Weather Service both forecast a storm of epic proportions. As a result, warnings were issued well in advance. The public was generally skeptical, however, and many took the forecast far too lightly. This lack of concern, based in part on the particularly fine weather all along the coast at the time of the warnings, proved unfortunate for many and fatal for some.

Years after I read the Perfect Storm and later saw the movie, I began noting parallels between that event and the state of primary care medicine. In a number of ways, the perfect storm is the perfect metaphor for the extraordinary circumstances we are facing. Among the more direct comparisons are multiple forces coming together at the same time and a lack of concern (not universal but common) among both the medical profession and the general public. Like the storm warnings, many of us are aware but skeptical.

In fact, it seems that most people just can’t imagine the need to get over that 100-foot wave before it crests.

A marked difference between the literal perfect storm and the figurative one is the fact that the weather event was the result of three major systems while the storm darkening the skies over primary care physicians is coming from at least nine major forces. In a theme I developed in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I plan to describe and share my thoughts on those forces in upcoming blogs, beginning tomorrow.

In his work on behalf of IBM Dr. Grundy evaluates health care delivery models around the world.

The Prophet in His Own Land

Written by Stephen Moberg. Posted in other.

As part of developing and writing my recently published book, The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I spoke with Paul Grundy, MD. Dr. Grundy is the Global Director of IBM Healthcare Transformation, a champion of the medical home and the founder of the Patient-Centered Primary Care Collaborative, an advocacy group of more than 1,000 stakeholders including major employers, health plans, primary care professionals, technology firms, pharmaceutical companies, policymakers and consumer organizations. In his work on behalf of IBM Dr. Grundy evaluates health care delivery models around the world.  As a result, he has the opportunity to look at best practices, government policies, private initiatives and supportive resources in countries with very high functioning health care systems in terms of quality care and fiscal sustainability.

He described an encounter with government health officials in Spain who had played an important role in that nation’s current health care system.  Commenting on the obvious effectiveness of their efforts, Dr. Grundy inquired as to how they got started.  “We hired some American consultants,” he was told.

Dr. Grundy went on to tell me his belief that “We have had the answers for years in America, but have been unwilling to change.”

I share that belief.  Although I have not had Dr. Grundy’s unique exposure to a wide range of different health care systems, I think that the combination of well-trained and highly-skilled practitioners, state-of-the-art facilities, exceptional teaching resources, advanced research and progressive technology available in the U.S. is unequaled anywhere in the world.

There’s no question that we’re part of a global economy with a level of interdependency that simply didn’t exist even a decade ago. But at the same time I don’t think you’d find much disagreement in the assertion that America remains the world’s leader in the area of innovation, and health care is no exception.

Once we move past the polarizing debates and vested interests that create an obstacle to discovery and change, the potential exists to re-engineer a health care system that can be presented to the world as a model of clinical, social and human advancement.  I may be a little biased, but I also think that particular health care system will be built on a strong primary care medicine foundation.

Shared Medical Appointments

What’s at stake when doctors favor shared medical appointments?

Written by Stephen Moberg. Posted in other.

Across the country, doctor’s offices are responding to the effects of burnout and limited time by offering shared medical appointments. Many doctors who facilitate these appointments believe it will solve the physician shortage we are experiencing in America, which is worsening as a result of increased healthcare insurance enrollment. Shared medical appointments are unique in that they are a combination of support groups and group therapy.

A more efficient way to use already limited time

Some doctors are advocating for shared medical appointments because they believe it is a more efficient way to use their time, which is already very limited.

“Rather than repeating the same advice about lowering blood pressure, or keeping glucose levels in check to eight patients individually, shared appointments allow physicians to see up to a dozen patients with similar symptoms at a time.”

Typical shared medical appointments consist of 10-15 individuals, who meet together in an open forum setting, for up to 90 minutes at a time. This is in contrast to the traditional appointment, where patients spend between 15-30 minutes with a nurse and provider collectively.

No additional financial burdens of implementing group-style appointments

Many think these appointments would be more costly based on the simple fact that patients spend more time with a provider. However, health insurers treat shared medical appointments just the same as traditional doctor’s appointments for an individual.

Shared medical appointments are not new; when they first were studied in 2005, the percentage of practices offering these unique appointments doubled within five years. The popularity of these appointments has been due in large part to costs remaining unaffected.

Patient’s privacy is no longer private

As more individuals are eligible for health insurance, providers are undoubtedly going to be feeling more strained; hence why shared medical appointments are relevant to improving America’s healthcare system, right now.

However, these appointments are not for everyone.

Non-believers in this model feel it is an inadequate solution. Some already avoid doctor’s offices because of embarrassment and shame; they most definitely will not share their personal problems in front of a group.

This is a legitimate concern; a patient’s private information, concerning their health, is now being made public to a group of strangers. Depending on the practice, exam rooms may be available for individualized care, as needed.

On the other hand, believers in this model feel they gain in-depth information and are assured about their health or are motivated to act because of hearing another person’s experience.

Bruce Moore, a teacher in the Ohio prison system who gets his annual physical with six other men at the Cleveland Clinic says, “When I see my stats up there on the board during group, they are my responsibility. I have to look at them and say what am I doing right and what am I doing wrong.”

For the time being, the ACA does not include any direct laws that would change Medicare, except for the IPAB and payment reform.

Medicare will come out somewhat unscathed

Written by Stephen Moberg. Posted in other.

Medicare was originally designed to serve as ‘major medical’ insurance for unexpected large expenses, but today it also includes preventive care, screening, annual exams and most routine care. Despite income level, Medicare applies to all individuals over the age of 65 years old. For the time being, the ACA does not include any direct laws that would change Medicare, except for the IPAB and payment reform.

The ACA is expecting about a 40% savings, by reducing payments to providers, under Medicare. In years past, many physicians have pulled out of the program, as a result.  The major concern of these cuts to Medicare payments is that there will not be enough physicians enrolled to see Medicare patients, if physicians drop out of the plan.

The Independent Payment Advisory Board (IPAB) consists of approximately 15 appointees, who control the costs of Medicare spending. This panel determines when and where cuts need to be made, if spending grows faster than the average consumer prices and medical prices, based on the Consumer Price Index.

Many oppose the IPAB because of their power to select or limit what is paid for by Medicare; they interpret this power as a way of rationing care or creating “death squads”.

Healthcare Leadership Council President, Mary R. Grealy said, the objective of healthcare reform “shouldn’t be to arbitrarily cut Medicare spending but rather to achieve better care and improve health outcomes. IPAB is not a mechanism geared to do that.”

Controversy has sprung up about whether states will adopt new Medicaid guidelines, or go their own route.

Federal government offers states incentive for compliance with Medicaid expansion

Written by Stephen Moberg. Posted in other.

A war has been brewing in state legislatures across the country over Medicaid expansion. Controversy has sprung up about whether states will adopt new Medicaid guidelines, or go their own route. Of the 40 million individuals who will be newly eligible to receive health insurance starting in 2014, half will be qualified for Medicaid assistance. The ACA is designed to expand coverage to all individuals; along with tax subsidies and tax credits, the government will create this new coverage by making significant changes to Medicaid rules.

Medicaid applies to individuals younger than 65 years old and who have low income. The federal poverty line (FPL) establishes the benchmarks that states use. Some states set Medicaid eligibility at 50% of the FPL, while others set it at 100%.

Medicaid enrollment is being expanded in two ways:

  1. In addition to children and single moms, participation is granted to parents, pregnant women and adults without dependent children

  2. Coverage is offered for individuals whose income is up to 133% of the FPL, before it was only 100%

A Supreme Court ruling in 2012 determined that the federal government could not force states to change the limit from 100% of the FPL to 133%. This is where the war initially broke out.

Government’s bargain for states

The federal government has promised to cover every state’s cost of Medicaid expansion for the first three years, in hopes that they will comply. This is why states are reluctant to expand because once the three years have ended they are going to be amidst a budget crisis.

A large number of physicians do not participate in Medicaid programs; therefore, the ACA is offering a temporary increase in payment rates. By doing so, the hope is to expand the physician pool so these new enrollees will have access to primary care providers, rather than over utilizing emergency rooms.

For states that refuse to expand eligibility, they are trying to figure out how to deal with those individuals who are caught between 100% and 133% of the FPL. Oddly, these individuals are making less money than those who qualify for assistance through the exchanges (which begins at 138% of the FPL), and yet will have no definite assistance.

It is possible that we will see a movement of people to states where they can receive health insurance coverage; this may differentiate states in terms of their overall economic environment.

As of late June, 26 states have decided to participate in Medicaid expansion, 13 were not participating and the rest were undecided.

Private healthcare insurance companies, like Cigna, Aetna, and Well Point, have had to make substantial changes to their coverage eligibility standards due to the ACA’s new federal laws.

Private Healthcare Insurance Companies Face New Changes Under The ACA

Written by Stephen Moberg. Posted in other.

Private healthcare insurance companies, like Cigna, Aetna, and Well Point, have had to make substantial changes to their coverage eligibility standards due to the ACA’s new federal laws. Their products will be the most likely source of insurance for individuals who make more than 400% of the federal poverty limit and are less than 65 years old. The insurance companies will be required to abide by these new standards, as of January 2014. These changes are so significant that many have said the ACA is insurance reform, not health care reform. I might be beating a dead horse here, but as I have mentioned before, one of the main goals of the ACA is to drive down the cost of healthcare. Healthcare insurance market reform aims to assist this goal, from the business perspective, by creating more insurance competition (i.e. exchanges, co-ops, a larger customer pool, like the individual mandate) and reorganizing the way insurance companies handle their profits.

With regards to how they handle their profits, 85% of the money that insurance companies receive has to be applied towards healthcare expenses; they can no longer make a 50% profit off of individual’s premiums and keep it. Now, if insurance companies net more than 15%, they have to do something that benefits their enrollees, not themselves.

Insurance reform can raise the cost of insurance premiums dramatically because insurance companies can no longer be selective in who they cover. They must abide by the following requirements when providing new plans to enrollees:

  • No one can be denied insurance – preexisting health conditions are no longer a determining factor

  • All conditions are covered – individuals are eligible regardless of status-related factors (i.e. health status, medical condition, medical history, disability, etc.)

  • Rates are the same across the board EXCEPT…

    • self-only or family enrollment premiums will be different

    • rating area – there is a provision that specified regions can charge different prices (i.e. suburbia), however everyone in one area will be charged the same regardless of disease

    • state specifications

    • age

    • tobacco use

    • There is no cap – as long as the healthcare services are considered essential health benefits

    • Preventive services are covered 100% by insurance companies

The fines for not purchasing healthcare insurance by January 2014 are not astronomical…yet. Healthy individuals tend to not purchase healthcare insurance because they feel as though it is a waste of money. I think young, healthy individuals will take the risk in not purchasing healthcare insurance in 2014, which the ACA is requiring, since the cost of healthcare insurance far outweighs the fines of not having it.

In order for insurance reforms to not increase premiums dramatically, it is critical that all individuals purchase insurance (i.e. the mandate), otherwise the ACA’s hope of decreasing costs, from an insurance perspective, will disappear.

Conversations around these two healthcare mandates have been making headlines week after week – let’s recap.

To Delay Or Not To Delay: A Look At Healthcare Mandates [Part 2]

Written by Stephen Moberg. Posted in other.

Yesterday I introduced the details of the two widely debated healthcare mandates – employer-coverage mandate and individual mandate. Conversations around these two mandates have been making headlines week after week – let’s recap.

Delaying mandates

The White House made a decision to delay the employer-coverage mandate by one year on July 3, 2013. Republican leaders are begging for an explanation as to why one mandate was delayed and not the other.

The New York Times reported that GOP leaders agreed with the employer-coverage mandate delay because it was, in fact, burdening, already overwhelmed employers. However, GOP leaders further said, “…American families need the same relief.”

The Office of Management and Budget reported that delaying the individual mandate would be “unnecessary,” thus causing insurance premiums to rise, the number of uninsured Americans to continue rising and it would undermine key portion of the ACA.

The American Academy of Family Physicians (AAFP), American Medical Association (AMA) and several other major physician groups support the individual mandate. They collectively agree delaying the individual mandate would be a mistake because it will prevent healthcare costs from rising for everyone. The President of the AAFP, Dr. Jeffrey Cain believes the individual mandate, “…is the foundation of improving access to care and vital to ensuring everyone has healthcare coverage.”

GOP leaders introduced two bills to the House of Representatives, in which they pass on Wednesday, July 17th. The first bill codified the employer mandate delay, while the second bill postponed the requirement that individuals purchase health insurance.

It may seem that Republicans are making headway on having the individual mandate delayed as well. Despite the fact that their efforts were successful in the House, CNN reports that they don’t see the bill passing through the Democratic-controlled Senate, but they feel all the publicity they are receiving about delaying the individual mandate will create public backlash and that’s what they hope for, in the least.

Now that employers are not required to provide health insurance coverage, there is no real way to determine who does and does not have insurance. The White House is powerless to decipher this information. If a person stays healthy and stays out of the doctor’s office, they will go unnoticed. That’s the crux of the two mandates.

The White House has been facing quite a bit of criticism for delaying the employer-coverage mandate.

To Delay Or Not To Delay: A Look At Healthcare Mandates [Part 1]

Written by Stephen Moberg. Posted in other.

The White House has been facing quite a bit of criticism for delaying the employer-coverage mandate. A war has been raging between the two political parties; some even find themselves on the opposite side of the argument.

Employer-coverage mandate

As of January 1, 2015, large businesses, defined as 50 full-time-equivalent (FTE) employees or more, are required to provide health insurance coverage for their employees; otherwise pay a fine.

Businesses with fewer than 50 FTE employees are not required to provide insurance coverage. This mandate directly discourages small businesses from growing into a 50+ FTE employee company because the fear of having to provide affordable health insurance coverage.

It is no question that businesses want to grow and employ more individuals; however, this mandate is threatening business owners with a high price for noncompliance that is causing some to stay small. This is particularly alarming for business owners because for the first time ever “full-time” is being redefined. Now, a full-time employee is someone who works 30 hours per week, averaged over the course of a month.

Individual mandate

As of January 1, 2014, individuals are required to maintain minimum health insurance coverage; otherwise pay a fine. Some individuals may be exempt, while others may qualify for financial assistance to help pay for their health insurance.

The penalties for noncompliance are as follows:

  • In 2014, the fines will be $95 per adult, $47.50 per child, up to $285 per family or 1% of family income, whichever is greater

  • In 2015, the fines significantly increase to $325 per adult, $162.50 per child, up to $975 per family or 2% of family income, whichever is greater

  • In 2016 and beyond, the fines are projected to be $695 per adult, $347.50 per child, up to $2,085 per family or 2.5% of family income, whichever is greater

The Henry J. Kaiser Family Foundation provides a helpful flowchart that explains how the individual mandate works.

Tomorrow I will talk about the most recent arguments surrounding the delay of the employer-coverage mandate and the proposed delay of the individual mandate.

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