3 health care predictions for the New Year patients should know

As we enter the New Year, I like to reflect on where we’ve been and where we’re heading in medicine. By far and away, this is the most tumultuous time I have ever experienced in health care.

It’s strange really.

I thought I’d try to make some realistic predictions of what patients should expect in the year ahead now that the “Patient Protection and Affordable Care Act” (PPACA) begins to sink it’s tap root into the American medical system.

Triage

With the sudden expansion of the patient pool without a relative expansion of the physician pool, patients can expect a greater degree of triage to occur in medicine when they need to see a doctor. Triage will occur in many ways, but will fall along two lines: (1) treat the most urgent, then (2) the most lucrative.

Like it or not, these priorities will drive care for most medical facilities, especially our newly minted accountable care organizations (aka, large hospital systems and care networks).  Specialists will become purely proceduralists, internists and family practice doctors will see specialty follow-up and manage a team of nurse practitioners and “physician extenders,” and these care extenders will become the front line care team for the more common ailments.

In effect, follow-up specialty care will shift down the health care food chain to those less specialized in the name of improving efficiencies in health care. Some will argue this is cherry-picking lucrative patients and procedures, others will see this as a survival necessity for health care systems squeezed for revenue. Call it what you will, but realize it’s another unintended consequence of the changes taking place in our health care market today.

Costs 

There is no question that out-of-pocket costs (both direct and hidden) for health care will continue to rise for patients.  Given the recent holiday season, most Americans are strapped for cash at the beginning of the year.  But insurer’s want their first installment for coverage as early as January 10, 2014.  Hidden in their premium will be a 2% tax added to the every insurance plan’s premiums, plus a $2 fee that goes to the Patient Centered Outcomes Research Institute (PCORI) created by our new health care law.

As I’ve previously pointed out, the costly PCORI replicates functions already performed by the Agency for Health Care Quality and Research (AHRQ). The PCORI’s budget is also scheduled to mushroom from $350 million to over $500 million annually in the years 2014-2019 with patients paying directly for this government agency thanks to this added fee.  And what do they get in return from the PCORI?  A wealth redistribution scheme to pay for even more “patient-centered” research redundancy.

Patient’s take-home pay will also be reduced for middle-class individual tax filers earning more than $200,000 and families earning more than $250,000.  This is because they will pay an added 0.9 percent Medicare surtax on top of the existing 1.45 percent Medicare payroll tax. They’ll also pay an extra 3.8 percent Medicare tax on unearned income, such as investment dividends, rental income and capital gains.

Finally, patients will quickly begin to understand what the terms “deductible,” “co-pay,” and “co-insurance” mean when it hits their pocketbooks.  My bet: they won’t be happy about it.

Finally there’s the issue of health insurance subsidies actually being tax credits.  As reported in the Wall Street Journal:

The federal subsidies that will help many people pay for their coverage are actually tax credits tied to their income. They will go to people making as much as 400% of the federal poverty rate—in most states, $94,200 for a family of four in 2013. The more you make, the smaller your subsidy. The subsidy process “will all be part of the tax computation,” says Judy Solomon, of the Center on Budget and Policy Priorities.

People can choose to receive these credits as monthly payments that flow to their insurers over the course of the year. But if they do this, and the subsidies turn out to be too large—if the consumer’s income was higher than expected and she should have received a smaller subsidy than was dispersed—the recipient may need to repay at least part of the overshoot.

To avoid this situation, people should report major changes in income to their exchange website when they occur. Consumers who know in advance that their income may fluctuate can also take “less financial support,” meaning a smaller subsidy upfront, or opt for a lump sum at year’s end, says Cheryl Fish-Parcham, of the consumer group Families USA.

The government giveth and the government taketh away.   Hey, someone has to pay for all of this bureaucracy.

Confusion

The difficulties experienced with the government’s Healthcare.gov website will have their trickle-down effects felt in 2014.  Given the number of vendors involved in development of the site, and their unwillingness to claim responsibility for the site’s shortcomings, patients who registered on the site are likely to have little recourse for their difficulties readily apparent.  Social workers will be saddled with helping these patients, along with their other duties.  As if they don’t have enough to do already.

Doctors will be introduced (perhaps “force-fed” is a better verb) to the “new and improved” ICD-10 coding scheme in 2014.  With bureaucracy run amok in medicine, this is another hassle foisted upon physicians and care-givers.  Compliance with the scheme is now a pre-requisite for physicians to be paid properly.  Expect more screen time, cursing,  and less patient-care time from your doctor as a result.

Insurers will be even more aggressive with denials based on insurance industry-developed “coverage decisions.”  Doctors and patients alike will continue to find this frustrating as insurers must assure their profit margins.

So strap in and get ready for health care 2014.

We’re all going to be taken for quite a ride by the changes ahead.  Rest assured, though, that there are still many doctors and nurses out there who will try to help ease their patients’ burdens in such a stressful time for everyone.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • whoknows

    Am already feeling it. The part I find frightening, is it seems like as a whole there is a lack of consciousness or concern from the clinicians in the medical industry bureaucracy as a whole. And it’s chilling to see. THese providers have convinced themselves that they are doing the standard of care when there are glaring defects in their thinking.

    Believe me Wes. Am already feeling it. No one is spending the time to diagnose. In my particular case,multiple MRI’s have been done but no one has spent the necessary time with me to accurately assess the clinical symptoms and compare to the imaging. But the specialists are all ready to act and get paid for a quick procedure. I feel beyond deflated. I am surrounded by huge medical bureaucracies and mangled care and feel down right exploited and alone wondering if anything will ever get resolved for me. They have made a small fortune from the imaging alone.

  • Ron Smith

    Hi, Wes.

    I’d like to add a couple of things that have come to light just in the past few days that have significantly altered some of my thinking.

    I understand that Dr. Whipple, a longtime Pediatrician in Newnan, Georgia, who was one of many who had sold their practices to the Piedmont folks who are buying up hospitals and practices left and right in our south Atlanta area, suddenly and without warning didn’t come to work this week. His staff didn’t either. He just decided to quit medicine altogether. I think his staff left Piedmont too, but those are all the details I’ve been told, and not first hand.

    He was well known and well liked as a Pediatrician and had practiced for many, many years in Newnan. Why did he leave practice this way? How many other physicians are thinking of leaving? If this becomes widespread, what will be the result?

    I’ve been solo most of my thirty years. The practice is very healthy, with some eleven employees and two nurse practitioners all who share in the profits. My practice manager and I together also have a medical consulting and software business that gives us a unique perspective on medical practice.

    We have one client presently and she is solo. She lives in the Newnan area where Dr. Whipple used to practice. A couple of her doctor friends who work for the same medicine corporation have been asking her how she got started? They were wanting out but didn’t know where to begin.

    Dr. Whipple and these other corporate employed physicians looking for a way out is very telling.

    Corporate medicine behemoths will command a lions share of health dollars and patients, and their focus will be profit. They will swallow up smaller multi specialty groups and small, poorly-run practices chasing success only by ever increasing daily volumes of visits.

    Small and solo primary care practices like mine which are run well, and focused on customer and patient care will flourish however. They will become esteemed for a better patient experience.

    if I’m right, there will be two different kinds of medicine. One will be like Wal-Mart and the other like Ace Hardware.

    What’s the difference?

    I have never been asked ‘Can I help you?’ in a Wal-Mart. When I go to their hardware section they almost never have the hardware that I need.

    Ace Hardware has outstanding customer service and almost always exactly what I need.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • http://hautuconsulting.com/ Shane Irving

      I agree with Dr. Smith. The smaller practices will need to be well run and patient focused/friendly to survive. It can be done but it does require the right Doctors to lead their practices and invest in the right people and systems….

  • Suzi Q 38

    I have had four very different neurologists in the last year or so.
    All with rather extensive experience and qualifications.

    The first one did not diagnose a huge condition for me: Severe spinal stenosis in my c-spine, just waiting for the next fall, stumble, or accident to render me a quadriplegic. This is despite having treated me for about a year and a half, with my constant complaints of escalating symptoms.
    I am not sure where his head was at. My outside specialists thought the same thing. Thank goodness I gave up on him and eventually left for a different teaching hospital and doctors.

    The next doctors could not agree if my stenosis was from a mechanical
    source, or something viral….possibly MS, Transverse myelitis, or the shingles. They decided to run a gazillion tests for my workup and wait until my right leg barely worked. I finally was cleared for surgery. This, I am sure, cost thousands of dollars. After surgery, I improved, but my diagnosis was still in “limbo” depending on who you spoke with.

    The neurosurgeon proclaimed that I did not have MS or TM, and he saved me from an almost certain paralysis.

    The MS specialist neurologists (2), on the other hand, said that the “white light,” located in my C-spine could very well be MS and I needed to be treated with MS drugs despite all other obvious tests producing a negative result for MS.

    What is a layperson to think after all of this?
    That the surgery was a success, or that it was unnecessary and I truly need to start the MS drugs before I got worse??
    If I had gone to a rheumatologist, would he/she say that the pain I felt after surgery was just arthritis? Would the orthopedic surgeon just say that my leg weakness was because I needed a total knee replacement?

    Whatever.

    It is sad that the treatment of ill people has been reduced to “the money.”

    I finally decided to return to the office of one neurologist, who told me that I did the right thing with getting my c-spine surgery and is keeping close tabs on my progress.

    She put me on a cheap, generic drug for my pain and asked me to return in two months to see how I was doing.

    No more expensive tests, drugs, or surgery.

    Finally, I feel that I can trust a physician again.

    • whoknows

      I am sorry for what you went through but glad I am not alone. At a glance one could easily just say that you were misdiagnosed and leave it at that. But you seem bright and question how this happened.

      Seems like the focus is on ordering as many tests as possible. Oddly enough, your initial presentation required likely emergency surgery. Or call it elective but make it quick.
      Yet that was obviously missed. Do you think that it was not just a matter of a few bad apples but that the system itself how should I say–can be so disconnected that it misses major problems for a lot of patients?
      If you had been diagnosed when you had brought this to their attention how do you think you would be doing now?
      I am also in a difficult spot. I can see that no one is accountable. I had an urgent MRI and NO oNE notified me of the results but they made$5000 in the process. I can see that in the current HC system I am in that is so dysfunctional, I will never get diagnosed. And I have also been through a lot prior to this as well. I can see that they are focused on making money with procedures but no one is accountable or cares. They should be ashamed but they’re not.

      • Suzi Q 38

        Thank you.
        Sometimes it is about all of the tests.
        i had already had 90% of them at the prior hospital.
        They wanted to do them all over again. This is where our money goes. They did the SAME tests all over again, less than a month from each other.
        To get notified of the results of your MRI, you have to go to the teaching hospital and sign a request to have the radiologist’s official report sent to your house. You could also pick them up. They charge a fee to do this. That being said, it is better than waiting for the doctor to call you.
        I had no idea that the HC system was so dysfunctional.
        Now, I request physician reports after not all but most visits. Why? They tend to write more than what actually transpired. I want to know that they really think about my medical condition.

        I will say that not all specialists are money hungry with respect to referring or the tests…..just several of my doctors were.

        • whoknows

          yes I have had many of the same complaints. It seems utterly wasteful. And each system is in competition with the next so they can’t read the mri from the competing place sometimes because of software issues.

  • Suzi Q 38

    Thanks for your response.
    No, they do not do it on purpose to annoy us, they all truly believe that their diagnosis is the correct one.
    No, I am not on any groups or chats for patients.
    If you want to recommend one to me, I will join you in a discussion there.

    • Becky

      How about heroes of healing? Not a good title, but it’ll work.

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