Physician Patient

Archive for January, 2017

ACA repeal will prove good for psychiatric practice (January 2017)

Saturday, January 28th, 2017

ACA repeal will prove good for psychiatric practice

By: Lee H. Beecher, MD DLFAPA, FASAM As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.

The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.

One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (The federal program that incentivizes physicians to use EHRs was part of the HITECH Act passed in 2009 and was strongly reinforced in the ACA which passed in February 2010.)
Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.

Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, hassaid.

“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”

To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.

The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.

Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.

Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?

An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.

Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.

In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.

We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.

I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.

In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.

MPPA Meeting Thursday January 12, 2017 at 6 PM in Central Medical Building, St. Paul.

Thursday, January 12th, 2017

Those present: President Lee Beecher, Bob Geist, Dave Racer, Hannelore Brucker, Scott Jensen, Carl Burkland, Steve McCue, Carolyn McClain, Lye Swenson, Don Gehrig, Steve Tobriani, Matt Flanders, Twila Brase, Greg Plotnikoff, Tim Herman. Two Board members were ill and could not attend.

1. Twila Brase presented the CCHF Wedge program which emphasizes transparent affordable pricing, freedom of clinician and patient to choose their direct relationship, true patient privacy, No government reporting or other outside interference in doctor-patient relationship, cash-based pricing, protected-doctor relationship, all patients welcome—see or 651-646-8935. Commentary: Questions about applicability to an ER was asked and examples of about 200 various practices in 43 states were described. Marketing will depend on funding. The consensus was that this program deserves everyone’s attention—it has already seen real expansion.
2. Peter Nelson and Sen. Steve Jensen discussed current legislative bills (HF 1 and SF 1) regarding the turmoil in the private individual market where premium prices have sky-rocketed from minus 33% of group policy costs years-ago to plus 40% in 2015. Sen, Jensen’s agenda includes price transparency, HSAs, inter-state insurance availability, resurrecting MCHA, an Any Willing Provider approach to narrow networks, address the problems of regional price setting, prior authorization problems, and so forth. Commentary: The apparent cause is ObamaCare repeal of state high risk pools, which put all those people into a small individual market population. The MN bills to subsidize individual premiums will end this year-end. Meanwhile, there is hope that Congress will come through with reforms and that the successful MN MCHA can be revitalized to re-create a MN high risk pool. The difference of GOP and Dayton bills was discussed. MNSure adequacy was questioned and the need for patient-centered free market place was noted.
3. Steve Tobriani, a Mpls neurologist, presented a very interesting health plan. The problem needing solution is the inexorable rise in costs because of a 3,100% rise in MCO administrative overhead to ‘control costs”, while the number of providers has increased 3% and physician pay has risen about 7% from 1990 to 2011—essentially stagnant. Attached as an appendix is his health plan to free employers and workers from paralyzing costs. See page 2-4.
4. RWG and Dave Feinwachs proposal for a Medicaid Family Medical Account (FMA) bill will be discussed the next meeting. See p. 5 for the rationale to be discussed later.
5. Dr. Beecher and Dave Racer noted a pending book recounting Lee’s experiences in medicine. From medical school, to specialization, to medical director, then to private practice, and eventually to a cash only practice.
6. Next meeting will be Tuesday, February 21, 2017—note change of date

Respectfully submitted, Robert W. Geist MD, Secretary pro-tem