Affordable Care Act

Understanding Healthcare: A Historical Perspective

“Understanding Healthcare: A Historical Perspective” is a new e-book in which I attempt to address the challenges facing physicians today in part by reviewing the history of healthcare.

The ACA Is Hammering State Budgets

  • Thirty-one states and the District of Columbia have remained within the ACA.
  • Healthcare enrollment in these states is significantly exceeding forecasts.
  • Medicaid is the largest line item in most state budgets followed by K-12 education.
  • The federal government currently reimburses 100% of the costs for new enrollees through 2016.
  • Federal reimbursement will fall to 90% by 2020.
  • Federal reimbursement to states for existing enrollees is just 50%.

ACA Leads to Fewer Readmissions Among Older Americans

  • The Affordable Care Act (ACA) levies fines for readmission rates that are above a benchmark, according to a study published in the New England Journal of Medicine.
  • Rates of readmission have declined for both targeted and nontargeted conditions since implementation of the ACA.
  • From 2007 to 2015, readmission rates for targeted conditions declined from 21.5% to 17.8%, and rates for nontargeted conditions declined from 15.3% to 13.1%.

Record Portability is a Moral Issue, Not a Technical One

Thirty-years after my death of my father, 20 years since the passage of HIPAA, and nearly 5 years since the death of my wife, not much has really changed. Patients, not providers; patients, not payers; patients, not the institutions are still responsible for shuffling healthcare data among providers and institutions. That is when patients can access those data, which, by the HIPAA act, is their own property.

Medicare Fraudsters are Mugging Your Government

  • The U.S. Department of Health and Human Services (HHS) Paid Nearly $14.5 billion in fraudulent claims in 2014.
  • A Texas physician was arrested for defrauding Medicare of more than $375 million, but the collection of smaller crimes cause more damage.
  • No Federal agency pays more in false claims than the HHS.
  • Under the Affordable Care Act, more than $600 million have been spent to prevent fraud and to recover fraudulent payments.

What is an Accountable Care Organization?


  • Accountable care organizations (ACOs) embody performance-based medicine.
  • An ACO is a network of healthcare providers and hospitals that shares responsibility for providing all types of healthcare to ≥5000 Medicare beneficiaries at a period of at least three years.
  • These providers and organizations must be able demonstrate that they can reduce costs while improving outcomes.
  • Studies have shown that ACOs do effectively achieve these improved results.

Studies Show Wild Variations in Healthcare Spending, Pricing

  • Cost of an orthopedic procedure can vary from $16,000 to $60,000 depending on the geographic location of the surgery.
  • Per-veteran spending within the VA system ranges from $25,000 per year in Boston to less than $6500 per patient on Cape Cod.
  • Hospital procedure pricing is seen as largely fictitious and unrelated to actual local financial conditions.
  • Blue Cross Blue Shield and the Centers for Medicare and Medicaid Services have published tools to help patients learn the cost of a procedure in advance.

Healthcare Data: Wild, Wild West or Brave New World?

  • Were paper records more secure?
  • Health records of more than 120 million Americans have been exposed to hackers.
  • Non-interoperability poses at least as great a threat to American healthcare as does stolen data.
  • Interoperability is a problem that could be solved by the EMR manufacturers.
  • How will healthcare IT solve this challenge?

Investigation Reveals Nearly 1200 Health Data Breaches Since 2009

  • Health data breaches can now be considered common in the U.S. with about 22 occurring every day since 2009.
  • Nearly 1200 “large-scale” breaches have been reported to the Federal government since 2009.
  • Approximately 120,000 “small-scale” breaches have been reported in the same period.
  • The medical data of more than 120 million American patients have been exposed.

Medicare’s April Fools’ Day Hang Hangover


  • Continue submitting Medicare claims at the old rates and hope the Senate passes the repeal bill by April 14.
  • Retain your Medicare claims for services rendered beginning April 1 and wait for final passage of the repeal bill — or a temporary delay of the 21% cut — before submitting them.
  • Remain calm and carry on.

Physicians Being Excluded from Narrow ACA Networks


  • Twenty percent of surveyed practices reported having been excluded from narrow-network ACA plans in which they would have liked to participate.
  • The percentage of insurers offering narrow-network plans has increased steadily since 2007.
  • Insurers use narrow-network plans to increase revenues but docs are blamed by angry patients.

How to Talk to Patients about the New Cholesterol Guidelines

  • The guidelines for LDL cholesterol have not changed. It remains the primary target of therapy.
  • Cholesterol blockers may be superior to statins for LDL control.
  • Advise patients to try eat a diet that contains more lean protein and vegetables and less carbohydrates and sugars.
  • The Mediterranean diet continues to be an attractive approach to maintaining heart health.

Think Twice Before You Sell Your Practice

  • Hospitals and healthcare systems managed by physicians perform better financially.
  • These mergers are not always profitable for both or either party.
  • A recent study of Kentucky hospitals found that 58% of responding hospital CEOs reported losses of greater than $100,000 per employed physician per year.

Reduce Risk, Improve Outcomes: Exhaust All Non-Opioid Analgesic Options

  • Pain specialists are increasingly suggesting that opioid analgesia be reserved for patients who do not respond to all other available pain therapies.
  • An increasingly wide variety of drug types are being used to effectively treat patients in pain.
  • Always request a pregnancy test in any woman of childbearing years before prescribing an opioid analgesic.

Patients and Payers Know Your Practice Metrics. Do You?

Your patients may know more about how you practice medicine than you do. Over the past several years, a number of private and government websites have begun to collect and publish data on a wide variety of physician practice metrics.

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