Mid-Level Providers Trending Away from Primary Care?

Congressional lawmakers are quietly advancing a bill that will probably have an immediate transformative impact upon primary care delivery, once the ACA kicks in. The bill (HR 2810) which aims to revamp Medicare also contains an ammendment that would reward all medical providers (not just physicians) running a medical home for chronic care management. Physician lobbying groups are pressing hard for only their recognition in such plans. It’s enough to deal with this as a potential problem for physicians, as nurse practitioners have heft on their side: QA organizations such as the NCQA also recognize patient-centered medical homes run primarily by primary care NPs. An interesting battle looms on this front. But, it’s not the only one.

A new study is out that details a growing number of mid-levels (both NPs and physician assistants) are going on to subspecialty work, with fewer than half of PAs choosing primary care ambulatory medicine. Efforts to incerease primary care provider numbers have been trending toward the mid-level supply side for a few years now, as studies like this seem to corroborate federal studies on the matter. Both of these issues seem to portend an unintended consequence of the ACA and its impact on primary care healthcare delivery: all providers agree that there is a potential mismatch between demand within increasing access under the ACA, and that, if physician orgs want that demand met — as I do — perhaps efforts to increase corroboration and planning and to decrease turf wars are in order.

19. August 2013 by Michael Douglas, MD, MBA
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During Weekly Radio Address, Obama Stresses Reform Law’s Individual Mandate as a Right

President Obama took to his weekly radio address this morning to stress something that I don’t think I have heard him say since the ACA was but a twinkle in his eye back in January 2009.

 In the United States of America, health insurance isn’t a privilege — it’s your right. And we’re going to keep it that way.

Well, alrighty, then. If his policies on the individual mandate and the universal offering of insurance (via exchanges) regardless of ability to pay (via subsidies, if needed) gain traction with the public (jury is still out at this point), then statements like this won’t sound as hysterical to the very insurance companies he worked so, so hard to woo. Catch the vid below.

17. August 2013 by Michael Douglas, MD, MBA
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Minnesota Exchange Debuts Product at State Fair

MNSure is getting ready for the big pitch at the Great Minnesota Get-Together.

The exchange, called MNsure, will be unveiling a marketing blitz within the next few weeks to begin attracting the roughly 1.3 million Minnesotans who are expected to use it to secure coverage.

The campaign will include a major presence at the Minnesota State Fair, plus radio, television, bus and billboard advertising buys, according to exchange officials.

By the end of the month, MNsure will announce a list of groups that received $4 million in available outreach grants.

Among other things, those federal grants are earmarked for the “navigator” program — a sort-of customer service initiative for exchange participants. Minnesota is one of several states in which healthcare consumers will be able to use these resources to make what the HHS hopes are informed decisions while shopping the exchange. | LINK

17. August 2013 by Michael Douglas, MD, MBA
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Groups Nationwide to Get Federal Grants to Promote ACA

Efforts to get Americans used to the idea of healthcare exchanges and mandated coverage just got a major shot in the arm, financially. HHS has ponied up the funds for local groups to aid consumers in the new healthcare marketplace ahead of reform. The agency will award almost $70M to states, many which have essentially ceded authority to the feds to set up exchanges (as dictated by the ACA), to fund marketplace “navigators” to help consumers with new choices for coverage. Continue Reading →

16. August 2013 by Michael Douglas, MD, MBA
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Michigan Physician Allegedly Engages in Most Egregious Fraud

Simply sad; I cannot even begin to imagine what this doctor was thinking…

15. August 2013 by Michael Douglas, MD, MBA
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Foreign Medical Graduates and the Rigor to Acquire a U.S. License

A modest proposal: foreign medical grads (FMGs)? Bring ‘em on! …or rather in. Slate Magazine has a great piece up this morning that explains further the lack of motivation for the U.S. to expedite the numbers of FMGs in this country. As numbers forecasting pending physician shortages are to be believed, we are facing some dire times ahead — especially so, considering the projected effects the ACA will have on (primary) care access come January.

Currently, Canada is the only international country in which medical school graduates do not have to repeat major aspects of their training in order to gain licensure in this country. Countries — like India — send many of its best and brightest to the U.S.; many, facing the daunting task of not only repeating rudimentary training — as well as testing, often choose primary care as an option, simply because achieving a parallel practice scenario in this country is just too ponderous a task. (Primary residency programs are usually three years in duration.) For that, I am grateful, but I would like to see U.S. efforts to tear down unnecessary barriers to FMG licensure hasten.

Given everything that the United States is doing to keep foreign doctors away, you’d think there would be some evidence that domestically trained doctors are superior. There is none. During the 1990s, a series of studies showed that graduates of foreign medical colleges performed slightly worse on exams than their U.S.-trained colleagues, and program heads gave marginally better reviews to domestic physicians. By the turn of the century, however, that gap had disappeared. International graduates now score higher than U.S.-educated doctors on many exams…

That’s just one of the points the article makes about the difficulty FMGs face in applying to practice in the U.S. With the demands the ACA will place on medical care delivery, it only makes sense to re-examine policies regarding FMG licensure. Talk of increasing the scope of practice of many mid-level providers raises the ire of many a physician (especially those in professional lobbying orgs) concerned about practice preparation, academic competence, and practice encroachment. Perhaps this issue should be part of that discussion, too. | LINK

15. August 2013 by Michael Douglas, MD, MBA
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New TV Spot: Obamacare “Just Works”

An ACA adovcacy group has just released its third TV ad aimed at promoting the law.

President Obama has always said that Obamacare constitutes the GOP’s “holy grail”, abutting incendiary comments of the law from many on the Tea Party right, including TX Republican Senator Ted Cruz (who’s threatened a government shutdown over the law).

15. August 2013 by Michael Douglas, MD, MBA
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Ahead of Reform, States Musing Options for Coverage Fluctuations

Most Internet startups have to think about the short term and the long tail when it comes to estimating revenue forecasts. Churn rates — or the rates at which customers sign up and subsequently drop out of services — are just part of the process companies have to sort through and account for when planning for the long range. Among insurance companies, the concern is no different, and in California, all eyes are watching how that state (the state with the 5th largest ec0nomy in the world and home to 40M people) handles fluctuating costs for healthcare consumers under the ACA once exchanges kick in this fall. Qualifying benchmarks with respect to family income and federal poverty line standards are key in determining costs due to Medicaid expansion and health insurance subsidies under the reform law; families whose circumstances fluctuate are of special concern when states have to deal with issues of sudden access within previously uninsured populations as part of reform come January 1. How is California planning on dealing with this?

“Currently there is no strategy,” Dana Howard — Covered California spokesperson — told California Healthline. However, he added that the exchange “does not see the implementation of the Affordable Care Act as causing an undue amount of fluctuation between Medi-Cal and Covered California.” Last summer, the exchange board commissioned a report to examine the effect of a [basic health plan] in California.

Could it be that this looming crisis really isn’t a crisis at all? Or is it just a matter of producing novel ways of stratifying coverage to guarantee access and allow the exchange greater influence in healthcare spending in the state, using federal tax dollars? Minnesota is one of those states testing such an option. If such a tier is but one solution to decreasing coverage churn within healthcare exchanges, it seems as though one is kicking the can down the road — as the potential for decreasing churn is there, but in reality, will that be the case? And will the federal government have to, once again, step in and rewrite the rules? | LINK

04. August 2013 by Michael Douglas, MD, MBA
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Republicans in House Vote to Repeal Obamacare (for the 40th Time)

Happy 40th! Fortieth vote to repeal the ACA by the GOP-led House, that is. Via Daily Kos:

It’s as baldly a base-frothing-up vote as any Republicans have taken on repeal, the last vote taken before an August that is going to be, once again, focused on feeding the base what it wants. They have to keep the base at as high a level of fear and paranoia and frenzied furor as possible to justify more Obamacare votes, to justify the extreme measure they’re toying with: shutting down the government over Obamacare. This is the debacle John Boehner has wrought.

It’s all about the Benjamins.

02. August 2013 by Michael Douglas, MD, MBA
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Ellison Sings in Support of Marriage Equality

The first out-Muslim member of Congress, and long-time friend to our LGBT community, Keith Ellison (D-Minneapolis), releases a ditty reaffirming his support of marriage equality on the day it became a reality here in Minnesota. Check it out, below.

02. August 2013 by Michael Douglas, MD, MBA
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Obama Working Behind the Scenes on Latest Pre-ACA Snafu

The Republican amendment to the ACA stopping government contributions to premiums of federal employees is being put to the test this week, as President Obama is reassuring Dem senators that he is working to “resolve the situation”.  At issue here is the amount of fed premium contributions to insurance plans of federal employees — some as high as 75 percent. Until the ACA takes effect, these contributions are part of the Federal Employee Health Benefit Plan, and they affect hundreds of Hill employees. What is not clear is if these payments will continue under the ACA, when beneficiaries are required to obtain coverage, via an exchange or otherwise.

The uncertainty is leading to dozens of lawmakers and aides considering leaving Capitol Hill. It is extraordinarily rare, to say the least, for the president of the United States to get involved in an inside-the-Beltway flap over the payment of health care premiums. Yet the anger over the administration’s inability or unwillingness to resolve this issue is bipartisan and deep. The feared “brain drain” of congressional staffers over rising health-care costs has become a topic of constant conversation on Capitol Hill .

Party leaders in both chambers want OPM to rule that the government can continue to contribute to health insurance premiums for members and staffers. OPM, though, has so far refused to say how it will handle the provision, despite months of lobbying by lawmakers. The controversy has to be resolved before Oct. 1, when members and staffers are slated to enter the exchanges.

It’s another wrinkle working against the White House PR push to get the reform law into the good graces of Americans ahead of implementation. The challenge is in assuring Democrats that these pre-rollout issues will not jeopardize the employment of those who actually do all of the legislative grunt work that produces legislation like this in the first place. Pretty ironic. | LINK

01. August 2013 by Michael Douglas, MD, MBA
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Rural Recipients of Care Access under ACA Stand to Benefit Greatly

It’s a little of a conundrum for states with a significant rural demographic: how to get the word out about the ACA and its expansive coverage benefits profile, as legislators and governors do little to spur the process along. As expected, some crimson red states are fighting the Medicaid expansion provision tooth-and-nail, with such high profile figures as Rick Perry (R-TX) leading the PR charge. But what about those rural, ideologically red states that have quietly accepted the SCOTUS-modified provision?

Sure, those states’ chief executives have all but perfunctorily held their collective noses while agreeing to be a part of reform’s drive into areas where population demographics — not electoral ones — seem to be guiding prudence into the provision’s implementation. The reticence of those red states that choose to go with Obamacare in this sense have done the bare minimum in accepting the provision — at the very least as a mechanism to ensure some sort of fiscal shield against ever-skyrocketing healthcare costs, while essentially refusing any sort of effort to publicize the potential benefits of Medicaid expansion and major susbsidies for huge swaths of uninsured in the nation’s rural locales.

Where does that leave ACA proponents? It’s all about getting the word out.

A larger proportion of the rural population than the urban population is uninsured and low income (living at or below 138% of the federal poverty line [FPL]) (9.9% as compared to 8.5%) and a larger proportion of the rural population than the urban population will be eligible for subsidized Health Insurance Marketplace (HIM) coverage due to income levels and current lack of insurance (10.7% as compared to 9.6%).

That, according to the director of the Rural Policy Research Institute’s Center for Rural Health Policy Analysis, a prominent think tank. Apparently the feds agree — education on this access issue among the nation’s rural population is key to the success of the ACA in the short term. The government is so intent on getting around PR pitfalls engineered by ACA opponents, it is willing to shell out more than $200M to make it happen. Game on!

31. July 2013 by Michael Douglas, MD, MBA
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Medicare Part D Premiums to Remain Relatively Static Next Year

Medicare funding may be “on the table”, and part of Obama’s grand bargain with House Republicans, but the federal outlay for its services looks to remain stable for 2014, according to CMS chief, Marilyn Tavenner. The process of competitive bidding among plans with Part D offerings is actually keeping premiums tolerable for consumers.

Medicare Part D premiums will average about $31 in 2014 — up from $30 for the past three years. The Part D deductible will fall from $325 to $310 in 2014. “There is continued very strong competition within the Part D plan,” said Jonathan Blum, deputy administrator and director for the Center of Medicare. When the coverage gap program began, “there was lots of concern that filling in the doughnut hole would cause Part D costs to go up…”

Fears concerning the speed with which struggling seniors would reach the donut hole gap have been largely unfounded, as generics account for the lions share of reimbursible transactions. Since the Medicare Modernization Act of 2003 established the Part D provision, under President George W. Bush, there has been a progressive increase in the economic benefit to seniors who have the freedom to choose between offerings yearly. This, and the recent relative lack of novel drug applications, have tempered rising costs for beneficiaries. | LINK

31. July 2013 by Michael Douglas, MD, MBA
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