As a key deadline nears, "Obamacare" fraudsters, under the guise of helping with enrollment in health insurance exchanges, are trying to dupe unwitting consumers into giving up personal information.
As states and the federal government scramble to meet a fast-approaching deadline to establish health insurance exchanges under the Patient Protection and Affordable Care Act, scammers are hoping to cash in on consumer confusion about the plans, the National Association of Insurance Commissioners warns.
"There are folks taking advantage because they know people are hearing blurbs on TV and radio," says Kansas Insurance Commissioner Sandy Praeger, chair of the NAIC's Health Insurance and Managed Care Committee.
"Consumers are not paying a whole lot of attention to it, but just enough where somebody comes along and says 'you've heard about this new health insurance. I am here to make sure you get signed up.' Obviously there is no phone solicitation that is going to occur."
Open enrollment in the new marketplaces begins Oct. 1, but bogus websites that claim to be part of the exchanges have been sprouting online for more than a year. Oftentimes the scammers are looking to sell phony policies or obtain personal information from unwitting consumers, such as Social Security/Medicare ID, credit card, or bank account numbers.
>Bogus Health Plan Offers
Praeger says anecdotal reports have been surfacing about the scams, but it's hard to know how widespread they've become. "We know there are some phony websites that have been created so it's hard to tell because sign-up hasn't really started yet," she says. "But that is why an ounce of prevention is worth a pound of cure—the old medical adage. It is important that we at least get information out there and alert people."
NAIC has red-flagged a handful of the most common scams. One ploy involves unsolicited calls from vendors claiming to have the consumer's new "Obamacare" insurance card. But first personal and financial information must be verified before the card can be mailed. This is a variation of another scam that targets senior citizens on Medicare with claims that bank account and Social Security numbers are needed for them to continue receiving benefits.
There is no requirement to get a new insurance card or a new Medicare card under the PPACA, and NAIC notes that anyone claiming to represent the federal government already would have access to personal and financial data and would not ask the consumer to disclose it.
Act Now or Go to Jail
Another scam identified by the NAIC include: Salespersons claiming that the premium offer is only good for a limited time. In fact, enrollment in the exchanges will be open from Oct. 1 to March 31, and rates for plans in the exchanges will have been approved for the entire enrollment period.
And scammers are known to employ scare tactics such as warning that consumers will got to jail for not having health insurance.
So far, Praeger says, no scams have surfaced that would require new laws. "Our existing consumer protection laws are adequate," she says. "There might be some creative scam out there we haven't thought about, but in most cases a scam is a scam and anybody trying to misrepresent the sales process or encourage someone to buy something that is not appropriate, our laws are sufficient."
Praeger says providers can help by steering patients to federal and state insurance department websites. "We set up our own separate website just for information about the Affordable Care Act called InsureKS.org," she says. "Hospitals, I am sure, are going to have their staff trained to be enrollment counselors. Most physician offices don't do the wallet biopsy before they treat somebody. They treat and if the person can't pay, hopefully physician offices will at least encourage people to look into the Affordable Care Act provisions."
Several mechanisms "end up leading to minority and uninsured patients having a higher death rate after trauma and I think that the hospital that they go to certainly plays a major role," says the lead author of a study that analyzed records from the National Trauma Data Bank.
Adil H. Haider, MD, trauma surgeon and associate professor of surgery at the Johns Hopkins University School
More than 80% of trauma centers that treat mostly minority patients have higher death rates than do trauma centers that treat mostly white and insured patients, a Johns Hopkins study shows.
The same study also found, however, that trauma patients of all races are 40% less likely to die if they are treated at hospitals with lower mortality rates, regardless of the severity of their injuries.
"Disparity issues are never simple," says the study's lead author Adil H. Haider, MD, a trauma surgeon and associate professor of surgery at the Johns Hopkins University School of Medicine. "There are several mechanisms that end up leading to minority and uninsured patients having a higher death rate after trauma and I think that the hospital that they go to certainly plays a major role into it. Certainly what this data shows is that not all hospitals are equal."
The findings detailed in an article published in the October issue of Annals of Surgeryare based on an analysis of records from the National Trauma Data Bank. Haider and his team classified 181 trauma centers across the nation into three categories and found 86 hospitals with lower-than-expected death rates; six with average death rates; and 89 with higher-than-expected death rates.
Researchers found that 27 of the trauma centers serve a population that is more than 50% minority, while 154 have patients who are mostly white. Of the trauma centers that serve predominantly minority patients 81.5% were classified as high-mortality, and 64% of black patients in the study group were treated at these high-mortality centers compared to only 41% of white patients.
Haider says detailed attention was given to making risk adjustments for the trauma patients cited by the study. "We risk adjust patients on age, the injury severity score, their physiologic state when they got injured and when they got to us," he says. "Every way we cut this it makes sense because it is very sensitive stuff. Once you say it, you can't take it back so you have to be super right when you do it."
The analysis also showed that 45% of patients at high-mortality centers don't have insurance, compared to 21% at low-mortality hospitals.
"We did not study hospitals' bottom lines, so now I am speculating, but if you have a better bottom line because you have more insured patients then you are able to invest in more stuff and you are able to do a better job and keep getting better," Haider says.
"On the other hand if you are working under extreme pressure and you have to take care of a lot of patients and you are not getting paid to take care of these patients, then it is difficult to improve quality. I don't mean to give a pass to hospitals that are on the bottom of the ranking, but I totally understand why they are doing such a difficult job. I have seen myself hospitals that are working in difficult circumstances that are doing a fantastic job with what they have. If they had more resources they would be fantastic and would go right up the list."
While the findings in the study are troublesome, Haider says he takes some solace in knowing that the results did not show any treatment bias on the part of trauma teams.
"We talk about healthcare disparity all the time but the fact is that no matter your skin color, white, black, or Hispanic, they ended up with the same results based on what hospital you went to," Haider says. "If you went to a low-performing hospital and you were white, you [would] have the same results as a black guy at that hospital."
"Similarly," he says, "if you went to a high performing hospital whether you were black or white you all did good. That was very heartwarming to see and a very positive finding for the study because a lot of disparity studies keep on showing that minority patients are doing worse, but this one shows that trauma centers do a great job if they are able to do a good job they do it no matter who you are. But obviously not all trauma centers can do a good job."
Research on Medicaid patients in North Carolina validates with data what we've known anecdotally for some time: Transitional care works, both to improve population health, and to save money.
Many studies examining the value of transitional care contain an obvious "Duh!" factor.
It's not a radical concept: If you follow up on patients post-discharge, make sure they're following a treatment plan, going to physicians' appointments, taking their medications, changing risky behaviors, etc., then it's less likely they'll be readmitted into the hospital.
Who knew! Get me rewrite!
Sarcasm aside, there is a lot of value in these seemingly obvious findings. They validate with statistics what common sense screams out and what we've known anecdotally for some time: Transitional care works, both to improve population health, and to save money.
A study out of North Carolina and published in Health Affairs makes that point on a statewide scale. Researches with Community Care of North Carolina, a public-private collaborative to coordinate care in the state, wants to reduce readmissions among high-risk Medicaid patients with chronic conditions. The study examined the medical records of about 13,000 Medicaid patients from across the state in a transitional program and who were hospitalized in 2010-11.
Their readmissions were compared with those of 8,000 Medicaid recipients who received little if any transitional care. The study found that patients in the transitional care program were 20% less likely to be readmitted in the following year and that one readmission was avoided for every six patients in transitional care, including one in three of the highest-risk patients, the study found.
"In terms of this being a 'no brainer,' one of the biggest things that this study adds to the literature is that it's becoming more and more evident that transitional care is effective," says Carlos Jackson, lead author of the study, and director of program evaluation at Raleigh-based CCNC.
"There are a number of randomized studies that show that the intervention is effective, but those studies are on a small scale in a very controlled setting. What is unique about our study is we were able to bring this to an entire statewide program, and that is very unusual. We are talking about an entire state, multiple healthcare systems and providers, different settings, different regions of the state with very different issues; being able to disseminate it in that way and actually show that it is effective. There is a lot of good stuff that has been shown to be effective on a small scale in a very controlled randomized study but when you try to roll it out into large scale program sometimes some of the effectiveness drops off. What was unique is that we could show that 'hey we are just as effective when we go statewide.'"
Reducing 30-day readmissions is hot topic in hospitals these days now that Medicare has attached financial penalties to the statistic. Jackson says it's only a matter of time before Medicaid carries the same stick.
"Certainly 30-day readmissions are the topic of the day and everybody is working to reduce it, not just in their Medicare population," he says. "You will find that when you start changing processes in your hospital or practice that you are going to have spillover to your entire patient population. As you do these handoffs better, hopefully you will be impacting more than just your Medicare population."
The North Carolina study did not include a cost-benefit analysis of transitional programs, although Jackson concedes that "that is the question everybody wants answered."
"What we say in our paper and what is true is that we can be fairly confident that there is a positive return on investment if you just do the math," he says. "When you do transitional care with just six patients you can prevent one admission in a year. Each admission costs $6,000. As long as that is higher than what it costs to manage those six patients for a relatively brief period of time in transitional care, it is a positive return on investment."
Why does transitional care work? Again, common sense provides obvious answers. If you make sure that the patient is following discharge instructions, taking medications, seeing his physician in an out-patient setting, monitoring chronic conditions, etc., of course there will be a better outcome.
However, Jackson says it's harder to pinpoint exactly why transitional care works on a larger scale. "That is a very challenging question to answer because the transitional care program is tailored to the individual," he says.
"If you have a patient who doesn't have a lot of needs, they only need a little support. Whereas somebody who is high risk and high need you have to give them a lot of support. Sometimes in the evaluation it may show that that person you have given a lot of support to still shows up back at the hospital but maybe you've kept them in the hospital a little bit longer. Those kinds of things are hard to tease out."
Anecdotally, Jackson believes that a key component of transitional care is the home visit by a medical professional. "A lot more comes out in the home. You learn a lot more than you would with a phone call," he says. "They are telling you one thing, but you clearly see that they are not. Maybe there are mobility issues, transportation issues, there may be environmental or nutrition or health issues. A picture paints a thousand words."
Jackson says patients appreciate the voluntary home visit too. "They like having the extra support and having a nurse come and check in on you and make sure you are OK and have what you need," he says. "They love the clarification and the support they need when they come out of the hospital."
Let's review: Transitional care reduces readmissions, improves patient outcomes, saves money, and engages patients to become an active partner in their own care plan. With every new study, the statistics and other objective evidence are lining up behind the common sense.
The pace of hospital job growth has slowed to a crawl this year. The root cause is "not just healthcare reform," says one analyst, citing about $100 billion of other cuts since 2010.
Healthcare reform, federal funding cuts, a sluggish economy, and new technologies and treatments are accelerating a longstanding trend that has seen healthcare job creation shift away from hospitals and toward outpatient ambulatory care.
Nicole Smith and Artem Gulish, analysts from the Georgetown University Center on Education and the Workforce, said in an email exchange with HealthLeaders Media that ambulatory care employment first outgrew hospital employment in 1995 with the gap widening ever since. For the past 13 years hospital employment has been growing at a slower pace than the overall healthcare sector while ambulatory services has grown at a faster pace than the sector.
"The slow growth in hospital employment and fast growth in ambulatory care services has been the trend in healthcare since the 1990s," say Smith and Gulish, citing Bureau of Labor Statistics data. "This trend has been driven by the move away from high-cost, high-risk hospital care and towards more convenient, lower-cost ambulatory care… In recent years this trend has been driven by development of new technologies that have allowed patients who previously required hospital care to be treated in ambulatory setting, such as the use of stents for many people who previously required bypass surgery."
Bureau of Labor Statistics preliminary data for August shows that the healthcare sector, which includes hospitals, nursing homes, ambulatory surgery centers, clinics, and physicians' offices, created 32,700 new jobs in August, which represents 20% of the 169,000 new jobs created in the entire economy for the month.
Ambulatory services accounted for 26,600 of those new jobs, and hospitals accounted for 900 new jobs. Hospitals shed 9,000 jobs in May, and 1,300 jobs in July, BLS data and preliminary data show. BLS data for August and July is considered preliminary and can be subject to considerable revision.
For the past five years the general consensus has been that the recession and sputtering recovery have played a role in reducing inpatient admissions.
"The pace of growth in hospital employment has significantly slowed down since 2008 following the beginning of the recession, even before 'Obamacare' was enacted," the Georgetown analysts say. "This is most likely due to impact of macroeconomic conditions and is indicative of the downward cyclical decline in employment. The pace of growth improved since the recovery started to take hold; though it is still much slower than before the recession."
"Ambulatory care employment has been largely protected from the recession, likely due to its cost advantage over hospital care. So, as cost became a greater consideration for insurers and providers, they were more like to use ambulatory care in place of hospital care."
In 2013 the pace of hospital job growth slowed to a crawl.
"We are seeing significantly lower job growth for hospitals this year than we did year-to-date in August 2012 and year-to-date August 2011," says Caroline Steinberg, vice president, health trends analysis at the American Hospital Association.
"Last year at this time job growth was about 44,500 by August and this year it is only 7,000, but that is not surprising given the mounting payment cuts to hospitals, particularly the 2% cuts to Medicare mandated by the sequester."
While ambulatory services created most of the jobs in healthcare, Steinberg says hospitals had been holding their own until this year. "The trend in terms of employment is really due to the cuts," she says.
"We had been seeing steady increases in hospital employment even as we saw a shift away from inpatient care because a lot of that inpatient volume is being replaced by outpatient volume. Overall demand for hospital care is not really dropping off. It's that the funding for the same amount of care is getting to be less."
Steinberg says hospitals are reluctant to hire because they're bracing for massive reductions in federal funding over the next 10 years. "It's not just healthcare reform. We've seen about $100 billion of other cuts coming that are not healthcare reform since 2010."
"You've got the sequestration, which is about $45 billion over 10 years, then you have the coding offsets and they've tacked on more cuts to Medicaid (disproportionate share payments) and cut the reimbursements for bad debt. There are a lot of other cuts that hospitals are facing that are causing them to really cut back on staff."
Adam Powell, a Boston-based healthcare economist, says the move away from fee-for-service reimbursements is changing the way healthcare is delivered. "We are seeing a movement toward accountable care organizations and contracting and this means that healthcare providers will have fixed revenues and can only increase their profitability by decreasing their costs. Now, seeing as providers tend to have the largest cost being their staffs the only way to decrease costs is to reduce staffing," says Powell, president of Payer+Provider consultants.
"There is naturally a certain rate of staff attrition which helps solve the problem. The way to reduce staffing costs without laying off people is simply not hiring as many. This is all part of a trend toward running leaner operations."
Hospital consolidation is also a factor. "Two merged hospitals don't need two CEOs and two CMOs. They can potentially eliminate positions that help reduce costs. The staff gets right sized. The community doesn't need two complete departments for a particular specialty," Powell says.
While it is indisputable that hospital hiring is down, Steinberg says the BLS data may not reflect the big picture because it does not account for hospitals' buying physician groups and other ambulatory services.
"If a hospital bought a physician practice and that practice continues to operate in an off-campus facility that would still be counted as a physician office for BLS data. So you have to be a little careful in terms how you are looking at the data. The data is collected at the establishment level and the establishment is a particular location," she says.
Adults earning below the federal poverty level who live in the 26 states that have either rejected Medicaid expansion or have yet to commit to it will be ineligible for a federal subsidy to help them buy coverage on the health insurance exchanges.
Many working poor who live in states that won't expand Medicaid also won't be eligible for federal subsidies that would make private health insurance affordable.
A Commonwealth Fund study released this week estimates that a glitch in the implementation of the Patient Protection and Affordable Care Act was created when the U.S. Supreme Court ruled last year that the Medicaid expansion was optional for states. Even with the ruling, no one foresaw that some state would actually reject the billions of federal dollars to prop up the expansion.
However, 42% of adults who've been recently uninsured and who live in the 26 states that have either rejected Medicaid expansion or have yet to commit to it will be ineligible for a federal subsidy to help them buy coverage on the health insurance exchanges.
In those states, the study says, the lowest-income adults—those earning below the federal poverty level, or less than $11,170 for an individual and $23,050 for a family of four in 2012—will not have access to either the Medicaid expansion or subsidized private insurance through the new state insurance marketplaces and are likely to remain uninsured.
"A primary goal of the Affordable Care Act is to provide health insurance coverage to the millions of uninsured people in the U.S., the majority of whom have low and moderate incomes and struggle to afford the health insurance and healthcare they need," Commonwealth Fund Vice President and study coauthor Sara Collins said in prepared remarks. "However, if states don't expand their Medicaid programs, adults with the lowest incomes will continue to live without the health and financial security provided by the Affordable Care Act."
The report, In States' Hands: How the Decision to Expand Medicaid Will Affect the Most Financially Vulnerable Americans [PDF] , is based on a survey of U.S. adults ages 19 to 64 that estimated that 55 million Americans were uninsured at least part of the time from June 2010 to September 2012. In the 26 states, 72% of adults whose incomes fell below 133% of the federal poverty level ($14,856 for an individual and $30,657 for a family of four in 2012) during the two-year period were uninsured at some point.
In a perverse twist of the ACA, Collins says that some of the lowest income adults, the very people for whom the programs are designed, will be especially at risk in the states that don't expand their Medicaid programs.
It's understood that people earning less than 133% of the federal poverty level in 2014 will qualify for Medicaid, while people making between 100% to 133% of the federal poverty level are eligible to purchase subsidized insurance coverage through the state marketplaces if they are not eligible for Medicaid.
Here is where it gets skewed: People making less than 100% of the poverty level in the 26 states are not eligible for marketplace subsidies because it was assumed that they would be enrolled in Medicaid.
As a result, Collins says, not only will the lowest-income people be unable to enroll in expanded Medicaid, but they won't be able to purchase subsidized health insurance through the marketplaces.
The Commonwealth Fund estimates that the glitch will affect two-in-five adults who live in the 26 states and who were uninsured any time over the two-year survey period earned less than the federal poverty level in one or both years. The report also finds that low-income people in the 26 states could lose coverage if their income changes.
For example, one year a family's income level could qualify them for subsidized coverage through the marketplaces. However, an income loss, such as that resulting from the loss of or change in a job, could drop them into the category where they no longer qualify to purchase subsidized coverage through the marketplaces. With no expanded Medicaid and no option for subsidized coverage through the marketplaces, they would likely become uninsured.
Collins says that 29% of people who would qualify for subsidized coverage saw an income change from 2011 to 2012 that dropped their income below 100% of the poverty level, meaning they would no longer qualify for subsidized coverage through the marketplaces. Another 12% of those earning between 133% and 249% of poverty in 2011 also experienced an income change that lowered their earnings to less than the poverty level in 2012.
In contrast, 30% of people with incomes below 100% of poverty had an income gain that would have made them eligible for subsidized coverage.
The study calls on states to accept the Medicaid expansion. In the likely event that they do not, at least in the near term, Collins says Congress could pass legislation that would allow those making less than 100% of the federal poverty level, who are not eligible for Medicaid, to be eligible for subsidized coverage through the state marketplaces.
Such legislation would be unlikely to clear the Republican-controlled U.S. House, which has voted 40 times to repeal the PPACA.
Gary M. Wiltz, MD, the newly elected chairman of the National Association of Community Health Centers, vows to expand the public profile of the organizations he calls "the base of primary preventive care."
Gary M. Wiltz, MD
Since the mid-1960s community health centers have done the heavy lifting and often thankless work of providing healthcare to poor and low-wage earners in underserved areas. In those decades they have proven their value and now serve about 22 million people who otherwise might go untreated. By some estimates community health centers will serve as many as 50 million people by 2019.
Gary M. Wiltz, MD, the newly elected chairman of the National Association of Community Health Centers, sees the role of community health centers growing dramatically over the next few years with the advent of the Affordable Care Act and its emphasis on population health and expanding Medicaid to improve access.
"We touch one in every 15 Americans right now, which is quite a statement about the expansion that we have enjoyed historically. We are projecting a lot of growth in the next five years, so there is a lot of work out there and a lot of people in need," says Wiltz, who also is the CEO at Teche Action Clinic in Franklin, LA.
"Quality is very important to us and we just want to make sure that we are making ourselves available and accessible. Our center here in Franklin is open six days a week, 12 hours a day, and a lot of our centers are trying to do extended hours to make sure we have the capacity to serve all of the newly insured that we hope when they come through our doors. It's the right thing to do for the country and the right thing to do by people."
Spend any time around these community health centers and the people who run them and it's hard not to be impressed, both with their dedication to their mission, and with the cost-effectiveness with which they deliver care.
Primary Care Starts Here
Community health centers have been around for close to a half-century because they deliver on both of those values. "If you look at healthcare as a triangle, we are the base of primary preventive care," Wiltz says.
"If we do our jobs correctly, if we bring people in and screen them for diseases and get those diseases under control and manage them and not always be reactionary, if we get people to quit smoking and lose weight, and exercise, do the cancer screenings and heart disease and do the things we do well then we can keep people from getting secondary and tertiary diseases, doing the prenatal care to protect against low birth weight bottles or preventing baby bottle tooth decay. That is our whole emphasis."
"I have been doing this for 30 years. I see patients now who I saw when they were 40 years old and got them to quit smoking and now they are 70 and they haven't had a heart attack or a stroke or developed cancer. That is the benefit of what we do."
Unfortunately for Wiltz and the people he serves his health center is in Louisiana, which is one of the 20 or so states that have opted out of the Medicaid expansion under the Affordable Care Act.
"In our state we estimate it will affect about 400,000 people who would be eligible for Medicaid expansion that are not going to get it," Wiltz says. We are going to try our best to get them into traditional Medicaid and the health insurance exchanges, but it really doesn't make any economic sense let alone moral sense. It is purely politics and philosophy that is operating and it's unfortunate for the people who are suffering and who could benefit."
Wiltz says expanding Medicaid would save money because treating people in community health centers costs a fraction of what it would cost in an emergency room. "On average, a Medicaid patient seen in a health center is $110. That same person in a hospital setting is almost $800. We have demonstrated tremendous savings."
Community health centers have also been caught in the budget battle between the Obama administration and Congress. The Obama administration included $11 billion in the ACA for capital improvements to the 1,128 federally funded community health centers across the nation.
Congress, however, cut funding for health centers by $600 million in 2011. Also, sequestration cuts are expected to cost community health centers about $120 million, which some studies estimate would translate into 900,000 fewer patients served. Community health centers are stutter stepping.
A Downward Slope
"Having prepared for a decade of strong growth, health centers now face significantly diminished funding and the prospect of a slower expansion of Medicaid, both of which exert downward pressure on health center expansion," the Kaiser Commission on Medicaid and the Uninsured stated in March.
"In light of health centers' role in our healthcare system and their unique potential to advance the goal of expanded access to care for the medically underserved, these shifts in the direction of retrenchment pose a challenge going forward." Wiltz says he is experiencing the effects of that retrenchment.
"We got money to do the capital development at almost all centers in the U.S. Before that we were in two double-wide trailers and an old house. A lot of centers were in churches and schools and had not gotten any money from capital development to even get out of those dilapidated buildings into more modern facilities," Wiltz says.
"We built these facilities with the thought that these uninsured would be covered through Medicaid expansion. That was the model that we have been operating on. I have two buildings that have been renovated and are ready to go but I can't open them because if I do and 80% who come to us are uninsured, I don't have operational dollars."
Wiltz concedes that community health centers have done an inadequate job of "tooting our own horns." He vows to expand their public profile during his two-year chairmanship.
"We represent 22 million people and I don't think all of our voices have been fully heard," he says. "I would like to see us get more media savvy and have people understand that when you touch one in every 15 Americans that says a lot."
Demonstrated Worth
He takes solace knowing that community health centers have endured for nearly a half-century because they've demonstrated their worth and no one else steps in to fill the need.
"When you look back on our beginnings in 1965, no one expected us to thrive and survive. We have a history of being creative and finding solutions. I don't have the exact road map, but I can tell you that we have enough talented and creative people and enough force and drive that we are going to make it happen one way or another."
"We are like that inscription below the Statue of Liberty: 'Send these, the homeless, tempest-tossed to me.' No one else wants to deal with them, but we have always provided a welcoming door. That is part of our DNA."
Part of the reason for the current shortage of family physicians harkens back to the perception in some medical circles just a few years ago that primary care was a specialty best to be avoided unless you wanted to work long hours for less pay.
For the seventh straight year family physicians topped the list of the 20 most sought-after specialties for recruiters Merritt Hawkins.
This should not surprise. It has been evident for the last several years that as healthcare reform eventually mandates a shift away from fee-for-service and rewards prevention, quality outcomes, and population health, primary care physicians will lead the way.
Another driver for the high demand is the growing numbers of service sites. Medical groups searching for primary care physicians increasingly find themselves competing against other medical groups, hospitals, community health centers, urgent care centers, retail clinics, academic centers, and government facilities.
It was fashionable in the 1990s and the Health Maintenance Organization era to refer to primary care physicians as "gatekeepers" who would map out and coordinate care strategies to reduce costs and waste. While the gatekeeper label might have gone out of fashion (or conjures up unpleasant thoughts of rationed care) the role clearly has come storming back.
Return of the Gatekeeper
"Everybody wants to be in primary care. The whole mantra with healthcare reform is wherever your patients are let's be there," says Kurt Mosley, vice president of strategic alliances at Irving, TX-based Merritt Hawkins.
"Back in the 1990s the whole issue was gatekeepers. I knew a CEO who had a sign on his desk that said 'He who retires with the most primary care doctors wins. ' And I think we are back to that."
Merritt Hawkins' 2013 Review of Physician and Advanced Practitioner Recruiting Incentives [PDF], the 20th edition of the survey, tracks the 3,097 recruiting assignments in 48 states the firm conducted from April 1, 2012 to March 31, 2013. The report shows that physician recruiters handled 624 searches for family physicians. General internal medicine came in a distant second with 194 searches.
Part of the reason for the current shortage harkens back to the perception in some medical circles just a few years ago that primary care was a specialty best to be avoided unless you wanted to work long hours for less pay.
"The problem is when all of those specialties started coming up years ago we started seeing all of these doctors making all of this money and there was a bias against primary care in medical school. Some of the faculty would say to students 'you are way too smart for primary care.' We bit off our own nose in spite of our face."
The report shows that demand for some medical specialists has decreased. Radiology, which was the most requested specialty from 2001 to 2003 did not make the top 20. Anesthesiology, also a one-time top recruiting assignment, also did not make the list in 2013.
Compensation Remains a Sore Spot
While family practitioners are in high demand, their average base salaries or guaranteed incomes of $185,000 remain near the bottom. Only pediatricians fared worse with an average base of $179,000.
"A key factor that people have to understand is that primary care is not necessarily growing in salary, but more specialties are coming down closer to them," Mosley says. "We used to talk about cardiologists in the $800,000 to $900,000 range. Now they are in the $500,000s and $600,000s. Also doctors in medical homes can make a heck of a lot more money because they are paid that base salary and they are paid a maintenance fee and they are paid the malady improvement fee. There are ways for doctors to make money. We are going to see it continue to rise."
Seventy-five percent of search assignments this year featured a salary with production bonus. Most such bonuses (57%) are based on a Relative Value Units formula. A growing number of production formulas also feature quality-based metrics. For example, 39% of the search assignments offered production bonuses that featured a quality-based component, up from 35% a year earlier.
By comparison, in 2011, fewer than 7% of recruiting assignments that offered a production bonus included payments based on quality-of-care metrics. In 2013 that number grew to 39%, which Mosley says illustrates the rapid shift away from rewarding physicians for the volume of services they provide and toward rewarding them for the value of services they provide.
Other Recruiting Trends
Nonetheless, quality measures averaged less than 10% of a physician's potential bonus in 2013 and volume is still the key driver of physician incentives. The survey identified these trends as well:
Also for the first time, geriatricians cracked the top 20 and are being actively recruited to supplement elder care traditionally provided by internists, pulmonary and palliative care specialists.
Hospitalists ranked third among the top 20 search assignments, probably because their training and emphasis on coordinating inpatient care and reducing readmissions are aligned with the goals of new care delivery models such as accountable care organizations.
Other hospital-based physicians, particularly emergency medicine physicians, are in increased demand, as data show that a greater prevalence of insured patients does not necessarily decrease emergency room visits – a significant trend as millions of the previously uninsured begin to obtain coverage through the Affordable Care Act.
The trend toward hospital employment of physicians continues and represented 64% of search assignments in 2012/13, up from 11% in 2004.
Demand for physicians is not confined to underserved rural areas. Merritt Hawkins worked in 48 states in 2012/13 and 49% of the firm's searches were in communities of 100,000 people or more, the highest percentage in the 20-year history of the review.
In a joint venture, Florida Hospital Healthcare System and Health First Health Plans will partner to form a commercial health plan in Central Florida. The coverage area will include Tampa, Orlando, and Daytona Beach.
Mike Schultz, President and CEO
Adventist Health System Florida Region
Florida Hospital and Health First Health Plans are partnering to create a commercial health plan that will serve 10 counties across Central Florida.
The new plan, which is expected to be operational on the state's health insurance exchange by mid-2014, will be a joint venture between Florida Hospital Healthcare System, which administers employee health insurance for Florida Hospital, and Health First's Brevard County, Florida subsidiary. A formal agreement is expected to be in place by the end of 2013.
Mike Schultz, president/CEO of the 23-hosptial Adventist Health System Florida Region, says the joint venture creates an opportunity to improve patient outcomes while attempting to contain the unsustainably high medical inflation.
"Florida Hospital's footprint is pretty big in Central Florida, so we believe we have the size that can have a positive impact on the medical spend," Schultz says.
"We believe that payers have to be aligned with providers to lower that medical spend with an emphasis on health and wellness. Right now we get paid when people are sick, so there is no incentive for us to keep them out of the hospital. We believe that aligning with a payer like Health First will provide us with the opportunity to focus on health and wellness and then over the course of time we believe that will bring down the health spend that will help our governments and our employers."
FHHS operates healthcare networks in 10 Central Florida counties stretching from Tampa to Orlando to Daytona Beach, with 23 hospitals, 22 urgent care centers, more than 4,000 physicians and ancillary providers. FHHS also provides third party administrative services for employers in the region.
Health First is Central Florida's only fully integrated health system, with more than 7,500 employees and four hospitals. Health First Health Plans offers plans in Brevard and Indian River Counties. Health First Medical Group is the largest multi-specialty physician group on Florida's Space Coast.
Adam Powell, a healthcare economist, says the new partnership is "yet the latest in a series of narrow network plans that have emerge in response to healthcare reform."
"These plans tend to offer people high-value care delivered from a concentrated set of providers in their area," says Powell, president of Boston-based consultants Payer+Provider.
"By keeping patient panels within a health system, these integrated plans make it easier for providers to manage the cost and quality of care. By encouraging patients to a house brand health plan, Florida Hospital can more fully capture profit across the healthcare value chain and can more firmly manage patients' care. The plan has the potential to improve the quality of care, as when patients stay within a health system, they tend to have better continuity of care and to have more complete medical records."
Schultz says the arrangement with Health First and the gradual roll out of the plan over the next three to five years allows Florida Hospital to position itself to become "owners of a health plan over time, and that helps align incentives."
"A number of systems that have the size are looking at areas of where they can get into the payer side of the business," he says. "We decided to go with Health First as opposed to building our own insurance company from the ground up. That was more of a speed-to-market deal. It's not unique from the standpoint of strategy that a number of people are doing. Payers are already buying physicians and I believe you will see payers buying hospitals to incorporate the same strategy. The incentives need to be aligned, whoever is doing it."
Powell says that Florida Hospital is hardly alone in its desire to manage more patient risk.
"The Advisory Board recently announced that of the 100 hospitals it surveyed, 34% responded that they already own health plans and 21% responded that they planned to launch a health plan by 2018," he says. "While Florida Hospital Healthcare System has experience operating as a third-party administrator, the partnership with Health First brings it the competencies it needs to launch commercial and Medicare plans."
Owing to a conflict with Georgia's stringent Certificate of Need laws, the FTC will grudgingly drop its attempts to nullify Phoebe Putney's 2011 acquisition of rival Palmyra Park Hospital from HCA for $195 million.
A two-year antitrust investigation launched by the Federal Trade Commission against Georgia's Phoebe Putney Health System and the Hospital Authority of Albany-Dougherty County has ended with a settlement that has both sides claiming victory.
Owing to a conflict with Georgia's stringent Certificate of Need laws, the FTC will grudgingly drop its attempts to nullify Phoebe Putney's 2011 acquisition of rival Palmyra Park Hospital from HCA for $195 million. Phoebe Putney will keep the hospital, now called Phoebe North Campus, but the health system and the Authority may not for the next five years contest potential competitors providing additional acute care services in the six-county area around Albany, GA.
Phoebe Putney and the Authority said the settlement allows them to object to CON applications for other projects, but they have agreed to tell the FTC when they do. The hospital will provide the FTC with annual compliance reports for the provisions for 10 years. The two sides expect to finalize the consent agreement within 30 days.
The FTC had sought to have the acquisition voided and another buyer found for Palmyra, but learned that doing so would prompt a Certificate of Need review from the state of Georgia. "Unfortunately, Albany is deemed ‘over-bedded' by Georgia's strict need assessment criteria making it unlikely that any possible divestiture buyer could obtain the necessary CON approval to operate an independent hospital," the FTC said in a media release.
Phoebe Putney said the consent agreement will stipulate that the FTC made no findings that the hospital or the Authority violated antitrust laws. "Instead, solely to achieve a compromise with the FTC, and for purposes of these proceedings only, Phoebe Putney and the Hospital Authority have stipulated that the acquisition of Palmyra might substantially lessen competition within the service and geographic markets alleged by the FTC," the hospital said in a media release. "The settlement expressly reserves the rights of Phoebe and the Authority to contest that allegation in any other proceeding"
Joel Wernick, president/CEO of Phoebe Putney, said a settlement after more than two years of legal wrangling allows the health system to "put this proceeding behind us…"
"Today's settlement means Phoebe Putney will be able to use the Phoebe north campus as planned, to meet current capacity needs and to expand its tradition of high quality healthcare for our entire community," Wernick said in prepared remarks. "The citizens of Southwest Georgia are well served by this compromise solution [which] we believe to be in the best interests of all parties. It will also allow us to continue moving forward at a time of great change in our country's health delivery system"
In a case that prompted a ruling in February from the U.S. Supreme Court, the FTC alleged in its antitrust complaint that Phoebe Putney constructed an elaborate scheme that used the Authority as a "straw man" to "cloak private, anticompetitive activity in governmental guise in the hopes that it would exempt the acquisition from federal antitrust law"
Phoebe Putney and the Authority countered that they were immune from federal antitrust liability under the "state action" doctrine—which provides an exception for anticompetitive conduct if it is an act of government.
A federal district court and an appeals court sided with Phoebe Putney and the Authority. In February, however, those rulings were tossed out by the U.S. Supreme Court, which ruled that the appeals court had "loosely" interpreted a state law cited by Phoebe Putney to justify a merger that would give the consolidated health system control of about 85% of the market in the region.
FTC officials said they were disappointed that they could not stop the Palmyra acquisition despite the favorable ruling from the high court, but they took solace in knowing that their complaint had established a more stringent legal precedent for state action exemptions.
"The FTC's efforts in this case produced a tremendous victory for consumers when the Supreme Court unanimously reined in overbroad application of state action immunity and allowed federal antitrust review of this merger," Deborah Feinstein, director of the FTC's Bureau of Competition, said in prepared remarks.
"Regrettably, that legal victory will not undo the acquisition's clear harm to competition. Because divestiture is unavailable in light of Georgia's strict certificate of need legislation, this proposed order is the most effective and efficient resolution that can be achieved at this time"
Lack of vendor readiness for the move to Stage 2 Meaningful Use means physicians will be unable to meet the requirements for EHR implementation and will be subject to fines starting in 2015, the Medical Group Management Association says.
The Medical Group Management Association has become the newest member in a grumbling chorus of prominent healthcare professional associations that want the federal government to modify components of Stage 2 Meaningful Use implementation.
MGMA-ACMPE President/CEO Susan Turney, MD, in a letter this week to Health and Human Services Secretary Kathleen Sebelius said that concern over "vendor readiness" for the move into Stage 2 Meaningful Use has left physicians in a lurch.
"It has become clear that the alignment between the more rigorous Stage 2 requirements and the ability of the vendor community to produce and deploy Stage 2 certified products has simply not occurred at the pace anticipated," Turney said in the letter.
"If the appropriate steps are not taken, we believe physicians that have made significant investments in (electronic health record) technology and successfully completed Stage 1 requirements will be unfairly subject to negative Medicare payment adjustments. Accordingly, HHS should immediately institute an indefinite moratorium on penalties for physicians that successfully completed Stage 1 meaningful use requirements."
A Lack of Vendor Readiness
Turney said vendors are lagging far behind on Stage 2 EHR systems. She said there are more than 2,200 products and almost 1,400 "complete EHRs" certified under the 2011 criteria for ambulatory eligible professionals. However, there are only 75 products and 21 complete EHRs certified for the Stage 2 criteria, which goes into effect for physicians on Jan. 1, 2014.
"This lack of vendor readiness has significant implications for (eligible professionals). Without the appropriate software upgrades and timely vendor support, EPs will be unable to meet the Stage 2 requirements and thus will be unfairly penalized starting in 2015," Turney said.
"Those EPs who invested considerable resources in their Stage 1 certified EHR, many of them in small or rural clinical settings, are now in danger of falling behind. To avoid the Medicare payment adjustments, EPs would be required to 'rip and replace' their existing EHR with one certified for the Stage 2 criteria. This is an unrealistic and unreasonable demand as the cost to the practice would be prohibitive and the disruption to organizational workflow and patient care would be significant."
AHA, AMA Also Want Delay
Last month the American Hospital Association and the American Medical Association sent a joint letter to Sebelius asking that the implementation date for Stage 2 be delayed. The two professional associations echoed MGMA's concerns about the lack of readiness on the part of EHR vendors as a primary reason for the needed delay.
Stage 2 implementation for hospitals takes effect on Oct. 1.
"Our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made," the AHA/AMA letter said.
The College of Healthcare Information Management Executives (CHIME) in May called for a one-year delay for implementation of Stage 2, noting that the delay "will give providers the opportunity to optimize their EHR technology and achieve the benefits of Stage 1 and Stage 2; it will give vendors the time needed to prepare, develop and deliver needed technology to correspond with Stage 3; and it will give policymakers time to assess and evaluate programmatic trends needed to craft thoughtful Stage 3 rules.
Last week, the Healthcare Information and Management Systems Society called for launching Stage 2 on schedule, but extending Year 1 of the Meaningful Use Stage 2 attestation through mid-2015 for hospitals and physicians. The society said the additional 18 months "encourages continued progress while simultaneously acknowledging short-term obstacles."
"Perfect Storm" of Regulatory Compliance Issues
On Aug. 7 the American Academy of Family Physicians asked Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner "not to delay the implementation of MU stage two, but to extend the timeframe for compliance with MU stage two requirements by 12 months."
AAFP Board Chair Glen Stream, MD, told Tavenner that "2014 brings a perfect storm of regulatory compliance issues for family physicians that, we fear, may derail health information technology adoption and substantially interfere with our shared progress toward achieving better care for patients, better health for communities and lower costs through improvements to the healthcare system."
