Future of Healthcare
The future of medicine is bright and great! Dedicated and bright physicians, frequently supported by PhDs, have unlocked many secrets of the body, of life and of disease processes that have led to continuous developments of new scientific and medical technologies and amazingly advanced breakthrough therapies. I, personally, have a hard time keeping up with the flood of advances in my own areas of interest.
However, when it comes to the future of health care delivery of these amazing advances for the population of our country, I am deeply concerned and worried. Our politicians under the influence of insurance companies are the ones constructing the future of health care delivery; keeping physicians that provide care out of the decision loop.
As a physician, I hold close to my heart the belief that all people should be helped to prevent their development of diseases. I also believe that when they become ill, they should have access to affordable and quality medical care without losing everything they had earned when they were healthy. It has been shown time and time again that in our society the lack of health insurance is frequently associated with less preventive health care, higher disease rates and higher morbidity and mortality rates. A healthy population is happier, more productive and more prosperous. This makes it highly desirable that 100% of our population have health insurance. The passage of the Medicare Act for senior citizens in 1965 was a giant step in creating affordable access to healthcare services for citizens during economically very vulnerable years of their lives. Unfortunately, at the beginning of this century an estimated 40 – 50 million citizens had no health insurance but with some frequency they required medical care. The medical sector provided unfunded but needed care and these costs got passed to the healthcare system and society. President Obama invested his political capital into passage of the Affordable Care Act with a goal to provide universal health coverage, but he didn’t understand the complexities of the healthcare system and its issues. He also hadn’t involved health care providers in finding a workable solution. ACA was muscled through the legislative process but without being given adequate thought and needed attention to details, which in the end contained many bad, banged up “fixes” and compromises. Eventually, only about half of the uninsured population got some kind of coverage. As already stated there have been many problems with this system, that have to be fixed before it can become a useful and successful healthcare system, BUT, it was a step in the right direction. Some of positive points were the abolishment of the life-time maximum expenditure ceiling for coverage, removal of coverage denial for pre-existing conditions, removal of copay for preventive screening testing, just to mention a few. The altruistic hope was that through a series of revisions, the healthcare system would become better and eventually coverage could be expanded to the remainder of the uninsured population.
With the Republican capture of the White House, Senate and House of Representatives we have seen an enthusiastic, visceral instinct to instantly repeal ACA. However, it became clear that after 7 years of continuous, incessant criticism and attacks on ACA and its costs, Republicans have not developed an alternative, workable, or better health insurance plan. It takes a short time to destroy but it takes a long time to build something. Just the act of repealing the ACA, reportedly would cause about 23 million Americans to lose health insurance coverage and would even lead to a larger increase in premiums for those with health insurance. Not surprisingly, many legislators did not support repeal until a better replacement system was developed. The ACA repeal without putting into place a better system will only return society back to the prior, even more unsatisfactory situation. An alternative is to start fixing the glaring ACA problems through a series of revisions, while increasing the number of those covered, making it less costly, more affordable and more functional. The administration and our political system need to include physicians and health care providers in the process of developing and designing better coverage and health care delivery system. Not teaming up with physicians and healthcare providers will be very detrimental to patients and costly to society.
I am concerned that if Republicans only repeal ACA, their next step will be to “reform” Medicare and Social Security, limiting and cutting coverage and slashing payments to most vulnerable segments of our society as they have been threatening for the last 2 – 3 decades.
My intent in addressing the above sensitive issue is to bring to our attention that we need to take a more active role in designing and running the health care delivery system. Become more active in public and political arenas. We can make a difference, if we act united. In Texas, there are an estimated 59,000 practicing physicians taking care of about 28 million Texans. 59,000 physicians represent a powerful force, and united through our Texas Medical Association, we can exert a strong influence on the development of better legislation and a better healthcare system in our state. There is an urgent need that we unite with physicians from other states through the American Medical Association to influence and advocate legislative changes and improvement to our national healthcare system.
This is a call to arms and I look forward to teaming up with you to battle for a better future healthcare delivery system.
Davor Vugrin, MD, FACP
Lubbock County Medical Society
Starting Aug. 31, physicians must submit all cause-of-death information and medical certifications to the Texas Department of State Health Services (DSHS) electronically through the state's new online death registration system, the Texas Electronic Registrar (TER).
DSHS Commissioner David Lakey, MD, said in a letter to physicians that the new system, required by state law, "allows physicians to quickly complete cause-of-death information and death certification via the Internet. As a former practicing physician, I appreciate this convenience."
Dr. Lakey says TER allows physicians to certify cause of death any time from any location with Internet access. It also "allows physicians to delegate completion of the death certificate to office staff, while still requiring the physician to enter a personal identification number to complete the actual electronic certification. This system is available at no charge to you."
In addition, he says, the speed of the electronic death registration will give medical researchers valuable mortality data faster than previously possible. "Based on cause-of-death data, public health resources can be best directed towards prevention and education. Ultimately, use of TER will benefit the health of all Texans," he said.
Blue Cross and Blue Shield of Texas' BlueChoice Solutions (BCS) physician-rating system does not use an accurate or independently validated method to determine a physician's risk-adjusted cost. That, combined with other problems with the program, "renders the method deceptive and invalid for credentialing and related performance assessment purposes at both individual and group physician performance levels as well," a Texas Medical Association ad hoc committee concluded.
Chaired by San Antonio emergency physician Robert W. Kottman, MD, the Ad Hoc Committee on BlueChoice Solutions/Risk Adjusted Cost Index (RACI) conducted a detailed examination of BCS. The committee looked at issues such as clinical attribution, accurate comparisons to peers, and expense of admitting/treating facilities.
The committee's report [PDF] to the TMA Board of Trustees and Council on Socioeconomics made four observations and recommendations:
The current method for "actual cost" assignment BCS uses to determine a physician's RACI is seriously flawed, is not scientifically validated, and should not be used as a relative measure of "affordability." Costs are inaccurately and/or unfairly attributed to physicians caring for BCS patients. "Examples would be imaging and/or lab tests ordered by other physicians, or a patient's decision to pursue an emergency department visit in lieu of scheduling a physician office/medical home visit. When more than one physician is involved in the care of a complicated patient with multiple co-morbidities, it often becomes virtually impossible to appropriately assign the costs of care to a single physician. The BCS RACI, however, does exactly that."
Blue Cross should immediately address and resolve claims coding and processing system problems. There is a serious question about Blue Cross's capacity to receive electronic or paper submissions with all of the coding information necessary to fairly and completely process BCS claims. The issue deserves Blue Cross's prompt attention since an important root cause of the problems with the BCS claims database is inaccurate and/or incomplete data generated from the Blue Cross claims coding and processing systems. These capacity concerns threaten the integrity of transactions in the network and the viability of the network itself.
Important information related to covered BCS benefits and related patient service costs outside physician offices is generally not available nor disclosed to participating and/or billing physicians. All relevant cost of service attribution and covered benefit information affecting BCS network physicians' service and referral decisions for patients/enrollees should be fully transparent, available, and disclosed to physicians and patients in all applicable, covered settings of care. Blue Cross should "substantially improve and make transparent all due process options…"
Clear and unambiguous information that describes the process for appealing their rankings is not easily available to physicians, their offices, and patients. In addition, the company's local provider service representatives sometimes give BCS physicians or their staff conflicting, incomplete, or inaccurate information about how to appeal, and the distinctions between requesting disputed data on RACI scores and actually filing a formal appeal. Blue Cross should substantially improve and make transparent all due process options under the Health Care Quality Improvement Act.
"I think the report speaks for itself, and I wanted to let you know that TMA fully stands behind and supports the recommendations in the report," TMA President Josie R. Williams, MD, said in a letter forwarding the report to Blue Cross Chief Executive Officer Darren Rodgers.
"The report is well conceived and researched, and also reflects the many reports we've received from our members about their experience with the BlueChoice Solutions risk adjusted cost index. As the report notes, it is our strong conclusion that the RACI methodology is sufficiently flawed to render it invalid for use in credentialing and recredentialing BlueChoice Solutions network physicians," she wrote.
"We sincerely hope Blue Cross Blue Shield of Texas will review the findings, and take appropriate action to discontinue the use of the BlueChoice Solutions RACI in that plan's network credentialing."
Physicians who don't agree with the rating Blue Cross gives them can log on to the TMA Web site for an explanation of the rating system, an easy way to log your complaint, and information on what you can do if you don't like your rating.