DISQUS

Robyn · 2 months ago

As someone who isn't a doctor - I don't know whether or not this is a joke. Can someone in the health care field define "bundled care" to me in 3 sentences or less? How do you bundle care when a patient has - for example - 2 problems. Like say my husband has a hole in his heart valve - and MS (which happens to be the case). Does the neurologist do his echo - or does the cardiologist do his EMG?
And who's going to do basic stuff - like his regular rectal exam (funny - that is something that no one seems to want to do). Or what about another patient with IBS and hypertension (hypothetical patient). When I read stuff like this - I think of a client who has to get his divorce and his slip and fall case "bundled" (a really silly concept IMO). Of course - these are relatively "healthy" patients. When you get to someone like my late FIL - who suffered from CHF - and 2 totally unrelated metastatic cancers - before he died from a stroke - well how do we "bundle" his care? The guy who does his bladder cancer surgery also removes the angiosarcoma on his head? And treats him in the ER when he has a double pneumothorax as well? Finally - does this mean we will all wind up having to get our care at one place (even though most places are really good at some things - and perhaps not so good at others).

Anyway - how does this work in practice - as opposed to theory?

Robyn · 2 months ago

And FWIW - like I've said before - I have nothing against hospitalists. They handled my FIL during his hospital admissions in terms of checking in on him - adjusting some of his meds if necessary - etc. (there was also an in-house doc from UF at my FIL's SNF - and he pretty much did the same things for all the residents). But could do they do anything about his cancers - no. Ditto with his CHF - except to try to keep it from getting to a crisis point.

sadsurgeon · 2 months ago

Make no mistake happy. Even if the program allows for good doctors/outcomes to be reimbursed at a higher rate initially, any sort of government program is eventually going to cut physician pay.

You are getting sucked into this like the American College of Surgeons, who initially came out supporting 3200, and after being slapped in the face a few times by the administration eventually withdrew their support.

All these guys want is cost containment and plausible deniability that the government rationed peoples health care. The pulled a fast one on us with the RUC, and they are going to do the same thing here.

"Payment Reform"=Payment Reduction

Robyn · 2 months ago

How can a doctor's income be based on a "good outcome"? If you're a plaintiffs' personal injury lawyer (which my husband was) - you get to pick and choose your cases. Because if you don't win at trial or get a good settlement - you get zilch. But - if you're a doctor - you're supposed to treat sick people. And frequently their medical outcomes have nothing to do with how good a doctor you are - or how good your care is.

terry bernardino · 2 months ago

A hearty THANK YOU to both of you, brilliant responses from both Robyn and sadsurgeon.

Plausible deniability is the name of the game and if you think in any way you will end up ahead after this mess is passed, you are sorely mistaken. Until physicians are literally walking out the doors of their hospital with their office belongings in hand, they will keep chipping away at doctors until they realize there is nothing left to do but actually fix the real problems with healthcare spending.

And I would like to know the answer to Robyn's question as well as I can't see any reasonable solution to the problem a payment plan like this would produce.

happyhospitalist · 2 months ago

the solution to not paying enough under bundled care is simply to not accept the bundled care payment. You are exactly correct. As long as physicians accept Medicare/Medicaid/Blue Cross and the terms that come with it, they have no one to blame but themselves

happyhospitalist · 2 months ago

Go read here for a real life discussion on proposed bundled care models by PROMETHEUS
http://www.prometheuspayment.org/publications/p...

Robyn · 2 months ago

I read it. It still approaches the problem from the viewpoint of a single disease - how to get the most bang for the buck for disease X - as opposed to dealing with a patient on a comprehensive basis. So you wind up with the "patient" being a bunch of (frequently) unrelated diseases/conditions. Now if I were inventing (or maybe reinventing) a model - I would start with the patient - and a single primary care doctor - probably a highly skilled but not totally specialized internist (or a pediatrician for kids). The primary care doc would see the patient on a regular basis (maybe once a year or so for most people). And do a complete physical. Complete with standard/necessary tests (like common blood tests - a pap smear - a rectal exam - a chest X-ray - a mammogram - etc.). You will catch a lot of common diseases that way - like diabetes and hyertension (both of which a good family doc should be able to manage assuming they're uncomplicated). If there is something more complicated - or outside the field of the primary care doc (whether a routine skin cancer screening or colonoscopy) - the primary care doc would refer to a specialist unless the referral was stupid. For example - a patient with a heart murmur might get sent to a cardiologist. A patient with a bum knee who was a candidate for surgery might get sent to a knee doctor. A 95 year old with a bad rotator cuff would not get sent to a shoulder specialist for an MRI. And - of course - if the primary care doc thought there was something wrong with the patient that was outside his/her area of competence - he or she would be free to refer to an appropriate specialist or group of specialists - even if he or she didn't know exactly what it was (because not all diseases/conditions/diagnoses are common/obvious). IOW - the family doc would be an informal "gatekeeper". That is the way we use our family doc - and we think it is a perfectly rational way to spend our health care dollars (we pay out of pocket). The compensation for a routine physical should be generous - as should the time allowed for it (our annual exams/meetings last for about 45 minutes).

If it turns out that the patient has to see a specialist on a regular basis - that doctor/patient relationship should be established separately. But sometimes you go to the specialist to get diagnosed - he or she puts gets you on an even keel with a common med - and then he or she can kick you back to your family doc. For example - a patient with really bad arthritis might wind up seeing a rheumatologist indefinitely (because a lot of arthritis drugs are pretty nasty). Someone with a simple case of gout can have his or her family doc continue gout medication. FWIW - one reason you have to keep seeing a doctor at least once a year - at least here in Florida - is if your doctor is prescribing meds for you. A prescription can't be renewed indefinitely - you have to see the doctor. So I wind up seeing my GI doc once a year for 10 minutes - we talk about the stock market - and he renews my Rx. I suppose this makes some sense - since people can change (although I usually don't). The area where things get really stupid is when you deal with senior seniors - they go to multiple doctors to get prescriptions renewed - but no one ever sits down with them to rationalize the (sometimes) dozens and dozens of pills they're taking a week.

Of course - if you have an emergency - like an accident - you will enter another part of the medical system through another door. But probably a very large percentage of patients never have what could be considered real emergencies (car crash - MI - etc.).

Anyway - I reckon if I had a week - I'd be able to come up with a pretty decent "flow chart" which would account for 70-90% of all patients (and if I knew more about medicine - I could probably get to 99%). But the family doc is at the center of things for most people who don't have horrible diseases - like cancer (which is a whole 'nother sub-topic of medical care). I love my family doc. She trained and practiced at Mayo (internal medicine/general practice) - and the way she approaches us as patients and our medical care is terrific IMO.

Robyn · 2 months ago

I forgot. You need some "teeth" to keep costs in control. You should be able to choose you own family doc. But if the family doc says "no" on a referral - whether you're in a private plan - or Medicare - or whatever - and you want to override your family doc - you have to pay "out of pocket". You should have a right to appeal your family doc's decision - but you would have to pay in the first instance with your own money to self-refer. Also - no family doc should *ever* be penalized financially for sending too many patients to specialists. If someone thinks the family doc is a quack or an incompetent - or getting paid under the table - or whatever (which happens to be the case with some doctors - particularly in certain geographical areas) - start proceedings to get his/her license yanked. But - short of that - leave doctors alone and let them practice medicine. And also - do away with all this nonsense about paying chiropractors and naturopaths and the like. I once had a case involving a naturopath. I liked the guy - because he had the good common sense to realize that he had no business dealing with a patient who had a fracture of his orbital eye socket (he didn't quite know what the problem was - just that it was something that required more than herbs). But no way he was doing anything I would consider the practice of medicine.

happyhospitalist · 2 months ago

sadsurgeon. you are falling into the trap of tying how you pay with how much you pay. Is it not obvious to you that payment under fee for service/RVU/SGR for the last 15 years has gone down for all physicians with the destruction of primary care a direct result of the RVU economics and payment models, under fee for service.

You need to separate the payment model from the the financing. Whether it's Medicare, Medicaid or Blue Cross, all insurance companies have cut physician payment over the last 20 years.

Creating a model that aligns the forces of hospitals and physicians has nothing to do with how much they (whether it's Medicare, Medicaid or Blue Cross) are going to pay and everything about getting the most efficient care.

If the issue is how much the bundled models are going to pay, then it's the same issue of how much the government or Blue Cross is going to pay under fee for service. Only, under fee for service there is no incentive from either doctor or hospital to practice efficiently.

One reason why our Medicare National Bank is so broke is because no one is held accountable for anything as it relates to cost. With bundling and gainsharing, you are.

Name · 2 months ago

I wouldn't support anything written by RJWF. Ugh they give me the shivers.

sadsurgeon · 2 months ago

And in a perfect world Happy, I would agree. Unfortunately we are dealing with a government monopoly. They will control both the RULES of the game AND the FINANCING of the game. They will manipulate the rules so as to give them the most benefit in the financing.

Look at the RUC. From the outset, seems like a good idea right? Leave the "health decisions" in the hands of the doctors, and using SGR allowing the amount of money paid in to rise every year! Who could argue with that? You like the SGR and RUC now Happy?

Just as with negotiations with insurance/medicare, we are going to get screwed. Sure, we can just say forget it, we won't work for that, but then how are we going to make a living? I don't know about you, but you take away the 25% or so of my practice that is medicare and I ain't getting much of a pay check once I cover my overhead.

As a wise man once said "dyspareunia is better than no pareunia at all".

happyhospitalist · 2 months ago

once again, show me how fee for service is different from bundled payments when it comes to the government monopoly?

The solution for physicians to underfunded models of care is not to participate. If enough physicians do not participate, then the funding will have to change or the beneficiaries will revolt.

That has nothing to do with the inherent efficiencies forced into a system with bundled care models. Which it does.

happyhospitalist · 2 months ago

If every surgeon quit Medicare, then either Medicare would have to change, or the beneficiaries would revolt. You have no more a right to Medicare dollars than I do. By accepting what they offer you are saying you are OK with it. If you quit Medicare and your income drops, so what? If there are other surgeons willing to work for less than you, that's the way the it should be.

Robyn · 2 months ago

Trust me. What is going to happen is primary care docs are going to get a few more bucks (not enough to convince them to abandon dermatology) and the specialists/surgeons will have fees reduced a lot. And by the time you need major heart surgery 30 years down the road - you'll be getting it from someone you wouldn't trust to take care of your lawn. What can I say? I'm glad I'm not 30.

Robyn · 2 months ago

Oh - and to see in the future - read the NHS Doctor Blog. My husband and I - being retired and having some time on our hands from time to time - have on a couple of occasions stopped by the NP in a box at Walgreen's and the like. The people staffing those places know less medicine than we do as retired malpratice lawyers (no offense to Nurse K - I'm sure there are doctors around today who know less than experienced nurses - but the people we've spoken with in drugstores are totally pathetic).

Kurt U · 2 months ago

Technically you are talking about a government monopSONY, a market form in which only one buyer faces many sellers. Sorta the other side of monopoly. (I know this sorta anal but

As the 25% of your practice grows to Mcare payment (the House reform bill says that any public option (if it survives) is specifically prohibited to negotiate with docs and MUST adopt the Mcare payment schedule) either from reform or just the higher relative percent of the population on MCare as the Boomers work through, are you going to have much of a paycheck period.

Robyn · 2 months ago

Hope my question isn't too intrusive - but what kind of surgeon are you (just curious in terms of putting your remarks in context).

Name · 2 months ago

I wish you physicians would stand up and revolt.

Robyn · 2 months ago

The physicians are revolting. They are avoiding primary care and becoming dermatologists. Many are refusing to accept Medicare patients (most have refused to accept Medicaid patients for a long time). Takes a while for all of this to work its way through the pipeline (Medicare patients didn't have many problems finding primary care docs 10 years ago - today they do). But it is working its way through the pipeline and will get a whole lot worse (remember - the first boomers won't qualify for Medicare for a couple of years - and right now they are upsetting all prior assumptions about Social Security by taking early SS in record numbers).