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Most people are aware of the main provisions of the ACA: elimination of pre-existing conditions, kids allowed to be on their parents' insurance until age 26, coverage without cost for preventative healthcare, expansion of Medicaid for states willing to accept billions of dollars from the federal government, and of course, and its insurance exchanges.

However, there is a smaller part of the ACA that has potentially far-reaching effects on all of primary care, and I've hardly heard a thing about it in the media. It is helping primary care physicians transform how we deliver care to our population of patients and it is actually kind of exciting.

Read on if you're interested in hearing a little more about the Comprehensive Primary Care initiative that just might save lives, provide better care, increase satisfaction for patients, doctors and their staffs, and might also gasp save a bunch of money.

For a brief piece of background, I am a family practice physician in a multi-specialty group of about 60 doctors, mostly primary care.

I think most people would agree that the American healthcare system has a lot of flaws. One of the biggest flaws is our fee-for-service system in general. It doesn't make any sense, but I get paid the same to see someone for an ear infection as I do to see someone with high blood pressure, high cholesterol, and diabetes. Someone comes for an appointment, and based on the level of detail I obtain in the history, the level of detail needed in physical examination, and the complexity of medical decision-making, that determines the fee for the visit. So as you can imagine, an ear infection or sore throat requires a LOT less work than managing three or more chronic problems, and the medications, labs, monitoring tests, etc. that go along with them. But again, you are paid the same to see the ear infection patient as you are to see the person with uncontrolled diabetes, high BP, and high cholesterol.

On the surface, that makes no sense at all, but the thinking is that it probably costs too much for the ear infection, too little for the diabetes/BP/cholesterol patient, but it all evens out in the long run. The rules for 'coding' a level of service for an appointment govern the fees, and they are relatively simple, as otherwise it would just be too complicated to have a different fee structure for every diagnosis. Anyway, the idea is that it all comes out in the wash. That might be true in a simple world, but of course we live in a complex world with a lot of moving parts.

As you can see, the fee-for-service environment does not really incentivize physicians to focus their efforts on chronic disease management. I'm not implying that physicians are not trying to do a good job or are just in it to make as much money as possible, but let's face it: if you make the same amount per patient, and you can see 30 patients with ear infections or 15 diabetic/hypertensive/hyperlipidemic patients, which would you choose? How would you set up your schedule?

Everyone agrees that prevention is the most cost-effective way to keep people healthy. Vaccines, for example, are arguably the single most cost-effective thing in all of medicine (get your flu vaccine if you have not already done so, by the way!). Preventative care is now covered without a co-pay because of the ACA. That is awesome. However, better care/control of chronic disease doesn't pay well, as discussed above. But better control of diabetes, of BP, of cholesterol, of COPD, of asthma, of heart failure will save lots and lots and lots of money in the long run because complications of all these diseases are expensive. It costs a LOT to be in the hospital, to have a heart bypass, to have dialysis, etc. A rough estimate is that a well-controlled diabetic costs the system an average of $4,000 per year to take care of, but an uncontrolled diabetic will cost $16,000 or more. So why would we pay doctors the same for an ear infection as we would to take care of serious chronic disease?

Part of the answer unfortunately is that people switch insurances and by the time they develop more significant complications, they are on Medicare anyway, so UHC, Humana, Anthem don't need to worry about paying for dialysis. In the long run, though, it saves us all money if we do a better job of taking care of chronic illness. So it makes sense to try to incentivize doctors to improve our chronic disease management instead of incentivizing doctors to just see as many patients as possible in the day.

So enough background. Here's the good stuff. The ACA provides funding and guidance for a new way to approach health care. The Comprehensive Primary Care initiative is a program that involves about 500 practices across the country, in several geographic areas. Southwest Ohio/N. KY, New Jersey, Arkansas, Colorado, New York, Oregon, and Oklahoma have participating practices. Practices were selected based on a number of factors, including past willingness to participate in such things as NCQA quality recognition, and patient-centered medical home (PCMH) certification. You can read more here:

Basically, CMS (center for Medicare and Medicaid services) provides funding outside of the fee-for-service environment for practices to do a better job of chronic disease management. There is/was a detailed application process, and multiple milestones you have to meet, but a lot of it boils down to CMS providing additional monies for practices to use as they see fit in order to help improve the care for their patients, particularly (although not exclusively) those with higher risk chronic illness.

The whole thing is actually really interesting. While there are quite a lot of specifics, there are also a lot of areas open to interpretation. CMS is partnering with multiple private insurance carriers to provide a monthly fee (outside of any appointment or fee-for-service interaction) to physician practices in order to help those practices invest in infrastructure which will help improve patient care. The amount per patient per month is based on risk assessment. Basically, the more diagnoses, and the more complicated a patient is, the higher the monthly fee. A well-controlled diabetic would have a lower fee than a diabetic with chronic kidney disease, heart disease, and neuropathy. So right off the bat, you can see how this is a paradigm shift from the traditional fee-for-service environment. You may actually be paid more to take care of a more complicated person and try to keep them out of the hospital.

However, and this is a BIG part, the money from this CPC initiative can NOT be paid to physicians as compensation. It is to be used to improve infrastructure. This is actually pretty cool because instead of just paying doctors more and saying, "hey, if we pay you more, you'll do a better job, right?", CMS is saying, "we will give you money to use as you see fit (within the structure of our program and its milestones) to improve patient care which should improve outcomes, decrease severe complication rates, improve patient satisfaction, and eventually decrease overall costs through an investment up front."

If you hadn't already guessed, my group has several practices involved in the CPCI program and we are excited about it. I don't know what the other 490-some practices across the country are doing, but we have used the money to hire more staff, including what we call Care Coordinators for each office, an RN who can reach out to patients before, during and after appointments to see how we can better coordinate care. We try to have labs drawn before folks come for appointments, so we can have already reviewed the results before walking in the room. This allows for more efficient care. If someone's cholesterol is not to goal, for example, we can increase the dose of their cholesterol medication while sitting with them and explaining why an LDL goal of under 70 is the target. This works a lot better than a medical assistant calling someone and playing phone tag three days after their appointment to try to make sure they know that the new dose is 40 mg instead of 20. Anyway, the Care Coordinator can help reach out to people who might need help paying for meds and see what assistance programs might help someone. She can help someone who was recently in the hospital understand their new medication regimen and help set up their follow up. If someone doesn't go for the colonoscopy or mammogram that we ordered, she can call them and find out why and/or encourage them to go (and maybe mention that preventative care is covered 100% now!). She can review their chart ahead of time and put in a reminder for the doctor that the patient is due for a pneumonia vaccine or a shingles vaccine. This is all part of the team-based approach to care which is helping to improve patient outcomes. Our practice would not really been able to afford a Care Coordinator without the CPCI monies. Our group has also decided to hire a diabetes educator. Insurance is often squirrelly about paying for diabetes education, despite study after study clearly showing the benefits. Now we will be able to offer diabetes eduction free of charge to all of our patients. This is pretty great all around. The doctors get more help, the patients get more individualized attention and care, outcomes improve, which specifically means someone didn't have a stroke. Someone didn't lose their vision because of diabetes. Someone had a precancerous colon polyp removed instead of being diagnosed with metastatic cancer a couple years later. Someone's grandmother didn't lose her foot. Oh, and all that stuff also saves money.

That's the other piece of the CPCI, which is a multi-year venture: "shared savings." You can calculate how much a population of patients is likely to cost over say, three years, based on how sick they are. If people get their blood pressure, cholesterol, blood sugar, asthma under better control, they will cost less to take care of because they will have fewer ER visits, fewer hospitalizations, fewer procedures. Sure, they might take more medications, get more frequent lab tests, maybe more frequent (outpatient) doctor appointments, but this leads to an overall reduction of the cost of care. So for the additional work to do a better job of taking care of patients, practices in each region get a chance to share in the $$ saved by providing more efficient care. This will be calculated and distributed equally among the 75 or so practices in each region.

There's of course a lot more to the story, but this diary is already rather lengthy. I'm excited about the program though. It really is a win-win. It has a lot of the things that us progressives like: government-initiated innovation. Science-based (or to use the medical buzzword, evidence-based) care. Regulations on how the money can be used, with the greater good in mind. Short term investment for long term success (I didn't mention that the money is eventually phased out with the hope that the infrastructure improvements will lead to overall better reimbursements, and a focus on "pay-for-performance" or better pay for better quality care). Using government dollars to help those who need it most (ie sicker patients). Shared benefits in the long run for all of us. If we are all healthier, we cost less to the healthcare system. We are more productive workers. We have fewer people on disability. We end up putting more $$ back into the economy and indirectly increase government revenue (if you can work more and make more money because you are healthier, you end up paying more taxes and of course can purchase more goods and services).

Anyway, it's a relatively small part of the ACA, and unless you go to a practice involved in the CPCI, you likely would never hear about it. But in the long run, the idea is that the extra $$ will help to transform how we provide care, therefore leading to a sea change in primary care across the country. If you get better outcomes, improve patient satisfaction AND save money while practicing a certain way, every practice is going to want to adopt these methods. Over the next few years, the 500 practices will be sharing (HIPAA-compliant) data, successes and failures, to try to come up with "best practices" we can all use to keep people healthier longer. Because everyone benefits from that, and that is really what the Affordable Care Act is about.

Originally posted to THirt on Sun Oct 27, 2013 at 11:00 AM PDT.

Also republished by KosAbility.

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      •  Nurse Practitioners are a strange case. (31+ / 0-)

        Therein lies the problem. Specialists presume that they are more capable. Feh!

        I've had good doctors and bad.

        N.P. M.D. and Specialists. So far, no bad Nurse Practitioners. GPs fear promoted nurses.

      •  Absolutely ... for example (5+ / 0-)
        If someone's cholesterol is not to goal, for example, we can increase the dose of their cholesterol medication while sitting with them and explaining why an LDL goal of under 70 is the target. This works a lot better than a medical assistant calling someone and playing phone tag three days after their appointment to try to make sure they know that the new dose is 40 mg instead of 20.
        Is there some reason a fully certificated MD, much less a specialist,  is needed to see that a set of lab numbers is out-of-spec, write a new script ... and recite the Diet and Exercise Mantra   that the patient will probably ignore anyway?

        That's a job for one of Chairman Mao's Barefoot Doctors ...  maybe with the help of an Intern reviewing  case folders and signing off on prescription changes.  

        •  <70. And I thought I was doing something (1+ / 0-)
          Recommended by:

          special to get mine <100.  It's always something.

          Blue, blue, my world is blue...

          by ZedMont on Sun Oct 27, 2013 at 05:30:19 PM PDT

          [ Parent ]

          •  Yeah (4+ / 0-)
            Recommended by:
            ZedMont, greengemini, fayea, MsGrin

            It depends on your risk. If you have diabetes or have had a heart attack/stroke/carotid artery blockage, under 70 is an optional goal. Some published guidelines recommend under 70, some do specifically say under 100 is the official goal and under 70 is optional. Anyway, under a hundred is pretty darn good for most people.

            •  No one is going to be able to get theirs under 70 (0+ / 0-)

              Absent some very good genetics, which people with diabetes and who have had/have a family history of heart attacks do not usually have.

              There are also some doctors who are saying that cholesterol is not the big thing you should be worried about, it is lack of exercise.

              •  IIRC mine might be. (0+ / 0-)

                In any case it's so good the results come back boldfaced. I've got awesome triglycerides, too. (So did my father, btw.) However I've also got arteritis (as found surgically on one of my ovaries, of all things) and a bunch of other things none of which any of my docs can figure out. (I have a hunch it's due to mold in my house.)

                Any jackass can kick down a barn, but it takes a good carpenter to build one.--Sam Rayburn

                by Ice Blue on Tue Oct 29, 2013 at 10:17:19 AM PDT

                [ Parent ]

              •  "Number Chasing" -- the path to prosperity (0+ / 0-)

                Setting unrealistic goals is a win-win-win for practitioner , the laboratory service  and the pharmaceutical company

                For the patient  "not so much."

                Trying to get an LDL down from a "livable" 125,  to an "ideal" 70 ... well, no generic atorvastatin for you, let's try to get the gatekeeper at the insurance company to sign off on  Crestor(tm)  at 4 times the price, twice the risk of serious side effects and four times the co-pay.

                Does this mean you will "have a better outcome" ... ie: live longer, have fewer heart attacks and strokes ?  

                Well, "possibly."  There's a statistical correlation with the lower LDL and the better outcome.  And if a little "better numbers" is good -- obviously MUCH better numbers must be much better.  It only stands to reason.

                And then you get into the question of diabetics management ...   if diet exercise and metaformin don't get the desired goal of < 100 -- why NOT go to injected insulin  testing before and after each dose and before and after every meal ?  

                 "The Insurance pays for it, right ?"

      •  I rarely see my Dr. (11+ / 0-)

        She is excellent and she is very busy. I laugh when people say that socialized medicine will make you wait, it takes at least 6 weeks to see my Dr. sometimes 8 weeks.

        I do see her PA and like her very much, but she's not equal to my doctor. I mean no disrespect to the PA, but my doctor is really caring and very, very smart. I miss not seeing her as much as I used to, but I know that she is overseeing my care.  

        And daddy won't you take me back to Muhlenberg County Down by the Green River where Paradise lay. Well, I'm sorry my son, but you're too late in asking Mister Peabody's coal train has hauled it away. John Prine

        by high uintas on Sun Oct 27, 2013 at 03:50:07 PM PDT

        [ Parent ]

      •  I received my primary care from an NP (10+ / 0-)

        I could have signed on with an MD, but the NP gave me the best care I could possibly have received. Not to mention the fact that she practiced in a walk-in clinic. If I needed a quick consult, I could just sign in and wait my turn. It reminded me of my childhood experiences in England with the neighborhood GP.

        Alas, the HMO closed the clinic.

        The AMA would hate the idea, but I've always thought that the best delivery system for primary care would be such neighborhood clinics staffed by NPs and RNs. They could handle the routine stuff - ear infections, sprained ankles, etc. - and refer the more complicated stuff. Such clinics could also monitor patients in the neighborhood with chronic conditions in consultation with their physicians. They could even make house calls!

        The best lack all conviction, while the worst Are full of passionate intensity.

        by chuckvw on Sun Oct 27, 2013 at 08:39:23 PM PDT

        [ Parent ]

      •  Getting worried about that (6+ / 0-)

        My sister started nursing at Peter Bent Brigham in the early 70's. She's worked in burn units, CCU, emergency rooms, and with primary care. She became an NP many years ago and is pretty fantastic at her job.

        That's the way NPs used to climb the ladder. Now colleges are graduating NPs right out the gate.

        It seems to me that the on-the-job training of the earlier group, where many were nurses for a decade or more before becoming NPs, was a big reason why so many were so great.

        •  the first NP program was created (0+ / 0-)

          At the University of Colorado in 1965, formalized training has been expanding ever since.  There was really no such thing as and "on the job training" for NPs, although many experienced RNs did indeed fill that role.  

          It should be noted that many states do not require certification for PAs and NPs so you will occasionally see individuals who work for a physician who are not certified and do not have formalized training beyond being a RN, paramedic, or a former Independent Duty Corpsman.

          In the end though, does it really matter for the discussion at hand if NPs or PAs are capable of handling most primary care visits?  Ever compare the the bill between an NP visit and a GP visit?  Most likely the cost is exactly the same.

          Heck, most NPs are making just as much as GPs anymore.

          The best reason, as I see it, to have NPs and PAs is for access, not cost savings.

            •  Not fair, not true, and not good points. (0+ / 0-)

              NPs DO NOT make as much as physicians.  Try less than half for twice the work and twice the caring.  I'd bet my neck that there actually is a cost savings long-term with the use of NPs, because NPs are more sincerely concerned, more patient, and more thorough; making it more likely that their patients will avoid bad outcomes.  Let’s say there isn’t a cost savings, though.  The current employment of NPs may not save the patient or the insurer money in individual fees, but that’s because physicians are taking all the profits.  The physician who employs an NP is able to charge the same fee for what she does and pay her CONSIDERABLY LESS than he'd pay a physician under his employ.  And why does this happen?  It is because, despite the well-studied and well-documented fact that NPs are just as capable of providing safe health care and more capable of providing respectful and compassionate care, physicians have a political-financial medical monopoly.

              NPs in most states cannot practice unless they have a "collaborate agreement" with a physician, meaning a physician takes most of the money she generates.  And no, those physicians absolutely DO NOT in reality, oversee the work done by the NPs.  These laws are only there to keep powerful people in power, preventing this new breed of caring providers from competing.  Supposedly in this country consumers are free to "vote with their dollars", but it's not happening in health care.  These laws exist because doctors lobby for them with all their extra money, extra time, and social connections made growing up rich and attending rich folk events as adults.  Meanwhile, doggedly tired, financially strained, and excessively humble nurses and NPs don't even know what is happening politically...and a huge part of this is that most NPs are WOMEN.  They are taking care of their families.

              Mothering means prioritizing love over politics and wealth.  Fathers are different; mothering involves undeniably strong instincts that prevent us from heralding our own egos above others.  Many female doctors are atypical women, indeed, and the number of women in this country who are masculinizing themselves in all fields is growing.  Mothering, the most feminine activity and state of mind, is sadly a political disadvantage.

              We all know the cliché of encouraging kids to grow up to be doctors, and we all know that kids who are very concerned with their egos aspire to do just that.  We also all know that achievement-oriented people tend to have a "bootstraps" mentality, not really being able to understand vulnerability, and not respecting unfortunate people.  And…well, these types are willing to hurt people to get more money/power.  I recommend the documentary Money and Medicine.

              I did, indeed, purposefully fail to mention PAs above.  There are some good PAs, just as there are some good physicians, but they are the refreshing exceptions to the rule. PAs and physicians are trained under the medical model.  NPs are trained under the non-authoritarian nursing model, and this accounts for the beautiful difference we recognize in NPs.  The nursing tradition is a feminist tradition, an open-minded and open-hearted profession.  The nursing tradition recognizes the strength and importance of vulnerability and humility in both the patient and in the care provider.

              Someone IS saving money, time, and hard work as a result of the employment of NPs, and that someone is physicians.  It's the same ole story, the rich take their cut so that no "innovation" actually helps the public at large.  NPs do indeed improve access to healthcare.  The truly best reason NPs are great is neither access nor cost savings, but humanity.  HealthCARE is about caring.  I await the day we no longer give the volatile reigns of power to uncaring patriarchal healthcare workers like most of the physicians I've met in my life.

              •  To be fair... (0+ / 0-)

                I think the point about the most compelling reason being access rather than cost IS both a fair and a true point.

                And one that doesn't diverge from much of your very powerful, if very, partisan rant.  And a righteous rant it is.

                Welcome from the DK Partners & Mentors Team. If you have any questions about how to participate here, you can learn more at the Knowledge Base or from the New Diarists Resources Diaries. Diaries labeled "Open Thread" are also great places to ask. We look forward to your contributions.

                Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

                by a gilas girl on Tue Oct 29, 2013 at 01:48:20 PM PDT

                [ Parent ]

    •  In the past Primary Care has been through CHC's (6+ / 0-)

      PCA's and Free Clinics. Funding from the government was minimal and forced a lot of creative programs such as neighborhood synergy,linkage, the New Markets Tax Credits program and other private non profit inititives.

      Now people are beginning to realize that like the PCA's, groups of CHC's that band together in Primary Care Associations to get more purchasing power by buying in bulk, and work together to share resources for expensive diagnostics with hospitals the ACA is acting like a sort of healthcare coop or union to do collective bargaining and simplify primary care with regular preventative checkups.

      From the government perspective it saves money because prevention is a lot cheaper than therapy. From the end user perspective its relatively hassle free, generally you are no longer spending all day in a clinic waiting room to get to see a doctor, or a dentist or an ophthalmologist.

      From the Doctors perspective 15 minutes in an Exam room is generally all it takes before a patient can be passed off to phlebotomy, gastro, pediatrics, woman's health or any of the other main primary care divisions. Colonoscopies, mammograms, biopsies, CAT scans and ultrasounds become routine and so does self help with glucose meters and  blood pressure testing at home.

      With Insurance companies and Hospital administrators as middlemen a lot of a doctors time could be taken up filling out forms and complying with regulations for as many as fifteen different authorities. Now its a lot simpler and that alone saves doctors money.

      Live Free or Die --- Investigate, Incarcerate

      by rktect on Sun Oct 27, 2013 at 01:53:49 PM PDT

      [ Parent ]

    •  Therein lies the problem (11+ / 0-)

      Primary Care providers are paid less than specialists, therefore specialties draw more applicants for residencies than primary care positions.  Doctors have HUGE college loans to pay and need to specialize to pay them off.

      This isn't a problem in countries with universal care.  Those nations provide for the education of health care professionals so there are not saddled with enormous debt.  As a result, they are not in need of enormous salaries.

      They're doing it right.  We're not.

      There already is class warfare in America. Unfortunately, the rich are winning.

      by Puddytat on Sun Oct 27, 2013 at 03:07:10 PM PDT

      [ Parent ]

      •  I'm replying to your italics more than your post (0+ / 0-)

        Here's why: I haven't heard it throughout the entire time I've been alive (before Medicare) concerning healthcare in America, but I feel this is an integral reason we are where we are. As the data pours in from the millions more people receiving healthcare, statistics concerning each of our other progressive values will crystallize to show the problems many of US suspected are actually worse than we have imagined. America is the most productive place on the planet, I've heard, and we're killing ourselves in the process. Name any issue you feel needs work and healthcare is part of the equation. Adding 45-million plus people and all their maladies will show the proof

        The rich ARE winning the most in America because money has been used to thwart progressive actions both in DC (lobbyists) and the rest of the nation (tea-baggers). Possibly 99% of the money is from wealth and power regardless of which end is funded.

        The most diabolical part are the tea-baggers who claim to be grass-roots when a look at their Dark Money reveals them as astro-turf, at best. Rather than find a way to profit despite regulation, those who pull the strings want everyone else to work and drop dead. The rabble which is the Tea Party are the worst because it works to keep facts off the table, and when that fails, declare them irrelevant.

        Today, elections are being held that have been influenced by Dark Money  as much as last year's election. We may not feel it in Washington as much as we will on the state, local, even school board levels. Fortunately we have the power of the Internet to discover and expose these villains for what they are: will it be enough?

    •  There already is an informal route for this (1+ / 0-)
      Recommended by:

      Doctors are working wonders these days - every year they get better at what the can do (work up some tantrum riffs though, the squeaky wheel and all.)

      With no shame whatsoever, the medical field has pretty much established that primaries refer patients to their preferred specialists. They're basically aiming a big fire hose full of money at their friends! I can certainly see why one doctor might like the X-rays he gets from one specialist more than another. When I had my neck fused by the best brain surgeon I could dig up for my insurance, he did it in a hospital 30 miles away instead of the local one, because... well, he didn't say, but I'm not going to all demand-y around brain surgeons? It's a completely wide-open and accepted practice, and I'm dead certain that when you aim the $35,000 disc-fusion hose at him time and time again, he will be...appreciative?  

      If I was going to go all hi$$y and stuff, I would more likely question the equally wide-open practice of holding doctors remedial training be entirely paid for by Big Pharm (who now have a drug for everything) - and the training sessions are held in the Bahamas smack-dab in the middle of four great golf courses. Free air fare and a box full of ballpoints...

      •  Not quite true (1+ / 0-)
        Recommended by:
        Catte Nappe
        If I was going to go all hi$$y and stuff, I would more likely question the equally wide-open practice of holding doctors remedial training be entirely paid for by Big Pharm (who now have a drug for everything) - and the training sessions are held in the Bahamas smack-dab in the middle of four great golf courses. Free air fare and a box full of ballpoints...
        As someone who works in the medical device industry I can tell you that the above statement is no longer SOP for the industry.  Trips, golf, sporting events, and big dinners are specifically against the law.

        As far as where a physician does your surgery, you have to consider that there is a whole team that is caring for you.  There are specific OR room setups that need to be considered, such as type of table, instruments, surgical pack, etc...  Then you have to consider recovery and such.

        Also consider as the accountable care organizations grow and expand, you can expect a lot of consolidation for many types of care.  You may have one hospital for ortho, another for hearts, and another for neuro.  This makes sense if you wish to contain costs and provide better outcomes.

      •  Actually this is addressed in the ACA as well! (2+ / 0-)
        Recommended by:
        worldlotus, Ice Blue

        There's another provision called the Sunshine Act which basically states that the monetary value of any and all "gifts" received by a physician from the pharmaceutical or medical device industry is now public record. It went into effect August 1 of this year. If a drug rep brings lunch to a 3-doctor practice for the staff and doctors valued at say, $300 for 30 people to eat lunch, $100 is assigned to each doctor.

        I'm not quite sure when and how the data will be published but a lot of physicians stopped accepting any and all gifts around August 1.

        More detail here:

    •  New Skinny Networks will cull Providers. (0+ / 0-)

      The O'care Insurance exchange networks have already culled doctors and hospitals.  Cancer patients have also been culled out of the offered networks.  This type of "accountable care" should be a neoliberal's wet dream and make Darwin smile.

      •  Link? (0+ / 0-)

        I've been very concerned about this, but a) haven't gotten to that point with, and b) haven't seen any analyses documenting network manipulation.

        I'm suspicious that this could be the technique whereby the insurance crooks completely screw over users of the exchanges, but I just don't have the evidence yet.

        I am become Man, the destroyer of worlds

        by tle on Mon Oct 28, 2013 at 07:02:32 PM PDT

        [ Parent ]

        •  Naked Capitalism & Correntewire are on it. (0+ / 0-)

          I'll post some links tomorrow to flesh out the new creations.  I don't think you will be pleased.  It's like peeling an onion.

        •  Look up at Shiny Airplane... (0+ / 0-)

          While we pick your pocket.

          Corporate Control of Medicine, Patients under the bus!

          And here’s what to expect:

          Physicians are expected to spend a limited amount of time with each patient, and are encouraged to see as many patients as possible during a workday. The insurance companies, sometimes with the token cooperation of a few physician-employees, create vast books of patient-care guidelines to which they believe their physicians must be “accountable” (remember this word, it will crop up again). These guidelines might mean documented Pap smear and mammogram frequency, weight management and exercise, colonoscopies for patients over 50, and getting that evil LDL (bad cholesterol) below 99 by any means possible…

          If the chart audit system discovers that a physician, for whatever reason, is an “outlier”–that she’s either not following the guidelines exactly or not getting the results anticipated for her patient population—she’ll be financially penalized. A quick example of what might occur: if your LDL is 115, you may be on the receiving end of a statin sales pitch from your doctor, not because bringing it down to 99 will improve your longevity, but because your refusal to do so will impact her financial bottom line.

          Now of course, you might say, “Well, in fairness, medicine is too much of a cottage industry. Look at how many doctors give unnecessary annual EKGs to patients in low risk groups. How else are we going to get to evidence-based medicine?” The problem is that what we as patients will get isn’t driven by best outcomes, it’s driven by profits. Edelberg explains:

          …the subtext of “standardized” always includes the unspoken “spend less money on the patient.” Thus, a doctor might be financially penalized for recommending nutritional counseling to lower cholesterol (“counseling is expensive”) instead of writing a generic statin drug (cheap). Or recommending psychotherapy (“therapy is very expensive”) instead of generic Prozac (cheaper than M&M’s). Or referring patients for massage, acupuncture, or even chiropractic (“expensive, expensive, expensive!”) instead of pushing an over-the-counter antiinflammatory (free to the insurance company, as it’s OTC).

          Obamacare Narrow Networks
          Bending the “cost curve” in this way appears to also bend “the care curve”
          As you can see from my results, the most under-represented specialties (on the left) are the ones that typically provide services to truly sick patients, such as oncology, cardiology, internal medicine, neurology. And no doctor specialty has more than about 75% representation on the Exchange provider networks. Hospitals are also included on the right of the graph. Their numbers are diminished in the Premera Exchange plan network via excluding specialty hospitals that are crucial to good care in this region, such as Children’s Hospital and the Seattle Cancer Care Alliance.

          What we’re seeing has been described as a quasi-Medicaid level of doctor access. I would have little problem with plans that “streamline care”. But using Premera as a case in point along with reading about left-out doctors and hospitals all over the nation, I see a pattern of drastically reducing access to care for the sickest patients. This is a method for insurers to subvert the mandated yearly patient out of pocket maximums, (as well as the loss of insurers’ ability to cap lifetime maximum payouts) by making access to expensive care difficult or impractical, especially for the poorest and sickest patients. And by limiting tax subsidies to Exchange plans only, I believe the Democrats wrote their law deliberately to let insurers do this.

          [Update] I see that Paul Krugman praises the Medicaid Model for its “willing[ness] to say no,” a trait that allows Medicaid to control costs better than any medical care institution in this country. I just want to say that I know all about that. When I was a teenager, my mother was hospitalized on Medicaid for acute clinical depression. She was discharged from the hospital during a time when her counselor was on vacation, and while she wasn’t ready. Apparently Medicaid had said no to more hospitalization. My mother committed suicide 3 days later. My personal experience is that when Medicaid says no, people die. Is this the level of care we want for the whole country?

          Action, Action, Action
          Come on, progressives! Is your party so important to you that you don’t care anymore about the principles that led you to join it? Don’t you think you need to fight this? Maybe you should do so for the sake of your party? I would love to spend 24-hours-a-day, 7 days a week in action on this myself. However, besides the fact that I feel powerless, I’m finding that the Exchange plans create in me an urgent need to leave self-employment and venture back into the world of employer provided health insurance. So those of you with a national audience, maybe those of you who have insurance yourself, how about stepping up!

          There are many more features to O'care to look at besides the shiny plane described in this post.
  •  Thanks - You might want to edit your link.... (5+ / 0-)

    to remove the '/Basically,'.

    "Detective, if ignorance was a drug, you'd be high all the time." Sam Tyler, 'Life on Mars'

    by Kokomo for Obama on Sun Oct 27, 2013 at 11:31:10 AM PDT

    •  Thank you. (6+ / 0-)

      Left out a space at the end of the link. Should be fixed.

      •  Excellent diary, but I'd like to give you my (16+ / 0-)

        take on the no co-pay preventive care piece of the ACA.

        And I'll begin with a disclaimer. I am a huge proponent of opening Medicare to all Americans--single payer.

        But back to the no co-pay.

        In my opinion, after a huge amount of time spent researching, I think most/many plans being offered in the exchanges are essentially insurance in name only.

        That is, the costs of using the insurance are prohibitive so people will be disincentivized to actually use what they are paying for.

        The designers of this flawed mess had to come up with some sort of escape hatch or carrot to get people to sign up, so they threw in some preventive care at no cost.  I think this is about all the care most people will be able to access.

        The copays and deductibles make the insurance product essentially worthless.  Most Americans don't have a spare $20 or $30 lying around. Most Americans can only dream about having $2000 or $4000 to use for a deductible.

        Sorry to be pessimistic, but people who know my writing will understand where I'm coming from.

        •  But the benefit to doing it that way is how (3+ / 0-)
          Recommended by:
          nyceve, ladybug53, splashoil

          Once again, the top ten percent of society is totally bankrolled and subsidized  by the bottom 90%.

          Offer your heart some Joy every day of your life, and spread it along to others.

          by Truedelphi on Sun Oct 27, 2013 at 02:36:57 PM PDT

          [ Parent ]

          •  My attempt to insert a sarcasm alert to my above (1+ / 0-)
            Recommended by:

            Post apparently didn't go through!

            Offer your heart some Joy every day of your life, and spread it along to others.

            by Truedelphi on Sun Oct 27, 2013 at 02:38:20 PM PDT

            [ Parent ]

          •  This is true delphi (2+ / 0-)
            Recommended by:
            potatohead, Blissing

            At its core the ACA is the most massive transfer of wealth form the middle class to the corporations which own the government.  After all, we are all now required to buy a very defective product and it due to its exorbitant cost the taxpayers are footing the bill. All this $$ is going into the coffers of the for-profit insurance industry.

            This is not sustainable. . .

            •  Ah, But Rents must be paid! (2+ / 0-)
              Recommended by:
              nyceve, Greyhound

              O 'care's finely tuned eligibility engines should churn out better returns for shareholder value.  Medicaid is a new growth area for rents too.  States can use privatized MERP to clawback on contingency fees from the 55+ crowd who may still have homes and savings.
              It's kind of like the HAMP mortgage program, just a few bugs to iron out to retain equity returns through rent collection on delivery.  Current estimate is about 70% efficiency on health care delivery after rents extracted.  More "young invincibles" should bump that a bit while the losers can be shunted to privatized managed care w/Medicaid with the +55 clawback feature to keep States happy.
              What could possibly go wrong?

            •  Simply not true (5+ / 0-)
              Recommended by:
              fayea, Loge, betson08, cocinero, worldlotus

              The ACA is actually the largest transfer of wealth from the upper classes to the working poor and middle class since the 1960s. (For example, about $220 billion, or a fifth of the 10-year price tag comes from surcharges on incomes over $200,000).  It doesn't go far enough, and I would like to see some more movement toward single-payer or a German system, but this is a massive improvement to the U.S. health care system over the status-quo.

        •  you know me, Eve, (5+ / 0-)
          Recommended by:
          createpeace, nyceve, THirt, Lisa, ColoTim

          and I can see a potential benefit here, planned or not, in that free annual check ups and other preventative attentions that people can access will ultimately mitigate later, more expensive crisis care by early diagnosis.

          don't always believe what you think

          by claude on Sun Oct 27, 2013 at 02:39:42 PM PDT

          [ Parent ]

          •  unfortunately, this isn't always true (2+ / 0-)
            Recommended by:
            nyceve, claude

            The problem is that sometime preventative care not only catches big problems early on that can be fixed for much cheaper than later (which you are right, is a VERY, VERY good thing.)

            It's that sometimes preventative care finds things that won't become a problem and pays  for unnecessary treatment that costs a lot and might actually harm the patient.

            One of the big factors to costs is treating things that don't need to be treated (or treating it with ineffective treatments, which is another story)

            The key is toward improving diagnosis to the point we can tell what needs to be treated in early points, and what doesn't (and not overusing diagnosis).

            The problem is that imagining technology is almost always ahead of our ability to diagnose -- and that's why we are always fiddling with the recommended frequency you should be screened for everything from breast cancer to prostate cancer on one hand and even how often you should have a routine physical on the other.

            I don't mean to rain on your parade though -- there are some preventative things that are almost always win-win-win for patients, effective treatment and costs. Immunizations are the biggest example of this.

        •  There are deductables and there are deductibles. (5+ / 0-)
          Recommended by:
          nyceve, Kevvboy, Fake Irishman, saluda, Loge

          I have two friends who own businesses, very small businesses.  They pay a lot for very high deductibles, well over $6000/year.  But what I don't know, is this amount of money the amount that needs to be met before they get any payment from their insurance?

          On my insurance, in net work deductible is $1500/year.  But labs and xrays are paid at 100% right away.  Office visits are $25 (primary care) or $50 (specialist) at the front desk, then I pay 20% of what the insurance doesn't pay.  There are other types of services that have the deductible to be satisfied first before the insurance pays.  Surgery is one of these.  Physical Therapy is paid for by some percentage that I don't remember.

          So when you start talking insurance jargon, just know that you might not be really communicating the facts.

        •  I'm a fan of single payer myself (6+ / 0-)

          But unless I misunderstand, preventative services should not apply to one's deductible. Of course you're right that health insurance is expensive, and even with the subsidies, it's still not cheap, but the ACA is still a hell of a lot better than going without. Most of us have probably heard the stat that most bankruptcies in the US are due to medical bills. That's insane.

          I totally get that most folks don't have an extra $50 for a co-pay or whatever, but again, unless I'm mistaken, preventative care does not affect your deductible. Now of course you can argue that paying say, $3,600 in premiums for the year doesn't justify the small benefit of a "free" mammogram, but if you have a mammogram, a shingles vaccine and a colonoscopy in the same year, you could be taking equal value.

          Of course one of the other complicated issues with the cost of health care is how insulated we all have been for years and years as to what stuff really costs, but that's another lengthy discussion all together.

          •  Are you saying $3600 cost for one mammogram, one (1+ / 0-)
            Recommended by:

            vaccine, and one colonoscopy?

            Because if so, excuse me, but that is insane.

            This health care system is a moral atrocity. Dr. Ralphdog

            by AllisonInSeattle on Mon Oct 28, 2013 at 02:39:42 AM PDT

            [ Parent ]

          •  Add in the cost of not having (5+ / 0-)

            an unwanted pregnancy.  I am thoroughly delighted that I can now prescribe the best contraceptive for each patient based on their individual needs.  All contraceptive types are without copay now.  In the past, 15 year olds could generally not afford the long acting implantable contraception that would be more appropriate.  Instead they got cheap pills.  Many 15 year olds are not the best at taking a pill every day.  

            I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

            by fayea on Mon Oct 28, 2013 at 08:38:18 AM PDT

            [ Parent ]

        •  hmmm (2+ / 0-)
          Recommended by:
          ColoTim, betson08

          56% of American adults have smartphones. I don't have one but if I did have one and I had to choose between my phone's Internet plan and a co-pay, I would hope I'd see the doctor.

          I don't think it's legitimate to say that "most" Americans can't afford the co-pay. The deductible can be too steep for a percentage of us. I would hope the subsidies can help with that.

        •  Eve, did you see this? CBO report (0+ / 0-)

          studied RAISING the Medicare age..what the hell, they didn't study lowering it when they had all their facts in front of them at the time?

          I remember some study showing lowering it to 55 saved tons of money...

          This machine kills Fascists.

          by KenBee on Mon Oct 28, 2013 at 02:40:45 PM PDT

          [ Parent ]

          •  Well, sure. (1+ / 0-)
            Recommended by:

            Identify the age at which 90% of people have already died.  Add 2 years.  Done - gotcher new retirement age.  Yer welcome.

            I remember when irony still lived.  Now the obscene formula above will, probably soon, become straightforward dogma among the psychos.  And it'll be good for you, dontcha know.

            I am become Man, the destroyer of worlds

            by tle on Mon Oct 28, 2013 at 07:21:25 PM PDT

            [ Parent ]

        •  Silver Lining (1+ / 0-)
          Recommended by:

          Just so you know, in the UK the NHS now offers incentives to doctors, practices and hospitals (which are all owned by the NHS) when their patients are healthier and their wait times are shorter. Maybe the CPCI is a hint of single payer sometime in America's future.

  •  good stuff. there are a lot of medicaid waiver (19+ / 0-)

    programs out there and more in the pipeline that have similar goals of better care coordination and better outcomes.

    hopefully, we can slowly wean ourselves from the fee for service system.

    "Don't Bet Against Us" - President Barack Obama

    by MRA NY on Sun Oct 27, 2013 at 11:35:05 AM PDT

    •  Maryland has a Model Waiver Medicaid program (2+ / 0-)
      Recommended by:
      MRA NY, worldlotus

      for children who have complex medical needs. Nurses are care coordinators who act as supportive partners with the family, and together, they develop a plan of care. Every six months, there is a conference with the team (physicians, school, therapists, medical suppliers, community resources, and others) during which the plan of care is reviewed and revised as needed.  Nurses can identify community resources that might be able to meet specific needs that are not a part of the medical plan, such as, finding funds for respite care, securing transportation to an appointment, and identifying services for well siblings.
      Nurses make visits to the home, to IEP meetings, to physician appointments, and to observe therapy services.
      The non-profit agency that developed the program and provides the care coordination is  The Coordinating Center in Millersville, MD. It is a tremendous invaluable organization highly regarded all over the state.

  •  Very interesting; thanks for posting. (53+ / 0-)

    This is the kind of benefit that doesn't boil down to a political talking point, so it's information that doesn't reach many people.  But you have on-the-ground experience with a part of the law that was designed to help patients and doctors and result in better outcomes.  I, for one, appreciate knowing that there is more to the law than the simplistic bumper sticker critiques we get from both sides.

    "It ain't right, Atticus," said Jem. "No, son, it ain't right." --Harper Lee, To Kill a Mockingbird

    by SottoVoce on Sun Oct 27, 2013 at 11:36:57 AM PDT

    •  Hit the nail on the head (53+ / 0-)

      I of course left out a ton of stuff in the diary, and at the same time, it's quite wordy. You can't explain this stuff without a good amount of background information, and it's a lot longer than someone could explain on a typical talk show. You just can't describe it adequately in 35 seconds.

      I don't know what all the practices are doing, but we are essentially approaching all our patients the same way, whether or not they are technically "in" the CPCI. In other words, someone who is 55 on a different private insurance is still going to get the call from our Care Coordinator (who is awesome, by the way), even though technically the program is supposed to be for Medicare patients and the other (I think 10) insurers who are paying the monthly fee. That's a whole slippery slope thing, and it's the reason CMS had to get buy in from the insurers. It's simply not fair for CMS to pay all this extra money to improve care, have all insurers benefit from it, and not have them pay a dime extra.

      Anyway, your comment was the EXACT reason I decided to write the diary in the first place - as President Obama said, the Affordable Care Act is more than a website.

      •  I'm not sure patients have to know. (4+ / 0-)

        It sounds like more physicians should know. Did your group receive notice from CMS that you could participate? I've heard talk about coordinated care vs fee-for-service, but until you explained it, I had no idea what that meant. Thanks.

        •  It's a pretty long story (1+ / 0-)
          Recommended by:

          We had to apply for the spots. I don't know how many practices applied for the 75 spots in my area (SW Ohio), but it was certainly more than 75 (our group got 6 out of the 9 locations in).

          So we have a bunch of communication with CMS and also with the other practices in our region. We have to report various data points, budgeting factors, etc. at least quarterly and submit our plans for the upcoming year. There are a bunch of specific things you have to do- improve patient satisfaction scores on standardized surveys, for example. There are a LOT of hoops to jump through, but it is kind of cool to be part of the "future of medicine" to test out new care delivery methods and see what works.

          Hope that made sense. In other words, we heard about the CPCI and worked for a while to make our locations attractive applicants. We were hoping for 9 out of 9, but the three locations that didn't get selected had 1, 1, and 2 doctors at the time of our application. We are guessing that's why those sites didn't get chosen but nobody from CMS was able to say for sure. Or at least they didn't tell us.

      •  As an HHS director in a rural county, I (20+ / 0-)

        write many similar nuts and bolts diaries. I agree with you completely. What is wonderful about the ACA is the way it incorporates payment reform that encourages the production of health. This is missing from our existing system.

        Great diary. I am part of a network that uses a care coordination model called Pathways that ties some part of compensation to individual health outcomes. The tough part is to keep the integrity of our network going despite peculiarities of New Mexico's roll out of the ACA.

      •  I'm interested, but you lost me a few times. (0+ / 0-)

        See if you can get your explanation down to a 60 second elevator pitch.  Something like: "Groups of doctors and nurses will get together to reform the way health care is billed, with a goal of lowering costs, and delivering better health care for patients."

        If a carpenter built a cabin for poets, I think the least the poets owe the carpenter is just three or four one-liners on the wall. Mike Lefevre - steelworker

        by Bob Friend on Sun Oct 27, 2013 at 02:21:45 PM PDT

        [ Parent ]

        •  Thanks for the feedback (3+ / 0-)
          Recommended by:
          potatohead, joynow, ColoTim

          I know this was quite long. I had a bunch of thoughts in my head about it and wanted to write them all out.

          The "elevator version" just doesn't get enough detail to fully explain stuff though. I figured on a Sunday, where the home page articles are longer than normal anyway, it would be ok to post a long diary.

      •  FYI if you want to keep your people healthy (1+ / 0-)
        Recommended by:

        bring in some alternative treatments to help yours work better, and keep people healthy. As a former nurse who has learned may types of bodywork but who now does Jin Shin Jyutsu exclusively, it is the real deal....Thank you for being open minded....

        "Compassion is the keen awareness of the interdependence of all things." Thomas Merton

        by createpeace on Sun Oct 27, 2013 at 04:59:02 PM PDT

        [ Parent ]

        •  Sure (0+ / 0-)

          I recommend stuff like tai chi, yoga, chiropractic quite often. It is difficult to formally "refer" folks for this but depending on your health plan (especially if you have an HSA), you might be able to get that stuff paid for if your doc is willing to write a "prescription" for it.

          •  Here is a different perspective. (1+ / 0-)
            Recommended by:

            I decided to go my own way when my BP medications caused too many side effects. I stopped them completely after getting short shrift at the doctor (just keep trying new a new one).

            I spent the next three years becoming my own advocate by immersing myself in the why's of High blood pressure. I read medical journals, books magazines, studies, and basically learning from the ground up. I went completely natural. Changed my diet to lean protein, beans, fiber, and the magic equation in this -VEGETABLES (every day, all the time, and at virtually every meal). Also, good fats only.

            I take a few natural supplements (CoQ10, fish oil, l-Argentine, plus anti-oxidants).

            My BP is now under control. This does not stop my doctor from wanting to still put me on some type of medication (I get white coat hypertension and seems a little elevated in the office).

            The thought of an advocate "harassing"  me to take medication truly is not appealing. The scope of conversation we might have is outside their normal operating parameters. I shudder just thinking about it.

            I know this is not a typical scenario for you but it does exist.

            Truth is harmonious, lies are discordant.

            by Babsnc on Mon Oct 28, 2013 at 06:54:46 AM PDT

            [ Parent ]

            •  Not that atypical (2+ / 0-)
              Recommended by:
              Blissing, Babsnc

              Your response to the thought of an "advocate" harassing you about taking medication, or otherwise doing what the standard medical/pharma community thinks you should do is not that atypical.  Many people self-treat because of problems with medications that their doctors either don't believe or don't think are as important as standard treatment.

              I think the medial community needs to be careful about not alienating people by preaching and harassing them.

              I know people who will NOT go to the doctor because they know they will get the lecture on being overweight and calories in/calories out....again.  Medicine blames just about everything that happens to people on their weight, and often takes the position that people just need to eat less and exercise more without even knowing what the person is doing or eating.

      •  I'm glad you put this up on Kos (2+ / 0-)
        Recommended by:
        ColoTim, worldlotus

        It gets good play among  a community of activists.

        But have you also considered trying to write up a 700-word simple version for a newspaper op-ed? I'm sure the Dispatch, Blade, Plain Dealer, Daily News or Enquirer might really be interested in it (all snark aside). You might also want to call up one of their metro reporters and try to get them interested in a news story on it.  

        I'd be willing to help you hone an op-ed to spec if you wanted to take a stab at it....

        •  Good thought (1+ / 0-)
          Recommended by:

          To be honest, I was a little apprehensive about posting this at all. It isn't like some big secret; all the practices are easily found with a simple google search. But if I were to post something more "mainstream," I would probably want to be extra careful I wasn't talking about stuff that isn't quite ready for prime time.

          I see from a lot of the comments that even my long-winded explanations are taken the wrong way to some degree. As I tried to explain, unfortunately, without a lot of background a lot of the stuff sounds weird.

          It is definitely worth consideration.

  •  There's something else I learned when I called (32+ / 0-)

    Covered California.

    As a family practice physician, no doubt you have elderly patients who eventually have to bankrupt themselves in order to qualify for Medicaid when they need long-term care.

    In the old system they could only have $3,000 in cash assets. To get rid of the money, they they had to renovate their homes or buy a car. They could not transfer any leftover money to their children. They had to use it up until they met that assets test. Then they could get Medicaid to pay for their long-term care.

    At least in California, and I therefore assume this is nationwide, there will be no further assets test for MediCal (our name for Medicaid) starting on Jan 1st.

    That's a major change I have not heard reported by anyone. People will be able to leave their money to their children, and let their spouses keep it.

    I have a 92-year old friend who had to do that in 1992 when her husband had Alzheimer's. She patched up her house bought a luxury car. She still has the car, but it's getting to be as elderly as she is. She has to rely on her son for cash to live on.

    If this new provision had been in effect then she'd still be comfortable in her own right, and her son could have inherited from her instead of the other way around.

    Enjoy the San Diego Zoo's panda cam! Now with new baby panda! And support Bat World Sanctuary

    by Fonsia on Sun Oct 27, 2013 at 11:37:31 AM PDT

    •  I'm pretty sure the MAGI approach that disregards (9+ / 0-)

      assets does not apply to the elderly or disabled, and therefore would not have helped your friend. It will apply to most applicants, but not the applicants representing the most expenditures - long term care elderly.

      BTW, your friend got pretty bad advice -- there were and are better ways to avoid that situation, and no one is required to buy a luxury car or renovate a house to do so. Her situation was almost certainly preventable by a competent elder law attorney or financial planner. Whether it should have been preventable is ethically iffy, but there are perfectly legal ways for most seniors to give their assets to their children and have the rest of us pay for their care while their children enjoy the money.

      •  Your last sentence summarizes the conundrum (3+ / 0-)

        with medicaid regarding nursing home care.    It's not right that the rest of us should be paying while the children are enjoying the money.  

        I know it's legal.  It's just not proper and fair.  

        OTOH...most, not all, but many Nursing Homes deserve their own chapter in Dante's Inferno and even if Me-Maw goes there courtesy of the taxpayer, it's no day at the beach.  

        This is an area that needs effort from all parties, and not just from the financial side.  Nursing Homes need to clean up their act and there needs to be some effort to control costs and prices while maintaining a decent environment for those incarcerated.

        The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis. - Dante Alighieri

        by Persiflage on Sun Oct 27, 2013 at 03:42:39 PM PDT

        [ Parent ]

        •  Agreed. (1+ / 0-)
          Recommended by:

          The nature of those places (and I know them from experience with my mother) is part of why I consider those asset transfer schemes one of those "things that aren't right but low on my list to fix." The truly wealthy make much more extensive and creative use of trusts and shelter so much more of their wealth than the mostly middle class folks who use these plans. But their elderly (except in the most dysfunctional families, perhaps) don't get stuck in those warehouses. They get royal treatment and pass on their wealth.

          Eliminating Medicaid planning, like eliminating the one-day lookback period for VA aid and attendance benefits, would probably be "right" in an ethically ordered economic world, but for now feels a bit like the crabs in the pot pulling back the one who almost escaped.

  •  Thank you! (17+ / 0-)

    This is a lengthy diary, but extremely informative and well-written. It's terrific to hear positive ACA news, especially from a physician.  

  •  I've always wondered about this: (19+ / 0-)
    We try to have labs drawn before folks come for appointments, so we can have already reviewed the results before walking in the room. This allows for more efficient care.
    Why wouldn't that be normal? I mean, I know that even for my annual, they'll check cholesterol, etc - why not draw in advance, to discuss?

    Thanks for this great diary, btw -

    The number of children and teens killed by guns in one year would fill 134 classrooms of 20 students each. (Chlldren's Defense Fund, 2013)

    by nzanne on Sun Oct 27, 2013 at 12:04:01 PM PDT

    •  I prefer my doctor do this (1+ / 0-)
      Recommended by:

      Because I am a "hard stick"  and most lab techs take 2-3 tries.

      Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

      by barbwires on Sun Oct 27, 2013 at 12:13:44 PM PDT

      [ Parent ]

    •  I see my doctor quarterly. (8+ / 0-)

      He gives me the lab orders each time I see him, and I have the lab work done a week before my next visit. To me, it doesn't make sense to do it in reverse. That means either two visits, or no opportunity to discuss the results. I thought that was the norm.

    •  The practice I go to schedules labs a week before (0+ / 0-)

      appointments, so the results are always available when I meet with my doctors (a primary and an endocrinologist). It would be difficult to discuss what I'm doing and whether medication changes are called for, unless we have the factual results from tests.

      I don't know whether this practice is part of the CPC initiative, but they have also gone completely computer-based for patient records.

      New signature coming soon!

      by NYWheeler on Sun Oct 27, 2013 at 02:24:21 PM PDT

      [ Parent ]

    •  It's normal in HIV care. (0+ / 0-)

      I have HIV, and I always have my labs drawn at least 10 days before I'm scheduled to see my doctor.  There's no point in seeing her unless she knows my absolute CD4 count, my viral load, and my CD4 percentage.  Those are the numbers by which she can judge how I'm doing on my treatment.  Without them, the office visit would be a big waste of time.

      "Ça c'est une chanson que j'aurais vraiment aimé ne pas avoir écrite." -- Barbara

      by FogCityJohn on Sun Oct 27, 2013 at 04:29:59 PM PDT

      [ Parent ]

    •  Thanks (0+ / 0-)

      This part isn't necessarily part of the CPCI, but it makes it a LOT easier to coordinate when you have someone specifically scheduling this stuff. Once we started doing it this way we thought, "why the heck have we not been doing this all along?"

      Another bit is that we try to not do refills outside of office visits. I don't mean that we refuse to give refills, but we try hard to "line up" refills and only give enough until someone is due for their next appointment. That way, if you know your meds are running low, you know that means you're due to be rechecked. It also means you don't end up with 69 leftover pills that you paid for and now cannot use if an rx was changed.

      We have found that more frequent appointments will lead to better control of chronic disease. A lot of that is just human nature. If someone tells you to eat well and exercise for three months, you can probably do it. If they say do it for a year, well... I mean, I procrastinate as much as the next guy.

      •  One thing that has bothered me a lot about pay for (0+ / 0-)

        general practitioners is that only being paid for one thing per visit thing. I can't recall what they were now, it was some years ago but medicare denied payment for something she did though it is a covered service.
        When I called medicare they explained only one of the things could be paid for in one visit.  We had a talk about the sense that did or didn't make. I have multiple chronic conditions she monitors in my quarterly visit and sometimes they flare and I might get some acute problem too. Do I go sit in the lobby and go back in to make it two visits?
        No, can't be on the same day.
        I don't drive any more and getting there is a source of stress...

        Well rules are rules. The doctor said not to worry about it but I do and actually skip bringing up multiple concerns on a visit. A different kind of payment system could ease that
        That rule might work with specialist since their focus is more limited. But family doctors deal with all our systems, our interconnected systems and symptoms.
        At least they are experimenting with a more sensible payment system.

        Do you know if inducements to get more general practitioners made it into the bill? I know many things were discussed including forgiveness of loan debt

        Did they improve Medicaid payments too? It is already mighty hard to find doctors/dentists who accept new medicaid patients both because of the low payment but also paper/time hassle at getting any exceptions to treatment or formulary. I assume they must have made changes to make it doctor friendlier.

        Thanks for your diary

  •  It's great to have a report (3+ / 0-)
    Recommended by:
    TheFatLadySings, llywrch, Bob Friend

    from the front lines.

    I hope you will keep writing here, but suggest you make your diaries a bit shorter for easier digestibility.  

    It's the Supreme Court, stupid!

    by Radiowalla on Sun Oct 27, 2013 at 12:04:14 PM PDT

  •  I always called what we have "commodity medicine" (2+ / 0-)
    Recommended by:
    Leap Year, TheFatLadySings

    Each doctor selling his/her particular product.  Of course, this gets into the more modern problem of instrumented diagnosis and fixed protocols -- and ultimately automated medicine.

  •  Thanks for this diary. (10+ / 0-)

    Even for those who are aware of the CPCI, descriptions and explanations bear repeating.

    “We do not inherit the earth from our ancestors; we borrow it from our children” ― Chief Seattle

    by SoCalSal on Sun Oct 27, 2013 at 12:20:31 PM PDT

  •  I had heard of this but was afraid (6+ / 0-)

    It would be like education, where you get punished for taking the hard cases. I wish they would apply this to the schools, where teachers are evaluated based on test scores regardless of the circumstances of the kids that come through the door.  I guess the people who designed this healthcare system actually want it to work.

    Be bold. Be courageous. Americans are counting on you. Gabby Giffords.

    by Leftleaner on Sun Oct 27, 2013 at 12:34:28 PM PDT

  •  There are a number of initiatives of this (8+ / 0-)

    nature built into the ACA. We lack infrastructure in America to create and maintain health, but by and large, the public is unaware. The beauty of the ACA is the many ways it modifies payment structures to encourage the production of health.

    One day, this will become apparent.

  •  I really appreciate that your group hired a (9+ / 0-)

    diabetes educator. When I was diagnosed, I was going to a low-cost clinic, and they had a wonderful education program. First I had a one-on-one, and then there were follow-up group meetings. My SIL has not been that fortunate, and he still isn't clear about his diet. I am constantly fielding questions. In fact yesterday I was yelling into the phone, "You want your feet to remain attached to your legs? You like being able to see? What you choose to eat can't taste that good!" The MIL from hell!!

    •  Yeah (1+ / 0-)
      Recommended by:

      We have had a lot of discussions over how to use the $$. A lot of physicians pushed hard for the diabetes educator. At one of our meetings, I went as far as to say that I didn't know why we would even be in a program that gives us $$ to improve infrastructure if we didn't hire a diabetes educator. Knowledge is power of course. You can only explain so much in 10-20 minutes, and quite frankly, the educators know a lot more than me about the specifics anyway.

  •  Thank you for writing an excellent piece with ... (12+ / 0-)

    information that most of us wouldn't get otherwise.

    Don't worry too much about the length of this diary.  Without the background information as a foundation, the new information would, at least to some extent, have been wasted and its importance greatly dimished.

    Kudos to you personally on your obvious love of knowledge and the caring that shines through in your writing.  I envy your patients.

    It's not a question of whether our founding fathers are rolling in their graves but rather of how many RPM they're clocking.

    by Eyesbright on Sun Oct 27, 2013 at 12:54:33 PM PDT

  •  I went to my clinic (6+ / 0-)

    because I thought I had an ear infection.  I saw a Physician's Assistant.  She looked at my throat and told me I have allergies, and that I should get some over-the-counter allergy medicine.  I was in and out of there in 3 minutes (no exaggeration!)  

    The bill:  $185.00

    I have insurance, but there's a $2,000 annual deductible per family member so this was all out of pocket.  On a public school teacher's salary, (36K), that's a significant amount of money.

    Pardon me if I don't get too excited about the ACA -- it just means that I, and many like me, continue with insurance that we can't afford to use.  I won't be going to the doctor again unless it's truly an emergency.

    America needs health care for everyone -- not just health insurance!

    Stand Up! Keep Fighting! Paul Wellstone

    by RuralLiberal on Sun Oct 27, 2013 at 12:57:42 PM PDT

    •  How would anyone know for sure (3+ / 0-)
      Recommended by:
      PinHole, fb, ladybug53

      just by looking that you don't have an infection? I don't understand why they wouldn't at least do a swab and try a culture to see. 19th century tech, works pretty well, rarely used though.

      I had both allergies and chronic sinus infections for years and years. I could tell when there was an infection but doctors/PA's typically resented my suggesting it and waved me away. My condition was undertreated resulting in a lot of suffering and long-term problems. When I finally had to get sinus surgery, the doctor said my sinuses were completely blocked with scar tissue, ie, chronically infected.

      Now I know about saline rinsing to keep the sinuses healthy. If I had  known this back in 1970 I'd be a better person today!

      Where in the Constitution does it say: "...on behalf of corporate interests" ???

      by sillia on Sun Oct 27, 2013 at 01:32:28 PM PDT

      [ Parent ]

  •  Questions (4+ / 0-)
    Recommended by:
    sillia, gooderservice, Bob Friend, PinHole

    I have to admit I did not finish the diary. I read most of it.

    The shift away from fee for service:
    - you talk about a change in funding. Practices are given extra money to invest in "infrastructure" and it can't be used for doctor compensation.  a) How does this help with the more complex and chronic illness patients; b) What will your practice use this money for? c) how does this funding help patients?

    I've got a chronic illness. So I'm particularly interested in this new incentive program.  I have to admit that I don't understand at all how this is supposed to improve the situation with outrageous cost of health care, though I'm not saying that I'm doubting you.  

    Can you boil it down a bit (in addition to some answers to the questions I asked, if you have a chance)?

    One concern - is this extra money for "infrastructure" going to just end up being funneled to medical device companies?  Is this a trend toward huge practices of doctors that pool all their resources to form something more like a small hospital or clinic?  

    One last thing if you feel like talking about it: in southern NJ our hospitals have consolidated.  We have several new ones that are really nice.  They're actually more like 4 star hotels in some ways. This is great and all, but hardly anyone can afford to even be in a hospital.  And the nurses are still doing most of the coordination and work, and are stressed, based on my experience and when it's all said and done, and you come out of it thinking "I've never seen so much waste in my life".  Then the bill comes and it's enough to sink a person for life.  The outrageous costs.   It's nothing to rack up a 100K hospital bill.   And ultimately it's the insurance company who decides when you're well. The doctors and nurses don't know when you're going to go home. They call the insurance company every day and some faceless person decides when you're leaving. I've seen this happen with my son several times.  The teams of doctors and we'd talk about the problem and the solution and then the day comes when the insurance company says he gets released and all the things you were talking about working on go right out the window.

    How does the ACA fix any of this?

    "Justice is a commodity"

    by joanneleon on Sun Oct 27, 2013 at 01:05:12 PM PDT

  •  Dear diary writers ... (5+ / 0-)
    Recommended by:
    sillia, gooderservice, Bob Friend, LNnois, JMR

    I appreciate the information, but face it: this is the internet.  Give us the main point right away

    There is no reason that we should have to go nine paragraphs into a diary before we reach this:
    "So enough background. Here's the good stuff. The ACA provides funding and guidance for a new way to approach health care. "

    I do not mean to be critical in particular of THirt, and again I do appreciate the information.  But all diarists should remember that people like to skim

    In other words, don't bury the lede.  The first paragraph should include the main idea, in this case that the ACA provides a new approach.  Then give us s short version of the main point--in this case name the CPCI and tell in a couple sentences what it is.  Then it is good (for the reader mind you--you want to be read after all) to circle back to the the background for those who want to read on and the extended analysis

    Remember you reader!


    •  Yes. N/T (1+ / 0-)
      Recommended by:

      If a carpenter built a cabin for poets, I think the least the poets owe the carpenter is just three or four one-liners on the wall. Mike Lefevre - steelworker

      by Bob Friend on Sun Oct 27, 2013 at 02:25:53 PM PDT

      [ Parent ]

    •  I disagree with your rant (8+ / 0-)

      May I make the assumption (without looking at your profile) that you are on the young side.  

      This is one reason today's young adults are not competitive with other nations such as those in SE Asia.  They expect to be able to skim everything and not analyze anything in depth.  This may be why the code for the ACA is so screwed up.  You need to have the curiosity and ability to be able to stick with something. Your definition of the Internet is not valid.  Maybe twitter and bumper stickers.

      Mr P, in a corporate IT security job, before he retired, often had to clean up mistakes made by 20-somethings.  He said they had no attention spans.  

      As one who was in administration of a med school, I know the admissions committee took the ability to absorb and coordinate in the mind, diverse details very seriously. They also demanded an essay, handwritten, to see how well applicants could communicate, knowing that was essential in the medical field.  

      This is not to say everyone needs to have this ability, but it certainly speaks to your impatience with it.  After reading THirt's diary twice, I am very grateful it was written as I now understand changes I see in my doctor's office.  It has also brought up some questions I have, which I will ask locally.  

      He did do the into & conclusion correctly. Why should we ask her to present a 100% polished diary here.  If it is too much for you, you are free to skip it.

      •  I'm 43 (2+ / 0-)
        Recommended by:
        Catte Nappe, JMR

        I do understand what you are saying.  

        But my point is not that this excellent and topical post should have been 140 characters or less.  I am not adverse to reading, in depth or otherwise.

        My point is that the average reader should know early on WHY she or he is reading the matter in the first place.  

        And that is, in part, because there is an awful lot of information here at DKos.  With limited time to read, one needs a filter.  Topic sentences help.

        I am not picking on THirt, but just pointing out that the otherwise excellent, thoughtful and timely post could be helped with an earlier introduction to the topic.  The reason I point this out is because many diarists fall into the same trap.

        Again, no insult to this author.  I do appreciate the effort and insight.

    •  actually I find it quite refreshing... (5+ / 0-)

      ...if not humbling, that a family physician would take the time out of his very busy life to explain the daily nuts and bolts of the operation(no pun). You're very fortunate that I didn't author this diary. If long dissertations are not your bag then may I suggest perhaps taking a speed-reading course? You would be begging me for mercy, as most of my diaries are in the 2,000 to 5,000 word category. And many, far too many of my comments pass for diaries here. Every writer has his/her own style. Some are long-winded and leave you crying for more. And a lot of them just leave you, well crying in pain, that they would've chosen to get a root canal that day instead.

      "I wish to have no connection with any ship that does not sail fast, for I intend to go in harm's way." John Paul Jones

      by ImpeachKingBushII on Sun Oct 27, 2013 at 04:19:29 PM PDT

      [ Parent ]

    •  RFJ - It seems your self-description (1+ / 0-)
      Recommended by:

      means you are probably a middle aged male lawyer, with a goal of being a judge.  My understanding of the decisions judges must make often turn upon detailed investigation of laws and past decisions.  

      Reading comprehension and understanding being important.  Being a liberal is not enough.  

      Therefore the short response to your rant is:

      "In this, you are mistaken"  

      •  You are absolutely correct (0+ / 0-)

        But here is the point.  Whether legal writing or other types, the object is to convey info.  There is a lot of info in this diary and I am not suggesting (as others seem to assume) that posts need to be short.

        But when I ask a judge for relief in some fashion or other, I tell the judge why right away.  Then I go over the background, the applicable standard, and the analysis.  

        •  Thank you for seeing a different POV. (0+ / 0-)

          We can agree to disagree on the usefulness of the content and presentation of the diary.

          It seems it is helpful and not a burden to most of us.  Clarity is always a good metric.  

          Peace & stay healthy : - )  

    •  No. (2+ / 0-)
      Recommended by:
      RunningForJudge, PinHole

      If you hope to become a judge, you'd better be able to read three or four pages of not terribly complex info without complaining.  Maybe practice?

      Still enjoying my stimulus package.

      by Kevvboy on Sun Oct 27, 2013 at 05:23:53 PM PDT

      [ Parent ]

      •  I've been practicing law 13 years (1+ / 0-)
        Recommended by:

        I hope to get it right eventually.

        Trust me, I read a lot of stuff.  That is why I appreciate when the author tells me early on why I should be reading it.

        I know that my comments may appear to be picking on THirt, but that is not my intent.  I read a lot of diaries on DKos that suffer from the same thing and I understand that diarist want to give context to their posts.  But with a long intro, the reader begins to wonder, "Context for what?"

        This is an example of a great post where it took me some time to find out what the thing is.  The main topic--in this case CPCI--should appear in the first paragraph as a favor to the reader.

        There is a lot of great stuff on DKos--too much for anyone with a job other than as a DKos diarist to read everything everyday.  I wish I could.

    •  Diary reads like a corprate ad for healthcare n/t (0+ / 0-)

      Evidence that contradicts the ruling belief system is held to extraordinary standards, while evidence that entrenches it is uncritically accepted. -Carl Sagan

      by RF on Mon Oct 28, 2013 at 06:33:51 AM PDT

      [ Parent ]

  •  Great diary, thanks for this (7+ / 0-)

    This is exactly why I come to this site.  In-depth frontline information on crucial aspects of an issue that the MSM will only gloss through.

    An investment in knowledge pays the best interest. -Benjamin Franklin

    by martinjedlicka on Sun Oct 27, 2013 at 01:15:52 PM PDT

  •  Brilliant... (3+ / 0-)
    Recommended by:
    fb, PinHole, THirt

    ...the kind of diary I come here to read.

    So right off the bat, you can see how this is a paradigm shift from the traditional fee-for-service environment.
    Absolutely. There will less incentive for crooked physicians.
    This may go a ways in reducing Medicare/Aid fraud.

    "Wealthy the Spirit which knows its own flight. Stealthy the Hunter who slays his own fright. Blessed is the Traveler who journeys the length of the Light."

    by CanisMaximus on Sun Oct 27, 2013 at 01:34:13 PM PDT

  •  "One of the biggest flaws is our fee-for-service (0+ / 0-)

    system in general."

    Not sure what you mean there.  Are you saying you favor HMOs that pay doctors per capita every month based on the number of people who have designated them their primary caregiver, no matter whether the patient is evaluated by the doctor or not in that month?

    •  He never said what he wanted (2+ / 0-)
      Recommended by:
      doroma, Jojos Mojo

      you are imputing a lot in that sentence.

      Although it is clear that in a perfect for fee service, there would be more pay for more complex visits.

      "I watch Fox News for my comedy, and Comedy Central for my news." - Facebook Group

      by Sychotic1 on Sun Oct 27, 2013 at 02:01:11 PM PDT

      [ Parent ]

      •  I asked a question. I got no answer. (0+ / 0-)


        •  Some kind of hybrid model (1+ / 0-)
          Recommended by:

          Would make the most sense to me. It would be a complicated formula, but some part of compensation tied to number of visits, some tied to quality of care (ie % of patients to goal on diabetes, htn, etc), some tied to outcomes (# of ER visits, complications, etc), and some tied to actual cost savings.

          As I tried to imply in the diary, it doesn't make much sense to pay the same for an ear infection as it does for a diabetic with chronic kidney disease, high BP, high cholesterol, and heart disease. There has to be a better way. Otherwise, you're actually incentivizing bad care.

          This is a while other discussion, but hospitals make money by having sick people. It's not really in their best financial interest to keep everyone healthy. That wouldn't really be good for the bottom line. But if (as is spelled out by another part of the ACA) a hospital gets paid a flat fee to take care of someone with a heart failure exacerbation whether they are admitted once or twice or three times, you'd better believe the hospital is going to do what they can to keep the patient from getting re-admitted for the same diagnosis.

      •  Actually, there is. (0+ / 0-)

        When I go to my doctor, there is a complex sheet that I turn in to the person collecting the payment.

        On that sheet are three choices of the type of "visit" I had.  I forget the exact wording, but it includes such things as moderate or extensive and follow-up.

        Although it is clear that in a perfect for fee service, there would be more pay for more complex visits.
  •  Thanks, Doc! (5+ / 0-)
    Recommended by:
    Jojos Mojo, Persiflage, fb, PinHole, THirt

    Post more!  Please!

    Visit for Minnesota news as it happens.

    by Phoenix Woman on Sun Oct 27, 2013 at 01:57:48 PM PDT

  •  But, but, but socslism.... (0+ / 0-)

    And we want them to get sick and die quickly, it saves so much money.

    And it's the Christianist thing to do, Right?

  •  OMG, this just makes so much sense... (4+ / 0-)
    Recommended by:
    Truedelphi, fb, PinHole, THirt

    thx for the diary/sh

  •  On behalf of my friends and myself, you're welcome (5+ / 0-)
    Recommended by:
    fb, PinHole, ladybug53, THirt, betson08

    All of us volunteer socialistic consumer advocates worked pretty hard on pushing for development of these evidence based, patient centered programs to improve the quality of health care for everyone.  The goal was to provide every patient with world class quality care. Funny thing, a bunch of folks figured out about 15 years ago that doing this actually saves money and lives.  

    Evidence based quality health care for all should become the norm if everything works out right.  Over testing, over treating and other medical errors should become a thing of the past.

    Note: these programs are supposed to be accompanied by a refocusing of public research dollars towards ensuring all health care practices are backed up by scientific evidence from peer reviewed research, regardless of how many fancy drugs and imaging machines your pharma and medical equipment folks try to sell you.  


    your friendly, yet persistent consumer reviewer

    If cutting Social Security & Medicare benefits for low income seniors is what Democrats do after they win a budget standoff, I'd hate to see what they do after they lose one.

    by Betty Pinson on Sun Oct 27, 2013 at 03:10:29 PM PDT

  •  Thank you for this and I hope you'll (6+ / 0-)

    post frequently so we can get the inside view.

    The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis. - Dante Alighieri

    by Persiflage on Sun Oct 27, 2013 at 03:44:32 PM PDT

  •  Nice Diary, Doctor (1+ / 0-)
    Recommended by:

    I presume the AMA Compliance and Conformity Committee will be calling you tomorrow.

    We will never have the elite, smart people on our side. - Rick Santorum

    by easong on Sun Oct 27, 2013 at 03:47:28 PM PDT

  •  I don't think the Republicans have ever thought (3+ / 0-)
    Recommended by:
    PinHole, THirt, betson08

    of ANYTHING like this.

    "He went to Harvard, not Hogwarts." ~Wanda Sykes

    Blessinz of teh Ceiling Cat be apwn yu, srsly.

    by OleHippieChick on Sun Oct 27, 2013 at 03:48:16 PM PDT

  •  exactly the way you do it... (0+ / 0-)
    " if you make the same amount per patient, and you can see 30 patients with ear infections or 15 diabetic/hypertensive/hyperlipidemic patients, which would you choose? How would you set up your schedule"?

    "I wish to have no connection with any ship that does not sail fast, for I intend to go in harm's way." John Paul Jones

    by ImpeachKingBushII on Sun Oct 27, 2013 at 04:04:39 PM PDT

  •  Paid the same to see various patients? (2+ / 0-)
    Recommended by:
    ladybug53, Catte Nappe

    I didn't understand something from the diary:  The writer said that he is paid the same for seeing an easy patient vs a more complicated patient.  Does that mean that he "charges" each patient the same? ie, he would "code" the visits the same?  Or that he is on a salary, so that he receives the same compensation whether he sees 25 patients/day that are fairly easy, say, follow up visits for uncomplicated problems vs seeing just a few patients for 45 minutes each?

    Having worked on the insurance end of things, I know that there are different codes that the doctor can use to designate the length of time/complexity of a visit.  As a patient, I know that my doctors have coded different types of visits when I have had to be checked.  

    And since I'm married to a family physician, I know that he has always been paid a straight salary, whether he sees 8 patients/day for complete physicals, which he did for one organization for seven years, or in the current position where  he sees what ever random type of patient schedules for a visit, meaning he might see 12-22 patients/day, plus taking care of the ER overnight.    Straight salary for 40 - 85 hours per week regardless.  [The extra hours each day come from all the "paper work" [computer work] that must be done for each and every patient to be thorough.]

    •  Don't want to give out a ton of specifics but (3+ / 0-)
      Recommended by:
      potatohead, Catte Nappe, betson08

      Relatively short version is that if a visit meets certain complexity criteria for history, exam, and medical decision making, it meets whatever E&M code. If it is an ear infection, the history will be reasonably detailed, say 4-5 factors, timing, quality, modifying factors, etc, with at least a couple review of systems; fever, chills, body aches, headache, hearing loss, associated cough, and so forth. The exam may be pretty straightforward; look in ears, throat, nose, examine lymph nodes in the neck, listen to the lungs. But the medical decision making would be "detailed" for a new problem requiring prescription drug management. That would be a 99214 visit.

      To get a level 5 code, you need two out of three of history, exam, and medical decision making to be complex. While for a diabetic patient with complications, you might get 10 review of systems, you don't usually need to do a detailed enough exam to get 12 different body systems examined. So that's why a diabetes/high BP/high cholesterol visit is also probably a 99214.

      Hope that made sense. For what it's worth, I'm not on a salary. Our group has been rather progressive as far as focusing on quality care rather than volume. It was really exciting when the CPCI came about. We had already been working on PCMH certification for a while when this came out.

  •  Hey Doc (4+ / 0-)
    Recommended by:
    ladybug53, THirt, potatohead, Catte Nappe

    A few ungrateful wretches have criticized the length of your diary but if I could tip and recommend it 1000 times, I would.  For a physician to take the time to carefully explain this possibly revolutionary aspect of the new law was EXTREMELY valuable for me and I will be sharing this information as I learn more.

    Still enjoying my stimulus package.

    by Kevvboy on Sun Oct 27, 2013 at 05:21:04 PM PDT

  •  Thanks for taking the time to explain it to us (0+ / 0-)

    it sounds like a good program. It'd be great if you're up for it to update us on your group's experience on an ongoing basis (say in six months).

    •  I'll try (2+ / 0-)
      Recommended by:
      middleclassadvocate, jplanner

      The program technically started November 1, 2012, although the first year was more of a see-what-happens year. I'll hopefully be able to share some specifics at some time down the road. It's a little weird, because my group has been focusing on quality and process-based care for quite a while (I finished residency in 2004, and we were already doing some things then). I say weird, because a lot of the things we are now doing as part of the CPCI program are natural evolutions of things we'd already put in process. Anyway, perhaps some follow up would be worth it in a few months.

      I'll try to keep that diary a little shorter!

  •  Value based care is the way of the future. (0+ / 0-)

    This is what my research has centered on as of late.

    I want to live in a world where George Zimmerman offered Trayvon Martin a ride home to get him out of the rain that night. -Bishop G. Brewer

    by the dogs sockpuppet on Sun Oct 27, 2013 at 08:53:35 PM PDT

  •  Pilot Programs are another hidden feature (4+ / 0-)

    They are supposed to give the ACA the flexibility to change as it needs to for improvment.

    Dr. Atul Gawande first wrote about them in The New Yorker. I don't hear many people referring to them but they made so much sense.

  •  Excellent diary (2+ / 0-)
    Recommended by:
    THirt, worldlotus

    I've been writing a lot on bigger structures in the ACA, but I've wondered how a bunch of the little programs are playing out on the ground. It's great to get a first-person perspective from a doc who has both the local view of a program in action and enough of a global perspective to think about how it fits into the broader ACA.  I'm encouraged that this made the rec list.

  •  This -- (2+ / 0-)
    Recommended by:
    Catte Nappe, worldlotus

    ". . .but we have used the money to hire more staff, including what we call Care Coordinators for each office, an RN who can reach out to patients before, during and after appointments to see how we can better coordinate care."

    This is similar to the way my son's care was coordinated through Medicaid/CMS (but it stands for Children's Medical Services).

    And it was wonderful!

    As the mom of a kid with chronic problems, requiring multiple specialists and semi-annual tests of varying kinds, depending, this woman was a sanity-saver.

    Now he is too old to qualify for CMS and is in (probably) the last year of care under Medicaid-Medically Needy (unless it's not his last year but nobody really knows) and then we'll be over at the local health department sliding fee clinic because we live in Florida (one of the stupid states not expanding Medicaid) and I already miss not having the guidance of someone who knows the medical side and can help navigate the bureaucracy of different appointments and tests.

  •  Question (1+ / 0-)
    Recommended by:

    Will there be enough doctors to care for all the newly-insured patients? What sort of transition is anticipated?

    •  Short answer: probably not (1+ / 0-)
      Recommended by:

      This is tough to answer for sure. There are not enough PCP's currently to handle the volume of patients, so adding more people into the system is surely going to overwhelm some doctors. I'm not really taking new patients except for family members of existing patients, for example.

      We need to make the environment more favorable for primary care (says the biased primary care physician). This, over time, will help more physicians choose primary care instead of the more lucrative specialties. This is a lengthy subject, so I won't get into it here.

      One issue is that a lot of practices may not accept the insurances purchased on the exchanges. I'm sad to report that our group won't be accepting the insurances offered in our state (Ohio, if I didn't mention that anywhere). So the transition might be pretty rocky. I'd actually thought about writing another diary about this subject, because it's complicated as well. Short version: the new insurance plans are paying roughly 80% of what the lowest-paying insurance plans currently do. So all the extra work described in the original diary because of the CPCI participation? For the new insurances, we won't be getting a monthly fee from those folks, and we'd be asked to take even less than our lowest-paying insurance provider. This is hard to argue without sounding like a money-grubbing jerk, but I'll just say that if I'm already essentially full every day and not taking new patients anyway, it doesn't make any sense to take on more work for less money.

      So I don't know what all practices are doing, but I'll wager that unfortunately, a lot of doctors won't be accepting the new insurance. This is a really really big deal, I think, but maybe more will take the insurances than I realize.

      Hope that answers your questions some. I don't know that there's any formal transition plan other than people now have insurance and can go to see a doctor in network.

      •  I appreciate (0+ / 0-)

        the input. I don't remember seeing this discussed before.

        Hmmm. . . .

        I do know there was a brief moment when my husband and I were covered by Medicaid because the two kids were young enough and we were poor enough as a family of four.

        The kids had wonderful care, especially my son. But both had no problem seeing their primary care doctor in a reasonable amount of time or on an emergency basis.

        OTOH, DH and I were assigned the closest doctor for adults. He was in the next county north, about a 45 minute drive.

        We never went to him. Didn't do any of the maintenance things we might have. We were happy to have coverage if we had had to go to an emergency room, which we didn't, thank goodness, but that was all it amounted to.

        Which is what the new insurance might be for those who get it (we are in the Medicaid gap) -- emergency care but really no practical way to go to the doctor on a normal basis.

        Hmmm. . .

  •  DEATH PANELS!!!! (1+ / 0-)
    Recommended by:

    Isn't this a death panel?  I was told there would be death panels.  Sounds like a death panel.

    jk.... great diary.  Thanks for pointing this out.  The idea of researching best practices and then sharing that research with the broader community is one of the highlights of ACA I think.

    Forward thinking!

    by TheC on Mon Oct 28, 2013 at 06:50:33 AM PDT

  •  There is a feature in good writing called (1+ / 0-)
    Recommended by:

    getting to the point.

    GOP Wars against: Iran, Iraq, Afghanistan, Immigrants, Mexicans, Blacks, Gays, Women, Unions, Workers, Unemployed, Voters, Elderly, Kids, Poor, Sick, Disabled, Dying, Lovers, Kindness, Rationalism, Science, Sanity, Reality.

    by SGWM on Mon Oct 28, 2013 at 07:37:59 AM PDT

  •  This is very important. (2+ / 0-)
    Recommended by:
    betson08, worldlotus

    Thank you for taking the time to post this and explain why it is so important.

    * Move Sooner ~ Not Faster *

    by ArthurPoet on Mon Oct 28, 2013 at 08:03:46 AM PDT

  •  Now if they could come up with a way (0+ / 0-)

    to make dermatologists increase availability for patients with actual skin diseases (instead of only cosmetic procedures.)  Someone with potentially malignant skin cancer shouldn't have to wait 6 months for an appointment just because other so called patients "need" Botox injections.  
      Melanoma survivor

    My Karma just ran over your Dogma

    by FoundingFatherDAR on Mon Oct 28, 2013 at 11:26:34 AM PDT

  •  Really appreciate the explanation (2+ / 0-)
    Recommended by:
    THirt, worldlotus

    Here in NY we're ahead of the game on the medical home model, and my new doctor uses it. I didn't know the rest of the details, except I thought that doing the bloodwork ahead of time was really efficient.

    The other part of the ACA that I don't see explained much is that it puts mental health coverage on par with physical health coverage, which will mean a lot to a lot of people.

    Helping a food pantry on the Cheyenne River Reservation,Okiciyap.

    by betson08 on Mon Oct 28, 2013 at 01:22:01 PM PDT

  •  Does the ACA do anything about ER costs?? (0+ / 0-)

    Not only does a PCP get paid the same for treating an ear infection as for managing multiple chronic conditions, but get this:  A couple of years ago, I tripped on an uneven sidewalk and the momentum from the heavy bag I was carrying pulled me down onto some exposed tree roots, breaking my wrist badly as you might imagine.

    The ER took x-rays, had them read by a specialist, administered a local anesthetic (although it didn't work), performed a closed reduction to get the 2 parts of a bone back in alignment (don't ask!), and casted the arm.  I was there for about 3 hours, as I recall.  My insurance company paid them almost $900.

    I had a bad reaction to the elastic wrap that was placed over the cast (although they swore it was latex-free) and by 48 hours later the skin of my inner elbow was actually blistering from it.  I called the ER and asked them whether I should go back to them or see my PCP, and they told me to come back immediately.  I went, and the treatment consisted of rewrapping the cast in a different bandage and telling me to take Benadryl.  (At first, they said they would give me Benadryl, but then told me to pick it up at a drugstore instead.)  The place was empty in the middle of a weekday and I was there for maybe 15 minutes.

    When I received the Explanation of Benefits from my insurer, it turned out they had to pay that ER the same $800+ that they had paid for the initial visit!!  If I hadn't been taking painkillers at the time, I probably would have realized that I should ask my PCP where to go, instead of calling the ER, but I wonder how often this type of thing happens.  I also wonder whether it was legal (it certainly wasn't ethical) for the hospital to tell me to return to them when they know the insurance company rules better than the patients do.

  •  In the meantime in Alaska, all efforts to sign up (0+ / 0-)

    folks for ACA is being suspended.

    NOT helping turn Alaska blue at the moment. Come on folks in charge of ACA, make this thing work.

    As a side note, signing up for Medicare Part D plans in Alaska is no easier.

    The system still needs a good overhaul....single payer please.

  •  Why are we finding this out now? (0+ / 0-)

    As bad as this law is I did support it and I do support the effort to provide all Americans with healthcare.  Being that this is what we got now I would have hoped the administration would have rolled it out in a more timely manner and that it would have marketed the ACA much better than it has.  It may be too late to overcome the negative press it is currently receiving because of the glitches in the computer program and now even some Democrats are calling for more delays.  If this happens we may never see healthcare for all again.  

  •  office visits (0+ / 0-)

    Is this guy really a doctor? He doesn't sound like a doc I'd want to use.

  •  It's "HIPAA", not "HIPPA" (0+ / 0-)

    Sorry I'm being picky and all, but as a doctor, I figured you should know that.

    "Please proceed, Governor"

    by betsyross on Mon Oct 28, 2013 at 02:20:39 PM PDT

  •  That does sound like a good thing. (0+ / 0-)

    Now if we could just get rid of the idiotic way insurance companies pass make you go from referral to referral and invite a little bit more collaboration into the process.

    My family has had some very bad experiences with cancer that wasn't caught until it was too late and non-cancer that was caught by good fortune and a determined radiologist literally as the family member was being prepped for surgery she didn't need.

    High costs, bad outcomes.
    This is not health care.
    It's a racket.

    LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

    by dinotrac on Mon Oct 28, 2013 at 02:25:51 PM PDT

  •  If you truly believe what you said.... (0+ / 0-)

    "I'm not implying that physicians are not trying to do a good job or are just in it to make as much money as possible, but let's face it: if you make the same amount per patient, and you can see 30 patients with ear infections or 15 diabetic/hypertensive/hyperlipidemic patients, which would you choose? How would you set up your schedule?"

    Then you are NOT a physician, as you claim. You are merely a businessman with medical knowledge.

    •  The quote was meant to illustrate the point (0+ / 0-)

      I actually agree completely with what you're saying here. That's actually one of the main things I was trying to get across. The incentives for physicians are messed up. The point is that you ought to be paid (at least roughly) the same to see 30 simple visits as you would for 15 complicated visits.

      Put another way, the value to the healthcare system is far greater in keeping diabetes, high BP and high cholesterol in check. Certainly an ear infection can be awful and lead to severe complications if left untreated, but the complications from diabetes are far more grave. So wouldn't it make sense to pay doctors more for the diabetes care than for the ear infection care? In the long run, that will drive down costs for everyone. And ohbytheway keep people healthier longer.

      Unfortunately, the incentives are not properly aligned at this time. But my whole point in writing the diary was to show that things are beginning to shift, with the help of this part of the ACA.

  •  Too much attention can keep people from care (0+ / 0-)

    The provision that is described as exciting, at least as it
    is being implemented by the writer may sound wonderful to him, but "Care Coordinators" who call you up and bug you about getting colonoscopies and such may very well drive people away and keep them from accessing care.

    The "team approach" sounds good on the surface, but
    many people, probably most of them, don't want to have multiple people getting together and making decisions about them, then "educating" them about why they need to do what they are told.

    This may seem "helpful" to the medical providers, but it can very easily seem condescending to patients, many who rather be sick than be treated as children.

  •  Won't this make it harder to find a GP? (0+ / 0-)

    Apologies if I missed something here. My concern is that, while it's great that we're incentivizing people to treat "bigger picture" illnesses that will cut down on healthcare costs, it also seems like it draws more General Practitioners out of the pool.

    I thought part of the problem now with the pool of GPs is that more people are coming out of medical school specializing instead of starting/joining a GP office. This seems like it would make that problem even worse, and if that's true, then who treats the ear infections?

  •  The doctor is an excellent doctor but, ... (0+ / 0-)

    He seems to have no understanding of patient economics. I am one of those with a chronic disease and pay HUGE bucks annually (and am thankful for the discoveries our pharma's made to give me a livable life) and I have studied the economics of health care over the past 50 years.

    When I was young people (even poor people) simply paid the doctor when they left the office. What happened to that? Our doctor/author must be very young.

    Since Medicare was invented, health care costs have risen faster than the cost of living. Why is that?

  •  costs of Obamacare (0+ / 0-)

    The letters from the  insurance bills are arriving now and the middle class is learning that their premiums will double (mine did) under Obamacare.  This is not going to fly.  The GOP will take middle class anger at higher insurance premiums under Obamacare and kill it faster than the disfunctional website is doing.  And it will take down progressives with it.  This is what we get for now fighting for single-payer.  Obamnacare will not last past next March.

    The best gift you can give your friends is your friends.

    by doctor o on Mon Oct 28, 2013 at 05:18:43 PM PDT

  •  Thumbs up ^^. (2+ / 0-)
    Recommended by:
    THirt, worldlotus

    "Basically, CMS (center for Medicare and Medicaid services) provides funding outside of the fee-for-service environment for practices to do a better job of chronic disease management."

    A step in the right direction...

  •  Caring Doctors. (2+ / 0-)
    Recommended by:
    THirt, worldlotus

    I am sure there are many more caring doctors like the one who authored this article, but I have never heard one so enthusiastic about providing better health coverage for his/her patients. I hope more doctors will take the time to express their appreciation for this law that will help more people keep or gain their health in the future.

  •  Side-by-side clinic and ER? (2+ / 0-)
    Recommended by:
    worldlotus, twocrows1023

    I have wondered why hospitals do not set up clinics next to the ER. If someone comes in bleeding to death they go to the ER. If they need non-emergency care take them into the clinic. The clinic could be staffed by NP/PAs and supervisory doctors.

    •  Some do. (1+ / 0-)
      Recommended by:

      But the ones I know of are all at academic medical centers.

      I work in public health research on a campus that uses this setup. The emergency department of our teaching hospital is actually a combined urgent care and emergency room.

      There is a single main entrance and check-in desk. Triage is conducted in small exam type rooms (for privacy) that are located behind the desk area. Urgent care is to the right/south wing; ER is to the left/north wing.

      Historically, the urgent care side also sees a large volume of patients for minor illnesses and routine care (folks with no health insurance so no "regular doctor"). ACA  presumably will change that. Medicaid expansion would help even more, but this is a red state.

      Just because you're not a drummer doesn't mean that you don't have to keep time. -- T. Monk

      by susanala on Mon Oct 28, 2013 at 08:28:23 PM PDT

      [ Parent ]

  •  medical system (0+ / 0-)

    the things Thirt is talking about will not save money. He is just excited about doing more of the same stuff that isn't really working.  Trying to get LDL down to unnatural levels does not prevent heart attacks. It does increase stroke risk, and mess up the brain, which needs cholesterol to function. Mammograms raise the risk of breast cancer 1% for each one, so 10 years of them raises risk 10%. Far better to be promoting thermograms, or breast ultrasound, two newer technologies that are more accurate, more sensitive, and involve no radiation or compression.  
    Flu shots? HA. Equal or better protection comes with taking 2000 or more IU of vitamin D a day, which will also build bones and teeth, improve mood, decrease risks of several cancers, improve blood sugar control, and a long list of other benefits. Why not a single mention of nutrition? Because this and all other doctors get their "continuing education" from drug companies, and their idea of treatment and prevention is drugs.
    If we want to improve this country's health outcomes and save both individuals and government from bankruptcy, we must break the grip of Big Pharma on our health system.

  •  I stopped reading by the 2nd paragraph (0+ / 0-)

    I am not a doctor.  I am not trained as a coder.  I am not knowledgeable on anything medical.  My only experience is marrying an FNP and I code & bill her charts.  (For this post, I am assuming we are talking about a simple outpatient office visit.)

    Your second paragraph says:
    "I get paid the same to see someone for an ear infection as I do to see someone with high blood pressure, high cholesterol, and diabetes."

    In that paragraph, you DO properly describe the ways an office visit should be evaluated per the CMS Evaluation and Management Services Guide, i.e. History, Examination, and Medical Decision Making.

    What I dis-agree with is your blanket statement:
    "you are paid the same to see the ear infection patient as you are to see the person with uncontrolled diabetes, high BP, and high cholesterol."

    Are you telling me that an ear infection requires knowledge of family history to treat?  Does an ear infection require on going monitoring of blood pressure?  Does an ear infection require that you find a regiment of medications?  (I suspect the answer is "no" to this question.)

    My point is: YOU decide the level of effort to put into each of the three key components.  If YOU are putting forth the same amount of effort for an ear infection as you do HTN, then shouldn't you get paid for it?

    If an ear infection requires less effort, then YOU should bill a lessor CPT code.

    No system is perfect but I was surprised to find that the CPT coding system accurately reflects my wife's time, effort, and knowledge put forth in her patients.

    So I thought it was an in justice or me not to continue reading, then I ran across your 4th paragraph. You said:
    "the fee-for-service environment does not really incentivize physicians to focus their efforts on chronic disease management."

    Again... I disagree.  You automatically get a pay bump from Minimal for "one stable chronic illness" to Low, another bump for "one or more chronic illnesses with mild exacerbation" to Moderate, and another bump for "one or more chronic illnesses with severe exacerbation" to High. Each "bump," as I'm calling it, could get you more money for the same amount of time as an ear infection patient.  Thus, my wife focuses on her chronically ill patients more than her ear infection patients.  She also knows her chronically ill patients better; that's her repeat business.  (I only remember her ever treating 1 ear infection patient.)

    Ok.  Time to stop reading and typing.  I'm sure your point of view is valid for your world.  I think the CPT system of coding seems pretty valid for my wife's world.  I see a host of complications for it in the big hospital world... but I don't plan to ever get that in-depth.

    Rob Stokes
    My CPT coding guidelines

    •  There are a couple of built-in assumptions (0+ / 0-)

      But sure, you need to look at a decent amount of detail in order to make the best assessment of an ear infection.

      Let's assume someone comes in complaining of ear pain.

      History: past history is relevant, including any past surgical history (Ear tubes? Sinus surgery?), past medical history (prior infections? Immune system issues? Other recent illness? High BP? That may affect medication choice. Kidney problems?), and social history (smoking status in particular). Maybe there is no relevant history, but you have to at least briefly review all of that.

      Any medication allergies?

      Your history should hit at least four bullet points: how long have the symptoms been there? How bad? What makes them worse or better? Any associated factors?

      You'll have to touch on at least two, probably three or more "review of systems:" HEENT, general, respiratory (fever, chills, body aches, hearing loss, sore throat, nasal congestion, cough, swollen lymph nodes would all be relevant to review).

      Examination should include at least your vitals (temp, BP, height/weight), general appearance, visualization of external ear canal and eardrums, assessment of hearing, nasal and oropharyngeal exam, lymph nodes in the neck, and probably listening to heart and lungs.

      Sure, most of the time, the main relevant findings might be a red swollen eardrum and some nasal congestion, and that's about it. But, clear lungs and no enlarged lymph nodes are certainly relevant.

      If someone is there with ear infection and it is a new problem with no additional work up needed, you have three diagnosis "points" (similar to a diagnosis point for each stable chronic problem). If you prescribe an antibiotic, that is a risk level of "moderate" since there is always some level of risk with any medication.

      Assuming this is an established patient, you have easily gotten enough history to count as "detailed" and you should certainly have touched on 12 bullet points on examination to make the exam level "detailed." Your medical decision making also qualifies as "detailed" for a new problem, no additional work up needed, but prescription medication given. You need two out of three of history, exam, and medical decision making to count as a 99214 visit.

      Assuming this is documented in the chart, you will have a very hard time convincing me that the ear infection appointment is not a 99214 visit.

      Now sure, most of the time, there is not much history there, but you'd better at least review it. Most of the time, there are not unusual physical exam findings, but you'd better at least check the relevant portions. And if there isn't much in the way of pertinent positive findings, the appointment won't take nearly as long as it would to review someone's home sugars, their home BP, their labs, whether they had an eye exam in the last year, whether their pneumovax is up to date, whether they have had a urine microalbumin/creatinine ratio in the last year, etc. But that's the whole point: you actually need to do a good amount of work to properly diagnose and treat an ear infection. You're certainly doing more for the diabetic, hypertensive, hyperlipidemic patient. But for now, both appointments would meet criteria for a 99214, which I think is kind of foolish.

      Sure, if someone comes in and says their ear hurts, you take a quick look, see that it is red, and give them amoxicillin, that's adequate more often than not. But I'd think most people would prefer a little more thorough appointment. The few extra minutes spent may very well uncover something else that will require attention.

  •  and how do we find one of these clinics? (0+ / 0-)

    I googled my city and CPCI, and got something about hardware manufacturing.

    •  Try the link in the diary (0+ / 0-)

      It should take you to the Medicare site which lists the practices by location. I couldn't tell you which sites are accepting new patients but the above link should at least be enough to get you started.

  •  Doctors vs clinics vs Naturopaths (1+ / 0-)
    Recommended by:

    My daughter had no ins. she became very ill. She went to a clinic for close to 30 visits over a 6 month period, they kept telling her she was fine according to her blood tests, she kept getting sicker and felt as if she were dying. her heart started doing weird things, she was having dizziness and nausea her appetite became voracious which was extremely unusual for her since she never really like to eat much, she told all this to the clinic Drs, they did nothing to help her to get better. Her aunt paid for her to go to a Naturopath Dr. the Naturopath looked at all her lab tests, spent 2 HOURS with her doing an extensive health backround which featured dietary, allergies etc.  she had gotten a hair analysis and that showed off the charts levels of lithium, mercury, and arsenic. She had never taken litium in her life (we assume these came from the city water she had been drinking for 5 years or food arsenic is found in rice, the mercury was from her tooth fillings). The naturopath put her on a special diet told her what natural, over the counter supplements to take and in what amounts, found out her potassium was way too high, also discovered her body was not absorbing B12 and her vit D levels were too low, She put her on a detox for her system and she started getting better in just ONE WEEK. She was found to have hypoglycemia as well and even though she told the Dr at the clinic all her symptoms and they fit the classic symptoms of hypoglycemia the clinic did not diagnose her with that after almost 30 visits. We never had any good outcome from any clinic, I've been to ones and they always seem to want to prescribe the generic meds (which they say are the same but are NOT) with the worst side effects like the flouroquinolone antibiotics which have been outlawed in some countries and should only be used as a last resort if all other antibiotics have been tried and don't work. I can't help but think it's like a culling, don't diagnose the poor who go to clinics and hope they die> presto more savings. I have not found regular medical Doctors to be as thourough as the Naturopath. I really feel like she could have died had she not gone to the naturopath. I do not understand why alternative medicine is not paid for by insurance, why not let the patient decide what kind of Dr they want to see? in our case we got better results from the Naturopath

    •  It's been my experience (0+ / 0-)

      after working as an X-ray tech for 15 years and as an Acupuncturist for 23 years that western medicine is generally very, very good at trauma and emergency medicine. It is not so good at "functional" medicine, which is where many of us have our greatest problems.

      Acupuncture and Chiropractic are covered by insurance in California; I'm not sure if naturopathy is yet. It depends on the licensing from state to state.

      Also, don't be discouraged if you don't get any other responses to your comment, since the diary was published on October 27th and people have moved on. But feel free to comment in more recent diaries as well.

      Welcome from the DK Partners & Mentors Team. If you have any questions about how to participate here, you can learn more at the Knowledge Base or from the New Diarists Resources Diaries. Diaries labeled "Open Thread" are also great places to ask. We look forward to your contributions.

      Oh, I used to be disgusted
      Now I try to be amused
      ~~ Elvis Costello

      by smileycreek on Wed Nov 06, 2013 at 04:12:48 PM PST

      [ Parent ]

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