There is a massive scandal raging at Michigan State University and widely across the national women's gymnastics program. One physician, left largely unsupervised for decades, is alleged to have committed perhaps hundreds (or more) sexual assaults on innocent athletes, some of them minors. We had policies for physician offices 25 years ago. Apparently not everyone was paying attention. A draft chaperone policy can be found at our Dropbox link. Updates will follow. This is NOT legal advice.
The U.S. health
care system was complicated before the Affordable Care Act, and the
overwhelming complexity of ACA made it much worse. Add to this
thousands of pages of Obama-era regulations and there is a lot to
know about the current health care system.
This cannot be
fixed with slogans.
The GOP Menu (maybe)
tanks and the GOP have been circulating the same ideas for decades.
Accounts – good for the affluent, not so good for anyone else
of health insurance – does absolutely nothing for consumers,
except expose them to lousy insurance plans - but good for lousy
insurance companies and salesmen
consumer choices – as in buying oncology is like buying a
subsidies, replace with tax credits (subsidies!)
for Big Pharma – yes, Congressmen are for sale (both parties)
Medicaid – give Medicaid policy to Sam Brownback and Paul Lepage -
Send poor people
back to Emergency Departments (which hurts hospitals)
So What Am I Saying?
The GOP does not
have a coherent plan to replace the Affordable Care Act and may never
have such a plan. There will likely be a repeal, total or partial,
but the replace will be difficult.
The GOP might
eventually have a plan to make Rush Limbaugh, the Koch brothers, the
Tea Party and Fox News happy, sort of. Even that may fail.
The GOP has been
blaming ACA for higher consumer costs (higher deductibles and
co-pays) , and may replace ACA with a plan with – you guessed it –
higher deductibles and co-pays,, including for seniors.
Repeal and Replace, or Partial
Repeal and Partial Replace, or Reform and Repair, or ?????
On Super Bowl
Sunday President Trump told Fox News that “repeal and replace”
could take up to a year. Huuuge!
A few days earlier
Rep. Jim Jordan, on the far right wing of Congress, said the total
and complete and quick repeal of ACA was the only viable strategy.
In the last ten
days or so “repair” has become a popular word, often in a phrase
such as “reform and repair.” This implies that not all of ACA
would be repealed, some of it would be repealed and new features
would be added as a repair.
Republicans in Congress and get seven or eight different answers.
There is also squabbling about whether health care should be done
before tax reform. The House majority and the Senate majority have
different ideas, and the Senate majority is pretty thin.
So, the GOP has
painted itself into a corner. The GOP could recover, stranger things
have happened in Washington, but as of early February consensus is
not looking either quick or easy, which makes near term legislation
IF, repeating IF
the GOP can agree on a plan, the various pieces and parts must
through the legislative process. Some parts could move through
reconciliation, others through the standard legislative process. This
could cause a problem in the Senate.
The Longer Term
House Speak Paul
Ryan has promised to”fix” Medicare.
There are ways to
fix Medicare, but Ryan apparently has no clue. There are serious
reform efforts already in motion to move Medicare from the original
fee-for-service model to a more sophisticated value-based model, the
legislation passed by bipartisan votes.
His approach is to
turn Medicare into a for-profit play pen for insurers and doing
tremendous damage to senior citizens. Wow.
President-elect Donald Trump has started inauguration week by promising to unveil a new replace plan for the GOP repeal-and-replace project.
Trump is now promising, or at least dancing around promising:
universal insurance coverage
In other words, none of this is realistic in the slightest. Reality is no longer a concern.
The only way "inexpensive insurance” works is if it really “cheap insurance.” Also known as lousy insurance.
Reports have Congressional Republicans wondering where this came from and what it will look like. Not to mention, what it would cost? And how is it conservative?
Trump has at least one good idea, the Medicare and Medicaid programs should be able to negotiate fixed prices with Big Pharma. Problem is, Congressional Republicans are committed to protecting Big Pharma even if the taxpayers continue to be cheated.
The Republican Party will control all branches of government
in January, and has a stated purpose to repeal and replace Obamacare (properly
the Affordable Care Act).
Repealing Obamacare may not be as easy as it sounds, and replacing it has many risks
Both parties agree the system needs reform. That is about
all they agree on.
Obamacare care is much more than a piece of legislation, it
is now six years of regulation and innovation, and is intertwined through the
health care system. There is no unpeeling of an apple.
There has been much to like about the intentions of
Obamacare, even if the design and
implementation were often
wretched. The latest regulations on Medicare physician payment run to 2171
pages of complex and convoluted
Obamacare gets a good grade on intentions, but not so good
on design or operations. Still, a full operational repeal is not possible, too
many changes are ingrained into the system for a full.
Timing is everything. I just finished reading House Speaker
Paul Ryan's A Better Way plan
including the health care section. Whether or not Ryan is popular with his own
membership, his health plan lays out the key ingredients of any GOP or
conservative health reform plan. I am not impressed.
Leading the list are Health Savings Accounts (HSAs) and the
interstate sale of health insurance policies, neither of which are likely to
provide the salvation promised.
Health care markets do not work like the markets for buying a shirt, a car or a head of lettuce. The HSA idea may
be overrated as a tool of salvation, but good for the affluent.
The interstate sale of insurance policies saves money only
if the insurers under price their products, and that can only happen for a few
years before something bad happens. This is much like several of the ACA
exchanges. I fear interstate sales will empower 1-800-Lousy-Policy companies, a
consumer nightmare in the making.
The replace program promises cost savings through consumer
choice, a profound misreading of how consumer find and use health care.
Like most GOP initiatives, the plan works well for the
affluent and not so well for anyone
else. And when the GOP talks about “protecting Medicare,” I know we are in trouble. The pro-life GOP
will find a way to punish Medicaid recipients, count on it (and punish
hospitals in the process).
Curiously, the GOP plan for patient protection includes many features – wait for it – of
Obamacare, just without the details. Lots of buzzwords though.
Perhaps I am a bit too cynical, but I think not. The Trump
administration will be a wild ride on many counts, and not the least of it will
be health care.
The Republican Party won all three branches of the federal government yesterday, which means the "repeal and replace" program for Obamacare will begin in earnest in January. This is going to be interesting. What do we do now? Stay tuned.
The American Health Care Association has filed suit again the federal government, challenging the prohibition of coerced arbitration agreements in long-term care admissions. ( https://www.ahcancal.org/Pages/Default.aspx) The lawsuit challenges regulations published in the new long-term care regulatory package (https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-23503.pdf). Providers use the arbitration to protect themselves against malpractice and business practices litigation. Providers think the malpractice system is a holy mess (which it is). Consumer advocates think arbitration is an attempt to deny due process to residents and families (which it is). U.S. businesses have increased the use of arbitration to avoid the courthouse and to deny due process to customers, employees, patients, etc. The push back is coming from the federal government.
Long-term care: Two weeks ago DHHS-CMS issued long-awaited updates on nursing home regulations. The package, 700+ pages, is largely updates and clarifications, plus the new compliance standards (which were due March 23, 2013).
Last week the new regulations on physician reimbursement dropped, all 2, 398 pages. Gasp. The regulations begin a phase-in of the MACRA reimbursement system, replacing the failed SGR. In brief the system will evolve from a failed fee-for-service system to a value-based system. Essentially this is a good idea - if it can be implemented. The feds have already admitted that small and rural physician practices are in a bad spot, and there are phase-in rules. Much heavy lifting. Stay tuned. https://qpp.cms.gov/docs/CMS-5517-FC.pdf https://qpp.cms.gov/education
______ DHHS-CMS = Department of Health and Human Services, Centers for Medicare and Medicaid Services MACRA = Medicare Access and CHIP Reauthorization Act of 2015 SGR = sustainable growth rate
Patient Protection and Affordable Care Act (PPACA or ACA or
Obamacare) contained a requirement that long-term care facilities
have a compliance program by October 23, 2013.
regulations were not ready on time.
regulations were finally dropped into the massive regulations package
to be published on October 4, 2016. [Code of Federal Regulations
a facility does not have a compliance plan, it should not wait more
than a year to comply. In a highly regulated environment enforced by
numerous criminal laws and civil sanctions a compliance program has
really been necessary all along.
heart of a compliance program is billing integrity, when you ask the
government for a check you certify the billing is accurate.
Facilities are subject to the false claims act and the anti-kickback
statute plus other civil and criminal penalties.
integrity is not the end of a compliance program.
Given the massive
regulatory program facing LTCFs the program must be broader.
regulations delineate a minimal standard as well as a standard for
groups with five or more facilities. Facilities are free to exceed
the minimum expectations and a more robust program is advised.
a compliance program more expense and work with no benefit? No, it
should be much more. A compliance plan can prevent government
sanctions and can also serve as a performance audit for numerous
aspects of your operations.
The “self-survey” used by many facilities are a preliminary
approach to the state survey which is a type of performance audit
that ties nicely to a compliance program.
My wife recently retired from a distinguished career as an
RN, and I have been alleged to know a little bit about health care.
So, like the proverbial doctor at a cocktail party, we get
asked about health care issues and health services. We gladly give the best
advice and best referrals we can.
We are also are the recipients of a great deal of venting
about problems in the health system. Lots of venting. And lots of venting about
the failure of the system to be even a little coordinated.
Some of the venting is shocking. The lack of coordination in
oncology care in some systems is almost scandalous. But oncology is not alone.
The era of hospital employed physicians is clearly causing
Patient: “When will I see my doctor, Dr. Smith?”
Nurse: “You won't see Dr. Smith until you are discharged,
here you will see the hospital doctors.
Patient: Well, who is that?
Nurse: “ Dr. Jones will be your cardiologist, except on
weekends when it will be Dr. Brown, but after 8:00 pm it will be the cardiologist
on call. Dr. Clooney is your hematologist and Dr. Pitt is your gerontologist,
except of course for after 8:00 pm and weekends and their day off.”
Patient (slowly): “Oh... my... God.”
And we wonder why patients are confused? Are we close to
violating informed consent standards with this parade of physicians?
Surgery patients are a little luckier, at least they know who
is in charge of the parade, usually.
And it can be worse after the discharge. Something even
worse happens when patients are referred to physicians willy-nilly, and after
the fact discover the physician is out of network. How do they find out,
usually when a huge bill comes in the mail three weeks later.
So who is to blame for this? Everybody and nobody.
The health care system has been evolving rapidly since 2010,
and most providers are trying to evolve and accommodate the change.
The September 2016 edition of the Annals of Internal
Medicine gives us a grim report – the employment of physicians by hospitals
has not improved care. The alleged benefits of better coordinated care, well,
are not benefits so far.