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Tuesday, July 22, 2014

Affordable Care Act---F.U.B.A.R. Supreme Court Throws out Subsidies for Federal Health Benefit Exchanges

Court Deals Setback to Health Care Law

WASHINGTON — A federal appeals court ruled Tuesday that the government could not subsidize health care premiums for people in three dozen states that use the federal insurance exchange, a ruling that could upend President Obama’s health care law.
The 2-to-1 ruling could potentially cut off financial assistance for more than 4.5 million people who were found eligible for subsidized insurance in the federal exchange, or marketplace.
Under the Affordable Care Act, the court said, subsidies are available only to people who obtained insurance through exchanges established by states.
The law “does not authorize the Internal Revenue Service to provide tax credits for insurance purchased on federal exchanges,” said the ruling, by a three-judge panel of the United States Court of Appeals for the District of Columbia Circuit. The law, it said, “plainly makes subsidies available only on exchanges established by states.”

For many people, their share of premiums could increase sharply, making insurance unaffordable


Share Your Experience With the Affordable Care Act

Friday, July 18, 2014

Health Care Reform......Do the Number of Enrollees really Matter?

The first five months of this year haven't brought more patients into doctors' offices, despite a large increase in sign-ups during the open enrollment for health insurance exchanges, according to a new report from the Robert Wood Johnson Foundation (RWJF) and athenahealth.
In fact, there was a slight drop in percentage of total visits with new patients compared to the same period last year.

This early finding on the effect of the Affordable Care Act may be misleading.  The reasons may be multiple. The argument that ACA will reduce costs by sending more patients to primary (and, in theory, preventative) care may not hold water, either, contends a post on a New York Times' blog post. .0

The RWJF report said the lack of change in patient volume might be caused by newly insured patients who are still unfamiliar with the healthcare system.
Many may have continued to seek care in emergency rooms instead of physician offices, for example, which could be because consumers don't understand how insurance works. A study published in the Journal of Health Economics found that only 14 percent correctly understood four basic insurance concepts--deductibles, copays, co-insurance and out-of-pocket maximumsFierceHealthPayer previously reported.

The Times post makes another point about patients who seek emergency care: "It is true that some people use the emergency room for minor problems. But that lack of access isn't all about insurance. Even for the insured, one of the major reasons people use the emergency room is that it's more convenient. That doesn't change with the ACA."

Another barrier to access:, it's likely taking some consumers with new exchange plans more time to shop for doctors, schedule appointments and see their new doctor, particularly if they have plans with narrow networks that limit provider choices, according to the JWJF report."

There has been an uptick in states with Medicaid expansion plans, although there is no indication that patients with chronic disease are seeing more providers.  The rate limiting factor in primary  care may be that it is already at capacity and there is no ability, or little to see more patients.  In fact many patients often see a specialist who will offer primary care. Networks an managed care attempt to limit this by blocking access to specialists, requiring primary care referrals. In fact insurers often deny a payment if their is no primary care referral. Prmary care doctors may also be 'maxed out' in processing referrals to specialists.

Based on my own experience primary care doctors may spend 10-20% of their day processing referrals, learning new network providers and deleting former providers due to narrow networks, which in turn will increase the patient load on select specialist increasing wait times for appointments. Patients are well advised to learn the specialists in their network to avoid delays and call for direct appointments after the referral is made.  Patients are creative, innovative and specialists will 'work around' the system as they have done for many years,  leaving te insurers to play with their meaningless paper work

Direct payment and concierge medicine is growing rapidly, and a quick cost comparison between what is called conventional medicine and direct payment reveals suprising and significant cost savings for most patients.  Insurers now are relatively safe following rules, and regulations imposed by state insurance commissioins who strictly set standards and scope of care in the na me of cost containment.  They would do far better by rejecting state and federal rules.

For the first time providers, patients and insurers are closer together in opposing what has been forced upon us all,  by our congress, which passed the affordable care act.  In our democracy the people do have power to vote them out of office.  President Obama is not the problem although he catalyzed events leading to passage of the ACA.

"These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for," the report said.

RWJF and athenahealth also determined that there hasn't been a rise in chronic conditions being diagnosed, meaning that so far new consumers aren't sicker than people who have had coverage. 

To learn more:
- here's the RWJF/athenahealth statement and report
- read the New York Times post

Tuesday, July 15, 2014


Number of Medi-Cal Providers Down by 25% in Spring 2014

Recently Paul Krugman a well known op-editorialist for the New York Times said, 

"Obamacare Fails to Fail"

How many Americans know how health reform is going? For that matter, how many people in the news media are following the positive developments?  

Nearly 25% fewer doctors participated in Medi-Cal during spring of this year than in the spring of 2013, HealthyCal reports. Medi-Cal is California's Medicaid program.   
The drop comes amid a significant increase in Medi-Cal beneficiaries.


Since Medi-Cal was expanded under the Affordable Care Act, more than two million individuals have enrolled in the program, bringing total enrollment to 10.6 million.
Meanwhile, about 600,000 Medi-Cal applications still are pending.

Details of Provider Participation

According to the state Department of Health Care Services, 82,605 doctors were enrolled in Medi-Cal in spring of this year, compared with about 109,000 in spring 2013.
Of participating doctors in May 2014:
  • 43,760 were specialists; and
  • 38,845 were primary care providers (Guzik, HealthyCal, 7/14).

Reasons for Decrease

Providers have noted that Medi-Cal reimbursement rates are among the lowest Medicaid payment rates in the country, and that low rates could cause doctors to stop treating Medi-Cal patients because their overhead costs outstrip reimbursements (California Healthline, 6/23).
However, DHCS spokesperson Anthony Cava said the drop in participating physicians is the result of the agency's efforts to remove providers from the program who have not:
  • Complied with the program's updated application requirements; or
  • Billed the program in 12 months or more.
Cava added that the updated application rules "have strengthened the department's ability to deny or terminate providers who do not comply."

Implications for Access to Care

Cava said that the drop in participating physicians "has not resulted in a decrease in access to care."
Further, he said the agency's provider lists do not specify whether physicians are accepting new patients or how many they are accepting. For example, Cava said that while some physicians on the list have treated about 2,000 Medi-Cal patients, others may only treat a couple or none (HealthyCal, 7/14).
Mr Krugman is an authority on economics and a Nobel Prize winner.  No one should question his theories or opinions .  The problem is that he and others have never had responsibility for individual patients, nor that the health system may sign up all these new consumers, and will fail to deliver...
Empty promises, reassurances, and like Sex, Lies and Videotapes leaves only disappointment and justified anger.
Attribution:  NY Times, California Health Care Foundation

Saturday, July 12, 2014

Patient Satisfaction....What is it ? What it is Not

3 Reasons Patient Satisfaction is More Important Than Ever

Social media, insurance coverage and patient experience are main drivers

How to balance patient satisfaction and quality care

"In essence, we want physicians to care about satisfaction, but not too much," Joshua J. Fenton, M.D., MPH, of the University of California, Davis, recently toldMedscape in an interview following up on his team's 2012 widely cited studyindicating that highly satisfied patients had higher hospital admissions, higher drug expenditures and were even 26 percent more likely to die.
The study has garnered both support and criticism during the two years since its publication in the Archives of Internal Medicine. With the opportunity to clear up misunderstandings in how the findings have been interpreted and offer current insights, Fenton made the following points:
  • In most settings, technical quality of healthcare is invisible to patients, and therefore has a weak relationship with patient satisfaction. "For example, in preventive healthcare, there might be an unadjusted relationship between patient satisfaction and receiving an appropriate cancer screening test," Fenton said, "but when you adjust for patient characteristics and other confounding factors, that relationship is no longer present."
  • Any incentive, if weighed too heavily, can become perverse, so "excellent" satisfaction at every encounter may not be an effective goal. "When difficult issues are raised, such as a patient's ability to drive, a possible substance abuse issue, or perhaps poor exercise habits, patients may have an affective response that leads to lower satisfaction," he said. "Yet compensation schemes that unduly award maximum satisfaction would discourage these important conversations."
  • Physicians in the bottom 20th percentile of satisfaction scores may need communication training. Physicians scoring well below their peers may likely be making "simple communication missteps" that can be easily corrected with the help of a trusted supervisor, colleague or consultant, Fenton said. "On the other hand, if a physician's satisfaction scores are in the middle of the bell curve for his or her peers and this physician is doing his or her best to communicate with respect, empathy, and care, then we have no compelling evidence to force that physician to change," he concluded.

In a surprising new study published in the Archives of Internal Medicine, patients who rated themselves as most satisfied with their doctors not only incurred 8.8 percent higher health expenses in a two-year period but were also 26 percent more likely to die shortly thereafter than those who rated themselves as less satisfied. In addition, the analysis of 51,946 patients' surveys revealed that although satisfied patients were less likely to visit emergency departments, they had more inpatient admissions.

More immediately, the takeaway for physicians may be that despite the benefits of patient satisfaction in keeping patients loyal and engaged, it's important that servicenot be confused with medical decision-making. In other words, there is probably no downside to offering convenient hours or streamlining a practice's phone systems, for example, but when it comes to deciding medical treatments, the "customer" is not always right.

"Practicing physicians have learned--from reimbursement systems, the medical liability environment, and clinical performance scorekeepers--that they will be rewarded for excess and penalized if they risk not doing enough," wrote Brenda Sirovich from the Department of Veterans Affairs Medical Center in White River Junction, Vt., in an accompanying invited commentary. "It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."

Tuesday, July 8, 2014

The New Era in Health Care

Californians report roadblocks in new era of health care

 Inaccurate provider lists are among the challenges facing customers as many transition from the ranks of the uninsured under the federal health care overhaul. Covered California, the nation’s leading state exchange, alone has signed up 1.4 million people through the Affordable Care Act.

“Health plans often use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians often do not know that they are listed as participating in certain network.

Read more here: than 1,800 complaints about the process were submitted to state regulators through June 8. Customers have complained that they haven’t received their identification cards and enrollment packets. They’ve said they had trouble navigating narrow networks to find a doctor who will take their coverage.

Thursday, July 3, 2014

Hospital CEOs--Not Doctors--among Medicine's top earners

NYT finds healthcare exec pay eclipses salaries of surgeons and general physicians

Healthcare and insurance executives' base pay outstrips physician salaries, according to an analysis for The New York Times by Compdata Surveys. 

Wednesday, July 2, 2014

Veterans Administration Debacle.....New or a Chronic Problem

No one should be pleased with the recent publcity regarding the VA hospital situation.

VA officials, Democrats work to offset scandal damage

As Department of Veterans Affairs (VA) hospitals work toward solutions to delayed care, vulnerable Democrats want to mitigate damage from the revelations surrounding the scandal.
The VA administration has taken several steps to fix departmental problems, So far, various agencies conducted several reviews and investigations, including a report from the VA's independent office of inspector general, an internal audit and a broad review of the VA network pointing to a "corrosive culture" in which management retaliated against whistleblowers, 
In addition, the VA banned executive bonuses and made several leadership changes; VA head Eric Shinseki resigned in June, and President Barack Obama this week nominated former Proctor & Gamble CEO Bob McDonald to replace him. In the meantime, interim VA Secretary Sloan Gibson reached out to more than 100,000 wait listed veterans to schedule appointments and discuss their healthcare needs, according to the Washington Post. Furthermore, the VA removed seeing patients within 14 days of appointment requests as a goal, a target White House advisor Rob Nabors called said was unrealistic, overly vague and had potentially "incentivized inappropriate actions."
The director of Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis is touting the results of steps the facility took to fix problems, telling visiting members of Congress that patient wait times are down two-thirds,according to the Indianapolis Star. Director Tom Mattice said the 229-bed facility reduced average wait times from 42 days to less than two weeks.

Obama to name former Proctor Gamble CEO as new VA head

Bob McDonald tapped to replace Shinseki as Secretary of Veterans Affairs

The choice of a successor to Gen Sinsheki is a bit out of the 'box' Typically the head of the VA is chosen from a list of military generals with a large amount of experience in military and government organization. Although Bob McDonald graduated from West Point and had a relatively brief career in the military, his most recent success was as head of Proctor and Gamble. His position at P&G (80 billion dollar business) gives him a strong consumer oriented approach to a product.
The VA administrative organization is heavy with ex-military personnel who have a direct path to civil service positions when they retire from their military activity. Their strength may be in organizational and hierarchal decision making, but lacks a patient oriented attitude unless they were in a health care related positon in the military.
The rigidity of the VA does not readily adapt to patient needs, and the prevailng attitude is to squeeze the patient into the system, instead of designing a system to fit the patient.
The change in leadership in this direction indicates that a 'patient centric' approach will mimic the change in other areas of health care.