Obamacare: Prognosis Terminal

Health Insurance Exchange Fails its Physical

Politics and science work together about as well as politics and religion.
What about politics and education… energy… economics… ?
Come to think of it, politics doesn’t get along with anyone.
So it’s no surprise that problems arose when politicians got involved in healthcare.IMG_3979

This blog is not about politics. You’ve had enough of that.
I’m writing about access to primary care.

I’m a family doctor explaining why I won’t be a part of Obamacare.
And it’s not because of politics.
In fact, most primary care physicians are opting out.
Because we simply can’t afford to participate. I’ll explain why.

IMG_4122Primary care costs less than your cell phone. And more Americans have a cell phone than have a family doctor.  Obama gave away phones during his campaign.
Now, some politicians want to give away family doctors.
But we don’t take too kindly to being given away.

Here’s the thing. While educated and powerful people debate the failure of a website, the nuances of a law, and the moral obligation of a country to provide healthcare, most of them have overlooked the obvious. We are just flat out of primary care physicians.
Kaput. Empty. No room at the Inn.

Let me spell it out for you.

1) There aren’t enough primary care physicians to care for Americans.
Obamacare doesn’t help that. There is nothing in the Affordable Care Act to enhance primary care. Nothing to motivate more physicians to choose a career in primary care. No incentive to keep established PCPs in practice. Nothing to expand our offices or reward the wonderful people that work in them. No increased pay, no less paperwork, no fewer regulations. In fact, the opposite is true. We have more laws and taxes, confusing rules, and increased overhead.

2) Policies being sold by the Insurance Exchanges have very high deductibles.IMG_4111
Most Americans with insurance know that a deductible means that they will have to pay for the first $5000 of their healthcare. But the patients who can’t afford insurance, even if their plan is subsidized by the ACA, still can’t afford to pay their deductible. The ACA was to help those 30 million people who couldn’t afford insurance. But even if the insurance premium is tax subsidized, how will these patients be able to afford their deductible? By the way, that deductible happens in the PCP office. So who doesn’t get paid? The primary care physician.

3) Most hospitals are not even in the Insurance Exchange networks.
Once a deductible has been met, which is usually within the first few hours of a hospitalization, the hospital can anticipate getting paid. Even knowing that, most hospitals have opted out of over 2/3’s of the Exchange’s insurance plans. There are few things harder for a primary care physician than trying to find a hospital bed for a seriously ill “out of network” patient. It would be better for the patient to have gone directly to the hospital ER instead of to their PCP’s office. If a patient is already in the ER, the rules requiring a hospital to keep a sick patient could help. But doesn’t going to the ER first raise cost?

4) The preventive care coverage is very limited as to which services are covered.
All non-covered services will go to the deductible. Meaning the patients who couldn’t afford insurance must still pay for their illness care. Patients are confused by this and get angry at the PCP because they expected a “free physical”. When told that “your physical is covered”, patients bring long laundry lists of their medical problems that have been neglected. These need significant attention. Disease care is not covered as part of a screening preventive exam. The lab tests, and the physician’s time to evaluate these problems, are not “preventive care”. There is no provision for PCPs to be paid for this care. It goes to a deductible and primary care doesn’t get paid.

IMG_37485) If a patient doesn’t pay their insurance premium, the PCP must refund the insurance company. The Insurance Exchange policies have a 90 day grace period. A patient can sign up for insurance, see a physician between days 30 and 90, then chose not to pay their insurance premium. The PCP that cared for that patient will be notified by the insurance plan that the patient didn’t pay for the insurance, the policy is cancelled, and the PCP must refund to the insurance company all fees paid. If the PCP doesn’t refund the insurance company, the funds will be subtracted from the next payment. The insurance company is protected. The PCP bears the risk and takes the loss.

6) The earliest enrollees will be the sickest.
The young, healthy people that were “forced” to buy insurance are not signing up. The healthy seem to prefer paying the $95/year penalty instead of paying hundreds of dollars each month for a high deductible plan. Without the healthy enrollees, the price will soon go up. Meanwhile, overworked PCPs that participate in the Exchange plans will be assuming care for those patients who were sick enough to fight through the enrollment process. These are the patients that need the most care, or have neglected the most serious medical conditions. These patients have put off their care because they couldn’t pay for it. When the PCP delivers comprehensive care and expensive tests, those charges will go to the deductible. You see the pattern here. The PCP bears the cost once again.

7) Your PCP is already providing charity care every day.IMG_3828
Primary care physicians quietly provide free care in their offices every single day. We can’t advertise our charity because we would be overwhelmed. Everyone has a friend or a family member that needs free care. And unlike non-profit hospitals, no one subsidizes our charity. We can’t afford to market our giving, and we’re not very good at saying “no”. So like the thousand points of light that make our country brighter, we quietly tell a patient “no charge today” or “pay me when you’re able”. Warm handshakes aren’t taxable.

Primary care physicians have been caring for the uninsured and the underinsured for much longer than Obamacare. Primary Care is the greatest value in healthcare.
Now, more than ever, it’s time to remind our nation,
“We’ve been here for you, we’re still here for you. Let’s keep the politics out of it.”

Guy L. Culpepper, MD

You Make Me Better

Our Team is Our Strength

My wife and I just returned from Wyoming for our anniversary trip.IMG_5416
27 years of marriage.
She tells me it feels like 27 minutes… underwater.
Who am I to argue?

Marriage is much like Primary Care.
It can be suffocating and elating, tearful and joyful.
Sometimes all in one day.

We left together and we returned together. Which is one answer to the question,
“How do you stay together for so long?”
Hang on and keep moving. Together.
The passion for marriage, much like for medicine, ebbs and flows.
So it is with tides, careers, hormones, and opinions.
Of course, the love is always there.
But at times, it’s less about love and more about holding on.
Primary care physicians are like my remarkable wife. They are very good at holding on.

Here’s another key:
(and you can forget everything else, if you just remember this)
Know that your partner makes you better.

When times are tough, when you’re tired, sad, or forgetful, turn to the ones around you.
Your team is your strength.IMG_5245

Some of the greatest people that I’ve ever known are physicians.
But this post is not about physicians.
It’s about the team that makes physicians better.

As our country struggles with ways to improve primary care,
we must be certain that our team is also rewarded.
We could not do what we do, as well as we do it, without these wonderful people.

IMG_5354Many of my patients are willing to put up with me because of the pleasant greetings that they receive from my front office staff.
My receptionist’s smile can make you feel better.

When my medical assistant reminded me about your drug allergy, she added it to your record. I looked like an attentive physician. I was attentive because she was.
It was my medical assistant that saved your life.

I am better because of my team.

I can remove your mole. Expertly. But you’ll want my assistant to draw your blood.
She has a gift. You’ll hardly feel it. She also gives much better shots than I ever could.

My nurse knew the moment she brought your husband into the exam room that he was really sick. I was with another patient, but she had the foresight to check his oxygen level. She’s very good at knowing when someone’s in trouble. She called the ambulance.
I gave her the flowers that you sent.

Oh… and about remembering the school that your son attends, which pharmacy you use, and the last time your mother in law visited you… yes, my medical assistant reminded me.

I am surrounded by dedicated and caring people. They make me better.

Our office is clean because of the delightful people that come in around 10 PM every night to clean it. Yes, I’m often here to see them. That’s a different post. You would notice if they didn’t show up. Doctors and nurses can be very messy.

Then there’s the business side of what we do. It’s called managing an office.
Somehow, a thousand times a day, our office manager does the impossible.
Orchestrating the moods and needs, complaints and requests, credits and debits
of a business wound tighter than a worn out pocket watch.
Every now and then someone says, “Thank you.”

Improving and rewarding primary care

improving and rewarding the people around us.

Independent primary care physiciansIMG_5374
must be rewarded for providing the
foundation of our nation’s healthcare.

And that reward must be sufficient
to share with our entire team.
Our partners make us better.

By the way, when my wife comes
up to gather air for another 27 years,
I’ll be telling her “thanks” too.
There’s nobody I’d rather be underwater with.

Guy L. Culpepper, MD

Wellness. Seriously?

There is no “I” in Wellness

Look up “Wellness”.meditation
Bam. 270,000,000 results.

Enough for all 114,000,000 United States households.
Plenty of wellness is available.

Wellness must be very important. Every healthcare provider in America, from cardiologists to chiropractors, emphasize it on their website. And every insurance company sells a program for it. You’ve seen the ads. That much caring could make a person cry.
In fact, you should be downright ashamed if you’re not promoting wellness. Right?
If not, you must be one of those people that promote sickness. What? That’s silly.

What is Wellness?

The National Wellness Institute defines wellness:meditation nat geo
an active process of becoming aware of and
making choices toward a more successful existence.

Now that’s deep. Boring, but deep. Like a well.
I get it… wellness is well… OK, I don’t get it.
Neither does anyone.

When you google “Wellness Programs”, you will get 57,600,000 results.
That’s about 57,600,000 more results than the actual wellness programs get.

Employers spend over 2 billion dollars each year on wellness programs, not counting the money spent on in-house policies, rewards, and initiatives. Money that could be used to facilitate primary care. That’s enough to pay for one office visit for each of the 25 million uninsured that we’ve turned our economy upside down trying to help.
It’s enough money to raise the income of every practicing primary care physician in our country by $10,000 a year.
Primary care… you know… those people that provide the real preventive care for our country. The ones that are getting harder to find.

Primary care physicians, in contrast to wellness programs, have been shown to improve healthcare and to lower costs. Real data. Real science.
But wellness programs market more effectively. They’re out there selling their stuff.wellness catfood

Our country seems determined to buy wellness.
As if the more money we spend, the more well we can be.
The bleeding edge of wellness.
The most wellness you can buy.
You need the latest version of wellness.”
“You don’t want last year’s wellness.”

Businesses feel obligated to purchase some type of comprehensive implementation of wellness protocols, with onsite biometric analysis and real time maternalistic nurturing feedback. If a company cares about its employees, it will invest in wellness. It’s right there in the brochures. There are actual contests to see who has the biggest wellness program. Spending more equals caring more. Right, parents? Oh? That explains a lot.

There is no consistent evidence that wellness programs work.
Sure, lots of companies sell these programs by quoting data of $3 returned for every $1 spent on wellness. But this data compares the worker’s who participate with those who don’t. Motivation is what made the difference, not a specific program. And even the data on those engaged has not yet shown statistically significant healthcare cost reduction.

Motivation drives outcomes. It also skews results.
Science calls that bad research. Salesmen call it marketing.

Physicians are expected to practice “evidence based medicine.”
Wellness programs, well, not so much.

The Rand Corporation research in 2013 reported that “statistical analyses suggests that participation in a wellness program over five years is associated with a trend toward lower healthcare costs… but the change is not statistically significant.”

The health promotion movement didn’t start with Forrest Gump running.
Dr. Kenneth Cooper published his life changing book, 
Aerobics in 1968.
We’ve known for a while what we need to do. Let’s review it.

Exercise more. Eat less. Drink less. No smoking. Any questions?

Has anyone noticed that obesity is more prevalent now than ever?
Despite four decades of wellness programs.
According to the CDC:
2000:    0 states had an obesity prevalence of 30%
2010:  12 states had an obesity prevalence of 30%
Americans are getting fatter.
Still smoking, drinking, and making bad choices toward a more successful existence.

If only they had primary care physicians. Evidence has proven that PCPs help.

But don’t worry, your neighborhood corporate insurance giant has got a program for it.
A Wellness Program. Just buy it. We can talk about obesity at today’s lunch meeting with our new wellness coach. And they have cookies.

Jefferson1Thomas Jefferson said in 1785:
“Give about two hours everyday to exercise:
for health must not be sacrificed to learning.”

2013 translation: “Just move it. Don’t over-think it.

Picking up his walking stick and curiously lifting his eyebrows,Thomas Jefferson might be heard adding, “Wellness. Seriously?”

Guy Culpepper, MD

Accountable Care Organizations – The Emperor

The Emperor’s New Clothes – Now About That Emperorthe_emperor__s_new_clothes_by_angelarizza-d5fc1wp

“Light as a spider’s web,” said the Emperor, as he wrapped the invisible cloak around his naked, royal buttocks.

While the weavers were cutting the invisible cloth and twisting the invisible thread, one after another of the Emperor’s staff commented on the magnificence of the garment. Not one of them chose to admit that he was unable to see the beauty, for fear of being judged inadequate. How then, could the Emperor himself confess that he couldn’t see the robes?

I have written about the weavers and the nature of the cloth, but the real story here is about the Emperor. Only the Emperor could stop the charade.

As physicians, and in particular primary care physicians, we are given the opportunity to seek truth. We are trained to look, listen, and touch so that we might see past the complaints and through the noise to find the true source of a problem. We are tasked with honesty, even if those around us, including at times our patients, are not so encumbered.

Our diagnostic skills do not seem to extend to our perceptions of healthcare systems.

The goal of an ACO is to lower cost by empowering PCPs to collect data and then make informed, cost effective choices to improve care. As I wrote previously, the weavers took control of the ACOs. That was never a surprise.

The startling thing is that PCPs have gone along with the charade, complimenting the weavers for their product. As if PCPs chose to see the   altered ACO as the way they wish it could be, instead of what it has become.

In January 2012, the Center for Medicare and Medicaid Services launched the Pioneer ACO Model. This was to be the banner bearer, the trail blazer, limited to only 32 organizations, chosen from 162 letters of intent from across the country. Those selected to participate were required to already have significant experience in coordinated care. Each was also required to have a minimum of 15,000 aligned Medicare beneficiaries. “Applications were reviewed by a panel of experts from the Department of Health and Human Services as well as from external organizations, with expertise in the areas of provider payment policy, care improvement and coordination, primary care, and care of vulnerable populations,” per the CMS report. 

The 32 networks selected were large, hand picked, stringently screened organizations, chosen specifically because of their high likelihood of success. If this were a pharmaceutical study, one would say that this was biased research, not fit for publication. The CMS wanted to ensure that they could show savings in their Pioneer ACO study, so they only accepted the participants that they thought would lower cost.       It didn’t work out.

The Pioneer ACO was to be a three year agreement, with a two year extension option. Now, in only its second year, 1/3 of the 32 expertly selected participants are dropping out… because they are losing money. Most of the remaining organizations are struggling to break even and are renegotiating their contracts.

Even after stringently selecting the participants for their Pioneer ACO, even after fancy accounting gymnastics, and even after investing hundreds of millions of dollars into the infrastructure, the CMS has to stretch to spin a positive.

The July 16, 2013 CMS press release can only point to 33 million dollars in savings to the Medicare Trust Fund for the 669,000 beneficiaries.

That’s $49 per patient. Total. For all of 2012. But please, pay no attention to the millions of dollars invested in the infrastructure, analysis, and start-up costs. We put that in a separate accounting category. It’s only tax dollars, anyway.

As PCPs, we still have an opportunity to get it right. Some of us even believe that we have a responsibility to get it right. Our Nation is counting on its primary care physicians.

The idea that PCPs can control healthcare cost with data and informed decisions is absolutely correct. PCPs are the best hope for the future of healthcare.

                           We do not have to be manipulated by the weavers                                                            or fall in line with our self-conscious advisors.                                     We have been empowered by our commitment to the truth. 

A large healthcare system with massive overhead, multiple agendas, and a giant pool of specialists in a limited geographic area can rarely reduce utilization. Especially over a long period of time. Usually the most significant savings can only be found outside of the large, vertically integrated system. To put it another way, sometimes a patient is better served by a competing facility. Period.

In order to provide the best possible care to our patients, independent PCPs must form networks. We already understand the core values of an ACO. We are the recognized leaders of cost effective care. PCPs are trained to work with multiple specialists and multiple resources from competing centers. New technology allows PCPs to share data and follow guidelines based upon performance and improved outcomes. We can reward behavior that results in healthier, happier patients. And primary care physicians certainly must be able to share in the savings that their efforts achieve. But to do all of this, PCPs must also control the infrastructure and the overhead. It must be our network.

Primary care physicians must be free and independent to utilize the healthcare resource that provides the best result for a given patient in a given circumstance. And that resource often changes depending upon the patient and the circumstance. Our patients, and our country, depend upon our unbiased decisions.

That’s the magic sauce. Independence, blended with honesty. The Emperor of healthcare, America’s primary care physician, must be independent.

And that primary care physician needs to put his clothes back on.

Guy L Culpepper, MD

Accountable Care Organizations – The Weavers

The Emperor’s New Clothes – The Weavers


Imagine the weavers staring at the naked, royal abdomen of the emperor. They knew full well the absurdity of the situation, but once the path of deception was taken, the weavers could only compliment their leader’s fine taste in clothing.

Last week I wrote about the clothing. Now, let’s take a closer look at the weavers.

An Accountable Care Organization, as a model of healthcare delivery, embraces the core values of primary care. The stated goals of measuring performance, improving efficiency, and coordinating care are undeniably worthwhile.

Rewarding primary care physicians to reduce the cost of healthcare

remains the right idea.

The ACO has the potential to do so much good. But the weavers got involved.

Hospitals, Insurance Companies, and Healthcare Entrepreneurs could see that the reimbursement system was changing. Billions and billions of dollars would be shifting from their control. 

Time to start weaving.

If primary care physicians were to be able to control costs, then the weavers knew that they needed to be able to control primary care physicians. 

The initial model of the ACO, proposed by the Medicare Shared Savings program in January 2012, empowered primary care to form networks with other providers to organize and coordinate delivery. That was the simple beauty of the ACO. Motivate PCPs. PCPs could use data to steer patients to more cost effective resources. By saving money, the PCPs could receive greater pay themselves. That would be a win for all.

Save primary care by helping primary care save money.

The problem for the weavers was simple. If PCPs saved money by keeping patients out of hospitals, referring to less expensive consultants, or using cost effective treatments… the money that they saved might be the weaver’s money.

That would never do. After all, weavers need lots of money… you know, to weave.

ACOs threatened to change the revenue of some very powerful and influential weavers. 

Those silly PCPs, they can’t save money on their own. The weavers must help these simple PCPs. Healthcare can only be delivered by complex, multi-layered vertically integrated networks. And these networks are very expensive because… well, they are expensive.

So messages were quickly spread:

Join an ACO or perish.

Don’t miss out. Never mind the details. Pay no attention to the beta testing. You need this. You want this. You got to be in this. We’ll worry about what an ACO is later. Sign up. Structure? Distributions?Ownership? This is the latest, greatest, new thing.

And just as with the Emperor’s new clothes, “only the ignorant” can’t see the beauty.

Physician’s anxiety to join an ACO was reinforced by….you guessed it…the very companies forming the ACO.  Hospitals, Insurance Companies, Specialists Organizations, and Entrepreneurs. Vertically integrated companies that much protect their market share, increase utilization, and support massive infrastructure. The very companies that contributed to our nation’s healthcare economic crisis. They don’t want to be part of the problem, they want to help….they just need lots of money to do it. 

And who are their key targets?  PCPs.

Remember that the only medical specialty required to form an ACO is primary care. So naturally all ACOs claim to be “primary care driven”. But ask who controls the revenue, who determines the overhead, and who steers the direction of utilization? Weavers are quick to point out the beauty of the clothing. But if you can’t see it, you must be ignorant.

In order to be recognized by the Department of Health and Human Services as an ACO the network must include sufficient numbers of PCPs to provide care for a minimum of 5000 patients. All of the other members of the ACO are infrastructure, overhead, and weavers.

So, if PCPs are the core component of an ACO, why don’t PCPs form their own ACO?

I’m so glad that you asked. I’ve written enough about the weavers.

Because, after all, only the Emperor himself could stop this charade.

Next week we’ll talk about the Emperor…  and oh, by the way…  you are the Emperor.

Guy L Culpepper, MD