<p>"I don’t understand why TatinG and texaspg are so interested in using my tax dollars and theirs to pay for procedures "</p>
<p>I am a conservative, been paying a lot in taxes for the past 20 years and don’t care for ACA but that is besides the point.</p>
<p>The goal of ACA is to help more people with healthcare. It was sold as “everybody gets to keep their care if they have it already” which means I shouldn’t care what ACA does since it should not impact me. If you are now telling me some committee somewhere will be telling my fully paid insurance company to do whatever the heck I want done to me when needed not to do it (my company and I have paid into the system for past 25 years with almost very little lifetime money spent) then I would fight that to the end.</p>
<p>In the end, as far as healthcare for survival is concerned, it is everybody for themselves, the greater good be darned is what usually happens.</p>
<p>Btw, if we need to stop surgeries somewhere, we should be stopping all scheduled C sections. About 75% are done for convenience.</p>
<p>Notice that the surgeon in the St. Joseph Medical Center case, Midei, egregiously lied to his patients, to the other doctors and to the insurers and the government. He manufactured symptoms that were not there, and falsified records, in order to justify his unnecessary surgeries. And he still maintains his surgeries were justified!</p>
<p>Not just scheduled C-sections, but the majority of C-sections in the US are medically unnecessary. texaspg, you and I are on the same page there; getting rid of unnecessary C-sections is a great idea.</p>
<p>As the IPAB is tasked with finding savings in both Medicare and Medicaid, it might well go after unnecessary C-sections. Medicaid pays for 40% of the births in the US every year. </p>
<p>Private insurance companies are not bound by IPAB recommendations. My guess, though, is that if IPAB decides a particular service is unnecessary, the insurance companies won’t pay for it either. But that is their choice.</p>
<p>The March of Dimes had a project that involved educating women at 25 hospitals that the last few weeks of pregnancy can really affect the health of the baby. C-sections went down 85% in those hospitals. Guess who’s not telling their patients about the benefits of those extra weeks?</p>
<p>Does IPAB make individual case by case decisions though? I am under the impression they own the overall rulemaking like whether a 91 year old needs very expensive surgeries to prolong life by 1 month if medicare or Medicaid needs to pay for it.</p>
<p>IPAB is a backstop in case spending is projected to outgrow targets. Congress can come up with other ways to curtail spending without using IPAB. It has already been determined that we’re in the clear until 2015 because health care costs are moderating already. CBO thinks we’re in the clear for at least a decade. Congress can also vote to amend the recommendations. It will not do any case by case recommendations. It is prohibited by law to ration so recommendations such as stopping particular procedures for particular groups of people won’t be allowed. One of the things they will look at is why certain regions of the country have a lot more success in treating certain conditions with far fewer procedures and re-admissions. Re-admission is a huge piece of spending and is also a factor in morbidity. That is something that needs to be studied. The results vary greatly from region to region and hospital to hospital and we should be very anxious to know why.</p>
<p>The first stage of Obama was never intended to curtail costs, except in making sure that 80% at least of payments was going to patient care (that’s actually quite a large piece of cost control.) The idea is first to get everyone into the system, everyone having a stake, no pre-existing conditions, no denial of coverage, no lifetime limits, preventive care included, and then work on cost control. I don’t think it will work because Obama already gave away the store to the private insurers and doesn’t have anything more to give. But I don’t blame ObamaCare for not doing something which it didn’t intend to from the beginning.</p>
<p>I don’t really understand why healthcare costs are moderating but they are. As long as they don’t go over whatever the target amount is - a formula spelled out in the legislation - then IPAB will remain dormant. The decision was make in April that there was no need for any IPAB recommendations in 2014. I am linking an article below that describes the program well and gives points/counterpoints. One of the fears is that the only viable way to cut costs is to continue to cut back on physician pay for medicare patients. The rationale behind IPAB is that Congress has proven an inability to curtail Medicare spending because of special interests. This takes the cuts out of Congressional control - except it really doesn’t. The Congress can just increase Medicare spending to get the formula back to where it should be or a super majority can override the recommendations, subject to a veto of course. </p>
<p>Received the first of what I’m sure will be many mailings from BS today. They are offering an extension of current small group (2-50) plans until December 2014. They will keep the rates the same - except if your rates would have gone up based on your renewal date - not at all sure what that means.</p>
<p>I have to say the ACA accomplished something I would not have considered possible in my wildest dreams…a letter from BS now causes more dread than a letter from the IRS.</p>
<p>Texaspg, there are cost savings aspects throughout the bill. The most substantial is the parameter around insurer profit and administrative costs. Most of the others are behind the scenes and aren’t really visible to us as patients/consumers. Perhaps the biggest example is the pay for performance initiatives. One way they do this is to get groups of providers - hospitals, independent physician groups, etc. - to join together to jointly try to reduce medical errors and improve quality. The patient has one set of tests done and the tests are shared among all those providers. For instance, let’s say Mrs CC feels a lump. She goes to her doctor then gets an MRI. The doc sends her to a specialist. Normally the specialist would order up separate tests. But they’re members of the same accountable care organization, so they share the same medical records among themselves. So already the patient’s life is easier because she doesn’t have to have multiple visits to X-ray or MRI sites. The Feds have grants available to providers who can show they have, in the aggregate, improved care and outcomes for their patients. </p>
<p>Basically, physicians used to be paid for each procedure. That incentivized them to over-prescribe. Then managed care came in to deal with that, and we were left with docs getting paid by head count. That helps the MCO, but hurts the doc and the patient. ACA is now attempting to incentivize providers for good outcomes, which is designed to help docs and patients. And of course, you can see how this wrings redundant cost out of the system.</p>
<p>Thanks for the link Mini. It looks like the ONE thing IPAB can do is reduce payments to doctors. :p</p>
<p>“Yet, the IPAB does have some significant limitations on the scope of its proposals. Namely, the IPAB cannot submit any proposals that would ration care, modify Medicare eligibility criteria, raise costs to beneficiaries, change cost-sharing for covered services, or restrict benefits in any way. 31 Prior to 2020, the IPAB’s proposals cannot include recommendations for changes to rates for hospitals and hospices, which are already receiving a reduction in their payments in other provisions of PPACA.32 There are no restrictions, however, on the IPAB’s ability to cut Medicare payment rates for physicians.33”</p>
<p>Thanks Hayden. I was trying to understand IPAB’s role in reducing costs in future when I need the care (hopefully 10-15 years from now). I am good friends with a few cardiologists. May be I should get those stents out of the way now if there is going to be any trouble when it is my time. :D</p>
<p>Then welcome to the world I’ve been living in for 20 years. My taxes don’t go up by 15-20% every single year, year in and year out. My health insurance premiums do. I dread that letter every January from Blue Cross, absolutely dread it.</p>
<p>Another ACA cost-saving incentive is the program penalizing hospitals for readmissions for heart attacks, pneumonia and a third diagnosis I forget (heart failure, I think). This means if a hospital has a tendency to discharge patients who had pneumonia, only to have to readmit them two weeks later for complications of pneumonia, they have to pay a fine. </p>
<p>This promotes better care and more cooperation between different caregivers at the hospital, as well as saving money. Even the best treatment for complications of pneumonia is not as good as not having the complications in the first place.</p>
<p>Previously, if a hospital discharged a patient, only to have to readmit them two weeks later for the same thing, they got paid twice.</p>
<p>Fang, that is VERY interesting @ re-admits. My dad has had to be re-admitted 3 times in the last 3 years, which is just terribly traumatic for him. It’s good to know that hospitals will have to start thinking twice about pulling the discharge trigger so quickly.</p>
<p>One issue is discharging patients too soon, and a second issue is discharging patients who might be healthy enough to go home provided they more professional oversight when they got there than they actually have. </p>
<p>In the last years of his life, my dad had gallbladder surgery, then was discharged. At the time he had a number of other issues; he was pretty sick. Mom and I were trying to take care of him, and we thought we were doing everything we were supposed to do and following all the instructions, but we didn’t realize until too late that while he was recovering from the surgery he had a heart attack. If we’d only known, or if he had had a professional nurse even visiting once a day, he wouldn’t have ended up with congestive heart failure. </p>
<p>I blame myself, but I didn’t know. And I’m pretty educated, and so is Mom. I can’t believe that other patients’ families in similar situations would have been any better off. Hospitals expect patients and families to be able to handle things they just can’t, reasonably, handle, and so people get it wrong and end up back in the hospital.</p>
<p>Oh no no no, you can’t blame yourself. You weren’t his doctor. We laypeople rely on the professionals to tell us what we need to know, and to tell us about what care is needed. When that doesn’t happen, are families supposed to figure it out for themselves? Of course not.</p>
<p>Our hospital is good about providing follow-up home care, at least for Dad. Maybe there’s a big red flag on his file that he’s a re-admit risk. But one thing I have noticed, which might explain what happened in your case, is that hospitals are dreadfully understaffed. Doctors, RNs, and CNAs don’t have time to do much more than run from room to room. I can easily see how something like making a note on the discharge paperwork that he suffered a heart attack, or taking the time to arrange for home health care, might get overlooked. We have a shockingly high rate of “death by medicine” in this country, no doubt some of it caused by harried medical professionals trying to handle caseloads that are much too large for attentive treatment.</p>