When we knew it

Without More Primary Care Doctors Medicaid’s Newly Insured Will Stress ERs, said Aaron Monceivaiz in September 2013.    There is no sense in expressing shock when the story – itself a repeat of data published in JAMA – showed that increasing coverage would flood ER’s without adding capacity to primary care.

How was this answered? “A two-year Medicaid federal rate increase for primary care providers is due to expire on the first day of 2015. On the same day the California Department of Health Care Services plans to implement its state-ordered 10% reduction in reimbursement rates for fee-for-service Medi-Cal primary care providers.” This all took place at the beginning of last year, in California. (link)

Back in 2013:

San Diego doctor Ted Mazer told Healthline, “The JAMA article and the declining access to care under current conditions for Medi-Cal (California’s version of Medicaid) patients should be seen as writing on the wall.”

Mazer fought against a 10 percent cut to Medi-Cal reimbursement, but the state ultimately won, earning the right to cut payments as long as service remained sufficient.

Even without looming cuts, Mazer says payouts are already too low. “In San Diego,” he said, “Medicare pays about $75 for a routine follow up visit for both primary and specialty offices, while Medi-Cal pays $24, and as of now that will be further reduced 10 percent in the next month. (October 2013)”

So the 2015 cuts happened on top of the baseline Ted Mazer was yelling about.  It sounds like the good old days of $24 Medi-Cal clinic visits are long gone.  Is it under twenty bucks now?

CPT 99214 equaled a base rate of $37.50 in 2016. How that “base rate” compares to the amount actually paid, is unfathomable.

“Over the past few years, many states have decreased Medicaid reimbursement payments to doctors. This decrease in Medicaid dollars may cause them to sit out of the program.

That sends primary care patients to the ER window. A 2011 Centers for Disease Control survey found that nearly 80 percent of adults visited the ER due to lack of access to other providers.”

Perhaps a psychotic break is in order.

Doctors Know It Must Get Better

“Standing before thousands of fellow doctors as the keynote speaker for the 2013 American College of Physicians conference, renowned bioethicist Dr. Ezekiel Emanuel—a proponent of voucher-based universal healthcare—made a bold statement: “Doctors, more than anyone else, will determine the future of the United States.

In 2012, he said, the U.S. spent $2.87 trillion on healthcare, including $979 billion in federal spending. If the U.S. healthcare system were a national economy, it would be the 5th largest in the world.

The problem is evident: 50 percent of all Americans account for three percent of healthcare spending, while 10 percent—those with multiple chronic conditions—account for 63 percent of all healthcare costs.

“We can do a better job cutting spending without rationing care,” Emanuel said.

Doctors can determine the country’s economic future by transforming the type of care delivered, he said, by focusing on delivering cost-conscious value to patients, standardizing processes, and delivering care in a team-focused system.

Price and quality transparency is “inevitable and coming faster than you think,” Emanuel said.”

Why Do We Get So Little Value from the Healthcare System? April, 2013 Ref.

And What Does Toby Say?

“Dr. Toby Cosgrove, Cleveland Clinic president and CEO, wrote in Time Magazine. “Physicians, after all, are evidence-based decision makers. By supplying doctors with supporting data, change will come naturally. And so will the savings.””

Same article 2013

What has happened since?  Do the Math.  (link)

In my state, we see $200-$400 per CITIZEN per YEAR simply for uncompensated ER care.  Such enormous numbers cover many gray areas, of course – the shortfall between billing and re-compensation is one of the many vagaries of the healthcare financial system.  But the newly insured are treated in the ER, not the clinic, and the economic forces are squeezing primary care doctors OUT of the system, not into it.

This is neither a coincidence nor a misunderstanding.  Care will soon be rationed by the absence of supply.  California has flirted with this many times for Medi-Cal.  Lower the reimbursement until nobody sees the patients.  Voila!  a system that saves money for the treasury.  Read the documents from 2013.  They are not ambiguous.  Yet they traced out exactly the path of disaster we have followed.

As the ER’s swiftly become broken-down by overwhelming demand, as Toby shared, “Change will come naturally.  And so will the savings.”  We cannot handle modern medical care, so let’s step away from the 21st century, and let nature take its course.

How It’s Gone Before

Butcher shops in the old Soviet Union had terrific prices on meat – lamb, beef, pork, chicken, sausage, you name it!  But they never had anything for sale at the moment.  One could look at empty displays with terrific prices – entirely affordable by the worker and peasant, not like in those capitalist countries!  But the refrigerators were empty, the displays clean and pristine, the smell of well-scrubbed and carefully-cleaned equipment.  But no meat.  Grandma pays nothing for health insurance these days!  But, also, Grandma gets nothing for healthcare these days.  We all miss her.