Mrs. Cassidy slowly walks into my office one busy afternoon. I see her out of the corner of my eye because she is hard to miss. Mrs. Cassidy has some serious style. She has a deep orange dress with a bright blue blazer on. There aren’t too many folks that can pull that outfit off, but she can. She has a wide slow smile, and she speaks with a slow southern drawl that belies her southern roots. This was supposed to be a routine follow up visit for a 67 year old woman with a history of a mechanical mitral valve replacement and coronary disease.
Unfortunately, she tells me a story that is concerning for angina. I think she needs a stress test. I slide over to the insurance tab on the EMR and I let out a somewhat audible groan. She has a Medicare Advantage (MA) plan. I explain to Mrs. Cassidy that we will need to go through an extra step to pre-certify her stress test. She expresses surprise and asks me what she should do. I will tell you what I told her, but first, let me tell you why.Continue reading…
Congressional leaders just agreed to a budget that would keep the government open through September 2016. I was happy to hear the government was not going to shut down. I was much less happy to hear about the fate of provisions supposed to fund the Affordable Care Act (ACA). The ACA – costing $1.2 trillion over 10 years – was supposed to ‘mostly’ pay for itself. Revenue was to be generated (in large part) by a series of taxes on a variety of different sources. These taxes did not fare so well in the current budget.
The ACA took aim squarely at high cost employer-sponsored plans. Economists believe that since employer health insurance is tax deductible, high cost plans proliferate as a mechanism to provide a tax free benefit to employees. These expensive plans are expensive because they cover most of the cost of medical care, insulating the patient from the actual cost of medical care. The ACA imposed an annual 40% tax on plans with annual premiums exceeding $10,200 for individuals and $27,500 for families to be paid by the insurers. The results were to be two fold: One, create a disincentive for employers to offer ‘cadillac’ plans, and two, generate revenue to pay for the ACA. A broad coalition composed of democrats and republicans lobbied to defeat this tax.
Safe, appropriate, effective care at a reasonable cost. Such a simple goal. The message is clear. Leaders in hospitals, congress, and even my chihuahua echo the dawning of a new age in health care. Down with the private practice, fee-for-service mentality, they all say. I pay attention to a lot of this chatter since I happen to be in private practice. I split my time on the internet between the latest exploits of the Kardashians and gravestones for my practice. I can picture the epitaph:
In loving memory of
3/1/2013 – 3/1/2016.
Shed not for her the bitter tear
Nor give the heart to vain regret
‘Tis but mere ashes that lie here
The gem that filled it sparkles yet
As I shuffled towards this abyss, my reverie was broken by a letter. It was from Independence Blue Cross (IBC) in Pennsylvania. It was titled: The Cardiology/Invasive Cardiology Comparative Cost report. It looked like a report card, so I opened it with some trepidation. Continue reading…