08/02/2015    Chet Vahovius, DPM

Obamacare and Podiatry

As a licensed insurance agent who specializes in
health insurance and a retired podiatrist, I want
to offer my opinion about the trend that I see in
healthcare. I think that this may have a larger
impact on podiatry because so many podiatrists
work in solo and small practices.

The writing is on the wall that the ACA
(Obamacare) is going to cause large changes in
the practice environment. This is due to the fact
that insurance companies are losing money on
these plans due to the absence of underwriting
(health questions). As written, the law
encourages unhealthy patients to join these plans
for services and then to leave once the expensive
medical care is complete. For example, a pregnant
woman can join a Gold plan on Jan 1st, have the
baby on the 3rd, and cancel coverage on February
1st. Of course there is a penalty, but is not
substantial enough to force healthy patients to
join these plans.

In the past, the companies would ask health
questions of patients to exclude the high risk
people who would cost them money. This is now
illegal. The only alternative for insurance
companies, outside of bankruptcy, is to reduce
the number of physicians on the plans (also known
as thinning the panel). The effect of this
rationing is to reduce costs by delaying care e.g
surgeries, tests, office visits.

Another disturbing trend is the recent
consolidation of several large insurance
companies e..g Anthem, Humana, Cigna. This
consolidation will increase their ability to
force price concessions and/or thin panels.

What is the solution for you? First of all, you
need to objectively evaluate your practice's
profit margin and come to terms with whether your
margin in decreasing or is stable. If it was
falling like mine was, you will either need to
start investigating a radical career change or
reduce your personal expenses substantially (e.g.
sell the expensive cars, home, and boat). As has
been stated many times before, group practices
can offer efficiency of scale that may be
helpful. However, I would be wary of accumulating
any debt in the process because there won't be
any guarantee that you will get on or stay on the
panels. I would also be wary of hospital based
clinics. I have read that they currently receive
more money from Medicare than private physician
owned clinics. However, what will the hospital do
to the physicians if Medicare implements payment
parity?

Finally, the most important thing to understand
is that you are not in complete control of your
practice. There are greater forces that are
attempting to get their way in this marketplace.
I fear that too many physicians personalize these
struggles and often turn to destructive coping
mechanisms to handle their perceived personal
failure. It is never a good time for negativity.
It is a good time for objective preparation.

Chet Vahovius, DPM, Enterprise, AL

Other messages in this thread:

---

08/05/2015    William Deutsch, DPM

Obamacare and Podiatry (Chet Vahovius, DPM)

Chet Vahovius lays it out pretty well. The
private practice is being phased out.
Participation with various panels is tenuous. The
podiatrist is being marginalized and those who
provide ethical care are being squeezed by
reduced payments, high deductibles that cause
patients to forego elective treatment and the
failure of insurers to see the preventive value
of timely foot care.

Dr. Vahovius also indicates that patients are
gaming the system as have physicians in the past.
Insurers will find ways to force legislation to
prevent the losses such gaming entails.

The concierge model or refusal to accept
insurance coverage is a big step for most private
practitioners. Those big billers who make the
most of diagnostic services will probably find
themselves either audited into non-existence, or
find coverage for diagnostic services reduced or
eliminated when provided by podiatrists. It was
apparent in reviewing the services provided by
the highest CMS podiatry billers that podiatric
care was almost completely absent from the
services provided by those billing in the high
six figures or seven figures. It's just a matter
of time before that avenue is closed.

So the question in my mind is whether or not
simply being a podiatrist is enough in today's
health care market? I really think that it isn't
and that a medical license is necessary to insure
the survival of the profession and the
professional. As podiatry care is being farmed
out to the orthotist and the PA and podiatric
assistant what's left for the licensed
podiatrist?

Apparently Dr. Vahovius sought relief out of the
profession. I'm sure many doctors are viewing
their options and possibly honing their
entrepreneurial skills in the event a successful
living is no longer available in podiatry.

It would also be wise to study how podiatry fared
in countries where national health insurance has
been the model for many years.

PPACA was implemented with little concern for the
physician as its aim was to get more bodies
covered and to eliminate pre-existing condition
exceptions for those needing the most care. While
that goal was met somewhat, at what cost to the
quality of care and to those physicians providing
the care?

William Deutsch, DPM, Valley Stream, NY

---

08/05/2015    Joseph Borreggine, DPM

Obamacare and Podiatry (Chet Vahovius, DPM)

This recent PM News post was quite interesting
with respect to the viability of a podiatric
practice in the Obamacare insurance environment.
I also enjoyed reading the form letter included
as a response that was written by Michael
Rosenblatt, DPM.

I must agree with both Drs. Vahovious and
Rosenblatt. Time is ticking and the reality of
our future as a profession is upon us. These last
5 years have been challenging to say the least.

I saw from the recent on-line PM News poll last
week that our profession is feeling the financial
pinch and revenues are dropping, as compared to
last year, for 33% of the DPM's polled. I am a
part of that statistic.

With ever increasing co-pays, deductibles, and
out-of-pocket expenses burdened on the patient
population at-large, the facts are simple: making
a living in medicine is getting more and more
difficult.

I believe that with ICD-10 coding it will get
worse. With the recent CMS response on the ICD-10
policy being posted on PM news along with the
APMA news and Codingline, I fear that there will
be many more predicted initial rejections
of claims after Oct 1, 2015. This is will
compound the already existent problem of the
downward trend in revenue collection in medical
practices. ICD-10 must be delayed until we know
that it will work for real.

This ICD coding change, in turn, will hurt more
the independent practitioner, such the podiatric
physician, as compared to the corporate or
employed physician since they will be insulated
by the salaries they get as opposed to fee-for-
service.

I have investigated switching careers and even
considered getting a degree as a nurse
practitioner or a physician assistant, but the
expense involved in restarting a career
at my age (52) would be cost-ineffective.

So, it looks like I will have to weather the
storm along with the rest of the profession who
are in my same situation.

I just hope I can come through it with some
financial nest egg and have the ability to
retire, if not, then I hope Social Security will
still be there when its time. I hear that
Medicare after these last 50 years and having 55
million lives insured through in the program will
be broke in the year 2030.

Again, the future of medicine as an independent
practitioner is bleak.

Joseph Borreggine, DPM, Charleston, IL

---

03/10/2014    Michael Rosenblatt, DPM

Letter to Patients About Obamacare and Podiatry

Recently a number of people have been writing me
to ask about the format of a letter they can use
for their patients to inform them about the
changes in Obamacare. So, rather than individually
answer them, I thought I would publish it in PM
News. I also included it in Español

Challenges You Will Face with the New Affordable
Care Act

You have no doubt read about some of the new
issues that will be raised with Obamacare. Some of
our patients have already started to see those
challenges with their other doctors. An example of
this is that many primary care doctors are now
switching to “boutique” practices, which require
that you pay them a large yearly fee in order to
remain their patient. The alternative is that you
may have to find another doctor. If this has not
yet happened to you yet, you should probably
expect it. This has become a trend.

We don’t anticipate requiring that for you, for
now. But Government now provides a high level of
care at bargain prices for people who have pre-
existing conditions. Without discussing the
morality or kindness of this, it is a fact that
healthcare costs are bubbles. If you try to push
them under, they will pop up in another place.

You became that “other place.” The money to fund
this will come from you. Government is already
planning a 6% reduction in payments for various
managed care insurance plans in 2015. That is only
the first. Many more are yet to come. This means
that many services you ordinarily had covered will
no longer be covered by Medicare. It also means
that for tens of thousands of Medicare recipients,
your monthly Medicare premium will increase
yearly. You should also expect your deductible and
co-insurances to increase.

Many podiatry patients have expected the trimming
of their nails and calluses, what we call “routine
foot care” (RFC) to be covered by insurance and
Medicare. Unfortunately, that is history. In order
to stay in business, we will be now be billing you
a fair and reasonable fee for those and some OTHER
services that you used to get Government to pay
for. We ask your understanding. You can try to
find other podiatrists who will “find a way” to
get these services covered. This is dangerous.
Doctors are losing their practices, their licenses
and going to jail for even attempting this. I’m
sure you don’t expect us to try this. The cost to
us is too high. Government will vigorously
prosecute this, which they regard as Medicare
fraud. We will ask you also to sign a form for
this which is called the “Advance Beneficiary
Notice” each time you obtain this care. This is
not our policy. It is required by Government.

Soon, even basic healthcare services that you had
covered by insurance will revert to your own
wallet. It is impossible for us to get into
political discussions with our patients. There are
also enormous changes for us, which include
requiring complete re-structuring of our numerical
coding systems, which cost us money, time and
effort. Being in private practice is enormously
difficult and challenging.

The question most patients are asking is: “Who
will pay?” The answer is you. The only option you
have is to make certain political changes to your
thinking and voting. We cannot counsel you on
that. That is up to you. But understand that the
alternative is that you will pay a much greater
percentage of your own care. This is a new-global
change that will come all through American health
care. This note is offered with respect and
appreciation to our patients.

Thank you for your understanding.

En Español:

RETOS Te enfrentarás CON LA NUEVA LEY DE
ASISTENCIA ASEQUIBLE

Sin duda han leído acerca de algunas de las nuevas
cuestiones que se plantearán con Obamacare.
Algunos de nuestros pacientes ya han empezado a
ver a esos desafíos con sus otros médicos. Un
ejemplo de esto es que muchos médicos de atención
primaria están ahora cambiando a prácticas de
"boutique" , que requieren que se les paga una
gran cuota anual para poder seguir siendo su
paciente. La alternativa es que usted tiene que
encontrar a otro médico. Si esto aún no ha
sucedido todavía , probablemente debería esperar .
Esto se ha convertido en una tendencia.

No anticipamos que exige que para ti , por ahora.
Pero Gobierno ofrece ahora un alto nivel de
atención a precios de ganga para las personas que
tienen condiciones preexistentes . Sin entrar a
discutir la moralidad o la bondad de esto, es un
hecho que los costos de salud son burbujas. Si
intenta empujarlos bajo , van a aparecer en otro
lugar .

Usted se convirtió en ese "otro lugar . " El
dinero para financiar esta vendrá de usted.
Gobierno ya está planeando una reducción del 6 %
en los pagos por diversos planes de seguro de
atención médica administrada en 2015 . Eso es sólo
el primero. Muchos más están por venir . Esto
significa que muchos de los servicios que
normalmente había cubierto ya no estarán cubiertos
por Medicare. También significa que durante
decenas de miles de beneficiarios de Medicare , su
prima mensual de Medicare aumentará anualmente.
También debe esperar que su deducible y co -
seguros aumenten.

Muchos pacientes de podología han esperado que el
recorte de las uñas y los callos , lo que llamamos
"cuidado rutinario de los pies " (RFC ) para ser
cubierto por el seguro y Medicare. Por desgracia ,
eso es historia . Con el fin de mantenerse en el
negocio , vamos a estar ahora está cobrando una
tarifa justa y razonable por esos y otros
servicios que ha utilizado para conseguir Gobierno
a pagar. Le pedimos su comprensión. Usted puede
tratar de encontrar otros podólogos que "
encontrar un camino" para obtener estos servicios
cubiertos . Esto es peligroso . Los médicos están
perdiendo sus prácticas , sus licencias y va a la
cárcel por intentar siquiera esto. Estoy seguro de
que usted no espera que intentemos esto. El costo
para nosotros es demasiado alto. Gobierno
perseguirá vigorosamente esto, que consideran el
fraude al Medicare . Le pediremos también que
firme un formulario de este que se llama el "Aviso
al Beneficiario por Adelantado " cada vez que se
obtiene esta atención. Esta no es nuestra política
. Es requerido por el Gobierno.

Pronto, incluso los servicios básicos de salud que
usted había cubiertos por el seguro volverán a su
propia cartera. Es imposible para nosotros entrar
en discusiones políticas con nuestros pacientes.
También hay grandes cambios para nosotros , que
incluyen requerir completa re- estructuración de
nuestros sistemas de codificación numérica , que
nos costó dinero, tiempo y esfuerzo. Estar en la
práctica privada es enormemente difícil y
desafiante .
La pregunta la mayoría de pacientes se preguntan
es: "¿Quién va a pagar? " La respuesta es usted.
La única opción que tiene es hacer ciertos cambios
políticos a su forma de pensar y votantes. No
puede asesorar al respecto. Eso depende de usted.
Pero entiendo que la alternativa es que usted
tendrá que pagar un porcentaje mucho mayor de su
propio cuidado. Este es un cambio nuevo - mundial
que llegará a lo largo de salud estadounidense .

En la presente nota se ofrece con respeto y
aprecio a nuestros pacientes.

Gracias por su comprensión .