Is Healthcare Changing for All?

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Changes with Preventative Care

The Affordable Care Act (ACA) also known as healthcare reform, required non-grandfathered health insurance (issued or substantially changed after 3/23/2010) to cover preventative testing such as mammograms; for females every year beginning age 40 and PSA testing for men every year for men beginning at age 50.

Interesting, since 2010, organizations have come out against mammograms and PSA testing stating these test cause over diagnosis and waste. For example, The US Preventive Services Task Force, three years ago “stopped recommending mammograms for women in their 40s based on the negligible lifesaving benefits seen in clinical trials and the high rate of false findings”.

 Two months ago, the National Cancer Institute recommended redefining cancer to eliminate the association with slow growing breast, prostate, lung and thyroid lesions and to prevent over diagnosis and over treatment. Their stated purpose was to prevent “unneeded tests” considered waste.

Kidney disease was to follow with researchers stating that too many people are being diagnosed with stage 3 kidney disease and this disease should be redefined. Dialysis is very expensive, could it be assumed that dialysis may be delayed in some cases?

I do not know all of the answers, but I am asking you to think. It is clear that our present healthcare system has fraud, abuse and waste. Fraud and abuse are more identifiable to eliminate, but waste is a tough one. Is it waste if a mammogram finds someone to have a lump and to have a follow up mammogram in 90 – 180 days? Is it waste to have follow up antibiotic treatment and reexamination if a PSA result is out of the normal range? Is it waste to biopsy a lung lesion?

Today, it is clear that many enjoy much freedom in our healthcare. We can see the doctors we wish, we need to be able to pay for services. In America, if we want a car; we buy the car we want within our means. Many times the car we want is too expensive so we settle on a lesser car. Healthcare is now fairly much the same way.

We do know that the current system cannot continue as is. The Sustainable Growth Rate formula was enacted as part of the Balance Budget Act of 1997. This Act set targets for yearly increases in provider reimbursement. These increases, based on what is considered manageable and sustainable growth is not enough to offset medical inflation. Therefore, an additional “doc fix” payment increase has been passed annually since then to pay providers. This increase is now 24.4%.

Last month a US House subcommittee examined changing healthcare fundamentally by removing the ‘fee for service” system now in place for Medicare patients. So what does that mean? Care for people on Medicare would then probably be managed. Like in the 1980’s HMOs required their insureds to use a primary care physician (PCP) as a gate keeper to all medical services. The HMO doctors were paid based on the amount of profit retained at the year. People vocally fought this method and a lesser restrictive system grew – Preferred Provider Organizations. PPO allowed patients more freedom to see doctors. To see providers not in their network, the patient would pay more in co-insurance.

 We are now seeing the return to the PCP gatekeeper model – example Accountable Care Organizations (ACOs) and some Medicare Advantage plans. As this model moves forward, we will see substantial change in the way we receive care. How does a country cover millions of people not currently covered? If diseases are redefined, could we see substantial changes in the treatment of disease? Is this a form of rationing? There are many question; the answers are yet to come as the system continues to evolve.

Written by

Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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