The Paradox: PPACA vs. Value-Based Healthcare

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ACA, Affordable Care Act, Benefit Solutions, buying health insurance, Caregivers, Chronic Condition Intervention, Health Insurance, Health Insurance Solutions, healthcare, Healthcare Benefits, Healthcare Discounts, Healthcare Plans, Healthcare Solutions, Human Resources, Medication Management, Obamacare, PPACA, Seniors, Solutions, Voluntary Benefits

“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.” – Thomas Sowell 

PPACA is 2,600 pages of regulations and procedures that, good intentions or not, have caused the opposite of many of its stated objectives, with unfortunate consequences to both the physician and patient.  And therein lies the paradox.  PPACA’s oppressive regulations have placed unaccountable bureaucrats virtually in charge of physician offices with unprecedented control over the practice of medicine, ostensibly to provide “better” healthcare. And these bureaucrats have no concept of what it’s like to run a business or live in the world of their own procedural making.

Over the past two years, physicians have spent enormous amounts of time and money just to be able to continue in the practice of medicine due to regulatory mandates associated with PPACA.  Here are just a few examples:

1) On-going training and software expense of Electronic Medical Records (EMR)

2) Implementation of the ICD-10 coding system

3) Updated compliance rules and software integration for Health Insurance Portability, HIPAA and the Physician Quality Reporting System (PQRS)

4) Additional staff to implement and communicate new regulations

5) Reduced reimbursement rates from private insurance and Medicare

These expenses and lower reimbursements have shifted to patients in the form of shorter office visits, less time with chronic disease patients and limited communication for complex treatment plans. Physicians have to see more patients and spend less time with each just to cover the extra expense of staying in business.  Consumers are waiting longer to see their doctor and spend less time with them when they do.

In a 2015 survey of 400 practicing physicians¹:

• 84% believe quality patient time may be gone forever.
• 78% say they frequently feel rushed when seeing patients.
• 87% say the “business and regulation of healthcare” has changed the practice of medicine for the worse.

As a condition of PPACA, government regulators are pressing physicians to practice value-based healthcare. Value-based healthcare by definition is healthcare delivery with quantifiably improved clinical outcomes coupled with a reduction in the overall cost of care.  Treating people with chronic disease accounts for 86% of our nation’s healthcare costs.² Clearly, the treatment of chronic disease is where the most focus and intensity needs to lie – focus and intensity that requires more time with patients, not less.  And so the paradox continues. PPACA, through its regulations and requirements, prohibits the very issues that it ostensibly requires in order to achieve value-based healthcare.  Mr. Sowell’s comment above couldn’t be more right.

Three significant issues will manifest in the fall of 2015 that will exacerbate the paradox and create more hardship:

1) Individuals and employers will see double-digit increases on their 2016 health insurance plans in almost all cases.

2) Provider networks will become more limited as physicians either drop out of accepting private insurance or insurance companies form more narrow networks to lower their cost.

3) Out-of-pocket costs to consumers will rise as deductibles increase and prescription drug formularies change to higher co-pays.

So What’s the Solution? For physicians, it’s a matter of leveraging their time in order to achieve better clinical outcomes.  For employers having to spend more on employee benefit plans, it’s a matter of reducing utilization on their health insurance. The train has left the station.  PPACA is here to stay.  The question now is “how do we live with it?”  The good news is, there are solutions that are available to physicians and employers alike.  Solutions that are quantifiable, proven and ready to deploy.

We look forward to facing the challenge and helping physicians and employers alike.

¹http://www.geneia.com/news-and-events/geneia-survey/
² http://www.cdc.gov/chronicdisease/

About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, TX.   Wellspring offers proven solutions to lower utilization of healthcare services for self-funded entities and significantly reduce out of pocket healthcare costs for individuals and small businesses.  Jim can be reached at jim.jones@wellspringbenefitsgroup.com or view website at ControlMyCare.com.

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Medication Management – The Future is Now

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ACA, Affordable Care Act, Benefit Solutions, buying health insurance, Caregivers, Health Insurance, Health Insurance Solutions, healthcare, Healthcare Benefits, Healthcare Discounts, Healthcare Plans, Healthcare Solutions, Human Resources, Medication Management, Obamacare, PPACA, Seniors, Solutions, Voluntary Benefits

Medication Management – The Future is Now

America’s senior citizens are living longer and more productive lives in their retirement years than ever before. Advancements in healthcare technology, therapeutic treatment and prescription medication continues to push life expectancy to new highs. According to a 2012 study from the Center for Disease Control and Prevention, today’s life expectancy for women is 81 years and men’s is 76 years. The number of people age 90 and older almost tripled from 720,000 people in 1980 to 1.9 million in 2010. And the 90-plus population is expected to more than quadruple between 2010 and 2050.¹

Obviously, this is good news from a mortality perspective but it brings up many questions that seniors and their adult children must begin to contemplate as they plan for the future. And in millions of homes around the country, the future is now.

This article will deal with one topic that is already a significant problem for seniors and their baby boomer children – and will continue to get worse if proper planning is not initiated – that is, medication management for chronic illnesses.

Among Americans age 60 and over, approximately 76% use two or more prescription drugs and 37% use five or more.² The longer we live, the more prevalence of chronic disease – which causes more prescription medication in order to control the disease process. The importance of taking prescription medication as prescribed cannot be overstated; however, the statistics show prescription non-compliance is rampant, costly and dangerous:

♦ In a survey of 1,000 patients, nearly 75% admitted to not always taking their medication as directed.³

♦ Even among chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as prescribed by their physician.⁴

♦ Poor medication compliance accounts for an alarming number of drug-related adverse events that result in hospital admissions.⁵

♦ Poor medication compliance is associated with up to 40% of nursing home admissions.⁶

♦ It is estimated that poor medication compliance costs the U.S. healthcare system over $290 billion dollars per year.⁷

The big question is “why”? Why do those with chronic illnesses not take their medication as prescribed? Let’s put it this way – seniors may only spend a few hours per year in a doctor’s office and spend the rest of their waking hours just living the rest of their lives. To a great extent, out of touch is out of mind. And if they are not monitored by healthcare professionals on a regular and consistent basis, they quietly slip off their medication regimens – intentionally or not – for several reasons:

♦ They forget. Most prescriptions today are electronic. The doctor electronically sends the prescription to the pharmacy and the patient forgets to get it filled because they didn’t have a paper prescription to remind them.

♦ They can’t afford the medication. They will not fill the prescription at all or they will take it every other day or cut the pill in half to make them last longer and stretch their dollars.

♦ Poor communication. Sometimes they just don’t understand what they heard from their doctor. Even with instructions on the pill bottle, the communication link with their doctor didn’t connect.

♦ They feel better so they stop taking their medication. They think there’s no need to take the medication if they feel better or no longer have symptoms.

♦ Side Effects. They stop taking their medication because of perceived or real side effects.

♦ Poor eyesight. They can’t read the label on the prescription so they compensate by self-medicating.

♦ Too confusing. Many seniors take multiple medications and sorting and organizing in the proper dosages, times and amounts is just too confusing.

So, what’s the solution? It’s called chronic disease intervention and medication management. This service is a must for seniors taking multiple medications, those trying to live independently with a chronic disease or for baby boomers / caregivers with aging parents. This service is done by telephone using a ‘care team’ of professionals, including a clinical pharmacologist to monitor, educate and serve as a “quarterback” overseeing the entire field of care. With multiple doctors prescribing multiple medications, all with different instructions, there needs to be one source that can manage the patient and see the entire playing field from a holistic standpoint. Today, too many seniors are left to their own devises to treat themselves, which as we have seen above, ultimately leads to a worsening of their medical condition, increased healthcare costs and perhaps, premature death.

There is no reason or excuse for seniors to have the burden of “managing” their own treatment regimens at a time in life when they’re most vulnerable to error and forgetfulness. With chronic disease intervention and medication management, treatment protocols are followed more closely and medication compliance and adherence drastically improves, resulting in the patient getting better and staying better. And while technology is an integral part of this process, it’s the “human touch” that makes the difference. A caring team of healthcare professionals are consistently monitoring and serving those that need the oversight and accountability that many lack today. The key is regular, consistent communication and education through a high-touch personalized service that builds upon a relationship of caring and trust.

As an added bonus, all prescription medication is sorted and pre-packaged for each patient so there’s never a question about what medication to take and when to take it. Each patient receives a calendar shaped, pre-packaged kit – hand built specifically for each patient – and sent free of shipping charges each month or when needed. No more guessing about what medication to take when, no more missing refills and no more confusion. Each patient has a pharmacist dedicated to them who pre-packages medication for their assigned patients. And communication is a two-way street – patients, children of aging parents and caregivers have 24/7 access to their care team for questions, education and advise.

Problem solved. For more information on chronic disease intervention and medication management, go to ControlMyCare.com/seniors or call 888-519-9355. The future is now. The time to take action is today.

About the Author:  Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Jim can be reached at jim.jones@wellspringbenefitsgroup.com or view website at http://www.ControlMyCare.com/seniors.

¹http://money.usnews.com/money/retirement/articles/2011/11/28/life-after-age-90
²U.S. Department of Health and Human Services, National Center for Health Statistics: Data Brief #42. September, 2010.
³Enhancing prescription medication adherence: a national action plan. National Council on Patient Information and Education. August, 2007.
⁴ibid
⁵Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010; 25:284-290.
⁶Peterson Am, Takiya L, Finley R. Meta-analysis of trials of interventions to improve medication adherence. Am J Health Syst Pharm. 2003; 60:657-665.
⁷2010 benchmarks in improving medication adherence. Health Intelligence Network, 2010.

Prescription Medication and Seniors: Risks and Rewards

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ACA, Affordable Care Act, Benefit Solutions, buying health insurance, Health Insurance, healthcare, Healthcare Benefits, Healthcare Discounts, Healthcare Plans, Obamacare, PPACA

Over the past decade, we have seen dramatic improvements in technology that have led to medical breakthroughs and new drugs that have drastically improved the lives of millions of people. As technology improves, the ability to discover new ways of targeting specific diseases becomes a reality like never before. Recent discoveries have led to new medication for the most promising cancer treatment to drugs that reduce symptoms for diabetic nerve pain and restless leg syndrome. And the pharmaceutical industry is spending millions of dollars in television ads to promote their drugs. Patients are walking into doctor’s offices asking for certain medication. Physicians are having to see more patients and spend less time with them, relying on prescription medication to provide instant gratification for symptom relief without spending time to treat the cause. In other words, prescription medication is so widespread that people are becoming desensitized to how many they’re taking. And doctors seem to be willing to accommodate their patients with more drugs.

Maybe a better way to describe the situation is like this: There’s nothing wrong with taking several medications for multiple problems. Medicine is an important tool for allowing us to live well and live longer – but there’s also additional risks the more we take and the older we get. This is where caregivers and senior citizens always have to be alert and very careful since many drugs look alike.

Among Americans age 60 and over, more than 76% use two or more prescription drugs and 37% use five or more.¹ This likely represents the need to treat several chronic conditions as we get older. Clearly, the more drugs that are taken, the more confusion about when and how much to take, adverse reactions between drugs and duplicate medication from multiple doctors becomes all too common. Safety and quality of life is directly impacted by these risk factors.

Risk Factors for Seniors
 Confusion – most seniors have a designated time each week when they organize and sort out their medications in their daily pill holder. Confusion easily occurs if: 1) they’re interrupted while sorting through their meds; 2) there’s a change in color or shape of a pill and; 3) there’s a lack of communication with their doctor. For seniors who do their own sorting, confusion can be one of the most common factors in over-medication, under-medication or duplicating pills that look alike.

 Non-Adherence – Overall, 41% of seniors and 52% of those with three or more chronic conditions reported being non-adherent [not taking their prescriptions as directed by their doctor(s)].² The main factors for non-adherence are: 1) forgetfulness; 2) cost; 3) bothersome side effects; 4) feeling well enough to where they believe they don’t need to take their medication as prescribed; and 5) a lack of understanding of their disease. According to the World Health Organization, medication non-adherence is 50% among those with chronic illnesses. Consequences of medication non-adherence includes a worsening of the medical condition, increased healthcare costs and premature death.³

 Adverse Reactions – Prescription medicine, dietary supplements and herbal remedies can interfere with one another and heighten or reduce the intended effect and purpose of the drug(s). For example, Warfarin, a blood thinner to prevent blood clots, in combination with aspirin, ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDS) greatly increases the risk of serious gastrointestinal problems. Nutritional supplements, such as iron and calcium, can interfere with thyroid medicine.4

 Duplicate Medications (Over-Medication) – Over-medication usually occurs when multiple physicians are involved in the care of a patient. “My cardiologist told me to take this”, they say and “my internist” or “my rheumatologist”, etc. which many times ends up being the same medication duplicated by two or more doctors. Most of the time these physicians don’t talk to one another so there’s no “quarterback” to see the big picture and not duplicate what the other doctors are prescribing . Duplication is often seen in blood pressure medication, sleeping pills, anxiety medication, pain medication and blood thinners. Over-medication causes serious side effects that may resemble other medical problems – ironically creating another prescription medication to treat the symptom of a problem caused by too much medicine in the first place.

 Missing Refills – Another problem created by multiple doctors prescribing multiple medications is missing refills. In most cases, before a doctor will refill a prescription, they need to physically see the patient to assess their condition and make any changes to strength and frequency of their medication. If a patient is taking 6 medications from 3 different physicians, they will need to refill at various times during the year. If they wait until they are out or almost out of their medication, they won’t get a refill until they see the doctor. If they can’t make the appointment for two weeks, they go without their medication altogether until they see the doctor. And the next month the problem potentially begins all over again with a different doctor for another medication since they refill at various times throughout the year. And the cycle continues.

Rewards for Seniors – Now the good news! Technology and innovation have created solutions to all the risk factors listed above. Clearly, many caregivers and seniors need access to “medication management” that reduces these risks and improves the clinical outcomes of those taking multiple medications. Remember the “quarterback” analogy? Now you can get a team of healthcare professionals to manage your medications and chronic conditions that’s available 24/7.

 Personal Care Team – Seniors today can access healthcare professionals who specialize in managing all their medication and creating a personalized treatment plan that reflects their lifestyle and habits. Healthcare is personal so why not have a specific treatment plan that provides on-going support, catering to an individual and their personal preferences? The Care Team oversees all prescription medications and chronic conditions providing a holistic view of each patient’s overall condition. This approach personalizes their healthcare making it far more probable that patients will comply favorably to treatment regimens.

 Education – If seniors understand why they’ve been prescribed a certain medication, they have a far better appreciation for the importance of taking it. Understanding their chronic disease(s) empowers the patient to become an active participant in their treatment. Educating seniors through a personal care team on a regular basis is key to drastically improving adherence and a better quality of life.

 Reduce Confusion – The best way to reduce confusion is to eliminate having to organize and sort out medication in the first place. Monthly pre-packaging of medication is available so seniors never have to wonder when or what pills to take. It’s already done for them in daily dose packs in the shape of a calendar (am and pm) for easy understanding. Hand packaged by their personal pharmacist, the senior has the safety and security of knowing their medication was packaged for them just like their doctor prescribed and in accordance to their lifestyle, habits and preferences.

 Benefits of Pre-Packaging – Because a pharmacist does the pre-packaging, drugs that may cause adverse reactions are virtually eliminated. The pharmacist dispenses and packages medications prescribed from all physicians (prescriptions and over-the counter) so a “quarterback” sees the big picture and eliminates adverse reactions between drugs. Also, the pharmacist can help eliminate duplicate medications prescribed by different doctors, often resulting in less cost to the patient. Overmedication is a real problem – both physically and financially. With the cost of drugs these days, eliminating those that aren’t needed helps seniors feel better and save money!

 No More Missing Refills – Part of the medication management program is to synchronize all prescriptions from each doctor so they can be refilled at the same time. This eliminates several different medications needing refills at various times throughout the year. The care team and pharmacist works with each doctor’s office to line up all prescriptions so they can be refilled without missing any medication.

 Free Home Delivery – The Pre-Packaging is a great solution to eliminating many problems. Most firms who specialize in medication management offer free home delivery – in calendar shaped pre-packaged, daily dosage kits for easy use. Not only does it show up on the doorstep at the appropriate time but it also eliminates multiple trips to the local pharmacy each month.

 Feel Better, Get Better, Stay Better – Seniors who have experienced the care team approach and medication management typically have far better clinical outcomes than those who don’t. Having a care team as a quarterback who sees the big picture is far more proactive than waiting until a problem arises that could have been prevented. These seniors experience fewer doctor visits, emergency visits and hospitalizations. They have a more productive lifestyle and typically experience an improvement in how they feel.

Conclusion
Fortunately, today’s healthcare can be far more interactive, personal and convenient. We must acknowledge the potential problem of taking too much, too little or unnecessary medication. If there isn’t a healthcare professional that can see the whole picture, the patient is susceptible to unnecessary risks associated with prescription medication. The good news is, today, that no longer has to happen. Medication management is a proactive way to live a better and healthier lifestyle throughout the aging process.

About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Jim can be reached at jim.jones@wellspringbenefitsgroup.com or view website at
AGA.ControlMyCare.com/seniors.

¹U.S. Department of Health and Human Services, National Center for Health Statistics: Data Brief #42. September, 2010
²Ira B. Wilson, MD, Cathy Schoen, MS, Patricia Neuman, Sc.D et al. Physician – Patient Communication about Prescription Medication Nonadherence: A 50-State Study of America’s Seniors., Journal of General Internal Medicine, January 2007, 22(1):6-12.
³Chisholm-Burns MA, Spivey CA. The “Cost” of medication non-adherence: consequences we cannot afford to accept. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23229971
⁴National Council on Patient Information and Education. Fact Sheet: Medicine Use and Older Adults, October 2010

©2015 Wellspring Benefits Group. All rights reserved.

Healthcare Access – New Concerns for Obamacare Exchange Plans

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ACA, Affordable Care Act, Benefit Solutions, Health Insurance, Healthcare Benefits, Healthcare Discounts, Healthcare Plans, Obamacare, PPACA

Healthcare Access – New Concerns for Obamacare Exchange Plans
Jim Jones, President, Wellspring Benefits Group

A 2014 survey by the Medical Group Management Association, a consortium of independent practice associations (IPA’s) and multi-physician medical practices, offered an alarming unintended consequence of Obamacare. The survey, taken as of May, 2014, estimates over 214,000 doctors will not participate in the Affordable Care Act (ACA) exchange plans going forward. This number appears to be growing as more physicians experience the unsustainably low reimbursement rates, increased risk of non-payment and excessive regulations and administrative requirements associated with ACA. According to the Kaiser Family Foundation, there are approximately 894,000 practicing physicians in the U.S. The simple math would indicate at least 25% of physicians nationwide are opting out of accepting Obamacare plans with more expected in 2015.

What’s even more alarming is what’s happening in the state of California. It’s estimated that 70% of California’s practicing physicians are not participating in Covered California1 (ACA exchange plans). There are people all over California paying premiums for ACA exchange plan health insurance and have little or no access to care.

Let’s look at the major causes of physicians opting out:

1. Reimbursements to physicians accepting ACA plans are at an all-time low. It’s estimated that where private or employer sponsored plans pay $1 for a service, ACA exchange plans are paying about $0.602. So in effect, ACA exchange plans are cutting physician reimbursements by up to 40%. Over 7 million consumers have purchased exchange plans3, many after not having health insurance for years. These patients appear to be utilizing their plans more frequently due to previously untreated conditions. Physicians, in turn, are spending more time treating more patients and being reimbursed at rates that cannot support their overhead.

2. If you purchase private health insurance (not on the federal or state exchanges) and you stop paying your premiums, you have a 30 day “grace period” before your coverage ends. If you pay your premium in the first 30 days, your coverage continues. If not, you no longer have insurance. However, ACA exchange policies are under different government rules. Insurance companies have to cover ACA consumers for an additional 90 days after they have stopped paying their premiums. The insurance company still covers the first 30 days but it’s up to the doctor to recoup payment for the next 60 days. Currently, over a million people have stopped paying their ACA premiums. So doctors are treating patients for months that have stopped paying premium but must still continue to treat them. If the patient is unable to pay, the doctor has no way of being compensated for potentially months of service.

3. For those consumers that qualify for a federal subsidy, many have chosen the lowest cost “metal” plan (Bronze) which has a high deductible. Many of these consumers are in lower income households or don’t understand their benefits and rack up thousands of dollars in cost before the deductible is met – once again leaving the physician in a position to not get compensated. So, physicians are asking themselves a simple business question when it comes to ACA exchange plans, “Am I willing to take sicker patients for significantly less money with the risk of not getting paid at all?”

4. If physicians accept Obamacare exchange policies, they must also accept the mandatory regulation and administrative overhead of ACA compliance. There are stringent administrative procedures for data capture, reporting, documentation and compliance of electronic health records that must be a part of each physician office. While the ultimate goal is to improve communication and help patients, the regulations were written by federal bureaucrats that have no understanding of what it takes to run a medical practice. Since these requirements must be met and there’s only so many hours in a day, the outcome is a significant decrease in the amount of direct contact with patients and more administrative overhead that must be absorbed by the physician.

So what does this mean to consumers who purchase ACA exchange plans? First, it’s very possible that the network associated with your ACA plan will be very limited in physician and hospital choice. It’s also possible that more physicians will be leaving these already limited plans putting more consumers at risk of finding a local provider. As a consumer, you need to understand the upside and downside of ACA plans. You may get a subsidy which lowers your premium (upside) but you may have limited choices in physicians and hospitals (downside). Having access to healthcare, no matter how much the subsidy lowers your premium, is still a major factor in the value you get for the money you pay.

There are some solutions. One of the most convenient and inexpensive ways of accessing healthcare for routine, non-emergency illnesses, is telemedicine. Telemedicine provides unlimited access to physician consultations by phone with a board-certified doctor who will diagnose your condition and if needed, call in a prescription to your local pharmacy. It alleviates an office visit and the out-of-pocket fees involved in physically going to the doctor’s office. And since telemedicine does not rely on a “network” like your insurance plan, you have access 24/7 on your terms. In the past, telemedicine has been mainly available only through employer or affinity groups. Today, individuals and families can get telemedicine for a fraction of the cost of paying out of pocket for routine healthcare. Many other products and services are available that can help lower out of pocket costs in addition to telemedicine. These products and services become more valuable as consumers experience the unintended consequences of Obamacare.©

About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare business, he has developed a business model that integrates insurance products and healthcare services for individuals and small businesses to manage their costs and coverage with customized plan options. Jim can be reached at jim.jones@wellspringbenefitsgroup.com.

 

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1 Richard Pollack, Doctors Boycotting California’s Obamacare Exchange, Washington Examiner (December 6, 2013); available at http://washingtonexaminer.com/doctors-boycotting-obamacare-exchange/article/2540272.

2 Roni Caryn Rabin, Doctors Complain They Will Be Paid Less by Exchange Plans, Kaiser Health News (November 19, 2013); available at http://www.kaiserhealthnews.org/stories/2013/november/19/doctor-rates-marketplace-insurance-plans.aspx

3 Sam Baker and Sophie Novack, 7.3 Million People Have Obamacare Coverage, National Journal (September 18, 2014); available at http://www.nationaljournal.com/health-care/obamacare-enrollment-drops-to-7-3-million-20140918

 

©2014 Wellspring Benefits Group. All rights reserved.