November 17, 2013

Coverage for epidurals and facets

As Obamacare gets implemented, we are seeing a ramping up of efforts to decrease the type of care that can be provided.

Obamacare has many components.  Individual insurance is regulated, by fiat, out of existence, forcing holders of those policies into the Exchange.  The Exchange will require patients to buy insurance they may not want, such as obstetrical care or detox.   The previous policies, which people tailored to their personal needs, are now described as bad.  New, more expensive policies, which include services the buyer may not want, are good.  What you want is bad; what someone else wants you to have is good.  This amounts to a tax on the holders of individual policies, in addition to double speak.

These more expensive policies provide access to a limited number of physicians, so called narrow networks.  As I write this, it is not clear who will be in these networks.  Physicians don’t know whether they are in them or not.   Patients are attempting to find out what network their doctors are in, so that they can stay with their doctor.  We do not know if the information the patients are getting is correct or whether patients will continue to have access to their provider.

Some patients have very complex problems which require treatment from the leading experts around the country.  Currently, people have access to these experts.  That will stop.  I am unaware of any plan to allow these patients access to these experts, although on a humanitarian basis, it is hard to imagine how the necessary care can be denied.

Doctors will get paid less for providing care.  Payment is based off the Resource-Based Relative Value Scale (RBRVS), which provides an objective way of determining the value of medical services.  Medicare pays doctors at the cost of providing service.  The exchanges will pay doctors at a fraction of the RBRVS, which means that they are paying at less than the cost of the doctor seeing you.  That means more care will be provided by what are called Non Physician Providers, or mid-level providers.  Basically, they are very competent, but lesser trained providers, nurse practitioners and physician assistants.  Nothing wrong with this change, but just understand you will, of necessity, have less access to the physician: the practice is simply not being paid enough to support seeing only a physician.  Expect also to see other changes, such a telemedicine and the use of remote devices, such as iPhones , to monitor chronic conditions.

Another interesting concern is whether enough physicians will sign up to see Exchange patients to meet the demand.  It is not clear how any potential imbalance between supply and demand can be met.  The only options are to increase supply or decrease demand.  Increasing supply could be done by increasing payments to physicians.  It could also be done by forcing, through legislation, physicians to accept these rates as a part of licensure.  The infringement on civil rights and social implications of such a mandate are sobering.  People who are willing to advocate it are examples of Samuel Johnson’s comment that those who do not feel pain seldom think that it is felt.   It does suggest a sobering arrogance.

The other option to increasing supply would be to decrease demand.  While the ACA has a goal of increasing coverage, it is also a political, top-down, centrally-controlled system.  There is no reason why those who control an Exchange would not elect to slow down processing of applications or make some regulatory change if the lack of physicians was causing politically damaging criticism of the Exchange.

In addition to limiting what doctors you can see and whether you can see a doctor, another way to control the costs of providing service is to limit what services are provided.  We live in a world of evidence based medicine, which means we only want to provide services which a systematic review of the literature shows to be of benefit to a given patient.  This is a good thing.  The difficulty is that different people have differing views of what the systematic reviews show, so that the same evidence is used to support different conclusions.  Payors are glad to jump on any opinion which supports their views.  Thus, we are now seeing determinations where such widely accepted procedures as epidural and facet injections are being denied or curtailed.

A related issue is what I call rubric medicine.  A rubric is a guide or list using in scoring papers.  If the item on the rubric is in the paper, that is good; if not, bad.  How that relates to medicine is that a guideline may make very specific requirements for a particular procedure.  For example, a request for an epidural must be documented and confirmed by an either an MRI or EMGs.  If the exam does not show radiculopathy, no epidural.  Low back only, no epidural.  No corroborating MRI, no epidural.  Don’t worry that MRIs are imperfect diagnostic tools; we will act as though they are perfect.  Another example is a repeat stellate ganglion injection, where the report in which the request is made must document that the diagnostic injection had at least a 1.5 degree C. temperature increase.  No documentation, no authorization.  This level of bureaucratic detailing decreases productivity at a time when we are trying to increase it.  The only way for the physician to get coverage is to create templates, so you pull in the criteria from the guidelines when you make the request and show that the request meets the guidelines.

All in all, the current system does not seem to be made for the long-term.