Dec 162016

Continued Disruption of the Healthcare Industry
(Is it true or is it a bad thing?)
Michael C. Gosney, DVM, MD, JD, MBA*

* Disclaimer: Michael C. Gosney, MD is a small-town anesthesiologist in the South. The opinions expressed in this series of articles are his own. In Dr. Gosney’s words, “I am an avowed advocate for physicians and physician-led medical care. Although the views expressed will try to be even and true, there will be an inherent slant toward promoting smaller government and physicians.”

I have been asked to look into the future and see what is in store for those of us who take care of patients, provide care 24/7, and try to work within the healthcare system designed by legislators, regulators, and private insurance companies.
With the election of Donald Trump as the 45th President of the United States, the healthcare world is again faced with the distinct possibility of change. I, for one, embrace this change because I believe the Patient Protection and Affordable Care Act of 2010 (PPACA) needs much tweaking to be more effective, cost efficient, and sustainable or it must be repealed and replaced. There is another narrative involving less centralized government control. With the passage of the PPACA, health care in the United States was changed in very profound and fundamental ways. This comprehensive governmental intrusion and takeover of an industry comprising almost 20% of the gross domestic product (GDP) was ambitious, broad, overreaching, packed with unintended consequences, and passed Congress with no bipartisan support. Such broad legislation without bipartisan support or compromise is usually not ideal legislation. The PPACA truly had to be passed to find out what was in it. I am not certain that it protects patients or it is sustainable and affordable. The PPACA succeeded in accelerating the reporting of “quality” measures, driving payment risk methodologies, and encouraging practitioners to embrace high-cost electronic records; funded organizations to drive innovation and research into evidenced-based medicine and population health; and made changes to the healthcare financing scheme. The insurance coverage component drove millions into Medicaid and developed an individual insurance market that was as ambitious as it was unsustainable. The cost of PPACA implementation is in the trillions of dollars and continually increasing. The financial impact of the PPACA is just beginning to affect beneficiaries with increased costs – 100% of federal subsidies of the Medicaid state expansion expire this year and states will begin feeling the cost of this expansion soon. With the stability, tranquility, and cost curve bend of the last 6 years in mind (Yes that is sarcasm), I look forward to exploring the potential opportunities ahead with the hope that we will have sensible, lasting, sustainable changes in the healthcare system.

What do we know?
We know that Republicans were/are against the ACA because they believe that it is government driven and central control over health care and that Republicans were not consulted or even asked to participate in the development of healthcare reform at the beginning of the Obama administration and the passage of this legislation by then House Speaker Nancy Pelosi and then Senate Majority Leader Harry Reid. Additionally, there are alternative philosophies from central government-controlled policy and more private, less centralized government-centered policy. Relying upon government subsidies and governmental payer payments is expensive and less patient friendly according to some views. As is, Democrats are not united on the ACA; many see portions of the PPACA that need to be eliminated, altered, modified, or changed. Republicans, including the President-elect, want it repealed and replaced.

What is likely to happen?
In this first article, I want to explore the landscape of health care and opine about the likely path forward.

The Macro View
1. The PPACA will be repealed probably over a 2- to 3-year period. An outright repeal would leave many without options for health care and Republicans would be blamed for removing insurance coverage from our most vulnerable citizens and the poor. This will not happen. There will be a phase out and gradual replacement by alternative payment schemes. All of the calls for “gloom and doom” are just political rhetoric and should be ignored.

2. Pre-existing conditions will continue to be covered. This is the most costly coverage issue, with a small number of individuals with expensive chronic conditions making up a significant consumption of the healthcare cost.

3. Young people will be covered under their parents’ policies until age 26 (or some other number). This is a very popular provision of the PPACA and again would be taking away a right of young people to be covered under perceived “free” insurance by the young.

4. How will the interim be financed? The devil is truly in the details and will be further detailed as financing schemes emerge.

What has President-elect Trump indicated he wants to do?
He is for repeal and replace.
1. President-elect Trump’s timeline for repeal is within his first 100 days.

2. Mr. Trump has indicated that insurance for young people covered by their parents’ policies is not something he wishes to change.

3. Mr. Trump understands that pre-existing conditions are a major issue and will need to be addressed in the repeal.

4. Mr. Trump does indicate that he is for gradually replacing the PPACA with common sense financing and insurance schemes that are affordable, sustainable, and reasonable for the all people needing health insurance.

What has President-elect Trump done?
Look at Mr. Trump’s nominees for the two most important positions in charge of government healthcare oversight.
1. He has nominated Dr. Tom Price for Secretary of Health and Human Services (HHS). Dr. Price has been a constant and consistent opponent of the PPACA. He has continually introduced his plan for repeal and replace over the last 6 years. The Empowering Patients First Act is the plan for the repeal and replace that embodies Dr. Price’s vision of healthcare reform.
2. He has nominated for Director of the Centers for Medicare and Medicaid Services (CMS) Seema Verma. Ms. Verma, who worked for Vice President-elect Mike Pence, ran the Medicaid program in Indiana, known as the Healthy Indiana Plan (or HIP 2.0). HIP 2.0 requires contributions to a health savings account (HSA) by Medicaid recipients.

Republicans in Congress
Speaker of the House Paul Ryan tasked Chairmen of House Committees responsible for the oversight of health care to develop a plan and present this plan to the American people. The House Republicans’ healthcare reform replacement plan is called “A Better Way.”

Broad Predictions
1. Medicare will stay virtually “as is”. Payment methodologies will remain in flux with a shift to “Value,” “Quality,” “Outcome,” and “Risk” linked payments. With Dr. Price as Secretary of HHS, hopefully the transition period to a Merit-Based Incentive Payment System (MIPS) and Alternate Payment Methods (APM) will be extended and requirements will be further simplified and improved. Much of the turmoil in Medicare payment methods is a result of the Medicare Modernization and CHIP Reauthorization Act (MACRA), a bipartisan replacement of the Sustained Growth Rate (SGR) methodology promoted by the American Medical Association. MACRA is a separate issue from the PPACA repeal and replace.
2. Medicaid will see a shift from federal government mandates and control to state “block grants” with broad requirements. This will allow states to experiment with different payment and treatment options to cover the eligible population in their states. These would not be “one size fits all” central government plans; rather, each state can determine how it delivers health care to its Medicaid recipients.
3. Commercial (private) insurers
a) Employer and group plans will remain virtually the same.
b) The individual market will gradually change from all federal direct subsidies to a blend of subsidies for low-income and poor recipients and tax credits for others.
c) Health plans will be sold across state lines. This will supposedly allow for more competition and allow more plans in each state. Presently, many insurers are pulling out of the individual market leaving many with no options, one option, or very limited insurance options.

The one thing that you can count on is every single special interest group will have its opinion on the PPACA repeal and replace. Everyone will be looking out for themselves and bemoan the largesse they negotiated in the PPACA. The sky is falling everywhere for these special interests, and you will hear them all. The media will make sure every negative possibility and potential pitfall are exaggerated to their fullest. I encourage you to take a deep breath and relax. I also ask that you please let us know what you want to hear about and we will try to explore the possibilities.

Jul 292014

Hello All, I am a practicing physician in a group of 4 Physicians with 5 employees.  About 5 years ago, before PPACA, the Blue Cross Blue Shield of Alabama (BCBS, BCBSAL) had a product that would cover small physician groups in spite of the unavailability of small group health products for others in the state.  I always figured that this was due to the fact that most physicians were in small group or individual group practices and would not have coverage by BCBS unless there were exceptions made for physician practices.  Up until recently (last 5-6 years) BCBS did not have individual coverage either.  All of this started to change in the late 2000’s or early 2010’s.  BCBS started an individual Blues program for individuals to obtain single coverage but they stopped doing small groups and dropped our physician group plan.  However, the Medical Association of the State of Alabama (MASA) had a group program that we joined and all was good.  Until PPACA!  Some provisions of PPACA make it difficult to impossible for Associations to offer health insurance coverage.  Probably has something to do with profits for insurance companies but that is the cynical me talking.

Everyone has heard of the 8-10 million of insured people who have had their insurance cancelled due to lack of having the government mandated essential benefits.  My family is part of that de-insured group.  I have always had and paid for all my health care through out of pocket or insurance.  Now I am being told what insurance is best for me and where I can get it if I go to a federal or state run health insurance exchange where I will get the opportunity to purchase with my money either a mandated insurance plan or pay a tax to get my insurance depending upon which side of the Supreme Court decision you agree with.

To continue the saga:  Went from my group plan to the medical association group plan and then was able to continue my insurance under a presidential waiver of the law for 1 year.  JUST GOT THE CANCELLATION NOTIFICATION DATED JULY 23, 2014, EFFECTIVE THE END OF NOVEMBER, 2014 – right after the election.  Coincidence you say!

Now we have a group of 9 individuals, all with families who are searching for health insurance before the end of the year.  Not uninsured yet, but closer to it.  Thank you Mr. President, Ms. Pelosi, and Mr. Reid.  Just hoping I can keep MY doctor and MY hospital because MY insurance is certainly gone.

To Be Continued…

Aug 112013

Community Health Systems (CHS) and Health Management Associates (HMA) proposed merger is giving rise to hospital mega-systems.  Following the merger of Tenet and Vanguard, this latest consolidation decreases the large publicly traded hospital companies to five (5).

Additionally, not-for-profit systems are like-wise consolidating and and combining, Catholic Health East and Trinity Health, for example.

With the for-profit and not-for-profit systems consolidating and therefore, theoretically, decreasing competition, the government will be increasing oversight of Federal Trade Commission (FTC) Anti-Trust issues.  There are legitimate business reasons to consolidate. A few examples are to reduce duplication of services (streamline systems), decrease costs (economy of scale), improve processes (best practices and evidenced based medicine) and systems (improve quality), pay for information system technology (data collection, data storage, data mining, ICD 10 implementation, integrating providers, and evolving ACO requirements, etc.).

Additionally, declining inpatient populations, decreased payments from governmental and non-governmental payers through audits and changing criteria, and the loss of revenue and cost shifting that the Patient Protection and Affordable Care Act (PPACA) envisions with the massive expansion of the Medicaid program all lead to a need, even a necessity to consolidate.


Yes and we have seen and will continue to see these unintended consequences.  Just look at the waivers given to groups from the PPACA, Congress’s exemption for aspects, the Presidential decrees to ignore (or not enforce) laws that are not convenient.  There are many, many unintended consequences from this ill-conceived Democratic law.  Can we work through them? Yes we can.  Can patients receive care?  Yes they can.  Will there be changes? Yes there will be.  Are all the changes for the better?  Not sure, stay tuned.

Tenet-Vangard merger information

CHS information

HMA information

CHS-HMA merger information

Aug 082013

Physicians have the opportunity to lead the nation to fiscal stability and should proclaim this intention wide and far.  This should be the message of organized medicine about the so-called “doc fix” that is making the rounds of Congress these days.

SGR… A model for Responsible Government Spending
Repealing SGR has been the long term goal of AMA and other organized medical groups. Due to an unforeseen downturn in the cost of a “fix”, this year, politicians are attempting to craft a solution quickly. This is the same scenario that got us into the SGR problem where fixes to manufactured problems are hurriedly cobbled together into a perceived solution that eventually results in unintended consequences. Only the AMA could consider below inflation annual updates to Medicare payments a successful lobbying campaign.  Now, 0.5% annual updates, way below real inflation rates are called “fair” by the Congress and stabilizing by organized medicine.  Physicians have been losing ground to inflation for over a decade and the SGR fix continues this “loss” in real dollars to be followed by something else which is not detailed or well thought out.  While expressing the gratitude of physicians for the proposed cuts in real dollar payments for their services, the real story is being missed.
Holding spending increases to 0.5% will result in declining deficits, eventual excesses, and result in a reduction in the national debt.
The Government plan is to keep the docs in Medicare as long as possible with tiny inducements until the wheels fall off and the public clamors for single payer government care. Hello Amtrak and USPS!

Mar 122013

Economic disparity in life expectancy informs Medicare eligibility age debate.

On its front page, the Washington Post (3/11, A1, Fletcher, 489K) reports on the disparity in life expectancies of poor and rich seniors, which informs the debate on whether raising the Medicare and Social Security eligibility ages is a fair way to cut costs in the program. As the article explains, “Even as the nation’s life expectancy has marched steadily upward, reaching 78.5 years in 2009, a growing body of research shows that those gains are going mostly to those at the upper end of the income ladder.” And so, “raising the eligibility ages – currently 65 for Medicare and moving toward 67 for full Social Security benefits – would mean fewer benefits for lower-income workers, who typically die younger than those who make more.”

Nov 202012

Those who missed the SMA meeting this year missed what many attendees described as the “Best SMA Meeting Ever!”  This meeting presented varied viewpoints from many different stakeholders concerning reforming the health care financing scheme in this country to proposed health care delivery models to the tools needed to implement change to the personal needs of physicians during this time of change.  This meeting developed by SMA and under the leadership of Mark Williams, MD, our meeting Co-Chair.  The next meeting that will be presented by the SMA on this subject is the Medico Legal Aspects of Medicine Meeting in Washington, D.C. in March.

Oct 102012

Shoals Pain Center’s Physicians and staff would like to express our deepest sympathy for those who have been affected by this terrible tragedy related to the steroid injections received by some patients that were contaminated.  This outbreak and concern is localized to one compounding pharmacy in Massachusetts that furnished medication to many clinics in several states.  The CDC has identified the compounding pharmacy and the medication and lot numbers of the contaminated medication.  This incident has affected many patients who only sought relief from chronic pain and has caused concern among those receiving epidural steroid injections.  As physicians and patients, the safety of medication should be expected.  In this case, that expectation was not met.

We wanted to assure the patients who have received steroids injections from Shoals Pain Center that we do not use any corticosteroids from any compound pharmacies for our injections.  The steroids we have used originate and are manufactured by Pfizer.  None of our patients were exposed to any of the medication that has been in the news.

As you may be aware, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) are currently investigating this recent outbreak of fungal meningitis among patients who received an epidural steroid injection after May 21, 2012.   Twenty-four deaths have been reported to the CDC as of October 25, 2012 and more may be occur.  317 people in 17 states have been identified with problems from this medication.  Our thoughts and prayers are with the patients and their families affected by this incident.

Again, Shoals Pain Center did not use any of this medication and only uses steroid from large commercial manufacturers.  For your information, the following CDC statement is provided.  Physicians who used any of the affected medicine should contact patients who have had an injection (e.g., spinal, joint) using any of the three lots of methylprednisolone acetate below to determine if they are having any symptoms. The three lots are:

  • Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012
  • Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012
  • Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013

    In addition, CDC and FDA recommend that healthcare professionals cease use of any product produced by the New England Compounding Center (NECC) until further information is available.:

Steroid injections are safe. 
Fungal meningitis is not transmitted from person to person. 
If patients have questions or concerns, they should contact their immediate health care provider.

  • The CDC further advises that, “For patients who received epidural injection and have symptoms of meningitis or basilar stroke, a diagnostic lumbar puncture (LP) should be performed, if not contraindicated.  Because presenting symptoms of some patients with meningitis have been mild and not classic for meningitis (e.g., new or worsening headache without fever or neck stiffness), physicians should have a low threshold for LP. While CDC is aware of infections occurring only in patients who have received epidural steroid injections, patients who received other types of injections with the contaminated methylprednisolone acetate from those three lots should also be contacted to assess for signs of infection (e.g., swelling, increasing pain, redness, warmth at the injection site) and should be encouraged to seek evaluation (e.g., arthrocentesis) if such symptoms exist.”
    For more information please visit the FDA and CDC websites and the list of all products produced by NECC that have been recalled:
    Medical Director, Shoals Pain Center
Jul 272012

The following link will take you to a serious article on the cost of Health Care Reform.  Charles Blahous discusses the law, CBO’s limitations and assumptions in their scoring, and tries to provide a real comparison between the PPACA and the cost of healthcare prior to the law’s enactment.  Truly interesting reading with links to other pertinent articles on the subject.

“If you think health care is expensive now, wait until it is free.”

Click Here

Jun 302012

Bad outcomes, personality conflicts, communication issues, emotions, and negligence all lead to possible litigation between and among patients and their care providers.  State boards who are tasked with the policing of professions have varying degrees of success.  The Courts and juries dispense verdicts that can be argued to be fair or not.  The system is not perfect.  What is agreed upon is that some lawsuits appear to be frivolous, some have merit, and it is sometimes difficult to determine which are which.

There are some states who have instituted tort reform and these states proclaim that tort reform is great for business.  There are injured patients in every state who have not gotten justice or fairness.  There are frivolous lawsuits.  Both sides of the professional liability issue have their poster cases of justice and injustice, of fairness and unfairness that are held up as examples of where the system has worked or has not worked.  The macro view of tort reform should, in my opinion, be focused on the issue of protecting patients from harm.  Compensating those who have been injured and trying to make them “whole” as much as one can financially.

Health care reform has introduced newer providers into the primary care marketplace.  Nurse practitioners and other physician extenders are being presented as physician replacements to insure access points into the health care system.  The government’s reform is pushing for the training of more mid-level and nursing providers to provide primary care for patients.  This is changing the health care system from “medical care” to “health care”.

One would think that the use of the highest trained and educated individuals to treat patients would result in the best care.  Will reducing the education and training of the primary care personnel in the health care setting result in a lesser quality of care or in bad care?  Will there be patient’s harmed when “medical care” is supplanted by “health care?”  Is this an acceptable or calculated risk under the concept of population medicine?  Medical care can only be provided by physicians (allopathic or osteopathic) who are educated and trained in medicine and can therefor provide medical care to patients.  Physicians may delegate certain duties and functions to other members of the care delivery team.  These physician extenders help the physician take care of patients and help provide care.  The leader of the medical care delivery team must be a physician.  Physicians do, should and must supply the leadership, quality, perspective, and patient advocacy to the care team.  In the arena of public awareness, the term “medical care” is being substituted by “health care”, the disclaimer of  “see or consult with your medical doctor” is changing to ” see or consult with your health care provider.”  Medical care by definition must be provided by a physician (MD or DO) or a physician led care team.

As physicians, we must expand our view of medical care and medical education to include preventive, coordinated, and cost effective care.  This change is inevitable and physicians should and must lead the way.  Nurse practitioners can provide nursing care because that is their training.  Nurses teach nurses.  Nurses have no medical training and cannot provide medical care.  Therefor, a government public relations, legislative, and regulatory campaign to lessen the value of medical training and inflate the value of nursing training in underway.  The medical profession is under assault by the government.  This can be the topic of another discussion.  (medical training, nursing training, medical care, health care)

Non MDs or DOs cannot provide medical care as they have no medical education and have only very limited exposure, if any, to medical training or clinical practice.  Nurse practitioners are trained by nurse practitioners.  Exposure to medical training as well as any clinical exposure is limited if not absent during a Master’s program.  This glaring lack of clinical exposure much less experience is glaringly lacking in the DNP curriculum.  More mid-level providers are being pumped out of programs with fancy bookwork degrees (Master’s and DNP) with little more “clinical” nursing experience than a Registered Nurse.  Many of these programs are through distance learning using a computer and the internet.

National mid-level provider trade associations and state boards of nursing are expanding the scope of practice (or being able to practice to the full extent of licensure and training) with little to no ability of medical boards to define, much less regulate, the practice of medicine by these non-medically trained persons.  State boards of nursing are not regulating the scope of nursing practice, but openly embracing unlimited “nursing” practices.  The IOM study, without any physician input, finds that these mid-level providers can function as primary care access points and provide care as good as a primary care physician.  The government, in PPACA, promotes mid-level, non-medically trained personnel as equal substitutes for primary care access points and as a solution to the projected physician shortage.  Numerous mid-level provider generated “academic” papers tout the equal care, equal outcomes, and, sometimes, superior outcomes of mid-level non-medically trained provider care.  Some of these poorly designed and questionable “studies” are then promulgated and touted as truths to further an agenda.

Everyone has anecdotal tales of over and under treatment, over and under diagnosis, inappropriate referrals for testing and consulting, and damage to patients that occur with mid-level providers who either work independently or in loosely collaborating practice arrangements.

Rather than everyone blindly clamoring for tort reform, as physicians, we should be looking out for those patients who will be harmed by the care provided by this vast wave of unregulated non-medically trained mid-level care givers.  The government is going to use these providers as physician replacements (just look at how the definition of physician has been revised).  The federal government, state boards of nursing, national mid-level trade associations, national policy organizations, and insurance companies are all willing to accept the premise that the care given by these “cheaper” replacements is at least equal to those of physicians.

It is time for the courts and the plaintiff’s bar to look at these individuals and hold them responsible for their actions.  If one truly believes that they are equal to a physician and are licensed to practice as physician replacements and substitutes, they should be held equally accountable and liable as physicians.  Patients should expect that the quality of care received and the liability of the practitioner be the same wherever the care is given.  The liability for the care should not be shifted to the “collaborating” physician when the decisions that lead to negligence are totally within the purview of the treating non-medically trained mid-level provider.  Plaintiff lawyers should be educated to identify and hold accountable the provider responsible and not just look for deep pockets.

Mid-level non-medically trained providers who practice independently or through loosely devised “collaborative” arrangements should have liability insurance coverage equal to or greater than a physician.  The cost of a mid-level’s insurance should be at least the cost of a physician’s liability policy when practicing independently or “collaborating” off site from a supervising or collaborating physician.

When practicing to the “full extent of training and licensure,” non-medically trained mid-level providers who are independent and/or offsite “collaborators” should be held to the standard of care provided by the physician that they are substituting or replacing in the healthcare delivery system.

I cannot see any other stance for true patient advocates to take.  Only by effectively and honestly advocating for equality of patient care and safety, for equality in the quality of care patients deserve or have a right to expect can physicians truly consider themselves patient advocates.

Tort reform, which will disproportionally protect lesser trained personnel providing less quality of care,should be advanced only with full disclosure of all unintended consequences.

I was allowed to read a manuscript on tort reform and a proposed method to make it more reasonable, if that is possible.  I was one of the guest editors to read and comment on this article before selecting it for publishing.  This article will be published in the SMJ (Southern Medical Journal) within a few months.  I would recommend that all read the article and think about what it proposes to level the playing field and reward provider’s quality, experience, compassion, and empathy when outcomes are less than ideal and litigation initiated.