zibazinski
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Post by zibazinski on Nov 7, 2014 17:26:52 GMT -5
Huge push to nurse practitioners and PAs seeing a lot of patients for run of the mill items, thereby freeing up doctors for things beyond the support staff's expertise.
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bean29
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Post by bean29 on Nov 7, 2014 17:56:31 GMT -5
A secondary issue with Medicaid (Medicare reimbursement falls under a different preview, it is not as much as private insurance, but not as bad as Medicaid) is that Medicaid patients are 3x (the last paper I read) as likely to cancel a scheduled appointment. If you set your practice such that no more than half is Medicaid, if 1/3 cancel, on any one day, you are out significant $$. I know the dental clinic had horrible problems with this. These days, canceling without notice is likely to get you charged at least a nominal amount if you are privately insured. Those on Medicaid wouldn't pay, so the doctor's office is left with empty slots and no income. About DTaP vaccinations, I would imagine some of this has to do with documentation records, and that is the reason that pharmacies are not an acceptable source. For the most part, vaccinations at a pharmacy are usually a one shot deal, where there is no need for the pharmacy to keep records for years after vaccinations. If you go to a health clinic, there is some requirement to maintain records. So Johnny changes schools, was vaccinated for DTaP at CVS 3 years previously and needs proof of vaccination. No proof = duplication of service that Medicaid is paying for a second, or third time. Mich, I don't think this is true, at least in WI the health department maintains the immunization record and any doctor call pull up the state record.
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Post by The Walk of the Penguin Mich on Nov 7, 2014 22:31:19 GMT -5
A secondary issue with Medicaid (Medicare reimbursement falls under a different preview, it is not as much as private insurance, but not as bad as Medicaid) is that Medicaid patients are 3x (the last paper I read) as likely to cancel a scheduled appointment. If you set your practice such that no more than half is Medicaid, if 1/3 cancel, on any one day, you are out significant $$. I know the dental clinic had horrible problems with this. These days, canceling without notice is likely to get you charged at least a nominal amount if you are privately insured. Those on Medicaid wouldn't pay, so the doctor's office is left with empty slots and no income. About DTaP vaccinations, I would imagine some of this has to do with documentation records, and that is the reason that pharmacies are not an acceptable source. For the most part, vaccinations at a pharmacy are usually a one shot deal, where there is no need for the pharmacy to keep records for years after vaccinations. If you go to a health clinic, there is some requirement to maintain records. So Johnny changes schools, was vaccinated for DTaP at CVS 3 years previously and needs proof of vaccination. No proof = duplication of service that Medicaid is paying for a second, or third time. Mich, I don't think this is true, at least in WI the health department maintains the immunization record and any doctor call pull up the state record. But I seriously doubt that pharmacies report immunizations to the health department. That is my point. Physicians and the health department, undoubtedly and this is llikely the reason that Medicaid does not pay for childhood vaccinations though pharmacies....because there is no reporting.
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Deleted
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Post by Deleted on Nov 7, 2014 23:01:05 GMT -5
Mich, I don't think this is true, at least in WI the health department maintains the immunization record and any doctor call pull up the state record. But I seriously doubt that pharmacies report immunizations to the health department. That is my point. Physicians and the health department, undoubtedly and this is llikely the reason that Medicaid does not pay for childhood vaccinations though pharmacies....because there is no reporting. I don't think physicians report to the health department in all states. when I needed records for school, I had to scrounge and find the records from 2 or 3 different peds. If the health department had it all I could have obtained them with one phone call. I would think schools would have the comprehensive record and if you needed a copy you could get it from there. I think the reporting thing is a very lame argument for medicaid not covering vaccines through pharmacies.
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Deleted
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Post by Deleted on Nov 8, 2014 3:19:50 GMT -5
I have to provide my school with a list of immunizations.
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Deleted
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Post by Deleted on Nov 8, 2014 8:39:57 GMT -5
I have to provide my school with a list of immunizations. yes and then once you provided it to them if you need a copy, you can get it from there which blows the whole 'pharmacies don't report to the health department so medicaid won't cover it' logic out of the water. once the school has it on record, it's there, you don't have to provide it to school every year unless you change schools/districts/
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Phoenix84
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Post by Phoenix84 on Nov 8, 2014 10:38:23 GMT -5
I believe it.
The more I see it, the more I think the ACA didn't really fix anything. It just shuffled the deck around a bit on who's paying and created a whole new level of bloated government bureaucracy that will burden an already burdened system.
As what usually happens, the poor and disenfranchised will be hurt the most by the measures that were supposed to help them. The road to hell is paved with good intentions.
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Post by The Walk of the Penguin Mich on Nov 8, 2014 11:55:50 GMT -5
Immunization rates are reported to health departments, there is some fairly comprehensive data on this.....just like there are reportable illnesses that physicians are required to report. Look at the MMWR, this is where most of this data is published.
My point, however was that pharmacies do not keep immunization records like physicians and health departments. You went back and got our child's records a few years after the fact for the school. Pharmacies do not keep medical records on immunizations, and since there are no records, there is no information available after the fact. No information available means services need to be duplicated.
If you have ever gotten an immunization at a pharmacy, all you do is sign a consent form. I suspect that these are tabulated to report how many doses are given, then tossed. If I go back to the Walgreen's pharmacy I got my flu shot at 4 years ago, they would have nothing on record that I received it.
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Post by The Walk of the Penguin Mich on Nov 8, 2014 12:01:19 GMT -5
I believe it.
The more I see it, the more I think the ACA didn't really fix anything. It just shuffled the deck around a bit on who's paying and created a whole new level of bloated government bureaucracy that will burden an already burdened system.
As what usually happens, the poor and disenfranchised will be hurt the most by the measures that were supposed to help them. The road to hell is paved with good intentions. Seriously? It allowed young adults to remain on their parent's insurance while they are first starting out. It eliminated the pre-existing clause in getting health insurance. You have no idea how important either of these are. I was terrified after I was diagnosed with my infection and went on disability. If my employer had not covered me the 2 years until Medicare kicked in, I was uninsurable. Not all employers do this, and COBRA doesn't cover you long enough. The last thing one needs when they are dealing with medical issues is to lose their insurance.
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Deleted
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Post by Deleted on Nov 8, 2014 12:51:33 GMT -5
Seriously? It allowed young adults to remain on their parent's insurance while they are first starting out. It eliminated the pre-existing clause in getting health insurance. You have no idea how important either of these are. I was terrified after I was diagnosed with my infection and went on disability. If my employer had not covered me the 2 years until Medicare kicked in, I was uninsurable. Not all employers do this, and COBRA doesn't cover you long enough. The last thing one needs when they are dealing with medical issues is to lose their insurance. I agree that Obamacare has done some good things. We have a ton of problems to solve with the way medical care is provided in this country and no, they didn't solve them all. Making lower-cost coverage available with subsidies if needed, and the 2 aspects Mich pointed out, are huge. I'm insanely healthy but at age 61 there are a few blips in my medical history that could be interpreted as pre-existing conditions by an over-zealous underwriter. I'm profoundly grateful I was able to get health insurance after I retired, since I have 4 more years before Medicare kicks in.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 9, 2014 23:25:29 GMT -5
A secondary issue with Medicaid (Medicare reimbursement falls under a different preview, it is not as much as private insurance, but not as bad as Medicaid) is that Medicaid patients are 3x (the last paper I read) as likely to cancel a scheduled appointment. If you set your practice such that no more than half is Medicaid, if 1/3 cancel, on any one day, you are out significant $$. I know the dental clinic had horrible problems with this. These days, canceling without notice is likely to get you charged at least a nominal amount if you are privately insured. Those on Medicaid wouldn't pay, so the doctor's office is left with empty slots and no income. About DTaP vaccinations, I would imagine some of this has to do with documentation records, and that is the reason that pharmacies are not an acceptable source. For the most part, vaccinations at a pharmacy are usually a one shot deal, where there is no need for the pharmacy to keep records for years after vaccinations. If you go to a health clinic, there is some requirement to maintain records. So Johnny changes schools, was vaccinated for DTaP at CVS 3 years previously and needs proof of vaccination. No proof = duplication of service that Medicaid is paying for a second, or third time. Mich, Pharmacies are required to keep records. A vaccine is considered a prescription and you have to keep records of it for at least 3 years. Most places keep it even longer (4-7 years), depending on their systems. As far as duplication of services, it doesn't work like that. The pharmacies are billing in real time (not afterwards like a medical office or hospital). They link with insurance company/Medicaid/Medicare system payment system. If the payer has already paid for the service, it rejects the claim immediately and won't pay again. Medicare Part B does this all the time (Part B pays for flu vaccines. If they have already gotten the vaccine, it should reject). Medicaid already does this with medications (That's why you can't get a month's worth of medication every week... the payer system knows when they last paid a claim for that drug/service and rejects the new claim if it is "too soon" by their guidelines).
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shanendoah
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Post by shanendoah on Nov 10, 2014 13:40:08 GMT -5
Sorry it's taken so long for me to respond- got busy on Friday and wasn't really online over the weekend.
It is easy to tie Medicaid in our minds to the ACA because the federal government offered more funds to support state Medicaid programs if they increased eligibility for Medicaid as part of (or in conjunction with, I don't remember exactly) the ACA. But talking about Medicaid as the problem with the ACA is fundamentally wrong. Medicaid programs are state run programs NOT federal. Your state has the ability to set it's reimbursement rates for Medicaid at whatever your state wants to set them at. The ACA in no way changes that. So if you have problems with Medicaid, that's something that needs to be taken up on the state level. (And something I can't discuss knowledgeably outside of my own state.) CA's rules are different than WA's rules are different than OR's rules are different than NV's rules, and those 4 states are nicely grouped together. Just imagine how different they are from WI's rules or NC's rules.
I have to believe that WA doesn't try and screw it's providers as badly as other states, because I have never once had a problem getting either kid (both on Medicaid) into the providers they needed to see in a timely manner. I'm not saying our Medicaid system is perfect (trying to talk to someone on the phone at the medicaid office who says they can't tell me anything because my daughter's case number is under the foster care system, and they have to get permission from her social worker before they can talk to me, and me explaining that since my daughter has been adopted, she no longer has a social worker, and no one at the state has the legal authority to talk to medicaid about her case. And the person on the line insisting they can't talk to me without state permission), it has it's problems. But those are problems that, while perhaps not unique to WA, are up to WA to solve.
But that is one of the problems with the ACA, in that it didn't go far enough, in my mind. Everything is still run by the states.
As for what the federal government can do to increase the supply of physicians, if the resources are available to increase the residency program, than I think they should. If not, I think they should be looking at what they do to make the resources available to increase the residency program. And again, the government can do a lot to incentivize people to go into a certain field, but it can't force anyone.
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Post by The Walk of the Penguin Mich on Nov 10, 2014 13:58:29 GMT -5
As for what the federal government can do to increase the supply of physicians, if the resources are available to increase the residency program, than I think they should. If not, I think they should be looking at what they do to make the resources available to increase the residency program. And again, the government can do a lot to incentivize people to go into a certain field, but it can't force anyone.
I know that the government has tried some things, that have not had great success.
There was a women in one of my PH classes that was a family physician and had signed on to work in a historically underserved area as an attempt to pay off her (rather substantial) medical school loans. The problems she dealt with in being the only physician in the area made her choose to move to a more populated area.
The biggies were: Her husband was also a professional and was stagnating in his career. Her kids were not getting the sort of education that she wanted them to receive. Neither she nor her husband had the time to do the sort of tutoring that they'd need in order to compete with better schools. They were in elementary school and were not being taught at grade level. Her professional development went into the toilet. In order to get her CE credits, she had to jump through an incredible number of hoops in order not to leave the area without a doctor. If she needed to go to a conference, it was even harder to get away. Forget about taking any sort of vacation. Her lack of peers, so she did not get any sort of help when she came up against a complicated case. There was no one else in the area that she could bounce ideas off of. She was essentially on call 24/7/365.
As it turned out, she just threw in the towel and decided to pay off her medical loans by moving to an area where she would get paid better. She hated doing it, but her decision was having an impact on her entire family, and her health.
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The Captain
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Post by The Captain on Nov 10, 2014 14:20:37 GMT -5
As for what the federal government can do to increase the supply of physicians, if the resources are available to increase the residency program, than I think they should. If not, I think they should be looking at what they do to make the resources available to increase the residency program. And again, the government can do a lot to incentivize people to go into a certain field, but it can't force anyone.
I know that the government has tried some things, that have not had great success.
There was a women in one of my PH classes that was a family physician and had signed on to work in a historically underserved area as an attempt to pay off her (rather substantial) medical school loans. The problems she dealt with in being the only physician in the area made her choose to move to a more populated area.
The biggies were: Her husband was also a professional and was stagnating in his career. Her kids were not getting the sort of education that she wanted them to receive. Neither she nor her husband had the time to do the sort of tutoring that they'd need in order to compete with better schools. They were in elementary school and were not being taught at grade level. Her professional development went into the toilet. In order to get her CE credits, she had to jump through an incredible number of hoops in order not to leave the area without a doctor. If she needed to go to a conference, it was even harder to get away. Forget about taking any sort of vacation. Her lack of peers, so she did not get any sort of help when she came up against a complicated case. There was no one else in the area that she could bounce ideas off of. She was essentially on call 24/7/365.
As it turned out, she just threw in the towel and decided to pay off her medical loans by moving to an area where she would get paid better. She hated doing it, but her decision was having an impact on her entire family, and her health.
This is by no means unique. A relative had to be transported over 200 miles to a hospital that had a specialist on staff to handle his complicated medical condition. In the area (which was not by any means rural) where he lived there was only one specialist certified in the needed area, and that guy didn't take medicare patients. This was in an area that was supported by three hospitals so it was pretty well populated. I know of another doctor who left a rural practise for pretty much the same reasons and now works for an insurance company and a case management coordinator and make more then she ever did in private practise PLUS she doesn't have to have malpractise insurance.
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Mardi Gras Audrey
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Post by Mardi Gras Audrey on Nov 10, 2014 14:52:37 GMT -5
shanendoahThe Medicaid expansion was a HUGE part of the ACA. You can't talk about one without talking about the other. A huge portion of people that were uninsured before the ACA are now "insured" by Medicaid. One source says that nearly half of the uninsured will now be getting Medicaid (http://obamacarefacts.com/obamacares-medicaid-expansion/) "ObamaCare’s Medicaid Could Insure 21.3 Million Americans in the Next Decade. So Why Did Some States Opt-Out Of Expanding Medicaid? ObamaCare Medicaid Expansion is one of the biggest milestones in health care reform. ObamaCare’s Medicaid expansion expands Medicaid to our nations poorest in order cover nearly half of uninsured Americans"As I already mentioned, Medicaid reimbursements are PALTRY! So, let's solve the problem of supply by increasing the demand and placing artificial price caps on what providers will get. That is a HUGE reason we have such a horrible supply. The govt doesn't want to own up to the problem they have created though because that would mean being honest about what health care costs, possibly rationing care, or raising taxes. Because no one can stand up and say the honest truth, we get more people dumped on a system that is taxed and told they "have insurance" and "are entitled to X, Y, and Z". It doesn't matter to the govt that no one can provide X, Y, and Z at the rates they are paying... the govt doesn't have to be the "bad guy" and tell people it is their (govt's) fault they can't get care. Yes, medicaid is state run but the $$ for it comes from the feds. So, no, a state can't "just raise" reimbursement rates. If they don't have the money, they don't have the money. They rely on what the feds give them, even though the feds KNOW that they don't give them enough resources. To make it even more fun, CMS (The Center for Medicaid and Medicare Services-Federal) puts restrictions and requirements on what needs to be done. So, the federal govt isn't just pushing the states a wad of cash and telling them "go forth". It is like the funding for the disabled in schools... "here's some money with a bunch of strings attached. Oh, BTW, the money won't cover your needs but you still need to meet all the strings. Good luck"
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milee
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Post by milee on Nov 10, 2014 15:07:16 GMT -5
Yes, medicaid is state run but the $$ for it comes from the feds. So, no, a state can't "just raise" reimbursement rates. If they don't have the money, they don't have the money. They rely on what the feds give them, even though the feds KNOW that they don't give them enough resources. To make it even more fun, CMS (The Center for Medicaid and Medicare Services-Federal) puts restrictions and requirements on what needs to be done. So, the federal govt isn't just pushing the states a wad of cash and telling them "go forth". It is like the funding for the disabled in schools... "here's some money with a bunch of strings attached. Oh, BTW, the money won't cover your needs but you still need to meet all the strings. Good luck" Another large issue with accepting Federal funding to expand Medicaid is that the feds are infamous for providing more funding at the start of a program to incentivize states to sign on. But there's no guarantee that the exact Fed funding will continue and it doesn't always continue, or the strings change to require ever more cash from the state. Then the state is in a pickle because they've set up and gotten people onto these programs so can't exactly kick people off even if the Fed funding dries up.
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