Affordable Care Act?

September 30, 2013 will probably not go down as a hugely memorable day in history. Yet, it represents   a pretty momentous confluence of events. On the one hand, there is the threat of an impending government shutdown based on partisan squabbling predicated on the defunding of the Affordable Care Act, or Obamacare, as it is widely known. We are on the brink of ......well, brinksmanship.

On the other hand, we are also on the brink of the inauguration of Health Exchanges-one of the cornerstones of the Affordable Care Act. The Exchanges represent a pretty grandiose social experiment. The goals of the Exchanges seem pretty laudable: reduce insurance premiums, allow those with preexisting conditions to get coverage, allow small businesses and families to have the same kind of leverage with insurers that large employers have.

There are many unknowns as to how, in fact, this will play out. And people should probably use a great deal of caution before chucking whatever plan they currently have. One of the gigantic question marks about the exchanges is a very practical one-how much will the insurance plans offered cost the consumer, and will that actually represent a savings over their current plan?

The fact that patients with pre-existing conditions must be allowed to purchase insurance on the exchange leads me to believe that insurance premiums are bound to go up rather than down. Obviously, if an insurer has a pool of insured people that are highly likely to use a large amount of medical services, they have to charge more to mitigate this risk.  In addition,somehow insurers must pay for the  laundry list of services that must be included for plans offered on the exchanges, such as prescription drug coverage and wellness services, somehow that must be paid for.

It is estimated that only a small portion  of the population will be using the exchanges. If you have existing insurance through your employer, you are only eligible for the exchange if your portion of the premium is over 9.5% of your income. Furthermore, Medicare recipients are not eligible. Further reducing the eligible pool of participants in the Exchanges, is that some states have elected to opt out of creating Exchanges. Those states who do not have an exchange will have a federally run exchange starting in 2014.  The exchanges will probably be applicable to only about 20 million people-more or less.

If you do not currently have health insurance, and you are eligible for the Exchange and you fail to purchase insurance, you will be fined $95. This fine will gradually escalate to $695 over the next few years.

So how will insurers try to keep down the cost of insurance plans offered on the exchanges? Physicians are very fearful that their reimbursement for work done under the auspices of insurance plans offered on the Exchange plans will go way down. One physician organization indicated that reimbursement was a low as 70% below more conventional insurance plans.

Colonoscopy Conspiracy?

Colonoscopy Conspiracy??

Don't get me wrong-I am not a conspiracy theorist....I am not one of those folks who is convinced that 9/11 was a government plot, or that the moon landings were a hoax. And, deep down, I really don't think that our government is really conspiring to phase out screening colonoscopy by trying to turn public opinion against it through the media. But.......you never know!!

I must confess, however, that my mind did start to wander about such possibilities when I happened to read two articles in large circulation newspapers(large circulation newspapers-that sounds like an oxymoron these days) that maligned colonoscopy. And interestingly, they were published only about 1 month apart. Coincidence? Maybe. Newspapers acting as a shill for government agenda-ie trying to curtail Medicare spending by convincing readers that colonoscopy is an unnecessary ripoff? Maybe.

If you are interested, one article was in the New York Times on June 2 of this year, while the other was in the Washington Post on July 20th of this year. I have attached the links below.

New York Times

Washington Post


Let's start with the New York Times article. The article is entitled: The $2.7 Trillion Medical Bill, with the subtitle:Colonoscopies Explain Why the US Leads the World in Health Expenditures.  Really?? Is it that simple? When the article starts out with that title, you know it isn't designed to present a balanced approach to the topic. The article goes on to discuss some anecdotal cases of patients who were stuck with some ridiculously exorbitant bills for their routine colonoscopy, and decries the overall cost of colonoscopy, quoting a figure of $10 billion per year in the US.  It goes on to quote Dr. Gilbert Welch, a Dartmouth professor as saying, “We’ve defaulted to by far the most expensive option, without much if any data to support it,” when discussing colonoscopy versus other screening tests for colon cancer.  The article failed to mention the fact that Dr. Welch has pretty much made his living over the last 20 years by bashing any attempts to achieve early detection of disease through screening tests. Hmmm, I wonder if he would discourage his mother or father from getting a screening colonoscopy. But, I digress. Oh, one more thing, Dr. Welch-there actually is plenty of data to support it.

Anyhow, the article flashes eye catching highlights, like patients who got staggering bills of over $9000 for a colonoscopy. You have to dig a little deeper into the article, however to find that Medicare paid, on average, $531 for a colonoscopy in 2011. ( By the way-of this total, the physician's professional fee for performing the colonoscopy is approximately $220) Is this really why we lead the world in health care expenditures?

Let's move on to the Washington Post article. This one is another doozy. It is entitled, "How a Secretive Panel Uses Data That Distort Doctors' Pay". The article goes on to describe how an American Medical Association panel, supposedly behind closed doors, hatches a diabolical scheme to tilt the Medicare reimbursement process in the favor of physicians. They cite the case of colonoscopy, the Relative Value Unit(RVU)-which is the basic currency of Medicare reimbursement, is based on 75 minutes of physician time. The article then goes on to question how this can possibly be valid if some physicians are performing 12 or more colonoscopies in a day, i.e. there just aren't enough hours in a day How can colonoscopy reimbursement possibly be based on 75 minutes of physician time when the procedure often takes only 20 minutes or so, etc, etc. Like the New York Times article, it sounds like another example of how colonoscopy is a ripoff being perpetrated by the evil empire of medicine. 

These articles were very disturbing to me, and they should bother you as well. Colon cancer is the number three cancer killer in America. There are approximately 150,000 new cases of colorectal cancer diagnosed per year in the United States, and approximately 55,000 deaths per year. While there are other less expensive, less invasive tests to screen for colorectal cancer, colonoscopy is the only one that offers both early detection, as well as prevention(by way of detecting and removing precancerous growths). Screening colonoscopy has been shown to reduce deaths from colorectal cancer.

Sensationalist headlines blaming colonoscopy for America's healthcare woes, and portraying it as some elaborate scam only serve to discourage those who might be on the fence about getting a screening colonoscopy which might save their life. As a physician who performs colonoscopy, if the American Medical Association is distorting data to provide me windfall profits for performing a colonoscopy, then they are doing a poor job of it. As I mentioned above, the professional fee from Medicare for performing a colonoscopy is about $220. While the procedure may take only 20-30 minutes to perform, that is only the tip of the iceberg in terms of the man hours that are involved. The performing physician also routinely reviews the patient's medical record prior to performing the colonoscopy, speaks to the patient and family in the recovery area following the procedure, tracks down and evaluates results of any biopsies performed during the procedure, communicates those results to the patient, along with any further actions based on those results, and indicates when-if any-followup exam should be performed, and documents all of the above.  So is the RVU for colonoscopy based on 75 minutes of time really a distortion? If anything, it may be an underestimate.