Healthcare yesterday, today, and tomorrow. Dr. John Braddock's presentation at the Bing Lounge with Lars Larson.

2. HealthCare in America
Yesterday
Today
Tomorrow

3. A PHYSICIAN’S PERSPECTIVE
Current State of Health Care
Patient Protection and
Affordable Care Act (ACA)
Health Care Post ACA
Concierge Medicine or
Private Medicine

4. The Good Old Days

5. Pre Insurance Paradigm
•Patient decides upon the Provider.
•Patient pays for service
•Payment may be in cash or credit of some
sort

6. Current System
• Concept of insurance added during Truman’s
administration
• Lyndon Johnson-1965-Medicare passed
• 1970’s insurance enters medicine and it
becomes oriented more towards business and
away from patient care

7. Current Paradigm
•Insurance tells physician what
services it can provide for what
costs and under what conditions.
•Physician bills insurer for
payment.
•Patient chooses insurance (via
the exchange, employer, or
other).
•Insurer tells patient what
provider(s) they can see and
what is and is not covered.
•Patient waits on the Provider.
•Eventually the patient gets a few minutes of “face
time” with provider.
•Provider reactively treats patient as allowed by
insurer, not based on best practices.

8. The current healthcare system is broken.
In 2007, Americans 15 years
and older collectively spent
1,611 years waiting for
medical services.1
The Average Wait Time to see
a Physician in 2009 was 22
minutes.2
“Lost Time is Never Found Again” – Benjamin Franklin
1. Feb 2009 New York Times Article “A Hidden Cost of Healthcare: Patient Time”
2. Oct 2010 Wall Street Journal Article “The Doctor Will See You Eventually”

9. Average Wait times by City
Longest wait times for
Family Practice, by
city;
• Portland 13 days
• Boston 66 days
• Los Angeles 20 days
• D.C. 14 days
• New York 26 days
http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/29/in-cities-the-average-doctor-wait-time-is-18-5-days/

10. Everyone knows…it’s Only Going to Get
Worse
1. ObamaCare is adding 30 million
more patients to an already
overburden system.
2. Fewer Primary Care Physicians are
entering the marketplace.
3. Physicians will have to see 30+
patients a day to keep up with
demand and carry up to 3,000
patients in their practice.
4. Focus remains on episodic care only.

11. AFFORDABLE CARE ACT
Biggest effort at social engineering since
Medicare and Medicaid in 1965
Requires most individuals to obtain health care
coverage
Requires insurance companies and employers to
provide consumer protection related to health

12. http://dailybail.com/home/obamacare-complicated-check-out-the-flow-chart.html

13. As this graphic shows, the new law creates 68
grant programs, 47 bureaucratic entities, 29
demonstration or pilot programs, 6 regulatory
systems, 6 compliance standards and 2
entitlements. What could possibly go wrong
with something so-well organized?

14. AFFORDABLE CARE ACT
Goals
1. Increase the quality and
affordability of health
insurance
2. Lower the uninsured rate
3. Reduce costs of health
care
4. Improve health care
quality

15. Affordable Care Act
• Signed into Law-March 23, 2010
• Upheld by the Supreme Court-June, 2012

16. Provisions of the Affordable Care Act
• In 2010
– Adults with existing conditions are allowed to join
high risk pools until health exchanges are opened
in 2014
– Council within HHS to develop national prevention
and health promotion strategies
– Those caught within donut hole will receive a
$250 rebate and donut hole will be eliminated by
2020

17. Provisions of the Affordable Care Act
• In 2010 cont.
– No more lifetime caps on illness
– Dependents can remain on parent’s insurance
until 26
– Insurers cannot consider pre-existing conditions
– Insurers cannot collect copays for certain
preventative measures.

18. Provisions of the Affordable Care Act
• In 2010 cont.
– Insurers ability to enforce spending caps will be
restricted and eliminated by 2014
– Insurers cannot drop policy holders when they
become ill
– Insurers are required to implement an appeals
process

19. Provisions of the Affordable Care Act
• In 2010 cont.
– Medicare patients with chronic diseases must be
reevaluated every 3 months for their medications

20. Provisions of the Affordable Care Act
• Effective 2011
– HSA’s, FSA’s and Health reimbursement accounts
cannot be used to pay for OTC drugs/medical
supplies

21. Provisions of the Affordable Care Act
• Effective 2012
– All new plans must cover preventative benefits
including mammograms and colonoscopies
without requiring a copay.

22. Provisions of the Affordable Care Act
• Effective 2013
– Income for self-employed or single individuals
earning more that $200,000 will be subject to an
additional 0.9% tax. ($250,000 for married
couples)
– 3.9% Medicare tax on unearned income

23. Provisions of the Affordable Care Act
Beginning January 1, 2014, every person must
either have health care that meets minimum
standards or coverage or pay a penalty when
filing tax returns.

24. Provisions of the Affordable Care Act
How much is the tax penalty?
1st Year-$95/adult and $47.50/child (up
$285/family) or 1% of income
whichever is greater
2nd Year-$325/adult and $162.50/child (up
to $975/family) or 2% of income
whichever is greater
3Rd year-$695/adult, $347.50/child (up to
$2085/fam. or 2.5% of income

25. Provisions of the Affordable Care Act
Who is exempt from purchasing insurance.
1. Are uninsured for less than 3 months of
the year
2. Have very low income and coverage is
considered unaffordable
3. Are a member of a specific excluded
group

26. Provisions of the Affordable Care Act
Effective January 1, 2014
– Insurers cannot charge higher rates or
discriminate against individuals based on gender
or pre-existing conditions
– No annual spending caps
– 2.3% excise tax on medical devices

27. Provisions of the Affordable Care Act
Effective January 1, 2014 cont.
– In participating states Medicaid is expanded
– Two year tax credits offered to small businesses
– Max deductible for employer mandated plans
established
– Qualifying medical expenses raise to 10% instead
of 7.5%

28. Provisions of the Affordable Care Act
Effective January 1, 2014 cont.
– Penalty of $2000 per employee for employers
with 50 or greater employees if employer does
not offer health insurance to full time employees
(delayed until 2015)
– Establish health insurance exchanges

29. Healthcare Exchanges
What must be covered in the plans
1. Emergency Services
2. Out patient or ambulatory services
3. Hospitalization
4. Mental Health
5. Care of the newborn and mother
6. Prescription Drugs

30. Healthcare Exchanges
What must be covered cont.
7. Laboratory services
8. Preventative services
9. Rehab and habilatative services and
devices
10. Pediatric services including oral and
vision care

31. Healthcare Exchanges
Open Enrollment
1. Began October 1, 2013
2. Ends March 31, 2014
3. Each year thereafter open enrollment
will be from Oct. 15 to Dec. 7
4. Coverage begins January 1, 2014

32. Who is enrolling in ACA?
Bloomberg: “About 30 percent of
new enrollees are under 35. White
House officials say that’s an
acceptable mix, and they expect
more young people to come on
board closer to the March 31
deadline. ‘We think that more and
more young people are going to
sign up as time goes by, based on
the experience in Massachusetts,’
Gary Cohen, deputy administrator
at the Centers for Medicare and
Medicaid, said on a conference call
with reporters. ‘We’re actually very
pleased with the percentage that
we have right now, and we expect
that percentage to increase.’
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/

33. Who is enrolling in ACA?
Bloomberg: “Under
Obamacare, insurers can’t charge
men and women different rates—
or, as Health Secretary Kathleen
Sebelius put it, ‘Starting in
2014, being a woman is no longer a
preexisting condition.’ That
generally resulted in lower prices
for women compared with
insurance markets where
underwriting by gender is
allowed, so it’s not surprising
women signed up in greater
numbers.”
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/

34. Who is getting a subsidy?
Bloomberg: “Most of the people
who bought coverage on the
exchanges this fall got subsidies to
help them afford the premiums.
That’s in contrast to the first month
of the program, when less than
one-third of buyers were
subsidized. People earning up to
four times the poverty rate—as
much as $96,000 a year for a family
of four—can get help buying
coverage. …
http://www.theblaze.com/stories/2014/01/14/the-current-state-of-obamacare-explained-in-three-charts/

35. Provisions of the Affordable Care Act
• Effective January 1, 2015
– Physician reimbursement for Medicare patients
based upon quality of care, not quantity
• Effective January 1, 2018
– All health insurance plans must cover approved
preventive measures without copays

36. Provisions of the Affordable Care Act
• Effective 2020
– Donut hole in Medicare Part D prescription
coverage is eliminated

37. http://dailybail.com/home/obamacare-complicated-check-out-the-flow-chart.html

38. WHAT ARE OUR ALTERNATIVES?

39. Country
Canada
UK
US
Infant
Life
mortality
expectancy
rate
81.3
4.5
81
4.8
78.1
6.9
Healthcare % of gov't
Physicians Nurses per Per capita $ costs as a
revenue % of health
per 1000
1000
on health percent of spent on costs paid
people
people
(USD)
GDP
health
by gov't
2.2
9
3,895
10.1
16.7
69.8
2.5
10
2,992
8.4
15.8
81.7
2.4
10.6
7,290
16
18.5
45.4

40. Canadian Healthcare
•
•
•
•
Single payor system
Funded federally/managed by each Province
Pt can choose provider
Services typically not covered
– Pharmaceuticals
– PT
– Ancillary services

41. Canadian Healthcare
• 2006-Gov’t tried to close private clinic
• Supreme Court
“Access to a list does not mean
access to health care”

42. Canadian Healthcare
Negatives
Wait times
Median wait times for specialist-4
weeks
Median wait times for diagnostic
services (MRI, CT, etc.)-3 weeks
Median wait times for surgery -4-5
weeks.

43. English Healthcare
English System
National Health Services (NHS)
July 1948
Single Payor System-British Govt.
Advantages
Cost per patient $2500/pt. vs $6000
Walk in services

44. NHS
Advantages (cont.)
Greater life expectancy
Fewer surgical/medical complications
Disadvantages
Higher mortality in cardiovascular and
Cancer deaths
Average wait time for services requiring
Hospitalization-8 weeks

45. NHS
Disadvantages cont.
Average wait times for outpatient
procedure-4 weeks
Average wait time for lab tests-2
weeks

46. Post ACA
Two Tiered System
Health Care via large corps
Private Medicine
Physicians will begin making choices as to which
model they prefer.

47. Concierge Medicine
In its simplest
form, Concierge Medicine is
a relationship between the
physician and patient in
which the patient pays a
monthly or annual fee to
insure the physician is
available to the patient. It is
fee for service medicine.
Other names include private
pay medicine, boutique
medicine, retainer-based
medicine, innovative medical
practice design.

48. Concierge Medicine
History
Begin in 1996 in Seattle Washington
Developed a national organization in 2003
Most practices are “mom and pop” type
operations
On average, one conversion per day from
primary care to concierge medicine

49. Concierge Medicine
Average Practice size of Concierge Medicine
Physician
100-1000 patients
Average Practice size of primary care physician
1800-3000 patients
Typical Costs of concierge medicine program
$50/month to $1500/month

50. Concierge Medicine
Services Offered-General
 Same day service
 Expanded physician
appointments
 Phone Access directly
to physicians

51. Basic/Advanced
• Insurance still tells physician
what services it can provide for
what costs and under what
conditions.
• Physician bills insurer for
payment.
•Patient chooses insurance (via
the exchange, employer, or
other).
•Insurer tells patient what
provider(s) they can see and
what is and is not covered.
•Patient makes appointment with provider, waits at no more than 2 days to be seen at
the practice and no more than 5 minutes in office before being seen.
•Patient gets 15-30 minutes of “face time” with provider.
•Provider proactively treats patient, with fewer restrictions from insurer, because
monthly dues offset financial losses from non-covered items.

52. New Paradigm, Premium
•The physician/patient
balance is restored.
Care is provided on best
practices and patient
needs, not insurance
mandates.
•Patient makes same
day appointments with
provider and has no inoffice wait time before
being seen.
•Patient gets all the
“face time” they need
with provider.
•Provider proactively
treats patient, with no
restrictions from
insurer.
•Patient still chooses insurance
(via the exchange, employer, or
other) as needed for services
outside of the Sendant
program, ie Hospital stay.
•Patient still chooses insurance (via the exchange, employer, or
other) for when they are not in the Sendant program. ie
Hospital stay.

53. Concierge Medicine
Services Offered-Higher Levels
Nutritionist on Staff
Personal Trainer on Staff
Preventative Approach
Expanded more inclusive annual exams
Weekly updates on medical issues

54. Concierge Medicine
Services Offered-Expanded
Specialized in office testing such as
ultrasound evaluations
Air Ambulance services
Bill reviews

55. Concierge Medicine
Current estimates of Concierge Medicine Docs4,400 vs 200,000+
72% decrease in hospitalizations among patients
35 to 64 who used a concierge medicine
physician (Am. Jour. Of Managed Care 2012)

56. Concierge Medicine
36% of primary care physicians interviewed are
planning to cut back on patients, work parttime, or retire in next 3 years (Am. Jour. Of
Managed Care 2012)

57. A PHYSICIAN’S PERSPECTIVE
Review current state of medicine
Look at PPACA (Obama care)
Look at alternative private practice

60. Provisions of the Affordable Care Act
1. Are uninsured for less than 3 months of
the year
2. Have very low income and coverage is
considered unaffordable
3. Are not required to file a tax return
because their income is too low

61. •
•
•
•
•
As this graphic shows, the new law creates 68 grant programs, 47 bureaucratic
entities, 29 demonstration or pilot programs, 6 regulatory systems, 6 compliance
standards and 2 entitlements. What could possibly go wrong with something sowell organized?
This chart was meticulously compiled over the last four months after perusing the
2,841 pages of Obamacare that no one who voted for the bill bothered to read.
The HHS czar, Kathleen Sebelius, has 2200 references in the law and 600 new
authorities which cannot be challenged. On the chart everything in dark blue to
the left are expansions, orange are those empowered with rationing healthcare in
the future. In the bottom left hand corner in blue, 150 new bureaucracies and
boards have been created between doctor and patient. Those in yellow are
specific mandates and there are 17 new mandates on insurance. Rep. Brady
stated this law is so complex he couldn’t get the chart to fit on one page, the chart
is only actually 1/3 of the size of the law so he shows “bundles of
bureaucracy.” For example, one brown bundle hides 59 grant programs. Green
diamonds are the taxes this law has created. In the far right corner are 19 special
interest provisions, including the “Louisiana Purchase” and special interests for
unions.
Buried deep in the law are 19 special sections that cannot be challenged by the
courts or any regulatory system. What the public is being sold and what the law
actually has are 2 totally different things.
And jobs created? Yes. Many. 16,500 new IRS agents to police the law and an
explosion of jobs in the HHS Department. Please print out copies of this chart and
hand to your friends, families and pass out wherever. The public needs to be
educated about the impact of this law and what it will mean for their future.

62. 4. Would qualify under the new income limits of
Medicaid but their state as elected not to
participate in the expanded Medicaid program
5. Are members of a federally recognized Indian
Tribe
6. Member of a religious sect with religious
objections to health insurance
7. Participate in a health care sharing ministry.

63. Provisions of the Affordable Care Act
Beginning January 1, 2014, every person must
either have health care that meets minimum
standards or coverage or pay a penalty when
filing tax returns.

65. Healthcare Exchanges
What they are suppose to offer
1. A choice of different health plans
2. Certify plans that elect to participate
3. Provide info so that consumers can
make an informed decision regarding different
plans

66. Healthcare Exchanges
Who is qualified to purchase insurance thru the
HIX
1. A lawful U.S. citizen or resident
2. Not currently in jail
3. Living in an area serviced by the
Marketplace

67. Healthcare Exchanges
What types of plans are available
1. Bronze 60/40
2. Silver 70/30
3. Gold 80/20
4. Platinum 90/10
5. Catastrophic plans will be available for
people under 30 and those with very low
income

68. Post ACA
Health Insurance Exchanges (HIX)
Set up in each state
Way to compare insurance costs
Four (4) levels depending upon
deductibility 60% to 90%