02.09.2014
"Blue Cross can contract with me only if I obey Kathleen Sebelius's regulations on how to provide healthcare."
The massive binder sits open on the desk Dr. John Sowell, revealing a short high-lighted paragraph in Part II, Section 1311, of the 906-page federal law known as Obamacare.
"Blue Cross can contract with me only if I obey Kathleen Sebelius's regulations on how to provide healthcare," says Sowell, a Huntsville dermatologist who has emerged as a sort of spokesman for Alabama doctors concerned the law will limit their ability to practice medicine.
Under a section marked "Affordable Choices of Health Benefit Plans," under a subsection marked "Quality Improvement," the law restricts payments to doctors. The law says insurers may contract with: "a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require."
Sowell sees a federal list of medical options, he sees doctors limited to "quality" treatments approved in Washington. The passage hasn't received as much attention as some other portions of the law. But Sowell's not the first doctor to notice.
U.S. Rep. Phil Gingrey, R-Ga, a medical doctor, objected to that passage in 2010. He put it this way in 2012 when pushing a bill to repeal that passage: "Under President Obama's health care law, should the HHS Secretary determine that performing mammograms on women younger than 50 violates a standard of care, the provider must comply, regardless of his or her concerns."
Gingrey argued that failure to adhere to such treatment guidelines could cause a doctor to lose the ability to work with federally approved insurers, effectively forcing a doctor out of business.
The new regulations won't take effect until Jan. 1, 2015. So neither Sowell nor Gingrey can know exactly what's coming. "I have no idea. That's the problem," agrees Sowell.
The U.S. Department of Health and Human Services now says it may hold off past the Jan. 1, 2015 deadline.
"We believe that implementing all of the requirements described in section1311(h) by January 1, 2015 could result in a shortage of qualified hospitals and providers available for contracting with QHPs (qualified health plans)," reads the federal discussion in Notice of Benefit and Payment Parameters.
But the department is still working on the rules for care. "HHS is currently in the process of researching the establishment of appropriate quality and patient safety standards for QHP issuers contracting with health care providers as described in section 1311(h)(1)(B)."
(See HHS discussion on page 24.)
Sowell, an early opponent of Obamacare, agrees that the U.S. medical system has to change.
"The problem is our system is too expensive," says Sowell, likening healthcare costs to ever-rising prices of college tuition. "I think the dialogue is healthy. The system we've got is unsustainable."
Sowell acknowledges that private insurance companies have always limited care. But he sees differences, both ethical and practical, within the Affordable Care Act.
Under private insurance, he says, doctors could exhaust less expensive options before ramping up to more expensive treatments. He also contends patients could switch insurers or appeal to the state regulators of insurers. He envisions few alternatives and no appeals in the face of federal standards.
On an ethical level, doctors take an oath to work on behalf of patients. Sowell says federal regulations could keep doctors from suggesting the best possible option.
Sowell, a charter member of Docs 4 Patient Care, joined the group of physicians in lobbying against Obamacare in 2009. The group now frames the coming debate over government regulations as a looming "moral crisis."
So far, Obamacare hasn't affected his practice. But he expects that will change with regulatory deadlines in 2015.
During a recent forum on Obamacare in Huntsville, Sowell shared the stage with two hospital administrators, an insurance executive and a legal expert. He alone spoke for doctors.
At that forum, Sowell predicted "tens of thousands" of early retirements among doctors. He sees limited access for patients, as more physician assistants and nurse practitioners attempt to meet the demand. He predicted top notch specialists moving their practices to places such as Costa Rica.
Sowell instead favors a three-prong approach, something he regularly discusses with patients. He says the United States first needs insurance competition across state lines.
Second, he argues to separate health insurance from employment. Third, he would have patients spend their own money upfront for minor treatments and reserve insurance for catastrophic injuries.
He argues that if patients knew the cost of a procedure, such as an MRI, they would be more conservative in their requests. And if they had to pay, fewer would seek medical care for colds and minor illness. "All of that should be out of pocket," he said.
But hospital administrators at that same forum last month worried that approach will already lead to increased long-term costs, as $6,000 deductibles under many new plans will deter preventative care. David Spillers, CEO of Huntsville Hospital, argued as more people will forgo care and become sicker before seeking expensive treatment at the emergency room.
"The hospitals stand to benefit from this in the short term," said Sowell of Obamacare.
He notes they are required to treat uninsured patients, and the law provides more coverage to more people.
But Alabama has elected not to expand Medicaid, leaving tens of thousands earning too much for insurance under Obamacare. Spillers has said that decision will force dozens of rural hospitals across Alabama to close.
Pam Hudson, CEO of Crestwood Hospital, seemed to share some of Sowell's concerns. "One of the things that worries me is an exodus of providers," said Hudson during the forum.
The members of the panel that night, including an executive from Blue Cross, predicted the Affordable Care Act would lead to a single-payer system. "Then we are literally taking orders from the government," says Sowell.
Yet he agrees. The nation is unlikely to repeal the Affordable Care Act, and the direction seems to be toward single payer. From a doctor's perspective, he says that means restricted treatment options for some subgroups, such as the elderly.
While that challenges his sense of duty to patients, Sowell said he has no plans to leave his practice. And he's encouraged his son, who is now planning to attend medical school. "It's a calling" he says.
source
"Blue Cross can contract with me only if I obey Kathleen Sebelius's regulations on how to provide healthcare."
Dr. John Sowell, Huntsville dermatologist, argues Section 1311(h)(1)(B) of the Affordable Care Act allows for the creation of a list of approved medical treatments, which would restrict doctors seeking the best options for patients.. (Challen Stephens / cstephens@al.com)
The massive binder sits open on the desk Dr. John Sowell, revealing a short high-lighted paragraph in Part II, Section 1311, of the 906-page federal law known as Obamacare.
"Blue Cross can contract with me only if I obey Kathleen Sebelius's regulations on how to provide healthcare," says Sowell, a Huntsville dermatologist who has emerged as a sort of spokesman for Alabama doctors concerned the law will limit their ability to practice medicine.
Under a section marked "Affordable Choices of Health Benefit Plans," under a subsection marked "Quality Improvement," the law restricts payments to doctors. The law says insurers may contract with: "a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require."
Sowell sees a federal list of medical options, he sees doctors limited to "quality" treatments approved in Washington. The passage hasn't received as much attention as some other portions of the law. But Sowell's not the first doctor to notice.
U.S. Rep. Phil Gingrey, R-Ga, a medical doctor, objected to that passage in 2010. He put it this way in 2012 when pushing a bill to repeal that passage: "Under President Obama's health care law, should the HHS Secretary determine that performing mammograms on women younger than 50 violates a standard of care, the provider must comply, regardless of his or her concerns."
Gingrey argued that failure to adhere to such treatment guidelines could cause a doctor to lose the ability to work with federally approved insurers, effectively forcing a doctor out of business.
The new regulations won't take effect until Jan. 1, 2015. So neither Sowell nor Gingrey can know exactly what's coming. "I have no idea. That's the problem," agrees Sowell.
The U.S. Department of Health and Human Services now says it may hold off past the Jan. 1, 2015 deadline.
"We believe that implementing all of the requirements described in section1311(h) by January 1, 2015 could result in a shortage of qualified hospitals and providers available for contracting with QHPs (qualified health plans)," reads the federal discussion in Notice of Benefit and Payment Parameters.
But the department is still working on the rules for care. "HHS is currently in the process of researching the establishment of appropriate quality and patient safety standards for QHP issuers contracting with health care providers as described in section 1311(h)(1)(B)."
(See HHS discussion on page 24.)
Sowell, an early opponent of Obamacare, agrees that the U.S. medical system has to change.
"The problem is our system is too expensive," says Sowell, likening healthcare costs to ever-rising prices of college tuition. "I think the dialogue is healthy. The system we've got is unsustainable."
"But I think what's been done is the wrong thing."
Under private insurance, he says, doctors could exhaust less expensive options before ramping up to more expensive treatments. He also contends patients could switch insurers or appeal to the state regulators of insurers. He envisions few alternatives and no appeals in the face of federal standards.
On an ethical level, doctors take an oath to work on behalf of patients. Sowell says federal regulations could keep doctors from suggesting the best possible option.
Sowell, a charter member of Docs 4 Patient Care, joined the group of physicians in lobbying against Obamacare in 2009. The group now frames the coming debate over government regulations as a looming "moral crisis."
So far, Obamacare hasn't affected his practice. But he expects that will change with regulatory deadlines in 2015.
During a recent forum on Obamacare in Huntsville, Sowell shared the stage with two hospital administrators, an insurance executive and a legal expert. He alone spoke for doctors.
At that forum, Sowell predicted "tens of thousands" of early retirements among doctors. He sees limited access for patients, as more physician assistants and nurse practitioners attempt to meet the demand. He predicted top notch specialists moving their practices to places such as Costa Rica.
Sowell instead favors a three-prong approach, something he regularly discusses with patients. He says the United States first needs insurance competition across state lines.
Second, he argues to separate health insurance from employment. Third, he would have patients spend their own money upfront for minor treatments and reserve insurance for catastrophic injuries.
He argues that if patients knew the cost of a procedure, such as an MRI, they would be more conservative in their requests. And if they had to pay, fewer would seek medical care for colds and minor illness. "All of that should be out of pocket," he said.
But hospital administrators at that same forum last month worried that approach will already lead to increased long-term costs, as $6,000 deductibles under many new plans will deter preventative care. David Spillers, CEO of Huntsville Hospital, argued as more people will forgo care and become sicker before seeking expensive treatment at the emergency room.
"The hospitals stand to benefit from this in the short term," said Sowell of Obamacare.
He notes they are required to treat uninsured patients, and the law provides more coverage to more people.
But Alabama has elected not to expand Medicaid, leaving tens of thousands earning too much for insurance under Obamacare. Spillers has said that decision will force dozens of rural hospitals across Alabama to close.
Pam Hudson, CEO of Crestwood Hospital, seemed to share some of Sowell's concerns. "One of the things that worries me is an exodus of providers," said Hudson during the forum.
The members of the panel that night, including an executive from Blue Cross, predicted the Affordable Care Act would lead to a single-payer system. "Then we are literally taking orders from the government," says Sowell.
Yet he agrees. The nation is unlikely to repeal the Affordable Care Act, and the direction seems to be toward single payer. From a doctor's perspective, he says that means restricted treatment options for some subgroups, such as the elderly.
While that challenges his sense of duty to patients, Sowell said he has no plans to leave his practice. And he's encouraged his son, who is now planning to attend medical school. "It's a calling" he says.
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