Category Archives: physicians

H-1B Visa Order To Limit Number of Foreign-Born Doctors

Before most of the Risk Management and Workers’ Comp industry goes to Philadelphia for next week’s Risk and Insurance Management Society (RIMS) annual conference, I want to share an article on Kaiser Health News about what the recent executive order on H1-B visas will have on healthcare, and by extension, workers’ comp.

I wrote about this two weeks ago when I said that the travel ban will affect the physician shortage in the United States.

According to Kaiser, limiting the number of foreign doctors who can practice in the US could have a significant impact on certain hospitals and states that rely on them.

A study in JAMA found that more that 2,100 US employers were certified to fill nearly 10,500 physician jobs nationwide in 2016, representing 1.4% of physician workforce overall.

States such as New York, Michigan, and Illinois account for most of the H1-B visa applications for foreign physicians. a third of the total.

North Dakota, on the other hand, had the most applicants as a percentage of its workforce, or 4.7%.

While the focus of the executive order was to clamp down on the loopholes in the program that allowed tech companies to hire foreign workers for high skilled jobs that Americans could take, it will also have a negative effect on how patients will receive care in some US hospitals.

And coupled with the fact that the process of getting to practice here without an executive order is difficult and time-consuming, means that both general health care and workers’ comp patients may not be able to get necessary treatment due to the predicted physician shortage.

So while general healthcare can offer an alternative in the form of medical travel, it is high time that work comp does the same.

Or do you really want your claimant patients to wait months before getting needed surgery or other medical procedures?

 

Travel Ban to Affect Physician Shortage: What Medical Travel Can Do

The following post, from fellow blogger, Joe Paduda, who has a guest post from former WCRI CEO, Dr. Rick Victor, states that the current political regime in Washington’s ban on travel from certain countries and ban on allowing a certain religious minority into the country will further exacerbate the already projected physician shortage that this writer had previously discussed in earlier posts on the subject.

Here is the link to Joe’s and Dr. Victor’s posts.

If there ever was a good enough reason for the implementation of medical travel into general health care, and into workers’ comp medical care, this is it.

Do you really want to see injured workers go without treatment or without needed surgeries because there aren’t enough US-born physicians and surgeons, because some narcissistic, egomaniacal, billionaire con artist has banned needed foreign-born physicians from entering the country?

Who knows? Maybe one of these doctors has a revolutionary new treatment or therapy that can bring relief to millions of Americans, or can cure a terrible disease?

Banning them only makes America weaker, not Great Again.

P.S. Here is a follow-up post from Peter Rousmaniere’s Working Immigrants blog.

 

ACA Repeal Opens Up Medical Travel: A Second Look

Note: Here is Laura’s second article on repeal of the ACA and its’ impact on medical travel. She breaks the article down by areas of the healthcare industry that will be affected by repeal and that might benefit from medical travel.

Repeal of Affordable Care Act Impacts International Medical Travel
by Laura Carabello

wphealthcarenews.com- The repeal of the Affordable Care Act (ACA) has been met with considerable market uncertainty. As the transition gets underway, many Americans will be scrambling to access affordable, quality care.

Fortunately, the international medical travel industry -“Travel for Treatment” – may finally gain the attention it deserves from the American public and U.S. employers. Experts predict that the number of Americans traveling abroad for medical care or episodes of treatment is expected to increase 25 percent annually over the next decade.

Medical travelers are likely to come from every market sector: the growing ranks of uninsured individuals, self-insured employers facing higher healthcare expenditures, disenfranchised Medicaid beneficiaries, as well as Medicare enrollees with high out-of-pocket expenditures and the loss of coverage for preventive care.

Individual Consumers
Once “minimum essential healthcare coverage” is no longer mandated, the burden of payment will transfer onto healthcare providers and systems that will be forced to continue cost shifting onto the backs of paying customers.

Fewer insurance companies will be willing to underwrite coverage in the exchanges. In fact, many will leave the individual marketplaces altogether because of the potential loss of federal subsidies for both beneficiaries and insurance companies themselves.

Burdened by hefty cost-shifting, more Americans will be forced to pay out of their own pockets for surgeries or treatments in the U.S. Those who can afford a plane ticket will find it increasingly attractive to travel outside the country for quality, affordable options, such as joint replacement, cardio-thoracic surgery, oncology, bariatrics, and a host of other medical procedures, including treatment for Hepatitis C.

Low-Income (Medicaid) and Seniors (Medicare)
For Medicaid beneficiaries who remained optimistic that their home state would offer expanded coverage, their prospects look dim. The unraveling of the ACA will leave millions of the poorest and sickest Americans without insurance. Many states may either abandon Medicaid expansion or be forced to significantly redesign their programs to ensure that individuals below 400 percent of the federal poverty level can receive affordable healthcare coverage and services.

While these low-income families may not have cash reserves to fund expensive care in the U.S., they might be able to gather the resources to access needed surgeries overseas – and pay less than half of the US rates. Those who have emigrated from Latin American countries, in particular, will take advantage of opportunities to travel to their homelands to gain access to care that is substantially less expensive, and in a familiar setting.

The 57 million senior citizens and disabled Americans enrolled in Medicare could also benefit from accessing international medical travel. Under a full repeal of the ACA, seniors face higher deductibles and co-payments for their Part A, which covers hospital stays, and higher premiums and deductibles for Part B, which pays for doctor visits and other services. Medicare enrollees may also lose some of their free preventative benefits, such as screenings for breast and colorectal cancer, heart disease and diabetes. The opportunity to access quality care at lower costs – plus prescription drugs that are sold at far lower price points outside the US – present attractive options.

Employers
Healthcare will continue to be driven through employers, and cost pressures will push high-deductible plans, risk-based contracting and consumerism. In the United States today, even a negotiated, discounted rate for a total knee replacement at a local hospital may well exceed $45,000, $60,000, or more. The bottom line for self-insured employers – the coverage model that now dominates the marketplace: even after factoring in the cost of travel and accommodations for the patient and the companion, as well as waiving deductibles and co-pays as incentives to program adoption, the savings on surgical procedures such as joint replacement are significant.

Employers will also be more likely to send workers to emerging COEs outside the country in light of the many partnerships that are underway between US providers and foreign hospitals. These collaborative programs are bringing American ingenuity, sophisticated technology and advanced levels of care to institutions throughout the world.

Quality and safety standards at many institutions are now equal to or exceed US benchmarks. Many foreign hospitals are accredited by Joint Commission International, an extension of the US-based Joint Commission. Select hospitals outside the country adhere to US clinical protocols.

In fact, one organization that serves self-insured employers – North American Specialty Hospital in Cancun – even offers U.S. surgeons with US malpractice insurance who perform pre- and post-operative care in the US and then travel to Cancun for surgery. This ensures continuous engagement and continuity of care.

Hospitals
The ACA has contributed to hospitals experiencing higher volumes of insured patients, but those volumes would drop with the law’s repeal. It could also cause fewer people to keep prescription coverage, which would be modestly negative for the pharmaceutical industry.

Experts believe the majority of primary care physicians are open to changes in the law but overwhelmingly oppose full repeal, according to a survey published in The New England Journal of Medicine.

Insurance coverage for the 20 million people who obtained insurance from the exchanges sparked growth in patient numbers for hospitals, which offset lower payments. Without this, hospitals can expect deepening economic problems. This could lead to higher prices, and greater impetus among individuals to seek medical care outside of the U.S.

Key Destinations for International Medical Travel
With the growing ranks of uninsured, medical travel options are likely to emerge as a critical solution to healthcare cost woes. Hospitals and providers in nearby locations such as Latin America – known as the LAC Region – are likely to become destinations of choice: less expensive travel expenses, reduced language barriers, and cultural familiarity. Individuals and employers will require guidance in terms of choosing the right providers and determining costs to overcome the challenges that lie ahead.

To view the original article, click here.

Models, Models, Have We Got Models!

FierceHealthcare.com today reported that CMS (those lovely folks with all them rules), launched three new policies Tuesday that continue the push toward value-based care, rewarding hospitals that work with physicians and other providers to avoid complications, prevent readmissions and speed recovery.

The newly finalized policies are meant to improve cardiac and orthopedic care, and also create an accountable care organization (ACO) track for small practices, according to the report.

There will be three new cardiac care payment models for hospitals and clinicians who treat patients  for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.

Federal officials said that the cost of their care…varied by 50% across hospitals and the share of patients readmitted to the hospital within 30 days also varied by 50%. Medicare, the article points out, spent more than $6 billion in 2014 for care provided to 200,000 Medicare patients who were hospitalized for heart attack treatment or underwent bypass surgery.

As for orthopedic care, the new payment model is for physicians and hospitals that provide care to patients who receive surgery after a hip fracture, other than hip replacement.

They also finalized updates to the Comprehensive Care for Joint Replacement Model, which began earlier this year.

So far, that’s three models. But wait, there are more where those came from.

There’s the new Medicare ACO Track 1+ Model, that has a more limited downside risk than other tracks in the Medicare Shared Savings Program (another model I discussed a while back in the post, “Shared Savings ACO Program reaps the most for Primary-care Physicians“).

These new five-year models provide clinicians with other ways to qualify for a 5% incentive payment through the Advanced Alternative Payment Model (APM) path under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program. (three more models — so many, in fact, I am losing count)

Why am I pointing out the problem with the release of new payment models?

I’ll tell you why. When I began my MHA (Masters in Health Administration) degree program, I took an online elective on Healthcare Quality. The textbook we read discussed how CMS over a period of several decades, created and instituted so many models and programs, that it made me wonder why our health care system was so complex, expensive and so out of whack compared to health care systems of other industrialized countries.

The answer was simple. Too many models, programs, rules, and so on that only gum up the works and make real reform not only impossible, but even more remote a possibility as more of these inane models are added to what is already a broken system.

Winston Churchill said that you can always count on Americans to do the right thing, after all the other things were tried. We are still on the trying part, and I am afraid we will never get to where Sir Winston said we would.

 

Tug-of-War Over Ailing American Knees: What the Medical Tourism Industry Should Know

Total knee replacements in the US is growing, according to an article today in Kaiser Health News.

660,000 are performed each year, and will likely grow to two million annually by 2030, as reported by Christina Jewett. Knee surgeries are one of surgery’s biggest potential growth markets, and one that the medical tourism industry needs to be aware of.

Ms. Jewett described how an orthopedic surgeon from the Bronx, underwent his own knee surgery in a Seattle-area surgery center performed by a friend of his. The surgery began at 8 am, and by lunch, the doctor was resting in his friend’s home with no pain and a new knee.

Medicare is contemplating whether it will help pay for knee surgeries outside of hospitals, either in free-standing centers or outpatient facilities. Several billions of dollars are spent every year by Medicare for knee replacements, so what may be a bold experiment, may soon be more standard.

However, this issue is dividing the medical world, and the issue of money is just as important as the issue of medicine, according to Ms. Jewett.

Some physicians are concerned that moving surgeries out of hospitals will land vulnerable patients in the emergency room, but proponents say it will give patients more choice and better care. In addition, they contend that it will save Medicare hundreds of millions of dollars.

An “overwhelming majority” of commenters, Ms. Jewett states, said they want to allow the surgeries out of hospitals, as specified in recent rule-making documents.

Even if a policy change is made, according to the article, Medicare would still pay for patients to get traditional inpatient surgery. There would be a huge shift in money, the article reports, out of hospitals and into surgery centers.

Medicare could save hundreds of millions of dollars if it no longer paid for multiple-day stays in a hospital, and investors at outpatient centers could profit greatly, as well as some surgeons, especially those who have an ownership stake in the facility.

An open question remains as to whether this shift is beneficial for patients. Patients on Medicare tend to spend nearly three days in a hospital, and forty percent also spend time in a rehabilitation facility for further recovery.

Data from 2014 suggests that Medicare patients are taking advantage of the post-operation support at hospitals and aftercare centers. However, it is unclear what the percentage of eligible patients would choose outpatient care.

Of equal concern to patients are the financial consequences, and here is where the medical tourism needs to pay attention, because even though less care is given, outpatient procedures require higher out-of-pocket costs.

Medicare covers inpatient procedures 100%, with no co-payment, but outpatient procedures require a 20% co-payment, which could easily add up to thousands of dollars for knee surgeries.

One surgery center in California advertises a knee replacement surgery for $17,0300, and those who support the change in policy believe that a strict criteria should be used by doctors to choose which patients are good candidates for outpatient surgery.

All this began in 2012, Ms. Jewett states, when Medicare first considered removing the surgeries from its “inpatient only: list. At that time, many doctors and hospitals protested, calling the proposal “ludicrous” and “dangerous”, and Medicare abandoned the idea.

Another objection cited research that showed that patients who received such surgeries as outpatients were twice as likely to die, and that even one-day stays were twice as likely to need follow-up surgery.

A panel recommended that Medicare remove the procedure from the “inpatient only” list in August, but if they make a change, it will not go into effect for a year or so later.

It is quite obvious to this writer what you in the medical travel industry need to do, but then again, when did you ever listen to what I say?

Say Goodbye to Comp

Fellow blogger, Joe Paduda, today wrote a very prescient article about the impact the jobless economy will have on workers’ comp in the coming decades.

While the idea of driverless trucks may be something in the works, there are many factors working against it from becoming reality in the near term, and perhaps for many years to come. Laws and insurance requirements and what to do if the truck breaks down on a stretch of highway not easily accessible by repair trucks or miles from the nearest truck stop, will have to considered before driverless trucks put drivers out of work.

Yet, as Joe points out, manufacturing is already seeing a loss of jobs due to automation and higher productivity, which will lead to lower consumer costs, but will exact an even higher cost on the nation’s stability and will force politicians to come to grips with what to do with a permanently unemployed population, especially those in the service sector, who are being replaced, and will be replaced by automated cashiers, as well as those occupations tied to the workers’ comp industry.

If, as I reported yesterday, that 50% of all jobs will be gone by 2025, what do you do with those individuals who lose their jobs to machines and software?

It is a question that few have asked, and one that fewer have provided answers for. Also, what happens, as I also asked yesterday, if the 50% goes to 75% or higher?

The UBI is one idea floating around, but short of that, what else can we do to put permanently unemployed back into the workforce once technology makes them, in the words of that “Twilight Zone” episode, “Obsolete!”

It makes no sense, Joe states, to reform a system that won’t be around much longer. So, say goodbye to workers’ comp, say goodbye to claims adjusters, occupational therapists and physicians and nurses in same, pharmacy benefit managers, rehabilitation personnel, return to work specialists, case managers, utilization reviewers and bill reviewers, as well as underwriters and lawyers.

Follow-up to Employee/Employer Choice: Three Years Later

Not that long ago, Michael Grabell of ProPublica, and Howard Berkes of NPR, published a report called “The Demolition of Workers’ Compensation”.

There was much industry condemnation about the report, and my fellow blogger, Joe Paduda, tried to set the record straight, but got nowhere.

I managed to write to Michael and corrected him on the issue of choice of treating physician, which I covered in these two articles: “Employee vs Employer Choice of Physician: How best to Incorporate Medical Tourism into Workers’ Compensation” and “Employee vs. Employer Choice of Physician Revisited: Additional Commentary on How Best to Incorporate Medical Tourism into Workers’ Compensation“.

I sent Michael all of my research and I think he was convinced that employees had more choice, it was just a matter of what options they had, given each state’s workers’ comp laws.

One of the sources I used back then, and today was a joint publication between the WCRI and the IAIABC,”Workers’ Compensation Laws As of January 1, 2016”, which can be purchased here.

Here is my version of their Table 3:

pic10

Notes: * Employee may seek reasonable care on his or her own at employer’s expense
** Can allow worker to select then other party may choose to direct it for next 60 days
*** Employee for non-network claims, any willing provider; network claims, from list by network
**** Employer may have on-site medical provider that employees must see first, then employee can select

But as you will notice, the far left column has the most number of states where the employees can choose their treating physicians, although some do have certain circumstances where the employer has the choice, or there are conditions that must be met.

Relying on the US Chamber of Commerce, as Michael told me he did, does not get you the right data. Using the statutes and laws themselves is the only way to know what is permitted and what is not permitted. And the employee for the most part, does have a say in his or her care.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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