Sunday 30 October 2011

15 things about US health reform that a medical resident should know

Health care reform and current state of health in US is a topic of active debate in the interview circles. From faculty to program directors to chief resident and even co-applicants are talking about these topics in the interview circuit. It would be a fantastic idea to read the entire 2800+ pages of the reform but it is highly impractical for a busy residency applicant. So to help the interviewee to be at least in the same information loop as some of his peers or faculty, I have come up with a few points that the residency applicant will benefit from knowing. So far, these things have not made it to the USMLE examinations but health care policy questions on the test may not be a very different situation from reality in the near future.

1. Mandated Health. Health care for US citizens is almost an entitlement (…certain unalienable rights, that among these are life, liberty and pursuit of happiness) [1]

2. Mixed market system. United States currently operates mixed market health care system. In the current system the cost is shared by the government (45%) and rest is by private agencies (38%) or out of pocket (17%). Managed care has not been successfully implemented even though it was proposed back in 2000 and as such up to 45 million Americans are uninsured [2]. 

3. The middleman. Insurance corporations have insinuated themselves between patients and health care providers. They profit by difference between premiums charged to patient and payments made to providers while adding questionable value to the system [3]

4. Areas of change. Current proposals for US health care reform focus mostly on extending insurance coverage, decreasing the growth of costs through improved efficiency, and expanding prevention and wellness programs [4]

5. Proposals for change. In view of the current ineffectiveness of health care delivery, a new proposal was made which was aimed at improving Health system focusing on three suggested systems,
a. Single agency to manage insurance
b. Mandatory insurance
c. Patient driven control of health care delivery.

6. Compulsory Medical insurance. Just as insurance is obligatory prior to driving in US, by 2014, The healthcare reform bill would mandate that most US citizens and legal residents purchase “minimal essential coverage” for themselves and their dependents. There will be penalties for non-coverage.

7. Insurance will be subsidized.  Criteria have been set to define income groups and patient sets that will be eligible for aid and subsidy from federal and state sources.

8. Single agency managing insurance. Exchange (health insurance exchange is a set of state-regulated standardized care plans, from which individuals may purchase health insurance) would offer approved policies (tailored to patients) to interested buyers that people must choose. This allows for some patient driven control of health care delivery.

9. Long term planning involved. The PPACA (Patient Protection and Affordable Care Act) has long term plans with milestones set for every year till 2020. [5]

10. No refusal for pre-existing condition. At present time, the insurance companies can refuse to provide insurance if the patient has a medical condition that may lead to escalating costs of medical care. This will be abolished with new act.

11. Medicare doughnut hole. At present time, there is an unusual policy. Medicare part-D (prescription drugs) will pay for expenses up to $2700 (total drug spending). It will not cover for expenses above $2,700 unless they reach $6,154, that’s when the ‘Catastrophic coverage threshold’ is reached and Medicare resumes coverage. This leaves many patients without Medication insurance. This will be done away with in the new PPACA by 2020.

12. Medicare and residency. Medicare plays an important role in financing medical residency training through payment to teaching hospitals for Graduate medical educations (GME)[6]. However, Medicare has frozen aid to GME (since 1997) and this is limiting number of physicians that can be trained in residency programs. AAMC workforce group endorses lifting of the freeze to make up for the shortage of about 45,000 primary care and specialty physicians.

13. Medi-care/aid distinction. Medicare generally covers citizens and long-term residents 65 years and older and the disabled while Medicaid, generally covers low income people in certain categories, including children, pregnant women, and the disabled. (Administered by the states.)

14. Moving the cheese. The new law supports redistribution of slots with emphasis on primary care and general surgery residencies [7].

15. Bonus practice. Establishes 10 percent bonus for select E&M codes for primary care practitioners and surgeons practicing in health professional shortage areas (HPSA)[7]. You can find these lucrative areas here . For US states that are best for IMGs to set up practice are good to know so you may look for HPSA in the state of your choosing. 


[1] The declaration of independence of the thirteen colonies, July 4, 1776

[2] Garson et al. US health care system 2010: problems, principles and potential solutions. Circulation
[3] Kereiakes DJ and Willerson JT, US health care: entitlement of priviledge? Circulation 2004, 109:1460-1462
[4] Murray CJL and Frenk J, Ranking 37th – Measuring performance of US health care system. 2010 Perspective N Engl J Med 362;2
[6] Hackbarth G and Boccuti C. Transforming GME to improve health care value. 2011 N Engl J Med 364:8

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