Medicare's new plan to reduce hospital overcrowding

Brandon Lopez6 said:So, the assumption is they go once a week for five years, right?
4x12x5=240

But most people actually go once a month.
1x12x20=240

The total number of sessions ends up being the same. And honestly, even if we ignore the fact that everyone is different and plenty of people just try to "patch things up" only for the illness to come back... in my book, you shouldn't be looking at averages when it comes to psychiatry.

I’m not quite sure where you're getting those figures from. If someone is only seeing a specialist once a month, that isn't really psychotherapy—that's just a quick five-to-ten-minute check-in.

Look, I’m talking specifically about psychoanalytic psychotherapy here. If you aren't meeting at least once a week, and if those sessions aren't lasting a minimum of 30 to 40 minutes—ideally 45—then you aren't actually doing therapy. At that point, you're just going in for check-ups.

The therapy I’m talking about isn't meant to be a lifelong commitment; it's designed to last just a few years at most. Also, just to clarify, a referral for therapy isn't quite the same thing as a referral for a routine check-up—with this type of authorization, you actually have the flexibility to visit the clinic up to four times a month.

Look, I think we’re talking about two completely different things here.
If someone is dealing with a chronic condition, like schizophrenia, obviously nobody should be stepping in to limit their autonomy—especially given how those diagnoses are typically managed (not that I’d know much about it; I'm just a regular neurotic myself), and it's certainly not what I'm suggesting here. I was simply mentioning something my therapist pointed out: apparently, there are groups at the psychiatric clinic where people have been coming in for therapy for twenty years straight. The thing is, that specific type of therapy isn't actually designed to last that long. That's all I was saying.

Let's say that person decides to go private and pays $300 out of pocket...$167 If we’re talking about individual sessions, let's be real: if a psychotherapist keeps someone in treatment for twenty years, most people would call that out as an abuse of power or just a way to bleed a patient dry. I mean, think about it—if you haven't made meaningful progress on a core issue within five or six years, something is clearly broken in the process.

Edit: I actually managed to find the original text about this! It's already in English, so I’ll just try to put together a rough translation of the bolded section.

No One goes to therapy for twenty years. In my view, if someone is seeing a therapist for that length of time, they aren't actually receiving therapy. How long someone stays in therapy really depends on the individual and the specific issues they're facing, so there isn't a one-size-fits-all timeline. Generally speaking, though, you can break treatment down into two main categories: short-term and long-term therapy.

Short-term therapy—often referred to as brief therapy—is designed to tackle specific, targeted issues. The core philosophy here is that once you hit those immediate milestones, you start feeling a sense of agency and competence in your daily life. That boost in self-efficacy often creates a ripple effect, positively impacting other areas of your world too. From the very beginning, this type of therapy is structured around a timeline. The goal is to reach specific objectives within a set window, typically ranging from six to twelve weeks, though sometimes it might stretch a bit longer depending on the situation. In my view, the kind of problems which short-term therapy (arguably) addresses best are primarily behavioral. These approaches usually come with very distinct labels based on their focus, such as anger management, impulse control training, or assertiveness coaching. It’s all about providing practical tools for specific challenges.

Long-term therapy is designed to dig deep, tackling those foundational issues and chronic conditions that drive emotional struggles. When you're looking at this level of intensive work, you have to realize it isn't a quick fix; typically, this kind of therapeutic journey spans somewhere between three to six years.The reason this method feels like such a marathon is quite simple: building a genuine therapeutic bond—much like any meaningful relationship in our lives—requires significant time to establish, nurture, and sustain. This type of therapy is modeled after the natural developmental milestones we see from childhood through adolescence. It follows a structured progression through beginning, middle, and final stages. That concluding phase is especially vital, as it represents the individual finally achieving true independence and transitioning into adulthood.

- See more at: http://www.queendom.com/advices/advice.htm?advice=484#sthash.6kvfRi6z.dpuf"

okvirni prijevod:
No One goes to therapy for twenty years. In my opinion, if someone is seeing their therapist for that many decades, they aren't actually receiving therapy anymore.
"Long-term therapy is really about digging deep to resolve the underlying causes and conditions that sit beneath the surface, driving those emotional struggles. On average, this type of process typically lasts anywhere from three to six years."

Look, hardly anyone can actually afford to hit up therapy every single week. Don't act like you're looking down on everyone else while you're out here rambling about some perfect utopia instead of facing reality. ☕

If you're paying your premiums and have solid supplemental insurance, you've got every right to get treatment for as long as you need. Just because you happen to know someone who’s been in therapy for twenty years doesn't mean that's how everyone operates.

I'm done here; you're just not being realistic.

Does anyone know how the whole sick leave thing works these days? Basically, I need to start a treatment plan that’s super aggressive—honestly, it feels worse than chemo. My doctor just dropped this bomb on me that I don't qualify for continuous medical leave anymore. Instead, she says I get maybe 3 or 4 days off when I receive the treatment, then I have to work for 1 or 2 days, and then it's back to being out sick again. 🙂Even during that last round, those 1 or 2 days I was actually at work felt terrible, and my job requires absolute, undivided focus... does anyone here have any experience dealing with this???

copperlynx22 said:A few days ago, a primary care physician refused to issue a referral for a young patient with Type 1 diabetes to see an ophthalmologist-retinologist—the specialist who normally monitors his retina—claiming they simply couldn't due to some new system model or similar bureaucratic nonsense.

I don't have all the specifics regarding this particular case, and I suspect the patient hasn't actually been diagnosed with retinopathy yet. However, given the primary diagnosis, he really should be seeing a retinologist for routine monitoring to catch any changes, perhaps once a year or at least once every two years.
That is the standard clinical recommendation for anyone managing diabetes. https://www.cardiosmart.org/~/media/...en/zu1686.ashx

The real question here is how his DM was managed during his last check-up.

casualcobra222 said:Does anyone know how the whole sick leave thing works these days? Basically, I need to start a treatment plan that’s super aggressive—honestly, it feels worse than chemo. My doctor just dropped this bomb on me that I don't qualify for continuous medical leave anymore. Instead, she says I get maybe 3 or 4 days off when I receive the treatment, then I have to work for 1 or 2 days, and then it's back to being out sick again. 🙂Even during that last round, those 1 or 2 days I was actually at work felt terrible, and my job requires absolute, undivided focus... does anyone here have any experience dealing with this???

Your primary care physician has the final say on your medical leave.

vividsailor7 said:The real question here is how his DM was managed during his last check-up.

Your primary care physician has the final say on your medical leave.

The ophthalmologist requested an appointment now; I assume that since they are the specialist monitoring this specific patient's retina, they have a clear reason for it.

Kyle Lee7 said:My psychotherapist mentioned to me last week that since their rehabilitation program doesn't actually account for psychotherapy (much like how they wouldn't include physical therapy in a standard plan), it falls under the category of a regular psychiatric consultation. Since those are limited to three visits per year, anything beyond that means we'll be paying out of pocket $33.
Normally, you'd see a therapist once a week. If you skip vacations and holidays, that works out to about 45 sessions a year. So, if I'm paying for 42 of them at $100 each, that's roughly $1400 annually just for psychotherapy. It’s still technically cheaper than seeing a private practitioner—who usually charges $300 or more per session—but it feels incredibly silly. I mean, psychotherapy is its own established category, and this specific clinic is a premier referral center that has been doing this for 60 years... and now, all of a sudden, psychotherapy effectively doesn't exist? Unless, of course, the folks over at the psychiatric hospital manage to talk their way out of covering it.

Bit by bit, we are starting to look more and more like the USA (and not in a good way...).
It's honestly not surprising when you consider the fact that 35% of the population ends up subsidizing healthcare for 100% of the users. ☕
Personally, I'm one of those people who pays for the standard coverage plus supplemental insurance, and yet I still end up going to my neurologist privately and my gynecologist privately...

Nicholas Myers said:I have to admit, this is news to me. I’ve heard whispers about extra fees floating around, but I haven't seen anyone state this officially.

From what I understand, there are referrals for outpatient care, and psychotherapy definitely doesn't fall under the umbrella of a simple "consultation."

Furthermore, there is no regulation stating a limit on annual visits—the mention of three follow-ups usually refers to post-hospitalization check-ins within a six-month window. There is also no rule saying, for instance, that a GP can't refer someone to a psychiatrist ten times a year.

Those kinds of numbers are just hallway talk, unofficial chatter. Officially, I haven't seen a single document mandating a cap on annual psychiatric visits or a specific number of physical therapy sessions for any given diagnosis. 🤷

To be specific about this, a primary care physician can issue a D1 referral that covers outpatient treatment for an entire year, provided they only issue one to a patient annually. They simply list psychotherapy as the reason...
It’s up to the specialist now to decide the duration and frequency of the treatment. Once they issue that referral, Medicare is out of the equation... We'll see if we need to renew it this time next year...

I know there’s been some debate about whether Medicare will actually cover weekly psychotherapy sessions over the course of a year, but from what I’ve gathered in these threads, there was also some confusion regarding the part under LOM’s jurisdiction. My response specifically addresses that... As for the initial number of sessions permitted per specialist, nothing has changed from the previous policy... For now, at least...

I was wondering if this D1 referral covers both blood work and seeing the hematologist at the hospital for the entire year. I mean, does that count as outpatient treatment? My mom usually sees her hematologist once a month, and she gets her blood drawn on that same day at the hospital. What kind of referral would we actually need for that? The doctor wrote on her last lab report that she should bring a referral for outpatient services next month, but he didn't specify which tests need to be done. It’s not like they run the exact same panel every single time. They always do the CBC, INR, coagulation profile, urea, and creatinine. Sometimes they also check transaminases and electrolytes. I finally asked the nurse at the hospital exactly what kind of referral we need to bring next time, but she just told me that the primary care physician decides on the referral and that she couldn't tell me what's required. It was strange because just the day before, I saw that same nurse giving a very detailed explanation to another patient about which referral they needed to bring, so I don't know why she wouldn't help me with my mom's situation. I'm honestly pretty worried that they might turn us away next time; Mom is in a wheelchair, so it’s not easy for us to get there, and I'd hate for us to be sent home just because of a paperwork error.

I caught a segment on 24 News today about this new model, and I finally got an answer to the question I had.

Basically, if Person A is entitled to go to Hospital B, but they decide they want to head over to Hospital C instead, they can still go to Hospital C—it just won't cover travel costs or transportation. The actual medical care itself is still covered under standard Medicare, though. It's pretty much identical to how things have always worked.

Updates to the new ordering guidelines were released yesterday:

A portion of this pertains to Type 1 diabetes, so I initially posted it in the diabetes thread, but since there are several other changes included, I thought it best to share the link here as well.

I honestly don't understand why they're making things so unnecessarily complicated. Between these new referral protocols, the sudden inability to get the same treatment we used to rely on, and this whole strike... it's just too much. I’m caring for a very seriously ill patient at home right now, and I have to say, I am deeply bitter about it all. This patient spent their entire career as a physician, dedicated to serving the community, and now? Now they're facing inadequate care and, frankly, what feels like an ironic smirk from our own doctors. Living in the North, it feels like we could just head over to Canada if we had to, especially since we're part of the European Union now. My patient isn't terminal—it's not like they have cancer and have already been written off. It’s a different kind of illness entirely, one where people can actually recover if there is genuine will and expertise applied. Yet, I recently received these incredibly vague, nonsensical suggestions to just administer morphine and let nature take its course, as if they're already a lost cause. That's despite the fact that they recovered remarkably well after their first major surgery and are functioning quite well within their current limits. It feels like these new systemic issues could be resolved if there was actual competence and effort, rather than just relying on morphine to mask the problem.

I have a question. I’m being treated for Hashimoto's by an endocrinologist at Mayo Clinic. Usually, the process was pretty straightforward: I'd book a specific day, show up, see the doctor, and she'd write down exactly which blood tests I needed. They'd draw the blood right there, the results would arrive at my house, and they'd include the date for my next follow-up on the report.

How is this going to work with these new models? My primary care physician gave me an A2 referral for an exam and an A3 for blood work.
I see in the document it says
When providing a consultative opinion based on a referral for a consultative exam (A1) or
a follow-up consultative exam (A2), the hospital/outpatient specialist is NOT
ALLOWED TO:
 issue internal referrals for further testing and follow-up exams
 order or issue recommendations for follow-up exams
 issue opinions regarding fitness for work

Does this mean my endocrinologist won't be able to schedule my next check-up anymore? Like, they won't be allowed to just write "next appointment on this date" on my lab results?
And does it also mean the endocrinologist can't decide on the spot if I need any additional blood work beyond what my GP already prescribed?

It seems like my primary care doctor isn't exactly an expert when it comes to thyroid issues; she wasn't even sure which hormone levels I needed tested. I really hope this doesn't mess everything up at the clinic and make things less smooth than they used to be.

Also, if the endocrinologist recommends a follow-up in a month or two—which is highly likely since I'm pregnant and need more frequent monitoring—will I actually be able to get an appointment? Because it looks like people are already booking as far out as November.
For centralized scheduling, you have to submit the referral, and from what I know, those are only valid for 30 days? But what if the appointment is scheduled for later? Now I'm seeing somewhere that a referral is valid for a year—is that actually true?

I think you'll probably need to get an C1 referral

Honestly, your best bet is just to check in with the American Medical Association.

Yeah, I'm looking at it now too, and honestly, it looks pretty much the same to me...

Let me know when you hear anything, because I’m facing the exact same thing at Vuk Vrhovac.

I'm going by VV right now, so I can't dig up any info at the moment. I'll try sending an email and see what happens.

My general practitioner is completely useless when it comes to this stuff...

So, I tried checking with my primary care doctor. They told me they’d issue an A2 referral, and then my endocrinologist would let me know when to come back for the next one—which would trigger another A2 referral. But looking at the paperwork, it seems like they aren't even allowed to tell me when my follow-up is scheduled.

I honestly get the feeling they’re just playing games with people's health.

Susan Martin4 said:I have a question. I’m being treated for Hashimoto's by an endocrinologist at Mayo Clinic. Usually, the process was pretty straightforward: I'd book a specific day, show up, see the doctor, and she'd write down exactly which blood tests I needed. They'd draw the blood right there, the results would arrive at my house, and they'd include the date for my next follow-up on the report.

How is this going to work with these new models? My primary care physician gave me an A2 referral for an exam and an A3 for blood work.
I see in the document it says
When providing a consultative opinion based on a referral for a consultative exam (A1) or
a follow-up consultative exam (A2), the hospital/outpatient specialist is NOT
ALLOWED TO:
 issue internal referrals for further testing and follow-up exams
 order or issue recommendations for follow-up exams
 issue opinions regarding fitness for work

Does this mean my endocrinologist won't be able to schedule my next check-up anymore? Like, they won't be allowed to just write "next appointment on this date" on my lab results?
And does it also mean the endocrinologist can't decide on the spot if I need any additional blood work beyond what my GP already prescribed?

It seems like my primary care doctor isn't exactly an expert when it comes to thyroid issues; she wasn't even sure which hormone levels I needed tested. I really hope this doesn't mess everything up at the clinic and make things less smooth than they used to be.

Also, if the endocrinologist recommends a follow-up in a month or two—which is highly likely since I'm pregnant and need more frequent monitoring—will I actually be able to get an appointment? Because it looks like people are already booking as far out as November.
For centralized scheduling, you have to submit the referral, and from what I know, those are only valid for 30 days? But what if the appointment is scheduled for later? Now I'm seeing somewhere that a referral is valid for a year—is that actually true?

Unfortunately, that workflow is becoming a thing of the past. You contact your primary care physician just to get a referral, while the specialist handles the thyroid management exclusively.

Essentially, for the diagnosis you're managing, issuing a standard specialist referral isn't typically justified. It isn't considered appropriate for an endocrinologist to write internal referrals for patients who already have an established diagnosis.

Checking thyroid hormone levels—which is pretty straightforward—can be done via a standard insurance referral before your scheduled specialist visit, and the endocrinologist can then review those results to decide if your medication needs adjusting.

Furthermore, the primary care doctor is supposed to determine the schedule for future check-ups. An endocrinologist shouldn't explicitly dictate the exact date of the next appointment, though they can suggest *when* a hormone check is necessary. You shouldn't be handed a printed appointment slip for your next visit.

However, I see that some colleagues at the hospital still recommend specific dates, and I hear rumors of patients receiving appointment slips for three or six months out based on certain types of insurance referrals, even though that isn't permitted.

In my view, the primary care physician acted correctly.

If additional tests are needed, such as a thyroid ultrasound, the endocrinologist can certainly provide a recommendation for them.

But for the comprehensive management of Hashimoto's, especially for patients already under a specialist's care, I don't see the justification for bypassing the GP. Primary care doctors need to remain involved in the process.

If their only role is signing paperwork, it begs the question: what purpose do they actually serve?

And if you feel uneasy about your primary doctor being involved in the management of this condition, then you'll simply have to find a new one—someone you actually trust.

Specialized referrals are being closely monitored, so primary care physicians will be writing them less and less frequently. This means they'll have to take a more active role in the diagnostic and treatment decisions for their patients. From what I can see, that was the entire point of this reform.

Thanks for the reply

Yeah, I’m having some doubts about the care at my primary doctor's office. She didn't even really know which hormone levels to check, so she just re-ordered everything from my last hospital report. They checked my antibodies last time—it was only the second time since I got sick—and my endocrinologist wanted to track the trend because if they're high, there's a bigger risk of complications during pregnancy... and yeah, they were huge. So now I have to do them all over again. It feels pretty pointless; even I know you don't need to be checking antibodies every single time you go in.

True, I have heard stories about people with insurance coverage getting their follow-up appointments scheduled right then and there. I guess I'll see what they tell me in two days.

It feels a bit different for me, though. Usually, I've heard people get their blood work done first and then head to the endocrinologist. But at Vuk Vrhovac, it's all in one day—see the doctor first, then hit the lab. Then the results come by mail with whatever recommendations they have. I need to figure out how they're handling things now, whether I'll need separate appointments for blood work and actual consultations.

Honestly, I don't have much to complain about regarding my GP. It's just obvious she doesn't have a ton of experience dealing with thyroid issues. Being pregnant on top of everything else just makes me a little more anxious... (for context, it's just a small-town practice with only two doctors working alternating shifts.)

And yeah, she even questioned me about why my OBGYN isn't writing the referrals for my thyroid checkups (since I have to go more often now due to the pregnancy). In my mind, since I'm pregnant, the thyroid isn't the main issue, so the OB should handle it. This is something I've dealt with long before this, and I'll still be dealing with it after I give birth.

Nicholas Myers said:Unfortunately, that workflow is becoming a thing of the past. You contact your primary care physician just to get a referral, while the specialist handles the thyroid management exclusively.

Essentially, for the diagnosis you're managing, issuing a standard specialist referral isn't typically justified. It isn't considered appropriate for an endocrinologist to write internal referrals for patients who already have an established diagnosis.

Checking thyroid hormone levels—which is pretty straightforward—can be done via a standard insurance referral before your scheduled specialist visit, and the endocrinologist can then review those results to decide if your medication needs adjusting.

Furthermore, the primary care doctor is supposed to determine the schedule for future check-ups. An endocrinologist shouldn't explicitly dictate the exact date of the next appointment, though they can suggest *when* a hormone check is necessary. You shouldn't be handed a printed appointment slip for your next visit.

However, I see that some colleagues at the hospital still recommend specific dates, and I hear rumors of patients receiving appointment slips for three or six months out based on certain types of insurance referrals, even though that isn't permitted.

In my view, the primary care physician acted correctly.

If additional tests are needed, such as a thyroid ultrasound, the endocrinologist can certainly provide a recommendation for them.

But for the comprehensive management of Hashimoto's, especially for patients already under a specialist's care, I don't see the justification for bypassing the GP. Primary care doctors need to remain involved in the process.

If their only role is signing paperwork, it begs the question: what purpose do they actually serve?

And if you feel uneasy about your primary doctor being involved in the management of this condition, then you'll simply have to find a new one—someone you actually trust.

Specialized referrals are being closely monitored, so primary care physicians will be writing them less and less frequently. This means they'll have to take a more active role in the diagnostic and treatment decisions for their patients. From what I can see, that was the entire point of this reform.

It’s all just incredibly complicated, and the patient is the one paying the price. At the end of the day, why are we even bothering with our family doctors if specialists are already available? It feels like they're just trying to lighten the load on the hospital at the expense of the medical associations... who should really be focusing on their specializations before moving into outpatient clinics. Just because I can't choose who treats me—especially when I'm seriously ill—and which medications I need to take, doesn't mean it isn't a way of restricting patient rights, the right to a second opinion, and so much more.

Being sick these days is a genuine luxury given all the nonsense we deal with—paying for supplemental insurance, copays, setting money aside for healthcare, only to end up not receiving the medication that actually works. Instead, you get the cheapest option in the group, and if for some reason it doesn't suit you, too bad; if you don't have the cash for the expensive version, that's your problem.

And don't even get me started on scheduling and "reducing the workload." I signed up for an MRI at the desk 15 days ago and got a notice at my house for an appointment on March 18th, 2014... I mean, 6 months isn't exactly a long wait, but still. Everything has boiled down to "take it or leave it"... sad, but true.☕