Archive for the ‘Funding Crisis’ Category
Friday, February 26th, 2010
 I may end up eating my words about this. We’ll see.
James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him.
I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now.
A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster.
Now the stakes just went up.
The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday.
Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years.
So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand.
Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care.
Initially, that may be true. Then what happens?
First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them.
Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need.
If a lot of physicians opt out of Medicare, the health care system will turn chaotic. Maybe a few of the well-to-do elderly patients will pay out of pocket to continue seeing their current physician. However, most will start calling around to find other physicians who still accept Medicare. The wait lists with those physicians will grow from weeks to months.
In the meantime, elderly patients will go to emergency departments for their health care needs because we emergency physicians will always be there to help them when their doctors aren’t available (I’m already starting to see this happen in my ED) and because the hospitals won’t dare to opt out of Medicare.
Hospitals accept Medicare … Medicare pays for care rendered to seniors … seniors go to hospitals. Seniors who come to the emergency department tend to get BMWs (but remember, folks, defensive medicine doesn’t exist), therefore costs to Medicare go up, not down. Medicare goes bankrupt sooner than anticipated.
A crisis like this is what we need to get legislators back to the table to create a better health care plan. It needs to happen. Even the status quo is unacceptable.
I doubt it will happen, though. CMS has announced that it will not process claims for Medicare payments for the first two weeks of March, so my prediction is that Congress will eliminate the pay cuts next week and that all the physicians will get their “full” payments after March 14. We’ll continue in the same dysfunctional system until the next crisis occurs about 10 months from now.
Unfortunately.
Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.
UPDATE FEBRUARY 28, 2010
See Throckmorton’s blog for another good point – with the cuts to reimbursements also come a cut to reimbursements for medical care to all of our soldiers. What happens to Congress?
There are already reports that a bill will be introduced this week to delay the effective dates of the cuts for another 30 days. And the AMA is actually showing doctors how to drop Medicare, if they so choose, including samples of documents to file (.pdf file – also contains excellent explanation of options physicians have regarding participation versus non-participation)
The merry-go-round continues.
VN:F [1.6.3_896] Rating: 9.2/10 (9 votes cast)
Posted in Access to Care, CMS, Funding Crisis | 42 Comments »
Tuesday, December 1st, 2009
 A couple of news headlines paint a bleak picture about the future of healthcare in this country.
First are some comments made by US Republican Senator George LeMieux. During a news briefing (video here), LeMieux expressed a concern that Obama’s healthcare plan would amount to “Medicaid for the masses” and would put all Americans on a government run or government controlled health care.
The Palm Beach Post News also ran a story regarding a speech given by Senator LeMieux where he stated that the cost of the bill over the next 10 years was grossly understated due to “funny math”. He estimated the true cost of the bill to be more than $2.5 billion over 10 years rather than the projected $849 million.
LeMieux stated that in order to decrease costs, the bill intends to cut Medicare spending by more than $500 billion – through $400 billion in cuts to home health providers, hospitals, hospices and others while decreasing subsidies to Medicare recipients by more than $100 billion.
My favorite quote from the article is the following: “If we really want to provide health care for Americans, why shouldn’t we give them the tools to go out into the marketplace and be a consumer, which we know will end up driving down costs.”
Another free market advocate. I love it.
As our legislatures plans to significantly cut spending on the Medicare program, today several Massachusetts hospitals are filing a lawsuit against the state of Massachusetts because the current reimbursements from Medicare and Medicaid are already too low. According to this article in the Boston Herald, Massachusetts currently reimburses hospitals for only 40% to 86% of the costs of providing care. Because at least 63% of patients going to these hospitals have Medicare or Medicaid, the low payments are pushing many hospitals “to the brink of financial ruin.” The state countered by stating that it recently increased payment to the hospitals by 10 percent. Unfortunately even a 10% increase still leaves hospital payments at 44% to 95% of the cost of providing care – still below the break even point.
No business can stay afloat when the costs of doing business exceed revenues.
Recall that in 2006, Massachusetts was the same state that established a mandate that every person in the state have health insurance … similar to the mandate proposed in the current US health care bill.
Also recall how, since this Massachusetts mandate was created, the number of visits to Massachusetts emergency departments increased 7 percent and how the cost of caring for patients in Massachusetts emergency departments increased 17 percent – due to the lack of primary care providers in the state.
Oh yeah, and in a survey last year, only 2% of graduating medical students in the country plan to go into primary care internal medicine.
So the plan in Massachusetts to insure all of its state residents has resulted in almost every state resident having insurance … and in more people having trouble finding care.
The greater number of insured patients increases the costs of providing care to those patients.
Then, to control costs, the government cuts or maintains ridiculously low payment schedules to providers – to the point that the providers are having difficulty staying in business.
Welcome, ladies and gentlemen, to your new national health care system.
The current health care bill plans to cut Medicare spending by $500 billion.
Medicare plans to cut physician reimbursement by 21% next month.
What good will your new health insurance be few providers are willing or able to provide care for you?
The biggest myth of this health care debate is that having “insurance” is equivalent to having “health care.” The two are not the same, nor will they ever be the same. Just ask people who have Medicaid “insurance.”
If the hospitals in Massachusetts want to get more reimbursements, suing the state is the wrong way to go about doing so. In this case, lawsuits are a costly lose-lose situation. All the money the hospitals spend in attorneys’ fees and court costs could be put to better use. Boston Medical Center already tried suing the state for the same reason and the litigation is still dragging out in court.
A lobbyist once told me that the quickest way to enact change is to cause a public outcry.
You hospitals want an increase in funding? Drop the lawsuits and just shut your doors. Take your ball and go home. Too many patients and almost every legislator in our government take their access to health care for granted. Let patients walk up to your facility with their insurance card in hand and let them jiggle the handle on on the door a few times before realizing that they cannot get inside. Stop providing care until the state and federal government provide better reimbursement.
If it costs these hospitals more to provide care than the hospitals are being paid, closing the doors would save the hospitals money each day that the doors are closed. Divert ambulances. Transfer admitted patients to other facilities. The 1.5 million patients each year, including more than 300,000 emergency department patients each year that are being treated at the near-bankrupt Massachusetts hospitals will have to be redirected to another facility to find their care – if care is available.
At the entrances of each closed hospital, post giant pictures of the state and national legislators and an explanation of how their actions or failures to act have caused the hospital to close. Make sure to include the date that the legislators are up for re-election.
Then give the local news stations a call to let them know what’s happening.
They’d have funding within a week.
VN:F [1.6.3_896] Rating: 8.8/10 (22 votes cast)
Posted in Access to Care, Funding Crisis | 46 Comments »
Saturday, October 10th, 2009
ERP here again while WC recovers from the revelling in Boston
Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.
The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.
Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.
VN:F [1.6.3_896] Rating: 9.2/10 (29 votes cast)
Posted in Funding Crisis, Insurance, Medicare | 23 Comments »
Friday, September 25th, 2009
In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits.
In February 2009, the two hospitals went bankrupt and closed.
In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity.
Guess what happened?
Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.”
The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs.
One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.”
At the heart of the hospital closures was funding.
New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt.
Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available.
Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending.
But we need to be very judicious in where spending cuts are made.
Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community.
Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.
VN:F [1.6.3_896] Rating: 10.0/10 (9 votes cast)
Posted in Access to Care, ED Closures, Funding Crisis, Insurance | 20 Comments »
Wednesday, June 10th, 2009
I don’t always agree with Uwe Reinhardt’s insights into the health care system, but he is so incredibly spot on with this quote that I had to post it.
[Countries with functional socialized systems] all mandate the individual to be insured for a basic package of health care benefits.
Many Americans oppose such a mandate as an infringement of their personal rights, all the while believing that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it. This immature, asocial mentality is rare in the rest of the world. An insurance sector that must insure all comers at premiums that are not contingent on the insured’s health status — a feature President Obama has promised — cannot function for long if people can go without insurance when they are healthy, but are entitled to premiums unrelated to their health status when they fall ill.
A central concept of medical systems in many other countries is “social solidarity,” not irrational demand for the best medical care someone else can pay for.
The US is going to have to emulate another functioning system if it is going to survive. The German model deserves some consideration.
——
In addition, Alexander sent me a link to an Investor’s Business Daily editorial about how Oregon is working on health care reform. Oregon has compiled a list of 680 treatments for medical conditions and has ranked them in order of importance. Oregon will only pay for the top 503 on the list. Treatment for everything below number 503 must be paid out of pocket. Patients with broken toes, cracked ribs, and liver cancer are out of luck – they’re all ranked below number 503. However, treatments for obesity, schizophrenia, pathologic gambling and sexually transmitted diseases are fully covered.
I foresee such a system as a way that health care spending will eventually be curtailed in this country. Liver cancer isn’t covered because not a lot of patients get liver cancer. Therefore, their collective voices are relatively small. When treatment is expensive and relatively few patients are affected, the treatments will be cut. Collectively, patients will receive more care for less expensive conditions that affect more people, but to keep things budget-neutral, patients who have less common diseases will receive less care. Even though Oregon admits that malignant neoplasms are a leading cause of death in anyone 11 years old and older (report pages PT4-PT11), it won’t pay for the care of “ill-defined malignant neoplasms” (#612). Doesn’t say anything about “well-defined” neoplasms, either. Refusing to pay for treatment of malignant neoplasms is great for saving money, but it is essentially a death sentence if you develop an ill-defined malignant neoplasm. Just hope to God that any neoplasm you get is benign. Those are still covered … unless you have a benign neoplasm of the eyelid (#516), kidney (#529), nasal cavities (#539), bone (#540), genital organs (#577 and 603), breast (#638), skin (#646), or digestive system (#656) – then you’re still SOL.
Also note how many of the things that will not be reimbursed are conditions with “no or minimally effective treatments or no treatment necessary.” Who determines whether a treatment is “minimally effective”? Why the same entities that pay for the treatments, of course: U.S. to Compare Medical Treatments
It’s the Golden Rule: He who has the gold makes the rules.
VN:F [1.6.3_896] Rating: 9.0/10 (5 votes cast)
Posted in Access to Care, Funding Crisis, Policy | 4 Comments »
Tuesday, June 9th, 2009
One way to get rid of your chest pain … threaten the nurses and hospital staff with a knife in the emergency department. Police will come and shoot you dead.
Quote from the director of Calgary’s three emergency departments: “We have huge numbers of very sick patients essentially left behind in hallways and on ambulance stretchers for long periods of time, and across the country, in every major Canadian city, in every large urban emergency room, you have patients who are deteriorating or having adverse events as a result of these delays to care.”
Canadian ED overcrowding isn’t due to non urgent patients clogging the EDs according to this study. Instead, the study author, a 25 year old master’s student, states that overcrowding is “rooted in insufficient physical and human resources and poor integration within and between hospitals.” Before the problem of ED overcrowding can be cured, he suggests “determin[ing] the purpose of EDs in order to best serve the patients, health care professionals, communities and the country.” Good advice.
Sutter Roseville Medical Center is at risk of losing federal funding after a patient “walked away from the emergency room … and hanged himself in a wooded area 500 yards away.” CMS alleged that the hospital did not adequately screen the patient under EMTALA. Part of me wonders whether this action is somehow related to Suter’s decision to close another emergency department in its system. I may be wrong, but I just get the impression that there’s more than meets the eye going on here.
Ten previously blogged about how his group had been surreptitiously ousted by hospital administration. This article shows that having a good relationship with hospital staff can save your job. When Mercy San Juan Medical Center tried to fire their current emergency docs and hire docs from California Emergency Physicians, the hospital staff got up in arms and the deal fell through.
One way to cut state Medicaid costs … address high utilizers. This New Hampshire editorial states that frequent “ER” users only represented 5% of the Medicaid population, but those users accounted for 41% of the total Medicaid “ER” visits in the state during 2006.
Another way to cut state Medicaid costs … stop providing services. North Carolina Medicaid recipients may soon feel the “bite” of budget deficits as state legislators propose to cut payments for dental visits by 50%. Think this through, folks. It’s not like people with cavities will just go away. Where do you think people with dental problems will end up? Receiving that nice inexpensive care in state emergency departments. I’ll bet that the state Medicaid costs will increase if they go this route.
Funding issues causing problems with access to Connecticut hospitals as well. Connecticut hospitals lost $156 million in the last quarter of 2008 and $200 million in the first quarter of 2009. The state is underfunding its Medicaid program and hospital emergency departments are “busier than ever,” with uninsured patients making up 45% of hospital emergency department visits. Some hospitals are now requesting payment in advance for elective procedures.
Want to reduce your risk of malpractice? Be nice. “Developing a rapport with the patient — is any physician’s best protection from eventually being sued by that patient.” One thing I don’t get – was this doc so busy that he couldn’t take off his surgical mask before posing for a picture in the article? Or is a surgical mask hanging around the neck the new fashion statement for surgeons?
A House Subcommittee recently approved a bill that would limit the Feres Doctrine for armed service members. Currently, members of the military and their families cannot sue the military for negligent medical care – regardless of how egregious the care was. The Carmelo Rodriguez Military Medical Accountability Act was named after a sergeant in the military whose bleeding buttocks lesion was repeatedly misdiagnosed as being a wart or a birthmark. Sgt. Rodriguez died from metastatic melanoma. I agree that doctors should be responsible for egregious care, but if we turn the armed services court system into another civilian medical malpractice system, how many military docs will leave? Another point of view from Walter Olson at Point of Law here. Fast care, free care, quality care – pick any two.
Physician’s Reciprocal Insurers, a med mal carrier that insures 25% of New York’s physicians has one foot in bankruptcy court and the other foot on a banana peel. State mandated insurance premium rate freezes appear to be partly to blame. How could this happen if insurers are raking in the money and are really responsible for the medical malpractice crisis?
VN:F [1.6.3_896] Rating: 10.0/10 (4 votes cast)
Posted in Access to Care, Funding Crisis, Policy | 1 Comment »
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Focus On The Cost
Tuesday, March 2nd, 2010Yeah, I agree with Howard Fineman. You got a problem with that?
Read his Newsweek article about his experiences being admitted to an Argentinian hospital and how he believes we should be focused on the costs of health care in this country.
His bill for a hospital stay with dehydration in Argentina: About $1500. Similar hospitalization in the US: $10,000 to $15,000 – if he was lucky. Money quote: “Most Americans have no idea how much their health care really costs, nor do they know how well it really works ….”
We desperately need price transparency in our health care system.
Look at the four systems in Pennsylvania that I reviewed in a previous post. If one hospital cost 4 times as much as another hospital for treating the same medical problem, would that affect anyone’s decision on where to go for medical care?
One commenter to the article noted that “Health services are often urgently needed and the consumer doesn’t have the time or inclination to shop around.” If people shop around for weeks to find the best deal on a car and spend all Sunday morning going through newspaper ads to find the cheapest head of broccoli at the grocery store, I have no sympathy for those who “don’t have the time or inclination” to research where they would want to go if their life was on the line or if they needed specialized surgery.
Regardless of what health care reform measures are taken, we still need to be educated consumers with our most important assets – our lives.
Posted in Funding Crisis, Health care reform, News Commentary | 36 Comments »