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Archive for the ‘Health care reform’ Category

Accepting Our New Normal and Finding New Opportunities

Friday, November 23rd, 2012

by Birdstrike M.D.

It Is Here To Stay

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and Contrasting With Other Industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What Government Will (or Will Not) Do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of….nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town!  That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary……doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some Physicians Will “Opt-In”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other Physicians Will “Opt-Out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.  More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The Silver Lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.

 

Obama vs. Romney vs. Honey Boo Boo

Sunday, September 9th, 2012

By Birdstrike M.D.

 

Once again, our upcoming election will have great impact on future health care policy.  Obamacare will either be kept intact, repealed or altered.  This will have great impact on patients, physicians in general, and especially Emergency Physicians.  By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis.  They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons.  Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow.  Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform.  They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use.  By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational.

The choice of the electorate will affect which pay for performance measures we and our salaries are subject to.  Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to.  Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings.  This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for.  How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients.

Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,”  which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.”  In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.”  Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech.  Does anyone know where Honey Boo Boo stands on health care?

Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention.  Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure.  However, two months before an election where we will choose a President, seat our entire House of Representative and 1/3 of the U.S. Senate, that will have a huge impact on future health care policy, I think it is worth discussing how informed or uninformed, and how engaged or apathetic our electorate is about the health care issues at hand.  Their decision will affect our patients, our health, our work environments, our salaries, and countless details of our health care system going forward.  It is our responsibility as physicians to educate the public on this part of their vote and its potential consequences.

Have we done our job as physicians to educate our patients, friends and co-workers on the issues at hand and how important this election is?  Have we come to grip ourselves, with how much this current election will affect the lives of our patients, our families, as well as every aspect of our profession?  If the answer to either question is no, then between now and Tuesday, November 6th 2012, we have a lot of work to do.

Which did you watch, the Republican Convention, Democratic Convention, or “Here Comes Honey Boo Boo”?

 

 

 

Political Quote of the Day

Thursday, July 26th, 2012

Maybe we should have started with you at the very beginning, talked to the physicians before they started writing a 2,000-plus-page bill that many of them [politicans] didn’t read, yet passed.”

- Republican Rep. Scott Tipton, commenting about the Affordable Care Act during a House Small Business Committee meeting last week which showed how “physicians have reached a tipping point” due to overregulation by Congress and insurance companies.

Dr. Louis McIntyre does a very good job at putting things into perspective during the included video interview. Not bad for an orthopedist … ;-)

 

The Individual Mandate For Dummies

Saturday, July 14th, 2012

This cartoon was sent to me in an e-mail.
Overly simplistic, but illustrates the issue. Credit here.

The Supreme Curve Ball

Thursday, July 5th, 2012

The Supreme Court decision on the Affordable Healthcare Act threw us a curve ball. Many people who predicted the outcome of the ruling swung and missed – including me.

The Court agreed with the government’s argument that the individual mandate contained in the Affordable Care Act was not a tax … for purposes of the Anti-Injunction Act (which would have prevented a lawsuit regarding assessment or collection of the mandate and forced those bringing suit to sue for a refund after paying it).
At the same time, the Court declared that the individual mandate contained in the Act was a tax … for purposes of validating and enforcing the mandate.
To me that’s a stretch. That’s like legal argument defending a dog bite lawsuit by simultaneously alleging that (1) I don’t have a dog, (2) you weren’t bitten, and (3) my dog didn’t bite you.

President Obama has declared the Supreme Court decision as a “victory” but this victory is largely Pyrrhic.

The Supreme Court’s decision will become a rally cry for the 41% of Americans who believe the law should be overturned and the 27% of Americans who believe the mandate should be overturned. Romney’s campaign will emphasize Romney’s commitment to repeal the law – whether or not he truly intends to do so. While some argue that “President Romney” wouldn’t have the ability to repeal the law, President Obama’s decision not to enforce our country’s immigration laws shows that an executive order refusing to enforce laws can have the same effect as repealing a law. A dog with no teeth can’t bite you.
In addition, President Obama and all the legislators who supported the ACA have essentially approved the largest tax increase in US history … in an election year. How many voters will be happy at the thought of a new and expanding tax that coerces us to purchase a commercial product which we may not even be able to use? The growing public backlash in this regard is probably the reason that the White House is backpedaling and stating that the mandate really isn’t a tax … even though the same White House stated that the mandate was a tax in the media and during oral arguments on the issue. The mandate stands because it is a tax and now President Obama and our legislators have to live with the consequences of their decision. In case you were wondering, here are how each of the House members and the Senators voted on ACA.

But many people will think that the tax … er, um … penalty is OK because our government is going to provide us with insurance. Millions of more patients will be INSURED! If you’ve read WhiteCoat’s Call Room on a regular basis, you know why this is such a false and empty promise. Insurance amounts to a series of promises. First there is a promise that, in exchange for a premium payment, someone else will pay for your medical care. Then there is a promise that someone else will provide your medical care. Finally, there is a promise that you will be provided with the medical care you need when you need it.

While the government wishes to expand the number of patients who receive our government-mandated “insurance”, many states are planning to restrict the eligibility for the “insurance” that our government wishes to provide to us. In other words, states don’t want to pay for your insurance. A House Ways and Means survey showed that 71 of the Forbes 100 companies could save a total of $28.6 billion in 2014 by dropping health care coverage for their employees. The Affordable Care Act creates a financial incentive for your employer not to pay for your insurance. It shouldn’t be surprising that thirty percent of employers are planning to drop health care insurance for their employees when the Affordable Healthcare Act is implemented.

Now think about the effects of just these few fact patterns. When those employees lose coverage, what will happen? Perhaps the employees will be able to afford to purchase a private insurance plan. Even if they did, it is likely that the plan would be high-deductible so that the employees could save money on premiums. Perhaps the employees earn so little that they will be eligible for government “insurance” – if the states don’t cut the eligibility. That leaves a large group of people who earn too much to get Medicaid but who don’t earn enough to purchase decent “insurance.” What will happen to them? They will pay the tax … er, um … penalty and end up with no insurance. When employers drop the insurance benefits for their employees … and they will … their employees will receive less coverage because less coverage will probably be all that they can afford. Sure, the Affordable Care Act will provide “insurance” to an additional 30 million indigent patients, but the Affordable Care Act will also create more uninsured and underinsured patients from the group of people upon whom our country depends the most – our work force.

Medical insurance is only as good as the health care professionals who are willing to provide care under the terms of the insurance policy. accept the insurance as payment. Suppose you had a million dollars worth of Japanese yen in your pocket and you were in a rural Kansas coffee shop trying to buy lunch. You may be rich, but no one accepts your money. Similarly, if a doctor that you need to see using your new government mandated magical insurance plan doesn’t accept your insurance, then you either pay out of pocket for your medical care or you find someone else who accepts your insurance as payment. If few doctors take your insurance, you wait for an open appointment. It’s that whole fast care/free care/quality care triangle. Pick any two.
By now you should know that many doctors refuse to provide care to patients who are on government insurance. In Texas, one third of all the physicians don’t take Medicaid “insurance” due to low reimbursements and governmental red tape. Mayo Clinic in Arizona stopped accepting Medicare patients in 2010 after losing $840 million in 2009 due to low reimbursement rates. Patients with Medicare in the Raleigh, North Carolina area are finding that physicians who accept Medicare patients are “scarce.” All of these people have the magical medical insurance plan that so many more people will be receiving, yet many of the “insured” patients still cannot find medical care. Even though you will coerced by the IRS to buy into the concept that health insurance and health care are synonymous, they aren’t and they never will be.
The health care that you are able to obtain with your “insurance” may less than adequate, as well. Walter Reed Army Medical Center was just one of the government hospitals plagued by allegations of patient neglect and shoddy medical care. And you won’t find any government hospitals on the government’s own Hospital Compare web site. Ever wonder why?

Finally, keep in mind that medical insurance is also only as good as its covered benefits. Your medical problems just might not be a covered benefit on your insurance plan. Even though you have paid into the insurance plan for dozens of years, your covered benefits can change at any moment. Ask patients who have had to depend on their government “insurance” for care of their cancer or injuries, or asthma.

So our elected officials have foisted what amounts to a medical Ponzi scheme upon us and most of them will be long out of office before the medical insurance house of cards collapses. Tough luck, suckers.

Perhaps the thing that concerns me the most about the Supreme Court’s decision is the precedent that the ruling sets. Our highest court has now held that it is permissible for the federal government to impose a tax … er, um … penalty upon citizens in order to force citizens to purchase a private commercial product. In oral arguments, Justice Scalia joked about next creating a mandate that everyone purchase gym memberships to make sure that people stay healthy. Wasn’t funny. His point was spot on. Where do the new taxing … er, um … penalizing powers of our government end? I fear that we will only learn the answer to this question after the election.

The Supreme Court’s ruling and the implementation of this law are another example of how the Court and our legislature are hopelessly out of touch with the needs of the people and how to meet those needs. If President Obama’s actions and the Supreme Court’s decision don’t make our citizens realize that we need a profound change in the governance of our country, then woe to us all.

What a disappointment we will have been to our forefathers.

Obamacare Is Wrong, But The Chief Justice Is Right

Thursday, July 5th, 2012

By Birdstrike M.D.

Yesterday, my 2 year old asked me, “Daddy, do clouds make rain by forming condensing nuclei of water vapor which act to form droplets which fall to the ground?”  I said, “No, son.  No.  You’ve got it all wrong.  Actually, those drops of rain are the tears of our founding fathers crying over the recent Supreme Court decision on Obamacare.”

As I predicted it would many months agoon Student Doctor Network, the Supreme Court upheld the

Supreme Court upheld the Affordable Care Act (ACA).  I was against “Obamacare” as it has come to be known, from the very beginning.  I am still against it, for reasons too numerous to count.  On the face of it however, the entire rationale for declaring Obamacare unconstitutional was absurd, and rather disingenuous.  Amongst the 2000 pages of this behemoth of a law, the one portion that makes the most sense is the “individual mandate”, which is the single portion that actually attempts to require all Americans to take at least a sliver of responsibility for the cost of their own health care expenses.  This is the one and only portion of it that is actually revolutionary and acts to reverse the central core of what is wrong with the health of our people, and our healthcare system itself: the complete lack of responsibility of so many individuals for their own health, and healthcare expenses.

Like many of you, I wished that the Supreme Court would overturn the law so that we could rebuild it in a way that makes sense both to patients and physicians, and less so to politicians.  However, as much as it pains me, I have to admit that Chief Justice John Roberts’ opinion was courageous and brilliant.  It tears my heart out to write it, but its true.  As I interpret it, what he essentially told America and the opponents of Obamacare was, “Don’t ask me or the spirits of our Founding Fathers to overturn your law, written by your representatives, and approved by your President with some fabricated technicality to fix your ‘Oops!’ Man up, and live with it.  Otherwise, if you don’t like it throw the fools out, elect a new government and start over, or fix it”.

Indulge me for a minute and allow me to play the “What Would Our Dead Relatives Have Thought, Game”:  The Founding Fathers of this country lived under true tyranny.  They were ruled by a tyrant King that would not hesitate to jail or execute someone for speaking an opinion infinitely less offensive that my own, and simply on a whim.  Many of them lost their lives fighting for the right simply to have representation. (Remember your history class, “No taxation without representation!”?)  I’m sure they would conclude that we have that luxury, and many other life easing luxuries they did without.  (You know, real important stuff like electricity, running water, insulin for diabetics, iPhone 4s with integrated Siri personal assistant.)  They didn’t have to worry about 40 million people being uninsured.  Health insurance didn’t exist.  It wasn’t a crisis for them, that only 80% of people could get an MRI.  0% of people got MRIs.  MRIs didn’t exist.  Neither did door-to-doctor times, ED wait-time billboards, sterile technique, antibiotics, cab vouchers or Sierra Mist with a meal tray.

If the “individual mandate” for all Americans to buy health insurance was severed from the ACA and we had to choose between it and the rest of the bill in its entirety, I would choose to keep the individual mandate, and strike down the other 2000 pages from this complex bill, the details of which no single person on Planet Earth has read let alone understands.  Most unknown, are the costs and unintended consequences of this bill.  As Nancy Pelosi has been repeatedly been quoted, so tragically and accurately, “We have to pass the bill so you can find out what is in it.”  This is an irresponsible and dangerous attitude that would never meet the “standard of care” any of us physicians have to live under, yet we are now ruled by it.

 

For decades I have been required to pay Medicare tax to pay for your Grandma’s health insurance (Medicare).  For decades I’ve been required to pay taxes to pay for your unemployed uncle Ed’s health insurance (Medicaid).  How come these things are not “unconstitutional”, the “Joe’s Grandma Mandate” and the “Billy Bob’s Uncle Ed Mandate”?  Now that the ever so radical concept comes along, of requiring me to pay for the health insurance not only for your Grandmother and your uncle Ed, but also for myself, all of a sudden it’s a cruel violation of my constitutional rights?  Give me a break.  The government can send 58,000 men to die in Vietnam, and that’s constitutional?  The government can take your house, bulldoze it and build a road in its place “for the common good” and that’s “constitutional”?  But to require Joe Six-Pack to chip in a few bucks for his ER course, ICU stay and redo CABG, half of the cost of which is eaten by insurance-buying Americans in inflated premiums, the other half of which is eaten by the doctors that took care of the patient in the first place, is unconstitutional?  Give me a break.

As much as it pains me that Obamacare stands, since I’ll be paying higher taxes, certainly get paid less from Medicare, Medicaid and private insurance all of whom will cut payments to doctors to cover the newly insured, and likely be overwhelmed by the masses of newly insured patients with government insurance that pays pennies on the dollar…. I still think John Roberts did the right thing.  We as Americans, and we as physicians allowed this to happen.  We let them walk right in, take over our house, repaint it, decorate it, rob it and remake it in their own image with nary a fight.  We are amazing healers, but the most hapless complainers and the feeblest of pushovers.  Let this be a lesson to us all.  We have allowed them to raise the stakes to a much greater height and will face a much more epic battle to save God’s profession.

 

Free Market Medicine and Lab Tests

Thursday, May 26th, 2011

As my surgical experiences come to a close, I have now begun to receive all the bills for services that were provided to me.

One bill shows what one national health care provider considers “fair payment” for laboratory testing performed prior to my surgery. I matched that bill up with my insurance explanation of benefits to determine which prices go to what tests. Click on the picture below to enlarge.

Fees for the lab testing were discounted anywhere from 70% to 90% off the provider’s published rates.
A CBC cost $8.12
PT/PTT (coagulation studies) cost a total of $10.15
A basic metabolic panel cost $8.12
Nearly $200 in “handling fees” was waived.
They accepted five bucks instead of the $16.70 they charged for drawing my blood.

In summary, it would have cost me $350 for the tests if I didn’t have insurance.
Instead, it cost me $31.46 for the tests since I do have insurance – more than a 90% discount.
Great for me, but a gouge to patients who don’t have insurance.

The thing is … if the medical provider advertised these rates to all the patients who don’t have insurance or who have high deductible plans, it would probably have lines of customers out the door waiting to have their blood drawn. In fact, they would probably still have lines out the door if they doubled the prices below.

I don’t care how much providers want to mark up their prices. That is their business and they can keep that secret.

We go to a grocery store and purchase products at the advertised price, yet few of us know how much the grocery store has marked up the price. The ability of shoppers to vote with their feet keeps prices down.

In order to decrease costs of health care, health care reform must include some form of transparency in pricing.

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Gaming ObamaCare

Thursday, January 27th, 2011

Remember my post a few months back about how some large companies were getting waivers so they didn’t have to pay into the new health care system? Things are getting worse.  According to this article on The Hill, the feds just granted new insurance waivers to more than 500 groups, bringing the total number of individuals covered by waivers to 2.1 million.

The system just isn’t going to work.

Let me get my soapbox out here. [Tap tap tap] Is this thing on? Good.

First, there’s still this misconception that the “mandate” to purchase insurance will somehow translate into accessibility of medical care. It doesn’t work that way. I’ve said it before. Purchasing health insurance doesn’t mean that you have access to health care any more than purchasing car insurance means that you have access to a car. If your insurance is cut-rate,  chances are that your medical care will be cut-rate. You can’t make a silk purse out of a sow’s ear.

The general idea of “insurance” is conceptually sound. Everyone pays into a system to spread the risk of paying for a catastrophic event. You pay$100 per month to presumably avoid having to pay $100,000 or more if you have a major medical event. The amount of money paid into a system is dependent upon how much money is taken out of the system. If there is a surge in the number of people needing medical care, one of two things happens: More money has to be paid into the system or less money has to be taken out of the system through rationing of medical care or providing lower quality less expensive medical care. There aren’t any other variables to change. Cost, availability, and quality. That’s it.

The proposed system creates too many loopholes. It caters to special interests. It changes the cost/availability/quality variables in ways that the public doesn’t realize. So lets look at a few examples.

First, what exactly are we getting for our money in the current system – or in the proposed system? Many people don’t know. With regular insurance plans, your policy guides coverage. Maybe you have exclusions for certain conditions. Maybe there is a limit on how much the insurance company will pay for a certain type of care. Maybe certain types of care (like dental care or vision care) is unavailable. But at least you know what you’re getting. Can anyone say with certainty what type of medical care they’re going to get once they start paying into the new and improved health care system? I sure can’t. The lack of specifics opens everyone up to being refused care once they’ve paid into the system. After all, the feds and/or insurance companies can just say “We never agreed to pay for that type of care.” In essence, we’re paying for what’s behind the curtain without really seeing what’s behind the curtain.

Speaking about “exclusions” on insurance, under the current plan, “exclusions” on insurance policies will be limited. True that insurance companies have used exclusions and rescissions unethically in the past, but when used appropriately, exclusions keep people from gaming the system. If you’ve had a bum knee for 20 years, you shouldn’t be able to pay one month’s insurance premiums and then be entitled to the newest titanium replacement, the services of the best orthopedist, and unlimited therapy. If everyone gamed the system that way, the system would collapse because there would be a tremendous funding input/output mismatch that couldn’t be sustained by just increasing insurance premiums. No one would purchase “insurance” because they know that they could just get a policy once a catastrophe either occurred or was about to occur. Outlawing or severely limiting insurance exclusions essentially amounts to allowing people to purchase homeowner’s “insurance” while their house is burning to the ground. Result: Quality of care will decrease or costs of insurance will skyrocket – or both. Our family’s health insurance premiums have jumped about 30% in the past 8 months, so we know where this is headed.

Then there is the issue of spreading risk. Remember how everyone needs to pay into the system to spread the risk? When fewer people pay into the system, either the amount of care decrease to create a new equilibrium point with input/output of funding  -or- everyone else must pay more into the system to maintain the status quo.  Look at all of the waivers that have been granted under the new health care legislation thus far. Multibillion dollar companies like Blue Cross Blue Shield, Cigna, Aetna, and McDonalds are all getting a pass on purchasing insurance. When people want to use the system but they don’t pay into the system, they create a greater expense for those who do pay into the system. Why there are so many insurance companies and unions receiving these waivers, anyway?
There is also a religious exemption to purchasing insurance. Whether Amish, Muslims, or other religious groups will be exempt from purchasing insurance under the new health care plan remains to be seen, but ultimately if they do receive care and don’t pay into the system, those extra unfunded participants will result in additional increases in expense and/or decreases in care.

Yesterday, I posted a comment to ERP (from ER Stories) on Kevin’s blog about ERP’s notion that the “mandate” was a good thing. In that comment, I noted that one of the other issues that we have to address is the tremendous amount of inefficiency in our current system. Bureaucracy has to diminish, not increase. Empowering the IRS to enforce the insurance mandate is heading in the wrong direction.

We also need to learn to say that we aren’t going to pay for medical care that has a negligible effect.
Providers have to be comfortable doing that and the public has to become comfortable hearing that.

End of life care needs to be compassionate, but made with the understanding that everyone is going to die. We need to become comfortable with the ideas of hospice care. Yes, maybe we can eek another few weeks out of your loved one’s life, but what will the quality of that time be? How much should we pay to keep the shell of the person that was once your loved one alive? There have to be checks and balances in place to prevent “death panels” but we can’t afford the system of end of life care as we know it. It’s a tough question, but it is one that needs to be asked and one that needs to be addressed.

Medications are another huge expense. Track medication use. Have a national database of what patients are getting what medications at what pharmacies. This will decrease multiple prescriptions from different providers and decrease adverse medication interactions or overdoses from the little old ladies who can’t remember their medications. If you aren’t taking your medications, a national registry will also let us know that you aren’t filling your prescriptions.
If you can’t afford your prescriptions, you can go to the federal medication dispensary inside the federal health care clinic at the free VA system and get your medications for free. They will have a limited formulary with mostly generic medications. If you don’t want to wait in line at the federal dispensary, then you go to the pharmacy and pay for the prescriptions out of your pocket. If you want the new designer medications that have the same effect as WalMart’s $4 medications, that’s fine. You need to pay for them out of your own pocket. If your doctor won’t work with you to find a medication on the $4 list, then find another doctor.
Introduce free market forces into the medication market and prices will have to come down. Pharmaceutical companies can’t make money on their blockbuster drug if no one can afford to purchase it. Want to hedge your bet against being stuck purchasing outrageously expensive medications for an orphan disease? Maybe there’s an insurance policy for that.

Stop playing semantics regarding the need to fund the system. The administration has already admitted that the “mandate” is really a “tax.” Call it a tax and implement it like a tax. If the public wants access to care, we need to increase everyone’s taxes. Kick up the Medicare tax deduction from everyone’s paychecks by 10% and forget about the “exemptions” and waivers from the “mandate.” Everybody pays their fair share. Tie the Medicare tax to costs of care. If costs go up, the tax goes up, but if costs go down, so will the taxes. Maybe we implement some type of consumption-based tax so that even those who are in this country illegally, who are visiting from other countries, or who do not work will still pay something into the system when they purchase groceries and other necessities of living.

Then do something to actually increase ACCESS to care. Open up the VA System to every citizen in this country. Expand the system to include county hospitals as well. Fund the systems exclusively with the new tax money. Then, if you walk in the door with your verifiable US ID, you get free care. All those taxes you paid are now funding your care. If you are visiting this country, you purchase insurance before your trip or you pay with a credit card – just U.S. citizens do when they visit your country. If you’re here illegally, you still get care, but then you’re getting detained, processed, and deported once you’re discharged from the hospital or you’re stable for transfer. You’re breaking our laws, so it’s about time that we either enforce our laws or we change our laws.

What would happen if we repealed the health care law and put the system above in its place?

Deconstructing Socialized Medicine?

Monday, July 26th, 2010

Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it.
The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize.
According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered.
They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities.
Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.”
The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England?
Providers will also be paid based on outcomes and performance.

So far, sounds like a lot of changes heading in the direction of free market medicine.

The plan would also both increase payments to … and increase involvement of … primary care providers.
And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs.

One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality.

But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.

Free Market Transparency on the Horizon?

Saturday, May 29th, 2010

Now THIS is what I’m talking about!

From an article in ModernPhysician.com (registration required)…

Pricing transparency gaining renewed interest
Led by a physician lawmaker, members of Congress on both sides of the aisle have shown renewed interest in mandating a boost in healthcare pricing transparency, including charges for physician services.

More on pricing transparency from an article in The Hill.

Rep. Steve Kagen, M.D., (D-Wis.) sponsored one bill (H.R. 4700) that would require all medical providers to openly disclose prices or face a financial penalty.”The “Transparency in All Health Care Pricing Act of 2010” would finally allow patients to see the price of a pill before they swallow it.”

Rep. Joe Barton (R-Tex.) sponsored H.R. 4803 which is a little more vague, but which still requires that all hospitals in each state report “the charges for inpatient and outpatient services typically performed by such hospital.” This bill has 11 co-sponsors.

Sources in the ModernPhysician.com article discussed whether the pricing scheme would be “too complex” and suggested that if competitors knew each others’ prices, they would raise prices in a given market. If hospitals have to list every little thing, I suppose it could be too complex. I don’t go along with the price fixing argument.

A few simple solutions:
1. If we’re worried about the complexity of pricing all hospital services, require that providers report pricing based upon CPT codes. That way, consumers can compare apples to apples (or codes to codes).
2. Any charges that do not correspond to a CPT code must be explicitly stated in simple English. No charges of $129 for a “mucous recovery device” when all they’re giving you is a box of tissues.
3. Require that any procedure or test or other charge whose price is not published must be provided free of charge to the patient. Patients have the option of accepting or rejecting items once they know the charges involved. You want to charge $129 for a box of tissues, you better tell me about it first. Then your charges will be out there for people like me to comment upon.

This whole pricing transparency thing is catching on. Just read a blog post about transparency from Paul Levy – the CEO of Beth Israel Deaconess Medical Center in Boston. In Massachusetts. You know, that state where they have insurance for everyone, but access for … well … not everyone.

“we should measure parties’ commitment to change by the degree to which they advocate and adopt the kind of transparency that exists in virtually every other segment of the economy”

Bingo.

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