Repairing the Healthcare System

How Is The Healthcare Insurance Industry Doing It?

Stanley Feld M.D.,FACP,MACE

President Obama is refusing to look at reality. I imagine it is hard to see what is going on at ground level when you are at 30,000 feet As long as the traditional media acts as his propaganda machine, he can continue to pursue his agenda for change that most Americans did not anticipate.

Time Magazine published an article filled with disinformation and sound bytes. One article was “How the Stimulus Is Changing America.”

An equally misleading article was entitled “After One Year, a Stimulus Report Card; The article was a report card grading the different programs of the $787 billion stimulus package. President Obama should read the public comments below both articles to see how people feel. He will realize that Americans are not buying his propaganda.

 

The healthcare insurance industry has President Obama just where it wants him. This is the open enrollment season for next year’s insurance policies.

Many states lack the health law authority to regulate healthcare insurance company rates. The healthcare industry is taking advantage of this fact.

“Kathleen Sebelius, the health and human services secretary, at a conference last year. The administration said its general approach was for states to “take a lead role in providing consumer protections, with federal enforcement only as a fallback measure.”

 

President Obama’s health care law has placed the responsibility for healthcare insurance rate reviews on the states.

Insurance commissioners in about half the states say they do not have clear authority to enforce consumer protection and to regulate rates.

“California, Florida, Hawaii, Michigan, Nebraska, Oklahoma, Virginia and Wyoming, among other states, said they did not have authority to enforce federal law.”

At a time when states are fighting the federal government over state rights, thirteen states do not have authority to review proposed health premium increases for most forms of healthcare insurance company coverage. The National Association of Insurance Commissioners also revealed that about a dozen states have limited power to review increases after they take effect.

How have the state governments been in protecting its citizens?

“Meanwhile, state governments that have for years allowed insurers to set premiums virtually at will are gearing up to establish procedures to review rate increases.”

All the state insurance boards would have to do would be to withhold that healthcare insurance company’s licenses. This is not done because of the influence of the healthcare insurance industry’s lobbyists and the fear of legal action by the healthcare insurer.

Our state governments are not protecting its citizens’ interests.

California has had many law suits against the healthcare insurance industry. These suits have been filed by the state, physician groups, and patients. Most of these suits against the healthcare insurer have resulted in large fines against the healthcare insurance industry. However, the actual percentage awarded is small compared to the amount of money the abuse earned the healthcare insurance company.

 

“Sara Rosenbaum, a professor of health law and policy at George Washington University, said this was an awkward arrangement. “The new law creates detailed federal standards for insurance, but takes away consumers right to sue if insurers don’t live up to their obligations,”

 

California insurance regulators just approved Anthem Blue Cross scaled-back rate hikes after a previous increase was canceled amid an uproar over its size. The uproar included a congressional inquiry. Originally, Wellpoint, Anthems Blue Cross’ parent company, wanted a 37% rate hike. It was quite a compromise.

 

“Anthem said it intends to put the new rates — averaging 14% and as high as 20% — into effect Oct. 1 for nearly 800,000 individual California policyholders.”
“Regulators also allowed one of Anthem's nonprofit competitors, Blue Shield of California, to move ahead with rate increases — averaging 19% and as high as 29% — for 250,000 individual policyholders.”

The state regulators are impotent. There is a lack of due diligence, negligence or pure stupidity on the regulators’ part.

Healthcare insurance company executive showed state regulators that the proposed increases meet the requirement that 70% of premiums go for medical care. As a result, the regulators said they could not stop the increases.

Did the regulators study the validity of the deductions for administrative service expenses?

Did these expenses include the enormous executive salaries?

The administrative services expenses are not discussed or available to the public. All one has to do is remember the millions of dollars in salary that Wellpoint’s executives receive are subtracted before the money is spent for patient care. Many receive salary and stock options in the $10 million dollar range.

On Wednesday, a Blue Shield spokesman said the company looked forward to moving ahead with its plan. "We wish the increases were smaller, but the cost of medical care for our members keeps rising dramatically," spokesman Tom Epstein said. "These increases are necessary to cover those costs."

How can that be when physician and hospital reimbursement decreases each year? Administrative service expenses are loaded and ignored by state regulators.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Why Is The Healthcare Insurance Industry The Villain?

Stanley Feld M.D.,FACP,MACE

As soon as President Obama’s healthcare reform law passed, rules and regulations had to be made by non-elected state regulators to interpret the new law.

For the healthcare insurance industry, the fight is now over the details. The healthcare insurance industry has graciously volunteered to help regulators craft these regulations.

Senator John D. Rockefeller IV, Democrat of West Virginia, sent a letter to regulators expressing his concern that the insurers could have too much influence on how the regulations were being drafted.

“The health insurance lobbyists failed to beat the health care reform bill in Congress — but with billions of dollars at stake, we cannot and we should not expect them to throw up a white flag and start looking out for the livelihoods of American families,” Senator Rockefeller said in a statement. “They’re working every angle of the implementation process to shirk their obligations under the new law.”

As stated in my last blog entry, the healthcare insurance industry is already increasing premiums without justification for a rate increase except actuary anticipation.

The individual State Boards of Insurance are supposed to regulate rates. The State Boards of Insurance have acted as if they are impotent in the past few years. President Obama has just given State Boards grants to regulate the new law.

“Senator John D. Rockefeller IV fears that insurers are affecting how regulators interpret the recent health care legislation.”

“The new law requires health insurers to spend at least 80 cents out of every dollar they collect in premiums on the welfare of patients, a critical issue for the companies’ bottom lines.”

State regulators are drafting the new regulations to reflect the laws mandate that 80 cents of every healthcare dollar be spent for patient care. This should result in a decrease in healthcare insurance rates.

In the past, Medical-Loss ratio meant a percentage of the healthcare dollars applied to medical care after the healthcare insurance industry’s administrative services expenses.

The healthcare insurance industry wants to keep it that way. They are going to do their best to help state regulators do the same.

Consumers are being ripped off. The healthcare insurance industry loads administrative services expenses with creative bookkeeping. The actual expenses are opaque. In 2008, administrative expenses in Minnesota were 65 cents of every premium dollar. After administrative expenses, if the healthcare insurance industry spent more than 90% of the remaining 35% of the healthcare dollars for medical care, the healthcare industry was permitted a rate increase by the State Board of Insurance.

DOUBLE CLICK ON EACH FIGURE TO ENLARGE

 

Figure 1 Sixty five percent of private insurance dollars in Minnesota went to administrative services including brokerage fees. Only 15% went to physicians and 20% to hospitals. Figure 2

Figure 2

"The social contract for medical care should be between the physician and patient. Private Insurers aggregate 32.6% of the dollars that Americans pay in the hope of getting care, and insurers pay out only 4.9% of the money collected from the nation's Consumers to physicians. Insurers pay out only 6.5% to hospitals.  Administrative service fees could not possibly add 15% value to the care of a patient. The administrative service fee can and must be reduced markedly."

http://www.state.mn.us/mn/externalDocs/Commerce/Blue_Cross_anfd_Blue_Shield_of_Minnesota_051606085017_BCBSM.pdf

Figure 3

Figure 4

 

The math is complicated. As pointed out by a reader, government officials are not anxious to uncover the creative bookkeeping for good reason.

“No career politician (Republican or Democrat) would touch attacking the Insurance lobby. Both the Democrats and the Republicans like the campaign donations from healthcare Insurance companies. Neither will the media attach the healthcare insurance industry because it biggest revenue comes from political advertisement. Who pays for this political advertisement in an era where the “media is the message.”

The healthcare insurance lobby and Big Pharma contribute heavily to political campaigns.

The good news is the traditional media is losing its impact on consumers in the era of You Tube, texting and Twitter. The cynicism is justified. Politicians are not interested in listening to the needs of the people.

As soon as a politician is sincerely interested in consumers’ needs, he will win. Many thought President Obama was that man. Unfortunately, he has another agenda.

What are the healthcare insurance industry’s administrative expenses it wants to include in the new regulations before it has to spend 80 cents for every healthcare dollar.

1. The cost of verifying the credentials of doctors in its networks. This cost is opaque. It is automated but the healthcare insurance industry wants to charge full price year after year.

1. The cost to ferret out fraud by identifying doctors performing unnecessary operations, procedures, and tests. Who should decide on unnecessary treatments? Peer physicians in local hospitals and local communities should decide. These physicians are usually not paid and are supposed to be immune from liability.

1. The cost for programs that keep people who have diabetes out of emergency rooms.

The healthcare insurance industry should not be doing this. It should be paying physicians to develop Diabetes Care Teams to teach the patients to self- manage their disease. The healthcare insurance industry has not universally paid for Diabetes Education. The help desks maintained by the healthcare insurance industry are not effective. These help desks are not an extension of the physicians’ medical care. They tend to undermine physicians and the physician patient relationship.

1. Healthcare insurers insist that typical business expenses should not be considered part of the Medical-Loss Ratio. The healthcare industry is not satisfied with a 20% profit on every healthcare dollar. It has managed expenses to receive 65% of every healthcare dollar by loading the administrative expenses.

1. The healthcare insurance industry believes it should be entitled to expense sales commissions for insurance agents. The expense is already built into the premium. It wants to continue to expense the sales commissions.

1. It wants to expense taxes paid on investments. These tax expenses should be subtracted before the 80% is calculated.

It is bizarre because the insurance industry bought the investment with profits. The profits were then leveraged with mortgages. Now it wants deduct the taxes as well as the interest paid on the mortgages. This is an excellent example of Wealth building 101.

1. The healthcare insurance industry wants to expense the insurance reserves. What are the rules for calculating insurance reserves? There is a line in the financial statements reporting outstanding accounts payable. Are the outstanding accounts payable the difference between what physicians billed and the physicians’ reimbursement? Our regulators are not protecting consumers.

1. It is essential to the healthcare industry to influence the rules for calculating for the Medical-Loss ratio.

The new law requires the healthcare insurance industry to provide a refund if it does not spend 80 cents on each healthcare dollar after administrative expenses. If the industry can achieve proper administrative accounting rules, it can continue to expense 65 cents of every healthcare insurance dollar.

Medicare and Medicaid do not escape this 65% administrative fee. President Obama claims Medicare’s administrative fee is only 2.5%. CMS’s administrative fee is 2.5%. The 2.5% is the fee to administer the outsourcing of administrative services to the healthcare insurance industry. Medicare pays 65 cents of every dollar to the healthcare insurance industry for these administrative services.

It sounds complicated. It is complicated on purpose. The goal is to keep the taxpayer stupid. The healthcare insurance industry can then blame hospitals and physicians for the rising healthcare costs. Hospitals and physicians become the healthcare insurance industry’s scapegoats.

I think Americans are starting to wake up.

If you’ve let your President and Congressmen know how you feel, tell them again and again-and again. It might help.

https://writerep.house.gov/writerep/welcome.shtml

http://www.senate.gov/general/contact_information/senators_cfm.cfm

http://www.usa.gov/Contact/Elected.shtml

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

And,The Real Healthcare Villain Is…. The Healthcare Insurance Industry

 

Stanley Feld M.D.,FACP,MACE

President Obama is playing a dangerous game with our healthcare system and the delivery of medical care in our country.

His ultimate goal is apparent. It is to develop a government controlled single party payer healthcare system. This goal makes Barney Frank and John Kerry happy. Physicians will be salaried employees of the government.

President Obama could not get congressional support for the present law unless he made secret deals. He also faked out many Senators and Congressmen with promises he could not keep. His healthcare law is also unconstitutional. He is in the process of trying to fake out the judicial system.

President Obama knows the bill passed will fail to achieve universal care at an affordable price. All he has to do is look at the failed Massachusetts healthcare reform act. It is obvious the healthcare reform law will fail.

 

Americans are already feeling the pain of his healthcare reform law. As the pain intensifies, Americans will be willing to accept anything the government has to offer. Heidi Klein described this strategy perfectly in her book “The Shock Doctrine.”

First, we will have the public option. The public option will fail. Next, there will be a total takeover of the healthcare systems by the government. The government will dictate the medical care Americans can receive.

I know it is hard to believe but I predict this is Obama’s ultimate goal.

President Obama has one problem in achieving his goal. . He does not hold the Aces or the Jokers in the deck. The healthcare insurance industry does. It hold the most important cards in the deck. It provides the administrative services for the government run healthcare systems. Therefore, the healthcare insurance industry controls the money and the hidden administrative overhead costs.

The healthcare insurance industry will increase in premiums to the private sector. If there is no private sector, it will increase premiums paid by the government. The government will raise the money by restricting access to care, rationing medical care and increasing taxes. Increasing taxes will be difficult because the government is bankrupt. With rising unemployment rates the tax base decreases.

I will walk you through the scenario as it develops. First, it is necessary understand the steps the healthcare insurance industry is taking to insure its secure hold on the Jokers and the Aces.

This year the healthcare insurance industry is increasing premiums once more as it is reducing patient coverage and decreasing physicians reimbursement to physicians. Where is the money going?

The increased premiums will choke the healthcare system. The result will be more uninsured patients. Small business is struggling to survive economically during this recession. They will be forced to drop coverage for their employees.

I received an email from a reader. The email tells the story. The reader described herself as a 40 year old MBA small business owner of a high tech company. She wants to provide healthcare insurance to her employees. Since she is also an employee of her company she feels it is also essential to provide healthcare insurance for her family.

This is her story.

As an employer, the options available are overwhelming. The information available to determine the differences in various plans is difficult to get to, analyze and understand.

Insurance premiums continue to go up yearly as plan options change. President Obama is wrong when he says if I like my plan I can keep it. My plan is not available.

As an employer, we’re trying to help our employees by contributing a similar contribution on % basis. We increased what we’re paying as an employer to cover the increase in price of this years premiums. We can barely afford the increased premium.

It’s equally difficult and confusing as an employee to determining the differences in the healthcare insurance plans available to me through my employer (me).

I’m use to PPO (choice of doctors – well, at least those within the network). HMO is less expensive, but I don’t really know what the difference is in terms of care, services, hoops to go through to get a primary doctor for referral to other doctors.

As an employee I’m paying $1600/yr, and my employer(me) is paying $14,500 for medical coverage for my family. This is for a $1500 per person ($3000 family) deductible.

In essence I am paying $19,100 ($1600+$14,500 +$3000) plus my copay per year for less coverage than I had last year. Where is President Obama’s promise of relief?

For the lower deductible plan I was on last year ($1000 / person, $2,000/family) the price is $17,500/year plus $1600 from the employee plus $2,000 deductible for a total of $21,100 excluding copay.

Dental and vision plans are optional and separate from this, and add another $1600/yr for basic emergency coverage.

This is insane! Expensive, very hard to understand and navigate plan differences, and although I have plan options, I don’t really have any options outside of a certain band of options provided to me through my employer, unless I want to go it alone, do more research and spend time/energy managing my health care options.

Sincerely

Where are you President Obama when we need you? The healthcare insurance industry is setting us up. These are unintended consequences for the non retired. Wait until we see the consequences for the retirees.

President Obama’s reply would be “I am on my way.” I’ll bet he is.

He would say everyone will have to live through this pain until I can stuff a single party government payer down the throat of congress. At that time everything will improve. The government will run the healthcare system correctly. The government will salary physicians. This will Repair The Healthcare System.

I suggest Americans should not hold their breath.

If you’ve let your congressmen know how you feel, tell them again and again-and again.

https://writerep.house.gov/writerep/welcome.shtml

http://www.senate.gov/general/contact_information/senators_cfm.cfm

http://www.usa.gov/Contact/Elected.shtml

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

President Obama. You Are Losing Your Workforce.

 

Stanley Feld M.D.,FACP,MACE

http://www.ama-assn.org/ama/pub/news/news/medicare-consultation-codes.shtml  Somehow, President Obama must attack raising cost of medical care. Physicians are the easiest stakeholders to attack. They are the least organized.

A sneaky reduction in specialist reimbursement occurred on April 1^st. Medicare eliminated consultation codes. Most specialty organizations fought hard for Medicare to recognize their physicians’ additional training and experience. Specialists are well deserving of their consultation codes and its increase in reimbursement.

Elimination of the consultation codes is a back door way of reducing specialists’ Medicare reimbursement. This sneaky reimbursement reduction is going to result in many unintended consequences. President Obama will to be very upset by the result of this action.

The AMA constructed and published a survey, along with many subspecialty organizations, about the potential effects on medical care by the elimination of the consultation codes.

The survey proves to me that physicians can get upset when they are taken advantage of once too often. I have been saying all along that the AMA has been cooperating with President Obama and his healthcare reform bill as if the AMA was President Obama’s indentured servant. I think President Obama has finally gotten under the skin of the “house of medicine” (AMA). It took a long time.

“The elimination of Medicare’s consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients, according to a new survey released today by medical specialty societies and the American Medical Association (AMA).”

Physicians who see Medicare patients have taken a number of cost cutting steps to offset the losses in revenues caused by the elimination of consultation codes. The cost cutting steps have resulted in seniors experiencing limited access to medical care. They have also experienced rationing of care. Unfortunately, these unintended consequences were predictable.

Highlights from the survey include:

• Three out of every ten (30%) have already reduced their services to Medicare patients or are contemplating cost-cutting steps that will impact care.
• One-fifth (20%) have already eliminated or reduced appointments for new Medicare patients.
• Nearly two-fifths (39%) will defer the purchase of new equipment and/or information technology.
• More than one-third (34%) are eliminating staff, including physicians in some cases.
• Following CMS’s suggestions that they no longer need to provide primary care physicians with a written report, about 6% have stopped providing these reports, while nearly another one-fifth (19%) plan to stop providing them.

On December 1^st when there will be a further 23% reduction in reimbursement. Seniors’ access to care will get worse. All this even before any of the major changes in President Obama’s healthcare reform act starts having its greatest effect on seniors’ care.

The Centers for Medicare and Medicaid Services (CMS) predicted, in its final physician payment rule for 2010, that no specialty would see Medicare revenues decline by more than 3%.

It turns out the minimum decline in revenue is 5%. Thirty percent of practicing specialists have experienced losses of more than 15%. This level of decrease was predictable. Most specialty practices cannot sustain cuts of this size. Specialists are reducing their services to Medicare patients.

CMS has also asserted that there is no longer any significant difference between a consultation and a routine office visit. CMS has to be kidding. Whoever believes this has no idea of the role of a consultant.

CMS has stated that consultants can send referring physicians the medical record rather than a written report. CMS recognized this dictum might discourage care coordination. Coordination of care is supposedly a priority for President Obama. CMS promised to make adjustments if there was evidence of deterioration in “effective coordination of care.”

Following CMS’s suggestion that specialists no longer need to provide primary care physicians with a written report about 6% have stopped providing these reports. Nineteen percent of specialists (19%) plan to stop providing reports and a number of others in the survey commented that they will continue providing reports but only very brief ones.

This regulation is destructive to coordinating care with the patients’ primary care physicians. The government is going in the wrong direction. There are other unintended consequences resulting from the elimination of the consultation codes. They are technical. The regulation limits payment for many services provided by the specialist.

President Obama promised the American people that he was going to reward cognitive services. Elimination of the consultation codes has the opposite effect.

One example is prolonged services for hospitalized patients. At issue is whether physicians can count time spent on any duties other than their face to face visit with the patient. Other duties include studying the patients past and present records for clues to diagnosis and treatment or discussing the case with the patient’s primary care physician or their family.

“CMS only recognizes face to face time and not other services such as establishing and reviewing charts and communicating with families and other health care professionals. In effect, Medicare is denying payment for these services and further discouraging coordination of care between professionals.”

There are other issues such as payment for a patient being seen by two specialists in one day and payment for new Medicare patients.

It is clear to me that whoever wrote these regulations has no idea of the mechanics of the practice of medicine. I doubt that anyone asked for physician inputs.

CMS is focused on changing the payment system for medical care. They are not focused on the retention of their workforce or improving the care of the American people.

President Obama believes that he will ultimately be able to force all physicians to become salaried workers of the government. I believe he will be unsuccessful.

There are many areas in the healthcare system that can be fixed to reduce the cost of medical care to affordable levels without losing the workforce.

Three important areas to improve to reduce medical costs would be effective malpractice reform, effective rules regulating the healthcare insurance industry and effective team management of chronic disease with the patient being in the center of the healthcare team under the leadership of physicians.

All this can be accomplished by consumer driven healthcare in combination with the ideal medical savings account.

I hope President Obama is listening. Somehow, I doubt it.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Britain Plans to Decentralize Health Care:When Will We Ever Learn?

Stanley Feld M.D.,FACP,MACE

Winston Church was right when he said, “You can always count on Americans to do the right thing—after they’ve tried everything else.”

Dr. Don Berwick, our new Director of CMS has touted Britain's National Health Service, as the ultimate role model. The British government has declared the National Health Service a fiscal failure.

Donald Berwick was appointed Director of the Center for Medicare and Medicaid Services during the Senate’s recess July 4th. President Obama avoided a confirmation hearing. The American people did not have the opportunity to hear Dr. Berwick’s philosophy and his plans for Medicare.

Dr. Berwick has some good ideas and some very bad ideas. President Obama’s ideas are not about repairing the healthcare system. His ideas are about central government control of the healthcare system.

President Obama and Dr. Berwick are portraying physicians and patients as the villains. It is easy to blame the physicians and the patients because both have some blame in the dysfunction of the healthcare system.

The villains are the healthcare insurance industry and malpractice reform.

Britain’s new coalition government has proposed a reorganization of its National Health Service

After 62 years, the British government’s goal is to decentralize its healthcare system. Unfortunately, Britain is making another complicated mistake.

Britain's National Health Service has continually changed over the 62 years. Various British administrations have searched for the formula to deliver high quality care at an affordable price. Britain has nevertheless experienced increasing costs and demand as quality and access to care has decreased.

What is missing from the British system?

The government believes that the people are not smart enough or responsible enough to figure out how to take care of themselves. The government is wrong. All government has to do is make the right rules, empower consumers with money, level the playing field among stakeholders and get out of the way.

We have learned that building bigger and bigger bureaucracies never solves social problems. They make the problems more complicated and more costly to fix.

The British government wants to shift control of the $160 billion annual health budget from its centralized bureaucracy to general practitioners at the local level. Under the plan, $100 billion to $125 billion a year would be provided to general practitioners to make medical decisions for their patients. The general practitioners will be responsible for buying hospital and medical services, medical equipment and pharmaceuticals for their patients.

General practitioners would be transformed into medical contractors. America made that mistake with the gatekeeper concept in the 1980s and 1990s. General practitioners would presumably keep the money not spent on their patients. This would provide general practitioners with the motivation the keep costs down. The government would save $35 billion dollars. General practitioners would make more money. Patients would be shafted even more than they are now.

The N.H.S plans to shifted responsibility for deciding on care needed from central control to the general practitioners. At the same time, the government is decreasing the resources available and restricting their use. It cannot work!!

The British government finally understands the need to eliminate the inefficient central bureaucracies. In the United States, we are going in the opposite direction under Obamacare.

“The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the N.H.S., and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management.”

I believe this is a pipe dream. It will be replaced by other inefficient layers of management.

“Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trusts — all of which would be abolished under the plan, with some of those choices going to patients. It would also abolish many current government-set targets, like limits on how long patients have to wait for treatment.”

President Obama and Dr. Don Berwick have 160 new agencies to administer healthcare care reform for Americans. Will it work? No!

“The British government has promised that the new plan will not affect patient care and that the health care budget will not be cut. But some experts say those assertions are misleading.” “History shows clearly that quality will suffer as a consequence.”

Where is patients’ responsibility for their care and health in the new British healthcare system?

The only thing that will save Britain is to put consumers in control of their own healthcare dollars and medical care. Consumer driven healthcare using ideal medical savings account is the answer. Let patients be their own police officers.

WHEN WILL WE EVER LEARN?

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

People Power!!

Stanley Feld M.D.,FACP,MACE

President Obama had a bad week. He cannot ignore the will of the people forever. Arrogance is catching up to him. People Power is speaking out.

1. The Missouri Vote

“Missouri voters on Tuesday overwhelmingly approved a measure aimed at nullifying the new federal health care law, becoming the first state in the nation where ordinary people made known their dismay over the issue at the ballot box.”

The Missouri voters’ intent was to protest a crucial element of President Obama's health care law, the unconstitutional mandate that forces people to buy healthcare insurance or pay a penalty.

Missouri is a bellwether state in presidential elections. The vote was 71% for and 29% against the referendum. A significant 933,000 plus people voted.

"My constituents told me they felt like their voices had been ignored and they wanted Washington to hear them," Jane Cunningham, a state senator and Republican who had pressed for a vote. "It looks to me like they just picked up a megaphone."

Which state is next?

Arizona and Oklahoma have similar referendums on the November ballot, and Colorado may have one as well.

A Florida proposal was pulled off the November ballot last week by a state judge. The judgment will be challenged.

Idaho, Utah, Virginia, Georgia, and Louisiana already have laws on the books approved by state legislatures opposing the healthcare reform bill. President Obama should listen to the will of the people.

1. Virginia Law Suit

President Obama’s administration had asked the judge, Henry E. Hudson of Federal District Court in Virginia to dismiss the challenge by Virginia’s attorney general, Ken T. Cuccinelli II to his healthcare reform act. Judge Hudson turned down President Obama’s request to dismiss last week.

“Mr. Cuccinelli had argued that Congress, in passing a measure that requires people to buy insurance or face a penalty, exceeded its limits under the Constitution’s Commerce Clause and tax powers. Mr. Cuccinelli had also argued that the federal law violated a state law, the Virginia Health Care Freedom Act, which declares that residents cannot be forced to buy health insurance.”

Virginia is one of 21 states fighting the health care reform law. This is the first ruling by a federal court on the important question of whether states have standing to suit. Judge Hudson felt that the case had merit despite President Obama’s claim that the Virginia could not win on the basis of the interstate commerce clause.

“Judge Hudson wrote that the law “radically changes the landscape of health insurance coverage in America.”

“The case, he wrote, “raises a host of complex constitutional issues”; the notion that the government’s authority could include “the regulation of a person’s decision not to purchase a product” was new to the federal courts, the judge concluded, and so the state’s protest could not be dismissed outright.”

On July 16^th President Obama and his administration sensing, Judge Henry Hudson would rule against the government, changed their argument. The administration now said this provision is not a mandate. It is a tax! Previously, President Obama insisted it was not a tax but a mandate.

The judge’s opinion does not address the merits of the health care law. It might not have a direct effect on the other state challenges. Then again, it might. I do not believe federal judges will bend to President Obama’s administration’s pressure.

The Medicare Chief Actuary Alternative Report: Richard Foster

After the Medicare Trustees Actuary Report was published, Richard Foster the Chief Actuary for Medicare warned “the projections in a Medicare Trustees Report “unreasonable” and “implausible.”

He encouraged everyone to ignore the report and view instead an “Illustrative Alternative” report. He said, “The projections shown in the report do not represent the “best estimate” of actual future Medicare expenditures.”

“Noting that the formal Trustees report assumes Medicare physician fees will be reduced by 30% over the next three years, Chief Actuary Richard Foster says that’s “implausible.” In addition, the Trustees report assumes Medicare fees will fall below Medicaid rates by 2019 and fall further and further behind private payment rates in future years, as the following chart shows:”

In his April 22 report, Richard Foster laid out the implausible aspects of the math. President Obama has used funny arithmetic to get his healthcare reform bill passed and budget neutral. He said;

• Cuts in Medicare spending of $575 billion over the next decade.
• 7½ million members of Medicare Advantage plans to lose their coverage and cause another 7½ million to face higher premiums and benefit cuts.
• About one in seven facilities — hospitals, skilled nursing facilities, home health agencies, and hospices — to become unprofitable and possibly drop out of Medicare altogether.
• Many doctors to quit seeing Medicare patients entirely.

The public no longer believes President Obama and his projections.They understand his motives..

4. The 1099 Repeal Fiasco.

Another of President Obama tricks failed last week. The House succeeded in voting to repeal another ObamaCare mandate. The target was an ObamaCare footnote that could wreak havoc with more than 30 million small businesses.

Nancy Pelosi rigged the vote so that the mandate repeal failed, even though repeal got a majority of votes. The mandate was the 1099 reporting detail snuck in by Democrats. It required companies to track and submit to the IRS all business-to-business transactions exceeding $600 annually.

The Democrats claimed the 1099 clause closed a tax gap that permits unreported income. Speaker Nancy Pelosi was terrified that rank-and-file Democrats would defect. She pulled their entire bill. She then reintroduced the bill a few hours later repealing the 1099 burden but adding additional taxes to the bill. Democrats can now say they voted to repeal the 1099 burden. However, effective tax on small business is unchanged.

Americans are tired of these tricks. Americans are starting to connect the dots. The implications of connected facts reveal that Democrats want centralized control of our lives and freedoms.

People Power can be powerful. The people vote for these congress men and women. People Power is saying you better protect our interests and not your vested interests or we will kick you out of office.

It is important that the people do not get tired of speaking out. People Power can limit President Obama’s policy and his abuse of power.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

I Am Not A Texas Governor Rick Perry Fan But….

Stanley Feld M.D.,FACP,MACE

http://www.nytimes.com/2010/07/28/health/policy/28texas.html?_r=2&th&emc=th

President Obama is ignoring the causes of the dysfunction in the healthcare system. The healthcare debate is supposed to be about setting up a healthcare system that delivers universal care of the highest quality at an affordable cost to consumers and the government.

I believe President Obama’s healthcare reform act is more about increasing government control over the people than it is about improving the delivery of healthcare.

My suggested solutions have been ignored by President Obama. Instead, he has created 160 new agencies and boards with regulatory power. Non-elected public officials appointed by the executive branch of government now have the power to make medical care policy.

The Department of Health and Human Services just published 864 pages of regulations to govern electronic medical records alone. There are many more regulations coming.

Does anyone think these bureaucracies are going to save money, make medical care affordable or universal? The greater the number of regulations the harder they are to execute and enforce. They will make criminals out of people who cannot comply with the maze of complex regulations.

The experts that President Obama has chosen are academicians. They live in the Ivory Tower. They do not live in the trenches and experience the problems of running a day to day medical practice. These experts (Dr. Don Berwick) believe central control of the healthcare system is essential. “The healthcare system is too complex for individuals to be responsible for their care and make intelligent decisions.”

I believe government has to make rules to level the playing field for all the stakeholders. Then it should let the stakeholders operate in the free market system. The central government should not control the stakeholders after the rules are made.

The healthcare debate is bizarre. Instead of fixing the defects in the healthcare system, like tort reform, the lack of individual responsibility for healthcare dollars, health, medical care, the lack of support to educate patients to self-management chronic diseases and lack of public service campaigns to combat obesity, the executive branch has taken total control of the dysfunctional healthcare payment system. The healthcare reform act does not have respect for individuals’ freedom to choose or their ability to be responsible for themselves.

The multiple bureaucracies are making it impossible for congress to have input into the healthcare law. What we central executive branch control without checks and balances.

The frightening thing about it is President Obama was able to force the healthcare reform bill through congress using all sorts of tricks and deals. It does not represent the will of the people. Nancy Pelosi and Harry Reid simply emasculated congress’ power.

I hope the American people realize what has happened. Americans still have the power to vote and demand the constitution be defended.

Texas Governor Rick Perry threatened to have Texas secede from the Union because the healthcare reform bill is unconstitutional. I hope he was a joking. He has vigorously opposed the healthcare law. He is concerned about the devastating effect it will have on the Texas economy, the citizens of Texas and the ability of the state to attract new industry and job growth.

Texas is America’s Top State for Business, according to a CNBC study that scored each state based on 40 different measures of competitiveness. The reason is Texas has maintained a free market economy in a fiscally responsible way. We do not have a state tax yet and our property taxes have been reasonable.

Governor Rick Perry has been vocal about what is being imposed on Texas by the federal government. I applaud him. I have included some of his recent statements

“This designation reinforces the fact that the Lone Star State is the best state in the nation to live, work and raise a family thanks to our low taxes, reasonable and predictable regulations and skilled workforce,” Gov. Perry said. “These policies have helped keep our economy comparatively strong through the national economic downturn, and will continue to make us globally competitive in the future.”

The federal government is going to change that by imposing a huge burden on the state to fund Medicaid for many new required recipients .

There are more uninsured residents of Texas — 6.1 million and counting — than there are people in 33 states. The state’s elected officials might be expected, therefore, to cheer a federal health care law that is likely to deliver billions of dollars from Washington to Austin and cover millions of low-income Texans.

“But leaders in Austin are focused on the fiscal threat it poses, which they estimate could cost the state $27 billion in the 10 years beginning in 2014.”

Governor Perry said it all in a few paragraphs. However, he did not mention that some favored states will receive a higher federal subsidy for Medicaid that others. This fact is demonstrated in the figure below.

The figure reflects increase in Medicaid eligible population and the relative difference in subsidies of various states reflecting the deals President Obama made with various State’s Senators to vote for his bill. “click to enlarge”

"Unfortunately, the health care vote had more to do with expanding socialism on American soil than it does fixing our health care finance and delivery systems. The Obama health care bill undermines patient choice, personal responsibility, medical innovation, and fiscal responsibility in America.”

"As passed by the U.S. House, the bill will cost Texas taxpayers billions more, and drive our nation much deeper into debt. Congress's backroom deals and parliamentary maneuvers undermined the public trust and increased cynicism in our political process.”

I never thought Rick Perry was much of a leader. However, his recently demonstrated leadership might get him elected for a fourth term.

"Texas leaders will continue to do everything in our power to fight this federal excess and find ways to protect our families, taxpayers, and medical providers from this gross federal overreach."

Twenty one states are suing President Obama on the constitutionality of his healthcare law. One of the attorneys general said,

“You can say a chicken in every pot, a car in every garage and health care for all, if taken in isolation,” said “But none of those are good things if it requires breaking the Constitution and breaking the bank to do it.”

I believe the bill will fail to achieve its goals. Massachusetts’ healthcare reform has failed. President Obama is making the same mistakes. He is not getting at the core of the problems causing the dysfunctional healthcare system. The healthcare reform law will make the healthcare system worse.

Hooray for Governor Rick Perry for defending Texas and the citizens of Texas.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Physicians, Expect More Grief From Obamacare

 

Stanley Feld M.D.,FACP,MACE

Physicians might not now understand the exact implications of President Obama’s healthcare reform act. The impact will be terrible for physicians and their patients.

“The act will reinforce the worst features of existing third-party payment arrangements in both the private and public sectors — arrangements that already compromise the professional independence and integrity of the medical profession.”

I am writing this for both patients and physicians. Both must increase their understanding of the provisions of President Obama’s healthcare reform law. The law will decrease, not increase, physicians’ ability to deliver care.

1. Physicians will find themselves subject to more, not less, government regulation and oversight.

1. Physicians will become increasingly dependent on unreliable government reimbursement for medical services.

1. Medicare and Medicaid payment, including irrational government payment updates, are preserved but expanded to larger portions of the population. Limited federal funding will result in lower reimbursement to physicians.

1. President Obama’s healthcare law will create numerous bureaucratic agencies. These not elected agencies the authority to dictate health benefits, and medical treatments.
2. Physicians will not receive serious tort reform relief. This is a major problem in the current system. There are no provisions in the law to compensate for the liability expenses.

1. Physician surveys reveal deep dissatisfaction and demoralization among medical professionals as illustrated in my blog entitled the Vanishing Oath. I predict the dissatisfaction will intensify.

Eighteen million people are expected to gain healthcare coverage through Medicaid in the next ten years. Medicaid is partly funded by the federal government and the individual states. Medicaid is administered by individual states. States outsource administrative services to the healthcare insurance industry. The federal government decides on the percentage of funding it provides to each state. Different states get different levels of funding according to the deals state representative make with the federal government.

Some might recall the fuss when Sen. Ben Nelson of Nebraska received full funding for Nebraska in return for his support of President Obama’s healthcare bill.

There are many problems with increasing the Medicaid burden on the states.

1. States are broke. The cumulative amount is $3.1 trillion dollars in unfunded liabilities. There is a $55 billion dollar collective gap between states’ income and obligations next year.
2. Some states have more people who will qualify for Medicaid than others.
3. States will have to raise local taxes on the middle class.
4. Medicaid reimbursement is lower than physicians’ costs to provide the service.
5. Many physicians do not accept Medicaid patients, creating a work force shortage.

Medicaid reimbursement is 56% of private insurance reimbursement. Medicare pays 81% of private reimbursement. However, private insurance reimburses 60% of physicians’ billings. Therefore, Medicaid pays 33.6% of the billed rate and Medicare pays 48% of the billed rate. Clearly, it is better for physicians not to accept Medicare, Medicaid or private insurance.

Reimbursement for Medicare and Medicaid services will be lowered further by President Obama’s healthcare reform act. The government cannot afford to increase reimbursement.

Medicare physician payment is annually updated on the basis of a defective Sustainable Growth Rate (SGR) formula.

The SGR cumulative reduction has been delayed until November 30th. Medicare reimbursement will be reduced by 21.3% percent on December 1st. The impact on the physician workforce is not difficult to imagine.

Rather than Repairing the Healthcare System, President Obama is moving forward in destroying the healthcare system.

Instead of trying to fix the unaffordable government entitlements and making them affordable with satisfied stakeholders, President Obama is expanding the entitlements and making them more unaffordable to patients and the government.

President Obama’s problem is the continuation of the negative elements in the healthcare system.

“Today there is sporadic access issues for patients in Medicare, and major access problems for patients in Medicaid.”

What is going to happen when the entitlement is expanded?

President Obama’s healthcare law does not change the general pattern of the government's systems of physician payment. It increases government control over physicians and adds layers of bureaucracy and regulatory restrictions to the delivery of medical care.

Three new bureaucratic agencies are created and have a direct impact on physicians and the practice of medicine.

1. Patient-Centered Outcomes Research Institute. The Institute will be financed through a Patient Centered Outcomes Research Trust Fund. By 2013, the fund will receive $150 million dollars a year from the government. Its mission will be to examine clinical effectiveness of medical treatment, procedures, drugs, and medical devices (Dr. Donald Berwick.) Just imagine the amount of government control this organization with have on a physician’s medical decision making ability.

1. The Independent Payment Advisory Board. Its goal is to reduce the per capita growth rate in Medicare spending. It will be a 15 member board appointed by President Obama. Its recommendations will be passed on to the CMS director. This is where rationing of care begins (Dr. Don Berwick). This Board increases the power of the executive branch and weakens congressional power.

1. The Physician Quality Reporting Initiative. Its goal will be to focus on the quality of medical care delivered to Medicare beneficiaries. I have not seen an appropriate definition of quality medical care. The initiative will institute rules and regulations. These rules and regulations will be time consuming to physicians and distract from patient care. This Board will try to develop pay for performance rules. Pay for Performance will not work for all of the reasons I discussed earlier. Government bureaucrats are good at making rules and regulations. The rule may be inefficient and ineffective. The government has not been proven efficient at implementation and enforcement.

President Obama should be constructing a healthcare system that eliminates the defects in the present system.

President Obama is disregarding consumers’ power and intelligence. If he created a system in which every consumer was responsible for his own healthcare dollars and his own health, he would be creating a system that would work for patients, physicians and the government. The healthcare insurance industry would have less expense and make less profit.

Instead, he is creating a system that is going to make everyone unhappy.

There is more grief ahead.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

A Doctor's Vanishing Dream

Stanley Feld M.D.,FACP,MACE

The healthcare system is dysfunctional. All the stakeholders are to blame. President Obama’s healthcare reform act is going increase this dysfunction because the healthcare reform act does not solve the basic problems in the healthcare system.

For many physicians, the realities of our health care system have led to an inevitable conclusion. In order to survive, physicians must abandon the very ideals that drove them to become physicians.

The problems that will not be solved but will be intensified under Obamacare are the complexity of billing codes, the threat of malpractice, the frustration of not having the time to relate to patients effectively and the burden of the administrative bureaucracy (paper work). Patients have been conditioned to be suspicious of physicians’ skills and motives. Physicians have become suspicious of their patients.

Ryan Flesher, MD an emergency room physician directed and produced a documentary, “The Vanishing Oath” with Nancy Pand. The dysfunction of the healthcare system is described from an emergency physician’s perspective.

It is the story of a physician’s disillusionment with his life’s dream and profession. It is the story of his discovery that many physicians feel the same way. It is a story of emotional exhaustion.

“Dr. Flesher's story is about himself, and also other physicians caught in the whirlwind of the healthcare system, their day-to-day exhaustion, and unhappiness woven in a tightening bureaucratic vice.”

He describes becoming increasingly unhappy in a system that seemed to unravel and become "critically wounded.” Doctors are bailing out of their chosen profession because they are not able to have enough time for their patients or themselves.

“Flesher hated being a physician in a manner that he says the system demands. “It was just pretty frustrating," he says. "Since I was young, I focused on becoming a doctor." Over time, as he grew more unhappy, " I began asking myself, 'what's wrong with me, why am I so unhappy?”

It was therapeutic for him to make this film. It was sad for him to see physicians weep with despair over their profession. Physicians were frustrated that they could not understand their patients’ illness beyond what their charts tell them. The time allotted to each patient has been truncated.

Medical care is an art as well as a science. Most physicians believe in order to be therapeutically effective there is more art than science in the patient physician relationship.

President Obama’s healthcare bill and Dr. Berwick’s philosophy assumes that medical care can be commoditized. They are wrong. They are going to destroy the physician workforce. The result will be many unintended consequences with a restriction of access to care and rationing of care.

These unintended consequences are already occurring in the dysfunctional healthcare system. President Obama’s healthcare reform act does nothing to correct the dysfunction which will only intensify.

"We're just jammed, ambulances everywhere, beds full, I'm carrying 16 or 17 patients of my own, pretty sick," Flesher says in the documentary. "Before I go three steps, I'm confronted with the billing agent for the ER who says we can't get paid because my charts — eight of nine — required review assistance components. Two, I'm confronted by the service rep for the hospital (who says) my patient satisfactory scores are only 93% - we've got to be above 96."

"The CEO says we are getting backed up (in the emergency room), and we need to get patients through the ER quicker," he adds. "The Joint Commission rep says she caught me drinking (soda) three feet too close to the patient care area and she's going to cite me for—whatever. I didn't even see a patient yet and my mind is already clouded."

It reminds me of the funny bit done in the 1960s.

“My name is Jose Jiménez. Jose said, “How would you like to be the monkey that presses the button and puts the scientist into space?”

The healthcare system is sick and getting sicker. The losers will be patients, physicians, and taxpayers. The winners will be the government bureaucrats and the healthcare insurance industry.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.