Physician Voice

Senate Vote Paves the way to SGR Reform

2010-02-01T18:29:00.002-05:00

From AMA Advocacy Update:

On January 28, the Senate passed H.J. Res. 45, a resolution to raise the federal debt limit along with several limited exemptions to the PAYGO rule. This includes exception for addressing the Medicare physician payment cuts about to be produced by the sustainable growth rate (SGR) formula.

This action means that up to $82 billion spent for an SGR fix would not have to be offset by other revenue or cuts. This amount could fund a five-year freeze. Thus, some have characterized the SGR exemption as a five-year freeze.

The House is expected to take up and pass H.J. Res. 45 this week. Congress must still enact separate legislation to stop the SGR cuts prior to March 1.

To obtain permanent repeal of the flawed payment formula, the PAYGO exception must be accompanied by an additional $130 billion in budget offsets.

AMA position: The AMA continues to insist that Congress pass legislation to permanently repeal the SGR.

Health Care: Too Big To Fail?

2010-01-31T10:26:00.005-05:00

Paul Volker wrote in the New York Times today of 'the implication that really large, complex and highly interconnected .... institutions can count on public support at critical times'. He refers, of course, to the financial sector.

Are there parallel lessons that apply to the health care sector (and to health system reform)? Certainly the health care sector, as well, is 'too big to fail.'

Leadership? MIA for Now

2010-01-22T08:18:00.003-05:00

President Obama indicated that he might be willing to scale back his proposed health care overhaul to a version without provision for near-universal insurance coverage. Speaker Pelosi says the House wants 'comprehensive reform' and (thankfully) won't pass the flawed Senate bill.

While Massachusetts enjoys the lowest percent of population without coverage (about 5%) and Texas enjoys the highest (about 25%), Californians now talk of reintroducing universal single payer legislation in order to eventually save money.

While White House officials and Democratic Congressional leaders still struggle to find a viable way forward for the health care bill, your blog-masters ask, "Where is the national leadership here"?

Everyone seems to agree that some reform is needed. But nobody needs a compromise for sellouts and lobbyists. What about true leadership, and what about a physician voice?

Assumptions and Guesswork

2009-12-27T16:38:00.005-05:00

A New York Times editorial outlines and opines on the differences between the House and Senate HSR legislation. Their opinion is wrong on two provisions that affect physicians:

They note that the House bill relies heavily on Medicare pilot projects to determine which approaches to restraining medical costs might work best. The Senate bill would, instead, empower an independent board to carry out 'successful reforms broadly within Medicare and recommend changes in private programs'.

The Times prefers the Senate bill because the House bill lacks a strong mechanism, like an independent board, to drive successful reforms into widespread use.

The Times incorrectly characterizes this board as a 'crucial cost-control mechanism'. This opinion is misguided because we've essentially been doing this for the past 30 years - only we've called it managed care.

Simply granting an 'independent board' authority is insufficient. After all, Medicare pilot projects have been ongoing for more than ten years! Sustainable, effective cost control will require integrative strategies and they'll need to be physician based. Physicians are truly the only entity, once empowered, that can initiate and sustain cost containing/integrative reforms.

The House Bill provides for the paying of primary-care doctors the same (amount) that Medicare pays.

The assertion that this would make it more likely that poor patients could find a doctor is spurious - inadequate reimbursement, albeit more generous, would still be inadequate. Just look at the access problems faced by (and those that threaten) the Medicare population currently.

Journalists and elected officials could better serve their clients were they to consider the vast experience of the provider community when they prepare their opinions. Some folks would refer to that as 'evidence based.' As in industry, a quality health care initiative (like the principles of six sigma) , ought to be driven by a commitment to making decisions on the basis of verifiable data rather than mere assumptions and guesswork.

AMA and House-Senate Conference Committee

2009-12-24T17:31:00.004-05:00

SP wrote that he had been ambivalent and confused about recent ama performance. But upon reading the ama hsr bulletin, he has decided to remit his ama dues. Below is an excerpt from that bulletin that clarifies ama position on the upcoming House-Senate Conference Committee, the committee that will craft the final hsr bill for the president to enact.

"The AMA has made it clear to senior White House staff, the Senate leadership and the House leadership that its support for a House-Senate conference agreement is contingent upon:

Movement on a clear pathway for passage of legislation to permanently repeal the SGR by the end of February
Modifications of the proposed Independent Payment Advisory Board
Refinements of the quality improvement and Medicare data release provisions
No new major problematic provisions surfacing in conference

While there were some earlier reports about efforts to circumvent the House-Senate conference committee process, recent statements from the House leadership indicate that the House will not take the Senate bill as is or with minor changes. As noted earlier, the House bill does not include an Independent Payment Advisory Board, and 53 House members signed a letter objecting to that concept.

The AMA's strategy of constructively working for changes at each stage of the process has put it in a position to have significant influence in the House-Senate conference committee negotiations. The AMA retains the ability to withhold support for a conference committee agreement if it fails to achieve our priority objectives.

We still have not seen the final bill that the president hopes to sign into law. The AMA will be actively engaged throughout the conference committee negotiations to positively influence the key issues for medicine."

No Caps Because 'The Lawyer Has to be Paid'

2009-12-21T02:47:00.001-05:00

Last summer, Tom Baker, professor of law and health sciences at the University of Pennsylvania School of Law and author of “The Medical Malpractice Myth,” was interviewed by a free lance author for a piece (published in the new york times blog) on medical liability.

He believes that making the legal system less receptive to medical malpractice lawsuits will not significantly affect the costs of medical care (because he measures the cost of liability as a percent of total health spending, yet he ignores that the burden falls disproportionately upon physicians). He acknowledges that:

"The medical malpractice system only works for serious injuries...
Lawyers discourage people from bringing suits if their injuries are not serious in monetary terms — a poor person or an older person who can’t claim a lot in lost wages ...
Gerontologists’ premiums are exceedingly low."

Still, he opposes caps on pain and suffering because (in states with caps) a plaintiff gets reimbursement of medical costs in principle... "(but) in fact, they don’t, because the lawyer has to be paid. These cases can cost $100,000 to $150,000 to bring, so the patient has to deduct that amount from any award. I’ve had lawyers tell me they would not take a case ... even if it’s a slam-dunk. The damages wouldn’t be enough."

So why is congress afraid to remove the lawyers from the equation - and allow a reliable system of justice that compensates victims better and at less cost to the health care system?

Senators to be Pilloried

2009-12-18T07:52:00.003-05:00

In the NY Times are two columns (link to a, link to b) suggesting that passing the Senate Health care Bill is worthwhile, despite its shortcomings. The shortcomings of the bill highlight the shortcomings of our political process.

In 'column a' David Brooks asks if the bill will "put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely"? He worries that "it will slow innovation. (Because) Government regulators don’t do well with disruptive new technologies ... (and) We’ll shovel more money into insurance companies". Yet his worries about the costs could easily be addressed (and the cost curve bent) if only the reformers would shovel less money to the insurance industry and instead give doctors the incentive to innovate - remember Gawande's accountable care organizations.

And we don't need new demonstration projects. Here in the downstate New York region, a hospital network clinically integrated (a huge hurdle were it a physician network) then emerged, to the consternation of the payers, as the low cost health care provider in its region!

In 'column b", Paul Krugman describes some Senators as "motivated largely by a desire to protect the interests of insurance companies."

Protection of the insurance companies is anti consumer - it is the enemy of physicians, patient interests and meaningful health care reform. Those Senators, and their bill should be pilloried.

Choice Worth Fighting For?

2009-12-17T05:00:00.001-05:00

According to the WSJ, Aetna Inc. spent less money on patient care for some small businesses than it originally reported. The Senate Committee on Commerce, Science and Transportation said Aetna overstated by $4.9 billion the amount of money it spent on patient care for small businesses. Aetna said the error was a simple mistake.

Last month, the committee chastised Cigna Corp. for mislabelling $5 billion in premiums.

Sen Lieberman and the Health Insurance Industry

2009-12-16T08:10:00.003-05:00

Mr. Lieberman now opposes both public option and early medicare buy-in, a change in position the senate majority leader has described as 'vexing'.

According to the WSJ, senate aides recalled a September interview with the Connecticut Post, in which Mr. Lieberman suggested giving people 55 and older "an option to buy into Medicare early."

The NY Times noted that Mr. Lieberman has taken more than $1 million from the industry over his Senate career. He ranked second in the Senate in contributions from the industry in 2006.

While he does seem to recall the industry contributions, what has become of his 'commitment' to health care reform?

Its Not Health Care Reform If the Doctor is Not In

2009-12-12T17:46:00.003-05:00

Centrist senators raised concerns about a major new element of the (senate) legislation, ... (that to) expand Medicare to cover some people ages 55 to 64.

Senator Olympia J. Snowe, Republican of Maine, said Democrats were moving to expand Medicare “without really understanding the ramifications ... I just don’t think it’s a policy we should embrace.”

This comment from US Senator George LeMieux (R-FL), 'It's not health care reform if the doctor is not in' begs that most important question yet to be considered.

Oxford Expands Fee Schedule to Non-Par Physicians - 'Free' Market?

2009-12-08T23:32:00.005-05:00

Oxford has notified several New York physicians of a change from 'charge-based' insurance reimbursement (including the fraudulent UCR) to 'fee-schedule' based out of network reimbursement.

According to the notification, out of network reimbursement will be limited to an amount of 140% of the published medicare reimbursement amount.

We first learned about the program, as applied to physicians, in an article which appeared in MSSNY News of New York, October 2009. In the article, Sanford P. Cohen, Chief Regional Medical Officer, UnitedHealthcare explained that the MNRP payment would be an option that could be elected by an employer. Cohen said that it 'will be based on 110% of the current year payments stipulated for Medicare patients by the Center for Medicare & Medicaid Services (CMS)'.

The schedule-based MNRP program was implemented in New Jersey in January 2009. At the time it applied to Hospitals (inpatient and outpatient), Free-standing ambulatory surgery centers, Free-standing radiology centers, and Free-standing laboratories.

Among the stated goals of the program is the promotion of provider participation and consumer choice. But this is a dangerous and anti-competitive precedent. If allowed, this program:

Harms Physicians - it further reduces a plan's incentive to negotiate with participating physicians, as an insurer's exposure is limited, irrespective of whether a physician is in network or out of network.
Harms Consumers/Patients - it strips much of the value from an out of network benefit, a benefit that 70% of insureds currently pay extra premium for.

Link to Oxford Materials:

Freshman Amendment to Senate Bill - Draft

2009-12-06T14:31:00.005-05:00

A group of freshman democrat senators have crafted a proposal to contain costs in the senate bill (PPACA). The proposal would allow an array of pilot projects aimed at cutting medical costs to be expanded more rapidly if there is evidence that they are successful in reducing expenses.

on administrative simplification they offer:

"Health Care Fraud Enforcement: We direct HHS to utilize technology to prevent fraudulent, abusive or improper payments prior to payment of claims".

as a physician, the legislation seems abundant in its focus on preventing payments - i would seek something that might enable us to be paid.

"Eliminating Legal Barriers to Care Improvement: We would require GAO to study current law and regulation to identify barriers that may impede providers’ ability to improve the quality of care and the ability to aggressively implement the innovative delivery system reforms PPACA makes possible".

this would be helpful, particularly if it results in relaxation of antitrust barriers to collaboration, accountable care organizations, and gainsharing. But shouldn't this be studied prior to health care reform?

Mostly, not unlike their senior colleagues, the freshmen have trouble unleashing the potential harnessed by the physicians.

Grand Bargain no Great Deal

2009-12-04T08:06:00.004-05:00

Economist Paul Krugman describes health care reform as a 'Grand Bargain', "coverage for (almost) everyone, tied to an effort to ensure that health care dollars are well spent."

He continues that well respected economists "are seriously impressed by the cost-control measures in the Senate bill, which include efforts to improve incentives for cost-effective care, the use of medical research to guide doctors toward treatments that actually work, and more ... 'the best effort anyone has made'...”

If Krugman senses a bargain, he's no horse trader. While economists may be 'seriously impressed', physicians (Gawande, Jauhar) know that meaningful and sustainable cost containment can result only from innovation - physician driven, physician centered innovation.

The 'medicare commission' is inadequate for the task and the current antitrust environment presents a hurdle barely addressed in the proposed legislation.

"Share the Savings ... See Them Grow" - Sandeep Jauhar, MD

2009-12-01T22:34:00.005-05:00

In a New York Times essay, Sandeep Jauhar, MD responds to the CMS plan to award bonuses to hospitals that lower readmission rates. He believes that, instead, some of that money should be shared with doctors.

"Current law prohibits hospitals from paying doctors for reducing hospital services, even if the goal is to provide more efficient care. But such “gainsharing” will align doctors’ incentives with broader cost-cutting goals.

Our system needs to provide inducements to decrease the amount of health care ... especially (to counter) ... the current incentives that encourage (un-coordinated care and) rampant over-utilization".

His conclusion could not be better stated, "Unless doctors view cost-cutting goals as their own, policy makers don’t stand a chance of achieving them".

Link to other Sandeep Jauhar, MD Articles

Link to Essay

Costs to Increase Under COBRA

2009-11-28T09:24:00.003-05:00

7 million unemployed Americans, laid off or downsized between Sept. 1, 2008, and Dec. 31, 2009, get a federal subsidy to help them buy health insurance under legislation known as the Consolidated Omnibus Budget Reconciliation Act. The COBRA subsidy pays 65 percent of their job-based health insurance premiums for nine months.

According to the Kaiser Family Foundation job-based coverage averages $398 per month for families and $144 for individuals, with the subsidy. Without it, premiums average $1,137 for a family and $410 for an individual.

That subsidy expires Monday (11.30.09) for thousands who began receiving it in March, when it first became available as part of the American Recovery and Reinvestment Act.

Before the subsidy was offered, only about 9 percent of people who were eligible for coverage under COBRA took advantage of it because it was so expensive. An analysis found that COBRA enrollment had doubled since the subsidy became available.

But industries with large job losses showed greater increases. Enrollment among industrial manufacturing workers went from 7 percent to 59 percent, while enrollment tripled among construction, leisure and retail workers.

It remains unclear when or whether Congress will address the subsidy expiration with specific legislation or as part of a major jobs bill.

Obama's 4 Pillars - Can He Deal With a Tripod?

2009-11-25T21:49:00.004-05:00

According to the NYTimes, "In a conference call with reporters Wednesday to highlight cost-containment provisions, the two senior presidential advisers, Peter R. Orszag, White House budget director, andNancy-Ann DeParle, director of health reform, cited a letter to Mr. Obama by a group of respected economists who strongly endorsed the (independent) Medicare commission ... which some House leaders view as encroachment on Congressional authority over Medicare."

Obama said of the commission, it "can help encourage the adoption of these common-sense best practices by doctors and medical professionals throughout the system — everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.”

Physicianvoice asks, wouldn't anti trust relief, such as limiting the hurdles for clinical integration and accountable care groups encourage better coordination - only better?

The Boobs at the The U.S. Preventive Services Task Force

2009-11-20T07:58:00.003-05:00

This week the The U.S. Preventive Services Task Force (USPSTF) released recommendations concerning breast cancer screening that seem stunning.

Among the recommendations is that against routine screening of those age 40-49. Your moderators are generally supportive of the concept of evidence based medicine, when the evidence considered is sufficiently broad. The task force recommendation is limited in that:

it is based on mortality and longevity data alone, ignoring other positive medical outcomes
it seems biased by the comparatively larger number of screens necessary to save a life, without considering the comparatively larger economic value of saving that younger life
it is absolute in its recommendation. The panel could have, instead, recommended less frequent screens in the 40-49 year olds had they created a decision tree that considers the results of an initial screen (this would preserve the existence of a baseline exam, which itself may impact the survival data of those age 50 and up). This action could reduce the number of exams required, under age 50, yet still save the same number of lives as the current protocol does
It ignores a wealth of unpublished clinical experience
it fails to consider the recommendations of several specialty societies (themselves experts in the field)
etc

The HHS Secretary Sebelius then made a statement reflecting her view that this report would not impact upon third party payment decisions. In doing so, she injected this action of the USPSTF into the health care reform discourse.

Basic Needs of Physicians Must Come First

2009-11-17T08:52:00.000-05:00

Concerned physicians (both those who do and those who do not oppose the AMA strategy on Health Care Reform) have asked, "Is the AMA ready to 'walk away from the table' IF the 'onerous provisions' remain in the final Senate version?"

AND IF the SGR is not eliminated without the substitution of another financial nightmare...
AND IF tort reform remains a mere promise...
AND IF collective negotiations remain a pipe dream?

PM writes "The basic needs of physicians MUST come first, (for only) then we can help those that desperately need our help to keep them well.

We are not public servants. We are healers that put our patients' welfare before our own personal needs. This time we must look out for us first. We cannot afford to settle for less (because it is politically correct) and hope to change 'onerous provisions' after the fact."

The Hypocrisy of Deficit Reduction & Health Care

2009-11-15T11:30:00.004-05:00

Daniel Gross, in a recent Newsweek column, describes the hypocrisy of those who loathe " deficit spending for the purpose of funding social insurance, but love it when it's used to finance military actions abroad".

Too often, "deficit reduction is a form of defense—... a shield for policies ... (that legislators) don't like," according to Maya -MacGuineas, president of the bipartisan Committee for a Responsible Federal Budget.

Hospital Associations and State Medical Societies alike have attempted to quantify the economic impact of health care. But the chart above, from the Bureau of Labor Statistics, suggests the importance of the health care sector on employment. In these times of high unemployment and debate on health care reform, the importance of health care as an employer should not be underestimated.

Gross concludes, "Being obsessed with deficit reduction when the economy has suffered its largest setback since the Depression is like being obsessed with water conservation when your house is on fire."

Can't We Pick One from Column A and One From Column B?

2009-11-06T08:18:00.004-05:00

The Republican bill leaves out a number of the key features of the Democrats' legislation (and thus does too little to alleviate the problem of the uninsured):

It does not require employers to insure their employees
It does not require nearly all Americans to purchase insurance
It does not block insurers from denying coverage to people with pre-existinghealth conditions

Instead, the Republican plan

increases incentives for people to use health savings accounts,
caps non-economic jury awards in medical malpractice cases at $250,000,
provides various incentives to states with the aim of driving down premium costs and
allows health insurance to be sold across state lines.

Link to Boehner Bill (Med Mal pp 150-169)

Universal Coverage and Life Expectancy

2009-11-05T07:37:00.003-05:00

From Nicholas Kristof in the NYTimes:

"The United States ranks 31st in life expectancy (tied with Kuwait and Chile), according to the latest World Health Organization figures .... (but) there is one American health statistic that is strikingly above average: life expectancy for Americans who have already reached the age of 65.

At that point, they can expect to live longer than the average in industrialized countries. That’s because Americans above age 65 actually have universal health care coverage: Medicare".

Enough Talk About Deficits, Will I be able to Afford the Premium?

2009-11-01T16:03:00.005-05:00

Health Care Reform has become a debate politicized well beyond, in your administrators view, the overriding objectives of

health care for all and
the sustainability of the system

The CBO has prepared estimates of the costs to the nation of health care reform under various congressional proposals, and has even estimated the further savings that can be achieved by including provisions such as liability reform into these proposals.

But there seems to be considerably less consideration paid to the affordability of premium. This is despite the fact that the ranks of the uninsured are populated by people simply unable to afford insurance. A mandate alone will not make the premium any less of an individual hardship.

Even if premium (and the proposed subsidy) is 'affordable', there is concern that pending legislation offers insufficient protection against the high payments required to meet deductibles, co-payments, and other out-of-pocket charges.

There is concern that some families would have to strain to pay their premiums and would probably have to cut back on such items as clothing, various household expenses, meals eaten out, and other activities. Additionally, their plight could worsen in coming years as premium would rise faster than wages.

It would be shameful that if due to poor planning and poor politics the under-insured became the under-clothed and the under-nourished as well.

'Consumer Option' to have Negotiated Rates

2009-10-28T23:35:00.004-04:00

According to the NYTimes, Speaker Nancy Pelosi has decided to propose a government-run insurance plan that would negotiate rates with doctors and hospitals, rather than using prices set by the government.

Ms. Pelosi said the public plan, which she prefers to call a “consumer option,” would compete with private insurers.

Members of the House Democratic leadership team offered these details of their bill, to be unveiled on Thursday.

It would provide coverage to 35 million or 36 million people.
The 10-year cost of expanding coverage would be less than the $900 billion ceiling suggested by President Obama.
The cost would be offset by new taxes and by cutbacks in Medicare, so would not increase the federal budget deficit in the next 10 years or in the decade after that.
The new bill retains a surtax on high-income people, but increases the thresholds to hit married couples with adjusted gross incomes exceeding $1 million a year and individuals over $500,000

Link to article

Small Business Premiums Double Last Years Increases!

2009-10-28T04:42:00.000-04:00

Insurance brokers and benefits consultants say their small business clients are seeing premiums go up an average of about 15 percent for the coming year — double the rate of last year’s increases. That would mean an annual premium that was $4,500 per employee in 2008 and $4,800 this year would rise to $5,500 in 2010.

Some experts ... think the insurance industry, under pressure from Wall Street, is raising premiums to get ahead of any legislative changes that might reduce their profits... Small businesses ... employ about 40 percent of the private labor force.

Owners of small companies say the lack of options is why they have been paying increasingly higher premiums for less and less coverage — this year perhaps more than ever.

NYTimes Article

Ingenix Replacement Announced - Unfair (Insurance Company) Practice Reversed

2009-10-27T15:35:00.006-04:00

New York State Attorney General Andrew Cuomo announced the establishment of an independent database for consumer health care reimbursement and a consumer website. Cuomo said that, previously, industry data was skewed to show lower health care costs so insurers could underpay for out-of-network services.

Mr. Cuomo, acting upon concerns raised by the AMA and MSSNY, achieved settlements with the major insurers to replace the flawed Ingenix database with a new database. This will be developed by Fair Health Inc. and an upstate research network headquartered at Syracuse University. Funding is from the Cuomo settlements.

Cuomo stated that this will bring much needed transparency, accountability and fairness ... to a broken system. According to the Cuomo press release, this announcement arises from a wide-ranging investigation which uncovered 'a fraudulent and conflict of interest ridden system'.

Link to WSJ

Link to LIBN

Link to Attny General Cuomo's statement

United Health's Better Than Expected 3Q Earnings

2009-10-21T08:20:00.002-04:00

Mr. Hemsley, the United CEO, said, ... that ... Ingenix -- a health-care data and consulting operation (and home of the fraudulent database) -- will be the company's widest-margin business in 2010.

Link to WSJ Article

SGR is not a Problem of the Uninsured

2009-10-19T08:15:00.003-04:00

On a NY Times blog was this entry regarding the politics of S 1776:

'(Providing an SGR fix), ... in legislation separate from the big health care overhaul, is raising uncomfortable questions for President Obama and for Democratic leaders in Congress ...

(This is so, because they) promised that revamping the health care system would not add to the nation’s deficits.'

Physicians recognize that the flawed SGR, and Congress's repeated 'patches' over the years, are essentially a 'loan'. Repayment of this loan, which itself derives from flawed budget legislation from 1997, does not in any way redress the current health care system problems of the uninsured and of expanding access. It would thus be illogical to consider this cost in the same breath as true Health System Reform.

Senate Bill on SGR

2009-10-15T22:19:00.003-04:00

Repealing the SGR is one policy objective that is a common goal of all physicians. The Stabenow bill, S. 1776, the “Medicare Physicians Fairness Act of 2009,” creates the pathway to achieve that goal. Call (888) 434-6200 toll free to leave a message for your senator.

S. 1776 will:

serve as the Senate legislative vehicle for eliminating Medicare’s sustainable growth rate (SGR) formula and
lays the foundation for establishing a new Medicare physician payment update system.

The procedural path for passing S. 1776 will be complicated, requiring the support of 60 Senators on several procedural motions over the next few days.

S. 1776 will be the subject of a cloture vote on late Monday afternoon (Oct 19). 60 votes are needed to invoke cloture to allow formal consideration of the bill.

A vote on final passage is expected to occur next Thursday (Oct 22) or Friday ( Oct 23).

Harry Reid, the Senate Majority Leader, Sen. Baucus, Chairman of the Senate Finance Committee, and Sen. Chris Dodd, along with President Obama all strongly support passage of S. 1776.

Again, call (888) 434-6200 toll free to leave a message for your senator. Keep the momentum going.

Health Plans Strike Back

2009-10-12T10:34:00.006-04:00

America's Health Insurance Plans engaged PricewaterhouseCoopers to examine the impact of four components of the health reform bill being proposed by the Senate Finance Committee. The report, on behalf of the insurers, will assert that under four of the provisions of the senate finance bill, health premiums will rise faster than they would under the current system.

According to the PricewaterhouseCoopers report, there are four provisions included in the Senate Finance Committee proposal that could increase private health insurance premiums above the levels projected under current law:

o Insurance market reforms coupled with a weak coverage requirement,

o A new tax on high-cost health care plans,

o Cost-shifting as a result of cuts to Medicare, and

o New taxes on several health care sectors.

The flaw in this analysis results from the failure to consider the impact of each of the four provisions independently. For example, the 'weak coverage requirement' of the senate bill alone is identified as promoting adverse selection for the health plans. This is the basis of much of the bill's impact upon premium. The report fails to project the impact upon premium should this 'weakness' be eliminated.

Additionally, the report is limited in that it examined just the four provisions considered likely to increase costs. No consideration is given to the beneficial effect on premiums of other provisions of the bill such as health exchanges or the public option (not contained in the senate bill) that would likely result in premium reduction.

The States and Health Care Reform

2009-10-10T11:45:00.005-04:00

A new compromise proposal by Sen. Tom Carper would spell out how to boost competition in the private market by enacting government-run plans at the state level.

Under the proposal, in its current form, each state would have the option to:

1) Participate as grantees in the CO-OP program and apply for seed funding.

2) Open up that state’s employee benefits plan to all citizens.

3) Create a state administered health insurance plan (public option) with the opportunity of banding together with other states to create a regional insurance compact.

"Conceptually, having the states take responsibility makes a great deal of sense," said Nebraska Sen. Ben Nelson, a key voice for moderate Democrats ... states are already in the health-insurance business because they administer Medicaid and other federal-state programs.

One key Republican in the debate, Maine Sen. Olympia Snowe, cast doubt on the Carper idea. She favors the so called 'trigger' should private insurers fail to provide affordable coverage.

But, when it comes to the twin objectives of lowering costs and providing coverage to all, the experience of state-by-state systems hasn't been a happy one. The vicissitudes of the business cycle make stable funding problematic. Unable to run budget deficits in lean years, recession-strapped state governments invariably must cut benefits, beneficiaries or even their programs altogether.

Most Republicans remain opposed to the president's plans. Yet recent census data suggest that those Americans lacking health insurance now are far more likely to live in states that usually vote Republican — the very states with senators and representatives least likely to support a law to extend coverage.

Opposition to health care reform thus presents a double quandary for the Republican leadership in Congress and in the states. It is their residents that need health care reform most, and as it turns out, the funding in part would come from blue state (northeast and midwest) taxpayers. Health care reform spending would be little different from the overall pattern of red state socialism (chart).

Retard Innovation

2009-10-09T08:06:00.005-04:00

David Brooks, in the New York Times, supports the Wyden approach to health care reform, which he says infuses a combination of universal coverage and (consumer) choice. Brooks favors a more transparent system, in which people see the consequences of their choices.

Brooks points out the many weaknesses of The Baucus approach. "It entrenches a flawed system. It creates greater uniformity and rigidity ... It squeezes people into a Rube Goldberg complex of bureaucracies ...

The biggest problem is that it will retard innovation. Top-down systems just don’t innovate well, no matter how many Innovation Centers you put in ... The bill will retard innovation"

The problem with individual consumer choice is that, while desirable (and transparent), it alone is insufficient to overcome such powerful forces such as insurers, employers, pharm, government, and even the complexities of illness itself. Neither the pending bills, nor Brooks himself, defines an important role for the physician. Physician driven innovation will be needed to define and to sustain true reform.

Baby Steps

2009-10-08T07:00:00.001-04:00

According to the CBO, "the bill would reduce deficits by a total of $81 billion in the decade starting next year ... the analysis “demonstrates that we can expand coverage and improve quality while being fiscally responsible ... (but) 25 million people — about one-third of them illegal immigrants — would still be uninsured in 2019"

Link

Get the Profit Motive out of Health Care Financing

2009-10-07T07:43:00.005-04:00

In a Letter to the New York Times, Burton C. D’Lugoff & James Hawthorne note that "The United States is the only developed country that allows for-profit companies to eat up 20 cents of every premium dollar to provide insurance for basic health care." Favoring no specific solution, they instead urge, " The important thing is to get the profit motive out of health care (financing)."

Thus far, Congress has balked at health care reform due to the projected costs, about $1 trillion over the next ten years. In contrast, the Fed has been most aggressive in supporting the market for mortgage-backed securities ... purchasing about $905 billion worth of government-guaranteed mortgage-backed securities through mid-September (about 80 to 85 percent of the market).

Referring to these purchases, George Miller, executive director for the American Securitization Forum declared, “This is public support ... the mortgage risk is held by the taxpayer.”

Viewed solely on the basis of its cost, health care reform does seem expensive. But, when viewed relative to other initiatives of similar cost (and less certain benefit) the investment in health care reform is good value.

Waste and the Big Doctors’ Salaries that Go With it

2009-10-05T08:19:00.003-04:00

Cohen's piece strikes a cord:

'In America ... There is endless worry that one’s neighbor may be getting more than his or her “fair” share.” ... (Americans) mythologize their rugged (always rugged) individualism as the bulwark against initiative-sapping entitlements.'

Cohen points out that, 'We’re not talking about health here. We’re talking about national narratives and mythologies — as well as money. These are things not much susceptible to logic.'

But he strays from his point, and loses my support when he provides as the second reason to support a public option; '... to provide competition to private insurers and so force waste, excess and cozy arrangements out of the American system. Behind all the socialized medicine babble lurks a hard-headed calculation about money — all the profits skimmed from that waste and the big doctors’ salaries that go with it.'

So, despite a decent appraisal of how the cultural differences between europeans and americans are shaping the discourse on health care, Cohen's (incorrect) assumptions about doctor's salaries, and their relation to waste and skimmed profits reinforce the important viewpoint of those skeptics within our profession.

'Trial Lawyers Trade on the Unreliability of Justice'

2009-10-01T10:34:00.002-04:00

Philip K. Howard is an outspoken critic of a civil justice system that creates 'legal fear'. He is chairman of Common Good www.commongood.org, an organization dedicated to restoring reliability to our justice system. In a recent WSJ article Mr. Howard makes the following observations:

"Eliminating (the unreliability of justice and) defensive medicine could save upwards of $200 billion in health-care costs annually ...

Although trial lawyers suggest (that) they alone are the bulwark against ineffective care, Congress now realizes it can't completely stonewall legal reform ... 83% of Americans believe that "as part of any health care reform plan, Congress needs to change the medical malpractice system"...

What has unfolded so far is a series of ... token proposals—all of which assiduously avoid any specific ideas that might offend the trial bar. According to Katharine Seelye on the New York Times's Prescriptions blog, "the comparatively small budget seems commensurate with the administration's level of interest in the subject."

A few thousand trial lawyers are blocking reform that would benefit 300 million Americans ... It's a scandal—it is as if international-trade policy was being crafted in order to get fees for customs agents"

Link to WSJ Article

It's About the Middlemen

2009-09-26T09:39:00.002-04:00

Published in the September 26, 2009 edition of the New York Times is a letter from a reader, Jack Luft. He acknowledges the complexity of the debate, proposals and the fixes.

But he truly hits the nail on the head with this point, "the difference this time is that the ... debate isn’t about the product, which is delivered by private-sector doctors and hospitals. It is about the middleman, who acts as arbiter of how health care is paid for."

link to Jack Luft's letter

Health Plans Cost Physicians $31 Billion A Year!

2009-09-23T01:07:00.000-04:00

Physician practices report that overall the costs of interacting with insurance plans is $31 billion annually and 6.9 percent of all U.S. expenditures for physician and clinical services.

Funny Video Link

Link to Article

Baucus Bungle?

2009-09-19T12:44:00.004-04:00

well, we finally have bipartisan support! there is support from both sides that 'there’s no way I can vote for the Senate package'

how long can these guys sit at the table anyway? is the food at this table that hard to swallow? the places that i eat have a thing called last call.

Link to NYTimes article

too lazy to read? try these (entertaining) video links:

Link to Bill Maher "BJ" to the health care industry

Link to Keith Olberman on Baucus

Link to O'Reilly on public option

Doctors and Nurses, Strange Bedfellows?

2009-09-16T22:26:00.013-04:00

Imagine having to pay out hundreds of thousands of dollars that you hadn't expected you'd owe. Now, imagine that you're only one step away from owing that money. While they may not know it, that is exactly how far away from the deep debt that healthcare costs can accrue many Americans are. One step, one diagnosis, is all it takes.

From diagnosis to treatment to unforeseen, but not uncommon complications, the cost of being ill in America is no longer paid in suffering alone. There is a dollar amount attached to all of this that is enough to plummet the vast majority of us into financial ruin.

Earlier this week, physicianvoice posted about the possibility of the 'public option' being administered through the state medical society, either independently or in conjunction with others. As we look forward to the delivery of not just a 'public option,' but healthcare in general, it is important for physicians to ask ourselves just which groups we would be well-placed to work in conjunction with.

When approaching patient care and thinking of the healthcare teams around us in our offices and hospitals, one comes forth rather readily, the nurses. In policy, however, we sometimes find ourselves working at opposite ends from our trusted ally in clinical practice. But does this have to be the case?

As the healthcare debate rages on, maintaining a patient-centered approach provides high common ground for physicians and nurses to work together. Just as both groups work in tandem in the healthcare setting, so too may we work together in the healthcare reform forum, particularly, where the benefits of creating a role for providers in administration of a 'public option' are concerned.

Just as, now is the time for dissenting physicians to come together, now, may also be the time for physicians to take that first step in reaching out to nurses to seek alliance where we agree, and settle differences where we do not.

It is important to recognize that nurses have had tremendous success in shaping their public image as well as lobbying. In fact, in 2006, nursing was the only field in the health services sector that saw an increase in government funding.

It is also important to recognize that when it comes to healthcare delivery, physicians and nurses share the front line perspective. We know firsthand that many of our patients, and us, are just one diagnosis away from not only medical, but also financial catastrophe.

Options to Consider In A "Public Option"

2009-09-14T12:00:00.005-04:00

While the details of the "public option" remain to be seen, critics are already quick to point to the likelihood that such an entity would merely build upon a faulty program and result in a disservice to beneficiaries and providers alike.

It is important to note, however, that there is nothing mandating that the federal government, while certainly providing the initial funding, needs or should be the body administering this option.

There is potential benefit, for both patients and providers, in having decisions regarding coverage and reimbursement be physician driven.

Given that insurance is regulated on a state level, state medical societies, whether working independently or in conjunction with other entities (such as government representatives and even plan beneficiaries) may be a logical option to fill this role.

Retail Health Clinics Lobby for Place in Heath Reform

2009-09-11T17:18:00.000-04:00

Retail health clinics are adding treatments for chronic diseases as part of their efforts to halt losses at the clinics.

The chains are also lobbying for more insurance coverage, and angling for a place in pending health-care reform legislation, while trying to temper calls for regulations.

Nurse Practitioners and Physician Assistants, who typically staff the clinics, "are very important parts of health-care teams," said Dr. Ted Epperly, president of the American Academy of Family Physicians.

But "for them to create retail health clinics and take care of the community as if they were family physicians, that's not their skill set."

Golden (not silver) Bullets?

2009-09-10T22:52:00.005-04:00

'Now, I don't believe malpractice reform is a silver bullet, but I've talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So -- so -- so I'm proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know...

... I know that the Bush administration considered authorizing demonstration projects in individual states to test these ideas. I think it's a good idea, and I'm directing my secretary of health and human services to move forward on this initiative today.'

President Obama

your administrators thank maria basile md for this link to Bush initiatives

Goldhill - Way Forward to Financing Health Care

2009-09-08T01:27:00.000-04:00

In The Atlantic, David Goldhill offers a solution to reform the way health care is paid for. The article is lengthy, perhaps flawed in some of the specifics (particularly the attempts to apply standard economic models to health care and in overstating the death rates due to medical error) - but at the end of the day offers a tractable and thoughtful remedy.

He proposes a move away from comprehensive health insurance as the single model for financing care. In addition, he includes indigent care and long term care in his plan.

He instead would make use of different sorts of financing for different elements of care—

routine care funded largely out of our incomes;
major, predictable expenses (including much end-of-life care) funded by savings and credit; and
massive, unpredictable expenses funded by (catastrophic) insurance.

Under Goldhill's plan, every American would maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap. All noncatastrophic care should eventually be funded out of (these) HSAs.

For care that falls through the cracks—major expenses (an appendectomy, sports injury, or birth) that might exceed the current balance of someone’s HSA but are not considered catastrophic - These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs.

Medicare & the 'Public Option' - Physician Perspectives

2009-09-05T01:07:00.005-04:00

A physician writes: "a public option (nationally or at the NYS level) is a necessary and desirable alternative to private health insurance."

Further, he reflects upon his own experience: "As a newly eligible Medicare user it is clear that the private Advantage options are both expensive for medicare and a rip off for the consumer.

The only issue that I have about Medicare ... is that after paying a fortune in Medicare taxes over 30 years and after (also) building an adequate retirement plan, I find that my Medicare premium is based on my 2007 income (including tax free bonds). For A and B it comes to over $300 a month and if I choose to not play, I will be surcharged 10% FOR EVERY YEAR that I wait."

Med Students Presage Pharm Fraud

2009-09-02T21:38:00.005-04:00

the harvard policy, predicated in response to the med students distaste for pharm intruding upon academia, shares space in today's paper with the news of pfizer's $2.3 billion settlement for health fraud.

pharm's settlements exceed those of the health plans, yet the administration (and your blog administrator) vilifies the insurers. certainly, the med student's rejection of pharm's behavior presaged news of their even more egregious conduct.

as healthcare stakeholders go, we doctors are saints - but, especially in the era of health care reform, we should be careful with whom we 'partner'.

Deficit Distortions

2009-09-01T00:06:00.000-04:00

This graph appeared in the print edition of the Sunday NYTimes. Analysis of the graph reveals a dip in revenue that exactly coincides (time wise) with a spike in spending.

Its creators employ a clever distortion relating to the current deficit situation. They put the 'entitlement spending' at the top of the graph, in order to illustrate that the magnitude of entitlement spending happens to correspond in magnitude to the deficit. This suggests that in order to eliminate the deficit, one should focus on Social Security, Medicare and Medicaid.

The truth is, it is the spike in the graph of 'other spending' around 2007-08 which pushes the Social Security, Medicare and Medicaid lines up, correspondingly, over the revenue line. Inverting the graph, (placing Health & Social Security spending at the bottom), would be far less disingenuous.

While the deficit could surely be offset by the elimination of Social Security, Medicare and Medicaid spending - it is wrong to conclude that such spending is the actual cause of the deficit.

In pondering health care reform, consideration of deficits should be directed to their cause, not merely at an easy target.

Lessons From 1986 Tax Reform

2009-08-30T00:01:00.000-04:00

"The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care ... let us hope, may be that Congress will surprise everyone this fall."

Bill Bradley, a former Democratic senator from New Jersey

A version of this article appeared in print on August 30, 2009, on page WK9 of the New York edition.

Political Affiliation and Health Reform

2009-08-29T01:20:00.000-04:00

According to a Rasmussen Reports poll:

78 percent of conservatives opposed the reform plan.
73 percent said that they would still oppose it even if the controversial public option was removed
By contrast, liberal support for the plan sans public option dropped by a third
A majority of unaffiliated voters are opposed to passing health care reform legislation with or without (regard to) the public option.

link to image

'They Are Not Evil' -He’s (Just) Embarrassed

2009-08-27T09:03:00.006-04:00

'Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil...'

Yet, his colleagues and bosses:

deny requests for expensive procedures
seizing upon a technicality to cancel the policy of someone
raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat

The insurers are open to one kind of reform — so as to give them more customers and more profits. But they don’t want the reforms that will most help patients...(instead they embrace a strategy to negate) the entire point of insurance, which is to spread risk.

Link to NYTimes Column

Link to Senate Testimony

Public Option - Employers Dump Benefits?

2009-08-25T23:12:00.005-04:00

'Indeed there are even some very serious concerns that with a public option, most employers will dump employee benefits. (This will leave) people no choice but a government plan with no clear cut selection of plan benefits as many private insurers (currently) offer'.

Kira A. Geraci-Ciardullo M.D. MPH

H. R. 3459 - Comprehensive Med Mal Reform

2009-08-24T21:12:00.003-04:00

HR 3459 IH

111th CONGRESS

1st Session

H. R. 3459

To provide comprehensive reform regarding medical malpractice.

IN THE HOUSE OF REPRESENTATIVES

July 31, 2009

Mr. BAIRD introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To provide comprehensive reform regarding medical malpractice.

Link to HR 3459

Texas Liability Reforms

2009-08-22T00:35:00.004-04:00

protected the patient,
shielded doctors and hospitals from unscrupulous trial lawyers eager to make a quick buck at the system's expense.
capped non-economic damages at $250,000 per defendant, or up to $750,000 per incident,
no cap on more easily determined economic damages, such as lost wages or cost of medical care due to injury.
ended the practice of allowing baseless, but expensive, lawsuits to drag on indefinitely, requiring plaintiffs to provide expert witness reports to support their claims within four months of filing suit or drop the case.

And what about the money that used to go to defending all those frivolous lawsuits? You can find it in budgets for upgraded equipment, expanded emergency rooms, patient safety programs and improved primary and charity care.

Link to Gov Perry's Op-Ed piece

'PBM Premium' - The Broken Drug Payment System

2009-08-21T23:57:00.004-04:00

"It's a scam of major proportions. When we're trying to find billions of dollars to fund health care reform, this is an area that absolutely has to be cleaned up."—Rep. Stephen Lynch (D-Mass.), June 24, Dow Jones Newswires

The sale of prescription drugs is tightly controlled by an ever-consolidating number of pharmacy benefit managers. They determine which drugs a plan covers and what the co-payments will be. These companies were originally hired by large employers and other health plan sponsors to rein in soaring drug costs. Instead, they have concocted a complex system that places their robust fees and profits above their clients' interests, not to mention the patient's.

(PBMs are middlemen who are unregulated by federal or state law. They are neither insurers nor providers of services)

(This is) costing employers, unions, the government and patients billions of dollars in higher insurance premiums. Quantifying exactly how high this "PBM premium" is can be difficult.

From Article in Rollcall.com

Managed Care, the Only Survivor?

2009-08-20T22:15:00.016-04:00

Unlike individual workers or even corporations, managed care companies can increase revenue by simply raising premiums, which uniquely situates them as survivors in this landscape.

The graph of health care costs, below, indicates that the slope of the rise in costs is untenable. It will bankrupt the country, its populace and physicians. The only survivor will be managed care.

This is a horrid view of the future which we as physicians must attenuate even at some cost to ourselves. You can't just sit there and say to heck with reform, as physician disinterest in a plausible solution will be tantamount to a death warrant to a great portion of the population.

This chart, below, shows the rise in workers' wages, corporate profits, and insurance company premiums adjusted for inflation over a 20 year time span ending in the present day.

As we can see here, the American worker has received only a one percent increase in wages over this time period, effectively paying for the rise in his or her health care costs. This also demonstrates the ease with which the managed care company will be able to weather the storm.

-Bob

Democratic Support for Tort Reform?

2009-08-19T15:16:00.007-04:00

When President Obama addressed the American Medical Association earlier this year, many in attendance criticized the fact that he brought up many of the issues facing physicians but didn't say much about what he would do to make sure they would be addressed as we move forward with health care reform. The one thing he made clear was that he would not support a cap on non-economic damages, something physicians have advocated for years. Naturally, the audience responded by voicing their disagreement with his stance on the issue. With so much uncertainty about what comprehensive health reform would look like, the only clear detail was that a top priority for many physicians was a non-starter.

In 1975, California passed the Medical Injury Compensation Reform Act (MICRA), which imposed a $250,000 cap on non-economic damages in medical malpractice suits. This legislation was adopted as a result of a medical liability crisis in California in the early 1970s. Not unlike today, many physicians then saw a rapid increase in their liability premiums due to rising frequency and payouts from malpractice suits. The result was that many physicians stopped providing high-risk procedures, left the state or stopped practicing altogether, leading to a physician shortage in many areas of the state. Anyone familiar with the liability crisis looming in states like New York, Illinois and Florida know this is a natural progression of medical liability that is left unchecked. Thirty-four years after MICRA and the resulting caps, California has some of the lowest liability premiums in the country. Texas followed suit in 2003. After it's implementation, Texas found they couldn't keep up with licensure applications for all the new physicians who elected to move to a state with a more favorable liability climate.

President Obama has, on several occasions, made reference to physician utilization and the suggestion that many patients receive "unnecessary care" based on increased reimbursements for services rendered. There is no denying that the provision of medical care in this country presents a perverse incentive: the ones who decide how much medical care patients need are the same ones who reap the benefits from providing more medical care under a fee-for-service model. The president and Congress are right in their attempts to identify instances where funds are utilized unnecessarily and remedy these. Their support for improved communication via health information technology and coordination of care through the medical home are examples of their commitment to improve utilization. Taking any discussion of caps on non-economic damages, however, is not. Accusing physicians of spending money that doesn't improve patient care while letting trial lawyers off the hook for their role in compromising patient care is just plain irresponsible.

Physicians are charged with providing necessary medical care. Similarly, lawyers are charged with protecting patients from gross negligence. Taking care of patients is both a privilege and a tremendous responsibility. The purpose of medical liability is to keep gross negligence in check, punish inappropriate physicians and, when necessary, remove them from practice. Not only does the current liability system fail to protect patients from gross negligence, it also fails to protect physicians who practice appropriately but whose patients suffer bad outcomes. Trial lawyers cream-skim cases where both potential payouts and likelihood of settling before trial are high, irrespective of whether inappropriate care was provided. Additionally, lawyers often promise to not charge a fee unless the patient is compensated as a result of the suit. With nothing to keep frivolous lawsuits in check and an incentive to select high-paying cases over ones where patients have experienced gross negligence leaves neither physicians nor patients protected. Only trial lawyers stand to benefit from this system.

Acknowledging that physicians have a perverse incentive to provide more care is important. Where President Obama and Congress have failed patients all across this country is their failure to acknowledge the perverse incentive the Democrats have to support trial lawyers. For years, trial lawyers have supported Democratic candidates in exchange for their obstruction in any attempts to achieve meaningful liability reform. In many states where liability crises loom large, Democrats have told physicians for years that caps on non-economic damages were off the table. Caps are certainly not a perfect solution: opponents rightly argue that limiting non-economic damages prevents some patients from seeking retribution in cases of gross negligence. But perpetuating a system that fails to protect physicians or patients while compromising access to care and wasting funds only calls the credibility of its Democratic supporters into question.

We as physicians are the guardians of the health and well-being of our patients. We are charged with ensuring that they get all necessary care but have the responsibility of preventing wasteful spending. As health care spending grows to nearly 20 percent of the GDP and the number of uninsured people in this country approaches 50 million, we cannot afford a system that wastes as much money as our current one. President Obama was right to recognize this and advocate for change to remedy what ails us. But holding physicians accountable while giving the trial lawyers a pass is not only irresponsible, it is nothing more than politics that compromises the health of our nation.

Employer Mandates

2009-08-18T11:13:00.005-04:00

As we focus in on a plan to reform healthcare, we must ensure that we learn valuable lessons from what works and what doesn't work in other health system. Cross national models of healthcare delivery provide valuable insight into the likelihood that reforms will have meaningful impact. We know that most of the developed world has managed to provide universal coverage for its citizens, but how did they accomplish that? In Brittain and Canada, they turned to a single-payer system managed by the government to provide healthcare to all citizens. As a result, they have faced shortages and rationing as government budgets dictate health delivery with all the incumbent political pressures. But the rest of the developed world has avoided this pitfall. How have they done it? Employer mandates.

Our country already functions largely upon employer provided healthcare. About 60% of Americans receive their healthcare through their employers. When combined with those covered under Medicare and Medicaid, we find that 15% of Americans remain uninsured in the current system. Who are these people? As Medicaid covers the unemployed, most of the uninsured are either at small businesses that cannot afford to provide health coverage for their employees, or they are freelance workers who either choose to go without health coverage or cannot afford the premiums. This number is growing in the economic downturn as more employers drop coverage when the cost becomes untenable.

Looking at other countries can allow us to determine what to do about this 15%. Most of Europe, Japan, Israel, and a host of other countries have utilized employer mandates to cover every citizen. Under these systems, every employer is required to provide healthcare for all workers. Small businesses receive assistance from the government to ensure their ability to pay for health coverage. Freelance workers enroll in insurance pools that greatly reduce the cost of health insurance. Most of these countries require that all citizens carry some type of health insurance either through their employer, through the freelance clearinghouse, or under the government's indigent program (much like Medicaid). To ensure that insurers treat consumers fairly, most of these countries also develop the "benefits basket" which are mandatory services that all insurers must provide. To compete in the marketplace, many insurers will provide additional services not included in the "basket."

So, why can't we do this in America? The simple answer is - we can. In the 90s, the Clinton healthcare plan actually approximated an employer mandate system, but was so complex and unwieldy and designed without stakeholder influence, so it was easily decimated by industries that would have suffered under it (e.g. health insurers who would face greater market competition that would cut into profits). According to a recent survey conducted by the Employee Benefits Research Institute (EBRI), 3 out of 4 Americans support an employer mandate for health care coverage. Clearly there is much interest in such a system, both from the perspective of policymakers and from the public.

What stands in the way of an employer mandate? Business, of course. The U.S. Chamber of Commerce and the National Retail Federation, amongst others, have been very outspoken on this issue which they feel will put an undue burden on business, especially small businesses. The Health Insurance Industry has been straddling this issue, fearful for the increased competition that might drive down profits while excited about the prospect of having an additional 15% of the population as members of an insurance plan.

Looking at so-called "ObamaCare," there are overtures toward an employer mandate system. There are incentives in the various bills for employers to cover their workers, especially for the small businesses that currently opt out of such a system. The President and many of his Democratic colleagues feel that a public option is also necessary, not only to plug the gap which may still remain between Medicaid and the employer system, but also to create even more competition on the insurance market. The fear that the public option would eliminate the private insurers due to better rates and services is largely grandstanding - this would only happen if insurers choose to NOT be competitive in order to maintain high profit margins or do not find internal ways to reduce their administrative costs which are currently well above those required for Medicare.

So, Obama's plan, while not an employer mandate and relying more heavily on government programs, does accomplish many of the goals of the employer based systems of the other developed nation. With an increased buzz about employer mandates and support from big businesses like Walmart and Target, later versions of the bill may find it useful to increase subsidies to small businesses for providing insurance and create insurance pools for freelance workers. Time will tell whether our great nation can learn from the experiences of others.

Anniversaries Are a Time to Remember: A Cautionary Tale

2009-08-16T23:29:00.004-04:00

Just ask any husband who has ever forgotten one, and he'll tell you, anniversaries are a time to remember. This past weekend marked the eighth anniversary of the announcement of a class action lawsuit brought against managed care companies by the Medical Society of the State of New York (MSSNY). In a coordinated effort, suits were launched at that time not only by MSSNY, but also by 17 other states and counties against six major insurers including Excellus, Aetna, Cigna and United.

“We just got tired of all the improper business practices of all the different insurance companies and a lot of states were getting like this, and we all knew we needed to do what we could to fight back against them,” says Dr. William Dolan, one of the primary plaintiff's in the MSSNY suit, former MSSNY President and current trustee of the American Medical Association (AMA).

Some of the improper practices outlined in the suit include: arbitrarily reducing a physician's payment for medically necessary care by "downcoding," or changing claims and billing codes to indicate a doctor should be paid less; bundling claims, or issuing a single payment for a group of related medical services; failing to pay physicians in a timely fashion; forcing physicians and their staffs to expend an unreasonable amount of time and resources attempting to obtain reimbursement to which they are entitled; exploiting the doctors' unequal bargaining power to force physicians to enter into one-sided HMO contracts.

Excellus was the first company to settle, and in the end, all but United Health followed suit. The settlements included both monetary payment and agreement to improve practices. For example, the Excellus $60 million settlement included a payment of $1500 to all of the physicians in the involved upstate NY counties as well as agreement to completely adhere to the CPT4 Codes, Guidelines and Conventions, which they had not previously been following.

In recounting the day the suit against Excellus was announced eight years ago, Dr. Dolan recalled the beautiful view of the New York cityscape, including the then still standing Twin Towers. And while the skyline of the city, and indeed our nation have undoubtedly changed since then, the battle between physicians and the bad practices of insurers has remained constant.

Just this past spring New York Attorney General Andrew Cuomo filed suit against United Health and Ingenix Inc., for allegedly altering data so insurers paid less and patients more for out-of-network services. “It's fraud. They deliberately cut the numbers so the consumer pays more of the cost,” Senator Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee told The Associated Press of the practice.

“There's a lot of excess money being spent on the part of practitioners on billing the insurance companies,” Dolan says. In 2008, the AMA launched the National Health Insurers Report Card (NHIRC), which evaluates major insurers on 13 metrics regarding the timeliness, transparency and accuracy of claims processing. With physicians spending close to 14 percent of their income on billing, it's clear that steps such as this and more are still necessary. A PNC bank study estimated that $200 billion are spent each year on billing.

“We're going to have to continue stridently, and to do battle if necessary or come to some negotiation with AHIP [America's Health Insurance Plans] and the various insurance companies with all our information, and they know, in the past, we've won these battles,” Dolan said.

As we move forward in the healthcare debate, it is important to remember and remain mindful of these past, present and future battles between physicians and insurers, as we won't be able to make up for forgetting them with flowers or expensive jewelry.

Obama, 'Four main ways (to) Provide Stability and Security to Every American'

2009-08-16T12:12:00.005-04:00

"No one in America should go broke because they get sick."

Link To Obama Op-Ed Piece

A Position on HR 3200 - Not Our Local Job?

2009-08-16T00:26:00.008-04:00

A growing disillusionment of the membership is leading the county medical societies to define a position on hr 3200. Several county and state medical societies have adopted a position to oppose the ama hr 3200 strategy.

But more than one county has positioned itself neither embracing nor condemning one side of the issue or the other.

One such county president, when asked how this position was developed, said,” I realized that solving national health reform was not our local job! We’re ... preparing to help our members deal with the fallout. “

Instead, their role is to keep the membership informed. This mission is vital and distinct from the national and state omnibus societies. This position avoids the alienation of an entire sector of the membership.

Link to County Society Alert

Malpractice Reform is Healthcare Reform

2009-08-14T08:04:00.003-04:00

In order to get physicians onboard with healthcare reform, the administration should push to reform the practice environment. Polling many physicians of disparate backgrounds and political persuasions, we find one area of unanimity. The present system of adjudicating claims of malpractice must be changed.

Duke University’s Donald H. Taylor, Jr. writes in the North Carolina News&Observer:

…A successful malpractice system would protect patients from harm via a deterrent effect of lawsuits, compensate patients for harm and exact justice. In addition, a good system would protect physicians from frivolous suits, identify substandard physicians so that medical licensure boards could remediate them or remove their licenses and provide a clear signal to insurers regarding the risk of insuring a physician.

Our malpractice system does none of these well.

http://www.newsobserver.com/opinion/columns/v-print/story/1638305.html

A large number of lawsuits are filed when no malpractice has occurred. Conversely, many cases of real negligence do not result in a lawsuit. Not only is compensation inequitable, but the system itself is ponderously slow. It takes about five years from summons & complaint until trial or resolution. Moreover the costs involved with filing, answering, expert opinions, depositions and the cost of trial are such that for every dollar paid a successful claimant, half again as much goes to administer this system. While the costs of malpractice may only amount to 2% of healthcare costs, this still amounts to over twenty billion dollars which is not a trifling sum, even when a budget of trillions is being considered.

And then there’s the cost of defensive medicine, which has been estimated to cost $100 billion annually. It appears that as the administration scrambles to answer concerns of runaway cost estimates, they are avoiding an obvious chance to bend the cost curve favorably – reform the US medical malpractice system. Professor Taylor lists several suggested modifications to the current system. Suffice it to say our medmal system can be reformed so that it is efficient, equitable and evidence-based. Reform medmal and achieve both cost-savings and physician support. Win – Win.

Art Fougner

The New Doorknob Question, And the Need for a United Answer

2009-08-12T23:40:00.002-04:00

The doorknob question, that important or embarrassing question our patients traditionally ask at the "close" of an encounter is a long-standing and common phenomenon. The chorus of this phenomenon, however, is changing from, "Oh, Doc, I've got this rash..." to "But Doc, I don't have the cash..." All too often prescriptions go unfilled and followups unscheduled because patients simply can't afford them. Physicians find themselves scouring the $4 prescription lists for a suitable alternative, which may or may not exist, or seeing if the local supermarket is still offering free antibiotics. Cost has become the rate-limiting step in our ability to treat, and is as paramount to our patients as their illnesses.

Years of school and training, constant review of emerging research, we as physicians spend much of our time and lives becoming expert in medicine. But along the way we also become expert in patient care. Medical students are taught how to communicate complicated medical pathology and treatment to patients in "layman's" terms because if they don't understand what we feel is necessary, they won't be able to carry out our prescribed course of treatment. So too, is it vital for us to communicate the complicated healthcare delivery issues we see every day to our representatives in "layman's" terms. If they don't understand what we feel is necessary, they won't be able to carry it out, and our patients and our ability to care for them will lay casualty.

There are many clamoring voices in the ongoing healthcare debate, but of all of these, ours is the one that is expert in patient care. The potential power of the physician voice is strengthened when we speak together. Just as a multidiciplinary care team needs to be on the same page when advising a care plan to a patient, we must harness the power of unity and clarity when offering our prescription to the ailing healthcare system.

The "doorknob questions" of comprehensive healthcare reform aren't just being asked in our offices, they're being asked on Main St, Wall St, Pennsylvania Ave and just about every other street in the country. And we as physicians need to come to a consensus on our answer. Failure to do so may not only compromise our ability to care for patients, but may prove far more dangerous and deadly than not taking a second look at that rash.

Expanding Access and Controlling Costs

2009-08-11T09:26:00.005-04:00

In his article today, Samuelson challenges President Obama's statement that "The status quo is unsustainable for families, business and government." He brings up the point that we, as a society, value expanding access because people tend to think of health care as a right (or at the very least, something that we should be able to provide our citizens as one of the richest countries in the world). At the same time, what makes our system unsustainable is not the number of people we cover, but the amount of money that we spend providing care for each person. Many uninsured currently seek primary care in the emergency room, one of the most expensive places to deliver care. Providing coverage for many of the currently uninsured and shifting their care to primary care settings will help to cut costs, but not enough to offset the cost of expanding coverage.

Our challenge now is to figure out how we can take the money we currently spend on health care and cover the uninsured, eliminate waste in the current system and provide better and more coordinated care for patients. There is no easy solution to this problem, but this must be part of any meaningful health care reform in order to create a more sustainable system.

Link to Article

Disinformation?

2009-08-09T22:03:00.003-04:00

The President gives great insight into the main street debate surrounding healthcare reform. (this link for example)

No longer just healthcare professionals talking about reform, it is now that much more important that we (physicians) stay present to the debate occurring at the American dinner table.

(Still, it is) disturbing that the White House asks the American public to report any dissenting opinions about health care reform that may be construed as "misinformed."

Robert A. Dugger II MPH

MS II - Stony Brook School of Medicine

http://www.whitehouse.gov/blog/Facts-Are-Stubborn-Things/

Insurance Reforms & New Yorkers.

2009-08-08T09:44:00.002-04:00

What would the insurance reforms in the federal healthcare bill mean to us New Yorkers. An insurance consultant responded thusly:

He stated that the ‘system’ wouldn’t change much in New York because the bill proposes extending the New York ‘system’ to the rest of the country. For example:

In New York a policy is guaranteed issue - a company can't decline you due to your health,
In most cases pre-existing conditions are already covered - in most areas of the country a health insurer requires a medical exam, and an insurance company can decline you for coverage

I asked about HSA’s and why they are not more popular. I learned that HSAs are both good and bad. They are advantageous because the premium is less expensive then most other options (HMO, EPOs, PPOs). But, the premium savings often isn't enough to justify the purchase of an HSA.

He stressed that insurance reforms alone are merely a component of HCR. He stated that needed reform also included tort reform, obesity issues, etc

link to health insurance protections

The Polls

2009-08-07T12:11:00.001-04:00

An article in the Wall Street Journal today by Scott Rasmussen (link below)

discusses the fact that 68 percent of voters have health insurance that they rate as good or excellent. He argues that this will be an obstacle to achieving health care reform, and I agree. Americans want to see everyone have access to high-quality, affordable health care, but not if it means their own health care or access will be worse than it is now. It seems reasonable enough; nobody wants reform that is going to make them worse off. To these people, health reform is a gamble. We won't know if reform makes each of us personally better or worse off until it actually gets implemented. So why take a gamble on health reform if you're happy with what you have and it might make you worse off. Essentially, if it ain't broke, don't fix it.

The problem is that too many people don't see that the system is broken (perhaps "broke" is the better word, since varying estimates show that Medicare will go bankrupt within the next 10 years). The cost of delivering health care continues to rise. Most working-age citizens still get their health insurance from their job, so people lose their coverage when they lose their jobs. More and more employers are shifting more of the costs of health insurance onto employees or are dropping health coverage altogether. Medical bills are the second-most common reason for filing bankruptcy in America. The uninsured are twice as likely to file for bankruptcy than those with health insurance, though nearly a third of all Americans who file bankruptcy for medical reasons have health insurance. In essence, the insured pay for the health care we provide to the uninsured, and at a greater cost. Those without coverage are more likely to seek care in the emergency room, the most expensive place to get care. Meanwhile, the uninsured are charged more for the care they get, since they don't have insurance companies to negotiate the discounted care those with insurance receive. And to top it off, having health insurance doesn't even guarantee that you won't need to file bankruptcy because of medical debt.

Clearly, Congress, the Administration and the key players advocating for health care reform aren't getting this message across. Though 68 percent of Americans may rate their current insurance as good or excellent, our current health care system isn't sustainable. It's broke, and now is the time to fix it. Health care reform is not a gamble; it's the only chance we have to come out ahead.

WSJ Article

Demonstrations or Demons?

2009-08-07T02:08:00.001-04:00

At town hall meetings, congressmen are shouted down, hanged in effigy, surrounded and followed by taunting crowds. Key organizers include two Astroturf (fake grass-roots) organizations: FreedomWorks and Conservatives for Patients’ Rights (itself with ties to the Columbia/HCA hospital chain).

Are cynical political operators exploiting public anxiety just to further the economic interests of their backers?

see Congressman Bishop video

Politicians Deal on Health Care Reform

2009-08-06T09:41:00.001-04:00

this article, in today's ny times, is the acknowledgement that everyone has been asking for - that the administration made 'deals' with health care stakeholders.

can anyone still doubt the assertion that the administration lured the other stakeholders (including the doctors) with promises as well - since they were part of the original 'coalition' (along with pharma) of health care stakeholders when it was announced in the spring?

a trustee has reminded society members that we are in the early innings of a planned nine inning game. i say to physicians, lets gather some consensus on what's important - especially if this thing goes into extra innings

see nytimes Article

Make the System Better, Make More Money!

2009-08-05T23:05:00.002-04:00

In the oft-cited New Yorker Magazine piece, Atul Gawande proposes Accountable Care Organizations (a gainsharing strategy) as his remedy to the seemingly conflicting goals of controlling health care costs while improving quality and efficiency.

While other savings proposals such as cuts in payment rates, bundled payments, and capitated health plans have faced opposition, “a voluntary payment reform designed around ACOs and shared savings offers an incremental and promising middle ground that could meet the interests of providers, beneficiaries, and taxpayers better than the competing alternatives.”

The ACO shared- savings model supports and rewards those who improve care and lower costs. According to former CMS head, Dr. McClellan, “Linking new investments in health care to demonstrated improvements in health and medical costs creates a win-win: providers and patients can get more support for real improvements in care, and we all benefit from lower costs.”

And most physicians and hospitals could form ACOs by building on their current practice patterns.

The problem, of course, is that gainsharing is illegal within the current antitrust environment.

see HR 2959

see New Yorker Article

Physicians... Unhappy With the Lack of Leadership

2009-08-04T23:11:00.002-04:00

'Jefferson wrote "A govenment big enough to give you everything you want is a government big enough to take everything you have". This monstrosity of a bill and the amendments they have just marked up make Gottfried look like a charm school book report. ... only physicians are in a position to advocate for our patients and ourselves, and there is only one MD representative that I know of on Waxman's committee, a Republican, who might as well have tape over his mouth. This legislation will undoubtedly be revised and amended, but even in altered form, will create a new powerful and controlling bureacracy which will change not only the practice of medicine, but the whole relationship of government to the people of this country.

The AMA failed to attack objectionable provisions in the bill and never pushed for tort and insurance reform, and other vital elements of our survival, as the bill was being formulated. It is naive to think they will be able to work with doctor haters like Waxman to alter those pieces of the legislation once they are finalized. Letters of complaint about the actions of the AMA and MSSNY are beginning to be received in numbers at county societies, and I would contend that most physicians in the country are unhappy with the lack of leadership, be it real or perceived. The profession should not be a commodity to be traded, nor a doormat for poorly informed, and agenda-driven politicians. One can only hope the voters are smart enough to vote these marauders out of office, and restore some sanity, before Big Brother says hello in a Big way.'

clyde locke