Blunting the Costs of Healthcare Reform

States of Personal Privilege
10/09/09 - WSJ Opinion by by Kimberley A. Strassel

Quip: This bill is vital to our country and will save a lot of money. We just don't want to depend on it.

[edited]

Powerful senators have avoided the most costly provisions of healthcare reform for their own states. They want "reform" for the nation, so long as it doesn't disadvantage the people who support or vote for them.

• The Baucus bill vastly expands state Medicaid programs, requiring the states to pay an additional $37 billion.

  Senate Majority Leader Harry Reid of Nevada is worried about losing his seat next year. He has arranged for the federal government to pay Nevada's increased Medicaid expenses for the next five years. This applies to only three other states: Oregon, Rhode Island, and Michigan, because they "are suffering more than most."

• The Baucus bill would tax expensive insurance plans at 40%, so that those with "luxury" health insurance help to pay for the poor. But states like New York and Massachusetts have a lot of those plans, having a lot of union members with great benefits, and high-cost insurance mandated by state regulations.

  New York Sen. Chuck Schumer didn't want angry, overtaxed voters, so he and other similarly situated Democrats carved out a deal to reduce the tax on 17 states, mostly with Democratic politics.

• The Baucus bill taxes pharmaceutical companies, on the principle that they are filthy rich and involved in health care.

  But, New Jersey boasts it is the "global epicenter" of the drug industry, where "15 of the world's 20 largest pharmaceutical companies have major facilities." Its Sen. Menendez has a deal for a $1 billion tax credit for companies investing in drug R&D.

• Many Dems assure us that the Baucus bill will "bend down" the health-care cost curve. Michigan Sen. Debbie Stabenow and Massachusetts Sen. John Kerry aren't counting on it. They included $5 billion in the bill to reduce costs for union members.

So, health-care "reform" is good, smart, and necessary, so long as it isn't fully applied to the states of the senators who are pushing it.

Most senators are saving up their special demands for the Senate floor. Then, we'll know how much change Democrats truly believe in.

-----
Baucus Bill Bull: The Hypocrites In DC Are Trying To Pass a Doozy
10/14/09 - PJTV: Medically Incorrect (video 3 minutes)

A video opinion of the Baucus bill by Dr. Peter Weiss.

Dr. Weiss is an OB/GYN at Cedars Sinai Medical Center in Los Angeles, the Medical Director of Rodeo Drive Women's Health Center and Rodeo Drive Dermatology and Aesthetics, and an Assistant Clinical Professor at the UCLA School of Medicine.

-----
Obamacare Bails Out Medicare
09/12/09 - Easy Opinions by Andrew Garland
"Healthcare Reform" is a huge tax hike plus rationed medical services.

Memo - Health Plan Deficit Reduction

From:   Chairman [redacted] of the [redacted] Committee
To:        Healthcare Reform Drafting Group II
Re:        Finessing the Health Plan Deficit

( This is a Class I rice-paper memo. )

The estimated deficit for our health reorganization plan is causing us trouble in the press. President Obama has promised not to raise taxes on the middle class, and not to increase the deficit. Unfortunately, we have to live with this until the plan passes Congress.

After passage, we will spend what it takes, just like the last times.

Please hold off on more complexity. I asked for enough boards, committees, commissions, and regulators to confuse things and distract our opponents. You went overboard, but that is not a big problem. Just don't add more.

(Jim, that advisory commission on do-it-yourself birthing is out. I know it would save money, but it is out for now.)

Here is how we will handle the cost. Pick a big cost to convince people that we are serious. Too small looks like we might be hiding things. (If they only knew.) Keep it under $1 trillion over 10 years. That seems to be the right psychological price point for the public.

Now, this is how we will "pay for it". Assign whatever fees (not taxes!) you want against insurance companies, big businesses, and "private" doctors. Make the fees big enough to cover the entire added cost of the plan. Yes, even if you think we can't raise that much money from those fees.

The Congressional Budget Office will score the plan based on the fees we say we will raise. They will find that the plan is covered, and that is all we care about. We have convinced the public that only deficits matter, not the actual cost.

Our opponents will express doubt that we can collect all of the money we say we will. But, that is just their opinion, and the CBO will go along with us.

So, we will have a plan that does not increase the deficit, and there are no taxes on the middle class, only fees on evil companies and rich doctors.

To Fred: Yes, the fees would be passed through, and effectively would be a tax on employees and patients. I appreciate your insight. Forget about it. We will be rearranging everything in any event, after the bill is in effect for a while.

Good work everyone. Just a few more all-nighters, and we will get this thing passed. Remember that there are enough boards, committees, commissions, and regulators to provide plum assignments for all of you.

__________
This is a rice-paper memo, distributed on edible paper and written in edible ink (raspberry). Please eat this memo after reading.

Nutrition Label: Fat 0g   Protein 0g   Carbohydrate 4g
Dietary Fiber 1g.  Free of gluten and tree nuts.

US Printing Office G5-034 236 Washington D.C.

ObamaCare May Save Social Security

ObamaCare Saves Social Security
08/11/09 - InsureBlog by Henry Stern

[edited] The healthcare bill we reference is "America’s Affordable Health Choices Act of 2009, Revised Standard Edition". It has the potential to save Social Security from bankruptcy:

Page 425. "The term ‘advance care planning consultation’ means a consultation between the individual and a practitioner [doctor] ... if ... the individual involved has not had such a consultation within the last 5 years."

So, seniors are encouraged to have these consultations at least every 5 years. What are they?

Page 432. "For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life sustaining treatment."  (note)Can you imagine 1000 pages of this language?

So, a "consensus based organization"The End of Life Quality Treatment Board will come to order. All in favor of 'Non-Heroic Treatment Plan 103' say Aye. The plan is approved by 8 votes to 1. I declare this a consensus. We are adjourned."" will determine advanced care planning. It will create orders for life sustaining treatment that will be measured for compliance. It could order anything from a pain pill to life saving surgery, depending on whatever utilitarian measures it wants. And, that will be that. Are you reassured?

This implements social justice. Rich and poor will be prescribed the most cost-effective lifesaving or pain-numbing treatment, according to expert guidelines.

If you are a federal politician, federal employee, or approved union member, you are not covered by this act. You have other, nicer choices for your care, provided by private insurance companiesAren't the insurance companies supposed to be the spawn of the Devil? arranged for you by your union or the federal government.

Social Security will save a lot as most people's lives end on a more rational basis.

----------
This prompted my comment (sarcasm warning):

It is shortsighted to bring quality of life issues into discussion only because of explicit costs for healthcare at the end of life.

It is obvious that we cannot support useless members of the tribe who are no longer able to work.

What is less obvious, and much more important, is to factor in carbon use. This is also a cost to society, and to Gaia herself.

We should accept that when our personal carbon footprint goes up past our productivity, then we need a talking to.

When an individual can no longer bicycle to work, it may be better to accept the end rather than be a carbon burden on us all.

It is inescapable. Some must continue on in the cycle of life so that others may live without damaging the Earth.

Cuban Health and Economic News

Via Don Surber, Daily Scoreboard Item 8.

Cuba must replace tractors with oxen
08/08/09 - Google Hosted News by Will Weissert (AP)

[edited] President Raul Castro suggested expanding a pilot program, giving private farmers fallow government land to cultivate.

"For this program we should forget about tractors and fuel, even if we had enough. The idea is to work basically with oxen. An increasing number of growers have been doing exactly this with excellent results."

The agricultural ministry proposed increasing the use of oxen to save fuel. Factory closings and turning off air conditioners at government offices has saved oil. The ministry said it had more than 265,000 oxen "capable of matching, and in some cases overtaking, machines in labor load and planting."

Cuba is running out of toilet paper
08/10/09 - Reuters by Nelson Acosta and Esteban Israel

[edited] An official with state conglomerate Cimex said: "The corporation has taken all the steps so that at the end of the year there will be an important importation of toilet paper."

The shipment will enable the state-run company "to supply this demand that today is presenting problems." Cuba both imports toilet paper and produces its own, but does not currently have enough raw materials to make it.

CNN reports Cuba is a model for a U.S. healthcare plan
08/10/09 - American Thinker by Humberto Fontova

[edited] The CNN report included clips from Michael Moore's "Sicko". CNN's Morgan Neill reported on location from a Havana hospital. "Cuba's infant mortality rates are the lowest in the hemisphere, in line with those of Canada!"

According to 2009 UN figures for infant mortality per 1000 live birtihs, Canada ranks 23rd best at 4.8, Cuba ranks 28th at 5.1, and The U.S. is 33rd with 6.3.  [My link and figures -ag]

Other statistics and reports question the truth of Cuba's rank.

• According to the Association of American Physicians and Surgeons, the mortality rate of children aged one to four years is Cuba 11.8 vs U.S. 8.8, 34% higher.

  This statistic doesn't figure into UN and World Health Organization spotlighted "infant-mortality rates", so there is no pressure to fudge these figures.

• Dr. Juan Felipe García, MD, of Jacksonville, Fla., in April 2001, interviewed several recent doctors who defected from Cuba:

  "The official Cuban infant-mortality figure is a farce. Cuban pediatricians constantly falsify figures for the regime. If an infant dies during its first year, the doctors often report he was older. Otherwise, such lapses could cost him severe penalties and his job."

• The maternal mortality rate per 1000 births is Cuba 33 vs U.S. 8.4, 3.9 times the death.

The comparison to the U.S. is too strange. Many more Cuban mothers and children aged 1-4 die in Cuba, but the statistic reported to the UN for "infant mortality" (birth to 1 year) shows the same health as in much wealthier countries.

----------
USA Healthcare is First - Infant Mortality is Low

Health statistics are intentionally misinterpreted to argue for socialized medicine. The major argument is that the US spends more than Europe, but lags behind in health outcomes. So, US healthcare is both expensive and inefficient.

Actually, the USA has better health.

A Few Words About Policy

President Obama recently held a prime-time press conference to present his desire to reform healthcare in the U.S. He suggested passing the bill in Congress, and asked for questions. He talked for about an hour and answered about 12 questions.

There has been a flurry of activity discussing what he said, whether there was any new detail, and criticizing some of his examples and facts. This told us very little about what is proposed in this sweeping grant of power to the government.

The press and the country are entirely wrong about what press conferences are good for.

Policy On Paper

Obama should have already released a detailed "white paper" describing his summary and justification for his health care proposals. (And such a paper for his other policy recommendations.) We need proposed results, methods, justifications, comparative studies, past successes, funding sources, the works.

Laws are not written as a random collection of thoughts, although they often look that way. They start with policies and reasons on paper. Legislator's staffs follow those policies when creating the details in these 1000 page bills. The white papers must exist, but they are not being presented to the public.

We should examine, verify, and criticize the policy documents, and then compare these to the details in the bills. Starting with the bills is like trying to approve a new building by looking only at the blueprints, without the purpose, graphics, and site requirements.

This is the United States Government, of, for, and by the People. The public cannot participate in a government that runs on policies that are hidden. The press and public should be able to review these undelivered documents. The government should be proud to display its carefully researched and supported policies. We deserve this as a free people.

The absence of these policy papers is appalling. Instead of open and proud policy, we have closed, imperial government. Sadly, we are controlled by a tyranny if our government sees no reason to explain and justify its actions. Are they ashamed or afraid of what they propose?

Be Informed

A press conference is supposed to question the President on his knowledge of the policy already presented in detailed, written form. The press conference is for the President to announce and defend the policy. It is to reassure the public that he knows about what he is proposing.

Instead, we have a few questions and vague speeches about what we would all like in a perfect world, and about the power and money that Obama wants ahead of time to work on it.

It is a magician's trick, to treat press conferences as if they could communicate the needed information, for either support or criticism.

We must ask our government for the important things. Among them is always a clear explanation of what the law will be, and why. If we ask and are not answered, then the responsible politicians must be voted out.

Government Healthcare by Experts

The Mayo Clinic weighs in
07/11/09 - Don Surber

Dr. Wood is the chairman of the Mayo Clinic, division of Health Care Policy & Research:

[edited] The clinic supports “value indexing” to determine how providers get paid. This would measure patient outcomes and cost over a period of time. The current bills in Congress contain very little that reflects payment for value.

Democratic Senator Amy Klobuchar:

[edited]If we just simply change who is paying for something and do nothing to make the system more efficient, we are really not going to get where we want to go.

Don Surber:

[edited] This is exactly what is wrong with government-run health programs. Their goal is to save money, not lives. More than anything, I oppose having Sen. Klobuchar decide how “to make the system more efficient.”

Jim B comments:

[edited] When Sen. Klobuchar can show me a record of the government ever making anything more efficient, ever, then maybe we can talk about health care. But she needs to put up or shut up. Government bureaucrats claim to be able to do things they’ve never once demonstrated an ability to do. There’s absolutely no substance to back it up.

So come on, supporters of ObamaCare, show me where you can back up your claims. Even one of them.

Links

Healthcare Reform Myths

One of the myths: If you like your current plan you can keep it.

You can keep your current plan if it is still offered and the company is still around. This is not a silly consideration. Proponents have learned from the Hillary Care proposal in the 1990's that radical transformation does not sell. The current plan provides a framework to take away freedoms one at a time, to minimize resistance, and obscure the ultimate goal.

A century of monopoly by the Post Office shows us how much Congress likes competition to one of its high-cost, inefficient activities. Private insurance likely will disappear or be made to conform to government rules, standards, limitations, and costs.

----------
Massachusetts Health Care Cuts

Henry Stern at InsureBlog examines the Massachusetts Health program that is the darling of Washington. Here is a part:

Massachusetts can't pay for the plan by itself. It needs Washington to distribute funds from the national money tree to pay for this program.

$32 million of the $115 million in claimed savings comes from slowing payments to the managed-care health insurance companies that won bids to offer insurance through the Commonwealth Care program. Regulators said that by slowing enrollment growth, the companies would receive less money than they had banked on when they submitted their bids earlier this year.

The Medicare Tomato Market

You Are Living In The Medicare Tomato
06/21/09 - The Happy Hospitalist

Say that tomatoes were declared vital to life and made available free through the Medicare National Tomato Bank. This translates the story of the healthcare market to the tomato market. A long, readable, and informative post. This is only an excerpt.

[edited] The government took over. A midnight Congressional mandate ended the free market in tomatoes, and replaced it with the Medicare National Tomato Bank (MNTB).

The demand for tomatoes took off. Grocery stores everywhere were selling out. Nobody could keep tomatoes in stock. The grocers were ecstatic. They sold their tomatoes and sent the bill to Uncle Sam, who then sent them a check for the market price. The people were happy. They were getting free tomatoes. Entitled Tomato Eaters (ETEs) everywhere loved Congress.

Unfortunately, the MNTB was not happy. They were paying the bill. That $200 billion tomato bill was rising quickly, faster and faster, 10% a year, year after year. The MNTB could not afford to continue paying for free tomatoes for everyone. Congress did something completely anti-American in an effort to control the costs of the MNTB. They took capitalism out of the tomato market.

In their stroke of genius, they tried something that had never been tried before under capitalism. They would lower the cost to the MNTB, not by cutting the demand (political suicide), but by paying only 80% of the market price.

The ETEs remained happy with free tomatoes. The grocers were not so happy.

(skip to near the end)

Access to free tomatoes was dwindling. No longer could the ETEs walk to the grocer down the street. They had to drive miles to get the government mandated access to the tomato market. Known as the emergency tomato grocer (ETG), the MNTB created rules and regulations that forced this group of grocers to stay open at all costs. No matter what. And to accept the price paid by the MNTB.

Grocer after grocer, bogged down by incredible regulatory costs associated with receiving 20, 30, 40 cents on the dollar for their tomatoes, one by one, they all left the entitled tomato market. No longer could you walk into any grocer, grab a bag of your favorite guaranteed tomato, and expect someone else to pay for it.

Moral

The Medicare Tomato is the reality of health care delivery today. It is the backwards approach to the rationing of a service that is finite. Health care is not an unlimited resource, and the policies of rationing will always best be determined by the personal financial stake that everyone has in their health care.

This doesn't mean cash only, insurance only, free care for all, or universal access. It is a rational approach to control demand, whether that be means tested or income dependent. Whether that means balance billing or high deductable policies. Whether that means shopping for service and quality through price transparency. Whether that means strictly catastrophic insurance coverage. Whether that means tort reform to reign in defensive medicine. Whether that means judicious use of a gate keeper Medical Home model. Whatever it means.

----------

Health Insurance is Not Health Care
High health insurance premiums result from high health care costs. If health care were not expensive, health insurance would not be expensive.

Military Healthcare is Not a Shining Example

Fix Military Healthcare First
06/24/09 - ChicagoBoyz by Shannon Love

We should test ideas and promises at a scale smaller than "everyone".

[edited] Megan McArdle asks (Via Instapundit): Why isn’t military healthcare a shining example, if socialized, politically managed healthcare is so great,? In fact, care sucks for both service personnel and their dependents.

My son-in-law in the Army injured his knee in a minor training accident. The Army hospital botched his treatment and almost cost him his career. Almost everyone in the military can tell a similar first- or second-hand story of poor treatment.

Pediatrician appointments must be arranged three days in advance. If my granddaughter develops a fever, my daughter must decide to tough it out or take her to the emergency room. The rules make care hard to get and increases costs by relying on emergency room visits.

The military system has all the advantages claimed for politically managed healthcare.

• It is huge and can buy medicines and technology at bulk discounts.
• Their personnel work for far less than the market
• They are under military discipline that no civil system can match.
• They have an integrated, computerized records system.
• The military standardizes treatments according to measured effectiveness.

All of these nominal advantages fail because the military healthcare system is a giant, politically managed system.

• The shear size of it makes it difficult for those at the top to know what is going on in the system. Small scale, bottom-up innovation is difficult.
• The system pays for the training of its personnel (just as Obamacare plans to), so managers have a disincentive to remove the careless or the incompetent. [A manager must spend money to train any replacements.]
• Patients have no other choices, so the system faces no market pressure. [It is a pre-paid service.]
• Politicians are more interested in cost control than in quality of care.

Leftists seem befuddled when asked to demonstrate that their ideas work on a small scale before imposing them on everyone. They believe that articulation and logic is enough and see no need to experiment.

For the rest of us, ideas need testing.

------------------

VA Medical System in Shambles
06/24/09 - Fox News by Joseph Abrams (via Instapundit)

So, a healthcare agency administered by government, for say 60 years, for veterans, isn't yet managed properly? Who would have thought that? (smile) Where is the internal oversight, dialogue, and search for excellence? More importantly, who are you going to sue?

[edited] Veterans Affairs hospitals botched radiation treatments to nearly 100 vets and exposed 10,000 to HIV and hepatitis viruses. Veterans advocates and lawmakers say the VA health system is in dire need of proper oversight and funding.

Veterans groups and lawmakers say VA hospitals have permitted these violations because federal regulations allow doctors to work with little outside scrutiny. They say the VA health system, with its under-funded hospitals and overworked doctors, is showing signs of an "institutional breakdown," in the words of one congressman.

"Lack of inspections, lack of transparency" were likely to blame, said Joe Wilson, deputy director of the Veterans Affairs and Rehabilitation Commission for the American Legion, who testified before Congress this month on transparency problems in a budgeting arm of the VA.

------------------

Canada's Healthcare Has Hidden Costs
"Access to a waiting list is not the same thing as access to health care"

Medicaid and Its Children

Medical Insurance 'Public Option' is Son of Medicaid
06/17/09 - WSJ by Daniel Henninger

Lard atop lard that only a politician could love

Medicaid is 44 years old, the first attempt to provide a healthcare safety net for the poor. Its scope has expanded and its costs are bankrupting the states. Obama's plan is a further expansion. Will a bankrupt country make good on its promises?

[edited] In 1965 Congress erected the nation's first two monuments to health-care "reform", Medicaid and Medicare. Medicaid was described as a modest solution to the problem of health care for the poor. It would be run by the states and "monitored" by the federal government.

Medicaid is worth our attention now because Mr. Obama is more or less demanding that the nation accept another reform, his "optional" federalized health insurance program.

Whatever Medicaid's merits, more than any other factor, it has put California and New York on the brink of fiscal catastrophe. I'd even call it scary.

Spending on health and welfare, largely under Medicaid, makes up one-third of California's budget of some $100 billion. Governor David Paterson notes in his budget message that "New York spends more per capita ($2,283) on Medicaid than any other state in the country."

I believe that $2,283 is the average cost per state resident to pay for the benefits that are delivered to only the medicaid recipients.

Medicaid has crushed state budgets. Over the years, Congress has loaded up more coverage, shifting about 43% of the ever-upward cost onto someone else, mainly the states. A 1988 congressional mandate requires local schools to pay for schooling and related services for disabled children. Because Congress underfunds its mandates, the states pay the rest through Medicaid.

The list of add-ons is endless, and little is thoughtful. Obama's "Public Option", like Medicare and Medicaid, will become an impossible fog for patients to navigate. The administrative complexity will provide work for bureaucrats, Members of Congress, their staffs, lobbyist spouses, and the "health-care" establishment of foundations and economists.

This is a public program inviting congressional meddling and litigation. Over time, the Sotomayors of the federal bench will make it bigger. For example, one piece of California's incredible budget mess flows from a federal judge's 2006 decision. He seized control of the state's prison-health system and made the state pay additional billions for new health benefits.

In his speech, Mr. Obama said the cost of the Public Option won't add to the deficit: "I've set down a rule for my staff, and I've said this to Congress. Healthcare reform must be, and will be, deficit-neutral in the next decade."

If we are honest, that means tax increases are inevitable. Sounds scary to me.

Lack of Competition in Health Care Insurance

Health care reform: The real problem is lack of competition
06/11/09 - St. Louis Post-Dispatch by David C. Rose

[edited] The Obama Administration is moving ahead on health care reform. Obama's plan will push nearly all Americans into government-provided health insurance. That is not a good thing. The problem with American health care is too little competition.

There is justifiable concern about the uninsured. Most Americans end up getting health care when they need it, but the current approach produces incredible anxiety and is ridiculously inefficient.

There is rising frustration with the increasingly shabby way insurance companies treat patients. Patients can't do what restaurant patrons do when they receive poor service, which is to go elsewhere. Most health insurance is tied to a job, so most patients are stuck with their insurance company. And it shows.

The Obama administration's plan will produce less competition. But, the solution is more competition.

Why is the health insurance market so uncompetitive, unlike other insurance markets? During World War II, a tax break was granted to non-wage benefits such as employer-paid health insurance premiums. Over time, this cost saving tied most American health insurance to employment. This forces patients to fire their employer before they can fire their insurance company. So, we get poor treatment from insurance companies.

For true competition in health care, it must be possible for individuals to fire their insurance company. This requires extending the tax break on employer-provided health insurance to all health insurance, including privately purchased policies.

Medicare is a good deal partly because the government drives a hard bargain with health care providers by offering artificially low payments. In a competitive market of many insurers, no one insurer could do this.

Artificially low payments don't cover the full cost of procedures, so health care providers shift costs to everyone else. In other words, the lack of competition in today's market leads to higher insurance costs for people who aren't old enough to qualify for Medicare. Extending Medicare-like insurance to everyone won't work, because no one will remain to pay the shifted costs.

[ The same applies to emergency room (hospital emergency department) prices. The law EMTALA forces ER's to treat all patients equally regardless of ability to pay. They must shift these costs onto those who can pay. This produces the amazing $10 ER aspirin. -ag ]

In a competitive market, driving such hard bargains is impossible, so prices reflect actual costs. The Obama administration plan will give us the worst of both worlds.

• Artificially low premiums will drive most private insurance out of business.
• There will be no place to shift costs.
• Shortly, we will have no reduction in cost from cost shifting.
• We will have substantially less competition.
• Less competition will result in higher actual costs.

This has been the experience in countries with nationalized health care. Many have an even worse looming entitlement problem than the United States.

The better solution is to give the same tax-free treatment to both individual-purchase and employer-provided health insurance. That would indirectly reduce the costs for covering the uninsured, which is the other major problem in American health care.

It is now very difficult to purchase insurance if you are not employed or if you work for a very small employer. Once insurance migrates out of large employer pools, sufficiently large pools will become possible with individualized insurance. Customers then would be able to vote with their feet if they are unsatisfied, and those who don't work for large employers no longer would have to pay higher premiums than everyone else.

There still would be some uninsured people. That could be handled directly through insurance vouchers. A voucher program would further eliminate distortions and reduce costs, not just shift costs.

A successful example is food stamps, which have essentially eliminated the problem of hunger in America. Food stamps are vouchers that provide direct payments while preserving competition. Small wonder they work so well.

A society may decide to provide benefits to people. The wrong way is to force the producers of those benefits to raise their prices to cover the extra costs. The right way is to give vouchers to those who are favored. The political problem is that vouchers reveal the value of the benefits, rather than hiding those benefits within the market.

-------------

ER Medicine and Bureacracy
08/31/08 - MDOD by 911DOC

Medicine becomes more expensive, harder to do, with worse outcomes, as government imposes intrusive regulation and arbitrary quality measures, despite any good intentions. Government Motto: "You say you are a caring doctor, so treat the poor for free."

Universal Health Care in Italy

Universal Health Care - Been There, Done That
06/10/09 - InsureBlog by Bob Vineyard

Cristina Folchitto reports her experience.

[edited] As an Italian citizen, I have experienced the “Utopia” of universal health care. It is a noble and ethically good idea, but it simply does not work.

It is not free. Every month a percent of your salary is taken out of your paycheck. You have no control of that money, you have no freedom to choose whether to have health care coverage or not. The more money you make, the more you pay, which is not fair nor directly linked to your health status or habits.

Hospitals are overcrowded, understaffed, mostly old buildings and infrastructure, without enough physicians or resources. You might have to wait several months to get a sonogram or an MRI. For a surgical procedure, you are put on a waiting list. You could be called months later at any time, any day to have the procedure.

If you cannot afford private care, after going through the painful process of public infrastructure, you still pay a co-pay according to the treatment you receive.

Private health care guarantees competition between doctors and medical institutions. The monetary gain stimulates a higher level of care and professionalism. This does not apply to the public system that often cannot afford to pay adequate wages to doctors, lowering the quality of medical service and almost eliminating research projects.

The psychological comfort of having health care “paid by the government” lowers the awareness and responsibility that people have towards their own health. It is easier for them to rely on future care instead of making the best lifestyle choices to stay healthy and in shape.

Having lived under both systems, I appreciate the freedom of choice that is given to me by a private health care system.

----------

They will pretend to pay - We will pretend to Treat

Political control of healthcare promises and payments has a sad history. Delaying payments has the same effect as reducing payments, since the state doesn’t catch up for a long time. The payment delays ensure that providers need to hold a big “rainy day” fund, since their employees want to be paid cash rather than IOU’s.

Medical providers can do little except complain to their local legislators. They can’t sue the State to speed up payments, and if they did, the state wouldn't care. Unlike insurance, which may be popularly perceived as unfair, there are no avenues of appeal if you feel the state is killing your business.

Begging for Medical Care

Natasha Richardson died from a ski accident due to a delay in treatment. Montreal does not have fast transportation to a full-service hospital, even near a ski area. Why not? Patients are a cost to the system.

The bureaucracy sees you as a cost, especially if you have already paid. All people and organizations seek income and avoid costs. Socialized or centralized healthcare is paid up-front and delivers services after the fact.

How hard will a system work to earn the money that they have already been paid? This is something that everyone can understand in their gut. A customer is lost without competition for his dollar.

More on Healthcare

Medical Rationing Details

How Will Medical Rationing Occur?
05/24/09 - MDOD by 911DOC

Dr. JN is a board certified Neurologist dealing with a flunky to get an MRI imaging test approved.

[edited] A 44 year old Rwandan woman with controlled HIV developed back pain with radiation down both legs. Bed rest and Advil don't work.

MRI Rejected by Medicaid "Not enough documentation, does not meet criteria". Call the MD line. Dr. X calls back, claims that he is a neurologist. "You're just too lazy to prescribe Advil, is that it? Or maybe you're just a chickenshit who doesn't want to get sued. You know it's nothing". Refused.

In 33 years out of school, no one has ever talked to me like that, least of all another physician.

Resubmitted with extensive documentation of infection risk in African patients with poor cellular immunity. Rejected.

Called again. Now they say, if I send her to a specialist and the specialist orders the MRI they'll do it. I AM a specialist.

5 weeks later, it's approved and finds a big spinal abscess, likely TB, cultures pending.

--------------
Can I Get Prior-Authorization To Kick Your Ass?
04/29/09 - MDOD by Lofty Zahari

[edited] Let me tell you how it usually goes when I try to get a wonderful, newer drug approved for my patients. I love Byetta and prescribe a ton of it. It is the only commonly-used drug for type 2 diabetes that lowers glucose AND helps patients lose weight. It often requires pre-approval from insurance carriers.

Dr. Lofty: Hi, I'm calling to get prior approval for Byetta for my patient.

CSR: And your question is?

Dr. Lofty: My question is, what information do you need to get this drug approved for my patient?

CSR: Yes (looks up questions to ask under 'Byetta protocol'). So, why does this patient need Byetta?

Dr. Lofty: Because they have gained 20 pounds over the past year on Actos and glyburide and in my experience I can get this patient's hemoglobin A1c down about 1% with about 20 pounds of weight loss using Byetta, and get them off of these other drugs.

CSR: I see. And what is the medical justification?

Dr. Lofty: I just told you the medical justification.

CSR: Yes, well, I'll need to fax over a two-page prior authorization form that will need to be filled out completely along with the last three chart notes documenting failure to achieve control with....

[Now, into the TWILIGHT ZONE, where we are magically free of social convention and can say what we wished we could say to one another ... ]

Dr. Lofty: Hey f---head with your G.E.D. diploma hanging on your cubicle wall, I went to f---ing medical school for four years, did three years of residency training plus a chief resident year, and have been practicing diabetes almost exclusively for ten years. My experience tells me this patient needs Byetta and I want him to have it NOW! Losing weight and shrinking the waist probably reduces cardiovascular risk in patients with type 2 diabetes.

CSR: Sir, we really don't give a flying f--- if your patient loses weight. We would prefer he or she remain on the cheaper, generic drugs that they are currently taking.

Dr. Lofty: Well, the patient sure would feel better in the long run losing twenty pounds and losing about 2 gallons of fluid from his legs.

CSR: Again, don't give a shit about this patient's quality of life. Too expensive to use this drug. This person won't be on our plan in two years, so we could give a rat's ass whether or not they lose weight or feel better. They'll be someone else's problem in two years.

--------------
Lateral Boomerangs
05/24/09 - Throckmorton's Other Signs by Throckmorton

Medicare makes the rules and people play the rules.

[edited] Medicare has a whole bunch of diagnoses that it will not pay for if a patient is discharged and readmitted within a short period of time. Nursing homes and extended care facilities are decreasing in number and want nothing to do with complicated patients, because of lawsuits and threats of lawsuits. Home care is the only option for patients that do no meet Medicare admission criteria and can't get into an extended care faclility. So, many go home and then need to be re-admitted.

The practical answer is to re-admit them at another hospital. A so-called "lateral".

A lot of folks went away for the holiday weekend, so they took grandma to the hospital! She was there 2 weeks ago for COPD breathing problems. The ER must admit her, but then the shell game starts to do the "lateral". Welcome to the world of federally managed healthcare.

+ + + + +

Why Test? You Are Already in the Hospital
It seems that Medicare wants to cut down on unneeded testing. The answer: Don't give the test at all if the patient is in the hospital. That will do it!

Together, We All Pay More For Healthcare

Health Care's Simple Economics
04/30/09 - by Donald J. Boudreaux, Chairman of the Economics Department at George Mason University.

Parable: "The ten of us went to dinner together. We agreed to split the bill. I ordered a bottle of wine, the Steak Grande, and the Fudge Remorse dessert. Eating as a group is quite expensive."

[edited] Consider Medicaid and Medicare, huge socialized health-care programs funded with tax dollars. Millions of Americans covered by them consume medical services without paying the full costs. The result is that these services are over-consumed.

Russell Roberts is my George Mason University colleague. He asks, if you go to dinner with a large group of strangers, and you know that the bill will be split evenly, will you order pricier dishes and drinks than if you were paying only for yourself?

The answer is surely "yes." Let's say that you'd be content to order the pork chop priced at $15, but would get even greater enjoyment from ordering the rack of lamb priced at $25. If you alone were responsible for your tab, you'd order the lamb only if it is worth to you at least the extra $10 that it costs. So suppose that you value the lamb by only $8 more than you value the pork chop. In that case, you'd order the pork chop. You wouldn't spend an extra $10 to get extra satisfaction worth only $8.

But if the bill is evenly shared among yourself and nine others, then if you order the lamb, your share of the higher bill will be only $1. That's $10 split evenly 10 ways. You'll order the lamb.

Such sharing of our medical-care bills takes place now on a massive scale. It is impossible to see how expanding this sharing will reduce the bill for each of us.

Why Test? You Are Already in the Hospital

The "Too Sick to be in the Hospital" Test
04/24/09 - Throckmorton's Other Signs by Throckmorton

Bureaucracies are amazing. They divide responsibility and ignore obvious problems to satisfy some grand plan.

It seems that Medicare wants to cut down on unneeded testing. The answer: Don't give the test at all if the patient is in the hospital. That will do it!

[edited] Medicare will not pay for a PET or CT scan unless it is done as an outpatient. If the patient is really sick from their cancer and is in the hospital, they can't have the test, even though it would help determine how best to treat them so that they can get better and leave the hospital!

Diagnosing people is expensive. If they are already very sick, just what is the point? (sarcasm warning)

All people and organizations seek income and avoid costs. Socialized or centralized healthcare is paid up-front and delivers services after the fact. How hard will a system work to earn the money that they have already been paid? This is something that everyone can understand in their gut. A customer is lost without competition for his dollar.

Begging for Medical Care
The bureaucracy sees you as a cost, especially if you have already paid.

Begging for Medical Care

Natasha Richardson and "Medical Capital"
03/21/09 - Blog.Mises.Org by William Anderson

The famous actress Natasha Richardson hit her head in a minor fall while skiing. She developed an increasing headache and serious symptoms that required emergency treatment.

She died from an epidural hematoma, bleeding between the skull and the tough membrane (dura) surrounding the brain. The blood pools, clots, and puts pressure on the brain, contained by the rigid skull. Pressure eventually pushes down on the brain stem enough to shut down neurological functions controlling heartbeat and breathing.

Montreal does not have fast transportation to a primary hospital, even near a ski area. Why not? Patients are a cost to the system.

[edited] Canada has socialist medical care. Socialist systems tend to be undercapitalized, because equipment costs money, but doesn't increase reimbursements from the state. For example, the county where I work in the U.S. has 80,000 residents and has as many MRI machines (internal imaging) as does Montreal with millions of residents.

It took three hours to drive Natasha Richardson from the Mount Tremblant ski area to the trauma center in Montreal, because Quebec has no medical helicopter system. Helicopters are common in the USA.

In Canada, no medical device or advanced service produces income for the hospital, because no one can charge medical consumers for anything. An MRI machine or helicopter is purely a cost in a budget. Medical facilities have only so much money, and the purchase of costly machines removes funds from paying medical workers.

When a hospital in the USA (for now) purchases an MRI, that machine provides an income to the provider as patients use it. It pays for itself by delivering superior care.

Lack of medical helicopter cost actress
03/21/09 - News.Yahoo by Mesfin Fekadu (via Econlog.Econlib) by David Henderson.

[edited] Tarek Razek is Director of Trauma Services for the McGill University Health Centre, representing six of Montreal's hospitals.

Driving to Mont Tremblant from Montreal is a 2 1/2 hour trip. That is the closest trauma center. Our medical system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States. Not being airlifted directly to a trauma center could have cost Richardson crucial moments. [This is what is available near a busy ski area -amg]

Richardson's initial refusal of medical treatment cost her two hours. Someone called 911 twice from her hotel room at the Mont Tremblant ski resort. She was driven to a local hospital that could not handle head trauma, then to a specialized hospital in Montreal, arriving about four hours after the second 911 call.

David Henderson:

[edited] The essence of "single payer" medicine in Canada is that only the government is allowed to pay for medical care. Thus the term "single payer."

The more serious the ailment, the more stringent the ban, with a few exceptions. So, if you want special treatment for cancer, you can't get it legally, and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world. It is far more extreme than the National Health Service of Britain.

That is what the world is like when you are a cost rather than a customer. When you go to an emergency room under socialized medicine, you are a pure cost. Your treatment may be directed by caring people of good will, but the institution is treating you only to raise its statistics, within the budget set at the annual (say) Medical Cost Process Review.

Another thought. What would the food be like at a socialized "free" gourmet restaurant run by the government? Would they even wipe the tables? Of course, tipping is forbidden, and please eat everything on your plate.

Did the Canadian health system fail Natasha Richardson?
03/20/09 - KevinMD

[edited] Would Natasha Richardson be alive today if she had gone skiing in the United States instead? I don't think it would have made a difference.

Epidural bleeds are treated by drilling a hole in the skull to relieve the pressure. This often results in complete recovery. However, time is of the essence, and some are wondering if Ms. Richardson would have fared better Stateside.

Community hospitals would likely lack neurosurgical coverage in remote resort areas in the United States. In fact, because of the huge malpractice risk associated with the field, a neurosurgeon might not respond to an emergency call at a community hospital.

It is very likely that Ms. Richardson would have been transported to a tertiary care center if her accident happened here. The difference is that she would have been flown by helicopter, rather than taking hour-long drives by ambulance.

Dr. Crippen in the UK blames the American wussification of today's doctor. A brave physician would have drilled the burr holes without the benefit of a CT scan (explanation and typical x-rays at the link):

It would be a career making or breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan.

Had this accident happened at base camp on Mt. Everest in a helicopter-blocking snowstorm, a doctor would likely have drilled. Had this accident happened in a ski resort forty years ago, before CT Scanners had been invented, a doctor would likely have drilled.

Then, a subdural/epidural haemorrhage was a clinical diagnosis. Apparently minor head injury, lucid interval, headache, sudden deterioration in consciousness, a dilated pupil, all adds up to an obvious diagnosis.

Medical technology has deskilled doctors.

Nurse Practitioners

Bilateral Queckenstedt's sign
02/20/09 - Throckmorton's Other Signs by Throckmorton

It seems that nurse practioners (NP's) are not a good replacement for doctors in an emergency room. But, they are "cost effective".

[edited] Nurse practicioners are nurses with 17 months of extra training. They replace an MD or DO who has 4 years of medical education plus 3-4 years of speciality emergency medical training.

ER cases that a doctor could treat and release can not be handled by NP's who either can't or don't know how. Worse, I am often called in for one problem and find that there is something totally different wrong with the patient. I wonder how many of the patients have been sent home with something badly wrong!

I asked a hospital administrator why the NPs are not discussing patients with their supervising MD's. He informed me that the supervising MD only reviews patient's charts. Further, the NPs can act independently.

Why don't they hire MD's? MD's cost too much because of their liability insurance. Nurse Practicioners are cheaper, with minimal insurance, because they are not held to the same standards! With EMTALA in the mix, I get called in for everything.

Medicare Witch Hunt

Dear Mr President, Medicare Stinks
02/03/09 - Distractible.org by Dr. Rob

Medicare is controlling waste, fraud, and abuse by driving doctors out of Medicare. We can wonder who will be left to treat Medicare patients "for free".

[edited] I am a primary care physician. About 20% of my patients are covered by Medicare. I consider it an honor to be a doctor to the elderly. The complexity of a person’s medical problems goes up exponentially as they near the end of their life. I spend more time per patient for my Medicare population - which is OK if I can be paid for my extra time and effort.

If Medicare auditors find “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. We will be presumed guilty unless we can prove that we are innocent.

They are looking for inconsistencies in the charting and the billing. These can be little things like:

• Failure to mention in the note the EKG we ordered, even if it is in the chart.
• The appearance of a “cookie-cutter template” in our notes. If all of our physical exams, review of systems, or impressions look similar, then it will be assumed we are trying to defraud Medicare.
• Forgetting to document a discussion about a diabetic eye exam.
• Certain ICD-9 codes will be accepted, but will “flag” that we are possibly trying to cheat Medicare. We need to be specific in our coding to avoid immediate suspicion.

We practice very good medicine and probably save money for the system, as a higher percentage of primary care in a community means lower cost. We use an EMR and are NCQA recognized for our diabetes care, and I think that our quality of care and documentation is in the top 10%. Yet we fear that your government employees are going to use us as scapegoats for the out-of-control costs of Medicare and put us out of business in the process.

We see what is being done to the hospitals by not accepting “No Pay” diagnoses (Never Events). That debacle is irrational and unfair, but the hospitals have no recourse.

That makes us extremely pessimistic about our odds when facing the hit-men from CMS. If a hospital with its lawyers and other resources can be hung out to dry, what chance does a primary care physician have?

We have never considered our acceptance of Medicare as something that actually makes business sense - we just like to care for the patients. But the increasing hostility we are seeing from the witch-hunters with their torches and angry mobs is making us really consider whether we can afford to stay on board.

Delayed Medical Tests

Emergency Primary Care (Not)
02/18/09 - DocsOnTheWeb by 911Doc

The Stark law (below) "stops" waste, fraud, and abuse by eliminating effective services. The government favors one-stop, no-other-choice shopping when the government provides medical services, but they require private doctors to fragment and delay their services.

[edited] Doctor's clinics are no longer allowed to provide on-site lab and Xray. The "Stark" law comes to mind. I witnessed a combination of poor primary care skills and the heavy hand of government.

An old man went in to his physician's office yesterday for a checkup. He 'wasn't feeling well' and the doc took him off one of his anti-hypertensive meds. Today he feels worse and WOW! the labs drawn at his checkup were resulted today and showed kidney failure and high potassium.

When the patient got to us in the emergency department, he was 'almost dead' with a pulse of 30. We brought him back from the precipice. I asked his primary doctor why the labs took so long to be resulted. He said, "We have to send out all labs".

This adds another pressure point to ER medicine. People know that their primary physician will not get answers that day. In this case it was almost a day late and a dollar short. Thanks Uncle Sam, you have prevented primary care physicians from committing fraud by over-ordering tests. Good job. Bunch of freaking putzes.

---------
Physician self-referral

The Stark law governs physician self-referral for Medicare and Medicaid patients.

Self Referral is a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement.

Critics of self-referral allege an inherent conflict of interest, because the physician can benefit from the referral. They suggest that such arrangements may encourage over-utilization of services, in turn driving up health care costs. They believe that it would create a captive referral system, limiting competition by other providers.

Others say that some problems may exist, but are not widespread. Physicians are responding to a need which would otherwise not be met, particularly in a medically underserved area.

Most laws are not written with a delicate hand. Instead of auditing abuse, our government eliminates efficient services, including standard lab tests, for all of the patients and doctors who are not defrauding the system. Broad-brush laws have real consequences.

Survive "Obama Care"

How to Survive "Obama Care"
02/11/09 - MDOD by 911DOC
A doctor in emergency medicine gives some advice about healthcare as specified by Obama and the "stimulus" bill.

[edited] Buried in the "stimulus" package is a bit on health care. It's not making the news in the way it should. It is the equivalent of a bomb threat to American Medicine.

Rationed care is on the way, and the folks who do the rationing will be government 'lifers' who can not be fired and just don't care. So here you go, get to work on these things quickly before the powers that be start watching you closely.

1. Obtain a second social security number and identification card that makes you ten years younger. Keep it well hidden and once you crack 70 years old, or whatever the new cut-off for 'extraordinary care' will be, you will not be kicked to the curb to die quietly at home.

The $500 you spend for this now may save your life later. And if you doubt that this will happen, I have a family member who left the UK twenty years ago because they would not do bypass surgery on her based on her age. She got it here.

(Read 2-5 at the link)

I can not conceive of the rationale for pushing this type of plan. It has been tried and has failed in the UK and, as we have detailed on this site, Canada has good primary care, but for those who do not get their brain cancer or breast cancer at a convenient time Canadians may wait until they die for their free care. They come here. That will stop.

The Benefits of Health Savings Accounts

Knockin' Wood: The Benefits of Health Savings Accounts - HSA's
02/03/09 - InsureBlog by Henry Stern

The Urban Institute doesn't like free market solutions to health care and insurance issues, so they decided to pick on the one product that is the most useful in reducing costs and insuring more people: consumer driven health care plans and HSA's. In reality:

• HSA's are attractive to people of all incomes.
• Those who need usual health care services benefit from these plans, which avoid costly "extras".
• High deductible HSA plans have lower premiums than expensive plans with lower initial co-pays. Since the plans have higher deductibles, it seems more likely that those with more health problems (up to a point, of course) will be more likely to make it through underwriting.
• 6+ million Americans are enrolled in HSA-eligible health plans. Their popularity is growing. Patients determine how much of their money to spend today, or save for tomorrow, for health-care expenses. HSAs allow patients to make prudent decisions for themselves.