Stanley Feld M.D., FACP, MACE Menu

Disinformation and the healthcare system

Permalink:

What Are The 3R’s?

July 22, 2015
inDisinformation and the healthcare system, Healthcare Insurance Industry, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests
• Leave a comment

Stanley Feld M.D.FACP,MACE

The 3R’s are the Risk Adjustment, Reinsurance, and Risk Corridors program built into The Accountable Care Act (Obamacare). The 3R’s were meant to encourage the healthcare insurance industry to participate in providing insurance to participants in the State Health Insurance Exchanges. President Obama has extended the 3R’s to included Federal Health Insurance Exchanges.

The 3R’s were activated because of the poor enrollment in the State and Federal Healthcare Exchanges. It was billed to offer protection to the healthcare insurance industry against any losses incurred by participation in Health Insurance Exchanges.

The healthcare insurance industry’s participation in Obamacare’s Health Insurance Exchanges was negative at first.

The Health Insurance Exchanges were viewed as a trap set by the Obama administration to control the healthcare insurance industry. In the process the healthcare insurance industry would ultimately lose money.

The healthcare insurance industry did not participate widely in the health insurance exchanges at first.

 “These risk-sharing programs are often called the “3 Rs” because they are Risk Adjustment, Reinsurance, and Risk Corridor.” The three risk-sharing provisions were intended to protect insurers financially, especially in the first few years the Exchanges are in effect if activated.”

The ACA includes various mechanisms to accomplish this goal including requiring insurers to cover everyone who applies, prohibiting insurers from imposing preexisting conditions limitations, and severely limiting the factors insurers can consider in setting premiums.  Obviously, these mechanisms put insurers at financial risk, since their underwriters won’t have sufficient data to predict claims costs, such as the number of people likely to enroll, their health status or claims history, or other demographic information on enrollees.

The Obama administration included this safety net for healthcare insurers. It also set the traps for the healthcare insurance industry.

Purpose of Permanent Risk Adjustment

To combat overall adverse selection since health insurance is now guaranteed to anyone who applies. Healthcare insurance carriers cannot impose pre-existing conditions limitations. They cannot vary premiums based on individual’s health status.

The trap is that the government will redistribute money between insurance carriers. The Permanent Risk Adjustment scheme is supposed to redistribute profit from insurers with lower claims enrollees to those with higher claims enrollees and losses.

All non-grandfathered insured plans in the individual and small group market, in or out of the health insurance exchanges, are supposed to pay for this redistribution of money. This redistribution is to be monitored by the federal government. (Another bureaucracy)

Does anyone think this can work? I don’t.The second R is the Transitional Reinsurance Program. It is to run from 2014-2016 and then stop running.

The Transitional Reinsurance Program’s purpose is to stabilize premiums in the individual market during the first 3 years the exchanges operate, because higher-cost (sicker) individuals are more likely to enroll early.

This program’s purpose is to redistribute money from group health plans that make a profit to certain insurers with Qualified Health Plans on the individual State and Federal Exchanges that have high cost (claims) enrollees to prevent loses for those insurance companies. This is supposed to encourage insurance companies to join the exchanges.

All group health plans are required to pay for losses in 2014. There has been no reporting as yet to let anyone know how this has worked out in 2014. This provision further exposes President Obama’s lie that “if you like your plan you can keep your plan.” He knew no one could keep their healthcare plan as the bill was written.

A specific waiver was provided for 2015 & 2016. There are a few self-insured plans that self-administer their claims. Most corporations use healthcare insurance companies as third party payers. Therefore, the wavier is essentially eliminated.

The traditional reinsurance program is going to be very difficult to administer.

The Temporary Risk Corridor for 2014-2016 makes the 3R program even more complicated and more difficult to administer.

The goal of the temporary risk corridor is to limit insurer gains and losses in first 3 years of Obamacare and place all healthcare insurance company risks on a level playing field. The healthcare insurers have a limited amount of data on the risk of claims for Health Exchange enrollees. The healthcare companies have histories of claims for Qualified Health Insurance Plans and the expected enrollment. The health Insurance companies have to guess at their actuarial risk if they participate in Obamacare in order to set premiums.

Limiting the healthcare insurance industry’s risk will be complicated for the government.

Insurers who have actual claims more than expected claims will be paid the excess if funds from these insurers are not sufficient. HHS is directed to pay the excess.

The problem is Obamacare (ACA) did not provide for creation of a specified source of funds or a revolving fund for HHS to pay this excess.

In 2014, the first year of the exchanges insurers received $450 million dollars. The source of the government funds is unclear.

An important concept about insurance reimbursement is always ignored. Insurance claims have nothing to do with the actual insurance reimbursement. Reimbursement is usually 50% less than the claims.

Therefore, the amount of supposed payment is doubled using claims to calculate payment and probably future premiums.

The government is hoping that the entire scheme is budget neutral. It will collect and redistribute the profit made by one insurance company to the insurance company that loses money from the high-risk patients.

The government thinks it will have no out of pocket reimbursement obligation.

The government plans to compare insurers within a state based on the average financial risk of their enrolled population.

“ To more evenly spread the financial risk among insurers, government payments are made to insurers who cover a higher-risk population (e.g., people who are older, sicker or have more chronic conditions) from the profit of lower risk insurers. “

Theoretically, the insurers who make a profit from the lower risk population pay the insurers who make less from their older, sicker population with many chronic diseases.

This is called redistribution of profit and wealth. I have a tough time believing that profit making companies will sign up for that.

Below are the formulas that will be used in 2014 and 2015 for the redistribution of profit of healthcare insurance companies.

“2014: Once an insurer has paid $45k in claims for an individual (the attachment point), the insurer is reimbursed for 80% of costs between $45k & $250k per person.  (Originally $45k was $60k)”

“2015: $70k attachment point per insured, then insurer will be reimbursed for 50% of costs between $70k & $250k per person.  HHS publishes a Notice of Benefit & Payment Parameters each March, with the numbers for following year.”

“If actual claims are within 3% of expected claims, insurers in Exchanges keep the profits or bear the risks.  If claims are 3-8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 50% of the gains (losses) and keeps (or bears the loss of) the other 50%.” 

“If claims are at least or > 8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 80% of the gains (losses) and keeps (or bears the risk of) the other 20%.”

It is all very complicated. It will be impossible to enforce. This is another Obamacare trick to fake out the very profitable healthcare insurance industry.

I think the healthcare insurance industry knows all this. They are taking steps at this very moment to dodge the Obama administrations trap.

The losers will be the American people who will experience an increase in healthcare insurance premiums and higher taxes.

Permalink:

CONGRESS DOES IT TO US, AGAIN

July 14, 2015
inDisinformation and the healthcare system, Healthcare Insurance Industry, Medicare, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP,MACE

Americans have lived through scandal after scandal and lie after lie during the Obama administration.

None of the guilty parties have been penalized.

President Obama lied about Obamacare. “If you like your doctor you can keep your doctor.” “If you like your insurance plan you can keep your insurance plan.”

Yet Obamacare continues to destroy our healthcare system as well as our economy with unconstitutional changes in the law, lies, increased regulations and an expanded bureaucracy.

Notable scandals have included the Benghazi affair, clandestine weapons to Syria, red line foreign policy retreats, IRS scandals, the Clinton email scandal, and now the Iranian nontransparent nuclear agreement scandal. I can go on and on.

The traditional media does not report the details of the scandals. There is little complaining from the traditional media about these scandals that President Obama reports as insignificant.

The scandals last only a few news cycles. Most of the scandals are then ignored. There is hardly ever accountability from or punishment for the guilty parties.

Republicans just sit back and do nothing to expose the scandals.

The number of uninformed Americans amazes me. Government policies are mentioned but are deemed by progressives as being insignificant. There is hardly ever any correlation between the scandals and the effect on our budget deficit and our economy.

I think Americans are finally starting to get it. They are becoming fed up with the unbridled arrogance of President Obama and congress.

The government is shafting American taxpayers without anyone knowing it.

The most outrageous scandal in Washington has been kept under the radar and away from the press.

The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staff with taxpayer dollars, sidestepping provisions of Obamacare.

How did this happen? Why wasn’t this reported in the press?

When President Obama and the Democrats were rushing the health care law through Congress without even knowing what was in it, Chuck Grassley (R-IA) managed, with strong public support, to insert a provision in the law requiring members of Congress and their staff to purchase insurance through the new health care exchanges.

Senator Grassley’s goal was to have Congress and their congressional staffs have the same healthcare insurance experience that millions of Americans were going to have.

His hope was to create a strong incentive for Congress to make sure that President Obama’s new healthcare insurance system worked.

When congress and the congressional staff realized the cost of being in the healthcare exchanges and they needed to give up Medicare C, Congress’ special Medicare program, congressmen and their congressional staff bitterly complained to President Obama.

President Obama had the Office of Personnel Management (OPM) issue a rule in 2013 allowing Congress and congressional employees to once again have taxpayers continue pick up most of the cost of their premiums.

State and federal health insurance exchange rules do not permit employers of large organizations to pay the premiums for their employees.

“Like many Americans being dumped into Obamacare exchanges, members of Congress and their staff stood to lose their employer contributions – in this case, the generous financing of their health benefits by taxpayers that they had before the law passed and took it away.”

The OPM ‘s rule makes clear that congressional members and staff  still can receive the contribution from the government even though they have purchased their insurance from their exchange.

Office of Personnel Management’s (OPM) changed the rule in 2013. The rule insulated these insiders from the premium increases of between $5,000 and $10,000 per person they would have otherwise faced if they were forced give up their taxpayer-subsidized policies and buy their insurance through the Obamacare exchanges.

This rule is illegal because it separates Congress and staff from the rest of the population. The only employers that can make contributions for their employees purchasing insurance through the exchanges are small businesses with less than 50 employees.

“There is no mechanism for employer contributions in the individual healthcare exchange market.”

Congress also filed false documents claiming the House and Senate each have less than 50 employees to qualify as “small businesses,” even though over 13,700 congressional employees have in fact signed up.”

 “ That’s fraud.”

Judicial Watch obtained these false documents in Freedom of Information Act litigation.

However, the documents were heavily redacted including the names of Senators and Representatives who signed these false documents under penalty of perjury.

The blatantly false documents stated that the Representatives and Senators each have only 45 employees. The congressional staff is not an individual Representative or Senator’s employee. They are government employees.

The employer, the federal government, has more than 49 employees and is not a small business.

“The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staffs with taxpayer dollars, sidestepping provisions of Obamacare.”

An important question the public has to know the answer to is which Senators and Representatives signed the false declaration.

“Senator David Vitter (La.), chairman of the Senate Small Business Committee recently tried to subpoena the documents in which the false declarations were made, but he ran into strong bipartisan opposition.”

Senator Vitter wanted to know how the House and Senate, with thousands of government employees, came to be officially designated as small businesses. He wanted to know who signed the false documents and have his committee question these representatives.

Fourteen (14 of the 19) members of his committee objected to Senator Vitter proceeding with the subpoena of documents.

Democratic senators on Senator Vitter’s committee all voted in lockstep to keep the signed documents a secret from the American people.

They are: Jeanne Shaheen (N.H.), Maria Cantwell (Wash.), Ben Cardin (Md.), Heidi Heitkamp (N.D.), Ed Markey (Mass.), Cory Booker (N.J.), Chris Coons (Del.), Mazie Hirono (Hawaii), and Gary Peters (Mich.).

Republicans on the committee who voted to keep the documents secret from the people are Mike Enzi (Wyo.), Jim Risch (Idaho), Deb Fischer (Neb.), Kelly Ayotte (N.H.) and Rand Paul (Ky).

Republicans on the committee voted with Chairman Vitter to issue the subpoenas to those whose signed the false documents were Marco Rubio (Fla.), Tim Scott (S.C.), Cory Gardner (Colo.), Joni Ernst (Iowa).

These Republicans were the only ones that voted for the vested interest of the American people.

This is a very significant scandal.

The traditional mainstream media should be reporting this scandal. I think the Representatives and Senators who signed the false documents should be booted out of office.

It is a perfect example of Congress and the President making backroom deals for the benefit of Congressmen their congressional staff.

The congress is ripping off taxpayers while taxpayers not only are paying for their illegally subsidizing healthcare insurance.

Taxpayers have to pay the increased premiums for their own insurance while they are paying for congress’ healthcare insurance by on illegal congressional maneuver.

This corruption should make the American people madder than hell if they knew this was going on.

However the media is the message. The media is keeping us stupid. This scandal like others will fade away as being insignificant.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

President Obama Tries To Bully The Supreme Court

June 10, 2015
inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama attacks his opponents, marginalizes them, throws them under a bus, lies, ignores reality, or bullies them.

The reality about Obamacare is that none of the stakeholders like it.

It is causing states with State Health Insurance Exchanges to go deeper in debt.

The government has been forced to create 37 Federal Health Insurance Exchanges. Premiums are skyrocketing because of poor enrollment and demographic distribution. Only people with pre-existing illnesses or those receiving subsidies are joining.

Premiums are now unaffordable even applicants receiving subsidies.

Obamacare is driving corporations providing healthcare insurance for their employees to figure out how to avoid providing healthcare insurance and penalties.

The government has provided waivers for companies such as McDonalds, Burger King and 1300 other companies to not participate in Obamacare.

 Obamacare has tried to take away Medicaid subsidies from states that did not start a State Health Insurance Exchange and would not expand Medicaid. The Supreme Court stopped that two years ago.

Obamacare has driven physicians into hospital employment. Many physicians are unhappy and less productive working for hospitals themselves.

Many physicians have retired early because of Obamacare. This is a bad sign in light of our present physician shortage.

Obamacare has created incentives for hospitals to create Accountable Care Organizations (ACOs).

Logically ACOs cannot work because they shift financial risk for patients on to physicians and hospitals and away rom the healthcare insurance industry.

Hospitals and physicians are finally starting to realize the risk and are dropping out of the ACO programs.

Obamacare has spent over one billion dollars for a web site that is still not fully functional.

The promise of universal healthcare coverage has resulted in more people being uninsured than before Obamacare was passed. Only 9 million people are signed up and 6.4 million receive subsidies.

The original prediction in 2009 for 2015 was 17 million participants.

The expanded Medicaid program in 14 states is  experiencing severe physician shortages and financial problems.

Obamacare patients and Medicaid and Medicare patients are starting to experience limitations on access to care and rationing of care.

I am only naming a few of the many problems Obamacare has created.

Yet with all these defects and failures President Obama has the gall to say,

 “There's something deeply cynical about the ceaseless partisan attempts to roll back progress.”  

"I understand people being skeptical or worried before the law was passed and there was no reality to examine. But now that we can see millions of people having health care—and all the bad things that were predicted didn't happen—you'd think it was time to move on."

Obamacare is not working despite President Obama’s claims.

I think it is time to move away from Obamacare and in another direction.

This week President Obama did another astonishing thing. It reveals   his consistent disrespect for the constitution and the separation of powers.

He has tried to intimidate the Supreme Court to rule in favor of Obamacare with his personal attack on the court and its upcoming decision in King vs. Burwell.

 “The law provides for subsidies only for policies purchased on exchanges "established by the state", inserted in the law as an inducement to states to set up exchanges.”

Congress limited the subsidies to State Health Insurance Exchanges to encourage the states to set up their own exchanges. Thirty-seven states saw the trap that President Obama was setting for them and refused to cooperate.  

The IRS, operating under the direction of President Obama, tried to “fix” the law by permitting federal exchange to provide subsidies.

The infamous Dr. Jonathan Gruber, a principle framer of Obamacare, who was paid by the Obama administration $375,000 for his consultations with the White House staff, said the exclusivity of state exchanges rewarding subsidies was put into the law to induce states to set up exchanges.

Dr. Gruber, a healthcare economist, also said the law would have not passed if the public was not so stupid and could recognize the lack of transparency of the law.

President Obama said at the time of the scandal that he did not know Dr. Gruber. President Obama said Jonathan Gruber played a minor role in the construction of Obamacare.

During the last month President Obama has used the traditional media to try to convince the Supreme Court and the American people that congress really meant to give the State Exchanges and the Federal Exchanges to ability to provide insurance subsidies.

Article after article was published confirming that what the law meant to say was both State and Federal Exchanges had the ability to provide subsidies. This was morally the right thing to do.

President Obama said this week. “That we have an obligation to put ourselves in our neighbor’s shoes, and to see the common humanity in each other.”

First of all congress didn’t write the law. It should have and it should have been bipartisan. Most Democratic congressmen who voted for Obamacare didn’t even read the law.

The IRS has no authority to change the letter of the law with a regulation.

The law as written should be the law. The Obama administration overstepped its constitutional limits. If the law is wrong, congress should amend the words to include subsidies for federal exchanges also.

Obamacare is a terrible law. It is distorting and destroying our already dysfunctional healthcare system. The Republican dominated House and Senate are not going to change a law that is self destructing, if the Supreme Court favors King and the letter of the law.

Since President Obama’s traditional media campaign has been a flop, he has personally gone after the Supreme Court. He tried to intimate it by challenging its integrity.

President Obama said, “Frankly, the Supreme Court should not have taken up the lawsuit challenging Obamacare subsidies.” 

Who is he to decide which cases the Supreme Court should take up?

 President Obama continued,“There is no reason why the existing Federal Health Insurance Exchanges should be overturned through a Supreme Court case,”

 President Obama is preparing the country to be angry at the Supreme Court if the Supreme Court rules in favor of King.

President Obama is disregarding the notion that the Supreme Court is interpreting and upholding the constitution, a concept he frequently ignores.

“I think it’s important for us to go ahead and assume that the Supreme Court is going to do what most legal scholars who've looked at this would expect them to do.”

 This statement is both a lie and a veiled threat to the court.

“Elena Kagan  recently wrote in another case that, "This Court has no roving license, in even ordinary cases of statutory interpretation, to disregard clear language simply on the view that (in [the IRS’s] words) Congress 'must have intended' something broader."

During oral arguments in March, Justice Antonin Scalia suggested Congress could step in and fix the problem.

“Congress just adjusts, enacts a statute. It would take care of the problem. It happens all the time,” he said. “Why is that not going to happen here?”

President Obama did say there was one way to resolve the dispute over the law: “Congress could fix this whole thing with a one-sentence provision.”

President Obama said, “He is puzzled by the legal challenges against his signature healthcare law, arguing there is ample evidence that the system is working.

“Fortunately, there's no reason to have to do it. It doesn't need fixing,”

President Obama keeps harping on the same lies. He believes if you tell a lie enough times it becomes the truth.

President Obama said, “Part of what's bizarre about this whole thing is, we haven't had a lot of conversation about the horrors of ObamaCare because none of them have come to pass.”

There has been limited conversation about the horrors of Obamacare in the media because President Obama and the traditional media have limited the conversation

President Obama cannot bully the Supreme Court into not of upholding the constitution and it obligation to interpret the constitution accurately.

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

Please have a friend subscribe

.

 

  

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Chaos Continues At HealthCare.gov

June 4, 2015
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems
• Leave a comment

 

Stanley Feld M.D.,FACP,MACE

http://wtvr.com/2015/02/20/obama-administration-extending-health-care-enrollment-deadline/

Chaos continues at healthcare.gov with the sudden departure of QSSI. QSSI was a minor hub manger of healthcare.gov in early 2014 when the site was failing. It became the major integrator and senior advisor.

CGI was the major integrator at first.  Michelle Obama’s college friend was a principle in CGI. The friend obtained the non-bid CGI contract. CGI was dismissed as the web site disaster unveiled itself. The contract was for more than $600 million dollars.

QSSI was hired as the senior advisor and the web site’s prime integrator.

QSSI is a subsidiary of Optum the IT healthcare arm of healthcare insurance company United Healthcare. 

 Andy Slavitt, a senior executive at Optum, joined CMS in June 2014. He had subsequently been heralded by CMS as the savior of healthcare.gov

He received a rare waiver from federal ethics rules at the time which allowed him to be involved in contracting issues involving Optum and the United Healthcare Group.

“When Slavitt joined CMS, a little known loophole in government hiring practices permitted him to pocket $4.8 million in tax-free money when he joined the government agency.”

Andy Slavitt was initially hired as deputy administrator of CMS. He was promoted to acting administrator when Marilyn Tavenenner left.

There has always been a question of conflict of interest between Slavitt , Optum and United Healthcare. It is not clear if Andy Slavitt is still at CMS.

“Republican Sens. Chuck Grassley of Iowa, and Orrin Hatch of Utah, asked CMS and United Health Group in June 2014 about Slavitt’s potential conflicts of interest.”

The answer to Senator Grassly and Hatch’s questions were never made public.

A scandal occurred recently when 800,000 Obamacare enrollees received incorrect subsidy information on the 1095-A tax forms sent by the federal exchange healthcare.gov.

Some enrollees were mistakenly told they received too large a subsidy, while others were told their subsidy was too small.

Publicity of this error was buried in the news that the Obamacare enrollment period for 2015 healthcare insurance was being extended until April 30th, after initially being extended to February 15th.

 The real reason for the extension appears to be poor enrollment in healthcare.gov despite the administration bragging that the enrollment was great.

 One month later Optum suddenly quit.

An Optum spokesman said,

 “Having achieved the goal of making HealthCare.gov a stable, reliable platform for people seeking health coverage, Optum will not seek to continue our role as senior adviser to HealthCare.gov,”

This isn’t the first time this has happened. Jeff Zients took over when healthcare.gov was launch in October 2013.

In December 2013 Zients, who Obama had turned to in the past to fix sticky issues, had “made it clear that he was not going to stay on the job past December.”

Kathleen Sebelius said in a blog post,

“Today, the site is night and day from what it was when it launched on October 1. I am very grateful for his service and leadership," Secretary of Health and Human Services.”

The Obama administration then announced that former Microsoft executive Kurt DelBene took over the operation of HealthCare.gov in December 2013 in consultation with Marilyn Traverner and QSSI.
 

Somewhere in 2014 CGI was rehired and DelBene left. QSSI remained.

CGI was then relieved in December 2014.

Accenture was hired. In December 2014 Accenture was rehired with a $563 million dollar contract to run healthcare.gov.

“The Centers for Medicare and Medicaid Services (CMS) in January dropped a key contractor on the project, CGI Federal, and selected Accenture Federal Services to rehabilitate and build out the portal.”

Suddenly, in May 2015, QSSI quit.

This all seems fishy to me. The price tag of more than $1.1 billion dollar for healthcare.gov seems very high. The web site is still incomplete. The healthcare insurance premiums are unaffordable and rising.

Consumers and physicians do not approve of Obamacare.

State exchanges are losing money they cannot afford. There is little evidence that the electronic medical records program is increasing the quality of medical care.

The individual health insurance market through healthcare.gov is a mess.

The public does not know how many people are uninsured, have become uninsured and do not have access to medical care.

Obamacare has been delayed in the group market. Private insurance has increased in price. Large corporations are increasing part-time employment to avoid paying for employees’ healthcare insurance and to avoid federal government penalties.

Yet, the Obama spin machine is trying to influence the public and the Supreme Court through the media saying the subsidy should be extended to the Federal Health Exchanges.

It all seems crazy to me. There is a better, more efficient way to help Americans purchase insurance and be protected in case of serious illness.

It is not a government run single party payer system. The government cannot even build an efficient website.

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

The Shovel Ready EMR Project?

May 22, 2015
inDisinformation and the healthcare system, EMR
• Leave a comment

Stanley Feld M.D.,FACP,MACE

  The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the $800 billion dollar economic stimulus package towards digitizing medical records.

This was considered one of President Obama’s shovel ready projects. This project has lots of problems and was much less than shovel ready.

It was George W. Bush, not Obama, who started the project to digitize medical records. EMRs make sense if they are directed toward improving patient care.

President Obama funded the project with his shovel ready economic stimulus package in 2009. Physicians dislike the project. Patients find little value in the project.

It is estimated that in five years 50 times more health information will be generated and digitized than today. Diagnoses, treatments, DNA, medical images and vital signs already are being analyzed and stored.

One large problem is Americans don’t own their own healthcare information.

In its present form patients find little useful information in the EMRs. Many of the EMRs do not fit the Obama administration’s criteria of meaningful use EMRs. Medical practices will experience a penalty this year.

Government punishment hardly ever works. Government providing for innovative opportunities works.

The government and the insurance industry own the information.

The big data is derived from meaningful use EMRs. The government is only interested in evaluating the quality of physicians’ care. The government would like to decide on the reimbursement of that care.

The EMR has not added value to patient care because physicians have to spend too much time concentrating on filling in required documentation. Much of the information is worthless because they cut and paste template reports that are required documentation for the government to judge. The medical record is cluttered with information that is not useful.

The cost is physicians do not have time to relate to patients.

Michael F. Raab, M.D.Sanibel, Fla writes in the WSJ

 “I recently received 147 pages of EMR which took me 30 minutes to review. I only found three lines that added new information.”

HIPAA (Health Insurance Portability and Accountability Act) requires hospitals, physicians, labs, pharmacies and other “covered entities” as well as the health plans and their “business associates” (for example, an information-technology vendor) to protect how your data. This rule applies only to paper record. It does not apply to digital records.

“Most EMRs aren’t covered by HIPAA at all, and providers and vendors can do whatever they want with your information.”

Digital records are vulnerable to hackers. Health records were stolen from nearly 80 million Anthem health-plan members. The façade of privacy has been exposed.

Electronic medical records companies, and hospitals and health systems that own physician practices own the patients’ digitized healthcare records.

These entities have withheld health information from patients in order to gain an edge over competitors. It becomes difficult for patients to switch to other healthcare plans or providers without their records.

Patients are entitled to their records but they must get past vendor delays.

There is great financial value of patients’ data beyond competitive advantages to these providers. The value is in marketing research for specific demographics. The revenue comes from using health information for drug research, targeted marketing and other efforts.

Many big data companies are investing heavily to own a piece of the multi-billion-dollar monetization of health information.

 “These companies know that whoever controls health information will dominate the health-care marketplace and its vast profit pool.”

Congress has been slow to fix these problems. It needs to update health-information policy and privacy rules.

These are the four most important rules that Dr.David Brailer (the former national health information technology coordinator in the Department of Health and Human Services (2004-06)has outlined.

"1. Individuals should have unqualified ownership of their health information. Every person should be able to access his information whenever he wants, without blocking or delay.

1a. Health information should automatically follow patients wherever they get treated, unless they don’t want that to happen.

1b. Patients should be able to control which people and organizations are allowed to see their information, and whether those organizations can retain that information.

2. Individuals should be able to designate an intermediary to manage their information on their behalf. Many people would not want to handle their health information, so an “infomediary” could assist them and ensure that their information is used to advance their health status.

2a. Intermediaries could be a spouse, a hospital, a health plan, a pharmacy or even a tech company like Google, SalesForce or Yahoo.

 3. Standards for security protection should be raised so that information is protected wherever it flows.

3a. A secure medical Internet—encrypted data lines that are walled off from hackers and other threats—is needed to protect the perpetual movement of information among hospitals, physicians and other legitimate data holders.

4. Every “covered entity” that touches health data, including every app, should follow the same rules."

Congress must act now!

The goal of the EMR was to have computers that could talk to each other for instant availability of patients’ medical information to enhance care and decrease retesting.

The availability of the $30 billion dollar Obama stimulus and the lack of consumer control has led to an evolving inefficient bureaucracy and rules and regulations that have created pain for the two most important stakeholders, patients and physicians.

The EMR project was not shovel ready as President Obama promised. It has turned out to be a waste of money. Instead of improving patient care it is hurting patient care.

An effective healthcare system would provide consumers with ownership of their healthcare data, their healthcare dollars and a desire to be responsible for their health.

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

Please have a friend subscribe

 

  

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Medicaid Extortion

May 17, 2015
inDisinformation and the healthcare system, Medicaid, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests
• Leave a comment

 

Stanley Feld M.D.,FACP,MACE

This topic is obscure. It is important because it is a defense of states rights opposed to federal control. The Obama administration wants to control states decisions through the use of subsidies 

I will try to make the issue as clear as possible.

The Obama administration has threatened to decrease funding of Medicaid in states (Florida, Texas and other states) that have declined to expand their Medicaid program.

The reason these states have declined to expand Medicaid is because at the end of two years these states would be stuck with increased costs they cannot afford to pay.

The Obama administration volunteered to pay all expenses for the first two years. When states that have expanded Medicaid under Obamacare are forced to raise taxes and increase their budget deficit, the people in those states will scream. The state will be hurt economically.

Obamacare and the state health insurance exchanges were designed to shift the financial responsibility for Medicaid from the federal government to the states. This action will drive the state budget deficits higher while slightly decreasing the federal deficit.

The federal government can print money. State governments cannot. State governments are required to have a balanced budget or an excess. A budget excess would result in lower state income taxes.

In June of 2012 the Supreme Court upheld the constitutionality of the Affordable Care Act by changing the “individual mandate” penalty for non-compliance to an individual tax.

I thought the court decision was wrong.

Americans must abide by the Supreme Court’s decision. This part of the decision captured the most media attention.

At the same time the Supreme Court struck down the Obamacare provision that let the federal government withhold Medicaid funding from any state that did not expand its Medicaid program or form a state insurance exchange as prescribed in the law.

 “This coercion of state governments—a “gun to the head,” as Chief Justice John Roberts put it—was a blatant violation of the constitutional principle of federalism.”

 The traditional mainstream media did not advertise this ruling widely. Many do not fully appreciate the significance of the ruling.

It is a decision in favor of states rights.

The traditional media has criticized the governors of Texas, Florida an eight other state governors that did not set up state health insurance exchanges. The criticism was that those states were wasting billions in federal funding.

In reality the ruling was a major blow to Obamacare. These governors know that Medicaid is a failed entitlement. All Obamacare did was expand Medicaid coverage to cover everyone earning less than 138% of the federal poverty level.

They knew they will be stuck with the cost overruns from a failed entitlement that did not fix the healthcare system. The ultimate result would raise taxes. These state were looking for a healthcare coverage program that would work and be budget neutral. Medicaid has not been budget neutral.

Everyone above 138% of the federal poverty level income threshold would get a subsidy to buy private coverage through the state health insurance exchanges.

The Supreme Court’s ruling has not bothered President Obama. He has a plan to get around that ruling. He has threatened to withhold more than $1 billion in Medicaid funds due the state of Florida under a waiver program first approved in 2005.

President Obama is threatening to cancel a five-year $29 billion dollar Medicaid waiver approved in 2011 for Texas.

Florida’s governor Rick Scott is suing the federal government for threatening to withhold that $1 billion. Greg Abbott Texas’ present governor will probably sue the federal government next. It will once more go to the Supreme Court.

The Obama administration is trying to get around the Supreme Court’s ruling .The scheme is called “cooperative federalism”.  Congress taxes a particular state’s residents. Congress then offers to give some of the revenue back to the state in exchange for that state adopting federal policies that the state had heretofore declined to adopt on its own.

President Obama is going to have a few problems. He needs a Democratic controlled Congress to pass the law to tax some states.

Medicaid payments are complex and vary from state to state. In Florida and Texas, Medicaid waivers allow these states to experiment with new forms of Medicaid coverage.

It is a smart move because Medicaid is a failed entitlement that needs a paradigm shift or a new system. States are supposed to be able to experiment with new ideas using these waivers..

 “States must get federal approval for their waivers, and although technically most are limited to five years, in practice they can be renewed or extended indefinitely. Some state waivers are decades old.”

Florida and Texas have waivers and get federal funding to pay for uncompensated care payment to hospitals treating Medicaid patients and the uninsured. 

The Obama administration informed Florida and Texas that expansion of Medicaid “would reduce the need for uncompensated care in the state and therefore he would link the waiver to expansion of Medicaid. If a state did not accept Medicaid expansion it might endanger the renewal of its waiver.

This sounds like extortion to me. I think Governors Scott and Abbott believe it sounds like too.

Chief Justice Roberts noted in the court’s ruling that Medicaid expansion under Obamacare “accomplishes a shift in kind, not merely degree.

“ Medicaid “is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage run by the federal government. ”

The Supreme Court found the conditions on federal funding of Medicaid to be coercive . 

When federal funds with conditions attached comprise such a large portion of a state’s budget, states do not really have any choice but to comply to the federal government’s wishes.

 States will find themselves unprotected from coercion by the federal government once they enter into the “cooperative federalism” scheme that President Obama and his administration concocted to bypass the Supreme Court’s ruling.

This example represents another trick play by President Obama and his administration in order to control and limit states’ rights.

I believe Chief Justice John Roberts understands this and the court will rule against the Obama administration.

However, the Obama administration’s threat will result in a huge waste of taxpayers’ dollars at both the state and federal level.

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

Please have a friend subscribe

  

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Obamacare Enrollment Deceptions Continues

May 3, 2015
inDisinformation and the healthcare system, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP, MACE

I made a big deal out of the poor enrollment in Obamacare throughout the winter.

There are more than 330 million Americans who should have healthcare insurance. In 2014, 15 million people lost their healthcare insurance because of Obamacare regulations.

At the end of the healthcare enrollment period for 2014 the Obama administration claimed there were 9 million enrolled in health insurance exchanges. The number was modified to 6.7 million enrollees because of mistakes in counting dental plans and non-payment of the enrollees’ initial premium.

Never the less President Obama did a victory lap and declared Obamacare is working. Nothing could be further from the truth.

It is very difficult to keep track of all the false numbers thrown at the public.

The 2015 open enrollment period was delayed one month until after the mid-term elections for political reasons. President Obama and the Democrats wanted to keep the conversation about Obamacare out of the traditional media headlines.

The enrollment period of November 15th to December 31st was extended to February 15th 2015. On February 16th it was extended to March 1st 2015.

On February 16, 2015 Aaron Albright, as CMS spokesman announced,

 “Americans who couldn't enroll in federal Obamacare insurance plans over the weekend because of computer glitches or long waits will now have until next Sunday to sign up, federal officials announced early Monday.

"We are pleased that the vast majority of consumers were able to apply and pick a plan through HealthCare.gov or its call center without a problem,"  

"For those consumers who were unable to complete their enrollment because of longer than normal wait times at the call center in the last three days or because of a technical issue such as being unable to submit an application because their income could not be verified, we will provide them with a time-limited special enrollment period for March 1 coverage."

“The special enrollment period begins Monday and ends Feb. 22.”

 The extension was prompted by the Saturday outage of an Internal Revenue Service function for Obamacare enrollment, which could have prevented about 500,000 people from enrolling.

The enrollment period was extended to allow those predicted 500,000 to enroll.

The enrollment period was was extended from February 15th to February 22nd and the March 1st.

 On March 1st a special tax penalty enrollment extension was started to expire April 30th.

Only 98,000 enrolled during that 2 month extension. The predicted five hundred thousand (500,000) people did not enroll as was announced.

On December 15th  2014 these were the published enrollment figures.

 

“ Confirmed 2015 QHPs: 3,039,524 as of 12/15/14”

“Estimated 2015 QHPs (Cumulative):


11/21: 610K (462K HCgov) • 11/28: 1.02M (765K HCgov) • 12/05: 1.80M (1.35M HCgov) Thru 12/15: 4.70M (3.52M HCgov”

http://acasignups.net

Enrollment by state can be studied in the following link.

The Obama Administration bragged:

“The number of people enrolling or re-enrolling last week was considerably higher than in previous weeks. Week one saw 500,000 enrollees, week two had 300,000 and week three saw 600,000 sign up through HealthCare.gov.”

Only 3.4 million sign ups were confirmed to receive healthcare coverage by January 1,2015.

This is only seventy percent (70%) of the expected enrollment through 12/15/14. The enrollment had been extended before New Year to February15, 2015.

“The government estimates a total 10.7 million will enroll by February 15,2015. On February 2,2015 there were 7.53 million qualified enrollees. The original estimate in 2010 was 17.5 million. The first 2015 estimate enrollment in 2014 was reduced 3 months ago to 13 million. The enrollment figure was modified.”

Somehow, the February 22 deadline was extended to April 30, 2015. The Obama administration continues to make up the rules as the go.

 On April 28th two days before the open enrollment period was supposed to close for 2015 http://acasignups.net/ publish these figures.

 

Confirmed Exchange QHPs: 11,897,180 as of 4/28/15
Estimated: 12.30M (9.38M via HCgov) as of 4/28/15
 

http://acasignups.net/

It is important to note that only 9.38 million people enrolled via HCgov in 2015. There is no change from the 2014 pre modification of the 2014 data.

It is not known how many enrollees paid their first premium.

None of these fact have been reported in the traditional media. Obamacare and the health insurance exchanges are not doing as well as President Obama says they are.

President Obama and his administrations continue to lie to Americans about enWhen is the American public going to demand a stop to the Obamacare deceptions?

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

Please have a friend subscribe

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

How Should Healthcare Quality Be Measured?

April 26, 2015
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D., FACP,MACE

 The U.S. Preventive Services Task Force’s (USPSTF) grading system for measuring the quality of healthcare is an wrong. It results in a way to limit physicians’ judgment and treats medical care as a commodity. It enables a computer program to judge if physicians have followed an algorithm to treat patients.

 “The U.S. Preventive Services Task Force (USPSTF).[57][citation needed has developed grading systems for assessing the quality of evidence for making judgments about treatments. 

  • Level I: Evidence obtained from at least one properly designed randomized controlled trial.
  • Level II-1: Evidence obtained from well-designed controlled trials without randomization.
  • Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
  • Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
  • Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.”

The grading system is wrong. I will lead to shabby medical care. If quality of care should be measured, it should be measured by using Evidence-Based Behavioral Practice evaluations

 “Evidence-based behavioral practice (EBBP) "entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected.”

“Empirically supported treatments (ESTs) in some clinical settings are defined as "clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population" [3]

Only when physicians’ clinical judgment and observations are included in the assessment of their quality of medical care should evaluation of that quality of care be measured.

The narrow criteria of the USPSTF will not define quality. It will only serve to restrict access to care and penalize physicians for using clinical judgment and consumers’ from receiving medical care.

Suddenly, it becomes easy to see how difficult it is to assess the quality medical care.

There is little question that an occasional physician practices terrible medicine. This is obvious to the medical community. The mechanism for improving a bad physicians quality of care is in place but not well executed.

Few, especially healthcare policy wonks, seem to understand the difficulty of assessment of medical care.

It should be easy for policy wonks to understand the limitations and criticisms of evidence based medicine.

Yet the Obama administration regards evidence-based medicine as measured presently as the gold standard of clinical practice,

Limitations and Criticisms of Evidence-Based Medicine (EBM)

  • EBM produces quantitative research, especially from randomized controlled trials (RCTs). Accordingly, results may not be relevant for all treatment situations.[67]

This is obvious to most physicians.

  • The theoretical ideal of EBM (that every narrow clinical question, of which hundreds of thousands can exist, would be answered by meta-analysis and systematic reviews of multiple RCTs) faces the limitation that research (especially the RCTs themselves) is expensive; thus, in reality, for the foreseeable future, there will always be much more demand for EBM than supply, and the best humanity can do is to triage the application of scarce resources.

The reasons for EMS shortcoming are listed below. The list is not complete.

  • Because RCTs are expensive, the priority assigned to research topics is inevitably influenced by the sponsors' interests.
  • There is a lag between when the RCT is conducted and when its results are published.[68]
  • There is a lag between when results are published and when these are properly applied.[69]
  • Certain population segments have been historically under-researched (racial minorities and people with co-morbid diseases), and thus the RCT restricts generalizing.[70]
  • Not all evidence from an RCT is made accessible. Treatment effectiveness reported from RCTs may be different than that achieved in routine clinical practice.[64]
  • Published studies may not be representative of all studies completed on a given topic (published and unpublished) or may be unreliable due to the different study conditions and variables.[71]
  • Research tends to focus on populations, but individual persons can vary substantially from population norms, meaning that extrapolation of lessons learned may founder.
  •  Thus EBM applies to groups of people, but this should not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.[56] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."[72]
  • Hypocognition (the absence of a simple, consolidated mental framework that new information can be placed into) can hinder the application of EBM.[73]
  • Valid enthusiasm for science should not cross the line into scientism, losing critical perspective.
  •  Although clinical experience and expert opinion are insufficient by themselves, neither are they valueless, as EBM fervor that approaches scientism sometimes tends to paint them.

This last point is repetition of a very important shortcoming.

  • An informed clinician can weigh confounding variables in a clinical case and decide that following a population-based guideline to the letter feels inadequate for the situation. Thus clinical backlash against "cookbook medicine" is not always misguided, and "guidelines are not gospel."[74]
  •  Conceptual models, by having fewer variables than always-multivariate reality, face limits of predictive accuracy, just as even the best supercomputer simulations cannot predict the weather with 100% accuracy, whether because of the butterfly effect or otherwise.
  •  Thus, just as clinical judgment alone cannot give epistemological completeness, neither can RCTs and systematic reviews alone.”

The answer to the reader’s last comment and question, “I believe a carrot and stick approach may be necessary with more carrot and less stick.  Your thoughts?” is

I believe that government must learn how to evaluate quality medical care accurately, if they want to base healthcare payments on the quality of medical care. Presently, the government is far from achieving that goal.

It could also be that measuring quality medical care is not President Obama’s goal.

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

Please have a friend subscribe

 

 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Meaning and Significance Of Evidence Based Medicine

April 22, 2015
inDefective scientific studies, Disinformation and the healthcare system, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP, MACE

I received the following from a reader after re-publishing Medical Care Must Not Be Converted To A Commodity.

"Hello Dr. Feld,

Can I ask a question regarding voluntary Physician compliance with evidenced based care. Your thoughts 

Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe a carrot and stick approach may be necessary with more carrot and less stick.  Your thoughts?

Thanks,

These are three great questions. They demand an answer.

1. Can I ask a question regarding voluntary Physician compliance with evidenced based care? 

This question is very difficult to answer with our present state of knowledge.

There is no Level 1 evidence based data available to the answer question.

Level 1 is evidenced based data is defined as;

Level I: Evidence obtained from at least one properly designed randomized controlled trial

2. Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe most practicing physicians try to comply with clinical guidelines written by their specialty organization. Most specialty organizations publish guidelines.

The guidelines are taught in courses physicians are required take to obtain Continuing Medical Education (CME) credits required for medical re-licensing. Guidelines by specialty groups differ slightly reflecting each specialty organizations clinical emphasis, clinical experience and clinical judgment in addition to the available evidence based medicine.

It would be nice to be able to determine if each physician in the country was up to date in every single area of medicine and surgery.

I would also be nice to have accurate measurable criteria to judge physicians’ practices.

How do you evaluate physicians’ judgment and clinical experience with a computer program? You can not.

This is the reason physicians object to cookbook medicine and the commodization of medicine and surgery. Physicians have been trained to use clinical judgment. Clinical guidelines and algorithms are a guide to help physicians reach the best conclusion they can reach.

The problem with evidence-based medicine is that does not define quality medical care. It defines the quality of studies that are rigid protocol studies that do not honor clinical observations, experience or  judgment.

I have made this clear with my observations about the deficiencies in the USPSTF’s studies and conclusions about subclinical hypothyroidism, the PSA value or the study of osteoporosis in men over 70 years old and breast cancer screening to mention a few.

In this era of decreased funding money for clinical studies that are random, double blind controlled research studies is rare.

Observational data studies and clinical judgment studies are considered weak and invalid.

Who suffers?

Patients suffer as the government takes over more of the healthcare payment system. Government is making consumers dependent on government’s healthcare decisions.  Government relies on the advice of the USPSTF to determine the value of treatments. Many of the USPSTF conclusions are invalid in my opinion.

Rather than going through the explanation of the shortcomings in Evidence Based Medicine (EBM), on which the conclusions of the USPSTF is based, I quote the literature and will let my readers judge for themselves.  

Evidence-based medicine (EBM) is a form of medicine that aims to optimize decision-making by emphasizing the use of evidence from well designed and conducted research.

Please note that clinical judgment and observational studies are not valued.

a. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations.

In my opinion meta-analyses is invalid statistical trick. It combines studies that do not have the same design. Each included study has different numbers of patient and different statistical power along with statistical significance. Combining different study designs does not increase statistical significance overall.

 b. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians.[1]

EBM is one factor in improving medical care treatment. It should not be used exclusively in evaluating quality and paying for medical care.

Consumers of medical care are the ones that can evaluate the many factors that make up quality care. Unfortunately the government has no interest in the consumers of medical care. The focus is on decreasing the cost of care and not on improving the quality of care.

c. Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to populations ("evidence-based practice policies").[2]

It has subsequently spread to describe an approach to decision-making that is used at virtually every level of health care yielding the broader term evidence-based practice.[3]

What is evidence-based practice?

Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992.

Its basic principles are that 1) all practical decisions should be made based upon research studies

2) That these research studies are to be selected and interpreted according to some specific norms characteristic for EBP.

Typically such norms disregard both theoretical and qualitative studies.

3) EBP considers quantitative studies according to a narrow set of criteria of what counts as evidence. If such a narrow set of methodological criteria are not applied, it is considered better just to speak instead of research-based practice.[1]

Students of EBM, EBP, and EBBP are starting to recognize the limitations of Evidence Based Medicine (EBM).

The methodology used by the Obama administration should be change before both healthcare and medical care are completely destroyed.

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.