Stanley Feld M.D., FACP, MACE Menu

Patients Problems

Permalink:

Those Indecipherable Medical Bills? Part 2 CPT Coding Is One Reason Health Care Costs So Much

Stanley Feld M.D.,FACP,MACE

After Ms. Wanda Wickizer was discharged from the University of Virginia Healthcare System (Part 1) the catastrophe caused by the healthcare system’s coding process began.

“The acronym HCPCS originally stood for HCFA Common Procedure Coding System, a medical billing process used by the Centers for Medicare and Medicaid Services (CMS).”

“Prior to 2001, CMS was known as the Health Care Financing Administration (HCFA).”

HCPCS was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care.

The cost of Medicare and Medicaid became so high that the government decided to start knowing what it was paying for and standardizing the payments.

Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner.”

This coding system has been dysfunctional since the government developed it for Medicare and Medicaid in 1978.

The unspoken goal was to decrease reimbursement for services provided for Medicare and Medicaid patients.

The government wanted to commoditize can reduce reimbursement by the evaluation of physician and hospital usage of procedure and services.

Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.[2]

Ms. Rosenthal’s story is about how this poor woman, Wanda Wickizer, got trapped in the dysfunction of the healthcare system’s coding system.

Wanda Wickizer should have been insured through Obamacare. However, through the inefficiencies of the government or Ms. Wickizer lack of understanding of Obamacare she did not have insurance.

The healthcare system makes no provisions for billing the uninsured.

There are multiple prices charged for treatments and procedures. Hospital systems and physician groups have their own individual retail prices for services and procedures.

These providers negotiate prices with the government and the healthcare insurance industry.

There are many different prices negotiated by many different providers with the healthcare insurance industry. A healthcare insurance company negotiates many of the government’s final prices. The healthcare insurance company acts as the surrogate for the government.

None of these prices are transparent.

There is no one that negotiates price for the uninsured. The uninsured are responsible for the retail price of the services rendered unless they can negotiate a better price.

“And so in early 2014, without an insurer or employer or government agency to run interference between her and the hospital, she began receiving bills:

  • $16,000 from Sentara Norfolk (not including the scan or the E.R. doctor), $50,000 for the air ambulance.
  • Her local hospital
  • By the end of January, there was also one for $24,000 from the University of Virginia Physicians’ Group: charges for some of the doctors at the medical center. “I thought, O.K., that’s not so bad,” Wickizer recalls.
  • A month later, a bill for $54,000 arrived from the same physicians’ group, which included further charges and late fees.
  • Then a separate bill came just for the hospital’s charges, containing a demand for $356,884.42 but little in the way of comprehensible explanation.”

The uninsured are the only people who are responsible for the original retail prices. All the rest of the payment providers, namely the government and various members of the healthcare insurance industry pay their negotiated fees.

Shouldn’t the government pass a law requiring hospitals and doctors to charge only Medicare prices to the uninsured? It would eliminate Ms. Wickizer bill, a bill that reflects retail prices for services rendered.

The big mistake the University of Virginia made was that it did not provide her with a line item bill identifying the price of each service and procedure.

The University of Virginia subsequently refused to provide a line item bill to the patient. It was as if the university was hiding something.

Any thoughtful hospital administrator would have solved the problem in a minute.

It must be remembered that each provider has a different retail price per procedure and service. The reasoning is that they are trying to collect the highest amount they can.

There is something called a “chargemaster price.” It could help the uninsured figure out the wholesale price for services and procedures if they knew what the line item services and procedures they were charged for were.

The patient could then figure out what Medicare pays for those services and procedures.

However none of these line item charges are in the patients (EOB) Explanation Of Benefits. The EOB is impossible to interpret.

A simple rule should be passed by congress or issued by CMS saying a clear explanation of charges is required for payment of the bill.

The Obama administration knew about this uninsured billing problem. It did nothing about it because it wanted to force patients into buying Obamacare insurance even if they couldn’t afford it or didn’t need it.

I believe Tom Price M.D. (President Trump’s head of CMS) is aware of the problem. He also understands this simple way of solving it.

The healthcare insurance industry and the government get a detailed EOB for services rendered through the CPT coding system first established in 1978.

The Obama administration added 74,000 new codes to the CPT coding system. The government and the insurance companies wanted to know what they were paying for in detail.

This led to the requirement for Electronic Medical Records (EMR) and then meaningful use EMRs. Physicians and hospital systems will not get paid if they do not have a meaningful use EMR this year.

This led to a very expensive EMR development industry. EMRs were expensive. They did not function as meaningful use EMRs. They had to undergo extensive upgrades.

An EMR function should really be a teaching tool, teaching physicians how to upgrade their services to the best evidence based medicine practices.

Instead it has become a tool for the government and the healthcare insurance industry to punish patients.

The EMRs are unaffordable to many physicians. It has force them to sign up to become hospital system employees.

The government should have built a universal EMR in the cloud and charged physicians by the click.

The increase in codes led to an expensive coding industry. People are trained to teach physicians and hospital systems how to use the new 88,00 codes correctly.

The industry essentially teaches those providers how to how to game the healthcare system so that they can collect the most money for their services from the government and the healthcare insurance industry.

The goal of the government is to reduce reimbursement to providers.

Where is the consideration for patients in all of these maneuvers?

Where is the consideration for the uninsured patients?

Ms. Rosenthal’s main point is that CPT gaming by the medical professions and hospital systems are driving up healthcare costs.

However, missing from her argument is who developed the dysfunction CPT system.

Why was it developed?

Why was coding made so complex that it drives users of the coding system to game the system?

Ms. Rosenthat gives a few examples of coding driving the costs up.

  1. The diagnosis code for “heart failure” (ICD-9-CM Code 428) instead of the one for “acute systolic heart failure” (Code 428.21), the difference could mean thousands of dollars.

“In order to code for the more lucrative code, you have to know how it is defined and make sure the care described in the chart meets the criterion, the definition, for that higher number.”

In order to code for “acute systolic heart failure,” the patient’s chart (EMR) ought to include supporting documentation, for example, that the heart was pumping out less than 25 percent of its blood with each beat and that he was given an echocardiogram and a diuretic to lower blood pressure. Submitting a bill using the higher code without meeting criteria could constitute fraud.”

“Each billing, then, can be seen as a battle of provider coder versus payor coder.

The coders who work for hospitals and doctors strive to bring in as much revenue as possible from each service, while coders employed by insurers try to deny claims as overreaching.”

Hospital based physicians are taught how to up-code to generate the most income. They have little say in the coding process. Patients have no way of knowing if a procedure or service is coded.

  1. In a doctor’s office, a Level 3 visit (paid, say, at $175) might be legally transformed into a Level 4 (say, $225) by performing one extra maneuver, like weighing the patient or listening to the lungs, whether the patient’s illness required that or not.
  2. E.R. doctors have been taught that insurers might accept a higher-reimbursed code for the examination and treatment of a patient with a finger fracture (usually 99282) if — in addition to needed interventions — a narcotic painkiller was also prescribed (a plausible bump up to 99283), indicating a more serious condition.

The actual cost and expertize that might go into these services are never discussed or considered by bureaucrats decision and policy makers.

Price transparency for the patients would make a world of difference to costs. It would drive the cost of care and healthcare premiums down.

It might even result in the development of competitive pricing and a free market system.

I am sure the Trump administration is aware of this defect in the dysfunctional healthcare system.

President Obama ignored the problem as he tried to control hospital systems and physicians. He simply down coded services.

He probably figured that a single payer system would make everything much easier.

All I can say is look at the government run Veteran Administration Healthcare System.

Why most politicians ignore the coding defect in coding is beyond me?

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Please have a friend subscribe

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

Permalink:

President-elect Trump Part 9

Stanley Feld M.D., FACP, MACE

I am extending my discussion on the importance of malpractice reform because politicians ignore the potential costs and decreased access of care resulting from the present system.

In 2003, Texas Governor Rick Perry and the Texas legislature unenthusiastically changed tort reform laws in Texas.

I thought it was inadequate tort reform. It turned out that the meager reform has had great results.

Rick Perry and the Texas legislature ended plaintiff attorneys’ practice of venue shopping for friendly judges.

They also put a cap of $250,000 on noneconomic damages like pain and suffering.

These reforms have changed the malpractice climate in Texas. The reforms limited plaintiff’s attorneys’ profitability on frivolous liability claims.

Texans believe that because of these reforms and the lack of a state income tax, Texas has become the country’s best state for economic growth and job creation.

A Perryman group report concluded,

“Perhaps the most visible economic impact of lawsuit reforms is the benefits experienced by Texans who have better access to high-quality healthcare.”

 

“Doctors and hospitals are using their liability insurance savings to expand services and initiate innovative programs; those savings have allowed Texas hospitals to expand charity care by 24%.”

The medical malpractice business for plaintiff’’s attorneys has dried up in Texas. plaintiff’s attorneys are moving to other states.

Physicians are applying for licenses to move to Texas from other states.

“In 2001, according to the American Medical Association, Texas’ ranking in physicians per capita was a dismal 48th out of 50.”

“Beginning in 2003, physicians started returning to Texas. The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years.”

 “Dr. Perryman, subsequent to the issuance of his Report, informed TLR Foundation that at least 1,887 of those physicians are specifically the result of lawsuit reform.”

 The Texas Hospital Association reported a 70% reduction in the number of lawsuits filed against the state’s hospitals.

Medical liability insurance rates declined. Many doctors saw average rates drop 20% to 50%.

The American Medical Association removed Texas from its list of states experiencing a liability crisis; marking the first time it has removed any state from the list.

A survey by the Texas Medical Association also found a dramatic increase in physicians’ willingness to resume certain procedures they had stopped performing, including obstetrics, neurosurgical, radiation and oncological procedures during the Texas malpractice crisis.

Two simple changes in the tort laws made malpractice suits unprofitable for plaintiff attorneys.

Rick Perry has been so impressed with the results of his tort reforms that he wanted to extend his state’s impressive tort reform record.

Mr. Perry is proposing a British-style “loser pays” rule, which would require plaintiffs to pick up the legal costs of their targets if they lose their suits.

The Wall Street Journal showed that Ezekiel Emanuel malpractice cost estimate was wrong. It is not $25 billion year.

According to the Pacific Research Institutes estimate it is at least $242 billion dollars a year. I think the cost is closer to $750 billion dollars.

 

President-elect Trump, there are other consequences of the present malpractice liability system in the U.S. that cannot be measured in dollars.

One is alawsuits emotional wear and tear on both patients and physicians,

In order to avoid potential lawsuits physicians are avoiding high-risk patients and high-risk patient procedures. The result is a decrease in patient access to necessary care.

The details of the Massachusetts Medical Society Defensive Medicine 2008 survey is profoundly important in explaining trends in the healthcare costs due to the lack of malpractice reform.

Unfortunately, the mainstream media has published only meaningless sound bites about malpractice reform significance.

The survey’s significance has not had the impact on policy it should.

The authors state that the dollar estimates do not include the diagnostic procedures, hospital admissions, specialty referrals and consultations, or unnecessary prescriptions by physicians in specialties not included in the study.

The eight specialties surveyed represent only 46% of the physicians in the Massachusetts. The real costs to the healthcare system from the practice defensive medicine in the state of Massachusetts are much higher.

I believe the costs of defensive medicine in many other states are also much higher because in many states malpractice awards are higher. This encourages litigation.

President-elect Trump, defensive medicine is a huge burden nationally to the healthcare system. Its costs will undermine any attempt at healthcare reform. You must take medical malpractice liability reform seriously. There has to be a fundamental change in the structure of adjudication.

The survey’s findings must be studied carefully. The physicians surveyed estimated their percentages for defensive medicine testing to avoid lawsuits.

The real percentages can be studied objectively using big data. . Nonetheless the current estimates reveal unsustainable waste in our dysfunctional healthcare system.

Radiological imaging is one tool overused by physicians defensively to avoid litigation. Physicians feel they must test everything even if the probability of a positive result is insignificant.

“Plain Film X-Rays: An average of 22% of X-rays were ordered for defensive reasons.”

“CT Scans: An average of 28% of CT scans were motivated by liability concerns, with major differences among specialties.”

About 33% of scans ordered by obstetricians/ gynecologists, emergency physicians, and family practitioners were done for defensive reasons.

The total number of unnecessary CT scans needs to be calculated along with its costs in order to understand the significance of the percentage presented.

The health policy solution should not be to lower the reimbursement for CT scans. The solution is to fix the medical malpractice liability system.

MRI Studies: An average of 27% of MRIs were ordered for defensive reasons, with significant differences by specialty.

Obstetricians/ gynecologists, general surgeons, and family practitioners reported the highest rates, with the lowest rates by neurosurgeons and emergency physicians.

Ultrasound Studies: An average of 24% of Ultrasounds were ordered for defensive reasons. Orthopedic surgeons (33%) and obstetricians/gynecologists (28%) reported the highest rates, with neurosurgeons (6%) and anesthesiologists (9%) the lowest.

I believe neurosurgeons are underestimating their use of radiologic procedures in order to look good. Neurosurgery is one of the specialties with the highest malpractice rates.

Please note that obstetricians/gynecologists take no chances and order the most procedures for defensive purposes.

Laboratory Testing:

An average of 18% of laboratory tests were ordered for defensive reasons, with emergency physicians (25%) reporting the highest rates and neurosurgeons (7%) the lowest.

Specialty referrals, consultations and hospitalizations are overused the most for defensive reasons. No one wants to take a chance and send the patient home even if the indication for hospitalization is small.

Specialty Referrals and Consultations:

“An average of 28% of specialty referrals and consultations were motivated by liability concerns, with significant differences by specialty.

 Obstetricians/gynecologists reported that 40% of their referrals and consultations were done for defensive reasons, and anesthesiologists and family practitioners said that 33% of their referrals and consultations were done for the same reasons.”

Hospital Admissions:

An average of 13% of hospital admissions were motivated by liability concerns, with surgical specialties reporting lower rates than the other specialties.

The cost of defensive medicine is very high and extremely wasteful.

The repair of the dysfunctional malpractice system is simple. The system must decrease financial incentives for plaintiff’s attorneys to file frivolous lawsuits.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Please have a friend subscribe

 

 

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

Permalink:

Women’s Health Initiative (WHI): The Medical Community Is Waking Up

Stanley Feld M.D. FACP, MACE

The Women’s Health Initiative’s conclusions changed how peri-menopausal and post-menopausal women are treated in the U.S.

The conclusions of the study were released to the media before the medical community had a chance to study or debate the findings.

Since the media is the message and damn the facts, it was clear that estrogen caused heart disease, breast cancer, stroke and pulmonary embolism when used in peri-menopausal and post-menopausal women.

The conclusions frightened every peri-menopausal and post menopausal woman in this country. Hormone Replacement Therapy (HRT) usage has decreased by eighty percent since the WHI was published in 2002.

Women were afraid to take HRT because they were afraid to contract these deadly diseases.

Physicians were afraid to prescribe HRT because of the fear of being sued in our litigious society if their patient contracted one of these diseases.

In the years before the WHI, observational data supported the conclusion that estrogen was of great value in treating symptoms associated with the acute menopausal syndrome, namely hot flashes, vaginal dryness, urinary tract irritation, skin changes and emotional instability.

Estrogen also seemed to protect against heart disease, osteoporosis and weight gain and promote a general sense of well being in peri-menopausal and post-menopausal women. There was no good evidence for or against breast cancer.

One common complaint about observational studies is they are not double blind studies. One observes the outcome against a control group that does not have the same outcome.

“One common observational study is about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator.[1][2] This is in contrast with experiments, such as randomized controlled trials, where each subject is randomly assigned to a treated group or a control group.”

This NIH sponsored double blind placebo controlled study (WHI) was performed to prove with a level A (double blind placebo controlled) study to test the validity of observational data reports of the positive effects of estrogen.

The WHI reported results that concluded that estrogen had the opposite effects of previous observational studies.

The WHI conclusions were that conjugated estrogen caused breast cancer, heart disease, stroke, and pulmonary embolism. The WHI claimed that conjugated estrogen did protect against osteoporosis.

The media is the message and the conclusion resulted in the media frenzy. The implication was the medical profession was killing women by prescribing estrogen.

Prior to the release of the study’s conclusions many women were afraid to take estrogen on general principles alone. Many felt that estrogen deficiency was part of the aging process.

However, women had a life expectancy of 50 years in the early part of the 20th century. Women today live much longer and observational data suggests estrogen therapy (HRT) results in a healthier life.

There are many statistical problems with the WHI study. These problems have not been discussed in the media.

Practicing physicians were confused by the WHI study’s conclusions. They were also enraged because the results were released to the public before there was peer reviewed by the entire medical community.

Patients taking estrogen were upset at their physicians for giving them estrogen.

There are many defects in the WHI study from a statistical viewpoint.

  1. Age Distribution: 66.6% of the patients were between 60 and 70 years old. 87% of the patients were 60 to 80 years old. The majority of the patients in the study receiving Hormone Replacement Therapy (HRT) for the first time were at least 10 years post-menopausal. This age distribution does not represent the usual population starting HRT.

 

HRT is usually started just prior to the onset of menopause or at menopause (48 years old).

  1. The drop out rate in the placebo and HRT group was 40%. The significance of the dropout rate was not addressed. This dropout rate nullifies the validity of statistical significance of all the conclusions in the study.

 

Maximal tolerable dropout rate for statistically significance of data in a study should not be greater than 20%.

Everyone had ignored this important statistical fact.

 

  1. The unblinding of 3000 women in the study represents a departure from the protocol. It biased the findings of treatment difference.

 

  1. A hazards ratio (HR) in a statistically significant conclusion should be greater than 2.0 in order for a conclusion to be valid. The Hazard Ration should not be expressed to two decimal places.

 

A Hazards Ratio of less than two does not discriminate causality from bias and confounding of variables.

  1. A 40% drop out rate nullified the power of the study. The study was not sufficiently powered to yield statistically significant results.

 

  1. Presenting data as a nominal confidence interval is valid only when one outcome is being studied against one placebo.

 

Adjusted confidence intervals must be used when multiple outcomes are involved that represent multiple confounding variables.

 

Confidence interval must not cross 1 to be statistically significant.

 

The WHI’s statistical conclusions of the WHI study were based on using nominal confidence intervals. The nominal confidence intervals were barely significant.

The WHI nominal confidence intervals came close to touching number one (1).

All of the WHI’s published adjusted confidence intervals were non significant because they all crossed 1.

These are the defects in the WHI study’s statistical analysis that invalidates its statistical significance.

The estimated Hazard Ratios (HRs), (Nominal 95% Confidence Intervals [Nom CIs] and Adjusted 95% Confidence Intervals [Adj CIs ) in the WHI study were as follows:

 

Cardiac Heart Disease: HR 1.29, Nom CI (1.02-1.63)                Adj CI 0.85-1.97.

Conclusion should have been the WHI was statistically insignificant for causing Cardiac Disease.

 

Breast cancer: HR 1.26, Nom CI(1.00-1.59),

Adj CI 0.83-1.92.

Conclusion should have been the WHI was statistically insignificant for causing Breast Cancer.

 

Stroke: HR 1.41, Nom CI (1.07-1.85)

Adj CI 0.86-2.31.

 

Conclusion should have been the WHI was statistically insignificant for causing Stroke.

 

Pulmonary Embolism: HR 2.13, Nom CI(1.39-3.25),

Adj CI 0.99-4.56.

The WHI conclusion for estrogen causing Pulmonary Embolism might be statistically significant if statistical analysis rules were not disregarded.

The Hazard Ratio (HR) was above 2. The Nominal Confidence limit (Nom Cl) did not go below 1. However it cannot be used for this study.

The Adjusted Confidence limit which must be used for this study crossed 1 making the WHI conclusion not statistically significant.

The adjusted confidence intervals were published in the original paper.

Media blitz publicity of the WHI’s invalid conclusions created a high level of public certainty about the results of the study.

Few physicians were in a position to dispute the statistical weakness of the data. Those who were in a position to dispute the statistical significance either remained silent or were marginalized.

The media blitz’ results changed the approach to women’s health in the U.S. in 2002. Eighty percent of women taking HRT discontinued estrogen replacement therapy.

In my opinion, the results have been a great disservice to women’s health. The media publicity also has had a devastating impact on the physician patient relationship and patients’ confidence in clinical research.

Even though estrogen might cause heart disease, pulmonary embolism, stroke, and breast cancer, the Women’s Health Initiative did not prove it in a statistically significant way.

Once again the media is the message.

Freedom of the press is vital to our freedom of speech, but the media’s tendency to sensationalize issues prior to proper judgment is disruptive to seeking the truth.

The medical community is starting to pick apart the conclusions of the WHI study.

I will describe some of the new and contradicting findings next time.

Dr. Joe Goldzieher, Reproductive Endocrinologist, helped me critique the statistics in 2002.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Permalink:

Managing Points Of View and Healthcare

Stanley Feld M.D.,FACE, MACE

Finally, it is official. Ben Rhodes, the deputy national security adviser for strategic communications, admitted that the Obama administration lied about the Iranian Nuclear deal to the press, public and congress.

His interview with David Samuels in a New York Times Magazine typified the approach to manipulating the truth by the Obama administration in all areas of the administration’s activities.

The administration has been trying to walk back Ben Rhodes’ statements for a week. The traditional media is trying to bury his statements even though the king of the mainstream media (the New York Times) published the interview.

The justification for this behavior is that it has been used by all-previous administrations including that of George Bush. It is therefore an insignificant objection.

Ben Rhodes explained to David Samuels, in the New York Times profile that,it was first necessary to lie to a corrupted and inexperienced American media about all sorts of things, beginning with the nature and intentions of the enemy in this case the Iranian regime.

Subsequent lies were added, as the White House took advantage of a dangerous mix of journalists’ ignorance, their ideological and partisan commitment to the administration, and finally, their career aspirations.

It reminds me of Jonathan Gruber’s attitude toward the press and President Obama’s pretense that he hardly knew Jonathan Gruber.

http://stanfeld.com/?s=Jonathan+Gruber

https://www.google.com/search?q=Ben+Rhodes+Iran+nuclar+deal&ie=utf-8&oe=utf-8

Rhodes went on to say, The average reporter we talk to is 27 years old, and their only reporting experience consists of being around political campaigns… They literally know nothing.”

This implies the lack of respect the Obama administration has for the press, Americans and for the virtue of honesty. It is not a good example for our youth’s future behavior and the way to mange a Point of View.

Thus they (the press) will believe what he tells them. He also tells friendly non-governmental organizations and think tanks what he is telling the journalists. Those outlets produce “experts” whose expert opinion is just what Rhodes wants it to be. These ignorant young journalists thus have quotes that look like independent confirmation of the White House’s lies. :

Ben Rhodes admitted, when David Samuels asked,We created an echo chamber of freshly minted experts cheerleading for the deal. ‘They were saying things that validated what we had given them to say.’

This is the apparent attitude of President Obama and his administration. It is applied to every lie they have told to the American people.

Ben Rhodes described a tactic that is an extension of Sol Alinsky’s playbook. I believe the American people are catching on.

The defendants of the Obama administration marginalize the people who expose the lies with additional lies.

The Obama administration and its defendants are usually effective in marginalizing their opponents.

The defendants of the lie have the power of the pulpit and a friendly mainstream media.

The same tactics are used in defending Obamacare as I have described many times in my blog.

I find it difficult to believe that so many smart people believe these lies.

Carl Sandberg said “if you tell I lie enough times its eventually becomes the truth. This is especially true when people start adjusting and investing in the lie.

Marilyn Travenner, now that she is CEO of the healthcare insurance industry lobbying group, has a different point of view than when she was the head of CMS. Someone else other than government is paying her.

I have said that the dysfunction in the healthcare system is the fault of all the stakeholders, namely the government, the healthcare insurance companies, the drug companies, the physicians and the patients.

Each group adjusts to a dysfunctional element making the healthcare system more dysfunctional. The growing dysfunction is driven by the multiple points of view.

President Obama’s ideology has accelerated the dysfunction.

Marilyn Travenner is now diverting blame for the dysfunction away from the healthcare insurance industry. Many do not realize that the government run healthcare system is totally dependent on the healthcare insurance industry. The healthcare insurance industry does the administrative services for the government.

The administration brags that CMS’ overhead is only 2.5-5% of Medicare’s cost. This is an illusion; It is false.

The percentage of overhead published does not include the cost paid by the government to outsource the administrative services to the healthcare insurance industry.

The administrative services overhead is added into the cost of healthcare. Insurance premiums are calculated using the Medical Loss Ratio calculation. Many insurance company expenses are considered direct medical care expenses. Direct medical care expenses should only be for direct medical care.

The government programs set payments to the healthcare insurance industry for administrative service according to the Medical Loss Ratio.

Insurance administrative expenses, like a help desk or network selection expenses, should not be included in direct medical cost. Presently, it is the method used by the healthcare insurance industry to ultimately take 30-40% of the healthcare dollars off the top.

President Obama and his administration brag that Obamacare is bending the healthcare cost curve for Medicare and Medicaid. The only reason this was true in 2012 and 2013 was because Obamacare’s hidden taxes from citizens at every income level were being collected while there were no Obamacare medical care expenditures until 2014. The 2014 and 2015 cost curve was bent upward contributing to the 19 trillion dollar deficit.

In my last blog I mistakenly left out the word contributing to the 19 trillion dollar deficit. Obamacare is not budget neutral. It is not presently bending the healthcare cost curve.

Some smart people believe Obamacare is bending the healthcare curve because they uncritically believe all the administration’s press releases.

In the last few weeks we have been warned not to believe everything President Obama and his administration tell us.

I am sure the judge in Texas who was lied to by the Department of Justice about immigration reform is not very happy.

The cost of physician services might be increasing on a retail level. However, government and insurance reimbursement to physicians is decreasing.

Travenner, in her previous life blamed the rising cost of medical care on physicians. In order to divert attention from the healthcare insurance industry she continues to blame physicians.

The cost for everything from office visits to complex surgeries is on the rise, so there’s not much that can be done here to ebb this common cause of premium inflation.”

This is an incorrect premise. It is true that hospital costs are rising. If the premise is incorrect the solution is usually incorrect.

Next, Ms. Travenner explains additional reasons for increasing premiums.

“Prescription drug price inflation is a far bigger problem. A lack of a universal health plan, long periods of patent exclusivity, high demand for pharmaceutical products in the U.S., and the speed with which approved drugs can be brought to pharmacy shelves are all reasons why prescription drug costs could continue soaring in 2017 and future years.”

She omits the most important reasons for the increase in drug prices to the public.

President Bush’s deal with congress to pass Medicare Part D was to eliminate government’s ability to negotiate drug prices with the drug companies. The government negotiates drug prices for the military and VA. It gets negotiated prices that are comparable to all other countries on the globe.

At the same time the government restricts consumers from buying prescription drugs in Canada, suppressing competition.

The Obama administration keeps blaming the drug rules on President Bush’s administration. Why hasn’t President Obama renegotiated a better deal in the last seven years, or just change the rules by executive order as he usually does?

Tavenner also hit onthe point that restructuring the insurance market hasn’t paid benefits as expected.”

New regulations requiring Obamacare insurers to provide plans with a host of minimum benefits, as well as being unable to deny benefits to people with pre-existing conditions, has left insurers exposed to adverse selection.

In plainer terms, it means sicker people who’d been shut out of the insurance system previously have flooded in, and not enough healthier individuals have enrolled.

This last point is valid. The claim that the insurance industry is losing money is not true. It is losing money on adverse selection but they are making up that loss by increasing premium prices to the government and the corporate market.

If they did not make money how could they pay CEOs of some healthcare insurance industry companies 100 million dollars a year?

Finally, Tavenner cautioned that the turbulence can be expected because insurers “sit in the three-R world.”

What Tavenner is alluding to are two programs that are set to end in 2017: the reinsurance program that provided payments to plans that enroll higher-cost members, and the risk corridor, which acted like a modern day Robin Hood by taking excessive profits from top-performing insurers and giving them to Obamacare insurers losing excessive amounts of money.

Without the risk corridor, new insurance entrants could be discouraged, since they’d be responsible for covering the entirety of their losses. The third “r,” risk adjustment, will remain in place to distribute capital from plans with low-risk enrollees to those with high-risk.

The reinsurance aspect of Obamacare was probably illegal. The government guaranteed the insurance companies that it would make up whatever loss they claimed. The Obama administration paid the healthcare insurance industry only 12% of the promised amount. This deception by the government has led to some of the reasons UnitedHealthcare and now Aetna are pulling out of Obamacare’s health exchanges.

However, the government is totally dependent on the healthcare industry for it administrative services.

The devil is always in the details.

There is an ever-growing need to lie to manage the public’s point of view in favor of Obamacare.

The public is becoming aware of the Obama administration’s attempt to mange the public’s point of view. Ordinary citizens are madder than hell at the Obama administration and the establishment in both the Democratic and Republican parties.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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

Permalink:

The Defects In Obamacare

Stanley Feld M.D., FACP, MACE

We live in an era of sound bites driving opinions rather than details driving opinions. The devil is always in the details.

The defects in Obamacare are too numerous to count. President Obama provides the traditional mass media with sounds bites leading to false conclusions.

The sound bites are misleading. Many of the sound bites are lies. One such sound bite is Obamacare is working and therefore does not need changing.

He and the Democrats keep the discussion on the sound bites level and do not dig into the real issue. President Obama even keeps the details away from congress the very people he is dependent on to pass the bill.

President Obama kept the facts and details about Obamacare away from the congress and the people. He is now doing it with the Trans-Pacific Partnership (TPP).

The Trans-Pacific Partnership (TPP) is a proposed regional regulatory and investment pact. Just as with Obamacare, President Obama expects congress to vote in favor of a pact they have not debated and have not had an opportunity to read the details in the final bill.

It is another one of those bills where the administration is telling the congress and the American people you have to pass the bill in order to see what is in it.

Americans are tired of his lack of transparency and lies. They do not trust President Obama anymore.

Congress should never make the same mistake they made with Obamacare. If they do all Americans should rally to throw all the bums out.

The devil is always in the details.

United States Senator Ron Wyden (D-OR) said,

   “Congress is being kept in the dark as to the substance of the TPP negotiations, while representatives of U.S. corporations—like Halliburton, Chevron, PHRMA, Comcast, and the Motion Picture Association of America—are being consulted and made privy to details of the agreement. […]

More than two months after receiving the proper security credentials, my staff is still barred from viewing the details of the proposals that USTR is advancing. We hear that the process by which TPP is being negotiated has been a model of transparency. I disagree with that statement.[98]

President Obama and the speaker have told us it is good pact for the country’s economy. Senator Cruz is right. “Don’t vote for something whose details you do not know.”

There are many defects in Obamacare. One major defect is that it is not affordable to consumers, the federal government or state governments. When fully implemented the cost of healthcare to the federal government will be at least 50% of our GNP not the 23% of GNP predicted. Twenty three percent is bad enough.

Federal and State taxes will have to be increased to cover all medical care entitlement costs.

President Obama keeps telling us that Obamacare is working. He says it is here to stay.

The reality is Obamacare is an unworkable and costly failure in multiple areas including the health insurance exchanges, healthcare.gov, insurance premiums and deductible costs, the development of Accountable Care Organizations, maintenance of employer insurance and more.

Americans deserve a better system than Obamacare.

It is impossible to cover all of the harmful details of every category in one blog. 

It is disingenuous for President Obama to claim, in his repeated sound bites, that there is no need to change anything in Obamacare because Obamacare is working fine.

The real cost of Obamacare to consumers (especially taxpayers), the federal and state governments and the economy have not been disclosed nor are they transparent.

The real costs start to leak out with stories about how the costs affect consumers and their lifestyle.

This usually leads to the sound bites that it will be better to have a government single party payer system.

The underlying defect is that this system leads to consumers being dependent on government and not responsible for themselves. Government changes rules on a whim. Consumers do not have options. This is a road to serfdom.

After the Affordable Care Act kicked in, a 52-year-old sales and marketing entrepreneur reported his monthly health-insurance premium to cover himself and his family grew to $848 from $513. Like others, he wasn’t happy about it. “It’s taking a lot out of pocket,” he said.”

He is one of millions of Americans who earn too much to qualify for government subsidies on policies purchased through the federal insurance exchange. He was in favor of Obamacare before he realized Obamacare’s effect on reality.

 Obamacare requires insurance companies to offer insurance policies with broad coverage and greater protection against catastrophic medical costs. It also requires coverage on illnesses and conditions such as pregnancy and birth control coverage for people who do not need this coverage.

Obamacare was supposed to save every family $2,500 a year. It costs families more than $2,500 dollars a year. It was not supposed to affect anyone making less than $250,000 per year.

It is true that many of the above a not taxes. However it is a cost burden on consumers making less than $250,000 a year.

Others, making less than $50,000 a year, receive complete or partial government subsidies. This is what is meant by redistribution of wealth. It is a significant cost burden on consumers making $50,000 to $250,000 dollars a year.

Everyone remembers President Obama promising that Obamacare will not cost families making less that $250,000 one dime.

Obamacare premiums have become unaffordable to people earning less than $50,000 per year as well.

Obamacare’s goal was to cover everyone with broad insurance coverage and greater protection against catastrophic medical costs.

Yet, only 10 million out of 330 million are covered by the exchanges. Each enrollee in the exchanges also has high deductibles. These deductibles can be as high as $6,000 a year.

Many of the insurance companies claim they will be losing money after the government’s health insurance industry subsidies disappear in 2016.

These companies will leave the Obamacare federal health exchanges reducing competition. This in turn will increase premiums further and make premiums more unaffordable.

Another detail overlooked is enrollees are poorer, sicker and older. The pool is not diluted by younger, healthier and richer. The result is more expensive insurance rates.

“ HHS was saying that it needed about 40 percent of the exchange policies to be purchased by people age 18-35 to keep the exchanges financially stable. It was 28 percent in both 2014 and 2015, according to HHS data. The CBO had projected about 85 percent of exchange enrollees to be subsidized, falling toward 80 percent as enrollment grew; instead, that number is 87 percent and actually rose slightly from 2014.”

According to a study last year by the National Bureau of Economic Research, people who bought silver and bronze plans on the federal and state health insurance exchanges saw total premiums and out-of-pocket payments rise an estimated 14% to 28% higher than pre- Obamacare premiums and out of pocket expenses.

Obamacare is not fulfilling any of President Obama’s sound-bite promises.

His claim that Obamacare is working well and does not have to change makes absolutely no sense.

If one tells a lie enough times it becomes eventually becomes the truth.

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

 

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:

How Should Healthcare Quality Be Measured?

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:

Restricting Access To Care

Stanley Feld M.D.,FACP, MACE

As a retired Clinical Endocrinologist I don’t have a vested interest in generating income for myself from the healthcare system.

What I am trying to do is help consumers and healthcare policy makers understand the present healthcare system. I fear they have no interest in understanding what would work to repair the healthcare system.

I am also trying to explain to consumers that few politicians are interested in helping them. Politicians are interested in power. They are interested in making the people dependent on them.

Politicians and the central government are interested in controlling the healthcare system, the financial system, the Internet and the environment. Once politicians control these systems the people have lost their independence and freedom. Politicians will have the power they seek.

Many of our constitutional freedoms have been disappearing. American have been on the Road To Serfdom for many years.

President Obama has hastened the journey on the road to serfdom with his blatant disregard for the constitution and the bill of rights. To my chagrin he is succeeding.

President Obama is pretending to want to provide universal care. His goal is to destroy the healthcare system so that the people will beg for the central government to control the healthcare system.  There are more uninsured people now than when he became President.

Paul Krugman is one of President Obama’s henchmen. He stated in a recent article that Obamacare is costing the government less money than the administration thought it would. He therefore calls Obamacare a success.

This administration and its henchmen in the traditional media flood us with half-truths.

Obamacare might be costing the government less than they expected. The Obama administration never told Americans what they expected to spend.

The Obama administration is the most non-transparent administration in my lifetime.  Meanwhile, the Obama administration tells Americans it is the most transparent administration in history.

CGI is a Canadian company with offices in the U.S. It had the contract to develop the Obamacare website healthcare.gov. The website was a disaster. The development cost overruns were unbelievable.

CGI received the contract through an Obama crony capital award and a non-competitive bid.

CGI receive another contract to complete the backend of healthcare.gov.

The Affordable Care Act (Obamacare) is supposed to be affordable for consumers. Consumers are experiencing higher premiums and out of pocket expenses for medical services.

1. Obamacare has been under subscribed. Only 10 million people are verified premium paying subscribers. The Obama administration projected 30 million subscribers by 2015 when Obamacare was passed in 2010.

2. The deductibles are unaffordable. Obamacare is even unaffordable to those people who receive subsidies.

The subsidized people have avoided seeing physicians in a timely manner. The result is government costs are less in the short run but will be more in the long run as people get very ill.

3. The Obama administration is keeping the expenses for infrastructure and bureaucratic structure non transparent.

4. Obamacare’s rules and regulations are resulting in restricting access to care.  

5. Paul Krugman and the Obama administration spin the truth by ignoring consumer out of pocket expenses.

There has been an explosive increase in premiums and higher deductibles though the health insurance exchanges as well as private insurance.

The Obama administration has been silent about this reality.

The Affordable Care Act is not affordable. It has not increased the “quality of care.”  

Paul Krugman does not publish the real truth in his New York Times articles. Those who still read the New York Times take his words literally. They are deceiving themselves.

One of the ways the Obama administration is restricting access to care to lower its costs is through the U.S. Preventive Services Task Force’s (USPSTF) recommendations.

I have criticized the USPSTF methodology in the past for its conclusions about many clinical practices.

The task force is composed of a group of physicians that do not have clinical expertise in the medical or surgical topic they are evaluating.

The group simply reads the medical papers assigned to them to evaluate. The committee decides the efficacy of treatment on the quality of the literature they are given to evaluate.  Clinical judgment is not included in their evaluation.

A positive decision is made if the literature contains a double blind controlled study yielding positive results.  

Last month the U.S. Preventive Services Task Force (USPSTF) issued its final recommendation statement on Screening for Thyroid Dysfunction. The USPSTF studied this topic in 2004 with the same final opinion.

This time Obamacare will probably take action and restrict the evaluation on the basis of this recommendation

  In its statement, the task force said that without more data from randomized clinical trials it could not assess the balance of benefits and harms from pre-clinical thyroid disease treatment and, thus, could not recommend that asymptomatic, non-pregnant adults be screened for thyroid dysfunction.”

 The Annals of Internal Medicine (AIM), a journal of the American Medical Association published the USPSTF recommendation without expert clinical endocrinology comment or critique.

R. Mack Harrell, MD, FACP, FACE, ECNU current President of the American Association of Clinical Endocrinologists (AACE) is having the AACE Thyroid Scientific Committee submit a note to the Annals of Internal Medical addressing AACE’s concerns with the USPSTF’s paper.

AACE has studied and written many guidelines on the evaluation and treatment of thyroid disease. Its members have vast experience as practicing clinicians in the treatment of thyroid disease. Its input should be sought by the Obama administration not ignored in favor of a default decision that saves Obamacare money and puts the financial burden of care on consumers.

The following is Dr. Mack Harrell’s comment to AACE’s membership.

In my opinion Dr. Harrell’s’ comments are totally correct and should be heeded by the Obama administration.

“While agreeing with the USPSTF’s call for new, controlled thyroid screening studies, AACE issued a press release outlining its position on aggressive case finding suggesting: that this approach is an appropriate alternative to screening in patient groups where thyroid risk factors are present.

More specifically, AACE stressed that testing and treatment are indicated in those patients who are at highest risk for developing life-altering, overt thyroid disease, including:

Patients over 60, in whom symptoms of hypothyroidism are often minimal, absent or atypical

  • Newborns (continued mandatory screening for congenital hypothyroidism recommended)
  • Those with autoimmune diseases often associated with thyroid disease, such as type 1 diabetes and pernicious anemia
  • Patients with a prior history of thyroid disease or thyroid surgery, an abnormal thyroid exam, or taking drugs known to affect the thyroid
  • Patients with a family history of thyroid illness

AACE further emphasized that careful consideration should be given to thyroid testing in women who are planning pregnancy or are already pregnant given the clear-cut detrimental effects of thyroid hormone lack on fetal development in the early phases of pregnancy.

We also intend to submit to AIM a formal statement from the AACE Thyroid Scientific Committee to address concerns that the task force’s “lack of data” argument could be incorrectly interpreted as a “lack of clinical need” to find and treat thyroid disease.

For years, members of AACE and the American College of Endocrinology have worked diligently to provide up-to-date, useful clinical guidelines and recommendations regarding decision-making about thyroid function testing for physicians. We will continue to keep our members and the medical community apprised as we communicate our position regarding thyroid disease testing.

Best regards,

R. Mack Harrell, MD, FACP, FACE, ECNU

The Obama administration has made many mistakes in writing Obamacare. Most of them have not been in favor of the consumers it professed to help.

About 50% of women over the age of 60% might have subclinical hypothyroidism. Overt clinical hypothyroidism can take several years to declare itself. During the time of subclinical hypothyroidism evolves to overt hypothyroidism patients can suffer mild to moderate symptoms that would decrease their quality of life on many levels.

I believe President Obama should show compassion and responsibility toward the millions of who people would suffer from subclinical hypothyroidism. President Obama is setting up the healthcare system to restrict access to care for these people.

I do not think he should rely on a committee that does not have the expertise in the field of clinical thyroidology.  

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 Tax Hikes That Are Forgotten

Stanley Feld M.D.,FACP,MACE

Americans have forgotten the increase in taxes written into President Obama’s Healthcare Reform Act. There are 20 hidden taxes in the law that effect citizens earning less than $250,000 dollars a year.

According to Grover Norquist there will be ½ trillion dollars ($500 billion) in new taxes collected from the group of people making less than $250,000 a year.

These new taxes contradict President Obama’s promise that “anyone making under $250,000 a year will not pay a dime in new taxes.” Many of these taxes on businesses have been passed on to consumers in the form of higher prices.

  

 

https://youtu.be/eHlRY3kHhBk

 

 

 

I am not talking about the increase in taxes on capital gains and dividends that seniors rely on to survive. I am talking about all the other taxes that affect purchasing power.

In 2012, Grover Norquist wrote an excellent summary of those new taxes for the public to review. President Obama’s hypocrisy toward the American people is obvious.

The traditional media have ignored these new taxes and Mr. Norquist’s summary.   No one is talking about how these taxes are hurting seniors and the middle class economically.  

Since the recent Supreme Court decision has managed to keep Obamacare alive, it is vital that voters in all income brackets understand the new taxes imbedded in the law.

President Obama was not telling the truth when he said people earning under $250,000 would not pay one single dime more in taxes.

I suggest everyone watch President Obama’s lying and defending of his lies. After the first You Tube let it keep playing to hear subsequent You Tubes.

  

http://youtu.be/56c1fSdTAWI

Grover Norquist is president of Americans for Tax Reform, a coalition of taxpayer groups, individuals, and businesses opposed to higher taxes at the federal, state, and local levels. The coalition organized the Taxpayer Protection Pledge, which asks all candidates for federal and state office to commit themselves in writing to oppose all tax increases.

In my blog “ The Supreme Court And Obamacare” I said Obamacare is the largest tax increase in American history. As things go sour for Obamacare the government is going to have to raise taxes even further.

Taxpayers earning under $250,000 will experience the burden of the $500 billion dollar increase in their taxes.

Mr. Norquist’s article appeared in 2012.

“Obamacare contains 20 new or higher taxes on American families and small businesses. 

Arranged by their respective effective dates, below is the total list of all $500 billion-plus in tax hikes (over the next ten years) in Obamacare, where to find them in the bill, and how much your taxes are scheduled to go up as of today:

Taxes that took effect in 2010:

1. Excise Tax on Charitable Hospitals (Min$/immediate): $50,000 per hospital if they fail to meet new "community health assessment needs," "financial assistance," and "billing and collection" rules set by HHS. Bill: PPACA; Page: 1,961-1,971.

2. Codification of the “economic substance doctrine” (Tax hike of $4.5 billion). This provision allows the IRS to disallow completely-legal tax deductions and other legal tax-minimizing plans just because the IRS deems that the action lacks “substance” and is merely intended to reduce taxes owed. Bill: Reconciliation Act; Page: 108-113.

3. “Black liquor” tax hike (Tax hike of $23.6 billion). This is a tax increase on a type of bio-fuel. Bill: Reconciliation Act; Page: 105.

4. Tax on Innovator Drug Companies ($22.2 bil/Jan 2010): $2.3 billion annual tax on the industry imposed relative to share of sales made that year. Bill: PPACA; Page: 1,971-1,980.

5. Blue Cross/Blue Shield Tax Hike ($0.4 bil/Jan 2010): The special tax deduction in current law for Blue Cross/Blue Shield companies would only be allowed if 85 percent or more of premium revenues are spent on clinical services. Bill: PPACA; Page: 2,004.

6. Tax on Indoor Tanning Services ($2.7 billion/July 1, 2010): New 10 percent excise tax on Americans using indoor tanning salons. Bill: PPACA; Page: 2,397-2,399.

Taxes that took effect in 2011:

7. Medicine Cabinet Tax ($5 bil/Jan 2011): Americans no longer able to use health savings account (HSA), flexible spending account (FSA), or health reimbursement (HRA) pre-tax dollars to purchase non-prescription, over-the-counter medicines (except insulin). Bill: PPACA; Page: 1,957-1,959.

8. HSA Withdrawal Tax Hike ($1.4 bil/Jan 2011): Increases additional tax on non-medical early withdrawals from an HSA from 10 to 20 percent, disadvantaging them relative to IRAs and other tax-advantaged accounts, which remain at 10 percent. Bill: PPACA; Page: 1,959.

Taxes that took effect in 2012:

9. Employer Reporting of Insurance on W-2 (Min$/Jan 2012): Preamble to taxing health benefits on individual tax returns. Bill: PPACA; Page: 1,957.

Taxes that take effect in 2013:

10. Surtax on Investment Income ($123 billion/Jan. 2013): Creation of a new, 3.8 percent surtax on investment income earned in households making at least $250,000 ($200,000 single). This would result in the following top tax rates on investment income: Bill: Reconciliation Act; Page: 87-93.

 

Capital Gains

Dividends

Other*

2012

15%

15%

35%

2013+

23.8%

43.4%

43.4%


*Other unearned income includes (for surtax purposes) gross income from interest, annuities, royalties, net rents, and passive income in partnerships and Subchapter-S corporations. It does not include municipal bond interest or life insurance proceeds, since those do not add to gross income. It does not include active trade or business income, fair market value sales of ownership in pass-through entities, or distributions from retirement plans. The 3.8% surtax does not apply to non-resident aliens.

11. Hike in Medicare Payroll Tax ($86.8 bil/Jan 2013): Current law and changes:

 

First $200,000
($250,000 Married)
Employer/Employee

All Remaining Wages
Employer/Employee

Current Law

1.45%/1.45%
2.9% self-employed

1.45%/1.45%
2.9% self-employed

Obamacare Tax Hike

1.45%/1.45%
2.9% self-employed

1.45%/2.35%
3.8% self-employed

Bill: PPACA, Reconciliation Act; Page: 2000-2003; 87-93

12. Tax on Medical Device Manufacturers ($20 bil/Jan 2013): Medical device manufacturers employ 360,000 people in 6000 plants across the country. This law imposes a new 2.3% excise tax. Exempts items retailing for <$100. Bill: PPACA; Page: 1,980-1,986

13. Raise "Haircut" for Medical Itemized Deduction from 7.5% to 10% of AGI($15.2 bil/Jan 2013): Currently, those facing high medical expenses are allowed a deduction for medical expenses to the extent that those expenses exceed 7.5 percent of adjusted gross income (AGI). The new provision imposes a threshold of 10 percent of AGI. Waived for 65+ taxpayers in 2013-2016 only. Bill: PPACA; Page: 1,994-1,995

14. Flexible Spending Account Cap – aka “Special Needs Kids Tax” ($13 bil/Jan 2013): Imposes cap on FSAs of $2500 (now unlimited). Indexed to inflation after 2013. There is one group of FSA owners for whom this new cap will be particularly cruel and onerous: parents of special needs children. There are thousands of families with special needs children in the United States, and many of them use FSAs to pay for special needs education. Tuition rates at one leading school that teaches special needs children in Washington, D.C. (National Child Research Center) can easily exceed $14,000 per year. Under tax rules, FSA dollars can be used to pay for this type of special needs education. Bill: PPACA; Page: 2,388-2,389

15. Elimination of tax deduction for employer-provided retirement Rx drug coverage in coordination with Medicare Part D ($4.5 bil/Jan 2013) Bill: PPACA; Page: 1,994

16. $500,000 Annual Executive Compensation Limit for Health Insurance Executives ($0.6 bil/Jan 2013). Bill: PPACA; Page: 1,995-2,000

Taxes that took effect in 2014:

17. Individual Mandate Excise Tax (Jan 2014): Starting in 2014, anyone not buying “qualifying” health insurance must pay an income surtax according to the higher of the following

 

1 Adult

2 Adults

3+ Adults

2014

1% AGI/$95

1% AGI/$190

1% AGI/$285

2015

2% AGI/$325

2% AGI/$650

2% AGI/$975

2016 +

2.5% AGI/$695

2.5% AGI/$1390

2.5% AGI/$2085


Exemptions for religious objectors, undocumented immigrants, prisoners, those earning less than the poverty line, members of Indian tribes, and hardship cases (determined by HHS).Bill: PPACA; Page: 317-337

18. Employer Mandate Tax (Jan 2014): If an employer does not offer health coverage, and at least one employee qualifies for a health tax credit, the employer must pay an additional non-deductible tax of $2000 for all full-time employees. Applies to all employers with 50 or more employees. If any employee actually receives coverage through the exchange, the penalty on the employer for that employee rises to $3000. If the employer requires a waiting period to enroll in coverage of 30-60 days, there is a $400 tax per employee ($600 if the period is 60 days or longer).Bill: PPACA; Page: 345-346

Combined score of individual and employer mandate tax penalty: $65 billion/10 years

19. Tax on Health Insurers ($60.1 bil/Jan 2014): Annual tax on the industry imposed relative to health insurance premiums collected that year. Phases in gradually until 2018. Fully-imposed on firms with $50 million in profits. Bill: PPACA; Page: 1,986-1,993

Taxes that take effect in 2018:

20. Excise Tax on Comprehensive Health Insurance Plans ($32 bil/Jan 2018): Starting in 2018, new 40 percent excise tax on “Cadillac” health insurance plans ($10,200 single/$27,500 family). Higher threshold ($11,500 single/$29,450 family) for early retirees and high-risk professions. CPI +1 percentage point indexed. Bill: PPACA; Page: 1,941-1,956

© 2012 Newsmax. All rights reserved.

Mr. Norquist left out the worst tax of all. The “tax” is under everyone’s radar. It has not been mentioned in the traditional mainstream media. It is the tax on Seniors who are on Medicare.

"The per person Medicare Insurance Premium will increase from the present
Monthly Fee of $96.40, rising to:

$104.20 in 2012

$120.20 in 2013

And

$247.00 in 2014."

 

All seniors are means tested. This means the greater your income from any source including work income, pension income, capital gains and interest or dividend income the higher the baseline premiums become.

 

This “tax” had been decided by a Democratic controlled congress that had not read the bill or understood all of its consequences.  

These are provisions incorporated in the Obamacare legislation, purposely
delayed so as not to anger seniors during President Obama’s 2012 Re-Election Campaign.

 

Please send this blog to all the seniors you know and their children. It is important for them to know that President Obama is throwing seniors under the bus.  Obamacare must be repealed.

Everyone must stay focused. President Obama is going to try to change the conversation.

Some of these taxes have already gone into effect. If the Republicans win the House and the Senate as well as the Presidency, Obamacare could be repealed.   

Everyone interested in America’s economic future must tell a friend. President Obama has deceived Americans.  

 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.