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I Told You What To Do 8 Years Ago

Stanley Feld M.D.,FACP,MACE

I started my blog Repairing The Healthcare System in 2006. I methodically described the defects in the Healthcare System.

I provided healthcare alternatives in policy and regulations to both Democrats and Republicans to Repair the Healthcare System.

No one listened to me.

In 2007 the healthcare system was unaffordable and unmanageable.

Republicans had some weak ideas and no inclusive business model for the future.

The election of President Obama and the partisan passage of Obamacare have accelerated our healthcare system’s demise.

I believe President Obama’s goal is to destroy the healthcare system. He wants it replaced with a single party payer system (2003). Consumers of healthcare know the government cannot manage healthcare.

American cannot sustain Obamacare financially. Consumers cannot be sustained medically with Obamacare or after the collapse of Obamacare with a government run single party payer system.

The obvious proof is the dysfunction and failure of the VA Healthcare System, Medicaid and Medicare.

All these healthcare systems are government run single party payer systems. All are unsustainable.

As I was archiving my blogs I ran across four blogs I wrote in 2007 outlining the problems and what should be done about them.

The government has made none of the repairs I have suggested. Obamacare has made the situation worse. I will present all four parts of “What Have I Said So Far? Spring 2007” consecutively as written.

What Have I Said So Far? Spring 2007 Part 1

Stanley Feld M.D.,FACP,MACE

April 01, 2007 in Medicine: Healthcare System

 In August 2006 I summarized my blog to that point. I outlined some important solutions necessary to Repair the Healthcare System.

Since then I have covered many of the solutions to the key questions I raised. Not one of these questions has been addressed effectively by our leadership or people in control of making policy.

One must ask: Do they really want to solve the problems in healthcare delivery in this country or are they focused on preserving their own vested interest to the exclusion of a breakthrough that might benefit not only their vested interests but the vested interest of all the stakeholders.

The questions were:

  • How do we reduce the cost of medical care? • How do we provide affordable insurance for the 45 million people uninsured?
    • How to we provide affordable medical care coverage so that all the patients can have access to medical care?
    • How do we align all stakeholder incentives?
    • How do we construct a system so that all the stakeholders make a reasonable return on investment?
    • How do we close the holes in the system to eliminate abuse by stakeholders?
    • How do we restore trust between stakeholders?
    • How do we restore trust between the patient and physician?
    • How do we stop secondary facilitator stakeholders from continuously destroying the patient physician relationship?

In reality, developing solutions to these questions are in themselves business opportunities for facilitator stakeholders that can help Repair the Healthcare System.

However, neither the insurance industry, hospital systems, nor the government see the long term advantage and economic opportunity.

In a comment to my blog Shel Isreal said “

98% of the people think it is broken and the other 2% work for the insurance industry.

The insurance industry has the money and the power.”

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/01/the_ideal_elect.html.

However, we have demonstrated the abuse and misuse of the power of information technology by the insurance industry. The misuse and abuse has lead to further dysfunction in the healthcare system and mistrust by the hospitals and physicians.

The insurance industry and the government have used information technology to penalize both physicians and patients using the wrong data to draw their conclusions.

Insurance companies do not have the information technology resources to measure the correct parameters to measure quality care.

I do not see an attempt on their part to correct this deficiency. I only see a movement to make the healthcare system worse with a Pay for Performance (P4P) reimbursement system that is not well thought out. .

It is essential that the solutions I have proposed be coordinated and introduced simultaneously as a single plan rather than introducing elements of the solution separately.

Unfortunately, the government with the pressures of its present political vested interest influences finds it difficult to present the components of repair as a single plan.

The solutions will have to be driven by the consumer (the patient) and not the government. The patients have the power to drive the solutions because they are the users of the healthcare system. If they were the purchases of healthcare, some clever entrepreneur could provide the option for a compelling insurance product that could reward the patient for being responsible for their own care and well being.

The insurance produce could be built to fix the healthcare system.

All that is needed is for the government to write sensible regulations, enforce them and get out of the way.”

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

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Healthcare Spending Increases To 18.2% of GDP

 

Stanley Feld M.D.,FACP, MACE

 

Healthcare spending has increased each year. Healthcare spending is now 18.2% of the GDP up from 17.7% in 2014.

In 2000 it was 14% of the GDP.

Healthcare GDP

National spend pic1

The data presented in the following charts are partially correct. They are derived from clams data which are also partially correct. The charts can give an idea on how the healthcare money is

spent. and wasted. Fuel medical costs 2

Wasted Money

Wasted money 3

Drivers of increased Healthcare Spending

Drivers 4

Distribution of Healthcare Spending

Distribution

There are many reasons for this increase. The Obama administration prefers to blame the increasing spending on his most popular reasons.

His reasons might not be completely true.

The traditional media then publicizes the President Obama’s popular reasons. The reasons get translated into public understanding and public opinion.

President Obama’s reasons for the increased healthcare spending are hospitals’ and physicians’ prices are increasing. Hospital and physician retail prices are increases. However, their insurance reimbursement has decreased. Public opinion then demands that physicians decrease their prices.

The reality is physician reimbursement has been steadily declining in recent years as spending has been increasing.

I have continually pointed this out.

Medicare, Medicaid and private insurance have forced physicians to accept lower reimbursement. Patients are increasingly discovering that “my doctor doesn’t take my insurance or my Medicare or my Medicaid.”

Consumers without insurance coverage are charged retail price by hospitals and physicians rather than the discounted prices hospitals and physicians accept.

These consumers can try to negotiate the prices. They are usually more successful with physicians than hospitals.

Decreasing reimbursement is one of the main reasons physicians are driven to see more and more patients in less and less time.

Physicians must continue to pay overhead and salaries.

This phenomenon of increased patient volume disrupts the magic of the physician/patient relationship. It is also the driving force behind the massive increase in concierge medicine.

If it is not the rise in physician reimbursement, what is the reason for the increase in healthcare spending?

There are several possibilities.

  1. GDP is increasing at a lower rate than healthcare spending.
  2. Consumers are sicker. They need more medical and surgical care than previously.
  3. Healthcare insurance premiums are increasing at a greater rate than the GDP.
  4. Bureaucratic support of the healthcare system is growing at a greater rate than the GDP.
  5. Pharmaceutical use is increasing because a sicker population needs more drugs.
  6. RNA Technology has lead to the discovery of more potent therapies that are costly to the healthcare system.

Statistics published by the Altarum Institute in July suggest that President Obama and his fans in the traditional media reevaluate their premises about the rising healthcare spending.

Out-of-control spending on prescriptions drugs and the soaring cost of health insurance administration continue to be the two major drivers behind rising healthcare costs.”

Healthcare spending grew to $3.3 trillion in this year.

 

  1. Prescription drug spending increased by 9.2% from the previous year. Part of that increase was the introduction of new drugs.

Source

The Obama administration ignores the fact that more people are becoming sick because of an increase in obesity, diabetes and hypertension. These people now have to take medicine, see doctors, and buy medical devices.

  1. Administration services costs and net costs of health insurance (after paying medical bills) have increased 9.4% from a year ago.

These costs included government bureaucratic costs, insurance bureaucratic costs, out of pocket expenses and insurance premium costs.

How much waste is in all these administrative services costs.

3. Hospital spending rose 6.1% from a year ago. Hospital bureaucracy has been try how to decrease spending by decreasing waste and personal. However, bureaucracy and unnecessary administrators and outrageous hospital executive salaries continue to increase.

  1. Physician and outpatient clinical expenditures rose 5.0%.

Physician investment in medical structures and equipment rose only 1.7%. Physicians are reluctant to make investments in a failing healthcare system.

Each category in the various graphs above reveals opportunities to decrease the cost of medical care.

It cannot be done by the government’s complete take over of healthcare.

The government is the problem as we have seen and still are seeing with the VA Healthcare system.

Socialism does not work. In leads to unintended consequences as consumers adjust to the rules and regulations of an attempt to manage society.

Consumers must demand rule changes and permit the market place to sort things out.

Repair of the healthcare system can only occur in a consumer driven healthcare system with consumers in control of their healthcare and their healthcare dollars.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Can Government Run Systems Function Efficiently And Cost Effectively?

Stanley Feld M.D.,FACP,MACE

It has been proven over and over again that government does not run its systems efficiently and cost effectively.

Think of the post office, the railroad, the military services, the EPA and the IRS, to name a few. One could go on and on and come up with the same answer to the question. No.

The same holds true for government’s goal to control the healthcare system. It will not work. It has already proven to not be cost efficient or effective.

The Federal Government’s goal is to take over more and more systems operating in the life of the average American. The excuse is to help all Americans live a better life, to help the poor and under privileged. Instead it has kept the poor dependent on government, poor and under privileged.

“Each according to his abilities and each according to his needs” has not worked wherever it has been tried.

Government’s real goal is to have power over citizens. It is to make citizens dependent on the central government.

It is hard to find an example on the planet where this strategy has worked for the people it claims to help.

The results are also just the opposite of what the U.S. Constitution guarantees.

The evolution of the VA Hospital System is a stunning example of how government controlling a system does not work. No matter how much money the central government throws at the system it does not help. Noble goals always go astray. It is because the structure and the incentives in the system are wrong.

No one seems to focus on the main defects. The most important questions are:

Who is the main customer?

What motivates the main customer?

How do you devise a system that fashions incentives to motivate that customer to help make the system work?

It is not a larger bureaucratic structure with larger budgets. Larger bureaucracies move the system further away from the goals of the main customer.

It is not a series of regulations that impose punitive measures on providers and customers who are in the system.

It is not guarantees of tenure for managers of the system.

It is a guarantee to have managers of the bureaucracy listen and understand lower managers in the system who point out the deficiencies in a system.

The larger the bureaucracy the more difficult it is to personalize the system and have participants in the system help and help make the system work. Bureaucracies isolate themselves from the main customers in a system. It is the reason they do not work.

Large corporations in the private sector fail also. These corporations form large silo like divisions that construct systems that do not relate to the main customers or each other.

Large corporations sometimes understand the dynamic and try to reformat the corporation to service their customers. If they do not, their product fails

The people do not have the power to force the government to service them, the customers. Citizens can vote their representatives out of power. The government tries very hard to keep the main issues that disrupt systems out of public view.

There are many government agencies and systems that are failing. Our representatives never fix the systems. Our representatives do not listen to the people who are involved in the systems or who run the systems.

The VA hospital system has had problems since at least the end of WWII. It came to a head since the war in Iraq and Afghanistan.

Veterans Affairs Secretary Robert McDonald had been a successful CEO in the private sector. He made some significant changes in the operations of the VA at the onset of his tenure.

He also needed a $16 billion dollar infusion through the passage of the Veterans Access, Choice and Accountability Act to keep the VA Hospital System open after the scandals in VA care came to the publics awareness.

As government bureaucracies usually act, congress and the president ordered independent multi-consulting firms to audit the VA and tell government how to fix the VA Healthcare system.

Analysts from Mitre Corp., Rand Corp. and McKinsey & Co conducted more than a dozen assessments. No one has told the public what should to be done and what these assessments cost the taxpayer.

“A sweeping independent review of the Department of Veterans Affairs health-care system made public Friday shows the multibillion-dollar agency has significant flaws, including a bloated bureaucracy, problems with leadership and a potentially unsustainable capital budget.”

All that was needed was a little common sense by an authorized executive to realize what the problems were and fix them. All the defects were reported previously.

The government did not need multiple high priced consultants to tell them their problems.

The Commission on Care was mandated by the Veterans Access, Choice and Accountability Act to create a comprehensive reform plan to congress and the VA in 2016.

How much is this going to cost taxpayers?

How long is it going to take?

“The report bears out collectively what I have seen individually, what I have seen in my role as chairman over the past nine months,” said Sen. Johnny Isakson (R., Ga.), chairman of the Senate Committee on Veterans’ Affairs. “There is a huge focus on some glaring deficiencies that need to be addressed.”

The VA needs a lot of common sense and less bureaucracy, not more bureaucracy.

“Mr. Isakson said the VA suffers especially from a system saddled with a number of different departments that can’t effectively talk with each other, as well as a number of vacancies in leadership positions that need to be filled.”

America never learns. Big government does not work. Americans are starting to believe it.

President Obama and Obamacare are leading us in the same direction. It is the path to failure.

We must wake up now and stop this.

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

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President Obama Keeps Doing It

Stanley Feld M.D., FACP,MACE

President Obama is trying to avoid the press attention about  Obamacare’s continuing mess.

The insurance industry announced that insurance premiums in both the federal and state health insurance exchanges are going up to 50% in 2016. The group private markets will increase by the same percentages.

Insurance rates for 2015 were unaffordable for small businesses, and large corporations.

One church that buys insurance in the private healthcare insurance market had its rates increased 37%.

Instead of dropping insurance for their employees and paying the penalty, the church agreed to the pay the increased premiums. The church compensated for this increase in expenses by increasing church membership dues. Some members had to quit the church.

Eighty-five percent of members in Obamacare are receiving a government subsidy. A high percentage of that 85% are receiving higher subsidies than they are entitled to receive because of government lack of verification.

Eventually, when healthcare.gov website connects with the IRS, the government will find out that people received higher subsidies than they are entitled to. The recipients will get a bill they cannot afford.

Obamacare’s reinsurance subsidies for the health insurance industries are expiring in 2016.

The insurance industry is raising insurance premiums to cover the revenue lost by not receiving the Obamacare insurance company subsidies in 2016.

President Obama opened the Obamacare reinsurance program when too few insurance companies signed up to sell insurance through the health insurance exchanges.

The reinsurance program was a subsidy to cover the healthcare insurance industry’s supposed loses.

Obamacare hoped that multiple insurance companies would sign up in order create price competition among the companies and result in lower consumer premiums.

The healthcare insurance industry did not want to sign up. The insurance companies knew there would be adverse selection for insurance consumers.

Sicker people would enroll in the federal or state Health Insurance Exchanges. These sicker people could not afford or were not eligible to buy private healthcare insurance. The participating insurance companies would be at risk to pick up these sicker and more expensive patients.

“After finding that new customers were sicker than expected, some health plans have sought increases of 10 percent to 40 percent or more.”

Obamacare healthcare insurance coverage requirements would also cause them to seek an increase in premiums.

None of these issues appear in news stories that are covering this aspect of the story.

The political spin by the Obama administration is that the Obama administration is trying to persuade states to cut back big rate increases requested by many health insurance companies for 2016.”

I predict if the insurance companies do not get their rate increases they will drop out of the healthcare insurance market.

This is exactly what the Obama administration wants. It is a de-facto victory for a single party payout system and all of its ramifications.

It will not work because the Obama administration still needs the healthcare insurance industry to process and pay the claim. The result will be a higher premium for the consumer and an increased payout to the healthcare insurance industry by the government.

The government will be required to raise taxes or increase the deficit.

Kevin J. Counihan, the chief executive of the federal insurance marketplace is trying to convenience the healthcare insurance industry to reconsider its decision.

The facts spin war is starting. Mr. Counihan said in a letter to state insurance commissioners “Recent claims data show healthier consumers.”

This is apparently not true.

Scott Keefer, a vice president of Blue Cross and Blue Shield of Minnesota, which requested rate increases averaging about 50 percent for 2016, said his company had not seen an improvement in the health status of new customers.

“Our claims experience has not slowed at all,” Mr. Keefer said. “The trend has gotten a little worse than we expected.”

I have recently shown that the Obama administration’s claim that it is bending the cost curve is fiction. The cost to the government and the direct out of pocket cost to the consumers has increased.

The government costs have not risen as quickly as predicted by some but they are rising even more now.

Another weak argument the Obama administration is using is the federal tax penalty is increasing in 2016.

The federal tax penalty for going without insurance will increase in 2016, he said, and this “should motivate a new segment of uninsured who may not have a high need for health care to enroll for coverage.”

Why should these people buy insurance when they cannot afford the premiums or the deductibles?

Two additional weak arguments are being used.

“Federal officials said, much of the pent-up demand for health care has been met because consumers who enrolled last year have received treatments they could not obtain when they were uninsured.”

There has not been a very large increase in those insured by the state and federal exchanges between 2013 and 2014 to eliminate the “pent up” demand.

“Federal officials have also told state regulators that medical inflation will be less than what many insurers assumed in calculating their rates for 2016.”

The Obama administration has told these lies over and over again.

Does the president really believe if you tell a lie over and over again it becomes the truth?

There is a much better way to deliver universal health care and spend less money.

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2012/10/business-model-for-medical-care-2020-the-ideal-future-state.html

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Lies About Government Spending

Stanley Feld M.D.,FACP,MACE

President Obama and the mainstream media have been bragging about how well Obamacare is working. They cite that Obamacare is bringing down government health-spending growth.

However they have not been telling the truth. They have taken numbers out of context and have spun a lie.

The evidence presented by federal actuaries is that health growth has been under 4% in the five years prior to 2014.

The Obama administration has made a big deal out of this finding. President Obama has bragged that he is bending the cost curve with Obamacare.

His statements are deceptive. It means government health spending growth has been just under 4%. It is still increasing by 4% year to year and not the usual 6%-10% increase.  

Obamacare spending for direct medical care did not go into effect until 2014. All that went into effect was increases in taxes from 2010 until 2014 and spending on the growth of the bureaucracy resulting in a 4% growth. The math had nothing to do with increased direct medical care.

According to federal actuaries, spending on all health care grew 5.5% in 2014. Actual enrollment was lower than expected enrollment in 2014.

2014 was the first year of spending on direct medical care. Healthcare spending will continue to increase in 2015 to 5.3%. The reason is spending for Obamacare took affect in 2014 and continued in 2015. The reason for the slight predicted percentage decrease for 2015 is at least two fold. Less people signed up for Obamacare in 2015 than predicted and reimbursement for physicians and hospitals decreased.

Other reasons for a government decrease in spending are consumers are paying a greater share of their medical bills and reining in their use of medical care services.

One in three Americans said they or a family member delayed medical care because of costs in 2014, according to a report late last year by survey company Gallup.”

President Obama and his administration are deceiving the American public about the success of Obamacare.

The cost to taxpayers and people who are insured has actually increased. President Obama continually tells us costs are decreasing.

The mainstream media, especially The New York Times and Paul Krugman, continually repeat the lie. If you repeat a lie enough times people begin to believe it is the truth.

A reader asked me where did the New York Times readers leave their thinking apparatus. Someone else pointed out that the New York Times readership is decreasing because the newspaper has lost its credibility.

The New York Times opinions seem to be presented without supporting evidence.

The truth is premiums are increasing, coverage is decreasing and insurance deductibles are increasing for everyone including the middle class. Access to medical treatment is decreasing. Out of pocket expenses are skyrocketing.

The deception continues unchallenged by Republicans. No one is talking about the fact that the Obama administration is lying about what is happening on the ground.

“According to a report from actuaries at the Centers for Medicare and Medicaid Services published in the journal Health Affairs. In the years through 2024, spending growth is expected to average 5.8%, peaking at 6.3% in 2020.”

The cost of healthcare to the government is going to increase further and faster than predicted by federal actuaries as a result of expanded government insurance coverage under the 2010 health law, and the ever expanding Medicare’s baby-boom beneficiaries entering Medicare age.

As technology increases and as the baby boomers enter Medicare and more expensive life-saving drugs are developed costs to the government are going to increase.

The cost of pharmaceuticals is reported to have increased by 12% last year. The deals the government makes with the pharmaceutical companies are pathetic. The prices continue to mount for the government as consumer out of pocket costs for drugs increase.

By 2024 healthcare costs to the government and consumers are projected to be over 20% of our GDP and rising at the present Obamacare rate.

Americans will be older and sicker.

There is little government focus on helping our population become motivated to become  healthier and more responsible for their health and their own healthcare as they age.

Obamacare is forcing Americans to become more dependent on the government for their healthcare needs.

Hopefully, people are noticing that government does not work and more government will be a disaster to our medical and financial health.

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What Are The 3R’s?

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.

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King vs. Burwell and The Supreme Court

Stanley Feld M.D.,FACP,MACE

I have received a couple of emails asking me why I have not responded to the Supreme Court’s ruling in King vs. Burwell.

A ruling in King’s favor seemed so clear to me. I thought the case would be decided in favor of the letter of the law. This seemed obvious since Jonathan Gruber, the author of Obamacare, admitted the words “state health exchanges are the only exchanges that could provide subsidies” were intentional.

It was clear that the author of the law (Jonathan Gruber) and President Obama wanted to encourage states to create State Health Insurance Exchanges.

The carrot was money. If the states did not create State Health Insurance Exchanges they would lose their government grants.

The legislators of the states that refused the Obamacare trap would experience angry voters and get kicked out of office.

Dr. Gruber also admitted that if there was transparency during the law’s creation it would never have been passed. Jon Gruber called Americans stupid.

This comment motivated President Obama to distance himself from Jonathan Gruber. He said Dr. Gruber was not a major player in the creation of Obamacare. President Obama claimed that he barely knew him.  He claim Jonathan Gruber had only been to the White House a couple of times.

President Obama’s statement has been proven to be a lie.

 http://www.foxnews.com/politics/2015/06/24/editor-says-owes-gop-sources-apology-after-new-gruber-emails/?intcmp=ob_article_sidebar_video&intcmp=obinsite

 The Supreme Court’s decision has been a mind blower to me. I still have not figured out how to respond.

I thought the Supreme Court Justices’ job was to interpret laws within the context of the constitution. They should not create new laws or create new meanings for laws.

They also should not allow themselves to be bullied by the executive or legislative branch of government.

President Obama has been doing heavy duty bullying of the Supreme Court to rule in his favor in the last four months. President Obama’s goal is to not let anyone stand in his way on the road to control the entire healthcare system.

The justices live in our society. They are aware of the media and have access to the same information as everyone else.

It should be obvious to them that all the stakeholders dislike Obamacare now that they “know what is in it.”

Obamacare is a terrible law. President Obama told many lies and has taken many unlawful steps to hide the law’s failures.

The justices should have recognized that Obamacare is not a bipartisan law. Only Democrats voted for the bill even though many have admitted they did not read it.

It hardly represents the will of the people as they are now recognizing all its faults and deficiencies.

The Supreme Court’s codifying the law seems bizarre to me.

I also thought that the Supreme Court’s decisions had to be made in the context and spirit of the law and the meaning of the constitution. 

I am especially disappointed in Chief Justice John Roberts. His reasoning for ruling on King vs. Burwell was just the opposite of his reasoning for his ruling on gay marriage.

It is as if he has been influenced by outside sources in each ruling. 

I know the ruling has stunned many people. Congress made the law. Congress should change the law to mean what the Supreme Court said it meant.

I have not figured out what an appropriately reasoned response should be.

I believe the will of the people will prevail once people understand the harmful effects of this law. Its affect on the economy is becoming obvious. Its affect on Americans individually is also becoming obvious.

Obamacare will eventually die under its own weight. The Democratic Party will never be able to get rid of the label “tax and spend party.”

The Democratic Party and President Obama are putting America into greater debt.

I believe the lower socioeconomic groups, who President Obama claims to help, are realizing President Obama is doing them more harm than good.

His goal is to make Americans more dependent on the central government.

I do not think President Obama or the Democrats are going to be able to survive the coming tsunami of a plebiscite against Obamacare.  

In the end Americans are not fans of socialism. They know it doesn’t work.

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

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The New Medicaid

Stanley Feld M.D.,FACP, MACE

President Obama let the regulation to increase Medicaid reimbursements to the level of Medicare reimbursement expire because it failed to accomplish its goal. The goal was to get more physicians to accept Medicaid.

The Obama administration has proposed new federal regulations for Medicaid managed-care plans.

These regulations pledge the program's beneficiaries will have adequate access to a doctor. The pilot programs for these new regulations have been completed.

Two years ago six states made a deal with the Obama administration. Arkansas, Indiana, Iowa, Michigan, New Hampshire and Pennsylvania were willing to cover families earning up to 138% of the federal poverty level as long as it was on the states' terms.

Each state relies on private insurers, which are required to come up with qualified health plansthat meet the standards of Obamacare.

While Medicaid plan “purchasers” are almost totally subsidized, five of six states require some of these very low-income beneficiaries to make financial contributions that range as high as 2% of their income.

The idea is that everyone has some skin in the game. The plans also focus on setting up health savings accounts for beneficiaries and establishing wellness programs.

“While these are common features in many of today's corporate-sponsored plans (with only limited evidence to support claims that “more skin in the game” and wellness incentives hold down costs), these elements discourage enrollment by people who are scrambling to keep food on the table and a roof over their heads.”

I think the Obama administration is making another complicated mistake. There is not enough incentive in the program for Medicaid patients to try to save money for the government.

There is not enough incentive for physicians to sign up to accept Medicaid.

The Obama administration is using surveys of Medicaid beneficiaries.

Their response is not much different from the perceptions of Medicare beneficiaries and the privately insured.”

“But closer examination, experts say, reveals that beneficiaries' satisfaction is boosted by the additional access that comes from visiting hospital emergency departments and government-subsidized community health centers.”

 The Obama administration now proposes to hold Medicaid managed-care plans to the network adequacy of Medicare Advantage and Exchange Plans.

The six states, Arkansas, Indiana, Iowa, Michigan, New Hampshire and Pennsylvania, have been doing this along with offering higher-than-Medicaid rates to primary-care physicians to attract more of them to their networks.

A reduction in cost starts by managing patients in ways that encourage them to visit the doctor's office instead of the Emergency Department.

It does not have an element of encouraging patient responsibility or providing indigent patients with financial incentives to be financially responsible for their health or health care.

The same mistake is made over and over again. It is focused on providing patients healthcare coverage. The Medicaid Advantage healthcare coverage plans make Medicaid patients dependent on the government. It does not provide incentives for Medicaid patients to be responsible for themselves.

The healthcare insurance companies are planning to have a field day at the expense of the Obama administration. It seems like the Obama administration does not care how much the new plan costs.

The Obama administration is overlooking the important point. Healthcare coverage cannot work as long as patients are dependent on the government. Patients must be given financial incentives to be responsible for themselves.

All of the healthcare insurance companies that participate in the government supported medical insurance plans are aware of the impending changes in Medicaid.

These insurance companies bid for the administrative services contracts in each state.

The government makes the rules for engagement but the individual healthcare insurance companies bid for the contract.

It is totally logical for all the healthcare insurance companies attempted to merge. If these insurance companies were permitted to merge it would make Medicaid, Medicare and private insurance unaffordable to all.

The healthcare insurance industry sets the prices for administrative services.

The price increases would lead to citizen protest. It would lead to total government takeover of the healthcare system and a single party payer system.

Insurance merge

 

http://money.cnn.com/2015/06/22/investing/health-insurers-mergers-cigna-anthem/

 

The CMS has released a sweeping proposed rule (PDF) intended to modernize the regulation of Medicaid managed-care plans.

 CMS plans call for health plans to dedicate a minimum portion of the rates they receive toward medical services, a threshold known as a medical loss ratio.

At the very last minute the Obama administration is proposing an 85% threshold for Medicaid managed-care plans, the same as the government’s regulations for large group plans in the private market. 

The formula is MLR= incurred expenses /premiums earned.

Private insurance and Medicare are subject to an 85% MLR. It means that 85% of the premiums earned must go to direct medical care. Seventy five percent means only 75% must go to direct medical care and 25% can go to expenses as opposed to 15%.

  MLRatio

The healthcare insurance industry also defines direct medial care expenses such as network formation, insurance salesmen’s commissions and other into the direct medical care column. 
 
As of 2015, plans doing business with Medicaid and the Children's Health Insurance Program are the only health plans that aren't subject to an MLR.

The Medical/Loss ratio is one large source of profit to the healthcare insurance industry for two reasons.

Each expense allowed goes into the incurred claims column. The insurance industry builds a cost plus profit into each expense.

  1. The more required services (Obamacare requirements) rendered by that insurance company the more fee for those services which include profit goes into the incurred claims column.
  2. Each expense allowed goes into the incurred claims column. The insurance industry builds a cost plus profit into each expense.
  3. The more premiums collected the more goes into expenses in the incurred claims column.
  4. The lower the percentage (85% to 75%) of the Medical/ Loss Ratio profit to the healthcare insurance company.

 An arbitrary cap on health plans' administrative costs could undermine many of the critical services—beyond medical care—that make a difference in improving health outcomes for beneficiaries, such as transportation to and from appointments, social services, and more,” interim AHIP CEO Dan Durham said in a statement."


The MLR that the CMS has proposed for Medicaid plans is a suggestion rather than an enforceable mandate.

Medicaid managed-care enrollment has soared by 48% to 46 million beneficiaries over the past four years, according to consulting firm Avalere Health. By the end of this year, Avalere estimates that 73% of Medicaid beneficiaries will receive services through managed-care plans.

"This proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”

America's Health Insurance Plans immediately said applying an MLR to Medicaid managed care fails to reflect much of what these managed care plans do to hold down costs.

 In essence the new Medicaid proposal will also fail if the healthcare insurance industry merges and the impending fight over the MLR continues.

 The cost of healthcare insurance will increase for the private sector, Medicare and Medicaid.

The fault lies in President Obama's lack of understanding in who should drive the healthcare system. Consumers should drive the healthcare system not the government.

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

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Double Digits Increases In Obamacare Insurance Rates Proposed

Stanley Feld M.D.,FACP,MACE

Thirty-seven states refused to setup Obamacare State Health Insurance Exchanges. Thirty-seven states refused because of the expected cost burden to those states and citizens. States are required to balance their state budgets. Most states have deficits and do not have balanced budgets. Obamacare’s requirements would simply add to their budget deficits. States would be forced increase state taxes.

The 37 states felt that the Obamacare State Health Insurance Exchanges were an attempt, by President Obama, to decrease the federal cost burden and shift it to the states.  

It was also a states’ rights issue.

None of those states felt that Obamacare State Health Insurance Exchanges could work and not become an increased cost burden.

The Supreme Court ruled in 2012 that states have the right under the constitution to refuse to create a State Health Insurance Exchange.

In June 2015 the Supreme Court will rule on King vs. Burwell.

Can the Federal Health Insurance Exchanges subsidize applicants the same way State Health Insurance Exchanges can subsidize applicants.

The law’s language is specific. The Obamacare law specifically states that only the State Insurance Exchanges can subsidies applicants.

The Obama administration media manipulation machine is already spinning the truth in case the Supreme Court rules against the federal government.

Eight million people will lose their subsidy. There are 330 million people in America. There are as many people uninsured in 2015 as there were before the law was enacted. In five years we are no closer to the promise that Obamacare would provide universal care.

Obamacare is failing because it is a bad law in many respects.

The essence of the Obama administration’s spin is that if the Supreme Court rules against the government the cost of insurance will escalate to unaffordable levels for Federal Health Insurance Exchange purchasers.

Subsidies that made insurance plans affordable face a crucial test with decision expected in June.

The truth is the cost of healthcare premiums are going to skyrocket for Obamacare applicants because the only people who signed up have pre-existing illnesses and had to buy insurance or the very poor because their insurance was fully subsidized.

 The adverse selection and the financial accounting rules for the healthcare insurance industry allow them to raise the premiums.

President Obama’s subsidies for Obamacare premiums expire in 2016.

 

Megan McCardle writing in Bloomberg says;

Insurance companies have been bullied by the Obama administration into keeping rates as low as they are, even though they can't make any money.

For sheer survival, most companies will begin to charge enough so they at least don't lose any money, or leave the exchanges altogether.

For those of you who have followed my blog carefully, you know President Obama has provided the healthcare insurance industry a subsidy in order to get them to participate. It guarantees that it cannot lose more than 2% of its expected profit.

The insurance industry determines its expected profit.

The insurance company subsidy is about to expire. The guarantee in Obamacare, of not losing any money, is going to evaporate. In addition, only the sickest and poorest people have obtained insurance from the federal and state health insurance exchanges. The federal and state exchanges have lost a great deal of money.

These losses are slowly being revealed.

The State Health Insurance Exchanges are starting to publish their losses at the same time the healthcare insurance industry is reporting their potential losses for next year. Those potential losses are reflected in the proposed premium increases.

Moda of Oregon says that its claims were 139 percent of revenue.

CareFirst of Maryland says claims were 120 percent of revenue.

Tennessee told the Wall Street Journal it lost $141 million on exchange plans last year.

 State of New Mexico says it lost $23 million on revenue of $121 million.

 The states that signed up for the State Health Insurance Exchanges are losing money. Maybe the states that did not sign up were right. It would be a financial burden on those states.

The clause in the law permits only those states having a health insurance exchange to provide subsidies to their applicants. It excludes all others, including the federal government.

The only question the Supreme Court has to consider is, can the federal health insurance exchanges provide subsidies to applicants according to the law as written?

The law was written to encourage states to create health insurance exchanges. It did not include the provision of subsidy to applicants for  federal health insurance exchanges.

If the federal exchange would be permitted to provide subsidies, the law should be amended by congress.

A Republican congress would have to amend the law.

Obamacare is an apparent disaster to consumers, insurance providers, hospitals and physicians.

The majority of Republican are calling for Obamacare’s repeal.

It is unlikely that a Republican congress will change that provision in the law.

The “States only provision” in the law has backfired on President Obama and those states creating health insurance exchanges.

The cost of setting up and administering this new bureaucracy was enormous. The healthcare insurance offered by Federal and State Health Insurance Exchanges were either too expensive for healthy or young consumers or had too many unnecessary benefits for those consumers.

The only consumers who signed up were people who were too sick to be able to buy private insurance or too poor to be able to buy insurance without being subsidized.

Those consumers comprise 85% of the applicants. The result has been an adverse selection pool.

If the Supreme Court rules against President Obama he is going to say that private insurance does not work. The federal government must create an entitlement to everyone.

The result will be socialized medicine with the federal government being the single party payer controlling rationing of care, access to care and the cost of care to consumers.

I believe it will make healthcare coverage even worse than it is now.

Why no one is considering my concept of consumer driven healthcare with my ideal medical saving account is beyond me.

Rather than making consumers actively responsible for their health, healthcare dollars and healthcare, we are on the road to making them passive recipients of their healthcare.

America is going to be further down the Road to Serfdom.

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

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