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Stakeholder Abuse of the Healthcare System

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President Obama Sneaks In Another Tax Increase: Means Testing for Medicare Part D

October 9, 2011
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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 Stanley Feld M.D.,FACP,MACE

 

I must interrupt the development of my theme, “Managing Complexity In Order To Repair The Healthcare System,” to bring you this special announcement.

Starting in 2011, Part D enrollees whose incomes exceed $85,000 (for individual tax returns) or $170,000 (for joint tax returns) will begin paying more for Medicare Part D (Drug Prescription Benefit Plan). These “super rich?” seniors will be paying up to 60% more for Medicare Part D per person.

Some really rich seniors who receive a total income from all sources, including retirement benefit, social security, capital gains and dividend will pay the government up to an additional 500% more than their Medicare part D premium costs.

The government should fix the Medicare Part D program by negotiating the drug costs with drug companies directly as they do in the Veterans Administration. The healthcare insurance companies lobbied hard for this concession.

President Obama has chosen to tax seniors for the outrageously constructed drug benefit rather than putting seniors first.

President Obama slipped the means testing regulation for Part D into last years budget. Means testing went into effect on January 1,2011. I missed the regulation and its implementation completely.

Congress and the mainstream media also missed this rather historic regulation. Some would say the regulation was in plain sight but congress did not bothered to see it.

It was also astonishing to slip this into law when President Obama specifically promised he would not change Medicare benefits for any seniors. 

President Obama cannot be trusted.

It reminds me of President Reagan’s famous line. “I am from the government and I am here to help you.” 

President Obama’s plans to collect more than $8 billion a year from “wealthy seniors” for Medicare Part D drug prescription benefit by “means testing” seniors for all sources of income.

Major Democratic members of the House and Senate have been opposed to means testing for Medicare Part D. President Bush tried to get congress to pass means testing for Part D in 2006. It was quickly rejected by the Democratic controlled congress.

The Democrats arguments were consistent with liberal dogma.

“Social Security and Medicare are participatory programs, designed for all Americans—rich and poor alike. You work hard, kick a portion of your income into these two retirement funds, and are guaranteed a payout in your golden years. This gives these programs broad popular support—they are not welfare for the poor, they are guaranteed retirement benefits for all.”

“Liberals fumed. Means-testing of entitlement programs would send us down a dreaded "slippery slope," they argued. Soon Medicare, and then Social Security, would lose their broad-based popular support, and be merely costly welfare programs! Both Obama and then-Sen. Hillary Clinton voted against a Republican proposal to means-test Part D last year.”

President Obama’s regulation has not gotten very much media attention.  Liberals declare the goal is to preserve Medicare's status. Wealthy seniors (earning retirement income from all sources of over $85,000 per year) did not recognize the increase in 2011. The tax is deducted from their electronically paid Social Security benefit.

This tax was another President Obama trick play.

Pete Stark must be fuming about the means testing. It contradicts his liberal philosophy.

“Requiring some seniors to pay more for Medicare is a red herring from Republicans who want nothing more than to end Medicare as we know it,” said Rep. Pete Stark, ranking Democrat on the Ways and Means Health Subcommittee. “Upper-income seniors paid more into Medicare when they worked. Applying a new surcharge is essentially double taxation and should be rejected.”

Charlie Rangel’s reaction to means testing for Part D was expressed in 2006.

“The beauty of Medicare is that we’re all in it together, whether you are rich or poor, healthy or sick,” commented Rep. Charles B. Rangel, senior Democrat on the Committee on Ways and Means. “Charging certain people more is the first step toward destroying Medicare’s universality and turning it into a welfare program.”

Nancy Pelosi’s take on means testing for Part D in 2006 was harsh.

“It is simply unacceptable that nearly 2 million Medicare premiums will double beginning this January,” House Democratic Leader Nancy Pelosi said. “Seniors, who are already struggling to make ends meet, should not pay the price for failed Republican policies. With further premium increases slated in the future for even more beneficiaries, we must act immediately to protect America’s seniors.”

The Part D premium increases, known as means testing, are based on the same income thresholds as Medicare Part B means testing.

2011 Income thresholds are as follows:

2011 Income Thresholds (single)

Joint per person

Less than $85,000

Less than

$170,000

$85,000 – $107,000

$170,000

to $214,000

$107,000 – $160,000

$214,00

to $320,000

$160,000 – $214,000

$320,00

to $428,000

$214,000 or more

$428,000

or more

2011 Part D Additional Premium (monthly)

$0

$12

$31.10

$50.10

$69.10

2011 Part B Premiums

(monthly)

$115.40

$161.50

$230.70

$299.90

$369.10

Part D plan members will continue to pay their regular premium to their Part D plan, but the income-related adjustments shown above will be paid to Medicare. It will be deducted from their monthly Social Security check.

These additional charges are sure to catch some seniors’ off-guard. Some who might be subject to the additional charges are those who own a business, those who are earning farm or investment income, seniors who are taking installments from their 401(k), or those selling a home for a profit.

“This potentially historic change (and others like it) will slide right through, and serve as a model for further means-testing of entitlement programs”.  

What bothers me most is that there was no public discussion or political debate on the issue that I recall. President Obama simply hid the increased senior tax in his budget. He has often promised to make the drug plan more affordable.

President Obama’s means testing regulation is really an assault on the retired middle class seniors of modest retirement income.

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

 

 

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Stop The Demagoguery

September 4, 2011
inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 Patients are first. Patients are the reason for the existence of the healthcare system. Physicians are second. They are trained to understand the pathophysiology of illness and to treat patients for their disease. Everyone else is a secondary stakeholder (provider).

 All the stakeholders create waste in the healthcare system. If an accurate analysis were performed, most of the waste and the resulting profits would be attributed to the secondary stakeholders. Patient and physicians drive this waste and profits into the hands of the secondary stakeholders. Neither patients nor physicians are aware of driving the waste and profit into these stakeholders’ coffers.

The patient-physician relationship should be a one on one transaction. Patients and physicians are frustrated and many have accepted the disappearance of this human-to-human interaction. 

 Healthcare insurance companies and hospital systems think they own the patients and the physicians. This will turnout to be a fatal misperception.

 To many observers of the healthcare system, there are no simple solutions to fixing the dysfunction. One reader wrote:

“ There are so many contending interests, physicians, patients, hospitals, surgeons, labs, health insurance companies, public funding, et al., there will never be an ideal plan simply because of the tensions that exist between the above actors.”

“This is compounded by the population diversity which impacts ability to pay, willingness to practice preventative health or comply with medical recommendations.  Add into the mix the highly influential emotions that cause patients and their family to make inappropriate or unwise decisions.”

 The dysfunction in the healthcare system is so complex that most people look to blame someone for the dysfunction. The easiest targets are physicians.

  I believe there is a simple way to solve the problems. It is by creating a consumer driven system that provides enough financial incentive to consumers to inspire them to prevent the development of chronic disease, teach them to treat their chronic disease with effective systems of care and provide information on finding physicians who will provide care. The solution has to be driven by individuals responsible for their care.

 A case in point is Kris Carr author of Crazy Sexy Cancer

 “Before finding Dr. Demetri at Dana-Farber, she spoke to four other oncologists. One kept her waiting for three hours, gave her 10 years to live and then abruptly left to see another patient. Another off-handedly suggested a triple organ transplant. But something about the wrongness of it all galvanized a previously untapped drive in Carr.

  “I realized,” she says, “that if I was going to make it through this, I needed to become the C.E.O. of my own healing start-up.” Carr called her imaginary company “Save My Ass Technologies Inc.” She began meeting with doctors as if they were applying for a choice job with her.

 Consumers can drive all the waste out of the system. People do not want to believe this because the profit created by the waste is counter to their vested interest. Many health policy experts think consumers are too stupid to find good medical care. It is not that they are too stupid. Consumers feel powerless in the present system.

 Right now the solutions are finger-pointing solutions based on hunches and little evidence.

A physician wrote an editorial in the Bangor Daily News.

 I think my profession collectively has failed miserably to lead on most hot issues of health care reform. It has not, for example, led efforts to get all Americans health insurance, to reduce medical errors, or to reduce waste in health care in order to help make it affordable for us all.

 

 The statement is meaningless to me. It is grandstanding. The problem is if you tell a lie enough times it becomes the truth. The big question is which testing and which procedures are appropriate to improve well-being.

"Which road will physicians choose when it comes to reducing the number of wasteful procedures they perform and for which they get paid? We do countless colonoscopies, heart catheterizations, MRI scans, joint scopings, office visits and much more that waste billions of dollars and cannot be eliminated without physician leadership of a “whack out the waste campaign.”

 A reader of my blog replied to the statement made in the article in the Bangor Daily News.

I'd like to know who are the docs that are doing all this overutilizing that we keep getting accused of by others, and even by members of our own bunch.  I haven't practiced that way, and I don't know docs who do.  Where are all those miscreants?  I'm wondering if that may be another example of a false statement being repeated so often that it eventually acquires a ring of truth."

In another departure from conventional thinking by the traditional media the same reader continues:

"And, while I'm thinking about it, what can we do with the percentage that healthcare expenditures form of the GDP when the GDP is going into the tank, and healthcare is not?  Doesn't that make the percent for healthcare seem a whole lot larger than it otherwise would be?  Maybe we should be railing away at the people who have allowed our GDP to get to the miserable level it now forms.  Instead of it all being Bush's fault, maybe it is the fault of the unions whose greed drove all those jobs overseas, not to mention the excessive government regulations and taxation of corporations that make disincentives to GDP growth in our country?  Maybe our view of things is narrower than it ought to be.  D"

We should not be satisfied with conventional thinking. Finger pointing doesn’t solve the problem of dysfunction in the healthcare system. What does is recognizing patterns and changing approaches to the healthcare system that serve to align incentives of all the stakeholders without totally disrupting the structure that exists.

The most important stakeholders in the healthcare system are patients. They should control the healthcare system. Consumers should make all the other stakeholders compete for their business. There is too much waste, too many middlemen, too many markups and too much abuse by all the stakeholders.

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

 

 

 

 

 

  • Reyna Dugas • December 29, 2011

    Reyna Dugas

    This is one awesome blog article.Much thanks again. Really Great.

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The Healthcare Insurance Industry Continues To Game The Healthcare System

August 28, 2011
inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

I have described how the healthcare insurance industry loads its expenses into direct patient care expenses to increase their profits. 

The Medical-Loss Ratio calculation of is not reported by the traditional media. The healthcare insurance industry spends less healthcare dollars on direct patient care after it is permitted by federal and local agencies to load its expenses into the direct patient care column.

Simply put, the healthcare insurance industry cooks the books to increase its net profit.

Another way to increase profits is to shortchange physicians on medical claims. In fact, 20% of medical claims payments are inaccurate according to the American Medical Association’s (AMA) fourth annual National Health Insurer Report Card. Claims-processing errors by health insurance companies waste billions of dollars and frustrate patients and physicians.

This is one of the reasons the RAND report about physicians controlling waste is so absurd to me.  The healthcare insurance industry creates waste in order to increase net profit.

 The AMA released its annual report card on insurers saying, "Eliminating mistakes would save doctors and insurers $17 billion a year." 

The AMA said, “Commercial health insurance companies have an error rate of 19.3 percent, up two percentage points from last year's report.”

The healthcare insurance industry’s computer systems become better each year. At the same time, the healthcare industry has a higher error rate each year.

 The healthcare insurance industry’s explanation of benefits becomes less comprehensible to patients and physicians every year.

 When physicians discover insurers’ mistakes in reimbursement they fight the healthcare insurer for their patients or themselves. It is costly to fight and it distracts physicians from their job of diagnosing and treating patients. 

I think the error rate in reimbursement is even higher than reported. A significant percentage of physicians or their billing services do not pick up many of the errors.

The 2011 report card is based on a random sampling of about 2.4 million electronic claims for approximately four million medical services submitted in February and March 2011 to Aetna, Anthem Blue Cross Blue Shield, Cigna, Health Care Service Corp., Humana, the Regence Group, UnitedHealthcare and, for comparison, Medicare, according to the AMA.

 The claims were gathered from more than 400 physician practice groups in 80 medical specialties in 42 states.

It must be recognized that the random sample is a small percentage of the total number of claims processed. The results can have a large margin of error and result in a higher percentage of mistakes.

“The increase in overall inaccuracy represents an extra 3.6 million in erroneous claims payments compared to last year, and added an estimated $1.5 billion in unnecessary administrative costs to the health system.”

The additional administrative costs have an insurance industry’s profit component added on to reprocessing the errors.

 Why hasn’t President Obama recognized this and gone after this abuse of the healthcare system?

 "Robert Zirkelbach, spokesman for America's Health Insurance Plans, said in an e-mailed response that insurers and providers share the responsibility of improving claims payment accuracy and efficiency." 

The response is lame. The response gets worse.

 "CIGNA maintained its industry leading low denial rate of 68 percent." Notably, "lack of patient eligibility for medical services continues to be the most frequent reason for denials." 

UnitedHealthcare was the only commercial health insurer included in this year’s report card to demonstrate an improvement in claims-processing accuracy.

UnitedHealthcare came out on top of seven leading commercial health insurers with a accuracy rating of 90.23 percent. Anthem Blue Cross Blue Shield had scored the worst of those measured with an accuracy rating of 61.05 percent.  

Insurer Non-payment. 

 Physicians’ total non-payment rate for claims submitted to all commercial healthcare insurer was almost 23%. There is no reason insurance claims should not be adjudicated at the point of service. 

The insurance industry uses non-payment to hold onto the float. It results in hassling physicians and patients. Physicians are starting to demand full payment for services at the point of service from patients. This leaves adjudication of claims to the insurance company and patients. It can represent a hardship to patients. 

Denials

 Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare cut denial rates in half in one year to 1.05 percent as a result of last year’s AMA report card. 

Administrative Requirements. 

There is an increase in the rate of claims requiring prior authorization. Physicians have to ask permission before performing services or treatments. 

This increased requirement has many effects. It undermines the physician patient relationship and the patient’s confidence in the physician. It delays or interrupts medical services to patients. It consumes a significant amount of the physician’s time. It complicates medical decisions. It should be patients who question their physician’s decisions and have their physician justify the treatment to them. 

Accuracy

The healthcare insurance industry agrees to contracted reimbursement fees. The fees vary depending on how much the healthcare insurance company needs particular physicians in its network. Healthcare insurers have been notorious about not processing claims accuracy.  

It seems to me that with the state of the art of information technology being what it is, contracted fee reimbursement should be automatic and accurate. Most insurers have gotten better over the last year.

“The exception was Anthem Blue Cross Blue Shield, which scored 14 percent lower on this measure than it did four years ago.”

This is inexcusable. It might be purposeful in communities where Anthem Blue Cross Blue Shield is the dominant insurer.

Timeliness.

The AMA report card has been effective in exposing response time for adjudication of claims by physicians to the healthcare insurance company. CIGNA and Humana have cut their median claims response time in half in the last four years.

 Response times varied for commercial health insurers from six to 15 median days.

The resulting waste in the healthcare system from all of these tactics is enormous. Total healthcare insurance industry administrative waste (unnecessary expenses) is about $150 billion dollars a year.

If President Obama really wanted the present system of employer sponsored insurance to survive, he would be putting resources toward solving these problems.

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

 

 

 

 

 

 

 

 

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The Role of Physicians in Controlling Medical Care Costs and Reducing Waste

August 24, 2011
inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

The Role of Physicians in Controlling Medical Care Costs and Reducing Waste by the RAND Corporation and David Geffen, University of California Los Angeles School of Medicine, Santa Monica was just published in the Journal of the America Medical Association (JAMA).  I do not think the JAMA should have published this article.

1.Why would the JAMA publish such an article?

2. Why are physicians blamed for all the waste in the system?

3. Why is it the physicians’ responsibility to eliminate waste when they are not the cause of the greatest percentage of the waste?

“The amount of money spent on medical care is increasing faster than the gross domestic product (GDP), and the federal deficit is increasing.”

The initial statement assumes that the government deficit is increasing because physicians control government spending for healthcare.

This is only partly correct. The question I have is maybe patients should drive medical costs and not the government.  

The government bureaucracy and the healthcare insurance industry has created this cost monster.

 “Budget experts believe that the deficit cannot be reduced unless medical spending can be controlled. What role will physicians play in controlling health care cost growth? Are physicians even willing to play a role?

The article outlines the steps physicians must take to reduce waste and therefore the budget deficit. The assumption is physicians are the main source of the healthcare system’s waste.

The RAND Corporation does not consider the waste of the government bureaucracy, the healthcare insurance industry’s excessive fees, the hospital systems’ excessive billings, nor the pharmaceutical companies excessive charges for medication. Not considered is the excessive waste that results from the forced practice of defensive medicine because of the lack of tort reform.

If all these issues were addressed, waste and costs would be markedly decreased. There would be no need to try to commoditize physicians’ medical decisions.

I cannot visualize success in trying to commoditize the physician’s decision-making processes.

The healthcare system should be consumer driven with the consumers owning their healthcare dollars and making their own healthcare decisions. The government must help teach consumers to make appropriate medical care decisions with their own money. The government could provide the money. It would eliminate all the bureaucratic waste and secondary stakeholder abuse because it would create a true marketplace driven by consumers and not an artificial marketplace driven by government inefficiency. Consumers must make their own medical care decisions and be responsible for their actions. 

The authors of the article suggest that physicians have three options for participation in controlling healthcare costs. The problem is it assumes the burden for controlling costs are the responsibility of physicians.

     1.     "Physicians can do nothing."

      2.    "Health care can be rationed."

     3.   " Physicians take the lead in identifying and eliminating waste in US health care system."

    4. (We have tried to lead.)

    5. (President Obama has ignored us.)

“Physicians could define waste by assigning all services to 1 of 4 types of care—inappropriate, equivocal, appropriate, or necessary”.

This is subjective busy work that is destined to fail. It will also stifle creativity, thinking, problem solving and innovation.

Physicians try to practice evidence-based medicine. There are defects in determining best practices. In many cases the conclusions drawn from clinical results are inaccurate. It is arbitrary based on the bias of the experts picked to be the judges.

1.Inappropriate care, the potential health benefit to the patient is less than the potential harm caused by the procedure, device, or drug

2. With equivocal care, potential harm and benefit are about equal.

3. With appropriate care, potential benefit to the patient exceeds potential harm.

Necessary care is appropriate, represents the only viable option, and produces a large health benefit.

Who decides appropriate and necessary care?

An excellent example is the difficulty deciding appropriate and necessary care in the use of post-menopausal hormonal replacement therapy. The study design of the Women’s Health Initiative (WHI) was defective, the execution of the study was ineffective and the statistical analysis was inaccurate. The conclusions of the WHI are suspect. Yet the WHI has been heralded as evidence based medicine for best practices. It has changed the course of women’s health forever.

A tool to measure clinical waste across all clinical services does not exist. This is because the definition of “clinical waste” is ever changing. Today’s best practices can be tomorrow’s clinical waste.

Physicians are constantly trying to define best practices. It must be the job of physicians. Physicians are constantly trying to teach other physicians best practices. Physicians are constantly trying to learn to keep current.

The best practices have to be put into context with changing scientific concepts. Potential bias must be evaluated.

The clinical decisions should not be the interpretations of policy wonks or bureaucrats.

None of this is black and white. Policy wonks, economists and bureaucrats have little understanding of the complexity involved in clinical decisions.

Their interest is to somehow try to quantitatively measure physicians’ clinical decisions against an artificially created set of standards defined as waste.

“Physicians prefer the medical definition. But it is not known how much clinical waste is in the system.”

Another excellent clinical example of the controversy is the treatment of choice for Graves Disease (hyperthyroidism). There are cogent arguments for the treatment of choice for Graves Disease with either radioactive iodine or medications such as PTU or Tapazole. There is no unequivocal scientific evidence for an advantage of either treatment.

Attempts have been made to prove an advantage of one treatment over the other. When there is a lack of unequivocal evidence for best practices, patients must be given a choice of therapy.

A defect in the attempts to determine best practice in clinical research is the elimination of patients’ freedom to judge and choose or participate in the best treatment choice for that individual. 

It is physicians’ responsibility to defend and maintain that freedom for their patients. The reasons for waste in the healthcare system should not be determined arbitrarily by bureaucrats.   

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

 

 

 

 

  

 

 

 

 

 

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Nation’s Health Care Bill Predicted To Double By 2020

August 17, 2011
inHealthcare Insurance Industry, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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 Stanley Feld M.D.,FACP,MACE

Massachusetts has experienced a sixty percent increase in healthcare costs since “Romneycare” was enacted in 2006.  The total cost of medical care in 2005 was $350,100,000. In 2009 the total cost of care had risen to $587,900,000. This represents an annual growth rate of 13.7% per year.

The Medicare Office of the Actuary reported it expects healthcare costs to increase from the $2.6 trillion dollars in 2011 to $4.6 trillion dollars by 2020 under President Obama’s Healthcare Reform Act.

“The Medicare Office of the Actuary estimated that health spending will grow by an average of 5.8 percent a year through 2020, compared to 5.7 percent without the health care overhaul. With that growth, the nation is expected to spend $4.6 trillion on health care in 2020, nearly double the $2.6 trillion spent last year.

I believe the Medicare Office of the Actuary growth rate estimate of healthcare costs is low. Obamacare is about expanding healthcare coverage for the uninsured. It is actually about driving the entire population into a “Public Option” which will be subsidized by the federal government. President Obama’s goal is to have total government control over the healthcare system.

The total rate of growth of healthcare costs will be greater than 5.8% per year. President Obama is not going to be able to decrease costs by insuring at least 30 million more people. Obamacare has done nothing to restrain the healthcare industry’s billing policies. The healthcare industry’s profit will escalate even further as the federal deficit escalates.

President Obama declared that Accountable Care Organizations, Pay4Performance and Electronic Medical Records would reign in costs. I believe this is a pipe dream.  These programs are in the developmental stages and have an excellent chance of failing as the entitlement expands.

President Obama has continued to ignore an important healthcare cost generator.  Defensive medicine generates between $300 billion and $700 billion dollars a year in costs. Tort Reform if done correctly could decrease the cost of defensive medicine to the healthcare system markedly.

“The federal health law, which will expand coverage to 30 million currently uninsured Americans, will have little effect on the nation's rising health spending in the next decade, a government report said today.’

I hope the American people do not let President Obama trick them again with his demagogary. Last week he told us he was going to decrease the federal deficit by 4 trillion dollars in ten years. It is not true because he is going to increase the federal debt by 9 trillion dollars or 4 trillion less than he had planned. Deficit spending continues unabated.

 Everyone has to watch closely. He is bankrupting the country.

 White House Deputy Chief of Staff Nancy-Ann DeParle tells us not to worry. "The bottom line from the report is clear: more Americans will get coverage and save money and health expenditure growth will remain virtually the same,"

 

She stated that the new programs that administration officials said they hope to implement would change the way Medicare and Medicaid pay doctors and hospitals. (ACOs, Pay4Peformance and EMRs). Doctor’s and hospitals are only part of the problem. A bigger part of the problem is the administrative service providers (healthcare insurance industry) expenses, the cost of government bureaucracy, and the increase in defensive medicine

“Meredith Rosenthal, a health economist at Harvard School of Public Health, said it is difficult to predict what impact the health law will have on slowing national health spending.  "Many of the components of the law that are intended to control costs are still in draft form,"

The key to President Obama’s deception to the American people is to distract Americans from connecting the dots. Fifty per cent of employers will drop employer sponsored insurance programs and pay the penalty. Employees will buy insurance through the state insurance exchanges. States are refusing to participate in the insurance exchanges. The federal government is picking the ball up for the states and will have total control over the insurance exchanges.

Baby Boomers are joining the Medicare roles in increasing numbers by the minute. The cost of Medicare will escalate. Seniors are not going to be able to find physicians who accept Medicare because President Obama is going to decrease reimbursement by thirty percent January 1, 2012.

President Obama believes physicians are the problem. He refuses to believe the reality of the dysfunctional healthcare system. All the stakeholders are the problem. Some stakeholders donate more to his reelection than others. He has a strong record of playing favoritism to those that support him.

Americans are waking up to his tricks. The healthcare system has to be reformed. He has the wrong approach. I hope the electorate does not fall for his charm again. 

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

 

 

 

 

  • Janmar Delicana • August 21, 2011

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RomneyCare: Does It Work?

August 14, 2011
inMedicare, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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  Stanley Feld M.D.,FACP,MACE

 In 2010, Massachusetts State Treasurer Timothy P. Cahill, an independent candidate for governor, offered a wide-ranging and scathing criticism of the state’s universal health care law (RomneyCare). “ It is bankrupting Massachusetts and will do the same nationally, if a similar plan is passed in Congress.”

I predicted this result when the RomneyCare was passed in 2006. Mitt Romney can deny the results of his plan all he wants. The results are the results and it is his plan. It was an ill-conceived plan. His plan was the model for Obamacare. The media forgets that the (CMS director) Dr. Don Berwick and his untested “idealism” was the architect of both plans.

“We haven’t done anything about driving down costs,” Cahill said. “We haven’t helped small business. We haven’t changed the way we pay for health care and the way we deliver it.”

“The real problem is the sucking sound of money that has been going in to pay for this health care reform,”

Timothy Cahill pointed out that the Obama administration had subsidized the state Of Massachusetts plan so it looked good. All of RomneyCare’s defects were camouflaged.

“And I would argue that we’re being propped up so that the federal government and the Obama administration can drive its healthcare reform plan through Congress.”

Commonwealth Connector, the independent state agency established to help residents find health insurance, has “totally failed” to create competition and connect people with affordable insurance. Cahill pointed out that 68% percent of the residents RomneyCare serves receives subsidies from the state.

Patients do not have ownership in and responsibility for their illness. The state of Massachusetts does. It is logical that there would be a rise in costs and overuse. Romneycare creates another uncontrolled entitlement.

The state's health care reform law dramatically reduced the number of uninsured individuals.  At the same time federal, local and state funding for safety-net hospitals was dramatically reduced. In Massachusetts, the thinking was the uninsured, now insured, would go to private facilities for their healthcare needs.

There would be less need for safety-net facilities. The state of Massachusetts could then save money by decreasing funding for these facilities.

Massachusetts’s survey data showed the opposite. The survey of data between 2005-009 found:

  • The number of patients receiving care at Massachusetts Community Health Clinics (CHC) increased by 31.0%,
  • The share of CHC patients who were uninsured fell from 35.5% to 19.9%.
  • Nonemergency ambulatory care visits to clinics of safety-net hospitals grew twice as fast as visits to non–safety-net hospitals from 2006 to 2009.
  • The number of inpatient admissions was comparable for safety-net and non–safety-net  hospitals.
  • Most safety-net patients reported that they used these facilities because they were convenient (79.3%) and affordable (73.8%).
  • Only 25.2% reported having had problems getting appointment elsewhere.

 Our findings indicate that, although health care reform substantially increased the number of people with health insurance in Massachusetts, the demand for services from safety-net facilities (CHCs and hospitals) also grew, particularly for ambulatory care. 

“CHCs have become an even more important source of primary care, perhaps because of increasing difficulty obtaining care from other primary care physicians' offices.”

 

Surveys are a tool of social science and are not necessarily scientific proofs. They have a tendency to miss important findings within the data.

 The state and federal governments have subsidized 68% of the uninsured. Private physicians’ offices in Massachusetts are overcrowded. The insured now have first dollar coverage. Patients overuse the system by seeking more medical attention raising the costs of care.

In Massachusetts patients have speculated with physicians’ appointment times. Physician appointment times have been sold on the secondary market.

In Massachusetts some insurance reimbursements are so low that physicians do not accept certain insurance policies. Patients then have to go to the safety-net hospitals.

Special reimbursement deals have been made with certain physician groups and hospital systems. The Boston Globe has published these deals in the past.

 The total money spent by the state has increased beyond affordability. The increase is the result of overuse of the healthcare system. Patients have no skin in the game.

Revenue 1 8 11 11

 The losers have been patients, the state and small businesses. The winner is the healthcare insurance industry. 

Americans will see the same results with ObamaCare.

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

 

 

 

 

 

 

 

 

 

 

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Pretenses, Pretenses, Pretenses

August 7, 2011
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

During the last few weeks I have discussed the problems with Medicare Part
B, D and F.

The problems are the result of abuse of the healthcare system by the various secondary stakeholders protecting their vested interests. The stakeholders use their resources to influence our elected politicians. The peoples’ votes should be their only influence.

Politicians take the money from these various lobbying groups because they need the money to campaign for re-election. Media advertising is not cheap.

“The media exercises its greatest influence during elections . Candidates who lack an effective media strategy are likely to be destined for failure.”

“Candidates routinely spend 80 percent of their “war chests” on television and radio advertising. In larger states such as California, Texas, and New York, television advertising is the only way for candidates to reach the tens of millions of voters. In 2000, political novice John Corzine spent a mind-numbing $60–80 million of his own money — most of it on television commercials — to win a Senate seat in New Jersey.”

These two outstanding sound bites summarize the issue:

“The media is the message. Marshell McCluen.”

‘If you tell a lie enough times, it becomes the truth. Carl Sandberg.”

I can imagine the number of jobs created in advertising and in the media during the election season. The media are not willing to relinquish jobs and revenue for unbiased reporting.

President Obama has already been funding his reelection campaign on the taxpayers’ dime. His goal is to raise $1 billion dollars. The goal of the $1 billion dollars contributed by donors implies the purchase by these donors of political influence to support their vested interests.

The traditional media has not been criticized this practice. Campaign advertising is a large part of the traditional media’s yearly revenue. The media is cautious about criticizing large donors for fear of losing the campaign advertising revenue.

The voices of American voters are being drowned out by special interest money. Millions of dollars are poured into campaigns each election, and the amount continues to climb. Instead of turning to their constituents, members of Congress look to wealthy individuals and businesses to fund their campaigns.

Public Citizen is working hard to change the current system of campaign finance so that members of Congress are responsible to their voters, not to their contributors.  

President Obama has been beholden to these special interests. He has used trick plays to fulfill his obligations to his donors. He has disguised his intentions by claiming he is doing everything for the interest of the little guy.

I have difficulty believing anything President Obama says anymore. I also have difficulty believing Democrats and most Republicans in congress.

The recent raising of the debt limit tied to deficit reduction is a case in point.

It is a total fake.

Let us assume a person makes $50,000 a year. He spends $150,000 a year. That means he spends $100,000 a year more than he makes. He must go to the bank to borrow the $100,000.

Will any bank lend him $100,000?  No! He would have to prove how he would pay the $100,000 back.

He promises the bank he will reduce his “deficit spending” of $100,000 by 10% a year over the next ten years. That means that next year he will spend $90,000 more than he earns. He will only have to borrow $90,000.  In ten years I would increase his deficit by 680,000 rather that the 1,000,000 if he did not promise to decrease his deficit spending by 10% a year for 10 years. The banker would still say no.

The United States is not decreasing its deficit or balancing the budget with this latest deal. It is increasing the deficit will decreasing the “deficit spending.” The net effect is creating more debt.

 Why the deal is a fake. President Obama and the congress are not interested is being serious about being fiscally responsible. President Obama has faked out the American public once again.

There are many things government can do for the American public.  Everyone would agree that corporate interests, if given a chance, would take advantage of the public’s interest and the government. The government must protect the public from corporate interests and itself.

It can be accomplished by aligning corporate interests with the public’s interests. The use of force and penalties (price controls) always fail.

An example is food inspection and the Cargill turkey scandal. How are the complex food safety regulations enforced? They were not enforced in the turkey scandal. The inefficiencies and possible corruption that exist in government bureaucracy made the regulations impossible to enforce.

Did the government correct the deficiency? I think not. Last year’s hamburger scandal should have created the incentive and opportunity to correct the deficiency.

Would the pharmaceuticals companies step out and not sell the antibiotics to Cargill? They have not.

How does this relate to the dysfunctional healthcare system?

Why is Medicare so expensive and healthcare costs rising so fast?

Growth of Medicarice. 8 4 2010png

 Physician fees are not rising. Why penalize physicians? Healthcare insurance fees are rising. Bureaucratic infrastructure is increasing, as it is becoming less efficient. As this is happening the waste, fraud and abuse is mounting.

The only way to get out of the healthcare mess is to let consumers own, control and be responsible for their healthcare dollars. Social networking will be the driver of consumers’ demand for independence from government control.

The government bureaucracy’s role must be to create appropriate rules to protect the consumers from abuse.

The conundrum is the government’s bureaucracy is the biggest part of the problem

Government must also create educational programs to help consumers make wise choices.

 Consumers should be given incentives to make wise healthcare decisions.  

Increased government control will only create a bigger government mess.

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

 

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Easy Things to Do To Fix Medicare Part D

August 3, 2011
inHealthcare Insurance Industry, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE 

Twenty seven million individuals were enrolled in Medicare Part D as of December 2009. The government spent $51 billion to subsidize Medicare Part D in 2009. The $51 billion dollars spent is in addition to seniors’ premiums and co-pays. The government subsidy was $1,889 per individual subscriber. 

Who is making the money?

 “A provision in the Medicare Modernization Act (MMA), known as the "noninterference" provision, expressly prohibits the Medicare program (the government) from directly negotiating lower prescription drug prices with pharmaceutical manufacturers.”

 This was a gift to the healthcare insurance industry by the government as a result of intense lobbying efforts. 

Over 300 private plans (Medicare Plan D sponsors) enter into negotiations with pharmaceutical manufacturers separately to deliver Medicare Part D benefits.

Medicare Part D eligible seniors are forced to deal with an overwhelming number of private plans with varying formularies, premiums, deductibles, and co-pays in order to receive prescription drug coverage. The differences in prices are available but it is difficult to make comparisons.

The government negotiates directly with the pharmaceutical manufactures for the VA system. The VA system pays 42% less than Medicare plans for prescription drugs. The high volume contracts save money for the government and are lucrative to the pharmaceutical companies.

The various Medicare Part D plans cover about 85% of the most popular 200 drugs on average. The VA’s national formulary covers 59% of the most popular 200 drugs.

If Medicare Part D negotiated the same drug prices as the VA, the government would be able to decrease its subsidy $510 per beneficiary per year or a total of $14 billion per year (2009 prices).

Research by respected economist Dean Baker shows that the federal government and Medicare beneficiaries would save $600 billion between 2006 and 2013 if Medicare were allowed to directly offer a Part D benefit and to negotiate prices with pharmaceutical manufacturers. 7Such significant savings could be used to close Part D's donut hole and to lower cost-sharing for Medicare beneficiaries.

There are reasons for the twenty-six percent difference in formulary. Either the government-negotiated prices are too expensive and deemed marginally more effective than the drug ordered or the less expensive drug is determined to be just as effective. 

The judgment is made by the procurement system that negotiates price.

Is the cheaper drug as effective for a particular patient? This decision should be made by the patients’ physicians and patients and not by bureaucrats. It should be the patient’s choice to pay the difference. 

The procurement systems bureaucrats could be wrong.  

If the government negotiated for all the Medicare Part D participants the government’s purchasing power should be greater than the VA system. Its negotiated price would be better. The savings should reduce the government’s Medicare Part D subsidy significantly.

President Obama sort of understood this concept. He included the government’s right to negotiate drug prices in his Healthcare Reform Act. He subsequently removed the provision from his Healthcare Reform Act in exchange for the healthcare insurance industry’s and the pharmaceutical industry’s support of “Obamacare.” Seniors and the Medicare Part D program have lost.

It is obvious that there is much fraud, waste and abuse in Medicare Part D. February 2011; the Government Accounting Office published an example of CMS bureaucratic inefficiency and waste.

The Government Accounting Office (GAO) has designated Medicare as a high-risk program. The size, nature, and complexity of the Part D program make it particularly vulnerable risk to fraud, waste, and abuse. The GAO and the Inspector General of HHS requires all Part D sponsors (healthcare insurance industry) to have programs to safeguard Part D from fraud, waste, and abuse.

 CMS is responsible for managing and overseeing the Part D program. CMS regulations require Part D sponsors to have compliance plans that must include measures that detect, correct, and prevent fraud, waste, and abuse. 

 Congress asked the GAO to examine the extent of CMS's implementation of the oversight of Part D sponsors' (healthcare insurance industry) compliance programs to avoid fraud and abuse.

  CMS bureaucrats have written extensive documents containing many rules and regulations to combat waste, fraud and abuse.  CMS then outsources the Medicare Part D audit to Medicare Drug Integrity Contractors (MEDICs) to support its Medicare Part D audit efforts.

 The 2010 audit was supposed to be finalized in early 2011. It has not been completed as of July 30,2011.

CMS officials reported that they conducted only 33 audits out of 290 Medicare Part D sponsors (Healthcare insurance industry) in 2010.

“The 33 sponsors represented 11 percent of Part D sponsors, 56 percent of plans, and covered 62 percent of enrolled beneficiaries in 2010 according to agency officials. As of February 2011, CMS had not made all audit findings available but had taken formal enforcement actions against several sponsors resulting from the on-site audits according to agency officials.”

 “As of December 2010, officials reported that the agency had issued five marketing and enrollment sanctions and one contract termination action based, in part, on the results of these audit findings noting failure to comply with CMS compliance plan requirements.” 

 It is hard to imagine how many deficiencies exist among the other 257 Medicare Part D sponsors not yet audited. How long should these audits take? How severe will the penalties be? How can seniors know if their Part D plan is sound?

CMS has not been able to audit or enforce its own regulations that are suppose to protect seniors from fraud and abuse efficiently and effectively.

What can possibly go wrong with ‘Obamacare” with 256 new bureaucratic agencies and many thousands of new regulations?

The only healthcare system that could work is a consumer driven healthcare system with alignment of all the stakeholders’ interests.

Unfortunately, that is not going to happen anytime soon. Seniors are starting to take things into their own hands.

“After investigating several Canadian pharmacies, my wife and I paid $624.77 for a three-month supply of drugs at an online Vancouver registered pharmacy. These same drugs cost us $1,208.04 buying at Walgreen's, Target, and Kmart where we shopped for the lowest prices.”

"What's the catch? If Big Pharma had its way, customs and the FDA would be confiscating all imported drugs, crying that the government can't guarantee their safety."

"But that just isn't the case. Your pharmaceuticals come in the same sealed packages you get at your corner drugstore."
 

"Anyway, it would be politically incorrect to arrest grandma for trying to make ends meet. Some members of Congress even encourage the practice by listing Canadian pharmacies on their Web sites."

The Wal-Mart $10 prescription fee for generic drugs also works if your physician accepts generic substitution. 

A reader sent me a link to a website. http://babayoga.drugcutpillsrx.com/?camp=priagiji

 I reviewed the web site. It is based in San Francisco. The site offers large discounts on branded and generic medication. It is much less expensive than Medicare Part D. Senoirs could afford to buy the medication without using up credits toward the donut and use Medicare Part D only when needed.

It is going to take proactive approaches by seniors (consumer driven) to force the government to serve their vested interests and not the vested interests of the healthcare insurance industry and the pharmaceutical industry.

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

 

 

 

 

 

 

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Healthcare Costs: Who Gets The Money?

July 17, 2011
inHealthcare Insurance Industry, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanly Feld M.D., FACP, MACE

The National Institute for Healthcare Management Foundations report also contained data on the amounts of money each provider received for patient care.  There are important take home points in the data.

The data was obtained from newly updated figures of the National Health Expenditure Accounts (NHEA), the official estimator of health care spending in the United States.

During the period from 2005 to 2009 healthcare spending rose, and premiums for private health insurance increased an average of nearly 15 percent per year.

In the last two years private healthcare premiums rose 35%. The 35% increase occurred in anticipation of the healthcare insurance industry being forced by President Obama’s Healthcare Reform Act to provide healthcare insurance to high-risk consumers at the same premium as lower risk consumers.

Physicians have been blamed for increasing fees and over testing. The reality is physicians have experienced decreases in reimbursement for their services.

It is true some physicians over test to defend themselves from lawsuits. Tort reform is essential to decrease the practice of defensive medicine. Texas has reversed this trend with its new tort reform laws. Few other states have followed.

How healthcare dollars are distributed is revealing.

The United States spent $8,086 per person for healthcare in 2009 . Total healthcare spending as a percent of GDP reached 17.6 percent in 2009. It is expected to increase in the coming years.

In 2005, the United States spent $6,827 per person on healthcare.

 

             Who Gets The Money?

 

                   2005/person      %        2009/person      %

Hospital Care                 $ 2071               36         $2471            31

Physicians and Lab        $1417               20         $1646            20

Home Healthcare           $ 869               13          $1066            13

Rx + Medical Devices     $910                 13         $1066             13

Dental and other           $473               7           $548                7

Non Medical Expense    $1109                 16         $1289             16

 

There are many important points to be made about these numbers.  Let us assume these numbers are close to correct.

  1. Hospital services include inpatient and hospital-based outpatient, home health care connected to hospitals, nursing home and hospice care connect to hospitals, as well as the services of inpatient pharmacy and resident physicians.

The higher the obesity rates the higher the incidence of chronic disease. The higher the incidence of chronic disease the higher the complication rates from chronic disease. This results in higher utilization of hospital services. 

Each hospital service has an inflated markup. Remember the $45 dollar aspirin.

Hospitals with resident physicians are subsidies. These hospitals receive higher reimbursement than other hospitals. 

Hospitals collected 36% of the $8,086 dollars for patient care. It is obvious that reducing the number of hospitalizations for the complications of chronic disease would reduce the total cost of care.

 2. The physician and clinical services category reflect the care provided by physicians (MDs and DOs) in their offices and freestanding outpatient care settings and services billed independently by freestanding laboratories.   

It is obvious that physicians do not receive 20% of the per capita spending for medical care.

Laboratories that do lab tests, x-ray studies, MRI scans, CAT Scans and Ultrasound share reimbursement for this category. Unless physicians own the laboratories, they do not share in the reimbursement. It would be important to know the percentage of physicians that own those independent laboratories. 

Physicians own a small but growing percentage of laboratories. It is difficult for a physician or group of physicians to make a living from cognitive reimbursements alone. Physicians needs to collect ancillary laboratory fees to stay in business.  

 

Companies owning these laboratories are secondary stakeholders. They feed off the intellectual property of physicians. 

It is fair to say that physician reimbursement is half of the 20% of the dollars spent of medical care in this category. Physicians’ reimbursement for care is 10% or $708 of the $8086.

 3. $1,100 or 13% goes to other secondary stakeholders for care provided by freestanding home health agencies along with other long-term care providers include freestanding nursing homes, rehabilitation facilities and continuing care retirement communities with on-site nursing facilities (assisted living). Other non-traditional settings and providers receiving reimbursement include school, worksite health clinics, residential mental health/substance abuse treatment centers, some ambulance providers, and services provided through Medicaid home and community-based waivers.

 

There are many independent companies involved it the home healthcare business. Medicare patients utilize the majority of these services. The fees charged by the Home Healthcare agencies are high. These Home Healthcare agencies know how to pile on the services in order to receive better reimbursement. These agencies receive much more than the family practitioners who referred the patients.

 4. $1,100 of the $8086 is spent for purchases of prescription drugs, durable medical equipment and other medical products.

Pharmaceutical companies receive a large and growing proportion of the healthcare dollars spent for medical care but not the entire 13%.

How many advertisements do we see on television for electric wheelchairs totally paid for by Medicare? How about home glucose monitors? If it were not a very profitable business, we would not see so much direct to public advertisements.

5. The care given by dentists and other non-physician health care professionals including chiropractors, optometrists, podiatrists, private-duty nurses, and physical, occupational and speech therapists are included in this category.

Dentists and other non-physician healthcare professionals consumed 7% of the healthcare dollars for medical care.

 

The study is inaccurate for this category. It does not capture the actual money spent for dental care. Dental insurance usually provides poor coverage. Most dentists do not accept dental insurance and most people do not have dental insurance.

If we assume most of the cost should be attributed to the other healthcare professionals, these healthcare professionals receive as much or more than physicians.

The difference will become greater because President Obama is going to reduce physician reimbursement 30% on January 1, 2011.

 6. The last group is money allocated as direct patient care but is considered non-medical. This expense totals 16% of the healthcare dollars. It is included as a patient care expense and not overhead used to calculate premiums using the  Medical-Loss ratio formula.   

Healthcare insurers have insisted that typical business expenses to improve patient care should not be calculated into the Medical-Loss Ratio. The industry lobbied President Obama’s healthcare team and achieved its goal. 

President Obama made this deal with the healthcare insurance industry in exchange for its support of his Healthcare Reform Act. 

These non-medical care expenses are included in direct medical care. These expenses are 16% of the $8086 dollars per capita. These expenses are;

a. The cost of verifying the credentials of doctors in its networks.  

b.The cost to ferret out fraud by identifying doctors performing unnecessary operations, procedures, and tests.  

c. The cost for programs (help desks) to try that keep people with chronic diseases such as diabetes out of emergency rooms.

d.The healthcare insurance industry believes it should be entitled to expense sales commissions paid to insurance agents.

e. It wants to expense taxes paid on investments.                                         

 Healthcare insurers insist that typical business expenses should not be considered part of the Medical-Loss Ratio.   

President Obama has insisted that the Medical Loss ratio should be reduced to15% from 20-30 %. This means that the healthcare insurance industry can add an additional 15% above expenses paid for direct patient care when calculating insurance premiums.

The additional 15% is for healthcare insurance companies salaries and other expenses.

The total premium percentage the healthcare insurance industry takes off the top is 31% under present rules. Previously the healthcare insurance industry took between 35% to 45% of the total healthcare dollars paid into the system. 

 

                                    The Take Home Points

  1. The healthcare insurance industry receives an excessive percentage of the healthcare dollar.
  2. Physicians receive a surprising low percentage of the healthcare dollars.
  3. Hospitals receive a large percentage of the healthcare dollars because of pricing standards and the increasing numbers of patients with chronic disease.
  4. Ancillary stakeholders receive a greater percentage of the healthcare dollars than physicians.

 

President Obama’s Healthcare Reform Act cures very few of these problems.

 

 

 

 

  • Jacqueline Wright • October 1, 2012

    The blog is substantial. This could enlighten the minds of many American citizens.

  • Kim Robinson • November 28, 2012

    Health is wealth! so the government must give their time to resolve this healthcare problem. They say that healthy community can be very productive compared to unhealthy community.

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