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Stakeholder Mistrust

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All Medical And Healthcare is Local

Stanley Feld M.D., FACP, MACE

It is apparent that Obamacare is failing. Obamacare was built on a defective business plan designed with the goal to have all medical care controlled by the federal government.

If a stakeholder could potentially develop a plan that would threaten the central government’s takeover of the healthcare system, President Obama and his administration would simply rewrite the rules to destroy the initiative.

A clear example is the new rules to destroy health savings accounts. Medical savings accounts are similar to health savings account. The difference is Medical saving accounts put the money in the consumers’ hands initially. If there is any money left of the deductible it goes into a retirement account that is not directed to healthcare. Health saving account direct the unspent money to healthcare costs in the future.

The states are responsible for Medicaid. States claim that the central government is impinging on states’ rights by directing states to do what the federal government tells them to do with respect to Medicaid.

States have fought and won their argument in the Supreme Court when the federal government was paying 100% of the bill for Medicaid if states extended Medicaid. The Federal government will pay 100% until 2017. Then payment will decrease to 95% until 2020. At that time it will decrease to 90%.

Twenty-two states are not participating. The issue is a states’ rights issue rather that a healthcare issue even though the states need the federal help.

Even with this help many people on Medicaid cannot find a physician or can afford the medical care.

Many plans are being canceled, and many doctors and hospitals are no longer being covered by the new plans on the health insurance exchanges.”

A Medicaid patient said, “Even though I am now on Medicaid, I cannot use it because I cannot find a doctor. “

Another recently discovered stifling of states innovative ability has come to light.

After much bickering after the Affordable Care Act was written state innovation waivers, also called 1332 waivers, which are to begin in 2017, were written into the law.

The state innovation waivers or 1332 waivers are like a golden parachute to states both participating and not participating in the Medicaid expansion program. They are allowed to dictate the conditions and receive federal money.

The 1332 waiver solves the states’ rights problem.

The 1332 waiver would provide states with block grant funding to provide healthcare insurance to state citizens. It also waives nearly every major component of the Affordable Care Act (Obamacare).

A major provision of the 1332 waiver is that it is deficit neutral.

Two things could happen.

States wanting to experiment with a single party payer system could pursue it.

States that want to experiment with a free market healthcare system could pursue it.

Two prominent examples of innovative experimentation have been proposed.

In Arkansas, Governor Asa Hutchinson has signaled that the state’s “private option” Medicaid expansion. Medicaid beneficiaries would receive private insurance plans.”

 These private insurance plans would require higher spending for Medicaid. Theoretically the decreased spending in the Obamacare Exchange would offset the increased spending and better service for Medicaid patients. It would remain deficit neutral.

Rhode Island and Hawaii want to pursuit innovative entitlement programs that would cost less than the inefficient bureaucratic central cost.

The Obama administration could not tolerate the thought of the states being independent of federal control. A recent Friday afternoon, at 3 pm, the Department of Health and Human Services announced a rule change.

“These 1332 innovation waivers must still be deficit-neutral. However,

Savings from Obamacare may not be used to offset increased costs in other parts of a state’s health-care budget.”

The ruling by non-elected officials now makes these state controlled innovative experiments mostly impossible because the states cannot offset the savings.

Since all medicine is local, common sense dictates that states should be able to do a better job than a bloated federal bureaucracy in serving its local citizens’ healthcare needs.

The present system is a multi-trillion dollar failure. The states are correct in wanting to try something new.

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

All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

 

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More Double Digit Obamacare Price Increases

Stanley Feld M.D., FACP,MACE

Its getting boring to hear about Obamacare’s double-digit health insurance premium increases each year. The healthcare insurance industry is now preparing the public for another round of double-digit premium increases in 2017.

It is important to remember the public experienced double-digit health insurance premium every year since 2014.

The cost of buying insurance has skyrocketed since Obamacare was enacted. The public is not forgetting this.

The table below compares health insurance premiums before and after Obamacare.

This table includes both the numbers in the federal and state exchanges and the private healthcare insurance markets.

Ost of Obamacare on individual market 2014

President Obama and his administration are bragging that the healthcare insurance markets are stabilizing.

All the federal funded state health Co-ops will be bankrupt before the 2017 enrollment period.

Updated state reports on enrollment since the close of 2016 extended enrollment period indicates that more than 1 million of the 12.7 million who were reported to enroll for 2016 have dropped their Obamacare healthcare insurance policies.

In 2015 only 1.5 million consumers out of 11.7 million enrollees dropped out the entire year.

Arielle Levin Becker of the Connecticut Mirror reported“In Connecticut of the 18,800 customers who dropped out (16%), 20% failed to provide required information; 53% didn’t pay; 10% asked to have their plans canceled; and 12% shifted to Medicaid.

Those exiting customers were partly offset by nearly 8,000 latecomers, more than one-third of whom lost Medicaid.”

The truth is the Obamacare health exchanges are not stabilizing the healthcare insurance markets. Obamacare is destabilizing the healthcare markets.

It is becoming more and more difficult to believe anything President Obama says or his administration reports.

United Healthcare declared they are dropping out of most of the exchanges they are participating in because of the toll the health exchanges have taken on their bottom line.

Aetna just announced it lost more than $100 million on its healthcare exchange business last year (2015) but hopes to break even this year (2016).

This is a pipe dream on Aetna’s part. Less people have signed up for Obamacare and the people who signed up have been sicker people with pre-existing illnesses.

Aetna chairman and CEO Mark Bertolini said Thursday, “ the nation’s third-largest health insurer still sees a good business opportunity, but Congress needs to provide leeway for companies to design lower-cost plans tailored to young, healthy people.”

President Obama is not going to let insurers design lower cost policies tailored for young, healthy people. His legacy legislation is built on equal premiums for all.

These announcements can put the healthcare debate back in the headlines for the general election. It can re-ignite consumer and voter backlash once again.

President Obama ignored the backlash before. Can Hillary Clinton ignore the upcoming price increase backlash?

“Hillary Clinton is the only one promising to build on the Affordable Care Act. She’s proposed an aggressive effort to increase enrollment along with measures to reduce consumer costs.”

Hillary Clinton is mouthing words that sound good but are impossible to fulfill. People understand these empty promises now.

“ The Republican candidates all want to repeal “Obamacare.”

No one has come up with a solid proposal. Not even Donald Trump.

“Vermont Sen. Bernie Sanders would incorporate it into a bigger government-run system covering everyone.”

 Bernie Sanders is dead wrong. America cannot afford the cost and it has been proven not to work in the healthcare systems in the rest of the world.

The health law has many problems. The problems are too numerous to list here. The biggest problem in terms of costs for next years premiums (2017) are the lower-than-hoped-for enrollment, sicker-than-expected customers, and a bloated bureaucracy that is not an efficient business model.

Obamacare has created a financial drain for many healthcare insurance companies. The increase in premiums and the government pressure to keep prices low have in turn created pressure on insurance companies to lower reimbursement to physicians and hospitals.

Hospitals have to participate in the health exchanges, Medicare and Medicaid for survival. Physicians do not. Obamacare has created a more severe physician shortage.

The healthcare insurance companies would never consider becoming more efficient and lowering their cost. Some top executives are making more than 100 million dollars a year.

The healthcare insurance industry is setting the stage for 2017 premium hikes that could reach well into the double digits.

Virginia has nine returning insurance companies participating in Obamacare in 2017. These companies have submitted premium price increases ranging from 9.4 percent to 37 percent to the state board of insurance.

I am sure the Virginia state board of insurance will start negotiating with the participating insurance companies.

Obamacare will only cover 11 million enrollees in 2016. As more enrollees drop out of Obamacare because they cannot afford the premiums the total might be closer to 8 million. Many of the enrollees are subsidized. These subsidized enrollees have dropped out because they cannot afford the remaining premiums and deductibles.

The healthcare insurance industry increases premiums in the individual and group private markets to protect its profit margin.

This is occurring on top of the destruction of Health Saving Accounts and does not speak well for a stable healthcare insurance market.

President Obama’s goal is to destroy the healthcare system and replace it with a single party payer system.

Does anyone think a government run single party payer system will be more efficient or deliver cost effective care?

If you do, please think of the efficiency and effectiveness of the VA healthcare system?

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

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

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Keeps Making The Same Mistakes

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If Something Works, Destroy It!

Stanley Feld M.D.,FACP,MACE

If a program is working well the Obama administration starts regulating the program out of existence. In a very quiet and deceptive way the Obama administration is destroying Health Savings Accounts.

The fastest growing health insurance plan in the private healthcare market is Health Saving Accounts (HSAs). HSAs are also available in Health Insurance Exchanges.

Consumers love HSA’s because the money not spent for their yearly deductible expenses go into a personal trust fund, which goes to pay future medical expenses. Consumers, employers or government can fund the deductible. Healthcare coverage starts after the deductible is reached. The trust fund can grow tax-free until funds are withdrawn.

HSAs are not ideal but they do act to provide a mild financial incentive to consumers to be responsible for their health and healthcare dollars. Consumers decrease their overuse of the healthcare system.

Health Savings Accounts are not as powerful as my ideal Medical Savings Accounts. Medical Savings Accounts provide greater financial incentive for consumers to be responsible for their healthcare and healthcare dollars.

Consumers seem to lack the desire to prevent obesity, which is responsible for many chronic diseases and their complications. These diseases are responsible for 80% of the healthcare dollars spent.

With my ideal Medical Savings Account consumers or the consumer’s sponsors (government or employers) pay a high deductible. The sponsor then buys first dollar reinsurance for healthcare coverage. The unspent deductible goes into a Medical Saving Account tax-free retirement fund. It does not stay in the healthcare system.

The Medical Saving Account provides greater financial incentive for consumers to become more responsible for their health care and healthcare dollars.

Why and how does Obamacare want to regulate Health Savings Accounts out of existence?

In case you missed it, final regulations published on March 8 will make it impossible to offer HSA-qualified plans in the future.

 The health insurance industry has been opposed to HSAs and MSAs because the premiums the healthcare insurance industry receives is lower than regular healthcare insurance premiums.

Once the premiums are put into a trust it does not belong to the healthcare insurance industry to invest.

The healthcare industry has tried to influence HHS to dissuade consumers from buying HSAs through Health Insurance Exchanges since the exchanges began.

However HSS has done nothing (a) to help consumers identify HSA-qualified plans on the exchanges or (b) provide information to individuals that choose HSA-qualified plans about where to get more information about opening and contributing to an HSA.”

Last year’s proposed standardization of healthcare plan design rule gave no hint that the proposal would eliminate the possibility of HSAs surviving.

This year’s rule change made it clear that this was President Obama’s goal.

1)” Plans must apply specific deductibles and out-of-pocket limits that are outside the requirements for HSA-qualified plans.”

2) “Plans must cover services below the deductible that are not considered “preventive care.”

“ Regarding the deductibles and out-of-pocket limits, no Bronze, Silver, or Gold plans adhering to the standardized benefit designs will likely be HSA-qualified for 2017.”

The first step was for HHS to change the definition of a qualified plan. The next step was to force the plan design to be incompatible with HSAs.

HHS and CMS have given the healthcare insurance industry another gift. Maybe it is a payback for CMS short changing the insurance industry on its reinsurance payback promise.

In any event HSAs look doomed. The Obama administration has succeeded in destroying the development of a viable healthcare system that the free market, not the central government controls.

John Dunn M.D.,J.D. wrote a wonderful summary of Obamacare’s failed attempts to control the healthcare system to his chat group followers.

He has summarized all the policies that have failed in the Obama administration’s goal to destroy the private healthcare market and eliminate the free market system.

 “ Subject: HSAs being eliminated?

Yep, Obamacare strikes again to accomplish the real goal, elimination of private capitalist free market healthcare.

 Now let’s tally up the failures of Obamacare in its attempt to destroy the healthcare system—

  1. more expensive, less accessible,
  2. restrictions on hospitals and care givers,
  3. promotion of mid level practitioners, extraordinary inefficiencies created by computer mandates,
  4. penalties for hospitals and physicians that are created by apparatchiks,
  5. no decline in the uninsured,
  6. in fact there might be an increase in the uninsured because of the cost of premiums and deductible,
  7. more movement of people to Medicaid where coverage is free,
  8. bankruptcies of COOP insurance programs,
  9. exchanges failing with insurers leaving the market for taking big economic hits from adverse selection,
  10. and most of all—the death spiral of private market insurance—with the goal being to destroy the private market ????  
  11. Why of course, Medicaid for all. 

 The goal of government bureaucrats is control and power, achieved in this case by the growth of single payer government controlled medicine—Medicaid on steroids—

The result will be mediocrity as far as the eye can see, and destruction of innovative and creative health care,

but also the loss of the ethics and patient consideration that comes from physician guided health care,

 instead a trade for mandarins with frowns and red pencils,

 Checking the data banks that aren’t secure from hacking.

 It leaves one almost breathless, but it started a long time ago.

Good intentions and unanticipated results—Bastiat von Mises, Fredrick Hayek warned us about the fatal conceit and the problem of government actions to protect certain interests or promote a cause—ignorant of the realities of markets and the benefits of free markets. 

Socialism and statism will produce mediocre, expensive healthcare run by bureaucrats and apparatchiks who aren’t interested in good patient care,

They are only interested in control.

Looks like I am not the only one who has figured it out.

I do not understand why the political establishment cannot understand why Americans are getting ready to cast a protest vote against them.
 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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

 

 

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More ICD-10 Codes

Stanley Feld M.D., FACP, MACE

Everything the Obama administration’s healthcare administrators do, to increase their control over the healthcare system backfires.

The Obama administration has not admitted that the new coding system (ICD-10) has not worked out as well as it should have.

The fact that CMS has to add 5,500 codes in 2017 suggests that somehow the new system is being gamed.

The increase in codes from16,000 codes (in ICD-9) to 68,000 codes (in ICD-10) is a way to force providers to more fully document their diagnosis and treatment.

It is described as a way to improve patient care. I suspect it will be used as a weapon to decrease reimbursement.

The best way to improve patient care and decrease healthcare cost is to let the patients be responsible for their health and healthcare dollars.

A way needs to be developed to measure medical out as it relates to medical costs. These outcomes must be provided to patients.

The more codes there are the more the coding system can be gamed and abused by hospitals, physicians and other providers.

At this point the government is paying many other providers. These providers can also game the system. The increase in codes can result in a further increase in costs to the healthcare system.

Never the less the Obama administration seems to spin everything that backfires on it into a positive. The people are not accepting the spin anymore.

One example of the spin is the information paper CMS published about ICM-10.

One section is entitled;

How will my practice benefit from ICD-10?

ICD-10 provides an enhanced platform for physician practice. As of October 1, 2015, the ICD-10 coding classification became the new baseline for clinical data, clinical documentation, claims processing, and public health reporting.

The statement means physicians have to provide more documentation in order for the government and the healthcare insurance industry to have more control over physicians’ practices.

From proper observation and documentation to improved clinical documentation, progress notes, operative reports, and histories, the benefits of ICD-10 begin with enhanced clinical documentation enabling physicians to better capture patient visit details and lead to better care coordination and health outcomes.

It does not enable physicians to better capture patient visit details and lead to better care coordination and health outcome.

It enables government and the healthcare insurance industry to capture patient visit details. It does not necessarily lead to better care coordination and health outcomes.

Ultimately, better data paves the way for enhanced quality and greater effectiveness of patient care and safety. The benefits of ICD-10 will impact everything from patient care to each practice’s bottom line.

Better data might not lead to enhanced quality care or lead to better care coordination and health outcome. It can lead to more paperwork and more false data.

It also could conclude that the best physicians are the best documenters. It will not tell us which physicians have the best clinical judgment.

Reasons to prepare for ICD-10 can be broken down into four categories:

Clinical

  • Informs better clinical decisions as better data is documented, collected, and evaluated
  • Provides new insights into patients and clinical care due to greater specificity, laterality, and more detailed documentation of patient diseases
  • Enables patient segmentation to improve care for higher acuity patients
  • Improves design of protocols and clinical pathways for various health conditions
  • Improves tracking of illnesses and severity
  • Improves public health reporting and helps to track and evaluate the risk of adverse public health events
  • Drives greater opportunity for research, clinical trials, and epidemiological studies.
  • A lot of this is just word salad.

Operational

  • Enhances the definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers
  • Affords more targeted capital investment to meet practice needs through better specificity of patient conditions
  • Supports practice transition to risk-sharing models with more precise data for patients and populations.

Professional

  • Provides clear objective data for credentialing and privileges.
  • Captures more specific and objective data to support professional Maintenance of Certification reporting across specialties.
  • Improves specificity of measures for quality and efficiency reporting
  • Aids in the prevention and detection of healthcare fraud and abuse
  • Provides more specific data to support physician advocacy of health and public health policy

This section clearly defines the intention of the expanded ICD-10. It is an attempt to define physicians’ quality of care by computer and award or penalize physicians based on a potentially faulty definition of quality care. It could lead to quality care being defined by documentation, not by clinical judgment.

Financial

  • Allows better documentation of patient complexity and level of care, supporting reimbursement for care provided
  • Provides objective data for peer comparison and utilization benchmarking
  • May reduce audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation

Physicians can interpret this category as a threat to their reimbursement and their clinical judgment.

Physicians might conclude that they should do what the government tells them to do or they will lose their livelihood.

The government’s healthcare policy wonks. They are not practicing physicians. They do not understand physicians’ potential reactions. They do not consider the unintended consequences of this policy.

Once physicians understand the goal is let the government control physicians’ medical judgment there is no telling what will happen to the quality of medical care.

Quality medical care is not a science or a social science that can be managed by computer. It is a learned process by physicians integrating scientific knowledge an art of personal relationships.

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

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

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Obamacare Co-Op Folly

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The Obamacare Spin Goes On

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Social Engineering

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Obamacare Is Failing

Stanley Feld M.D.,FACP,MACE

The problems the Obama administration is having with Obamacare have not been in the news lately. They appear in government publications as minor policy changes or in press releases. They also appear in minor trade magazines. Little that is new has appeared in the mainstream media.

Readers of the New York Times are under the impression that Obamacare is working and is successful. The readers’ impression is that President Obama has done a great thing for the nation by getting Obamacare passed into law.

If a lie is told enough times it becomes the truth. The media is the message. All one has to do is lie to the media and the message gets through whether it is true or not.

The public’s perception of reality is not more complicated than the information fed to it whether it is true or false.

A key element in getting the message through is trust. It is my opinion, President Obama and his administration have lied to the public so much that there is a lack of trust in him and his judgment. The Republican and Democratic parties have lied to the public so much that there is a lack of trust in both parties.

It has been shown over and over again that Hillary Clinton as lied to the public. Yet, she is gathering millions of votes in her primary contests while others who have told the same lies have ended up in prison.

Black people are figuring out that the Democratic party has lied to them. The war on poverty started in 1965 and little progress has been made to eradicate poverty since then.

Why is there so much poverty and unemployment in the black community?

Why can’t black kids have a choice of public schools or charter schools in New York City? Why can’t education be a top priority?

As Leonard Cohen says, “the deck is rigged.”

I think the reason Donald Trump is running the table on votes in the Republican primaries is people do not trust politicians.

He promises to unrig the deck and make America great again. The politicians, pundits and traditional media are confused about why the public is listening to him.

The public does not trust or believe them. The public trusts Donald Trump and his promises without having objective reason.

Two significant events have occurred in the Obamacare world in recent weeks which are contributing to Obamacares further failure.

  1. President Obama caving in on the “Cadillac tax”

As part of the budget deal President Obama agreed to sign another delay in the Cadillac tax until 2020.

An Obamacare law provision levies a hefty 40 percent tax on the most expensive employer-provided insurance plans: those costing above $10,200 for individuals and $27,500 for families.

The Obama administration predicts it will generate $87 million per year in new taxes.

“If a plan cost $11,200, it would face a $400 tax — 40 percent of the amount above the threshold.”

The Cadillac insurance premium was a 100% tax-deductible expense to an employer providing a high cost healthcare insurance policy to employees.

High paid executives and some unions or union executives enjoy this high cost insurance. President Obama’s goal has been to provide a disincentive to employers from providing this type insurance.

The Kaiser Family Foundation estimates 26 percent of current plans could get hit with the tax in 2018; Towers Watson pegs it at 42 percent. This is the result of healthcare insurance rate increases.

I think it is a trick by President Obama to discourage corporation from providing healthcare insurance for their employees. The Obama administration would like to force corporate employees to buy healthcare insurance from the federal health exchanges. When the federal health exchanges fail the government could take over everyone’s healthcare insurance and dictate the terms of that insurance.

The “Cadillac tax” was suppose to go into effect in 2017 but has been previously delayed until 2018.

Lawmakers on both sides of the aisle agreed to delay Cadillac tax implementation even longer now until 2020. Some sort of political pressure has forced President Obama to sign the amendment to Obamacare. This new law will decrease the funding for Obamacare.

The traditional media has not emphasized this event leading to Obamacare’s demise.

  1. President Obama backs away from new Obamacare rules for 2017.

The execution of Obamacare by the Obama administration has not stabilized the healthcare insurance industry market as promised. In fact the federal exchange markets have become more chaotic. This is partly because of the inefficient bureaucratic structure and the lack of attraction to non-sick people, who would fund the federal health insurance plans. The healthcare insurance plans dictated by the federal government do not fit the needs of the people who would buy them. Instead, even though the health insurance plans are too expensive they attract people with pre-existing illnesses. These people have no choice.

The Obama administration’s typical response to fix unintended consequences is to create more rules and regulations. The new rules and regulations will lead to more unintended consequences.

The Obama administration just backed off of two big new. The Obama administration proposed tight physician and hospital network adequacy provisions and new standardized health plan options provisions.

The previous Obamacare rules and regulations resulted in the healthcare insurance industry’s adjusting to their loss of income by creating narrower networks of physicians and hospitals. Many of the healthcare exchange plans use HMOs only and narrow networks of hospitals and doctors as a way to keep premiums lower.

The result was a decrease patients’ access to care. CMS basically backed off of the strict network options it wanted to dictate. The Obama administration once again proved that it depends on the healthcare insurance industry to function. The healthcare industry is dictating the rules.

The goal of the Obama administration to standardize options was to make it easier for consumers to compare the various levels of healthcare plans offered in the health exchanges. The Obama administration also felt it was necessary to define the levels of basic benefits to make shopping for the most affordable plan easier.

The winner is the healthcare insurance industry. The loser is the Obama administration. The biggest losers are patients both in Obamacare and those who have private insurance.

As time goes on it is becoming clearer to everyone that Obamacare is not the success that President Obama and Paul Krugman are talking about.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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