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President Obama Continues to Deceive i.e. The Public Option

Stanley Feld M.D., FACP,MACE

President Obama continues to deceive the American people about Obamacare’s success as his term in office is winding down.

He is trying to use his charming personality to erase the fact tat Obamacare is failing.

The public must keep their eyes and ears open.

Obamacare is falling apart as the months continue. President Obama and the liberals are queuing up to pour more money into a failing healthcare reform model by reintroducing the need for a public option.

On June 30, 2016“CMS division of the HHS Dept. released the HHS Dept. released the actual Q1 effectuation report,

Each year the Obama administration has lied to Americans about enrollment in the health insurance exchange program.

As of June 30,2016, only 11.1 million people have signed up and continued to pay their premiums for Obamacare coverage in the 38 federal health exchanges as opposed to over 13 million that were published. State exchanges are closing monthly.

The latest prediction is that only 10.2 million will have insurance through Obamacare for the entire year. Eighty-seven percent of those insured through the federal health insurance exchanges have government subsidies in the government’s attempt to make health insurance purchased through the exchanges affordable.

If President Obama is correct about Obamacare providing insurance for 20 million people who did not have healthcare insurance previously then 9 million new people have signed up for Medicaid coverage.

Medicaid coverage is completely free to the recipients and is a single party payer system. The federal government presently pays for Medicaid coverage. The increased enrollment is also increasing the federal deficit.

Soon the federal government is going to dump some of the financial responsibility on participating states that are already running budget deficits.

It is only a matter of time before all the 23 state Co-Ops will go out of business and the federal health insurance exchange will take over.

Illinois is the 16th state to close its Co-Op doors. It followed one week after Oregon Health Co-Op closed its doors.

Land of Lincoln Health received $160.1 million in loans from the Centers for Medicare and Medicaid Services. More than 54,000 enrolled in coverage from the co-op through March 31.

 Where are these 54,000 people going to go for healthcare insurance?

 “It’s a bad day for the marketplace in Illinois and our consumers,” Jason Montrie, Land of Lincoln Health’s CEO said. “This is the end.”

Who is going to pay CMS back for these federal loans? The state of Illinois cannot afford to pay CMS back. The American taxpayers will re-pay the loan.

So far the total number of federal loans given to the failed nonprofit insurers is more that $1.5 billion for an experiment that was destined to fail from the start.

When are the liberals and progressives going to learn? You cannot keep spending other peoples’ money. You will eventually run out.

These last two weeks have been a big distraction because of party conventions.

Hillary Clinton announced her healthcare proposals. She has proposed an increase of $40 billion dollars in mandatory federal spending insulated from annual budget fights over the next 10 years to develop community health centers.

Hillary Clinton also wants to expand Medicare by letting people age 55 years old or older to opt into Medicare.

In addition she wants a public option.

“Bernie Sanders tweeted. “Together these steps will get us closer to the day when everyone in America has access to quality, affordable health care.”

Who is paying? The middle class taxpayer will pay the burden of the increase in taxes. It will not be paid by the 50% of the entitled citizens who do not pay taxes.

This is an attempt by Hillary Clinton to expand coverage for middle-aged adults. It also gives us a glimpse at how she wants to make Obamacare her own.

President Obama was not taking this lying down. He published an article in the Journal Of the American Medical Association, a “scientific journal.” This article is complete progressive propaganda. Why the AMA permitted this publication is beyond my understanding?

In his “special communication” President Obama once more presents another Trojan Horse (A destructive program that masquerades as a benign application.) to the physicians of America and the consumers of healthcare.

Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan.

Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers.59,60

The public plan did not make it into the final legislation. Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited.

Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.61

In 2009 Barney Frank and John Kerry insisted that a public option was essential for Obamacare to evolve into a single party payer system.

President Obama told them they would get to a single party payer system without a public option.

He has now changed his mind.

https://youtu.be/f3BS4C9el98

 

I have written extensively about the defects in a public option. http://stanfeld.com/?s=public+option

The New York Times writers did not describe the meaning or consequences of the public option in articles about both Hillary Clinton’s and President Obama’s call for a public option.

The American people should be told the real reason for the public option.

The combination of a “public option” within a health insurance exchange system was originally developed by liberal health policy analysts as a dual action mechanism to secure a “single payer” system. It presents the facade of a free market system but the end game is a full-scale government monopoly.

“If a public option became part of government-run health, the Health and Human Services secretary would establish such a plan, set its benefits, and fix its payment rates.

While private plans must negotiate market rates with doctors and hospitals, a Medicare-like “public option” would fix payment rates by fiat, well below the rates that would otherwise prevail in a real market.”

The “public option” would be a better deal for consumers rather than private healthcare coverage. The government would artificially force premiums down with subsidies. It could indiscriminately lower non-negotiated reimbursement to physicians and hospitals and force insurance companies out of the healthcare market.

It would result in an increase in federal taxes.

Additionally, the result will be a defacto single party payer system with less choice and access to care.

President Obama continues to ignore the fact that the government is dependent on the healthcare insurance industry to perform the administrative services for this government program. He ignores the fact that he needs doctors and hospitals to treat and care for sick patients.

He is only interested in financing the healthcare system and controlling the consumer’s ability to choose.

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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    Really very best to know about your blog really this site has been updating about life on the line, thank you for sharing with us. All knowing you are the professional whose job it is to advise keep it up.

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The Folly of Obamacare

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America Is Being Set Up By Progressives

Stanley Feld M.D.,FACP, MACE

During the past six months the Obama administration and its surrogates have being setting up Americans to believe that Obamacare is increasing in popularity in America. The surrogates being used are the New York Times, the Washington Post and progressive organizations such as the Kaiser Foundation and various think tanks that issue surveys geared to make that point.

Donald Trump is correct. The system is rigged.

The widely quoted Kaiser Health Tracking Poll published monthly spins its information in the direction the administration wants it to be. The conclusions of the February 2016 survey were;

  1. Americans (36 percent) say policymakers should build on the existing law to improve affordability and access to care than any other option presented.
  2. Sixteen percent say they would like to see the health care law repealed and not replaced.
  3. 13 percent say it should be repealed and replaced with a Republican-sponsored alternative.
  4. 24 percent say the U.S. should establish guaranteed universal coverage through a single government plan.

There are several things wrong with these findings.

  1. The Republicans did not have an understandable alternative at the time of the survey and they still do not have an understandable alternative.
  2. In February 2016 the Real Clear Poll survey of all state polls resulted in 51.9 % opposing Obamacare while 43% of all those surveyed approved of Obamacare.

Here is the rub in the February 2016 Kaiser Health Tracking Poll. Opinions of those surveyed were swayed after hearing counterarguments about Obamacare.

Before those surveyed heard the counterarguments the survey found that 50% were in favor of a single party payer system with the government running the system. 43 percent were opposed.

After the counterarguments were explained, the survey results were completely different. When it was understood that taxes would go up many changed their vote. Now, 43% of those surveyed plus an additional 20% opposed a single party payer system. Only 30% of those surveyed were in favor of a single party payer.

When the question was asked after the counterarguments were understood about how many would want the current healthcare law (Obamacare) eliminated or replaced, 14% switched their vote to favor eliminating Obamacare for a total vote of 14% plus 43% (57% total).

This is a very different view of the popularity of Obamacare.

These numbers appear in the weeds of the survey and were never advertised. One has to look carefully but they are there. The percentages opposed in these survey numbers are higher than the percentages in the Real Politics Poll.

Since the media is the message the conclusion of a casual reading would be that more than 50% want a single party payer system.

The disinformation creates a false impression of Obamacare’s popularity for the public. The hope is that the public would believe that more people like Obamacare and the prospect of a government controlled single party payer system.

In June 2016 the Kaiser Tracking Poll followed up with another survey that contained more disinformation.

The conclusions were:

  • Current attitudes about the ACA are divided, with 44 percent expressing an unfavorable opinion and 42 percent reporting a favorable opinion; 16 percent of Democrats report an unfavorable opinion, down from 25 percent in April.

It is not at all divided as reported by the Real Politics Polls or Kaiser’s previous corrected survey.

In May 2016 a Real Clear Politics survey of all state polls showed that 48.8% percent of all polled opposed Obamacare and wanted it repealed. Only 39.2% were in favor of Obamacare. The media had set the administration’s false message.

  • Increases in the amount people pay for their health insurance premiums tops health care costs concerns; premiums and deductibles are the biggest financial burdens.

This is true but the increases noticed it is because of the 10 hidden taxes for Obamacare and the healthcare insurance companies projected premium increases as of result of Obamacare.

  • A majority of Americans are following the news about rising health insurance premiums, but the public doesn’t differentiate reports about ACA marketplace premiums from private insurance premiums overall.

In the individual private insurance market premiums were always high and not tax deductible to the individual. Now that everyone is guaranteed healthcare insurance coverage in the individual private market the projected premiums have increased. This is the result of Obamacare regulations. I have described the exact details previously.

However, it is convincing enough to say Obamacare is falling short of providing universal care. The administration’s conclusion is that Obamacare must be expanded to a single party payer system with the government in control to achieve universal care at an affordable cost.

All I can say is everyone should remember the cost of VA Healthcare System is astronomical as well as universal. In this government controlled single party payer system our veterans are treated very poorly despite several scandals and the infusion of more government money.

Three weeks later, on July 10, along comes Hillary Clinton declaring that Obamacare must be expanded and more money must be spent. What will follow is higher taxes and more government bureaucracy.

Can anyone deny that something fishy is going on?

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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Deals With The Devil, How To Destroy The Healthcare System

Stanley Feld M.D., FACP, MACE

President Obama’s goal is to destroy the healthcare system. His deals and regulations lead the healthcare system on the path of destruction.

The strategy is creating so much pain to all the stakeholders that the healthcare system will implode.

At that time public opinion will demand the government take over the healthcare system.

What makes the government a better manager than the free market? The key is to have a system that aligns all the stakeholders’ incentives.

The government is not doing a good job keeping Medicare and Medicaid solvent and providing access to care. It is providing horrible healthcare services to our veterans in the VA system.

The government has conditioned progressive Democrats to continuously declare; “ I don’t mind paying a little more to make the system better.”

The destruction of the healthcare system is a slow process. The Obama administration is proceeding step by step in a very organized fashion.

When it is replaced by a single party payer system controlled by non-elected bureaucrats, consumers will have no control over their free choices.

Hopefully, the U.S. and its citizens are too diverse and too accustomed to freedom of choice and freedom of expression to let this happen.

Hopefully, consumers realize that central government control and socialized medicine doesn’t work. The concept of central control and socialism has failed too many times to count.

Our founding fathers certainly understood this concept.

Hopefully, consumer will realize that Adam Smith was right. The free market is self-correcting. It is only self-correcting with everyone plays by the rules and the government enforces the rules.

A government run by the political establishment that is controlled by vested interests does not work. It will eventually generate mistrust among all parties.

The mistrust of government is building to a tipping point.

Two recent examples of approaching the tipping point are the new ACO rules and the deception involved in the Obamacare reinsurance scandal.

Most of the 242 ACOs out of 3000 potential ACOs have three-year contracts. Many ACOs are not about to reach their Shared Savings goals for the reason I have mentioned.

I don’t know if these ACOs realized in their quest to become more efficient they would eventually lose money. Next year’s sharing goal will be this year’s modified to be the new profit sharing benchmark.

It might be impossible to deliver care more efficiently by the new benchmark.

When the ACO automatically progress to track 2 and fall short of the most recent efficient cost sharing savings benchmark these ACOs will have to repay the government for the losses.

The second important point that is propelling the healthcare system to the tipping point is that the new ACO rules do not take into consideration the healthcare systems that signed up to become ACOs initially.

Any savings the new rules offer in order to attract more healthcare systems to sign up for the ACO program have not been offered to the original signees until 2019. The original 242 have to wait until 2019 to be eligible for the extra bonuses given to new signees.

This might get the original hospital systems to quit their ACO participation completely. If the old ACOs quit the program, it would create more dysfunction in the healthcare system.

It would be just the thing the Obama administration wants to happen. The more dysfunction, the closer America is to a single party payer system.

An equally frustrating example was the money promised to the healthcare insurance industry to guarantee it a profit if it participates in the federal and state health insurance exchange program.

I have described President Obama’s reinsurance program in detail previously.

I was opposed to the reinsurance program. The Obama administration is totally dependent on the healthcare insurance industry to perform healthcare administrative services.

I am not sure either house of congress was aware of or appreciated the implications of the reinsurance program until it because obvious three years after Obamacare was passed.

The healthcare insurance industry knowing full well that they couldn’t make legitimate profits selling coverage through Obamacare’s exchanges, relied on Democrat guarantees that their losses would be covered by the taxpayers.

But a funny thing happened on the way to easy profits. Congress refused to appropriate the funds.”

When congress realized what was going on it capped the funds appropriated to the reinsurance program. President Obama is still trying to find the fund to pay the healthcare insurance industry.

President Obama paid only 12.6% of the 2.87 billion dollars the industry claimed the government owed it.

Now the healthcare insurance companies that have not been paid are starting to sue the Obama administration.

The companies included are Health Republic Insurance Company. It has filed a class action lawsuit against the government for $5 billion, Highmark Health has sued for $223 million, Moda Healthfiled filed a $180 million suit. Blue Cross & Blue Shield of North Carolina has sued for $129 million. Land of Lincoln Health has filed a $70 million suit.

It isn’t clear that these lawsuits aren’t going anywhere. “

“The defendant in the class action suit, for example, is “The United States of America” and the plaintiffs ask the court to strike down provisions of two congressional budget resolutions that require the risk corridor program to be budget neutral.”

Congress is the only branch of government that has the power of the purse. It is not the administration or the court.

As U.S. District Judge Rosemary Collyer put it in a ruling against the Obama administration in a similar case involving unauthorized HHS spending, “Congress is the only source for such an appropriation … See U.S. Constitution, Art. I, § 9, cl. 7”

“(‘No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law.…’).” And a budget resolution becomes law once it has been signed by the President. That’s why the 2015 spending bill is titled, “Public Law 113–235.” Yet the Health Republic class action suit holds that losses somehow render the law invalid:”

Qualified Health Plans have incurred even greater compensable losses in 2015 that CMS and HHS cannot pay as a result of the 2016 Spending Bill.

“Neither the Obama administration nor the congressional Democrats with whom they made their cynical deal can save them. In the end, the Devil will have his due.”

Another way to look at the entire debacle of Obamacare is this is exactly the way President Obama and his administration wanted it to turn out. It will lead the way to a single party payer system. The single party payer system will be another disaster.

Was Obamacare designed and implemented with such incredible ineptitude that Co-Ops like Health Republic and Lincoln Health were doomed from the onset?

Were Texas and the thirty other states that did not join smart enough to know the Co-Ops and state exchanges were destined to fail and go bankrupt?

Was it done purposefully by the Obama administration in order to create chaos in the healthcare system?

Why would anyone believe that a central government that runs and controls the healthcare system be any different than the VA system and the insolvent Medicare and Medicaid System?

Who is responsible for the debacle? The traditional mainstream media such as the New York Times and the Washington Post will blame it on a Republican congress that is refusing to change the law to pay President Obama’s illegal debts.

Who do you think will pay for the upcoming debacle?

You guessed it.

The taxpayers will pay for President Obama and his administration’s obvious fiscal irresponsibility.

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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Final ACO Rules

Stanley Feld M.D.,FACP, MACE

In the hope of getting more hospital systems and practices to participate in Accountable Care Organizations CMS has again changed the rules.

Below is a summary of the new rules.

  1. Regional benchmarks will replace national benchmarks.Cost benchmarks will now be based on regional spending data, as opposed to national spending data, when an ACO signs up for a second or subsequent contract period. ACO efficiency will be measured against other regional providers instead of against past performance.
  2. Track 1 ACOs will have the option of renewing under a two-sided model.If the application for renewal is approved, the ACO can defer exposure to downside risk for one year before transitioning to Track 2 or Track 3.
  3. Timeframes have been established for appealing calculations for shared savings or losses.ACOs will have four years to file an appeal.
  4. The new methodology will be implemented in phases.It will begin with ACOs entering contract periods on or after January 1, 2017.”

 

The goal of CMS is to use the ACO model to move reimbursement from a fee for service model to a value-based model.

Health policy wonks got the idea that if you attach reimbursement to quality care you will get less expensive care.

The problem is it is not known how to measure the value of medical care in automated computerized terms. The government needs medical care to be measured in computerized terms so that value can be automatically determined and related to reimbursement. Reimbursement should be congruent to both medical and financial outcomes.

Many false assumptions are made in evaluating quality medical care. Many important elements of quality medical care are ignored.

Three of the most important elements of quality medical care are the patient-physician relationship, the patients owning the responsibility for their health, their adherence to the care recommended by their physician, and making sure they are responsible for their follow-up care.

The new rules also ignore a consideration of physicians’ medical judgment in evaluating quality medical care. Medical judgment is very important in the delivery quality medical care.

These three elements of quality medical care are difficult to measure on a computer in an ACO model. ACOs focus on best practices using evidence based medicine and documentation of appropriate testing and treatment. The goal is to reduce the cost of healthcare.

ACOs shift financial risk to physicians and hospitals. ACOs ignore the financial responsibility of patients and their performance in their self-care.

In the new rules the healthcare policy wonks got one thing right. They are trying to increase the financial incentives for physicians and hospitals to do a better job. However, the methods the measurements are wrong.

So far there are only 433 Medicare Shared Savings Program ACOs. There are 3000 hospital systems that should be participating in Obamacare’s ACO program.

Only 14% of the hospital systems are participating after 3 years.

There are many large physician practices that should be participating in the ACO program. The number of physician groups that would qualify for an ACO program is unknown.

Only 22 of the 433 ACOs are in the track 2 group. Track 2 shares in both the profit and the loss of the group at the end of a year. There are 411 in the track 1 group. These 97% only share in the profit and not in the loss.

In the new rules the government is attempting to move from a fee for service system to a value-based care system with physicians and not the government or insurance companies being at risk.

What are the problems with the new rules?

The government is trying to increase the incentives for everyone to accept financial risk for increased quality care using inaccurate and unproven quality measurements.

The government is trying to soften the blow by giving ACOs an optional 4th year of staying on track 1 before being forced into tract 2. It doesn’t encourage the non participants to participate in the ACO program.

The changed rule does not encourage non-participating hospital systems and physician groups. The non-participants might not have the resources to participate.

The government believes benchmarking savings is the problem. In 2017 the government is changing to regional benchmarking in an attempt to encourage greater physician and hospital buy in and participation.

The elephant in the room is not the benchmarking rule,” said Clif Gaus, CEO of the National Association of ACOs, a trade group run by hospitals and physician groups.

 

“It is: What is CMS going to do to improve the business model for the one-sided ACOs and provide a lower-risk track for the two-sided programs?”

 

The determination of bonuses and penalties has been difficult for CMS. There is a deep mistrust of government and new rules in the medical community. The government is now saying trust me it will work out.

Many have raised concerns that the CMS still is not doing enough to increase provider trust and ease providers fear into riskier ACO models.

The government has basically gone all-in with the ACO as the vehicle to try and control fee-for-service, and they will continue to tinker with the regulations and the rules until they find something that works,” healthcare consultant Nathan Kaufman said.

 There was an inherent unfairness to the initial benchmarks the government set. It was based on the historical Medicare spending of a hospital system or practice.

Periodically the benchmarks were reset. Healthcare systems with higher costs and waste in the ACO system were more likely to share in the savings with the government than a more efficient system that had less potential for eliminating waste.

It also meant that at the next reset of the benchmark the newly improved healthcare system would have less chance of improving efficiency and therefore less chance of sharing savings with the government. In the track 2 of the ACO system, the hospital system would have more chance of having a penalty.

In other words the sharing system become a disincentive to improve because physician and hospital payment would decrease against a continuingly improving delivery of care.

The new rule sets regional benchmarks. In the long run it would have the same negative effect if everyone improved.

“ Some health systems have pulled out of the ACO programs in the past few years due to the lack of regional factors associated with bonuses.”

“The problem is so few ACOs have been able to generate the incentives to encourage physician participation,” Kaufman said.

Experts say the benchmarking changes will not fix an underlying problem. Most physicians and hospital systems are wary of the program’s more aggressive tracks. They are afraid of facing sizable penalties if they don’t contain costs as directed by the government and the healthcare insurance industry.

These providers are still are risk to keep patients healthy. It might be a risk that physicians understand are not under their control.

The risk of keeping patients healthy is under patients’ control! They must follow the advise of their physicians.

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 ACOs Rules Will Mean More Problems For Obamacare

Stanley Feld M.D.,FACP,MACE

 I have written many articles on why I believe Accountable Care Organizations (ACOs) will fail.

ACOs are critical to the success of Obamacare as are many the other programs introduced by the Affordable Care Act.

If one listens to the Obama administration’s propaganda about how wonderful Obamacare has been for the American public, one would be living in a dream world, not the real world.

Obamacare has failed on many levels. The administration believes the public will not remember the previous failures.

Here are the failed promises.

  1. You can keep your doctor if you like your doctor.
  2. You can keep your health insurance policy if you like your health insurance policy.
  3. Each family will save $2500 dollars on healthcare each year.
  4. Anyone making less than $250,000 a year will not pay one red      cent in new tax.

The failures of Obamacare

  1. Obamacare will bend the healthcare cost curve. It bent the cost   curve for the first three years because Obamacare collected new taxes without providing healthcare services until 2014.
  2. Thirty-two (32) states refused to expand Medicaid.
  3. Twenty-two (22) of 50 states signed up to have state health insurance exchanges.
  4. All of the states that developed state co-ops with federal loans are under water. Fourteen of the 22 are bankrupt now. All will be bankrupt by 2017 or 2018.
  5. Private insurance enrollment though the federal health insurance exchanges has not increased for the last 3 years. Many of the buyers of health insurance exchange insurance have pre-existing illness. The health insurance exchanges are the only available insurance.
  6. The hospital system and private practice meaningful use electronic medical records have not increased percentage wise as expected.
  7. Worthless electronic medical records have increase at high costs to medical practices and hospital systems. These electronic medical records are providing some false big data information to the government and healthcare insurance industry to generate defective policy regulations. Hospital systems and physicians benefit little from the data generated.
  8. Healthcare.gov is still not right after spending billions of dollars over budget.
  9. Healthcare insurance premiums have skyrocketed for companies providing healthcare insurance to its employees.
  10. Healthcare insurance premiums have skyrocketed for people buying healthcare insurance from the federal and the few remaining state health insurance exchanges.

The only success I have seen is in Medicaid enrollment for the poor and illegal immigrants. The access of care has not improved for tax paying people.

These are just a few of the Obamacare failures. The public would never remember there have been so many failures reading the propaganda and press releases that appear from the government in the traditional mass media.

The Obama administration’s information has blurred those failures. I sense the public does not want to know about the impending disaster in the healthcare system.

Many intelligent people ignore these facts. They keep reciting the administration’s talking points about Obamacare’s success.

ACOs were supposed to lower healthcare costs. They were supposed to provide incentives for hospital groups and private practice groups to save money by providing more efficient medical care.

If these groups did lower the cost of care they would share in the savings along with the government.

There are many ways to achieve these savings and many measurements to determine these saving.

In short, ACOs were designed to shift the financial risk of care from the government to the physicians. If the physicians didn’t hit the benchmark they would lose money. The goal was also to shift to a flat rate payment for each illness from the individual fee for service based payment system.

Physicians will get paid a flat rate for a particular illness. It means that the risk for taking care of the illness at a particular cost shifts the financial burden to physicians and not the insurance company or the government.

The gigantic defect in the system is there is no burden on the consumer nor is there an incentive for consumers to be responsible for their health or healthcare dollars.

No risk is placed on the patient for compliance with treatment advice.

I have pointed out most of the defects in the ACO model in past blogs. ACOs are essentially an HMO on steroids. Hillary Clinton did not do too well in 1993 with the HMO model

ACOs do not address the problem of the high salaries of hospital administrators and healthcare insurance executives (who provide administrative services for the government). These salaries increase the cost of the healthcare system.

Last week CMS released another final rule intended to improve the way Medicare pays accountable care organizations (ACOs) in its Medicare Shared Savings Program (MSSP).

It is clear that if another final rule is made the last final rule is not working.

The hype of this new final rule is that the Obama administration has solved what many viewed as a critical flaw in the bonus structure for Medicare’s accountable care organizations.

I think the new final rule might make ACOs fail completely.

CMS spokesman said, ”Physician buy-in is critical for the long-term sustainability of the ACO program, which could play an important role within Medicare’s broader reforms to physician payments under the Medicare Access and CHIP Reauthorization Act, or MACRA.

MACRA is another poorly designed program that makes payment for physician service more difficult to understand.

MACRA could inspire physicians to quit the whole ACO enterprise.

A group of executives on the MACRA (Medicare Access and CHIP Reauthorization Act) task force said,

“The goal is to force physicians and payers determine how to most effectively tie payment to performance and value.”

“A panel of healthcare experts and organizational leaders who began adapting to value-based payment years before the Medicare Access and CHIP Reauthorization Act started fleshing out regulations talked about their programs at the event sponsored by the Commonwealth Fund.”It is obvious to me that you cannot force anyone to do anything they do not want to do. You can only provide motivation and incentive for people to do what is best for themselves from their point of view.

MACRA will not get physician buy in because it will be too restrictive, arbitrary and controlling.

So far there are only 433 Medicare Shared Savings Program ACOs. There are 3000 hospital systems that should be participating in the Obamacare’s ACO program.

Only 14% of the hospital systems are participating after 3 years.

There are many large physician practices that should be participating in the ACO program. The number of these groups are unknown.

The lack of participation is a result of the complexity of the ACOs, the inability to form a unified culture of physicians in a hospital system and the difficulty hospital systems have with pricing risk.

Pricing risk is the job of the healthcare insurance industry and not physicians or hospital systems.

The government wants to put that task on the shoulders of the physicians and hospitals.

There are two risk tracts for ACO. Tract one is called one-sided risk.

The ACO only shares in the savings and does not participate in the losses if they spend more than the benchmark costs.

Tract 2 is call two-sided risk. The ACO shares in the savings with a more generous bonus from Medicare than the bonus of the tract 1 participants but pays a penalty to Medicare if doesn’t save money or demonstrate high quality care.

Only 22 of the shared-savings 433 ACOs or 5% of the participating ACOs have chosen two-sided risk. The Obama administration’s goal is to have all 3000 hospital systems participate the two-sided risk model.

The participation rate is .7% participation rate for the 3,000 hospital system that should be participating. It is far short of the Obama administration’s goal.

I would not rate the ACO participation rate as a success after 3 years.

This absolute failure has not been acknowledged by the Obama administration or the Obamacare praise singing traditional mass media.

The new final regulations and MACRA will not fix this failure. It will only make the failure worse. I will discus both the new final rule and MACRA next time.

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 On Women’s Health, HRT And WHI

Stanley Feld M.D.,FACP,MACE

The Women’s Health Initiative (WHI) was published in 2002. I presented a critique of the study in 2003. I gave a lecture in different parts of the country at that time debunking its statistical significance.

No one paid attention to the statistical results. The media was the message and the message has lasted despite good data refuting the message.

My last blog reviewed the lack of statistical significance of all the conclusions of the WHI study.

I published these thoughts once before in a 2007 blog post. I was stimulated to republish my comments last week because of two excellent lectures I heard at a recent American Association of Clinical Endocrinologists (AACE) meeting reviewing the recent literature as to the value of estrogen replacement therapy in post-menopausal women.

Holly L Thacker M.D. presented “Women Getting Older-and Even Better”.

Dr. Thacker is the Director of the Center for Specialized Women’s Health at Cleveland Clinic.

  1. Mitchell Harman, M.D. presented “Hormonal Treatment of Menopausal Women: What Are The Data Telling Us (and Not Telling Us)?”

Hopefully these two presentations will help us move forward in getting to the truth about hormone replacement therapy in the post menopausal woman.

Neither presentation stated outright that the Women’s Health Initiative conclusions were invalid because of the fact that none of WHI conclusions were statistically significant.

However, several important new points were added to the discussion using the WHI’s own data. I will present the discussion.

First, I want to present an email exchange a reader had with a retired statistician about my last blog.

Mon, Jun 6, 2016,

S wrote:

R,

The blogger writing below is a now retired endocrinologist, academician and oft critic of ObamaCare.

In his post below he takes on many of the reports that were published based upon the WHI and related.

Passing it along to you FYI owing to his assertions as presented below.

 Perhaps instructive after all.
S

June 6.

Stan,

I sent your post on the flaws of WHI data and interpretation to a retired statistician for comments.

He applauds your evaluation and comments.  As do I.

FYI.
S

From: R
Sent: Monday, June 06, 2016
To: S
Subject: Re: FW: Repairing the Healthcare System

 The points made are good ones.  The major point missed is that the study was done with horse piss estrogen, not human biologically identical estrogen which have been shown to produce none of the negative effects of horse derived estrogen.

None the less, the scientific criticism of the reported study are very accurate and very good.

R

In 2011 AZ LaCroix using the WHI’s own data analyzed the myocardial event risk. Women talking estrogen between ages 50-59 had less risk of having a myocardial infarction than women starting to take estrogen replacement therapy from age 60-69 and from age 70-79.

The WHI lumped conclusions lumps all three groups together in its analysis.

  Estrogen early Memopause results

 

It is well known and accepted that the incidence of myocardial disease increases in women as they age and increases in post menopause to the same incidence as males.

Estrogen slide 2

The timing hypothesis for starting estrogen therapy was proposed as a result of this new interpretation of WHI data.

The effects of HRT on CVD are dependent upon time HRT is initiated relative to menopause and/or age (the “timing hypothesis”).

E3

The upper two curves reflect the thickness in the carotid artery tested with ultrasound in women starting to take estradiol ten years after menopause. There is not a significant difference in the increase in intimal thickness between the placebo group and the treatment group (p==.029). Significant p values are 0.05 or less (i.e. 0.001).

Whereas the lower curves where estrogen started in less than 6 years post menopause the placebo thickness increased greater than the estradiol thickness for a very significant p value of 0.007.

This data reflect the influence of estrogen on vessels when taken shortly after the onset of menopause. The result presumes the protective effect of estrogen in post-menopausal women as opposed to the conclusions of the WHI.

I believe that WHI stimulated fright that estrogen causes breast cancer has been exaggerated. Only 4% of the causes of death in women are the result of breast cancer.

It is true the WHI was published in 2002. Prior to 2002 early detection of breast cancer with mammogram and treatment with surgery and chemotherapy was prevalent. It certainly resulted in a decrease in the incidence of death from breast cancer. Today the incidence of death from breast cancer might even be lower.

There is a sense that the breast cancer death rate might be even lower if estrogen is used immediately in postmenopausal women. There has been an 80% decrease in women being treated with hormone replacement immediately post menopause.

The goal should be to lower the death rate from breast cancer to zero.

Causes of death in women

The huge death rate from cardiac disease in women easily surpasses the death rate from breast cancer.

There is evidence that estrogen replacement might serve to lower the 4% death rate from breast cancer if given appropriately as opposed to the message that estrogen raises the breast cancer death rate as the WHI concluded.

Eliminating patients with Breast Cancer genetic makers from receiving estrogen replacement would lower the death rate even further.

Estrogen only cofidcience limits

The subgroups in the WHI Estrogen only arm were analysized in 2004. Please note that all subgroups at all the diseases catagories crossed 1 and is not statistically significant. Only the incidence of stroke in the 60 – 69 group did not cross 1.

Therefore none of the subgroups except the 60-69 stroke subgroup was statistically significant. However that group did not attain a hazards ratio above 2 required for it to be statistically significant.

Importantly, the Breast Cancers subgroups all crossed 1 indicating there was no difference statistically significant between estrogen treated age groups and placebo age groups. It cannot be concluded from the WHI study that estrogen causes breast cancer.

Estrogen adjusted reative risk nurses

Colditz,in the Nurses Health study did not use nominal confidence limits as did the WHI in its conclusions. Colditz considered all of the confounding variables such as age, age of menopause, BMI, hysterectomy or normal onset of menopause, BMI, blood pressure, cholesterol level, smoking, oral contraceptive use, and family history of cardiac disease, or breast cancer.

He used adjusted confidence limits required to be used with confounding variables.

The confidence interval for the occurrence of breast cancer in nurses currently using estrogen was 0.59- 1.00 and using estrogen in the past was 0.63-1.09 both touching or crossing 1. Therefore the results were not statistically significant.

The game changer after all the evidence that the WHI data was misinterpreted was the Danish study DOPS published in the British Medical Journal in 2012.

Game changer

I have presented this data to my readers to ponder after I heard these two excellent reviews at the American Association of Clinical Endocrinologists (AACE) meeting.

I wanted to point out once again that the media is the message. The media without proper peer review of data has changed the way women are treated post-menopausal forever.

Hopefully disseminating this data will help remove some of the emotional stigma that has influence the thinking and use of estrogen replacement therapy since 2002.

It might stimulate the medical profession, the government, the malpractice legal system and women to start re-thinking their recommendations and conclusions.

This is especially true when women are living longer and estrogen therapy can alleviate some of the emotional, and physical effects women suffer in menopause when estrogen is prescribed appropriately.

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

Stanley Feld M.D. FACP, MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

 

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

Everyone had ignored this important statistical fact.

 

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

 

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

 

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

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

 

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

 

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

 

Confidence interval must not cross 1 to be statistically significant.

 

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

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

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

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

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

 

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

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

 

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

Adj CI 0.83-1.92.

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

 

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

Adj CI 0.86-2.31.

 

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

 

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

Adj CI 0.99-4.56.

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

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

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

The adjusted confidence intervals were published in the original paper.

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

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

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

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

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

Once again the media is the message.

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

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

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

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

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

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

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Managing Points Of View and Healthcare

Stanley Feld M.D.,FACE, MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

President Obama’s ideology has accelerated the dysfunction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The devil is always in the details.

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

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

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

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

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