Sunday, July 29, 2012

One Hundred Days

The woman on the phone was adamant. She demanded to know what benefits are now a part of new health policies and what does she have to do to change her old contract to a new one. Damn it, she wants her share of all of the free stuff. It was the second one of these today. I told her that she was already getting the no copay annual preventive care visit. Neither she, nor her twelve year old, had any need for the new birth control, IUD, and Morning After Pill benefit. And since her daughter is only twelve, the opportunity to stay on her parents’ policy to age twenty-six is hardly relevant. It didn’t matter. She KNEW that there was something that someone was getting that she wasn’t.

We have reverted to a nation of ten year olds, jealous of the kid who broke his arm and now has a cast. Where is our cast? I want my cast, and crutches, too.

And so we begin the next stage of the Patient Protection and Affordable Care Act (PPACA), the over-promise and under-deliver phase. The calls come in daily from people who believe that they are suddenly going to get fabulous coverage for free. “The doctor told me that I can’t be turned down or charged extra even though I have Type I Diabetes and a stent”, the gentleman insisted last week.

I have begged physicians to honor a simple agreement. I won’t practice medicine and they shouldn’t practice insurance. It makes sense to me.

It is important to again point out that we are not talking about health care. We are discussing the payment of health care services. Who is going to pay for the doctors, hospitals, and other medical providers and products?

In this highly politicized environment, this issue may be the most contentious of all. There are a couple of reasons for the heat:
  1. We are talking about almost 20% of the economy
  2. We are potentially discussing life and death
  3. We all have a stake in the final product
  4. We all think we know what we are talking about
Heat, but no light. The truth is that the differences between the real actions on the right vs. the left are hard to find. So the fight isn’t about real differences, but about vague notions of entitlement. The Republicans promise to repeal “Obamacare” and institute patient-centered health reform, a term that happens to test well in focus groups but means more than simply eliminating malpractice suits.

Look at Medicare Part D (Rx), a program that was created by a Republican controlled House, passed by a Republican controlled Senate, and signed into law by a Republican President. Here is a law that trampled on patients’ rights, states’ rights, and common sense. But it did help certain people get reelected and did a world of good for both the insurers and the drug companies.

When buying and selling are controlled by legislation, the first things to be bought and sold are legislators. - P. J. O'Rourke

So one side has a large segment of the population frothing at the mouth in anticipation of more free stuff, while the other side is desperately trying to convince Americans that the current system is a stone’s throw away from perfection. Of course, the only perfection is the cynicism that both sides have mastered.
Medical costs are rising as doctors and hospitals adjust pricing in anticipation of more government involvement. New fees, like facility charges, are appearing on our bills. Medical buildings are now hospitals, and that increases all charges. Your insurance premiums reflect those increases. There isn’t anything complicated in this. Every time the cost of care increases, every time you are given a new ‘free” benefit, every time the definition of what constitutes preventive care is expanded, your premium has to increase.

And if the government, an organization incapable of comprehending the concept of a balanced budget, prevents the insurer from raising the premium as the costs increase, the policy is terminated. Governments can print money. Insurers can not.

We have just less than 100 days till the election. Just under 100 days of exaggeration, distortion, and out-right lies from both sides. But one day, a year from now or maybe two, you will need to go to the doctor. Who negotiates the fees, who processes the paperwork, and who writes the checks will matter that day. If you happen to talk to any of the people running for office, ask them who is going to be doing that for you.

And more importantly, ask them where the money is coming from.


Tuesday, July 17, 2012

Follow The Money

This may come as a total shock to some of my readers, but even here, in the USA, the greatest country EVER, there are poor people. For the purposes of this blog post, it doesn’t matter why some Americans are poor. It is irrelevant as to whether the poor have had access to help or if they have abused the programs designed to lift them from poverty. It doesn’t even matter if there aren’t enough jobs or if they are too lazy to work.

I simply need for you to admit that there are poor people. Nod your head if you are with me.

Great. Now that we all accept that there are poor amongst us, we are no longer capable of pretending that they don’t exist. They do exist and the poor – adults and children – have health care needs. They can’t help it. They are human. The poor get sick. Their children suffer injuries.

Who pays for the health care of the poor? We do. We pay in the higher taxes that fund Medicaid. Our costs for doctors’ visits, hospital stays, and major testing are inflated to help cover the costs of the uninsured and the lower reimbursement rate of Medicaid. And hospitals bear the burden of “charity” care.

Medical providers may not like Medicaid, where their payments are a political football, but some compensation is better than none. That’s why our major local hospitals are counting on the Medicaid expansion of the Patient Protection and Affordable Care Act (PPACA). The possibility of extending coverage to 133% of the federal poverty level, which is about $30,000 for a family of four, would protect a lot of people.

Two other key elements: The PPACA adds childless adults to Medicaid, people usually not covered by this program. And, in an effort to encourage more primary care doctors to accept Medicaid patients, family doctors will now be paid at the Medicare rate.

The recent Supreme Court ruling made that expansion optional. Some states may participate. Some may not. Governor Kasich is still weighing his options. There are reasons, beyond the political, for each state to participate or to pass on this program.

The negatives are easy: Yes, the federal government is committed to covering the bulk of the initial cost, but what happens if the money stops? Can the federal government, regardless of who is in the White House, be counted on to honor this obligation? History casts doubts on Congress’s willingness to fund Medicaid, cut expenses, or resolve issues. Worse, the money, if it does come, isn’t forever. No one really knows how much this will cost the states after 2020.

Another issue is the increase in pay to primary care physicians. There was a real interest in funding this provision when the Democrats controlled the House of Representatives. Today, none at all. If this is initiated and funding for this part of the program ends, can the Ohio legislature, for example, screw the Cleveland Clinic and cut physician compensation? Congress budgeted $11 Billion for 2013 and 2014. It takes a willing Congress to allocate another penny.

It is important to remember that all cost estimates are, at best, guesses. New diseases, new treatments, new rules, and greed will all affect the final taxpayer outlay. Did anyone predict the AIDS epidemic in 1980 and the costs associated with the treatments? New and expensive medications and treatments are being developed here, in Cleveland, and around the world. It is impossible to predict, with certainty, the costs for care three, four, or eight years from now. We are writing Blank Check commitments.

Rule changes must also be a major concern. Did any member of the House or Senate know in March 2010 that the Preventive Care Benefit of the PPACA would include free birth control pills, IUD’s, and the Morning After Pill? Of course not. What will suddenly be covered, for free, under the Medicaid expansion?

So what are the positives? There is only one. If we accept that there are, and always will be, poor amongst us, then we have to make a decision as to whether or not we care. Are the poor our responsibility? If so, then we must craft a proper plan designed to meet their needs. If not? Well, I prefer to not think about a country that chooses “If not”.

This program, the Medicaid expansion, fails like so much of the Patient Protection and Affordable Care Act because of its lack of straight forward purpose. It is time to stop pretending that spending money will save us money. The Obama Administration needs to sell its vision to the American public. Tell us why we need to take action and how much it will cost.

This isn’t about health care. It is about how doctors, hospitals, and other medical providers get paid. And if you want to understand this, you have to follow the money.


Monday, July 2, 2012

A Rose By Any Other Name

“As a Democrat, you should be outraged”, the client said in lieu of “Hello”. I paused for a moment and he identified himself. I replied that I’m seldom outraged. “Weren’t you shocked by the decision?” Of course, if he had ever read this blog he would have known the answer. “Nope, I’m not shocked.” “You knew that Roberts would do this”, he asked incredulously. “No”, I replied. “I had no idea. No one did. The pundits and blowhards on both sides told their audiences what they wanted to hear. No one really knew. I never wasted a moment worrying about the Supreme Court or guessing the outcome. You can only be shocked if you believed in the prognostications of a bad guesser.”

“But it is a tax! Obama said it wasn’t a tax, but it is. This is the largest tax hike in U.S. history.”

If I may quote the hero of the right, Ronald Reagan, “There you go again.” Every time a Democratic president raises revenue, it is the largest tax hike in U.S. history. What possible pleasure could they derive from yelling “Wolf!” so often? When will even they grow tired of this refrain?

And so I reminded the client and others that I’ve talked with over the last few days that a rose by any other name would smell as sweet. Governments tax us. Period. Sometimes the legislators use the word TAX. Sometimes we are treated to the threats of penalties or fines. We are forced to purchase licenses and permits for everything from driving a car, to fishing, to installing a new hot water heater in certain suburbs. They are all taxes.

A new law was recently passed in Beachwood forbidding the use of a hand operated cell phone while driving. Does Beachwood really care? Get serious. How often have you seen a Beachwood patrol officer driving while talking on a cell phone? But this new law carries a fine (tax) of $101 and two points on your driving record. This is just another way to fill the depleted coffers.

I view all taxes, fees licenses, etc… the same. They feed the addiction politicians have to other people’s money. Some of us place a great value on defense and military spending. Some of us feel that more help should be given to the poor and less fortunate. And of course, there are those that believe that our job creators need more help and incentives. If funds are unlimited, there is no conflict. But funds aren’t unlimited, so the arguments continue. What we have not had is an honest debate about priorities. Do we care enough about defense, healthcare, poverty, et al to spend some of our own money to solve these problems?

So, let’s stop the silliness about taxes and get back to the matter at hand. Does the Patient Protection and Affordable Care Act (PPACA) cover the uninsured (allegedly 50 million Americans) and control costs? My answer is still NO. Have the Republicans put forth a comprehensive alternative? Also, still NO.

You can’t beat something with nothing.

Millions of dollars have been spent by insurers, government entities at every level, and businesses to comply with the PPACA. Simply repealing the law makes all of that money wasted. Though some Americans have been hurt by the law, others have benefited. Repealing the law runs the risk of eliminating their insurance coverage. Repeal without a better, more comprehensive solution, is irresponsible.

Repeal and Replace is cynical political rhetoric if there isn’t another option ready to fill the void. Responsible lawmakers, more focused on governing and the public good, might consider a different R word, Revise.

Working together, something that has yet to be tried, our legislators could attempt to create an amended PPACA that might have a better chance at accomplishing a couple worthwhile goals. That law might not be as useful as a fundraising tool, but could help to deliver affordable care to more Americans.

What will it take? The first step may be a little intellectual honesty. The second is to notice the flowers hiding amongst the thorns.