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Tag Archives: Medicare

Death Panels and Access to Care

I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access. Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture. But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs? That is the problem with which most governmental entities are now faced. Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.” Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care. Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them? This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for. If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine? If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available. As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least. Don’t get sick and you’ll be just fine.

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More Visits, Less Availability

A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth. Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics. Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government. The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession. Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons),  homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents. In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007. Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program. With the increase in visits, there are longer waits and less availability of medical care. Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years. The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures. Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what? I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.

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Deconstructing Socialized Medicine?

Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it. The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize. According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered. They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities. Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.” The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England? Providers will also be paid based on outcomes and performance. So far, sounds like a lot of changes heading in the direction of free market medicine. The plan would also both increase payments to … and increase involvement of … primary care providers. And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs. One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality. But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.

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I Suppose It's Better Than Death Panels …

Revealing article in Bloomberg online today about the latest way in which elderly patients are getting screwed by the system. Medicare reviews all admissions and if the patients don’t meet indications for admission, the hospital doesn’t get paid by Medicare. Medicare has also recently implemented a mercenary system called Recovery Audit Contractors (or RAC for short) in which third parties audit hospital charts to see whether Medicare “overpaid” for a patient’s visit. If the auditor finds an “overpayment”, the auditor gets to keep a percentage of that overpayment.  Just as an aside, most states have laws against percentage “fee splitting” such as this since paying someone on a percentage basis creates a conflict of interest that encourages the contractors to do things to enhance their income. Hospitals have the ability to classify Medicare patients as an “observation” admission during the patients’ stay. “Observation” admissions are apparently paid at a lower rate, but don’t come under as much Medicare scrutiny. Additionally, under Medicare rules, “observation” patients may have to pay a 20% co-payment that wouldn’t be required if they were admitted. Medicare “observation” patients also have to pay full price for any subsequent care that is rendered after they have been discharged. For example, if a Medicare patient needs a nursing home care or physical therapy after a hospital stay, Medicare will pay if the patient has been admitted for three days or longer and will not pay if the patient is classified as an “observation” stay. The Bloomberg article gives an example of one 76 year old patient who was saddled with more than $36,000 in bills based on his “observation” stay for eight days. Another 90 year old woman was billed more than $11,000 after fracturing her hip and then undergoing five weeks of physical therapy so that she could walk again. Sorry, grandma, you weren’t admitted. You were only “observation.” Pay up. If a patient is a borderline case, hospitals appear to be leaning toward keeping patients in “observation” status. The number of patients receiving the “observation” designation doubled between 2006 and 2008. Also note how Medicare is planning to penalize hospitals that re-admit too many patients, which will only increase the number of patients classified as “observation” status. On one hand, hospitals get paid more for admitting Medicare patients. On the other hand, hospitals could be accused of false claims and penalized for admitting Medicare patients who don’t meet Medicare’s strict admission criteria. Medicare’s RAC mercenaries will be combing through charts because they have a financial incentive to find patients who have been “inappropriately” classified as “admissions.” So hospitals play it safe and classify more and more Medicare patients as “observation” status. Who gets stuck in the middle? The patients … many of whom worked their lives and paid into a system so that they would have medical care when they reached age 65. Now they’re finding that they only have “insurance.”

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Dr. WhiteCoat Goes to Washington

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference. I attended some excellent lectures about leadership. Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions. I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional. I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for. There were other lectures about how health care reform fell short and some possible options for the future. One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference. And I went to legislators’ offices. The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff. I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input. I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer ...

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Medicare Cuts Delayed Again — PHEW

I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare. While perusing the morning news, I discovered that once again the Senate has made a last-minute decision to delay the Medicare pay cuts — this time until October 1, 2010. I’ll be linking back to my Brinksmanship article somewhere around September 15, 2010, I’m sure. According to one Senate Republican, this means that the federal deficit will increase by $100 billion. Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion. That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12) Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars. Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year. Lets say that there are 50 million Medicare enrollees (these Kaiser numbers are from 2008, so I increased the estimate from 44.8 million to 50 million). Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year. Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country. So what are all of us rich doctors complaining about? How about politicians who are full of hot air. Where’s the money really going?

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