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Kick the Can Down the Road? Print E-mail
Written by Michael Joseph Newhouse   
Wednesday, 13 April 2011 15:29

For Crying Out Loud!

OPINION

If one was to receive a message from the future, say twenty years from now, describing the national scene, circa 2030, one would be totally incredulous. Here's a snippet:

We can no longer afford entitlements, diabetes threatens national security, USA is bankrupt and a war is fought on four fronts if one includes Mexico.

All signs point to the classical model of an empire in rapid decline. See video feature entitled Why Great Nations Fail.

How we got here isn't important. What is important is how we are going to get back to prosperity. Here's my plan:

  • No more career politicians. They are dinosaurs. Therefore, term limits on everybody. Every one of these public servants needs to go back into the private sector eventually.
  • No more salaries for these politicians once they are out of office.
  • No more special health plans or other little goodies for them. They serve the people let them be one of the people. Use the same health plans as the rest of us.
  • Simplify the tax code. For example, GE made $5B profit last year and didn't pay a single dollar in taxes! [Editor's note:  This was originally reported in the New York Times.  Since then Fortune.com has reported that GE did indeed pay taxes in 2010.  Fortune estimates GE's effective tax rate at 7%.  See the story The Truth About GE's Tax Bill.] Yet the CEO believes it's patriotic to pay taxes and off shore American jobs. How much did you pay Uncle Sam?
  • US announces to the world that our rules of engagement are reverting back to pre WWII standards so no body better mess with us, our buddies or our national interests. No such thing as civilized warfare. The gloves are off.
  • Everybody that is overweight (i.e. pre diabetes type I and II) must have a comprehensive plan to get in shape and it is incentivized by taxes.
  • Incentivize employers to create jobs.
  • Pull back manufacturing jobs to the US.
  • Allow health insurance across state lines.
  • Bring back all US military bases that are no longer necessary
  • Have all politicians sign the Mount Vernon pledge.
  • Require all politicians to post a weekly and quarterly productivity  report on their time spent, with whom and for what objective along with corresponding expenses and variance report on their operating and capital budgets just like the rest of us.
  • All lobbyists must report weekly and quarterly just like the politicians.
  • Government health programs must send volume to the best value provider; no more sweetheart deals. 

We can no longer afford business as usual. We have come to the perennial fork in the road. And for crying out loud, please remember our government works best when neither party is in control.

Last Updated on Thursday, 14 April 2011 09:37
 
Feedback on Dr. Epstein's Article Entitled: The Price of Certainty Print E-mail
Written by Various Readers   
Sunday, 30 January 2011 14:24

READER RESPONSE

Nice article on health care- not sure I agree with everything he says! (No surprise!!)  It's very complex!

-Jack Wolfsdorf, MD, Pediatrician, Pediatric Critical Care, Editor Miami Childrens International Pediatrics Journal

This is one of the most reasoned and very well written articles on the topic of tort reform!  Many thanks to Dr. Epstein for this very accurate and refreshing article!

-Dan Reale, Medical Malpractice Insurance Specialist, Danna-Gracey Agency, Orlando

I concur with Dr. Epstein’s letter.  However, may I inject the following into his “Susie” scenario:  ER doctor says to Susie’s mother, a CT is not medically indicated and thus will not be covered by your insurance.  Of course if you would like to pay the $700 hospital fee and the $300 Radiologist fee out-of-pocket, then we will be happy to provide that service for you.

You can take it from there…

-James "Jim" Craig, Vice President Middle Market - Healthcare
Fifth Third Bank, Sunrise

This is one of the best articles on the reasons for ordering extra tests that I have ever read.  Thank you!!

-Medical Doctor, Boca Raton

Last Updated on Wednesday, 30 March 2011 16:05
 
The Price of Certainty Print E-mail
Written by David H. Epstein, MD, FACR   
Friday, 28 January 2011 00:00

IN MY OPINION 

 As the debate over health care reform is assured to continue into the next congress, questions about the role of tort reform will undoubtedly also persist, as we, physicians, will assert the centrality of tort reform to the control of medical care costs.  While the cost of defensive medicine is real, quantifying it is difficult and risky, and any attempt to profess that tort reform will produce prompt measurable reductions in the cost of health care provision may imperil our credibility where and when tort reform is accomplished.

In our zeal to communicate to the non-medical population our belief in the imperative of tort reform, we must also be realistic about the many causes of the progressive rise in the cost of medical care, the extent to which defensive medicine contributes to the cost, and the ability of tort-reform to stabilize or reverse these increases in the near term.

Contributors to the excessive and increasing cost of medical care are legion, and are mostly well recognized, if not necessarily their exact proportion.  For some, such as the felonious operators of non-existent Medicare and Medicaid clinics and the bogus personal injury rackets, better law enforcement is needed.  Greedy insurance companies, avaricious drug and durable medical suppliers, and inefficient wasteful hospital administrators, are all substantial participants that need in some way to be dealt with.  At some point, however, we must also confront those parts of the medical cost conundrum that are ours.  By that, I am referring first to that part of our community that has placed financial gain above the welfare of our patients.  In some cases this behavior can be quite blatant; with others it occurs only at the margins of our practices and is justified, erroneously, as good, thorough practice.  Unfortunately, where good medical practice is usurped by greed is probably more frequent than we would like to believe, and is inviting ever greater and unwanted scrutiny and interference by non-medical entities into our day-to-day practices.

Secondly, we have to look at how the nature of patient/physician interaction, along with its irrationalities, fears, habits, and quirks, has changed, and what this means to the future of the practice of medicine.  For example:  Susie comes to the ER with her perky 5 year old son Bobby who had just fallen off a piece of recreational equipment striking his head on a padded floor.  After a few moments of dizziness, he returns to his normal pre-event status.  Despite his apparent normalcy, Susie takes him to the ER, where Bobby is evaluated thoroughly by the ER physician, who can find nothing disconcerting.  Based on the history and physical exam, the doctor recommends observation and Tylenol as needed.  Susie, though somewhat reassured, mentions that a friend of hers knew someone who knew someone else that had a cousin whose daughter had a similar fall and got a CT scan.  That she thinks showed something.  And therefore, shouldn't Bobby get one? 

Ten, maybe twenty years ago, we would have confidently said no, and that would have been the end of it.  But now the discussion slips into the realm of "can you be sure?" and "would it hurt to..." and...You get the idea.  Knowing the severe penalty our legal system exacts if the highly unlikely but not impossible has happened, in all likelihood Bobby will get the head CT to assure that there is no intracranial injury.  While this can be called "defensive medicine," in reality what has happened is the result of a generation of interactions between physicians and patients that seek, no, make that demand, an absurdly high level of diagnostic certainty.  And usually just to prove that nothing is wrong.  We aren't seeking disease where we expect to find it as much as we are confirming the absence of disease where we don't expect it.  The latter, of course, is much more expensive.

Besides my concern that this style of practice is totally unaffordable, there is the peril that it places us in as a profession as we seek legitimate relief from the litigation drenched society in which we must function.  If we claim that 40% of the "excess" utilization is driven by defensive medicine, the logical conclusion is that once the burden of impending litigation is magically lifted off our shoulders, there will be a commensurate decrease in utilization.  My specific concern is that there is no such one-to-one correspondence.  In reality the practice patterns that have developed in the US are not just a response to mal-practice, but also to the profusion of and consumer demand for highly accurate but expensive tests and procedures which has conspired to create in our nation an unparalleled intolerance for uncertainty.   And while we must immediately and continuously advocate for tort reform, I believe with the utmost certainty that there will be little measurable change in patient/physician behavior until we have a new generation of physicians trained in a tort-restricted environment under the umbrella of respected and followed practice guidelines, and a generation of new patients that live in a world where the level of certainty that is attainable is commensurate with that which is affordable.

As we seek changes in medical tort law, we must not mistakenly suggest that tort reform will have an immediate payout in the form of recovered medical expense dollars.  If we make this mistake we are certain to disappoint, and are likely to suffer a backlash that may reverse any hard fought gains made in tort-reform and substantially delay the institution of meaningful and long-lasting improvements in medical tort law. 

Dr. David H. Epstein, MD, FACR, a partner with Radiology Associates of Hollywood,  is a senior attending with the Memorial Health Care System, member of the Florida Medicare Contractor Advisory Committee and Blue Cross/Blue Shield Physician Advisory Panel, and former Florida Radiology Society President.

Last Updated on Wednesday, 30 March 2011 16:05
 
Skepticism Regarding ACO's Print E-mail
Written by Name Withheld   
Thursday, 27 January 2011 16:26

READER RESPONSE

Regarding ACO's A Viable Concept? By Michael Casanova Click here to view original article

As a practicing physician, I see ACOs as just another administrative layer that siphons off funds that could be used to pay for healthcare. Since hospitals and hospital systems are infinitely better financed and unified, physicians will unfortunately probably become the junior partner, meaning more profits for hospitals and smaller profits for physicians.  Politics within the medical community may also play a part. For example, a surgeon may take much more time to perform various procedures than others of his specialty and he may even have more complications all of which increase costs, but he is chief of staff, chief of surgery, or even a share holder in the ownership of a hospital. It would be difficult to remove him from an ACO.  Likewise, a particular surgeon may have all the most difficult high risk cases referred to him, so that his complication rate seems higher. As he runs the risk of being dropped by an ACO because his costs for care are higher, he may choose to refuse these difficult cases, though he may be the most qualified in the community to accept them.

In South Florida, we had a system called capitation, in which the primary care physician got a fixed payment each month based on how many of that HMO's patients were assigned to him and he had to pay for those patients.  If none or few of the patients needed care, he made a lot of money.  If many patients needed care, and in particular surgery, he didn't make any or very little.  By slowing down the process, delaying or denying consultations with specialists, scheduling tests or procedures, and other gimmicks, he could insure a better profit at the expense of his patient population.  This could and did happen.

There are so many other ways in which Medicare could save huge sums of money that ACOs aren't really necessary.  What is necessary is for politicians to take appropriate steps and stop protecting powerful groups like trial attorneys and insurance companies.  I have a number of ideas that I think would work.

-Name Withheld by Request

Last Updated on Wednesday, 30 March 2011 16:06
 
Pollice Verso: How State Legislators try to revive an ancient custom Print E-mail
Written by Bernd Wollschlaeger, MD   
Wednesday, 19 January 2011 10:24

IN MY OPINION                        

A recent article in the Wall Street Journal, Health Studies Cited for Transplant Cuts Put Under the Knife, highlights the looming issue of cost control.  Faced with skyrocketing healthcare costs, states will be forced to make tough decision on care allocation and coverage. 

Arizona already has taken drastic steps to drop Medicaid coverage for some organ transplants as the state tries to plug a $1 billion gap in its health-care budget for next year.  The state agency that recommended that Arizona stop paying for transplants of lungs and, for certain patients, hearts and livers, has defended the move by citing studies and figures that it says demonstrate the ineffectiveness of the procedures.   But the state agency has gone a step further by selecting studies that prove the point that certain transplants are ineffective.  To make its case for cuts, the Arizona agency cited several sets of numbers.  In dropping coverage of liver transplants for patients with hepatitis C, the state said liver recipients suffer recurrence of the disease at a rate of 100%.  And the state argued that candidates for lung transplants would live just as long with other medical care, citing data from university studies.    

Several transplant experts, however, point to flaws in the data and the way the state's Medicaid agency, called the Health Care Cost Containment System, has used the figures.  Arizona "used data that were outdated or data that made no sense, or they misinterpreted or misrepresented what experts said," says Michael Abecassis, director of Northwestern University's comprehensive transplant center and president of the surgeons' group. For lungs, a crux of the state's position was a 1995 study of 49 patients at the University of Washington, 25 of whom received transplants; the rest were waiting at the time of the study. The study concluded that transplant recipients would live half a year longer than those who didn't get a new lung, but the difference wasn't statistically significant-in part because the sample size was so small. Also, researchers didn't wait to track patients' survival, instead extrapolating long-term mortality rates from deaths and sickness in the short run.

So, what's the solution? States should not be permitted to arbitrarily decide what services can be covered under the state's Medicaid program. Instead, they should follow evidence-based data and, most importantly, comparative effectiveness research data.

Otherwise, we will revert to the Pollice Verso (thumbs turned) used in ancient Rome by the crowd to indicate if the defeated gladiator should be condemned to death.  Soon we do not need gladiators to revive this custom.  We just need legislators who will decide the fate of condemned Medicaid recipients.

Last Updated on Wednesday, 30 March 2011 16:06
 
Government Takeover Concern Print E-mail
Written by Reader   
Sunday, 02 January 2011 17:56

READER RESPONSE

In response to Challenging conservative truisms about HCR by Bernd Wollschlaeger, MD

Click here to see original article

First things first; "PolitiFact Lie of the Year" has about as much journalistic credibility as "Pravda Lie of the Year".  PolitiFacts progressive/socialist editorial bias is unbridled and undeniable.

  • Unelected federal government bureaucrats will define up to (possibly fewer than) five plan definitions.  All American citizens will be obligated to purchase one of the plans that the federal government has designed.  Real lie of the year: "You will be able to keep your insurance coverage".
  • As dictated by the federal government, these plans may be sold only on exchanges constructed by State governments, under the criteria designed by federal government bureaucrats.
  • Purportedly free American companies will be prohibited from selling plans of their own design, even if there is strong demand for those designs from purportedly free American citizens.
  • Half of the current uninsured citizens will be enrolled in Medicaid, which will increase those rolls by approximately 50%, thereby dramatically increasing the number and percentage of citizens who are dependent on government run healthcare.  This is in spite of the fact that approximately 50% of primary care physicians' offices today will take no new Medicaid patients, and approximately 30% of primary care physicians' offices will take no Medicaid patients at all.  And, Medicaid is the largest budget item by far in nearly every State in the country, and is breaking the budgets of the majority of States in the country, before the planned 50% increase in enrollment. (Yes, the federal government will pay a disproportionate share of the increased Medicaid expense for a few years.  However the increased expense is permanent, not just for a few years,)
  • Half of the remaining uninsured are young, healthy people who can afford healthcare insurance, but have made the free choice not to purchase it.  They will no longer have that free choice, they will be required by the federal government to purchase this product that they don't want.
  • The other half of the remaining uninsured will be paid for by increased taxation on the 53% of American citizens who actually pay federal income taxes.
  • Federal bureaucrats have been empowered to design reimbursement schemes that they will be able to enforce upon the payors and providers of healthcare services.

Regulating with great specificity and dramatic impact the activities that private companies and citizens are permitted to engage in under penalty of law ("at the point of a gun"), and taking money from some of the citizens to give to those who pay nothing, for the purposes of achieving objectives that a self-appointed elite class has decided is in the best interest of the people, is textbook socialism/fascism, otherwise known as Government Takeover of Healthcare!

James "Jim" Craig

Sunrise

Last Updated on Wednesday, 30 March 2011 16:07
 
Is it possible to de-politicize the health policy discussion? Print E-mail
Written by Jeff Herschler   
Sunday, 02 January 2011 17:45

        Probably not. That said it might be a good idea to temper our rhetoric a bit.  Although popular with politicians, health policy is not easily formulated against a political backdrop.  Countervailing values push and pull the debate and an ideological solution appears remote.  Meanwhile the polarization so evident in the broader community is apparent in our own ranks.  See Nurses, doctors at odds on politics, 10-13-10 - Health News Florida.  Progressives and Conservatives do agree on at least one aspect of health policy.  There is a general consensus  that significant change must be applied to our health system to cope with healthcare inflation, unfunded liabilities and an aging demographic.  But gridlock might be the result if a middle ground cannot be found. 

Healthcare is a bit of a policy conundrum.  On the one hand civilized society must provide as a basic humanitarian duty.  On the other, personal responsibility is critical for resource allocation efficiency. Progressive insist that government must underwrite healthcare as an essential resource/infrastructure investment in the same way it finances/operates schools, bridges & roads, law enforcement & the courts, and national defense.  Then Conservatives remind us that runaway costs demand a market solution and market price discipline.

And it's not as if the health policy riddle is a new one.  Allen D. Spiegel, Ph.D. describes a healthcare system created by King Hammurabi of Babylon: "AT THE DAWN OF CIVILIZATION, about 4,000 years ago, nomadic Semite tribes developed a managed health care system. Using cuneiform, a hieroglyphic writing, they inscribed the concepts on clay tablets and chiseled them into stone between the 17th and 21st centuries B.C.  Adapting the existing edicts, King Hammurabi of Babylon incorporated ... managed care precepts in the Codex Hammurabi, a huge stone stele erected about 1700 B.C."

Meanwhile, Wikipedia describes the Healthcare system in Ancient Rome: "The importation of the Aesculapium established medicine in the public domain. There is no record of fees being collected for a stay at one of them, at Rome or elsewhere. The expense of an Aesculapium must have been defrayed in the same way as all temple expenses: individuals vowed to perform certain actions or contribute a certain amount if certain events happened, some of which were healings. Such a system amounts to gradated contributions by income, as the contributor could only vow what he could provide. The building of a temple and its facilities on the other hand was the responsibility of the magistrates. The funds came from the state treasury or from taxes."

Or consider this passage from All Quiet on the Western Front, by Erich Maria Remarque describing the health system in World War I Germany:  "The dressings afterwards are so expensive" says my father.  "Doesn't the Invalid's Fund pay anything towards it, then?" I ask.  "Mother has been ill too long."  Sounds like mom hit the policy limits or perhaps is the victim of a pre-existing condition clause. 

A reader recently complained that "we (seemingly) inexorably evolve toward socialized medicine".  But a pure market based solution is unthinkable.  Could you imagine this scenario: "I am sorry sir, we can't treat you following your life threatening diagnosis; we were unable to get an approval code on your AMEX".  So some sort of government involvement including safety nets and income redistribution is mandatory.  We just need to figure out to what degree.

The Conservatives believe the Healthcare Reform of 2010 goes too far.  Some Progressives believe that it is woefully short of what's necessary.  The discussion will continue and we will evolve towards, I am sure, a uniquely American solution.  The fact is both extremes have valid points so compromise is the only reasonable outcome.

Healthy debate is a good thing and I encourage it in the pages of FHIweekly and FloridaHealthIndustry.com. (See LAST WORD article where Jim Craig engages Bernd Wollschlaeger on Government Takeover of Healthcare.)  But polarizing, ideological rhetoric is counterproductive.  As the sun rises on 2011 and we continue to emerge from the Great Recession, our challenges are enormous.  So gratuitous talking points are out.  Discussion and debate are encouraged. 

About the author:  Mr. Herschler is the Publisher & Editor of FHIweekly and FloridaHealthIndustry.com
Last Updated on Wednesday, 19 January 2011 17:11
 
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