Vol. 80 December 15, 2012 Pet Health Insurance

December 15, 2012

hubThis subject springs to my mind this month
because my friend got a free kitten for Christmas last year.
Her daughter had rescued him from a dumpster.
His name is Charlie.
More on Charlie later.

According to industry statistics $13 Billion (yes, that is a “B”) was spent in 2010 on veterinarian care for pets in 73 million households; a 40% increase over 2006. In 2006 there were about 86 million cats in the U.S. If they could vote, and did so as a bloc, they would bury the 78 million dogs. With the number of pets and costs rising like that, I wondered what the pet health insurance market was like. Does the pet health insurance marketplace have lessons, or even “best practices”, for us in our struggle with health insurance costs and coverage for humans? Is it time for an Affordable Care Act for pets? I decided to take a look.

As I surfed through pet health insurance plans I was struck by the similarities to our (human) health insurance plans of the 70’s and 80’s. The subscriber pays the vet and gets reimbursed 90% of “usual and customary” fees. The companies promise “quick-turn around” of claims, of course. The vet has no forms to fill out or sign. The subscriber does it all. These familiar phrases sound like “the good old days” to physicians who now have two or more full-time office people filling out all sorts of insurance billing forms and/or an IT consultant to do it electronically.

You can go to any licensed vet. There is no concern about “eligible providers” or being “out of network”, but policies do differ from state to state. Reimbursement is not dependent on diagnosis (no need for bulky code books or sophisticated computer programs). None of the policies cover pre-existing conditions or preventative care services (routine visits to the vet). Those are optional coverages available for additional premium.

It all sounds pretty simple and straight forward until you start reading more closely. An asterisk here and a double asterisk there sends you to fine-print footnotes defining “eligibility criteria”, “waiting periods”, “continuing care”, “pre-existing conditions”, and “congenital conditions”. That’s not only identical to our “good old days”, but it also holds true today.

A neighbor just spent $400 on the annual visit and necessary vaccines for his three Labradors. When I asked him if he had health insurance for them, he replied, “No way was I going to spend all that time figuring out what they covered, and when, and for how much. It was too complicated. I struggle enough trying to understand the policies I buy for my employees.”

Pet health insurance was started in Sweden in 1924  and was adopted  in the U.K. around 1947. The first pet insurance policy in the U.S. was written in 1982 for the protection of our TV hero Lassie.  (Do Socialist countries always lead the way in developing health insurance plans?)  NAPHIA, North American Pet Health Insurance Association, was founded in 2007. In Canada there are 10 cat health insurance plans while in the U.S. you have the choice of 36 plans for cats. (Capitalism is so-o-o predictable sometimes)

Back to Charlie….Remember Charlie?….This is a blog about Charlie.
He is an extremely cute, solid black kitten that made my friend’s last year’s Christmas stocking begin to wiggle. When his head popped out with those big, wide open green eyes, the mystery of the stocking was over, and the love affair began. Health insurance for him was available after a mandatory 30-day waiting period (the insurance company wanted to be sure he survived that long I guess).  The waiting period for coverage of “congenital conditions” is 180 days, presumably for the same reason. It would cost from $4.08 per month to $67.14 per month depending on coverage options, BUT excluded preventative care and routine visits to the vet.  After reading Consumer Reports my friend decided not to buy any.

The first visit to the vet cost $103.75. That included $26.00 for a FVRCP shot against Feline Viral Rhinotracheitis, aka “a bad cold”, and $21.75 for a fecal specimen exam. The second visit a month later was $161, and the third month it was $277. That one was higher because of the anesthesia charge for the neutering ($36.00) and a Catalyst Chem 10 test ($62.00). The lab business for pet tests seems as lucrative as for our tests. The neutering operation itself seemed like a bargain at $50.50.  It was only slightly higher than the placement of the ID microchip under his skin. (ER docs and police eat your hearts out!  The technology is here.)

Rather than continue to bore you with the details, suffice it to say, my friend’s “free” kitten cost over $500 for vet visits in the first year alone. I am not even going to try to total up all the other costs because someone else already has.  According to a 2010-2011  survey the average annual maintenance cost of a cat in the U.S. is $1217.

Maybe a “free kitten” should have been included in my list of Christmas presents to give your enemies rather than your friends.  But as the commercial says:

” Vet visits -$500…
Food for a year – $400…
Toys -$21…
Having Charlie’s warm meows greet you when you return home or when you awake in the morning – Priceless!”


Vol. 69 June 15, 2012 How to Avoid the “R” Word.

June 15, 2012


“We make those decisions all the time. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.” –Donald Berwick, MD

When infinite demand exists for finite resources certain decisions have to be made by those responsible for distribution of the resources. It is called “rationing“.  And that is what is causing all the palaver about reducing medical care costs. Who decides, how do they decide, and how do the decisions get implemented? “Rationing” has become the political lighting rod of that discussion and any politician or candidate (or even Director-designee of CMS) that does not successfully avoid its use is at great political peril.

A recent thoughtful essay in the NEJM advances the case for substituting “avoidance of waste” for the “R” word. (1) Since 30% of our medical care costs go to tests, treatments, drugs, and medical devices that in truth result in no patient benefit (2), the author argues that, at least, we should first eliminate the non-beneficial expenses. Consumer Reports in cooperation with American Board of Internal Medicine and 16 other medical specialty societies has recently published its list of non-beneficial medical activities for us to avoid. They call the campaign “Choosing Wisely”.

Since many very expensive items can be categorized as new technology, the author also argues for a more rigorous standard for the approval of new technology. New technology currently needs ONLY to prove that is safe and that is better than a placebo. There is NO requirement that it show that it has better outcomes than existing technology. This is true for drugs, PET scanners, linear accelerators, organ and bone marrow transplants, cardiac surgery, and all the different kinds of heart vessel stents. Highly technical, complex, and expensive gene treatment (“personalized medical therapy”) is just now peeking at us around the corner.

If a standard of improved outcome for new technology were in place, how would it be implemented? The ACA established the Center for Comparative Effectiveness Research within CMS to gather comparative outcome data and make recommendations, but the ACA also explicitly denies the CMS the authority to use such recommendations in setting Medicare reimbursement rates!

For example, in the very same issue of the NEJM there is an elegant multi-center study that leads to the implementation questions for a less dramatic, not-quite-so-emotionally-laden, but much more common condition than heart transplants and exotic “savior” cancer drugs; urinary incontinence in women. This study showed beyond a doubt that urodynamic testing results on women who go to a urologist because of urinary stress incontinence had no effect on the outcome of the surgery. The surgery is successful 69-72% of the time whether the urodynamic testing is done or NOT. In other words, the clinical judgement of the urologist in the office is enough to indicate who is likely to benefit from the surgery.

The urodynamic testing, with it’s charge in the U.S. of $640-$1503 depending on the insurance company and region, adds no benefit. The article’s authors (all 34 of them) flatly state that urodynamic testing for women presenting with stress incontinence should not be done. (the same conclusion made by NICE, National Institute for Health and Clinical Excellence, in the U.K. in 2006). The article does list four specific instances where urodynamic testing might prove helpful; 1) patients with previous surgery for incontinence, 2) presence of neurological disease, 3) patients planning more extensive pelvic-organ relapse corrective surgery, and 4) urge-predominant incontinence rather than stress-incontinence. All of these definable situations can be documented in the medical record for the few patients who have them.

How could such a reasonable, well-founded recommendation to reduce costs without compromising quality be implemented?

1) Medicare could refuse to reimburse for urodynamic tests in uncomplicated stress incontinence patients. This is without doubt the most direct way to save these costs. Private insurance would soon follow suit after the political and medical backlash quieted down (urodynamic studies are almost always done in the urologist’s office and can represent a significant revenue stream to the office). Current ACA language explicitly prohibits this action.

2) ACO’s could implement a practice guideline recommending avoidance of urodynamic testing before usual stress continence surgery. Any resulting cost savings could be shared by all the physicians in that ACO. Urologists would receive a portion of the savings to offset their revenue loss, and they in turn could ask the other specialties in the ACO, “What have you done for us lately, so that we can share in some of your cost savings”.

3) Physician leaders in the urological specialty and academic centers could support educational efforts to inform their members of the non-benefits of urodynamic testing for most patients and wait for its use to fade away under the weight of replicating, confirming studies, and editorial comments.

This third option is often how our practice patterns currently change, but it is a slow process as shown by our continued discussions of the comparative benefits of open heart surgery or various vascular stents. That this “revelation” about the non-benefits of urodynamic testing has been around since 2006, but still warrants an article published in a 2012 NEJM is another clue about the pace of change. Given the inevitability of rationing and the moral repugnance of doing so with broad-brush budget caps monitored by bureaucrats, arbitrary decisions by non-accountable insurance companies, price-based decisions by for-profit drug companies, age-based discrimination, or by economic or social class classifications, we can only hope that we can find a better way.

Comparative Effectiveness Research under the ACA could develop evidence-based standards to be implemented by ACOs of high quality, cost-conscious physicians who would then share in the savings resulting from their hard work of changing practice patterns appropriately. Otherwise, we may have to settle with our current system of “muddling through” and try to be patient with the plodding pace of change as we watch the treasury run dry.

It might help if we did replace “rationing” with “avoidance of waste”, but I don’t hold out too much hope for that. It will take more than one article and a less insipid term to capture our imagination.

In my next blog on July 1, I will describe how to avoid the “F” word.

Refererces:
1. “From an Ethics of Rationing to an Ethics of Waste Avoidance”, Howard Brody, M.D.,Ph.D; NEJM 366;21 May 24, 2012: p. 1949
2. “The Implications fo Regional Variations in Medicare Spending”, Wenneberg et al., Ann Intern Med 2003;138: p. 288
3. “A Randomized Trial of Urodynamic Testing before Stress-Incontinence Surgery”, Nager et al., NEJM 366;21 May 24, 2012: p.1987


Vol. 58 January 1, 2012 Top 15 Medical Fun Facts of Hubslist 2011

January 1, 2012

“WHAT IS PAST IS PROLOGUE”
-William Shakespeare, The Tempest

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1. Measles vaccination does NOT cause autism and the author of that study, discredited as a physician in the U.K., now runs a profitable private clinic in Texas without a U.S. medical license. 1/15/11

2. Many hospitals, physicians and more than half of consumers currently favor a single-payer system. 5/1/11

3. Fishermen die at work 15 times more often than policeman and 45 times more than firemen. 5/15/11

4. Four men jogging can produce MORE carbon dioxide emissions than a hybrid car driving them the same distance. 5/15/11

5. 93% of 44 children who were avoiding 111 foods because of non-threatening allergic reactions (eczema, atopic dermatitis, and hives) were NOT allergic to those foods. Milk allergy was the most common over-diagnosis. 5/30/11

6. Your parenting style has less effect on your child’s “success” than your own educational level, income, and where you live. 9/1/11

7. Watching Sesame Street is entertaining for infants and toddlers , but it is NOT educational until they are 2 ½ years old. The educational benefits to the over 30-month old viewers persist to age 17 years. 11/1/11

8. Eating turkey is no more apt to make you sleepy than eating chicken, pork chops, lamb chops, or salmon. 12/1/11

9. The average DAILY number of text messages by a high school kid is 300-500. 11/1/11

10. 85% of teenagers take their cell phone to bed at night. 11/1/11

11. The five-year trial of “managed competition” between private health insurance companies in the Netherlands resulted in increased health care costs, increased percentage of people receiving government subsidy for health insurance, and increased number of uninsured, now called “defaulters”. 8/15/11

12. The many modes of obesity treatment other than surgical gastric bypass are only 4% effective. 8/1/11

13. Ninety million (90 MILLION) swine flu (H1N1) vaccinations were given in China and only 11 cases of Guillian-Barre syndrome (GBS) occurred. This rate was less than the rate expected in a general, unvaccinated population. 5/15/11

14. Baseball players CAN see better than umpires. 2/15/11

15. If your friends on Facebook are obese, you are more apt to be obese. 1/1/11


Vol. 52 October 1, 2011 Medical Costs of Prisons, Medicare Cost Projections

October 1, 2011

Please excuse the September 15th hiatus. The cyber-devils made my website go down and it took a
while for my consultant to diagnose the problem between the website host and the domain registry.
It was more like “Who’s On First” then “Tinker to Evers to Chance”.

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25% of all Americans with HIV, 33% of Americans with hepatitis C, and 33% of all heroin users spend some time in prison. (1)

U.S. has 5% of the world’s population and 25% of the world’s prisoners. That was 2.8 million prisoners in January 2008.

40% of federal inmates have mental disorders which is 4X the rate in the general population. If you count all types of jails, the number peaks at 60%. The largest facilities housing psychiatric patients in the U.S. are jails. 7% of inmates receive mental health treatment while incarcerated.

Released prisoners are 129 times more likely to die of a drug overdose within 2 weeks of release then the general population. Most are uninsured. They are terminated by Medicaid upon incarceration and are ineligible to re-enroll upon release in most states. The Affordable Care Act permits former prisoners to receive health care coverage.

State correctional spending is the fastest-growing sector of government spending other than Medicare.

Rhode Island spends an average of $41,346 per year per inmate. That jumps to $109,026 per year per inmate for maximum security inmates. Massachusett’s average annual cost per inmate is closer to $46,000.

The $5.6 TRILLION surplus projection in 1995 that turned into a $6.2 TRILLION deficit projection was spurred in part by the $272 BILLION prescription drug coverage (Part D) and the $1.9 TRILLION tax cuts passed during George Bush’s administration (plus a couple of wars, of course). (2)

The savings in Medicare costs projected by “health care system redesign” and changes in coverage and/or benefits will have their first real effect in 2022. “People say you can’t solve the deficit problem without dealing with health care, but you can’t solve the near-term deficit problem by dealing with health care either.” (3)

Under Rep. Ryan’s proposal, if you are under 55 years old you will pay $12,500 out-of-pocket for your health care  while the government will spend $8,000  in 2022 . Under current policy that cost to you would be $6,250 with the government paying $8,500.

$500 BILLION has already been cut from Medicare costs by reducing payments to Medicare Advantage plans (HMO-like plans that studies showed did not reduce medical costs for enrollees) and to acute care hospitals (Helps explain all the recent public scrambling for “policy reviews” and pleas for help coming from many urban acute care hospitals in most states.)

Medicare is projected to consume 6% of the GDP (Gross Domestic Product) in 2035. Raising the eligibility age for Medicare from 65 to 67 in 2014 would reduce Medicare costs only about 0.4% of that 2035 GDP. (5)

If you are 65 years old today you paid an average of $150,000 in Medicare and Social Security taxes over your lifetime and will receive about $350,000 in retirement benefits. A 46-year-old under current policy will pay over $200,000 in Medicare and Social Security taxes and will receive over $500,000 in retirement benefits. (6) Hence, all the discussion about higher premiums for the affluent, restrictions on gold-plated Medigap plans, and increases in co-insurance and deductible amounts.

My Conclusions:
1. It seems to cost more to consider drug addiction a crime than to treat it as a medical disorder.
2. Medical technology will continue to improve and cost more, so be prepared to pay more taxes and/or higher premiums for your health care insurance at any age.

References:
1. Medicine and the Epidemic of Incarceration in the United States, NEJM 362;22 June 2, 2011, Rich et al
2. Money, Pat Regnier and Amanda Gengler, October 2011, p.107-115
3. Henry Aaron, economist, Brookings Institute, ibid
4. Kaiser Family Foundation, Congressional Budget Office, ibid
5. Congressional Budget Office, ibid
6. Urban Institute, ibid


Vol. 50 August 15, 2011 “Want To Go Dutch?” …or French…or German?

August 15, 2011

Before we learn FROM other countries’ experiences with medical care,

we first need to learn ABOUT them. (1)

Since all other developed countries have universal health care insurance it is a no-brainer that we, the sole remaining developed country without universal health care insurance, should look to other countries’ experiences for help in our incremental struggle towards it. Looking to the United Kingdom’s NHS has been the most frequent step because of our common language. It has also been the most politically risky one because of the potential stigma of being labeled as “soft on Socialism”. All Dr. Berwick had to say was that there were parts of the NHS that he thought were good, and he was immediately barraged by Congressional criticism as the interim head of Medicare.

So, what about France and Germany that have 5% administrative costs as compared to our 20%? (Remember, Capital One Visa card charges about 7-8% to its users.) We spend around 16% of our gross domestic product on healthcare while the French (see SICKO by Michael Moore, 2007) and the Dutch spent around 10-11% in 2007. You are already familiar with peri-natal morality rates and other measures of quality showing that our health status is no better and is sometimes even worse than those countries despite our higher costs.

2007    Infant      Mortality  Life Expectancy
Germany    4.1 79
France    4.2 79.9
Canada    4.6 80.3
U.K.    5 78.7
U.S.    6.4 78

…the DUTCH ? !

The recent proposal from Congressman Paul Ryan (R-WI) to replace traditional Medicare with a voucher system for individuals to purchase private health insurance brought the Dutch universal health care system into our spotlight. Both Ryan’s Plan and the Dutch system rely on regulation of private insurance, so-called “managed competition”. In 2006 the Netherlands switched from a system of mandatory social insurance administered by nonprofit sick funds to mandatory basic insurance that citizens had to buy from private insurance companies.

A recent analysis of the Dutch system (1) indicates that despite the intention to control costs while continuing universal access, the reality of “managed competition” has fallen short in four key areas:

1. the growth of health care spending has NOT slowed and the administrative cost and complexity has increased (600 workers were added to the tax department to verify eligibility and dispense vouchers),

2. the number of Dutch people who have “defaulted” on their premiums and have, therefore, become “uninsured” has increased the number of uninsured from 1.5% to 3%,

3. the value of “consumer choice” has proved to be very small with an average of only 4% per year changing their insurance between the 4 insurance conglomerates that control 90% of the health insurance market,

4. the amount of government regulation did not decrease; price controls, global budgets, and patient cost-sharing remained in effect. (In 2010 payments to specialists were reduced in response to budget overruns)

The Dutch Ministry of Health requires that insurance companies accept all applicants regardless of health status and must charge only community-rated premiums to avoid “cherry picking” of the most healthy portions of the population. Also, risk equalization formulas are used to protect insurance companies from excessive losses incurred by the sicker, higher-risk populations. Insurance companies are expected to compete in price and quality through SELECTIVE contracting with networks of hospitals and physicians. These same policies are shared by many of the health care reform proposals in the U.S., including Ryan’s Plan.

The actual outcomes of this “managed competition” in the Netherlands include:

  • total costs of health insurance for Dutch families has increased by 41% since 2006
  • the country now spends 15% of its gross domestic product on health care rather than 10%
  • more than 40% of Dutch families receive government subsidies to pay their health insurance premiums, and that will increase as the government moves to protect “defaulters” from losing their insurance after six months of non-payment of premiums.
The article ends with this statement:
“The idea that the Dutch reforms provide a successful model for U.S. Medicare is bizarre.”
The Ryan Plan is based on the same principles, but would also gradually reduce governmental contributions so that a 65 year old beneficiary would pay for 2/3 of his or her medical costs. It is obviously no panacea for U.S. health care insurance problems.

References:
1. Managed Competition for Medicare? Sobering Lessons from the Netherlands , NEJM 365:4 , p. 287, July 28, 2011, Okma, Marmor, and Oberlander


Vol. 44 May 1, 2011 Why Can’t Medicare Be Like Visa?

May 1, 2011

Last week I made two purchases on the same day with my Visa card, one for $293 and one for $273, but the two transactions could not have been more different.

I spent $293 for three pieces of metal to repair line cutters on the two propeller shafts of my boat. The $273 was for a shot of the shingles vaccine, Zostavax.

At the marina, I told the parts manager what I thought I needed, and after a brief exchange he went back into the large storage area, brought out what I needed, showed me how to install them, and swiped my Visa card. I left with the parts, the receipt, the confidence that the parts would solve my boat problem, and the certain knowledge that the charge would appear on my Visa statement next month.

At the doctor’s office, I filled out the short registration/information form, was greeted by the nurse who ushered me into a small exam room, gave me the injection, and sent me back out to the front desk to sign out. And that is where all semblance to my other purchase ended. The receptionist began a little speech which sounded well-rehearsed but only because she delivers it 20 times on a vaccine day,

 “If you have Medicare Part D we can not bill your insurance. You may pay today with check, Visa, or Master card, and we will give you written instructions on how to be reimbursed by your insurance carrier. Here is the detailed receipt for today’s service that you will need to send in to your insurance carrier. Also, here is the list of the numbers they will require you to provide; our tax ID number, the physician’s  NPI number, the procedure code, and the National Drug Code number of the vaccine. Please note that there are 6 physician NPI numbers on this list, and we have circled the one you should submit as the supervising physician for today’s injection. You will need to go to your insurance carrier’s website to print out a claim form, complete it, and mail it in for your reimbursement of today’s charges. Don’t forget to include todays’ detailed printout even though you have provided much of the same  information on your carrier’s claim form. Keep copies of everything that you submit. Usually the carrier will reimburse you in about 60 days. Any questions?”

I had two…no, three immediate reactions.
1) what the hell?,
2) what is so special about this service that I need to do this instead of them?,
3) what if once a year all doctor’s offices did this for all their services to all their patients?
Boy, wouldn’t that be an eye-opener for patients!  Talk about transparency! A taste of the reality of what doctors’ offices go through every working day to get paid by multiple insurance carriers with different forms, review procedures, and deadlines might jumpstart a consumer campaign for single-payer health insurance!

But, I kept quiet and handed her my Visa card. She swiped it, had me sign the slip, and gave me a copy along with a detailed encounter printout, a page of instructions, a page with the required numbers, and a wish to “Have a nice day”. I went home printed the claim form on my carrier’s website, completed it (9 digits for practice tax ID#, 10 digits for NDC#, 10 digits for physician’s NPI#, two 5-digit procedure code #, and two 5-digit diagnosis code # ). There was no line to record one of the numbers, so I just wrote it on the bottom of the form. I attached the doctor’s office printout (being careful to follow instructions to NOT staple or paperclip any of the pages together), copied all the pages, and mailed it. The carrier’s website told me to expect them to take at least 30 days to process my claim. There was no note about when I could expect payment.

By the way, $46 of the $273.21 charge that day was for the physician. The rest was for the vaccine.

Why can’t that medical service transaction be as simple as the one for my boat parts?

Medical Services are too complex, and there are so many of them?
Have you ever seen a marina chandlery or more commonly an auto parts store? Shelves stacked with myriad parts, big and small, rising right up to the ceiling and a countertop piled high with catalogs and specification books that make the ICD-9 code books look like magazines. All  sharing space with a computer terminal usually on a swivel to make it easier for the customer to help spot the picture of the one part for the boat or car model he wants. No, complexity of inventory can’t be the barrier. Just think Amazon.com.

Fear of fraud?
By the patient? My doctor’s office staff knows me by sight, but I still have to confirm my date of birth and Medicare number every time I go in. On the very first visit I had to show a picture ID. By the doctor? In 30 days I will “audit” the charges on my Visa bill. I could do it the next day on-line if I wanted to. If I don’t agree or think that something is amiss, an email or a phone call to Visa will put it on hold. If I didn’t challenge or question the charge within 30 days, Visa could let Medicare know and Medicare could transfer the same amount as a credit to my Visa account. I’ll get to see the correctness and timeliness of that credit in my next Visa bill. If several patients reported charging problems with the same physician or office, Visa would be all over them.

If  Visa can call me within 24 hours to verify my purchase of diesel oil at a marina two states away from my home state where I had purchased oil just two days previously, I would expect them to be able to set up programs that would flag potential physician fraud. Certainly the current government and insurance carrier computer programs that have missed millions of dollars of fraudulent charges, in Florida alone, are nothing to brag about.

Too expensive?
The 7%  that Visa charges merchants and retailers for conducting transactions seems like a real bargain to me. If Citizens Bank can make enough profit on the $20 pre-payment “float” of Fast Lane, Visa could probably make an acceptable profit on the “float” from a $50 annual fee for health insurance transactions.

Lack of standard pricing?
Visa seems to be able to handle that quite well now among different airlines, hotels, catalog stores, and everyone else with a weekly special, redeemable coupons, and the like. Of course, a national standard, or at least a regional one, for health services pricing might make everyone’s life a little simpler, and easier to monitor.

Inertia, or fear of changing how we do things now?
Many hospitals, physcians and more than half of consumers currently favor a single-payer system, not because they are social liberals, or muddle-headed do-gooders, but because they are exhausted by and fed up with our current complex, inefficient, and bureaucratic payment system that is so easily manipulated by the insurance companies for their own benefit.

WHADDAYA THINK?    Take this poll to let me know.


Vol. 42 April 1, 2011 Updates on Health Care Reform

March 31, 2011

“You can always count on Americans to do the right thing – after they’ve tried everything else.”
-Winston Churchill

Mitt Romney announces his candidacy for Governor of Massachusetts

Persistently harassed by Tea Party leaders and other conservative Republicans for the inclusion of the “individual mandate requirement” in his Massachusetts Health Care Reform Act and tired of defending it as “good for Massachusetts but not necessarily for [insert name of any state in which Romney is that day]”, Mitt Romney has announced that he will abandon his exploratory campaign for the Presidency. He will return to Massachusetts to run for Governor against Duval Patrick. “Since this annoying issue of the individual mandate just won’t go away, I am going back to Massachusetts to undo it,” said Romney.

Donald Berwick, MD apologizes to Congress for his extreme behavior during his hearing

Though most reviewers remarked on Dr. Berwick’s evenhanded responses to the sometimes hostile questioning at the Senate Finance Committee hearing on his nomination as CMS Administrator, this blogger has a different view. I was present in the hearing room just after the TV cameras and microphones were turned off. Dr. Berwick, having kept his cool for so long, literally exploded, cussing the senators for their “mean-spirited, narrow-minded, myopic views of the federal government’s role in health care”. “Arguing with you is like talking to a dinner table.” When this outburst hit You Tube via someone’s cell phone the next day, Dr. Berwick quickly apologized. “As a pediatrician I thought I knew how to control temper tantrums, but somehow that hearing just conjured up all the adolescent turmoil that I thought I had outgrown, and I flew off the handle. I am extremely sorry, but am very thankful that my staff took away my iPhone before I was able to tweet.”

President Obama was so shaken by Dr. Berwick’s outburst that he has begun seeking a replacement; one who has experience in public policy, is a strong individual, is acceptable to most Republicans, and who is currently unemployed.  Arnold Schwarzenegger springs to my mind, though he is rumored to have returned to acting, “I lift things up and then put them down.”

Sarah Palin withdraws her opposition to “Death Panels”

According to David Williams writing for the Health Care Blog: “Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person's] ‘level of productivity in society,’ whether they are worthy of health care.” One ingredient of end-of-life planning is patients’ opting for palliative care. He summarized a recent study in New York state where patients who received palliative care cost Medicaid almost $7000 less in hospital costs per admission than a matched control group that didn’t receive palliative care. Patients receiving palliative care spent less time in the intensive care unit and were less likely to die there. They were also more likely to receive hospice care after discharge and to be discharged to appropriate settings.

Impressed by this report and other studies, Sarah Palin has withdrawn her opposition to the reimbursement of  “Death Panels” to help patients and families plan for end-of-life care. However, her newly found acceptance of rational end-of-life care is tempered by the unintended consequence of the increased satisfaction of families receiving palliative care.  “Most people on Medicaid are unemployed, deadbeats, or probably illegal immigrants, so why should we be spending time and money increasing their satisfaction with our health care system?”

Starbucks will add Urgi-Care Centers to their stores

Howard Schulz, CEO of Starbucks, announced that as of April 1 they would be establishing urgent care counters in selected urban stores. He is impressed with the successful implementation and rapid growth of convenient medical service centers in CVS pharmacies and wants to remain competitive in the crowded field of one-stop-service retail stores. According to Schultz, “Starbucks is the quintessential experience brand and the experience comes to life by our people.  The only competitive advantage we have is the relationship we have with our people and the relationship they have built with our customers.”

Analysts remark that this move is consistent with Starbuck’s image as a “home away from home and work” where one can go to relax, listen to music, buy a CD, work on a computer, read a newspaper, eat a snack, trip over a stroller, smile at the dogs tied up outside the door, and …get a cup of coffee.

Schulz also announced that a new flavor shot, “Potassium Iodide”, will be introduced in selected West coast stores in response to recent consumer inquiries there. Despite the phenomenal growth of medical marijuana stores in California and Colorado, Starbucks has no current plans to add this to their offerings. “A double espresso mocha caramel Vente is as high as you can go at Starbucks for the moment.”

Congress to hold hearings on what to call the new medical care payment system

The Accountable Care Organizations (ACO) proposed by the Affordable Care Act (ACA) will require the replacement of fee-for-service provider payments with a collecting together of all kinds of medical care bills which will then be paid out of a single account. Congress has known for a long time that no one knows what “ACO” means, and now, no one seems to agrees on what to call this new billing and payment method. The CMS, GAO, AMA, AHA, and AAMC just issued issued a report of their study of possible labels and asked for congressional hearings on their conclusion. Here are selected samples of the rejected names and their recommended conclusion:

“fee-splitting”- Though functionally similar to ACO methods the AMA objected to this because of their successful, long time efforts of labeling it as unethical.

“capitation” (also called “capitation-light” or “neo-capitation”) – Again, though functionally very similar to the ACO method, it was felt that this word had too many negative political, economic, and patient-control associations.

“global payments” – This one was very popular and is still in use by some people, but the negative associations with the weird weather we are having and with Al Gore nixed it. The fact that “global” corporations seem to be very successful in  avoiding anti-trust litigation was a definite plus for this label.

“rational budget allocation” – Sounded too much like the U.K. National Health Service,  definitely requires the advance planning dreaded by most physicians, and the  second word was the only one with a meaning accepted by all.

“single payment to all medical providers for a patient’s illness for life” (SPAM PILL)- An accurate statement, but much too long for an acronym or sound bite, and though the acronym implies a use of electronic networking (good), it has an  annoying connotation (bad).

After many meetings, exhaustive staff work, and numerous drafts of over 100 pages each the report finished with this final conclusion:

‘The one word that captures the collective nature of the new payment system with both warm, fuzzy connotations and a positive image is ‘bundling’, as in the soft, warm bundling of a baby in a blanket. Who could be threatened by that?”

HAPPY APRIL FOOLS DAY


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