Qualify for government subsidy: become a(n involuntary) unionized government employee

 Next up: doctors, section 8 housing owners, ????? Grocery stores, drug stores???

A year ago in December, Ms. Berry and more than 40,000 other home-based day care providers statewide were suddenly informed they were members of Child Care Providers Together Michigan—a union created in 2006 by the United Auto Workers and the American Federation of State, County and Municipal Employees. The union had won a certification election conducted by mail under the auspices of the Michigan Employment Relations Commission. In that election only 6,000 day-care providers voted. The pro-labor vote turned out.

Many of the state's other 34,000 day-care providers never even realized what was going on. Ms. Berry tells us she was "shocked" to find out she was suddenly in a union. The real dirty work, however, had been done when the state created an "employer" for the union to "organize" against.
Of course, Michigan's independent day-care providers don't work for anybody except the parents who were their customers. Nevertheless, because some of these parents qualified for public subsidies, the Child Care Providers "union" claimed the providers were "public employees."
Michigan's Department of Human Services then teamed with Flint-based Mott Community College to sign an "interlocal agreement" in 2006 establishing a separate government agency called the Michigan Home Based Child Care Council. This council was directed to recommend good child-care practices—and not coincidentally, to serve as a "public employer." Although the council had almost no staff, no control over the state subsidies and no supervision of the providers' daily activities, it became the shell corporation against which the union could organize.
Thus the state created an ersatz employer and an ersatz "bargaining unit" against which what was essentially an ersatz union could organize.
Today the Department of Human Services siphons about $3.7 million in annual dues to the union—from the child-care subsidies. The money should be going to home-based day-care providers—themselves not on the high end of the income scale. Ms. Berry now sees money once paid to her go to a union that does little for her. She says she is "self employed and wants nothing to do with the union."

?No self breast exams?

The recommendation *not* to teach exams throws the whole report into question for me. If we are changing the frequency of mammograms, should we also change the recommendation to do self exams? Won't the first change the effectiveness of the second?


In the news, the report by the Agency for Health Care Research and Quality. The "conventional wisdom" about breast cancer screening was turned on its head - or, at least tweaked, this week.

I think we might have been over doing the mammograms ("MMG"), but the old recommendation to do a "baseline" MMG between 35 and 40, with self exams each month and MMG each 2 years from 40 to 55 and then one a year or each 2 years according to risk, made sense to me.

What I absolutely don't get is the recommendation to stop teaching self exams. Teaching self breast exams received a "Grade D" recommendation - meaning there's no empirical evidence that the procedure is "effective." In other words, it has "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The practice would be "discouraged" -- considered bad medicine, and actually put the doctor at risk for criticism. It most certainly won't be paid for.

There's a reason to find masses: it will change what we do, we have treatment that we can and should do for positive changes. Any mass that's fast growing and lasts over a month is highly suspicious and any mass we can feel should be biopsied. Even though the sensitivity may be low (compared to MMG), patients who do regular exams have been proven to be more likely to find masses earlier and smaller than the doc would at an annual exam, and it's non-invasive, cheap, and accessible. Teaching the self exam gives me something to talk about while I'm doing my own exam of the patient and is an opportunity to explain what I've written, above.

It looks like the fuss over the recommendation will be the first test of the realities of "Comparative Effectiveness Panels" which was funded by $1 Billion allocated in the 2009 "Stimulus Package."  Emotions and reactions are high, with Health and Human Services Secretary Sebelius,  Medicare and most insurance companies already reporting that their policies (paying for annual MMG and recommending teaching at doctors' exams) won't change. The Mayo Clinic has absolutely renounced the recommendations.

For more information on the policies of other nations, see this article.

Politics bites science

For a clear outline as to why you shouldn't believe that 45,000 people die each year because they don't have insurance, read the blog entry by John Milloy, publisher of "Junk Science" on last week's report in the American Journal of Public Health.

Forget that the authors are blatantly biased members of the "Physicians for a National Health Plan."

All you need to know is:
# Among the many problems with the study, here are four of the most glaring; all of which will likely be missed by the media:

* The researchers assumed that study subjects lacking health insurance at the time of the interviews did not subsequently gain or regain insurance coverage. In fact, a study subject could have received health coverage the very next day after the interview and this would not have been considered by the researchers.
* The researchers essentially assume that lack of health insurance at the time of interview is the causal factor in the deaths that occurred. No data was gathered to back up this assumption.
* None of the data collected during the interviews, including insurance status, was validated by the researchers.
* The study result is statistically weak. Combined with the peculiar date-of-death cutoff (the year 2000 as opposed to any other year), it raises questions as to whether the study result was produced by “data dredging” – essentially cherry-picking data that provides the desired result.

Comments on President's 9-9-9 speech

You can read the speech, here.

As of 8:30 AM on September 10, there's not much comment from the AMA or other powerful, interested observers. I wonder if, like me, they're waiting to see the actions that result from the speech?

Here are my own(Beverly Nuckols) thoughts after the speech:

Quality, timely, or cheap medicine: Pick two. If you think you can have all three, please, tell Walmart how to do it.

The President is still talking about mandating that everyone buy insurance. He still ties it to employers and there is no mention of tax breaks for individuals who buy their own insurance. (Will companies still be forced to ensure dependents, and will "children" include adults to the age of 26?)

Instead, we hear about fines and new taxes, and more negative comments about profit-seeking companies and "the wealthiest Americans."

First, show me the wording in the actual proposed Bill, give me time to read and understand it and reassure me that you’ve read it. Will that wording be clear on the various promises?

Second, let’s get this straight: tax cuts don’t cost the government, taxes cost the taxpayers. If the government wants more money, give incentives to those who earn money that you tax. Don’t punish them by taxing them at higher rates! If the government has less, the government should do what the rest of us do: cut what you spend!

It seems illogical to me to tax insurance companies for offering "the most expensive plans." These are plans that people decide to buy for themselves. The only result of such a tax would be to kill the "expensive plans."

If the government mandates well care for everyone, there will not be enough manpower or other resources for sick care. If you mandate the addition of both numbers of people and services to the health care that is paid for not only by private funds but public funds, you will increase costs and demand.

Show me the “patient safety trials” that will decrease defensive medicine. As to the tort reform and "trials" to allow doctors to practice with less concern about lawsuits, I suggest that the President simply look at Texas since our own tort reform passed in 2005.

President Obama promised that abortion will not be funded by federal funds and that the current conscience laws will remain in place. Does this mean that no mandates for private insurance to cover abortion will be allowed? Does this mean that he will enforce the conscience laws that exist?

We must remember that the President signed an Executive Order in his first week to fund organizations that pay for abortions and referral for abortion overseas and who overturned the last Administration’s ruling to affirm the enforcement of conscience laws. What will he do in the face of the House’s passage of a Bill that will fund abortions in Washington, DC?


Cross-posted at Comal GOP blog.

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Daschle/Dole/Baker! Health care on the fast track -along with the entire Nation's finance

Right after this Yellow Brick Award ceremony, I'm thinking that it may save my life for me to learn to use Twitter and Facebook. Now.

While President Obama is planning to take over the entire finance world ASAP, ABC is planning their all-day infomercial for Obama and his push - there is no "plan," yet - for health care "reform" by July 4. No opposing or alternate viewpoints will be allowed. They're even refusing to take a paid-for program in rebuttal, according to the Drudge Report.

ABC REFUSES PAID ADS OFFERING ALTERNATIVE VIEWPOINT FOR WHITE HOUSE HEALTH CARE PROGRAM
ABC is refusing paid ads for its health care program at the White House. Thus they're refusing even a paid-for alternative viewpoint.

Conservatives for Patients Rights requested the rates to buy a 60 second network spot immediately preceding the broadcast of the Town Hall meeting.

While looking for verification of this story, I came across several that report that former Senators Tom Daschle, Bob Dole and Howard Baker are working on a health care "compromise." (Come on! there's a reason they aren't Senators any more!)

See their report, "Crossing the Streams Lines" here.

So, we'll have a Secretary of the Treasury (who claims to be unable to do his own taxes using Turbo Tax) running Wall Street and all the banks. We'll have a known plagiarist and serial failed Presidential candidate (who also can't figure out that gifts and services are taxable) working with another serial failed presidential candidate (who took money for telling the world that he needs a little pharmaceutical help in the bed room) working to reign in the cost of doctors, hospitals, and those pharmaceutical companies. (The third player in the health care waters is Baker, another serial failed presidential candidate. It's just that no one's ever heard of him.)

But don't worry -- even if you are able to vote for a completely new House and a turnover of a good portion of the Senate in 2010, Obama will still run the Census out of his Committee to Reelect the President.

In the meantime, Obama is planning to cut Medicare fees to Hospice, hospitals and doctors while instituting a new tax on health care insurance benefits from employers, according to the Washington Post.

Why not? After all, Daschle had to pay taxes on his limo and driver and Geithner had to pay them on his kids' summer camp!


Addendum after skimming the report:
The "Crossing the Lines" report is full of calls for more regulation with a sprinkling of pablum.

First, they demand that everyone have health insurance. (Could be acceptable if we were allowed to chose between Major Medical and From-First-Dollar. And if it weren’t for the rest of the trash.)

They believe - or at least claim to believe - that it will pay for itself. (Who knew old white haired men could be so funny?)

How will the money be raised?

By a “trigger” to enforce cuts when costs reach a certain point and by not paying for those treatments that are considered less effective.

What are they going to do with all the men and women who insist on antibiotics, today, for their bronchitis? Will they protect the doc when the patient develops bacterial pneumonia?

How about my man in his mid-80’s with a 102 fever in the ER, a bladder infection, multiple falls that resulted in bruises and skin tears, and potassium at 2 (normal is 4)? Medicare would not allow me to actually admit him because he turned out not to be septic by their criteria. He ended up on “Observation” for 3 days while his wife and I tried to find some safe place for him to go after discharge and I tried to get a handle on his potassium. He left for the rehab hospital with a potassium of 2.6. On a heart monitor. Because Medicare rules threaten us with charges of “fraud and abuse.”

How about our local hospice? Obama has announced his intention to cut funding to hospice. I guess there’s not much efficacy in hospice. After all, the hospice patient is, by definition, expected to die within 6 months. However, hospice patients are less likely to present at the ER, with the costs of their care much less than hospitalization.

Force Medicare "reform" without proof that it will work?

The Washington Post reports on the latest findings of the "Medicare Payment Advisory Commission" (MedPAC) today. According to the WaPo, this is a "commission that advises Congress on the federal medical program for older Americans."

In other reports, there is mention that President Obama plans - at the same time - to cut Medicare and Medicaid funding by over $900 Billion dollars, to somehow expand the numbers of Americans who are given "guaranteed health care" under some government "public plan," and to pay for any expansion by taxing insurance benefits given by employers.

And it all has to be done in the next two weeks:

For months, Obama remained on the sidelines of the health-care debate because "he felt it was important to not be too proscriptive," Axelrod said in an interview. "Now we're into a different phase, where decisions are being made very quickly, so it's time to weigh in to a greater degree."

The Obama strategy, articulated in the speech here and in a series of private meetings, is to present each major stakeholder with an enticement in return for a bit of sacrifice.

Again, there's mention of "accountable care organizations," and how to force doctors into them. This time, we do learn that coercion will be necessary to form these organizations and that there's evidence that these sort of interventions don't save money or improve the health care of patients caught up in the schemes. In fact, some of these interventions are now considered wasteful and the first place to cut:

To illustrate what it might take to save Medicare, the commission describes how primary-care doctors, specialists and hospitals could be reorganized into "accountable care organizations" whose members would receive bonuses if the organizations met quality and cost targets. To ratchet up the incentives, health-care providers that fail to meet cost and quality targets could be penalized, the report says.

Even then, any projected savings would be highly uncertain, the report says. What is certain is that Medicare cannot maintain its current trajectory, it adds:

"If current spending and utilization trends continue, the Medicare program is fiscally unsustainable. . . . Part of the problem is that Medicare's fee-for-service payment systems reward more care -- and more complex care -- without regard to the quality or value of that care."

The report underscores the challenges facing President Obama and Congress as they seek to overhaul the health-care economy. The administration has put a spotlight on what it considers wasteful spending, but it has offered sparse details as to how it would change the incentives that produce the waste.

The report identifies some areas that are ripe for savings. MedPAC estimates that the government is paying private Medicare health plans -- which were supposed to save the government money -- much more than it should. In addition, the government could save money by adopting a more streamlined approval process for "follow-on biologics" -- products that imitate biotech treatments already on the market.

Getting doctors to join accountable care organizations may require pressure, MedPAC Executive Director Mark E. Miller told reporters: "If you want people to voluntarily organize, you may want to make sure that the current system isn't as pleasant a place to be."

The model for accountable care organizations resembles that of large, tightly managed physician groups, practices that have been the subject of demonstration projects, and Medicare's experience with those offers limited encouragement, according to the report. Measurable quality improved in the areas of care monitored, such as for diabetes and congestive heart failure. But "whether the demonstration has actually generated savings for the Medicare program is debatable," the report says.

Policymakers hope that money can be saved by better coordinating care. But, according to the MedPAC report, Medicare pilot programs intended to coordinate care for patients with chronic diseases -- programs that involved insurance companies and other private groups -- generally achieved modest quality improvements. Most of the programs cost Medicare more money than it would have spent without them, the report says.

Obama to push public health plan, forced physician participation

The New York Times is covering the opposition to a public health plan (government pre-paid health care) by the American Medical Association.

Within that article is the news that the Democrat leadership intends to not only implement a government insurance plan that would compete with private insurance companies, but the legislation would force doctors who already accept Medicare to accept this new plan, also.

America’s Health Insurance Plans, a lobby for insurers, said Tuesday that the government plan proposed by some Senate Democrats could “dismantle employer-based coverage and significantly increase costs for those who remain in private coverage.”

Under a proposal favored by many Democrats, doctors who take Medicare patients would also have to participate in the new public plan. Democrats say that requirement is needed to make sure the public plan can go into business right away with a large network of doctors.

The medical association said it “cannot support any plan design that mandates physician participation.” For one thing, it said, “many physicians and providers may not have the capability to accept the influx of new patients that could result from such a mandate.”

“In addition,” the A.M.A. said, “federal programs traditionally have never required physician or other provider participation, but rather such participation has been on a voluntary basis.”

Those who had Medicare supplements that paid for their drugs before the Medicare Part D plan was implemented will remember their surprise when they were forced out of their old plan and onto the new one. The big surprise came when they hit the "donut hole," or the level when they had to pay for all of their own prescriptions.

Imagine your boss has the choice between buying insurance, or (as in Massachusetts) paying a fine that is less and allowing you to be absorbed by the government plan.

Now, imagine that you can't find a doctor that is taking new patients. Or a doctor that can see those patients within a reasonable time frame.

Here in Texas, some Medicaid patients are assigned to clinics, not doctors. Their "primary care providers" are not doctors, but groups that hire nurse practitioners to see them, to take call, and to manage their care.

In fact, Rural Health Clinics are required by Federal law to hire Physician Assistants or Nurse Practitioners who *must* do a certain percentage of the visits and patient care - I believe it's 50%. In other words, the government forbids the doctor who owns the clinic from seeing all his own patients and keeping the patient load at a reasonable level. Just another example of unintended consequences of government interference.

Why the medical home sounds good but won't work

A sister Family Physician says in her blog, "Musings of a Dinosaur,"

It is the source of endless angst among family doctors in solo and small group practice, because the structure of the PCMH excludes us by definition. The PCMH is advertised to work best in large group practices like Kaiser and the Mayo Clinic. All I can say is "DUH!"You know what the PCMH really is? Nothing more than this:

IT'S A WAY TO MAKE LARGE GROUP PRACTICES WORK MORE LIKE A SOLO DOC!!!

I am already performing every meaningful function of the PCMH. So is virtually every physician in solo and small group practice. There is absolutely nothing to be gained -- and a significant amount of money to be lost; this thing is expensive! -- by adopting any of this PCMH shit. Somehow that doesn't seem to stop our Academy from tossing us to the wolves by simply ignoring us.

Health care reform conversation

There's a comment from a proponent of single payor health care payments on one of my November posts. A few points need to be clarified:

The numbers about infant mortality are skewed in the US because we count more infants as "live births" than other countries.

We use Medicaid money to finance special education and Medicare to finance medical education -- are those included in those numbers?

Also, that $7000 is an average - that includes all the expensive care for very ill patients. It would be more interesting to note per-capita bone marrow or other organ transplant.

I would like to see how much of our medical spending is actually elective - Botox and plastic surgery as well as contraceptives and abortions.

The majority of Family Physicians are against or conflicted about about single payer. We don't have a great history of changing policy to the benefit of our practices. Medicare, medicaid, and Workman's Comp pays better for procedures like surgery and invasive tests than they do for cognitive and preventive skills.The Family Doctor could do more if we weren't under pressure to see 4 to 5 patients per hour.

Health care outcomes are strengthened where primary care is strongest, according to research.


What I want to see is a public policy that allows patients to own their own health insurance and for doctors to work for the patient. Medicare still won't pay for tetanus shots when a covered patient needs one.

I just worry that what we have is not working because of regulations and laws. I don't want more of those.

Healthcare lottery

When you buy a lottery ticket, do you choose the cash option with its immediate payout of half the winnings or do you choose the payment of the full amount, doled out over 20 years?

I've found this question to be a good way to help other people understand the difference between conservativism and those who think that someone else can take care of them or the "totalitarian mamas" who believe that they can take better care of us than we could ourselves and for our own good. (Of course, some Conservatives tell me don't gamble, so they never buy lottery tickets.)

It's amazing how many people tell me that they always buy the "cash option." Some say they worry that their families wouldn't get anything if they die before the 20 years is up. Some tell me that they believe they can manage and invest the money to earn more than they would if they wait out the smaller payments. A few tell me that they would rather not have all the money at one time, preferring the guaranteed income over the years or fearing blowing the money.

The latter group never understands why I suggest that their health insurance should be something that they own and control, rather than something doled out by government and their employers.

A "right" is something that we each have without conditions and which we can call on society and government to enforce or punish if someone infringes that right. The right to life is actually the right not to be killed. We expect our fellow citizens to protect us through providing armies and law enforcement, a militia and by allowing self-defense. If another person infringes our right not to be killed, we expect society to punish him.

Last night, Democratic Presidential Candidate Barack Obama stated that health care is a right. I strongly disagree.

"Health" and "health care" are difficult terms to define. Instead of people and their actions, health is threatened by disease, age and injury. If I'm not well, how will society protect my health - and who or what will be held responsible as I inevitably age? If I have a "right" to health care, then I want everything possible to maximize my health. Rights can't be rationed.

What we're really talking about is health care funding. Funding certainly can be rationed. Take a look at Medicare, Medicaid, and the Veteran's Administration.

These systems work fairly well most of the time. However, they rely on limiting the costs of health care. The limitations fail when demand for cutting edge, expensive treatments or emotional arguments override them. That's why Medicare won't pay for a tetanus shot after a dirty wound, but will pay for annual physicals, screening mammograms and prostate specific antigen tests, although there's no evidence that these prolong life.

Or why Oregon Health sends notes telling patients that they won't pay for cancer treatments, but they will pay for assisted suicide.

For more on this subject, here's another opinion.

Dr. Nurse? Why not just Doctor?

Get ready for Dr. Nurse, who will call himself/herself "Doctor," but who, after 4 year bachelor's degree in nursing, has gone to the Doctor of Nursing school for two years with a one year internship -- that's compared to the 4 years of college, 4 years of medical school, followed by at least 3 years of residency that Family Physicians, Pediatricians and Internal Medicine docs devote to training..

The Wall Street Journal reports (please let me know if you can't access this page) that the National Board of Medical Examiners will begin testing these "DrNP" candidates this fall.

From the Wall Street Journal:

As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

So,the supposed reasoning behind the new doctorate is this shortage of primary care doctors. That shortage has been artificially encouraged by all sorts of federal interventions. For some reason, no one's considered paying Family Doctors more!

Instead, there are schemes to divide and re-divide the Medicare "Pie." There are the rural health clinics, which are paid more by Medicare and Medicaid than your local family doctor, pediatrician or internal medicine doc for seeing the same patients. In order to qualify, the clinic -- get the distinction, there, not the doctor, but who ever it is that owns the clinic and contracts with doctors and hires the rest of the staff - must hire at least one "mid level practitioner" to see patients. They can't hire a doctor to do the same work and/or for the same money -- they must hire a Physician Assistant or Nurse Practitioner.

As the article notes, the main reason for the loss of primary care physicians, however, is the low pay for the thinking part of what we do, compared to the procedures of specialists, such as all the varieties of surgeons, urologists, gynecologists and gastroenterologists. We analyze, examine and determine treatment or treatment change, resulting in "Evaluation and Management" visits. Rather than the codes used for procedures, the E&M visits are divided into levels of payment based on a set of check lists and diagnoses. The money from Medicare - followed closely by the insurance companies - has consistently shifted from the office visits toward the procedures.

Needless to say, the smart medical students -- or at least the ones more interested in money than in your family history, living arrangements and whether Junior ate his peas and carrots will become interventional sub-specialists, not a Family Physician or Pediatrician.

A few years ago, Medicare payments increased for home health agencies, which encouraged RN's and LVN's to leave the hospital. Medicare quit paying your family doc to "scrub in" with the general surgeon or orthopedist as an assistant during your gall bladder surgery, colon resection or hip replacement. But, they did pay the surgeon enough to justify the hiring of a nurse practitioner or physician assistant. And studies said there was no difference or even better outcomes, since the "team" worked better in the Operating room and the peri-surgery procedure became more efficient.

(Of course, the NP or PA won't be available to your wife or kids for questions next week, and won't watch the effect of your new level of activity on your blood pressure or diabetes. And your family doctor may no longer even know that she should, since she won't even find out about the surgery until your next visit or hospitalization. But that has nothing to do with the outcome of the surgery, right?)

The increase of Federal funding for Nurse Practitioners has exacerbated the loss of good RN's and LVN's - leading to more of the Federal pie going to nursing schools. And the DrNP will probably have the same effect. The WSJ article mentions the lack of faculty in the nursing schools. The funding will have to come out of the Medicare and Federal "pie."

However, what patients need to consider is whether the DrNP training can truly accomplish the same training in 3 years that our Medical Schools can do in 5 to 7 years. Some have said that mid levels can handle 80% of what doctors do.

It's that 20% that is the difference between knowing what you don't know and planning for the 2 AM crisis.

Medicare Pie Cut Thinner

Think of the money that Medicare pays doctors for seeing patients as though it's a pie called the "Sustainable Growth Rate." This pie is not going to get bigger unless Congress cooks some more pies by New Years. Otherwise, when more patients join Medicare and more pieces are needed next year, we will have to cut the pieces that doctors are paid each time we see a patient into smaller and smaller pieces.

I wimped out: I closed my office in 2003 because I saw the costs of the requirements for medical reporting and "privacy" coming and I figured that I could work part time for other people and make more money than I was making as a solo doc. (And I hate the business part of medicine.) I'm not sure how many others are making the same decision, but we often read about "boutique" practices and docs who won't take Medicare or new Medicare patients. Have you noticed how many doctors in your town are adding things like Botox shots, laser therapy and other cash-pay services?

Medicare will cut doctors' reimbursement by 10% in January if Congress doesn't act before the end of the year. This cut is separate from the Veterans Administration, Medicaid and SCHIP funding and is written into the current law. Since many doctors have contracts with insurance companies that pay based on Medicare, the cuts will go even deeper.

If you don't understand the impact that this cut will have, ask the next person you meet who is over 65 years old whether they had to change doctors when they became Medicare eligible. Ask them whether they have any choice other than to use Medicare and how hard it is to get in to see their doctor.

As I've said before, get ready for it to become even harder.

10 years ago, financial advisers told us that Family Physicians shouldn't have more than 20% of our patient population mix made up of Medicare patients if we wanted to stay in business. Since that time, most doctors have worked harder to be more efficient and have cut out any costs in the office that we don't need. My colleagues cannot afford a 10% cut in pay, while all of our costs continue to go up.

Primary care docs are paid about $160 per hour for office visits by Medicare. We are more likely to see the patients who have 5 or 6 diagnoses, 10 or 12 medicines to straighten out, and who bring in a family member to each visit. These patients take time. If the payment goes down to $155 per hour, most doctors will not be able to afford the cut.

In order to earn that money, we need the office and furniture, utilities, supplies for the patient room and office staff, at least a couple of staff members to check patients in and assist us, someone to answer the phones, those phones, refrigerators for medications, someone to handle the billing and banking, and all of the fees and insurance that normal businesses handle, like property taxes, slip and fall insurance, fire insurance, employee tax to the State, property tax on the building, furniture and supplies, and unemployment insurance, etc.


Then, we have malpractice insurance, professional dues to the County Medical Society and most likely our State and national AMA dues in order to remain "Board Certified," State licensing fees, DEA licenses from both the State and Federal systems, hazardous waste disposal fees, CLIA (office lab) fees, and the fees to keep our computer systems that are increasingly mandated by law if we want to be paid the full $160. The new electronic medical records can cost as much as $30-$40,000 per doctor up front and several hundreds to thousands per month.

In addition to these costs, Medicare requires the highest level of reporting, risk and red-tape. This year, there was a planned delay of payment from the Federal government for 2 weeks at the end of October built into the Federal budget to make it appear balanced. There were also unplanned delays when doctors began using the new National Provider Numbers phased in this year as part of the Medicare laws. (A lot of that expensive computer software in the office, at the insurance companies, and at the Center for Medicare and Medicaid Services couldn't handle the numbers.)

Now do you see why I hate business?

For more information and history, read this article or watch this video from the Texas Academy of Family Physicians.

Please consider calling your Representative to the House, your two State Senators, and the White House and ask them to protect Medicare payments to doctors.

Varied and deep rooted (cost of health care)

I'd just add a few observations to the New York Times editorial (free registration required) on the cost of health care in the US.

I'm a big proponent of making patients responsible for more of their health care costs. Health Savings Accounts, long term care insurance, and even deductibles are good ideas. I would also add that the vast majority of the people on Medicaid and public assistance could do some sort of public service work in payment for their health care. (Medicare, disability, and veteran's health care has been paid for already.)


I especially like the idea that primary care should be emphasized. How about *paying* doctors to do it instead of ensuring that we lose money for every Medicaid and Medicare patient we see?

And they don't mention some of the problems that I see:

1. Over the counter medicines that probably aren't needed in the first place and don't do what they are believed to do. Did anyone notice that the baby cold medicines are not useful and no longer standard of care? And please don't get me started on homeopathy - I'll irritate a couple of million of my readers if I go on about the useless idea that a substance diluted millions of times in water can't do anything.

2. Botox, cosmetic surgery, and beauty treatments - Do these services, when provided by a physician go into that giant number?

3. The hidden costs of school-based health care and the need for "notes" from doctors for school and work. I doubt that many people are aware of how much of Medicaid money is spent on "mainstreaming" and on learning disabilities in our school systems. I'm sure that few would understand the pressures that doctors face to provide the testing, medications, and follow up required to get mom back to work after the baby is too sick for daycare or school, for the note for the Tuesday patient who says they had food poisoning on Monday, or for the demand from a school or from the parents to get the 7 year old tested for a learning disability for all sorts of reasons.

4. Salaries and perks for insurance big wigs that could pay for the healthcare system of a couple of nations. United Healthcare, which threatens to swallow up every insurance company in the nation, has paid at least $120 Million dollars to its CEO for at least 10 years.

5. I don't want it to go away -- but -- Medicare pays for quite a bit of the research and medical education in the country. We need to see this research and the doctors, medicines and treatments that come from these funds as the valuable commodity they are and quit dinging "health care costs" for it.

Privacy, politics, and medical records

The editors and pseudoeditors of the American Journal of Bioethics blog are talking about all the people who accessed the hospital records of George Clooney after his motorcycle accident.

Somehow, according to the author of the post, it's all President Bush's fault.

In light of the news and comments on the latest iteration of SCHIP and Hillary Clinton's health care plan, I've been doing a little research. We ought to learn and remember the history of the privacy laws, the push for electronic records. But we certainly can't claim that the problem began in January 2001.

HIPAA began the whole electronic record push and originated in 1996. It's about anything but "privacy." See the records available on line, here.

The Privacy Rule, a later part of the Act (the Summary is 25 pages), specifically mandates full disclosure to the Secretary of Health and Human Services, or any agent of the Secretary, of all information in any facility that participates in any way (or ever hopes to do so) with Medicare. It also allowed those entities to make copies to take out of the office and to write their own subpoenas that need to be vetted by a judge after the fact. Attorney General Janet Reno advocated the use of the technology to track down Medicare fraud and abuse back in 2000.

The first big influences toward electronic medical records (EMR) and digital imaging are even older. Back in the late '80's, when I was in medical school, the Veterans Administration pioneered the EMR. (I used to practice diagnosing patients from their list of medications and procedures, the first elements of the record, before our notes could be entered.)In the early '90's, radiologists discovered the benefit of taking call from home while being able to read emergency head CT's and other images.

The electronic medical record and digital storage of images is a good thing - but like all tools needs to be used properly.

The whole coding and reporting of medical care has grown into the usual government "leviathan" (to use Ira Magaziner's defense to the lawsuit against him and Hillary Clinton for the unknown status of the consultants on their 1993 Health Care Task Force).

We still hope that the EMR will help us do better than we have in the past. Although I believe that most clinicians will disagree with the the "quality" markers used, see today's NEJM article about child health care.

However, I don't think that the incident involving Mr. Clooney's records proved anything about electronic records other than the hospital had the ability to monitor who accessed the records - and that human beings are curious about celebrities.

In the meantime, Texas seems to be volunteering to be a lab for privacy issues with the correlation of drivers, insurance, and cars as well as photographing and surveying the people who use US IH 35. Car 54 can run your license plate at a red light or while you're driving down the highway and then cite you if you're uninsured. My taxes should definitely go down if these tactics can be used to generate revenue.

More on Clinton Health Plan

After my review about some of the news coverage of Hillary Clinton's proposed government healthcare plan, I did some more digging. The Kaisernetwork.org review is here. A Wall Street Journal editorial is here.

The proposed Clinton plan mandates coverage and depends on 1/3 of its revenue from "$35 billion in savings to the government through a more efficient health system." (I wonder who will be considered less "efficient" - doctors or very sick patients?) And mandates that insurance premiums remain below a certain percentage of household income and that tax rates increase in households above $250,000.

All of which, the history of HMO's, capitated plans, and most especially government funding tells us, will result in restrictions in services, long waiting times, and less convenience combined with loud demands for more.

I know it seems a cliché, but how does government "efficiency" work at the Post Office? Fed-ex, UPS and DHL don't have nearly the restrictions medical care does: They charge according to weight, size and distance, but the customer and the recipient decide the contents of the package and the destination. I've never heard of Fed-Ex telling a customer that their package wasn't necessary or couldn't be moved because some Ph.D. (Doctor of Packing handling) had set a formulary - or that they'll take the package 100 miles and no farther. The biggest difference is convenience and the variety of options offered. Although they are able to compete financially and functionally with the US Postal Service, the lines aren't as long and the system is built to handle the unusual. The unusual is a large part of our business in Family Medicine.

The US First Class stamp is great for letters that don't need to be delivered for a day or two. Maybe the government should cover preventive health and let insurance cover sick people.

Mandates don't guarantee coverage. In Texas, we have to show our insurance card when we register the car, get our license renewed and each year when we have the car inspected. The uninsured rate is estimated to be around 24% (anywhere from 20 to 60%, according to the numbers of tickets issued in the big cities). In Colorado, it may be as high as 35%. (More here.) To compensate, Texas will soon begin correlating driver's licenses, car registration and insurance by a data bank accessible to the police car behind you in traffic. Wait 'till Bubba catches wind of this.


A little bit for everyone from the first dollar that cuts off above a certain level is dangerous. I know Medicare eligible patients who had great drug benefits through their retirement plans. They were forced to go to one of the "donut hole" plans, and now pay more out of pocket than before. We now have a good indication that the "donut hole" in the Medicare Part D drug plan leads to an increase in hospitalizations.

However, while researching all this, I did read about one plan that seemed to make sense to me. I've copied, pasted, and changed the name to "the Plan."

The Plan Gives All Americans The Same Tax Breaks For Health Insurance And Helps States Make Affordable Private Health Insurance Available To Their Citizens.

1. The Plan Will Help More Americans Afford Health Insurance By Reforming The Tax Code With A Standard Deduction For Health Insurance – Like The Standard Deduction For Dependents. The primary goal is to make health insurance more affordable, allowing more Americans to purchase coverage. The Plan levels the playing field for Americans who purchase health insurance on their own rather than through their employers, providing a substantial tax benefit for all those who now have health insurance purchased on the individual market. It also lowers taxes for all currently uninsured Americans who decide to purchase health insurance – making insurance more affordable and providing a significant incentive to all working Americans to purchase coverage, thereby reducing the number of uninsured Americans.

* Under the Plan, Families With Health Insurance Will Not Pay Income Or Payroll Taxes On The First $15,000 In Compensation And Singles Will Not Pay Income Or Payroll Taxes On The First $7,500.
o At the same time, health insurance would be considered taxable income. This is a change for those who now have health insurance through their jobs.
o The Plan will result in lower taxes for about 80 percent of employer-provided policies.
o Those with more generous policies (20 percent) will have the option to adjust their compensation to have lower premiums and higher wages to offset the tax change.

2. The Affordable Choices Initiative Will Help States Make Basic Private Health Insurance Available And Will Provide Additional Help To Americans Who Cannot Afford Insurance Or Who Have Persistently High Medical Expenses. For States that provide their citizens with access to basic, affordable private health insurance, the Plan's Affordable Choices Initiative will direct Federal funding to assist States in helping their poor and hard-to-insure citizens afford private insurance. By allocating current Federal health care funding more effectively, the Plan accomplishes this goal without creating a new Federal entitlement or new Federal spending.

There's no list of covered benefits, no mandates. However, each family would choose how much and what kind of coverage to buy. The current system of larger tax breaks to employers for more expensive health insurance and smaller breaks for less expensive coverage would disappear. Tax breaks for insurance would no longer be tied exclusively to a given job. Government subsidies would only be necessary for the indigent and those "hard-to-insure."

The plan was proposed by President Bush in his 2007 State of the Union address and is outlined here.

Government mandated healthcare is government-controlled healthcare

According to this article from the Associated Press, Hillary Clinton envisions a day when you will have to show proof of insurance to your employer prior to being hired for a job.

By BETH FOUHY, Associated Press Writer Tue Sep 18, 12:59 PM ET

WASHINGTON - Democrat Hillary Rodham Clinton said Tuesday that a mandate requiring every American to purchase health insurance was the only way to achieve universal health care but she rejected the notion of punitive measures to force individuals into the health care system.
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"At this point, we don't have anything punitive that we have proposed," the presidential candidate said in an interview with The Associated Press. "We're providing incentives and tax credits which we think will be very attractive to the vast majority of Americans."

She said she could envision a day when "you have to show proof to your employer that you're insured as a part of the job interview — like when your kid goes to school and has to show proof of vaccination," but said such details would be worked out through negotiations with Congress.

Coincidentally this month, we read about a man in the UK who is being refused surgery by National Health Service docs because he won't quit smoking - although he did cut back to 10 cigarettes a week. And there's the woman who was required to cover her hair or risk being turned away by an NHS dentist.

Here in the US, beginning in 1996, there was a push to punish Medicare recipients who went to docs who charged more that the Medicare allowable. As it is, docs have to "opt out" officially if they want to do a cash-only practice - cheaper or higher - and are not allowed to charge Medicare, Medicaid, or any Government insurance for at least 24 months. This pretty much locked all Medicare eligible patients into the system - they must see a doc who plays the ICD, CPT game or all procedures, hospitalizations will mean going to another physician who has not opted out.

However, back in 1997 and 1998, there were some opinions given by the Clinton administration that Medicare eligible patients were themselves breaking the law if they chose to go out side the system.

Of course, that was just at the time that the E&M codes and all the Uber-reporting rules came into force due to the Balanced Budget Act of 1997. Here's a page full of stories covering that period.


It was also about the time that the Office of the Inspector General started making armed raids on hospitals and Reno, Shalala, and Freeh held rallies in football stadiums to teach Medicare recipients to turn their docs and hospitals in for fraud and abuse and $1000 reward.

Medicare fees tied to reporting

"Pay for Performance" (P4P, sometimes called "Pay for Play" by some of us who aren't fond of the scheme) just got a huge boost from Congress. Expect to see more docs carrying computers equiped to run an "electronic medical record" (EMR) around the office.

And don't be surprised to see more solo and small group practices withdraw from participation with Medicare and insurance companies, merge with ever-bigger groups or close down completely as the docs find other ways to make a living.

The current lines of EMR cost $50,000 per doc or "provider" to start, and can cost $8000 or so each year for up keep. (I have no idea why, but that's what I hear.) And EMR's will be necessary in order to charge for the work that the doc does in the near future.

Initially, the scheme will measure the doc's ability to report data, more than any health benefits. From today's Wall Street Journal, subscription only:

This is clearest in Medicare, the federal health program that covers more than 40 million elderly and disabled people. Congress agreed to erase a scheduled reduction in payments to physicians, but it made a 1.5% bonus payment available only to physicians who report to Medicare how they perform on certain specified barometers of health-care quality. Initially, the payments will be based on whether the physician reports the data, but the system lays the groundwork for higher payments to better-performing physicians.

Among the information Medicare officials will collect: whether doctors provide aspirin and beta blockers to patients having heart attacks, and whether elderly patients are screened for their risk of falls. These practices are considered indicators of good patient care.