Archive for the ‘Health Care’ Category

Author: Yvette Cowlishaw

America’s movement to mandate health insurance coverage will fundamentally change the way America does business and will extend the reach of the government into American’s lives in an unprecedented manner. Since the introduction of the Interstate Commerce Act in 1887 (Nash et. al., 2011, p 515) the act has been used by the federal government to justify laws and agencies from the FDA to the Patient Protection and Affordable Care Act. Due to America’s long history of maintaining individual rights and leaving the power of the government in the hands of the people the Patient Protection and Affordable Care Act has caused concern amongst many Americans and has led to multiple court actions questioning the constitutionality of the act. Extending the reach of the American government into every American home by demanding the purchase of a product as a condition of citizenship will change the relationship of Americans with the American government.

Historical Background
For the first time in the history of America the American government has utilized the commerce clause (Article 1 Section 8 ) of the constitution to dictate to Americans that they will purchase a product. Section 1501 of the Patient Protection and Affordable Care Act (The Library of Congress) requires that each citizen of the United States is required to “maintain minimum essential coverage” and cites the Supreme Court ruling in United States v. South-Eastern Underwriters Association (322 U.S. 533(1944)) as the basis for insurance falling under the interstate commerce clause of the constitution. The most controversial part of this act is the Personal mandate that requires every American to purchase health insurance.
The Patient Protection and Affordable Care Act moves America far from the Articles of the Confederation that kept the rule of government close to the people (Skousen, 1981). Even as the American Founders moved from the Articles of the Confederation to the American Constitution they intended government to be “of the people and by the people” as President Lincoln stated in the Gettysburg Address and demonstrated by Skousen in The 5000 Year Leap (Skousen, 1981). Since the founding of America government has kept growing and in 2010 the Patient Protection and Affordable Care Act allows the federal government control over the purchasing habits of the American people in an unprecedented manner as discussed below.

Discussion and Evaluation
Supporters of the Patient Protection and Affordable Care Act claim that legislation is needed to keep insurance plans from engaging in unfair underwriting practices (Carman, 2011). Others feel that that many parts of the act, including the mandate and the dismissal of the Conscience Act (Lanham, 2011) oversteps the bounds of constitutional government reach into individual’s lives. While American healthcare needs to be reformed the reform must begin in the behaviors of the American people not in the halls of government.
The individual mandate has been brought to court by over 28 American states. As of November of 2011 the lower court decisions are evenly split and the question of the constitutionality of the mandate will ultimately be decided by the United States Supreme Court. The controversy over the individual mandate of the Patient Protection and Affordable Care Act extends well beyond the healthcare and demonstrates a growing shift in Americans view of their country.
Since 2007 there has been a rise of two groups with some similarities but also great differences. The fiscal conservative movement has become represented under the moniker of The Tea Party while the Occupy movement is representing the view that the top 1% of money holders owes support to the other 99% of Americans. This split in American’s view is not new but the legislation demonstrated in the Patient Protection and Affordable Care Act demonstrates the extent that the progressive (Nash et. al., 2011) movement has been able to influence American legislation.
Ultimately the Patient Protection and Affordable Care Act on its own is not the able to change America but it is the first time that a law has been passed that tells Americans what they must purchase because they are American. If the mandate is allowed to stand it sets the precedent that America’s government can tell Americans what they must purchase and where they must purchase said product. This power in the hands of the government will ensure that business will have to spend more time assessing future government legislative moves than they have in the past.
While legislation and taxation have influenced American business for generations a government that can dictate the features and marketplace for a product is a game changer for American business. In the past business has used various methods to determine the products the American public will buy and the sales channels needed to sell the product. The individual mandate in the Patient Protection and Affordable Care Act dictates the design of acceptable product specifications and creates a government maintained sales channel for the distribution/sale of the product. This precedent will allow the government to become the product designer and seller of any product they desire if it is ruled constitutional.
This governmental reach into the purchasing habits of every American has a twofold effect. It creates a precedent for government to mandate purchases by its citizens and makes the government the ultimate decider of product design undermining free market principles of supply and demand. This precedent has the potential to change both the business and government climate in America by allowing the government to dictate to the American consumer what products they will purchase and from where they will purchase said product. It also has the potential to further the system in which those with more resources are forced to provide for those with fewer resources.
In Overtreated Shannon Brownlee lays out the current American system and how over utilization and lack of coordinated care contributes to the growing cost of American Healthcare and uninsured populations (Brownlee, 2007). The question facing the American people is who is responsible to manage utilization and to coordinate care. The insurance concept of managed care was designed to place the insurance company and a primary care physician in this position but full managed care limited the consumer’s choice of specialists and hospitals and led to a backlash by the consumer (Walker, 2009 & AHIP, 2007). From personal experience I have learned that when the consumer manages care effectively both the care and the willingness of insurance to cover costs are raised. However, the complexities of the healthcare system and the lack of expertise of the American consumer has led to a lack of personal accountability of the American consumer (Brownlee, 2007).
While the American healthcare system needs improved the Patient Protection and Affordable Care Act is not the solution to the problem. The act does not address the actual problems of the system (JAMA, 2011, AHIP, 2011, Overtreated, 2007) and allowing the government to mandate the purchasing actions of individuals is too high a cost for America to pay to resolve the issue.

As stated in Overtreated (Brownlee, 2007) the actual issues of American healthcare are not inherent to health insurance but disconnects within the healthcare system itself. There is a multiple level approach that needs to be taken to address the healthcare breakdown in America.
First and foremost American healthcare consumers need to become empowered to be their own advocates and healthcare coordinators. This can be accomplished by the consumer’s willingness to participate in their own healthcare and in healthcare providers being willing and trained to treat consumers as partners. In addition both patients and healthcare providers (doctors, hospitals, specialists, pharmaceutical providers, etc.) need to become partners with the insurance agencies and vice versa.
The patients and providers need to view the costs spent on healthcare in the same manner they would view the same services if they were paying cash for the service. This awareness of cost would help keep doctors from over utilizing tests and specialists when they know full well that the likelihood of the test providing for the care of the patient is minimal.
In addition doctors need to maintain a relationship with the patient and all specialists the patient is referred to in order to assure no over utilization of the system or overmedication of the patient. In the current system doctors do not have the time or incentive to practice this level of patient management. Due to the existing payment structure of Medicare, Medicaid, and private insurance the doctor must move patients through the exam room every 15 minutes for a general visit and 30 minutes for a chronic condition visit. This economic need for quantity over quality motivates doctors and doctor administrative offices to encourage fast “diagnoses” or to move the patient off to a specialist.
Additionally the legal system needs reformed to discourage lawsuits against healthcare professionals where there is no intentional negligence or neglect on the part of the provider. Currently providers will over utilize services in an effort to assure they have left out no test in case someone sues them in the future. This is not based on the need of the patient but on the need of the doctor’s malpractice insurance company.
For the American healthcare system to not be a drain on American purse strings and for all Americans to be insured all parties involved in healthcare will have to change their habits and the consumer will have to take ultimate responsibility for their actions. More legislation will not resolve the American healthcare crisis but will continue to add to the reluctance of doctors to only recommend and utilize needed services. The American consumer has to be on the front line of the reform issue by changing their view of healthcare and utilization practices and demanding their healthcare providers coordinate care appropriately. It is also important for the consumer to seek out doctors that will participate in a doctor patient partnership.
While this sounds overwhelming and impossible to many people my husband and I are proof that a disabled person with a chronic condition can receive adequate care and help the insurance companies control costs when the patient and the patient’s family are willing to put a reasonable amount of time and effort into managing their own care and understanding their health insurance plan. 



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This week the DOJ (Dept of Justice) has come out and stated the health-care mandate (the one that states everyone must have insurance) is a tax. This appears to be their stance because that is the only way to apply any constitutionality to the mandate. Interestingly enough the President is stating it is not a tax in a recent New York Times article.

“For us to say that you’ve got to take a responsibility to get health insurance is absolutely not a tax increase,” the president said last September, in a spirited exchange with George Stephanopoulos on the ABC News program “This Week.”

The presidents response feeds into all the legislation being presented by this administration. They feel it is their right to mandate behavior and the long lived American right to make our own decisions is offensive to this progressive movement.

This same mentality is evident in the Cap and Trade legislation, the recently passed fiscal reform bill as well as the many spending bills that have hit congress in this administration and even the Bush administration.

writes a great article on the widening class system developing in America.

Never has there been so little diversity within America’s upper crust. Always, in America as elsewhere, some people have been wealthier and more powerful than others. But until our own time America’s upper crust was a mixture of people who had gained prominence in a variety of ways, who drew their money and status from different sources and were not predictably of one mind on any given matter. The Boston Brahmins, the New York financiers, the land barons of California, Texas, and Florida, the industrialists of Pittsburgh, the Southern aristocracy, and the hardscrabble politicians who made it big in Chicago or Memphis had little contact with one another. Few had much contact with government, and “bureaucrat” was a dirty word for all. So was “social engineering.” Nor had the schools and universities that formed yesterday’s upper crust imposed a single orthodoxy about the origins of man, about American history, and about how America should be governed. All that has changed.

While the American people truly embrace diversity those in power do their best to keep us fighting amongst each other so that they can solidify their kingship.

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Judge Andrew Napolitano calls on Americans to stand for freedom

“Ask your member of congress…where in the constitution is it authorized for the federal government to regulate health care? They will not be able to answer that question.”

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CNN money provides a cost breakdown from a practicing doctor:

….He spends about $60,000 a month on “fixed costs” to run his practice. “That’s more or less my breakeven point,” he said. “If I spend more, I’m in the red for the month.” Business costs include rent, payroll, utilities, medical and office supplies. Because he maintains electronic health records for his patients, Schreiber also pays for equipment maintenance and other management services associated with patient billing.

Fixed costs for a private practice also include malpractice insurance. He pays about $7,000 a year for himself and $2,000 each for his two nurse practitioners. Schreiber admits that his cost for malpractice insurance is relatively low, compared to specialists such as ob/gyns, who pay upward of $100,000 a year. (Rx for money woes: Doctors quit medicine) Finally, his fixed costs include benefits to cover his employees, including himself. Those costs go against the $800,000 or so in revenue, which includes about $100,000 in income, he said his practice collects in a given year….

This story also gives insight into the reason many doctors are in a hurry to diagnose and get on to the next patient.

Overall, Medicare pays between 63% and 72% of the costs for one of Schreiber’s patients — although the Center for Medicare and Medicaid Services applies different payment rates in different states. According to Schreiber, four billing codes make up the “bread and butter” of claims submitted to Medicare.

The first code represents a simple visit, which might include blood pressure and cholesterol checks. Schreiber gets about $44 from Medicare for the $70 fee he charges. The second and third codes correspond to a sick visit, when he spends 15 to 20 minutes evaluating a patient for symptoms such as coughing or shortness of breath. Schreiber charges $92 for a sick visit, of which Medicare pays about $58. The last billing code is a complex visit. “This is where a patient comes in with many problems like heart disease, hypertension, diabetes,” he said. Such a visit requires about 30 minutes of his time. Schreiber charges $120 for these visits, and Medicare pays $88 of that…..FULL STORY HERE

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I have spent the majority of my life immersed in American health care. I have worked on the profit and non-profit sides of the industry and have many friends working in hospitals etc. To top it off I also have a husband with a chronic and rare condition so I have experienced being the user of many specialties.

I have experienced health care with insurance and with out insurance, with major medical issues and with few/no medical issues, I have also experienced government health care (Medicaid/Medicare & VA).

In my experience there are a few clear cut cost drivers:

Over utilization – or in real words words, too many tests  – Your general practitioner just sent you for a MRI last week but the specialist orders another one. This generally occurs because the specialists does not know you had one last week, they want to use their own radiology department, or they are concerned they will be sued if they don’t order the test themselves. Not only is this expensive, but it can cause additional harm to the patient by over-exposure to radiation

“The latest and greatest equipment” – The doctor or hospital has to have the newest MRI even though they can send you down the street to have the same test with the same equipment. Too often “owning” equipment is a competition or marketing ploy. After all how many hospitals advertise their state of the art equipment. It sounds nice until you are in the hospital for a blood draw and it costs twice as much as the hospital down the road because someone has to pay for the multi-million dollar equipment that is only needed for 1% of the population.

Government regulations/paperwork – Astonishingly you don’t have time to read ERISA, HIPAA or other legislation, but you keep being notified of your rights and how your claim will be denied due to a provider not giving the proper information to the insurance company. Your insurance company just spent 40% of your premium on producing paperwork for the government.

Lack of consumer education – You don’t know you can ask for copies of your scans and take them with you from doctor to doctor. Hospitals and doctors don’t list their prices for services on their website and no one told you to price shop for medical services. Do you know what is in your medical record? Do you have a copy? Do you have a copy or your x-rays/scans?

Over prescribing/brand name drugs – You saw it on TV and you have to have that brand even though there is a comparable and cheaper option. You see a general practitioner and various specialists and none of these doctors are sharing medical records. The doctors are prescribing incompatible or similar medicines for different conditions.

Medical record systems – You see various doctors and they all have separate files and don’t share with each other thus creating duplications and extra work. Note: Many specialists send reports to the referring doctor but if you were not referred they don’t know to send a report. Specialists will often send a report to another physician if you request it.

And let’s not forget improper utilization — because of EMTALA, hospitals cannot turn anyone away from the Emergency Dept, and so uninsureds often go to the ER for non-emergent care, such as fevers or check-up of chronic conditions. An ER visit is always more expensive than a visit to a primary care provider, but the hospital and the doctors don’t get paid so they have to make up for it by increasing prices elsewhere.

Over the years We have partnered with our doctor to keep some of these costs under control.

Many other cost drivers and other health care information can be found at Campaign for an American Solution

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I for one was thrilled to hear Paul Ryan dissect the actual costs of ObamaCare during the “Health Care Summit”. After all everyone is always throwing around numbers but do any of us ever know if the numbers represent reality? After all ‘junk in = junk out’.

The Wall Street Journal details the true costs.

‘Every argument has been made. Everything that there is to say about health care has been said, and just about everybody has said it,” President Obama declared yesterday as he urged Democrats to steamroll his plan through Congress. What hasn’t been heard, however, is even a shred of White House honesty about the true costs of ObamaCare, or its fiscal consequences….

Nearby, we reprint Wisconsin Republican Paul Ryan’s remarks at the health summit last week, which methodically dismantle the falsehoods—there is no other way of putting it—that Mr. Obama has used to sell “reform” and repeated again yesterday. No one in the political class has even tried to refute Mr. Ryan’s arguments, though he made them directly to the President and his allies, no doubt because they are irrefutable. If Democrats are willing to ignore overwhelming public opposition to ObamaCare and pass it anyway, then what’s a trifling dispute over a couple of trillion dollars?….

Mr. Obama’s fiscal assertions are possible only because of the fraudulent accounting and budget gimmicks that Democrats spent months calibrating….

The real cost over a decade is about $2.3 trillion on paper, Mr. Ryan estimates, and even that is a lowball estimate considering how many people will flood to “free” health care and how many businesses will be induced to drop coverage. Mr. Obama claimed yesterday that the plan will cost “about $100 billion per year,” but in fact the costs ramp up each year the program exists. The far more likely deficits are $460 billion over the first 10 years, and $1.4 trillion over the next 10….

Yesterday Mr. Obama again invoked the “nonpartisan, independent” authority of CBO, which misses the reality that if you feed the agency phony premises, you are going to get phony results at the other end….FULL STORY HERE

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Copied from Sean’s Medical Blog

My name is Sean Cowlishaw and I have a rare condition (fibrous dysplasia of the skull). In short my skull has never quit growing and bone is surrounding my optic nerves, has filled my sinus cavities, and is putting pressure on my brain. My condition is extremely rare in that the bone growth did not end in puberty and the bone continues to grow to this day (I am in my thirties).

About three years ago I finally found a doctor that not only helped me find answers but that works closely with me and my family to assure us a high quality of life. I have also been blessed in that I have had good insurance (for the past five years) and a wife that understands the health care system. My wife and I have worked closely with our doctor to keep costs down for both us and the insurance company and to maintain a high quality of care (see my blog entry about cost containment).

As the Health Care Reform debate heated up in 2009 my quality of life was significantly lowered. The first blow was that my costs for specialists were raised due to the media and Congressional blitz about high quality insurance plans. At first this was not a huge issue for me as I have seen ever specialist possible and there is nothing they can do for my condition. The specialists had sent me back to my general practitioner for pain management and for almost a year my quality of life was the best it had been for a long time. I had one doctor managing my care and he took all aspects of my quality of life into consideration as well as doctoring my full person not just my fibrous dysplasia.

In February of 2010 the second and worst blow fell. I was called into my general practitioner’s office and told he was no longer allowed to practice pain management. The clinic management has determined that because of the DEA practices of treating pain management doctors as drug dealers it was too big of a risk for their doctors to prescribe pain medicines. The clinic was only able to give us the names of two practices that are still willing to prescribe pain meds. One option will cost us and our insurance three time as much as our general practitioner. The other option costs over $1000 more a visit and is not covered by insurance. We have our first visit with the new doctor on Tuesday and will update this blog continuously.

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Earlier this year (2009) the Commonwealth Fund Commission issued multiple reports asserting a government-run health care plan could cut insurance premiums approximately 20%. It asserts that private insurance spends 40% of claims costs on administrative expenses. The Sherlock Company was commissioned to do a study of private insurance costs in 2009 (the study most frequently quoted in the debate today dates from 1988).

The full report can be found at http://tinyurl.com/kjo9hq

Top health insurance lobbyist fires back at the White House

I. Executive Summary
Health plan administrative expenses often are cited as consuming a significant share of health insurance premiums. Proponents of a public health insurance plan often state that Medicare is more efficient than private insurance companies. However, these statements are based on outdated data and misconceptions about private administrative expenses, especially in the small group and individual markets.

Recent reports claim that health plan administrative expenses in the individual and small employer markets can exceed 30%. However, these estimates are based on data from Hay-Huggins that is more than 20 years old (1988) — a time when most claims were paper-based and many electronic processes were in their infancy — and based on estimated, rather than actual, administrative costs for companies that no longer provide health insurance.
An independent analysis by Sherlock Company of health plan administrative costs finds that prior estimates do not reflect the actual administrative costs for Blue Cross and Blue Shield Plans and other major health plans. Based on our review of actual health plan administrative expenses, we find that:

• Private health plan administrative expenses are grossly overstated in previous reports.
Based on combined data from 36 health plans participating in our performance benchmarking studies in 2008 (2007 data) and other data, administrative expenses for all commercial products represented 9.18% of premiums. Administrative costs are 11.12% of premiums for the small group market and 16.35% of the individual market, amounts that are nearly one-half and in some cases nearly one-third of other estimates.

• Traditional Medicare performs only a fraction of the administrative functions of private health plans because it retains its original fee-for-service design and is, therefore, not comparable.
Private plans use their administrative costs to promote care coordination and wellness, reduce unnecessary utilization and aggressively combat fraud and abuse. No precise, generally accepted measure of Medicare administrative expenses exists that is comparable to private plans. Moreover, Medicare does not need to market its coverage, develop provider networks, negotiate provider rates or maintain capital. If the government were to create a public health option to compete with private plans in a health insurance exchange, it would have to take on many additional functions that are not part of Medicare’s administrative costs today, resulting in increased administrative costs.

• Private plans perform those administrative functions that Medicare performs at lower costs.
In comparing only those administrative functions that Medicare performs, private administrative costs are actually lower — $12.51 per member per month, compared to a $13.19 per member per month in traditional Medicare. Many of Medicare’s administrative functions are, in fact, performed by private administrative contractors.

• Comparing administrative expenses between Medicare beneficiaries and people under age 65 should consider the unique health care needs of seniors.
Medicare beneficiaries have higher costs per claim compared to private plan enrollees. This means that the service requirements are less per dollar of health benefit, and administrative expenses are less for Medicare simply by virtue of the higher cost per claim.

• Comparing administrative costs as a percentage of claims overstates the difference
between plans for small groups or individuals and large groups.
Instead of calculating administrative expenses as a percentage of premiums, which is the most conventional metric used for comparing administrative costs, Hay-Huggins and subsequent reports have expressed the values as a percentage of claims, which is very misleading. Because health insurance premiums pay for both health claim costs and administrative expenses, the Hay-Huggins approach, repeated by Lewin, of dividing administrative expenses by claims costs unrealistically magnifies the differences between administrative expense ratios.

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Rep. Paul Ryan

He started off good but now in 2014 not so great

 Paul Ryan on Glenn Beck about Progressivism 

Paul’s roadmap for America

Great summary of Rep. Ryan’s career & health care work.

“To be clear: it is not sufficient for those of us in the opposition to await a reversal of political fortune months or years from now before we advance action on health care reform. Costs will continue their ascent as the debt burden squeezes life out of our economy. We are unapologetic advocates for the repeal of this costly misstep. But Republicans must also make the case for a reform agenda to take its place, and get to work on that effort now.”…FULL OP-ED HERE

Today (March 15, 2010) Rep. Ryan did a wonderful job of defending the true will of the majority of the American People.


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