Kids, You Won't Have to Worry About Mom and Me ...unless

. . . . "They" (insert suitable descriptive political party,  faction or candidate name) repeal The Affordable Care Act and -

*We are old, sick and unable to take care of ourselves (eating, toileting, grooming, dressing, bathing and transferring) and the State decides to send us (or one of us) to a miserable nursing home  bed in another county instead of providing us (or one of us)  with inexpensive home and community based attendant services and support to rehabilitate us and get us (or one of us) going again.

* The State says that I have no right to be independent.

* One of us gets very sick and "They" have done away with our protection, as recipients of home and community services, of protection against spousal impoverishment.

*"They decide that, in spite of the Olmstead Supreme Court Caser ruling, neither Mom nor I have a right to choose long term services in the community, rather than in an institutional setting.

*"They" wipe out the "Elder Justice Act" which protects Mom and me against physical or psychological harm,elder abuse, neglect and exploitation, improves Long Term Care facilities and gives you the information to know - as our kids - whether those taking care of us are trained, doing their jobs competently and honestly, or are crooks stealing our property and your meager inheritances.

So don't worry - unless . . . .

You, Your Family, the US Preventive Task Force Recommendations and Health Reform (ACA)

If you have time on your hands and have chosen to study the Patient Protection and Affordable Care Act,  you have seen many references to the US Preventive Task Force Recommendations.  The ACA references Grade A and B recommendations and tells you that you will qualify, often without charge at all, to receive care specified in those A and B recommendations and implies that that your physicians and insurers had better be familiar with those recommendations because they are binding on them.

I have been around long enough to know that some patients are more knowledgeable about health issues on the internet than their physicians and other providers, so here is the link to the task force preventive services recommendations with my personal recommendation (I am your blogger, not your doctor) that you read through them and - when you have questions about how the recommendations apply to you, your spouse or partner, your kids or parents or grandchildren,  you ask your doc (or other provider or even insurer) those questions.  You may get some blank stares. You may even face some obvious discomfort or annoyance.  But do it anyway, if for no other reason, than your doctor (or other provider) needs to know about them and needs to know that you and other patients and their families know about them. That's how we change behavior and impose new and BETTER societal standards of medical care.  So let's do it.

Response To Comments About Health Care Costs

The Congressional Budget Office projected a $196 billion dollar savings over 10 years. Almost $13 billion from hospitals, about $14 billion from SNFs, about $22 billion from  Medicare Part B cuts (durable medical equipment, labs, ASC, Dialysis and other services),  and almost $40 billion from home health. Medicare Part D premiums will rise as much as 9% over 10 years, primarily as a result of donut hole closure steps.

Here are some links to interesting reading about the economics of US health care costs. I don't pretend that I have personally read every one:
http://www.gao.gov/htext/d04793sp.htmlhttp://www.gao.gov/docsearch/featured/healthcare_spending.html
http://www.gao.gov/docsearch/app_processform.php

If the Republicans Repeal Health Reform -- Then What?

As I have reported, and one of my sons mentioned to me in this morning's phone call, I have plowed my way through  906 single-spaced pages of the Patient Protection and Affordable Care Act ("ACA") which President Obama signed last March. I have read numerous blogs (including those of the Director of the Congressional Budget Office which, being written for Congress people and their staffs, are written clearly) some of which demonstrate complete unfamiliarity with the actual text and meaning of the ACA. I am convinced that many public statements about the ACA reflect uninformed for personal-profit political positions more than hard time-consuming actual work to understand and think about the act.

A disclaimer - I have my biases.  As a physician specialist, I took care of very sick people, never turned anyone away because of  insurance status or lack of it, and have no respect for those that do. I have a large family which has seen more than "its share" of sickness and disease and death and my family has been significantly impacted by our severe recession. I have been the Chief of Staff of a large mid-city hospital, now closed and abandoned, and have seen what economists call "dislocation" and the rest of us call bankruptcy in health care. I have seen excellence and incompetency in health care and the systems which deliver it. I was a member of Stanford University's clinical faculty, providing one morning a week of unpaid time for thirteen years, taking care of veterans with blood diseases at the Palo Alto VA hospital and teaching medical students, residents and hematology fellows. As a member of a powerful well-financed state hospital industry board, I have seen political and economic jousting within and outside the hospital industry. When I practiced health law, among others, I represented a large medical group and was heavily involved in the analysis and negotiating of managed care contracts as well as contracts among physicians and their practice entities.

Bottom line - if health reform is repealed we will be worse off.  The good outweighs the rest.

The ACA will provide access to insurance for Americans who have lost employment and their families' health insurance and don't have enough money to buy Cobra extended coverage.  The ACA outlaws insurance company abuses and will provide health insurance and care to our kids and grandchildren. The ACA will provide incentives to employers to sign their workers up for insurance, insurance which cannot be rescinded or be subjected to unreasonable annual coverage limits or lifetime limits. The ACA will expand Medicare coverage for Part D beneficiaries although there will be a modest increase in premiums over the next ten years and it will even help seniors to stay out of nursing homes, or if in nursing homes, have better quality of care (Also see the Elder Justice Act within the ACA at pages 664 and following) The ACA will improve access to care in rural and underserved areas and the care of the poor. It will train doctors, nurses and others in the health professions without burying them and their families in debt. It incorporates an "Elder Justice Act" which may safeguard seniors against some of the terrible things that I saw happen to my older patients. It has strengthened protections against fraud and abuse. And, it encourages advances in medical inventions, products and care which moves us into a new generation of health services.

The projections are that it will save about $14 billion dollars each year for the next 10 years and thus control the rise of premiums and out-of-pocket expenses that each of us experiences each year. And interestingly, it will make it possible - through support of America's families and children - to grow our workforce so that in coming  there will be young working people able to fill the jobs that America offers and  help America's businesses.

My study indicates that health reform is good for families, good for working-people and those who would work if they could find work, good for America's supply of doctors, nurses and health care workers, good long term for large and small business and less costly than the alternative - no health care reform.

Doctors Groups Fail Because They Don't Understand Risk

The October 7, 2010 New England Journal of Medicine has two interesting articles, one by Harold S. Luft, Ph.D.  titled "Becoming Accountable - Opportunities and Obstacles for ACOs" and the other "The Effects of the Affordable Care Act on Workers' Heath Insurance Coverage" by Christine Eibner, Ph.D. and others. Like the Affordable Care Act, neither of the articles discusses an issue which my experience tells me has played a major role in the failure of a number of physicians' practices to survive managed care and other forms of contracted health care relationships.

Insurance companies understand risk: they hire skilled actuaries to analyze underwriting risk and to tell them about it and how to shuffle it off to others.  The Federal Government understands risk, and as one plows through the 900+ pages of the Affordable Care Act, there are many references to the requirement that highly sophisticated actuarial studies be done to guide future policies and actions  But individual doctors don't have the financial means to hire actuaries (or attorneys)  to tell them about the risks that they blithely assume, and even if they did, their fracturing into relatively small business entities makes the per-doctor cost of securing actuarial advice prohibitive.  And then there are antitrust issues when groups of physicians combine resources to strengthen their ability to negotiate with employers, government and insurers.  So insurers, government and business shift risk to physicians who bite off more than they can chew - and choke.

The current proposals for health reform is not going to solve that problem. As physicians learn that the emphasis on "efficiency" and driving down the cost of services leaves their bank accounts empty, I expect them to resort to their experience-tested means of generating income: see more patients, do more procedures, order more tests and ramp up the billing. In this era of "evidence-based care," ironically it is the physicians who lack evidence about the business risks they are asked to undertake by insurers, government and businesses.

Acountable care organizations will not survive in that environment.

The Prism of Ethics: Quiet Plans to Change MEDIGAP Insurance

I remember Dan Rostenkowski's expressions of disbelief, when he joined our meeting of the executive committee of the National Health Lawyers Association in Chicago about 20 years ago.  A couple of days earlier, he had been physically attacked with canes and umbrellas by little old men and women whom had represented in Congress for years.  Their concern that legislation he supported would raise their costs of prescription drugs made them furious. Twenty+ years later, other Chicago based political figures have chosen not to learn from Rostenkowski's experiences

The following vaguely-written section of the Affordable Care Act buried at page 342,  seems to predict significant MediGap change (you will have to refer to your own MediGap insurance brochures to determine how it might affect you). I have underlined the words which I consider most problematic.The approach appears to be double-barreled: (1) reduce Medicare beneficiaries access by raising the cost of plans which might give their purchasers more extensive (or appropriate for their needs?) physician Part B services and (2)  directly or indirectly create barriers to physicians' services to reduce high users (i.e., the sick elderly) access. Since my experience is that older Americans choose their MediGap insurance very carefully and pay the increasing premiums out of hard-earned dwindling financial reserves, I am concerned about the implications of this section for seniors.

SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS.
(a) IN GENERAL.—Section 1882 of the Social Security Act (42 U.S.C. 1395ss) is amended by adding at the end the following new subsection:
‘‘(y) DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDICARE SUPPLEMENTAL POLICIES.—
‘‘(1) IN GENERAL.—The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part B. Such revisions shall be based on evidence published in peer-reviewed journals or current examples used by integrated delivery systems and made consistent with the rules applicable under subsection (p)(1)(E) with the reference to the ‘1991 NAIC Model Regulation’ deemed a reference to the NAIC Model Regulation as published in the Federal Register on December 4, 1998,
and as subsequently updated by the National Association of Insurance Commissioners to reflect previous changes in law and the reference to ‘date of enactment of this subsection’ deemed a reference to the date of enactment of the Patient Protection and Affordable Care Act. To the extent practicable, such revision shall provide for the implementation of revised standards for benefit packages as of January 1, 2015.
‘‘(2) BENEFIT PACKAGES DESCRIBED.—The benefit packages described in this paragraph are benefit packages classified as ‘C’ and ‘F’.’’.
(b) CONFORMING AMENDMENT.—Section 1882(o)(1) of the Social Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ‘‘, and (w)’’ and inserting ‘‘(w), and (y)’’.

The Prism of Ethics: Was This Change to Medicare Part of the Plan?

In preparation for a talk about Health Care Reform that I am scheduled to give to the West Valley Bar
Association, later this month, I have been going through the Patient Protection and Affordable CareAct [the "ACA"] page by page, line by line and word by word.

At page 271 of the AFA, PART III is entitled "Encouraging Development of New Patient Care Models" which seems benign enough. But as I moved along to page 277, I came upon Section 3022 "MEDICARE SHARED SAVINGS PROGRAM" which describes "Accountable Care Organizations" (ACOs), groups of providersd who may "work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization." Sounds benign enough.  But then I read on.

At page 279 there was this language:  "(c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE BENEFICIARIES TO ACOs.-The Secretary shall determine an appropriate method to assign Medicare fee-for-service beneficiaries to an ACO based on their utilization of primary care services provided under this title by an ACO professional described in subsection (h)(1)(A). (Underlining supplied)  Just a moment - I thought that under fee-for-service Medicare, patients chose their own doctors, but this section appears to take away that choice in the interest of a Medicare Savings Program study.  And then, I found this section at page 280:

"(g") LIMITATIONS ON REVIEW.-There shall be no administrative or judicial review under section 1869, section 1878 or otherwise of -
"(1) the specification of criteria under subsection (a)(1)(B);
"(2) the assessment of the quality of care furnished by an ACO and the establishment of performance standards under subsection (b)(3);
"(3) the assignment of Medicare fee-for-service beneficiaries to an ACO under subsection (c) (underlined supplied) . . . . .

So, some Medicare fee-for-service beneficiaries may be plucked out of their chosen physicians' offices and reassigned to an "ACO" with no right of appeal?  Is my reading correct?

Gee, did President Obama, or the people pushing this "reform" bill through Congress mention that to the people potentially affected?