Think Of It This Way ....

When I arrived at the lab, in this large new clinic building decorated with spectacular art work, it was 6:35 AM. Many of the chairs were filled and those that were empty were soon occupied by people waiting to be called for their tests.  Six or seven people lined-up at the intermittently-staffed lab reception desk.

You might not recognize this as cost-shifting, but in my opinion, it is.  Clinic management has decided that it is more efficient, in terms of their needs, to keep 18 people waiting for more than a half-hour each, rather than bring in phlebotomists to draw blood and instruct patients on how tests are to be performed.  Those patients, waiting for their blood to be drawn and specimens to be taken, were not at work, were not earning wages, and had just used expensive cars and expensive gasoline so that they could sit and wait and wait and wait.

When government and insurance companies calculate the costs of care, rarely are patient transportation costs and lost opportunity costs (not being at work earning a living) added to the equation. Those dollars come out of the patients' pockets, not the government or insurers pockets.  The cost has been shifted and no-one seems to notice or care.

So think of this as a cost shift and as an uncounted tax that each of us pays.

It Wasn't The Government Saying Goodbye Too Soon

I recall one of our Thursday lunches, to which the physician organizer invited representatives of a local hospice to talk about hospices and specifically about their hospice's services to patients and their families. It was an informative interesting talk, enlivened by a lot of questions from doctors. But the really interesting conversation came after the hospice people left.

Several cancer specialists angrily complained about a local hospital. These physicians found that immediately upon a patient's diagnosis of cancer, someone in the hospital (perhaps social services?) arranged for a prompt hospice consult before a cancer specialist could review the case with the patient, his or her family, the patient's primary physician, pathologists, radiologists, and other experts. Patients and their families were having "the crepe" hung for them, with the gloomiest possible prognosis. The cancer specialists said that patients were being whisked out of the hospital, consigned to hospice care, when they could have been treated palliatively (even during hospice care), to relieve pain and suffering and perhaps to prolong life, or could have explored the possibility of an effort at curative treatment.

Now, this wasn't the government convening a "let's shorten your life" committee. The physicians felt this was an apparent hospital policy.

Before we again shake our fingers at Senators and Representatives, and accuse our government of rushing people off to die to save money, let's think about other actors: insurers, hospitals and institutions which - if there are no ethical safeguards - could be advantaged by hastening the process of dying.

Senate's HELP Bill Helpful?

A week ago, I posted a link to the Senate's Health, Education, Labor and Pensions Committee's "Affordable Health Choices Act" narrative with my statement that I would comment on it after a chance to review the long document. Today, President Obama noted that the Senate Finance Committee has not yet issued its proposal (which will probably deal with Medicare and Medicaid spending or savings), which is no small matter, because the two bills will have to be combined before the Senate votes on the penultimate bill (the conference committee opus will presumably be the ultimate bill). So, what you read in the Affordable Health Choices Act is not predictive of the substance of the Senate bill. But it's worth comment anyway.

The bill promises insurance market reforms. Since, under pressure from national employers and insurers, a game that the states and insurance industry has played has been insurer incorporation and policy-writing in states with employer-favorable insurance laws. However, some states have larded insurance laws with requirements for specific services demanded by provider, and sometimes patient, pressure groups. I wonder whether there will be federal licensing/certification of all health insurers in the United States which intend to write insurance under health reform legislation, and whether the federal government will usurp (a fighting word for "preempt" in this case) state health care insurance regulatory authorities. If so, there will be significant fight-back from the entrenched insurance regulatory interests, and their political and financial buddies, in all 50 states (except, perhaps, California which is so dysfunctional it might not even notice).

The bill seeks to assume that health insurers engage, with the federal government, employers and the public, in "the collaborative articulation of shared purposes" (a Harvard Law School phrase favored by the late professor Lon Fuller). Again, with my Brooklyn upbringing, I go back to the concept that where there's a lot of money to be divided up, expect the insurers to find techniques and devices to maximize their revenues and reduce their exposures to risks. In the 39 years that I have focused on health insurance, HMOs and other means of financing health care, I have never known an insurer to be particularly interested in anything other than its self-interest. I see no reason to believe that President Obama can change this perspective, reduce health insurers' greed, self-serving behavior and indifference to the suffering caused by their business plans, and control the inflationary pressure on health care costs that they generate.

Subtitle B, "Available Coverage for All Americans" will shunt many "health care" dollars into States' Affordable Health Benefit Gateways. Dollars that should be used to purchase health care will be sucked into bureaucratic byways, never to be seen again or accounted-for though government bean-counters will create expensive paper trail requirements. Instead of insurers getting their 25% overhead, the bureaucracy will share a chunk of that revenue. Where's the efficiency that President Obama promised?

Subtitle C, "Affordable Coverage for All Americans" promises subsidies in the form of a yet-to-be-defined "credit" system. There is a geographic adjustment provision, which if past experience is any guide, will favor southeast states (which will salve their Congresspeople's political wounds and give them something to point to in the next election).

Subtitle D speaks of "Shared Responsibility for Health Care" but only deals with shared responsibility for paying for someone else's alcoholism, smoking, drug use, lack of exercise, dangerous driving practices, poor eating habits, and understated but very real toxic industrial exposures.

Subtitle H deals with "Community Living Assistance Services and Supports." While this may be a laudable goal, should it come from the national health budget? Is it truly health care?

I have only dealt with subtitles of Title I. There's lots more, and I suggest that my readers look at this material critically. What is proposed is a mouse built by a committee. What we will get is an voracious uncontrollable elephant which will leave no grass standing in the health care arena.

Insurer's Religious Principle: It Is Better To Receive Than To Give

Kaiser reports that insurers decline to stop their practice of canceling some of their "insured" ill patients' policies. Read the article by clicking the title above. May not be suitable for all ages and may cause the sudden onset of extreme nausea.

Response to "A Troubling Question"

On May 4, 2009, I posted a complex question which asked for my response. I asked for comments from readers but received none. Here are the facts presented:

"Patient: has worked in health care as an R.N. for 27 years; was required, by the employer to join a union for health care benefits; received great health benefits until a decline in health necessitated multiple transplants in the period of one year; maxed out the lifetime benefits allowed; desired to return to work but still owing much in medical expenses related to transplant; told by employer that because unionized no further benefits were allowed, whereas if not unionized benefits could be restored; back working and making a substantial salary once again; still no way to pay off former medical expenses; does not qualify for any "programs" to assist.
Double edged sword here? What is the answer for people like this who have worked, and paid into the system, and desire to keep working but for unforeseen circumstances have encountered medical costs that are way beyond reach?"

The general approach to issues such as this is to question every element of every bill as to accuracy, completeness, veracity, failure to record all payments, failure to pass on discounts to patients. Make no assumption that charges or payments are correct because they often are not.

Because I have retired from law practice, I cannot give specific advice to the questioner. However, I recommend that you contact Peter Liebold, the executive director of the American Health Lawyers Association (202-833-1100), and ask for the names of several attorneys in your area who are experts in health care law dealing with the issues you described. In addition, you can contact your local bar association, your state bar association or even the American Bar Association to learn the names of attorneys who may help you. You might find a competent health care attorney who would be willing to provide pro bono" services, though that is not very likely.

My own experience, when I sat on committees reviewing charges by hospitals and their business associates, physicians and other providers was that there were often major discrepancies between services and products actually rendered and listed, and what should have been charged and what was charged. And on the other side, there were discrepancies in insurance company payments. Some insurance payers got special discounts which were not always passed on to patients and their families, whose bills were improperly inflated as a result. So it might be worth your while to request that your union to which you have paid dues for years - at its expense - obtain an expert audit of all charges and payments in your complex situation. If the union won't do it, you may find free legal assistance organizations in your area who might advice you on obtaining an audit at no cost to you. Sometimes, a non-profit charitable association dealing with particular diseases may have resources, and you may wish to contact the organ transplant association dealing with your problem to ask their assistance in obtaining an audit.

There are laws which protect insurers and employers from the consequences of decisions which may be disadvantageous (or sometimes injurious) to employee patients and their families. But some of these employer/insurer protection laws may not apply to your situation, as a competent health law attorney can determine for you.

You and your attorney may be able to negotiate a fee reduction based upon your financial hardship if you were dealing with a non-profit transplant center, hospital, and providers. After all, such institutions obtain tax benefits for their charitable services and the Internal Revenue Service might be interested in your experience with an institution which did not fulfill its charitable obligations and played hard-ball with you.

The Workhorse Group - A Club For Market Allocators?

While there's lots of captivating bad news, television networks are highlighting Friday the 13th-style horror movies' commercials, and the messages from stock brokers and advisory services are rightfully producing panic among those impacted, a series of different recent events has me worried.

On February 20, 2009, the New York Times described "behind closed doors" talks involving major health care players, lobbyists, unions, national organizations, financial interests, and staff of Senator Ted Kennedy. From the NY Times information, it seems that requiring all individuals to purchase health insurance is a major issue of discussion and various options for funding are on the table including individual responsibility, employer contributions, and public programs.

My concern is that under cover of cooperation with Senator Kennedy, and possibly free from the scrutiny of anti-trust enforcers, monied interests are dividing up the health care marketplace and lining up to offer political endorsement (and, presumably dollars), to those who support their positions.

Mr. Kennedy - open the doors now. An industry approaching $3 trillion, requires fresh air and sunlight, not the clubby atmosphere of restricted membership, drawn curtains, winks and nods.

Cost Shifting: From Airlines to Health Care

The concept of cost-shifting is easy to understand: once upon a time, when you flew from New York to San Francisco, your fare included an edible meal. Then the fare went up. That was not cost-shifting. But when the airline took away the meal and made you buy it yourself or go hungry, the airline cost-shifted dollars you paid for your meal to its bottom line.

In health care, it's a bit more difficult to understand. If you incur a hospital bill and your payer has to pay more for the same services than another payer, part of the costs of hospitalization have been shifted to your insurer (and probably to you if you have a copayment requirement). If the government doesn't pay the full beneficiary bill, based on fancy higher-mathematical calculations (read - "guesses") to justify paying a lower amount, the government has shifted costs to your insurer and to you. If your HMO says that you have to leave the hospital on the second day after hospitalization, when you still are pretty sick and can't take care of yourself, and your family has to stay home from work to take care of you, the HMO has shifted costs from itself to you and your family and perhaps your employers. And if the uninsured in the emergency room can't pay their bills, you and your insurer and the government will have to subsidize their care. Neat, huh?

Now, let's take it a step further. If you work for a small employer and have several co-workers who have incurred high health care costs, the premium for health insurance at renewal time may go up disproportionately, making your employer look somewhere else for coverage. Not only has the initial insurer rid itself of what it considers an adverse actuarial risk, but if another insurer takes on your company, the first insurer may have moved an adverse risk to a competitor. A number of years ago, when an aggressive national HMO took on bartenders (and, if my memory is correct, grave-diggers) in one city, its competitors were joyful: they knew their insurance experience with those occupational groups was awful and were glad to get rid of them to the new competitor in town. Incidentally, the HMO eventually went into bankruptcy. Apply the same way of thinking to the decisions of hospitals to move from high-cost low-reimbursement areas (center city) to low-cost higher reimbursement areas.

So, in health care, cost shifting is a way to increase profits, move costs to someone else's pocket, disadvantage your competitor and game the system. Cost-shifting is a monetary concept, not a quality-related one.

Health Care - Who Works Where?

Health care-related articles appeared in the New York Times on March 2 and March 3, 2008. The Times focused on the Presidential candidates' positions (for a useful summary of these positions see: Kaiser's "health08.org" ) and looked at the causes of high cost health care and the tools available for cutting health care costs. The articles quoted an authority as saying that "spending on unneeded procedures, medical errors and hospital infections is a more dire problem than the cost of calling for the uninsured, and that waste accounts for a much larger share of the country's $2.1 trillion health care bill."

In 2006, the U.S. civilian workforce was about 144 million, of which about 14 million were employed in health care. In 2000, the figures were about 137 million and 12 million, respectively. In the last eight years, health care has absorbed and increasing proportion of the workforce. Physicians and dentists have shown an approximately 8% increase in the percentage of employment, hospitals have decreased from 42.6% in 2000 to 39.8% in 2006. Health care is a major U.S. employer and most of the employment occurs in hospitals. Perhaps the first place to look for efficiency in the expensive world of health care is in hospitals, or in the insurers who control the gateway to hospitals and shift costs from their insured, to other payors such as government, the self-insured, employers, and taxpayers. The largest portion of "waste" may not be unneeded procedures, medical errors or hospital infections, but in the enormous administrative overhead of commercial insurers who provide no true health services in exchange for the expensive administrative overhead wrung out of billions in premium dollars.

Do You Receive Adequate Quality Health Care?

If you are a young man or woman, and see your doctor infrequently because you know you are in good health, the insurers want you. The young healthy nonuser of health care is what keeps insurers and HMOs not just solvent, but profitable. So there you are, making money for your health care insurer or HMO, going to see your doctor every few years - probably for a bad cold. When you see your doctor, what is the quality of the care you get? Do you know how to assess quality, other than by the time you have to wait to see the doctor and the age of the magazines in the waiting room?

Does anyone check your skin for melanoma? Does anyone check your neck for a thyroid nodule? Does the doctor (or other health care professional) check a young man's testicles for a mass? Does the doctor check the woman's breasts or instruct her on self examination? How about checking lymph nodes? Does the doctor listen to your heart and lungs through three or four layers of fabric because there isn't enough time (or professional interest) to have you take off your garments. Is the doctor (or other health care professional) sufficiently skilled in physical examination to be able to recognize an abnormality or is his or her professional continuing education dictated by the programs which insurers and pharmaceutical companies offer? Or does the doctor or other health care professional ignore the role of history and physical examination and believe that the only way to find disease is by lots of lab tests?

If no one looks, no one finds treatable pathology. If no one finds treatable pathology, the patient will probably change jobs, move to another insurer, and the first insurer or HMO will not be burdened with the costs of diagnosis and treatment. As the insured, you have fulfilled your duty of providing profit for the insurer or HMO and allowed the health care provider to see his or her allotted number of patients.

You may know a lot about football or baseball. In both sports there are rules and umpires. What are the rules governing the care you should be receiving and who is enforcing the rules? If you don't know the rules, you may be the loser.

Who Is Kidding Whom?

In the mid 1980s, I suggested that in twenty years we would have six major health care systems in the United States, in addition to government systems. We are pretty close to that number now, and the insurance/HMO/health care industry has opted to consolidate which makes their operations virtually indistinguishable in principle from Medicare. There is one major difference: with the exception of Medicare and the Permanente health care system, the others soak up a lot of dollars that should be used to purchase health care and divert those dollars to administrative overhead. One research study demonstrated that about twenty five percent of the premium dollar wasn't buying physician services, hospital services, ancillary services, preventive health services or the other items we recognize as health care - the twenty five percent of the premium dollar was buying clerks and offices and administrative salaries and generous payments to top executives, while business and the individual purchaser of insurance products were struggling to manage their own health care costs. If Medicare and Permanente can provide the range of health services that their beneficiaries/members need for near 3 percent of the health care dollar, and since the insurers and their subsidiaries have become large impersonal, inefficient, unfriendly and difficult to deal with, why don't we exercise some common sense and move to a single or near-single payer system - so that we can use health care dollars for health care and maybe even have some money left over to provide for the 47 million uninsured in America?