America's Paradox

In the days of my medical practice, I would find people in my office who had been through one romantic relationship after the other, all ending unsatisfactorily. These patients eventually recognized that they had developed relationships again and again with partners who were virtually identical in terms of looks, behavior, abusiveness, handling of money and unfulfilled promises to do better. They were with virtually the same person over and over, with the same unsatisfactory result, and rarely learned from their experiences.

For years, Americans have had relationships with insurers who act like my patients' lovers. The insurers promise a new world of health care in slick brochures, television commercials and sales presentations, provide no real health services themselves, engage in abusive business practices - such as policy cancellation or denial of services, tests, and prescription - to patients who need care, pocket large portions of the premium money entrusted to them for inflated administrative overhead, and then promise to reform. But never do . . . .

And yet, the insurers demand that we love them. Should we? Don't we ever learn?

Physicians - Info About Rules & Your 2010 Medicare Fee Schedule

Individual physicians have traditionally been shy about responding to rule proposals by Medicare (CMS - The Centers for Medicare and Medicaid Services). So if you are a physician or medical group administrator, you might read this document (click title above for direct link to a large file) so that you can add your (or the organization or institution you represent) input to the decision makers (including Congress people) who are planning to reduce Medicare physician payments by about 21.5%. If you don't care, don't bother, but then don't complain at the lunch table in the doctors' lounge when you get slammed next year.

Below is a brief extract from the large document (click title for direct link).

"SUMMARY: This proposed rule would address proposed changes to Medicare Part B payment policy. We are proposing these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This proposed rule discusses: Refinements to resource-based work, practice expense and malpractice relative value units (RVUs); geographic practice cost indices
(GPCIs); telehealth services; several coding issues; physician fee schedule update for CY 2010; payment for covered part B outpatient drugs and biologicals; the competitive acquisition program (CAP); payment for renal dialysis services; the chiropractic services demonstration; comprehensive outpatient rehabilitation facilities; physician self-referral; the ambulance fee schedule; the clinical laboratory fee schedule; durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); and certain provisions of the Medicare Improvements for Patients and Providers Act of 2008. (See the Table of contents for a listing of the specific issues.)"

If Ronald Reagan's Health Coverage Was Cancelled

The story was told to me in the mid-90s with great enthusiasm, by a former executive of a major California-based health insurance company. It seems that a major California health insurer, which had enrolled State of California employees for many years, did a study to find out why writing health insurance for this group was becoming less profitable, and learned that it was experiencing adverse selection: all of the State of California employees who had selected the program were over age 40; the younger employees joined Kaiser which had much lower premiums.

So the insurer did just what insurers still do to employers. It notified California that it was no longer interested in the state's business, and that upon the termination of the contract, it would no longer provide coverage for state employees. The insurer "fired" the State of California.

Though I don't remember the name of the man who told me the story, I remember his grin and the twinkle in his eyes, when he related that among those who lost his coverage was then governor, and soon to be President, Ronald Reagan. The person who told the story said that when the insurer discovered its politically disastrous mistake, it withdrew its health insurance termination decision so that, once again, Ronald Reagan was insured.

I had no independent verification of the story. But it strikes me as quite consistent with health insurers' behavior. So I thought I'd pass it on. Perhaps one of my readers can give us additional details.

HHS Sec. Delegates Admin. & Enforce. Authority to OCR

Here is the Announcement from OCR concerning HHS delegation of privacy administration and enforcement to the Office of Civil Rights To save time, and get directly to the Federal Register, click the title above.

"Announcement

"Monday, August 3, 2009

"Secretary Delegates HIPAA Security Rule to OCR

"On August 3, 2009 OCR announced that the Secretary of Health and Human Services has delegated to the Director of OCR the authority to administer and enforce the HIPAA Security Rule. This action by Secretary Sebelius will improve HHS’ ability to protect individuals’ health information by combining the authority for administration and enforcement of the Federal standards for health information privacy and security called for in the HIPAA.

The transition of authority for the administration and enforcement of the Security Rule is expected to be seamless with no interruption in the management or processing of any complaints filed prior to the transition. Consumers may continue to submit HIPAA security complaints using the on-line resource – the Administrative Simplification Enforcement Tool (ASET), found at https:htct.hhs.gov/aset. New security complaints may also be sent to the Office for Civil Rights. For more information and detailed instructions on how to submit a complaint to OCR, visit the OCR website: http://www.hhs.gov/ocr/privacy/hipaa/complaints/. The transition of security complaints from CMS to OCR has no impact on how complaints about Transactions and Codes Sets or Unique Identifiers are filed or processed. CMS retains its enforcement authority for these other HIPAA rules.

:View the Federal Register notice of the Delegation of Authority at http://www.hhs.gov/ocr/privacy/srdelegationofauthority2009.pdf and the Secretary’s press release at http://www.hhs.gov/news/press/2009pres/08/20090803a.html."

The Appearance of Impropriety

Page 1 of The New York Times (July 30, 2009) describes the river of money flowing, in part, to the Democratic Senatorial Campaign Committee ($500,000), individual candidates ($120,000, and the Democratic Congressional Campaign Committee (House of Representatives) ($800,000+). The sources can be traced to McAllen Texas and the funds were traced by the Times to entities or individuals connected, in one way or another, to Doctors Hospital. (See my blog from 7/14/2009 with its link to the New Yorker article on McAllen Texas' health care costs.)

At a time when President Obama proclaims that his party's health care reform will drive down health care costs and prevent health care inflation, the Democratic Party seems blissfully unaware that the party and its members have provided American citizens with an appearance of impropriety which gives the lie to political rhetoric from Obama, Pelosi and Reid. Our health care system is being sold, without public benefit, to self-serving bidders while Democratic and Republican politicians and their parties reap the economic rewards. All of this while American adults' and childrens' health interests are being violated.

The public is silent. It is not apathetic, and one can readily sense frustration and anger bubbling below the surface.

Ethics, Quality, Compassion

I listened carefully to President Obama's AARP televised and internet-carried conference On July 29, 2009. I heard nothing about the ethical construct for health reform. I heard nothing about health care quality. I heard nothing about assuring Americans that there would be competent qualified physicians available to provide the care that is being promised to them. I find myself more and more concerned that the only subject for Obama and Congress seems to be cutting health care cost inflation and saving money.

I have proposed changes to the health system in earlier blogs. Others have proposed different changes. But the only change that seems to be in the wind is that insurers and pharmaceutical companies' revenues and profits will be protected, with no apparent concern for the quality and ethics for the services they provide.

Years ago, one of my patients with advanced metastatic breast cancer was in the Oncology Unit of a local hospital with a fractured hip. She was in agony and her quality of life was poor, but could have been helped by appropriate orthopedic surgery. MediCal (California's Medicaid) refused, saying that the expense was not justified by the patient's poor prognosis. I called the MediCal authorization number and asked Medical's "authorizer" for the address of MediCal's office. She asked why I wanted to know. I told her that it was because I was going to put the patient in an ambulance and send her to their office for care, because I couldn't take care of her under the circumstances they dictated. After a few moments of silence, I received the authorization. The patient had surgery by a competent and compassionate orthopedic surgeon, went home without devastating hip pain and died several months later appreciative that her pain had been treated, her ability to walk restored, and she could be at home with her family.

I have seen the value of ethical commitment, concern about the quality of care that patients receive and compassion. It is unfortunate that Congress does not address these issues. The Administration and Congress just don't have the words to discuss ethics, quality of medical care, and compassion.

It's The Money, Stupid!

John Roach, the late academic political scientist, said it succinctly: no-one can compromise on matters of principle. We fought the American Civil War, incurring massive losses of life, because neither side could compromise its principles. Some pro-life partisans are in prison for life, because they followed their principles and murdered physicians who performed abortions.

It's not matters of principle which shapes the health care reform debate, it's political money.

Do politicians have commitments to principle? When there is a hot contentious issue with enormous public interest, such as health care reform, politicians can play one side against the other and cash in through political contributions and other financial support. There is no issue of principle: there is only the issue of price. The more contentious the issue, the longer the process, the more money key politicians can garner for their coffers. It's not a party matter, it's money. It's not constituent interest, it's money. It's not principles, it's money. It's not ethics, it's money. It's not doing the right thing for the public, it's money in the treasuries of well-positioned political figures.

$127 million in lobbying by the health sector, which was well-represented in Senator Kennedy's closed office meetings, in the first quarter of 2009 is no small change. Senator Baucus brought in $3 million in the 5-year period ending in 2008 and according to the Kaiser Health News (click the blog title for the link) big contributors included major pharmaceutical manufacturers, insurers and a major pharmaceutical executive.

As you watch the political maneuvering, remember, it's not health care that key people in Congress worry about, it's their economic status and political bankroll. The issue isn't "where's the beef," its "where's the money"?