The new Republican-controlled Congress has passed yet another symbolic bill to repeal the Affordable Care Act (ACA), although many say that it can’t really be repealed until 2017, with a Republican in the White House. Obama is protecting his legacy: a “signature” bill that is hated by the majority of Americans, which is becoming more entrenched and doing more damage every day.
Potentially good, possibly unintended consequences of ACA include severing the link between employment and medical insurance, the cause of much of the problem of pre-existing conditions. Unfortunately, many will switch to dependency on bankrupt government (Medicaid or taxpayer-subsidized Exchange plans).
Another benefit might be decreased spending because of increased out-of-pocket requirements—maligned by Progressives when achieved through Health Savings Accounts and “high-deductible” health plans—but without the latter’s benefits of low premiums and untaxed dollars in HSAs. Costs, however, are increased because of the added administrative overhead.
At this point, there is no going back to the status quo ante, the insurance market having been largely destroyed, and the abuses of managed care magnified. The patient has a nearly occluded left main coronary artery, and no timely congressional bypass is likely. Survival depends on the collaterals.
Exiting the ObamaCare Trap
In a series of informative videos, Bert McComas makes the case for being uninsured (medicalselfsufficiency.com). Many Americans with their new ACA plans are feeling that they lost their insurance already, though still throwing fistfuls of money out the window every month for premiums.
Health costs are on course to devour 31% of per capita income by 2022, up from 7% in 1960. Family insurance premiums are heading for $17,500 in 2015, up from $5,791 in 1999. Yet insurance, for the top 50% of healthy Americans, pays out only $248 each year, and for 95% pays out less than $10,000.
So why buy insurance? There is the ACA penalty, which, according to the Congressional Budget Office (CBO), only 13% of the uninsured would have to pay. Then there’s the threat of the Giant Hospital Bill for unanticipated emergencies.
McComas references the movie Dr. Strangelove in a section entitled “How I Learned to Stop Worrying…and Love ObamaCare.” He points out that the penalty could be viewed as “pre-existing condition insurance” because of ACA’s guaranteed issue. The open enrollment period is a barrier, but there are many ways around that.
In Communist China, people had to utilize the “back door” to get anything done, such as dental care, in a timely, competent way, as explained by Nien Cheng in her book about the Cultural Revolution, Life and Death in Shanghai. McComas discusses the “back door,” with steps leading out of the trough of uninsurance.
The first step is to save the huge insurance premium, and use the money to pay directly for services only if and when they are needed. The next is to pay the real price, not the grossly inflated Chargemaster rates. McComas considers the real price to be the Medicare price because for all its faults, and despite the fact that the free-market price unencumbered by Medicare rules may be lower, it is accepted by most hospitals to pay for nearly 60% of services. And, one can independently determine what it is.
McComas has found two hospitals that will accept the Medicare rate from self-pay patients: Maricopa Integrated Health System in Phoenix, Ariz., and Huntington Hospital in Pasadena, Calif. Many others may do this although they don’t advertise it—but patients or their family must demand it as soon as possible and not wait for the bill to go to collections.
“Not-for-profit” (tax-exempt) hospitals have used egregious “extraordinary collection measures” against patients of very modest means. However, IRS rules updated in 2014 are greatly advantageous to uninsured patients, including two back-to-back 120-day waiting periods during which the hospital must work to qualify a patient who has asked for financial assistance. Rules limit qualified patients’ charges to an “amount generally billed” (effectively, Medicare), if the hospital wants to keep its tax exemption.
Tax-exempt status may be worth 30% of excess revenues, and some hospitals may be eager to qualify patients for financial aid to help save their exemption. Many have updated their charity care policy to include all uninsured patients, writes McComas.
For elective care, more facilities, especially ambulatory surgi-centers, are posting package prices. To get the best price, say that you’re uninsured and pay cash, advises Twila Brase, especially if you are unlikely to hit the deductible. You are not legally required to disclose your insurance status.
Independent Doctors Are Critical
Our system erects barriers between patient and physician—Pharma, insurance, government, and hospitals, McComas explains. “You must bypass insurance companies as they exist today,” writes Lee Bellinger. “Get a medical advocate [private doctor] now because getting one later will be like trying to make the last lifeboat on the Titanic.” “Befriend doctors,” advises Richard Maybury (EWR 1/15).
The AAPS Non-Participation Policy is still the only answer.
Privacy
While we are focused on the National Security Agency recording our phone conversations and every keystroke on our computer keyboards, government’s invasion of our privacy is proceeding at many other levels as fast as technology will allow, writes Arthur B. Robinson, Ph.D., in Access to Energy, January 2015. Highway scanners are recording your license plate and facial photographs, from which they can identify each person and determine his emotional state. Commercial behavior data alone provides 1,000–2,000 data points on most Americans. Why?
The danger lies in the logical future use of the data. In most uses, large amounts of data (many parameters per person, n dimensions per set in science jargon) are compressed to one dimension, because decisions are generally based on one dimension, e.g. sick vs. well. Not all such uses are benign.
What about a linear axis from “pro-government” to “anti-government”? Or “can be trusted with a firearm” to “cannot be trusted”? Or “needs therapy and incarceration because he might become a criminal” to “our kind of guy.” Such calculations are not only dangerous but imperfect. Individuals will often be classified incorrectly—a hazard facing all Americans.
What can be done? Robinson suggests considering a law or Constitutional Amendment making personal data on each American his personal property. He could give or sell it to any entity, but recording or using personal data without permission would be theft, punishable by a large fine payable to the person whose privacy was violated.
Fiscal Notes
- Wreck of the Monetary Hesperus: David Stockman writes: “For 73 months running the Fed has lashed the money markets to the gross financial anomaly of ZIRP [zero interest rate policy]. Never before in the history of the world has any central bank or other monetary authority decreed that overnight money shall be indefinitely free to gamblers or that liquid savers should have their hard earned wealth chronically confiscated by negative returns after inflation and taxes”
- Extend-and-Pretend Unserviceable Debt: “I never thought I’d agree with a rabid socialist about anything,” writes Craig Cantoni, referring to a letter from new Greek prime minister Alexis Tsipras to the German people. Tsipras criticized the 2010 loan not for being too small but for being much too large. “Europe adopted the tactics of the least reputable bankers who refuse to acknowledge bad loans, preferring to grant new ones to the insolvent entity so as to pretend that the original loan is performing and extend the bankruptcy into the future.” Instead of stabilization, the result is “to undermine the foundations of Europe itself.”
- Magic Check Book: The Fed’s quantitative easing (QE) purchases have become one of the largest sources of government revenue, a net of $101.5 billion from $115.9 billion in interest income on securities acquired through “open market operations.” The Fed “acquired” $4 trillion in marketable securities by writing checks to individuals or institutions on an account that has no assets. If a private party “bought” assets in this way, it would be called check forgery or bank fraud, writes Ben Domenech (The Transom 1/13/15).
Alienation of a Profession
Although we may disagree with Karl Marx on most points, he suggests an interesting perspective on what happens when a shrinking percentage of physicians own the “means of production.” In 1983, 78% of physicians were self-employed. By 2012, the percentage had fallen to 53%. In 2014, 3 in 4 new physicians will go to work for hospitals and health systems. In Marxist terms, employed physicians become alienated from each other, their work, their patients, and even within themselves. Physiciams are vendors, patients mere purchasers, and medicine is commoditized.
Facts on Physician Employment
- Happiness: About 70% of physicians who left employment to become self-employed report being happier, and only 9% unhappier. Less than half (49%) of formerly self-employed (now employed) physicians are happier, and 25% unhappier (Medscape 3/11/14).
- Paperwork: About 26% of self-employed, and 35% of employed physicians spend at least 10 hours per week on paperwork and administrative tasks.
- Costs: While consolidation is supposed to led to efficiencies, hospital ownership of physician groups in California led to a 10% to 20% increase in costs overall (LA Times 10/21/14). Smaller practices (1-2 physicians) had 33% fewer preventable hospital admissions than practices with 10 to 19 physicians. Physician-owned practices also had fewer preventable admissions than hospital-owned practices (Health Affairs 8/14/14).
Medical Pricing
Frequent overbilling of uninsured patients has triggered more than 120 lawsuits in 2004 and 2005, and fueled calls for legislation. Calls for transparency have met hospital resistance and produced little useful information. Appeals to professionalism can work. In Australia, more than half of the privately insured patients with planned hospital admissions in 2007 consented to pay pre-specified prices. Price regulation in California caps charges to the uninsured on the basis of Medicare rates. Richman et al. suggest an implied-contracts approach until informed financial consent is established as an essential element of medical practice that provides a market counterforce to price escalation (NEJM 8/2/12).
AAPS Calendar
Jun 5, 2015. Thrive, Not Just Survive XXII and
Jun 6, 2015. Board of Directors meeting, Raleigh-Durham, NC.
Oct 1-3, 2015. 72nd annual meeting, St. Louis, MO.
ACTION OF THE MONTH
Share your views: Participate in our Patient Access Survey. Return the enclosed card OR answer online (not both, please) at http://AAPSonline.org/medicaid2015.
.
Liabilities from Anthem Data Breach
The potential legal liabilities from the unprecedented breach of some 80 million individuals’ records at insurance giant Anthem could entangle nearly 60 health insurance plans from Hawaii to Puerto Rico, legal experts say. More than 50 class-action lawsuits related to the breach already have been filed in less than a month.
The plans could be held responsible because of HIPAA business associate agreements signed to facilitate the BlueCard claims payment network. Through this network, records of more than twice the 37.5 million Anthem policyholders were compromised.
The HITECH Act extended legal obligations to business associates, and increased penalties to $1.5 million/year.
Anthem retains a vast amount of data about its insured in unencrypted form (Joseph Conn, Modern Healthcare 2/23/15).
Chinese hackers are suspected of mounting the massive cyberattack, perhaps to compromise important persons in U.S. commercial and government networks. (KrebsonSecurity).
The “healthcare industry” will be spending a lot more on data security. Encryption may not be enough, writes John Commins (HealthLeaders Media 2/6/15).
King v. Burwell: the Downfall of ACA?
Although the Obama Administration is assuming that the U.S. Supreme Court will uphold the IRS ruling that allows subsidies for insurance in the 30-plus states that did not establish their own exchanges, the possibility that it may not has “struck fear in the heart of…ACA supporters.”
A state that declined to set up its own Exchange “probably will not be able to stave off the immediate destabilization of its insurance market,” write Bagley et al. (NEJM 1/8/15).
A flood of amicus briefs has poured in. Supporters of the IRS rule include the American Hospital Association and America’s Health Insurance Plans, the chief lobbyist for the insurance industry. Hospital Corporation of America (HCA) argues that “the Affordable Care Act is functioning as intended” and that “the plaintiffs’ interpretation of the law would produce consequences ‘so absurd that Congress could not possibly have intended them’” (Robert Pear, NYT 2/21/15).
Supporters of petitioners, including AAPS, argue that the law means what it says, not what the Executive Branch thinks it should mean.
What Alexander Hamilton, one of the greatest lawyers of his generation, might say is that an interpretation of the law is not necessarily wrong just because it goes against the general intent of the law. Carson Holloway explains: “In order for the rule of law to function, the decisions of courts have to be derived by clear rules of reasoning from data that has a discernible meaning. The words of a statute ordinarily are data with a discernible meaning, … even if it turns out that the law is incompetently drafted.” In contrast, suppositions about the general intentions of the law cannot be known with certainty.
A brief filed by the U.S. Justice Foundation and others states: “The history of [ACA], to put it bluntly, is a history of lawlessness.” It argues: “If the rule of law is to mean anything, this Court must not sanction policies promulgated by an unelected bureaucracy—like the IRS—in direct contradiction of the written text of a duly enacted statute.”
All briefs are available at http://www.scotusblog.com/case-files/cases/king-v-burwell/.
A Strategy: Freedom
Former Sen. Phil Gramm writes: “If the Supreme Court decides to let Congress clarify its own intent on federal exchange subsidies, Republicans should demand that all American families be guaranteed the freedom to opt out as a precondition to bringing up any legislation to ‘fix’ ObamaCare” (WSJ 7/25/14).
Fraud and Abuse Update
- Do You Have to Keep Records Forever? In Kellogg Brown & Root Svcs v. United States ex relat. Carter, U.S. No. 12-1497), the U.S. Supreme Court may overturn a Fourth Circuit decision finding that “the statute of limitations is no longer a viable defense against a large majority of FCA [False Claims Act] matters.” The question is whether the Wartime Suspension of Limitations Act, 18 U.S.C. §3287, applies to civil claims brought by qui tam relators. Is the “war on terror” an indefinite or perpetual state of war? (BNA’s Health Care Fraud Report 1/21/15).
- Quality, or Fraud? As “providers transition from a volume-based payment system to a value-based system,” the HHS Office of Inspector General will be looking at “access to care, the quality of that care and things related to patient safety” (HCFR 2/4/15). FCA actions may be based on the theory that services may be so inadequate as to be “worthless” (HCFR 1/7/15).
- Reverse FCA Claims: In United States ex rel. Kane v. HealthFirst, Inc. (S.D.N.Y., No. 11-cv-02325-ER), the government alleges that failure to refund overpayments within 60 days is a reverse FCA violation (HCFR 1/7/15).
New York Law Protects Lyme Patients, Others
Gov. Andrew Cuomo signed a bill that prohibits the Office of Professional Medical Conduct from investigating a licensed physician based solely upon the recommendation or provision of a treatment that is not universally accepted by the medical profession. Although broad in scope, the bill was proposed to protect doctors who prescribe lengthy courses of antibiotics for Lyme disease. Some doctors say that chronic Lyme does not exist, and patients were often denied treatment because doctors feared discipline for not adhering to established specialty society “guidelines” (Poughkeepsie Journal 12/19/24).
Rule by ‘Guidance’
American freedoms are increasingly circumscribed by administrative agencies that bypass even informal rulemaking and thus any requirement for public notice, comment, or explanation. Agencies may even set their own budgets by determining user fees. Their rules determine who must sign up for healthcare, who is subject to immigration law enforcement, and what constitutes pollution. Congressional oversight and citizen access to courts is needed (C.W. Calomiris, Forbes 1/5/15).
Correspondence
From Letter to President, American Academy of Neurology. Onerous Maintenance of Certification® (MOC) requirements were implemented without any evidence that they improved quality of care. Had a physician provided such a non-evidence-based treatment, he would likely be eligible to be sued for malpractice.
AAN did little or nothing to oppose MOC. Conflicts of interest are pervasive. Specialty boards found a new highly lucrative revenue stream, and they exploited it. Specialty societies did little to oppose onerous and unnecessary MOC requirements because they too found a new revenue stream of supplying what was needed to comply. Little concern by either specialty boards or specialty societies was shown for already burned out and bureaucratically overloaded physicians.
MOC cannot be “fixed.” It needs to be terminated. We already had lifelong learning; it’s called CME. Physicians choose courses based on relevance to their individual practices. Lawyers have CLE and see no need to re-take the bar exam every 5–10 years, or to continuously complete self-assessment modules. Lawyers would not submit to such abuse.
The American Board of Internal Medicine has now admitted they “got it wrong.” Other specialty boards should do the same.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
FSMB Compact. The Interstate Medical Licensure Compact being pushed by the Federation of State Medical Boards is a back-door attempt to make FSMB the federal licensing lord, and to sneak in ABMS board certification and MOC® as a requirement for basic licensure. FSMB has weaseled its way into state medical boards by selling its products and financing junkets by board members to its meetings. It is a wealthy tax-exempt corporation with gross revenues of $44 million from testing fees and certifications. Its IMLC facilitates nothing; physicians must still pay licensing fees in every state in which they wish to practice. Contrast this with the interstate nursing licensure compact, started in 1999 and now encompassing 24 states, which does facilitate mobility, without additional fees or corporate influences.
Paul M. Kempen, M.D., Weirton, WV
War on Women and Blacks. According to the NYC Dept. of Health and Mental Hygiene, the number of black babies aborted in New York City in 2012 (31,328) exceeded the number born there (24,758). The number of black babies aborted constituted 42% of the total abortions performed (73,815).
Jim Vanne, Aurora, IL
Obama Wants Your Genetic Code. Obama’s “Precision Medicine Initiative” includes databasing medical records, genetic blueprints, and lifestyles of a million or more Americans. As to effectiveness, this could be the new Solyndra. The Administration claims that “privacy will be rigorously protected,” but he who holds the data makes the rules. With only 2 years left to fully establish federal control over American medicine, Obama may be building a system for using genetic information for the precise purpose of rationing care.
Twila Brase, R.N., Citizens Council for Health Freedom
Secret Scoring. When you call an insurance call center, and hear that “this call may be recorded,” computer algorithms are scoring your voice to determine your state of mind. Insurers are buying your credit card data to see whether you renewed your gym membership or are buying larger-size clothes. It’s easier to get a credit card because someone is subsidizing those who default—and profiting from selling their data.
Barbara Duck, Orange County, CA
Sharing Your Medical Data. Plans call for at least 35 federal agencies to help collect, share, and use electronic health information. There is no way to keep data secure with so many agencies having access.
Robert McQueeney, M.D., Marinette, WI
No-Privacy Disclaimer. When I went to the CMS Health Care Quality Improvement System Provider Resources website to check my information, I found that: “By using this information system, you understand and consent to the following: You have no reasonable expectation of privacy regarding any communication or data transiting or stored on this information system. At any time, and for any lawful Government purpose, the government may monitor, intercept, and search and seize any communication or data transiting or stored on this information system.” No one of sound mind would log in, except perhaps a physician.
Craig Wax, D.O., Mullica Hill, NJ, @IP4PI
“Hack me.” While Anthem promptly notified 80 million customers and employees of a data breach, and hired a cyber-security firm to help remedy the consequences, the federal health exchange is under no obligation to notify users of similar intrusions, and HHS has no specific policies for investigation of data breaches. It has plans to share information you provide with employers, consumer reporting agencies, brokers, CMS contractors, and many others, in addition to federal agencies.
Greg Scandlen, Consumers for Health Care Choices
