On Wednesday, Nov 17, the AMA is urging physicians to call their congressional delegation to beg for another reprieve from the scheduled Medicare fee cut. This game of “chicken” has been going on for 8 years now. http://www.aapsonline.org/newsoftheday/001097
AAPS consistently sends a better message: Never mind the “sustained growth rate” (SGR). Do away with the price controls—the ban on balance billing. Allow patients and doctors to contract privately, without government interference.
We know that Medicare is insolvent. It will be cutting payouts because it has no money. But it does not have the constitutional authority to deny seniors access to care.
Medicare has the power to determine reimbursement any way it likes. Currently it uses the values set by the 29 members of the powerful, secretive RUC (Relative Value Scale Update Committee), which is convened by the AMA. These Solomons determine how to divvy up the $60 billion that Medicare spends on physicians’ fees. Then the government sets the “conversion factor” in an effort to determine total outlay.
But the federal government should not be dictating fees. Only patients and doctors can determine a fair fee that will allow the doctor to keep his office open so his patients can continue to receive care.
We agree with the AMA on one thing: physicians should be re-evaluating their Medicare status. Finally, the AMA is making its members aware of the possibility of opting out. (AAPS is the number one site for information on how to do this.)
We suggest you call your Senators and Congressman (the Capitol switchboard is 202-224-3121) or find your Congressman’s and Senators’ contact information at http://www.contactingthecongress.org/.
Tell them that Congress should:
- Free patients from the price controls that are destroying their access to care. Doctors should set fees; Medicare should only set reimbursement.
- Never mind the SGR. Eliminate the ban on balance billing and the penalties for charging a fee different from the one calculated by CMS.
- Allow unrestricted private contracting outside of Medicare.
- Be aware that if Congress does not act, you will (opt out of Medicare; stop seeing Medicare patients, cut certain services, retire, etc.).
Note that this Wednesday will also be the first time that new CMS head Donald Berwick, M.D., will appear before Congress. He will testify before the Senate Finance Committee, which will hold a hearing on the effects of the Affordable Care Act (ACA or ObamaCare) on seniors and consumers.
By Jane M. Orient, M.D.,
Some have suggested piecemeal repeal of the most obnoxious features of the Affordable Care Act (ACA). The risk of this approach is comparable to that in cancer surgery: you might not get it all. In 906 pages of arcane statutory language, a lot can be hidden.
I suggest instead that we wipe the slate clean with a total repeal, and then consider reenacting any features that most agree are good. This would be the most efficient method because the list of items is shorter. Much shorter.
The most popular part is probably the elimination of “pre-existings.” You can’t eliminate the uninsurable condition of course, only the insurance company’s ability to deny coverage to people who have it. How would such an isolated law work?
In a free market, coverage for people with pre-existings might well be available, without any law—if insurers could simply charge a premium reflecting their risk, or limit the potential pay-out. The premium, naturally, could be very high. That would be a strong incentive to buy insurance when young and healthy, and resist temptations to spend the premium money on iPods and new cars instead. But for many it is already too late.
The U.S. already has the equivalent of fire insurance for those whose house is burning down. It is called Medicaid. Roll into the emergency room desperately ill, and the hospital will treat you, and probably enroll you in Medicaid—likely after you have spent through any assets and lost your SUV and your home.
To prevent such personal tragedies, how about a law that simply said: “Insurance companies must take all comers, without price discrimination for pre-existing conditions.” This is called “guaranteed issue” and “community rating” (GI/CR).
GI/CR would work well, if insurance were a magical money multiplier (MMM): put $100 in the slot machine, pull the lever, and watch $6 million in medical services pour out. The problem is that if a lot of healthy people who don’t expect to need medical services decline to feed in their premiums, knowing they can always do so as soon as they get sick, premiums will have to escalate rapidly. This is called adverse selection (only sick people sign up), or the death spiral. It has happened every time GI/CR has been tried.
This popular part of ACA is impossible without the hated and unconstitutional individual and employer mandates.
What about doing away with limits on lifetime coverage? Limiting out-of-pocket expenditures? Doing away with copayments? All of these have the same problem: lack of an MMM, such as a money tree or the Philosopher’s Stone that turns base metal into gold. The more we require insurance to pay out, the more money has to be poured in, with the inevitable loss to administrative overhead.
How about “giving doctors incentives to be more efficient”? In a free market, that is called the profit motive. In the ACA, the “incentives” are sticks painted to look like carrots, involving vast new reporting systems, with payments funneled through managed-care mechanisms. The choice is freedom—or ACA bureaucracies. Which of the some 159 new bureaucracies do we want to keep?
What about “affordability” provisions? Since prices are going up, in ACA “affordable” means forcing someone else to pay. It’s a matter of redistributing money from those who earn more than 400% of the federal poverty level (around $88,000) to those who earn less. Americans are divided into winners and losers, guaranteeing constant fights over one’s share of a shrinking pie.
One part everyone might favor is the one about allowing people to keep their insurance plan and their doctor if they like them.
Oh, that’s not in the bill. That was just a Presidential promise. The ACA has rules for “grandfathering” some plans—a good term since they are not expected to have a long life expectancy. ACA also appears to be designed to drive independent doctors out of practice, and it virtually outlaws new doctor-owned hospitals.
If we continue to scour through the ACA looking for isolated good points that will make things better or less costly, rather than worse and more expensive, I predict that our thought experiment will lead to what in mathematics is called the “null set.”
So far I have found no such provisions, zero. Nought, nada, nichts, zilch.
Jane M. Orient, M.D., On Air contributor speaking on Healthcare Reform. Dr. Orient has appeared on NBC, MSNBC, ABC and many major broadcast venues throughout the US, as well and her Op-eds have been printed in hundreds of local and international newspapers, magazines and followed on major blogs.
Dr. Orient is the Executive Director of the Association of American Physicians and Surgeons. She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at www.drjaneorient.com.
Dr. Orient’s position on Obama’s healthcare reform: “The Obama plan will increase individual health insurance costs, and if the federal government puts price controls on the premiums, the companies will simply have to go out of business. Obama makes promises, but the Plan will deliver higher costs, more hassles, fewer choices, less innovation, and less patient care.” Doctor Orient resides in Tucson, AZ and can be reached at [email protected].
By: Alieta Eck, M.D.
ObamaCare is a wildly unpopular law for anyone who knows anything about healthcare. The election proved that. Physicians came together in Washington, DC to film the following national ad:
Perhaps it is time for the politicians to admit that the government cannot provide health care. Period. All government can do is set up an administrative scheme that pays many people to decide who qualifies for which government program, gives out entitlement “insurance” cards, but then underpays for the actual care. Bureaucrats get paid while physicians do not. Taxpayers get fleeced.
Before 1965, the administrative costs in a doctor’s office were negligible, especially when it came to caring for the poor. Typically the doctor would not even bother to write out a bill. For the average patient, the doctor charged a reasonable fee and if the patient had insurance, it was his job to get reimbursed. People bought “hospitalization” insurance policies.
Today the poor seek Medicaid– the huge federal/state program that entitles the recipient to “free,” care. But since the physicians must fill out forms only to be given a fraction of a reasonable fee several months later, most refuse to take Medicaid at all. So Medicaid recipients with sore throats inappropriately clog up the emergency rooms with twice the frequency of the uninsured. The system is expensive for taxpayers, demeaning to patients and generally unworkable.
An innovative solution to our health care crisis would involve several layers of care.
The first layer could involve the average person paying his doctor directly for services rendered. Paperwork would be minimal, patient-physician confidentiality would be maintained, and prices would be kept down by simple competition. Living healthy lifestyles would save money.
A second layer would be personally obtained, non-cancelable health insurance for unforeseen major medical maladies and accidents. These policies should have the coverage and deductible that fit a family budget. The states should merely oversee that the contract terms are met, but not mandate what is to be covered.
Thirdly, safety net non-governmental charity clinics could to be scattered throughout every county in every state with each clinic deciding ways to determining the eligibility of those seeking the free care.
The Zarephath Health Center was started in central New Jersey in 2003 and uses volunteer physicians and nurses to provide free care to the poor. Patients include the homeless, the mentally ill, the jobless, the undocumented immigrants and even patients with Medicaid cards. Physicians there diagnose and care for patients with acute and chronic illnesses. The patients are treated with kindness by those who are willing to donate their time, and currently 300-400 patients get free care each month.
The cost to provide services at the ZHC comes to $15 per patient visit compared to $150 per patient visit at the federally qualified clinic in the neighboring town. The latter clinic has huge bureaucratic administrative overhead and collects funds from the federal and state governments and the patients. They are constantly asking government for more money.
The Federal Tort Claims Act of 1996 provides free medical malpractice coverage for professionals who volunteer at any free clinic. Freed from the specter of frivolous lawsuits, the physician can offer common sense care leaving compliance up to the patients.
Why not devise a similar plan with state rather than federal government involvement?
We could set up a system where the physicians donate, say, four hours per week in free care. A surgeon might agree to take on one charity case per week. Then, to compensate the professionals who donate their time and expertise, each state could agree to provide full medical malpractice coverage for their entire practice. Such coverage is already provided for physicians who work or teach in medical school university hospitals. The state would not be laying out money for medical malpractice insurance, but just agree to pay the costs of litigation and payouts.
The result? Poor patients would get care. Physicians would be rewarded with lower office overhead, not having to pay expensive medical malpractice premiums. Taxpayers would not have to fund the enormous Medicaid bureaucracy or payments for actual office-based care to the poor. Unnecessary defensive medical tests would be eliminated causing health insurance premiums to drop for everyone. The number of lawsuits would diminish.
It is time to think “outside the box,” come up with workable solutions, and lower the cost of healthcare for all. President Obama said he is willing to entertain any reasonable proposals. Let’s start the discussion. Charity care and tort reform– perfect together!
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Dr. Alieta Eck, MD graduated from the Rutgers College of Pharmacy in NJ and the St. Louis School of Medicine in St. Louis, MO. She studied Internal Medicine at Robert Wood Johnson University Hospital in New Brunswick, NJ and has been in private practice with her husband, Dr. John Eck, MD in Piscataway, NJ since 1988. She has been involved in health care reform since residency and is convinced that the government is a poor provider of medical care. She testified before the Joint Economic Committee of the US Congress in 2004 about better ways to deliver health care in the United States. In 2003, she and her husband founded the Zarephath Health Center, a free clinic for the poor and uninsured that currently cares for 300-400 patients per month utilizing the donated services of volunteer physicians and nurses. Dr. Eck is a long time member of the Christian Medical Dental Association and in 2009 joined the board of the Association of American Physicians and Surgeons. In addition, she serves on the board of Christian Care Medi-Share, a faith based medical cost sharing Ministry. She is a member of Zarephath Christian Church and she and her husband have five children, one in medical school in NJ.
Congress and the Administration disregarded the clear will of the people in enacting the government takeover of our medical care; we must de-authorize, de-fund, and REPEAL it.
To do so, we must create accountability, so there is no more saying one thing and doing another. “The Repeal Pledge” organized by The Independent Women’s Voice, and mentioned in the Wall Street Journal and on the Rush Limbaugh show, will help hold our elected officials to their word.
Please go to http://www.therepealpledge.com/the-repeal-pledge-peoples-promise/ to sign the “Citizen’s” pledge and then learn how you can help get candidates and incumbents to sign too.
After you sign, watch The Repeal Project You Tube video featuring several women physicians including AAPS director Alieta Eck, MD.
By : Jane M. Orient, M.D.
Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA) emerged.
The “affordable” trillion apparently means net additional federal government expenditures, with the Treasury envisioned as one big pot of liquid gold. All the revenue gets mixed in, and the financial engineers turn the valves to direct the outgo. Less will go into some channels (“savings”), and more into others.
Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?
Consider Medicare, the key to the whole calculus. The net trillion depends on about half a trillion in “savings” from Medicare, over 10 years starting in 2010. (If we start in 2014, it’s $800 billion in 10 years, and up to $3 trillion in 20 years.) Assume the savings happen, despite the influx of Baby Boomers. How do we distribute them?
Medicare revenue for Part A (hospitalization) comes from the Medicare payroll tax. That is by law a dedicated tax. Anything not immediately spent on benefits goes into the sacred Trust Fund. Will ACA loot the Trust Fund to pay for expanded Medicaid, or the new civilian medical corps, or improved care for “health disparity populations,” or community health centers? Wouldn’t that be illegal?
Congress could conceivably just legalize the looting—except that it is impossible anyway. There is nothing in the Medicare Trust Fund except IOUs. It has already been plundered for other government spending, and is part of the unacknowledged public debt.
The latest Medicare Trustees report showed a dramatic drop, of $6.2 trillion over a 75-year horizon, in Medicare’s unfunded liabilities—the amount by which anticipated expenditures exceed projected revenue. A statement by the White House said this shows “how the Affordable Care Act is helping to reduce costs and make Medicare stronger.”
Medicare’s Chief Actuary, however, noted that there is no “reasonable expectation” that this will occur, as it depends on cutting physician payment by 30% now and more later. But suppose that it does happen—that Congress wipes out a liability by reneging on its promises to seniors. One cannot use the same money both to cancel a liability and to fund a new entitlement.
And how will the savings be achieved? ACA has all kinds of mechanisms for control, which will apply with special rigor to seniors. Remember, “control” does not mean cost reduction, just payment reduction, translating to care reduction. The money not paid to doctors and hospitals or suppliers of oxygen may well be “saved,” if it is not funneled to the controllers. And the doctors and other providers who don’t get paid won’t be there for seniors, or anybody else—leading to more “savings.”
The non-Medicare sector is still more imponderable. Premiums for private insurance will have to cover far more generous benefits—now the mandated “minimum”—and are escalating rapidly. Insurers who lobbied for ACA may have expected swelling revenues from millions of reluctant new customers. Instead, politically powerful companies like McDonald’s are requesting and getting waivers. Politically weak small companies or individuals may go out of business or opt to pay the penalties for being uninsured.
It’s not clear where those “penalties” go, but they won’t be able to cover the subsidies of around $10,000 on premiums for persons making up to 400% of the federal poverty level (more than $80,000). Nor will they cover the cost of swelling Medicaid enrollment—perhaps 16 million newly eligible persons.
Will taxes on the “rich” cover all that? Let’s assume that all we need is the CBO’s (under)estimate of half a trillion not taken from Medicare: $500 billion, or $500 thousand million. To grab that in $10,000 chunks would mean a big tax bite out of 50 million Americans.
The controllers intend to direct spending of both government and private funds. The mandates will get funded first: bureaucrats, smoking cessation counselors, multicultural health educators, translators for patients with limited English, weight monitors, hemoglobin A1C measurements, IRS agents, and quality assurance personnel who assure that you get an aspirin for your heart attack.
Not on the favored list are cancer treatment, stroke rehabilitation, trauma surgery, or coronary artery bypasses—the modern treatments for the Big Killers.
There’s no funding for death panels, but they won’t be needed.
ACA was sold with fiction-based accounting of phantom savings and revenue, and illusion-based benefits. Implementation means extracting real money from real people and productive enterprises, diverting it from the care of the sick into untraceable channels at the discretion of unaccountable bureaucrats, and pouring much of it into politically correct money sinks. Some would describe it differently, but even in the most favorable view, the numbers on the money flows just don’t add up.
We need to end ACA—or it will end the life of American medicine.
Jane M. Orient, M.D., On Air contributor speaking on Healthcare Reform. Dr. Orient has appeared on NBC, MSNBC, ABC and many major broadcast venues throughout the US, as well and her Op-eds have been printed in hundreds of local and international newspapers, magazines and followed on major blogs.
She is the Executive Director of the Association of American Physicians and Surgeons, has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at www.drjaneorient.com. Additional information on health-related issues: www.aapsonline.org and www.takebackmedicine.com.
