Volume 63, No. 12 December 2007
While many are preoccupied with fighting the Single-Payer
bogeyman which is not too likely at the present time in the
United States the real threat is unopposed, writes Greg Scandlen
of Consumers for Health Care Choices. That is mandatory insurance
coverage for all Americans.
"Universal coverage" is the stated goal of the AMA as well
as most presidential candidates. And "there is no
voluntary path to universal coverage," writes George
Halvorson, chairman and CEO of Kaiser Foundation Health Plan and
former CEO of HealthPartners of Minneapolis.
The American model will probably be different from the
British or Canadian. "Government-controlled public/private
arrangements in which federal subsidies are used to justify the
federal government regulating and controlling everything, but
leaving the financial risk to private parties...are the risk
in...all the proposals coming from Democratic candidates for
president," writes AAPS member Richard B. Warner, M.D., immediate
past president of the Kansas Medical Society.
There's a $2.5 trillion pie to divvy up, and stakeholders
are gathering: the American Hospital Association, America's
Health Insurance Plans, Service Employees International Union,
Phrma, the Business Roundtable and the AMA.
The Pieces Are Already in Place
Eight developments "finally make health care reform
possible," states Halvorson in his book Health Care Reform
Now! a must-read, according to Rep. Pete Stark (D-CA) and
Alain Enthoven. The first is the "common provider number," the
NPI, which makes it possible to "track individual provider
performance using available electronic data bases." (He ignores
HIPAA-noncovered entities). Other essentials include inter-oper-
able computer databases; the government's willingness to make its
Medicare data on provider performance available to the public;
and lawmakers' readiness for reform.
Competing Behemoths (a.k.a. "Managed Competition")
Once all that data is available, plans can compete on the
basis of performance. Since individual consumers are unlikely to
make caregiver selection decisions well, and will not have the
market clout to "transform any single multimillion-dollar revenue
provider of care into a more accountable vendor," Halvorson
writes, "we need to hire a vendor to set up and administer those
market forces," using both wholesale and retail purchasing
leverage: an infrastructure vendor (IV).
Companies like General Electric, which has "world-class
reengineering capabilities," set Six-Sigma quality standards for
themselves. These allow only 3.4 defects per million opportun-
ities. The best score among all health plans in the country for
breast cancer screening compliance is 88.6%, a mediocre two-sigma
level. Only with extensive and 100% complete data
collection impossible without universal coverage can we hold
providers accountable to a six-sigma standard of compliance with
best practices. And to find out what the best practices are, "we"
need to hire someone to do the "keeping up" work, as no mere
physician can possibly read all relevant studies.
Already, for the chronic-disease patients who incur most
medical costs in America, "we know exactly what care they need."
Patients with congestive heart failure, asthma, diabetes,
coronary artery disease, and depression need to have their lab
tests and take their medicine. And they need to make lifestyle
changes (the IV will therefore assign patients a case manager and
care teamlet): "The potential positive impact of patients giving
up cigarettes, losing weight, and exercising regularly are
massive." If we could achieve those goals, "Medicare funding
would disappear as an issue," Halvorsen thinks.
Since America still has some independent physicians, the IV
needs to create the functional equivalent of vertically
integrated care: "virtually linked" care to overcome endemic care
linkage deficiencies (CLDs).
Employers will continue to be major buyers, and they'll be
purchasing benefit delivery packages and a health reform agenda
from IVs. They will also be paying for population health
improvement and provider performance management. IVs will have
"negotiated prices with each care provider," and will have
patients "appropriately incented and supported to make the right
decisions about coverage, care systems, caregivers, and care."
Only "higher income" (>300% of federal poverty level) working
people would buy coverage directly and be forced to buy a
$10,000-deductible plan from the government if they didn't attach
proof of insurance to their IRS form 1040. Taxpayers, of course,
would be buyers for others without employer-owned coverage. A new
program called HealthPrime would use Medicaid's infrastructure
for those not qualified for Medicaid. The problem with just
expanding Medicaid is getting enough providers to sign up.
The cost shift from the uninsured could be ended. (There
apparently is no cost shift from Medicare or Medicaid.) A health
care sales tax and/or an in-lieu tax on employers who don't
provide insurance would provide any needed extra money in case
the cost savings were insufficient.
It is essential for everyone, including noncitizen residents
(and all "providers"), to be in the system to eliminate health
disparities, to know every needed service that a patient is not
receiving, and to achieve health solidarity as a core value.
"We are truly blessed by living in a democratic form of
government, where all voices can be heard some better than
others.... But the people who are heard the most may have
interests not optimally aligned with the cause of true reform."
While it's generally good that "it's hard to stampede
American lawmaking in any given direction" its stability
protects us from "the dictatorship of the current majority," it
"also makes crisp and immediate reform in any area highly
unlikely." Thus, while we "need the government to do some heavy
lifting to move the reform process along," we need to use
"another leverage factor": market forces.
George Halvorson, Health Care Reform Now!
"Socialism is democracy."
"Democracy is like the grave it perpetually cries `give,
give,' and, like the grave, it never returns what it has once
taken. Do not surrender to democracy that which is not yet ripe
for the grave."
Bulwer Lytton, quoted in TCSDaily 10/3/07
"Replacement of `republic' with `democracy' has done very
great damage to our country.... It is the remnants of our
republic that protect our freedom remnants that are continually
under assault from the advocates of democracy."
Arthur B. Robinson, Access to Energy, June
Debt Tsunami Begins
The first baby boomer has filed for Social Security
heralding what David Walker, comptroller general of the
Government Accountability Office, calls a "tsunami of spending."
Payouts will exceed tax receipts in 2017, and the loans made by
the "trust fund" to finance government spending will be called.
The unfunded liabilities of Social Security and Medicare, over
the next 75 years, total $440,000 for every American household
(Natl Center for Public Policy Research).
"Medicare has really been bankrupt since it began in 1965,"
wrote Anthony Gregory of the Independent Institute in 2004. Even
with seven payroll tax hikes in 21 years, today's elderly spend
twice as much out of pocket as they did before 1965, even
accounting for inflation.
Medicare is "democracy at work," wrote Rep. Morris Udall (D-
AZ) in 1965. The people got what they wanted, after a bitter and
protracted fight. Private insurance had failed.
"Plans vary enormously; the lower the premium, the less you
get. The `Golden 65' plan of Continental Casualty is fairly
complete, but costs a couple over $600 a year obviously more
than millions of retired persons can afford."
From Medicare, physicians should have learned that today's
congressional promises as to pay well and not interfere with
medical practice are not binding on future Congresses, points
out Greg Scandlen.
Curtis Caine, M.D., Honored
Curtis Caine, M.D., long-time AAPS director and a former
president, received the Eileen Shearer Eternal Vigilance Award at
a national gathering of the Constitution Party. Dr. Caine is a
member of the party's Executive Committee and also serves as its
AAPS Elections, Committee Report
At the 64th annual meeting in Cherry Hill, NJ, Mark J.
Kellen, M.D., of Rockford, IL, was elected President-Elect. Other
officers: Tamzin A. Rosenwasser, M.D., of Lafayette, IN, is
President; Charles A. McDowell, Jr., M.D., of Alpharetta, GA, is
Secretary; R. Lowell Campbell, M.D., of Corsicana, TX, is
Treasurer; Kenneth D. Christman, M.D., of Dayton, OH, is
Immediate Past President. Elected to the Board of Directors are:
John H. Boyles, Jr., M.D. of Dayton, OH; Claud A. Boyd, Jr., M.D.
of Augusta, GA; Robert J. Cihak, M.D., of Brier, WA; Richard
Dolinar, M.D., of Phoenix, AZ; and Dennis K. Gabos, M.D., of
Allison Park, PA.
Resolutions Committee Chairman John Boyles announced rules
for the 2008 annual meeting: Resolutions must be received, in
writing, 90 days before the meeting.
AAPS Testifies at Hearing on TMB
On Oct 23, the Texas House Appropriations Committee held
hearings concerning alleged abuses by the Texas Medical Board.
AAPS General Counsel Andrew Schlafly and several AAPS members
testified. AAPS was the only medical organization speaking on
behalf of physicians. Video and audio recordings are available at
Formal complaints against TMB president Roberta Kalafut,
D.O., and executive director Don Patrick have been filed with the
Travis County District Attorney for alleged abuse of power.
Stephen Hotze, M.D., charged that Kalafut had her husband file
anonymous complaints and then used her position to see that their
competitors were disciplined by the board.
British NHS Updates
Required to ensure that everyone has a general practitioner
(GP), the National Health Service has responded to shortages by
trebling "compulsory allocations" in some areas forcing doctors
with closed lists to accept hundreds of new patients. A downward
spiral could occur as doctors choose to retire at age 55 or even
sooner (Independent 11/1/07).
Since 2003, GPs have had static pay but rising expenses,
except for performance-related pay based on patient outcome.
Doctors hit far more targets than expected, and earned much more
than the government intended. Salaries soared to �110,000. "My
profession is being vilified for doing what was asked," writes
Dr. Laurence Buckmann (Independent 11/1/07).
"This is a pay scheme imposed by government and now they
don't like it that we have done well."
Feb 1-2, 2008. Seminar, Board of Directors, St
Sep 9-13, 2008. 65th annual meeting, Phoenix, AZ.
Sep 30-Oct 3, 2009. 66th annual meeting, Nashville,
State Raids Fund; Wisconsin Medical Society Sues
Wisconsin Gov. Jim Doyle's third attempt to raid the Injured
Patients and Families Compensation Fund succeeded; the
legislature voted to transfer $200 million out of the fund as
part of a deal to finalize the state budget.
"This amounts to a special tax on physicians to help balance
the state budget," writes AAPS member Al Fisher, M.D., a family
physician in Oshkosh. Wisconsin physicians are forced to
contribute to the fund or lose their license. Any deficits will
be covered by increased assessments on physicians.
The purpose of the Fund is to pay malpractice judgments
exceeding policy limits. Its establishment has been touted as one
of the great accomplishments of the Wisconsin Medical Society.
Those who support similar funds in other states "should be
studying what is going on with the Wisconsin Compensation Fund
now," writes Dr. Fisher.
The Society filed suit on Oct 29, asserting that the raid is
an unconstitutional taking of property without just compensation,
an unconstitutional impairment of a contract between physicians
and the state, and an illegal tax on physicians. The complaint is
posted at www.wisconsinmedicalsociety.org.
Doctor Excluded Until Loan Repaid
If a physician is excluded from federal health programs
because of default on a loan for his professional education,
there is no basis whatsoever on which an administrative law judge
can overrule the Inspector General's decision, as long as it has
a foundation in some nexus of fact and law. The minimum
exclusionary period lasts until the debt is paid. (Michael J.
Rosen, M.D. v IG DAB No. 1566, Feb 22, 2007, Civil Money
Penalties Reporter, Fall 2007). An excluded person cannot be
employed in any capacity by any medical facility that
accepts money from federal programs, or in an organization that
contracts with such a facility (see AAPS News, May 2006).
Tip of the Month: Most conflicts over Medicare opting
out have resulted from a failure to renew the opt-out every two
years, pursuant to the regulations. Remind yourself to do this,
and start the process early. When communicating with Medicare,
physicians should build in a level of redundancy in anticipation
that officials will "lose" what they were sent. Include a cover
letter with your opt-out documents requesting acknowledgement.
Send copies of important mail to the administrator of the CMS
regional office as well as the Medicare contractor. It is
desirable to have your opt-out affidavit notarized. Review the
section on opting out on www.aapsonline.org for any updates.
Hospital Enjoined Against Filing NPDB Report
In an amicus brief filed Nov 9, AAPS urged the Supreme Court
of Montana to uphold a preliminary injunction by the District
Court that prevented a hospital from improperly denying medical
staff privileges and filing a report with the National
Practitioner Data Bank (Jesse A. Cole, M.D., v. St. James
Healthcare, No. DA-07-0410).
The case concerns whether a hospital can circumvent the
procedures established in its own medical staff bylaws. Dr. Cole,
a radiologist, was "investigated" by an attorney with no medical
qualifications, who was hired by the hospital's board of
directors, not the medical staff. The hospital was enjoined from
disseminating the results of this sham peer review.
"An unjustified, adverse report to the...NPDB is plainly
`irreparable harm' that has no adequate remedy at law," states
the AAPS brief. The NPDB procedures provide less protection than
required by the Privacy Act by permitting dissemination of a
disputed report, without even requiring a "reasonable" check on
its accuracy, completeness, or relevancy.
The Health Care Quality Improvement Act (HCQIA) only
provides immunity from monetary damages, not from injunctive
relief, AAPS notes.
The hospital pleaded for deferential treatment on the basis
of poverty. Being held accountable for violating a physician's
rights might "reduce...ever diminishing margins." Amici argued
that the hospital might have a difficult time making a credible
case on remand, referring to the hospital's form 990.
Implicit in the hospital's case is the assumption that the
judiciary is not up to the task of assessing the issues involved
in hospital staffing disputes. The Michigan Supreme Court
rejected that argument, noting that courts routinely review
complex issues of all kinds.
"Sham peer review interferes with quality medical care and
impedes the benefits of competition and free enterprise. In
short, sham peer review is not `peer review' at all, but rather
tortious conduct disguised as `peer review' to escape liability,"
amici argue. The brief is posted at
High Technology Targeted on Medicaid Fraud
Colorado Gov. Bill Ritter aims to save the state $47 million
over the next 5 years through a high-technology initiative to
reduce Medicaid fraud. Claims will be reviewed using artificial
intelligence. To assure that providers meet minimum fiscal
standards, they will be required to reapply every 3 years. New
applicants will be subject to site visits and to criminal
background checks (BNA's HCFR 10/24/07).
Perez Seeks Post-Conviction Relief
Office manager Edgardo Perez-DeLeon was convicted of health
care fraud in 1993, along with his wife Wanda V�lez-Ruiz, M.D.,
and served one year in the county jail. The Supreme Court of
Michigan refused to hear the appeal. The issue was whether a
physical examination is the sine qua non for billing for an
office visit. Through the Freedom of Information Act, Perez
turned up evidence of perjury by a key government expert. He also
alleges that the prosecutor, Ronald Emery, tampered with evidence
by not placing on the witness stand one of his listed experts,
who recently testified at a trial that the physical examination
was not required for billing for an office visit of an
established patient, under codes applicable to his conviction. A
conflict of interest of trial judge Peter D. Houk is the third
basis cited in an appeal for relief.
"Office managers will always be held responsible for their
billing decisions," Perez writes. The best protection is "not
seeing patients covered by government health programs...."
Physician Punished for False Work Releases
Physicians may be tempted to simply give in and write an
excuse for work on request. A New York physician who routinely
wrote false sick notes for transit workers was convicted of a
misdemeanor and had to pay $15,241 restitution to the MTA. The
licensure board then put him on 36 months probation and fined him
$50,000 (News of New York).
What's Your Color? Coming on the heels of Homeland
Security's color-coded terrorist threat system is the physician
profiling software that rates the purported "threat" that
individuals pose to hospital administrators.
Hospitals are using very sophisticated data-mining tools to
monitor physicians, such as the Physician Profile Reporter
Software from the Greeley Company. Physician performance is
reduced to green, yellow, or red. The same red color is used in
their "Pyramid Approach to Great Performance": it means "take
corrective action." Rated items include "pharm recommendations
accepted," "severity-adjusted LOS index," "severity-adjusted cost
index," and use of certain drugs (ACEI at discharge in patients
with CHF or AMI).
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Fatherly Advice. When my two daughters applied to
medical school, I advised them to get a second degree. "If things
keep going in their current direction, the only treatment your
M.D. may get you is the equivalent of a place on the Jiffy Lube
assembly line where your job description is to open the cap to
the oil pan." They both got an M.D./M.P.H.
Stephen Levinson, Easton, CT
Greed. The level of greed is astonishing. The greed for
other people's money permeates health policy discussions.
Taxation is discussed as "what can we collect from politically
weak groups." There is no concern for the damage done by this
grasping attitude. There is a complete lack of compassion for
people who work hard to earn that money. There isn't even any
implicit acknowledgement that it is someone else's money. Anyone
who has more than someone else ought, it is presumed, to be able
to get by with less. This attitude also corrupts people who are
dependent on public programs. In the public hearings I've
attended, these beneficiaries have never expressed any
gratitude to those who fund them. They demand more.
Always. If you have an inexhaustible source of other
people's money, it will always be spent, and the newly
impoverished will be back seeking more. And more.
Linda Gorman, Independence Institute, Golden, CO
Hospital Costs. I'd be more comfortable if I could
think of hospitals as mere money-grubbing opportunists. But they
fall more into the category of generally mismanaged, out-of-
control financial vacuum cleaners that can't even figure out what
their costs are. No doubt the primary culprit is the government.
Medicare and Medicaid have so polluted the system that any kind
of traditional business solutions are useless.
Frank Timmins, Dallas, TX
Referral Source. The Tennessee Board of Medical
Examiners increased funding to the Tennessee Physician Health
Foundation charged with monitoring and treatment of impaired
physicians. The Tennessee Board also appears to enjoy a very
productive cooperation with a self-proclaimed "excellence center"
known as the Center for Personalized Education for Physicians
(CPEP) [read: Disruptive Physicians Reeducation Gulag]. They are
also helped a lot by the Vanderbilt Comprehensive Assessment
Program for Professionals (VCAP). I wonder what these folks would
do without the referrals coming to them from the medical board?
How many physicians would voluntarily sign up for 3 months of
"education" there, no matter how high their charges are, to learn
to avoid problem behavior such as defending themselves if a
drunken ER patient tries to beat them up?
Walter Borg, M.D., Lafayette, LA
Mandated Coverage. The healthy must be forced to enroll
in health insurance to keep premiums down. That is why men in New
Jersey have to buy pregnancy coverage. If nondrivers were forced
to buy car insurance, the rates would be lower. And perhaps
people who live in the desert ought to have to buy flood
insurance, so those with nice houses on the beach could have
Alieta Eck, M.D., Somerset, NJ
GM's Problem. Since 1978, General Motors has complained
that it spends more on health care than on steel. Yet there is
nothing easier to fix than the amount an employer spends on
health benefits: move to defined contribution. In fact, one
reason U.S. medical expenditures are so high is because GM and
others have been willing to pay so much.
Greg Scandlen, Consumers for Health Care Choices
Moving toward Fascism. Government regulations are
creating such problems that businesses are forced to grow ever
larger. Children are "educated" in government schools to be cogs
in a machine. Government seeks to expand control, but will retain
the outward pose of capitalism, while partnering with big
business to restrict who gets to be a capitalist. Citizens will
be told that everyone is working together for the good of society
(the State), and they need to follow leaders (F�hrers) who know
better what needs to be done.
Edward Dee Hinds, CLU, Paso Robles, CA
Mandates Destroy Private Medicine. If the state
mandates purchase of insurance, it will soon mandate what doctors
can do. It's improbable that patients forced to pay premiums for
mandates could or would contract privately also.
Laurence Marsteller, M.D., Tucson, AZ