Unintended Consequences (Part XXIV)

Our government’s attempts to control all aspects of our lives have numerous unintended consequences. In healthcare, one of these is directly related to the government’s staunch refusal to fix the Medicare Fee Schedule (which in turn affects other reimbursement arrangements) and to develop payments for medical treatments that actually cover the cost of the care being delivered: inadequately staffed medical offices.

The latest news is that the government is going to enact another "doc fix" to the fee schedule. The "fix" is that there will once again not be a cut (it will be moved to next year), but there will once again not be an increase, either; the fee schedule will remain fixed where it has been for over a decade.

The history of the doc fix is covered very well by Anthony Wilson and Hanna Dubansky. In their post “The Sustainable Growth Rate Formula: Then, Now … and Forever?” Anthony and Hanna provide a helpful timeline of the Doc Fix's many versions, from 2003 under President Bush, through this year under President Obama. It's very helpful background towards understanding the Sustainable Growth Rate formula (SGR), which drives so much of this.

Due to the continuing instability of payments since February 2003, physicians have been unable to financially plan for their business needs. When a business is faced with a continuing money crunch it has two choices: increase income or decrease costs. As medicine has a fixed payment (revenue) as determined by the SGR, physicians cannot increase revenue by increasing prices because the government has determined the cost of the procedure. Thus, they are left with one avenue: cut costs. In any business, payroll accounts for up to 30% of overhead and is one of the (if not the) largest costs. Now, a physician has a choice: does he cut his own salary or does he reduce his staff? 99.99% of the time, the physician will reduce staff. It is happening to more and more of my colleagues: physicians are letting go of managers and taking over the management of the offices to “save money”. Additionally, they are freezing or reducing wages for the remaining employees.

Now it does not take a business maven to predict what will happen. When a service industry that makes money based on the volume of people served begins to make drastic cuts in its personnel, how will that affect the quality of the business? The business will need to continue to see the same number of customers to maintain its current revenue level, but with fewer employees. And what is the number one complaint about doctor’s office? Long wait times:

* Industry average for a specialist is over three months.

* Long wait times in the office; appointments are set in 15 minute increments, but it takes closer to 25 minutes for a physician to complete an appointment.

* Finally, long wait times on the phone trying to talk to someone about your medical condition, your bill, or if your test results are ready.

Simply put, very few physicians' offices in America have adequate staff to deal with the demands. Add to that low pay, long hours, and (often) arrogant doctors and it is amazing that any medical office has staff at all.

So, the unintended consequence of not having a fee schedule that accurately reflects the cost of medicine today is a medical system that is unable to meet its core purpose - medical care - in an efficient manner. Physicians have decided that administration is the area to cut, leaving only medical personnel to man the fort.

But, Kelley, you may ask, why do I need that manager or billing office or scheduler if I only want to find out if I have strep throat or mono? Because the actual medical treatment done by the physician is only one small piece of the overall appointment life-cycle:

* People to make the appointment, check you in and verify your insurance

* Billing folks to make sure you’re up to date on any payments due and process your claim after the appointment

* Medical personnel to get you to the proper room and make sure all the coding is correct for your insurance claim

* A practice manager to make sure all the government regulations are met (OSHA, HIPAA, and HITCECH to name a few), and that the staff is appropriately trained

As in any system, if one of those components is removed, then the entire system will not work as efficiently. If the cog that ensures that the entire system works correctly is removed, then the system will eventually grind to a halt.

Most American’s believe that the money crunch to physicians will incentivize them to work harder for the fewer dollars. The opposite is true: physicians will not increase the number of patients that they see to make more money, they will simply cut overhead, which in this case is personnel, to ensure that their salary stays the same. The loser in all this is not the doctor, it is the American public.

Monday Afternoon (Not So) Funny

HHS Secretary Shecantbeserious offers this gem:

"Group health insurers will join with individual health insurers to fund a temporary individual health insurance reinsurance program ... officials developed the risk-management final rule and the analysis to implement provisions in [ObamneyCare©]."

Well, aside from the fact that the end-game is the elimination of health insurers, the use of the term "risk management" is quite rich, considering Ms Shecantbeserious has added convenience items birth control to the list of mandated benefits.

Self-awareness is apparently not a job requirement for Madame Secretary.

1,000 Words for Mid-March

Courtesy of our friend Holly R, the real reason the President isn't talking about ObamneyCare©:

[Photo courtesy of the Washington Post]

ObamneyCare© Doubling Down on Campus

Dropping all pretense at rational thought, Secretary Shecantbeserious and her boss have decreed that, henceforth, university students will be supplied "free" convenience items birth control:

"[Shecantbeserious] said student health plans will be treated like employees’ plans, meaning they will have to ... provide contraception without charging a copay."

First, it should be noted that, contrary to popular belief, convenience items birth control is not a "women's health issue." In fact, it is not a "health issue" at all. So it makes little sense to mandate that student health plans, mediocre as they are to begin with, should pay for it. The irony, of course, is that these plans don't actually pay very well (if at all) for real health care.

Second, the "consciousness clause" opt-out (for religious institutions) is again paid short shrift:

"Religious universities will treat their student plans the same as their employees’ plans ... they will not have to directly offer contraception in their plans, but students and workers will be able to get birth control from their insurance companies without a copay."

This is stupid on two levels:

Yes, it means that these schools won't be directly funding convenience items birth control, but their students who (unfortunately) sign up for these plans are paying for it for themselves and their fellow students.

[By the way: anyone else notice the schizophrenic nature of ObamneyCare© here? These students, most or all presumably aged 26 and younger, are eligible to stay on Mom and Dad's insurance, but they're also supposed to buy the so-called student health plan? How does that even make sense?]

Third, there's this little gem:

"Religious schools that self-insure ... do not have to provide [convenience items] to their students. How the mandate will work for the employees of self-insured religious institutions is still being decided."

Well, perhaps we can help out here. FoIB Nate Ogden is a Third Party Administrator, and he has some thoughts on how self-funded plans will have to deal with this new mandate:

"In their latest effort to protect women from the unaffordable $9 a month for birth control, the Obama administration is proposing the TPA of a self funded plan provide birth control for free.

Here's the problem with that:

I charge $10-$25 Per Employee Per Month (PEPM) which works out to $120-$300 per year. My profit margins currently run around 10%, meaning I have $12-$30 per year per member after paying expenses like rent, salaries, paper, postage, etc. Obama and his HHS now wants me to cover up to $3000+ per year in contraceptive benefits per female employee/student. Obviously I can’t pay a $3000 bill with $30 of revenue so I would need to terminate clients.

Is this keeping the coverage you have?"

Regular readers know that that promise went under the bus a long time ago.

Shecantbeserious thinks you're a jerk

Pot. Kettle. Some assembly required.

Context: regarding a video admonishing young people to avoid name-calling, Madame Secretary recommends ... name-calling:

"Stop it! You know, you’re being a jerk! "

cf: Dunning-Kruger effect.

[Hat Tip: Co-Blogger Mike F]

Readin'. Writin' and (um) Dyin'?

As if seasoned citizens don't have enough to worry about, it turns out that those prototypical Three R's can also be lifesavers:

"Being unable to read and understand basic health information might have a deadly outcome for older people ... Specifically, the test assessed a person's understanding of written instructions for taking aspirin. About one-third of the participants could not completely understand the instructions"

And of course it's not just aspirin, but the myriad other pills that seniors are likely to be taking. Mixing up an aspirin and a vitamin probably won't be fatal, but doing the same with a blood pressure med and [fill in the blank] just might be.

Unfortunately, there doesn't seem to be an easy fix for this. Perhaps senior centers could offer remedial reading comprehension courses.

On the other hand, bet this makes HHS Secretary Shecantbeserious smile.

And so it begins...

The consequences of the new insurance mandate to cover convenience items birth control is heating up on the employer front:

"A conservative civil rights group has filed a first-of-its-kind federal lawsuit against the Department of Health and Human Services on behalf of a Missouri business owner who says the HHS contraceptive mandate violates his constitutionally-protected religious beliefs."

So it's not just the Catholic Church that takes exception to this ridiculous over-reach, but for-profit businesses, as well:

"Frank R. O'Brien, a Catholic, is the chairman of St.-Louis-based O'Brien Industrial Holdings, LLC, which operates a number of businesses that explore, mine, and process refractory and ceramic raw materials."

The company's core values reflect his own, and the new mandate directly affects its ability to conduct its business in a way that honors those values. While the company doesn't discriminate against those who profess a different faith, Mr O'Brien feels that the "mandate would require business people ... to leave their religious beliefs at home every day as a condition of doing business in our society."

Why does HHS Secretary Shecantbeserious (and her boss, apparently) hate the 1st Amendment?

Shecantbeserious takes a Padawan

"The federal government ... will probably be running health care exchanges in many states."

So sayeth HHS Secretary Shecantbeserious acolyte Sandy Praeger, Kansas Insurance Commissioner. Ms Praeger also leads the NAIC's (National Association of Insurance Commissioners) Health Care and Managed Care Committee.

Nothing but the big guns here.

On Ms Preager's world, each state's Exchange "is going to have a different flavor"

Uh-hunh.

She believes, for example, that each state will have the autonomy to define its own package of "essential health benefits," conveniently forgetting that ObamneyCare© is a Federally mandated plan. Does she also think that each state gets to define convenience items "birth control?" If so, she's in for a (very) rude awakening.

Shecantbeserious, Jr also believes (naively) that states will themselves "perform many functions for HHS, especially including the rate and form review and network adequacy functions" including the SERFF Program. The (ironically-named) SERFF is a "System for Electronic Rate and Form Filing;" its purpose is to generate income for the NAIC "streamline" various state-based ratings and filings.

As if to prove that one need not be self-aware to have an opinion, Ms Praeger doubles down, averring that "there could be some sort of memo of understanding between the federal government and the states with regard to integrating the SERFF system within the exchanges."

Were the stakes not so high, this would be laughable: haven't the Feds proven enough how determined they are to run the whole shebang?

Apparently not on Ms Praeger's home world.

Decapitating Global Budgets

Gotta give the ObamneyCare© folks credit: they sure know how to obfuscate the truth. Take, for example, their latest excursion into the bizarro world of rationed health care:

"Also encouraging is the spread of global payment plans as an alternative to the traditional fee-for-service system ... Global payments encourage physician practices to communicate with patients between visits, and to make better use of nurse-assistants and other professionals for routine care and follow-up."

Now here it is in English:

"We've run out or bankrupted most of the really good physicians here, and we've provided - at great taxpayer cost - insurance to thousands of slackers, thus creating an even greater strain on an already struggling system .. so we'll now go to a [de]capitated care model in hopes of staunching the flow."

Let's continue, shall we?

"To continue to make progress, global payment systems and tiered networks need to be expanded, and the government can help. The state could standardize the distinction between high-cost and moderate-cost providers, which can be an incentive for hospitals to lower their costs."

And now in standard English:

"Help! Our system is already bleeding dollars, we don't have enough providers as it is, and we've encouraged more folks than ever to seek care on the taxpayers' nickel. Let's just cut reimbursements so everyone gets the same crappy mediocre care."

That about do it?

[Thanks to FoIB Elena Marie for the tip!]

Cavalcade of Risk #153: Call for submissions

Jason Shafrin hosts next week's CavRisk. Entries are due by Monday (the 19th).

To submit your risk-related post, just click here to email it.

You'll need to provide:

* Your post's url and title
* Your blog's url and name
* Your name and email
* A (brief) summary of the post ("Remarks")

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).
Thanks!

HHS on ObamneyCare©

What with ObamneyCare©'s current troubles - cost overruns, mandates for convenience items birth control, and will-they-or-won't-they Exchanges - it appears that HHS Secretary Shecantbeserious is definitely playing defense.

And so, she recently sent out one of her minions to explain the intricacies of the bill we had to pass to learn what's in it:

Health Wonk Review: St Paddy's Edition

Boston's Tinker Ready presents this week's green (as in Luck 'the Irish)-themed HWR. You'll be green with envy if you miss out on the green-tinted selection of great wonky posts.

Calling (for) the Question

Here's an offer for our loyal readers:

In email, dri.org ("The Voice of the Defense Bar") is offering access to attorneys representing both businesses in general and insurers specifically. These folks will be available to answer questions to new-media types (such as InsureBlog) about the ObamneyCare© suit(s) going before the Supreme Court later this month.

So:

If you have specific questions you'd like to ask one (or more) of these fine legal eagles, please leave them in the comments. If we get enough interesting questions, I'll take DRI up on its generous offer.

Pony up, folks!

Now Playing on SIFI

That would be "Systemically Important Financial Institution," a new phenomenon introduced by the Doddering-Frank reform law. Briefly, it seeks to force a square peg (an insurer, for example) into a round hole (ie banking), and subject that square peg to a battery of financial stability exams, aka "Stress Tests."

Which is what MetLife recently underwent.

And apparently failed:

"MetLife, Inc. (NYSE: MET) was one of four large financial institutions late Tuesday deemed to have failed a “stress test” imposed on large banking institutions by the Federal Reserve Board"

To which I say: "And so?"

In case our betters in DC hadn't noticed, an insurance company is not a bank. Just as convenience items birth control is not medicine, and squirrels aren't fish. Seems simple enough for even a DC bureauweenie to grasp, but apparently not:

"Industry analysts said the decision was based on evaluating MetLife by using criteria used to evaluate banks and not insurance companies."

But that's just folks who actually understand the difference between a bank and an insurer. In the meantime, the results now make it difficult for MetLife to shore up their own financials, barring them from a planned stock buyback and dividend increase.

Heaven forfend that a company try to improve its financial outlook.

To paraphrase Bob, "Clueless regulators, Papa Washington."

A $Billion here, A $Trillion There

Never let it be said that ObamneyCare© does things by half measures. Earlier this month, we reported that a CongressCritter had noticed an extra $111 billion had been added to the price-tag for this train-wreck.

Who knew that that'd be the low-ball estimate?

"[ObamneyCare©] will cost $1.76 trillion over a decade, according to a new projection released today by the Congressional Budget Office ... the ten-year cost of the law's core provisions to expand health insurance coverage has now ballooned to $1.76 trillion."

"Trillion." It's the new "Billion!"

Wednesday Health Tip

Offered without comment:

"Men who are circumcised may have a lower risk of developing prostate cancer, a new study finds."

According to the survey of some 3,400 males, about half of whom had prostate cancer, those who had undergone the procedure (presumably as infants) were about "15 percent less likely to have prostate cancer."

Them's good odds.

Koch vs Cato

No: Cato, as in "Cato Institute," the well-know libertarian think-tank. That Cato's been in the news of late, because several of its founders are embroiled in a lawsuit regarding the ownership of shares owned by a now-deceased partner.

There are, of course, political overtones in this case, but I'd like to concentrate on something else: the buy-sell agreement.

As we've mentioned before, a buy-sell agreement is a contract between the owners of a company (or other enterprise) about how to handle each other's ownership interests should one partner die. There are two basic methods (and copious variations thereon): Entity Plans and Cross-Purchase Plans.

Entity Plans are most often used when there are more than two owners. Under these plans, the company purchases the shares from the deceased's estate (or widow, or whatever). There is often a life insurance policy on each owner, payable to the company to fund that transaction.

Under a Cross-Purchase Plan, each shareholder agrees to buy out the interest of a deceased partner's estate (or widow, etc). Again, a life insurance policy on each partner's life is quite helpful in ensuring a fair and timely disposition.

Both methods, however, share a common theme: properly executed, they are legally binding contracts. That is, the widow or other heir doesn't get to decide whether or not to sell those shares.

Which brings us to the Koch/Cato kerfluffle [ed: I see what you did there]: based on the (admittedly sparse) information available, it doesn't appear that the partners' buy-sell agreement was well-written. Else how to explain this:

"[Ownership of] Cato was divided between four shareholders: the two Koch brothers, Cato president Ed Crane, and former Cato chairman William Niskanen ... At the heart of the dispute is the fate of the shares owned by Niskanen, who died in October .. The Koch brothers believe that they have the option to buy Niskanen’s shares, while Cato officials believe that the shares belong to Niskanen’s widow" [emphasis added]

A properly executed, legally binding buy-sell agreement would leave no room for the term "believe" in this context. Obviously, it's too late now to determine the late Mr Niskanen's desires or plans. But it could be a great lesson for still-vertical business owners to review their own agreements, to make sure that their heirs and partners don't have to resort to the courts for resolution.

Avik Roy *nails* it

Unlike ill-informed Ezra Klein, our friend Avik Roy actually knows what he's talking about when it comes to health care. And he's at his best when he brings to light issues and facts that no one else seems to have glommed on to (yet). For example, his latest:

"The US Government Spends More Per Capita On Health Care Than Almost Every Other Country"

This is a distinction I've not seen anywhere else, and it's an important one. Although we've log-debunked the canard that the US spends more on health care and gets worse results, Avik points out that the US government itself is a major spender that exacerbates an eminently-solvable problem. And he starts with shredding misconceptions from both sides of the political spectrum:

"Both liberals and conservatives believe that the American system is a "free-market" or "capitalistic" one, and that European systems providing universal coverage are "socialized" ... both of these conceptions go wrong."

By isolating and identifying how the *government* skews the numbers, Avik provides a real service for those of us seeking to find real-world solutions. And he makes an important point about those Medicare For All folks:

"The thing to remember in America is that we have single-payer health care for the elderly and for the poor: the two costliest groups." Avik goes on to compare and contrast some of the world's other health care systems. I don't necessarily agree with all of his conclusions, but his is an intellectually honesty discussion. By all means, Read the Whole Thing.

Diabetic? There's an App for that!

If you have diabetes - and a Smart Phone - then this could be just the ticket:

"Diabetics will be able to manage their condition with an Apple iPhone thanks to a device unveiled today.The £48 glucose monitor allows patients to check their blood sugar levels at any time using the phone."

Debuting in the UK, there's no word yet on when (or if) the $75 device will find its way to our shores (or whether Wilford Brimley will be touting it).

Medical Tourism Update

Earlier this year, Mike reported on a relatively new (or at least seldom reported) phenomenon known as "circumvention medical tourism." This refers to cases where the patient seeks treatment that would otherwise be illegal in his own country.

But here's a more compelling reason to travel abroad for health care:

"If you're willing to hop on a plane, you can find significant savings abroad."

And it's not just about cost, but choice:

"Some procedures lend themselves to international travel ... The five most-popular overseas procedures ... are cosmetic surgery, dentistry, orthopedics, in vitro fertilization and other reproductive services, and weight-loss surgery."

Obviously, some of these would be excluded from insurance coverage here (eg IVF and certain weight-loss procedures). But the point is that careful consumers could save money and (in some cases) receive higher quality care by hopping on a jet (or taking a cruise, one supposes).

Of course, not all procedures lend themselves to this method:

"Cancer is a gray area, with travel dictated less often by potential cost savings and more often by the desire to undergo treatment close to friends and family."

And the cost of the actual care doesn't include ancillary expenses (such as airfare and hotel rooms). Most insurance plans aren't going to help pay for this, unless one's plan specifies that it's covered, or one has a supplemental plan for the purpose.

And there's this: many folks also participate in "alternative benefits" plans (HSA's, HRA's and FSA's). According to our favorite Alternative Benefits Gurus, as long as the procedure would have been eligible had it been performed in one of the 58 states, then it should also be eligible if done elsewhere. So, for example, a purely elective cosmetic surgery that wouldn't be eligible here wouldn't pass muster if performed "over there," either. But, as in the back surgery example cited in the JWR piece, one could use some of one's Health Savings Account (for example) dollars to offset the costs.

Margaritas (probably) not included.

Food, Workout and Coffee Insurance

Some five-and-a-half years ago, our own Mike Feehan (commenting under a pseudonym) proposed a "national, single-grocer plan." He observed that "many people go hungry because wholesome groceries cost too much."

Mike envisioned a national ID card to facilitate the program, and a means-testing component so that what we now call "1%'ers" would pay their fair share.

In today's Wall Street Journal, assistant editor Allysia Finley strikes a similar tone. Observing that insurance plans must now pay for convenience items birth control, she suggests that this is simply not enough - that plans should also be required to pay for "[f]itness club memberships ... Massages ... Yoga classes ... Coffee ... [and a] Salad bar"

Now, one may pooh-pooh this as an overreach, but as Ms Finley points out, it's really not so much that as an acknowledgement that the government is simply living up to its role as self-appointed arbiter of what its citizens must buy.

After all, it's for our own good.

Cutting off the nose to spite...

First off, he (or she) with the gold gets to make the rules. That said, methinks that Ms Shecantbeserious is taking things a bit too personally:

"The federal government will withdraw funding for a Texas program providing more than 100,000 poor women with birth control and other health services because Planned Parenthood clinics are not allowed to participate"

That's right: because one vendor is barred from participating, Madame Secretary has put at risk the health (and perhaps lives) of over 100,000 folks on the bottom rungs of the socioeconomic ladder. Notwithstanding the Hyde Amendment, and the fact that all of the services that PP provides (save one in particular) are available from other providers, HHS has now put at (increased) risk the most vulnerable among us.

Of course, as we've pointed out, convenience items birth control is generally not medically necessary, so why we're paying for it in the first place is a mystery to me [ed: not really]. But one wonders whether or not this Federal overreach is really about "the rules" or, perhaps, something else entirely.

AnnuityJail Update

Last week, we reported on the unlikely story of an agent facing major problems for selling an annuity to an 83-year-old. Today comes word that - incredibly - "Glenn Neasham's request for a new trial was denied on Feb. 29 by a county judge and he was sentenced to 300 days, reduced to 90 days."

What's so striking about this is that all of the paperwork (check, app, etc) were submitted in a timely manner to Allianz (the carrier whose product Mr Neasham sold) where it was reviewed for suitability and the like, and ultimately issued.

Allianz has apparently washed its hands of the matter:

"Allianz is not familiar with the evidence introduced at trial, or the basis for the jury’s conviction. Accordingly, Allianz Life cannot comment on the verdict or the jury’s basis for reaching its verdict."

Nor is it willing to get involved at any other level.

On the one hand, because Mr Neasham was apparently an independent agent who represented Allianz but was not an employee, it's under no obligation to step up. But here's the thing: by failing to do so, isn't it tacitly admitting that it, too, may have failed in its review? At the very least, it seems to me to bring into question the viability of its indexed annuity product - if a judge and jury say that it was never appropriate, then doesn't that reflect back on Allianz practices, as well?

One wonders, of course, why the family of the "victim" hasn't sued Allianz for a return of that premium. Of course, it could be that it's because the contract (which she still owns) has earned north of $40,000. So what, exactly, is the crime here?

For now, Mr Neasham is headed for jail pending his next appeal.

Methinks we haven't heard the last of this.

Ezra K keeps whiffing it

Never let it be said that Ezra Klein lacks persistence. He keeps on swinging, despite his 0 for (whatever) record. His latest silliness posits that genetic testing will destroy the health insurance industry.

To which I would reply: take a number, pal.

Here's his theory:

"The New York Times reports that the cost of sequencing an individual genome will soon be less than $1,000 ... The legislation bars insurers from denying coverage or raising premiums on individuals who show a genetic predisposition toward particular diseases ... it armed a time bomb beneath the health-care industry."

First, we see the classic (and disingenuous) sleight-of-hand conflating health care with health insurance. If you can't even get that right, Ezzie, why are you playing at all?

To continue setting the stage:

"Eventually, genomic testing will be a powerful predictor of future illness. And it raises the potential that young people will get themselves tested and then purchase insurance based off the result."

And this is where he goes completely off the rails. How? It's really all about ObamneyCare©: either it will "stick." or it won't. If it does, then "young people" aren't going to have a choice about whether or not they'll buy health insurance: they will, or they'll hit the hoosegow. If it doesn't, then why does Ezzie believe they're going to be any more motivated when the test is $1000 - or $100! - than they are now?

He offers "solutions" - an Individual Mandate or "Medicare for All" - to a problem that doesn't (and won't) exist. But let's say it does: I thought these guys were all "pro-choice?" How does that square with forcing folks to buy something they don't necessarily want or need? It certainly doesn't solve the problem of increasing health care costs (just ask the Brits).

Strike three.

[Hat Tip: FoIB Holly R]

Something to consider

As we hear of more and more employer groups doing whatever they can to deal with the dramatic health insurance increases caused by ObamneyCare©, it's worth remembering that employers don't really pay for health insurance now.

As we pointed out many years ago:

"Companies – businesses – pay neither taxes nor insurance premiums ... They pay employees a portion of their salary, and forward the balance to the insurance carrier (and/or state government)."

And in fact, this will be exacerbated the closer we get to 2014. Because it's extremely unlikely that the portion of one's pay currently going to the insurance company is going to end up in one's pocket.

Be careful what you wish for....

You're not gonna believe this...

In what can only be described as a bizarre turn of events, I may have been premature in awarding this week's winner of the "D'uh! Award" in my recent post on Exchanges. This morning's email brings us this breaking news:

"Willis Survey: [ObamneyCare©] Driving Up Health Plan Costs for Employers"

Seriously? This is news?

Well, according to The Health Care Reform Survey 2012, provided to us by the folks at Willis (a self-described "leading global insurance broker") and available in pdf form here, it is. More and more employers are un-grandfathering their plans in an effort to stay ahead of rising premiums (rotsa ruck with that, by the way). And these costs are being passed on, of course, to their employees.

D'uh!

[Hat Tip: Colleen McCarthy]

Hey Kathy, Show Me the Money!

As we recently noted, ObamneyCare©'s ability to adversely affect the budget continues to grow apace. This much is known even by those of us in fly-over country, far from the Halls of Power inhabited by our political betters.

But what excuse, pray tell, does HHS Secretary Shecantbeserious have?

Here she is trying her level best to not look completely clueless.

And failing miserably:



[Hat Tip: Ace of Spades]

Oooh - Exchanges Coming?! Wait for it....

As noted yesterday, The Exchanges Are Coming! The Exchanges Are coming!

Maybe, maybe not:

"The final rule of U.S. Health and Human Services on affordable [sic] insurance exchanges is expected out this month, with reports that it can be as soon as this week or by the end of the month."

Granted, this isn't exactly Newhart-level humor, but it's at least SNL-worthy, no?

The truth is, HHS Secretary Shecantbeserious has no clue how these are to going to work, or even when she'll get around to "finalizing" the rules. There's a good reason for this, of course: she still hasn't figured out how to make the ExchangeWaiver©'s work.

And there's this:

"In the event that the Supreme Court rules that [ObamneyCare©] is constitutional, state officials are split on whether to proceed with implementation ... some states have gone to great lengths to block the health reform law’s implementation."

Behold the great uniter.

The Latest Skinny on the MVNHS©

Well, you knew it wouldn't be long before the Much Vaunted National Health System© went from referring its plus-sized patients to zoos to actively denying them urgent medical care:

"The NHS has been accused of rationing vital treatments after refusing to help ‘undeserving’ patients unless they lose weight"

That's right: the "health care" system that prescribes water to treat virtual epidemics of dehydrated hospital patients has decreed that care will be rationed according to weight (and other lifestyle issues). While that may, in fact, lead to healthier (and skinnier) Britons, there are a couple of real problems here:

First, today it's Death Panels based on weight and tobacco use. But tomorrow, maybe it's sexual orientation, or genetic testing results, or...well, you get the picture.

Second, it's one more (metaphorical?) nail in the "Nationalized Health Care is More Cost Effective" canard. After all, if these systems are so great, how come whatever (mediocre) care is available must be carefully doled out, lest the budget be broken?

Fat chance.

Cavalcade of Risk #152: Short & Sweet edition

Emily Holbrook hosts this week's collection of risk-related posts. It's lean and mean, and has some great selections.

No-new-news Exchange News

The Gray Lady wins this week's "D'Uh!" Award for its less than timely grasp of the obvious:

"States are lagging in the creation of health insurance exchanges ... waiting for a Supreme Court decision or even the November election results, to see whether central elements of the new law might be overturned or repealed."

Ya think?

But the Times doesn't stop there. In the kind of incisive, hard-hitting investigative journalism for which its renowned, The Paper of Record posits that this delaying tactic may backfire:

"By Jan. 1, 2013, the Obama administration will decide whether each state is ready to run its own exchange or whether the federal government should do the job instead."

As if Ms Shecantbeserious has such a great track record for punctuality.

Of course, with 58 states to lord over supervise, I'm sure she'll get right on it.

[Hat Tip: FoIB Holly R]

Health vs Common $ense

It's become common knowledge that installing workplace health-promotion plans will result in lower health and insurance costs:

"Employers pay people to meet sales goals, hit productivity targets, put in overtime. It works — people show up, do what they need to do and collect a paycheck ... By that logic, paying people cash incentives to lose weight, quit smoking, lower their blood pressure or engage in other healthy behaviors also should “work”

Unfortunately, that which is "logical" isn't always true. According to a study conducted by Carnegie Mellon University, there are certainly short-term payoffs to instituting these kinds of programs. The problem is that the positive results last for exactly as long as the positive reinforcement:

"[O]bese U.S. military veterans were paid to lose a pound per week for 24 weeks. Eight weeks after the incentive program ended, the vets had regained the weight they had lost."

Why this would be a surprise to anyone certainly eludes me: one who buys into a healthy (or healthier) lifestyle has, obviously, bought into the benefits thereof. But if it's just a monetary transaction, there is no "buy in" to be had.

This is of a piece with Bob's post last month about the disingenuous nature of the preventive care argument.

Grand Rounds: Super Distractable edition

Dr Rob presents this week's Super Tuesday-themed collection of interesting medblog posts..

UPDATE: Just noticed that Dr Rob has an alternate version up, as well. If you love limericks and/or Dr Seuss, don't miss it!

Oh, Even Braver New World !

Remember the Fair Nancy said "we have to pass this bill so that you can find out what is in it"??

From PowerLine, we learn about yet more that the law gives the Secretary of HHS the unilateral authority to do - and Ms. Sebelius has, predictably, done it.

Specifically, the same regulation that is at the heart of the present contraception kerfuffle, "institutes a modern day version of eugenics that targets Down syndrome for 'prevention' through abortion."

Yes indeed we are now finding out what is in the law.

And we are rightly appalled.

Another Broken Window

Last month, we discussed Bastiat's Fallacy of the Broken Window as it related to the vandalizing of one of those "evil" insurance companies. Today, FoIB Holly R alerts us to a more peaceful - yet no less destructive - incidence of economic vandalism.

This story is about a cottage industry growing by leaps and bounds as a result of ObamneyCare©'s crushingly expensive compliance regulations. For example:

"As part of [ObamneyCare©], new rules increase penalties if techs, nurses or even doctors see patients while their license is flagged in another state ... Redhage's IT startup -- called Provide Trust -- offers what amounts to a non-stop background check, and business is booming."

While this is certainly good news for Mr Redhage, it's bad news for the rest of us.

Why's that, you may ask?

Because just as in the case of Kaiser Permanente’'s literal broken window, dollars that must be spent on (for example) compliance regs are dollars that aren't being spent on actual, you know, care. And every hour that a doc or a nurse or a tech spends dealing with these reg's is one less hour being spent on, you guessed it, patients.

But then, ObamneyCare© was never really about the "care" in the first place.

Military ObamaCuts©

So, wonder how we're going to pay for all that birth control and other freebies?

How about, at the expense of those who risk their very lives for our freedom to do so:

"[ObamneyCare©] seeks to save $1.8 billion from the Tricare medical system in the fiscal 2013 budget and $12.9 billion by 2017 ... service members should expect a 30% to 78% increase in Tricare annual premiums for the first year. In five years, service members will expect an increase ranging from 94% to 345%"

Keep in mind, the average wage for single enlistees is about $34,000. Obviously, folks who volunteer to serve our country do it for reasons other than financial gain, but this is offensive.

Maybe they can get a waiver from HHS Secretary Shecantbeserious?

$1 here, $111 BILLION there...

"A powerful House Republican wants the Obama administration to explain why it’s asking for an extra $111 billion to implement part of the healthcare reform law ... a spike in the estimated costs of subsidies to help people buy private insurance — a central, and expensive, component of the new healthcare law."

Wait, what?!

Wasn't ObamneyCare© supposed to decrease health insurance costs by 3000%?

Looks like someone missed the memo.

ADDENDUM: It occurs to me that one very reasonable explanation for the sudden spike is the mandate to cover convenience items birth control.

Sell an Annuity, Go to Jail?

This is kind of scary:

"An agent sells [an] annuity to an 83-year-old. As it turns out, the client had some form of dementia (although the agent didn’t see signs of it and was not informed by the client or her relatives about her dementia)."

So far, sounds pretty ordinary. One might question the suitability of an equity indexed annuity for someone in that demographic, but if one assumes that the agent did his "due diligence" in determining that, then there wouldn't seem to be much of a problem.

Apparently, though, there was:

"[I]nvestigations ensued, and the agent was charged with felony theft. This is ironic since he did not steal anything and since the annuity never lost money."

There were some surrender charges (although one would imagine that the carrier would probably waive these under the circumstances). But theft? That seems a stretch. I've never sold an equity indexed product, so there may well be something I'm missing here, but this certainly seems to be shooting a fly with an elephant gun.

Anyone sense a theme?

Just a thought or three:

First, Mike's post on how the Netherlands' euthanasia "notification" system works (hint: don't get dementia).

Then, my post on HHS Secretary Shecantbeserious and the real motivation to mandate coverage for birth control.

And then, Mike (in comments to his own post) points us to this article, about Dr Kevorkian's next big thing.

And, finally, FoIB Elena Marie alerts us to this article, published in the Journal of Medical "Ethics:"

"[T]he authors argue that what we call ‘after-birth abortion’ (killing a newborn) should be permissible"

Brave New World? More like Animal Farm.

Cavalcade of Risk #152: Call for submissions

Emily Holbrook hosts next week's CavRisk. Entries are due by Monday (the 5th).

Just click here to submit your post.

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Shecantbeserious: The Mask Slips

So now we know the real reason behind the push for convenience items birth control coverage:

"Health and Human Services Secretary Kathleen Sebelius [sic] told a House panel Thursday that a reduction in the number of human beings born in the United States will compensate employers and insurers for the cost of complying with the new HHS mandate that will require all health-care plans to cover sterilizations and all FDA-approved contraceptives, including those that cause abortions."

'Nuff said.

Brave New World?

Bob recently came across the 2010 Annual Report of the Netherlands’ five Regional Euthanasia Review Committees. The Report states that “notifications” increased 19% in 2010 – from 2,626 to 3,136. A “notification” is an official notice from a physician to one of the Dutch Regional Euthanasia Committees that the physician has terminated a life - a human life - by request of the patient. It is important to understand that the reviews conducted by the Euthanasia Committees do not take place prior to the death of the patient, but afterward.

This Report is relevant to the debate that is growing in the United States over end-of-life care, and I recommend reading the whole article.

End-of-life care can be very expensive and, by definition, does not save lives. Discussion of such care quickly brings up many difficult ethical and financial issues. For example, “dying with dignity”. For example, a very large share of Medicare expenses are incurred caring for people in their last 6 months of life. For example, Medicare does not cover non-medical expenses for people who can no longer perform basic activities of daily living, which places a large and growing social burden on families, plus a large and growing financial burden on Medicaid. There is debate whether care that is “futile” should be delivered anyway – or withheld. If you read the Euthanasia Report, reflect that such issues frame one of the most critical medical, social, ethical, and financial problems America faces – in our lifetimes, and for generations to come.

The Dutch are attempting to face these issues explicitly. Whether or not you agree with the Dutch approach to end-of-life care, I recommend you be aware what the Dutch are doing, and why.

What are my own opinions?

I don’t yet know enough about it, but several things about the Dutch approach seem positive. First, their euthanasia law does not grant government the power to terminate any life. The decisions are reserved to the patient, the patient’s family, and the patient’s physicians. Also, instead of a priori review the law sets out uniform criteria that physicians must follow, requires a review process to evaluate compliance, and then publishes the review findings for all cases.

(I think it’s unsettling that the Dutch government has not adequately staffed the Euthanasia Committees, so that their findings are not being published. Of the more than 3,000 notifications received in 2010, apparently the only findings actually published are the 15 or so included in the 2010 Report. While unfunded government programs are nothing new, this one is unsettling. The Euthanasia Committees “greatly regret” this - see Page 3 - expressing no regret at the sharply rising numbers of self-requested terminations.)

But.

Alexander Solzhenitsyn wrote about a regime that not so many years ago, officially found political opponents "mentally ill" as a convenient excuse to imprison them.

I don't mean to compare the Netherlands with the USSR. I only mean to pose a few questions - - because laws can be changed:

Is the next step for the world’s progressive states to embrace the morality of killing those judged to be in sufficiently poor physical health? And if so, by what criteria will "sufficiently poor" be judged? (e.g., before they run up our taxes or spend our inheritances?) Criteria decided by whom? (Bureaucrats or physicians?) Should physicians be willing partners in this type of activity? Is the Hippocratic Oath now fully euthanised?

I also worry that once a nation has stepped onto the path of euthanasia - as the Netherlands did several years ago with newborns - it is flirting with moral free-fall and no one should be surprised how that may evolve.

O Brave New World that hath such people in’t.

Health Wonk Review: Paduda-style

HWR founder Joe Paduda hosts this week's collection of interesting and wonky posts on the state of health care policy and polity. Be sure to check it out.

Ze plane, ze plane!

No, no, no - not that Tattoo. This tattoo:

"Some medical tattoos are being used to take the place of bracelets that commonly list a person's allergies, chronic diseases or even end-of-life wishes."

The idea is that one could have, for example, "No CPR" permanently (and prominently) emblazoned on one's chest, because an EMT might overlook a bracelet, but couldn't help but see the tattoo.

The downside is that, so far, "[m]edical tattoos don't appear to carry much legal weight." As it turns out, neither do the bracelets. I spoke with a client (a FD bigwig) who told me that it's not really an issue: the bracelets are "descriptive" (i.e. "I'm diabetic" or "I'm allergic to penicillin") not "prescriptive" ("Do not resuscitate").

Now you know.