Off the Beaten Path(way)

As we noted late last month, MVNHS© "trusts" (hospitals) that participate in the British Death Panel Liverpool Care Pathway have been handsomely rewarded for their efforts. This makes sense: by scrimping on care they save the system cold hard cash, thereby earning their (not so) little finder's fees.

But all that may be coming to an end:

"Ministers ... ordered an independent inquiry into why hospitals have been paid to hit targets for numbers of patients dying on the Liverpool Care Pathway."

I'm sure this will be welcome news for those currently on the path; for those whose lives bought Angus steak dinners for the bureauweenies, not so much.

I did find this little tidbit darkly humorous:

"Mr Lamb said the inquiry would ‘consider the value of locally set incentives, and whether they are leading to bad decisions or practice’"

Well, that really depends on whether one believes killing off patients is a bug or a feature, doesn't it?

ObamaTax Job Killer

As we've previously noted (most recently here), the ObamaTax is quite the efficient job killer.

Orlando Health (FL) is a large hospital system employing some 16,000 folks.

Strike that.

Orlando Health (FL) is a large hospital system which used to employ 16,000 folks, but which has just downsized 400 of them in anticipation of changes being wrought by the ObamaTax.

Meanwhile, the Community College of Allegheny County (PA) is drastically reducing the hours of 400 employees of its own. These adjunct professors will be re-classified as part-time to avoid the ObamaTax Employer Mandate. But of course they'll be able to find quality, affordable coverage of their own through the Exchange.

Eventually.

Right?

And speaking of killing the goose that lays the golden eggs jobs, here's an ObamaTax "benefit" that's been flying under the radar:

"Section 4205, the menu labeling provision .... meant to “aid consumers in selecting more healthful diets” ... the regulation will likely have job-killing effects and result in little, if any, significant reductions in obesity rates and/or improved health."

The problem is that, as benign as the idea might appear, it is just one more unfunded (by gummint) mandate that will drive up the cost of doing (food) business, with no discernible positive effects, but with the very real consequence that employers will have to pay for implementation at the cost of their employees' jobs.

Ooopsies.

A Belated Thank You

I inadvertently let Thanksgiving come and go without acknowledging the invaluable contributions made by my fantastic co-bloggers.

I'd like to remedy that:

Thank you Bob, Mike, Nate, Kelley and Bill for all of your great posts, insightful advice and unstinting help here at IB.

There's no better team in the blogosphere.

"Free" keeps getting more expensive

Dr Peter Weiss, Director and Founder of The Rodeo Drive Women's Health Center, is finally catching on to at least one ObamaTax gotcha, the "free" annual exam. As Bob noted last summer, "if you don't follow the rules, your free annual exam could cost you $500 - $1000 or more."

Fast forward a few months, and Dr Weiss reports some changes reflecting this reality at his practice:

"I have now posted a notice in my office and each exam room stating exactly what Obamacare will cover for those yearly visits. Remember Obama promised this as a free exam — no co-pay, no deductible, no charge. That’s fine and dandy if you are healthy and have no complaints."

Aye, thar's the rub: as long as you're fit-as-a-fiddle in the first place (and/or if you had previously treated and now stable conditions) then you're likely to get out of the examining room with wallet intact. But woe to the patient who also has new issues:

"[Y]ou will not be covered if you want to discuss any new ailment or unstable condition. I cannot bait and switch to another code — that’s illegal."

In other words, if you're in for your routine exam, make sure not to ask the doctor about your stiff neck or new-found acid reflux. You'll need another appointment for that, one in which your deductible or co-pay will apply.

But hey, it's free, right?

BONUS: Dr Weiss also takes his scalpel to the canard of "the rich doctor" (gee, where have we heard that term before?):

"[D]octors are not rich and, like most of you, actually work terribly hard for a living. Second, Obamacare is the law — and as I said earlier, we are audited all the time now."

And this is only going to get worse: as we've noted, there's already a shortage of providers, and Dr Weiss thinks we're seeing just the beginning of of that trend:

"By 2014, less than 25% of physicians will be in private medicine. Obama was right in stating you can keep your doctor if you want to — the problem is he or she will rarely be available."

Three cheers for the ObamaTax, no?

ObamaTax Rule Dump: More Questions Than Answers

As Bob noted the other day, we're still awaiting final rules on full implementation of the ObamaTax. But that's about to change.

Today, HHS Secretary Shecantbeserious is set to "pump three major [ObamaTax] regulation proposals into the Federal Register." These include new rate review rules (say that 3 times fast!), the new group wellness program rules, and new provider accreditation rules.

Of course, the phrase "clear as mud" comes to mind, but I'm sure that there'll be no problem implementing all of these rules, and that providers and insurers will be delighted to comply with them. After all, it's only taken almost 4 years to develop them.

Meanwhile, some parts of the ObamaTax have already been rolled out, and their effects are starting to take their own toll. For example, the 2.3% medical device tax:

"This damaging tax will force job cuts and investments in tomorrow's treatments and cures ... Continued medical innovation is key to driving public health gains by reducing costs associated with chronic diseases like diabetes and obesity ... Simply put healthier lives mean healthy economies."

That last bit is a sketchy (I've never seen that particular claim before, nor evidence of its veracity) but the rest is spot on. Throwing up additional barriers (ie taxes) like this discourages new tech, while making the delivery of health care ever more expensive.

But then again again, that's apparently where the IPAB Death Panels come in.

How pointless will CER be...

...and how long till we realize it was nothing but a slush fund for Obama like his green jobs money?


"The routine use of mammograms has led to more than 1 million women being unnecessarily treated for breast cancer over the past three decades, according to the latest scientific report to cast skepticism on the effectiveness of the test."

"Even before those findings, in November 2009, a key federal panel revised its guidelines on mammograms to say that women should begin regular screenings at age 50 rather than age 40, and then get the exam every other year rather than annually."

"In 2010, lawmakers tweaked a mandate in the health-care law requiring insurers to cover preventive services recommended by the task force free of charge. The law specifies that when it comes to mammograms, insurers must follow the task force’s old guidelines"

Why spend the money if we are just going to ignore the results? 

Do premiums matter under PPACA?

As a small claims payor I am always keeping my eyes open for experienced claim processors by searching resume boards. The last few months I have seen a large number of adjusters that used to work for Anthem. Normally you don't see adjusters leaving the large carriers as they pay great and have better benefits and retirement opportunities. Seeing a couple let alone a dozen is rare. In speaking with a few of them I was told they outsourced their claims processing to the Philippines and India. This got me wondering what this foretells of the future.

If you're a carrier and you're locked into 15% of revenue, do you spend that money on claims adjusters to control your claims cost, and thus reduce your revenue...

...or do you auto-adjudicate as many claims as you can, 70-80%+, then outsource the remaining claims to some low cost foreign country?  They won't do as good of a job (meaning they will pay more in claims then they should) but that actually increases their revenue, a perverse reward for a job poorly done.

This has been the Medicare model for decades and resulted in the most inefficient and fraud ridden program in the country. But if no one is directly paying the bill who cares? Medicare beneficiaries pay a minute fraction of the actual cost of their benefits so they don't care if 10%+ is lost to fraud. If the majority of the exchange members are going to be subsidized they won't mind either. The only people that would care are workers actually paying federal taxes, a minority when it comes to voting.

From the anecdotal evidence I have seen so far, it appears private insurance is adopting the worst qualities of Medicare already, before the exchanges even start.

For claim processors, 60% of expenses going to salaries is normal; if you drastically reduce that the business goes from low margin commodity to very profitable very quickly.

This Sceptered Isle - Part CCXXIV

"A new system of “virtual clinics” is being planned in which GPs connect with patients via iPads and Skype, an idea that NHS bosses are importing from India.  The reforms would save £2.9billion “almost immediately” and improve the lives of most patients, for example by avoiding the need to find child care during appointments, Health Minister Dr Dan Poulter said last week."

Notice the best NHS can say about this "reform" is that this will improve Brits' lives by "avoiding the need to find child care during appointments"?  Really? That's it??

But don't forget - NHS will save £2.9billion ($4.65 billion)  “almost immediately”.  We must assume those savings will also improve the lives of most patients almost immediately even though the article does not say how. 

Anyhow my guess is, if you're not British, and not a patient, you won't much care.  This kind of thing could never happen here. Government doesn't have that much control over the U.S. medical care system.  Right?

Cavalcade of Risk #171: Call for submissions

Emily Holbrook next week's Cavalcade of Risk - Entries are due by Monday (the 26th).

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

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.

Thanks!

Remembering the First Thanksgiving

One of the earliest and arguably most historically significant North American colonies was Plymouth Plantation, founded in 1620 in what is now known as Plymouth, Massachusetts.

The original Plymouth Plantation had written into its charter a system of communal property and labor.

illiam Bradford recorded in his Of Plymouth Plantation, that a people who had formerly been known for their virtue and hard work became lazy and unproductive. Resources were squandered, vegetables were allowed to rot on the ground and mass starvation was the result. And where there is starvation, there is plague.

Plague. Lest we forget: there was, and remains to this Thanksgiving Day, an unbreakable connection between economic productivity and public health. The Plymouth Colonists' very survival was threatened (and they had neither NHS nor ObamaCare).

After 2 1/2 years, the leaders of the Plymouth colony decided to abandon their socialist charter and create a different system - one which honored private property.

Under their new system, the colony not only survived but thrived, and the abundance which resulted was celebrated at the iconic First Thanksgiving feast.

More here.

May everyone enjoy a peaceful Thanksgiving Day with our families and loved ones - and may we also not forget where the bounty of our great country actually comes from.

Winning Carrier Trick

Bob's written before about P.A.R.E. claims (Pathology, Anesthesiology, Radiology, Emergency), wherein certain providers choose not to participate in networks, and thus are free to charge pretty much what the market will bear. While there's not much one can do about that, one can at least reasonably expect such providers to follow the rules that are in place.

Like not double-billing for the same procedure:

"Blue Cross and Blue Shield of North Carolina ... argued that radiology practices were charging double for services provided only once and wanted the opportunity to cut reimbursements. It estimated that some $16 million was improperly charged annually because of this billing method."

That's not exactly pocket change.

As one might expect, the radiologists cried foul, arguing that this was tantamount to a contract re-negotiation without, you know, negotiation. BX countered that they were simply looking to "protect consumers and our customers from unreasonable charges."

In the end, the Tar Heel State's Department of Insurance sided with the BX folks; the losers doc's retain the right to appeal the decision in court.

[Hat Tip: FoIB Jeff M]

Die, Baby, Die (MVNHS© Edition)!

Turns out, it's not just our Neighbors to the North whose health care "system" has no real use for the weakest among us. Across the pond, the Brits' Much Vaunted National Health System© has its eye on the prize, as well:

"A mother has described how her baby was left to die 'like an abandoned animal' after hospital doctors repeatedly ignored her desperate pleas for help."

Hayley Fullerton, barely a year old, had survived a major heart procedure, but experienced complications that left her struggling to breathe. Her mother tried, desperately but unsuccessfully, to get those compassionate government health care "providers" to even look at the little girl.

Of course, they couldn't be bothered.

Nearly 3 years later, an official inquest concluded that "there had been 'serious failings' in Hayley's care."

Um, dunh?

Oh, but there's a bright side:

"Birmingham Children's Hospital admitted full liability for her 'avoidable' death."

See, everything's doddle!

[Hat Tip: Power Line]

MedTourism close to home

One of the issues we've had with the Not So Vaunted Health System© is that health care is becoming more scarce. As providers scramble for a way to stay in business, the cash-only model of health care delivery seems to be growing in popularity.

On the other side of the ledger, employers looking for ways to rein in health care costs are thinking outside the box, as well:

"This year, grocery giant Kroger Co. has flown nearly two dozen workers to Hoag Orthopedic Institute in Irvine and several other hospitals across the U.S. for hip, knee or spinal-fusion surgeries in an effort to save money and improve care."

As Bob reported last week, Wal-Mart is offering its employees free heart and spine surgery at a half dozen health centers of its own.

A major challenge is, as we've so long lamented, the lack of consistency and transparency in the cost of health care. Compounding the problem is the fact that there are separate fees for each service, so that a patient receives a bill from the hospital, the surgeon, the anesthetist, and so on. So-called "global billing" hasn't really happened, so employers are taking a cue from the cable and phone companies, putting together "bundles" that can help hold costs down and make price negotiations more meaningful.

As Rand Corporation's senior policy analyst Susan Ridegly puts it:

"We want to stop paying by the widget in healthcare."

Well said.

Ohio Draws a Line [UPDATED]

[Although we rarely do this, I am changing the published headline of this post to more accurately reflect what's actually going on. HGS]

This just in:

"Ohio will let the federal government run its health care exchange, a key portion of health care reform, Gov. John Kasich said today."

Oh, well, guess that means we avoid a nasty state constitutional crisis.

And this is priceless:

"Benefits of a federal exchange start with cost ... annual operating costs of a state exchange would range from $19 million to $34 million, excluding technology. Fees from providers and insurers would pay most of those costs." [emphasis added]

Yeah, be sure to let us know how that works out.

Not to mention: Buckeyes now get the privilege of susbsidizing the folks in states that set up their own Exchanges, forcing up our costs while driving down theirs (at least for a while).

Yippee!

[Hat Tip: FoIB Holly R]

UPDATE: Unlike Ohio's Gov Kasich, Pelican State Gov Bobby Jindal was a bit more forceful in rejecting a state-built ObamaExchange. Co-blogger Mike tips us to the Governor's official rejection:

"The full extent of damage the PPACA causes to small businesses, the nation’s economy, and the American health care system will only be revealed with time. The State of Louisiana has no interest in being a party to this failure by implementing a state based exchange."

That's gonna leave a mark.

UPDATE THE 2ND: And now add Texas to the list:

"Texas Gov. Rick Perry officially notified the federal government on Thursday that the state will not set up an exchange to help people buy health insurance."

I'm wondering if perhaps thinking that my title for this post was inappropriate.

Hmmm....

UPDATE THE 3RD: Thanks to the folks at RedState, here's the latest tally of states which have told Shecantbeserious to take a flying leap off the nearest ObamaExchange:

Oklahoma, Okay?

A month ago, Bob posted on a "unique practice at the Surgery Center of Oklahoma" which accepts only cold, hard cash on the barrel head.

No insurance, no Medicare or Medicaid, no third party payors of any kind.

So, how's that working out for the folks who run the joint?

From the horse's mouth:



[Hat Tip: Hot Air]

Consequences and Eddies

The fallout from the recently affirmed Not So Vaunted Health System© continues to build. And it's not just pizza, but a host of seemingly unrelated institutions.

FoIB Jeff M tips us to the recent announcement by Wake Forest Baptist Medical Center, which has recently axed almost 1,000 employees as a result of "the challenges of health-care reform, federal budget deficits and a decline in research funding from The National Institutes of Health and private industry.”

But it's not just the Baptists. At the other end of the spectrum, "the Roman Catholic church will not comply with the Obama administration requirement that most employers provide health insurance covering birth control." This is in response to the convenience items birth control mandate handed down by HHS Secretary Shecantbeserious.

And the hits just keep on comin': Palm Beach, Florida restaurateur John Metz has come up with a novel way to unbundle the extra costs of the NSVHS©. He's planning to "charge his customers a five-percent surcharge and decrease his employees’ hours to offset the costs of Obamacare on his businesses."

That's really a two-fer: by specifically noting the extra charge, customers get a real-world intro to the extra costs the train-wreck imposes on business. And servers get to see the effects of these costs on their own lives, both in terms of fewer hours (and lower net pay) and, presumably, lower tips (and thus lower net pay) as customers decide how much that service is worth versus the surcharge.

Talk about a Grand Slam.

Merp, Merp!

Hard to believe, but we really haven't covered Medical Expense Reimbursement Plans (MERPs) much here at IB. Back in August, Nate alluded to them when discussing small group plans and Health Reimbursement Arrangements (HRAs). MERPs allow an employer to help employees pay their health insurance premiums (among other things). Hamilton County (OH) is trying one out in an effort to manage its out-of-control health insurance costs by encouraging its employees to bail on the County plan in favor of a spouse's (or another job's).

It's kind of a neat deal, actually:

"Hamilton County, which employs about 4,000, is doing everything it can to prevent layoffs ... The MERP Hamilton County is implementing is a bit different from a traditional MERP ... The plan reimburses medical expenses incurred under “alternate coverage”

To get the full benefit of the plan, an employee has to waive off the County insurance plan in favor of the aforementioned spouse's or other employer-based health insurance plan. Interestingly, that plan cannot be a Health Savings Account. No can do? Fine, then stay on the County plan, but count on getting dinged more on your premiums.

And there's this: in addition to reimbursing an alternate plan's premiums, the new MERP will also help towards that plan's out of pocket expenses (deductibles, co-pays and the like). Even with all that, the county is looking to save upwards of $3 million next year.

Getting folks off group plans isn't new - we've seen this trend for a while. But it's generally been a "if you can go on your spouse's plan, you must go on it" type of deal. This "carrot" instead of "stick" approach may be the next big thing.

Thanks, Bob, for the tip!

Um, D'unh?!

I don't get why this would be "news:"

"Obamacare to Jack Up Insurance Premiums ... According to a survey from the National Business Group on Health, employers  expect their health insurance costs to increase 7%."

Hey fellas? Stop inhaling: only 7%? You wish.

And this:

"60% of those employers plan to ask workers to pay higher monthly premiums."

Also ignores reality. As we pointed out many years ago:

"Companies do not pay taxes, and they do not pay for health insurance.

In case you missed that, let me repeat: Companies – businesses – pay neither taxes nor insurance premiums.

Companies do collect (sales) taxes, and pass them on to the states in which they do business. They also include any business taxes due in the price of the product or service. They pay employees a portion of their salary, and forward the balance to the insurance carrier (and/or state government).

They do not actually pay the taxes, nor the insurance premiums."

So this whole notion that employers are going to be asking what employees they have left to "contribute" more towards their premium is silly. And it ignores the fact that a lot of employers will be dumping either full-time employees or their group health insurance plans. Or both.

Of course, we'll continue to hear about how it's all the fault of business, but the reality is that businesses exist to make money, not to pay increasignly high labor costs (such as health insurance premiums). And now that our own Not So Vaunted Health System© (nee: ObamaCare) has been affirmed, this is just the beginning.

Kinda wish we'd read it before they passed it, no?

Can you hear me now?

The Brits' Much Vaunted National Health System© (MVNHS©) has long been a passion of ours, for (mostly) obvious reasons. The latest installment in the long-running joke that is the MVNHS© demonstrates what happens when physicians answer to bureaucrats:

"Doctors are failing to really listen to patients' views on how they want to be treated ... Involving patients in discussions about treatment could cut the cost of healthcare around the world"

Now, I'd take issue with that last - after all, "the world" is a pretty big place, and that which works in one country or culture might not translate so well to another - but the greater point is that docs in government-run health care schemes are accountable to the government, not their "patients." Indeed, since the government pays the bills, the patient really has little (if any) say.

The problem is that the payer (government) isn't the patient, who may well know best what it is that needs to be done:

"[P]reference misdiagnosis" - misinterpreting or ignoring the patient's wishes - is a significant problem which is damaging to both doctors and patients ... it can lead to, what they call, "silent" misdiagnoses - when doctors choose the wrong treatments because they fail to assess their patients' preferences correctly."

This was one of the most important aspects of consumer-driven health care (now outlawed under our own Not So Vaunted Health System©): transparency and financial empowerment (the premise and promise of Health Savings Accounts) did, in fact, rely to at least some extent on the patient's engagement with their provider.

As under the British system, the absence of this interaction can lead to devastating consequences:

"In one study they looked at, doctors believed that 71% of patients with breast cancer rate keeping their breast as a top priority, but the figure reported by patients was just 7%."

Of course there are trade-offs (life is, after all, a series of them), but divorcing the patient from his or her own care decisions seems a pretty drastic one. Of course, the person (or institution) with the gold makes the rules (cf: IPAB Death Panels).

[Hat Tip:Dr Dino Ramzi]

Cavalcade of Risk #170: Risky Business

Louise Norris at Colorado Health Insurance Insider presents an outstanding Cavalcade this week. Interspersed with risky quotes and photos, it's obvious that she's read all the entries, and provides helpful context for each one.

Do check it out!