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Volume 65, No. 2 February 2009
In his alleged pay-to-play scheme to sell Barack Obama's
Senate seat, Illinois Governor Rod Blagojevich did only one thing
wrong, said Meredith McGehee of the Campaign Finance Center: "he
was stupid enough to say it out loud."
The scheme itself is not much different from the usual
American political enterprise only more blatant and caught on
tape by the FBI, writes Allan C. Brownfield (Conservative
Curmudgeon 1/9/09). The power to make or destroy an
enterprise or even an industry is worth a lot of money.
Sen. Charles Schumer (D-NY), for example, is said to have
precipitated the run on IndyBank. Yet he used his position on the
Banking and Finance Committee to weaken oversight of persons
writing the checks to fund his political ambitions, and saved
the financial industry billions (ibid.).
Conflicts of interest are rife, especially in the revolving
door between Goldman Sachs and the U.S. Treasury Dept. Secretary
Henry Paulson had to divest himself of $500 million in Goldman
Sachs stock to assume his position, but was exempted from some
$200 million in capital gains taxes by a special rule (www.marketwatch.com
6/30/06).
The secrecy that surrounded the Clinton
Task Force on HealthCare Reform, challenged by AAPS in
AAPS v. Clinton,
was minor league compared with that surrounding the massive
Treasury rescue/bailout, the Troubled Assets Relief Program
(TARP). The Federal Reserve has refused to answer a Freedom of
Information Act (FOIA) request by Bloomberg News to
disclose the recipients of $2 trillion in emergency loans and the
assets the central bank is accepting as collateral, citing
potential harm to the bank's customers. Bloomberg filed suit Nov
7.
Yet the Fed is proposed as a model for controlling American
medicine by HHS Secretary-designate Tom Daschle, who cites Alan
Greenspan's 1996 speech on the need for transparency in his book
Critical: "It cannot be acceptable in a democratic
society that a group of unelected individuals are vested with
important responsibilities, without being open to full public
scrutiny and accountability."
Payers and Players; Tax Sink to Tax Source
"Health care" constitutes some 16% of the GDP, and 85% of
the amount flows through a third-party payer largely through
"proprietary" channels, so that who pays how much for what may be
very difficult to discern. The average family is spending 20% of
its consumption on health-related expenses, hidden in taxes,
lower wages, and cost-shifted health insurance premiums, notes
John Goodman (NCPA Health
Alert 10/3/08). Health spending also absorbs more than
one-third of state and federal tax revenues (JAMA
2008;300:1929-1931).
At the same time that we purportedly are not
spending enough for uninsured persons, chronic care, and
preventive care, overall spending is helping to bankrupt
the economy.
Would-be reformers clearly intend to decrease
expenditures in the long run, while offering undisclosed
deals to potential opponents. Ultimately, private
insurance could be destroyed but in the short term,
preferred companies could gain 47 million new enrollees.
As promised "savings" will be delayed if they occur at
all new funds are needed. While rejected if it means self-
payment of medical bills, "individual responsibility" is the
new watchword for mandatory insurance.
Forcing individuals to "contribute" to the third-
party system by purchasing a product they would
otherwise reject amounts to a new, privatized form of
taxation a highly progressive tax, in the AMA's version.
High earners would have to pay two to three times as
much for the same government-dictated insurance plan as
low earners in addition to taxes they would pay to
subsidize low earners' purchases.
A Health Dictatorship?
The U.S. Federal Reserve System has "skillfully
managed monetary policy for decades, while earning a
reputation for political independence," Daschle writes. It
enables politicians to "tacitly support the Fed's wrenching
policies without having to embrace them publicly" the
perfect means for distributing pain, while making it
pointless to write to Congress.
With fewer tools at their disposal 40 years ago,
"individual doctors didn't need much outside guidance to
help them select the best course of treatment for their
patients." But with our "national bias in form of
innovation," new treatments continue to proliferate, so it
will be "increasingly difficult for politicians to
make the right healthcare choices [emphasis
added]."
Hence the need for an expert entity, impervious
to the "human shield" strategy employed by doctors,
hospitals, and drug companies. Something like the British
National Institute for Clinical Excellence (NICE) and the
U.S. Securities and Exchange Commission (SEC). It
would "even out [level down] the delivery and efficiency
of care," figure out what works, improve quality, and
control costs. Like the Fed, it will be accountable to Con-
gress which could dismantle it at any
time.
Can the Bubble Be Re-inflated?
A world economy based on borrowing sums that
cannot realistically be repaid is unraveling. Public
insurance plans are a major component of the unfunded
liabilities. The most viable sectors may be plundered to
divert resources to the politically powerful players
desperate to restart the game. It may not succeed. A
financial collapse is already well along.
Saving the seed corn, and preserving the custom
and culture of the medical profession, must be our first
priority. The destruction of private medicine turning
doctors into automata, and patients into expendable
components of "population health" is the main goal of a
Health Care Fed.
From observing the collapse of the Soviet
Union, Dmitry Orlov outlines the stages: (1) financial
collapse; (2) commercial collapse; (3) political collapse; (4)
social collapse; (5) cultural collapse (Energy
Bulletin 11/01/08).
Orlov notes that "a shrinking economy cannot
sustain an ever-expanding level of debt." The loss of the
ability to finance oil imports will be a tipping point. He
believes that the U.S. has not yet experienced any of the
major, earth-shattering realizations "the ones that look
preposterous immediately before and completely obvious
immediately after they occur."
Social collapse is guaranteed to happen, he
writes, whenever society is utterly dependent on finance,
commerce, or government. The responses needed to stave
off the unthinkable include: (1) learning to live without
much money; (2) providing for basic needs; (3) local self-
government; (4) cohesive community with mutual
responsibility; and (5) classical human virtues.
As Ludwig von Mises noted, "there is no means
of avoiding the final collapse of a boom brought about by
credit expansion." The choices are sooner, from voluntary
abandonment of further credit expansion, or later, as a
final catastrophic destruction of the currency.
In May 2000, the CEOs of Partners Health Care
and Blue Cross/Blue Shield of Massachusetts shook hands
on a deal that BC/BS would give a huge insurance
payment increase to Partners, and Partners would not
allow other insurers to pay less. This "market covenant"
was not put in writing lest it raise concerns about
anticompetitive behavior between the state's biggest
hospital company and biggest insurer. It marked the
beginning of a rapid escalation in Massachusetts insurance
prices. Partners now dominates what was once one of the
most competitive markets in the world, with networks
big enough to overwhelm competitors and intimidate
insurers.
"I'm not being cute here," said Partners board
chairman Jack Connors. "I don't ever remember anyone
suggesting that if we merged, healthcare would become
cheaper."
The best kept secret in Massachusetts medicine is
that elite hospitals are paid much more for care that is
often no better than average (Boston
Globe 11/16/08, 12/28/08).
"It's 'proprietary' information," explains Russell
Faria, D.O. "We cheat and we don't want anyone to
know."
"I believe that banking institutions are
more dangerous to our liberties than standing armies. If the
American people ever allow banks to control the issue of
their currency,...the banks and corporations that will grow
up around the banks will deprive the people of all property
until their children wake up homeless on the continent their
fathers conquered." -- Thomas
Jefferson Debate over Recharter of the Bank
Bill (1809)
It was a pleasure to present "How to Finance
Free-market Medical Care" at your annual meeting in
Phoenix last September (click here to watch video). I often get
requests for "noncovered care," or requests from my HRA
clients for medical care for which they intend to pay cash.
They want a doctor not burdened by financial and time
constraints imposed by third-party payer contracts. For
these clients, I market their cases to a list of doctors much
as I would market a client to a list of insurers, with the
client making the choice. AAPS members interested in an
occasional cash referral can contact me: Ralph Weber,
CLU, (888) 720-8889, or by email at [email protected].
The media and its politicians never tire of
quoting the Institute of Medicine's estimate of 98,000
annual deaths from medical errors, though the flawed
methodology has been debunked (AAPS
News 1/00, 4/00, 3/04, 4/06, 9/06). For all the panic, there have
been only three patient safety studies, done in 1974, 1984,
and 1992, notes John Dale Dunn, M.D., J.D., in
Heartland Perspectives 2006 (cited in Dr.
Del Meyer's Medical
Tuesday, January 2009). All showed about
a 1% rate of some kind of negligent error, and a less than
0.25% rate of negligent injury or death. The 1992 rate
was half that of the 1984 rate; a reduction by 50% was the
Institute of Medicine's stated goal. As A.E. Miller, M.D.,
of Idaho pointed out, the reviewers did not and could not
estimate the potential life-days lost as a result of the
error; some patients were terminally ill.
It is not at all obvious that the U.S. has worse
health outcomes or even higher per-capita expenses than
nations with socialized medicine, writes Linda Gorman.
On measures such as sickness and disability prevented by
rapid access to care, cardiac and cancer survival, hospital
adverse events, and blood pressure control, the U.S. is
better (AAPS News 12/06; www.westandfirm.org/docs/Gorman-01.pdf).
Other nations rampantly suppress medical
professionals' income, and cost calculations vary by
currency conversions and measures of health spending. It
is unlikely that the Japanese or Scandinavian system
would perform well with a heterogeneous population as
in the U.S. Illegal aliens, who make up some 5% of the
U.S. population, would not receive
standard care in Canada, notes Gerald Yorioka, M.D., of
Washington State.
"We must not compare our apples with billiard
balls," writes Dr. Yorioka.
Jan 30, 2009. Arizona chapter, Prescott,
AZ.
Feb 6-7, 2009. Workshop, board
meeting, Dallas, TX.
Sep 30-Oct 3, 2009. 66th annual
meeting, Nashville, TN.
Overturning a lower court decision, the
California Supreme Court ruled that hospitals and
doctors may not bill patients for emergency care not fully
paid by their health plans. It found that any billing
disputes over emergency care must be resolved solely
between providers and health plans.
Since 2006, 1.75 million Californians who
received emergency treatment were billed about $528
million for charges beyond their copays, deductibles, and
reimbursed amounts. The average bill was for $300
(Sacramento Bee 12/14/08).
Connecticut, Pennsylvania, and Alabama have
also banned balance billing, according to the California
Department of Managed Health Care (Wall St
J 1/8/09).
In New York, the billion-dollar profit generating
HMO industry is attempting to set default rates for
reimbursing noncontracted providers. MSSNY and other
organizations testified that this would devastate the
state's emergency care safety net. They note that the
market power of the five plans with 75% of the managed-
care market makes it impossible to negotiate needed
changes. HMO net income per subscriber is twice as high
in New York as in New Jersey, and three times as high as
in Connecticut. Employer premiums have doubled over
the past decade, while coverage has been cut (Med
Soc Bull Counties of Erie and Chautauqua,
winter 2008).
The NY Medicaid Fraud Control Unit reported
bringing in $551 million in FY 2008 from criminal, civil,
and administrative recoveries for fraud, waste, and abuse.
This was twice the amount required by a 2006 agreement,
and nearly twice the total recovered in all other states
combined. It included mistaken payment to managed-care
plans for deceased or imprisoned persons (BNA's
HCFR 12/17/08).
Responding to AAPS allegations that sham peer
review is "epidemic in this country," the AMA House of
Delegates passed a 2007 resolution directing the Board of
Trustees to investigate. In B of T report 24-A-08, Edward
L. Langston, M.D., Chair, writes: "Since the passage of
HCQIA in 1986, the AMA is aware of only exceptional,
isolated instances of peer review determinations that have
resulted from improper motivations, rather than a good
faith desire to improve patient care." As "proved cases,"
Langston lists Patri
ck v. Burget, two cases identified by a
Colorado legislative committee,
Rosenblit v. Superior Court, Clark v. Columbia/HCA Information
Services, and the Poliner case, noted to be under appeal.
(This is the only reference to Poliner on
the AMA website.)
Langston details the difficulties of proving a case
and the legal disincentives against bringing it. While
these might explain the paucity of cases, it is "more
likely...[that] peer review abuse is a rarity." A claim of
inappropriate peer review may be difficult to prove, but
not impossible. "If abusive peer review were indeed
'epidemic,' there would probably be a more substantial
track record of definitive and proven malfeasance. The
absence of such a record suggests that the claims of
widespread or frequent 'sham peer review' are
speculative."
Policy H-375.983 provides "guidance to medical
staffs" on procedural safeguards; amendments creating
"further complex-ity could obscure its value as an
understandable guideline."
In the Petitioners' Reply Brief in
Poliner v. Texas Health System supporting
a Supreme Court review of the Fifth Circuit decision, Dr.
Poliner's attorneys note that "If Poliner
stands, abuse of peer review for malicious purposes will
remain unchecked...." Powerful groups such as hospital
associations and systems, insurance companies, and large
hospitals joined in an amicus opposing Poliner before the
Fifth Circuit.
The Fifth Circuit's decision means that
there is apparently no evidence that could
be used to rebut a presumption of "reasonable belief."
Hospitals can, with impunity, recite "facts" that are
simply not true or are misleading, and the jury's fact-
finding role is usurped in cases in which immunity is not
determined as a matter of law.
See
www.aapsonline.org for Petitioners' brief
and the AAPS amicus, and the winter
2008 issue of J Am Phys Surg.
From an email from Lorraine T. Doo of CMS to
an AAPS member: "[M]y colleagues...directed me to a
form that patients use to bill medicare for reimbursement
directly, which does not require a provider's NPI. Are
you already familiar with this form... [www.cms.hhs.gov/cmsforms/downloads/cms1490s-english.pdf], and are your
patient's [sic] trying to use this form for
Medicare reimbursement unsuccessfully? Do you know if
any of the other insurance carriers have similar forms? It
would seem likely that they do, and perhaps the patients
can be encouraged to call their health plans or insurance
carriers to request access to such a form either on line or
[by] mail.
"With respect to labs, pharmacies and
clearinghouses navigating with alternative provider
numbers when dealing with non covered entities, these
entities should already have those systems in place. CMS
has provided ample education on this subject, and those
organizations can access the CMS website for specific
instructions; certainly from a Medicare perspective. Each
health plan would have similar guidance. If there are
specific entities with whom you are having difficulties,
please use our system to file a complaint so that we can
work with those organizations directly. https://htct.hhs.gov/aset/. We'll be happy to contact any one who
continues to have difficulty accommodating either NPIs,
or providers who do not have NPIs."
AAPS members are invited to share
communications with CMS or insurers (write [email protected]).
Citing a desire to "rededicate my energy and
focus on my family, my practice, and my community,"
Roberta Kalafut, D.O., stepped down as president of the
TMB, a position she had held for 3 years. Her term was
not due to expire until 2013. She has been appointed by
Gov. Rick Perry to serve on a district review committee,
in which capacity she will attend disciplinary hearings
and help determine their outcome.
Kalafut is the third key board official to resign
since AAPS began calling attention to conflicts of
interest, abusive secret proceedings, and draconian
enforcement measures. Previously leaving the TMB were
Keith Miller, M.D., former head of the TMB Disciplinary
Process Review Committee, and Donald Patrick, M.D.,
J.D., former executive director. Director of Enforcement
Mari Robinson, J.D., is interim executive director.
Pirates, Congressmen, and Medicare.
Reading through an article entitled "Boomtowns have
pirates to thank," it occurred to me that there's little
difference between Somali pirates and congressmen. Both
take things that don't belong to them. Pirates take
hostages and collect ransoms. Congress holds taxpayers
hostage and collects taxes. Both live in high style on
other people's money. "The pirates [congressmen] depend
on us [to vote], and we benefit from them." "There are
more shops, and business is booming because of the
piracy." [There are more motorized scooter dealers, and
business is booming because of Medicare.] "In Haradhere,
residents came out in droves to celebrate as the looming
oil ship came into focus." [Seniors celebrate the expansion
of Medicare.] "I can buy a packet of cigarettes for about
$1, but I will charge the pirate $1.30." [HMOs charge the
government 12%-15% more to care for Medicare
hostages.] "[R]egional officials say they have no power to
stop piracy....[which] is generally considered a sure bet to
a better life." [Many in the U.S. think that government
subsidies are a sure bet to a better life.]
Meanwhile insurance premiums for ships are
going up, and some ships are looking for alternate routes
so as to avoid the pirates. And some physicians are
looking for alternate practice models so as to avoid
Medicare.
What will happen when there are no more ships
to loot? Or when people are taxed into poverty, and there
is no incentive to work?
Computers Can Be Dangerous. While
doing my part to keep my medical costs down
(exercising), I watched the old movie The
Net with Sandra Bullock and Dennis Miller. It
concerns a corrupt billionaire who is trying to take over
the country by selling a security system to fend off
cyberterrorists, while creating the attacks so he can sell
his system.
Dennis Miller's character is killed when the bad
guys hack into the hospital's system and change his
diagnosis from penicillin allergy to diabetes. Then the
nurse kills him by following a computer-generated order
for insulin.
Even now, nurses are so overburdened with
computer charting that they can easily not know their
patients. Computers are fantastic tools, but we need to
control them, not they us.
Public Misconceptions. Many people
don't know they can file their own insurance claims or
pay cash and get medical care. They've been convinced
that no insurance = no care!
Letter to a Colleague. Why do
physicians continue to fall for government/insurer
schemes such as "pay for reporting"? Quality can't be
measured by bean counting, and if it could people would
just game the system. What will it take to show them
that these meddlers are a mix of academics, who want to
impose their ideology; politicians with a passion to rule
others; and financial types who want a scheme to
maximize profits? We do not need these people, none of
whom share our knowledge, motivation, or ethics, to tell
is how to "improve" what we are doing. They have done
nothing except cook up ways to waste our time and
interfere with our work. They need to leave us alone,
instead of manipulating us to serve their ends. Why do
you help them and cooperate with them?
How Much Do Patients Want EHRs?
Patients say they want their doctor to use an electronic
health record and e-prescribing, but they don't want to
pay for it, and neither does anybody else. How about $10
extra per visit for a year to pay the initial cost, and $5
forever to pay for maintenance and upgrades? Nobody is
asking the question because we already know the answer
to it.
Zero Care. According to the Physicians'
Foundation survey, 49% of U.S. physicians plan to reduce
or quit their practice within 3 years. "Insuring" all
Americans means nothing if there are no physicians. The
government and insurers have regulated medicine to the
point that there is no care. There are
reimbursable events, but no relationship. Doctors are
done.
End the Zero-sum Game. Balance
billing is the way to allow both primary
physicians and specialists to get paid adequately.
Otherwise, where will primary physicians send patients
when they need specialist care? To the medical homeless
shelter?
Medically Homeless. In one country I
recently visited, you don't have "a doctor." You just go to
a clinic, where your record is retrieved from a computer
and you are seen by someone, doctor or nurse. Come
early because there are no appointments, and the doors
are locked after the day's quota of patients has arrived.
The average wait for surgery is 3 months. Because of a
shortage of radiologists trained to read them, the
Ministry of Health may stop routine mammograms!
"Universal health care" sounds comforting and
supporting, but results have been consistent around the
world: bureaucracy, high costs, high taxes, and rationing
of services.
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