Archive for the ‘medicine’ Category

Medicine and Evolution.

Friday, February 7th, 2014

A Final Word: I went by that site today to see what additional comments might have been posted after I left. Here is what remained:

I was referring to your claiming that people were being dishonest in their claims not to be YECs. It’s not that you disagreed with the values expressed by their self-identification, it’s that you didn’t accept that they were who they claimed they were. This makes productive conversation much more challenging.

Does that make sense?

I didn’t claim that people were secret YEC members. I commented that I was astounded at the vehemence of people who described themselves as “non-creationist Christians,” at attacking a person who supports and thinks evolution will be important in medicine in the next 50 years. Read some of the comments in italics below to see if I am overstating this.

I am very concerned, after this, at the role of Fundamentalist Christians in the GOP. They are far less tolerant of other opinion and resemble the global warming alarmists in the unwillingness to allow dissent.

Update #4: I am saving some of the material from the thread to remember what Ricochet is like.

The pseudo sympathy: Mike, frankly, you never had them straight in the first place. The entire thread, you thought you were fending off attacks from a group of Young Earth Creationists, but there was only one YEC among them. The rest of them were believers in one form of evolution of another, and just upset with your attitude.

Attitude !

Do you bear any of the blame for making this thread so unpleasant? I’m perfectly willing to have a discussion with you, and I’m semi-sympathetic to your viewpoint. I’m definitely not a YEC. But I can’t understand why you are being so flippant.
Flippancy is the problem !

No, you’re not. You might try reading the thread. I’ve been listing all the insults over on my own blog as a study of how this happens.

“Mike, I am personally not a young-earth creationist, but I think you are confusing two concepts here. ”

I’m always the one confused. Explained by the Ivy League.

This: “Or would he create a universe that showed millions of millennia of age, even though it was only seconds old?”

Led to this: “It’s nice that you all believe this. Good luck. Let’s hope your doctor doesn’t.”

Now that was my mortal sin to the crowd here. From that the following resulted:

“You are very flippant in dismal of my case for faith. Once again I have no problem believing that someone who believes that God put together the world in 6 days .”can also understand the significance of mitochondria. ”

I doubt that. Instead: “I have a far greater trust of a doctor who believes in God and lives it in his own life rather than one who is merely technically competent and sees the universe, and my life, as a happenstance of evolutionary doctrine.”

Now, the folks who are denying this is about creationism and is about my “attitude” seem to ignore those parts.

“Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent. ”

Now there’s a thoughtful statement.

” If I’m just an expression of evolutionary pressures, he might want to trim it up. (Has the advantage of being supported by all the various eugenics of recent history, including the ongoing slaughter of those unborn suspected of having genetic illnesses.)”

So now abortion has been dragged into it.

“You slander many very good doctors with your dismissive remarks.”

And I’m the problem.

“But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.”

More friendly repartee.

“In my opinion, the whole argument is silly. Humans simply don’t have the intellectual capacity to comprehend the creation. It’s like a dog trying to understand how a television works;”

More brilliance. My tolerance for this is less than yours or you didn’t read it.

“Mike has argued that we should (or, at least, he would) place professional barriers before those who disagree with his creation myths ”

Another mis-statement of what I wrote. I only mentioned my own letter writing which was not a barrier the last time I checked admission requirements.

“You are the one who said that you would keep Creationists out of med school.”

More mis-statement.

“Believing that the paleo- fields have very badly miscalculated the age of the earth has nothing at all to do with the ability of a doctor to conduct medicine. ”

I guess you agree. I don’t.

I then gave up. This colony of creationists, even those who deny they are “YEC,” wore me out.

UPDATE #3: The attacks continue and it has been several days !

I am also a Christian who doesn’t hold to a YEC point of view. (I would also add, although I hate to flaunt credentials, that I am a more recently trained physician than you, Ivy-League-trained, and hold a faculty position at a medical center that’s a bit fancier than yours.)

So there ! I have decided that I am a Libertarian and not a conservative, if that is what this is about.

UPDATE #2 The pushback has finally succeeded in making me a villain.

(Yes, I know the things I cited don’t make him right about YEC, necessarily. My point is that he’s been successful despite Mike K insisting that people like him should be prevented from being doctors.) ·

This followed a long list of accomplishments by a supposed acquaintance who had had a successful career as, as best I can tell, a pediatrician. This all began with my comment that, aside from not being willing to recommend a student who did not believe in evolution for medical school, I was neutral. I think I am no longer neutral. The “Young Earth Creationist” community seems to have a determination to oppose any evolutionary thinking by anyone. They also seem to have an very convoluted way of explaining why obvious facts are not as they appear.

UPDATE: The pushback from creationists surprised me a bit. I guess it shouldn’t have. I expected “We will just have to agree to disagree” sort of thing. Instead I got an interesting series of attacks on me.

Is it impossible for the Creator to have built all the evidences of age into His new creation? The reality of natural selection isn’t necessarily required to have a long and indefinite period of activity to apply today.

and

Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent.

and

There are plenty of good Christian doctors and biologists who are well-versed in cell biology and in how mutations happen and in natural selection processes that affect microbes and higher organisms.

This all reminds me of the epicycles, which were used to explain why Ptolmeic astronomy could not explain certain phenomena like the movement of planets. It took Kepler’s discovery of the elliptical orbits to resolve the matter finally.

The creationists seem determined to ignore the implications of molecular biology about evolution and maintain “Young Earth Creation” in the face of the evidence of ancient biology.

But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.

Even Copernicus wanted to learn why the planets did not follow the rules of Ptolmeic astronomy. Today, that is considered rude. I may have to reevaluate my opinion of creationists. I have considered them harmless ill educated religious fundamentalists. They are far more aggressive than I had believed in attacking any disagreement.

I accidentally got into a debate about evolution at another site today. I didn’t want to get into this as I know there are many people, many of whom share my political affiliation, who are adamant about creationism, as the left often refers to it. Still, I have posted my opinions here in the past. I think molecular medicine is going to become even more important in the future and I do not understand how a physician can understand molecular medicine without molecular biology. There are many examples of evolution that must be understood to appreciate certain areas of medicine.

I think a physician can practice as a GP and not believe in evolution. I know a few. They are not likely to understand the future of medicine but they are my age and will not be practicing for long, if they are not yet retired.

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More Obamacare news

Saturday, January 18th, 2014

UPDATE: More News.

This is supposed to be reassuring.

Obamacare contains a $25 billion federal risk fund set up to benefit health insurance companies selling coverage on the state and federal health insurance exchanges as well as in the small group (less than 50 workers) market. The fund lasts only three years: 2014, 2015, and 2016.

The government’s risk management program for the insurers has three parts (the “3Rs”):
A revenue neutral Risk Adjustment System designed to level adverse claim costs between health plans.
A Reinsurance Program that caps big claim costs for insurers (individual plans only).
A Risk Corridor Program that limits overall losses for insurers.
Of the $25 billion, $20 billion is earmarked for the Reinsurance Program and $5 billion goes to the U.S. treasury.

First, the Reinsurance Program caps big individual claim costs for insurers––in 2014, 80% of individual costs between $45,000 and $250,000 are paid by the government, for example.

Then comes the Risk Corridor program. Participating health plans will receive payments from the federal government in any of the following circumstances:
The plan’s costs for any benefit year are more than 103% but not more than 108% of the health plan’s targeted amount. The feds will reimburse 50% of all costs in excess of 103% of the medical cost target.
If the plan’s costs are more than 108% of the annual target, the feds will first pay the health plan a flat 2.5% of the target and then reimburse the plan for 80% of their claim costs above the targeted amount––with no upside limit.
Target cost is simply defined in the new law as a health plan’s “total premiums (including any subsidies) reduced by the administrative costs of the plan.” It is whatever the health plan projected its premium needed to be to pay medical costs.

The CMS has a new contractor for Obamacare, not just the web site. The previous contractor, CGI Federal, has been replaced rather suddenly.

“Accenture, one of the world’s largest consulting firms, has extensive experience with computer systems on the state level and built California’s large new health-insurance exchange. But it has not done substantial work on any Health and Human Services Department program.
“The administration’s decision to end the contract with CGI reflects lingering unease over the performance of HealthCare.gov even as officials have touted recent improvements and the rising numbers of Americans who have used the marketplace to sign up for health coverage that took effect Jan. 1.”

CGI Federal is the company connected with Michelle Obama through her classmate, a fellow Princeton alumna.

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Obamacare progression to Medicaid.

Thursday, December 19th, 2013

UPDATE: A new wrinkle appeared today. Obama now says anyone who was canceled can buy a “catastrophic plan” and keep it for a year. Of course, the “catastrophic plans offered are larded with Obamacare mandates. It is looking like surrender is getting near. The lefties look like fools but what did we expect when this thing began?

All of this, along with previous time extensions for sign-ups, suggests Obamacare is heading for a spectacularly awful January. The president is so obsessed with ameliorating the political problem that he is dismantling his own plan, bit by bit, both undermining its economic viability and aggravating voters and political allies. Is this the handiwork of the triage maven John Podesta? If so, they’ll need a clean-up man to clean up from Podesta.

The comments after this post should be hilarious. Let’s look…

Obamacare is a done deal. Obama has three more years to patiently work this through. Even if GOP takes the senate in 2014 they will not have a veto proof majority. GOP has absolutely no alternatives (except selling across state lines, which is another way of saying huh..).

Heritage foundation worked this out carefully in pre-Obama days; Romney was not stupid when he did this in Mass.; they knew that individual mandate is the only way to cover preexisting conditions (you may want to think this through if you are a bit slow….or ask anyone who works in insurance)

There is the old lefty lie about Heritage and the mandate plan from 20 years ago. This one is even funnier…

Not sure why there’s so much concern from Jen on whether Dems will stick with the President in 2014. ACA website glitches will be a thing of the past; people will find out that taxpayers are quite generous with subsidies.

The nature of Obamacare is becoming more and more clear as the months go by. A hearing before Darryl Issa’s committee brought out a few facts which have been thin on the ground lately.

Dr. Patricia McLaughlin, an ophthalmologist based in New York City, said insurers are introducing limited networks and announcing new plans that will offer only in-network benefits, excluding all out-of-network doctors.

She noted the problem of limited networks is that many health plans have substantially reduced or eliminated previous coverage options that allowed patients to see the doctor of their choice.

This is necessary as the insurers try to limit their losses as the risk pools evaporate. I haven’t yet learned if out-of-network doctors can charge cash prices. As employer sponsored plans dry up, there will be fewer contracts to be violated by offering services at lower prices. At present, a doctor who offers a cash price substantially below the contract price risks cancellation of the contract. Medicare is even more ferocious in protecting its “discounts” by threatening prosecution of a Medicare provider who offers more or cheaper services than those “allowed” by Medicare, even though payment is a fraction of the “allowed” charges.

Dr. Jeffrey English, a neurologist at the Multiple Sclerosis Center of Atlanta, said the law punishes doctors like him because he recommends too many costly procedures, such as MRIs and brain-image scans, compared to his peers.

“In reward for my passions to prevent real people from becoming disabled, CMS and insurance companies like United Healthcare are going to post negative grades in my name,” he said. “They will financially penalize me or the institution I work for, as I am trying to practice quality care to some of our most vulnerable patients.”

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Building the airplane during takeoff.

Tuesday, November 19th, 2013

Henry-Chao

We are now learning that a large share of the Obamacare structure is still unbuilt. This is not the website but the guts of the system.

The revelation came out of questioning of Mr. Chao by Rep. Cory Gardner (R., Colo.). Gardner was trying to figure out how much of the IT infrastructure around the federal insurance exchange had been completed. “Well, how much do we have to build today, still? What do we need to build? 50 percent? 40 percent? 30 percent?” Chao replied, “I think it’s just an approximation—we’re probably sitting between 60 and 70 percent because we still have to build…”

Gardner replied, incredulously, “Wait, 60 or 70 percent that needs to be built, still?” Chao did not contradict Gardner, adding, “because we still have to build the payment systems to make payments to insurers in January.”

This is the guy who is the chief IT guy for CMS.

If the ability to pay the insurance companies is not yet written, how can anybody sign up ?

Gardner, a fourth time: “But the entire system is 60 to 70 percent away from being complete.” Chao: “There’s the back office systems, the accounting systems, the payment systems…they still need to be done.”

Gardner asked a fifth time: “Of those 60 to 70 percent of systems that are still being built, how are they going to be tested?”

The answer was the same way the rest was tested.

We are halfway down the runway and the engineers are still bolting on the engines.

Of course, the unions will resist any payment for “risk corridors”

Risk Corridors are plans to bail out insurance companies that are put at risk by Obama’s “fix” by stopping the mandate penalties.

If they decide to un-cancel some plans and end up taking a beating financially from the adverse selection that results, Uncle Sam will be there to make everything right. I must have read three dozen blog posts yesterday wondering how O would be able to keep insurers on his side, working together with the White House to implement Healthcare.gov and the rest of the law, now that he’s gone and made them scapegoats for the cancellation mess. Turns out the answer’s simple. He’s going to buy them off.

Part of this is the “reinsurance” plan. The unions want nothing to do with this.

A provision in Obamacare would collect a fee from health insurance companies and third-party administrators (TPAs) of administrative services only (ASO a.k.a. self-insured) group health plans, to fund a reinsurance program to help “stabilize” premiums available through the exchanges. A significant number of unions are self-insured. Unions were pissed they had to pay this fee of between $60 and $80 per insured (now said to start at $63 and reduce in following years), and as recently as last week were demanding President Obama change the law. Obama caved.

The unions are not stupid. They want no taxes on their plans.

The tax, known as the reinsurance fee, requires self-insured organizations, such as unions and some large companies, to pay $63 for each covered member and an additional $63 for each additional family member on a health plan.

Curiouser and curiouser. Some of these guys have read the small print.

Now, it’s gotten even worse. Obama is trapped !

What happens now ?

Wednesday, November 13th, 2013

healthcaregal

The Obamacare web site now has lost its happy photo of the Obamacare girl. The fact that she is a non-citizen seems appropriate. The web site is supposed to be fixed by November 30. Will that happen ? Well, maybe not.

On Friday, the man tasked with the digital fixes said the site “remains a long way from where it needs to be” as more and more problems emerge.

“As we put new fixes in, volume is increasing, exposing new storage capacity and software application issues,” Jeff Zients told reporters on a conference call.

And at Tuesday’s White House Press Briefing, Press Secretary Jay Carney again said there was “more work to be done” on repairing HealthCare.gov.

Carney, along with Zients and other administration officials, have repeatedly said the November 30 deadline is to get the health care website working for a “vast majority” of Americans looking to enroll in the Obamacare exchanges.

So, what happens December 2, the Monday after the “glitches” are fixed ? First, they won’t be fixed. The contractor that designed the program, not just the web site, has a terrible record.

CGI Federal’s parent company, Montreal-based CGI Group, was officially terminated in September 2012 by an Ontario government health agency after the firm missed three years of deadlines and failed to deliver the province’s flagship online medical registry.

The online registry was supposed to be up and running by June 2011.

Officials at the U.S. government’s Centers for Medicare and Medicaid Services awarded six technology contracts worth $87 million to CGI Federal for Obamacare website work, according to the U.S. Government Accountability Office.

So, assuming the program isn’t working, what next ?

First, Democrats are jumping ship already.

Sen. Dianne Feinstein (D-Calif.) has decided to co-sponsor legislation from Sen. Mary Landrieu (D-La.) that would require insurance companies to continue offering their existing health care plans, becoming the most high-profile non-red state Democrat to buck party lines on the Affordable Care Act.

I don’t think that approach will work.

the “Keeping the Affordable Care Act Promise Act” would “grandfather” in all health insurance plans that existed as of Dec. 31, 2013, not March 23, 2010, meaning that insurers could continue to offer a number of plans that they have been forced to cancel under the Affordable Care Act.

The insurance industry is not going to change all this for a temporary and uncertain law change.

Even Bill Clinton is jumping ship, no doubt in the interest of Hillary’s 2016 campaign. I doubt that will help except among her most devoted followers. After all Hillarycare is the grandmother of Obamacare.

I have previously speculated on what might come next and that was early in the disastrous rollout, which I anticipated. I wasn’t the only one.

Moreover, data from existing surveys indicates that employers are quickly moving to high-deductible plans with health savings accounts, away from more expensive plans with high premiums, but low deductibles and co-pays. Notably, when employees are offered a “defined contribution” – a fixed amount of money from their employers with which to shop – they also (although not always) opt for more high-deductible options.

I think this may be the way the country copes with the ongoing disaster of Obamacare. Allow the system of high deductible insurance and health IRAs to expand. Legislation can do this. No Congress can bind another Congress.

What to do about those with pre-existing conditions ? Well, maybe the problem was slightly exaggerated.

12 million people purchased private direct purchased health insurance on the eve of Obama Care. Insurance industry studies show that one in eight applicants for private health insurance have preexisting conditions that affect their eligibility or premiums. This gives a total of 1.5 million Americans who were denied health insurance or paid higher premiums due to pre-existing conditions.

The Washington Post, of course, bought the Obama administration lie without a blink.

But must we change our whole health care system to handle a problem that affects one half of one percent? If we gave a $10,000 subsidy to each person denied coverage or paying a higher premium, we could keep our existing health-care system and solve pre-conditions for one tenth the projected cost of Obama Care.

There are other questions about motives.

You tout the Affordable Care Act as a triumph over special interests, but the stock prices of the insurance industry have enjoyed a huge run-up. Isn’t this because your program, boiled down, just throws more tax dollars at an unreformed health-care system that every analyst, including you, says spends resources inefficiently?

Insurance companies have never been enthusiastic about health insurance. I’ve worked in the insurance industry. They were co opted by Obama because they were promised (with a wink and a nod) that they would be administering a government funded program and would have “no skin in the game.” That’s what the employer health plans are and that’s what they understood to be the plan. The recent vilification of insurers risks some getting off the reservation.

Later, in discussing how he would pay for expanding health-insurance coverage, he alluded to his plan to cut the subsidy payments private insurers receive for administering Medicare advantage plans. “I would rather be giving that money to the young woman here who doesn’t have health insurance than giving it to insurance companies that are making record profits”

Then, a man who said he makes a living selling individual health-insurance plans asked Obama, “Why is it that you’ve … decided to vilify the insurance companies?”

We know he was lying. His lips were moving.

What about the poor ? Most of those signing up on the exchanges are, in fact, signing up for Medicaid.

More than 55,000 people in Washington state enrolled in health coverage in October — most in Medicaid . In fact, almost all of the people who have “signed up” for Obamacare have signed up for expanded Medicaid. They will not contribute to the risk pool; they will only draw more tax payments. Is Medicaid the best choice for the poor ? Avik Roy doesn’t think so. I have reviewed his book on the site and disagree with his proposed solution but his data is correct.

I have previously suggested the French system as a model for us. France is a large country, larger than most of the other European examples, and its system, unlike the British NHS, works well. It has been put under enormous pressure by the French unemployment problem but it still does a better job than any other I know of. The German system is older and more bound up in German traditions.

I doubt that this sort of reform is an option any longer. I think the catastrophic insurance and health IRA is the best choice for a transition now.

Why healthcare is in trouble.

Friday, November 8th, 2013

Our health care system has been built up over the years in a jury-rigged, ramshackle fashion. Before World War II, there was very little health insurance and what there was often was the product of labor union contracts. The early years were concerned with accident insurance and workers compensation laws.

The American life insurance system was established in the mid-1700s. The earliest forms of health insurance, how­ever, did not emerge until 1850, when the Franklin Health Assurance Com­pany of Massachusetts began providing accident insurance, to cover injuries re­lated to railroad and steamboat travel. From this, sickness insurance covering all kinds of illnesses and injuries soon evolved, but the first modern health insurance plans were not formed until 1930.

The Baylor program for school teachers was the first in 1929.

Medical insurance took stride in 1929 when Dr. Justin Ford Kimball, an administrator at Baylor University Hospital in Dallas, Texas, realized that many schoolteachers were not paying their medical bills. In response to this problem, he developed the Baylor Plan – teachers were to pay 50 cents per month in exchange for the guarantee that they could receive medical services for up to 21 days of any one year.

In those days, the concern was lost wages more than hospital care.

In 1939, the American Hospital Association (AHA) first used the name Blue Cross to des­ignate health care plans that met their standards. These plans merged to form Blue Cross under the AHA in 1960. Considered nonprofit organizations, the Blue Cross plans were exempted from paying taxes, enabling them to maintain low premiums. Pre-paid plans covering physician and surgeon services, includ­ing the California Physicians’ Service in 1939, also emerged around this time. These physician-sponsored plans com­bined into Blue Shield in 1946 and Blue Cross and Blue Shield merged into one company in 1971.

The modern insurance plans were very recent in origin. I was there for much of it. The commercial insurers fought the status of Blue Cross, which was not required to have reserves. Blue Cross asserted that it promised hospital care, not payment, so reserves were not necessary.

The 1940s and 1950s also saw the proliferation of employee benefit plans, and the included health insurance pack­ages became more and more compre­hensive as strong unions negotiated for additional benefits. During the Second World War, companies competing for labor had limited ability to use wages to attract employees due to wartime wage controls, so they began to compete through health insurance packages. The companies’ healthcare expenses were exempted from income tax, and the resulting trend is largely responsible for the workplace’s present role as the main supplier of health insurance.

The war produced much of this as wage limitations were in force but fringe benefits, like health insurance, were permitted. A lot of this history is contained in Paul Starr’s book The Social Transformation of American Medicine.

From the first, commercial insurers focused on employer plans while Blue Cross and Blue Shield (which was founded by the California Medical Association to pay doctor bills) were individual plans.

In 1954, Social Security coverage included disability benefits for the first time, and in 1965, Medicare and Medicaid pro­grams were introduced, in part because of the Democratic majority in Congress. In the 1970s and 1980s, more expen­sive medical technology and flaws in the health care system led to higher costs for health insurance companies. Responding to higher costs, employee benefit plans changed into managed care plans, and Health Maintenance Organizations (HMOs) emerged. Man­aged care plans are unique in that they involve a particular network of health­care providers that have been verified for healthcare quality and that have agreements with the insurer about price and related issues. HMOs were originally primarily nonprofit, but they were quickly replaced by commercial interests, and managed care only suc­ceeded in temporarily slowing the growth of healthcare costs.

Two major changes came in the 1970s. In 1978, the federal government established what were called Professional Standards Review Organizations or PSRO. All doctors had to receive training in how to do these reviews and it was immediately apparent that cost was the only consideration, not quality of care.

I decided to educate myself and took a course from an organization called “The American Board of Quality Assurance and Utilization Review Physicians. I took the exam and passed, then attended the annual meeting. This was about 1986. People I met at that meeting informed me that the exams were graded by throwing them up in the air. Any that landed balancing on one edge were flunked. Nonetheless, the experience was valuable because I could see what was coming.

I was president of the Orange County Medical Association that year and had served for eight years on the Commission on Legislation of the CMA, now called The Council on Legislation. This gave me an opportunity to meet many legislators, many state level and some federal. The impression they made on me was that few knew anything about medicine and most were not very intelligent.

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The rolling catastrophe

Monday, November 4th, 2013

Obamacare debuted on October 1. It is now November 4 and the mess is worse. I have been posting about it, here, and here, and here, and even here.

The political left is trying very hard as can be seen here.

keep-your-plan-flowchart

It’s kind of complicated so I will summarize. You are screwed !

There are accusations that insurance companies are using this to drop high risk subscribers. Maybe that is true but it is the consequence of ignorant people designing Obamacare. Did these guys ever set up a new business ? As Casey Stengel once said to the Mets , “”Can’t anybody here play this game?”

I guess not.

The New York Times has done what it can.

We are also told that “in all the furor, people forget how terrible many of the soon-to-be-abandoned policies were. Some had deductibles as high as $10,000 or $25,000 and required large co-pays after that, and some didn’t cover hospital care.” Never mind that we have seen cancellations of insurance policies with deductibles much lower, and customers forced to purchase replacement policies with higher deductibles, and with premium increases of 100%, if not higher.

Then there is this argument.

Why can’t people opt out of mental health coverage if there is not a reasonable chance that they will need that coverage? Why can’t they get mental health coverage when it is needed? After all, pre-existing conditions can no longer be denied, so in the event that mental health coverage is needed down the line, it can be obtained and the insurance companies cannot deny people who already have pre-existing mental health conditions. The Times assures us that over-coverage–and the high premiums that come with it–is “one price of moving toward universal coverage with comprehensive benefits.” They don’t explain why having unnecessary coverage is a step towards social justice, but as we saw from the beginning of this intelligence-insulting, repulsively dishonest op-ed, the New York Times is less about explaining, and more about covering up a disastrous rollout with disastrous policy consequences for the country.

Weak attempts at best.

Peggy Noonan, who has frustrated me with her obtuseness at times, gets it now.

Politically where are we right now, at this moment?

We have a huge piece of U.S. economic and social change that debuted a month ago as a program. The program dealt with something personal, even intimate: your health, the care of your body, the medicines you choose to take or procedures you get. It was hugely controversial from day one. It took all the political oxygen from the room. It failed to garner even one vote from the opposition when it was passed. It gave rise to a significant opposition movement, the town hall uprisings, which later produced the tea party. It caused unrest. In fact, it seemed not to answer a problem but cause it. I called ObamaCare, at the time of its passage, a catastrophic victory—one won at too great cost, with too much political bloodshed, and at the end what would you get? Barren terrain. A thing not worth fighting for.

So the program debuts and it’s a resounding, famous, fantastical flop. The first weeks of the news coverage are about how the websites don’t work, can you believe we paid for this, do you believe they had more than three years and produced this public joke of a program, this embarrassment?

She assumed that it wasn’t worth it if it worked !

The problem now is not the delivery system of the program, it’s the program itself. Not the computer screen but what’s inside the program. This is something you can’t get the IT guy in to fix.

They said if you liked your insurance you could keep your insurance—but that’s not true. It was never true! They said if you liked your doctor you could keep your doctor—but that’s not true. It was never true! They said they would cover everyone who needed it, and instead people who had coverage are losing it—millions of them! They said they would make insurance less expensive—but it’s more expensive! Premium shock, deductible shock. They said don’t worry, your health information will be secure, but instead the whole setup looks like a hacker’s holiday. Bad guys are apparently already going for your private information.

This is the worst that could be imagined. The New York Times is trying.

We are also told that “in all the furor, people forget how terrible many of the soon-to-be-abandoned policies were. Some had deductibles as high as $10,000 or $25,000 and required large co-pays after that, and some didn’t cover hospital care.” Never mind that we have seen cancellations of insurance policies with deductibles much lower, and customers forced to purchase replacement policies with higher deductibles, and with premium increases of 100%, if not higher. Really ?

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Update on cash medical practices.

Tuesday, October 29th, 2013

Titanic; Vancouver; 1912

I can’t resist this graphic as a metaphor for the present health care crisis.

Some time ago, in fact several years ago, I posted a piece on coming changes in health care. I didn’t necessarily recommend this for reform but it was something I saw coming.

Perhaps more than most people, Reitz, a senior HIV?AIDS scientist with the Institute of Human Virology in Baltimore, appreciated the need to be examined quickly. And thanks to a recent trend to help personalize physician care, he got an appointment the same day — but not because of his professional status.
Reitz, like any patient of Dr. Philip Henjum, can get a same-day appointment because Henjum and his partner, Dr. Robert Fields, practice retainer medicine in their Olney office.
Their patients pay a $1,500 annual retainer fee to see them as soon and as many times as they need to. They also make house calls.
As it turned out, Henjum diagnosed Reitz with Lyme disease, an infection from a tick bite, and prescribed antibiotics. If not diagnosed and treated early, Lyme disease can lead to severe headaches, muscle pain and serious heart problems.
Fields and Henjum are two of about a dozen doctors in Maryland and an estimated 600 nationally who won’t take insurance coverage. Instead, they charge a yearly or monthly retainer. Some work out of comfortable medical office such as Fields and Henjum, next to Montgomery General Hospital.

That was 2009. I added another post on Chicago Boyz in 2010. Here it is.

The reason why I believe this trend is growing rapidly is that some states, like Massachusetts, plan to pass laws requiring doctors to accept Medicare as a condition of licensure. If they were not worried, why write a law about it ? Medicare has a provision that they determine the price and there are no extra charges allowed.

A participating physician agrees that payment for Medicare services based on the fee schedule represents the approved and full charge. This means a physician cannot collect or balance bill an amount in excess of the approved charge listed on the fee schedule for services furnished to Medicare patients.

That, plus the rationing, drives most primary care doctors out of the field or, more recently, out of Medicare. Those who remain, hire Physician Assistants or Nurse Practitioners to see Medicare patients. That works for a while but PAs and NPs are still expensive.

With the passage of Obamacare, Forrest says he’s seeing more physicians aggressively search for alternatives, as he once did. Over the years, he’s helped a couple of dozen offices open across the country, and he’s started speaking at industry conferences about his practice. But in recent months, he’s been flooded with inquiries from fellow doctors. “Since the health care reform bill passed, you wouldn’t believe the number of doctors who have said they’ve had it and want to operate outside the system,” he says.

Now, Obamacare is here and we are seeing the first glimmerings of the problem coming into focus.

This was a week ago.

Health plans are sending hundreds of thousands of cancellation letters to people who buy their own coverage, frustrating some consumers who want to keep what they have and forcing others to buy more costly policies.

The main reason insurers offer is that the policies fall short of what the Affordable Care Act requires starting Jan. 1. Most are ending policies sold after the law passed in March 2010. At least a few are cancelling plans sold to people with pre-existing medical conditions.

By all accounts, the new policies will offer consumers better coverage, in some cases, for comparable cost — especially after the inclusion of federal subsidies for those who qualify. The law requires policies sold in the individual market to cover 10 “essential” benefits, such as prescription drugs, mental health treatment and maternity care. In addition, insurers cannot reject people with medical problems or charge them higher prices. The policies must also cap consumers’ annual expenses at levels lower than many plans sold before the new rules.

But the cancellation notices, which began arriving in August, have shocked many consumers in light of President Barack Obama’s promise that people could keep their plans if they liked them.

Just for curiosity, I did a search on cash medical practice in Orange County CA.

The results were interesting. Among other things, I found a bunch of family practices for sale.

I also found a long list of practices that accept cash. Quite a few have good Yelp reviews. For example:

regular physician normally does! And I was only charged $75 for the visit! (To put that in perspective, my PPO insurance copay would have been $60 had I waited another week for an appointment.

There are 15 pages of reviews. Children’s Hospital is even listed as taking cash: for his recent cold. Parking is underground $7 they take checks and cash only. Parking distance from emergency entrance is very close. We checked in soon after we were called, minimal wait… No mention of costs here but a good review.

The possible outcome of all this, and I don’t believe that employer health plans will survive, is a new system of cash payment for primary and routine care plus insurance for insurable events. That’s what we had in 1950 and it worked well. Doctors didn’t get rich but they often ran their offices with one person helping, sometimes the wife. I remember an orthopedic surgeon and family friend whose office had one large waiting room and telephone person for about 30 doctors. He was later the team physician for the Chicago White Sox so he was no slouch. He also did the first cup arthroplasties in Chicago. One of them was on my aunt.

The medical world will be changing.

Conservatives and the health care mandate ssue.

Monday, October 28th, 2013

The latest meme I’ve noticed on the Obamacare implosion is that the Republicans are to blame. After all, it’s Romneycare, or it’s the idea of the Heritage Foundation.

In fact, the mandate was promoted by Hillary in 2008 and opposed by Obama. Of course, he doesn’t know much about what is going on so we can understand. In fact, the entire website fiasco, slipped by him, unnoticed.

President Barack Obama didn’t know of problems with the Affordable Care Act’s website — despite insurance companies’ complaints and the site’s crashing during a test run — until after its now well-documented abysmal launch, the nation’s health chief told CNN on Tuesday.

Of course he may just rewrite the code himself. After all, he is so talented that he is bored.

David Remnick, editor of The New Yorker, quotes White House senior adviser and longtime Obama friend Valerie Jarrett: “I think Barack knew that he had God-given talents that were extraordinary. He knows exactly how smart he is. … He knows how perceptive he is. He knows what a good reader of people he is. And he knows that he has the ability — the extraordinary, uncanny ability — to take a thousand different perspectives, digest them and make sense out of them, and I think that he has never really been challenged intellectually. … So what I sensed in him was not just a restless spirit but somebody with such extraordinary talents that had to be really taxed in order for him to be happy. … He’s been bored to death his whole life. He’s just too talented to do what ordinary people do.”

Oh well, at least we know if we really get in trouble, we have someone who can bail us out. I don’t doubt the comment about him never being challenged intellectually.

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Where health care may be going.

Wednesday, October 23rd, 2013

Titanic; Vancouver; 1912

I couldn’t resist this graphic. It’s so appropriate for the moment.

I have watched the failed rollout of Obamacare this past three weeks and wondered where it was going. I have some suspicions. There is a lot of talk about delaying the individual mandate, as Obama did with the employer mandate. Megan McArdle has a post on this today. I think it is too late to fix or delay Obamacare.

With Nov. 1 storming toward us and the health insurance exchanges still not working, we face the daunting possibility that people may not be able to sign up for January, or maybe even for 2014. The possibility of a total breakdown — the dreaded insurance death spiral — is heading straight for us. The “wait and see if they can’t get it together” option no longer seems viable; we have to acknowledge that these problems are much more than little glitches, and figure out what to do about them.

She has already described the insurance death spiral. I think it is here.

Am I exaggerating? I know it sounds apocalyptic, but really, I’m not. As Yuval Levin has pointed out, what we’re experiencing now is the worst-case scenario for the insurance markets: It is not impossible to buy insurance, but merely very difficult. If it were impossible, then we could all just agree to move to Plan B. And if it were as easy as everyone expected, well, we’d see if the whole thing worked. But what we have now is a situation where only the extremely persistent can successfully complete an application. And who is likely to be extremely persistent?

Very sick people.

People between 55 and 65, the age band at which insurance is quite expensive. (I was surprised to find out that turning 40 doesn’t increase your premiums that much; the big boosts are in the 50s and 60s.)
Very poor people, who will be shunted to Medicaid (if their state has expanded it) or will probably go without insurance.

Levin points out: It is now increasingly obvious to them that this is simply not how things work, that building a website like this is a matter of exceedingly complex programming and not “design,” and that the problems that plague the federal exchanges (and some state exchanges) are much more severe and fundamental than anything they imagined possible. That doesn’t mean they can’t be fixed, of course, and perhaps even fixed relatively quickly, but it means that at the very least the opening weeks (and quite possibly months) of the Obamacare exchanges will be very different from what either the administration or its critics expected.

The insurance industry is already reacting to Obamacare and this will quickly become irreversible. This article is from September.

IBM, Time Warner, and now Walgreens have made headlines over the past two weeks by announcing that they plan to move retirees (IBM, Time Warner) and current employees (Walgreens) into private health insurance exchanges with defined contributions from employers.

The article calls it “maybe a good thing” but that supposes the exchanges will function. What if they don’t for a year or more ? What will health care look like in November 2014 ?

What happens next — as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package — is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again . . . until it’s so expensive to buy insurance that almost no one does.

Will that be apparent a year from now ? I’m sure the administration, and the Democrats, will do almost anything to avoid that. What can they do ? They’ve already ignored the law to delay the employer mandates. It’s too late to delay the individual mandate because individual policies are being cancelled right now.

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