Archive for October, 2013

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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Global Warming and Cooling.

Sunday, October 20th, 2013

I have been frustrated by the antics of the AGW alarmists. Scientific American, for example, has lost whatever reputation it once had for objective science. In an another example, the actions of Michael Mann should make for an interesting discovery in his suit against Mark Steyn.

Today, I find a nice discussion of global warming and cooling over the past epoch. The Greenland ice cores are, or should be, the gold standard of temperature measurement. For example.

Summary:
Records of past temperature, precipitation, atmospheric trace gases, and other aspects of climate and environment derived from ice cores drilled on glaciers and ice caps around the world. Parameter keywords describe what was measured in this data set. Additional summary information can be found in the abstracts of papers listed in the data set citations.

Now, to the data.

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Flashdance

Monday, October 7th, 2013

falshdance

I watched the 1983 movie “Flashdance” tonight. It was the big movie of 1983 and I was in England with my kids that summer. I had six teenagers and my wife Jill with me and we spent two weeks driving around the country in a VW van. We spent the first week in London and I got the kids all 7 day passes on the Underground. We rented two apartments in a building at 202 Kensington Church Street where I had stayed many times before.

202 kensington

The building is in the Notting Hill area which has become very fashionable since I first stayed there. Portobello Road is nearby but is no longer the antique market attraction it was when I first visited in 1977. The Notting Hill Underground station is around the corner and the kids were able to go everywhere in London from that base. We had three boys and three girls so I told the boys they had to stay with the girls but they could otherwise stay out late and go where they wanted to go. The oldest was my son, Mike Jr. who was 18.

One place we went for dinner, another old haunt, was Geale’s Fish Restaurant.

notting-hill-1

I have been going there when in London since the 1970s and it is always good. The neighborhood is a bit fancier now. Another wonderful restaurant, which is gone now, was a South African place a few blocks away. We found it because of a profile in Gourmet magazine and when I told the owner about it, they gave us free drinks. I can’t remember the name anymore.

The kids all stayed out until 4 AM and we could never get them up in time to do the tourist things. Leicester Square was the big movie center and I suspect they spent most evenings there. We went to nice restaurants and they went to fast food places and everybody was happy.

One night we had tickets for Cats, which was still a big hit then. I had seen it two years before and it had morphed into a children’s event with the cats remaining on stage at intermission so the kids could go up to them.

cats

During the show, one cat, Rum Tum Tugger sat in the lap of one of the girls and we all had a nice time.

Another day was devoted to a side trip to Richmond and Hampton Court palace. The kids all went and we toured this old Tudor palace. Elizabeth of York had rowed across the river to reach the palace and her son, Henry VIII, used the palace which has many paintings of him.

hampton-court

When we were ready to return to London, Gary, Jills’s son who was 15, somehow got lost and he finally came running to the boat with considerable worry on his face.

After a week, we picked up our rental van and set off for the Isle of Wight. I had stayed there before on another trip although the owner ship of the B&B had changed. It was located on the grounds of Osborne House, the summer residence of Queen Victoria and her children.

osborne

The guest house was called “New Barn House” and it was on the grounds of Osborne House. I can’t fnd it anymore and haven’t been there in years so maybe it is gone. There is a “New Barn Street.” Maybe this is it as I can’t get to a photo. The first time I was there, Osborne House was still one half museum and one half veterans home. The vets stayed in the old servants quarters of Osborne House but their wives could not stay with them and New Barn House was a B&B for the wives. The proprietor was Captain Brooke-Smith a retired naval officer whose son worked at Jeremy Rogers yacht builder in Lymington. When I asked the son for a recommendation on the island, he called his father and verified that they had room for the four of us.

The experience the first time was fun. We were the only Americans and were the object of considerable curiosity in the dining room. All the other tables were taken by individual wives with a few visiting husbands. Before the call (with a bell) to dinner, Captain Brooke-Smith conducted a small cash bar where one could get a glass of sherry for 50 pence.

When we went back in 1983, the house was still there but the proprietors, and the atmosphere, had changed. The wives could apparently stay with their husbands in the rehabilitation facilities in the old servants’ quarters. The new proprietors were a young couple, Toby and Jenny, who had connections to the London art and music scene. The food had improved and the entire scene was very different and much more fun for the kids. In fact, they insisted on staying longer than we had planned. One night, one resident took the girls out on a pub crawl as he checked out the various rock groups entertaining on the island’s club scene. The girls were 14 and 15 so I was a bit concerned but they got back about 4 AM and told us they had seen this new group called Duran Duran.

We finally dragged the kids away from the island but not before we had visited Cowes and saw the Admirals Cup crews, including Ted Turner who gave my wife an appreciative eye.

Our next stop was Broadway in the Cotswalds. Because we had all the kids, we stayed at the Broadway Hotel, which is very nice and one step below the Lygon Arms. The latter is luxury and too expensive for the crew we had. The Broadway Hotel is very nice and we were there again a few years ago with Claire and her husband, Derek.

broadwayhotelvillagegreen

The hotel had one large room in back, almost like a bunkhouse, and the kids stayed there.

Broadway was the home of J.M. Barrie, the author of Peter Pan, the play and novel. It is a delightful village, heavily over run by tourists in summer. Claire and her husband Derek met Kate and me for New Years at Heathrow airport when they were spending a year in Spain. We spent New Years Eve at the Broadway Hotel and had a great time.

Our next stage was to return home so we checked into a cheap hotel near Heathrow and planned to drop off the van at the airport in the morning. The next day we were driving to the airport when I saw a sign “Stoke Poges.” That, of course, is the village whose church yard was immortalized in Grey’s Elegy. We turned off and stopped at the church, St Giles.

All the kids, except Kate who refused to get out of the car, trooped into the church where there were copies of the famous poem.

789px-Stoke_Poges_Church

place0012

There is an old photo which better shows the churchyard.

So, I will end this small reminiscence with the poem. It is alleged that General Wolfe, as he was rowed to shore for the invasion, recited the poem and said, “I would rather have written this than take Quebec.

The shutdown

Wednesday, October 2nd, 2013

Since I am a Department of Defense contractor, examining military recruits. I expected that we would not be called to come in after Monday but I worked Tuesday and was told they expect no slowdown. Of course, maybe they won’t pay us but that is still in the future.

So far, the shutdown seems to be working with the assistance of Democrat verbal and active mistakes. I always thought Gingrich fumbled the ball in 1995. This time, the GOP strategy of passing small directed bills to fund popular programs, seems to be working. Certainly the Democrats like Harry Reid and the National Park Service are helping all they can.

Washington politicians may have the time to debate how to fund the government, now that their pig-headedness has shut it down, but the nation’s World War II veterans don’t.

“World War II veterans are dying by the hundreds every day,” says Fred Yanow, of Northbrook, Ill., who spent 1942-45 in the Pacific theater as an Army private. “It’s a shame that they don’t care about World War II veterans when so many of them are dying off.” The 16 million men and women who wore their nation’s uniform in the so-called “Good War,” from 1941 to 1945, are leaving for eternal R&R at the rate of 650 a day.

Which Washington politicians ?

Harry Reid ?

Claire McCaskill had some clever comments.

McCaskill also made it clear that she felt some members of Congress at the memorial were only because they had “nothing to do” but try to score political points.

“There’s people here that have nothing to do – they’re just trying to score political points,” McCaskill told MRCTV’s Dan Joseph.

Reps. Louie Gohmert (R-Texas) and Ann Wagner (R-Missouri) had different takes on the situation. Rep. Gohmert disagreed with the senator, and thinks that those who bring that point up are usually the ones guilty politicization of it in the first place:

She is doing what she can to show who is responsible for this stalemate. Congratulations.

The DoD canceled the military academies sports programs, including the Army Navy game which is sold out.

Update: According to statements released by the schools, the Department of Defense has suspended intercollegiate athletics and these games have been tentatively canceled. We’ll find out by noon ET Thursday if these games will go on.

Update 2: CBS says it’s working on alternate programming in the event Air Force-Navy is canceled.

This site is generally not the right site for discussing the government shutdown, just as Politics-Right-Here-USA.com or whatever is probably not the place you should go for breaking college football news. But every so often, our worlds collide, and such is what we’ve got here, with Saturday’s Air Force-Navy and Army-Boston College games suddenly imperiled by the bozos in Washington.

We repeat: Air Force-Navy might get canceled. Because of the government.

Then we hear they may have backed down.

The Democrats’ message is not very consistent.