Apr 20, 2014

The Business of Medicine

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The primary reason I love what I do is that gaining competitive advantage (as in being able to stay in business and provide for a family) requires a commitment to continuous learning. If I could change one thing about myself after all these years it would be to increase my reading speed without sacrificing comprehension. I often get frustrated by not having enough time to learn everything I would like.

Sometimes learning isn’t so much about discovery as it is connecting the dots you’ve discovered previously. You are engendered to reconsider what once were disparate pieces of knowledge and see how they can be formed into new thinking. This was the case for me recently when I read a blog post of A Country Doctor MD contributing to the KevinMD.Com blog site.

The article, If a doctor isn’t face to face with a patient, is he still a doctor? explores the fundamentals of a physician’s business model in lieu of regulated fee for service payment methodology. It explores the often paradoxical relationship between between time and money in the practice of medicine. I found that the issues and challenges described resonated with me because I have to deal with the same business issues and challenges.

There are parallels between the practice of medicine and consulting. Both businesses’ core value proposition is individual knowledge, reasoning and the ability to collaborate with others to solve problems. The risks and consequences of getting the right solution in medicine are decidedly much greater – and this should be reflected in higher comparative compensation. But I don’t think that is universally true by a stretch, and here’s why.

As the leader of a small boutique consulting firm determining how to price and sell engagements is a constant challenge. You are always building on your knowledge, so that the next client gets the benefit of what you learned working with the client before (I don’t know this to be true, but I would imagine it’s a similar situation with physicians: it’s a practice). We are always wrestling with how to price services when the value proposition is a desired outcome while the measurement of cost is in units of time.

And you get more efficient as you practice, so that the relative work effort to produce solutions decreases as experience increases. But that doesn’t necessarily translate into higher income because you have to remain market competitive. Of course, ideally over time your hourly rate increases to reflect the increase in value provided: getting the right solutions faster. That is, in consulting at least.

I don’t want to belabor the nuances of professional services business models. I share these observations simply to make a point. In consulting, we have the luxury of pricing our work based upon what we think is in the best long-term financial interests of ourselves and our consulting practice. The physician who is forced to accept a payment schedule – whether from governmental agencies or private insurers – does not have that luxury.

With the recent release by CMS of the Provider Utilization and Payment data there have been reverberations in the media about physician income and the relative contribution of cost to our healthcare system. I am not advocating for less transparency even if, as I wrote last week, the data as it was released is quite misleading. All I am saying is that given the comparative amount of education required (time and cost), the stress level involved and the regulatory handcuffs applied, I wouldn’t want to trade. I think this is something that policymakers had better consider and understand very soon – because I can’t stand the site of blood, nor read fast enough.

Cheers,
  Sparky

Photograph: from thechart.blogs.cnn.com

Filed Under: Editorials & Opinions · Tagged: , , ,
Apr 19, 2014

Readmission for Life

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Readmissions. A term that has become ingrained in the lexicon of governmental agencies, elected officials, healthcare policy analysts, healthcare provider institutions – and even care providers. The case is made simply enough: it is far less costly to care for someone at home or in a congregate setting than in a hospital. More nuanced, the logic follows that both efficiency and quality can be maximized by utilizing the setting that costs just enough to provide quality outcomes.

And so a lot of money is being spent – by the government in the form of research and testing grants, as well as both for profit and nonprofit healthcare providers, all wanting to better understand how to keep people out of the hospital without impacting their health. Of course, Medicare’s Hospital Readmissions Reduction Program is also providing an incentive as hospitals seek to avoid up to a 3% reduction in Medicare reimbursement.

The Internet is replete with articles and stories on the how and why of reducing readmissions. I have written about the topic extensively on this blog. It has captured my attention because that is where Artower Advisory Services, positions itself: at the intersection of acute and post-acute/long-term care.

I have a growing concern that the dialogue over readmissions is becoming increasingly academic and pedantic. The measures of programming success have not been clearly defined because of the simple reality that success needs to be defined differently for each patient.

People react to environmental stimuli in different ways. Two patients with the same condition and otherwise similar health may be better served in different settings. One patient might have great comfort in being at home – to the extent where their mental state promotes healing faster than in an institutional setting. Another patient may need the real or perceived sense of security from being at the hospital where immediate attention is just down the hall.

In more than a few ways the initiative to reduce hospital readmissions has been an effort to pick the low-hanging fruit. Anecdotally, I am convinced from spending years working with healthcare providers that patients needlessly end up in the hospital because of poor communications, silo operations and the practice of defensive medicine.

There are tremendous opportunities for performance improvement. Along with reducing costs and improving outcomes, however, we must be diligent in developing outcome measures that reflect the subjective reality that every patient is unique.

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, Hospital Readmissions · Tagged: , ,
Apr 13, 2014

I Made HOW Much ?!?!

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This past week CMS released Provider Utilization and Payment Data: information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. In case you weren’t following along, there has been quite a bit of controversy over the data release, including from both the American Medical Association and the Medical Group Practice Association.

Donald W. Fisher, Ph.D, MGMA President & CEO:
MGMA is troubled about the potential for unintended consequences as a result of the release of this type of data and the effect it may have on Medicare beneficiaries. This release could result in patients making decisions about their care based on faulty assumptions about physicians. Claims data are not a proxy for quality, especially when provided in isolation, from a single payer. MGMA is also concerned about the impact on physician privacy, as releasing physician’s personal financial data and National Provider Identifier (NPI) information could make providers susceptible to fraud. Physicians should have had the opportunity to review the data before it was made publicly available in order to modify or appeal any inaccuracies.

Ardis Dee Hoven, MD, President of the AMA:
Thoughtful observers concluded long ago that payments or costs were not the only metric to evaluate medical care. Quality, value and outcomes are critical yardsticks for patients. The information released by CMS will not allow patients or payers to draw meaningful conclusions about the value or quality of care.The AMA is disappointed that CMS did not include reasonable safeguards that would help the public understand the limitations of this data.

Back in February of 2013 I wrote, Pick a Price – Any Price, describing how and why healthcare provider pricing is typically both misleading while at the same time meaningless. But the focus then and there was on hospitals. People in general are a lot more envious of other people than they are buildings and groups of people working in those buildings. Thus you can easily understand why there is concern over public perceptions – particularly when those perceptions are likely to be different than reality in most instances because of not understanding how to interpret the data.

Theoretically, I weigh this concern against a belief that in most cases more information is better than less.  Obvious exceptions include issues of personal privacy and national security. Transparency and accountability should be hallmark pursuits of the Medicare system. And I think most physicians are in favor of sharing data that helps empower the patient to make more informed healthcare decisions.

It is not at all clear the data released last week will be able to do that any time soon. In fact, the arguments positing the data’s release will do more damage than good are persuasive. These include a lack of any data on quality; inability to track actual service levels to individuals providing those services; misunderstanding of charges versus payment; inability to risk adjust for patients treated; no adjustments for site of service differences; discrepancies caused by changes in billing codes; and – most importantly – no way of knowing how much reimbursement the physician uses to cover overhead costs, which is required in order to determine real income.

So on balance I have to side with the physician groups on this one. CMS made a very poor decision to release the data, as-is, without any real thought about releasing it with all of the disclaimers addressing the issues and concerns described above. I hesitate to say it – but I say what I think – this sure feels like another backdoor attempt to promote victimization at the expense of disinformation.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Provider Utilization and Payment Data · Tagged: , , ,
Accountability Without Responsibility?
Mar 13, 2014

Accountability Without Responsibility?

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PHO-10Sep15-267645Earlier this week Rep. Jim Renacci (R-Ohio), together with a bipartisan group of 25 other House members introduced H.R. 4188, the Establishing Beneficiary Equity in the Hospital Readmission Program Act. Text of the bill is not available through the Library of Congress yet, but from what has been discussed publicly its purpose is to provide hospitals with financial relief from Section 3025 of the Affordable Care Act: Hospital Readmissions Reduction Program.

The hospital readmissions program has received a great deal of discussion, but with implementation beginning last year hospitals that exceeded the excess readmission ratio in their 2013 fiscal years are now seeing reductions in Medicare reimbursement of up to 1%. Unless those hospitals are able to improve that ratio the potential payment reduction could increase to 2% next year and 3% the year after. For an organization already struggling with tight margins a 3% reduction in revenue that represents approximately 20% of total revenue without any commensurate reduction in costs has serious clinical and operational ramifications.

Previous PolicyPub posts on Hospital Readmissions:

The Trouble With Avoidable Readmissions ~ February 2012
Is Focus on Hospital Readmissions Misguided ~ May 2012
Update: Hospital Readmissions ~ February 2013

Not unsurprisingly, H.R. 4188 has already garnered rather broad industry support from the likes of hospitals and the trade associations representing them – i.e., anyone standing to benefit from more revenue as opposed to less.

As I understand it H.R. 4188 doesn’t provide blanket relief for hospitals affected by the readmissions program. Rather it is intended to recognize and adjust for the penalty impact of caring for patients who are financially unable to afford post-acute housing, services and care in a manner that would otherwise facilitate their ability to avoid a readmission. And the logic goes that if all those altruistic hospitals are unselfishly willing to open their doors to care for the poor, well then penalizing them for that willingness is grossly unfair.

But hold on. The readmissions reduction program wasn’t thought of, planned or designed in a vacuum. The challenges associated with securing and providing affordable post-acute housing, support services and care has been a widely recognized problem that predates Medicare and Medicaid. The purpose of the program is to provide incentives for hospitals to take a more active and holistic approach to managing patient care post-discharge – regardless of the patient’s wealth and income. No penalties – no incentives.

The program wasn’t designed to change the type of patient cared for – but the manner and scope of patient responsibility. What hospitals have argued in return is that they are being held accountable for a scope of services and care for which they have not historically been responsible (accountability without responsibility). CMS’s de facto response is pretty straight forward: then don’t accept Medicare anymore. If hospitals want to continue benefitting from taxpayer dollars, they will have to help find ways to reduce the costs of healthcare subsidized by those taxes – and not just the costs that manifest inside their walls (or more properly, their historical sphere of influence).

We are just now beginning to see the benefits of the readmissions program’s incentives manifested in efforts of hospitals across the country to integrate with post-acute/long-term care provider organizations. That has required their gaining a better understanding of PA/LTC patient care models, understanding the challenging dynamics of care transitioning and working with physicians to better appreciate the post-acute challenges they have wrestled with for generations.

So now that hospitals are finally taking notice of the potential cost and quality benefits of post-acute care integration we want to tell them “ah, never mind – it’s too hard?” Really?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Hospital Readmission Penalty · Tagged: , ,
Agnes Riolato Will Live to Be 95!
Mar 3, 2014

Agnes Riolato Will Live to Be 95!

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Quentin_Matsys_-_A_Grotesque_old_womanToday the Environmental Protection Agency announced new sulfur emission limits, which they virtually guarantee will add five years to Ms. Agnes Riolato’s life. Don’t believe me? Well okay, maybe that’s stretching things a bit. But they did say this new regulatory requirement would prevent as many as 2,000 respiratory deaths per year without costing refiners and automakers any significant increase in costs.

Of course, as you might expect, the American Petroleum Institute disagreed. Their analysis – no less biased than the EPA’s I am sure – claims the new regulation would raise gas prices while providing little environmental benefit – and could in fact cause interrupted supply lines. House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) expressed concern as well, noting that, "the American people have endured an unprecedented three straight years of gasoline above $3 per gallon. This winter’s cold snap underscores just how vulnerable American families and businesses are to any increases in energy costs, and yet the administration is moving forward to raise prices at the pump … this rule is all pain and no gain."

While that may be true, what about poor Agnes? Is her life worth nothing? Now, I should note that Agnes is a fictitious character – at least as far as my Google search indicated. I am pretty confident out of 7.2 billion people in the world there is at least one person with that actual name, and in the 1 in only slightly less than that amount chance she were to read this blog post, I apologize in advance for any perceived derision.

But what I am driving at here is that I’m not at all sure the EPA’s claim of reducing respiratory deaths by 2,000 a year isn’t just as fictitious as Agnes. I don’t know that it’s fictitious. I have no reason to doubt – but that’s the point. Now stop and think for a minute – no, I mean really stop and think (if you’ve read this far, you’ve already committed more of your life than you had planned, so what’s a few more seconds).

How would you go about projecting a reduction in respiratory deaths (however hundreds of ways that might be defined) attributable to regulatory standards at such a macro level that it would be nearly impossible to predict the many variations in implementation? Just imagine trying to construct a model that would account for those possibilities. Head hurt?

I’m sure there are folks much smarter than me out there who can do that sort of thing. How they convince someone else that doing so produces value sufficient to earn a living is another matter. But even if you can model it, you are still left with making all kinds of assumptions on how things will actually play out. To me, the complexity involved here makes me really question the validity of the assertion: 2,000 lives a year saved. But there you have it.

Let’s face it, we’re living in a sound bite media reality where we toss around portended facts & stat’s as if they were as ingrained in our communicative lexicon as contractions. It’s hard to tell what’s worse: that sound bite reporting does little to build knowledge, awareness and understanding – or that it has been so overused that its effect is now largely ignored (i.e., there is no informing and educating whatsoever going on ).

So I think what we need is a new governmental agency. This is where my conservative colleagues frown and get angry that I was leading them on. But really, why not – who is going to notice one more agency at this point? I want a nonpartisan group of very smart thinking types with strong analytical and mathematical skills (something similar to the CBO) whose responsibility it is to score every official promulgation that comes from another federal agency.

I want them to build the type of model that I described above and understand it in a way that I most certainly could not. And I want them to assess the variability around all of the key assumptions. So, for example, if one of the assumptions used to project the 2,000 lives saved was to assume Agnes would spend 600 hours a month living at her home in the suburbs and 130.5 hours a month in the city (this of course is assuming that’s the only two places she will travel in a month – guess we’d have to assess that assumption as well) I want to know what the probability is of the assertion being made coming true given the variability around those assumptions.

And then I want them to use whatever mathematical techniques are necessary to produce a scoring of the reported assertion. They can play with the reporting language, but I am envisioning something like this using the real life example shared above:

Last year at this time it was reported by the Environmental Protection Agency (I’m just trying to be pragmatic here) that annual respiratory deaths would be decreased by 2,000 through implementation of new emission standards that are just about ready to be released as a first draft. The Agency of Factual Standards and Selective Omissions has determined that there is approximately a 10% chance that between 1,800 and 2,200 lives will actually be saved; that there is a 25 % chance that between 500 and 4,000 lives will actually be saved; that there is a 50% chance that between –2,000 and 10,000 lives will actually be saved . . . etc. You get the point.

If those projections don’t bear out, we would have another agency whose purpose it is to discipline the modelers who made the bad assumptions about the other agency’s assumptions. And then you can see how a scenario similar to the opening credits of Monty Python’s Holy Grail would play out with various, repeated sackings . . .

There is, of course, a more serious side to all this. Today with electronic and social media being what they are, public policy is often discussed and debated with varying amounts of ultimate ability to have any impact in venues like this Policy Pub. And in the passion of those debates it is often overly tempting to pick and choose facts & stat’s that help support our beliefs. That might help the ego through the night – but it really doesn’t do much in the interest of promoting educational discourse.

Okay, lesson over. I’ll have a Macallen 18 y/o neat please, Sam!

Cheers,
  Sparky

Image: Painting by Flemish artist Quentin Matsys around 1513

Filed Under: Editorials & Opinions · Tagged: , , ,
Healthcare & IT: Oil & Water?
Feb 28, 2014

Healthcare & IT: Oil & Water?

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I don’t think it has to be that way, but the history of IT adoption and implementation in healthcare might lead many to believe otherwise. True, there have been major advancements just over the past decade, but from a public policy perspective, have federal policy initiatives helped – or hindered – that progression?

I think most everyone would agree that information technology holds great promise in improving the value of healthcare delivery. And by greater value I mean assisting caregivers and clinicians produce better outcomes at lower cost. Except that in many instances it’s not working that way.

Practical Experience
Courtesy of the healthcare policy-oriented site, KevinMD, I recently came across a blog post by Dr, Christine Sinsky that made me decide it might be a good time to bring this topic up again with you. Dr. Sinsky’s blog post, Hazards of Poorly Designed Decision Support, is an anecdotal yet nonetheless compelling reality of IT utilization in healthcare. The decision support system in question is Trinity Health’s mandatory DVT Advisor.

DVT stands for deep venous thrombosis, which in laymen terms means a blood clot that that forms in a vein deep inside a part of the body. DVTs are most common in adults over age 60 but can occur at any age. If the clot breaks off into the bloodstream, it is called an embolism, which can get stuck in the brain, lungs, heart, or other area, leading to life threatening situations.

DVT Advisor was implemented in response to Meaningful Use requirements. You can read Dr. Sinsky’s post if you would like to understand the practical frustrations she found in using it, but for the purpose of this post I will summarize the key points.

Shortcomings
From her perspective (my interpretation now) there are two key areas of the system that are counterintuitive to facilitating value creation as I describe above: unnecessary input requirements and decision tree logic rigidity that was unable to capture and reflect the patient’s situation (i.e., usability challenges). In essence, the system created more work – and more importantly, introduced a new level of potential risk – than would not have existed without its use. Now that, Pub patrons, is what’s known in laymen terms as, “stupid.”

In the interest of fairness and disclosure I want to note that Dr. Sinsky was complimentary of certain elements of the system; e.g., “the information in the DVT Advisor can be a useful reference if a physician is uncertain about anti-coagulation, but its intrusive and insistent characteristics are based on hope and belief, rather than evidence.”

Policy Issue
And so here’s the policy issue: you have an IT decision support tool that has the potential to add value but for the fact that its design has actually lowered it. Now, I have been an ardent proponent of supporting advancements in HIT as a primary means of improving productivity and efficiency – and thus lowering care delivery costs. I have been less enthusiastic about the top-down approach of HIT policy the federal government has employed to advance those efforts. I have also believed, however, there is the need for an active role of government in helping advance health IT adoption. The what and the how of that role is less certain today.

So for me, Dr. Sinsky’s post is not the needle-in-the-haystack that generated an intellectual epiphany on my part regarding the effectiveness of HIT policy efforts. There is more than enough research and literature supporting logical skepticism for the open-minded to consider. Rather it was more of the straw within the haystack that broke the camel’s back. I am looking for some pub patrons that understand this subject-matter much better than me to weigh in here.

There are some of the most brilliant minds in the world working in HIT – in the clinical and nonclinical arenas – but I sometimes wonder if they can’t get out of their own way to understand the pragmatic nature of value creation. And I wonder if federal policy and governmental agencies haven’t been just willing abettors counting more on hope than evidence as Dr. Sinsky points out.

Please, prove me wrong – show me the evidence where HIT public policy has been more effective than not.

Cheers,
  Sparky

P.S. Please click on the hyperlink above associated with Dr. Sinsky’s name. This will take you to her website where there is a wealth of information on HIT based upon her and her husband’s professional contributions.

Filed Under: Editorials & Opinions, Healthcare Information Technology · Tagged: , , , ,
Feb 16, 2014

You’re No Prince, Mr. President

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Last week the Administration announced that the Employer Mandate would be again further delayed – at least in part. Businesses with between 50 and 99 employees working 30 hours or more will not be required to make available mandated healthcare coverage until 2016. While businesses with 100 or more employees working at least 30 hours only need offer coverage to 70% of their employees in 2015, rather than 95% (which will not be mandated until 2016).

“Well, isn’t that conveeeeeeeenient . . .”

A little too thinks Senator Mike Lee (R-Utah). On this morning’s Fox News Sunday with Chris Wallace, Lee said that he believes the President is creating a “government of one” by further delaying the mandate – and in his view, ignoring the Constitution in the process.

Sidebar: how much longer do you think Mr. Wallace will be able to withstand Fox’s propaganda machine?

E.g., watch embarrassing exchange between
Chris Wallace and Tucker Carlson.

The premise of Mr. Lee’s position was that the president’s choice to delay the employer mandate was, “a shameless power grab that’s designed to help the president and his particular party achieve a particular outcome in an election. And that’s wrong.”

I think Mr. Lee is right.

Rep. Xavier Becerra (D-Calif.) defended the initiative on Fox News Sunday by claiming, “the president is simply providing small businesses with the flexibility they need.”

Sorry Mr. Becerra, that rings hollow and you should have been embarrassed to even pretend to believe that had anything to do with the delay. I obviously can’t speak for other supporters, but from my vantage Mr. Obama’s renegade approach to policy making has gone too far.

I have been  a pretty ardent supporter of the Affordable Care Act, and I continue to believe that, on balance, it will ultimately bring about necessary and desperately needed changes in the way our healthcare delivery system is designed. I also continue to believe that our failure to address the cost trajectory of our delivery system would have ultimately resulted in fiscal choking from within and ultimately destroy our economy. Finally, because of the unique characteristics of healthcare as an economic commodity – as well as the regulatory infrastructure that has already been in place for decades – I do not believe it is either wise nor prudent to think that a market-based system of healthcare can be successfully compatible with a progressive society. Most of the rest of the developed countries in the world agree.

Those beliefs notwithstanding, the wisdom of Nancy Pelosi grows daily: it’s not just that the ACA had to be passed to find out what’s in it – it’s that clearly the promulgation of regulations implementing the ACA under executive authority has at times supplanted the function of legislative authority. Regardless of how frustrating and demoralizing this Congress has been, there are reasons why certain powers are reserved to the legislative branch and certain powers are reserved for the executive branch.

But the timing of this latest action – whether a tipping point or accumulative – is not only a supplanting of legislative authority but also crosses an ethical line between governing and politics, which of course in Washington requires quite a journey to traverse.  In using what I will term, Obamavellian Authority, the president has repeatedly overstepped executive authority and dared to tread over boundaries that presidents of both parties from the past respected (well okay, maybe not Nixon).

It’s time the president’s supporters call him to account in the interest of democracy and respect for a way of life that transcends political allegiances. Hope you agree, but if not, I would love to hear from you.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Obama Administration · Tagged: , , , ,
Jumping On—And Off—The CBO Report Bandwagon
Feb 10, 2014

Jumping On—And Off—The CBO Report Bandwagon

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In its February 2014 report to Congress, The Budget and Economic Outlook: 2014 to 2024 (see Appendix C: Labor Market Effects of the Affordable Care Act: Updated Estimates) the nonpartisan Congressional Budget Office created quite a stir last week as it reported 2.5 million individuals will leave the labor force by 2024.

A number of the nation’s media intelligencia pounced on the report as an opportunity to provide evidence of the Affordable Care Act’s real, underlying threat to our economy. Trouble is, they got it wrong. Entertainment networks like Fox News had the bandwagon gassed up and ready to roll, so all that Republican candidates and lawmakers had to do was jump on board (see video below). By now most have hurriedly jumped right back off because of the simple practicality that when someone leaves a job the job does not disappear – at least not immediately.

Thom Tillis jumps on the bandwagon . . .

Now, the broader, long-term impact on overall economic growth due to the contraction of personal income is a legitimate debate, but that calls to mind an entirely separate issue: politics aside, has anyone stopped to think how utterly ridiculous it is to try and support that 2.5 million number? How many subjective assumptions had to be made in order to determine who would and would not leave the workforce? And how do you possibly define what it means to leave the workforce anyway in lieu of the inherently transient nature of today’s labor markets?

In the report the CBO states that it was already once way off its “estimate” just a few years ago:

“CBO’s estimate that the ACA will reduce aggregate labor compensation in the economy by about 1 percent over the 2017–2024 period—compared with what would have occurred in the absence of the act—is substantially larger than the estimate the agency issued in August 2010.”

“In 2010, CBO estimated that the ACA, on net, would reduce the amount of labor used in the economy by roughly half a percent—primarily by reducing the amount of labor that workers choose to supply. That measure of labor use was calculated in dollar terms, representing the approximate change in aggregate labor compensation that would result. Hence, that estimate can be compared with the roughly 1 percent reduction in aggregate compensation that CBO now estimates to result from the act.”

In other words, in three years they doubled their estimate. That’s what they call it, an estimate. I would argue you can only estimate that which already exists, so it’s really a projection or forecast – an a pretty meaningless one at that.

Still others have sought to bend the report findings as driving individuals out of the labor force. The ramifications of that of course being more slackers on the dole sucking on the teats of the shrinking middle class rather than working for a living like the rest of us. Right. See the Washington Post’s article, They quit their jobs, thanks to health-care law.

I agree there is reason for deep concern about how to break free of the psychological conundrum we have created with the US welfare state. Personal responsibility should be a mantra of any candidate running for political office – beginning with themselves would be a refreshing change. Working to support yourself and your family should be a socially supported sense of pride – not looked on as being misfortunate you aren’t poor enough for the handouts. But no one should ever have to make the choices that individuals in this country have had to historically because they lack affordable access to quality healthcare. That’s not pushing someone out of the labor force – it’s recognizing the value they have as a human being.

And here’s another sobering thought. The demand for at home services by an aging population with chronic disease and long-term disabilities is going to skyrocket. Since there is virtually no likelihood that additional funding will be available to increase the amount of home care services provided under Medicare or Medicaid, it would be very beneficial to have affordable healthcare in place for the millions of informal caregivers being driven out of the labor force because they choose to provide those services and support to a parent or elderly loved one.

Cheers,
  Sparky

Filed Under: ACA Economic Ramifications, Editorials & Opinions · Tagged: , , ,
Feb 1, 2014

Repeal & Replace Becomes Fix & Embrace

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So we can add the U.S. Chamber of Commerce as one of the ACA’s stalwart detractors dedicated to Repeal & Replace now reluctantly advocating for Fix & Embrace© (you heard that term here first – I Googled it). Last week Chamber President Tom Donohue said, "we’re not going to get rid of that bill [actually, it’s been an enacted law since 2010, Mr. Donohue], and so we’re going to have to devise ways to make it work."

This of course begs the question just how is he hoping to define, “make it work.” How do you make something work that you’re already convinced – at least that’s what you said – absolutely cannot work? Wouldn’t you be better served to just pack up your bags, feel sorry for the country you’ve left behind and head for greener pastures? To a country that isn’t saddled with the weight of a social conscience advocating for equal access and affordability to a basic human right: healthcare.

Having a family history in this country that dates back to the 1670’s (including relatives that fought in both the Revolutionary and Civil Wars) I feel some sense of hosting duties here. I feel compelled to offer some assistance to our departing friends that no longer find this country palatable because of its social largesse. As you depart – besides not letting the proverbial door of fairness and equality hit you in your hard ass on the way out – here are a few countries you probably ought to avoid:

In Africa: Rwanda, Algeria, Egypt, Ghana, Libya, Mauritius, Morocco, South Africa and Tunisia

In Asia: Bhutan, Bahrain, Brunei, China, Hong Kong, India, Iran, Israel, Japan, Jordan, Kazakhstan, Kuwait, Macau, Malaysia, Mongolia, North Korea, Oman, Pakistan, Qatar, Saudi Arabia, Singapore, South Korea, Sri Lanka, Syria, Taiwan, Tajikistan, Thailand, Turkey, Turkmenistan and UAE.

In Europe: Albania, Austria, Andorra, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Moldova, Monaco, the Netherlands, Norway, Poland, Portugal, Romania, Russia, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine,[and the United Kingdom.

In North America: Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, Trinidad and Tobago.

In South America: Argentina, Brazil, Chile, Columbia, Peru, Uruguay and Venezuela.

Oh, almost forgot – Australia and New Zealand should be avoided too. They, like all of the countries listed above, provide some form of universal healthcare for their citizens. So you couldn’t possibly find happiness there.

But you won’t find North Korea listed above. Happy trails!!

Cheers,
  Sparky

Filed Under: Editorials & Opinions · Tagged: , , , ,
Jan 28, 2014

Once More Unto the Breech

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Ah yes, here we go again. Yet another attempt by the Republican Party to repeal and replace the Affordable Care Act. This time, as reported by Sarah Kliff in the Washington Post’s Health Reform Watch, Republican Sens. Richard Burr (N.C.), Tom Coburn (Okla.) and Orrin Hatch (Utah) last week released, “…what is arguably the most complete Obamacare replacement plan offered by their party to date.”

Entitled the Patient Choice, Affordability, Responsibility, and Empowerment Act (abbreviated as the “Patient CARE Act”) – it has a familiar ring to it, but read on – it is in certain enough ways similar to the Affordable Care Act that I was reminded of several works by Shakespeare. The first of course is the comedy, Much Ado About Nothing. The second is a quote from Hamlet: “the [Party of No] doth protest too much methinks.” And the third was a quote taken from Henry V, which I invoked as the title of this post.

Both Ms. Kliff’s piece as well as a Forbes’ magazine article written by Avik Roy provide excellent coverage in comparing and contrasting the two pieces of legislation, and I refer readers there for better explanation than I can offer here. To be sure there are marked differences in the way key concepts of healthcare reform are addressed in the Patient Care Act. But where the hypocrisy is laid bare is in noting the overarching points of likeness.

For starters, the Patient CARE Act is said by its own sponsors to have little impact on the federal deficit (i.e., budget neutrality) over a 10-year period following enactment. So much for conservative austerity.  It maintains the insurance restrictions on pre-existing conditions and benefits, though it shifts more risk back to the individual for maintaining coverage prior to such conditions. There is the concerted effort to expand coverage to poorer Americans, though less emphasis is placed on Medicaid while abandoning insurance exchanges.  It also recognizes the importance of attracting healthy individuals into insurance pools to thwart adverse selection.

The most significant difference has to do with financing. The Patient CARE Act would repeal most of the industry taxes on insurance companies, hospitals and medical device makers and replace that lost revenue by limiting the tax exclusion for employer-sponsored insurance to 65 percent of the average health insurance plan. This is a favored approach by many economists because of the regressive nature this historic tax preference, but given the impact it would have on millions of employed workers it’s not likely to gain much political traction even if Republicans do gain control of the Senate.

Despite key differences, however, what is interesting – or perhaps remarkable – to note is that the Affordable Care Act was used by Patient Care Act’s authors as the baseline upon which to develop healthcare policy. This is in marked contrast to claims of the Affordable Care Act being illegal, unconstitutional and/or socialistic. It almost appears as if there could have been a constructive and compromising effort for the two parties to work together in crafting the ACA, rather than the Republican Party being fixated in denying President Obama any modicum of political success.

For all of the cajoling, haranguing and caterwauling we’ve endured from the likes of Ted Cruz, Bobby Jindal, Marco Rubio and Rand Paul, this latest effort to appear politically constructive and contributing something meaningful to the healthcare policy debate comes off dreadfully sublime in comparison to the political rhetoric of the past several years. And its well placed timing only days before the State of the Union Address is of course par for the course in electoral hypocrisy.

When it’s all said and done I am left wondering whether we should retrospectively view the politial machinations and hijinks the Republican Party has wrought upon this country over the past several years as comedy or tragedy. Perhaps both. A number of Shakespeare’s best works after all were tragicomedies: Hamlet, Macbeth, Othello and King Lear. I only wish watching the Republican Party’s performance of political implosion would have been as entertaining.

Enjoy the SOTU Address! Could be some real fireworks in the great hall tonight.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Patient CARE Act · Tagged: , , ,
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