After the debate, I decided that there really wasn't enough information in each of the candidates posted healthcare plans to really formulate an accurate assessment of them. So, I decided to try to contact each candidate through their websites and asked specifically for additional written information or, better yet, a conversation with a person who is "in the know" about their respective healthcare plans.
I received an automated response from Clinton and Obama with the usual dribble about being so busy because of all the emails and support they receive that they can't respond to every email personally. But the emails were able to direct me to links that informed me about how to contribute to their campaign, become a registered member of their team or how to find more information about them (but not about healthcare).
Interestingly, McCain didn't even respond with an automated email. I guess he's feeling so comfortable being unopposed on the Republican front that he doesn't need any more help.
Anyway. None of them seem willing to help a poor helpless healthcare provider figure out how their individual healthcare plans are supposed to work. If they can't explain it to me and I can't figure it out on my own, how the heck is anyone else going to be able to understand it?
We're all on our own. You'll all be expected to vote for a candidate when you have less than full disclosure about their positions. Sounds like another election of the lesser of evils. God help us.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Thursday, February 28, 2008
Tuesday, February 26, 2008
Healthcare Post Debate
Oh boy, oh boy! What fun.
Obama and Clinton faced off this evening in Cleveland, Ohio during a debate at Cleveland State University. NBC carried the debate with Brian Williams and Tim Russert moderating.
And of course, I had to be blessed with the two of them discussing healthcare as the first issue of the evening. And of course, they went at it like we knew they would. According to Brian Williams, "14 minutes on one subject".
They both gave their opinions of each others' plans but nothing truly new was discussed. The basic differences between them are the same that we have all heard before. So, was there any benefit to the voter watching the debate? Probably not.
Again, the specifics or "nuts and bolts" of the plans are absent. I have a very hard time getting my hands around either of their plans. Not necessarily in terms of concept, but from a position of wanting to see HOW it will actually function. I want to see a step by step presentation of the plan. Take a family of four and show me how each of their "talking points" applies to them. SHOW ME how, and how quickly, their cost saving measures will be implemented. What improvements in quality, not just required documentation, can they show?
Eventually, some form of universal healthcare will be attempted, either by the Republicans or the Democrats. And, it doesn't really matter which plan gets implemented. The whole process is going to be slow, painful, confusing, expensive and inefficient. It will take YEARS before the smoke clears and we see what we really have or don't have.
Can you imagine the amount of effort it will take to make a change in an industry that is responsible for 16% of the GDP of the United States? Talk about a 400 pound gorilla.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Obama and Clinton faced off this evening in Cleveland, Ohio during a debate at Cleveland State University. NBC carried the debate with Brian Williams and Tim Russert moderating.
And of course, I had to be blessed with the two of them discussing healthcare as the first issue of the evening. And of course, they went at it like we knew they would. According to Brian Williams, "14 minutes on one subject".
They both gave their opinions of each others' plans but nothing truly new was discussed. The basic differences between them are the same that we have all heard before. So, was there any benefit to the voter watching the debate? Probably not.
Again, the specifics or "nuts and bolts" of the plans are absent. I have a very hard time getting my hands around either of their plans. Not necessarily in terms of concept, but from a position of wanting to see HOW it will actually function. I want to see a step by step presentation of the plan. Take a family of four and show me how each of their "talking points" applies to them. SHOW ME how, and how quickly, their cost saving measures will be implemented. What improvements in quality, not just required documentation, can they show?
Eventually, some form of universal healthcare will be attempted, either by the Republicans or the Democrats. And, it doesn't really matter which plan gets implemented. The whole process is going to be slow, painful, confusing, expensive and inefficient. It will take YEARS before the smoke clears and we see what we really have or don't have.
Can you imagine the amount of effort it will take to make a change in an industry that is responsible for 16% of the GDP of the United States? Talk about a 400 pound gorilla.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Presidential Healthcare or Universal Healthcare?
Now that the Democratic nominee race has turned into more of the typical "not so nice" form of campaigning, we finally see the finer points of attack between Obama and Clinton. Mailers sent out by Obama's camp recently have blasted Clinton's healthcare plan where it hurts the most. In the voter's pockets. And Clinton is starting to look desperate and angry.
The mailer, which you can read here, focuses on the main point of contention betweenObama and Clinton; mandated coverage. While it may have appeared to be a plus when the plans were first announced, mandated coverage is now a weakness thatObama is exploiting with vigor.
Clinton's plan, as I addressed in an earlier post, mandates coverage regardless of ability to pay. Yes, it does promise tax credits, but unless tax credits have changed, you don't realize those credits until it's time to file your taxes. And you still need to wait to get your refund. For families living payday to payday, they won't be able to afford it when it's mandated and will always be a year behind, waiting for the credit and refund. It also doesn't say how much of a poor family's premium the credit will cover.
The mailer also mentions "fines" for those who don't purchase healthcare. So you make someone pay a fine who can't afford healthcare in the first place, and then take MORE money out of their pocket? Sounds like the Sheriff of Nottingham.
When the weakness of mandated coverage was first discovered, Clinton made an appearance on THIS WEEK WITH GEORGE STEPHANOPOLOUS. He repeatedly and directly asked her about mandated coverage, fines and garnishing of worker's wages. She skirted the whole issue initially, but George wouldn't give up. Finally she did admit that if necessary, "we will have an enforcement mechanism -- whether it's that (wage garnishing) or it's some other mechanism through the tax system or automatic enrollments". She looked very uncomfortable while she said it too. You can read excerpts from the interview;
http://www.cnsnews.com/ViewNation.asp?Page=/Nation/archive/200802/NAT20080204b.html
http://abcnews.go.com/ThisWeek/story?id=4235448
http://abcnews.go.com/Politics/wireStory?id=4235304
In the interview with George, Clinton seemed as if she really hadn't thought through the whole issue, referring to congress and that they may "have some ideas" on how to mandate coverage. When is the last time congress came up with a practical or simple solution to anything? By the time they come up with their complicated,irrational and expensive solution, we'll all be on Medicare.
Is the mailer factual? Absolutely. Does it make Clinton look bad? Absolutely. Is it smart to exploit someone's weakness during a battle? Absolutely. Point to Obama.
The real winner in this battle is actually George Bush. Don't hear much about the president with one of the lowest approval ratings in recent history anymore. He must be sooooooo happy.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
The mailer, which you can read here, focuses on the main point of contention betweenObama and Clinton; mandated coverage. While it may have appeared to be a plus when the plans were first announced, mandated coverage is now a weakness thatObama is exploiting with vigor.
Clinton's plan, as I addressed in an earlier post, mandates coverage regardless of ability to pay. Yes, it does promise tax credits, but unless tax credits have changed, you don't realize those credits until it's time to file your taxes. And you still need to wait to get your refund. For families living payday to payday, they won't be able to afford it when it's mandated and will always be a year behind, waiting for the credit and refund. It also doesn't say how much of a poor family's premium the credit will cover.
The mailer also mentions "fines" for those who don't purchase healthcare. So you make someone pay a fine who can't afford healthcare in the first place, and then take MORE money out of their pocket? Sounds like the Sheriff of Nottingham.
When the weakness of mandated coverage was first discovered, Clinton made an appearance on THIS WEEK WITH GEORGE STEPHANOPOLOUS. He repeatedly and directly asked her about mandated coverage, fines and garnishing of worker's wages. She skirted the whole issue initially, but George wouldn't give up. Finally she did admit that if necessary, "we will have an enforcement mechanism -- whether it's that (wage garnishing) or it's some other mechanism through the tax system or automatic enrollments". She looked very uncomfortable while she said it too. You can read excerpts from the interview;
http://www.cnsnews.com/ViewNation.asp?Page=/Nation/archive/200802/NAT20080204b.html
http://abcnews.go.com/ThisWeek/story?id=4235448
http://abcnews.go.com/Politics/wireStory?id=4235304
In the interview with George, Clinton seemed as if she really hadn't thought through the whole issue, referring to congress and that they may "have some ideas" on how to mandate coverage. When is the last time congress came up with a practical or simple solution to anything? By the time they come up with their complicated,irrational and expensive solution, we'll all be on Medicare.
Is the mailer factual? Absolutely. Does it make Clinton look bad? Absolutely. Is it smart to exploit someone's weakness during a battle? Absolutely. Point to Obama.
The real winner in this battle is actually George Bush. Don't hear much about the president with one of the lowest approval ratings in recent history anymore. He must be sooooooo happy.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Monday, February 18, 2008
Universal Healthcare: Promise of HIT reform
All of the candidates proposals so far have included an estimate of savings related to improving Health Information Technology. All of them are quoting the RAND report which was published in 2005 as a monograph.
The monograph is very detailed, 105 pages long and includes the calculations used to arrive at their conclusions. Interestingly though, they provided their estimate of savings BEFORE the estimated cost of implementation. Kinda like the cart before the horse. They also state that their estimates do not include any cost or savings related to the different systems being able to communicate patient information with one another across any distance. In other words, your doctor's office system can't talk to your pharmacy's system that can't talk to the hospital's system.
Many hospitals and physicians offices have already started implementing EMR's (Electronic Medical Records), at their own cost. Many have done so in response to HIPAA (Health Insurance Portability and Accountability Act) requirements. HIPAA dictates how health information transactions are to be carried out between applicable agencies/businesses (the standard) mostly for billing purposes.
The estimates for the cost of implementing an EMR quoted in the RAND report did not take into account any economies of scale, since most practices comprise 4 or fewer physicians. The estimate for implementation was $22,000 per physician as initial start up costs and $4,400 per physician for annual maintenance costs. Not an inexpensive project.
How do these figures compare to a real world practice? A moderate size specialty group in our communty is currently implementing an EMR for their practice. They have been planning the implementation for some time and took the effort to look at a large number of available products before making their final selection. Ultimately, the product they chose is costing each of the physicians in the group 30K-40K each, not including the loss of prductivity mentioned in the RAND report.
This group has 30+ physicians and physician extenders. If they are not able to achieve some measure of economies of scale, imagine the cost to a smaller practice. The often quoted RAND report likely needs to adjust it's figures, especially since the data in it is from 2004.
If we assume 30 physicians and an average cost of 35K per physician, then the total one time set up cost is $1,050,000 PLUS lost productivity during a training period (RAND estimates this loss at 15% of revenue). The annual cost of maintenance is 20% of the initial cost or $210,000 per year for this practice of thirty physicians. They have to make up that additional practice expense somehow, somewhere. How about charging more or seeing more people?
Can't charge more because insurance will only pay $XX for a certain visit/procedure, no matter what you charge and the providers' contracts prohibit them from charging the difference to you (except for deductibles and copays). Seeing more patients? The more patients you see, the less time you spend with each one, the fewer things you can address at a visit. Kind of goes against the whole idea of improving quality and quantity of care, doesn't it?
I don't know who the candidates think is going to be SAVING money by implementing the HIT improvements they are all promoting, but I doubt it is going to be the providers. At least Obama is willing to spend money for the HIT improvements, and his estimate of the cost to do so over a five year period seems reasonable.
As I've mentioned before, there is not going to be a no-cost, painless solution to the problem of healthcare and coverage for the under and uninsured. But, so far I'm not impressed that anyone has come up with a comprehensive, budget neutral, fair, quality driven program that meets the NEEDS, not wants, of the patient citizenship.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
The monograph is very detailed, 105 pages long and includes the calculations used to arrive at their conclusions. Interestingly though, they provided their estimate of savings BEFORE the estimated cost of implementation. Kinda like the cart before the horse. They also state that their estimates do not include any cost or savings related to the different systems being able to communicate patient information with one another across any distance. In other words, your doctor's office system can't talk to your pharmacy's system that can't talk to the hospital's system.
Many hospitals and physicians offices have already started implementing EMR's (Electronic Medical Records), at their own cost. Many have done so in response to HIPAA (Health Insurance Portability and Accountability Act) requirements. HIPAA dictates how health information transactions are to be carried out between applicable agencies/businesses (the standard) mostly for billing purposes.
The estimates for the cost of implementing an EMR quoted in the RAND report did not take into account any economies of scale, since most practices comprise 4 or fewer physicians. The estimate for implementation was $22,000 per physician as initial start up costs and $4,400 per physician for annual maintenance costs. Not an inexpensive project.
How do these figures compare to a real world practice? A moderate size specialty group in our communty is currently implementing an EMR for their practice. They have been planning the implementation for some time and took the effort to look at a large number of available products before making their final selection. Ultimately, the product they chose is costing each of the physicians in the group 30K-40K each, not including the loss of prductivity mentioned in the RAND report.
This group has 30+ physicians and physician extenders. If they are not able to achieve some measure of economies of scale, imagine the cost to a smaller practice. The often quoted RAND report likely needs to adjust it's figures, especially since the data in it is from 2004.
If we assume 30 physicians and an average cost of 35K per physician, then the total one time set up cost is $1,050,000 PLUS lost productivity during a training period (RAND estimates this loss at 15% of revenue). The annual cost of maintenance is 20% of the initial cost or $210,000 per year for this practice of thirty physicians. They have to make up that additional practice expense somehow, somewhere. How about charging more or seeing more people?
Can't charge more because insurance will only pay $XX for a certain visit/procedure, no matter what you charge and the providers' contracts prohibit them from charging the difference to you (except for deductibles and copays). Seeing more patients? The more patients you see, the less time you spend with each one, the fewer things you can address at a visit. Kind of goes against the whole idea of improving quality and quantity of care, doesn't it?
I don't know who the candidates think is going to be SAVING money by implementing the HIT improvements they are all promoting, but I doubt it is going to be the providers. At least Obama is willing to spend money for the HIT improvements, and his estimate of the cost to do so over a five year period seems reasonable.
As I've mentioned before, there is not going to be a no-cost, painless solution to the problem of healthcare and coverage for the under and uninsured. But, so far I'm not impressed that anyone has come up with a comprehensive, budget neutral, fair, quality driven program that meets the NEEDS, not wants, of the patient citizenship.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Friday, February 8, 2008
Healthcare-Barack Obama's Vision
Well, now that Super Tuesday is over, there's only one candidate to review; Barack Obama. McCain has effectively eliminated his Republican opponents, while Clinton and Obama have turned the Democratic race into a much needed slugfest.
Turning my attention to Obama's Healthcare plan gives me reason to think that all of the candidates are looking at hybrid systems. Shame. In the long run, they are not going to work. If the goal of universal healthcare is the goal, it shouldn't have to cost more than it does now. And it IS going to cost.
Obama's plan varies from some of the others in that there is no mandate for coverage. If you want to opt out and pay, you can. If you come in contact with the healthcare system, such as a hospitalization, you will be required to sign up. Seems reasonable. You can read Obama's entire plan here.
Things I like; universal care available, but not mandatory; sense of personal responsibility for your healthcare coverage; concentration on chronic disease management and disease prevention (same as everyone else); National Health Insurance Exchange and portability; guaranteed eligibility
Things I don't like; expanding SCHIP; protect against natural disasters?; government subsidies; small employers to contribute a percentage of payroll; Federal reinsurance; ensuring healthcare quality and transparency; promise of maplractice "reform" isn't really reform at all.
There are many common themes in the healthcare plans of all the candidates. Obama's seems to vary from Clinton's mainly with mandated vs voluntary coverage. I like the idea that people take responsibility for themselves in some form or fashion. Entitlement programs, to date, have created a subpopulation of our country that are so dependent on their government that they CANNOT care for themselves. It's time to wean them.
Obama's National Health Insurance Exchange is a good idea to promote some forms of competition, make shopping for insurance easier by offering comparisons (although, according to Obama, all plans have to offer similar benefits anyway-how much shopping will you need to do?), and provide a location for comparison's of qauilty-which I think is it's best benefit.
EXTREME care needs to be given to the assessment of quality as is currently being reported by such places as Healthgrades, some state government websites and being contemplated by Medicare. So far none of the reporting sites takes into account differences in documentation, severity of a patient's illness (some people with the same illness are just sicker than others), complications or comorbidities.
Documentation is the key to assessing true qaulity and outcomes. If the documentation comparing two hospitals, for instance, is exactly the same, then you could compare them with a greater expectation that the "grade" they are given is an accurate reflection of quality. Take Healthgrades as an expample. Compare two hospitals in your area and look up their grade for Stroke, Pneumonia or Myocardial Infarction (heart attack). Look at the ranking of the two hospitals, then expand those hospital's specific data. If the hospital with the lower ranking has a lower rate of mortality, then the issue is most likely poor documentation, not poor quality of care. But of course, that's not the perception that Healthgrades gives you.
Expanding SCHIP, or any Medicaid program without eliminating the waste in it is irresponsible. Looking back at an earlier post with the national healthcare data shows how expensive Medicaid and SCHIP are already. Not a very cost-effective way to provide care. And now the government is trying to contract out Medicaid in an attempt to develop a product comparable to Medicare Advantage, which Obama acknowledges contains a large amount of administrative waste. It also means that the new administrative overhead is NOT being spent on patients or the providers who care for them.
The plan as a whole will be more expensive. Employers will be expected to contribute a percentage of payroll towards coverage if they don't offer it as a benefit. The natural response to keep the employer "budget neutral" will be a reduction in wages. Federal subsidies just mean the government will be spending money on healthcare indirectly, but spend it nonetheless.
His promise of healthcare reform really doesn't address two important areas. First is tort reform. Our current system rewards attorneys for large settlements. That alone is a huge incentive for the attorneys to file frivolous suits in hopes of hitting the jackpot. Award caps or reasonable caps on attorney fees/charges would help to stem alot of that problem. No more contingency fees. If the case has merits, they'll take it anyway. also, states with caps have seen liability insurance rates decrease significantly.
Second, with regards to tort reform, is protection from prosecution if the providers have followed accepted best practice guidelines. Shit happens and not every death is preventable despite our best efforts. Why should someone be sued if they have provided the best care possible and followed accepted best practice guidelines?
Obama's plan also stinks of "Big Brother". The National Health Insurance Exchange is going to monitor quality, competition, pricing, monopoly, benefits offered, profit and premiums. Sounds a lot like a public service commission. Regulation does work to control cost but not to foster competition, which is the reason most industries were deregulated in the 1980's. Prices did increase, but each company did it's best to differentiate itself from the competition, either through innovation or products/services offered.
All in all, the big three have similar plans with some differences. Too bad all of them think that the government's involvement in a partnership with the insurance industry is a good idea. Insurance companies are greedy and the governement is wasteful and inefficient. What a combo.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Turning my attention to Obama's Healthcare plan gives me reason to think that all of the candidates are looking at hybrid systems. Shame. In the long run, they are not going to work. If the goal of universal healthcare is the goal, it shouldn't have to cost more than it does now. And it IS going to cost.
Obama's plan varies from some of the others in that there is no mandate for coverage. If you want to opt out and pay, you can. If you come in contact with the healthcare system, such as a hospitalization, you will be required to sign up. Seems reasonable. You can read Obama's entire plan here.
Things I like; universal care available, but not mandatory; sense of personal responsibility for your healthcare coverage; concentration on chronic disease management and disease prevention (same as everyone else); National Health Insurance Exchange and portability; guaranteed eligibility
Things I don't like; expanding SCHIP; protect against natural disasters?; government subsidies; small employers to contribute a percentage of payroll; Federal reinsurance; ensuring healthcare quality and transparency; promise of maplractice "reform" isn't really reform at all.
There are many common themes in the healthcare plans of all the candidates. Obama's seems to vary from Clinton's mainly with mandated vs voluntary coverage. I like the idea that people take responsibility for themselves in some form or fashion. Entitlement programs, to date, have created a subpopulation of our country that are so dependent on their government that they CANNOT care for themselves. It's time to wean them.
Obama's National Health Insurance Exchange is a good idea to promote some forms of competition, make shopping for insurance easier by offering comparisons (although, according to Obama, all plans have to offer similar benefits anyway-how much shopping will you need to do?), and provide a location for comparison's of qauilty-which I think is it's best benefit.
EXTREME care needs to be given to the assessment of quality as is currently being reported by such places as Healthgrades, some state government websites and being contemplated by Medicare. So far none of the reporting sites takes into account differences in documentation, severity of a patient's illness (some people with the same illness are just sicker than others), complications or comorbidities.
Documentation is the key to assessing true qaulity and outcomes. If the documentation comparing two hospitals, for instance, is exactly the same, then you could compare them with a greater expectation that the "grade" they are given is an accurate reflection of quality. Take Healthgrades as an expample. Compare two hospitals in your area and look up their grade for Stroke, Pneumonia or Myocardial Infarction (heart attack). Look at the ranking of the two hospitals, then expand those hospital's specific data. If the hospital with the lower ranking has a lower rate of mortality, then the issue is most likely poor documentation, not poor quality of care. But of course, that's not the perception that Healthgrades gives you.
Expanding SCHIP, or any Medicaid program without eliminating the waste in it is irresponsible. Looking back at an earlier post with the national healthcare data shows how expensive Medicaid and SCHIP are already. Not a very cost-effective way to provide care. And now the government is trying to contract out Medicaid in an attempt to develop a product comparable to Medicare Advantage, which Obama acknowledges contains a large amount of administrative waste. It also means that the new administrative overhead is NOT being spent on patients or the providers who care for them.
The plan as a whole will be more expensive. Employers will be expected to contribute a percentage of payroll towards coverage if they don't offer it as a benefit. The natural response to keep the employer "budget neutral" will be a reduction in wages. Federal subsidies just mean the government will be spending money on healthcare indirectly, but spend it nonetheless.
His promise of healthcare reform really doesn't address two important areas. First is tort reform. Our current system rewards attorneys for large settlements. That alone is a huge incentive for the attorneys to file frivolous suits in hopes of hitting the jackpot. Award caps or reasonable caps on attorney fees/charges would help to stem alot of that problem. No more contingency fees. If the case has merits, they'll take it anyway. also, states with caps have seen liability insurance rates decrease significantly.
Second, with regards to tort reform, is protection from prosecution if the providers have followed accepted best practice guidelines. Shit happens and not every death is preventable despite our best efforts. Why should someone be sued if they have provided the best care possible and followed accepted best practice guidelines?
Obama's plan also stinks of "Big Brother". The National Health Insurance Exchange is going to monitor quality, competition, pricing, monopoly, benefits offered, profit and premiums. Sounds a lot like a public service commission. Regulation does work to control cost but not to foster competition, which is the reason most industries were deregulated in the 1980's. Prices did increase, but each company did it's best to differentiate itself from the competition, either through innovation or products/services offered.
All in all, the big three have similar plans with some differences. Too bad all of them think that the government's involvement in a partnership with the insurance industry is a good idea. Insurance companies are greedy and the governement is wasteful and inefficient. What a combo.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
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