I consider myself to be pretty handy with most household repairs. In fact, I actually remodeled a kitchen in one of my early homes by myself, a bathroom in another and built a mahogany wet bar in my current one. But when it came done to the detail work, I called an expert.
For the kitchen remodel, I called an electrician to rewire my circuit breaker box, run the additional wiring for the new lighting and upgraded cook top. I also had someone come out and measure, cut and install the counter top. I knew better and wanted the finished product to not only look fantastic, but functional too.
The wet bar is a beautiful raised panel design. I did all of the rough carpentry and paneling. But when it came time for the crown moulding, I called a professional. It looks fantastic.
I appreciate anyone who knows their limitations and knows when to call a professional to supplement their work or complete an important project. As a physician, I have no problem telling my patients that I don't know, but I follow that up with "I'll find out for you". And I do.
I could never imagine myself going to Washington, sitting in on a Congressional meeting and then commence to tell them, not only what they are doing wrong, but telling them how to fix all their problems that I just described for them. But this is exactly what THEY are doing with healthcare. Who are they to tell such a large percentage of our GDP what to do? What expertise, or day to day experience, do they have to tell anyone in healthcare what is wrong or what needs to be done in order to fix it? None.
One comment that Mr. Obama made in his speech the other day was that the reforms he wanted to put into place would decrease medical errors and increase quality and one way of measuring this quality was by monitoring the re-admissions of patients. I'm afraid that is NOT a measure of quality in my experience, but a measure of the severity of a patient's illness, a measure of the number of associated medical diagnoses and a measure of patient compliance. For example:
A 65 year old white female admitted with shortness of breath is found to have congestive heart failure. She is treated appropriately with diuretics, angiotensin converting enzyme inhibitors, nitrates and beta blockers. She has an echocardiogram to measure the heart's ability to pump blood. The hospital and doctors order all of these in order to comply with Medicare's "core measures" of quality (yes, they watch each case that closely). She is discharged after 5 days in the hospital feeling much better. She goes home and the next morning slips on some split tea, and falls to the ground. She is readmitted to the hospital with a hip fracture. Is this an issue of quality?
A 74 year old black male with a 50 year history of tobacco abuse, oxygen dependent emphysema, heart disease and high cholesterol. He is admitted with an exacerbation of his emphysema. He receives steroids, hand held nebulizer treatments and antibiotics. He improves slowly and is discharged home. He refuses his pneumonia and flu vaccines. He is counselled on smoking cessation. Once home he resumes smoking, catches a cold from his grandson and is readmitted. He is intubated and placed on a ventilator in the intensive care unit. Is this an issue of quality?
A 67 year old white male with cirrhosis of the liver from life log alcohol abuse, repeated bouts of pancreatitis, chronic anemia, ascites and thrombocytopenia (low platelets) is admitted with an upper gastrointestinal bleed secondary to esophageal varices. He undergoes endoscopy with sclerotherapy to stop the bleeding, a blood transfusion and medicine for alcohol withdrawal. he is referred to the transplant service for possible liver transplant but is rejected again, because of his ongoing alcohol abuse. He is discharged home but continues to drink daily. He is readmitted for an episode of bacterial peritonitis (infection involving the ascitic fluid in the abdomen). Is this an issue of quality?
None of those scenarios are issues of quality by anyone standards except for Medicare. What is truly lacking is common sense. Just like the restriction on the use of restraints. Patients who are demented and confused, who used to be restrained for their safety, are now denied that safety by Medicare guidelines and allowed to walk, fall down and break a hip. Why should common sense ever be included in decision making?
I would propose that for every member of Congress, Legislator and member of the executive branch who is debating or contemplating healthcare reform, should have a partner who has practical, hands on experience in the trenches, where patients are actually cared for.
What is really needed is practical, common sense, comprehensive reform but with the guidance of experts so the final product will be one we can all be proud of. Gotta know when to call the carpenter.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Friday, February 27, 2009
Thursday, February 26, 2009
Healthcare Reform: At What Cost?
The initial pieces of the Obama healthcare reform, revealed today in excerpts published in newspapers and by Obama himself, show us some of the "how" behind the financing of his healthcare reform. Of the 634 Billion to be raised on the backs of "upper income" Americans, 318 Billion will come from reducing or eliminating certain tax deductions for upper income earners. All of the examples state that these net tax increases will not effect "families" earning less than $250K per year. Fairness depends on how you define "family".
Take for example the tax filing status of two very common scenarios. First is the "family" definition used by many of the examples sited by Mr. Obama and his spokesmen. Married filing jointly implies a family of two, one or two income earners, with an income of $250K or less. This equates to an adjusted gross income (AGI) of approximately $208,850 per year (according to Mr. Obama and company). For that couple, it also means a tax liability of $47,649.
Another very common family scenario is a single adult home with children, called head of household. Assume the same income with three children of varying ages, all in school. The AGI for this family is also $208,850 and their tax liability is $51,483. Include the parent's health insurance contribution, state taxes, social security taxes and local taxes, leaving about $140,010 (assumes social security and medicare taxes on the first $105K-didn't include the remainder of the medicare taxes, state tax rate of 7%, no local taxes, health insurance contribution of $150 per month).
Why would a family household with apparently greater financial needs be taxed at higher rate? Does the IRS think that it is cheaper to care for children than for two adults? Do they think families with children have more disposable income than two adult households? Perhaps they think the children should all work after school and on weekends to supplement the household income.
Which family do you think will be more heavily impacted by Mr. Obama's tax increases?
If I were working at Walmart as a cashier, making $32,000 per year, married with five children, I could potentially pay no taxes and with the Earned Income Credit, get a refund of $2,000. I would also qualify for food stamps, with a maximum allotment of more than $900 per month. I and every member of my family would also qualify for Medicaid under the Categorically Needy definition of eligibility, as published by the Centers for Medicare and Medicaid Services. Keep in mind that Medicaid is the most costly of the government run health programs at a whopping $14K per person per year (see my previous post for the cost per person of the different programs). This brings my Walmart family's total annual income and benefits to $142,800. All tax free.
Talk about a redistribution of wealth!
Under the circumstances, I don't think it is fair to ask any American to pay one more penny of tax until the waste is removed from our mostly costly program. First and foremost are Medicaid and SCHIP, with a cost per person of more than $14K per year. Next is Medicare. Both government run, government managed (or mismanaged). Lastly is private insurance and self pay.
Our original scenarios above show how unfair the increase in taxes can be to heads of household. I think all we really need is some common sense, and a real sense of fair play. Don't just look at a household's income, look at the people in that household. They might need every penny. They struggle. They earned it. They work and pay taxes. And the government isn't giving them any handouts. The government is wanting to take more from them. Not fair.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Take for example the tax filing status of two very common scenarios. First is the "family" definition used by many of the examples sited by Mr. Obama and his spokesmen. Married filing jointly implies a family of two, one or two income earners, with an income of $250K or less. This equates to an adjusted gross income (AGI) of approximately $208,850 per year (according to Mr. Obama and company). For that couple, it also means a tax liability of $47,649.
Another very common family scenario is a single adult home with children, called head of household. Assume the same income with three children of varying ages, all in school. The AGI for this family is also $208,850 and their tax liability is $51,483. Include the parent's health insurance contribution, state taxes, social security taxes and local taxes, leaving about $140,010 (assumes social security and medicare taxes on the first $105K-didn't include the remainder of the medicare taxes, state tax rate of 7%, no local taxes, health insurance contribution of $150 per month).
Why would a family household with apparently greater financial needs be taxed at higher rate? Does the IRS think that it is cheaper to care for children than for two adults? Do they think families with children have more disposable income than two adult households? Perhaps they think the children should all work after school and on weekends to supplement the household income.
Which family do you think will be more heavily impacted by Mr. Obama's tax increases?
If I were working at Walmart as a cashier, making $32,000 per year, married with five children, I could potentially pay no taxes and with the Earned Income Credit, get a refund of $2,000. I would also qualify for food stamps, with a maximum allotment of more than $900 per month. I and every member of my family would also qualify for Medicaid under the Categorically Needy definition of eligibility, as published by the Centers for Medicare and Medicaid Services. Keep in mind that Medicaid is the most costly of the government run health programs at a whopping $14K per person per year (see my previous post for the cost per person of the different programs). This brings my Walmart family's total annual income and benefits to $142,800. All tax free.
Talk about a redistribution of wealth!
Under the circumstances, I don't think it is fair to ask any American to pay one more penny of tax until the waste is removed from our mostly costly program. First and foremost are Medicaid and SCHIP, with a cost per person of more than $14K per year. Next is Medicare. Both government run, government managed (or mismanaged). Lastly is private insurance and self pay.
Our original scenarios above show how unfair the increase in taxes can be to heads of household. I think all we really need is some common sense, and a real sense of fair play. Don't just look at a household's income, look at the people in that household. They might need every penny. They struggle. They earned it. They work and pay taxes. And the government isn't giving them any handouts. The government is wanting to take more from them. Not fair.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Tuesday, February 24, 2009
Obama Healthcare. Finally? Part II
Anyone watching the presidential address this evening has no doubt that Obama will be known as one of the "great communicators" among American presidents. His speech was forceful, uplifting, emotional and at times, tearful. One topic of interest to me was related to the process of healthcare reform.
Previously, the promise was for universal healthcare. Now the promise is for healthcare reform. The post election Obama/Biden plan is now posted on the White House website here. The WH website rehashes what Obama/Biden were promoting during the election. The concept was touched upon during the speech this evening, but with much less detail. One aspect Obama did touch upon was the development of electronic health records as a way to reduce costs and medical errors. Is that really the best we can do?
I have spoken to many physicians whose hospitals have all electronic data entry including progress notes, laboratory reports, nursing notes, radiology and pathology reports and the like. What they tell me is that because of the "templates" used (pre-formatted outlines for ease of entry) it is much easier to document a patient's information but it is also easier to make mistakes. Let me explain to you how that works.
During a patient's stay a progress note is completed each day. The template automatically imports vitals signs from the nursing notes, lab data from the laboratory, etc. What it also does is pull up your previous days note in it's completed form for you to review and modify for the current day. If you're in a hurry, you can simply leave it the way it is and submit it for that day's note with no changes, even if there may have been changes that should have been addressed and recorded. This can be done day after day, with no change in the note but with significant changes in the patient's condition. So, did the expensive electronic medical record save money, provide better quality of care or increase efficiency?
Some of the concepts of the Obama plan are sound, should save money and extend healthcare to more people. Importation of safe drugs, more stringent scrutiny of the insurance companies, increased competition among them will all help to control, and even decrease, costs. But unless the government looks within to trim waste and corruption, they will never be able to eliminate it elsewhere.
By making the waste inherent in any government endeavor the first and most public target, Obama will provide much needed credibility to further his efforts out into the private sector. Everyone respects a person who admits and overcomes their faults and shortcomings. If they can conquer their own, maybe they can help me with mine? Absolutely.
Just as Obama stated there would be open accounting of the cost of the war in Iraq, he should offer an open accountability of the waste in Medicare and Medicaid. Let all of us see just how our tax dollars are being spent by the very people who are asking us to trust them with even more of our money.
Mr. President, put our money where your mouth is!
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Previously, the promise was for universal healthcare. Now the promise is for healthcare reform. The post election Obama/Biden plan is now posted on the White House website here. The WH website rehashes what Obama/Biden were promoting during the election. The concept was touched upon during the speech this evening, but with much less detail. One aspect Obama did touch upon was the development of electronic health records as a way to reduce costs and medical errors. Is that really the best we can do?
I have spoken to many physicians whose hospitals have all electronic data entry including progress notes, laboratory reports, nursing notes, radiology and pathology reports and the like. What they tell me is that because of the "templates" used (pre-formatted outlines for ease of entry) it is much easier to document a patient's information but it is also easier to make mistakes. Let me explain to you how that works.
During a patient's stay a progress note is completed each day. The template automatically imports vitals signs from the nursing notes, lab data from the laboratory, etc. What it also does is pull up your previous days note in it's completed form for you to review and modify for the current day. If you're in a hurry, you can simply leave it the way it is and submit it for that day's note with no changes, even if there may have been changes that should have been addressed and recorded. This can be done day after day, with no change in the note but with significant changes in the patient's condition. So, did the expensive electronic medical record save money, provide better quality of care or increase efficiency?
Some of the concepts of the Obama plan are sound, should save money and extend healthcare to more people. Importation of safe drugs, more stringent scrutiny of the insurance companies, increased competition among them will all help to control, and even decrease, costs. But unless the government looks within to trim waste and corruption, they will never be able to eliminate it elsewhere.
By making the waste inherent in any government endeavor the first and most public target, Obama will provide much needed credibility to further his efforts out into the private sector. Everyone respects a person who admits and overcomes their faults and shortcomings. If they can conquer their own, maybe they can help me with mine? Absolutely.
Just as Obama stated there would be open accounting of the cost of the war in Iraq, he should offer an open accountability of the waste in Medicare and Medicaid. Let all of us see just how our tax dollars are being spent by the very people who are asking us to trust them with even more of our money.
Mr. President, put our money where your mouth is!
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Saturday, February 21, 2009
Obama Healthcare. Finally? Part I
Things related to healthcare have been quiet lately, mostly because of the current economic crisis. President Obama inherited a huge mess from George Bush, and it will take nothing short of a miracle, or just good old fashioned time, to make it better. During his first month in office, Obama has overseen the most expensive piece of legislation aimed at defibrillating a dead economy back to life.
What has taken a backseat was healthcare. That is until the number of unemployed began to increase to some of their highest monthly levels in years. These displaced workers became some of the very "uninsured" that the candidates were drawing to their respective bosoms in an attempt to get their vote at election time. Now that the number of uninsured have swelled because of increasing unemployment, the government again will have to step in to provide coverage, or they will be an even greater drain on an already strained healthcare system.
Obama's first move was to extend CHIP to cover more children. Some of these are children of the recently unemployed or children who did not qualify for coverage previously. And most people think that by extending that coverage fixes a problem. But it really does not. What it does is drive a self-paying patient into the healthcare system where the reimbursement for that patient is LESS than the cost to see them, process their claim and pay for the overhead costs associated with their visit. Many physicians would rather NOT process the claim and just see them for free. The feeling is that it is cheaper!
In my state of Ohio, Medicaid pays about 45% of the usual and customary fee that Medicare pays for the identical service. Once that reduced payment goes through one of the managed Medicaid programs like Molina Healthcare, Amerigroup or Buckeye, the amount of reimbursement is much less, if you get paid at all. No wonder they are successful! Just don't pay. Great concept. As a result, many physician groups have refused to see these patients, limiting their choice for true quality healthcare.
If you look back to my previous post of 1/26/08, I looked at the cost of healthcare in the US using the same data that the candidates quoted last election to whip everyone into a frenzy. Looking at the data again, you'll see that by expanding CHIP, the government just increased funding for one of the most expensive healthcare programs in the country. At nearly three times the cost of the private sector, it covers far fewer people for the same dollar. And this is the type of fiscal responsibility that is pushing a 787 Billion dollar stimulus package through Congress.
What if the stimulus package has as much waste as the CHIP program the government thinks is so wonderful? Sounds like politics as usual.
Doc B
My opinion is free
Advice is worth exactly what you pay for it.
What has taken a backseat was healthcare. That is until the number of unemployed began to increase to some of their highest monthly levels in years. These displaced workers became some of the very "uninsured" that the candidates were drawing to their respective bosoms in an attempt to get their vote at election time. Now that the number of uninsured have swelled because of increasing unemployment, the government again will have to step in to provide coverage, or they will be an even greater drain on an already strained healthcare system.
Obama's first move was to extend CHIP to cover more children. Some of these are children of the recently unemployed or children who did not qualify for coverage previously. And most people think that by extending that coverage fixes a problem. But it really does not. What it does is drive a self-paying patient into the healthcare system where the reimbursement for that patient is LESS than the cost to see them, process their claim and pay for the overhead costs associated with their visit. Many physicians would rather NOT process the claim and just see them for free. The feeling is that it is cheaper!
In my state of Ohio, Medicaid pays about 45% of the usual and customary fee that Medicare pays for the identical service. Once that reduced payment goes through one of the managed Medicaid programs like Molina Healthcare, Amerigroup or Buckeye, the amount of reimbursement is much less, if you get paid at all. No wonder they are successful! Just don't pay. Great concept. As a result, many physician groups have refused to see these patients, limiting their choice for true quality healthcare.
If you look back to my previous post of 1/26/08, I looked at the cost of healthcare in the US using the same data that the candidates quoted last election to whip everyone into a frenzy. Looking at the data again, you'll see that by expanding CHIP, the government just increased funding for one of the most expensive healthcare programs in the country. At nearly three times the cost of the private sector, it covers far fewer people for the same dollar. And this is the type of fiscal responsibility that is pushing a 787 Billion dollar stimulus package through Congress.
What if the stimulus package has as much waste as the CHIP program the government thinks is so wonderful? Sounds like politics as usual.
Doc B
My opinion is free
Advice is worth exactly what you pay for it.
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