Tuesday, July 22, 2014

Kindle book Direct Pay Independent Practice: Medicine and Surgery, is now available on amazon Book makes point that ObamaCare, which raises premiums and deductibles to unaffordable levels for many, is a potent incentive sales program for direct pay concierge and direct pay ambulatory care practices as alternative to ObamaCare.
Appeals Courts Conflict on Health Law Subsidies

It is emphatically the province and duty of the judicial department to say what the law is.. If two laws conflict with one another, the court must decide.

John Marshall (1755- 1835), First Supreme Court Chief Justice

It is starting to look like the Supreme Court will again have to decide if ObamaCare meets the letter of laws governing the President and his executive actions.

Today, Tuesday, July 22, 2014, two appeals courts issued two conflicting rulings of ObamaCare within hours of each other.

• The D.C. circuit court rules 2:1 that subsidies could only be available in state exchanges, not in the 36 federal exchanges, thereby ruling invalid subsidies given in the recent health exchange launch, which ended on April 1 and in subsequent two weeks.

• The U.S. Appeals Court for the Fourth Circuit in Richmond , unananimousliy struck down this challenge to ObamaCare subsidies, which effectively the entire intent of the ACA.

These conflicting decisions come in the wake of the Hobby Lobby decision to invalidate part of the Contraceptive Mandate, a setback for ObamaCare.

If subsidies are blocked, an estimated 7.3 million people – about 62% of those expected to enroll in federal exchanges by 2016 – will lose out on $36.1 billion in subsidies. As matters now stand, people qualify for subsidies with incomes under $45,960 for individuals and $94, 210 for families of four.

On the other hand, if subsidies continue, health care premiums may rise to unacceptable levels for many of the middle class.

A negative rulings by either the full court of appeals, expected soon, or the Supreme Court latter, should it accept the case, would effectively kill the Employer and Individual mandates and ObamaCare itself.

If the subsidies case goes before the Supreme Court, ObamaCare success is not a given court rulings so far on Hobby Lobby and the 13 to 0 record of recent negative Court rulings against Obama.


1. Paige Winfield Cunningham, “Wild Day for ObamaCare: Appeals Court Rulings Conflict, Politico, July 22. 2014.

2. Robert Pear, “Courts Issue Conflicting Rulings on Health Care Law,” New York Times, July 22, 2014.

Looking at Health Reform Anew

Our obligation is about generating new ways to reconceptulize the world and new ways to participate in it, new ways to imagine, to shape, and make it.

Mariko Silver, “Show the World Anew,” President of Bennington College, 2014 inaugural address to alumni, students, faculty, and friends of Bennington College

I am not an alumnus of Bennington College. But one son, Carter, went there. The other son, Spencer, presented his poems there.
And it was at Bennington that my society mentor, Peter Drucker (1909-2005), taught and learned what he needed to know to develop the theories that inspired and informed modern management.

There Drucker learned about makes America tick – its history, government, philosophy, and religion. Drucker believed in limited government but also in business management that created and led institutions with larger social purposes.

I am writing this because I am engaged in writing an ObamaCare triology spanning the period from ACA passage, March 23, 2010 to November 4, 2014. I believe the midterms will determine the fate and shape of health reform.

What am I learning from this writing engagement, this process, of writing about ObamaCare?

Much of what I am learning was expressed eloquently in Mariko Silver’s inaugural address as President of Bennington College.

One, “Life has never been lockstep or linear.” Neither has the process of implementing ObamaCare. ObamaCare is a new way of reconceptualizing health reform, a sometimes bizarre combination of government and the private sector, as a means of reshaping and remaking health care delivery.

Two, “Humans are ever seeking to capture the complexity of the world and to bind it into little boxes.” I have tried to capture the essence of ObamaCare by binding them into 600 little boxes called blogs and then to rebox them into bigger boxes called categories and then into even bigger boxes called books.

Three, “But if we want change, if we want progress, if we want fundamental shifts and improvements in the human experience – and the state of the planet as well – then we need to require our institutions to advance and even to break course and take on new, as yet never realized or even yet imagined, directions – new boxes, or maybe no boxes.” ObamaCare does not fall neatly into little boxes, like blogs, or even into big boxes – like liberalism or conservatism, or single-payer, government- driven care. or competition, and market-driven care.

Instead ObamaCare advocates and distractors and the alternatively-minded opponents should seek “liberate and nurture the individuality, the creative intelligence, and the ethical and aesthetic sensibility” of students and perpetrators of health reform for “constructive social purposes” , rather than for raw political power.

The quest for the right health reform is an ongoing, perpetual , creative – and chaotic – process. It has no definite endpoint. There will always be room and gloom for improvement.

But we as a resilient nation can do it because of our endowment of individual, natural, and freedom-loving resources. We can do it by defying conventional wisdom that there is just one right way of doing things. Let us do it the American way by embracing complexity and diversity and by thinking of our creative restlessness as an asset, rather as an exercise in political partisanship.

Monday, July 21, 2014

Less Doctor Pay, More Health Costs

Less is more.


Of all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster.

Sandeep Jauhar, MD, “Busy Doctors, Wasteful Spending,” New York Times, July 20, 2014

If something sounds too good to be true, it often is. Such is the case with cutting doctors’ pay. American doctors are among the highest paid in the world. Why not just cut their pay, put them on salary, bundle their services, just pay them for what works? Wasteful spending costs the U.S. $750 billion a year. What doctors order accounts for or affects 80% of health costs.

But alas, less may not be more. As Doctor Jauhar, an internist, points out, when you receive less pay, you have to see more patients to make up for the loss. And when you see more patients faster, you make mistakes and you miss things.

To keep those mistakes and misses from hurting you and the patient, you worry more about malpractice.

When you worry more about malpractices, you make more referrals to specialists, who order more tests. And who will certain do something. That is what they are trained to do - do something.

You may order more tests yourself, just to make sure you haven’t missed something.

You may order an MRI or CT scan , which have been embedded in the public’s mind as a standard of care and the magic answer for finding out or ruling out the causes of back pain or joint pain or headaches or belly or chest pain, or whatever else ails you.

You may write a prescription. The patient came to you for help. They want something done for them. And writing a prescription is something. It is better than simple talk and counseling, which takes more time. And more time is something you do not have.

To create more time for yourself and your family and to assure yourself of a more secure financial future, you may go to work for the local hospital. Unfortunately, because of a law allowing “facility fees, “ more and larger fees are charged if the patient is seen in a hospital-owned facility Fees charged are often 50% to 60% higher than fees charged in a physicians office.

And so the physician payment and health cost cycle goes. Where it stops no one knows.

Perhaps we could slow it down by reducing the pay differential between hospital-owned and independent doctors, by cutting regulatory paperwork, which takes 25% of doctors’ time, by punishing doctors for ordering those procedures patients and lawyers expect, by spending more time counseling patients to walk more, eat smarter, drink less, and take better care of themselves, but that would take more time, of which you have less and less.

Sunday, July 20, 2014

Existential Threats to ObamaCare

Existential – Pertaining to existence or existentialism, as in a threat to the existence of something.

In my reading, I keep coming across the word “existential” when applied to politics. Most commonly, use of the word implies some problem or movement threatens the existence of something.

To wit, the Tea Party is existential to conservatives and the Republican Party, or the botched healthcare.gov or a failed ObamaCare law, is existential to liberals and Democratic party.

I turned to the dictionary for the definition of existentialism and came up with this:” A belief or movement that man has an absolute freedom of choice but there are no rational criteria saying on what basis of choice and the universe is absurd producing anxiety and alienation”.

That definition pretty much sizes up the current prospects for ObamaCare.

So what are threats to the existence of ObamaCare?

In my mind, the existential threats are:

• Persistent public disapproval in the 58% to 37% range in the latest poll , with an average disapproval margin in 14.5% in multiple polls. How can this continue? It likely will continue because ObamaCare has been helpful in bringing down the number of uninsured Americans from 18% to 13.5%, but if the GOP wins the Senate, the existence of ObamaCare in its present form will be hobbled, maybe even threatened with extinction and repeal.

• Legal threats - One, The Boehner and the House threat to sue President Obama for those multiple executive actions resulting unilateral changes and delays in ObamaCare without seeking Congressional approval as required by the Constitution. Two, the wording in the ObamaCare law which states that only the states, not the federal government, can offer subsidies for health exchange plans. There are undoubtedly ways around these legal problems given that Democrats run the Justice Department. These may be issues the Supreme Court decides.

• Public and election revolts, locally, regionally, and nationally , against premiums and deductible spikes to unaffordable levels, cancellations of millions of existing plans due to onerous coverage requirements , narrowing of health plan networks resulting in losses of trusted doctors and hospitals, coercion of individuals and employers to buy health plans or cough up penalties, a continued unacceptably slow economic recovery attributed to ObamaCare, and, of course, threatened or actual fiscal insolvency of Medicare, Medicaid, and state and federal governments.

These various dreadful scenarios are unlikely to threaten the existence of ObamaCare or the major political parties, but sometimes fear of going out existence or becoming irrelevant hastens change. However, with the presence of multiple vested moneyed interests, policy adjustments signaled by polling, and the resiliency of the two major political parties, existential obsolescence is not in the cards.

Saturday, July 19, 2014

An Interview with CMS as a Person

Where does an 800 pound Gorilla sit? Where it wants to sit.

Common Expression

Q: Many people think of you as a huge faceless bureaucracy – a government godzilla.

Do you mind if I address you as a person?

A: Not at all. It’s about time someone recognized me as a living, breathing person, rather than as an impersonal entity or as some kind of dominating force of government.

Q: I hope you don’t mind if I remind you many doctors think of you as an 800 pound health care gorilla, controlling and dictating everything they can and cannot do and what they are paid, even though you are far removed from the point of care.

A: I would prefer to be known as a paternalistic, compassionate sugar-daddy – bent on improving the health system with well-spent federal dollars and protecting people against free market predators and poachers, some of whom are physicians.

Q: So you regard yourself as a kind king and guardian of the health care jungle.

So you have tHis perception of yourself, as someone with a public protector with a passion for compassion?

A: Well, yes. After all, I cover 100 million Americans in three programs – Medicaid, Medicaid, and Children Health Insurance Program (CHIP), presumably the vulnerable, under-served, and uninsured among us.

The need for my services will only grow. Fifty million more Americans will qualify for these programs in the next five years.

And my policies essentially govern the health care coverage of 215 million other Americans, thereby protecting the other thow-thirds of the population.

Q: But there is a downside to your view of yourself. Follow your rules, or else, you seem to say. Otherwise, you will not be paid to deliver care or receive care. Obey the king of the health care jungle – the biggest health care payer and giver on the planet. The health care world must heed your instructions - or not be part of that world. That's pretty arbitrary. Is it not?

A: I carry a heavy burdent. Since 2010, I have been responsible for implementing ObamaCare, the biggest national health care program since Medicare, far bigger than Medicare/Medicaid/CHIP, since it covers everyone. The Office of the Budget estimates ObamaCare will cost over $2 trillion over the next 10 years.

Q: Who can argue with that projection? Since its 2010 passage, ObamaCare has already resulted in $1800 increases in premiums for families, rather than its promised $2500 decrease by 2016.

My question is: How big is Medicare/Medicaid/CHIP/ObamaCare going to get, and what will it cost the taxpayer?

A: I know not, but I am certainly big, and I’m getting bigger every day in every way. That is the curse of being a bureaucratic care giver. You have to spend big to get big results. I have a budget this year of $1 trillion, and, if history is any guide, that will grow, along with the current $17.6 trillion federal deficit, with debts of $900 billion for Medicare/Medicaid, $55,000 for each citizen, and $151,000 per taxpayer.

In 1965, when I was introduced to the health care world, it was projected I would only cost the U.S. $9 billion by 1990. That projection came before my little sister, Medicaid, the children of CHIP, and the budgetary beasts of burden of ObamaCare arrived.

Look how big I have become. By 2020, my collective costs may exceed $1.5 trillion. As Doctor Seuss would say, I'm figuring on biggering and biggering and biggering.

Q: Why do you cost so much?

A: That’s not an easy question to answer. But among other things, over the last 50 years, the life expectancy of women has increased seven years and 10 years for men. I regard myself as primarily responsible for the increased longevity and better health of Americans.

There’s all those new technologies, allowing organ transplants, long-term dialysis, and CT, MRI, and PET imaging, not to mention all those life-saving drugs. The list goes on and on. I take credit for financing them.

Then there’s the simple incentive that government promises of a “free lunch”, especially when you’re spending other people’s money, demand skyrockets. My job is to meet the demand.

Q: Some people claim U.S. has no health system. People don’t seem to acknowledge the hard reality – you are the system, and it's basically single payer in tht you set the fees.

A: How so?

Q: Look, I ask the questions here. Anyway, what I mean is this. You set the standards of how many doctors there will be, how much money for physician training you will provide, what doctors will be paid and for what , what their payment codes will be, who can and cannot practice, what much data doctors must collect, how they they must prescribe online, what electronic systems they must install in their offices, how they will transmit that data to you, what patients will be covered and who will receive subsidies, what federally improved plans they can enroll in, what doctors they can go to, who can run a hospital or any other health facility and who will own it, and what they can charge. Other health plans follow your lead.

A: When you pay the money, you set the fees , you dictate the choices, and you make the rules. You have to account for each dollar spent. You have to watch out for fraud, which is why I initiated a $210 million fraud protection programs. You have to control what doctors order because what they order accounts for 80% of health costs.

Q: What would happen if the costs of your policies cause health premiums and deductibles become unaffordable, bureaucratically unfathomable, and unacceptable to Americans.

A: That will never happen.

Q: Any closing comments?

A: Go to medicare.gov and healthcare.gov to appreciate the breath and magnitude of what I do and what I promise to do for the American people.