Medicare: The 800 Pound Healthcare Gorilla

Medicare, that is the gorilla in the room, and you’ve to put all of it on the table.

Joe Biden, Vice-President of the United States

Vice-President Biden knew about what he was talking.  Medicare is the gorilla in the United States health system. Some say the Medicare gorilla weighs 800 pounds. Citing Medicare as a gorilla was a fashionable thing for Biden to say, and  he likes to speak the language of the people.  

If you don’t understand why a gorilla should weigh precisely 800 pounds,   I invite you to read this definition in Wikipedia.

"800 pound gorilla" is an American English expression for a person or organization so powerful that it can act without regard to the rights of others or the law. The phrase is rooted in a riddle:

"Where does an 800 lb. gorilla sit?"

The answer:

"Anywhere it wants to."

Medicare dominates American health care.  Other health insurers obsequiously and meekly follow its policies, and it OKs the  AMA’s  Reimbursement Update Committee’s recommendations, which establishes the codes by which doctors are paid.   It pays and dictates fees  for hospitalized Medicare patients as well.   Medicare is, in effect, the prototype of a single payer system.

Kathy Means, a Medicare expert and principal  of Old Creek Consulting, and Ken Monroe, an expert on non-profit organizations,  put it this way in white paper supported by the Physicians Foundation, Healthcare Highway II, Crossing the Electronic  Divide: Health Reform Gateway to 2013:

“To a major degree, the Medicare program, due to its sheer size and national centralizing policy making structure, is the primary instrument  by which many of the ACA’s trials for changes in medical care, as opposed to health insurance improvements, are being wielded.”

These changes include adoption of electronic health records, quality measures and reports, accountable care organizations, bundled billing , medical home concepts, value-based payments, financing medical education, and serving underserved populations.

To carry out these functions, Medicare is deploying comparative effective research,   best practice models,  pay for performance, all supported  by health information and digital technologies, and its various electronic means of communication, including its multiple Medicare websites.  The government is also launching a national media campaign to sell its health law, with its reductions in Medicare benefits, to the public.

There are problems with this strategy:

·         One, the health care jungle is of a finite size and can grow only so large.  Medicare costs have doubled in the last decade.  It is the fastest growing component of  the national debt,  which may exceed $20 trillion in Obama’s second  term.

 

·         Two, there are no 800 pound gorillas on the planet. The biggest gorilla on record weighs only 600 pounds.   For the 800 pound gorilla to grow to 1000 pounds is unlikely given the size of the debt, and the public’s desire to reduce government spending.

·         Three, there are  other animals competing for  power. For example,  hyenas and jackals, known as identity thieves,  hack $ 60 to  $90  billion out of the Medicare nearly $ trillion  budget. Unfortunately,  little elephants in the jungle room, called patients and doctors, resist pleas to  structurally change Medicare and to advance its age of entry.   Then there is that  GOP elephant, which is competing for Medicare turf by insisting upon vouchers.   The GOP elephant   also weighs almost 800 pounds/  It forages and governs in 30 states with an aggregate population of 184 million.

These problems do not bother the 800 pound gorilla. It has been the top gorilla 48 years now, and most of the inhabitants of its hunting rounds rely upon it. These now include 55.6 million in Medicaid,  48.8 million in Medicare, and nearly 50 million on food stamps. True, physicians can be a nuisance.  They charge for their services. Although paying them for their services cost only 12% of the Medicare budget, they order services that consume 80% of Medicare costs.  But physicians  are vulnerable: 550,000 of them, you see,  bill Medicare.  Physicians depend on Medicare for their livelihoods. Medicare can marginalize them by systematically reducing or denying their fees, disqualifying them from payments, and penalizing them for not meeting Medicare standards. Besides, physicians are not united and don’t have any single leader.  They can further be divided and conquered by herding them into Accountable Care Organizations in the name of Medicare savings.

Why worry?  When you are the 800 pound gorilla,  everybody else has to play by your rules. You can do what you want to do.

Tweet: Medicare is a 800 pound health care gorilla. It is the biggest payer, pays only what  it wants to pay, and sets the rules for engagement.

Top Five Issues Impacting  Physicians and Patients in 2013

Lest we forget, physicians and patients are what health reform is all about.

Anonymous

The Physicians Foundation, a nonprofit whose mission is to advance the work of practicing physicians and patients, has released a Watch List of trends to watch on 2013.  The report is based on research studies and policy papers issued by the Foundation in 2012, including the 2012 Biennial Physician Survey, the 2012 Next Generation Physician Survey and the 2012 U.S. Healthcare Highway Report, among others.

1. Ongoing uncertainty over PPACA. Despite the Supreme Court decision upholding most of the provisions in the Patient Protection and Affordable Care Act (PPACA) and the re-election of President Obama, considerable uncertainty persists among patients and physicians regarding actual implementation of the Act. Much of the law has yet to be fully defined and a number of key areas within PPACA – including accountable care organizations (ACOs), health insurance exchanges, Medicare physician fee schedule and the independent payment advisory board – remain nebulous.

2. Consolidation means “bigger.” But is bigger better? Large hospital systems and medical groups continue to acquire smaller / solo private practices at a steady rate. According to a Foundation report on the future of U.S. medical practices, many physicians are seeking employment with hospital systems for income security and relief from administrative burdens. Increased consolidation may lead to monopolities, raise costs, and reduce the number of  solo / private practices.

3. 12 months to 30 million. In 2014, PPACA will introduce more than 30 million new patients to the U.S. healthcare system.

According to the Foundation’s Biennial Physician Survey, Americans are likely to have difficulties finding a physician if  current physician practice patterns continue. If physicians continue to work fewer hours, more than 47,000 full-time-equivalent (FTE) physicians will be lost from the workforce in the next four years. Moreover, 52 percent of physicians have limited the access of Medicare patients to their practices or are planning to do so. As the 12-month countdown to 30 million continues across 2013, physicians and policy makers will need to identify measures to help ensure a sufficient number of doctors are available to treat these millions of new patients – while also ensuring the quality of care provided to all patients is in no way compromised.

4. Erosion of physician autonomy. The Physicians Foundation believes that physician autonomy – particularly related to a doctor’s ability to exercise independent medical judgments without non-clinical personnel interfering with these decisions – is markedly deteriorating. Many of the factors contributing to a loss of physician autonomy include decreasing reimbursements, liability / defensive medicine pressures and burdensome regulatory environment. In 2013, physicians will need to identify ways to streamline these processes and challenges, to help maintain the autonomy required to make the clinical decisions that are best for their patients.

5. Growing administrative burdens. Increasing administrative and government regulations contribute to pervasive physician discontentment, according to the Foundation’s 2012 Biennial Physician Survey. Excessive “red tape” forces many physicians to decrease their time spent with patients to deal with non-clinical paper work and other administrative burdens. In 2013, physicians and policy makers will need to work closely together to determine steps to reduce gratuitous regulations that negatively affect physician–patient relationships.

“2013 will be a watershed year for the U.S. healthcare system,” said Lou Goodman, Ph.D., president of The Physicians Foundation and chief executive officer of the Texas Medical Association. “It is clear that lawmakers need to work closely with physicians to ensure that we are well prepared to meet the demands of 30 million new patients in the healthcare system and to effectively address the impending doctor shortage and growing patient access crisis.”

“We hope that the Foundation’s research and insights serve as a pragmatic resource that will help policy makers, physicians and healthcare providers formulate smart policy decisions that are beneficial to America’s patients and doctors,” said Walker Ray, MD, vice president of The Physicians Foundation and chair of the Research Committee.

Tweet:  Top 5 2013 issues: ACA implementation, hospital/physician consolidations, M.D. patterns of care, doctor autonomy erosions, and red tape.

 

My email has been fixed, and it is OK to contact me at the new address, docreece79@gmail.com

A Personal Note on Hacking Havoc Harm

Hackers are breaking the system for profit. Before, it was about intellectual curiosity and pursuit of knowledge, and now hacking is big business.

Kevin Mitnick (born 1963), online security consultant, convicted criminal, and hacker

Hacking emails of government, celebrities, and millions of the rest of us by email hijackers has become a big and lucrative business.   But it doesn’t hit home until your personal email has been hijacked, as mine has over the last three weeks.

Emails purportedly from me have been sent to those on my address book list on multiple occasions in the last month asking for money to free me from supposedly dire economic circumstances  in Belgium, the Philippines, and the Caribbean. You may have received one of these spurious emails, which may infect and harm your email system.   Frequently changing my password and installing antiviral systems has not stopped these attacks. This hacking has prevented emails from reaching me.  

As a result of these repeated email invasions, I’ve changed my email address form rreece1500@aol.com to docreece79@gmail.com.  You may reach me at this new address.

Richard L. Reece, MD

docreece79@gmail.com

 

Obamacare Implementation Blues

I got the Weary Blues

And I can’t be satisfied.

Langston Hughes (1902-1967),  The Weary Blues

Americans are growing weary, wary, and uncertain about implementation of Obamacare.   It is scheduled to take full effect January 1, 2014.  It is becoming obvious that the Obamacare administration  is not ready.

The two main  pillars of implementation are the individual mandate and health  exchanges.   The mandate is supposed to bring everybody on board to pay for Obamacare.  Its full implementation will effect mostly the young , who comprise 48% of the uninsured, and small busineses.  Not only will the young  and healthy be compelled to buy insurance to fund the elder and the uminsured  but their premiums and overall costs will be higher – by 32% overall according to the American Society of Actuaries.   Health care costs for small businesses will spike sharply upward, and those with over 50 employees may be forced to reduce workers to part-time status to make ends meet.

The health exchanges are another kettle of ill smelling fish. More than half, some says two-thirds, of the states, are unwilling  to set up exchanges and will leave the implementation to an ill-prepared federal government.   The Blues, i.e., the Democratic states, are willing to go along with running exchanges but not most of the Reds,  the states with GOP governors. This mixture of cooperation and obstructionism makes for a messy and confusing situation and delays in implementation.

The Obama administration is responding to this messiness in two ways: 1) by delaying  implementation by one to two years  the choices for 29 million small businesses on which plans to choose (Robert Pear, “Small Business  Health Plan Choices for Obamacare Delayed,” April 1, New York Times); and 2) by gearing up for a national market campaign to sell Obamacare to a skeptical and distrusting public.  The campaign will begin this summer and is intended to influence uninsured and Latino voters as a run-up to the 2014 midterms.

How these strategies will turn out no one knows.  But the strategies will unquestionably prolong the uncertainties surrounding Obamacare.   These uncertainties plus rising costs for benefits to workers will almost certainly negatively impact hiring and will probably  cause more employers to drop existing coverage.

Tweet:  Americans grow more uncertain, weary, and wary about Obamacare as its implementation for small business is being delayed by 1 to 2 years.

Poetic Justification and Medicine

April, the poet told us, is the cruelest month. As it happens, it is also National Poetry Month, which makes its debut on April Fool’s Day. And the biggest fools of all may well be those who believe that contemporary poetry matters in the least… My main point is that of any of your children or grandchildren comes to you and declares a wish to become a poet, send that child to bed without any dinner, and return to your place on the couch before the television set.

Joseph Epstein, essayist and writer, “The Poetic Justice of April 1,” Wall Street Journal,  April 1, 2013

Joseph Epstein’s comments that poetry ia a dead art that shouldn’t be wished upon one’s children is a well-written.

But I disagree with his point  that poets only speak to each other,and not to the world at large,  and that he wouldn’t want his children to become poets,

My son, Spencer, is a naturally known poet.  He won the Breadloaf prize for poetry. Winning the prize revitalized his life.  James Franco, the actor, produced a film based on his book The Clerk’s Tale.  The film was shown at the Cannes Film Festival, and a documentary is now  being made of his teaching of poetry at the Little Roses Orphanage in Honduras.   You can view a preview of the film on You Tube at ourlittlerosesfilmteaser.com.  It may be shown at the Sundance Film Festivel and o HPO,

Spencer is now an Episcopal priest, which expedited his admission the Tale Diviinity School. For the next year,  Spencer will be in Honduras on a Fulbright scholarship at an orphanage, teaching children to express their feelings and experiences in poetry.    He and Richard Blanco, the inaugural poet for President Obama,  will  then co-edit a book of poems written by children at the Orphanage.

Good poetry allows you to tap your inner emotions in a few words.   Good poetry, according to Garrison Keillor in his book Good Poems, has wit, frankness , passion, and utter clarity. Good poetry touches our souls.  It has a more profound effect than you might think.  If you give the matter any thought at all, you will realize poetry s a the heart of lyrics of  patriotic songs about the fruited plain and the purple mountains' majesties, and for that matter make up the lyrics of popular and country music songs and Broadway musicals.. Good poetry and good lyrics are the spontaneous and powerful overflow of  powerful feelings. Poetry is simply  a beautiful way of saying things,  Bad poetry is obscure, arcane, and inaccessible.

In my opinion, there is a renaissance of poetry and spirituality. The two  are closely linked.   Last Sunday,  Richard Blanco was highlighted on CBS’s Sunday morning show.  The TV  Bible Stories, just concluded,   have achieved record market share.  PBS regularly features poets.  And, of course, this new Pope Francis , with his message of simplicity,  has attracted worldwide attention.   There’s a hunger out there for what life means, and poetry and religion  are potent vehicles for satisfying that hunger.

I have found poetry,  or perhaps I should say rhyming verse, allows me to say what I want to say in a few words, to get to the nub of a blog,  to cut through the tangles of  a complex subject with grace, humor, and brevity.  As my favorite limerick goes,  seek brevity, with a touch of levity, in short be terse, for nothing is worse, than verbal longevity,

Poetry, I maintain,  has a  place in medicine.  That is what I tried to say in my first book Physicians, Parodies & Poems in a series of books New Voice of Health Reform:  the 3Rs- Rhyme, Rhetoric Reality.   You may order that first book, which sells for $12.50, at 203-245-3959, or at rjulia@ondmeandbooks.com.

A Historic Health Care Day

Democracy is a great word, whose history remains uncertain, because that history has yet to be enacted.

Walt Whitman (1819-1892), Democratic Vistas

This is a historic health care day.  A new and revised health law is being enacted.

It is the best day and the worst day, depending on your point of view.

It is a day of great compromise.

It is a day of celebration. The Art of Compromise has returned to government.

On the Presidential front - It is no pipe dream – President Obama just  OKed the Keystone Pipeline  so workers can  have jobs and health care coverage, we can become energy independent, we can afford Obamacare, and we can reduce the national debt.    He  agreed to accept the Simpson-Bowles report, which he had commissioned and which includes reasonable entitlement cuts and tax increases.   Through these and other presidential actions,  he has converted a travesty into a legacy.

On the Congressional front -  Nancy Pelosi has  agreed to read the 2700 pages of the health law.   Congress has withdrawn its 20,000 pages of regulation enforcing the law. It  said it will  not need 16,500 new IRS agents to chase down and prosecute those who do not pay for the individual mandate.   It informed businesses they could offer their own health care coverage rather than the more expensive comprehensive government approved plans.  It  would remove  uncertainties  surrounding the law, so businesses could hire full-time workers.   It told the states they could use block grants to care for their Medicaid populations rather than swallow and fund  health exchanges, which will attract millions more Medicaid recipients.  It promised to ease up on the $256 billion in Medicare cuts used to finance the  law.   It  acknowledged that the law may cause businesses to hire fewer employees  and to cancel coverage for as  many as 20 million workers.  It apologized for passing a national law effecting every American without a single vote for the minority party, thus poisoning the political well, and provoking an endless partisan stalemate. It  promised it would move the eligibility for Medicare and Social Security from 65 to 67 and to means test affluent Americans.

On the physician front – Congress agreed to permit and finance the expansion of primary care residences.  It said it would change the rules for membership the Reimbursement Update Committee (RUC) so that codes for primary care could be raised.  It would repeal the Sustainable Growth Rate (SGR) formula for paying physicians as unworkable and unfair. It would no longer punish physicians financially  for not installing electronic health records at their expense.  It would back off its plans for Accountable Care Organizations,   Pay-for-Performance, and an Independent Payment Advisory Board (IPAB) as neither accountable,  nor  performance related,  nor  independent.  It would permit seniors to negotiate private contracts with physicians.  It would pass a national tort reform law, and by doing so,  dramatically reduce total health care spending.

It is April Fool’s day.