Health Bills: What’s At The Core

[Dardedar]

A local law professor lays it all out nicely (thanks to Larry W. for passing this along):

From Northwest Ark Times, Nov 30

GUEST COMMENTARY

Health Bills: What’s At The Core

By ROB LEFLAR

Editor’s Note: This is the second of three guest columns from Prof. Leflar about health policy.

Most anyone willing to inspect content would find plenty to like about the health reform bills before Congress.

The controversial issues - public option, abortion coverage - have more symbolic than practical importance. The practical issues - who pays, how much - can be resolved.

Here’s what the House and Senate bills do, and how they differ:

Both bills end discriminatory insurance practices based on health status, such as coverage rejections for preexisting conditions and unaffordable premiums for high-risk patients.

Both bills expand Medicaid to cover the near-poor (incomes up to about $30,000 for a family of four), provide support for disabled beneficiaries, and offer preventive care such as quitsmoking programs for pregnant women. Both bills provide tax credits for premium costs to many middle-class Americans (incomes up to around $80,000 for a family of four).

Of 473,000 Arkansans lacking coverage in 2008, virtually all would be eligible for federal assistance.

Both bills contain programs to improve quality and consumer information. “Pay-forperformance” initiatives such as penalties for hospital-acquired infections move the payment system toward rewarding good outcomes, not high treatment volume. Chain restaurants have to disclose calorie content (Senate).

Nursing home information becomes more available (House).

Insurers must offer coverage fitting into four tiers: bronze (“minimum essential” benefits), silver, gold, and platinum (most comprehensive). Interstate sales are allowed. Medium and large employers must provide coverage for employees. Small employers are exempt, or subsidized if they provide coverage.

Everyone must have “minimum essential” coverage. This could be public (Medicare, Medicaid, VA, etc.), employment-based, or existing coverage, or coverage bought through state- or regionally-operated “exchanges.”

“Exchanges” are key new institutions. They certify and rate health plans, present insurance alternatives in standardized format through Internet portals, enroll individuals and take applications for subsidies - “Travelocity for health insurance.” Exchanges can negotiate prices with insurers (House) or require insurers to justify premium increases (Senate).

Public Option: No Big Deal

Debate rages about whether exchanges should offer a “public option,” and if so whether states could opt in or out. The debate’s more about symbolism than practical health care. Here’s why.

Advocates of “public option” see it as symbolic of America caring for all its people. Many hope it would outperform private health insurers, thought responsible for abuses, and cause them to shrivel. Opponents of “public option” view it as symbolic of bureaucratic big government encroaching on individual freedoms.

In fact, if enacted, it’s likely to be no big deal either way. The Congressional Budget Office (CBO) estimates that of 31 million newly covered Americans, only three or four million would likely choose “public option” insurance. Why? Higher premiums.

Although (like Medicare) it would be more administratively efficient than private insurance, the public plan would likely enroll people with greater medical needs and limit services less aggressively, projects the CBO. Higher cost means higher premiums.

Absent public option, private insurers would have to cover those with greater medical needs.

A nationwide majority supports public option, but even among Democrats it’s only seventh highest priority. No politician should have to die on the public option sword.

Abortion Funding

The House bill forbids people receiving federal subsidies from choosing a plan covering elective abortions. The Senate bill, less stringent, excludes abortions from “minimum essential” coverage and segregates federal premium subsidies from abortion payment unless states choose to require abortion coverage in the public option.

Careful drafting should allow compromises so neither side feels, “We lost.”

Financing It

Reform doesn’t come cheap. Who pays? Both bills hit the well-off.

The House places a five percent surtax on couples earning more than $1 million. The Senate adds half a percent to Medicare payroll tax for the wealthy.

It also taxes high-benefit “Cadillac” health plans. Savings are promised, vaguely, from Medicare payment reforms. The Senate’s phase-in for subsidies and tax credits is longer, to diminish deficits.

Why no cost savings from medical malpractice reform?

My next column addresses that issue.

ROBERT B LEFLAR IS A PROFESSOR AT THE UA LAW SCHOOL (FAYETTEVILLE) AND THE UA MEDICAL SCHOOL (LITTLE ROCK).

[kwlyon]

I made a stop into the emergency room here in fayetteville over the thanksgiving holiday. I had a cough general bla that was getting progressively worse over the course of several weeks and it finally got rather scary serious over the break so I went in against my better judgment (though I suppose my better judgment would have landed me in a doctors office a week prior) and went in to the emergency room. The hospital has sent me a bill for my "out of pocket share" of $300 dollars. My insurance paid 600 dollars. They have charged me 900 dollars for literally five minutes of a doctors time and a prescription for some general antibiotics. The insurance would not pay the full amount as the cost "exceeds the reasonable and customary charge for this service". Don't blame them. I would have thought $600 would have been excessive. I intend on calling them and asking them to explain why the cost is so much higher than the "customary charge for this service". At any rate I would certainly like to know how people without insurance survive. I will manage a $300 dollar bill though I will pay it in a couple pieces as I damn well get around to it. I don't know if I could cough up $900. It would hurt rather severely at any rate. I wish Rush would explain to me how this is not out of control.

Kevin

[Savonarola]

I would have thought $600 would have been excessive.

Several years ago, I took myself to the hospital with severe stomach pain. I gave a urine sample, waited on a gurney for six agonized hours, and finally saw a doctor after the pain had actually gone away on its own. The ER doctor told me nothing except for an idea that even he thought wasn't true (and I knew wasn't true), refused to write a prescription for painkillers, and didn't provide me with any information about how to treat or even simply learn more about this recurring problem in the less than six minutes he was in the room with me. In hindsight, I concluded that the hospital workers thought that I was a drug addict trying to score narcotics, but that didn't stop them from charging me $1200 plus over $200 for the physicians' group. (For the record, I wrote a letter to the group and they waived my fee without further question.)

I recently had my appendix removed. I took myself to a local hospital where I had radiology done, then was transferred to another hospital where surgery was performed and a one night stay took place. Due to a lack of communication between the two hospitals, I got a look at what an uninsured person would have been charged at hospital #2: nearly $14,000. Plus $2000 for the surgeon, plus $2000 for the anesthesiologist. I then got notice from my insurance that hospital #1 submitted $15,000 of charges.
Now, it's a bit of a mess because I simply can't tell for sure what is what as a result of the insurance information debacle, but I'm under the impression that an ER visit, a CT scan, a shot of painkiller, a non-emergent ambulance transfer, a complication-free laparoscopic appendectomy, and a one-night stay costs the patient about $35,000. But suppose I'm wrong and that the two charges of around $14,000 each are actually duplicates, meaning that the charges "should" be "only" about $20,000.

And I thought that the original $14,000 was almost ten times too much.

Don't get me wrong: I have insurance, I got excellent care, and my surgeon especially deserves a great wage. But I have insurance because I have a good and reliable job, and if I had to pay these bills, it would cost me 100% of my savings and I'd be in debt for years. And we're talking about an appendectomy, easily one of the most basic, simple, common surgeries done today. If I'd had a heart attack and needed emergency cardiac surgery, I'd die in the recovery room from the stress of thinking about how to pay.

[kwlyon]

Sav, you are just being overly dramatic. There is no problem with the health care system.

Here is an email response from my father in law:)

"The reason they can do it is because they are familiar with a deadly cancer called Republicarcinoma. It inflicts people who are too stupid to reason things out and think logically but it makes those afflicted block clear thinkers from doing what is needed to be done.

In 1964 I went to the emergency room because I thought I had appendicitis. The doctor quickly determined what was wrong and administered an enema. Total cost $2."

[kwlyon]

You would think anyone charging such amounts for such a minute service would be required to supply an invoice before services are rendered! I think I will call them and ask for an itemized bill. It would be interesting to see the source of these charges. I wouldn't mind such rates if I could be assured that my expenditures are aiding those less fortunate. I am not convinced that this is the case at all.

[Dardedar]

You would think anyone charging such amounts for such a minute service would be required to supply an invoice before services are rendered!

DAR
An invoice, they won't even give you a price. I've tried.

I think I will call them and ask for an itemized bill.

DAR
You must do this. There is a good chance it has errors.

[Doug]

...that didn't stop them from charging me $1200 plus over $200 for the physicians' group. (For the record, I wrote a letter to the group and they waived my fee without further question.

DOUG
So much for the long-standing assertion that doctors are somehow public servants. Imagine if I thought I saw a burglar sneaking around outside my house, and I called the police, and they come, look around, and find nothing. Then they send me a bill for $1400. Could they still claim to be altruistic public servants?

[L.Wood]

.

A good friend, John Gray, recently had an experience with a dentist. John had a bad motorcycle accident last year and two of his teeth were badly damaged.

After all the analysis the dentist told John what he should do which was to have two dental implants. Very expensive.

John then looked at him and asked: "Is this best for me or best for you?"

He fully realized that the dentist was "in business." That means in business to make a profit.

When you have for-profit health practices surrounding you the best or more appropriate decisions are forced to give way to what is more profitable for the profit seekers.

In a meeting last Saturday a Korean War vet remarked that his two Mds at the VA hospital have TWO assistants, one each. Total. That's it. They are not under a compulsion to see a record setting number
of patients per day. It is not for profit. In comparison, the pulmonary specialist I see 2x per year has a staff of 5. About two of his staff do nothing but process claims. One is a personal, RN,
assistant who prepares patients and gives care instructions. One does nothing but manage the Md's schedule. The vet remarked that all of U.S. health care should be like the VA. The doctors are paid well above average income but not the $1-3 million per year that beginning surgeons and specialists expect upon entering private, for-profit practice.

The Bush tax cuts end next year, 2011. At that time about $2.3 trillion yr will flow back into the federal treasury. This is what is causing the howling from Koch, Scaife, Dick Armey, Murdock, Hannity so as to cause them to stimulate the t'baggers into a disinformation campaign and to run a disinformation campaign from their positions. It has nothing to do with medical care. It's simply about their bottom lines.

Savings in Medicare. Allow me to give you one simple example from local experience. My girlfriend is a RN. She worked for a Home Health Agency (HHA) for six months making house calls. It's a practice that was supposed to have reduced costs for Medicare patients by sending them home from hospital care several days earlier. Girlfriend was paid $30 per home call. She could always do two calls per hour. That's a good hourly rate for a local RN. If supplies like bandages, tubing, meds, filters, etc were required the HHA billed those as extras. Girlfriend was paid .45 per mile for travel outside of the city. The HHA billed Medicare $297 per visit. They had 3 people in the local office running things. One was an RN the other were clerks.

There are lots of savings to be made from our for-profit medical delivery system.

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“The modern conservative is engaged in one of man’s oldest exercises in moral philosophy: that is the search for a superior moral justification for selfishness.”
–John Kenneth Galbraith

.

[Dardedar]

About ten years ago I was having tooth pain. Went to some dentist I didn't know on Colt square. He said I needed a root canal, about $600 I think. I was skeptical for some reason and not so impressed (having never had one and only heard bad experiences). I accepted that I needed one but being cheap (prudent) I was going to shop around. A better price was at the Smile Center in Springdale so I went there. After examination he said I didn't need a root canal and they could put a patch on the top of the nerve (and fill the cavity) which was fine and healthy but just a little pissed off with tooth decay nearby. That was ten years ago, it was a fraction of the cost and I have a healthy tooth and nerve.

Moral of the story: Be especially skeptical of all claims made by someone selling you something. Get a second opinion, check and double check the bill. They can be wrong or snooks. It's not getting any smarter (or honest) out there and these problems are RAMPANT.

D.

[kwlyon]

...that didn't stop them from charging me $1200 plus over $200 for the physicians' group. (For the record, I wrote a letter to the group and they waived my fee without further question.

DOUG
So much for the long-standing assertion that doctors are somehow public servants. Imagine if I thought I saw a burglar sneaking around outside my house, and I called the police, and they come, look around, and find nothing. Then they send me a bill for $1400. Could they still claim to be altruistic public servants?

I'm not so sure it is the doctors who are to blame for this. I know they make a very nice living however when I go to my regular general practice physician I seldom see a bill over and beyond what my insurance pays and for this visit we would have been talking about $100.

Kevin

[kwlyon]

Moral of the story: Be especially skeptical of all claims made by someone selling you something. Get a second opinion, check and double check the bill. They can be wrong or snooks. It's not getting any smarter (or honest) out there and these problems are RAMPANT.

D.

Yes this thought occurred to me. At no point, during my visit to the emergency room or debra's extensive fiasco this year, did I EVER communicate with my insurance. It seems this system is wide open to potential fraud. What if the hospital just decided to bill my insurance for some random procedure I did not receive? Who would be the wiser? All I get from the insurance company is an "explanation of benefits" that give nothing more than a dollar amount and to whom it was paid out. From the hospital I got a bill for the remaining balance however it only states that this is my "out of pocket" cost that was not covered by my insurance. There was no explanation for the charges on the bill. For all I know I am about to pay for having my left testicle removed.

[L.Wood]

What if the hospital just decided to bill my insurance for some random procedure I did not receive? Who would be the wiser?

This happens much more often than one may suppose.

I have a good friend who audits Medicare reimbursements for a big heart center in Dallas. His job (by contract) was to examine their billings to Medicare to look for
instances of underpayment by Medicare. He was paid based upon a percentage of the underpayments he discovered. He earned an above average rate of pay for being a former RN.

What my friend found was his employer (principal) over-billing Medicare in a routine manner. He issued them two written warnings about what they were doing. The practice
ceased for about a month. Then he noted it began all over again but for larger amounts.

So, he reported the over-billing to Medicare, via an attorney. Whistle blowers rewards are set at a given rate of the recovery that is subsequently made. His settlement was a
few million dollars. So, he is taking it easy for a few years.

Several years ago I was looking over my mother's itemized hospital bills after she had broken her hip. The hospital, a private one, had double billed on a few items but it was the expensive
items. I pointed this out to her. She politely told me they do that routinely. I asked her about reporting it or asking the private hospital about it. She was too cautious and said she was
afraid of being rejected by them should she need to go there again.

Lots of room for savings in many for-profit health plans.

.