Doctor David Fisher » Health Care Reform

Day 6 of 206- reading the Senate Health Care Bill

davidfisher — Fri, 26 Feb 2010 04:25:34 +0000

Pressing on…

Today’s health care “summit” did not seem to alter the course of things, and it looks like Congress is going to push this bill through, so I am motivated to continue reading since this may indeed become a reality.

Pages 77-88

Continues to outline how the government will collect fees and penalties from insurance plans that are not compliant with federal rules

Subtitle C Part 1

“Health Insurace Market Reforms”

Prohibits insurance plans from denying people based on a pre-existing condition
Sets rules for insurance plans regarding the increase of premiums
- Can only increase based on:
  - Individual vs. Family
  - “Rating area” (geography within a state)
  - Age
    - No one can be charged more that 3 times the lowest rate offered by that plan
    - Government will establish “age bands” by which insurance plans will rate people
  - Tobacco use (can only raise premiums 50% for this)
Requires insurance plans to accept every employer and individual who applies for coverage
Requires plans to renew coverage no matter what
Prohibits plans from setting up rules of eligibility based on health status or

This all sounds great. I just wonder how health insurance plans are going to abide by these rules. On the one hand, they are required to never turn anyone away or drop coverage based on health status, no matter how ill the patient. This sounds like a reasonable requirement. However, they also are forbidden from raising premiums on these patients whose health care will be very expensive. So, where will the money come from? Caring for people with chronic illness does cost money. I’m not suggesting that people with serious illness should be dropped or denied coverage. And, in today’s system it seems impossible for anyone with serious illness to be able to afford their own health care out of pocket, so who will pay? If the insurance plans cannot raise premiums, but are required to accept and care for sicker patients, where will the money come from? So far this bill does not offer a solution. Insurance plans will be forced to find ways to raise premiums and fees in other ways. Health care companies will spend much effort and time figuring out how to survive under this system, rather than figuring out how to better care for patients.

Day 5 of 206- reading the Senate Health Care Bill

davidfisher — Wed, 10 Feb 2010 05:34:18 +0000

Ok, I am back on the saddle. I’d explain why I couldn’t get to this for a week but it would be too boring.

Pages 65-76

Begins to outline the rules for implementing the plan.

The part I find funny… “The Secretary shall adopt operating rules under this subsection… having ensured consultation with providers.” Does this mean that the government is supposed to consult with us health care ‘providers’ before implementing the bill? I don’t recall getting a survey in the mail. Maybe that’s not what this phrase means.

(By the way, don’t call me a ‘provider’. I am a clinician, as are my physician, nurse practitioner, and physician assistant colleagues. We do more than ‘provide’ health care. We bring our skills and experience to your unique person and evaluate complex information to make the best clinical decisions. We are clinicians.)

Section B says that participating plans can require the use of a “machine readable identification card.” Also allows for automatic debit to pay premiums.

Gives deadlines for health plans to provide documentation that they are compliant with the rules established by the Secretary and the chosen non-profit rule-making organization. It is not clear in what form the health plan will have to provide this documentation.

Also gives the Secretary the power to contract with outside entities to ensure that these insurance companies comply and provide adequate documentation, and sets up a plan for auditing the companies as well.

Here the government is given the power to demand documentation from health plans, and could also create or contract with another bureaucracy to ensure compliance. A bureaucracy to monitor the bureaucracy!

Establishes a fee for noncompliant health plans. Any plan not in compliance will be fined $1 per “covered life” per day until they become compliant.

The fee increases each year in correspondence to the increase of the total national health expeditures. The maximum fee is $20 per person/per day.

So far this bill continues to follow the theme of expansion of bureaucracy and increased government control.

Today’s bone: left temporal

Day 4 of 206- reading the Senate Health Care Bill

davidfisher — Sat, 30 Jan 2010 04:52:01 +0000

Pages 52-64

Section 1102 Reinsurance for Early Retirees

Gives federal money to insurance plans to cover part of the cost of insuring people who retire early from their job.

In other words, people who stop working at age 55 can receive Medicare-type coverage, but not exactly. You must have a job that provides health insurance, and then if you retire at 55, you can keep your insurance, and the Federal government will pay for 80% of your expenses between $15,000 and $90,000 per year. The money will be paid to the insurance company, and the bill states that the money is to be used to lower premiums, deductibles, and copays. You will still be receiving health insurance through your previous company, but the government will essentially make it easier for the company to keep you on even after you stop working.

The bill gives this program $5 billion.

When you hear people talking about the Senate bill lowering the eligibility age for Medicare to 55, I think this is the section they are talking about. I don’t think this is a horrible idea, except that the amount of money contributed by the government will probably not be enough to offset the cost to insurance companies for keeping people on the plan who are no longer contributing to the plan through their employment. This would mean that insurance companies would have to raise premiums on everyone else in order to stay in business.

Section 1102 Immediate Information that Allows Consumers to Identify Affordable Coverage Options

Establishes an internet site where consumers can “identify affordable health insurance coverage options in that State” and compare them based on percentage of money spent on administrative costs, premium rates, eligibility criteria, etc.

Seems helpful. There is no mention of how much this would cost or the amount of funds being given to this project.

Section 1104 Administrative Simplification

Gives the HHS department the authority to standardize a set of “operating rules” for the management of the financial and administrative transactions that will occur as a results of this bill. Also gives authority to the federal government to contract with a non-profit organization to develop these rules.

What a sweet contract for the business that gets that project!

The section continues several more pages… more tomorrow.

Today’s bone: Left frontal

Day 3 of 206- reading the Senate Health Care Bill

davidfisher — Thu, 28 Jan 2010 06:24:47 +0000

Pages 41-52

Section 2794 Ensuring that Consumers Get Value for Their Dollars

Lets HHS establish a process to review insurance plans “unreasonable increases in premiums for health insurance coverage”.

Requires States who participate in the “Federal Exchange” (first time mentioned in the bill?) to report on premium increases in the State, and allows HHS to determine if the State can continue to receive Federal funds to participate in the Exchange.

Gives HHS $250 million to give as grants to States who qualify for the Exchange. This will also be based on the number of plans in each state and the population of the state.

Section 1101 Immediate Access to Insurance for Uninsured Individuals with a Preexisting Condition

Establishes a temporary high risk health insurance pool program until 2014 when the full program begins.

The government can contract with eligible companies (a State program or a nonprofit) to provide this insurance.

Plan rules

An “immediate access” plan must not exclude anyone for a pre-existing condition.

Also establishes limits on premiums and out of pocket expenses for people in the plan.

Individual rules

For individuals to qualify for an immediate access, they must:

be a citizen or be in the US legally
have no health insurance for at least 6 months
must have a pre-existing condition

Gives HHS the authority to examine if people in the “immediate access” plans were “dumped” by their prior insurance plans. If HHS determines that the person was “dumped” then they can fine the insurance plan for the amount of health care expenses that were incurred by the individual who was “dumped.”

Examples of “dumping” practices:

paying someone with money or other incentives to leave the plan
raising premiums on the “unhealthy”

Gives HHS $5 billion to administer the “immediate access” plan, with a provision allowing them to ask for more.

In 2014, those in the immediate access plans can be transitioned to a plan in the Exchange.

My Thoughts:

Gives a lot of power to the federal government (seems to be a theme so far).

They will have the ability to probe the history of anyone in the immediate access plan to see if they were unfairly dropped from coverage by a prior insurer. No statute of limitations is outlined, so can the government go back 10 years and then fine the insurance company for 10 years worth of medical expenses for anyone they dropped? And to whom will that money go? It does not appear to go to the individual as reimbursement for their out-of-pocket expenses over those 10 years. Instead it goes to the government. In effect, this is simply a transfer of resources from private insurance companies to the federal government, with no apparent benefit to the uninsured, unless you consider punishment of the company that dropped the individual as a benefit.

It’s hard to know how many people will actually qualify for this “immediate access” plan. Only those with a pre-existing condition will qualify, but these were not defined. Does it have to be a pre-existing condition for which a person was turned down by insurance? Or can it be any health condition? If it is any health condition, that would vastly expand the number of people qualifying for immediate access.

The final clause in this section states that the bill will supersede any State laws on this issue. Again, more power to Washington

Day 3 goes to the Right temporal bone.

Day 2 of 206- reading the Senate Health Care Bill

davidfisher — Wed, 27 Jan 2010 05:54:50 +0000

Pages 30-40

Section 2717 “Ensuring the Quality of Care”

This phrase alone makes me shudder. What makes government think it can “ensure” quality of care? So far it has been unable to do so with the plan it does run, Medicare.

Says that the government will establish “reporting requirements” whereby health plans will have to show that they have improved health outcomes and are compliant with government-established “best practices.” Other activities they will be required to report on are “wellness and health promotion activities” (i.e. smoking cessation, stress management, physical fitness, nutrition, etc.) and “activities to prevent hospital readmissions.” These reports must be submitted annually.

In my experience with government, this will do nothing to ensure quality of care. It will ensure that doctors, insurance companies, and hospitals spend a lot of extra time and effort figuring out how to generate these reports and how to ‘look good’ to the government. Time spent jumping through more hoops is time taken away from you, the patient.

Section 2718 “Bringing Down the Cost of Health Care”

a) Health plans have to submit a breakdown of their expenses into 3 categories:

direct clinical services
activities that improve overall health care quality
administrative costs (excluding State taxes)

These reports will be posted on the internet by the Dept of Health and Human Services

b) Each year, health plans must give a rebate to their enrollees if they spend more than 20% of their premiums on administrative costs, as described in the report.

This will simply lead insurance companies to hide administrative costs in their “clinical” services. Under this rule, there is no way a smart health insurance company would ever let their report reflect that they spent more than 20% of premiums on administrative costs, whether it benefited their customers or not. Therefore, they will rename certain administrative costs in order to get them to fall under the first 2 categories in the above report, clinical services or health care quality improvement. You may end up dealing with more administration and bureaucracy in your health plan, so that the insurance company can claim these administrative activities were a clinical service.

Bottom line: insurance companies will be financially motivated to place more bureaucratic hoops between you and your doctor

The bill claims to protect against this maneuvering by promising to establish “uniform definitions” of the activities that are to be reported.

Section 2719 Appeals Process

Establishes a process for appealing a claim- most plans have this already

Section 2793 Health Insurance Consumer Information

Lets the federal government give grants to States ($30 million per year) to set up departments of “health insurance consumer assistance” to help people find insurance, file claims, and track problems.

These departments will then report on the “types of problems and inquiries encountered by consumers” and the Secretary of HHS will use this information to determine “where more enforcement action is necessary.”

The bill only mentioned reporting on problems. HHS is apparently only interested in where people are complaining. There is no mention of reporting States that are doing things well. Essentially, this is the establishment of a nationwide “complaints” department with outposts in every state sending reports back to HHS so they can bring more “enforcement action” against the states that are getting the most complaints.

A tremendous amount of government control in this bill so far.

Let’s call today the Left parietal bone.

Day 1 of 206- reading the Senate Health Care Bill

davidfisher — Tue, 26 Jan 2010 07:12:58 +0000

As a physician in full-time practice, reading the 2400+ page Senate health reform bill seems a daunting task. Indeed, most physicians I know have not read the bill, and we rely on the press or “expert” analysts to give us a summary version. Yet, in my experience, these summaries are inadequate at best for getting the full picture. Therefore, I have set out on a quest to read, page by page, the Patient Protection and Affordable Care Act. At 12 pages per day, I can finish in approximately 206 days, the number of bones in the human body. I will share my thoughts on every dozen pages right here. Check in regularly to follow me on my quest.

Pages 1-17 are the table of contents, so I am skipping those

Pages 18-29

Establishes rules for health insurance plans:

Cannot put lifetime limits on the amount they pay
Cannot put “unreasonable” annual limits on the amount they pay
- here they point to section 223 of the internal revenue code for a definition of “unreasonable”- no idea what that could mean
Cannot disenroll participants from their health care plan once enrolled, unless the participant commits some form of fraud

Requires insurance plans to cover preventive services:

Must cover all “evidence-based” items that have an ‘A’ or ‘B’ rating from the US Preventive Services Task Force
- This includes basic things like blood pressure and cholesterol screenings, etc.
- Includes immunizations and “evidence-based preventive care” for children
- A specific provision was made to ignore the most recent USPSTF recommendations on breast cancer screening, and to revert to those prior to Nov 2009
- The HHS Secretary can establish a minimum length of time between when a recommendation is released and when insurance companies must start covering the recommended procedure/treatment- must be at least one year

Allows the HHS Secretary to develop guidelines for “value-based insurance plans“.

In these types of plans, the more effective a therapy, according to the latest evidence, the lower the cost to the patient. On the other hand, patients will have to pay more for therapies that have no “proven” benefit.

Extends the age of dependence to 25. Parents can claim unmarried children as dependents on their plan up to this age.

Outlines how the insurance plans must presents a summary of benefits to enrollees.

Can’t be more than 4 pages, has to be 12-point font
Must be presented in a “culturally and linguistically appropriate manner”
Goes on to describe what must be included in the summary
Imposes a fine of $1000 per enrollee if insurance company willfully fails to provide this information

My Thoughts

Prohibiting health insurance companies from setting lifetime limits or disqualifying patients seems like a good thing. It wouldn’t seem fair for an insurance plan to drop someone just because they contracted a serious and expensive-to-treat illness. On the other hand, what about the people who continue to smoke or engage in other unhealthy behaviors? Should we all have to pay for their health care costs, too? Under this arrangement, we would have to, because the only reason an insurance plan could drop a heavy smoker, for example, would be if they lied about smoking on their application. The plans will have no choice but to pass along the costs to the rest of the plan members who strive to live a healthy lifestyle.

Relies heavily on “evidence-based” principles. Also sounds good, but this can be dangerous, as Dr. Jerome Groopman points out in the article I highlighted in a previous post. The Senate specifically singled out one piece of science they would not follow. It’s funny how politicians like “evidence-based” recommendations until they are politically unpopular. The USPSTF’s recent breast cancer screening recommendations were the essence of evidence-based: the panel came to their conclusion because the science did not support routine mammograms for women in their forties. Cost was not a factor they considered in their analysis. Yet, because of the public uproar caused by this announcement, the Senate went out of their way to reject this specific USPSTF recommendation in the bill. This decision had nothing to do with science- only emotions and politics. It points out that for all the talk about evidence and science, politics and emotions often win the day, which is one reason why I think putting tough decisions like these in the hands of a few politicians or commission members will put patients in danger.

I have the same concerns about “value-based” insurance plans. Patients will be forced to pay more for things that “don’t work” according to scientific evidence, yet we have seen case after case of an established “best practice” that turns out to be dead wrong. For example, we put every postmenopausal woman on hormone replacement therapy in the 1990s. This was considered a “best practice” until we discovered that is was giving women heart attacks and strokes. Under a value-based plan, women and doctors who chose a different approach would have been penalized financially by insurance companies for going against the “best practice” of giving hormones. This would have caused more doctors and patients to opt for hormone replacement, even amidst reservations about the safety of the treatment. The same thing will happen with many procedures that turn out to be wrong, but when doctors and patients do not have the financial freedom to explore a different approach, it will be less likely that we will even discover that the current practice is not really the “best practice.”

Whew- a lot for day 1 but I learned something. Hope you did too.

(Let’s see, if I’m going to do this in 206 days I may as well assign a bone to each day. Let’s start at the top and work our way down. So Day #1 will be represented by the right parietal bone).

The Best Article on Health Care Reform I Have Read So Far

davidfisher — Mon, 25 Jan 2010 06:56:15 +0000

This week’s New York Review of Books features an article by Jerome Groopman, MD, author of one of my favorite books on the practice of medicine, How Doctors Think. In the article, Dr. Groopman explores the idea of “comparative effectiveness research” and the role it might play in our health care system if a reform bill passes. He also points out that many politicians leading the push for reform believe that doctors should be forced to follow certain “standards of care” or “best practices” as determined by government panels and commissions. Dr. Groopman brilliantly explains why forcing these government-mandated protocols on physicians will harm patients. Read the article here.

Resources for Health Care Conscience Protection

davidfisher — Sat, 16 Jan 2010 19:23:29 +0000

My thanks to Janet Parshall and Talking it Over for a great conversation today about protecting the rights of conscience for health care workers. The best source of information that I have found on this issue is Freedom2Care. Visit this website to learn more about this important issue and to find out what you can do to ensure that our health care system preserves your right to receive care from a physician or health care worker who is freely able to practice according to their deeply held beliefs, whatever those may be.

Nonpartisan Agency says House Bill will reduce Senior Care

admin — Sun, 15 Nov 2009 04:18:00 +0000

In June, I wrote about why the proposed health care reforms will end up reducing benefits for seniors. This week, a major nonpartisan agency agreed. Today’s Washington Post has a story about the report from the Centers for Medicare and Medicaid Services. It reads:

“The report… found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether.”

Read the full article here.

Good intentions do not always equal good results. Congress needs to consider the unintended consequences of asking our health care system to do more with less. As the Post article explains, the weakest and most infirm could still end up out in the cold. We need different solutions to the problems with our health care system than the ones currently being proposed in Congress. The bill offered by the Republicans, while not perfect, offers more common sense solutions, like giving incentives to individual States for reducing their numbers of uninsured, increasing tax benefits related to Health Savings Accounts, and at least addressing problems with medical liability. Before the Senate votes on health care reform, let your Senators know that the current proposals are a bad prescription for America.

Chicago Tribune article on "End-of-Life Conversations"

admin — Mon, 07 Sep 2009 00:12:00 +0000

Today’s article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

The article also explains more about Someone to Trust and what we are trying to accomplish in Chicago.