26 July 2009
Correct Me if I'm Wrong- -please!
Health Care as a Moral and Constitutional Issue
In the past five years, we have had a national focus on the American system of providing health care to its citizens. During his first term, President Obama sponsored and achieved the passage of federal legislation aimed at establishing a national policy for health care. Attempts by many groups to introduce a single payer system, basing health care for everyone on a federally-funded insurance program akin to Medicare or the Veterans Health Services. The private insurance industry and the AMA fought for no changes, invoking 1930's images of socialized medicine under a totalitarian state and by providing media coverage to assert that the American approach to health care has resulted in the best health care possible in the world. Neither end of this political spectrum was successful in defeating all aspects of the other's arguments. The Affordable Care Act of 2010 (ACA) was the result. Almost immediately and henceforth to today, the Republican leadership in Congress has attempted to repeal the ACA and repealing the act was a principal theme during the Presidential election of 2012. To date, those efforts to repeal have been defeated by vote and by reelection of President Obama for a second term.
WHAT MORE NEEDS TO BE DONE?
The Cost of Medical Education One cost driver in the health care industry is the cost paid to educate and train a physician. While a student in medical school, student loans help pay tuition costs and housing expenses in excess of $50,000 per year. After four years of medical school and their residencies of up to three additional years, the amount of personal debt from student loans for a licensed, medical doctor makes the National Debt seem trifling when compared to the monthly payments on her loans.
In the past five years, we have had a national focus on the American system of providing health care to its citizens. During his first term, President Obama sponsored and achieved the passage of federal legislation aimed at establishing a national policy for health care. Attempts by many groups to introduce a single payer system, basing health care for everyone on a federally-funded insurance program akin to Medicare or the Veterans Health Services. The private insurance industry and the AMA fought for no changes, invoking 1930's images of socialized medicine under a totalitarian state and by providing media coverage to assert that the American approach to health care has resulted in the best health care possible in the world. Neither end of this political spectrum was successful in defeating all aspects of the other's arguments. The Affordable Care Act of 2010 (ACA) was the result. Almost immediately and henceforth to today, the Republican leadership in Congress has attempted to repeal the ACA and repealing the act was a principal theme during the Presidential election of 2012. To date, those efforts to repeal have been defeated by vote and by reelection of President Obama for a second term.
We pay taxes so that the government can provide the entire nation with a just program or entitlement. We like our highways, our air controllers, our ports and shores protected by our military. Why don't we like the government to provide a decent health care system for ensuring our human right to life, liberty and the pursuit of happiness? Why is not a healthy life a communal responsibility that our taxes should support and sustain?
WHAT MORE NEEDS TO BE DONE?
The Cost of Medical Education One cost driver in the health care industry is the cost paid to educate and train a physician. While a student in medical school, student loans help pay tuition costs and housing expenses in excess of $50,000 per year. After four years of medical school and their residencies of up to three additional years, the amount of personal debt from student loans for a licensed, medical doctor makes the National Debt seem trifling when compared to the monthly payments on her loans.
Part of the expense for training medical doctors is the period during which they are supervised by a senior physician, either faculty member or by an expert in a specialty. During their internships and residencies, doctors-in-training make the mistakes for which a practicing physician risks being sued for malpractice. A patient who consents to this level of care will have at least two doctors at all times. If the patient's attending [viz. own] physician monitors the care and treatment while hospitalized, the patient has three physicians who are paid from several sources. Level of care, or intensity, affects the prices as well, because of additional clinicians-nurses and technicians-plus specialized monitoring equipment, breathing assist equipment, and so forth, will raise costs as soon as the patient's physician orders it. In a teaching hospital, the patient's own physician normally defers to the attending physician, a senior resident or hospitalist physician or a consulting physician accountable for the patient while in the hospital. Because mistakes concerning a patient's care and treatment--including survival--are part of the learning process, patient care at teaching hospitals costs more. We learn from our mistakes.
Provider Fees A part of the cost algorithm that receives the most press and legislatures represents the prices hospitals and physician groups charge for their services. The public does not get information about why one hospital charges $X and another charges $Y for the same treatment. Physicians set their own fee schedules, even if their revenues reveal a variety of payments for fees charged seemingly unrelated to any published fee schedule. The expenses that institutional providers accrue from having recruited "the best and the brightest" clinical staffs, constructing modern facilities, and updated laboratories and equipment available to support a star surgeon or treatment group, plus granting practice privileges.
The key at each level of purchasing and for approving reimbursements has two parts: the wage, or manufacturing cost, plus overhead. Overhead includes the employee wages and benefits for administrative and technical support personnel, the proportionate expense for providing the clinical facilities, medical equipment used for diagnosis and treatment, the patient beds and rooms, utilities, acquisitions for nuclear medicine plus containment facilities, and a portion of the institution's debt service for those bonds that built the place. There are hundreds of additional components of administrative overhead costs built into each service charge, procedure done, etc.
Medicare's vetting and reimbursement bureaucracy is not an overnight service. For large medical centers and hospitals, the delay between incurring an expense and receiving revenue can extend weeks and months. Therefore, an additional piece of overhead are the costs incurred before receiving revenue from services, i.e., the cost of the float or sufficient cash to pay employees and its vendors.
To help hospitals with their float, Medicare instituted regular cash payments each month on the assumption of the amount Medicare eventually will pay, or not pay. Hospitals negotiate their overhead percentages with Medicare. The reimbursement rates from Medicare and Medicaid are set in Washington.
Hospitals bill private insurance companies for services rendered and, after a lengthy vetting of these claims, decide whether or not to reimburse the hospital, physicians, medications and other supplies required by that disapproved procedure. If the patient has Medicare A and B, private insurers will be billed for the difference between the expected Medicare payments and the retail or, most often, negotiated plan prices for the service. Hospitals maintain a list of prices for all of their services; Medicare/Medicaid will pay a percentage of the price, now below 50 percent; private insurers will make up some of the difference according to negotiated plans; and the patient pays co-payments. If the service's price represents 100 percent, and the revenues from insurers, research funds and Medicare only add up to 70 percent of the price, the hospital may bill the patient for that 30 percent. However, providers write off the difference between Medicare reimbursement and amounts of co-pays. Such write-offs are referred to as contractual allowances. Under Medicare Part B, the patient may be on the hook for 15-20 percent. Fifteen cents on the dollar may seem fair, except for the inability of the patient to decide whether to incur a cost being billed at full price. Routine operations on the heart and lungs, other organs or the body, are part of "accepted" practice today, whereas they may have been declared "extraordinary" or "experimental" compared to the state of the art at some prior time.
Costs for Inpatient Care The Admission process does not inhibit providers from full-cost-plus pricing. Once a patient signs the admission form, the patient accepts responsibility for all costs incurred while hospitalized. From that point on, our private health care system gives the green light for spending what the physician considers prudent, necessary care and treatment. After all, we agree to inpatient care because we "know" that the hospital is the place for the best care. As dubious as the patient's assumption may be, our society expects the best care. We Americans are reminded quite frequently in the media and by the health care industry that "our country offers the best health services in the world." That assertion is a pernicious public myth that is interfering with reforming our national health care system.
Costs for Inpatient Care The Admission process does not inhibit providers from full-cost-plus pricing. Once a patient signs the admission form, the patient accepts responsibility for all costs incurred while hospitalized. From that point on, our private health care system gives the green light for spending what the physician considers prudent, necessary care and treatment. After all, we agree to inpatient care because we "know" that the hospital is the place for the best care. As dubious as the patient's assumption may be, our society expects the best care. We Americans are reminded quite frequently in the media and by the health care industry that "our country offers the best health services in the world." That assertion is a pernicious public myth that is interfering with reforming our national health care system.
According to this commercial propaganda, a public-option health care system takes away our choice of physician. Most HMOs, keystones of Managed Care, require members to choose from among the physicians they have. Leaving one's physician may seem traumatic after a number of years, but employer-based health insurance can require one to do so in a job transfer. We have to inquire if our regular physician accepts our private insurance plan before receiving services. There are no standard reimbursement rates for professional fees and office visits. Medicare and Medicaid beneficiaries have to ask if a doctor accepts those patients. Sometimes, one hears that the doctor is no longer accepting new Medicare patients. I doubt if that is legal. The Medicare law maintains that if a doctor has just one Medicare patient out of hundreds, that doctor must accept new Medicare patients. The only way a doctor can refuse a new Medicare patient is if that doctor stops treating all Medicare patients in the practice. I have had to find a new physician because my doctor closed his mostly-Medicare/Medicaid practice. He said he could no longer afford to maintain his practice.
Will rationing Health Care force me to wait when I need treatment? Another argument is that our health care will be rationed and we will have to wait long periods to receive needed care. Prior to the full implementation of the Affordable Care Act of 2010 (ACA) unless it is an emergency, we have been content to wait for our doctor's next available appointment. If during that office visit our doctor orders x-rays, CT-scans, PET scans or an MRI, plus blood work, we have to wait until we can get to the pharmacy or the laboratory that will do the procedure. For the scans, we have to wait for the next available slot. After the patient accomplishes all of this, and regardless of the patient's transportation resources, the next waiting period will be with our doctor or with a specialist to whom the patient has been referred. Further, if the attending doctor concludes, the patient needs a specific surgeon or other specialist physician for the best treatment, or if the patient needs an organ transplant, another waiting period happens. Having to wait for necessary care and treatment is already the major inconvenience and potentially harmful to the patient in our American health care system. The patient incurs the costs of time, transportation and less-than-optimal health without any recognition of these costs being included in the economic cost algorithm.
Informed Consent for Medical Services While In The Hospital When a comatose, or mentally inhibited, or parent of an Emergency Room dependent child as patient, or a non-English speaker or someone who knows nothing about medical procedures, a nurse, social worker or doctor tells them at the time to sign a form that he or she has been informed about a pending procedure. How does the provider or physician expect the patient or patient's representative to sign an informed consent to treatment before the fact? Even though the patient must assume financial responsibility for the entire inpatient episode, patients have no information upon which to make such a choice.
And yet, the most cited cause of individual bankruptcy is a person's inability to pay for health care received. Suppose that person makes about $45,000 per year in take-home pay. What rationale exists to expect that patient to pay $25,000 $50,000 $300,000 and still have a place to life, food to eat, and time for rest. Sure that person signed that agreement of financial responsibility, but he or she may have made a different choice even to live with infirmity. A parent may choose to contribute to a retirement fund or a college fund, rather than be impoverished by medical bills. A patient may decide that he or she will treat or live with a health condition until they die. That is personal accountability and an informed one if the amount of money required for inpatient treatment could be known in advance.
And yet, the most cited cause of individual bankruptcy is a person's inability to pay for health care received. Suppose that person makes about $45,000 per year in take-home pay. What rationale exists to expect that patient to pay $25,000 $50,000 $300,000 and still have a place to life, food to eat, and time for rest. Sure that person signed that agreement of financial responsibility, but he or she may have made a different choice even to live with infirmity. A parent may choose to contribute to a retirement fund or a college fund, rather than be impoverished by medical bills. A patient may decide that he or she will treat or live with a health condition until they die. That is personal accountability and an informed one if the amount of money required for inpatient treatment could be known in advance.
Have a pet? Every veterinarian has a listing of prices per procedure, so you might decide not to treat your pet for cancer because it will cost $3-5,000 for the surgery, chemotherapy and radiation, or you can look for another, more affordable price. That is an informed payment process.
The Constitution does not make a provision for arbitration as a substitute for access to the courts system. What is the motivation for arbitration? It is to lessen the costs of a mistake, an accident, or malpractice. The patient does not have to agree to arbitration, regardless of consequences. The court system remains available.
There is more work to do for improving our health care system. These questions are for politics, not religion-based morality or individual codes of ethics. Our society that accepts living within the social and political boundaries of our Constitution and judicial due process determines the secular basis for such a question through its laws. We as a nation should be more scrupulous about knowing the content and intent of proposed legislation as they enter our legislative process, not after they are enacted.
Change, reform is happening. Love it or leave it. (I did not originate that last challenge, but it now seems useful)
Sherfdog
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