Tag Archives: Affordable Care Act

What would a Biden economy look like, and what will healthcare go from here? Also, When Should We Get Vaccinated for the Flu?

As I listened to the Democratic convention, I was horrified by the hate against President Trump, and the in general. My wife doesn’t want me to say it, but the average citizen, especially the socially and history ignorant citizens are basically stupid and believes those of the liberal democrats. As an Independent I don’t believe. But I thought that I would skip the updates regarding the Corvid pandemic and consider the economy and healthcare with former Vice President Biden in control. Oh, Horror!

The Week Staff wrote that if you’re wondering what a Biden presidency would mean for the economy, look to Biden’s last financial crisis, said Jeffrey Taylor at Bloomberg. In 2009, as vice president, Biden approached the crisis from a middle-class, Rust Belt viewpoint, aggressively pushing for an auto bailout while championing tighter restrictions on banks and arguing against Wall Street in key debates. While today’s situation is obviously different from the Great Recession, Biden sees “common threads” that could help him pursue an agenda focused on addressing income inequality and promoting public works. His top priority is a massive $3.5 trillion infrastructure, manufacturing, and clean-energy program “that appears likely to grow substantially if he is elected.” He plans to pay for the program by raising the corporate tax rate from 21 percent to 28 percent and increasing taxes on wealthy real-estate investors. In the wake of the pandemic, Biden has “edged away from the moderate economic approach he advocated last year,” but he is still not likely to “embrace punitive demands from the Left.”

“There is nothing ‘moderate’ about Biden’s tax plan,” said Mark Bloomfield and Oscar Pollock at The Wall Street Journal. For taxpayers with income above $1 million, Biden wants to tax capital gains as ordinary income. Combined with an upper-income tax increase, that would make top capital gains tax surge from the current 20 percent to 43 percent, exceeding the rate in “every one of the 10 largest economies.” We are not going to compete with China by adopting “tax policies that discourage those who are best able to invest, take risks, and start companies.”

Certain industries are sure to be in Biden’s crosshairs, said Anne Sraders at Fortune​. “Trump’s fight to lower drug prices will likely be carried on,” meaning “potential headwinds for Big Pharma.” And energy and “environment-sensitive industries” such as oil and gas production could underperform under a Democratic administration. But the naming of Kamala Harris as his vice-presidential nominee “might actually be good for Big Tech” because of her ties to Silicon Valley. For the first time in a decade, Wall Street donors are actually giving more to Democrats than to Republicans, said Jim Zarroli at NPR. Trump “still has friends in finance,” but many investors have “soured on his management style,” which makes it hard for them to make long-term plans.

Whatever the outcome, investors are starting to worry about “stock-market mayhem” surrounding the November election, said Gunjan Banerji and Gregory Zuckerman at The Wall Street Journal. “Markets tend to be volatile ahead of elections,” but pessimism about what might unfold appears “even more intense this time around.” One adviser is urging clients to insure themselves against losses by buying options that will profit if the S&P 500 index plunges more than 25 percent through December; other firms are telling clients to bet on gold. The behind-the-scenes anxiety is unfolding even as markets hit a record high. “October and November tend to be the wildest months of the year” in any case, and market uncertainty could skyrocket if in the days after the election there is no clear winner.

Here’s Where Joe Biden Stands on Every Major Healthcare Issue

Lulu Chang reviewed Biden’s stand on healthcare. The stage is set, the players have been finalized, and the countdown has begun in earnest. In less than three months, voters across the United States will head to the polls (or mail in their ballots) to elect their president.

The Democrats recently finalized their ticket, making history with the inclusion of Kamala Harris as Joe Biden’s vice-presidential pick, making her the first African American and Asian woman to appear on a major party ticket. Over the course of the next several weeks, the Biden and Harris team will make clear their platforms and policy suggestions to win over voters. I’ll discuss Harris’s stand on health in the next section of this post. And of course, in the face of a global pandemic, high on the list of priorities for many Americans is the Democratic nominee’s position on healthcare.

We’ve put together a list of where Joe Biden stands on every major health issue to help you make a more informed decision as you mail in your ballot or head to the polls in a few short months.

Medicare

  • No Medicare for All
  • Lower age to 60 (currently 65)
  • Add a public option

Biden supports making Medicare, the federal health insurance program for folks older than 65 and certain younger Americans with disabilities, more readily accessible to a greater swath of the population. He does not, however, support Medicare for All, which would offer complete health care to all Americans regardless of age without out-of-pocket expenses. Instead, Biden advocates for lowering the eligibility age for Medicare to 60, which would certainly expand the program’s reach.

In addition, Biden wants to add a public option to American healthcare, which was discussed during the writing of the Affordable Care Act, but ultimately passed over. A public option would allow folks to select into government-run insurance—like Medicare—instead of a private insurance plan. This too would allow a greater proportion of the population to access government-run healthcare options. As Biden explains on his campaign website, “If your insurance company isn’t doing right by you, you should have another, better choice…The Biden Plan will give you the choice to purchase a public health insurance option like Medicare. As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers.”

Undocumented Immigrants

  • Allow undocumented immigrants to buy into a public option

The Biden Plan emphasizes the importance of providing affordable healthcare to all Americans, “regardless of gender, race, income, sexual orientation, or zip code.” But it is not only Americans who Biden seeks to cover under his policies—rather, his plan would allow undocumented immigrants to purchase the public option, though it would not be subsidized.

Affordable Care Act

  • Strengthen the ACA
  • Increase subsidies
  • Bring back the individual mandate

The Affordable Care Act was passed under the Obama administration, so it comes as little surprise that Biden wants to bring back many of the provisions from the bill that were dismantled under the Trump administration. As he notes in his official platform, Biden seeks to “stop [the] reversal of the progress made by Obamacare…[and will] build on the Affordable Care Act with a plan to insure more than an estimated 97% of Americans.”

This would involve increasing tax credits in order to reduce premiums and offer coverage to a greater swath of Americans. In particular, Biden wants to do away with the 400% income cap on tax credit eligibility, and lower the limit on cost of coverage from today’s 9.86% to 8.5%. In effect, that means that no one purchasing insurance would have to spend any more than 8.5% of their income on health insurance.

Biden would also bring back the individual mandate, which is a penalty for not having health insurance. Trump eliminated this element of the Affordable Care Act in 2017, but Biden claims that the mandate would be popular “compared to what’s being offered.”

Are you kidding? Remember the burden on our healthy young newly employed or new business owners!

Prescriptions

  • Lower prescription drug pricing

The prices of prescription drugs have skyrocketed in recent years, making big pharma companies a common target among presidential candidates. Biden promises to “stand up to abuse of power by prescription drug corporations,” condemning “profiteering off of the pocketbooks of sick individuals.”

The Biden Plan includes a repeal of the exception that allows pharmaceutical companies to avoid negotiations with Medicare over drug prices. Today, nearly 20% of Medicare’s spending is allocated toward prescription drugs; lowering this proportion could save an estimated $14.4 billion in medication costs alone.

Furthermore, Biden would limit the prices of drugs that do not have competitors by implementing external reference pricing. This would involve the creation of an independent review board tasked with evaluating the value of a drug based on the average price in other countries. Biden would also limit drug price increases due to inflation, and allow Americans to buy imported medications from other countries (provided these medications are proven to be safe). Finally, Biden would eliminate drug companies’ advertising tax breaks in an attempt to further lower costs.

Abortion

  • Expand access to contraception
  • Protect a woman’s right to choose

Joe Biden has been infamously inconsistent in his position on abortion; decades ago, Biden supposed a constitutional amendment allowing states to reverse Roe v. Wade. As a senator, Biden voted to ban certain late-term abortions as recently as 2003. But his official position as the Democratic nominee is to protect a woman’s right to an abortion, and increase access to birth control across the spectrum.

Under the Biden Plan, the proposed public option would “cover contraception and a woman’s constitutional right to choose.” Biden would seek to “codify Roe v. Wade” and put an end to state laws that hamper access to abortion procedures, including parental notification requirements, mandatory waiting periods, and ultrasound requirements.

Biden would also restore federal funding for Planned Parenthood, reissuing “guidance specifying that states cannot refuse Medicaid funding for Planned Parenthood and other providers that refer for abortions or provide related information.”

Surprise Billing

  • Stop surprise billing

Surprise billing, as the name suggests, allows healthcare providers to send patients unexpected out-of-network bills, often in large sums. Biden’s plan would prevent this practice in scenarios where a patient cannot decide what provider he or she uses (as is often the case in emergency situations or ambulance transport). While ending surprise billing could save Americans some $40 billion annually, it is not entirely clear how Biden would end surprise billing.

The plan suggests that Biden would address “market concentration across our health care system” by “aggressively” using the government’s antitrust authority. By promoting competition, Biden hopes to reduce prices for consumers, and more importantly, improve health outcomes. Next is Kamala’s stand on healthcare.

Kamala Harris’ Stance on Healthcare Is Pretty Different from Biden’s

Katherine Igoe noted that healthcare is also an issue that sees a lot of variety across Democratic candidates, ranging from a single-payer healthcare system (meaning that all health insurance is covered through the government, and everyone is covered) to a more hybrid approach that doesn’t exclude private healthcare companies (half of the American population is currently enrolled in private plans).

At least according to her stance in the past, Harris favors the latter, hybrid approach—and it’s quite different from what Biden has proposed. What is her take, and how may her stance have shifted?

As a presidential candidate, Harris proposed Medicare for All.

The issue is personal for Harris. Citing her mother’s terminal cancer diagnosis, she’s said that her interest in improving coverage comes from that relationship: “She got sick before the Affordable Care Act became law, back when it was still legal for health insurance companies to deny coverage for pre-existing conditions. I remember thanking God she had Medicare…As I continue the battle for a better health care system, I do so in her name.”

The details can vary, but the basics of Medicare for All would be to vastly expand the government’s role to include everyone’s healthcare needs. By making Medicare more robust, the program would work to reduce costs for the insured, increase coverage to include those who were previously excluded, and expand upon existing plans in an effort to allow people to keep their existing doctors. But unlike other, more extreme proposals, Harris’ plan would subsequently allow private insurers to participate—in a similar way to the current framework of Medicare Advantage. “Essentially, we would allow private insurance to offer a plan in the Medicare system, but they will be subject to strict requirements to ensure it lowers costs and expands services,” she explained.

The candidates’ stances have had to incorporate what governmental influence would do to the private market, and Harris didn’t favor a plan that would abolish private insurance. She had initially expressed support for something along that lines, but then changed that stance; her perspective on the subject has evolved. She’s also proposed a decade-long “phase-in” period for this new Medicare plan to be put in place.

When they were both presidential candidates, Biden and Harris clashed over healthcare—she said his plan would leave Americans without coverage, he dismissed her plan as nonsensical.

Biden’s take on healthcare is vastly different.

Biden worked with President Obama on the Affordable Care Act (ACA), and thus his plans for healthcare would be to expand upon and further develop the ACA, while protecting it from current attacks. People could choose a public plan (i.e., they wouldn’t be mandated to join Medicare) and the government would provide tax benefits. “It would also cap every American’s health-care premiums at 8.5 percent of their income and effectively lower deductibles and co-payments. Biden recently said he also wants to lower the Medicare enrollment age by five years, to 60.”

The plan would separately take on exorbitant pharmaceutical pricing, which is another hot-button issue that hasn’t had any resolution. Multiple bills have been debated in Congress but the House’s recently passed bill is heavily opposed by Republicans.

Harris wasn’t the only one to criticize Biden on his plan, which may still exclude many from coverage. But now that the two are running mates, they may need to come up with a cohesive strategy that incorporates both of their stances (or, Harris may have to adopt a more moderate approach).

Harris has proposed several healthcare solutions for COVID-19.

Harris has been active in proposing economic relief towards individuals, families, and businesses during the pandemic, and healthcare is no exception. She’s proposed the COVID-19 Racial and Ethnic Disparities Task Force Act, which (among other things) would be designed to address barriers to equitable health care and medical coverage. This is one of the area’s in which she’s pledged to act towards racial justice—and it may be another area in which her stance impacts the Biden-Harris platform.

It’s crucial to get a flu shot this year amid the coronavirus pandemic, doctors say

I just received my yearly flu vaccination this past Wednesday and I have been advising all my patients to get their flu shots now! Adrianna Rodriquez that the message to vaccinate is not lost on Americans calling their doctors and pharmacists to schedule a flu shot appointment before the start of the 2020-2021 season. 

Experts said it’s crucial to get vaccinated this year because the coronavirus pandemic has overwhelmed hospitals in parts of the country and taken the lives of more than 176,000 people in the USA, according to Johns Hopkins data.

It’s hard to know how COVID-19 will mix with flu season: Will mask wearing and social distancing contain flu transmission as it’s meant to do with SARS-CoV-2? Or will both viruses ransack the nation as some schools reopen for in-person learning? 

“This fall, nothing can be more important than to try to increase the American public’s decision to embrace the flu vaccine with confidence,” Centers for Disease Control and Prevention Director Robert Redfield told the editor of JAMA on Thursday. “This is a critical year for us to try to take flu as much off the table as we can.”

Here’s what doctors say you should know about the flu vaccine as we approach this year’s season: 

Who should get the vaccine?

The CDC recommends everyone 6 months and older get a flu vaccine every year. State officials announced Wednesday the flu vaccine is required for all Massachusetts students enrolled in child care, preschool, K-12 and post-secondary institutions.

“It is more important now than ever to get a flu vaccine because flu symptoms are very similar to those of COVID-19, and preventing the flu will save lives and preserve health care resources,” said Dr. Lawrence Madoff, medical director of the Bureau of Infectious Disease and Laboratory Sciences at the Massachusetts Department of Public Health.

When should I get my flu shot? 

Dr. Susan Rehm, vice chair at the Cleveland Clinic’s Department of Infectious Diseases, said patients should get the influenza vaccine as soon as possible.

CVS stores have the flu vaccine in stock, and it became available Monday at Walgreens.

“I plan to get my flu shot as soon as the vaccines are available,” Rehm said. “My understanding is that they should be available in late August, early September nationwide.”

Other doctors recommend that patients get their flu shot in late September or early October, so protection can last throughout the flu season, which typically ends around March or April. The vaccine lasts about six months.

The CDC recommends people get a flu vaccine no later than the end of October – because it takes a few weeks for the vaccine to become fully protective – but encourages people to get vaccinated later rather than not at all.

Healthy people can get their flu vaccine as soon as it’s available, but experts recommend older people and those who are immunocompromised wait until mid-fall to get their shots, so they last throughout the flu season.

What is the high-dose flu shot for seniors? 

People over 65 should get Fluzone High-Dose, or FLUAD, because it provides better protection against flu viruses.

Fluzone High-Dose contains four times the antigen that’s in a standard dose, effectively making it a stronger version of the regular flu shot. FLUAD pairs the regular vaccine with an adjuvant, an immune stimulant, to cause the immune system to have a higher response to the vaccine. 

Research indicates that such high-dose flu vaccines have improved a patient’s protection against the flu. A peer-reviewed study published in The New England Journal of Medicine and sponsored by Sanofi, the company behind Fluzone High-Dose, found the high-dose vaccine is about 24% more effective than the standard shot in preventing the flu.

An observational study in 2013 found FLUAD is 51% effective in preventing flu-related hospitalizations for patients 65 and older. There are no studies that do a comparative analysis between the two vaccines.

Is the flu vaccine safe?

According to the CDC, hundreds of millions of Americans have safely received flu vaccine over the past 50 years. Common side effects for the vaccine include soreness at the injection spot, headache, fever, nausea and muscle aches.

Dr. William Schaffner, professor of infectious diseases at the Vanderbilt Medical Center in Nashville, Tennessee, emphasized that these symptoms are not the flu because the vaccine cannot cause influenza.

“That’s just your body working on the vaccine and your immune response responding to the vaccine,” he said. “That’s a small price to pay to keep you out of the emergency room. Believe me.”

Some studies have found a small association of the flu vaccine with Guillain-Barré syndrome (GBS), but Len Horovitz, a pulmonary specialist at Lenox Hill Hospital in New York City, said there’s a one in a million chance of that happening.

Not only is the flu vaccine safe, but the pharmacies, doctors offices and hospitals administering it are also safe.

Horovitz and Schaffner said hospitals take all the necessary precautions to make sure patients are protected against COVID-19. Some hospitals send staff out to patients’ cars for inoculation while others allow them to bypass the waiting room. Doctors offices require masks and social distancing, and they are routinely disinfected.

“Call your health care provider to make sure you can get in and out quickly,” Schaffner advised. “It’s safe to get the flu vaccine and very important.”

Will it help prevent COVID-19?

Experts speculate any vaccine could hypothetically provide some protection against a virus, but there’s little data that suggests the flu vaccine can protect against the coronavirus, SARS-CoV-2, which causes COVID-19.

“We don’t want to confuse people of that … because there’s simply no data,” Schaffner said. “Flu vaccine prevents flu; we’re working on a coronavirus vaccine. They’re separate.”

A study in 2018 found that the flu vaccine reduces the risk of being admitted to an ICU with flu by 82%, according to the CDC.

“People perhaps forget that influenza is something that we see every year,” Rehm said. “Tens of thousands of people die of influenza ever year, including people who are very healthy, and hundreds of thousands of people are hospitalized every year.”

Doctors said it will be even more hectic this year because some flu and COVID-19 symptoms overlap, delaying diagnosis and possibly care.

What can we expect from this year’s flu season and vaccine?

“Even before COVID, what we say about the flu is that it’s predictably unpredictable,” Rehm said. “There are some years that it’s a light year and some years that it’s horrible.”

Flu experts said they sometimes look at Australia’s flu season to get a sense of the strain and how it spreads, because winter in the Southern Hemisphere started a few months ago. 

According to the country’s Department of Health surveillance report, influenza has virtually disappeared: only 85 cases in the last two weeks of June, compared with more than 20,000 confirmed cases that time last year.

“Australia has had a modest season, but they were very good at implementing COVID containment measures, and of course, we’re not,” Schaffner said. “So we’re anticipating that we’re going to have a flu season that’s substantial.”

The CDC said two types of vaccines are available for the 2020-2021 season: the trivalent and quadrivalent. Trivalents contain two flu A strains and one flu B strain and are available only as high-dose vaccines. Quadrivalents contain those three strains plus an additional flu B strain, and they can be high- or standard-dose vaccines. I made sure that I received the quadrivalent vaccine.

Though some doctors may have both vaccines, others may have only one, depending on their supply chain. Natasha Bhuyan, a practicing family physician in Phoenix, said people should get whatever vaccine is available.

“Vaccines are a selfless act. They’re protecting yourself and your friends through herd immunity,” she said. “Any vaccine that you can get access to, you can get.”

Horovitz said vaccine production and distribution have been on schedule, despite international focus on coronavirus vaccine development. He has received his shipment to the hospital and plans to administer the vaccine with four strains closer to the start of the season.

“I don’t think anything suffered because something else was being developed,” he said. “(The flu vaccine) has been pretty well established for the last 20 to 30 years.”

Producers boosted supplies of the flu vaccine to meet what they expect will be higher demand. Vaccine maker Sanofi announced Monday that it will produce 15% more vaccine than in a normal year.

Redfield told JAMA the CDC arranged for an additional 9.3 million doses of low-cost flu vaccine for uninsured adults, up from 500,000. The agency expanded plans to reach out to minority communities.

What about the nasal spray instead of the shot? 

After the swine flu pandemic in 2009, several studies showed the nasal spray flu vaccine was less effective against H1N1 viruses, leading the CDC and the Advisory Committee on Immunization Practices to advise against it.

Since the 2017-2018 season, the advisory committee and the CDC voted to resume the recommendation for its use after the manufacturer used new H1N1 vaccine viruses in production.

Though agencies and advisory committees don’t recommend one vaccine over the other, some pediatricians argue the nasal spray is easier to administer to children than a shot.

Other doctors prefer the flu shot because some of the nasal spray side effects mimic respiratory symptoms, including wheezing, coughing and a runny nose, according to the CDC. Horovitz said anything that presents cold symptoms should probably be avoided, especially among children who are vectors of respiratory diseases.

“Giving them something that gives them cold (symptoms) for two or three days may expel more virus if they’re asymptomatic with COVID,” he said.

So, get vaccinated!!

Middle Americans Again Pays the Higher Price for the Affordable Health Care

It seems that when ever a law is passed that forces many to finance the cost of a program for all, that the big corporations can always fond a way to avoid the costs and the responsibilities that the rest of have to bear. Even better is that there develops another industry who benefits from finding ways around the laws.

Take for example the Manahatan-based startup called BeneStream who offer a subscription service to employers that analyzes the pay of each employee and help them enroll eligible candidates in the Medicaid program. This way the business can capitalize on language in the employer mandate, which will go into effect on January 1 that allows a family of four making less than $32,900 to enroll in Medicaid in lieu of private coverage. The so-called “employer mandate” requires companies with more than 50 full-time employees to provide health insurance will take effect, and commensurate surge of insurance business is expected to follow. BeneStream charges subscribers a one-time $40 registration fee and $200 annual maintenance fee per employee and estimates that between 20% and 40% of employees at hospitality and home healthcare companies are eligible for Medicaid.

This doesn’t sound too bad until you realize the future problems. First, more Medicaid patients in the healthcare system means that those patients covered by Medicaid will have to find physicians and health care systems that will provide services for the lowest paying insurance coverage. Many physicians now limit or deny coverage for the Medicaid covered patients. I myself as a health care practioner will not allow these patients into my practice due to the fact that Medicaid pays our practice basically 10 cents for every dollar billed when compared to what other third party insurance companies will pay. Most of the time, in a surgical practice, this will not even cover the overhead of the practice.

Also, companies can’t force employees to enroll in the Medicaid program, but they can encourage them strongly to do so by offering a plan that complies with the ACA’s minimum requirements, but provides less coverage than the Medicaid option, while simultaneously providing an easy pathway to enrollment in the government program. The BeneStream plan cost employers considerably less per employee than providing a private insurance plan that ensures that they avoid the expensive fines and penalties associated with flouting the employer mandate.

This then forces the middle class working stiff to come up with additional funding for the ACA through higher insurance premiums and higher deductibles to maintain a sustainable health care system.

“It’s a false promise of affordability,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms. “If you ever have to use the plan, you won’t be able to afford it.”

Remember that coverage through the Affordable Care Act is divided into five types of plans that require different levels of cost-sharing. Platinum plans pay 90 percent of medical expenses, on average; gold plans, 80 percent; silver plans, 70 percent; and bronze plans, 60 percent. Tax credits to help pay premiums are available for people with incomes up to 400 percent of the federal poverty level ($46,680 for an individual in the 2015 plans). In addition, a catastrophic plan is available, mainly to people younger than 30; it covers only limited services before the deductible is met and isn’t eligible for subsidies.

People are worried about being able to pay for health insurance. So the insurance industry and a group of Democratic senators have proposed offering cheaper, skimpier “copper plans” on the health law’s marketplaces that could draw in people who were unhappy with the cost of available plans.

But consumer advocates and others who study the insurance market suggest that there may not be a big demand for these plans and that they could expose people to unacceptably high out-of-pocket costs if they got sick, which includes the very higher, and in the future even higher deductibles. But the corporations are finding the ways around their responsibilities, just like their approach to paying taxes by having a European office or other foreign partner to avoid taxes, which the rest of we tax payers have to make up the deficit.

Professor Jason Reed made an interesting comment when he was discussing the March on Wall Street movement in order to understand economics and parasitism. A part of his lecture can be applied to our discussion: A successful parasite is one that is not recognized by its host, one that can make its host work for it without appearing as a burden. Such is the Ruling class and Big Business in a Capitalist society.

From the Patient’s Point of View-Why will they be Miserable?

 The 15-minute visits also take a toll on the relationship of the patient-doctor relationship. The patient who sits patiently in the exam rooms waiting patiently for the doctors to arrive for their visit and to finally speak with their physician. They have already seen the administrative secretary and the nurse, but they came here to see their physician. So, now the physician presents his or herself. Based on my complaint he or she looks in my mouth, throat and up my nose, said that my throat was inflamed and told me to see the nurse for a prescription and that I was suffering from a sinus infection with inflammation of my throat from posterior pharyngeal drip.

When I protested the drug that he wanted to prescribe he cut me short and told me to see the nurse……and he was out of the exam room. It must have been a visit that lasted for a total of 9-11 minutes, if that.

This story is becoming increasingly common. The patients as well as the physicians are feeling the time crunch as never before. The doctors and nurses feel like “running” office hours on rollerblades. Doctors have to see more patients and perform more procedures to make up for the discounted, flat or declining reimbursements.

This problem will worsen with the Affordable Care Act (ACA). Remember, millions of consumers who are gaining healthcare through the ACA begin to seek care, many of whom have never, or very rarely, have seen a doctor and therefore this patient population presents with a list of untreated problems. Often in the primary care as well as in other specialties, the patient is seen for only one diagnosis per visit. This is very inconvenient for the diagnostically/multiple disease patient. They then don’t get the comprehensive care with continuity associated with the individual patient. This is happening today as evidence by one of my patients with complex endocrine disease (diabetes and thyroid disease) who has been frustrated by these short visits with the results that her complex disease is out of control. I quickly referred her to an endocrine specialist.

In today’s world it seems that the doctors have one eye on the clock and the other on their laptop computers, typing away to capture the correct amount of “points” for the highest reimbursement for the visit.

As Roni Caryn Rabin stated in her article in WebMD, short visits take a toll on the whole relationship of the doctor –patient, which I have already stated in an important part of the good care equation. As I presented last week, we have to have a change in behavior in both the doctor as well as the patient. The office visit and the physician-patient relationship represents missed opportunities for getting patients more actively involved in their own health care. Research and the surveys show that there is less of a dialogue between the patients and their doctors, which increases the odds that patients will leave the office frustrated. Also, the shorter visits also increase the likelihood that patients will leave the office with a prescription, instead of discussion about behavioral changes like trying to lose a few pounds by going to the gym/exercise.

The physicians also don’t like to be rushed either, but for the primary care physicians and now even with specialists, time is is, quite literally money. Primary care doctors are paid mostly per visits with only minor adjustments for those that go longer than the time allocated for the diagnostic codes. Specialists who do procedures also need to see an increasing number of patients to generate a proportion of patients an increased number of procedures to compensate for the decreasing/discounted reimbursements for those procedures. The struggle is getting worse and worse with doctors thinking about meeting the bottom line, paying the overhead, having to pay staff and keep the doors open.

The pressure becomes even worse between both physician and patient when the patient has waited 9 months for his or her appointment and when the doctor comes in the exam room the patient pulls out a long list of complaints. Remember, the patient is thinking that they have waited sometimes a few months for the appointment and I’m going to try to get the most of my time that I have taken off from my work or have had to get paid childcare so that they could get to the appointment.

The situation became worse when doctors started participating in managed care networks where the doctors gave the insurers discounts on their rates in exchange for the promises to steer more patients to their office. Therefore, to avoid a cut in income the doctors had to see more patients.

In medical school the students are drilled in the art of taking a careful medical history, but studies have found that the doctors are falling short and that they have a bad habit of interrupting. A 1999 study of 29 family care practices found that doctors let patients speak for only 23 seconds before redirecting them and that only four patients got to finish their statements. Today the technical doctor of the present is often, and the interview is interrupted by the physician’s beeper, their cell phone or an email notification as their typing in the patient information on their laptops.

Communication between the physicians and their patients is important and making the patient feel they have been heard may be one of the most important elements of the healthcare equation. People are feeling dissatisfied when they don’t get a chance to say what they have to say, when they don’t get their questions answered, that they got their monies worth.

What happens when the patient doctor relationship suffers? Well, the patients lose trust in their caregivers and don’t fully engage in their care. How then do you change the patient’s behavior leading to better care, a healthy patient that leads to a more sustainable health care system?

It is predicted by this writer and physician, that with the increased numbers of patients forced into a system with less and less physicians that this relationship between the physician and their patient will get worse and worse. So, the middle class will get poorer healthcare and have to pay more for it.

Myth of Health Care Charity

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First, before I initiate a discussion regarding charitable health care, let me question the intelligence of voters in the State of Maryland. I already discussed weeks ago regarding the horrendous roll out of the Maryland healthcare system under the Affordable Care Act (ACA). Who was responsible? The Lieutenant Governor of the State of Maryland, Anthony Brown was responsible and he botched up the roll out eventually costing the taxpayers of Maryland about $200 million. However, the campaigning lies are promoting the wonderful job that he did regarding the ACA. The latest TV ad suggests that he did so much, especially for the aged/seniors. Those that know anything and have minimal intelligence, probably the minority of voters, realize that the seniors/aged are covered by Medicare and have very little to do with the roll out of the ACA. So, as I have said multiple times, wake up America, wake up Marylanders!!

Now on to our Sunday evening discussion.

Anne Zieger reported that in an effort to force patients to buy policies through the ACA health insurance exchanges, hospital systems around the country have started cutting back on financial help for lower- and middle-income people who don’t have health insurance. They are assuming that these families can afford the health insurance plans offered on the exchange, but have declined to make the investment.

While the number of systems that are taking this tack seems limited so far, many hospitals and health systems are considering a “get tough” approach to charity care, and experts predict that that more restrictive policies will become increasingly common, according to the piece in The New York Times. The State of Maryland is different because has waivers for uncompensated care as well as a TPR or total payment system.

One example that stood out in the Times piece comes from St. Louis, where Barnes-Jewish Hospital has started charging copayments to uninsured patients, no matter how little money they’ve got. Another example comes from the Southern New Hampshire Medical Center in Nashua, which no longer provides free care for most uninsured patients above the federal poverty line of $11,670 for an individual. Yet another hospital taking a stricter approach to the uninsured is Burlington, VT-based Fletcher Allen Health Care, which has cut back on financial aid for uninsured patients who earn between twice and four times the poverty level, the Times piece notes.

Unfortunately, these providers’ assumptions about patients’ ability to pay are incorrect. Those at or near the poverty line may not be able to afford even heavily-subsidized policies, and the middle class — who get little or no subsidies — often find that the hundreds of dollars a month they are expected to pay is far beyond their reach

The open but little-discussed secret to the health exchanges is that they really haven’t made health care that affordable after all. In Virginia, for example, the cheapest policies are approximately $350 per person with a $4,000 deductible and a 20% coinsurance requirement. Not only is that a sizable premium level even for middle-class family, the deductibles and coinsurance requirements reduce the value of such a policy dramatically, as low- and middle-income families are seldom equipped to meet such deductibles and coinsurance requirements. Here in Maryland we are seeing deductible as large as $5,000-$7,500 with insurance premiums rising by 42-50 percent. Therefore, they now have catastrophic care insurance policies. Who is winning in this scenario? Not the insurance companies! No, once again, as I have previously pointed out, it is the middle class working tax paying person who is footing the bill for the ACA and who suffer the most.

Health systems are continuing under this assumption as though this were a reasonable option, and that the less prosperous patients are simply being intransigent. “Do we allow our charity care programs to kick in if people are unwilling to sign up?” Nancy Schlichting, chief executive of the Henry Ford Health System in Detroit, asked the Times. “Our inclination is to say we will not, because it just seems that that defeats the purpose of what the Affordable Care Act has put in place.” 

Another hospital, Southern New Hampshire Medical Center, had previously provided free or discounted care for patients who were at or below 225% of the poverty level, or about $26,260 for an individual. Now, however, patients who “refuse to purchase federally mandated health insurance when they are eligible to do so will not be awarded charitable care,” the hospital’s new policy states. Notice the use of the word “refuse” — it implies a lot that’s simply not true about the uninsured.

Ultimately, all of this posturing is in vain, and merely punishes lower-income patients to no avail. If hospitals hope to save money by cutting back on charity care, they’re probably out of luck. If a family can’t afford premiums on the health exchange, they aren’t going to be able to pay massive hospital bills either.  Depriving them of charity care won’t magically force them to take on a larger percentage of their hospital bill, it will simply increase the level of bad debt a hospital must account for, and what’s more, makes it more likely that frightened consumers won’t come in to the hospital for help when it’s needed.

It’s understandable that hospitals want to see the health exchanges work, and want to see as many lower income people buying policies on the exchanges as possible. After all, that does give them a shot at reducing their bad debt.  But if they really want to deal only with insured patients, it’s time they gear up campaigns to subsidize health exchange premiums through thirdparty payers, a strategy that actually has a chance of working. Taking a position that tries to force the poor to produce premium funds out of thin air is just plain wrong.

But also, expecting the middle class to shoulder the high premiums as well as having to deal with extreme deductibles makes no sense. We, as physicians, are already seeing patients cancel their office visits, surgery and routine diagnostic tests, which can and will lead to poor care and delayed diagnosis of diseases. Therefore, they delay treatment leading to more extensive surgical procedures, additional chemotherapy and or radiation with threat of recurrence of disease, cancers and additional treatment.

A recent “edict” was passed in Europe, which we should all pay attention. In discussing affordable health care, socialized medicine or what ever you want to call it in the European countries we want to evaluate how these countries pay for health care. The British Isles depends on the Value Added Tax or VAT tax. Up until this recent change the tax was 17%. However, change is coming in two phases. Number one is the use of co-payments, which haven’t been part of the system since the 1940’s. Number two is the raising of the VAT tax to 27%. Yes, a tax elevation of 10%.

We will spend more time reviewing and evaluating the ACA, other comparative systems and hopefully will strategize modifications to the ACA, if possible.

Memorial Day Review of Affordable Health Care

Looking at the key provisions of the ACA:

▪   Basic benefits package defined by the federal government

▪   Increased Medicare payroll tax on upper income earners

▪   Penalty for employers (with 50+ employees) who do not offer healthcare

▪   If an employer doesn’t offer insurance, people will be able to buy it directly in the Health Insurance Marketplace.

▪   Tax credits to small business – by 2014, 50 percent of the employer’s contributions.

▪   The Medical Loss Ratio. At least 85 percent of all premium dollars collected by insurance companies for large employer plans must be spent on healthcare services. For plans sold to individuals and small employers, at least 80 percent of the premium must be spent on benefits.

▪   Eliminating annual limits on insurance coverage for new plans and existing group plans.

▪   No out-of-pocket for many preventive services. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance.

▪   Children up to age 26 can stay on their parent’s health insurance plan.

▪   No denial of coverage due to a pre-existing condition.

▪   Insurance companies cannot limit the coverage someone receives over his or her lifetime.

▪   Expand who will be eligible for Medicaid. States will receive 100 percent federal funding for the first three years, phasing to 90 percent federal funding in subsequent years.

▪   The law provides consumers with a way to appeal coverage determinations or claims to their insurance company.

▪   Tax credits for middle-low income uninsured. These individuals may also qualify for reduced copayments, co-insurance, and deductibles.

▪    The Individual Mandate. People who are not already covered or fully subsidized will be required to purchase coverage or face a penalty – with some eligible to receive subsidies towards private insurance premiums.

Vincent Vallejo on August 20, 2013, in the Banktec report, reviewed four observations on how the Affordable Care Act will impact healthcare business process outsourcing (BPO)., which are continuously being developed to decrease the administrative burden

With the ever-changing landscape of the U.S. healthcare system, the U.S. healthcare business process market is undergoing a significant transformation. This year, the U.S. healthcare payer, provider, and pharmaceutical outsourcing markets are valued at $11.1 billion, $6.8 billion, and $65.6 billion.

Today’s healthcare industry generates more than 8 billion claim transactions annually, resulting in $2.7 trillion worth of payments processed through a network of costly channels. Unbelievably, a huge percentage of the processing of these transactions is done manually and on paper – resulting in massive inefficiencies and high-dollar write-offs, estimated to exceed $92 billion each year. A healthcare provider’s back-office is typically buried in mountains of claim and payment paperwork. Duplication is rampant, two to three intermediaries handle transactions, payment to providers is always slow – the cost to providers is staggering. The object of outsourcing in healthcare is to:

▪   Improve efficiency and reduce costs

▪   Improve collections and increase yields

▪   Help eliminate write-offs

▪   Enhance in-process claim visibility

▪   Improve provider/patient relationships

 

1. The Medical Loss Ratio does not offer a clear means to lower administrative costs. Thirty cents of every dollar spent on healthcare in the U.S. goes toward administrative costs. While the law says to lower these costs, it doesn’t offer a clear path to make this possible. The law provides for small businesses needing to offer insurance to its employees. The law provides tax credit to middle class families and expands Medicare to the lower class. However, payers and providers are left to figure this puzzle on their own.

 2. Business Process Outsourcing can alleviate the Medical Loss Ratio burden. Services to assist providers in payment reconciliation, denial management and re-billing disputed claims can increase providers’ revenues by as much as 3 to 5 percent. In order to comply with the Medical Loss Ratio, every percentage point counts. The healthcare industry will discover what large corporations have always known. Outsourcing high-volume, data-intensive business processes can drive down costs.

3. Providers will be motivated to claim every dollar available to remain profitable. Healthcare providers write off over $92 billion per year due to an inability to get accurate and timely claim and payment information. BPO companies do not just offer savings on administrative personnel. By improving the process, providers can make more money from abandoned claims. Business process outsourcing companies streamline the revenue cycle and make the payer-provider relationship more efficient.

 4. The Affordable Care Act requires standardized billing and an electronic exchange of health information. More than half of transactions between payers and providers are paper-based – significant contributor to the high cost of healthcare. Healthcare remains one of the few industries that relies on paper records. A BPO company with expertise will be able to clear out the warehouse of dusty paper records and replace it with fully secure, searchable data.

The Affordable Care Act is large and complicated, but outsourcing solutions exist to simplify the added administrative burden, which we will discuss further in future blogs.

Over the last many weeks we have discussed a number of pros and cons regarding the Affordable Care Act. Whether we want to argue the nature of free health care for all and the constitution, the fact is that health care for all is a great concept. Yes, our health care system is broken or sick and that it is considered to be the most costly with an extremely poor return on investment. Why?

The answer is simply yet complex. Our rights, our freedom, and desire to make money, allow us to make bad decisions and with no cost consequences. We demand CT scans or MRI’s when we get headaches at no cost to each of us and “forcing” the health care worker to provide these expensive tests to cover “their behinds” so that they won’t get sued.

Traditional medicine and our freedoms are making us sick. We as a notion lack self control and the results are that chronic diseases such as heart disease, stroke, cancer, diabetes, and arthritis are among the most common and preventable of all of the problems on the US.

I site the Mark Twain quote: “The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you druther not” That is, the four modifiable health risk behaviors that we just fail to improve are the lack of exercise or physical activity, poor nutrition, tobacco use and excess alcohol consumption. As Ron Graham further discusses in the Healthcare blog, these health risk behaviors are responsible for much of the high health care cost, illness, suffering and early death related to the chronic deases that we discussed. Consider that the latest reported obesity rates is the US is 27.7%. Unbelievable!

How then can we improve the health care system if we “give” insurance coverage without consequence for bad behavior?

So, go have a wonderful Memorial Day picnic and think and chose healthy while you prepare, cook and eat at your holiday outing.

Does the Affordable Care Act Work?

Today is Easter Sunday, which is a time of reflection and renewal for those of the Christian faith. Easter is also a time when we reaffirm family traditions and break bread with our friends and loved ones. I’m hoping that everyone had a wonderful Sunday no matter what your religious beliefs and what holidays you celebrate.

It brings to mind an article that Dr. Ben Carson wrote and appeared in today’s Opinion section of our local newspaper: Recovering America’s exceptionalism. He reflects on the famous French historian Alexis de Tocqueville, who came to America to study our nation. He concluded his American analysis by saying, “America is great because she is good. If America ever ceases to be good, she will cease to be great.” Interesting observation. Our we seeing the degradation of our greatness??

Dr. Carson delves into religion, slavery and history. He further discusses the wisdom and goodness of learning from our mistakes. He finds it “disturbing in the pursuit of goodness the turning of a blind eye toward corruption, much like the Romans did before the fall of their empire.” He is concerned regarding scandals that been characterized as “phony scandals” based on politics and “tells you a great deal about the loss of honesty in our society.”

So, how does this discussion fit our discussion of the Affordable Care Act? “The fact that one party is willing to use its majority status to cram a health care bill down the throats of the minority party and the American people and then refuses to acknowledge the obvious illegitimacy of a bill passed largely on the basis of false information provides a barometer on the lack of importance placed on virtue in our society today. How can such a society in any way claim to be good?”( The Sunday Star, April 20, 2017, Page A7).

My son this weekend, after a number of frustrating discussions with me, his mom and his friends, asked the question-What is really wrong with “Obamacare”? It really seems like such a great idea. My very intelligent wife then pointed out reality to the younger generation, who will soon see the obvious errors of the Bill. She realized the fallacy of the design when she was notified of her huge jump in our health insurance premium as well as the more than doubling of our deductible. She is now considering the delay in many of her doctor visits and diagnostic tests/exams.

Interesting and it brings up the major topic of discussion of this weeks blog. Read on.

Normally I appreciate and respect the opinion of Donna Brazile, appearing many times in our local opinion section of our and I’m sure many other newspapers.

In her article “Health care works on many levels” she tries to point how well the ACA works for the enrollees. As she ends her rant, she states “Numbers do not measure the ACA’s sign-up success. As a result of the Affordable Care Act- Obamacare- illnesses are prevented, people have a greater security in their lives, more money in their pockets (because insurance companies can’t make a profit higher than 20 percent), and families have a parent or child with them because a disease was cured. These are the true measures of success. And that is priceless” (The Star Democrat, April 9, 2014, Page A4).

My problem with these comments and the whole process is what we are really seeing in our medical practices. That Middle Class Americans are really being missed or made to bear the burden/cost again of the “real” health care solutions. Also, the numbers may really do measure the sign-up failure and the failure of the bill/law itself. We need to evaluate the breakdown of the enrollee numbers carefully.

Our President, when he first got into office, stated that he was going to protect the middle class of America. However, the middle class enrollees have had their insurance premiums increased by double digit percentages as well as have had huge increases in their deductibles, as I cited with my wife’s experience. They then are delaying their routine follow-ups for primary as well as specialty care as well as diagnostic tests and even surgeries. How does this prevent illnesses, give people a greater security in their lives or more importantly, keep more money in their pockets? In fact with the increase in deductibles, as seen by examples of $ 4,500 on average, they are now paying more out of pocket portions toward their health care bills. I was pulled aside by one of my”former”patients,who wanted to apologize for having to cancel his routine cancer post operative exams. He explained that his deductible of $5,000 made it very difficult to see me as well as his primary care doctor. Again, this is reality not media hype!

To the rich, this probably will never be a problem or a concern for this group. The poor, who is the only group that this program will help, are not going to contribute to the sustainability of the system. Paying $66-$110 toward their health care insurance coverage does little to cover the costs of health care. Unless health care system pays very little to the doctors and nurses who are given the job of caring for the increased numbers of patients that are going to seek care. Also, the statistics show the enrollees represent a sicker portion of the patient populations. This represents a more costly group of enrollees to treat. Yes, the government is going to subsidize this group of patients, but where are we going to see evidence of sustainability? We do need to see evidence of young, healthy enrollees who can afford the huge premiums and deductibles to assist in sustaining the health care system.

So, Chris, my son with the questions, read on as I attempt to point out the problems with the ACA. But unlike most of the people that object to the Bill and try to repeal the Bill, let us see if there is a way to make it work and provide what the President really wanted- a valuable health care program for all. Is there anything wrong with this goal? No, as long as the population for which it serves realizes the limitations and what is required by all of the enrollees. Look to the British health care system and their problems!