Tag Archives: Medicare

Examples of Single Payer Health Care Systems

I guess I should have been horrified about the allegations that came to light these past two weeks in regard to the Veterans Administration Health Care problems. However, since I have worked in the VA system as well as see patients who have used the VA system and have needed my surgical care due to the inadequacies found within this health care system. So, I have included the latest article regarding the whistleblowers bringing to light more examples of revelations.

The allegations of wait times, delayed care for veterans and cooked books began in Phoenix, but new revelations by two more Veterans Affairs whistleblowers in two different states suggest the VA problems are endemic.

“What really bothered me was that this delay was a direct result of this extremely low sense of caring for the patient,” said Dr. Jose Mathews, the chief psychiatrist for the VA Medical Center in St. Louis starting in Nov 2012.

Mathews and another whistleblower in Texas detailed their concerns to Fox News.

According to Mathews, he noticed that the doctors he oversaw who were responsible for seeing veterans with post-traumatic stress and other acute mental health issues were working just a few hours a day. They were seeing about half the patients they could, Mathews alleged in a federal whistleblower complaint filed last year. Meanwhile, there were mounting suicides among veterans being treated at his facility — and officially, the St. Louis VA was reporting to its headquarters in Washington that its productivity was among the highest in the nation.

“They all got bonuses — that’s the sad part. Because in reality we were not really doing a good job, but it shows up on paper as if we are,” Mathews told Fox News.

When Mathews complained, he was removed from his job, assigned to an isolated office to oversee pensions and compensation. He was told not to contact the other doctors or patients.

“I think they have some form of moral blindness or something. They’re not able to see that this is not right, what they’re doing is not right,” said Mathews, a soft-spoken psychiatrist who says the veterans would have to wait a month or more for mental health treatment.

Spokesman Paul Sherbo, of the St. Louis VAMC, said in a written statement: “The St. Louis VA Medical Center leadership is aware of and is addressing the alleged issues. VA is committed to providing the best quality of care that all our nation’s Veterans need and deserve.”

A second whistleblower — from Harlingen, Texas – Dr. Richard Krugman accused the VA facility he oversaw in southeast Texas of delaying life-saving colonoscopies in order to cut costs. He provided a memo from his boss from 2011 outlining the shift in policy. He, too, was fired.

“I was treated like an animal. I was treated like a leper. I was treated like, how dare you attack me, or how dare you say what you’re saying,” said Krugman, a former associate chief of staff at the Veterans Affairs health care system.

He argued that his boss told them to require three successive fecal occult blood tests before sending the patient for a colonoscopy, a delay that could cause potential colon cancer to go from a treatable stage 1 to a deadly stage 4, if unaddressed.

His boss — now a VA director in Texas — pushed back, issuing the following response:

“Allegations such as the [VA] stopped sending patients for colonoscopies because the agency could not afford non-VA care and instead utilized a fecal occult blood test instead of colonoscopies was not substantiated” by the independent Office of Special Counsel that investigated Krugman’s charges and closed the case last November, according to the statement provided by Jeff Milligan, former director of VA Texas Valley health network. Krugman disputed the claim.

The Office of Special Counsel found none of Krugman’s claims to be substantiated. But when it closed the case, it admitted in a report and letter written to President Obama last November that it was forced to rely on an internal investigation carried out by the VA itself. It did not have the ability to independently investigate Krugman’s claims. The investigative panel assigned to get to the bottom of Krugman’s allegations was appointed by VA Under Secretary of Health Robert Petzel, who resigned Friday.

As first reported by Fox News last September, Petzel told congressional oversight committee members he had “no regrets” about awarding $63,000 in bonuses to hospital administrators in Pittsburgh after more than five veterans died of preventable Legionnaire’s disease contracted at a VA facility. 

“What I really got upset about was, over the last couple of weeks, everybody is now saying, ‘Oh, I never knew that. Oh, I didn’t see that,” Krugman said in an interview with Fox News. “The reports have been there since 2010, 2011, and each article, or each new material that I received, I purposely sent to those different gentlemen, with a backup copy, just so that they can’t say, ‘Oh, I never knew this, or I never knew that because every time that they say, ‘I don’t know this or I don’t know that,’ somebody else dies.”

Veterans’ groups met in Washington this week to call for secure hotlines so that more whistleblowers feel they can come forward and not face retaliation.

Jennifer Griffin currently serves as a national security correspondent for FOX News Channel . She joined FNC in October 1999 as a Jerusalem-based correspondent. 

I was approached by one of my patients who posed the question-If Kaiser Permanente can run a health care system effectively and efficiently, why can’t the government? This is an interesting question, which brings up a few points.

When I was training I found the VA system inadequate in health care delivery, but very cost effective for the patients, the veterans. However, the treating nurses and physicians were inadequate, either in their training, their qualifications or their dedications and concern regarding their patients. Very often, as a resident in training, I would stay after my rotation to care for the patients to make sure that they received their wound care or received their proper medications, etc.

Shift to my present experience where my practice consists of many cancer patients.

How do I experience the VA system and its inadequacies now? A number of my patients, who are veterans, proceed to the VA clinic or hospital when asked by their primary care doctors where they wanted to go for evaluation and treatment. Often they are referred to my office due to the waiting times to gain access to the system or due to inadequate treatment. Now I am faced with more advanced cancers to treat, challenging my surgical skills. Sometimes the malignancies are so advanced that radiation or chemotherapy are necessary, or even the patients showing up being now deemed untreatable.

This system, like the Medicaare system is a government health care run system. Unlike the Medicare program, the VA system is a true system consisting of delivery of health care through clinics, hospitals, employed delivery personnel such as physicians and nurses and finally the payment part of the equation.

I worry; looking at the government managed health care examples such as the VA system, Medicare and Medicaid programs, that the Affordable Care Act and all that it consists of will suffer the same poor quality and financial stresses leading to limitations or care delivery.

Let’s look at Kaiser’s history and examine their successes, failures, strategies, and organization. We should also compare it to other medical health care systems like Massachusetts and the European countries have worked out. Have they all been successes and what determines success? How are they financed and what limitations are “required” to make their systems sustainable?

Kaiser Permanente evolved from industrial health care programs for construction, shipyard, and steel mill workers for the Kaiser industrial companies during the late 1930s and 1940s. It was opened to public enrollment in October 1945.

The organization that is now Kaiser Permanente began at the height of the Great Depression with a single inventive young surgeon and a 12-bed hospital in the middle of the Mojave Desert. When Sidney Garfield, MD, looked at the thousands of men involved in building the Colorado River Aqueduct Project, he saw an opportunity. He borrowed money to build Contractors General Hospital; six miles from a tiny town called Desert Center, and began treating sick and injured workers. But financing was difficult, and Dr. Garfield was having trouble getting the insurance companies to pay his bills in a timely fashion. To compound matters, not all of the men had insurance. Dr. Garfield refused to turn away any sick or injured worker, so he often was left with no payment at all for his services. In no time, the hospital’s expenses were far exceeding its income.

Founded in 1945, Kaiser Permanente is one of the nation’s largest not-for-profit health plans, serving approximately 9.3 million members, with headquarters in Oakland, Calif. It comprises:

            Kaiser Foundation Hospitals and their subsidiaries

            Kaiser Foundation Health Plan, Inc.

            The Permanente Medical Groups.

At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible.

Kaiser Permanente’s creation resulted from the challenge of providing Americans medical care during the Great Depression and World War II, when most people could not afford to go to a doctor. Among the innovations it has brought to U.S. health care are:

            1. Prepaid health plans, which spread the cost to make it more affordable

            2. Physician group practice to maximize their abilities to care for patients

            a focus on preventing illness as much as on caring for the sick

            3. An organized delivery system, putting as many services as possible under one roof.


As of January, 2014, Kaiser consists of 38 Hospitals, 618 medical offices and other outpatient facilities.16, 942 physicians (all specialties), 48,701 nurses and 174,259 employees, which represented technical, administrative and clerical employees. In 2013 they had operating revenue of $53.1 billion. It has since become the largest organization of its kind an HMO. In its modern form, the HMO combines a large group practice, contracts with employers to care for a group of workers, and a prepayment plan for both hospitals and group practices.

So, how can Kaiser be so successful delivering healthcare efficiently as basically a single payer system, which is sustainable, and the VA and Medicare reek with so many problems? The difference government control and management or better, mismanagement.

Consider the latest error of judgment by our President. He choses former White House Aide Kristie Caneegallo as the next person to oversee the health care law. What are her credentials and should she be in charge? Canegallo worked at the U.S. Embassy in Afghanistan in 2007 and served in Iraq in 2008 as a governance and budget adviser to Anbar provincial government.

When is this administration going to learn that we need someone experienced in health care to oversee the ACA?

The VA and Medicare will continue to have their problems in delivering health care, and so will our new Affordable Care Act.

Wake up America!

Medicare patients –Another set of losers in Obamacare

I decided to change my blog plan and discuss the changes in Medicare as the ACA goes into full action. Consider the following letter from a Medicare patient and if you are a senior citizen tremble with fear!


Letter from a senior gentleman in Mesa, Arizona:


  Dear Family, Friends, Neighbors and former Classmates,


I just found myself in the middle of a medical situation that made it very clear that  “the affordable care act” is neither affordable, nor do they care.


  I’ll go back about seven years ago to a fairly radical prostate surgery that I underwent. The Urologist (a personal friend) who performed the surgery was very concerned that it was cancer, though I wasn’t told this until the lab report revealed it was benign.  Since that procedure, I have experienced numerous urinary tract infections, UTI’s. Since I had never had a “UTI” prior to the prostate surgery, I assume that it is one of the side effects from surgery, an assumption since confirmed by my Family Doctor.


  The weekend of March 8-9, I was experiencing all the symptoms of another bout of UTI. By Monday afternoon the infection had hit with full force. Knowing that all I needed was an antibiotic, I went to an Urgent Care Center in Mesa, AZ., to provide a specimen, a requirement for getting the prescription. After waiting 45 min. to see the Doctor, I started getting very nauseous and lightheaded.


  I went to the Receptionist to ask where the bathroom was as I felt that I was going to throw up. I was told that I would have to wait for the Doctor because I would need to leave a specimen and they didn’t want me in the bathroom without first seeing him.


  That was when the lights went out, my next awareness was that of finding myself on the floor (in the waiting room) having violent dry heaves, and very confused. At this point, I tried to stand up but couldn’t make it, and they made it very clear they weren’t going to let me get up until the ambulance got there. By the way, when you’re waiting to see the Doctor and you pass out, you get very prompt attention.


Now, “the rest of the story”, and the reason for sending this to so many of  you.


  I was taken to the nearest hospital, to emergency. Once there, I was transported to an emergency examination room. Once I had removed my clothes and donned one of those lovely hospital gowns, I finally got to see a Doctor. I asked  “what is going on” I’m just having a UTI, just get me the proper medication and let me go home. He told me that my symptoms presented the possibility of sepsis, a potentially deadly migration of toxins, and that they needed to run several tests to determine how far the infection had migrated.


  For the next 3 hours I was subjected to several tests, blood draws, EKG’s, and demands for specimens. At about 7:30 the nurse came back to my room to inform me that one of the tests takes 1- 2 days to complete, I asked if they (the results) could be emailed, at which point she informed me that I wouldn’t need them emailed because I wasn’t going anywhere. I started arguing with her but was told, “if you don’t start behaving, I’ll start taking your temperature rectally, at which point I became a perfect gentleman. I did tell her I wanted to see the doctor because I had no intention of staying overnight.


  Now, this is what I want each of you to understand, please read these next sentences carefully. The doctor finally came in to inform me that he was going to admit me. I said,  “are you admitting me for treatment or for observation?” He told me that I would be admitted for observation. I said Doctor, correct me if I’m wrong, but if you admit me for observation my Medicare will not pay anything, this due to the affordable care act , he said that’s right, it won’t. I then grabbed for my bag of clothing and said, then I’m going home. He said you’re really too sick to be going home, but I understand your position, this health program is going to hit seniors especially hard.


  The doctor then left the room and I started getting dressed, I was just getting ready to put my shoes on when another doctor (the closer) came into the room, he saw me dressed and said, “where do you think you are going?” I simply said,  “I’m going home, to which he replied, quite vociferously, no you aren’t. I said, “Doc, you and I both know that under the “affordable care act” anyone on Medicare who is admitted to a hospital for observation will be responsible for the bill, Medicare won’t pay a cent”.  At which point he nodded in affirmation. I said, “You will either admit me for a specific treatment or you won’t admit me.” Realizing he wasn’t going to win this one, he said he would prepare my release papers.


  A few minutes later the discharge nurse came to my room to have me sign the necessary papers, relieving them from any responsibility. I told her I wasn’t trying to be obstinate, but I wasn’t going to be burdened with the full (financial) responsibility for my hospital stay.


  After making sure the door was closed, she said, “I don’t blame you at all, I would do the same thing.”  She went on to say, “You wouldn’t believe the people who elect to leave for the same reasons, people who are deathly sick, people who have to be wheeled out on a gurney.” She further said, “The ‘Affordable Care Act’ is going to be a disaster for seniors.  Yet, if you are in this country illegally, and have no coverage, you will be covered in full.”


  This is not internet hype folks, this is real, I just experienced it personally.  Moving right along, this gets worse.


  Today I went to a (required) follow up appointment with my Arizona Family Practitioner. Since my white count was pretty high, the follow up was important. During the visit I shared the experience at emergency, and that I had refused to be admitted. His response was “I don’t blame you at all, I would have done the same thing”.  He went on to say that the colonoscopy and other procedures are probably going to be dropped from coverage for those over 70.


  I told him that I had heard that the affordable care act would no longer pay for cancer treatment for those 76 and older, is that true? His understanding is that it is true.


  The more I hear, and experience the Affordable Care Act, the more I’m beginning to see that we seniors are nothing more than an inconvenience, and the sooner they can get rid of us the better off they’ll be.


  November is coming folks; we can have an impact on this debacle by letting everyone in Congress know that their responsibility is to the constituents, not the president and not the lobbyists. We need to let them ALL know that they are in office to serve and to look after the BEST INTERESTS of “we the people”, their employers, and not to become self-serving bureaucrats who serve only out of greed. And if they don’t seem to understand this simple logic, we’ll fire them.


  On the mend, (signed)


  REMEMBER:   Demand your hospital admission is for TREATMENT and NOT for OBSERVATION!

Letter from a senior gentleman in Mesa, Arizona:

So, is this a reality?

Consider the article written by Craig Joseph Dan, Medicare Patients are the First Casualty In Emerging Healthcare Revenue Battles. It turns out that how patients are technically admitted to a hospital, and how many “midnights” they stay, both play a critical role in what Medicare wi cover and what the out-of-pocket costs will be. Revenue battles are going to continue to heat up as the government decides how to pay for the care for the underinsured that will be covered by the ACA (Affordable Care Act).

The United States Department of Health and Human Services (DHHS) through the Medicare Modernization Act of 2003, created the Recovery Audit Contractor (RAC). The RAC identifies and recovers improper Medicare payments paid to healthcare providers under fee-for-service Medicare plans. The DHHS made the program permanent for all states by January 1, 2010 under section 302 of the Tax Relief and Health Care Act of 2006.

Dr. Bart Caponi wrote a summary of the RAC issue on te Hospital Leader blog site who offered his assessment. He stated that Medicare patients don’t really know that CMS uses private bounty hunters who are paid on contingency to audit and deny hospital claims. Therefore, hospitals provide the care and then either lose an audit or have to fight through a lengthy appeals process for reimbursement of services. This perceived risk or set of risks has changed the behavior of hospitals, which means, as we have seen in this letter, that patients can get blindsided with big out-of-pocket expenses.

Also, earlier this year, Maryland received a waiver from the Centers of Medicare and Medicaid Services (CMS) to institute a five-year demonstration program known as the all-payor model contract. This program attempts to reduce spending for hospital services by keeping the rate of revenue growth in hospitals from all sources- including private insurance, the government, and employers- to no more than growth in the overall state economy. The goal is to keep costs down by reducing the number of patients admitted the hospitals and encouraging hospitals to work with physicians to maintain their patient’s health. This program, implemented under H.B. 298 permits the Health Services Cost Review Commission to set rate levels and increases, which is the most comprehensive attempt by any state to control health care costs and includes all health care payors and most hospitals, as well as an enforcement mechanism. Interestingly, this commission is represented by a majority of the insurance industry. Lack of bias much???? Now who do you think is affected by these restrictions? Again consider the Medicare patients, especially in regions where the dominant people are the retired Medicare patients.

Beware senior citizens and those of you who will be covered by Medicare insurance in your future.

The ACA or Obamacare will force more consideration of costs and sustainability. Who will pay the cost of a flawed roll out and a flawed health care system?

Also, consider what the future of the ACA will be and what the future of health care will be?

Wake up America!

The Biggest Losers

I ended the last blog hinting about the losers in this new health care program and was encouraged to pursue this discussion while reviewing two articles.

But let me first set things straight, as a strategic planner, the reason we are where we are is due to the lack of real research and planning. As much as I am not a President Obama fan, I really believe he and years before, Hillary Clinton, really believed what they were proposing was a good thing for the American people. I only object to the method that was chosen and the politicization, the lack of real research and planning with people in the know.

I comments in this last paragraph were further strengthened when I read the comments by the Speaker of the House discussing the Republicans mistakes and the lack of ability to overturn the health care law and the need to modify it and make it work. It was interesting to read that House Speaker John Boehner inadvertently revealed that repealing Obamacare “isn’t the answer,” and that “Republicans also need to offer a replacement.”

I also object to Harry Reed and Nancy Pelosi being so arrogant and closed minded in not allowing a non partisan discussion and resolution of difficulties to result in a bill which can “get the job done” efficiently and effectively for all the American people.

This has become a political ping-pong ball and shows that our elected officials really don’t care about Middle America especially and also points to the necessity for term limits.

Jonathan Bernstein wrote that“ The challenge is that Obamacare is the law of the land. It is there and it has driven all types of changes on our health care delivery system. You can’t recreate an insurance market overnight…. So the biggest challenge we are going to have is—I do think at some point we’ll get there—is the transition of Obamacare back to a system that empowers patients and doctors to make choices that are good for their own health as opposed to doing what the government is dictating they should do.”

This is interesting to me due to one of my previous blogs and the strategy that needs to be embraced- getting over the repeal idea and instead find ways to make the law work.

Think about the question that I posed at the end of my last blog-Who are the Biggest Losers? Byron York in his latest Op-Ed piece notes that Obamacare losers are harder to discern. I think not! He finally noted that “The plans being offered through the exchanges in 2014 appear to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than employment-based plans do.” The Congressional Budget Office (CBO) said “These features allow insurers that offer plans through the exchanges to charge lower premiums (although they also make plans somewhat less attractive to potential enrollees).”

The health care analyst, Bob Laszewski, questions who is harmed and points out that “when carriers converted their old policies to Obamacare-compliant policies, it was typical for the insurance company to increase costs about 35%” and “That increase could come in the form of higher premiums, more co-pays and deductibles and narrower networks.” This is what we are seeing in that enrollees are facing higher premiums and higher deductibles, which add up to a total higher cost, as well as a narrower choice of hospitals, doctors and prescription drugs than they had before. Therefore, what we are finding is that health care is becoming a more expensive and troublesome system.

Rick Newman in his article in The Exchange (April 25, 2014) points out that there are three subsets of people whose policies were canceled and then are the posers under the Affordable Care Act (ACA): people who are self-employed, those over 35, those who are white, or some combination of all of these three.

The biggest losers to ACA are the people who lost their insurance coverage but are unlikely to qualify for subsidies through one of the exchanges, which require an income of less than $47,000 for an individual or $95,000 for a family of four. Some of these people who lost insurance coverage report paying twice as much with deductibles of $4,500-$7,500 or more. It was interesting that Mr. Newman pointed out that it so happens that these groups so impacted negatively tend to be Obama’s political opponents.

Do the insurance companies lose? In a previous blog I pointed out that WellPoint was planning to increase their premiums and now I read that CEO of Aetna, Mark Bertolini, stated that their premium increases would range from low single digit to double digits, based on its first quarter earnings. So the insurance companies never lose. The have to make a profit and usually the profit is much larger than the proposed profit margins that the committees and government departments are demanding for health care facilities.

Ethan Rome (The Truth About Health Insurance Company Profits: They’re Excessive) reviewed health insurance company profits and went on to further review the American trade group American Health Insurance Plan’s (AHIP) focus on profit margins which he thought was misleading when they quoted 4.4%, and designed to protect their massive income by shifting attention away from their return on equity — a key measure of profits as a percentage of the amount invested. “That return is a phenomenal 16.1% as of today. By that measure, health insurers are ranked fourth highest of the 16 industries in the health care sector. They also deliver a higher return for investors than cellphone companies, beer companies, mortgage companies, life insurance companies, TV broadcasters, drug store companies or grocery stores.”

In May 2011, the New York Times reported “the health insurance industry is enjoying record earnings while millions of Americans get less medical care. Wall Street investors are delighted with the industry’s profits, and to health insurance executives, that’s all that counts. Insurance CEOs want investors to buy their stock and keep share prices marching higher, and that’s exactly what has happened. To achieve excessive profits, insurers are happy to gouge consumers and small businesses, do little to rein in medical costs and spend billions of our premium dollars on lobbying, secret political activities, bloated executive pay and stock buybacks.”

How about the greedy doctors? Are they losers? In the beginning and for quite a while they will lose as they have for years as their reimbursements (what they are paid by the insurance companies and the government, i.e. Medicare and Medicaid) are further discounted. But they will not be able to keep their offices open unless they become employees of the hospitals, universities or convert to boutique type practices. The boutique practices will charge patient fees to become practice members and or start to do procedures that they are not trained for and for which the complication rate will be high. But the added income will be necessary to maintain their overhead expenses.

Having insurance policies that include $5,000- $7,500 deductibles means that almost all health care needs, office visits, tests and surgery will be out of pocket expenses. How does the new plan then encourage good health care behavior and encourage preventative care?

Yes, the uninsured, if they fulfill the requirements for the government subsidies, will get coverage, but who will take care of these patients and cane you change their “bad” behavior? Will we have enough doctors to provide care and what type of care will be provided? I will discuss these topics further in future blogs.

Let us also consider who is in control of the ACA and what their history predicts. These are the same government systems that have control of the problematic Medicare, Medicaid and Veteran health systems. Remember what we have been hearing about concerning the Veteran Administration Health Care problems in the last few weeks. Long waiting times, poor care, lack of care, deaths, suicides, etc. What then can we expect for the future control and management of the ACA?