Relevant and even prescient commentary on news, politics and the economy.

Health Care Thoughts: The Other Side of the Equation

by Tom aka Rusty Rustbelt

Health Care Thoughts: The Other Side of the Equation

Obamacare is in the news every day, with much discussion of jobs and exchanges and insurance and many other topics. My beat is the other side, the provider side, and a great deal of confusion and chaos lives there.

What are providers supposed to be doing?

improve quality

cut costs

install complex EMR systems able to link into EHR networks

work through a massive transition to ICD-10 coding

move into a complex “big data” environment

move to innovative delivery and revenue models

(ACOs, bundling)

overall, develop and implement new and unknown clinical and business models

So what’s the problem?

No one, in or out of government, can tell us what the destination is. This is a ginormous lab experiment with patients as the white mice.


Health Care Thoughts: Obamacare Meets Immigration Reform

by Tom aka Rusty Rustbelt

Health Care Thoughts: Obamacare Meets Immigration Reform

With the passage of the Senate version of immigration reform we have some details to ponder.

Illegals who become “provisional” for up to 13 years will not qualify for some Obamacare credits and subsidies.

Workers who receive “unaffordable” insurance coverage from employers will be available for Obamacare subsidies, and the employer penalized up to $3,000. Provisional aliens would not be qualified for the subsidies, which could give provisionals up to a $3,000 cost advantage over U. S. workers.

Whether this was intended or just thoughtless drafting remains to be seen.

And of course, the Senate bill is just a starting point in a long hot political debate, so this may become nothing at all.


Health Care Thoughts: More Complexity Grumbling

by Tom aka Rusty Rustbelt

Health Care Thoughts: More Complexity Grumbling

I have made the point many times that if anything stops Obamacare it will be the inability to implement an extremely complicated program. Call it “Rusty’s Theory of Complexity.”

The feds have now published (link below) the draft application for financial assistance in health care exchanges and low income plans. Oh boy.

With attachments this could easily run 30 + pages, and of course someone is going to have to process this (there will be an online version). Having helped people with paperwork for nearly 40 years I can guarantee this will be intimidating and confusing to many people.

Complication is the enemy of implementation. Count on it.

PS: HR Block has already positioned itself as a likely fee-for-service form fill-in service. Somebody is going to profit here.

Health Care Thoughts: The CPR Kerfluffle

 by Tom aka Rusty Rustbelt

Health Care Thoughts: The CPR Kerfluffle

According to numerous media reports:

On February 26th, Lorraine Bayless, an 87 year old resident of the Glendale Gardens independent living facility, collapsed in the dining hall. Someone called 911, and eventually a person identifying herself as a “nurse” was on the call (whether she was working as a “nurse” appears to be in doubt).

The 911 operator pleaded, implored and demanded someone do something, and the “nurse” replied that facility policy prevented any such actions. The “nurse” refused to hand off the phone or to get anyone else involved. Ms. Bayless died. Someone notified the media (911 calls are public record in many states). Ka-boom!!! This became a media feeding frenzy. The stuff has hit the fan.

The initial media reports, both broadcast and written, were inconsistent on the facts. Recent reports (several dozen) seem to be more consistent, many based on AP reporting.

This has become a debate about possible legal duties, ethical duties, the duties of licensed health personnel in a non-medical setting, the need for advanced directives and consumer advocate criticism. Ms. Bayless’ family has issued a statement to the effect she would not have wanted life prolonging intervention and the family is not upset or litigious.

So have we learned anything here?

1) Most of us should have advanced directives and make copies of those directives available to anyone who might in anyway be responsible for our health and safety.

2) Anyone living in any sort of elder care facility should verify the presence or lack of medical services, both routine and trauma.

Health Care Thoughts: PPACA Health Exchange Oops

by Tom aka Rusty Rustbelt

Health Care Thoughts: PPACA Health Exchange Oops

On March 1, 2013 employers were supposed to notify employees in writing of information relating to the health insurance exchanges, including a 1) description of services, 2) employee eligibility for a premium tax credit IF the employee purchases an exchange insurance product, and 3) the downside of the employee purchasing through the exchange.

On January 24th the Department of Labor announced the suspension of the notice rule, because there is very little guidance currently available, as the feds are behind on implementation actions and exchanges are still in a confused infancy.

It is possible the DOL will require the notices to be issued in late summer or fall, ahead of an October (?) startup.

I am now putting the probability of a major delay of exchange start ups at 30%.

Healthcare Reform; Socialism or Fascism?

by Run75411

Healthcare Reform; Socialism or Fascism?

Whole Foods CEO John Mackey in 2009 originally called President Obama’s healthcare plan a form of Socialism while writing an op-ed for the Wall Street Journal:

“The problem with socialism is that eventually you run out of other people’s money.” Margaret Thatcher”

and added to Thatcher’s statement:

“While we clearly need health-care reform, the last thing our country needs is a massive new health-care entitlement that will create hundreds of billions of dollars of new unfunded deficits and move us much closer to a government takeover of our health-care system,” he wrote.

Mackey joins other CEO’s (Papa Johns, Olive Garden, Applebees, etc.) (Raising the Cost of Pizza 10 to 14 cents); who refuse to understand the need for healthcare reform, support a commercial healthcare insurance and industry solution even though both have done little to voluntarily rein in costs, are willing to penalize their employees for the PPACA, and ignore the results of doing nothing and associated increased costs. Since Hillarycare (1994), the industry has ignored increasing costs and has not provided solutions to mitigate them. As shown in Figure 1 annual healthcare cost has grown much faster than inflation. Figure 4 shows the increase in House hold expenditures since 1994 when Hillarycare was considered.

“American Healthcare since 1994” Center for American Progress

Recently during an NPR interview, John Mackey changed his opinion calling the PPACA fascism instead of Socialism:

“Technically speaking, it’s more like fascism. Socialism is where the government owns the means of production. In fascism, the government doesn’t own the means of production, but they do control it — and that’s what’s happening with our health care programs and these reforms.” Obamacare Is Fascist, Not Socialist

In a short period after labeling the PPACA as fascism, John Mackey reconsiders his words after a public uproar and retracted his name-calling of President Obama as a fascist and the PPACA as fascism. All of this from a Liberal now turned Libertarian.

The term fascism today stirs up too much negative emotion with its horrific associations in the 20th century,” he said. 

“I believe that, if the goal is universal health care, our country would be far better served by combining free enterprise capitalism with a strong governmental safety net for our poorest citizens and those with preexisting conditions, helping everyone to be able to buy insurance. This is what Switzerland does and I think we would be much better off copying that system than where we are currently headed in the United States.Whole Foods CEO Regrets . . .”

It has only been since the passage of the PPACA (see S&P Healthcare Indices) has the healthcare industry begun to rein in costs as reflected in Medicare, Medicaid, and SCHPS through efficiencies. Much of this is due to the healthcare industry rapidly preparing for the 2014 final implementation of the PPACA. More will come after 2014.

You would think this would be enough? At the same time, the Republicans are calling for cuts to the three programs to lower deficit spending; the President is offering to consider modest cuts and shows willingness to sell-out the citizens to achieve his Grand Deal. Cuts in any of the programs will do nothing to lower healthcare industry cost as these programs are a reflection of the industry. In the end, such a Grand Deal will lay the burden of healthcare costs on the elderly, the poor and the children of this nation. The “I Made This” John Mackeys of the world who became rich as a result his customers buying from Whole Foods will absolve themselves of any social responsibility.

Health Care Thoughts: Electronic Medical Record Meltdown

by Tom aka Rusty Rustbelt

Health Care Thoughts: Electronic Medical Record Meltdown

In the past I have predicted the EMR focus of the Obama administration might not work as well as intended. Sadly, and many billions of dollars later, I may be correct.
(The New York Times has run many pieces on this, the latest on the hard copy business page on 1/11/2013 – I can’t find the link.)

And next year we make the ICD-10 conversation, sort of throwing gasoline on a raging fire.

There are a multitude of problems:

  • Too many vendor systems, making EMR to EHR linkages difficult
  • Crazy long and complex federal regulations
  • The input devices irritate physicians and disrupt the flow of the office practice
  • Medicare thinks EMRs are inflating billings, due to text cloning and auto-coding
  • The hospital and nursing home systems are distractions to nursing
  • Going totally paperless is largely a myth so far
  • HIPAA security issues abound

So where will EMRs work? Based on recent observations perhaps in very large integrated systems where every provider is on the same system, although some of the front line personnel are singing the same sad songs as others.

E-prescribing may be one area with some success.

Health Care Thoughts: CPA Retirement Funding Act

by Tom aka Rusty Rustbelt

Health Care Thoughts: CPA Retirement Funding Act

So I spent a part of the weekend reading summaries of the new IRS regs on the Obamacare 3.8% net investment income tax.

Holy complications Batman!

These rules are so complex and convoluted CPAs will spend their spare time reading yacht catalogs. Sure, the rules apply to high earners (although not that high, e.g. a two income professional couple may get whacked), but for those in the lofty category these rules are really really messy. There are lots of really difficult issues such as S-corp sales and what happens to real estate professionals.

This is not the way to finance a health care system , IMHO.

Health Care Thoughts: Re-admissions, Resident Rights and Pie

by Tom aka Rusty Rustbelt

Health Care Thoughts: Re-admissions, Resident Rights and Pie 

A follow up to a post on evidence based medicine….
PPACA is putting extreme pressure on hospitals to reduce Medicare re-admissions.
Hospitals are putting increasing pressure on nursing home to reduce re-admissions, particularly due to diabetes.
Nursing homes are under constant pressure to respect “resident rights” including the right of residents to eat just about whatever they want, including piles of junk food provided by families of diabetics.
Nursing home nurses are under extreme pressure to 1) respect resident rights, 2) maintain blood sugar levels at the same time, and 3) document all of this at an extreme level.
Mrs. Rustbelt and a couple of other nurses may be in trouble for denying pie to a really, really sick diabetic (both legs amputated) who regularly sends his blood sugar readings north of 400.
The fans of increased regulation should think through some of the conflicts and consequences.

(My thoughts in comments…Rdan)