"Odd Things" Part 1

The historic bill has passed. I've been perusing it (H.R. 3590, search for the bill online here) and looking for random things that made their way into the bill. Here is part 1 of "Odd Things That Made the Cut As Healthcare Reform:"

SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS.

Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 207) is amended by adding at the end the following:

`(r)(1) An employer shall provide--

`(A) a reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child's birth each time such employee has need to express the milk; and

`(B) a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.

First of all, if you breastfeed more than a year, you're screwed. Also, I can see some unscrupulous business owners sticking women into closets and the lawsuits rolling in claiming this misses the spirit of the law when it says a place "other than a bathroom."

I'm glad this provision made the cut. The current bill just wouldn't be the same without it.

Delusional (statements by) doctors

Lest I be accused of libel, note that I believe the following statements are delusional, not the actual physicians themselves. First, see this article. One of the Mayo Clinics in AZ will no longer be accepting Medicare patients. What is disturbing, however, is a statement by Robert Berenson, a fellow at the Urban Institute and proclaimed expert in Medicare. Apparently, when you are out of practice for some time (I did a limited search and had trouble finding out the last time he actually took care of patients but I bet it's been a while), it gets easier to make such blanket statements about the everyday doctor. From the article:

Robert Berenson, a fellow at the Urban Institute’s Health Policy Center in Washington, D.C., said physicians’ claims of inadequate reimbursement are overstated. Rather, the program faces a lack of medical providers because not enough new doctors are becoming family doctors, internists and pediatricians who oversee patients’ primary care.

“Some primary care doctors don’t have to see Medicare patients because there is an unlimited demand for their services,” Berenson said. When patients with private insurance can be treated at 50 percent to 100 percent higher fees, “then Medicare does indeed look like a poor payer,” he said.

This is some twisted, convoluted logic. Why does he think there aren't enough providers going into primary care? There are many reasons but one is certainly because they get paid less than specialists, which includes reimbursement from Medicare and other insurers. So, Dr. Berenson thinks that Medicare doesn't really underpay, it just looks like it does because other insurers pay more? That gets into the question of how much he thinks physicians should be compensated. What is the fair market value of a physician? Oh wait, he doesn't really believe in the market when it comes to the medical profession. After these ridiculous comments I did a little research and came across the following from a letter in the Journal of the American Medical Association, May 27, 2009 (subscription required; in response to original article January 21, 2009):

We did not express opposition to health care competition per se, but rather to a specific form of competition core to the "consumer-driven" approach that encourages patients to shop for discrete health services to find the best match of quality and costs.

Anytime someone says they don't agree with something per se, yeah, that means they don't agree with it but they're afraid to admit it outright in case others might think they're crazy. Then in the letter, they (includes Dr. Cassel, more on her later) use direct-to-consumer advertising of drugs with its evils as an example of why competition among physicians is concerning. Talk about a non sequitur. How are these even related? As mentioned before, they still completely ignore other areas of competition such as LASIK and cosmetic plastic surgery which has improved care while lowering rates with little insurance penetration (until lately).

I love how Berenson later quotes his own article to bolster his claim: "See, read this article from another smart man; what I'm saying is true."

The other part of the "they" is Christine Cassel, current president of the American Board of Internal Medicine which certifies most internists in this country, including me. Scary.

Berenson's comment on the "unlimited demand" for primary care MD's is equally bewildering. If there is such an unlimited demand for something, how is it that people are moving AWAY from it? Oh yeah, it's because you're trying to cut their pay. Completely opposite of free market but apparently this type of thinking is common. Note this comment by Senator Conrad recently:

And let me say, if I can, on this question of reducing Medicare, there are $500 billion of savings to Medicare. Most of those savings have been negotiated with the providers. They're going to get less than they were anticipating. They've agreed to those savings because they know they're going to get 30 million more customers. That is a dramatic increase in business for them, and they are sharing some of the savings so that we can pay for this bill. There's not unreasonable.

This kind of comment highlights how clueless non-physician legislators are about physician practices. As if physicians are just sitting around twiddling their thumbs and so excited about all these new patients that will be filling their offices. No, physician offices are typically busy. Why? Because of this unlimited demand? No, because they have to cram 40 patients a day into 15 minute slots in order to make a buck. And why do they have to do that? Because of overhead, administrative and insurance junk they have to deal with that take up so much time and money. Add to this complex patients, late patients, more insurance problems and a whole bunch of other junk and there you have your overflowing waiting room. No wonder why many doctors aren't taking insurance anymore. They can spend more time with patients, treat them properly and still break even. Here's one example.

Taxes and more taxes

Got a lot to write about, Senate headed towards passing their version of health reform. More on that later, though. First off, I have decided to start using typical capitalization. I realize it's a lot easier to read than the all lower-case version. Sorry e.e. cummings, you were an inspiration but it did not last.

I have never been a huge fan of lifestyle taxes--you know, additional taxes on cigarettes, alcohol, soft drinks (proposed). In case you missed it, included in the Senate bill is a 10% tax on tanning salons. You heard that right, tanning salons. The government is delusional enough to believe this will bring in $2.7 billion dollars over the next 10 years to help pay for reform. This information is in today's Wall Street Journal. Originally, there was supposed to be a 5% "Botax" on cosmetic procedures which would have brought in an estimated $5.8 billion. Not surprisingly, the AMA and AAD (Dermatology group) opposed this idea and somehow, they decided to tax tanning salons instead. Even before the article, I thought it would hurt many of the small businesses that operate these salons, many which are already failing without the tax. Pun intended, let's face it, an additional 5% tax on cosmetic procedures isn't going to ruin any dermatologist or patient seeking said procedures. Nevertheless, that's why you need a strong lobby in D.C. and apparently the tanning industry's isn't.

What gets me even more ("what grinds my gears" in the words of Peter Griffin) is the condescending attitude of people like Dr. David Pariser, president of the AAD. I guess feeling a little smug at his victory on Capitol Hill, his justification for the tax is because "Indoor tanning is a practice which is a known carcinogen." Are you kidding me? Newsflash, Dr. Pariser: the sun is a known carcinogen. Do you propose additional federal taxes for swimming pools, beaches and any business with outdoor exposure? Furthermore, sticking needles into and cutting or freezing body parts is also a known hazard, increasing risks of infection, bleeding and other problems.

This doesn't even cover Obama's pledge not to increase taxes a single cent on anyone making less than $250,000. That's why he's a smart man. I guess he means no tax increase on anything that actually shows up on a federal tax form but if you increase taxes on every other area of life, that's okay. But of course, as I've mentioned before, the "fee" proposed for not having health insurance really is a tax anyway, collected by the IRS.

tough crowd?

from the new york times, monday september 21:

"Mr. Obama is not usually one to avoid high-risk interviews or dodge hostile crowds. He was the first sitting president to appear on “The Tonight Show With Jay Leno,” ... "

so leno is now a "high-risk interview" or has a "hostile crowd"? now that's funny.

the above quote was in a story regarding obama's record 5 sunday am interviews pushing his healthcare agenda. most of the interviewers tossed softball questions. kudos, however, to george stephanopoulos. he tried to challenge the president about the "tax" under the house and senate plans for people who are able to afford insurance but choose not to get it. as you can imagine, this is a problem because obama promised to raise no taxes of any kind for those making under $250,000 a year. here's another good analysis of it. it's almost as confusing as clinton's definition of "is." basically, it's not a tax because he says it's not? even though the bill says it is and the irs would be the ones collecting it? as pointed out in the ap piece, of course the tax issue is already moot with the passage of schip which raised tobacco taxes and predominantly affects those making less than a quarter mil. and as a refresher, i'm getting tired of the car insurance analogy. we can opt out of paying car insurance by not having a car--a way of life many people in this country live. the only way to opt out of a health insurance "tax" is by not making any money or being low-income which isn't exactly a motivating policy.

healthcare reform 2.0

well, it's the eve of obama's big speech to a joint session of congress trying to sell his healthcare reform. or is it health insurance reform? regardless, here are a few random thoughts on this whole mess.

1. upon further inspection, the additional 2.5% tax on adjusted gross income isn't completely unprecedented (see prior post). heck, we already pay a whole bunch in medicare and social security so the idea isn't new. it's not necessarily a tax on being alive but a tax on making money. so technically you can opt out by not making any money but that makes life a little difficult. plus, we already pay enough taxes.

2. i'm not necesarily against a public option per se. it's true a type of public option already exists with medicare and medicaid. so if there was a public option to cover those who can't afford any insurance and to cover catastrophic events, that's not necessarily a bad thing. but the problem is, how will we afford this??? i am in awe (in a bad way) when i hear people talk about how medicare is not that bad and why not expand it to everyone? hello?! it's about to freakin' go bankrupt, that's why. recently they moved up the estimated year when this thing would go belly up unless something changes, see here. if we can't even keep up with medicare costs, how in the world are we going to afford this for everybody?

3. i still don't understand how you can focus on cutting costs in healthcare without addressing tort reform. well, okay, it's easy to understand from this perspective: trial lawyers are a big part of the democratic party. that's why obama doesn't want to add tort reform to this bill. howard dean himself acknowledged this point (do a search for "trial lawyers" on the link). it is simply not an honest discussion about cutting costs if this issue is not addressed.

dean's comment is so telling. this bloated 1000 page bill covers almost everything under the sun including how to change time accounting for training resident physicians yet they didn't want to add more by addressing one of the most important issues?! that is nonsense.

why the need to tackle so many issues in such a large bill that many haven't even read? this whole reform started on a platform of "the 47 million uninsured" but has now encompassed more than they can handle. why not just start with the few important issues and settle those without trying to disrupt the whole system? some will say that it's because the whole system needs fixing, which i don't necessarily disagree with but it's not in ways that these guys are talking about. i will discuss those below and in later posts.

4. i'm tired of hearing all the complaints about the republican party. now, for full disclosure, i do tend to align myself with conservative ideas usually but am certainly not a card carrying republican. nevertheless, the democrats have a filibuster-proof majority. if they want to pass a plan, they can, so quit complaining about the republicans and formulate a plan that your own party can at least approve. the opposition party is not the problem when you have a majority congress and the white house!

5. it's a myth that anyone can guarantee that you can keep seeing your same doctor under the current proposal. see section 102 and 142 on the prior post with the link to the full summary of the bill. first of all, obama wasn't even familiar with the details of the bill as is evidenced here. section 142 basically sets up a health care "czar" who can force all plans to meet certain requirements. section 102 says that if you are in a plan after the bill takes place, that plan has 5 years to meet these requirements. now, i don't want to sound skeptical of our government, but if they decided to formulate the requirements in such a stringent way that no limited resources private plan could meet it, that would essentially eliminate all other plans. since this is more than a remote possibility, the fact is, if you have a new doctor and new plan after the bill (theoretically) passes, you ARE NOT guaranteed continuity of care. this is made even worse by employer-based health insurance which needs to be eliminated. more on that later.

6. what i find most amazing is some of the comments obama has made regarding physician practices. not surprisingly, most of these comments are made ot (off teleprompter). for example, remember the july 22 press conference when he said the following (full text here):

"And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works -- because that's not how it's working right now. That's not how it's working right now. Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there.

So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out. Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

are you freakin' kidding me? is this how he thinks doctors think and act? now i know he never took any type of hippocratic oath in law school but most doctors i know act in the best interest of their patients. you'd be surprised to find out how frequently surgeons are actually unwilling to cut! and while we're on this topic, can we please dispell another myth? most doctors do not get paid by ordering more labs and tests and scans. this is patently false and ridiculous. this is only true if they own their own lab or testing machines which is not the majority of doctors.

now, if you thought the above statement was crazy, the one below is more unbelievable (from august 11):

"All I'm saying is let's take the example of something like diabetes, one of --- a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family -- if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 -- immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money. (Applause.)"

now, in all fairness his main point is to pay primary care providers more money for preventive care. not gonna argue against that. but again, he shows his incredible ignorance (most likely ot again) about how doctors get paid in this country. there is a wide gap between what a hospital might charge for a procedure and how much a doctor actually gets paid. in fact, medicare pays aorund $1000 to a surgeon for an amputation, not tens of thousands of dollars! and to assert that this reimbusement is immediate??? are you kidding me? yeah, what you do is bill medicare and hope to get money within 90 days for services you already provided.

in all honesty, this is the kind of stuff you would expect spewing out of the mouth of w, not this supposed post-partisan president who is such a fluent orator.

7. the big question comes up, how are we going to pay for such sweeping reform? not receiving as much press is the question as to who is going to take care of all these patients? already many do not want to go into primary care for a variety of reasons so you can expand health insurance to every plant and animal in this world but if there aren't the doctors around to take care of them, have we solved anything?

who is for this bill?

8. why is the ama for this reform bill? who knows but one thought is because they got a deal from obama to eliminate the sgr, the sustainable growth rate which is an archaic formula that medicare uses to pay physicians. that itself is actually a good thing but the ama is a joke and the organization does not represent the majority of doctors. is there some other reason they are supporting this bill? i have no idea.

9. why are the hospital organizations for the bill? section 1156 which essentially eliminates physician-owned hospitals as of this year by choking off the current supply. here's a commentary.

10. why is pharma (pharmaceuticals research and manufacturers of america, the umbrella organization for the nation's drug companies) for reform? because they get the guarantee that the governmentwon't negotiate for lower prescription drug prices. here's one article on this. another slate article.

so then, what's the answer? read this article for a closer glimpse into the problem. here's another one but i'm not sure how long it will be accessible. first off, you have to identify the real problems. the first article is written by david goldhill, a democrat but a businessman and he identifies many problems very well from a business perspective (although i don't agree completely with all his solutions). the second article is written by whole foods ceo john mackey. the essence of both articles is actually to use less insurance and to increase transparency in pricing. this will promote more competition but to facilitate this, you also need to remove barriers to insurance access, in particular allowing portability of insurance across state lines. it's too late to get into this in detail right now so i will in a post to come real soon i hope.

health care (?) reform

well, as we are being told now, we're in the midst of health insurance reform, not health care reform. i guess our health care is good enough. it's the insurance that needs work.

i thought i would finally weigh in on the debate a little. by no means will this be an exhaustive evaluation; heck, i'm here with a glass of wine with cnbc on in the background. not exactly the setting for changing national policy, i'm sure.

as a reference, here's a link to a detailed summary of the house bill which has been proposed. since this thing is already out there, i guess a few comments about it would be in order.

problem 1
one proposal i find very unamerican is the 2.5% tax added (see section 401) if you refuse to sign up for any insurance. now, in the spirit of full disclosure, i actually thought this idea should be considered several years ago but have since changed my mind. i haven't done any significant research into this yet but can you think of any other tax that you have to pay just for being alive? people compare this to car insurance which is also mandatory but plenty of people opt out of car insurance by not owning or driving a car. you can opt out of property tax by renting. you can opt out of sales taxes by not buying stuff (or not buying as much). you can opt out of just about any tax currently out there one way or another (may not necessarily be the most feasible option in the world but possible) but you can't opt out of this health insurance tax unless you die! THAT is unamerican. next thing you know, i'm gonna have to pay tax for breathing. oh wait, that's probably gonna happen soon too.

problem 2
before i go on, i have to reference an npr story that aired a couple of weeks ago. you can read the transcript here and here is a link to an explanation of the story. you should read some of the comments in the original article. pretty funny stuff. some guy even posted a link to i think a washington post article (okay, can't help myself, click here) this same chick did about buying the right mattress. hard hitting stuff april fulton has been working on. anyway, the npr article was one of the most grossly biased and misleading things i have ever heard on the air. now that's saying something, even for npr! you hear this business about the public plan option and the reason for its being to keep private companies honest. the administration has even said it. for people who honestly believe this, i would encourage you to think about it further. let's take the example of private versus public primary/mid/high schools and use this as a substitute in the npr piece. do you see a large population of private schools who are "nervous" about public schools because "people really like it" and it offers such a value? are private schools drastically slashing their prices to "attract customers back" because the public schools are stealing all the students away? that is ridiculous. in the same way, don't expect the public plan option to all of a sudden make private insurance plans so much better. you know what? if there are unscrupulous activities going on in private insurance (which is definitely the case for patients AND for physicians) then fix those problems. don't expect a public plan to do it for you.

there are many more things to discuss. more later.