04/19/2010 David Secord, DPM
The SGR formula, Healthcare Reform and Us
I’m finding the current debacle of “health care
reform” and its implications both disconcerting
and fascinating at the same time. The
disconcerting part is obvious: none of us could
continue seeing Medicare patients if an absurd
21% reduction in reimbursement is instituted
somewhere along the line. I’m finding the
current situation fascinating for the following
reasons:
1. There was a time when being a doctor was a
truly middle class occupation and compensation
was not that divorced from the pay rates of the
plumber. Like the plumber, it was fee for
service and staffing for billing procedures was
minimal. All you needed to do is balance the
books. Of course, in like manner, malpractice
liability was commensurate with income levels.
2. It was the onset of health insurance offered
by companies after WWII as an employment
incentive which started the indexed
reimbursement problem into which we now are
immersed. The HMO was the natural management
offshoot of insurance to control rates and
maximize profits. The critical mass of
intolerance of costs/benefits has now been
reached, wherein the attempt to cover everyone,
regardless of whether they could afford
healthcare (based upon the specious claim that
it is a ‘right’) is costing so much that the
system is now unsustainable.
3. The government’s attempt to control costs by
making Medicare worthless to the beneficiary may
usher in a return to the straight fee for
service arrangement that was the norm back in
the old days. I say ‘worthless’, as the cost of
care to the provider or facility will be more
than the reimbursement rate for that care and
the inevitable result will be caregivers
dropping out of both Medicare and private
insurance plans who follow the reimbursement
rates of Medicare, making both ‘worthless’.
4. The devastating effects upon the United
States health care system includes causing a
large number of hospitals to go out of business,
a large number of doctors to retire or quit the
profession, a large number of students who
considered medicine to reconsider and reject
that choice of profession and will drive the
technocracy of high sophistication we enjoy in
the US into the mud, where it will falter, as no
one will be able to afford a heart transplant, a
single photon element computed tomography study
or very expensive pharmaceuticals out of pocket.
Is this the natural course of things in the free
market? Perhaps. The pendulum swings both ways
and inexorably so. We have known for a long time
that the more you attempt to artificially
manipulate the market, the more agonized the
self-correction. John Stossel was the first
person I've read who advocated a correction for
the out-of-control costs of US healthcare by a
return to fee for service and medicine going
back to a middle class occupation. The
contention is also that if doctors are not rich,
the incentive for lawsuits will largely
disappear as well, but I’m not so sure, as we
will still be required to carry malpractice. It
is unclear how we will afford it, but like
death, intrusive government and taxes—is
inevitable. As we are on the cusp of a paradigm
shift in U.S. healthcare delivery, I’d love to
hear people weigh in on the topic. I’m not
asking people to be clairvoyant, just rational
in thought as to what they think the future
holds.
David Secord, DPM, Corpus Christi, TX,
david5603@pol.net
12/18/2009 Pat Caputo, DPM
RE: Healthcare Reform (Thomas Nolen, DPM)
RE: Healthcare Reform (Thomas Nolen, DPM)
From: Pat Caputo, DPM
Healthcare reform and “end of life” medical care
are not mutually exclusive issues. Dr. Nolen
raises an interesting point, and although he
does not reference the $100,000 figure, I do not
disagree with it. And it might even be true in
his assessment that the $100,000 is “many times
with no added quality of life, only miserably
extended life. There is no limit to how much
money can be spent on each patient.”
My questions: Who decides on end of life care,
and more importantly who decides what is defined
as “end of life care.” How is end of life care
different from old age care that is often (but
not always) very helpful. The line between them
is VERY wide and gray. My own mom was bed-
ridden before she had two total hip replacements
after the age of 90 and two years later still
lives in her OWN home outside of Newark, NJ,
alone and independent, where she has lived since
1942. I have seen her medical bills, and after
hospital costs for 2 THRs and 2x thirty day
rehab stays and home PT and radiology and maybe
an ambulance trip to the ER b/c she felt it slip
(even though it didn’t) and yes, there goes 100
grand. But, at age 93, like a good nonna
(“Grandma” for the culturally incompetent), mom
is making me a “nice meatball ‘sangwich’” when I
go up and visit Saturday afternoon and put up
her Christmas lights.
My point is I don’t want the government nor
private insurance making those “end of life”
decisions. Yet I fully understand that someone
has had to pay for my mom’s medical bills; she
has received services that needed to be
compensated. No one is denying the need and
usefulness of Medicare or the wonders of modern
medicine. But there is a financial cost.
Suppose some gov’t or insurance bureaucrat had
denied her surgeries in the name of cost savings
or because my mom is more the exception than the
rule? Would you blame him/her?
Bottom line is if we as Americans want to have
medical care at end of life or any age, we must
realize that it costs money. The reason that
healthcare is 17% of our GDP is that it is
expensive. Medical services are not cheap. I
cringe when I hear politicians sugar-coat
solutions. Trimming waste and punishing fraud
is good and wholesome, but isn’t anywhere near
enough to cover the expenses. (To paraphrase a
bumper-sticker): If you think healthcare is
expensive now, just wait until it is free!
Until a real solution surfaces (which I don't
profess to have), what our elected
representatives should be saying is, “Are we
willing to accept and pay the costs or deny
services?”...Are we?
Pat Caputo, DPM, Holmdel, NJ, capstops@aol.com
12/11/2009 Jon Purdy, DPM
Healthcare Reform (Bob Kornfeld, DPM)
RE: Healthcare Reform (Bob Kornfeld, DPM)
From: Jon Purdy, DPM
Although I disagree with notion that we are
more “pathologic,” I don’t disagree that
proponents of universal healthcare are using
absurd cause and effect analysis to try and make
their point. What is unarguable is the fact
that we have become much better at detecting
disease and are doing so earlier. It is also
unarguable that the United States leads the
world in rates of successful treatment of almost
every major cancer and other top causes of death
and morbidity.
I would think one could draw a conclusion as to
why our healthcare costs are higher than many
nations based alone on legal statistics. Some
may find it interesting to note that the cost of
malpractice litigation has increased 12% a year
since 1975. Even better is the fact that
medical malpractice awards have increase 43%
since 1999. How about the fact that compared to
Canada, the United States files 350% more suites
per year?
If it helps to see how this hits your pocket
book, consider the fact that the National
Association of Insurance Commissioners reported
that malpractice insurance premiums have
increased by 920% during the past three
decades. The most unfortunate finding is that
trial lawyers get $75 for every $1 the victim
receives. [The need for tort reform in the
current healthcare debate; David H. Sohn, JD,
MD; Javad Parvizi, MD, FRCS; and Charles S. Day,
MD, MBA]
So, with trial lawyers firmly embedded in our
political system does anyone think there is
going to be a serious debate about the true
costs of healthcare in this country and how to
fix them? Not a chance. As they say, it’s
tough at the top. We are one of the most
prosperous nations in the word with the most
amount of disposable income. We have some of the
latest diagnostic and treatment technologies
available, and accessible, and that comes at a
higher cost. Our citizens chose to go to the
doctor more often and to pay huge out of pocket
costs for procedures such as plastic surgery.
All of this contributes to our high healthcare
spending figure, none of which translates into
true healthcare outcomes as some would like you
to believe.
Jon Purdy, DPM, New Iberia, LA,
jpurdy@mindspring.com
12/10/2009 Bob Kornfeld, DPM
Healthcare Reform (Joseph Borreggine, DPM, William Reider, DPM)
RE: Healthcare Reform (Joseph Borreggine, DPM,
William Reider, DPM)
From: Bob Kornfeld, DPM
Drs. Borreggine and Reider reference the
statistic that "America's healthcare industry's
costs represent 17% of this country's gross
domestic product (GDP). This is much too high
and is unsustainable. In other developed
countries their GDP runs about 8%."
Much has been said about the "high cost" of
healthcare in this country but no one seems to
want to focus on the mechanism. So we throw more
money at a system that is broken from within and
without in the hopes of making healthcare
delivery "cheaper". Hence, the focus remains
finances. As long as the focus remains
financial, healthcare in this country will never
be fixed. In other words, we need to look at the
bigger picture. The biggest reason why
healthcare costs are spiraling out of control is
because pathology is spiraling out of control.
The focus, if we are to improve the cost-
effectiveness of healthcare, must be health
itself. In this day and age, we have more
epigenetic influences on pathology than ever
before. We have polluted air, water and food. We
have refined, nutrient deficient food on the
shelves at the supermarket. We consume more
things artificial than natural. We are exposed
to and are consuming numerous poisons every day
in the form of herbicides, pesticides,
preservatives, household cleaners, automobile
pollution, industrial waste emissions, acid rain
that washes toxic heavy metals into our soil and
hence into our food, and radiation in our
atmosphere. We have an entire nation that has no
clue how to feed themselves healthfully. We have
an entire nation that instead of working to
understand their symptoms and correct the
underlying causes, are popping pills to suppress
their symptoms and believe they are better off
for it. We have diet, lifestyle and
environmental factors that are killing us daily.
And to top it off, we have a healthcare system
that waits for people to get ill before it does
anything about it. This is why healthcare costs
have spiraled out of control. There is little to
no focus on prevention of pathology. We are
getting better at early detection and diagnosis,
but that is not good enough.
This is a country deep in the throes of the
biggest pathology of all - NDD. This is what
costs us all that money. What is NDD? Nature
Deficiency Disorder. And as long as NDD does not
get addressed, no amount of legislation from
this government is going to put a dent in the
problem.
Wake up America!! The problem is not your
insurance coverage. The problem is each and
every one of you that remains silent
participants in the biggest atrocity ever on
Earth. It has been said that we are destroying
the planet faster in the past 100 years than in
all the eons that there has been life on this
planet. I say that could not be further from the
truth. We are not destroying the planet. We are
destroying ourselves. And when we are gone, the
Earth will heal and Mother Nature will again be
free to create the beauty and miracle of life on
this planet.
Bob Kornfeld, DPM, Manhasset, NY,
holfoot153@aol.com
11/25/2009 Bob Kornfeld, DPM, Thomas Nolen, DPM
Healthcare Reform and Our Survival (Arden Smith, DPM)
Dr. Smith's concern's are echoed by this
practitioner as well. Where are the protests? I
absolutely cannot understand how any podiatrist
can continue to participate with this insanity
and contract with insurance companies that are
getting rich off of your backs. If you don't dot
the i's and cross the t's properly, you will not
be paid. If you do not obtain the proper prior
authorization to do the treatments you have been
trained and licensed to do, you will not get
paid. If you step 1/4 of an inch outside the
standard expected percentage in each treatment
category, you will be investigated. If you have
hired the right number of employees necessary to
insure the fact that you will be paid for your
education, time, efforts and expenses, you will
be paid...but very very little.
Medicare has published their 2010 Fee Schedule
with the much talked about 21% decrease. I have
been billing Medicare for almost 30 years, and I
can honestly tell you that they were paying
about 3 - 4 times higher back then. Now add 30
years of inflation!! It is no wonder insurance
companies want to follow the Medicare formula
for reimbursement. Has anyone seen a 21% drop in
their own health insurance premiums? This is not
a problem that will be offset, as per Dr.
Smith's tongue in cheek assertion, by selling
products in the office. This is a problem that
won't go away unless WE stop accepting these
payment limitations and refuse to participate
with insurance companies (Medicare now may be
included in that as well).
While it is a given that we are all expected to
provide the absolute best quality of care in
keeping with the accepted standard of care, it
is also impossible to do this and maintain the
high expenses that go along with this type of
practice.
That said, I have friends and relatives who are
M.D.'s and D.O.'s and they are not immune from
the same issue. Some, like me, have dropped out
of all of their participation agreements, only
to find greater freedom and better income. While
others remain "scared" to make a move. I'll tell
you what I tell all of them. There is no better
voice than the collective voice. This needs to
be addressed by the entire medical community in
unison in order for the "voice" to be heard. How
likely is this to happen? Not very, in my
opinion. So I think what it comes down to is
this...what kind of lifestyle do you want to
create for yourself? How do you want to practice
podiatric medicine? Who do you want calling the
shots in your office?
I did a favor for other local podiatrists in my
area because when I dropped out of insurance,
many of my patients sought other practitioners
for care. I did myself a favor too. I vastly
improved the quality of my life. Anyone can do
this. I am not unique. You can only fall prey to
victimization by insurance companies if you
allow it. The truth is, you are only a victim of
your own beliefs. Victim mentality begets
victimization. You choose.
Bob Kornfeld, DPM, Manhasset, NY,
Holfoot153@aol.com
Our problem is that there seems to be a
disconnect in communication with the moderate
and independent Congressmen and Senators as
exhibited by Senator Ben Nelson a Nebraska
Democrat that stated " I don't want a big
government, Washington run operation that would
undermine the...private insurance that 200
million Americans now have" The Senator is
implying that private insurance provides
healthcare. Of course, private insurance does
not provide any health care, they only provide
insurance.
The evolution in health care is one of
universal coverage by the industrialized
nations. The U.S. healthcare system is not the
model for which any other nation aspires.
Mistakes have been made in national coverage by
other nations leading to their modification.
Universal healthcare has to start In the U.S. at
sometime so it can improve.
It is unfortunate that The Republican Party has
effectively eliminated themselves from the U.S.
health care reform by sending a directive to its
members to not support a Democratic health care
initiative. The Republicans could have been able
to start meaningful tort reform for health care
providers if it had given the plan bipartisan
support. Universal Health care reform will have
to start with a Democratic majority since
historically there has not been significant GOP
healthcare nor tort reform.
If we had initiated a national healthcare system
in 1912 under Theodore Roosevelt or really any
year since then, the United States could have
had a well evolved system that was the envy of
the world. Does anyone know of a modern
industrialized nation that started with
universal health care that evolved into a more
expensive system private system with partial
coverage. There is fierce competition to sell
arms to the U.S. Government's sponsored military
system just as there is fierce competition for
pharmaceutical companies to get their drug
covered under Medicaid and for medical suppliers
to get covered under Medicare.
There is little price competition among sellers
of insurance because there are so many variables
to consider when making a purchase. As an
example when I hired an associate last year we
had to sign into 92 different health plans
covered under a few Insurers that all paid at
nearly the same rate as Medicare. They pay the
same rate they just differ in 92 ways to make
choice difficult for the buyer and payment
difficult for the provider.
The Healthcare reform bills that were passed in
the House and Senate are far from perfect and
will be the start of universal coverage and a
national health care plan. The Dems and GOP
agree that reform is necessary. Universal
healthcare is the evolution of modern
government. Change will have to start
somewhere. It is something that healthcare
providers, insurers, suppliers, and even
attorneys will have to survive.
Thomas Nolen, DPM, Centralia IL,
nolendpm@yahoo.com
10/26/2009
RESPONSES / COMMENTS (HEALTHCARE REFORM)
RE: Obama’s Healthcare Plan
From: Jason Kraus
The one thing that everyone seems to agree on is that there is great disagreement about the healthcare system in our country. It is interesting to note that most of those who took exception to my comments felt...
Editor's note: Jason Kraus' extended-length note appears at: http://www.podiatrym.com/letters2.cfm?id=29890&start=1
07/28/2009
HEALTHCARE REFORM LEGISLATION
Medical Groups Split on Support for Healthcare Reform
The American Medical Association has thrown its support behind a Democratic national health system reform measure making its way toward the House floor, so far the first comprehensive bill that addresses Medicare physician pay.
But not all doctors are on board with the House bill. Led by the Medical Assn. of Georgia, seven other state and local medical societies and three surgical specialty societies signed a July 21 letter to Congress that opposes the legislation. Two former AMA presidents, Donald J. Palmisano, MD, and William G. Plested III, MD, also signed the letter. The inclusion of a government-sponsored public insurance plan option that would compete with private plans is a major reason for these physicians' opposition. They also reject individual and employer insurance mandates in the bill.
The AMA does not consider the pending bill to be a finished product, AMA's president Dr. J. James Rohack said. The Association aims to push lawmakers to include medical liability reforms missing from the measure and reconsider the bill's ban on self-referral for new physician-owned hospitals.
Source: David Glendinning, AMNews [7/27/09]
07/25/2009
HEALTHCARE REFORM LEGISLATION
Reform Legislation Deadline Pushed Back in Senate
Not 24 hours after the president went on national television to quell growing criticism over his effort to reshape the U.S. healthcare system, Senate Majority Leader Harry Reid (D-NV) officially unchained a key Senate committee from a White House-backed deadline. Reid said that the Senate would not vote on a comprehensive health reform bill before its August recess. The Senate officially goes on break Aug. 7, returning in September. The top senator said, “The decision was made to give them more time for the Finance Committee part of what we are trying to do, and I don't think it is unreasonable.”
President Barack Obama has said that he wanted a bill before the recess, but shrugged off the delay. “That's OK, I just want people to keep on working,” Obama told a town hall meeting in Cleveland, according to the Associated Press. “I want it done by the end of the year. I want it done by the fall.”
Source: Matthew DoBias, Modern Healthcare [7/23/09]
07/23/2009
HEALTHCARE REFORM LEGISLATION
Panel Making Headway on Reform Package: Baucus
Senate Finance Committee Chairman Max Baucus (D-MT) said that a bipartisan team of negotiators have locked down “two major issues” that will be part of the broad framework for healthcare reform, but declined to provide details. “We're making significant headway,” Baucus told reporters. “I'm probably more upbeat and optimistic now compared to where we were earlier.” Emerging from a closed-door meeting, Baucus said the group focused on insurance issues, including cost and coverage questions that have arisen over individual and employer mandates.
Meanwhile, the committee is searching for ways to bridge about a $100 billion to $200 billion gap in financing the legislative package, which likely will cost around $1 trillion over the next decade.
Source: Matthew DoBias, Modern Healthcare [7/21/09]
05/28/2009 Carlos I. Montes, Jr., DPM,MS
Healthcare Reform Must Include Illegal Aliens: NY Podiatrist (Jonathan Purdy, DPM)
Dr. Purdy prefaces his comments about illegals
and healthcare with..."I'm not sure I understand
the debate". May I preface my own comment
with " It's about time we all understand this
debate". Whether illegals receive care in our
country or not, it's high time we understand the
importance, necessity, and pure civility in
healthcare provision in what we call the
greatest country in the world. And on this
front, may I say we absolutely can provide the
best care for all who live here, but on the
other hand, we should be shameful of the
consequences of private, for profit management
system currently prevailing. The notion that
anyone can get healthcare through free clinics
or emergent care facilities as an argument that
we do have care for all is too simple and
shortsided. It's not free at all. It costs
plenty and becomes a moral hazard to our society
as a whole.
More and more physicians across the nation are
getting on board with single payor healthcare,
or some form of nationalized, universal care.
Indeed, as time passes, this issue becomes the
new "civil rights" issue of our times. It has
no boundaries of color, race, creed, gender,
etc. It must be born in a realization that we
as a civilized society see it just and moral to
provide healthcare to everyone in our country.
That includes visitors, or illegals if that's
what you want to call them. That's definitely
another debate.
As private insurance gains and retains more
political and economic power, do you think it
will get any better for you? We've been dealing
with this mess in our offices well over a decade
since the inception of so-called managed-care.
I've participated in board rooms of physician
multispecialty groups with experience in
contracting with private insurances. The
conversation, to my soul, is skewed against the
physician and the patient. So you see, to me,
it is first a moral issue, secondly our bottom
line, for we as physicians will always be much
better off than the average citizen. And, as a
citizen, it affects us deeply. So I applaud the
gaining momentum of physicians who are realizing
that single payor healthcare, or a Medicare for
All system truly is the best solution. Of
course, this invokes the psychologically
manipulative "socialist" mantra.
On the contrary, as we grow and new problems
arise in our society, we must have the courage
to stand up to powerful forces who will
immediately squash common sense solutions in
favor of retaining their economic and political
clout to the detriment of the country. There
are several main arguments opponents loudly
spew. Two main ones are, a "government"
healthcare would deny a free choice of doctors,
facing long waiting periods for care or
rationing care, and that the care would somehow
deteriorate.
My dear fellow podiatrists, well, these
arguments mirror our complaints present today
against private insurance. The earlier post
regarding capitation is a prime example. If
you're not on the panel, guess what? You don't
get to see or care for that patient. And of
course, they pay what they want to, when they
want to, and how much they want to. Just look
at the hoops you have to jump to get studies
authorized and performed for your patients
today. And to the deterioration of healthcare,
won't you still be providing it? The same
physicians and hospital systems providing care
today will remain the providers. How will that
change? Will you succumb to inferior care for
your patients? Aren't your Medicare patients
happy with your care? Extend that thought and
imagine everyone with the same payor? No more
private insurance hoops to jump. Only one place
to submit your claims with the same rules
everyone has to follow, all doctors on board
the "panel." Have you thought about the likely
increase in your patient base? No more Medicaid
or capitation, or whatever other complaints you
have.
As a pure business decision, the economies of
scale are already present. Surely it would not
be eutopia, but certainly a much better civil
system for us all, patients and doctors. If the
rest of the civilized, highly developed nations
of the world have already accepted that,
certainly, an important role of the government
is healthcare provision, when will we grow up?
And to the cost....what is it costing now?
Isn't that what's started this "debate"? I say
it will cost us more if we don't make this
choice now rather than latter. I will end my
rant here today with this thought.....in many
other countries, if you travel and require a
need for medical attention, they will provide it
for you, and many at no cost at all. Regardless
you are or aren't a citizen of their country.
So who is the grown up?
Carlos I. Montes, Jr., DPM,MS
Rockledge, FL
cimontesjr@aol.com
05/27/2009 Jon Purdy, DPM
Healthcare Reform Must Include Illegal Aliens: NY Podiatrist
RE: Healthcare Reform Must Include Illegal
Aliens: NY Podiatrist
From: Jon Purdy, DPM
I’m not sure I understand the debate. Anyone
without health insurance can already receive
free care through free clinics, the emergency
room and some government programs whether or not
one is in the country legally. The big debate
should be how we are going to enforce our laws.
If something is illegal it is … illegal. It’s
like saying speeding causes accidents, not
enforcing speeding laws, and then trying to
convince the public we need to spend more money
on life flights to the hospital so we can save
people’s lives. Here is the real impact of not
enforcing our laws.
Estimates of the number of illegal aliens in
this country are actually as high as 20 million
[http://www.csmonitor.com/2006/0516/p01s02-
ussc.html]. Health care and public safety
related to illegal immigration, and not
including education, costs $1 billion annually.
[http://www.cbo.gov/ftpdocs/87xx/doc8711/12-6-
Immigration.pdf]
Other costs including violent crime, theft, MVA
accidents causing a rise in insurance premiums,
are all readily available.
One reason we are so lax on our immigration laws
is because it is used as political leverage.
The US Census Bureau, believe it or not, does
not distinguish between legal and illegal
immigrants. We have a 15.8% uninsured rate, with
10.2 million of those being non-citizens.
Thirty seven percent of that figure contains
households making incomes over $50,000, and it
also includes people who are uncovered for only
weeks or months at any given time in a year.
Estimates are that only 8.9% of Americans need
assistance with medical coverage
[http://www.sciencedirect.com/science?
_ob=ArticleURL&_udi=B6V8K-49PYPTB-
1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&vie
w=c&_acct=C000050221&_version=1&_urlVersion=0&_us
erid=10&md5=0c137dbef66660ffa31a313c8a94ec63]. ]
According to the CDC foreign born citizens have
a nine times higher incidence of TB among other
diseases. Tuberculosis resurgence in the U.S.
has been linked to this immigration pattern.
Illegal immigrants do not get checked for this
disease as is required prior to all green cards
awarded.
[http://www.cdc.gov/ncidod/eid/vol8no7/01-
0482.htm]
Now, what should we do, use these facts to
enforce our laws or ignore the main cause and
throw money at the symptoms?
Jon Purdy, DPM, New Iberia, LA,
jpurdy@mindspring.com
05/25/2009
HEALTHCARE REFORM AND PODIATRISTS
NY Podiatrist Says Healthcare Reform Should Include Illegal Aliens
Healthcare reforms aiming for universal coverage won't provide insurance for illegal immigrants and may not address the cost to state and local governments for providing medical care to this large group of the uninsured, the chairman of the Senate Finance Committee said Thursday. "We're not going to cover undocumented aliens, undocumented workers," Sen. Max Baucus, D-MT, said at a meeting with reporters. "That's too politically explosive."
.jpg) |
Dr. Jamie Torres |
Some immigration advocates have argued health care reform will be incomplete if it does not extend coverage to illegal immigrants. "In light of what's happening right now with the flu pandemic, it's pretty clear that, for any healthcare system to work, it has to cover everyone residing in the United States," said Dr. Jamie Torres, a New York-based podiatrist who is director of Latinos for National Health Insurance.
Source: Jim Landers, The Dallas Morning News [5/22/09]
