Sunday, August 5, 2012


Am I a heartless baboon? Some might think so. But then so are we all. We share 99.6% of the genetic structure, so yes we are kissing cousins on the evolutionary tree. But that is not what provokes me to write this post. What I have to say might cause some irritation and position changing discomfort to some and I am sure the invectives will follow. I am sure there will be an incantation of the Bonobo species, but I digress.

The disassembly of the former edifice of healthcare is underway. The passion and logic rings loud. Thoughts and words abound to please the emotions of the heart and smoothen the wrinkles of the soul.

What gives?

Why the tempest?

Maybe there are mitigating circumstances that rattle the bottled-up fears and emotions. But what of this new Law? Let us look at it with open eyes for a change. After all the Supreme Court of the United States of America voted 5:4 in favor.

What are all the things I love about the Healthcare called Affordable Care Act?

1)    It invokes the premise that everyone will get insured even with pre-existing conditions and be granted medical care. And we will all live happily ever after. A laudable intent!

So what is it about the ACA that raises concern?

1)    Stating that it covers the 43 million people who did not have insurance or did not choose to have it before. It raises the premiums of the remaining 270 million people in the USA who had it before. Mine went up 44% last year and I had to increase my deductible to maintain the same policy premium. (Anecdotal, but true)

2)    Forcing a tax on people who cannot afford it or who do not want the healthcare insurance. The semantics of Penalty or Tax do not matter since both take money out of the pocket of an individual. Hiring 15,000 IRS agents to play guardsmen to oversee those that refuse to have health insurance is a burgeoning travesty on an individual's right. Although that money would be better spent on healthcare itself don’t you think?

3)    The ACA increases the volume of patients to an already burdened system. With less doctors (a projected deficiency of 125,000 in a few years) whilst adding millions to the roll, the writing of a Greek Tragedy is underway. The solution probed is to allow Nurse Practitioners and Physician Assistants to assume the role of the doctor while the doctor takes the back seat and the legal responsibility. Not too many doctors will be happy about that either, I think. The terminology of “Healthcare Providers” levels the playing field, doesn’t it? Doctors, Nurses you are in the same category as the transporters and house-keepers. If you ask the question why? No! you may not! Words, you see, have powerful connotation. Call someone "Hey you," demeans whoever the "you"is.

4)    A few will decide the fate of the many. The IPAB will ration the care based on expense and age and not on need. The stalwarts point to the NICE in the United Kingdom as the model to model after. Really? The Pluribus comes before the Unum. Although I do agree that sometime we spend an enormous amount of resource in a futile cause and a more judicious path might be to educate the patient and let them make the decision, rather than mandate. But that is too common sensical.  Advocating a single mantra for the many will not bring comfort to the one and for that matter to the many in the long run.

5)    Taking $575 Billion out of an already cash-strapped Medicare system that is currently unsustainable, as an unfunded liability and based on the targeted costs of the entire care running up $2.6 Trillion, projected to engulf over 20% of the GDP is akin to a titanic struck by the iceberg and the Captain says, "Everything is okay folks, this is an unsinkable ship." That in a $15.7 Trillion economy is a mammoth burden. Might I add just for the bean counters that the current debt is running at $15.933 Trillion or 103% of GDP while accruing billions each hour. Oh, the future horror of it all!

6)    Establishing 13,000 pages of regulations from a 2,500 ACA Law, that gives legal eagles powers in the legal system to rip and shred the patient-physician relationship further as they please (as if it is not already tattered and lies bleeding). The current system is already forcing the doctors out of business given the regulatory environment. The present mandate and its future unintended consequences seem inexorably marching the doctors to the disenfranchised, disillusioned and some to the unemployment line. Of course it would make some very happy at the thought, but I digress again.

7)    Completely ignoring the desires and wishes of the physicians in the enactment of the Law, is a one-sided affair in the extreme. The AMA as an arbiter does not count since this was in the organization's bag with the earnings from the ICD coding business for several millions a year contracted with the government. As a matter of fact neither the AARP which stands to gain a $1 Billion or more from the Law over the next five years is a real advocate. By invoking insurance for all and receiving large wads of money from the premium payors and the government, their motives are unwashed at best. Neither entity in this case benefit others but themselves. Ultimately the beneficiaries are the Group Insurers who have and will collaborate to bring the masses in their fold with impunity and do the devils work of premium surcharge. Even the hospitals stand to make money for their corporate heads by slicing and dicing the running-scared physicians, (Hospitalists: who will account for 75% of all newly minted and old practitioners in this field of science, within two years) who ultimately are going to suffer the grave consequences. The simple equation is: The CMS controls payment to the hospitals and the hospitals ratchet down reimbursements to the doctors and they in turn acquiesce to the "deemed unnecessary care" in the patient management by eagerly discharging or not admitting or denying expensive care. The doctors and the patients will be the pawns in this game of chess, sponsored by the “movers and shakers.” “Queen to Pawn: Checkmate!”

8)   In all this the one main concern of Medical Malpractice Reform is never mentioned. I wonder why? I guess it is easy to understand that the lawmakers are the lawmakers and they are the  ones that reap the benefit from frivolous litigation.

9)    The very poor people on Medicaid who will now not be covered by the States since the SCOTUS deemed that the Federal Government cannot impose penalties upon the states for non-compliance are the ones this ACA was aimed at. But that is another story. From their perspective it all becomes "Much ado about nothing!"

10)    The Hospitalist physician being an employee, having no skin in the game will treat it just as others in the public sector do, look at the clock unwind. This will create a two-tiered system just like the one that exists in the UK, Europe and Canada. Oh how we have eyed, lusted over and loved their system of healthcare. We are there now and we have arrived. But hold on! now where will the rich and famous go? Cuba? India? or some Fashionable Boutique Institute of heated stones and coffee enemas?

11)  In the end it comes to this: a) The poor will suffer. b) Middle class and the wealthy will have higher premiums or face a fine/tax/penalty and they will suffer. c) The corporations with medium sized individual covered entities will take the penalty/tax of $2000 for each individual rather than make payments of $10,000 average per person coverage and shift some of that in compensation. That will reduce expense for the corporations and businesses and "raise" the salary component for each individual as an inducement. d) Overall care will deteriorate but the talking heads will talk it up gathering slices of data to shore their arguments. e) Innovation will suffer as mandated prices of equipment and drugs is lowered and regulatory stimuli peck and tatter the remains of a once golden age of Medicine. And as Prince Escalus exclaimed his bitterness over the battles between the Capulets and the Montagues and the loss of Romeo and Juliet, with this warning, "All are punished."

12)  Eventually charity care will rise for those that cannot afford and fee for service for those who can. The cycle will renew itself. The Ouboros dragon will have chewed on its tail.

Be careful of what you wish for, it just might come true. And there may be no turning back.But then maybe calmer minds will prevail.

But I digress...

1 comment:

  1. So where do we go from here? The only thing larger than our unfunded liabilities is our nation's waistline. Medical costs are soaring, millions of baby boomers are headed into retirement every year, and we don't have the growth or demographics to keep the Titanic afloat...