Wednesday, December 28, 2011

Stopping the Over Charging in the U.S. Health Care System

How Profit-taking Distorts Health Care Delivery in America
Recently, a Public Broadcasting Station (Channel 9) featured a story on a for-profit hospital group which was using obscure diagnostic codes to achieve higher Medicare payments. The level of unethical and fraudulent activity was so egregious that more than one of their billing coders quit their jobs and testified against their former employer. The Wall Street Journal has also reported on fraudulent Medicare billing, including requisitioning public records from CMS(Medicare) and identifying abusive billing practices by multiple clinicians. For example, the New York City osteopath who billed Medicare 2 million for family medicine, when this was not the nature of her medical practice. WSJ staffers examined the Medicare database and uncovered 25 billing codes for an array of expensive medical tests which were regularly performed by 20 other clinicians in the country. Of that group, 33% have already been convicted of fraud, have undergone professional ethics investigations, or worked in the same firm as the convicted physicians. It is safe to say that this high correlation of billing blips is no accident. Unfortunately, because the American Medical Association prohibits the government from disclosing clinician compensation, even if billing practices are fraudulent, those physicians are not publicly named. Basically, this means a lot of people are still getting away with fraud. This article reviews how profit-taking motives distort the U.S. health care system and does not contribute to health care improvement.

First of all, it is legal to deliver health care services and make a profit in the United States, but it is not legal to defraud the government or private sector insurance companies by making false claims to incur higher reimbursements. In plain language, this is known as stealing and this article will show how the incentives to steal are so high in the current U.S. health care system that despite penalties, including jail sentences, the phenomena continues to rob money from all U.S. health care payers. The payers are the individuals who must obtain health care services at inflated prices to subsidize excessive profiteering and fraudulent activities in many sectors of the national health care milieu.

By focusing on changing the alignment of reimbursements for many health care providers from a volume-based principle to outcome-linked measures we will be able to identify the outliers in the shell game of medical monopoly. Several aspects of the 2010 health care reforms seek to address the abuses of health care reimbursement in the country, including more stringent requirements for health insurance company financial reporting of premium payment utilization. Additionally, there are financial incentives for clinicians who achieve better outcomes for targeted medical conditions under the Shared Savings Rules. And finally, the systemic review of medical supplier over-charging is also included in the reform provisions.

Accountable Care & Incentives for Health Care Outcomes
Accountable Care rules for hospitals and integrated health care organizations include Shared Savings methodology or a bonus if you will, for those medical groups which produce desirable clinical outcomes. This realignment in Medicare & Medicaid reimbursements will ultimately save U.S. taxpayers money for federally funded health care programs. In other words this changes the equation from paying for volume to actually paying for clinical performance, and the best performers will receive more money than those who have poorer clinical quality. For example, if your facility has more hospital re-admissions for a specific procedure than the evidence shows is desirable, that will impact your reimbursement. This is a good thing for the country, although I am sure some health care providers are concerned about the ramifications for their practices. Clinics and hospitals are not required to become designated as Accountable Care Organizations at this time, but the pay-for-performance methodology will ultimately be spread throughout the country as organizations respond to this trend.

Creating Efficiencies System-wide
As previously reported in 2010, the establishment of the Comparative Research Institute seeks to review system-wide data on medical equipment suppliers and clinician practices, in order to optimize value for U.S. taxpayers who fund federal health care programs like Medicare. Though this has been criticized as just another government agency, the purpose is to look across the health care system of disparate providers including; medical equipment suppliers, purveyors of high-tech devices, and clinics to find ways to save money for the entire system. Certainly not everyone will be happy with this process, but one wonders how many of them are in fact the excessive profiteers.

Like it or not, several components of the 2010 landmark health care legislation are here to stay because they profoundly impact Medicare and Medicaid programs, which consumes 32% of the 2011 federal budget. We do need to spend taxpayer money more wisely and part of that process includes scrutinizing all of the components of health care delivery. The government oversight is necessary to curtail cheating and other criminal activities.

A Clinical Case: How America’s Private Health Care System Is Not Producing Best Practice Results for Kidney Dialysis

A basic tenant of a capitalist economic system creates a disproportionate incentive towards money making activities which often fall short of optimal patient care. A good example of this capitalist infusion is the kidney dialysis system in the United States, which sprang up because of the congressional ruling to cover end-stage-renal-disease under the Medicare umbrella in the 1960’s. The entities that seized this “new market” were largely for-profit corporations. For those of you who do not know, kidney dialysis is a mechanical cleansing process which is lifesaving for those whose kidneys have ceased to support their renal systems. International data on dialysis treatment shows that Americans on dialysis do not survive as long as patients in other industrialized countries and also experience more clinical complications. This should come as no surprise when the corresponding American health care incentives are based only on providing the dialysis procedure, not optimizing patient health.
For the profitable dialysis centers, like DaVita, business has been brisk as the American population undergoing dialysis has grown from 11,000 people at inception to over 300,000 people today. Each patient on dialysis brings in about $72,000 just for that procedure, so the industry is worth billions. Examples of how the maximization of profit has impaired clinical processes include the dialysis center protocols which discourage the use of fresh kidney processing devices for each patient and thereby greatly increase the chance of infection. So some MBA figured out they could save their organization money by reusing artificial kidneys on a critically ill population and this has become a standard of practice.
Another example of a U.S. renal failure outcome which differs from other global practices is the limited number of dialysis patients who use the peritoneal process, which can improve the individual’s the quality of life. Clinicians have suggested that American patients are often too ill to be eligible for the home-based peritoneal process. As a society which is paying for this treatment, we need to be asking what we can do to treat these people earlier in their disease progress, so they may become eligible for less taxing treatments(and less expensive). Too often the U.S. health care system steps in literally at the “end-stage-of-treatment” because our system of economic reinforcements only assures payment at that time. This dichotomy is what needs to change.

Evidence-based planning which I have previously written about (and continues to be one of the most popular articles for this readership) is all about reviewing appropriate scientific data to discern the optimal blend of clinical intervention and patient outcomes to benefit a population. This process is what we need to be doing as a nation in order to optimize health care services for the entire population.

Election Implications
Since 2012 is an election year, when you start to hear the rhetoric of “getting the government off our backs” remember that doesn’t mean you will pay less for your health care premiums or services. In our blended system of public and private health care services, we must have an external audit and enforcement arm and the government does this for us all. Like it or not, our government does perform essential services which benefit the average American. The 2012 election mantra should be focused on creating government oversight linked to performance outcomes, not merely less government.

Basic Economics
Anyone who has taken basic economics coursework knows that government intervention occurs when there is a failure-to-perform in the private sector. Certainly, the executives at Premera Blue Cross understand this principle, which also explains that entity’s rush to embraces some changes in their health insurance model. The old insurance company model was a paternalistic one where insurers dictated what they would cover, but the new model requires further explanation and reporting of clinical results, because of government requirements. Reporting results is a good thing for the health care consumer and the edict to explain them in an understandable transparent manner is a victory for health care consumers. This transparency also includes the disclosure of the commissions your insurance agent makes and there is nothing to be ashamed of there, if your agent or broker is working on your behalf and is not over charging (group insurance commissions are negotiated for experience-rated groups). In the truest sense of an open market, price information is available to the consumer who is then empowered to choose an agent or service provider for both the price and the value. Hopefully the disclosure will extend to voluntary health and accident programs as well, as some of the greatest abuses of value occur in that area.

The healthpolicymaven will be speaking at the Northwest Women’s Show March 2nd, 3rd, and 4th on the U.S. Health Care System and How to Optimize Your Health Care Outcomes in the Face of Reforms.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

5 Ways to Happier Life - A year passed, the range of achievements you may have already achieved. However, whether the various success was followed by a reassuring feeling of happiness? If happiness be the one thing that you are still trying to make happen, started the new year, prepare yourself with a number of ways to achieve complete happiness.

Michele Woodward, a career planning specialist and author of I Am Not Superwoman: Further Essays on Happier Living, saying, "You can feel happy to have time to make friends, and connect with people around you, which can enrich, give meaning and valuable experience other. "

Here are five ways that suggested Woordward for your happiness began to run in the new year:

1. Give credit for your accomplishments during the year 2011. Sit down, and grab a pen and paper, then make a list of your top 25 achievements that you managed to accomplish during the year 2011. "Maybe this will surprise yourself because, without realizing it, you have successfully achieved many achievements during this year," said Woodward.

This method is important to do as a form of appreciation on yourself and improve self-confidence. With more respect yourself, you helped to have the mindset that you're capable of doing many other great things, next year.

2. Determine a realistic goal. You will feel the happiness when it succeeded in meeting the target of the goals that had been developed previously. The economist Angus Deaton, PhD, and psychologist Daniel Kahneman, PhD, reveals that the happiest people are those who set realistic goals for themselves. The goal is more likely to be achieved.

In line with this, Woodward said that setting realistic goals this does not mean you give up on your big dreams. However, finding out what you want and to be achieved, then the focus to find ways to achieve it.

3. Find fun activities outside of work. "Do variety of activities that are meaningful and useful as well as fun for you," said Woodward. Various activities such as volunteer activities, starting a personal creative project, or develop your social relationships in various communities.

4. Responsible for the condition of your life. Woordward said that while working, goal to achieve financial comfort is still needed. However, responsibility for ourselves not just measured by the amount of money that you can get. Form of responsibility for yourself also means you can change various things that you do not like, in order to live a more enjoyable.

"If you have a terrible life's journey and weight, then consider turning it into a more convenient way to give meaning in your life. One way or another, looking for a new job or moving to a new place better," added Woodward.

5. Surrounded by people you care about. When surrounded by the people closest to you, such as family, friends, spouse or lover usually you will feel the excitement. This is because it turns out, being around the people you care about bringing positive energy for yourself.

Ready to be happier in the new year?

Wednesday, December 7, 2011

6 Food Support Job Interview - Stress, nervousness, stomach pain, psychosomatic complaints like this are often attack at the crucial moment, including during a job interview. Although already practicing to answer questions, but if the nervous attack, everything on the head can be blank instantly.

Instead of answering questions candidly, you just respond to questions with the words of obscure meaning, or even forget to say anything. When this happens, chances are you stricken from potential candidates.

One way to avoid it, you can eat certain foods that make you feel more calm, focused, and able to think fast. Eat these foods at least one half hour before the interview, so most food is digested and have a positive effect on the brain.

1. Whole grains and green vegetables.
B vitamins, like vitamin B6, B12, and folic acid is proven to help memory, focus resources, and health and ability of the brain as a whole. In fact, folic acid can help produce red blood cells and improve the well-being and mental clarity.

Whole grains like brown rice, a major source of vitamin B. Meanwhile, green vegetables such as spinach, kale, and Swiss chard contain high folic acid and vitamin K, which will also help the brain to focus and fight memory impairment.

According to Beth Reardon, nutrition experts of Duke Integrative Medicine, Durham, South Carolina, three bowls of spinach could supply 40 percent of the magnesium. It is a mineral that can reduce the effects of stress in the body by preventing high blood pressure soaring.As a variation makanana, you can also put the spinach into the omlet or a sandwich.

2. Fat-free protein.
It is better to avoid carbs before a job interview because it can cause drowsiness. A study of two groups, ate breakfast of protein and high carbohydrate breakfast, it was found that two hours after eating, the group that ate a high carbohydrate had tryptophan levels four times higher than the group who ate the protein. Tryptophan is a substance known as a trigger sleepiness.

Meanwhile, protein helps the body produces two chemicals made from tyrosine, norepinephrine and dopamine. This substance will increase mental alertness. Fat-free protein you can get from white meat and eggs.

3. Healthy fats.
The brain requires a supply of healthy essential fatty acids or omega-3 fatty acids in order to function optimally. Fat is a major building block of brain tissue. It will even help you stay focused, protecting brain cell membranes, and reduce disease dementia, Alzheimer's, stroke and other brain diseases later in life.

These fatty acids can only be obtained from food. Therefore, the human body can not produce it naturally. You can get it from fish, walnuts, olive oil, avocados, and flaxseed.

Hemp seed is also the best source alfalinoleat acid, a type of healthy fat that increases the performance of the brain cortex, where the brain processes sensory information. As for fish, especially salmon contain omega-3 can enhance the ability of the brain and reduce senility. The study, published by the Diabetes & Metabolism, shows through cognitive tests, participants who ate salmon during three weeks of anti-stress hormone known to spend a higher level.

4. Orange
Eat an orange for stamina awake during the interview. According to a study conducted by researchers from Carnegie Mellon University in Pittsburgh, healthy people who are stressed can be a pain.

Basically, blood pressure greatly affects the immune system. However, it can be combated with regular consumption of vitamin C that is widely available in orange. Vitamin C will increase the body's immune cells and reduce the risk of viral entry.

5. Chocolates.
During this chocolate is known as a stress reliever food. According to Alan Hirsch, MD, director of the Smell & Taste Treatment and Research Foundation, Chicago, chocolate will increase the level of the neurotransmitter substances into the brain. Increased spending on these substances will trigger hormone maker happy and relaxed, like hormone dopamine.

6. Coffee
As long as your body is no problem with the coffee, you are advised to consume these drinks before facing a job interview. According to the researchers, coffee can increase short-term memory performance and help increase the capacity of attention and problem solving skills.

But, it is better not to overdo when drinking coffee. Too much coffee not only will make you urinate frequently, but also will make you jittery and nervous. As a result, you can look unprepared in front of the interviewer.

Sunday, December 4, 2011

Why Diabetes Prevention and Management and the U.S. Health Care System Are At Odds

Diabetes Current-State and Changes to Come

Unless you are Cro-Magnon-man and just emerged from a glacial field you are probably aware of some of the 2010 health care reforms. This article reviews how the United States got to be in such poor shape, health-wise and how some provisions of the 2010 reforms will create incremental changes.
Since I am nearly finished with my second book, the Russell Guide for Diabetes: Type I or Type II This Could Happen To You, let me share some mind boggling information about this scourge. The American statistics on this disease have a huge impact on government funded health plans, including Medicare and these metrics from the CDC explain why :
• The proportion of diagnosed diabetics in the United States has increased by more than 50% since 2007; 17.7 million in 2007 and 25.5 million in 2010
• Fully one third of the U.S. population is expected to be diabetic by 2025; 115 million
• In 2010 18.7% of the 25,564,000 U.S. residents diagnosed as diabetic were African Americans and 10.2% of that number were non Hispanic ( White)
• More than 90% of all diabetics are Type II, which is controllable by diet and exercise
• The CDC estimates that 33% of the country is in pre-diabetic mode in 2011

Type II Diabetes is caused from obesity and a diet high in simple sugars and carbohydrates (think fast food, doughnuts, etc,) Being over-weight significantly increases your chances of becoming diabetic. I think it is time we Americans call a-spade-a-spade, so if one of these criteria fit you are fat:
1. 20 lbs. over weight-Yes, you are fat
2. 50 lbs. overweight-This qualifies you as obese
3. 100 or more lbs. overweight-Then you are exogenously obese
4. Body Mass Index or BMI exceeds 30 you are fat
5. If you have to replace the shocks on the driver’s side of your car more frequently than the passenger side, this is a clue that your girth has impacted vehicular performance.
6. If you have broken chairs in your house or someone else’s by sitting in them, yes my friend you are fat.
7. If you need to buy your clothes at Tacoma Tent and Awning, need I say more?
It is time we as Americans put down the doughnuts and look in the mirror. The country needs to go on a 12-Step Program for Over Eaters Anonymous. No more excuses, just bust a hump and get out there. Like everyone else I have had to battle-the-bulge as I’ve aged, but so far I do not qualify in any of the categories above.

Food is fuel and it really does matter what you consume. If you are going to persist in a diet that is high in simple sugars, lacking in fiber, and complex carbohydrates, it is similar to starving your body of essential food, so it craves more food. Diets which are high in “the whites” meaning white rice, white pasta, white bread, and sugar cause spiking in glycogen which is what the body creates when it breaks down food. Foods that convert to simple sugars cause the glycogen rush and over time damage the pancreas which ultimately ceases to work properly. At that point, listlessness, fatigue, and a sudden weight loss may be symptoms of diabetes. The United States has at least 5 million more people who are undiagnosed diabetics. The later diabetes is diagnosed the worse the damage is to the body systems. Here are some tips on wise food choices:
1. The large pizza is not intended for one person
2. 32 ounces of a soda-you may as well drink three beers calorically speaking; put down that big gulp unless you want the catheter that goes with it when you are on kidney dialysis later

What Happens If America Doesn’t Slim Down
Diabetes was the 7th leading cause of death in the United States as reported by the CDC for 2006 and it is advancing all of the time. And death from diabetes is not a quick process, but a torturous route of injections, circulatory problems (including amputations), hyper tension, and kidney failure. In the United States, 40% of diabetics end up on kidney dialysis. These metrics contrast sharply with other industrialized countries that have much lower renal failure rates, such as Austria at 30% or 34% in Germany. Life expectancy for someone on kidney dialysis in the United States is only a few years.

The link between heart failure and kidney dialysis is pronounced and a 2011 study showed that 36.1% of dialysis patient had high blood pressure, 38.2% had a history of heart infection, and 25% had excessive weight gain between dialysis sessions. All of these symptoms are exacerbated by the dialysis treatment process in the United States, which pushes patients to conform to business practice hours and not optimal clinical outcomes.

What are the Costs
The U.S. Medicare program has financed the cost for kidney dialysis for all persons who have Social Security numbers and are legal residents since 1973. President Nixon signed the legislation and at that time renal dialysis cost $12,273 per patient and 11,000 people needed it in the country. Fast forward to current time and dialysis now costs $77,000 per patient and there are over 350,000 people on it. The vast majority of people on dialysis are diabetic, with age being correlated with an increased incidence of renal failure. In 2010, Medicare spent 20 billion dollars on the renal dialysis program.

What Can Be Done
The vast majority of renal dialysis centers in the United States are operated by for-profit companies, like DaVita, fueled by Medicare’s reimbursement policy which rewards the process not clinical outcomes for dialysis centers. This may all be changing with President Obama’s endorsement of the Comparative Effectiveness Research Institute in 2010. This institute will look at clinical processes and outcomes across systems and compare them to global data to find ways for improvements. For example, the mortality or death rate for patients on kidney dialysis is much worse in the U.S.A. than in other industrialized countries, so this needs to be reviewed. And of course, a much greater percentage of American diabetics end up on dialysis than in other countries.

Another aspect of the 2010 Health care reforms was to require insurance companies to offer wellness or preventive care benefits. In my former career in the insurance business there was always a lot of teeth gnashing over offering preventive benefits because the industry promoted the idea the employees should pay for this service themselves. The industry also discouraged low co-payments or cost sharing as a means to lower the insurance premiums for the employer group. The problem with this mentality is it is inherently short term and the health of a person is a long term process. This is just one example of how the insurance industry has been at odds with promoting health for our country. Though it should be obvious, let me state that by mandating a base level national health surveillance system, such as an annual physical, offered gratis, we can find the people that are hypertensive or pre-diabetic and prevent more serious health damage. By reaching out and treating people earlier we will save money in government funded health programs. In order to accomplish this goal as a nation the country needs to continue to look at aligning provider incentives and reimbursements to promote national health not just a medical service. The goal of the country should be to work towards optimizing the health of its citizens not just treating their illnesses and injuries . If private sector insurance is to be a part of that equation, disease prevention services that are measureable and effective need to be included. Perhaps another model could include national clinics where physicals are administered by public health officials, which would provide privacy for the employee who may not wish to share his personal health metrics with the employer. Despite all of the HIPAA privacy hype, I can assure you there are a myriad of ways for an employer to discover employee health data, especially for a group which is self-insured.

On that note the healthpolicymaven is going to sign off and log my eight miles, which I have averaged per day this year. I recommend that you also slam down that pizza and put on your shoes.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.