Why We Don't Want To Get Rid of Medicare-Our Best Tool for Health Care Reform

Why We Don’t Want To Get Rid of Medicare-Our Best Tool for Health Care Reform

The pressure is on for federal budget slashing and of course social programs (not defense) are top-of-the-list for cost reductions, including the malignant call for block granting the Medicare program. Having previously analyzed the Bush Administration’s Deficit Reduction Act of 2005, including the odious federal government, “claw back provision” for reducing federal contributions for state Medicaid programs, this article reviews some potential impacts of a block grant or per capita allowance for Medicare participants. Parallels are drawn between the Medicaid changes and what may happen to Medicare if it is schlepped to the states. Finally, Medicare’s impact on overall health care policy making in the United States is analyzed.

Would Block Granting Medicare Look like the Medicaid 1115 Waiver Plans?

As of 2005, half the states already had approved Medicaid 1115 plans including: Alabama, Arizona, Arkansas, California, Colorado, The District of Columbia, Florida, Georgia, Idaho, Illinois, Maine, Massachusetts, Michigan, Missouri, New Jersey, New Mexico, New York, Oregon, Puerto Rico, South Carolina, Tennessee, Texas, Utah, and Washington. Oregon is famous for its health care plan which assesses a clinical and cost/benefit value for treatments covered by its subsidized public health care program. Most of the other states with Medicare 1115 Plans have eliminated benefits under the programs or drastically cut enrollment for poor residents. By example, Missouri eliminated 500,000 people from its Medicaid program. Many of the states with Section 1115 waivers used the provision to charge co-payments and premiums to certain Medicaid eligible constituents.

Impact on Drug Costs-Zip

In addition to cutting back on benefits, one of the trends for state implementation of Medicaid 1115 Waiver Programs is to pass more of the prescription drug costs to their plan participants. This does nothing to contain costs and merely makes low-income people pay more for their medicines. Medicare is also doing this with its drug program, by allowing pharmaceutical companies to charge retail market prices (the highest-in-the-world) for drugs while offering “discounts” to Medicare participants. It doesn’t take a rocket scientist to figure out that the pharmaceutical companies just raise their prices to include the “discounts” to the Medicare set.

Side effects of Medicaid 1115 Waiver Programs

Deferring Health Care

One of the provisions that Medicaid 1115 Opt-Out Plans can make, is to transfer more plan costs to the poor who are enrolled on these plans, however, that may mean people avoid medical care. This is a conundrum, though Medicaid enrollees have health insurance, they may not have enough money to contribute to the co-payment requirement. The Journal of Health Affairs published an analysis of the Utah State Medicaid program which showed that cost sharing up to 10% did have a negative impact on the indigent patient’s ability to obtain health care (AKA they deferred treatment).[1]. 

Clinician Access

Patients enrolled on Medicaid plans have insurance, but may not have a primary care clinician who will see them. Merely having insurance does not mean there are clinicians willing to accept those patients.  Medicaid has notoriously been viewed as paying poorly for medical services, although some states have taken steps to alleviate that road block to care. This problem of access to clinical care, especially for wellness or primary care is also rampant for Medicare participants. If they don’t have private insurance, it is very difficult for a Medicare patient to find a clinician who will accept them into their patient mix. This phenomenon is reflective of the poor reimbursement CMS provides for its primary care clinicians.

Another one of the methods that states have used 1115-Waiver provisions to change their Medicaid plans is to offer private insurance coverage, but this is hardly more cost effective, since the administration costs are three times as high as what the Centers for Medicare and Medicaid (CMS) charge, with no cost containment. This could however increase access to doctors who are willing to treat Medicaid patients.

Medicare as the Policymaker for Health Care Treatment and Payment

CMS, which administers health care for Medicare and Medicaid, is by far the largest health care program in the United States. Administrative cost for CMS run about 6%, as opposed to 18% for the private insurance sector. In addition to administering health care programs for the elderly and the poor, two constituents whom the private insurance sector has historically had little interest in insuring, CMS also finances demonstration projects with clinics throughout the country to figure out how to improve health care. An example of such a project is the Advanced Primary Care Demonstration Initiative[2], which is looking at patient-clinician engagement to improve health outcomes and pay clinicians for coordinating well patient care. There are also similar projects for the Accountable Care mandates, which reward clinics that produce better clinical results than those who are more marginal. These efforts are possible with a large enough patient population and an integrated patient tracking system, which coincidentally, is representative of a national health care program.

Fraud Detection-The Government Has the Bigger Stick

Medicare is the number one detector of fraudulent billing for health services in the country and it is essential that this bully pulpit be preserved. In The Battle Over Health Care[3], big pharmacy is now cited as the number one defrauder of the government and hence the United States people, even ahead of the perennial defense industry. Do any of us really trust the drug companies to police themselves, or for that matter any of the medical suppliers? In a fragmented Medicare system fraud detection would be more difficult not less.

Patient Safety-Do You Want to Leave it up to the Private Sector?

 In Rosemary Gibson’s and Janardan Prasad Singh’s brilliant, The Battle Over Health Care, numerous frightening examples abound of drug company, medical device supplier, and hospitals actually harming patients. Perhaps most egregious are the methods some of these companies (most of the abusers are for-profits) use to avoid accountability when they harm patients. A bright spot on this tarnished map is the University of Michigan Health Systems, which has a protocol mandating that its clinicians/facilities which harm patients; take responsibility, offer transparent information on what occurred, offer a settlement to the patient/family(without litigation), apologize, and provider free ongoing health care.[4]It is this type of candor which would go a long way toward improving patient safety in American health care. Imagine clinicians and hospital administrators who fess up rather than lawyer-up.

Conclusion

Though Medicare certainly has its detractors and is not lithe when it comes to adopting changes, it is more economical than any private sector health insurance program, and it covers  high-risk populations like the elderly and those with end-stage renal disease. Medicare drives policy changes throughout the entire United States health care system by determining how it will pay for services. This is ultimately the way the country can start to reduce its health care costs, by negotiating with drug companies, eliminating fraud, and equally important, unnecessary procedures. Because Medicare changes also impact private sector insurance companies, it is an essential component of health reforms and well as other national health care initiatives. CMS, which administers both Medicare and Medicaid, provides the nationwide health care partnership to test and deploy health care program changes. Through this surveillance process we can learn what works for the disparate U.S. health care system and attempt to lower costs and improve not only primary health care, but also preventive care. Too much of the U.S. health care dollar is spent on late-stage disease treatment versus patient health maintenance. If we hope to be competitive in a world economy, we must bring the per capita cost of our health care in line with the rest of the world and turning it over to the private sector foxes is not the answer.

For more discussion on this health care article, feel free to comment below. This article was written by Roberta E. Winter, the healthpolicymaven, and may be reprinted with her permission. Feel free however to share it voraciously with your friends and family.

Also, for those who want to read more of The Battle Over Health Care go to the New York Journal of Books for my review, by following this link: http://www.nyjournalofbooks.com/review/battle-over-health-care-what-obama%E2%80%99s-reform-means-america%E2%80%99s-future

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[1] http://content.healthaffairs.org/content/25/2/532.full

Samantha Artiga, David Rosseau, Barbara Lyons, Stephen Smith, and Daniel Gaylin, Can States Stretch the Medicaid Dollar Without Passing the Buck? Lessons from Utah, Health Aff., March 26, 2006, vol. 25, no. 2. p. 532-540

[2] http://healthreform.gov/newsroom/factsheet/medicalhomes.html

[3]Rosemary Gibson and Janardan Prasad Singh, The Battle Over Health Care, chapter 2, page 24

[4]Rosemary Gibson and Janardan Prasad Singh, The Battle Over Health Care, chapter 13, page 163

3 Big Mistakes Affiliate Marketer And How To Prevent

3 Big Mistakes Affiliate Marketer and How to Prevent


Affiliate Marketing is one effective and powerful way to monetize online from the Internet. But just like a business, there are many pitfalls that can make us lose the run Affiliate Marketing Business.


Therefore, in this occasion I would like to share with friends all about : 3 Big Mistakes Affiliate Marketer and How to prevent it. Errors that may often occur done, it would be very detrimental to us if not immediately detected and avoided.

Here are three fundamental errors that we need to know and be avoided :

1. Choosing One Affiliate Program

Not a few people who want to earn money in a way that instantly and quickly as possible. With this attitude in a hurry, the Starter immediately joined the business being "HOT", aka the rapidly growing business, or Business is Booming, or also commonly called the Business bandwagon.

I did not say do not join the business being sold, but I'm trying to explain here is Join the business that really match your interest. That's it.

For every business that we do, of course, we need to take the time to make a plan and determine what we need to do. In this case, to promote more products you like and you are interested, it will be much easier and enjoyable than promoting products that only with the motivation of money alone.


2. Too Much Registration in Multiple Programs

Right, because it is a way to earn revenue through multiple channels. But remember, it also will reduce our concentration in every program that we follow. As a result, the maximum revenue potential that we want the possibility of failure we get. The money we get does not match what we expect. And it was inevitable.

The best way is : Participate In One or Two Courses just terlegih first. Then give your best effort to promote the product. Well, once you reach the profit according to the target and maintain it, you will be able to go even further by joining other programs.


3. No or Not to Buy Products and Use

Learn and use the product first before you join as an Affiliate Marketer. Why is that ? Because it is imperative that you can measure whether the product is profitable or not. After that, then you explain the advantages and shortcomings of these products objectively and not with a hoax. Be honest in business, buddy !

Well, the way that this would be a pretty big impact, because potential customers will see and feel your sincerity and honesty. And finally, they may be interested and try the products you offer.


Netter's, third mistake on this, whether consciously or not, in fact already been done by the Affiliate Marketer. Do not fall and get stuck into the same situation. Try to do everything in a positive way so that you avoid these three mistakes.


The key is TIME....

For that, take your time to analyze a variety of your marketing strategy. And continue to evaluate whether you are on the right track or not. If you've done right, of course you will be able to maximize your affiliate marketing program to earn the maximum as well.


OK buddy,
Hopefully there are benefits

source ; celoteh online

State by State Analysis of Health Insurance Exchange Adoption

State By State Analysis of Public Health Service Act Requirements for Employers in the United States

The Public Health Service Act of 2010 requires most employers in the United States to provide group medical insurance for their employees. Employers who choose not to comply with this law will be fined, as authorized in Section 490-H of the Internal Revenue Code. Employers with fifty or more employees are required to offer health insurance to their employees who work, on average, thirty or more hours a week. And the insurance plan must meet certain affordability standards, the employer must pay part of the cost and the plan has to meet certain eligibility requirements for enrollment equity. The global purpose of this act is to increase the proportion of people who have access to health care in the United States.  Evidence of the ability to pay for medical treatment through insurance thus contributes to this goal. The data source for the fifty-state-analysis, came from the National Conference of State Legislatures web site.[1] Also my book, Unraveling U.S. Health Care includes 50-state surveys for health care legislation as well.

Health Insurance Exchanges

Small employers are slated to enroll in regional insurance exchanges by 2014. Large employers may elect to enroll in the exchanges by 2017. The latter is the most intriguing, because initially it is thought that large employers will not choose the insurance exchanges. However, based on my experience as a former insurance broker here are some reasons why employers may ultimately choose insurance exchanges.

1.      1. The insurance exchanges will have federal compliance components built into the design and employers will not have to worry about being fined if they go through that process.

2.      2.  Employers can finance and have their employees enroll in insurance exchange health plans and avoid group health insurance administration hassles by having their employees make individual elections.

3.    3.    The insurance industry will see a shrinking of health care providers over time, especially in some states, so the insurance exchanges will become markets of choice.

4.      4.  Insurance exchanges are slated to include strict criteria for administrative transparency and target levels for allocation of insurance premium contributions to actually pay health care claims(AKA consumers like this)

5.      5.  Applying the law of large numbers, a large association of employers can expect some purchasing power and stability. In any case this is what the insurance industry has been saying for decades.

6.     6.   The insurance exchanges are designed not to discriminate and once again, consumers like that.

States Which Have Authorized Health Insurance Exchanges

Despite the tumultuous cries of calamity about the insurance exchanges, nearly half of the states have already adopted laws to implement them including: Alabama, Arkansas, California, Colorado, Connecticut, District of Columbia, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Nevada, Oregon, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

States Which Have Pending Legislation to Authorize Health Insurance Exchanges

Alaska is working to establish its own insurance exchange. The Georgia governor signed an executive order to authorize a Health Insurance Exchange. Mississippi has a state high risk pool for insurance and it is authorized to serve as a Health Insurance Exchange provider. North Dakota plans to create its own Health Insurance Exchange by 2013, otherwise the federal government will implement one. The Rhode Island governor signed an executive order to create a Health Insurance Exchange on September 19, 2011. The Texas Office of Insurance and the Office of Health & Human Services have partnered together to create its own Health Insurance Exchange. Vermont is working on creating its own state-wide single payer health plan. There are other states with pending legislation, but they were not cited because programs were not yet specified.

States Which Have Outlawed Health Insurance Exchanges

New Hampshire SB 148 became law on July 14, 2011 and it prohibits Health Insurance Exchanges.

It is important to note that a failure to authorize an insurance exchange is not the same as a ban and no other state had banned the exchange as of the end of 2011. Further, nearly all states have accepted money to implement the exchanges, some as much as fifty million dollars, so unless they are planning on giving the money back, they will also be creating their own exchanges.

Exceptions to the Rule

First of all, any employer who wishes to self insurance under the ERISA rules can exempt itself from all of these 2010 insurance plan design requirements. What this basically means is contracting with a third party administrator to pay claims and buying reinsurance through a broker.

Secondarily, the law seeks to provide financial subsidies for small employers who heretofore have had difficulty affording health insurance. This will mean more customers for the profitable insurance industry, which will now benefit by federal government subsidies for customers who are mandated to buy their product.

Thirdly, and perhaps most lucratively, employers who are enrolled or will enroll in “Professional Association Plans” or multiple employer trusts will be able to meet the requirements of the law.  These large employer plans are underwritten and managed by insurance brokerage firms. This is how the large brokerage firms deal with the small business sector; they fit them into their multiple employer association plans.

Though many insurance agents have been whining about the Public Health Services Act, the mandate for this act was promulgated by the insurance industry as a means to avoid obsolescence. Though the national insurance requirement will prove very lucrative for the industry, this does not necessarily mean it will benefit American health care purchasers to the same degree.

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

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[1] http://www.ncsl.org/issues-research/health/state-actions-to-implement-the-health-benefit-exch.aspx

How Medical Insurance Impacts Access to Health Care in the United States

Without Insurance Access to Health Care is Limited in the United States
Why the Insurance Model Was Chosen for Increasing Health Care Access
One of the things I learned while a student at the School of Public Health and Community Medicine was that people who lacked health insurance also lacked reliable health care. Let us review some of the national data in this regard. In my fifty-state analysis I reviewed the following components for individual health care measures: evidence of employer based health insurance, the state uninsured population, infant mortality and other clinical outcomes. Listed below are the top performers for the criteria, as well as the laggards.

States with the Highest Levels of Health Insurance, Public or Private
Using the latest Kaiser Family Foundation Insurance Survey , the 2010 results show the number one state for health insurance coverage is Massachusetts, with 95% reporting health insurance plans. Massachusetts has been the model for the national insurance exchanges because its state mandate has achieved near universal coverage and is self supporting. Other states deserving honorable mention for securing health insurance for 90% of their residents include: Hawaii, Vermont, and Wisconsin.

States with the Lowest Levels of Health Insurance, Public or Private
Women ages 19-64
In the same survey, the worst state for provision of medical insurance either public or private was Texas, with only 70% of its women reporting medical insurance coverage. The national average for insured women was 80% at the time of the survey. Florida reported that 74% of its adult women had medical coverage. A host of states reported only 75% of their adult female populations had medical insurance including: Arkansas, Mississippi, Nevada, and New Mexico.
Men ages 19-64
The national average for men with medical insurance was 76% by 2010. For Texas men only 65% had medical insurance. Other low fliers for men with medical insurance were: Georgia (71%), New Mexico (67%), and Florida (69%).
Children <18
Across the nation only 50% of our children had health insurance provided through their parent’s place of work. Though 90% of the nation’s children have medical insurance now, 36% of that figure is provided by public programs like Medicaid. For the children’s health survey, Texas also posted an equally poor level of insured children, the lowest in the nation, with 17% of the state’s children lacking medical insurance. This is despite the federally subsidized Children’s Health Insurance Program, so is Texas failing to enroll its children or are their parents making too much money to qualify?
Other states with high levels of an uninsured children included Florida (16%), Nevada (16%), and Arizona (15%). You would think Nevada could come up with something creative like a gambling tax to subsidize health insurance for its residents. Why do some of these states have so many more children without health insurance?
Cost of Deferred Health Care
Since the United States has chosen to finance its health care through a public and private system, the lack of payment for services for the uninsured gets allocated to hospitals and insurance plans. The federal insurance mandate is an attempt to stave the high costs for hospitals and communities from serving the uninsured population. Those states with higher levels of uninsured individuals mean that more health care is either delayed or delivered in emergency settings. Additionally, uninsured patients are not receiving preventive or basic health care. States that are laissez faire place a disproportionate burden on their hospitals to serve uninsured patients and this impacts the overall health care safety net.
Clinical Outcomes
If evidence of insurance is a factor in securing better health care, let’s see what the clinical data shows for these states. Infant mortality is an indication of prenatal and postnatal care and here are the infant deaths per 1,000 babies for the states with high levels of insurance, versus the low levels. These infant mortality rates are drawn from the 2009 Kaiser Foundation Survey. Infant mortality is just one measure of childhood health, but in adherence to brevity I am not going to list the other metrics I used in my full scorecard evaluation.
Infant Mortality
Best in class for both percentage of the population covered for insurance (95%) and the lowest infant mortality rate in the nation at 4.9 deaths is Massachusetts. Way to go mother Mass! This makes their prenatal and postnatal care equal to most of Europe, which is a high standard. And here is how the other well-insured states ranked for infant mortality per 1,000 babies: Hawaii-6.1 deaths, Vermont-5.6, and Wisconsin-6.3. Now let us compare this metric to the states which reported the lowest levels of children with health insurance and here are the infant deaths per 1,000: Texas-6.3, Florida- 7.2, Nevada-6.2, and Arizona-6.6. When you compare the average infant mortality of the states with higher insurance levels to those without, there is a difference of nearly one life per 1,000 babies, which is significant. Also, in case you don’t know, the United States infant mortality rate on average is 47th in the world, behind all of Europe and most of the developed world. And if you don’t already feel bad enough, some countries, including Singapore boast an infant mortality rate which is one third of the U.S. average at 2.31 deaths per 1,000 babies.

As we listen to the harping about Americans not having a right to basic health care, bear in mind that the United States has the highest percentage of children living in poverty in the industrialized world, at nearly one fourth (24%) of our child population. You have to ask yourself, what do our nation’s children have a right to in this wealthy country?

For more information on 50-state performance metrics come to the Northwest Women’s Show on March 2nd to hear excerpts from my book, Unraveling U.S. Health Care.

This article was written by Robert E. Winter, MHA, MPA and may be reprinted with her permission, but feel free to share it virally.

Congressional Wrangling Over Proposed Insurance Exchanges Takes A Nasty Turn

Wrangling Over Proposed Insurance Exchanges and Standard Health Care Benefits Takes a Nasty Turn

Barely recovering from the last congressional gaffe about redefining the rape of a woman in a transparent attempt to get out from under the federal Hyde Amendment criteria for Medicaid payments, the “powers-that-be” have made another mind blowing error in public engagement. In a nutshell and yes, I do mean all of these puns, here is the latest blunder by the Republicans controlling the house.

In a public hearing for testimony on the federal health insurance exchanges and standardized benefits for primary health care, which includes birth control options as benign as birth control pills, no women were allowed to testify at the hearing. It certainly is curious that those who are actually capable of pregnancy are excluded from the hearing. This refusal was despite vigorous opposition by female congresswomen. I actually listened to the hearing in order to believe it. And the woman they refused to allow to testify about the insurance exchange’s proposed standardized women’s health care was a college student. Yah, that is just what we want to discourage in this country, a woman with an education using prudence in reproductive matters.

And if that isn’t enough to befuddle a rational thinker, the reason the committee chairman gave for denying any woman the right to speak was because the meeting was about voting and safe guarding conscience in decision making. Interesting, I wasn’t aware that women lacked conscience, especially when you look at the violent crime statistics. But then again I guess these boys have turned their eyes away from those statistics. One wonders if they also were party to the move to redefine rape of an unconscious woman as a noncriminal event. If this is a matter of conscience, one wonders about theirs.

We are constantly assailed with Republican blather about fighting against big government, yet they seek to prevent birth control services from being covered on private insurance plans. As I have previously reported, several states already have enacted laws which prevent even private insurance plans from covering birth control services. Here are the members of this hall of shame: Kentucky, Missouri, Oklahoma, Idaho, and North Dakota. According to a 2003 Kaiser Foundation survey on contraceptive care, 87% of private employers provided coverage for birth control services, including abortion. So despite the anti-big-government talks, this smacks of big brother to me, or is it daddy?

For more straight talk on health care attend the Northwest Women’s Show on March 2nd, as the healthpolicymaven™ will present findings from her book, Unraveling U.S. Healthcare with my conscience intact.

Prediction Personal Investments 2012

KOMPAS.com - Many people hope offered by Indonesia in 2012. One is the improvement of Indonesia's economy in the next year. "In a meeting with Commission XI some time ago, the government gave a positive signal about economic growth in Indonesia due to an increased demand for domestic products," said an expert financial planner Aidil Akbar Madjid, MBA in outlook 2012 AFC exposure Financial Check Up.

Although Indonesia's economy is predicted to slowly strengthen, but it seems in terms of personal investment you need to remain cautious. Akbar following the advice given to private investment in 2012:

1. Investment in property. If banks continue its commitment to lower interest rates including the interest rate mortgage loan, it can be said that the investment property has a great opportunity and good in 2012. In fact, this property is estimated that the business will go up even higher. "But be careful with the price is high enough," he wrote. In big cities like Jakarta, apartments at a price below USD 800 million, Flats Property or Rusunami (subsidized apartments) can be used as an alternative to long-term investments are profitable.

2. Investment precious metals is not very profitable. If the conditions of the Middle East heats up, then world oil prices will rise in line with rising world gold prices. But this will not be too influential on the price of precious metals because of the exchange rate of dollar to rupiah weakened. If this condition is reversed course in which the dollar strengthened and the crisis in the Middle East and re-heated, then this precious metal investment will be excellent. Precious metals can be selected, among others, in the form of jewelry such as necklaces, bracelets, earrings or gold bullion.

3. Equity investments. If you are interested to invest in a variety of things a bit challenging, it would not hurt to invest in stocks. If the investment grade increased, the flow of foreign funds will go even more and one of them entered the stock exchange. This will push the stock exchange to crawl up and through high level as in early 2011 and then, obviously Akbar.

With a controlled inflation and low interest rates, bonds will be much coveted by financial institutions and companies. SUN, ORI, Retail Sukuk Sukuk and can also be considered for an investment option other than Fixed Income Mutual Funds. "Stocks still gives a pretty good potential in 2012," he explained.

4. Investment securities. With the limitation of the number of credit cards and loans, banks have access to funds that have not been channeled. If funds can not be used for consumer loans, mortgages, and credit vehicles can be diverted to the possibility of such securities Debt securities and Setifikat State Bank Indonesia (SBI).

5. Short-term investments. For short-term investments should still use banking products and precious metals. Its primary focus is to raise funds and hold before the Composite Stock Price Index (CSPI) moved up. After JCI rising, you should invest in the stock market.

Note Akbar others are wary about investing in some type of insurance or unit-linked investments that will mature in 2012 (10 years from its launch in 2002). "If it turns out unsatisfactory investment returns, after deductions and other expenses, can lead to disappointment and even complain. So you should be careful with your insurance choice," he advised.

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.