Category Archives: Healthcare Reform

Thoughts on the Denninger Healthcare Reform Plan

The only way to improve U.S. healthcare while bringing costs down is to introduce serious competition for healthcare dollars.

This post is for U.S. citizens since the federales are going to tinker with our health insurance reform very soon. This would be a great opportunity to make helpful changes  to the system. I have no faith they will do it.

Healthcare in the U.S. consumes one of every five dollars spent in the economy. We are not getting our money’s worth, at least judging from average lifespan.

Karl Dennnger has put a lot of thought into the problem over the last decade, and has a concrete legislative proposal that makes a lot of sense. I endorse it. As you consider the possibilities, you need to keep in mind that the cost of healthcare will drop drastically. Not just by 50%. More like 80% or more. Healthcare will be so cheap you won’t even need insurance to pay for most of it.

How are these price reductions possible? Because the Dennniger plan introduces competition and moves us closer to a free market situation without third-party interference from insurers and government.

Here are the major points:

  • All healthcare providers must publicly post (e.g., on the web) prices which apply to everyone. E.g., not  a price depending on which insurance you have, whether you are paying cash up front, etc.
  • All customers must be billed for actual charges at the same posted prices at the time services or product is rendered. This removes the third party (insurer or government). You file the claim and every one pays the same price. In a way, medical care isn’t too expensive; too often it’s “free,” because someone else is paying. So there’s no comparison shopping. You see posted prices and you pay them yourself when you buy gasoline, groceries, cell phones, computers, TVs, cars, and houses. A valid and collectible bill must be consented to in writing before the service or product is provided. Actual price, no open-ended add-ons.
  • No event caused by or a consequence of treatment can be billed to the customer. (I’m not sure I like this. What about unforeseeable complications like C diff infection after antibiotics, or anaphylactic reactions to drugs? Providers could eventually get insurance to cover those costs, but it would be a brand new insurance market.)
  • True emergency patients who are unable to consent must receive the same price for same service as a person who consents to said service.
  • All medical records belong to the patient and shall be delivered to the patient (customer) at the time of service.
  • Auxiliary services (e.g., x-rays, lab work) may not be required to be purchased at the point of use. Example: an orthopedist wants you to get a knee MRI scan on his machine. You can shop around other places for a cheaper or better-quality MRI scan.
  • All anti-trust and consumer protection laws shall be enforced against all medically-related firms, and any claimed exemptions are hereby deemed void. Stiff penalties and fines for violations. Private lawyers must have access to sue.
  • You are free to purchase any medical test you want if no radiation or drug is required to perform the test. (You can already do this in Arizona, but in many states you need a “doctors order” for the test.)
  • There will be no government payments for care or products when a lifestyle change will provide a substantially equivalent or better benefit, when the customer refuses to implement the lifestyle change. (This point needs some fine-tuning. Who decides when and which lifestyle change would provide an equivalent benefit?])
  • Health insurance companies must sell true insurance, to sell any health-related policy at all. No insurance coverage for an event or condition of which you received treatment over the last 24 months.  If an adverse event occurs, insurance pays for all of it. E.g,, if you get an expensive cancer, the insurance company cannot drop you. The insurance must cover, with a selection of available deductibles, all accidental injuries and true life-threatening emergencies. Medical underwriting is permitted (e.g., insurers can charge higher premiums for smokers, couch potatoes, obese folks, etc. I have long thought that people in the top 25% of fitness, determined by a treadmill exercise test, should get a discount on insurance premiums).
  • All health insurers providers selling true insurance, in whole or in part, must provide within their “true insurance” the ability to replace like with like.” (I don’t know what Karl means by this.)
  • Medicare becomes just another insurance provider. No more Part B (outpatient services).
  • Medicaid is repealed entirely.
  • What about U.S. citizens and “lawful permanent residents” who can’t pay for care but still need attention? For true emergencies, the hospital or Emergency Department bills the U.S. Treasury, who pays within 30 days. For non-emergencies, the provider bills the U.S. Treasury and will be paid within 30 days except no billing for government payment if the condition resulted from a lifestyle decision the patient made. After the Treasury Department pays the provider, Treasury will send an invoice to the customer (patient or taxpayer), which may be settled within 90 days at no penalty. If charges are not paid, they become a tax lien subject to collection from refundable tax credits, tax refunds, other entitlement checks (except Social Security retirement), and windfall amounts (either money or property).
  • Repeal all aspects of Obamacare/PPACA.

You need a break after all that. Almost done. Hang in there!

I don’t recall Karl recommending a specific deductible amount, but often saw mention of $2,000 as a deductible. “Deductible” is what you pay out of pocket before insurance pays anything. I like a high deductible over “first-dollar” coverage, because the high deductible automatically creates 200 million shoppers who are going to check prices for sure before buying healthcare. (Of 320 million people in the U.S., I’m guessing 200 million are adults.)

Karl favors “catastrophic” policies, as do I. Your car needs new tires every few years, oil changes much more often, and periodic repairs, but you don’t expect car insurance to pay for those non-catastrophic costs.

Who would get hurt by this plan? Lobbyists, insurance and healthcare administrators, drug reps, pharmacy benefits managers, and those who refuse to make healthy lifestyle changes.

I don’t recall Karl addressing unreasonable insurance mandates, managed care plans (like Kaiser Permanente in CA), accountable care organizations, liability reform (we need the English Rule), tax parity (businesses buying insurance for employees get a tax break, but private individuals buying their own policies don’t), or much about enforcement. But he may have; Karl’s a very smart guy.

Steve Parker, M.D.

 

Let’s Call it KarlCare

Karl Denninger has fleshed out his U.S. healthcare system reform recommendations in a form ready for legislation.

I’ve only read it once and admit I don’t fully understand it. But I can tell already that it would be a major improvement over our current system.

Steve Parker, M.D.

Karl Denninger’s 5-Point Plan to Reform U.S. Healthcare

Imaginary view from my office

Healthcare costs represent almost 20% of the U.S. economy, a much higher percentage than seen in other first-world countries. And we’re not getting our money’s worth (judging from average lifespan, for instance).

The Republicans just rolled out a healthcare reform plan to replace Obamacare and address other issues. I haven’t read it. But I have zero confidence in those clowns being able to solve this problem.

Denninger has sussed out a plan that you may enjoy considering if you’re a policy geek. In brief:

  • If you sell “insurance” to anyone in a given state, you must accept all persons in that state on the same terms and at the same price. to open. For acute conditions where adverse selection becomes most important this restriction resolves the problem.
  • All “insurance” companies must offer a true insurance policy covering only unlikely-but-catastrophic events on the same terms as their “full service” policies.
  • All health providers must publish a price list and may not bill or accept payment at anything other than that price; doing so becomes a violation of Robinson-Patman and exposes the provider to civil suit for treble damages.
  • No event caused by the provision of your treatment may be billed to you. Period.
  • If you show up without insurance or ability to pay with a life-threatening condition, you will be treated, but the hospital cannot cost-shift the bill – it instead bills The Federal Government.

He concludes:

“Five points and a fully free-market solution that brings affordable health care coverage to all who can buy it, yet protects those who cannot, while, to the greatest possible extent, forces everyone to bear the cost of their own decisions.

If you choose not to be insured and pay cash you are free to make that choice. If you have a catastrophic illness or injury, insist on treatment but have no means to pay then you are subject to attachment of wages and assets by the IRS, a debt that is only discharged by your death.

Simple, fair, free-market and this path will dramatically control costs as free market competition will be forced to the forefront among health providers who will be compelled to make available their pricing schedules to everyone before they show up for treatment and are presented the bill.”

My Fellow Americans: How About Paying 80% Less for Your Healthcare?

Karl Denninger has a plan that he thinks would reduce the cost of healthcare in the U.S. by up to 85%!

Almost one in every five dollars spent in the U.S. is for “healthcare.” That’s probably the highest percentage of any country, and I don’t think we’re getting our money’s worth.

Karl’s plan hinges on the reality that the healthcare system here is not operating as a free market. There’s too much price-fixing, lack of price transparency, lack of competition, and consumer fraud done by collusion among the big players, such as health insurers, hospitals, physicians, and politicians. Karl says such practices have been illegal for decades, but applicable laws simply have not been enforced by the powers that be.

I’ve always had the impression that health insurers were exempt from anti-trust laws. Karl says that ain’t so.

Read the whole thang if you’re interested in U.S. healthcare reform. For example:

I’ve repeatedly, over some 30 years time, heard that there’s “some law” that exempts health care from anti-trust [laws] when the discussion turns to the topic of price-fixing, collusion, differential billing for commodities of like kind and quantity and similar. Every time I hear this claim I respond the same way: “Show me the law.”

Nobody ever has.

And I haven’t asked just once or twice. I’ve asked dozens of times since the 1990s. I’ve asked politicians. I’ve asked lawyers. I’ve asked political candidates. I’ve asked policy “wonks” of various flavors. Gary Johnson got asked (Lib candidate for President) in person a number of years back in his suite during the Libertarian convention in Orlando. Yet not one of the people I’ve asked has ever replied with a title, chapter and section of US code that provides such an exemption.

As just one of many examples I heard this claim during the campaign from a (Democrat) candidate for the US House when I asked him whether he would demand that the executive enforce anti-trust law against all medical providers and suppliers. He said he’d call me with a cite to the law when I responded that with all due respect the exemption he claimed did not exist at a meet-and-greet in a room full of Libertarians. He never did call me. (He lost the election, incidentally.)

I’m utterly convinced that’s because the oft-claimed exemption doesn’t exist. I’m in fact quite sure of it, because I can actually read the US Code — it’s public, of course, and the sections that could bear on this matter are reasonable in size (that is, I can and have read through them in a day or two.)

Never mind the contravening evidence too – like this case from 1979 that went to the Supreme Court which ruled that Mccarran-Ferguson does not protect insurance companies against anti-trust claims related to drug “discounts” on collusive actions. In other words the insurance company took the case to the Supreme Court and lost, which is damn good evidence that (1) anti-trust does apply to health care broadly including the criminal provisions in the Sherman and Clayton Acts and (2) health insurance firms and providers are not exempt to the extent they collude to restrain trade or fix prices.

It is thus my considered position that the reason the law isn’t enforced isn’t because it doesn’t apply — it isn’t enforced because the Executive voluntarily chooses to refuse to enforce it in collusion with Congress and the States and has done so for 30+ years despite the evidence being clear that the law — a law that carries both ruinous civil and felony criminal penalties — is being violated on a daily, continuing basis by the entirety of the so-called “health system.”

Is Medicare Abolishing the “Two Midnight Rule”?

I was never very good at math, either

I was never very good at math, either

In the U.S., Medicare pays most of the hospital bills for people over 65. If a Medicare patient comes to the emergency department or is otherwise “admitted” for treatment, that hospital stay is considered “observation” if  you can be sent home before the third midnight strikes. Observation status has some important financial implications for the patient; probably more expenses out-of-pocket compared to a regular or full admission.

MedPageToday reported that this “two midnight rule” is being abolished by Medicare.

Most of you are probably already bored by this. I bring this up here because the issue is important to my work as a hospitalist, and I want the public to know what physicians are dealing with as we try to stamp out disease and suffering.

MedPageToday linked to the pertinent announcement by Medicare (aka CMS):

“IPPS Rate Adjustments for Documentation and Coding and Two Midnight Policy:

In the FY 2017 IPPS final rule, CMS is finalizing two adjustments in addition to its annual rate update for inpatient hospital payments.

First, CMS is finalizing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008. For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments.  For FY 2017, CMS calculates that $5.05 billion of the $11 billion requirement remains to be addressed.  Therefore, CMS is finalizing a -1.5 percent adjustment to complete the statutorily-specified recoupment.

Second, CMS is taking action regarding the -0.2 percent adjustment it implemented in the FY 2014 IPPS/LTCH PPS final rule to account for an estimated increase in Medicare expenditures due to the Two Midnight Policy.  Specifically, in the FY 2014 IPPS/LTCH PPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of-0.2 percent to the payment rates.  CMS believes the assumptions underlying the -0.2 percent adjustment were reasonable at the time they were made.  Additionally, CMS does not generally believe it is appropriate in a prospective payment system to retrospectively adjust rates.  However, in light of recent review and the unique circumstances surrounding this adjustment, for FY 2017, CMS is permanently removing this adjustment and also its effects for FYs 2014, 2015, and 2016 by adjusting the FY 2017 payment rates.  This will increase FY 2017 payments by approximately 0.8 percent.”

Source: Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Final Rule Policy and Payment Changes for Fiscal Year (FY) 2017

I’m not dumb. I’m not under the influence of drugs or alcohol. But I’ve read that twice and I don’t understand what it has to do with eliminating the “two midnight rule.” I understand very little of it. If you can explain it to me in plain English, please do so.

Steve Parker, M.D.

PS: Medicare is the reason I closed my office-based medical practice and became a hospitalist in 2001

Karl Denninger’s Solution to the U.S. Healthcare Mess AND Federal Deficit Spending

Steve Parker MD

One of two bridges over the Colorado river in the Grand Canyon near Phantom Ranch

Karl says that U.S. healthcare and health insurance are way too expensive because of:

  • monopolistic practices
  • collusion among the major players (e.g., insurers, labs, Big Pharma, politicians, doctors)
  • ignored violations of the Sherman, Clayton, and Robinson-Patman Acts (15 USC)
  • ignored violations of state consumer protection laws
  • absence of market forces
  • price-fixing

Eliminate those problems, and you’d cut the cost of healthcare by 80%, the point at which you would need only catastrophic health insurance coverage, if at all. We’d have enough money left over to stop our federal deficit spending and eventually retire the entire federal debt. According to Karl.

What are examples of an absence of market forces?

  • Have you ever seen health insurance companies or hospitals compete on the basis of cost? Doctors rarely do it, either (and only when insurance isn’t involved).
  • Have you ever tried to get a firm estimate on the total cost of a proposed procedure before you have it done? Good luck with that.
  • The consumer of healthcare services usually isn’t the one paying for it. Your insurance company or the government (e.g., Medicare) is paying. You’ll get no thanks for your time spent shopping around for the best deal.
  • Scorpion antivenom costs $100 in Mexico, but if you get it in an emergency department in the U.S., you’ll be billed $40,000 for it. And don’t think you can go to Mexico and stock up then sell it to emergency departments for $150—that’s illegal.

Karl sings the praises of the Surgical Center of Oklahoma. They post their prices up front, work on a mostly cash basis, and eliminate the bill-padding and wasteful bureaucracy of other facilities. Their prices are a fifth of what others charge.

One possible fly in Karl’s ointment is that insurers are exempt from federal antitrust laws per 1945’s McCarran-Ferguson Act. Only a handful of industries are exempt. Karl doesn’t mention that. Nor does he talk about the cost of medical malpractice insurance and defensive medicine, wherein doctors order excessive testing to protect themselves from lawsuits.

I appreciate Karls’ efforts. He’s a smart guy with many good ideas.

RTWT.

Steve Parker, M.D.

Could Smart Healthcare Reform Solve the U.S. Budget Deficit?

Karl Denninger makes the case that the U.S. federal budget deficit is the fault of medical monopolies that are exempt from the Sherman and Clayton anti-trust laws. In his 20-minute video, Karl mentions that a vial of scorpion antivenin costs $10,000 in the U.S., but only $100 across the border in Mexico.

In a free market, a buyer of a product or service can easily determine how much it costs, whether it’s a haircut or a house. If you think U.S. healthcare is anything near a free market, just call up your local hospitals and ask how much they charge for an uncomplicated hospitalization to have a baby or groin hernia repair. Go ahead, I’ll wait.

They won’t or can’t give you the numbers. Nor do they advertise the prices so you can be a smart shopper.

Have you noticed how advances in science and technology tend to lower the cost of most goods and services, such as computers, cell phones, food, and clothing? Why don’t we see that in healthcare? Because of monopolistic practices and other excessive governmental regulation and bureaucracy affecting not only healthcare providers but also Big Pharma and health insurers.

Unfortunately, I don’t see the situation changing anytime soon.

Steve Parker, M.D.