RE: RE Republican, Democrat or independent

September 28, 2009

In exactly what way do I pit insurance companies against each other? Be specific I have 4 in maine plus medicare and medicaid I do not ake Aetna becasue they are a nightmare to deal with though I did negotaite rates with them

I cannot take HArvard PIlgrim becasue they make indpeendet docs join a network where you have to take all insurances in the network unless you are a bitch which I am but still harvard Pilgrim turns out to " co brand " whatever that is with the very evil United Healthcare,

Exactly what power do I have tell me and I will use it. I live in a world of old reitred disbaled people -most worlking people have blue cross or nothing at all Tell me where my power lies please.The other independetn docs around?

Well 1 is ophthalmology, one is internal medicie about to retire ,one works mart time at a lucrative industrial job and one could not care less as her husband d has a great job and she just left yrs of a high paying job herslef Everything else is hospital empolyed and tehya re " provider based " which no on e understands but which charges 117.00 in rural MAine ofr a 99213. Tell me my power please.

Someone commented that it is crazy to give the insurance companies any more power. I am an independent, and think it's crazy to give the government any more power. At least when dealing with an insurance company, you can always choose to not contract with that company and instead go with others. A monopoly is never a good idea, especially it's with the power of the gun (i.e government power by fiat). The government should tax way less and then we can cover the uninsured with charitable giving and pro bono work. If that's " unrealistic " , then at least let it be decided on a state by state basis so that again, there will be some competition; remember, a monopoly is never a good idea.

I am a former member of PNHP in the 1990's but now realize a government run health care would be a nightmare. We're already too close to that already; essentially Medicare runs the show. Who is running Medicare? Not doctors, certainly.

don't be afraid of the insurance companies, just learn to negotiate with them, which I have. Pit them against one another. You can't do that with the government.

Harter MD

Phoenix AZ

-- If you are a patient please allow up to 24 hours for a reply by email/Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

September 28, 2009

I have been thinking a lot on the notion of competition which is

being touched upon in this thread. I believe there is ample evidence to show

that there is not enough competition through private insurances to truly effect

health care prices (the most damning of which is the fact that we spend more

per capita than any other country and yet we have the most competitive private

insurance market in the world). Perhaps this is because Medicare is what private

insurances base their reimbursement on or perhaps it is because they need to

keep a medical loss ratio of 80%, but I don’t believe the notion of keeping

private insurances around to keep costs down makes much sense (this same logic

holds true for allowing insurances to practice across state lines—still not

enough competition to make a dent). I also don’t believe ANY insurance

company private or public is likely to change their reimbursement very much unless

someone else does first (although Medicare is experimenting with the PCMH). The

only way to have true competition (i.e. the kind which would bring costs down)

is to get rid of all insurance companies and force the doctor and the patient

to settle the deal amongst themselves (an example of which is Lasik eye

surgeries). The problem is that on a large scale, this would lead to a state of

health care anarchy where millions will end up going without care and dying

early and unnecessarily (Many of my seniors already cannot afford their generic

medications. If they did not have Medicare, even if I gave them free care, God knows

what would happen if they needed to be hospitalized).

So that is where I am right now as I try and figure this stuff

out. If we (the nation) feel health care is a privilege and we want true price

containment in a capitalistic manner, then get rid of all insurances and let

the market decide costs and reimbursements and let’s turn the care of the

elderly, the sick and the poor over to the churches and free clinics (we can

call it “Medieval Revivalist Medicine”). If we feel basic health

care is a right, then only a universal system with a strong single payer using its

monopoly to contain costs (ex. an MRI in Japan is $98) will work. Perhaps some variation

of the theme could be used for primary care given how inexpensive we are, but I’m

still kind of stuck with these views for the larger system.

Someone please tell me I am wrong.

From:

[mailto: ] On Behalf Of Jean

Antonucci

Sent: Sunday, September 27, 2009 6:15 PM

To:

Subject: Re: RE Republican, Democrat or independent

In exactly what way do I pit

insurance companies against each other?

Be specific

I have 4 in maine plus medicare and medicaid

I do not ake Aetna becasue they are a nightmare to deal with though

I did negotaite rates with them

I cannot take HArvard PIlgrim becasue they make indpeendet

docs join a network where you have to take all insurances in the network

unless you are a bitch which I am but still harvard Pilgrim

turns out to " co brand " whatever that is with the very evil United

Healthcare,

Exactly what power do I have tell me and I will use it.

I live in a world of old reitred disbaled people -most worlking

people have blue cross or nothing at all

Tell me where my power lies please.

The other independetn docs around?

Well 1 is ophthalmology, one is internal medicie about to retire

,one works mart time at a lucrative industrial job and one could not care less

as her husband d has a great job and she just left yrs of a high paying

job herslef Everything else is hospital empolyed and tehya re

" provider based " which no on e understands but which

charges 117.00 in rural MAine ofr a 99213. Tell me my power please.

On Sun, Sep 27, 2009 at 5:28 PM, harterchris10

wrote:

Someone commented that it is

crazy to give the insurance companies any more power. I am an independent, and

think it's crazy to give the government any more power. At least when dealing

with an insurance company, you can always choose to not contract with that

company and instead go with others. A monopoly is never a good idea, especially

it's with the power of the gun (i.e government power by fiat). The government

should tax way less and then we can cover the uninsured with charitable giving

and pro bono work. If that's " unrealistic " , then at least let it be

decided on a state by state basis so that again, there will be some

competition; remember, a monopoly is never a good idea.

I am a former member of PNHP in the 1990's but now realize a government run

health care would be a nightmare. We're already too close to that already;

essentially Medicare runs the show. Who is running Medicare? Not doctors,

certainly.

don't be afraid of the insurance companies, just learn to negotiate with them,

which I have. Pit them against one another. You can't do that with the

government.

Harter MD

Phoenix AZ

--

If you are a patient please allow up to 24 hours for a reply by email/

Remember that e-mail may not be entirely secure/

MD

ph fax

impcenter.org

September 28, 2009

..... hmmmm .... a thought:

Require patients to obtain catastrophic insurance (that's what insurance is for,

right?) with an HSA. (We require people to have auto insurance).

Medicaid/Medicare/County health plans supply their patients' catastrophic

insurance and put money into the HSAs.

Primary care then goes on retainer. No dealing with insurance. If you provide

excellent care and excellent service, then you can charge more ... and see less

patients.

Have primary care to provide 30% free/charity care for those who show financial

need and don't meet federal/state/county limits. (We already do this).

Specialists go on fee for service for office visits. No dealing with insurance

and a primary care doc can work with their favorite specialist to get better

rates for their patients.

I'm sure it's not perfect but it's a better framework than we have now ... which

is saying VERY little.

Craig (I've been called socialist, independent, and conservative ... and crazy

all in the same month)

>

> Someone commented that it is crazy to give the insurance companies any more

> power. I am an independent, and think it's crazy to give the government any

> more power. At least when dealing with an insurance company, you can always

> choose to not contract with that company and instead go with others. A

> monopoly is never a good idea, especially it's with the power of the gun

> (i.e government power by fiat). The government should tax way less and then

> we can cover the uninsured with charitable giving and pro bono work. If

> that's " unrealistic " , then at least let it be decided on a state by state

> basis so that again, there will be some competition; remember, a monopoly is

> never a good idea.

>

> I am a former member of PNHP in the 1990's but now realize a government run

> health care would be a nightmare. We're already too close to that already;

> essentially Medicare runs the show. Who is running Medicare? Not doctors,

> certainly.

>

> don't be afraid of the insurance companies, just learn to negotiate with

> them, which I have. Pit them against one another. You can't do that with the

> government.

>

> Harter MD

> Phoenix AZ

>

> --

>

> If you are a patient please allow up to 24 hours for a reply by email/

> Remember that e-mail may not be entirely secure/

> MD

>

> ph fax

> impcenter.org

>

September 28, 2009

Craig,

Good thinking for a socialist conservative with independent tendencies.

Yes, this actually could work well. My hesitation with HSAs is how does the

money get in there (?wage garnishing vs. other) and what happens when you run

out of HSA money. But, if set up right, it could work pretty well. The only

concern I would have is that there would be everyone and their cousin marketing

for the HSA dollars and that might just result in MORE overall spending and not

less. None the less, it would certainly be worth a “pilot study.”

From:

[mailto: ] On Behalf Of Craig Ross

Sent: Monday, September 28, 2009 11:46 AM

To:

Subject: Re: RE Republican, Democrat or

independent

..... hmmmm .... a thought:

Require patients to obtain catastrophic insurance (that's what insurance is

for, right?) with an HSA. (We require people to have auto insurance).

Medicaid/Medicare/County health plans supply their patients' catastrophic

insurance and put money into the HSAs.

Primary care then goes on retainer. No dealing with insurance. If you provide

excellent care and excellent service, then you can charge more ... and see less

patients.

Have primary care to provide 30% free/charity care for those who show financial

need and don't meet federal/state/county limits. (We already do this).

Specialists go on fee for service for office visits. No dealing with insurance

and a primary care doc can work with their favorite specialist to get better

rates for their patients.

I'm sure it's not perfect but it's a better framework than we have now ...

which is saying VERY little.

Craig (I've been called socialist, independent, and conservative ... and crazy

all in the same month)

>

> Someone commented that it is crazy to give the insurance companies any

more

> power. I am an independent, and think it's crazy to give the government

any

> more power. At least when dealing with an insurance company, you can

always

> choose to not contract with that company and instead go with others. A

> monopoly is never a good idea, especially it's with the power of the gun

> (i.e government power by fiat). The government should tax way less and

then

> we can cover the uninsured with charitable giving and pro bono work. If

> that's " unrealistic " , then at least let it be decided on a state

by state

> basis so that again, there will be some competition; remember, a monopoly

is

> never a good idea.

>

> I am a former member of PNHP in the 1990's but now realize a government

run

> health care would be a nightmare. We're already too close to that already;

> essentially Medicare runs the show. Who is running Medicare? Not doctors,

> certainly.

>

> don't be afraid of the insurance companies, just learn to negotiate with

> them, which I have. Pit them against one another. You can't do that with

the

> government.

>

> Harter MD

> Phoenix AZ

>

> --

>

> If you are a patient please allow up to 24 hours for a reply by email/

> Remember that e-mail may not be entirely secure/

> MD

>

> ph fax

> impcenter.org

>

September 28, 2009

This is the solution Goldhill advocated in Atlantic Monthly.

http://www.theatlantic.com/doc/200909/health-care

> >

> > Someone commented that it is crazy to give the insurance companies any more

> > power. I am an independent, and think it's crazy to give the government any

> > more power. At least when dealing with an insurance company, you can always

> > choose to not contract with that company and instead go with others. A

> > monopoly is never a good idea, especially it's with the power of the gun

> > (i.e government power by fiat). The government should tax way less and then

> > we can cover the uninsured with charitable giving and pro bono work. If

> > that's " unrealistic " , then at least let it be decided on a state by state

> > basis so that again, there will be some competition; remember, a monopoly is

> > never a good idea.

> >

> > I am a former member of PNHP in the 1990's but now realize a government run

> > health care would be a nightmare. We're already too close to that already;

> > essentially Medicare runs the show. Who is running Medicare? Not doctors,

> > certainly.

> >

> > don't be afraid of the insurance companies, just learn to negotiate with

> > them, which I have. Pit them against one another. You can't do that with the

> > government.

> >

> > Harter MD

> > Phoenix AZ

> >

> > --

> >

> > If you are a patient please allow up to 24 hours for a reply by email/

> > Remember that e-mail may not be entirely secure/

> > MD

> >

> > ph fax

> > impcenter.org

> >

>

September 29, 2009

Hi - (sorry this is a bit tangled and

long)

I don’t think there is an easy

answer. (Well OK, if we mandated 1 hour of fitness activity per person

per day in the US,

our health care bill would probably drop in half. There is actually a

study that shows moderate exercise for those in need of a stent is better for their

health outcomes than actually getting the stent. But I digress.) I

think the key is in moderate changes toward primary care and away from

government mandates. (Think of our educational system. Think not

getting paid for an A1C if it is 2 months 29 days and being penalized if it is

not done every three months. Think Washington State Medicaid which just

took on thousands more kids, but doesn’t have any doctors who can afford

to give away anymore care to them. Our office loses at least $50 every time

we see a Medicaid patient. But the kids are “covered,” they

just can’t see a doctor.)

I think we don’t actually have

competition and choice in any meaningful way. The only things that

insurance companies in Washington

can change are the preventive/primary care side of things and the

deductible. But that means we can drop the single thing that will

decrease the overall cost of healthcare. But the insurance companies

cannot drop out the super expensive treatments. Our insurance options all

cover the same things and the list is just about every surgery and life

sustaining trick in the book. We don’t have a death with dignity

insurance plan that skips the third resuscitation and extra two weeks of “life”

in the CCU. The response tends to be “I want all the care for mom

that is possible” without considering if mom’s welfare. So

what is my idea?

I think we should require some base level

of care available to everyone. We pay for it through a combination of mandatory

employer contribution and employee contribution, paid to various private

insurance companies that offer the base insurance contract. Everyone gets

vaccinations. Everyone gets contraception. Everyone gets office

care with a copay. Everyone gets ER care with a copay. Then it gets

tricky. Everyone under 65 can have cardiac surgery. Or was that

everyone under 70? But it needs to have a line so that it is possible to

project cost through that level of care. The level of care should exclude

most of the treatments that exceed a $100,000(or maybe its $50,000). If

we figure out this lower cost version, then we can add more treatments

in. What if someone wants additional insurance for additional care?

They can purchase it. “I want the cardiac insurance.”

Great just fill out these forms and pay the extra premium.

The idea that we can afford to offer

everyone every bit of care they desire is not realistic- especially when we keep

devising ever more expense ways to keep great grandpa alive for an extra two

weeks (or months). Our national debt is projected to hit $10 trillion and

our total federal government budget to be allocated 54% to just paying the

interest. The “no cost is to high” approach to deliver care

is not reasonable. And I think the idea the “cost savings”

will pay for the sudden coverage of 43 million people to be laughable (or maybe

cryable?) And when taxes on insurance, pharmaceuticals, and the other

companies are added, it will just funnel back down into the overall cost of

healthcare and increase it by roughly the same amount as the taxes. The

solution is not in taxing the people who are delivering the services.

I think the solutions have to be through

private companies as the federal programs just get too stupid to be a part

of. (See the example from today below.) But maybe the options

should be defined. (When our office went to get insurance, BlueCross

could create a plan just for us with $5 copay increments, many deductible

options, many options for preventive care. But the plans could not be

compared with Lifewise in an apples to apples comparison.)

I think the failure of primary care to

thrive here is an indication of the strong single payer being a bad

option. CMS does have lots of power and it exercises that power in the

creation and editing of the CPT’s. But the emphasis gets put on

paying for procedures. A simple way to increase primary care would be to

mandate that primary care gets paid 150% of the fee schedule of the specialists

for E & M codes. By my guesses, based on data from one of our insurance

companies, the total cost of the increase would only be about 1% of the cost of

health care. But I bet you would find primary care enrollment at

residencies up. And if the data about the cost savings of having people

see PCP’s is correct, there would then be a decrease in the overall cost

of care as access is improved.

Our patent laws that allow drug companies

to be making premiums on HFA inhalers is an example of the US spending its

healthcare dollars to fund research that benefits the world. That is

great until you consider the total cost of pharmaceuticals and the inefficiency

of funding research that way, as well as the fact that Europe

really ought to share some of the burden of research costs.

My rant for the day: I just received

notification that we will either have to drop all medicare products or conduct

a training session on FWA. My first question is what the heck is

FWA. It turns out it is Fraud Waste and Abuse. I dig into the information

I received. I find a 17 page document outlining why I have to do the

training. Hmm. What training? I find a training

document. Only 7 pages. Hurray! Wait a minute . . . These are

bullet points. I am supposed to research examples of PBM Fraud and

Pharmacy fraud and other fraud and then create a training session. It is

a list with 7 main categories with subcategories down to Q. I didn’t

even do the math. I think for our three doctors and staff to attend a FWA

class that satisfies medicare it will cost our office somewhere around $2500 in

lost revenue and wages paid. So I called my congress idiots. One

office doesn’t answer. One says politely that she will forward my

concerns to the senator. Ya right. The final one is a

representative’s office who is going to have someone come look at the situation

with me. But no, they did not allocate money for the training. Just

a good PR commercial for the incompetents in charge.

Bottom line. We either are willing

to violate federal law and continue to see our elderly & disabled patients

or we see them for free. I absolutely refuse to waste a few thousand

dollars for some idiots’ idea of cost controls. We are planning to

drop Medicare before January 1, 2010 and avoid breaking the law. We will

see some of our patients for free and send others away. But in our area,

no one is taking Medicare. No one is taking Medicaid. Except the ER’s.

Great medical care through our government option.

From: [mailto: ] On Behalf Of Dr. Brady

Sent: Sunday, September 27, 2009

6:09 PM

To:

Subject: RE:

RE Republican, Democrat or independent

I have been thinking a lot on the notion of competition which is

being touched upon in this thread. I believe there is ample evidence to show that

there is not enough competition through private insurances to truly effect

health care prices (the most damning of which is the fact that we spend more

per capita than any other country and yet we have the most competitive private

insurance market in the world). Perhaps this is because Medicare is what

private insurances base their reimbursement on or perhaps it is because they

need to keep a medical loss ratio of 80%, but I don’t believe the notion

of keeping private insurances around to keep costs down makes much sense (this

same logic holds true for allowing insurances to practice across state

lines—still not enough competition to make a dent). I also don’t

believe ANY insurance company private or public is likely to change their

reimbursement very much unless someone else does first (although Medicare is

experimenting with the PCMH). The only way to have true competition (i.e. the

kind which would bring costs down) is to get rid of all insurance companies and

force the doctor and the patient to settle the deal amongst themselves (an

example of which is Lasik eye surgeries). The problem is that on a large scale,

this would lead to a state of health care anarchy where millions will end up

going without care and dying early and unnecessarily (Many of my seniors

already cannot afford their generic medications. If they did not have Medicare,

even if I gave them free care, God knows what would happen if they needed to be

hospitalized).

So that is where I am right now as I try and figure this stuff

out. If we (the nation) feel health care is a privilege and we want true price

containment in a capitalistic manner, then get rid of all insurances and let

the market decide costs and reimbursements and let’s turn the care of the

elderly, the sick and the poor over to the churches and free clinics (we can

call it “Medieval Revivalist Medicine”). If we feel basic health

care is a right, then only a universal system with a strong single payer using

its monopoly to contain costs (ex. an MRI in Japan is $98) will work. Perhaps

some variation of the theme could be used for primary care given how

inexpensive we are, but I’m still kind of stuck with these views for the

larger system.

Someone please tell me I am wrong.

From:

[mailto: ]

On Behalf Of

Sent: Sunday, September 27, 2009

6:15 PM

To:

Subject: Re:

RE Republican, Democrat or independent

In

exactly what way do I pit insurance companies against each other?

Be specific

I have 4 in maine

plus medicare and medicaid

I do not ake Aetna becasue they

are a nightmare to deal with though I did negotaite rates with them

I cannot take HArvard PIlgrim becasue they make indpeendet

docs join a network where you have to take all insurances in the network

unless you are a bitch which I am but still harvard Pilgrim

turns out to " co brand " whatever that is with the very evil United

Healthcare,

Exactly what power do I have tell me and I will use it.

I live in a world of old reitred disbaled people -most worlking

people have blue cross or nothing at all

Tell me where my power lies please.

The other independetn docs around?

Well 1 is ophthalmology, one is internal medicie about to retire

,one works mart time at a lucrative industrial job and one could not care less

as her husband d has a great job and she just left yrs of a high paying

job herslef Everything else is hospital empolyed and tehya re " provider

based " which no on e understands but which charges 117.00 in

rural MAine ofr a 99213. Tell me my power please.

On Sun, Sep 27,

2009 at 5:28 PM, harterchris10 <christine.hartergmail> wrote:

Someone commented that it is crazy to give the

insurance companies any more power. I am an independent, and think it's crazy

to give the government any more power. At least when dealing with an insurance

company, you can always choose to not contract with that company and instead go

with others. A monopoly is never a good idea, especially it's with the power of

the gun (i.e government power by fiat). The government should tax way less and

then we can cover the uninsured with charitable giving and pro bono work. If

that's " unrealistic " , then at least let it be decided on a state by

state basis so that again, there will be some competition; remember, a monopoly

is never a good idea.

I am a former member of PNHP in the 1990's but now realize a government run

health care would be a nightmare. We're already too close to that already;

essentially Medicare runs the show. Who is running Medicare? Not doctors,

certainly.

don't be afraid of the insurance companies, just learn to negotiate with them,

which I have. Pit them against one another. You can't do that with the

government.

Harter MD

Phoenix AZ

--

If you are a patient please allow up to 24 hours for a reply by email/

Remember that e-mail may not be entirely secure/

MD

ph fax

impcenter.org

September 29, 2009

Thanks Ernie for your thoughts. My responses:

1)

If there were a single or integrated system, perhaps we could do

something innovative like pay people for doing a one hour workout. “Here’s

$5, thanks for staying healthy.” I bet just getting that fiver would

encourage a lot of people to work-out (even if the money originally came from

their insurance premiums)

2)

Educational system? Sorry, I don’t follow that problem (although

there are problems, our society would be a lot worse off without public

education)

3)

Reimbursement from Medicaid definitely is an issue, but my

reimbursement from the Medicaid + private plans suck as well.

4)

In your plan, would you be for a mandatory cap on insurance

profits? Ex. they must maintain a medical loss ratio of no lower than 95% (the

rate it was in the 80s before they all became for profit)? So, are you saying

that we as a society should not pay for heart bypass for those without an

additional insurance? Same for chemo? And you have set the age at 65? Who do we

trust to make these decisions?

5)

I should probably know this, but how do other countries afford

it? I know that there is rationing in other countries, but certainly we already

have huge rationing here (it is just inconsistent here based on the whims of

the insurance company).

6)

I, too, worry greatly about the national debt and deficit, but

believe health care will be “the straw that breaks the camel’s back”

if we do nothing. I don’t know if it is possible to assume we can cover

everyone without governmental intervention. Even if private insurances do the

real work, they have to be reigned in somehow or no one will ever have anything

paid for.

7)

CPTs were created through the influence of the AMA. Sadly, the

government was listening to us docs. I do think in order to rejuvenate primary

care, we need to be reimbursed more, but I disagree that it should be through

the same system. We need to also break the paperwork insanity. You have a FWA

lecture to plan, but wouldn’t need to if the stupid system was less

complex and completely transparent. I realize this kind of change is a long shot,

but boy one can dream.

8)

Don’t know enough about patent laws to comment on that

part, but it seems to me that taking a generic medication (albuterol) and

putting it in a new delivery system did not likely cost billions of dollars.

Changing the price from $2 a month to $80+ dollars a month makes billions.

Something seems a bit off.

9)

Sorry about the FWA thing. You are right to rant. Thanks again for

your thoughts on this and I look forward to further responses.

From:

[mailto: ] On Behalf Of Ernie Leland

Sent: Tuesday, September 29, 2009 4:39 AM

To:

Subject: RE: RE Republican, Democrat or

independent

Hi -

(sorry this is a bit tangled and long)

I

don’t think there is an easy answer. (Well OK, if we mandated 1

hour of fitness activity per person per day in the US, our health care bill

would probably drop in half. There is actually a study that shows

moderate exercise for those in need of a stent is better for their health

outcomes than actually getting the stent. But I digress.) I think

the key is in moderate changes toward primary care and away from government

mandates. (Think of our educational system. Think not getting paid

for an A1C if it is 2 months 29 days and being penalized if it is not done

every three months. Think Washington State Medicaid which just took on

thousands more kids, but doesn’t have any doctors who can afford to give

away anymore care to them. Our office loses at least $50 every time we

see a Medicaid patient. But the kids are “covered,” they just

can’t see a doctor.)

I think we

don’t actually have competition and choice in any meaningful way.

The only things that insurance companies in Washington can change are the

preventive/primary care side of things and the deductible. But that means

we can drop the single thing that will decrease the overall cost of

healthcare. But the insurance companies cannot drop out the super

expensive treatments. Our insurance options all cover the same things and

the list is just about every surgery and life sustaining trick in the

book. We don’t have a death with dignity insurance plan that skips

the third resuscitation and extra two weeks of “life” in the

CCU. The response tends to be “I want all the care for mom that is

possible” without considering if mom’s welfare. So what is my

idea?

I think we

should require some base level of care available to everyone. We pay for

it through a combination of mandatory employer contribution and employee

contribution, paid to various private insurance companies that offer the base

insurance contract. Everyone gets vaccinations. Everyone gets

contraception. Everyone gets office care with a copay. Everyone

gets ER care with a copay. Then it gets tricky. Everyone under 65

can have cardiac surgery. Or was that everyone under 70? But it

needs to have a line so that it is possible to project cost through that level

of care. The level of care should exclude most of the treatments that

exceed a $100,000(or maybe its $50,000). If we figure out this lower cost

version, then we can add more treatments in. What if someone wants

additional insurance for additional care? They can purchase it.

“I want the cardiac insurance.” Great just fill out these

forms and pay the extra premium.

The idea

that we can afford to offer everyone every bit of care they desire is not

realistic- especially when we keep devising ever more expense ways to keep

great grandpa alive for an extra two weeks (or months). Our national debt

is projected to hit $10 trillion and our total federal government budget to be

allocated 54% to just paying the interest. The “no cost is to

high” approach to deliver care is not reasonable. And I think the

idea the “cost savings” will pay for the sudden coverage of 43

million people to be laughable (or maybe cryable?) And when taxes on

insurance, pharmaceuticals, and the other companies are added, it will just

funnel back down into the overall cost of healthcare and increase it by roughly

the same amount as the taxes. The solution is not in taxing the people

who are delivering the services.

I think

the solutions have to be through private companies as the federal programs just

get too stupid to be a part of. (See the example from today below.)

But maybe the options should be defined. (When our office went to get

insurance, BlueCross could create a plan just for us with $5 copay increments,

many deductible options, many options for preventive care. But the plans

could not be compared with Lifewise in an apples to apples comparison.)

I think

the failure of primary care to thrive here is an indication of the strong

single payer being a bad option. CMS does have lots of power and it

exercises that power in the creation and editing of the CPT’s. But

the emphasis gets put on paying for procedures. A simple way to increase

primary care would be to mandate that primary care gets paid 150% of the fee schedule

of the specialists for E & M codes. By my guesses, based on data from

one of our insurance companies, the total cost of the increase would only be

about 1% of the cost of health care. But I bet you would find primary

care enrollment at residencies up. And if the data about the cost savings

of having people see PCP’s is correct, there would then be a decrease in

the overall cost of care as access is improved.

Our patent

laws that allow drug companies to be making premiums on HFA inhalers is an

example of the US spending its healthcare dollars to fund research that

benefits the world. That is great until you consider the total cost of

pharmaceuticals and the inefficiency of funding research that way, as well as

the fact that Europe really ought to share some of the burden of research

costs.

My rant

for the day: I just received notification that we will either have to drop all

medicare products or conduct a training session on FWA. My first question

is what the heck is FWA. It turns out it is Fraud Waste and Abuse.

I dig into the information I received. I find a 17 page document

outlining why I have to do the training. Hmm. What training?

I find a training document. Only 7 pages. Hurray! Wait a

minute . . . These are bullet points. I am supposed to research examples

of PBM Fraud and Pharmacy fraud and other fraud and then create a training

session. It is a list with 7 main categories with subcategories down to

Q. I didn’t even do the math. I think for our three doctors

and staff to attend a FWA class that satisfies medicare it will cost our office

somewhere around $2500 in lost revenue and wages paid. So I called my

congress idiots. One office doesn’t answer. One says politely

that she will forward my concerns to the senator. Ya right. The

final one is a representative’s office who is going to have someone come

look at the situation with me. But no, they did not allocate money for

the training. Just a good PR commercial for the incompetents in charge.

Bottom

line. We either are willing to violate federal law and continue to see

our elderly & disabled patients or we see them for free. I absolutely

refuse to waste a few thousand dollars for some idiots’ idea of cost

controls. We are planning to drop Medicare before January 1, 2010 and

avoid breaking the law. We will see some of our patients for free and

send others away. But in our area, no one is taking Medicare. No

one is taking Medicaid. Except the ER’s. Great medical care

through our government option.

From:

[mailto: ] On Behalf Of Dr.

Brady

Sent: Sunday, September 27, 2009 6:09 PM

To:

Subject: RE: RE Republican, Democrat or

independent

I have been thinking a lot on the notion

of competition which is being touched upon in this thread. I believe there is

ample evidence to show that there is not enough competition through private insurances

to truly effect health care prices (the most damning of which is the fact that

we spend more per capita than any other country and yet we have the most

competitive private insurance market in the world). Perhaps this is because

Medicare is what private insurances base their reimbursement on or perhaps it

is because they need to keep a medical loss ratio of 80%, but I don’t

believe the notion of keeping private insurances around to keep costs down

makes much sense (this same logic holds true for allowing insurances to

practice across state lines—still not enough competition to make a dent).

I also don’t believe ANY insurance company private or public is likely to

change their reimbursement very much unless someone else does first (although

Medicare is experimenting with the PCMH). The only way to have true competition

(i.e. the kind which would bring costs down) is to get rid of all insurance

companies and force the doctor and the patient to settle the deal amongst

themselves (an example of which is Lasik eye surgeries). The problem is that on

a large scale, this would lead to a state of health care anarchy where millions

will end up going without care and dying early and unnecessarily (Many of my

seniors already cannot afford their generic medications. If they did not have

Medicare, even if I gave them free care, God knows what would happen if they

needed to be hospitalized).

So that is where I am right now as I try

and figure this stuff out. If we (the nation) feel health care is a privilege

and we want true price containment in a capitalistic manner, then get rid of

all insurances and let the market decide costs and reimbursements and

let’s turn the care of the elderly, the sick and the poor over to the

churches and free clinics (we can call it “Medieval Revivalist

Medicine”). If we feel basic health care is a right, then only a

universal system with a strong single payer using its monopoly to contain costs

(ex. an MRI in Japan is $98) will work. Perhaps some variation of the theme

could be used for primary care given how inexpensive we are, but I’m

still kind of stuck with these views for the larger system.

Someone please tell me I am wrong.

From:

[mailto: ] On Behalf Of Jean

Antonucci

Sent: Sunday, September 27, 2009 6:15 PM

To:

Subject: Re: RE Republican, Democrat or

independent

In exactly what way do I pit insurance companies against each

other?

Be specific

I have 4 in maine plus medicare and medicaid

I do not ake Aetna becasue they are a nightmare to deal with though

I did negotaite rates with them

I cannot take HArvard PIlgrim becasue they make indpeendet

docs join a network where you have to take all insurances in the network

unless you are a bitch which I am but still harvard Pilgrim

turns out to " co brand " whatever that is with the very evil United

Healthcare,

Exactly what power do I have tell me and I will use it.

I live in a world of old reitred disbaled people -most worlking

people have blue cross or nothing at all

Tell me where my power lies please.

The other independetn docs around?

Well 1 is ophthalmology, one is internal medicie about to retire

,one works mart time at a lucrative industrial job and one could not care less

as her husband d has a great job and she just left yrs of a high paying

job herslef Everything else is hospital empolyed and tehya re

" provider based " which no on e understands but which

charges 117.00 in rural MAine ofr a 99213. Tell me my power please.

On

Sun, Sep 27, 2009 at 5:28 PM, harterchris10

wrote:

Someone commented that it is crazy to give the insurance

companies any more power. I am an independent, and think it's crazy to give the

government any more power. At least when dealing with an insurance company, you

can always choose to not contract with that company and instead go with others.

A monopoly is never a good idea, especially it's with the power of the gun (i.e

government power by fiat). The government should tax way less and then we can

cover the uninsured with charitable giving and pro bono work. If that's

" unrealistic " , then at least let it be decided on a state by state

basis so that again, there will be some competition; remember, a monopoly is

never a good idea.

I am a former member of PNHP in the 1990's but now realize a government run

health care would be a nightmare. We're already too close to that already;

essentially Medicare runs the show. Who is running Medicare? Not doctors,

certainly.

don't be afraid of the insurance companies, just learn to negotiate with them,

which I have. Pit them against one another. You can't do that with the

government.

Harter MD

Phoenix AZ

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ph fax

impcenter.org

September 29, 2009

Ernie,

I like your ideas. It is very similar

to how Oregon Medicaid is run. Everything “above the line” is

covered and everything “below the line” is not. The problem

is in drawing the line. And where the line is changes constantly.

Former Oregon

governor Kitzhaber has a plan that sounds almost identical to the one you

are proposing. I, too, am worried about “universal” coverage

for all. What I read of Baucus plan (and I read through most of what was

originally released) sounds very expensive and unsustainable. Given the

extra taxes and burden on employers (and individuals if they choose to not have

the type of plan that the government wants to mandate, as we currently have a

catastrophic-only type plan with a high deductible), I don’t know that we

would actually see an increase in income here at home.

We are going to have to consider whether

or not we will continue to take new patients with Medicare products, not for

the reason that you state (I have not seen anything come through mandatory for

training for us in Northern CA), but because the new contracts we’re

getting from the PFFS plans are stating that we must take everyone (including

those that have Medicaid secondary even though we are not a Medicaid provider –

requiring us to write off the 20% on each of those patients). Currently,

we are closed to all Medicaid patients, including those that just have it as

secondary. But the new contracts specifically state that we have to take

Medicaid as secondary because to not accept them would be discriminatory

against people with low income. I’m not discriminating against them

because of their income (and in fact would be willing to take them if the

patient understood that they had to pay what Medicare does not because we’re

not Medicaid providers), but we are NOT ALLOWED to bill the patient for the 20%

even though we are NOT Medicaid providers. Needless to say, this is

ludicrous. But then again, so is forcing ER doctors to accept the

contracted rate for seeing patients in the ER even when they aren’t

contracted with that insurance. But I digress. These contracts are

currently sitting on Steve’s desk, awaiting an email to the CMA to find

out about the legality of this.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ] On

Behalf Of Ernie Leland

Sent: Tuesday, September 29, 2009

1:39 AM

To:

Subject: RE:

RE Republican, Democrat or independent

Hi - (sorry this is a bit tangled and long)

I don’t think there is an easy answer. (Well OK, if we

mandated 1 hour of fitness activity per person per day in the US,

our health care bill would probably drop in half. There is actually a

study that shows moderate exercise for those in need of a stent is better for

their health outcomes than actually getting the stent. But I

digress.) I think the key is in moderate changes toward primary care and

away from government mandates. (Think of our educational system.

Think not getting paid for an A1C if it is 2 months 29 days and being penalized

if it is not done every three months. Think Washington State Medicaid

which just took on thousands more kids, but doesn’t have any doctors who

can afford to give away anymore care to them. Our office loses at least

$50 every time we see a Medicaid patient. But the kids are

“covered,” they just can’t see a doctor.)

I think we don’t actually have competition and choice in any

meaningful way. The only things that insurance companies in Washington

can change are the preventive/primary care side of things and the

deductible. But that means we can drop the single thing that will decrease

the overall cost of healthcare. But the insurance companies cannot drop

out the super expensive treatments. Our insurance options all cover the

same things and the list is just about every surgery and life sustaining trick

in the book. We don’t have a death with dignity insurance plan that

skips the third resuscitation and extra two weeks of “life” in the

CCU. The response tends to be “I want all the care for mom that is

possible” without considering if mom’s welfare. So what is my

idea?

I think we should require some base level of care available to

everyone. We pay for it through a combination of mandatory employer

contribution and employee contribution, paid to various private insurance

companies that offer the base insurance contract. Everyone gets