Archive for March, 2010

Dueling Shrinks: Uncompensable Depression

Monday, March 15th, 2010

Depression is by no means a rare occurrence in the workplace, but depressions that lead to compensable claims under workers comp are very rare, indeed. The burden of proof on the claimant is substantial, generally requiring a conclusive demonstration that work is the “predominant cause” of the depression. Given all that goes on in our lives, this can be a very tough standard to meet.
Janina Guz was a factory worker until 2002, when she sustained a work-related injury and filed for workers’ comp benefits. She had bilateral carpal tunnel syndrome, later amended to include a neck injury and an aggravation of a preexisting back condition. In 2007, she amended her claim to add a major depressive disorder. Her case reached the Appelate Division of New York’s Supreme Court.
Shrink One, Shrink Two
The case revolved around the testimony of two psychiatrists, one hired by the insurer and one by the claimant. The two shrinks approached Guz’s complaint with very different perspectives, which naturally influenced their conclusions.
Dr. Areyeh Klahr conducted independent medical examinations in 2006 and 2007. In 2006 he found Guz to be exhibiting some symptoms of depression, but in his opinion this depression did not prevent her from working. One year later, he concluded that Guz no longer suffered from an ongoing psychiatric condition and had reached maximum medical improvement. Klahr cast a sceptical eye on Guz: he found significant inconsistencies in her responses and concluded that her complaints did not correlate with his objective findings. Klahr ultimately concluded not only that Guz did not suffer a work-related psychiatric disability, but that she was not really depressed.
A claims adjuster would call this IME a “home run.”
The evidence in support of Guz came from her own psychiatrist, Alina Marek, who treated Guz on five occasions beginning in January 2008 – which the court noted was more than five years after her injury. Marek diagnosed Guz as having a major depressive disorder that was causally related to the work accident. However, she she acknowledged that she had no information about the circumstances or nature of Guz’s work-related injury. She was also unaware that Guz had been involved in two prior motor vehicle accidents which involved injuries to her neck and hands. Marek had to concede that such prior injuries would be important in diagnosing Guz and determining the cause of her depression. Marek further conceded that she had no information regarding Guz’s daily activities or her personal life history, including the fact that she was divorced. When pressed to specify the basis for her opinion that Guz’s depression was related to her workplace accident, Marek admitted that she relied entirely upon Guz’s subjective account. The Board found Marek’s testimony on the issue of causally related psychiatric disability to be “entirely lacking in credibility.”
Objective, Subjective
It’s interesting to note the radically different frames of reference used by the two psychiatrists. An independent doctor with no ongoing relationship to Guz, Dr. Klahr zeroed in on the inconsistencies in Guz’s complaints. Using the “objective” standards of his profession – not always as objective as they appear – he concluded that Guz was fabricating her complaint in order to preserve her comp benefits.
In distinct contrast, Malek took Guz at her word. Guz said she was depressed and she said that the depression was related to her work. Malek did not feel the need to probe any deeper.
In the world of comp, medical opinions quickly turn into dollars: if a condition is work related, all the medical bills are paid and the claimant receives indemnity. If it’s not work related, no such payments are made. While it’s tempting to make a judgment about the relative quality of the two psychiatric evaluations, that might not be entirely fair. From a workers comp point of view, the court had ample reason to conclude that Guz’s situation did not rise to the level of compensability. From a purely medical perspective – regardless of whether work caused the problem – Guz is in pain and in trouble. Given the court’s decision, she will find no further solace in workers comp.

Traumatic brain injuries (TBI): in the workplace and in the field

Thursday, March 11th, 2010

The Brain Injury Association reminds us that March is Brain Injury Awareness Month, so it was timely to see that our colleague Peter Rousmaniere has an important piece on brain injury recovery in the current issue of Risk Management magazine: Gray Matters: The Employer’s Role in Brain Injury Recovery. It is important for two reasons: it sheds light and hope on the issue of traumatic brain injuries and the improved prospects for recovery, including return to work; and it serves as an illustration of some important differences between workers compensation and group health
The article notes that each year, 50,000 Americans die of a traumatic brain injury and 235,000 are hospitalized. There really aren’t good statistics to tell us the prevalence of work-related brain injuries. Although there are better statistics available for what Rousmaniere calls “the signature wound of today’s wars,” many think that the estimate of 320,000 war-related traumatic brain injuries may be on the low side.
The good news, as Rousmaniere documents with examples, is that with proper medical care there have been great advances for a type of injury that was once written off as lost cause: “In the past, many adults with work-related traumatic brain injury were simply warehoused. But with advances in treatment and care strategies, including an employer that is ready and willing to help in gradual return to work, many survivors of severe brain injury can regain most of their former way of life.”
Part of the challenge is early identification, rapid response, and aggressive treatment early in the injury, and aggressive recovery goals. Patients who are treated in the workers comp system, where care is often managed and coordinated and where insurers and employers aggressively advocate for recovery and return to work, often have an advantage over those patients treated under group health. With workers compensation, employers/insurers have financial responsibility for the life of a claim and, therefore, more incentive to work towards maximum recovery. Rousmaniere cites a case manager who says, “You have a workers compensation brain injured patient who is in the same hospital room as a nonworkers compensation patient, and the difference in resources is like night and day.”
Rousmaniere cites examples of successes, along with best practices that contributed to those successes – including the important role that the employer can play in maximizing recovery, some of the challenges that occur, and some of the best practices:

As with all successful brain injury recoveries, job coaching is a critical phase that demands employer participation. Rehab counselors often make the trip with the worker back to her or his workplace. Memory failure, a signature feature of brain injury, is sometimes best treated, in part, at the physical site of the employer. So for several months, the vocational specialist helps the worker find ways to organize the day, reinforce memory and work with others. In this way, the patient’s prospects for recovery are greatly improved.

Department of Defense embarks on more aggressive brain injury screening program
Rousmaniere discusses the prevalence of war-related TBI and some of the promising medical advances. He cites the recovery of reporter Bob Woodruff, perhaps one of the cases that we are all most familiar with due to the news coverage. After returning to his job as a reporter, Woodruff became an advocate for our soldiers in the field, developing a ReMIND, a foundation to provide resources and support to injured service members, veterans and their families.
In speaking of his own recovery, Woodruff praised the quality of the care and support that he received, but saw with dismay that such treatment and recovery resources were not always available to service members with similar injuries. He saw the military culture as often stigmatizing or impeding screenings, and treatment options being limited once a vet returned home. That’s why the Department of Defense’s recent policy announcement is such welcome news: head-injury evaluations will be mandatory for all troops who suffer possible concussions. Moving to an incident-based response is a significant change from prior protocol, which depended on service members to self-identify with a complaint. The weakness in this approach is that service members are highly mission-focused and can shrug off complaints that can later prove to be serious problems.
America’s Heroes at Work is a U.S. Department of Labor project that addresses the employment challenges of returning service members living with Traumatic Brain Injury (TBI) and/or Post-Traumatic Stress Disorder (PTSD). The resources and links pages are particularly helpful – and a good resource for employers who are working with either vets or non-vets who are recovering from TBIs.
TBI resources
Brain Injury Association of America
Survivors’ Voice
Traumatic Brain Injury Survival Guide
Brain Injury Resource Center

Cavalcade of Risk #100 (!) and other news of note

Wednesday, March 10th, 2010

Is the 100th time the charm? Cavalcade of Risk celebrates its centesimal issue today – that’s a lot of risk coverage! Our host for this landmark issue is Russell Hutchinson of moneyblog – tip of the hat to him for a good issue. And kudos to Cavalcade founder and visionary, Hank Stern of InsureBlog.
Chronic Pain – a few weeks ago, we brought you one approach to chronic pain management. In Risk and Insurance, Peter Rousmaniere discusses the CT Workers’ Compensation Trust approach to chronic pain. This self-insurance pool of 390 healthcare employers introduced a a five-pronged program in 2009, which Rousmaniere outlines. He challenges readers to “consider how many of the five you or your vendors apply.”
Uncovered in Georgia – a loophole left 88 injured workers without workers’ comp coverage on the recent failure of Atlanta-based workers’ compensation insurer Southeastern U.S. Insurance (SEUS) Inc. Normally, the state’s insolvency pool would serve as a safety net for failed insurers, but up until a law change in 2008, captive insurers were not covered by this pool. While SEUS had converted from captive to become a traditional insurer, 88 workers claims predated the conversion and are responsible for their According to the article, “Eight of those workers have catastrophic injuries and will need lifetime care. One has medical needs exceeding $45,000 a month.”

“Twelve other firms that operated under rules that exempted the failed company’s clients from drawing from an insolvency pool still do business in the state. And while they all now pay into that pool, 10 have claims predating the 2008 change in the law that required them to do so.
If any fail, workers with active pre-2008 claims could find themselves in a similar bind. State insurance regulators say they don’t know how many people ultimately could fall in that category. But they say they don’t think any of the 12 companies is in danger of failing.”

Mad as a hatter – On the recent release of Tim Burton’s Alice in Wonderland, the CDC reminds us that the phrase “mad as a hatter” originated from on-the-job mercury poisoning. To shape felt hats, hat makers used a solution of mercuric nitrate and, as a result, often suffered from agitation, tremors, slurred speech and other neurological symptoms – thus, “mad as a hatter.” Hat manufacturers used mercury until 1941. Mercury is still used in many industries and the CDC article has some interesting statistics, as well as a page devoted to recommendations, reports, and other resources for preventing hazardous exposures to mercury on the job.
Fatal Injury mapping – via Occupational Health & Safety, we learn that OSHA has introduced a new fatal injury mapping module, which “…allows users to create customized, color-coded maps of injury-related death rates throughout the United States. It defines injury-related deaths according to intent (e.g., unintentional, homicide, suicide) and mechanism of injury (e.g., motor-vehicle traffic, fall, fire or burn, poisoning, cut).” CDC’s Fatal Injury Mapping Module. Other data and statistics are also available from CDC’s WISQARSTM (Web-based Injury Statistics Query and Reporting System), an interactive database system that provides customized reports of injury-related data.
NY crane deaths followup – Liz Borowski of The Pump Handle offers and update on the 2008 crane NY crane disasters. The owner of the city’s largest construction crane company is expected to be indicted for manslaughter in the death of two workers in one of the incidents. She also updates status on OSHA’s crane & derrick rule.
Legislator, heal thyself – More than 70% of congressional offices violate OSHA safety standards – but the good news is that violations have dropped. “The number of Occupational Safety and Health Administration (OSHA) violations found in each office has significantly decreased over the years as well — from an average of about 8.15 violations per office in 2007 to an average of 1.75 hazards in each office this year.” (via Advanced Safety and Health)
March is workplace eye wellness monthReliable Plant offers some tips on eye and face protection. Other resources: OSHA Eye and Face Protection; NIOSH: Eye Safety; National Safety Council: Protecting Your Eyes from Injury; Healthy Vision 2010: Occupational Eye Injuries
Briefs

Annals of Compensability: Mountain Dew, Mountain Don’t

Tuesday, March 9th, 2010

Henri Cyr was a part-time mechanic for McDermott’s, a Vermont company that transports milk from dairies to processing plants. A co-worker offered Cyr a bottle of Mountain Dew. As he was not thirsty at the time, he put the bottle in the workplace fridge. About a week later the fridge was cleaned out, so Cyr took the bottle home.
Some time later, Cyr came home after a workday, drank a couple of beers and then, feeling thirsty, he opened the bottle of Mountain Dew and took a deep swallow. Alas, the bottle contained toxic cleaning fluid. Cyr felt a severe burning sensation in his mouth, throat and stomach. He was rushed to the hospital, where blood work and urinalysis revealed that his blood alcohol level was .16, well above the legal limit for driving.
So here is the question for workers comp aficionados: is Cyr’s (severe) injury compensable under workers comp?
The initial claim was denied by the Vermont Department of Labor because Cyr was intoxicated and intoxication is an “absolute bar” to benefits – even though, we might add, the intoxication did not in any way contribute to the injury.
Now the Vermont Supreme Court has ruled that Cyr may indeed have a compensable claim. They have remanded the case back for consideration as to whether the injury arose out of “the course and scope of employment.” The majority wrote:

Here, we find that claimant’s injury arose out of his employment when he accepted the bottle containing the caustic chemicals. That act put the mechanism of injury in motion. This is not to suggest that his injury was inevitable once he received the bottle or that no superseding, intervening factor–such as intoxication–could have prevented his injury or altered its mechanism. However, no one suggests he was intoxicated at that time. …His injury would not have occurred had not his employment created the dangerous condition.

In his dissent, Justice Reiber returns to the language of the statute that precludes compensability for any injury “caused by or during intoxication [emphasis added]” He believes that compromising this absolute language in the statute runs contrary to legislative intent.
Whether he was technically drunk or sober, poor Henri Cyr was the victim of horrifying circumstances when he took a swig from the bottle mislabled “Mountain Dew.” He would have been better off if he had resorted to the beverage transported by his employer, wholesome milk.
The lingering mystery in this sad tale is how the toxic chemicals got into the Mountain Dew bottle: who did it and why? Such questions may be beyond the technical issue of compensability, but surely they are the questions most in need of answers.

AIG: Equal Opportunity Thievery?

Monday, March 8th, 2010

As the holder of a couple hundred shares of AIG stock (your condolences are accepted), I feel compelled to track the remnants of the former empire, rather like an archeologist who finds fragments of an ancient civilization buried in a forgotten forest. The latest twist involves a lawsuit by two former female staffers in AIG’s Financial Products unit – the unit at the very heart of AIG’s collapse. Susan Potter, 56, and Deonna Taylor, 62, both former VPs, have filed suit alleging that Joe Cassano, the now-fabled head of the operation, favored younger staffers and ran the rogue operation like a “boy’s club.” Now that’s a shock!
Potter and Taylor said that managers misled them about salary caps, paid younger, male employees more for similar work and fired them in retaliation for filing discrimination charges. Cassano’s lawyer is disappointed by the lawsuit, because his client treated staff “fairly.” This will be one fascinating discovery.
Raging Bull Management
Cassano is not actually a defendent in the lawsuit, as his employment ended prior to the firing of both women. But his over-sized personality placed a stamp as clear as a neck tatoo on the entire operation.
To get a flavor for Cassano’s modus operandi, check out the fascinating August 2009 profile by Michael Lewis in Vanity Fair. Here is an example [obscenity alert]:

“One day he got me on the phone and was pissed off about a trade that had lost money,” says a Connecticut trader. “He said, ‘When you lose money it’s my fucking money. Say it.’ I said, ‘What?’ ‘Say “Joe, it’s your fucking money!”‘ So I said, ‘It’s your fucking money, Joe.'”

Here’s another example of micro-management, Cassano style:

According to traders, Cassano was one of those people whose insecurities manifested themselves in a need for obedience and total control. “One day he came in and saw that someone had left the weights on the Smith machine, in the gym,” says a source in Connecticut. “He was literally walking around looking for people who looked buff, trying to find the guy who did it. He was screaming, ‘Who left the fucking weight on the fucking Smith machine? Who left the fucking weight on the fucking Smith machine?'” If that rings a bell it may be because you read The Caine Mutiny and recall Captain Queeg scouring the ship to find out who had stolen the strawberries. Even by the standards of Wall Street villains, whose character flaws wind up being exaggerated to fit the crime, Cassano was a cartoon despot.

Joe Cassano famously stated on an investor conference call: “It is hard for us, without being flippant, to even see a scenario within any kind of realm of reason that would see us losing $1 on any of those transactions.”
Ah, the irony of that line: AIG stock was trading around $55 when Cassano spoke. After all the losses and the $182 billion government bailout, the stock is worth…about a buck.
It appears that Cassano believed his own blustery rhetoric. He was no Bernie Madoff. He was Joe Cassano, True Believer:

“When he said that he could not envision losses, that we wouldn’t lose a dime, I am positive that he believed that,” says one of the traders. The problem with Joe Cassano wasn’t that he knew he was wrong. It was that it was too important to him that he be right. More than anything, Joe Cassano wanted to be one of Wall Street’s big shots. He wound up being its perfect customer.

Serving Justice?
All of which leads me back to Susan Potter and Deonna Taylor. Their complaints are likely true, yet I am having some difficulty summoning up sympathy for them. They were part of a pirate crew. They simply wanted an equal share of ill-gotten bounty. Yes, they were forced to walk the plank (terminated) in 2008 (Potter) and 2009 (Taylor). But the entire operation is scheduled for shut down later this year.
The atmosphere in the financial products operation must have been difficult for middle-aged managers, especially women. Taylor and Potter were probably paid less than their male counterparts. But when you look at the actual work of the unit, which brought the world-wide financial system to its knees, it’s difficult to feel sorry for them. Had they turned whistle blowers, had they been fired for calling attention to the house of cards being built by Joe Cassano and his pirate crew, I might feel different about their plight.
We’ll let Jim Walden, Cassano’s attorney, have the last word: Financial Products “had many capable women at all levels, including in senior management, who thrived under Joe’s supervision, including these plaintiffs. That they would now turn around and accuse Joe of tolerating, let alone encouraging, chauvinism is disappointing indeed. Joe Cassano hired, promoted and supported employees based upon a single criteria: merit.”
We can probably reduce Cassano’s philosophy to a single criteria, but it would not be “merit.” “Greed” is more like it, unadulterated, F-bomb greed.

The Annals of Law: The Caper of the Counselor’s Coat

Friday, March 5th, 2010

William Ogletree practices personal injury law in Texas. On the most recent New Year’s Eve he planned to fly from Houston to Las Vegas, presumably to celebrate the new year with libation, games of chance, and, who knows, a little extra fun in the city that tells no tales. Prior to his flight, he had dinner in the airport food court. He ate a slice of pizza, if you must know, and the service was lousy. But the real bummer involved the loss of a black leather coat, Polo brand, extra large, with a plaid lining. Ogletree was very fond of the coat, but he left it behind after his dinner. We have all lost things in the course of our lives. Most of us chalk it up to inattention, punish ourselves for being forgetful and move on. But not William Ogletree, esq. Someone not named Ogletree is going to pay for the lost coat.
As we read in the Smoking Gun blog, Ogletree has notified the operator of the food court, Continental Airlines and the city of Houston that he is holding them responsible for what happened to his coveted coat. Sure, he forgot it, but as soon as he exited the food court, the three parties assumed liability for the coat. They are jointly and severally on the hook for taking control of his lost property and securing it until he was able to claim it. He is kind of pessimistic that any of the parties will be able to locate the coat: “I am looking forward to discovering how all of you deal with lost property in the airport.I suspect that your record is dismal and that employee theft runs rampant.” [An image comes to mind: an underpaid waitress leaving work in an elegant coat that is three sizes too large.]
The Clock is Ticking
Ogletree has given the three parties 10 days to come up with the coat or $800 to replace it. After that, he sues. Now you might think that Ogletree has a pretty weak case and that the three parties will blow him off. Don’t be so sure. If you go to his firm’s website, you will find a “settlement calculator” which helps people determine just how much they are owed. Here are the elements entering into the calculation:

  • Medical Expenses $
  • Future Medical Expenses $
  • Rehabilitation $
  • Prosthetics $
  • Lost Wages $
  • Future Lost Wages $
  • Pain and Suffering $
  • Future Pain and Suffering $
  • Disability $
  • Future Disability $
  • Loss of Quality of Life $
  • Future Loss of Quality of Life $
  • Impairment $
  • Future Impairment $
  • Disfigurement $
  • Loss of Consortium $
  • Loss of Services $

I am sure that Attorney Ogletree has already plugged in his numbers and the $800 is chump change compared to the “future pain and suffering, future loss of quality of life, and future loss of consortium” directly connected to the loss of his black leather coat, Polo brand, extra large with a plaid lining. I would advise the three parties to pony up $266.66 apiece and pay the man his money. As Shakespeare meant to say, “Hell hath no fury like an attorney scorned.”
Posted by Jon Coppelman

Health Wonk Review, kabuki style, and other noteworthy news briefs

Thursday, March 4th, 2010

Fresh HWRHealth Wonk Review, Kabuki Theater Edition is freshly posted by Brad Wright at Wright on Health. In this edition of the biweekly best of the health policy blogoshphere, Brad rounds up recaps and rounds up reactions to last week’s Health Care Summit. A good edition, plus, some nice Japanese art prints!
Happening right now – On Thursday March 4 – that’s today – from 9 am to 6 pm, join OSHA’s live webcast, a first-ever live streamed public meeting. Over 200 people have registered to attend and more than 45 presentations will be made on to the Assistant Secretary of Labor for OSHA, Dr. David Michaels. If you can’t make the event, keep up with OSHA happenings on its newly launched Twitter feed: http://twitter.com/OSHA
Google & pharma – At Health Business Blog, David Williams posts about the Google crackdown on ads for online pharmacies – only VIPPS-certified pharmacies (as selected by the National Association of Pharmacy Boards) will be allowed to post adwords. This will eliminate “rogue” pharmacies, which sounds reasonable. But it also eliminates Canadian pharmacies and some smaller outfits. Consumer protection or kowtowing to the big pharma interests? Read more about the controversy.
P&C industry: don’t lump us in financial reform – have you heard about the Property & Casualty Leaders Coalition? You may yet. This is a new coalation eleven CEOs from the nation’s largest property casualty insurance companies – among them State Farm Insurance, Allstate Corp., Travelers Companies Inc., Chubb Corp., ACE Group, Nationwide Insurance, Liberty Mutual, and Zurich Financial Services Group – who have banded together to urge Congress to leave them out of the financial services overhaul legislation. “There is no public policy justification for taking funds from companies in our industry, especially on a pre-event basis, to bail out other financial institutions deemed to be overexposed to failing ‘systemic’ companies.”
How much risk is too much? – In Jobs to Die For, Yvonne Guilbert looks at people who risk their lives to work in jobs they love. One of the cases profiled is that of animal trainer Dawn Brancheau. Claims Journal features this related item: SeaWorld Death Raises Questions About Animal Entertainment Safety. And on the topic of high-risk endeavors with passionate participants, some are wondering if this year’s winter Olympics went to extremes.
Director’s cut – Here’s a topic you won’t see much about in the upcoming Oscar awards: Hollywood and risk. Fireman’s Fund dishes up its annual list of the riskiest films it insures.
Other noteworthy briefs
At Comp Time, Roberto Ceniceros ponders Schwarzenegger’s legacy and what comes next for California’s workers comp.
Check out The Great Captive Shuffle, by Dave Lenckus of Risk and Insurance: Fresh blood courses through the captive regulatory veins in Vermont, Delaware, Arizona, Utah, Hawaii and Nevada, as new faces prepare to alter the captive landscape.”
Joe Paduda always has the lowdown on the medical side of workers comp and this week, he has Texas covered in a recent pair of posts at Managed Care Matters: Texas’ efforts to add science to the art of work comp medicine and Texas’ efforts to control WC Rx.

Medicare and Physician Pay: Jim Bunning’s Bean Ball

Wednesday, March 3rd, 2010

There are four things that are memorable about Jim Bunning’s professional baseball career: First, tossing a perfect game for the Philadelphia Phillies against Trace Stallard and the New York Mets on the afternoon of 21 June 1964, lowering his ERA to 2.07 in the process (Phillies: 6 runs, 8 hits and no errors; Mets: Zip, Nada and Zilch); second, finishing second in the Cy Young voting in 1967 (Mike McCormick of the Giants won with 18 first place votes; Bunning got one, but, hey, it was good enough for the silver medal); third, from 1955 to 1963 while pitching for the Tigers, striking out Ted Williams more than any other pitcher Williams faced (and, as Jim Bouton’s Memoir, Ball Four, tells it, Teddy Ballgame did not like it one bit); and fourth, entering the Hall of Fame compliments of the Veterans Committee in 1996.
About this time in Washington, DC, there are many Republican Senators, baseball fans all, who are wishing that the 6’3″, 190 pound righthander had called it quits right there and retired to the backwoods of Kentucky. But, of course, he didn’t. He had to go ruining it all by running for and winning a Senate seat from the blue grass state in 1998; and then he did it again in 2004! The political version of the Peter Principle.
Republicans politely call him “cantankerous” – at least that’s what they say in public. Behind the scenes, they’re not so nice about it. Senator Bunning marches to his own drummer, and always has.
One Pitch, Three Strikes
He’s retiring this year, but not before throwing one more hard-breaking slider (his best pitch back in the day). On Monday he managed something he never could in the Big Leagues – he threw three strikes with one pitch. By preventing a vote on an emergency spending bill, Senator Bunning: first, at least temporarily, killed an extension of unemployment and COBRA subsidy benefits for more than a million long-term unemployed Americans; second, shot down a short-term extension of the Highway Trust Fund, which is a federal fund set up to pay for transportation projects nationwide, after which Transportation Secretary Ray LaHood said that up to 2,000 employees at the Transportation Department will be furloughed without pay as a result; and third, insured that Medicare would immediately reduce fees to physicians by 21.3% via the Medicare Sustainable Growth Rate Factor (SGR). Wow, a “threefor!”
Strike 3 is what concerns us here. We’ve written often about the steep and steadily rising costs of Medicare, and now along comes Senator Bunning saying we have to lower costs and let’s do it on the backs of hard-working primary care physicians. He certainly has a point that we need to lower Medicare costs, although he expressed it in a wild pitch sort of way. Here’s a chart from the Centers for Medicare and Medicaid Services (CMS) that shows what will happen to Medicare costs in the future if nothing changes. The vertical axis is percentage of GDP:
medicare-in-the-future.jpg
And here’s a summary from a Congressional Budget Office (CBO) Issue Brief on the Medicare Sustainable Growth Rate Mechanism (PDF). It’s from September, 2006, but is still appropriate: The Supplemental Medical Insurance program (Part B of Medicare), which will cost about $158 billion in 2006, pays for physicians’ services, outpatient hospital services, durable medical equipment, physical therapy, and certain other outpatient services. About 38 percent of those expenditures are payments for services provided by physicians, which are based on a schedule of fees that specifies the amount to be paid for each type of service. Most of Medicare’s payment rates are simply adjusted each year for inflation–but not those for physicians’ services (emphasis added). Those rates are governed by a complex formula — the Sustainable Growth Rate (SGR) mechanism.
The SGR is pegged against a target originally established in the 1997 Deficit Reduction Act. Its aim is to hold down Medicare costs. It’s calculated every year, and every year since 2004 this complex and nearly Byzantine calculation has called for an annual reduction of physician reimbursement rates by an average of 3% to 4%.
Nonetheless, every year since 2004 Congress, yielding to the medical lobby, has voted to override it by delaying the triggering of it. The trouble is, the law is cumulative. So, what Congress has done in a typically heroic display of moral courage, is to dig itself into an ever-deepening hole by not facing up to yet another looming catastrophe. Sound familiar?
Docs Rush the Mound
The AMA is nearly apoplectic about the SGR and the prospect of Senator Bunning causing it to be finally triggered. Monday, the organization was out in force in DC making its views known. The current President, Dr. James Rohack, went on Bloomberg and, later, CNN with Larry King. President-Elect Dr. Cecil Wilson even did an hour on Washington Journal C-Span answering questions from Democrats, Republicans and Independents, and, generally making his case.
And his case was that for a while now, physicians have been abandoning the Medicare ship, because, even though their Medicare fees have remained steady due to the congressional overrides, they claim they’re losing money with Medicare patients because their costs have been inexorably rising. Moreover, it’s no secret that there is an ever-increasing shortage of primary care physicians, and CMS reports that, while 92% of primary care physicians participate in Medicare, only 73% are accepting new patients. If nothing changes, that will surely drop precipitously.
Case in point – the Mayo Clinic, President Obama’s iconic national model of high-quality health care efficiency, lost $840 million on Medicare in 2008, and, as of January 1, 2010, stopped seeing Medicare patients at its Glendale, AZ, clinic. The Mayo claims Medicare covers only 50% of its costs every time it sees a Medicare Patient.
So, we’re left with another one of those rock and hard place things. Medicare could bankrupt the nation, but physicians don’t get paid enough from it.
Yesterday, Congress stole second base on Bunning by extending unemployment and COBRA benefits for another month and by delaying the 21.3% Medicare physician pay cut until the end of March, at which time we’ll probably have to go through this whole thing all over again. (Yogi Berra’s “déjà vu?)
Perhaps Senator Bunning’s out of left field move will actually cause Congress to do something it has thus far been absolutely incapable of doing regarding our nation’s health care. That is, fix it.
Right. And tomorrow 78 year old Jim Bunning will quit the Senate and to great expectations accept a $100 million free-agent contract to rejoin the Phillies as their Pitching Ace.

Noe Go: Con Man in a Corner

Tuesday, March 2nd, 2010

Four years ago (time flies when you’re having fun!) we blogged the saga of Thomas Noe, the power broker who parlayed his relationships with highly-place politicos into lucrative contracts with the Ohio workers comp bureau. The state invested $50 million of comp funds in his coin business. Unfortunately, Noe’s inventory of coins and his tracking of the funds fell short of bookkeeping standards. He was convicted on both federal and state charges. The “Coingate” scandal brought down some heavy hitters, including the governor.
In an article in the Columbus Dispatch by Mark Niquette and Joe Hallet, Noe outlines his next moves.
“God has a plan for me, and what I’m going to do (is) I’m going to make the best of my time in Hocking {Correctional Facility],” he says. Much of his time is tied up in his appeal, which is wending its way to the Illinois Supreme Court, where he subliminally hopes the judges remember him fondly: last time around, five of the seven judges removed themselves from a previous case because they had taken campaign contributions from the ever-generous Noe.
His appeal appears to be based upon a technicality: “Believe me, I’m not sitting here saying I didn’t make mistakes. I made a lot of mistakes. I’m just saying I’m not guilty, in my opinion, of what they said I’m guilty of.”
To put it mildly, the prosecutors aren’t buying Noe’s claiming of innocence.
Assistant Lucas County Prosecutor John Weglian says: “He’s a liar.”
“There isn’t a single embezzler in the history of embezzling, I think, who has not intended to pay the money back,” Weglian said. “They all say that. … He’s a salesman; he’s trying to market himself.” (With all due respect, Mr. Weglian, Bernie Madoff knew all along he was never going to pay people back.)
Accentuate the Positive
For the disgraced Noe, the marketing options from a jail cell are clearly limited. But Noe prides himself on being a positive person.
“I’ve always said a negative thought’s a down payment on failure. I’m not going to fail. I’m not going to fail on the outside. I’m not going to fail as a prisoner.”
One might argue that Noe’s conviction on multiple charges of corruption was a failure on the outside, and that his prospects for success from the “inside” are remote. But as Noe says, it’s just part of God’s plan – a plan, at the moment, that calls for another decade or so in Hocking. The former high roller used to enjoy steaks and cabernet at the best restaurants in Ohio. His current fare falls rather dramatically short of that standard, but, heck, it’s free and there’s no tipping.
It would be nice to think that if he ever gets another opportunity to make business decisions on the outside, Noe will have learned how to say “no way” to the Noe Way. I’m not exactly holding my breath.

On redefining disability

Monday, March 1st, 2010

When is a worker disabled and unable to do his or her job? This is an issue that surfaced in a recent post about an employer that was reluctant to make workplace accommodations for employees who had been injured on the job but who wanted to return to work. This case came to mind again after viewing a presentation by record breaking athlete Aimee Mullins. In her most recent appearance at the TED conference, Aimee delivers an outstanding talk that properly redefines the word ‘disabled.’ The video clip is about 22 minutes, but it’s guaranteed to be one of the best things you see this week. Here are a few excerpts that we liked:
“It’s not just about the words, it’s what we believe about people when we name them with these words – it’s about the values behind the words and how we construct those values. Our language affects our thinking and how we view the world and how we view other people.”
“…we have to make sure that we don’t put the first brick in a wall that will actually disable someone. Perhaps the existing model of only looking at what is broken in you and how do we fix it serves to be more disabling to the individual than the pathology itself. By not treating the wholeness of a person, by not acknowledging their potency we are creating another ill on top of whatever natural struggle they may have.”

More about Aimee Mullins
TED profile – with links to additional presentations she has made
Aimee Mullins website
Aimee Mullins on Wikipedia