Posts Tagged ‘politics’

Fresh Health Wonk Review at medicareresources.org blog – check it out!

Friday, February 10th, 2017

Steve Anderson has posted the latest and greatest Health Wonk Review – the #alternative_facts Edition at medicareresources.org blog.

The Affordable Care Act (aka Obamacare) is not all that’s on our wonks’ minds of late, but it certainly takes up a huge portion of the mind share as evidenced by the plethora of related posts. We are a diverse crew, though, so there are also posts about a variety of other topics: the reaction to/impact of the immigration ban on healthcare industry, best cancer treatments, the process of healthcare M&As, legal liability in the form of class action suits for a data breach. and workers comp. One thing we find: the contributors are all very knowledgeable people – even if a topic is not on your radar, it’s a good way to learn something new.

Two posts we think are particularly worth calling out:

If ACA is repealed, how many will max out on restored lifetime coverage caps?

If ACA is repealed, how many are at risk of losing coverage by U.S. Congressional District? (Data covers 35 states)

Honor Sold, Trust Betrayed: Unbridled Greed in California

Wednesday, February 26th, 2014

“What is here?
Gold? Yellow, glittering, precious gold?”

— Timon of Athens by William Shakespeare
Suppose you’re a doctor in California with a patient who complains that his back hurts a lot. Suppose further that Michael Drobot, the owner of California’s Pacific Health Corporation, will give you $15,000 if you refer your patient to his Pacific Hospital of Long Beach for lumbar fusion surgery, which may or may not be warranted. And what if Drobot’s Pacific Hospital were hundreds of miles away and that other qualified hospitals that wouldn’t pay you a kickback were much closer. What would you do?
It is illegal under both California and Federal law to pay doctors for referring patients to hospitals. Yet, according to Andre Birotte, Jr., U.S. Attorney for the Central District of California, this is precisely what Drobot was doing on a massive scale in California from 2003 through 2008. The kickbacks amounted to between $20 million and $50 million. That was chump change compared to what Drobot netted from the surgeries. On Friday, Birotte announced that Drobot had pleaded guilty to paying the kickbacks in what amounted to a $500 million dollar fraud conspiracy and now faces up to 10 years in prison.
Drobot began building his health care empire in the mid-1990s. He bought a number of hospitals, but Pacific Hospital was his jewel in the crown. It was his “spine center,” and, according to U.S. Attorney Birotte, it is where doctors, who apparently think the Hippocratic Oath a mere suggestion, would refer patients for questionable lumbar fusion surgery at $15,000 per surgery. That is, unless the referral was for a cervical fusion, in which case the kickback was only $10,000. Needless to say, there were more lumbar fusions.
Workers compensation paid for all of this. More than 150 insurance companies were “ripped off,” according to Eric Weirich, Deputy Commissioner of the California Insurance Department’s Enforcement Branch.
The Los Angeles Times has been covering the Michael Drobot saga for the last 6 years. Drobot’s Pacific Health Corp. got itself out of big trouble in 2012 when it agreed to pay $16.5 million dollars to the government to avoid criminal conspiracy charges. From 2003 to 2008 it recruited homeless people, drove them to one of Pacific Health Corp’s hospitals and then charged Medicare and Medicaid for services never performed. The whole thing makes “ambulance chasing” look like a PBS donor acknowledgement.
But that little traipse into the dark side pales in comparison to the spinal fusion scheme.
In 2012, California SB 863 threatened to put more than a little crimp in Michael Drobot’s hose of money. Up until SB 863, Pacific Health Corp was paid highly inflated prices for both the surgeries and the surgical hardware, because it could charge duplicate invoices for the surgical implant hardware. The provisions of SB 863 would have severely limited duplicate payments beginning 1 January 2013. If Dobrot couldn’t collect the duplicate payments he wouldn’t be able to pay the kickbacks to get the patients he needed to keep the scheme going. He desperately wanted those provisions to be mitigated to some degree. To do that, he needed help.
He got it from friends in high places – the California Legislature. It’s a little murky as to method, but prior to final passage, SB 863 was changed to allow half the duplicate payments to continue, status quo, for all of 2013. The authorities have been looking into this, and U.S. Attorney Birotte has begun to reel in the fish.
The day before he indicted Michael Drobot, Birotte indicted state Senator Ron Calderon and his brother, former Assemblyman Tom Calderon, on 24 charges, including bribery and money laundering. Ron Calderon is alleged to have been paid more than $100,000 in bribes by Michael Drobot and in an FBI sting operation that Calderon thought was a film studio. If convicted, he faces up to 400 years in prison. And that’s the blood in the water that California’s media sharks now circle. Here’s an LA Times infographic of the Calderon family’s tree of connections and alleged corruption.
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However, as that great TV salesman, Ron Popeil, used to say, “But wait! There’s more!”
An FBI affidavit leaked to, of all places, Al Jazeera America, is making life uncomfortable for at least four other legislators, including Senate President Pro Tem Darrell Steinberg. Look deeply enough at this and one begins to think that Teapot Dome was nothing more than a benign business deal gone bad. (See the full associated Al Jazeera story: State Compensation Insurance Fund’s lawsuit against Michael Drobot)
Notwithstanding all of this, I keep coming back in my mind to those doctors, those chiropractors, those medical professionals who sold their souls and endangered their patients for all that “yellow, glittering, precious gold.” I ask, “Where is the outrage?” At some point, one hopes that U.S. Attorney Birotte turns his eyes to them.

Massachusetts Insurers Take One for the Team (Again)

Tuesday, September 11th, 2012

I have written before about what I consider to be a true Massachusetts Miracle: The 1992 reform of the Commonwealth’s workers’ compensation system and the results achieved following that reform. Bottom line – premium rates in Massachusetts are among the lowest in the nation while benefits are among the highest.
To make that happen back in 1992 all of the varying and vested constituencies had to come together and enter a grand compromise where everyone lost something so that the system could flourish as it has ever since (I won’t bother to mention that the current crop of folks we Americans have sent to the nation’s capital might learn something from this).
Employers and injured workers have benefited hugely from the 1992 reform. Insurers not so much, especially lately. Early this year, the Massachusetts Workers Compensation Rating and Inspection Bureau, representing insurers doing workers comp business in the Commonwealth, requested that Massachusetts Commissioner of Insurance, Joseph G. Murphy, approve a premium rate increase of 18.8%. After the Division held hearings and thought about it for a while, Mr. Murphy announced that he was denying the request – all of it. Result: Status quo, just as in New York a few weeks earlier. But if you think about it, this might actually be an insurer victory of sorts, because Massachusetts Attorney General Martha Coakley had made her own rate filing, which called for a reduction in rates of 8.8%. After Commissioner Murphy announced his decision, Ms. Coakley issued a press release saying, “The industry’s request to raise rates could not have come at a worse time for small businesses in Massachusetts.” She also congratulated herself and Commissioner Murphy by saying, “The decision will save Massachusetts workers compensation insurance customers approximately $175 million compared to the rates they would have paid if the proposed rate hike was approved.”
The decision will also cost the Commonwealth’s insurers the same $175 million.
But let’s get real for a minute. As Bill Clinton said last week, “It’s all about the arithmetic.”
Now, there are many variables impacting premium rates in any state. For example, workers compensation medical loss costs have been rising in Massachusetts. Just a couple of years ago they comprised an enviable 36% of total loss costs; now they’re up to about 40%, and rising. But I thought perhaps I could put things in perspective if I just looked at the Massachusetts evolutionary development of a few key factors since the 1992 reforms. And those factors would be workers compensation premium rate changes, wage development and the progression of the CPI. The data in the chart below is taken from the Bureau of Labor Statistics, the Massachusetts Division of Unemployment Assistance and the Massachusetts Department of Industrial Accidents (DIA), summarized in the Massachusetts Division of Insurance’s Annual Report of 2010 (PDF) and DIA Circular Letter 336, dated 6 October 2010 (PDF).
ma-rate-changes
In the 17 years since 1994, there have been six years with double digit rate reductions, the largest being 21.1% in 1998, five years with single digit reductions, ranging from 1% to 4%, five years without change, and one year with a whopping big rate increase of 1%. The result is that rates in Massachusetts are where they were in the early 1980s. One by-product of this situation is that many Massachusetts employers seem to have lost the sense of urgency when injuries occur.
On the other hand, the CPI has increased every year since 1994 with the exception of 2010, when there was no change (it’s interesting to compare the CPI development with periods of recession; look at 2009 and 2010, for example), and the average weekly wage in the Commonwealth has grown from $586 in 1994 to $1,088 in 2010 (in 2012, it’s now more than $1,100).
The result shows a steady increase in costs and a steady decline in rates. I have to say that the reductions from 1994 through 1999 were entirely appropriate; those are the result of the 1992 reform. However, the six years with reductions since then, totally 28.3%, are questionable.
The consequences of both Commissioner Murphy’s current decision as well as the recent reductions are now being felt. The Massachusetts Assigned Risk Pool is growing quickly; in the last year it’s jumped from 12% of the market to 15% ($152 million in premium), and that was before the decision of two weeks ago. It would not surprise me to see Pool growth accelerate in the immediate future.
You can only keep the pressure cooker’s lid on for so long.

How does your state score for insurance, ethics, accountability, corruption?

Tuesday, March 27th, 2012

Here’s a quick summary. In a 50 state overview, there were no “A” students.
The State Integrity Investigation is a $1.5 million public collaborative project designed to expose practices that undermine trust in state capitols — and spotlight the states that are doing things right. It describes itself as “an unprecedented, data-driven analysis of each state’s laws and practices that deter corruption and promote accountability and openness. Experienced journalists graded each state government on its corruption risk using 330 specific measures. The Investigation ranked every state from one to 50. Each state received a report card with letter grades in 14 categories, including campaign finance, ethics laws, lobbying regulations, and management of state pension funds.”
Click on the U.S. map to see your state’s corruption risk report card. No states scored an “A.” New Jersey, Connecticut, Washington, California, and Nebraska scored in the “B” range. Eight states flunked, scoring 60% or less: Michigan, North Dakota, South Carolina, Maine, Virginia, Wyoming, South Dakota, and Georgia. All the remaining states were “C” and “D” students, with our home state of Massachusetts scoring a lackluster 74%, coming in at 10th “best” overall.
How did the insurance departments score?
As citizens, both corporate and private, we find the whole report fairly intriguing, but for the purposes of this blog, we were particularly interested in the ratings for State Insurance Commissions. PropertyCasualty360’s Mark Ruquet did a good analysis of this in his article 16 State Insurance Commissions Fail Integrity Evaluation.
The state Insurance Commissions were evaluated on these questions:

  • Is the state insurance commission protected from political and special interest influence?
  • Does the state insurance commission have sufficient capacity to carry out its mandate?
  • Are there conflicts of interest regulations covering members of the board and senior staff of the state insurance commission?
  • Are the conflicts of interest regulations covering members of the board and senior staff of the state insurance commission effective?
  • Can citizens access the asset disclosure records of the state insurance commission?
  • Does the state insurance commission publicly disclose documents filed by insurance companies?

One of the things we like about the map and the site is that you can keep drilling down. Click your state, then click a specific category – such as “State Insurance Commissions,” “Ethics Enforcement Agencies” or “Public Access to Information” and then click again to see the specific areas that were evaluated. Click any one of those criteria to see how the score was derived, and click again for further detail. You can also read or submit comments. On each individual state page, there is also a narrative story behind the score and a running list of related news articles.
We’ll be spending some time exploring the site further, but our first reaction is positive and we applaud the effort: we love sunlight when it comes to the public good and think it benefits everyone. We’d love to hear reactions about how accurate or inaccurate readers think reports are relative to their own state scores.

Health Wonk Review’s Memorial Day Edition

Thursday, May 26th, 2011

Chris Fleming hosts a substantive Memorial Day issue of Health Wonk Review at Health Affairs Blog – there are a lot of good submissions on a variety of topics, from Medicare and the Affordable Care Act to quality and healthcare IT.
If you have an interest in health care – and with medical costs comprising a bigger and bigger portion of the claims dollar every year, you probably do – Health Affairs Blog is a good candidate for your regular reading list. The Blog is an offshoot of the publication of the same name, a peer-reviewed health policy journal that has held a premier place in the health policy arena for the last 30 years. The blog is a welcome adjunct to the journal. According to their “About” page: “The Blog features posts from noted health policy experts on both sides of the political aisle as well as regular Health Affairs contributors and staff. Recent bloggers have included Former Bush HHS Secretary Tommy Thompson, economists Uwe Reinhardt and Gail Wilensky, California HealthCare Foundation President and CEO Mark Smith, and Congressman James Cooper (D-TN).”

Illinois Comp: The Nuclear Option?

Tuesday, May 17th, 2011

Illinois is struggling mightily with its bloated workers comp system. Currently ranked 3rd highest for overall cost in the Oregon study, the governor and legislature are under intense pressure from the business community to lower the cost of comp insurance. Aiming its powerful bulldozers at the state capital, the Caterpiller Company has threatened to move their business somewhere else if reforms are not implemented immediately. In exploring all options, the legislature has gone so far as to think the unthinkable: abolishing workers comp.
In looking for ways to save money, Illinois does what all states do: first, identify the cost drivers and then try to change the statute to bring down costs. Among the hot issues on the table are the medical fee schedule (too generous), employee choice of doctor (too flexible), duration of benefits (too long), causation (too vague). Ah, behind every cost driver is a vested interest (perhaps literally vested, with many of the lobbyists wearing three piece suits). The common denominator among all states struggling with high comp costs is the omni-present stakeholder, who is deeply committed to the status quo.
Governor Quinn would like to see a number of reforms, including the capping of carpal tunnel benefits, denying claims where employee intoxication is a significant factor, attacking fraud (see our blog on Illinois’s dubious arbitration services), capping wage differential benefits at age 67 or five years after an injury, and implementing utilization review for physical therapy, chiropractic and occupational therapy services.
Going Nuclear
The Illinois legislature is so frustrated with the slow progress and with stakeholder resistance to change, they are now threatening to blow up the entire system. Interesting to note, this pressure is coming from the Democrats. John Bradley (D-Marion) has filed House 1032, a bill to repeal the workers comp act and send all workplace-injury issues into the court system. Should this happen, Illinois will find itself in the world prior to 1912, when injured workers had to sue their employers and could collect benefits only if their injuries were caused by someone other than themselves. They would collect no benefits while awaiting adjudication of their claims. They would be out of work and out of luck.
In all likelihood, repeal of workers comp is not a serious option in Illinois; it’s a political strategy for getting the attention of inertia-bound legislators. But the prospect of abolition does raise an interesting issue. Workers comp came to America 100 years ago. By the end of the World War II, every state had implemented the program.
What if there were no workers comp programs today? What if each state were starting from the beginning and tackling the issue of protection for injured workers? I find it hard to imagine that state legislatures would be willing to implement a program, totally funded by employers, that provides indemnity for lost wages and 100 percent medical benefits for injured workers. Why so generous? Why so inclusive? It’s too expensive. It will create disincentives for working. The cost will drive employers out of business or out of state.
With today’s acrimonious, ideology-driven debates, workers comp would be a hard sell. That’s too bad, for despite its problems and inequities, despite the wide variations in benefits and costs from state to state, comp is a compelling example of effective social engineering. In Illinois, cooler heads will likely avoid the meltdown option. To be sure, Illinois comp is a mess, but the alternative – a workplace without workers comp – would be far worse.

Are events in Wisconsin part of a union busting initiative?

Tuesday, March 8th, 2011

Later this month, we will mark the 100 year anniversary of New York’s horrific Triangle Shirtwaist Fire, an event that claimed the lives of 146 garment workers – young girls and women – who had been locked in the sweatshop to prevent theft. Most died in stairwells, jumping down the single elevator shaft, or by hurtling themselves from 9th story windows in desperate attempts to escape the fire. PBS recently ran a special on this disaster. (If you missed it, you can watch online: Triangle Fire). My colleague Jon Coppelman has also written about the fire in his post The Original “No Exit”.
This fire was a watershed event that galvanized the nation. It occurred in an era where there were no regulations or labor protections. Workers often worked 12 hour shifts, 7 days a week. There were no child labor laws or safety mandates. Ironically, the day before the Triangle Fire, New York courts had struck down the state’s first compulsory workers compensation law as unconstitutional.
This tragedy, along with some of the horrific mine disasters that resulted in wholesale loss of life, were catalysts which led to the enactment of various worker protections – including statutory workers’ compensation.
Meanwhile, today in Wisconsin …
We think this bit of history is an important backdrop to what’s going on in Wisconsin today.
Wisconsin has the distinction of being the first state in the union to have enacted a workers’ compensation law that survived legal challenge in May of 1911. In fact, the state of Wisconsin has a long, storied and sometimes bloody history of being on the front lines for worker rights. Workers and labor unions were in the forefront of the fight for the 8-hour day and the 40-hour work week. In 1932, Wisconsin was the first state to enact unemployment compensation.
To any who know this history, it comes as no surprise that, once again, Wisconsin is on the front lines in the battle for labor’s future.
It’s the budget, stupid – or is it?
The ostensible issue, according to Governor Walker, is that the state of Wisconsin is broke and a large part of the problem lies with overly generous benefit packages of public workers – teachers, prison guards and the like – which are said to be crippling the state. He called on unions to do their part and to make a sacrifice for the greater good.
All that might be well and good. The unions have indicated their willingness to take a financial haircut. But the part of Governor Walker’s Budget Repair Bill that is going over somewhat less well is a call for the elimination of collective bargaining — and therein lies the rub.
With a Republican majority in Wisconsin’s House and Senate, the bill was all but a given until the Democratic senate contingent fled the state to prevent a vote. Since that time, there have been massive protests over three weeks and the so-called Fab 14 remain holed up in un-named Illinois’ hotels. And there has been no shortage of drama in this story: an embarrassing and revelatory 20-minute prank call to Governor Walker from an impersonator of corporate financier David Koch; and a sheriff’s refusal to play the role of “palace guard”, among other things.
Part of national union busting agenda?
Critics of Walker’s Budget Repair Bill say that the issue is not about budget balancing or overly generous benefits, but an ideological push to eliminate or curtail public unions – in a phrase, union busting. Opponents say that this is a corporate-funded campaign to eliminate public unions in Wisconsin and other states, and to privatize many institutions that are currently staffed by public workers. No less a staunch Republican than former Congressman and now host of MSNBC’s “Morning Joe” program, Joe Scarborough, has publicly called Governor Walker’s actions, “Un-American.”
In Wisconsin, suspicions are high because Koch enterprises funded a large part of Walkers gubernatorial campaign. The fact that the budget bill contains a provision authorizing Walker to conduct no-bid sales of some state properties also heightens suspicion. Many are troubled by his plans for privatization of some public services. In his prior role as Milwaukee County Executive, Walker also used budget emergency as a justification for privatizing security guards, a move that proved less than successful.
Other states have also embarked on this path: Ohio may be making more headway in curtailing unions. In Indiana, Democratic legislators have followed Wisconsin’s lead and left the state to postpone a vote. In Rhode Island, nearly 2000 teachers have been dismissed. Other states may be contemplating similar measures, although some may be a bit shy of action given the shifting public sentiment, which favors retention of collective bargaining and has given Walker a black eye – to a point where voters say they would not elect him again if they had a do-over. (see Wisconsin Public Research, Rasmussen, USA Today/Gallup, Public Policy Polling and various other polls. )
It’s uncertain what will happen in the next chapters, but we will be watching. It is clear this is another watershed point in labor history, a public policy fork in the road, perhaps the beginning of the end of the movement that was propelled into mainstream America by that terrible fire 100 years ago. While polling indicates that sentiment is currently on the side of the teachers in this dispute, the future of public unions is under serious threat. Is the role of unions obsolete? Has the public dialogue achieved an equilibrium between the rights of workers and those of management?
At Lynch Ryan, we have great respect for unions, which have historically played a critical check-and-balance role in labor-management power dynamics. They have also been in the forefront of the fight for worker safety and other worker protections. We also admire and respect many employers we have been privileged to work for who are perceptive and wise enough to manage their companies so well that unions are not needed. We’d like to say that all employers are this enlightened and do not need union checks and balances to do the right thing, but unfortunately our experience tells us that this is not always the case.

The Politics of Workers Comp Rates

Wednesday, May 12th, 2010

Massachusetts has the lowest workers comp rates among the major industrial states and just about the lowest rates in the nation. The cost of comp in the other New England states is roughly double that in the Bay state. So you would think that the rates in MA would at best stay the same from year to year, or increase slightly. Well, think again. Martha Coakley (yes, that Martha Coakley), the current and future Attorney General, has brokered a deal for yet another rate reduction: an average of 2.4 percent across all classifications. The insurance industry had argued for an increase of 4.5 percent. I guess they did not exactly convince Martha.
The AG thinks that the insurers are overstating future losses. In my experience with carriers operating in MA, they are actually understating losses, but that’s a matter for the actuaries. If, as the AG argues, rates are too high in MA, what can you possibly make of rates in the other New England states and across the country? Are MA employers really that much better at preventing injuries and at getting injured workers back to their jobs? If you buy that argument, I have a nice bridge spanning the Mystic River that you might be interested in owning.
The trends in MA are no different from those across the country: while frequency is down, severity is rising at an alarming rate. In MA, severity is spiraling out of control. The state’s generous wage benefit structure, combined with a first rate (and pricy) medical system and a judiciary that tilts strongly toward the injured worker, are making six figure reserves all too common. It’s truly puzzling that the AG can look at the performance numbers for the insurance industry and conclude that rates are too high. They are way too low.
Politics: Local and Loco
It’s not hard to fathom why an elected official chooses to drive deflated rates even lower. It’s politically popular; any rate increase – even the marginal bump proposed by the industry – would be met with howls of outrage from small businesses, who are already under seige in a struggling economy. Strange to say, the depressed cost of comp is subsidizing the otherwise high cost of doing business in MA.
The AG is not finished with her rate scalpel: she thinks a few more points can be carved out next year. It will be fascinating to see how the carriers respond. Not too many folks think there is much money to be made in MA comp. And that rapidly dwindling club is about to get a lot smaller.

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.

Health Wonk Review: SCHIP Veto, Health Reform Prospects, and more …

Friday, October 5th, 2007

Jane Hiebert-White has posted a most excellent edition of Health Wonk Review at the Health Affairs Blog. Among other matters, she takes the pulse of the blogosphere in the aftermath of the presidential veto of the State Children’s Health Insurance Program (SCHIP). As the political debates about health care and health care policy heat up from now to the election, HWR offers a great bi-weekly snapshot.