Wednesday, January 13, 2010

The latest nuttiness from Britain's government health scheme

Note: No acknowledgment that medium-weight people live LONGER than skinny people

Overweight people could be paid up to £1,750 for slimming under the latest trial involving NHS trusts and privately-run schemes. Earlier this year, the Telegraph disclosed that NHS has spent more than £3m in three year sending overweight patients to slimming classes at taxpayers’ expense. The latest trial follows a successful pilot in Kent where patients earned up to £425 from private firm Weight Wins for meeting weight loss targets.

Although the NHS pays a £185 administration fee for enlisting each patient, the bonus payments are made by Weight Wins. Eastern and Coastal Kent Primary Care Trust, which supervised the pilot involving about 400 NHS patients and about 150 private members, said it was pleased with the results.

One person in the pilot earned the maximum £425 payout after reaching the target of losing three stone 8lbs (50lbs) in seven months and keeping the weight off for six months. The scheme has now been extended and the maximum payments increased to £1,750 for shedding ten stone in 21 months. Other NHS trusts are understood to be taking part in the latest trial.

In 2006, the NHS's rationing body, the National Institute of Health and Clinical Excellence, recommended that GPs send patients to free slimming classes, because it was cheaper than weight loss pills or stomach stapling. Since then, Slimming World has sold more than 53,000 vouchers costing £45 to the NHS at a total cost to the taxpayer of more than £2.3 million.

In 2007 and 2008, more than 20,000 people were referred from the NHS to Weight Watchers, for courses which cost the NHS £35 per head, and £700,000 in total.


Australian public hospital negligence: Couple forced into dangerous baby delivery at home

And the response is theorizing. No inquiry ordered. It needs a front-page story in a major newspaper to generate an official inquiry

A Stafford Heights couple forced to deliver their baby alone at home are seeking a ``please explain’’ from their hospital. Royal Brisbane & Women’s Hospital (RBWH) sent Louisa Tomon home seven hours after she presented at the maternity ward on December 22.

When Mrs Tomon returned to her parents’ house, she knew the baby was coming. The Tomon’s called the ambulance ``straight away’’, but within 10 minutes the baby had arrived. Husband Matt Tomon delivered baby Julian despite the umbilical cord being wrapped around his neck.

``The first few minutes weren’t great, he was pretty blue when he came out and wasn’t really breathing and then he eventually started crying,’’ Mr Tomon said. "It was the best sound. It’s just one of those situations, it could have been a lot worse.’’

They question why they were sent home when Mrs Tomon claimed to have had three contractions every 10 minutes and had undergone an internal examination, a process known to kick-start childbirth.

RBWH executive director of Women’s and Newborn Services, Professor Ian Jones, said there were often a variety of reasons for a patient to leave a birthing suite after being admitted. ``One of the most common is because contractions become less intense and less frequent, or stop all together,’’ he said. ``This is called spurious labour.’’

Professor Jones said in these cases the patient was given the option to go home and return if they progressed to labour, or be admitted to an appropriate ward. Professor Jones said there was no evidence to suggest the high standard of care was not followed in this case.

Queensland Minister for Health Paul Lucas did not wish to comment specifically on the case but a spokeswoman for the minister said: ``If the patient or any patient has any genuine concerns they are welcome to contact the Health Quality and Complaints Commission (HQCC) regarding this.’’


Obama health reform bill makes Bernie Madoff look like a piker

Today the Wall Street Journal asks what many of us have been asking for quite some time – why aren’t the numerous and specific warnings about the real cost and destructiveness of the proposed health care plan being heeded?

Of course the simple answer is those who are determined to take health care under the government’s purview really don’t care – they finally have the opportunity long denied them and they plan on taking advantage of it. So, much like the “science” of man-made global warming, they’ve picked their narrative, settled on it and will not entertain anything which might impede them from attaining their goal – government control of the health care market.

Those who’ve read this blog are very familiar with how Democrats have gamed the system (CBO’s statutory 10 year window) and used cheap accounting tricks (collect taxes immediately, don’t start paying benefits for 5 years – gives the appearance of bending the cost curve down) to make the case that they’re actually spending less on health care over the years and saving us from the bankruptcy they claim the status quo will eventually bring.

Another report, which I mentioned last week, carries a devastating warning about the plan being considered behind closed doors by Congressional Democrats. Yet it has received no major media exposure.

It is the Centers for Medicare and Medicaid Services (CMMS) report. And chief actuary Richard Foster is very candid about the impact of what Congress is planning. Not the smoke and mirror show Congress puts out there, but a peek at the reality of what Congress is proposing:
Richard Foster, the chief actuary for the Centers for Medicare and Medicaid Services, reports that under his analysis national health spending will rise under the bills by $222 billion over the next 10 years. In other words, ObamaCare really does “bend the cost curve”—up.

Even that estimate exists only on paper, as Mr. Foster has the honesty to admit. Because “most of the coverage provisions would be in effect for only six of the 10 years of the budget period, the cost estimates shown in this memorandum do not represent a full 10-year cost for the proposed legislation,” he writes. The report is punctuated by phrases like “unrealistic” and “doubtful,” and Mr. Foster adds that “the scope and magnitude of these changes are such that few precedents exist for use in estimation.”

Let’s stop right here with the obvious point to be made. The $222 billion, as mentioned, is the estimate for the next 10 years. However, as Foster points out, the spending would occur in only 6 of those 10 years. So that spending is offset by 4 years of revenue collection. If we remove that buffer and simply take 6 into 222 and then multiply it by 10, we’re most likely a bit closer to the real spending number than the contrived one – $370 billion, a difference of a mere $148 billion. Or, in reality, the $222 is a number that was tweaked to ensure when it was added to the other numbers the total fell below the threshold of $900 billion – the point at which it was claimed the cost curve would be bent upward. Had Congress found that to get to the number they needed they would have to collect taxes for 10 years and not provide benefits for 8 years, that’s how the bill would have been written.

It was never really about actually bending the cost curve down – it was all about creating the perception that the cost curve was being bent down, nothing more.

And there’s more to understand about that $222 billion number:
That $222 billion is a net figure, even after accounting for the fact that most of the newly insured—18 million people—will be dumped into Medicaid, “where provider payment rates are well below average.” And for the fact that ObamaCare is “paid for” only in the sense that Medicare’s payments to doctors are assumed in the bill to be cut by more than 20% this spring and even deeper after that, which will never happen in practice.

Mr. Foster adds that other planned Medicare cuts would damage doctors and hospitals: “Over time, a sustained reduction in payment updates, based on productivity expectations that are difficult to attain, would cause Medicare payment rates to grow more slowly than, and in a way that was unrelated to, the providers’ costs of furnishing services to beneficiaries.” This is how price controls would work in practice, even as Medicare has hit its spending targets only four times in the last 25 years.

Again, we know that Congress plans a “doc fix” which will amend the law to keep the 20% cut from taking place this year. And there’s nothing, given the history of this program, that argues that 20% cut will ever take place. It is a figure based on an assumption that will most likely never happen. Note well the last sentence – with an addition of 18 million new Medicaid insured, how many times in the next 25 years do you supposed Medicaid will hit its spending targets? You might also want to keep in mind that is mostly a federally mandated program administered by the states who share the cost. What will this addition of 18 million new insured do to state budgets – especially if the assumed cuts in payments are never made?

But let’s say Congress, somewhere along the line, finds the intestinal fortitude to cut those payments to providers as they say they are. What would be the impact?
He says many providers will be forced to stop accepting patients who are insured by the government, as opposed to those who have private coverage “with relatively attractive payment rates.” The resulting two-tier health-care system “should be considered plausible and even probable initially.”

If they cut, those patients they bring on may not be able to find a health care provider, so the patients suffer. If they don’t make the cuts, spending goes through the roof and the taxpayer suffers. It’s a lose/lose. But what should be patently obvious to anyone reading all of this is the $222 billion net spending claim by Congress for this particular part of the health care reform bill is as bogus as their promise of transparency.

Just delving into the particulars of this one portion of the bill should disabuse any objective person of the belief that what is being proposed is going to cost less than what we presently have. It is all a wretchedly wrought political fa├žade designed to gain your support for long enough to pass this monstrosity. And my guess is should it pass, we’ll all be poorer and eventually sicker for its passage.


Medicare rationing begins in 2011

House and Senate Democrat leaders, and President Obama, argue that they can "pay for" health insurance "reform" by cutting $500 billion from Medicare spending over the next decade—largely through arbitrary reimbursement cuts,— without reducing the quality of care delivered to beneficiaries.

Yet, in January, 2011, Medicare will implement a new payment system for patients receiving dialysis for end stage kidney disease that will severely ration care to this vulnerable (and largely minority) population based on equally arbitrary payment reductions. These patients will be the unfortunate canary in the Medicare coal mine: "reform" legislation will expose millions of Medicare patients to rationing and reduced quality of care.

In 1972, Congress passed legislation creating an entitlement to Medicare for patients diagnosed with end stage renal disease. The bill allocated about $140 per treatment (or $1820 per month) per patient. This facility fee was large enough to incentivize the creation of dialysis centers, the expansion of dialysis treatment to all patients, and an end to what were very real "death panels." The ESRD program became a model for what good government could accomplish. There was broad consensus that payment for this catastrophic illness was a legitimate federal function and use of taxpayer funds. Unfortunately, Congress neglected to index the payment for inflation, leading the constant-dollar value to dwindle to around $14 per treatment. Dialysis units were able to survive, and even prosper, by aggressive cost-cutting (substituting technicians for nurses), consolidation into ever-larger chains, boosting efficiency (sometimes by cutting treatment times with a negative impact on outcomes), and by generating revenue from sales of drugs used during dialysis.

In the late 1980s and early 1990s, recombinant erythropoietin (Epogen®, manufactured by Amgen) was introduced to treat the anemia associated with chronic kidney failure. An active vitamin D analog (Calcijex®, by Abbott) was also synthesized to replace deficiencies associated with kidney disease. Both drugs were administered during each dialysis session intravenously, and were paid for separately by Medicare. Medicare paid dialysis units 95% of the average wholesale price for these drugs. The units, especially the large chains, were able to buy at deep discounts below the AWP, generating significant margins. These margins became the major source of profit for dialysis units over time. A debate of the scientific merit of using these agents and their clinical outcome benchmarks is beyond the scope of this article. But clearly the payment model that had evolved led to incentives to prescribe that were potentially hazardous, and needed reform.

Evidence that treatment of anemia might not be beneficial or benign emerged in 2006, and this led to partial payment reform. Congress, in 2003, also instructed the Center for Medicare and Medicaid Services to come up with a "bundled" payment system for dialysis in which one payment per treatment would cover these additional medications. Under contract with CMS, the University of Michigan Kidney Epidemiology and Cost Center provided early in 2008 a detailed report on how this could be instituted. Congress then mandated implementation of a bundled payment system by 2011.

The UM-KECC model proposed payment of roughly $235 per treatment, with some adjustment for local wages and patient case-mix variables. Using this methodology, small dialysis providers Premila and Ganesh Bhat modeled their patient population in an article published in Nephrology News and Issues in June, 2009. They estimated losses in excess of $100,000 per year.

Last month CMS shocked the nephrology and dialysis community when they issued the final rule: Payment would be $198 per treatment. In addition, oral drugs typically used by dialysis patients were to be included in the bundle, with only an extra $14 per treatment thrown in to cover this added burden.

Nephrologists prescribe medications to dialysis patients to limit absorption of phosphorous from foods, and other drugs to treat the bone disease that accompanies kidney failure. Some of these are expensive, but are often covered under private insurance, Medicaid, or Medicare Part D (Full disclosure: I have received honoraria from companies that manufacture several of these drugs). Again, this is not the forum to debate the relative merits of these medications. However, no one in the medical community thinks they should be banned, or their use severely curtailed.

Yet that is what will almost certainly happen if the current scenario is enacted (The official comment period ended on December 16). Dialysis providers have already been looking at different strategies to lower the use of epogen and vitamin D analogs to minimize the financial impact of bundling. There is no question that similar cost-saving strategies will be used for these outpatient drugs. Formularies will almost certainly be introduced that will make it difficult for physicians to prescribe expensive oral medications since these will now be coming out of the dialysis unit budget.

The new rule contains even more disincentives for high quality dialysis care, including higher levels of federal micromanagement, lack of incentives for home dialysis, pressure to limit laboratory testing and hospitalizations, and increased staffing that would be required to administer outpatient medications. The end result is a highly restrictive practice environment that imposes de facto rationing of care to the most vulnerable population of Medicare patients.

Remember that the current payment structure is a result of congressional mismanagement of the basic dialysis payment. The "solution" now being proposed will greatly increase financial pressure on the dialysis industry and will very likely lead to bankruptcies and closures of many independent units, further limiting the availability of dialysis. Even the large dialysis chains will struggle to remain afloat. Their situation will worsen dramatically if private insurance (which covers dialysis at rates well above Medicare) disappears as a result of the added costs and regulatory burdens imposed on them by ObamaCare. In effect, this legislation sets the stage for an eventual nationalization of the dialysis industry.

The dialysis community has been under the heavy hand of federal regulation since the beginning. We are the first victims of Congress' misguided price control schemes. Whatever happens to us will eventually be extended to other segments of health care that come under government control. Medicare rationing is well under way.


No Buggy Required to Avoid Health Care Mandate

Bob McCarty is thinking particularly well today:

My first thought after reading the headline of an article in the Watertown (N.Y.) Daily Times, was, “I’m gonna become Amish.” The headline: "Amish families exempt from insurance mandate".

Delving into the article, I learned that the health care reform legislation now floating through the halls of Congress does not specify that members of the Amish community are the only ones who will be exempt. In fact, the provision could apply to other groups.

The article mentioned Old Order Mennonites and perhaps Christian Scientists by name, but I suspect members of other denominations — Baptists, Catholics, Jews, Muslims et al — will experience “health care awakenings” in the near future and and decide they, too, wish to exercise “religious conscience” and, in turn, receive the same break as the Amish.

In the case of the Amish, according to the article, the religious conscience exemption stems from the fact that, among other things, the Amish “generally rely upon a community ethic that disdains government assistance.”

If you’ve read a newspaper, watched television, listened to the radio or surfed the web lately, you’ve heard of people protesting against government-run health care. I have, and I’m willing to bet that most of those protesters would say they, too, generally rely upon a community ethic that disdains government assistance.

Do you see where I’m going with this? There’s a giant loophole in the government-run health care legislation Democrats are trying to force down the throats of the American people. It allows people of faith to be exempt from the so-called “ObamaCare.” So, I say, let it pass!

That’s right! Stop the protests, stop calling your elected officials, and just let it pass! As soon as it passes, declare your religious freedom! No buggy required!


I'd say that libertarians could make very similar claims to the Amish

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