reform

‘Twas the night before reform when all in the House…

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‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payors or we’ll be at your throats.”

With Pelosi and her Botox and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral)

The docs sat on the sidelines, bemoaning their fate,

While payors dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried?

“What about uninsured, don’t you care if they died”

“This is about people you meet on the street.

People who must choose between their meds and to eat

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right, do what’s right or we’ll bag ‘ya”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made payoffs, and said the time is now.

Festooned all in new regs from NHS to VA

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last,

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

A reply to the idea of Mandated Coverage

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Below is a comment on a Washington Post article on mandated coverage, http://www.washingtonpost.com/wp-dyn/content/article/2009/10/25/AR2009102502607_Comments.html

Great movie, poor reform—at least that’s my take on how poorly the current healthcare legislation will actually work regarding a mandate.  There are probably more federal judges with gangsta rap on their iPods than congressmen who have actually read the reform bill.

I call the idea of the mandate “must carry”.  The only option of the public option and must carry provisions is the option to “opt”.  Individuals can “opt” and so can firms.  “Opt-in”, “Opt-out”—like clap-on clap-off.

However well intended it may be, as structured, the mandate will not work; neither for individuals or for firms.  The individuals who will be required to carry, can opt out for a $750 annual fine and “opt” in when they are sick or injured.  The fine will be less than the cost of the insurance premiums.  That way, their out-of-pocket costs are actually paying co-payments not premiums.

It appears that firms may be able to pay the fines on a per person basis rather than opting to pay for healthcare insurance for their employees.

Hence, mandated coverage may only apply to those who haven’t figured out that it doesn’t apply.

sainttop5

Is the term “Payor” healthcare’s oxymoron?

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One of the great things about fall is that as I prune back the vestiges of my virtual garden I am able to collect basketful upon basketful of overly ripe metaphorical tomatoes, perfect for tossing at aberrant analogies and inappropriate idioms.

It’s a curious time.  We give away money to the middle class and rich so they can upgrade their BMWs on the backs of the poor.  The feds market that idea as though that pittance will either jump start the economy, or to hide the fact that that the administration has managed to budget for a nine trillion dollar deficit gap over ten years.

By now we know there are no quick fixes, no magic formulas for fixing the economy.  Finding a formula that works will be more difficult than learning how to neatly fold a fitted bed sheet.

“Is it the essential paradox of the age of Obama that we have to destroy the village in order to save it, bust the budget in hopes someday we’ll balance it?” Nancy Gibbs, Time, September 9, 2009.

“It takes an idiot to raze a village.” Paul Roemer, today.

Congress is trying to decide what the final bill will look like without ever having read the first draft.  How will we know when they have something that makes sense?  Do we watch the Congressional chimney to see if the smoke is white or black?  Does that mean we have a bill, or is it simply that the chef burnt the Peking Duck?

Then there are the payors.  Get me started, or don’t.  We all know that one of the driving factors for reform is the behavior of the payors.  A friend asks—for full disclosure I note that she is one of “them”—why do people view health insurers differently from auto, life, or home owners insurance.  She was serious.

Here’s my take on the answer.  If the health insurance firms provided life insurance they’d be exhuming the deceased and trying to prove they weren’t dead.  Car smashed, get a check.  House leaks, get a check.  Die, get a check.  Need surgery.  Not so fast.  Let’s see if you’re covered for that.  If not, whew.  If yes, let our doctors decide if you really need the surgery.  It won’t cost you a minute of your time as our doctors don’t even need to examine you.  You see how this plays out?

It happened to me after my heart attack, albeit with my disability payor, sort of the evil step sister of the health side.  My doctor put me on six months disability, naturally, the payor declined to pay.  There doctor, who never examined me decided I was fine, at least that’s what their letter stated.  How do we know these doctors even exist?  Have they ever been seen in the daylight?

Most Americans don’t believe that insurance companies are interested in helping people.  They like us fine when people are payors.  They are much less fond of us when people become patients.  It’s a simple matter of flow theory.  As long as the flow of cash is in-bound, all is well.  When people move to the dark side, from payors to patients, payors have no patience.

Is there anyone who believes that there is a single payor in the country whose mission statement says anything about doing all we can to help those who need us?  Of course not.  Payors have claims adjusters.  What is their role?  It’s certainly not to adjust the payment higher.

Do payors incent their employees to pay out as little as possible?  I believe they do.  Do payors penalize or retrain people who pay out too much?  I believe they do.  Do they design the claims and dispute process so as to make it so cumbersome on patients and doctors that parties give up prior to settling?  I believe they do.

I believe the payor business model is not much different from that of tobacco companies.  For years tobacco firms claimed there was no public evidence to support the fact that nicotine was addictive.  It turns out they buried the evidence.  Payors claim they are not bad actors.  Some claim the moon landing was faked.

I am a firm believer that pictures can sometimes convey more than mere words.  To me, this link explains a lot about what’s wrong with healthcare.

http://www.youtube.com/watch?v=Z7Forzj5-O0 Start playing at 6 minutes and 40 seconds.

pastedGraphic.tiff.converted

A different way to look at the public option

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Louisiana Senator Landreiu was interviewed on NPR and was asked why she does not favor a public option.  Finding it to be the most reasoned argument on either side of the discussion, I felt it worth sharing.

She began by using an analogy she learned from Senator Lieberman.  Assume that the roofing companies in America were so expensive that twenty percent of homeowners could afford to put a roof on their house.  What would the government do?  Would they set up their own roofing firm and offer roofs at lower prices?  Of course not.  It would regulate the roofing companies to bring about lower and more competitive prices.

Landreiu also stated that the government hasn’t done very well managing its other two public options, Medicaid and Medicare, so why trust them with running a third.

saint

Reform’s possible negative impact on payors

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Don’t start cheering yet, but there may be a negative financial impact for payors.  How?

A fine will be imposed on people who do not get insurance.  The fine will be an annual charge of $750, far less than what insurance would cost.

People can opt-out of insurance until they are ill enough to require treatment.  Insurers  must provide coverage for those people. When healthy people pay premiums, the margins earned by the insurers are almost infinite.  If payors could figure out how to legally offer insurance to rocks and get the rocks to write a premium check each month, they probably would.  (Can’t you just see the business development people getting sweaty palms over this idea?)

When healthy people cross over to the dark side–going from insured to patient–margins go from infinite to very negative which is why it there is no business model that works if all you do is insure sick people.  To really mess with their minds and their margins, all that needs to happen is for people to opt-out of paying premiums when they’re healthy and opt-in when they are sick.

Of course, payors will build this into their actuarial tables, and simply pass on the cost  of these occurrences to the rest of us thereby making it a wash for them.   Well, the idea that the payors might be adversely impacted was nice for the minute it took to read this.

saint

Reform: confessions of a drive-by mind

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My wife said she had to call DC.  “All of it?” I asked.  Failed to even crack a smile—she must have left her funny bone in her briefcase.  I described her mom’s dog as a tennis ball with lips which seemed to be bred to be terrified of everything.  That had me zero for two, and losing ground quickly.

Today’s social networking technology allows one to take umbrage with everything from reform to how your neighbor shovels the snow from their sidewalk.  It’s an especially neat set of tools for those of us who have borderline control issues.  Which I do not, I told the unfunny woman next to me.  “You want to tell people how to tie their shoes because you think you do it better than them,” she remarked.  “Which is probably why flying bothers you so much; your nagging belief that the pilot isn’t qualified.”

Where was I before I interrupted myself?  Now, before anyone starts name-calling, I shall admit that I can be a bit of a heterodox.  Sometimes instead of talking I write, it’s like taking my thoughts for a walk in the park with an occasional pause at a fire hydrant.

I am beset by several unanswered questions about reform.  What do you think?  Is healthcare reform an attempt to make America a risk-free society, to rid people of what might be in order to exercise control where none exists?  Is it possible Jerry Springer was asked to provide ad hominem comment over the healthcare reform legislation, or that the plot line was a rerun of something written by David Mamet?  Does the tedium of reading the bill’s thousand-plus pages make stamp collecting seem like a full contact sport?

It’s too bad the Administration had the misfortune of drafting the reform legislation without having the luxury of hiding behind the Iraq maelstrom as we did during the Cheney presidency.  We may find some solace in that even with it now looking like some form of reform—version 5.0—will pass this year, our system will still be better than the UK’s, which is essential since they do much better with Shakespeare than us—I think it has something to do with their dedication to the diction of the British English.  “O, yet defend me, friends; I am but hurt.” (Claudius in Hamlet.  Is this where Python got the idea for, “I’m not dead yet?”)

We would be more likely to turn Hamlet into a navel gazing rap musical, than try to do it justice by reciting the original English.  Perhaps that is why we enjoy PBS as it gives our snobbery a chance to imagine the world as a series of Masterpiece Theater renditions.

If the reform effort still smacks of vestiges of nineties healthcare kitsch, it may be because nostalgia is still what it used to be and never was.  Either way, it looks like we will have something more concrete at which we can pit our opinions.  It will cost in the neighborhood of nine hundred million dollars, and yet we still aren’t able to distill the main talking points on two or three PowerPoint slides.

saint

Reform: Congress must answer, “What’s in it form me?”

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If reform fails to pass, what’s the reason?

Is it because Congress ignored that ninety-eight percent of healthcare is local; Hyperlocal?  I think the answer is a resounding yes.  What is hyperlocal?  You know the saying, “All politics is local?”  Well, hyperlocal is local on steroids.  It’s moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

I think individuals see the bill as “What’s in it for them—them is defined as anyone other than me” and “What will it do to me?”  HR 3200 isn’t viewed as improving my healthcare, nobody sees it as meCare.  That is why when viewed nationally so few are behind it.

It’s not that nobody is interested in providing healthcare to those who don’t have it.  What concerns people who do have healthcare is their belief—which may have nothing to do with reality—is that to provide healthcare to those who don’t have it requires that those who have it to give up some of their benefits.  Those with healthcare see reform as a zero sum game.

What has people trying to kill the bill is that nobody who currently has healthcare believes they will see any net gain benefit from the bill—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, they certainly can’t articulate the benefit.

To gain support for HR3200, Reform 3.0, or whatever it comes to be called the bill must address first person interests, not second or third.  Does that sound selfish?  It may be.  However, they are toying with reforming a fifth of the economy and a service of which eighty percent of the people are generally pleased.

For reform to pass, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What Congress hasn’t come to grips with is that there is no meCare in heCare, sheCare, or theyCare—hence, people don’t care to support reform.

What do you think?

black saint 2

A question on reform

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If reform becomes Obama’s Kryptonite, does that make him a lame duck with three years to go?

What happens to the EHR roll out and ARRA if reform doesn’t pass?

Healthcare 2.0, can you get there from here?

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water2

From a business perspective, not clinical, the critical success factor for H2.0 relies on healthcare’s ability to move from being an 0.2 industry.

H0.2 is the “As-is” model.  H2.0 is the “To-be” model.  To reach H2.0 healthcare must bridge that functional, work flow, change management, user acceptance, and technical GAP.  The Gap will differ by provider.  There is no singular work plan to help providers know what they need to do to build a custom plan to bridge the gap.

None of this matters until the healthcare provider willingly acknowledges that they have a long way to go to get to anything that resembles H2.0.

H0.2 – H2.0 = GAP

If you don’t mind the gap,  H2.0 is just H2O–all wet

black saint 2

Is EHR so distasteful that providers need incentive?

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broccoli

Of what were we last speaking?  Do you ever wonder if perhaps you are the only person who was never photographed with one of the Kennedys?  That got me thinking about our presidents.  Yesterday NPR interviewed the person who spent eighty hours interviewing Clinton during the eight years during which he was allowed to park freely anywhere in DC.  See how this is already starting to come together?

The interviewer mentioned that Clinton described the Lewinski episode as a distraction.  I also employed several descriptors of that series of affairs—of course, the pun is intentional—but I must have overlooked calling it a distraction.  People on both sides of the dialog call the episode a stupid thing.  Here’s how I look at it—doing long division and forgetting to carry the one is ‘a stupid thing’; mixing a red sock with a load of whites is ‘a stupid thing’.  Sometimes politics can have us all screaming infidelities.

When I share my thoughts about these things, some look at me like they are staring at an unlabeled can of food.  I guess objectivity is only for the truly unimaginative.

So all of that thinking about presidents got me to thinking about Mr. Obama, reform, and EHR.  Remember that a lot of the original economic reform discussion had to do with TARP monies being almost tossed at the banks.  It was almost like a reverse bank holdup, making the banks take money.

Which now takes us to healthcare reform and EHR.  ARRA money and states like New York providing a stimulus to the stimulus.  What would make governments offer money for EHR?  How might we illustrate this?

Let’s say I offer my children a choice of two things to eat; broccoli and chocolate cake.  They make a bee-line for the cake.  The broccoli requires an incentive to get any takers.  I ask a few questions—they are prepared to suffer untold penalties instead of eating the broccoli.  There may be some financial incentive which will entice them to eat broccoli, but it will be pricey.  Telling them it’s good for them, or that they have to eat it makes no difference to short people—they want to be bribed.

Telling healthcare providers EHR is good for them, or that they have to do it makes no difference to tall people—they want to be bribed.  What does this signify?  What is it about EHR that requires incentives and some foreign force majeure to get the discussion underway?  It’s not as though the healthcare providers don’t want to do things that will improve their business.  What is it they know that we don’t?  What would make them run towards EHR rather than away from it?

You don’t suppose it has something to do with broccoli, do you?

For those who enjoy Dana Carvey, here’s a link to his song about chopping broccoli.

http://www.youtube.com/watch?v=gO57XRDDodk

saint