The Obama care runaway train.

There is talk of repealing Obamacare if the Republicans take over Congress on November 2. Of course, that is unlikely with President Obama ready to veto any repeal legislation. “OK, we will defund it,” is the response. I doubt anyone realizes how fast this is moving and how difficult it will be to alter the course of this program.

A week ago, I posted on my blog a set of new rules that are being implemented for physician reimbursement. I review workers compensation cases as a part time job. The company that employs me has now come out with a new line of business to review cases for Obamacare. I have been asked if I would be willing to review cases on a 24 hour timeline. This includes weekends. I have spent 40 years reviewing cases for Medicare and the state medical boards for poor care. Now, I am being solicited to do concurrent review on a 24 hour basis for healthcare. I do some concurrent review for workers comp cases but the timeline is usually 3-5 days. Why weekends ? Does this mean that care cannot be provided without approval ?

The pace of change is breathtaking. Today, the Wall Street Journal explains.

A wave of consolidation is washing over the health markets, and the result is going to be higher costs.

The turn toward consolidation among insurance companies is not new, and neither is it among doctors, hospitals and other providers. Yet the health bill has accelerated these trends, as all sides race to anticipate and manage political risk and regulatory uncertainty. This dynamic is leading to much larger hospital systems and physician groups, and fewer insurers dominated by a handful of national conglomerates. ObamaCare was sold using the language of choice and competition, but it is actually reducing both.

The first surge will come among the 1,200 insurers doing business in the U.S., given that a major goal of ObamaCare is to convert these companies into de facto public utilities. Those regulations are now being written—and once they’re up and running some medium-sized carriers will collapse under the new mandates and higher overhead. State insurance commissioners warned the Administration this month that “improper or overly strident application . . . could threaten the solvency of insurers or significantly reduce competition in some insurance markets.” They also implied that bankruptcies are likely.

With these headwinds, investors and Wall Street analysts are now predicting a lost decade for health insurance stocks. But it may be more accurate to say that there will be a lot of losers and some very big winners. Mergers and acquisitions will increase dramatically once companies get a better look at the regulation and figure out the valuation of M&A targets. Larger carriers will swallow smaller ones quietly before they fail.

The pace of change is far more rapid than is appreciated.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

The Mayo Clinic has concluded that it cannot afford to treat Medicare patients. The Phoenix branch of the Clinic has already informed patients that they will accept no more Medicare. The model does not think it will work.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

I spent a few minutes researching the doctors who appeared in white coats to support Obamacare last spring. Those who really were doctors were all hospital employees. Most of them had been hired right out of residency.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

This is an impossible situation and the Medicare patient will become indistinguishable from the Medicaid patient, a burden on the system to be treated by “physician extenders.”

The changes are coming like a runaway train and they will change American medicine irreversibly. Private medicine cannot afford to care for the discounted Medicare patients. Obamacare will convert private care to Medicare. Every one will be a charity case except for the gentry class that votes for Obama. University Hospital physicians may feel that they are immune to these changes but it has been known for 50 years that the value of salaried university physicians is directly related to the income of private physicians. In fact, the university physician has no overhead but they can always tell the administration that they can leave and earn as much, if not more, and this has given them a lot of power.

When I was in training, my surgical training program had three full time faculty members. Now, the same program has 90 full time members. In the same interval, their success in having graduates pass the American Board of Surgery has declined. That may or may not be significant but the culture of medicine is changing rapidly. Many physicians no longer recommend medicine as a career for their children. What this all means, I don’t know. What I do know is that it is coming very fast and few people realize it.

Anti-Vaccination Hysterics Kill Seven Babies

Great, anti-vaccination hysteria has killed seven infants in California. Whooping cough, once thought to be virtually wiped-out in the developed world, is making a comeback thanks to illegal immigration and greedy anti-vaccination activists.

As I noted in my previous post on the subject, too many people make emotional decisions based on graphic images. They see pictures of kids with autism or whatever the anti-vaccination hysteria du jour is but they don’t see countervailing images of the diseases that vaccinations prevent.

Just to provide some real education, here is a video of a 12-week-old infant with whooping cough. You can hear the distinctive strangling intake of breath at the end of a coughing fit which gives the disease its name.

As you listen to this, recall that in the normal course of the disease, this horrific coughing last for a month with two more months of less-harsh coughing. The disease kills by sheer exhaustion.

There is an adult whooping cough booster available. If you have contact with infants and/or a large illegal population (legal immigrants have to get vaccinations), I strongly recommend you get the booster.

And, if you know some anti-vaccination idiot, strap them down and make them listen to the video in a loop.

VAT Tax Redux, New Proposal, and Barone’s piece in SF Examiner

This lonnnnng post was prompted by an email linking Michael Barone’s latest SF Examiner piece, which asks Republicans “Now what?” after assuming some strong gains in November.  I have a few ideas on the “now what?” question, and I can’t think of a better place to post them than on this excellent blog.

First, I can’t thank you all enough for the excellent commentary and critiques on my recent “Swapping a VAT for failing income tax is Good Policy” post a week or so ago.  I’ve commented on many of your ideas, and I think you’ve changed my mind on a thing or two, which you will notice below.

I wanted to follow up that post with another proposal that fixes the primary problem with going to consumption taxes, which is their impact on the working poor and middle class. One benefit of a consumption-based tax regime is that it captures money from every transaction, making every one a part of the solution to our fiscal mess.  It is also far more stable than a highly skewed progressive system that only taxes the rich. (Social Security notwithstanding)

The most difficult political and policy problem preventing the adoption of a consumption based tax system is that it places a “burden” on the working poor and middle class. (burden being interpreted both in policy and political terms)

Simply put, in a consumption tax system, the lower end of the earning spectrum pays a much greater share of their income in taxes than the rich.  Many will argue that this is “unfair.”  Leaving that argument aside, it is fair to say that this problem MUST be resolved before any politician is going to risk moving the entire system away from income taxes.

I propose such a solution in this post, beginning with my answer to Barone’s “Now What?”

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Paying for Health Care

I have found a lot of confused thinking on the right lately regarding how to pay for health care. The left is hopeless but items like this, complaining about the FDA taking Avastin off label for stage four breast cancer don’t get to the heart of the matter. What is the right process to figure out whether you’re going to undergo a medical treatment?

Even if you are independently wealthy and have no insurance to complicate things you would not limit your consideration of treatment to just the medical discussion with your doctor. Your financial team would come into play as questions of bankruptcy, how much this is going to impact your estate, etc. are going to affect your decision. And in that discussion, if your sole heir starts getting creepy and talking down all the expensive treatments, you have a problem.

Putting insurance into the equation doesn’t change the conversation. It just adds a large cast of characters to the discussion and some extra money that you don’t control. The possibility of somebody going creepy and acting in their own best interests but not yours is still there. In fact, the more distant the 3rd parties, the more likely it’s going to happen. Add in the government and the chance explodes.

The FDA and Medicare are acting like the creepy heir on the make and there are a lot of people who sense it without being able to articulate it. Nobody can *prove* anything, but the vibe is not good.

A Nexus Between Academic Medicine and Government

The Wall Street Journal has one more article on the effect of Obamacare on doctors. A couple of interesting statements bring up some comments on an excellent medical blog I read.

First the WSJ points about Obamacare.

The act will reinforce the worst features of existing third-party payment arrangements in both the private and public sectors — arrangements that already compromise the professional independence and integrity of the medical profession.

Doctors will find themselves subject to more, not less, government regulation and oversight. Moreover, they will become increasingly dependent on unreliable government reimbursement for medical services. Medicare and Medicaid payment, including irrational government payment updates, are preserved (though shaved) and expanded to larger portions of the population.

The Act creates even more bureaucracies with authority over the kinds of health benefits, medical treatments and procedures that Americans get through public and private health insurance. The new law provides no serious relief for tort liability. Not surprisingly, various surveys reveal deep dissatisfaction and demoralization among medical professionals.

I’ve been posting about this for a couple of years and it is no surprise.

Now here is where it gets interesting.

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