105 replies »

1. Looking for some passionate people with web cams,
   to join the debate answer this question, in a video.
   The Federal Government should provide free health care for all Americans.
   Do you agree? yes or no,
   Tell us why, make a video. Use a web-cam or camcorder be funny be creative use animation, clay-mation, wear a mask, make a sock puppet or just stand in front of a blank wall and make your point. Post the link in the comment section on:
   http://videodebater.com/?p=17
   Health care | VideoDebater.com

2. Very interesting discussion about USA Health Plans. I know it’s not easy to manage healthcare from political aspect and countries should learn one from others.
   This blog is a extremely nice innitiative, congratulations.
   I also posted the new in http://health2.info/story.php?id=72 to be discussed.

3. It’s unfortunate that we have to see such blatant examples of ignorance. The fact is most people don’t even know what a tax deduction is or how to take advantage of it. The only ones that will benefit from this particular measure would be the upper middle class…the ones who can afford a significant health care which would actually be a pricey enough type of health care plan that a deduction of the premium might actually be a significant savings.

4. Everyone should have the same health care coverage that Bush and members of Congress have. No exceptions!! Why should low income people be paying taxes for health care for these people when they cannot afford health care for themselves?

5. 1998 –U.S.Attorney General & Office of Inspector General – Health Care Fraud and Abuse Control [ T18CFR371Crime ] would be established as an expenditure account within the Federal Hospital Insurance (HI) Trust Fund.
   .
   OPM FEHBP [CITE: 5CFR185.104] PROGRAM FRAUD Sec. 185.104 Investigation. (d) Nothing in this section modifies any Responsibility of an Investigating Official ( OIG ) to Report Violations of Criminal Law [ DHHS Anti-dumping & Anti-Kickback Violations T42CFR417 Against Retired ‘Entitled’ Federal Beneficiaries CITE: 5CFR890.105 for criminal HCFA Medicaid kickback conversions T18CFR286 ] to the U.S.Attorney General.
   .
   Office of Inspector General – Misprison of a felony T42sec417 Hospital Insurance Fraud
   Office of Personnel Management – CITE: 5CFR890.105 criminal Denial of Covered Claims
   Dated: 14 May 2003
   Joseph Frech Investigator – T18CFR371 illegal agreement to defraud Entitled Individuals and Federal Health Care Programs with respect to claims
   C 03-206 Quote:
   .
   ” Your only recorse is to file suite against the Office of Personnel Management in Federal Court. ”
   .
   The Region V HCFA [ Michigan ] office had a record high 940 new MSP cases filed in 1998. Contributing to this were PARTNERSHIP Arrangements with [ Federal HMO T42CFR417 Hospital Dumping ] Contractors and U.S. Attorneys [ T18CFR1518 – T18CFR286 – T18CFR371 ] in Michigan and Ohio ……….
   .
   OPM TITLE 5 > PART III > Subpart G > CHAPTER 89 > Sec. 8912. Prev | Next Sec. 8912. – Jurisdiction of courts – The District Courts of the United States have Original Jurisdiction, concurrent with the United States Court of Federal Claims, of a civil action or claim against the United States founded on this chapter.
   .
   Read the October 2006 Health and Human Services (HHS) Office of Inspector General report on Medicaid Payments [ MI OFIS/HCFA T42CFR417 anti-dumping violation/kickback ] for deased [ Federal ] beneficiaries – for more insite into the ongoing Criminal Abuse [ Federal Hospital Insurance Fraud T42CFR417 ] Against Elderly American Citizens with Federal HMO Policies.
   .
   1998 — HEALTH CARE FRAUD AND ABUSE CONTROL PROGRAM [ subject to prosecution ], under the Joint Direction [ T18CFR371-illegal agreement to induce forfiture of Hospital Insurance Benefits DHHS T42CFR417 Anti-dumping violation ] of the ATTORNEY GENERAL and the Secretary of [ DHHS ] the Department of Health and Human Services (HHS)(1), acting through the Department’s [ OIG ] Inspector General (HHS/OIG), Designed [ HMO Grievance Procedure T42CFR417 criminal denial of covered Hospital Insurance claims/Volentary Disclousure/SELF-Audit Program ] to coordinate Federal, State and Local Law Enforcement activities [ misprison of a felony / defrauding federal health insurance programs OPM FEHBP CITE: 5CFR890.105 ] With Respect to ( Claims ) Health Care Fraud and Abuse.
   .
   CITE- 18 USC Sec. 1518 01/02/01-EXPCITE- TITLE 18 – CRIMES AND CRIMINAL PROCEDURE PART I – CRIMES CHAPTER 73 – OBSTRUCTION OF JUSTICE-HEAD- Sec. 1518. Obstruction of criminal investigations of health care offenses -STATUTE
   .
   1998 Health Care Fraud and Abuse Control Program –INDUCED FORFITURE — Hospital Insurance Fraud – enacted by Hospital DHHS Employees ‘ discharge procedures/anti-dumping violation/felony fraud/intent to harm- TITLE 42-[ DHHS ]-PUBLIC HEALTH HUMAN SERVICES PART 417-[ Federal HMO ]-HEALTH MAINTENANCE ORGANIZATIONS, [ Special Services / misprison of a felony ] Subpart B-( HMO )- Qualified Health Maintenance Organizations: ” Services ” (g) Grievance procedures: DENIAL OF Existing OPM FEHBP HMO Hospital Insurance Services [ DHHS Anti-dumping violation for criminal HCFA Medicaid kickback conversions ]. (h) ” Special ” rules : Enrollees ( Covered Individuals ) under the Federal Employee Health Benefits Program ( FEHBP ). An HMO that accepts enrollees under the ( OPM ) FEHBP (Chapter 89 of title 5 of the U.S.C.) may obtain and retain Federal qualification if….[ 1998 OIG Volentary Disclousure Program/illegal agreement to Induce Forfiture DHHS enactment T42CFR417-criminal denial of OPM FEHBP Hospital Extended Care Benefits w/OPM FEHBP CITE: 5CFR890.105 criminal denial of covered claims – approx Value $288,000 each defrauded individual / ‘ General Public ‘ – to force criminal HCFA Medicaid kickback applications/conversions -T42CFR417 DHHS employee and Federal HMO employee Hospital Dumping ]
   .
   DHHS OIG News Release 21 October 1998
   Volentary Disclousure of Health Care Fraud <~ T18CFR371 illegal aggreement ( SELF-Audit )
   For Immediate Release Contact: ……………Judy Holtz (202) 619-0893
   Wednesday, October 21,1998 ……………….Ben St.John (202) 619-1028
   .
   The ( DHHS OIG ) Department of Health and Human Services’s Office of Inspector General ( OIG ) today unveiled an expanded and simplified Program For [ Federal HMO Hospital Insurance Contract ] Health Care Providers to 'volentarily report' [ misprison of a felony / T42CFR417 ] Fraudulent Conduct ( Hospital Insurance Fraud DHHS T42sec417 CRIME ) Affecting Medicare, Medicaid and other [ OPM FEHBP et al ] Federal health care programs.
   Unlike the piolet program,which was only available to ‘certain’ ( Federal ) health care providers in a few STATES and had strict eligibility requirements, the New Program is OPEN TO ALL ( Federal ) providers NATIONWIDE under signaficantly Relaxed Requirements ( misprison of felony/T42CFR417 ) for ( Health Care fraud ) participation.
   NOW ALL ( Federal ) health care Providers Doing Business with Medicare, Medicaid,or Other Federal health care programs [ OPM FEHBP / TRICARE / CHAMPVA / etal ] that ” Want to ” disclose Violations of Law [ Title18CFR24Crime ] are eligible for acceptance into The [ National – Health Care Fraud & Abuse -illegal agreement to induce forfiture T42CFR417 Control ] Program. The [ Federal ( OPM FEHBP ) HMO Contractor ] Provider will have the option of doing 'SELF-audit' [ DHHS T42CFR417 Anti-dumping violation ] in conformance 'with OIG' [ defrauding federal health insurance programs with respect to claims: OPM FEHBP 5CFR890.105: criminal denial of COVERED Claims T18CFR371 to FORCE illegal HCFA State Medicaid kickback conversions ]
   .
   The Health Care Financing Administration ( HCFA ) administers the Medicaid
   program. Authorized under Title XIX of the Social Security Act.
   .
   The Anti-Dumping Statute [ Hospital Insurance Fraud DHHS T42CFR417 anti-dumping violation for illegal HCFA Medicaid kickback conversions ] is Enforced Jointly by the Health Care Financing Administration [ HCFA ] and the Office of Inspector General [ OIG ] of the [ DHHS ] U.S. Department of Health and Human Services (HHS).
   .
   DATED: November 24, 1998
   _______/s/______________________
   June Gibbs Brown
   [ DHHS ] Inspector General
   .
   DATED: November 24, 1998
   _______/s/_______________________
   Nancy-Ann Min DeParle
   [ HCFA ] Administrator, Health Care Financing Administration
   .
   1. Separate and apart from the anti-dumping statute, in accordance with sections 1857(g), 1876(i)(6), 1903(m)(5) and 1932(e) of the Social Security Act, the OIG (acting on behalf of the Secretary) has the authority to impose intermediate sanctions against Medicare and Medicaid contracting managed care plans that fail to provide [ DHHS & Federal HMO T42CFR417 criminal denial of covered Hospital Insurance Benefits/Services ] medically necessary services, including emergency services, to enrollees where the failure adversely affects (or has a substantial likelihood of adversely affecting) the enrollee. Medicare and Medicaid managed care plans that fail to comply with the above provision are subject to civil money penalties of up to $25,000 for each denial of medically necessary services.
   .
   According to the Detroit News, Between 1999 & 2001 Michigan's Medicaid clientele ballooned [ DHHS T42sec417 induced forfiture of existing federal hospital insurance benefits for illegal Mediciad kickback conversions ] to 1.25 million from 1 million, at a cost of approximately $6,000 on each Medicaid Reciepent.
   The Detroit News stated according to Paul Rienhart " a Medicaid Expert " in
   The State Budget Office of Michigan, says
   [ OFIS/HCFA ] Medicaid consumed 8% of Michigan's General Funds in 1998.
   [ OFIS/HCFA ] Medicaid will consume 32 % of the General Fund budget by 2004.
   .
   THE MEDICAID FALSE CLAIM ACT (EXCERPT)Act 72 of 1977
   400.603 Application for, or Determining Rights to, medicaid benefits; false statement or false representation of material facts; concealing or failing to disclose certain events; felony; penalty. [M.S.A. 16.614(3) ] …………. DHHS T42CFR417 Hospital Insurance Fraud by Fright /Anti-dumping violation and OPM T5CFR890.105 Criminal DENIAL of COVERED Hospital Insurance Claims to Force illegal HCFA Medicaid Kickback Conversions – misprison of a felony 'grievance procedures' DHHS & Federal HMO Hospital Dumping.
   .
   Retired OPM FEHBP Health Insurance Preiums are taken out of Retiree Checks Befor they recieve thier checks. These ' Federal Beneficiaries ' are paying for 'Hospital Extended Care Benefits'/Services, that has not been available to them since the 1998 DHHS OIG Volentary Disclousure Program was created to defraud them of that benefit – DHHS T42CFR417 automatic denial of Hospital Insurance Benefts, to force illegal HCFA State Medicaid kickback conversion – eligibility / Poor.
   .
   The OIG is an independent entity within -[ white collar criminals ]- the Department of Justice, that reports to both the Attorney General and Congress on issues that affect the Department's personnel or operations.
   .
   U.S.Attorney…………Gonzales aide said that she had considered politics in screening applicants. The expanded inquiry, conducted by — the department's [ OIG ] Inspector General and ITS Office of Professional Responsibility —, comes after testimony Wednesday by former Gonzales aide Monica M. Goodling.
   .
   ABOVE the LAW — T18CFR371Crime — U.S.Attorney General & Office of Inspector General — 1998 — The Health Care Fraud and Abuse Control [ DHHS T42CFR417 anti-dumping violation ] Account would be established as an expenditure account [ MI OFIS / HCFA Kickback ] within the Federal Hospital Insurance (HI) Trust Fund.
   .
   The OIG has jurisdiction over all [ criminal ] complaints of misconduct against Department of Justice Employees [ T18CFR371 Misprison of a felony federal health care offences against american citizens & federal health care programs ] including the Federal Bureau of Investigation; Drug Enforcement Administration; Federal Bureau of Prisons; U.S. Marshals Service; Bureau of Alcohol, Tobacco, Firearms, and Explosives; United States Attorneys Offices; and employees who work in other Divisions or Offices in the Department of Justice. ( The one exception is that allegations of misconduct involving Department ATTORNEYS a that arise from their AUTHORITY TO INVESTIGATE, litigate, or provide legal advice are the responsibility of the Department's Office of Professional Responsibility.)
   .
   Sincerely,
   .
   All Entitled Federal Employee Health Beneficiaries being criminally denied [ DHHS T42CFR417 ] Existing Federal Health Insurance Coverage Title18CFR1001Crime.

6. To solve the health care situation in the U.S., the two main issues that need to be addressed are the lack of a requirement for coverage and individual accountability. This proposal attempts to solve both problems.
   For any type of insurance to work, the risk needs to be spread out as widely as possible. Since everyone will at some point need some type of coverage, possibly extensive, it only makes sense that everyone should pay an equal portion to health care for the span of his or her life. This is the only sure way to keep rates for everyone as low as possible.
   This sort of coverage, henceforth called Necessary Coverage, will cover anything necessary to survive. This means that without the medication or treatment, the person would be unable to carry on day to day activities. Any treatment that doesn’t satisfy this requirement would be Supplemental Coverage and would not be required. An analogy to this would be the liability and full coverage systems in auto insurance. If a person has no Supplemental Coverage, everything not covered by Necessary Coverage would need to be paid for in full out of pocket.
   What is proposed is to add a new payroll tax for every American to cover per capita costs for Necessary Coverage. No business would provide insurance. Instead, the money that is currently being spent to provide coverage for the employee would be added to the amount that he or she is paid. The important difference of this system from many advocated socialized programs, however, is that people would then use this taxed money to choose a provider. Any funds not used to provide Necessary Coverage would be refunded, and any additional funds required would be added as a tax. Doctors and pharmacists would then bill the insurance company as they now do, and the insurance company would bill the government for the cost of a person’s insurance. The government would then disburse the tax money collected to the insurance company and the IRS would then tax or refund accordingly. Although this system would add a bit of logistical work to the current one, it should still be workable.
   By keeping competition in the marketplace, much of the extra wasted money with the current system could be avoided, and everyone working would have no choice in whether or not at least basic coverage is obtained. However, the quality of health care that we enjoy in this country should still be maintained, since insurance companies will try and cut costs and improve service to keep their customers. Currently, people with business coverage have no accountability. Many pay nothing, so they waste dollars unnecessarily with unneeded tests and prescriptions. More importantly, drug companies are being given a “blank check.” They can charge as much as they want, and since the individual consumer isn’t paying, there is no personal incentive to reduce cost or choose a cheaper alternative.
   If a person is unable to pay for insurance because they do not work or make too little money, the tax burden for their costs should then be assumed by the rest of the taxpayers.
   An in depth numerical study is necessary to determine what the cost per person for a program like this would be and if it is a feasible solution, and I have neither the time nor resources to complete this. I am hoping that someone reading this document will.

7. I am an insurance broker who talks to people in need of insurance coverage. I also talk to medicaid people (Under 150% income level) who use government run health care. It is clear to me that government can not provide health care directly to the people. Government can not issue pass ports in a timely manner and would not be able to issue health cares in a timely manner. Look to New Zealand for what national health care does. In New Zealand people buy health insurance supplement plans becasue if they don’t have a supplement plan they can not see a doctor. I like the European medication model where they have no prescriptions and you can get medication easily and cheaply. People buy health food things that are more dangerous than medications being take today. Nationalize the drug companies because it is making and distributing a tangable product but medical services are not something our government can manage effectively or efficiently.

8. Thanks for the comments, Dr. Thom!

9. Jack,
   Your entire argument is based on administrative expenses and you’re using old data. Administrative cost ratios are down to the 14% to 16% range, which is a significant savings for the entire system. Is it still too high, certainly, but they will never be eliminated and you fail to recognize that fact as well. Medicare and most state Medicaid systems use the private sector to administrate claims; therefore the notion of a single payer system is truly a farce.
   Furthermore, you have failed to address the real causes of raising healthcare costs in this country…our aging population and the demand for more services. Basic and simple facts you can’t ignore. Where are your facts that to address increased cost of medical technology, drugs, physician fees, medical malpractice, private for-profit specialty hospitals, hospitals sitting on $100’s of millions of dollars and spending billions on expansion projects, etc.? Your single payer system solution is simplistic and narrow-minded and will solve nothing without addressing “ALL” aspects of the healthcare crisis. And no single system payer system in a major industrialized state has been able to resolve the issues either.
   As far as looking to our friends up north as a model, you must be kidding? Their program is under funded and demands constant infusions of cash from the provincial governments and has annually reduced benefits to their citizens. For example, we enjoyed two visits to the dentist per years in this country, in Canada; it’s one visit every two years. There is a cost benefit differential you are failing to recognize when making you comparison. Germany’s single payer system is having the same problems and their worker nationally went in strike a few short years ago because the government had to cut benefits. If a single payer system is so great, why are we seeing an expansion of private insurance in all of the countries?
   The fact is there are multiple problems with multiple solutions available to us today. To fail to look at all causes and all solutions is wrong and will only result in putting a band-aid on a hemorrhage.
   I would agree with you that the Medicaid system is the fist place to look. I would propose expanding enrollment into Medicaid in a similar manner as current Medicare Supplements are sold. A defined number of benefit programs to choose from that meets your personal needs, with modest premiums based on you ability to pay using brackets of percentage of the poverty level. Currently Medicaid is only available to people who fall at the 150% level and below. If we simply expand this program up to the $50,000 income level we will resolve nearly 2/3 of the uninsured problems in the country.

10. W’s HEALTH PLAN = two new Ws’ (Germs?): WINDFALL(W1) and/or WHEREWITHALL(W2)
    At least that is my conclusion re the following excerpt from THCB dated January 25, 2007 POLICY/POLITICS: Bush’s Health Plan:
    “The Bush proposal that woke me up was the creating a tax deduction for health insurance that would apply to everyone. Potentially this really matters, and inside it is the germ of the right idea. But I guarantee you that most Americans won’t have a clue where this came from, and why it made it into the president’s speech.”
    Initially, Kudos’ to you and THCB for being a terrific resource for those involved or interested in health care issues. I believe THCB will prove indispensable for tracking and discussing health care developments in the future.
    I agree with you a) that the Bush plan contains a germ of the right idea and b) that most Americans don’t have a clue as to where (the Bush plan) came from or why it was included in the state of the union address. Further, I suspect we might agree that the mere fact that President Bush proposed the plan is likely to generate most of the resistance to it. I think we might also agree that at this point most Americans don’t (at least yet) understand, care or appreciate the impact of the plan. Do these issues really matter? I don’t think they do. My experience suggests a good idea will prevail, and often will take on a life of its own, regardless of who suggested it. With the internet and blogs like THCB, ideas, good, bad or even ugly are not easily suppressed.
    So, does the Bush tax deduction proposal have merit?
    I think the Bush plan has a great deal of merit, more merit and the potential for implementation of sound health care policy than any proposal I’ve observed in some forty years of dealing with insurance and health care issues as an attorney in private practice and in both state and municipal government, as a health care lobbyist, and one shot as political candidate (unsuccessful). Currently, I’m a 67 year old seasoned citizen in a state of job lock (for the pay and benefits) and fearful of retirement. This personal stuff is not to elicit sympathy but is offered to afford some background on those experiences which might affect my views. Now, as to the merits, or at least my personal view based on the rather limited information currently Clearly new information, congressional modification, amendments etc. might change my views on any of these points from a plus to a minus.
    Plus Side:
    1. The plan places primary responsibility for health care spending decisions on the individual or family subject to state and local government regulation. The federal government role is more limited but is still significant and of course is always subject to change via Congressional action. I View this as a positive but I realize that many may might disagree.
    2. States would appear to have broad discretion on how best to deliver, regulate or provide healthcare. ERISA issues aside, insurance regulation would continue at the state level.
    For example, it seems that a federally based one size fits all single payment system would not be possible. On the other hand a state based or regional or even local based single payor systems would be possible if permissible under state law. Multi-state or regional plans involving more than one state appear problematic without additional Congressional action.
    Again, I would anticipate that some will consider this attribute as a negative and agree that in some instances such views might be well founded given the power and resources of the insurance industry.
    3. The Bush plan is simple and easy to compute.
    I think most would agree that this aspect should appear as a plus. We will soon find out since every taxpayer should know by April 16 or be able to calculate a ballpark figure of how the proposed changes will affect them.
    4. At the Federal level, the Bush plan would tax the rich – the rich being those whose healthcare expenses exceeded the proposed (generous) exemptions – $7500 for single taxpayers, $15000 for joint taxpayers.
    Everybody but the rich is likely to agree that this is a positive.
    5. At the State/Local Level the “Germs” dubbed WINDFALL(W1) and/or WHEREWITHALL(W2) kick in and taxpayers will be impacted in accordance with their state & local tax structure.
    a. The WINDFALL(W1) germ impacts those (relatively few) states with no state or local income taxes. In these states, as I understand it, the working poor will receive tax relief from payroll taxes including social security for health care expenses. With no state/local taxes, this new “income” spending on health care should have a positive impact. I dub the W1 germ WINDFALL because state and local economies would benefit from this additional spending power upon the effective date of the plan with no legislative action on their part. It appears that withholding amounts would simply be adjusted downward and fatter paychecks would follow. It is not clear how it would be assured that such amounts are spent on health care. I suspect significant penalty and interest charges would be applied.
    b. The WHEREWITHALL(W2) germ would impact the substantial majority of states, those that have state and/or local income taxes . Unlike W1 states, the W2 impacted states would need to take prompt state legislative action to offset the highly regressive impact of their income taxes on the new non cash but taxable income – the value of a taxpayers health care benefits or expenses. Even after adjusting the for the regressive effect (presumably by exemptions or credits), there should still be plenty of money left for states to design and implement more efficient health care plans to meet the needs of their citizens and perhaps other needs as well. Dubbing the W2 germ WEREWITHALL seems appropriate since it addresses the most serious and most frequently omitted issue in most health care proposals – how are we going to pay for it.
    Though the answer to who or how do we pay for it is always we all do, the Bush plan has a quite novel wrinkle. This because Congressional action taxing and exempting health care benefits or taxing the rich actually generates substantial increases in state and local taxes in the W2 states. The state legislatures then have to correct the regressive effects, carve out sufficient amounts for their health care reforms and stave deal with all other interests who might wish to share in any unallocated balance of the WHEREWITHALL.
    Just imagine how many blogs will be generated during this process. Is THCB ready for this?
    To sum up, my take is that both W1 and W2 are good “germs” and there appears no urgent need to find or administer a vaccine. All states and local governments and more importantly the people could benefit from this plan. The plan clearly places the ball in the states court with what appears to me to be an adequate and appropriate financing mechanism, which in itself is a remarkable feat. I believe President Bush has presented a serious and well thought out plan for health care reform.
    Surely the Presidents plan is worthy of further discussion and debate. I certainly hope we can agree on this last point and further that you and THCB make it possible. Imagine THCB reporting on the progress of the 50 little crucibles of democracy hard at work fashioning health care reforms appropriate to their citizens.
    Thanks for taking the time to read this post. I urge and will be pleased to reply to any comments or criticisms email Email: jnewco@earthlink.net
    Jim Newcomer

11. his site has a hybrid proposal for the uninsured:
    Creates 50 new state workforces of Universal Health Care Workers, at lower labor rates to provide direct health care to the uninsured vs. insuring them with health care policies. This would separate them from the current system which must raise rates to cover the 42 million who are uninsured.
    This policy does not or using Canadian style health care for everyone. Utilizes non for profit retired, college and foreign workers. The new UHC workers would not need medical policies themselves.
    It also issue a New Universal State (Part B Policies) so Current Medical Polices can be reduced from $5millon to $50,0000 or by 99%. You current $5,000,000 medical policy would no longer need to be larger than $50,000.
    This combined with the Workers will drive premiums down.
    Check out this sit http://www.mypaysaver.com.

12. his site has a hybrid proposal for the uninsured:
    Creates 50 new state workforces of Universal Health Care Workers, at lower labor rates to provide direct health care to the uninsured vs. insuring them with health care policies. This would separate them from the current system which must raise rates to cover the 42 million who are uninsured.
    This policy does not or using Canadian style health care for everyone. Utilizes non for profit retired, college and foreign workers. The new UHC workers would not need medical policies themselves.
    It also issue a New Universal State (Part B Policies) so Current Medical Polices can be reduced from $5millon to $50,0000 or by 99%. You current $5,000,000 medical policy would no longer need to be larger than $50,000.
    This combined with the Workers will drive premiums down.
    Check out this sit http://www.mypaysaver.com.

13. Whoa there Mr. Leith, your fallacious premise is showing.
    You are assuming the that the average medical school matriculate would earn the average income in some other field. They would not. They would excell. They are talented, driven individuals who would earn many times the average in their chosen fields of endevour.
    An average achiever in our general population could not survive much less much less excell in the medical school curriculum. It takes uncommon ability to adequately grasp the concepts required to safely apply current medical knowlege. The “economic rent plus” you describe is the price society pays for the opportunity costs incurred by the human being who decides to commit himself to this rigourous training program of 9-15 years in legnth. If you want a good system, you need to have good providers. You are going to have to pay for them.
    I have always tried not to have a big head, but medical school was damn hard, getting in was damn hard. Residency was damn hard and the most I ever made in one year was $17,000. If you don’t make the profession renumerative, even the perfect system will fall to the mediocre level of its providers, as this economy has too many opportunities for the skilled. If I was presented with your scenerio at the front end, I wouldn’t go through the training. If it changed now, I would strongly counsel every potential physician against the profession unless society recognized their value. Life is too short.
    Fortunately, you can do compensate phsyicians adequately without the apparently distasteful option of actually paying them based on their value. Removing barriers, like universal free medical education, liability reform and advantageous tax treatment of capital investment in systems which have been demonstrated to improve outcomes, such as a colposcope, will go a long way.
    All this talk of reform is pointless unless you are planning to allow physicians to control costs as you control their payments. Make the reimbursement too tight without such control and watch the practioners flee the system. Ir the upcomming 10% Medicare cut illustrates how society values me, at the end of the year, I will not be taking any new Medicare patients. If future cuts are not addressed in a year or two, I will opt out. Those offended by paying my rates up front can take their care elsewhere.
    I say once again we get the system we deserve.
    by the way, if the AMA is the cartel you describe, it has got to be the worse one in the history of the planet. It hasn’t even won me the right to collectively bargain like the lowest paid service sector employee does, my Medicare reimbursement has gone up 1% year for each of the past five years and I am due to take a 40% pay cut from them over the next ten. I wish folks would stop referring to them as some sort of monolith. They are mostly a running joke among my colleagues, especially since the Sunbeam fiasco, and are seen as being in the pocket of corporations. I haven’t been a member for years.

14. I am a firm believer in paying good docs well ($200-500K in wages), just not on the basis of how many tests they order or don’t order. That also falls in the “top 10%” in case we are being picky. The bad docs should be used in lesser responsible positions until they work themselves up the ladder. Of course we have no way of judging that today, but over time we should develop a national database that tracks practice patterns, practice variations, successes and failures, and etc. I would guess with this info the clinics can compete for the better docs. With a single-payer system and a CMS-like reimbursement system the wages will be held in line.
    The public “should forgive the loans” of the top 10% of physicians. Provide an incentive and the public will benefit. The government could reimburse the medical colleges for those docs with high grades in needed specialties. (And incidentally, I have no horse in this race. I’m retired and not a physician.)

15. Jack Lohman writes:
    > Good docs should indeed earn in the top 10% wages
    Well, that means a “good doc” would earn around $75K per year. $100K puts him in the top 5%. So by your lights this problem is entirely solved already.
    A very gross analysis could look something like this: median income in the US is about $40K. People ought to expect a return on their investments. If a doc invests $1M in his own training (tuition, foregone income) let’s say he ought to realize 5% on that each year, or about $50K. ~$40K + ~$50K ~= $90K, so it seems to me docs are due in justice about $90K in “personal income” each year from a reasonable amount of “medical labor”. Anything docs generally earn above this amounts to economic rent on medical licensure, which is entirely at the pleasure of the government. This of course explains lobbying by the AMA: they have to protect those economic rents. There are about 1M docs in the USA and their fees are about 25% of $1.6T. On a per capita basis, they each get $400K in gross income. Practice expenses are about 50%, leaving them with $200K in “personal income”. Apparently the economic rent on a medical license runs in the neighborhood of $100K per year. I realize this is not uniformly distributed, but that’s a problem for The Guild to solve. Its all very rough but I think I have the outline right and even the figures should be close. The Healthcare Economist may wish to weigh in on this.
    If a doc also has his own business (private or group practice, whatever) he is due also the returns on his ownership stake in that. Of course, the return on that investment will depend on his management skill, and if he’s distracted from doing “medical labor” in order to manage the business, the “medical labor” component of his income will fall.
    > their medical training should be totally forgiven if
    > they ranked high in the graduating class.
    How will you determine which is a “good doc”? And who pray tell should “forgive” their training? The medical schools (i.e. the docs who did the training)? The bank that holds their student loans? Who?
    But no matter. As we have seen, the “problem” of educational debt is already handled by their income levels: they’re getting a return on their investment PLUS economic rent on their medical licenses.
    t

16. sunkyu park, who the hell really knows? As with all Bush proposals, follow the money. It is he who gives the most money to Republicans that will gain the most benefit. And with Bush you know that it will never be the taxpayers or patients. The Dems are only a little bit better because they get much of their money from unions. And unfortunately, from trial attorneys that will block tort reform. It is unfortunate. Without political money driving the system we’d see a fix to the health care system and malpractice fiasco virtually overnight.

17. Barry, I think that’s what we can expect from all Democrats, with the trial lawyers giving some 80% to their campaigns. That’s why I’d prefer seeing tort reform moving forward without tying it to health care. We can’t wait for the latter.

18. You wrote: So, today, you’re better off getting insurance paid for by your employer than taking the cash, getting taxed and buying the same insurance yourself
    I’m confused by your comment on the last paragraph.
    Didn’t Bush “propose” the tax cut for whoever purchases his own insurance?
    My understanding was that “for an individual”, Bush’s proposal wouldn’t reduce or increase health care spending because if he would opt out of the employer provided health insurance, the wage will go up and with that extra money, he could buy the health insurance.
    I thought Bush’s new proposal would alleviate the industry’s burden of providing health insurance to employees.
    Am I getting this right?

19. Dr. Thom,
    Thanks for the great comments. It’s very helpful to hear from someone like yourself who has to deal with this every day.
    I notice that the recent seven page description of the health reform plan offered by presidential candidate John “Trial Lawyer” Edwards had exactly zero to say about malpractice reform or health courts. I suspect that the trial lawyer puppets among his former Senate colleagues are of the same mindset. Perhaps we can get some of the states to adopt health courts. I think the constitutional issue relates to guaranteeing a jury trial which is what would have to be changed, probably by constitutional amendment, for this category of disputes.

20. Thanks for getting back to us DrThom. A weekend of call is certainly good reason for tardiness. Having spent 25 years owning my own cardiac lab and sleeping more on the couch in my office than at home, I certainly understand.
    Most of us on this thread agree with your suggestions on liability reform. I don’t think a constitutional amendment would be needed but it may indeed be claimed by the trial attorneys. We wouldn’t suggest changing the criminal justice system that requires a twelve man jury, only the civil court system as it relates to medical lawsuits. The “peers” a doctor should have to convince should be qualified peers that understand medical decisions; other doctors. I would not oppose making it a part of the Medicare-for-all deal, but these things are usually easier to get passed if they are not laden with other issues. I’d like to see them move forward on parallel tracks, but that’s not a deal breaker for me.
    Your Medicare fraud sensitivity is a legitimate issue, but you can thank the docs in the lower segment of your profession for that. And not just docs; the nursing home environment is probably more rife with fraud than doctor’s offices. I can imagine even your clerks doing the upcoding without the doc’s knowledge, and then benefiting as a whistle blower. I don’t know if having a 2-3 person internal committee would help mitigate any charges, but voluntarily increasing your own oversight may be of some help. Certainly requesting a letter from the Medicare carrier on questionable codes would be advisable.
    In my old business CMS is attempting to cut the per-test reimbursements on cardiac monitoring, when instead they should be effecting cost reductions by cutting the over utilization. Far more Holters are done in the doctor’s office because they are easy and profitable, and less often because they are a legitimate diagnostic tool. Sometimes the results are meaningful, but not enough physicians really know how to deal with a thousand PVCs on an asymptomatic patient. That’s why I’d like to see a national database that compares practice patters.
    I don’t have a big problem with private insurers providing Medicare Advantage plans, even at 12.5% higher than Medicare itself. I’d insist that they be non-profit and self-contained (no exorbitant consulting fees to replace overpaid CEOs), and their books are open. I’m concerned with their cutting care to increase profit spread and hiding those profits to look like good guys.
    The real thing doctors have to worry about is the direction of the system if we don’t fix it now. Rather than belaboring that here I’d refer you to http://www.throwtherascalsout.org/How_doctors_are_yielding.htm. It’s not going to be a pretty sight. If you think Medicare is tough wait until industry takes over.

21. Well, I’ve learned I can’t post before a three day call weekend. It sounds like, even though your blog is obviously widely read by folks smarter than me, you guys don’t get many regular docs chime in very often. I am flattered by the interest in my opinions, I will do my best to be as honest and direct as I can.
    Health courts as described are the standard by which all other solutions are measured. The reaction to their implementation as far as patient management is concerned would be toward known quality indices as opposed to the shotgun approach to try to cover all the bases. The increased quality of care and increased efficiency of care would result in positive multiplicative effect. In short, it would be a good thing.
    What is unclear to me is, considering how the courts are treating judgment caps, how they could ever be implemented short of a constitutional amendment. I don’t see how they can be. Without some sort of tort reform any healthcare reform is doomed to be fatally incomplete. The price will be paid by either a decrease in the quality of the practioners in the system (and a concomitant decrease in the quality and efficiency of the system itself)and/or increasing utilization out of survival instinct. I have seen this issue discussed many times but never toward the issue of how to convince the trial lawyers to give up their stake in the system. I would be very interested to hear your opinions on how to make such as system a reality.
    Finally, and this might change your opinion of me, but I will have a singular lack of interest in any real work on universal coverage that does not deal with the liability issue front and center. Any idea that does not effectively moderate liability costs will eventually be unaffordable and from most physician’s point of view, a non starter.
    With regard to using Medicare as a single payor, as a small, ok medium businessman, I would take a single payor Medicare system in a heartbeat as long as it addressed the weakness of the current Medicare system. In its current form, I would still need about the same number of billing staff for reasons I will outline below. I don’t think any of the changes I need are deal breakers from Medicare’s standpoint but they absolutely are by mine.
    The punitive nature of the program must change. Honestly not a week goes by that I am not reminded of the consequences of Medicare fraud. Medicare fraud, I am told by our attorney, is the only felony crime on the federal books where you do not have to form intent in order to be convicted. In other words, if I overcode, or demonstrate a pattern of overcoding I could be held criminally liable even if I did it unintentionally. I am not saying this is likely, but it is explicitly the current law. It is also what Medicare constantly, and I mean constantly, reminds me of whenever they send out their bulletins. The harping in Washington on “waste, fraud, and abuse”, while politically cheap, has resulted in an environment where I a presumed to be a criminal. Not the way to encourage provider participation in such a system. I don’t want to sound maudlin, but it is a significant stressor and the more of it there is, the shorter my professional life will be.
    What is more, the poor office worker who presses the buttons on the computer is equally liable. Even more, if she recognizes the pattern and tells CMS before she tells me, she gets to keep a sizeable percentage of the take. Keep in mind that the rules for coding, like IRS regulations, are kept deliberately vague so as to keep me a little uneasy when I determine a level of care. I know that lots of unethical people cheat Medicare, but I would prefer extremely clear rules and extremely harsh criminal penalties to the current system. If we were to try to cover everyone in Medicare and not change this presumption, I would not accept a single new Medicare patient. If I was compelled to accept them in such a system, I honestly believe I would quit.
    Current covered services in Medicare also reflect this bias that I am a crook. Diagnosis based restrictions on testing significantly hamper my ability to care for patients. Documentation requirements are equally onerous and even more nonsensical. Medicare wants me to improve my foot care in diabetics, but in order to meet the requirement to get paid twenty four bucks for trimming toenails, I have to provide one printed page worth of information. I should only have to dictate “toenails trimmed without complication”.
    Wellness care is also woeful. Medicare should at least pay for screening tests at intervals that the government’s own joint task force on preventative services recommends. Indeed, it is its lack of coverage of theses services that enables private insurance plans to push their Medicare Advantage plans. Also, the new Medicare D plans may be holding down costs to the consumer, but their use of prior authorization for drugs is onerous (sp?) and a significant barrier to care. PAs must go if you want me to be efficient enough to care for my share of all these newly insured. Hell, at least 80% of the value of a drug is found in the generic version of most classes of meds. Just make sure I have unfettered access to at least one drug in each class. And now that I don’t need their samples to treat my indigent patients, keep that pretty drug rep with the low cut blouse out of my office too (leave the Viagra, though).
    Even with recent changes, current payments from Medicare do not recognize the importance of high quality primary care physicians who drive the costs in the system. Payment levels are unstable from year to year, making planning difficult in the extreme and, at current levels, they are not enough to meet the income thresholds I described in my previous posts. Although Medicare pays relatively quickly, buffing these claims takes considerable time and expertise as does all the compliance I have to do in this overly punitive environment so I can feel I have a reasonable chance of staying out of prison. Therefore don’t expect my overhead to change much with a Medicare based single payor system, I’ll need all my commercial staff to help with the increased Medicare claims.
    That said, I think that all these issues are fixable relatively cheaply as long as there is some way to compel the proceduralists to participate in the program enough to keep services available while at the same time allowing them to make enough money on a private FFS basis to make their training worthwhile.
    Reading back, this sound awful whiny. Look, I practice medicine because I love my patients, I get a good income even considering the time I put in up front, I get some societal respect (except, of course, from out government which seems to think I don’t pay my fair share of taxes on income they assume I stole from them in the first place) and a personal sense of accomplishment. If it takes a single payer to cover everyone I’m in. The costs of my providing care can be easily covered by reducing the barriers in place rather than printing more money.
    Of all physicians, primary care docs are the ones who need to buy in, after all someone has to provide quality care for the millions of newly insured. It seems to me it is just as important to keep us practicing as long as possible as it is to get new ones in the pipeline. Reform the tort system, forbid physicians from receiving the technical component of testing and compel every physician to participate in a single payor to some level (but not too much). In return, you must completely get out of my face as to what interventions I order, give me clear billing guidelines and trust me to do the right thing. Do that and see how long I stay in practice. There would be no reason to retire, ever.
    We just bought a comprehensive nextgen emr/practice management system (1.5 million with absolutely no help and much hindrance from our government). I hope it will do everything as advertised. However, if it merely halves my efficiency and triple my work, it will exceed my expectations. More on that later

22. I don’t know Barry, I could go on forever. He may have to take some vacation days so we can get through the list. 🙂

23. Jack,
    Maybe we should develop a global budget for the number of questions we ask Dr. Thom before we ask him any more!

24. Let me add three more:
    3) Does Medicare interfere with your treatment decisions?
    4) What are the major weaknesses of Medicare?
    5) Is your office aleady using electronic records, and what would you like to see them do to help your practce?
    (Aren’t you glad you asked?)

25. And I’d two more questions:
    1) If we had a Medicare-only system, how many people could you reduce your billing staff from/to?
    2) Does Medicare most often under-pay, over-pay, or is their fee schedule fairly on target?

26. Dr. Thom,
    Very interesting comments. I have two questions regardings #1 and #3 which are:
    1. Could you make a satsifactory (to you) income if you collected Medicare rates from all of your patients?
    2. If we had a sensible malpractice system (like health courts) that you and other docs perceived would resolve disputes fairly and objectively based on sound science and accepted medical practice, how would your practice pattern change, and how much of the healthcare costs that you and other docs currently “drive” could be safely eliminated?

27. Thanks DrThom, you’re my kind of doctor. I agree with you 100% on your list of seven. Good docs should indeed earn in the top 10% wages and their medical training should be totally forgiven if they ranked high in the graduating class. What we need most is to get the non-health care services out of the health care delivery system. Insurance company marketing, commissions for the 50,000 brokers, salaries for the 100,000 underwriters, excessive salaries for the executives, and profits for the sharehoders add absolutely nothing to patient care.
    The knee surgery went well, thank you. I went to a doc who believes that if only half of the knee is bad, replace only that half. Two days out I discarded the crutches and two weeks out I’m walking fine though with some pain, but mostly during therapy.

28. love the discussion
    As a family physician who is an owner of a multispecialty clinic and the driver of all health care costs, let me tell you what a system should look like.
    I would be happy if
    1. it paid me enough to pay off the 200k worth of debt I piled up getting here and not feel like a sucker for giving up the first 9 years of my professional life. Idon’t have to get rich, but I had better be in the top quintile of income if want to have enough talented motivated providers to keep the system going. There are too many other opportunities in this economy and I can satisfy my desire for service in other ways that won’t shorten my life expectancy
    2. There is no insurance company droid getting between me and the intervention my patient needs. Want to improve my efficiencey? don’t make me waste time trying to communicate the justification for my judgement. Limit my choices if you must, but don’t make me jump through any hoops for any of them. Any system that doesn’t essentially trust me won’t work.
    3. It removes any profit incentive for me to do one test over another or any test at all for that matter. although I do pretty well myself, it is a distraction
    4. It removes the worry that some malpractice attorney will make my life hell for 6 years, using the system to stress me until I settle or have a heart attack. This is a deal breaker. I have never been named but I have seen that scenerio up close and personal over a dozen times. It honestly is a and sometimes the primary consideration in absolutely every decision I make. If your think any system that does not address this will work, you all are living in a dream. Looks to me like health courts will require a constitutional amendment before the liability attorneys will give up on the current litigation model.
    5. It gets the marketers out of my face, another distraction
    6. It didn’t put any more costs on me than any other business man faces esp taxes on me because I am a physician
    7. It gives me the option to work for myself. it will take 5 employed physicians to provide the service of two self employed ones. If you don’t understand this, you will have one unsatisfied patient base
    I hope your knee is getting better.

29. Bev, regarding paying “list price” for health care… no… you are not. You get the same discount as anyone eles with the same carrier as you. That is one of two things.. the ONLY two things… you should look for when buying insurance. Network ( for the discounted rates ) and a stop less you can live with, that’s IT.