The Sad Case of the Patient Protection and Affordable Care Act

[jerphisch]

Re: The Sad Case of the Patient Protection and Affordable Care Act

That's cute. Now let's see the entire offering. I mean ****, most people could take their deductible up to $1,000 and pay a fraction of what they pay for car insurance premiums.

Did you call The General? My employer's plan has a $3,000 deductible, and I pay the same for 1 month of health insurance for my family that we pay for 6 months of car insurance on 2 cars.

[dxmnkd316]

Re: The Sad Case of the Patient Protection and Affordable Care Act

That's cute. Now let's see the entire offering. I mean ****, most people could take their deductible up to $1,000 and pay a fraction of what they pay for car insurance premiums.

[unofan]

Re: The Sad Case of the Patient Protection and Affordable Care Act

So after years of 10-15% premium increases, this year's insurance premiums for state of Iowa employees are set to remain flat or even drop by up to 7%, depending on the plan. We just got the spiel from our HR director since the open enrollment period starts monday.

But I'm guessing the ACA had nothing to do with that, amirite?

As a followup, got the numbers today. They show a 6.2-6.7 percent drop in premiums for every plan offered to state employees starting 1/1/2013.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

In theory this looks awesome. Some of the issues include:
- lack of aftercare availability- VNA around here is strapped. We can order all the approp f/u we want but they don't have the bodies
- lack of financial means- again, all the orders are there but the person cannot afford what is ordered- meds/PT/etc
- lack of communication- can't speak for other areas but locally the charts aren't getting completed sometimes for months after discharge because they are so time consuming (previously you could dictate the d/c but now there is a bunch of BS that needs to be done that apparently takes a huge amt of time). We get rudimentary info but the whole note can be months in coming
- pt is just not compliant- they can tell you the discharge plan but have no intention of following it. THe hosp gets screwed, the patient doesn't really get a consequence other than another hosp.
- once again it is riskier to take on complex patients. If you are willing to treat medically messed up people you bear the risk they are more likely to have complications even with stellar care. The tertiary hospitals (teaching hosp, trauma centers, etc) are at huge risk. They get the worst cases and also the burden of the people more likely to be unable to afford things.

On the plus side- hopefully it will deal with the cavalier attitude of the hospitalists and specialists who discharge the patient with little if any preparation and tell the pt to call the Primary knowing full well all the resources aren't in place. Supposedly they reimbursement is tied to the Doc who did the admission. If the pt shows up after discharge with a post op infection DING! out goes the lights.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Got that sick relative that seems to be an ER constant customer? May not be happening anymore....http://news.yahoo.com/medicare-fines...084833994.html

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

So which is it, Fishy? A great idea, or a horrible thing?

Somewhere in between, I'd say. It's an interesting experiment; lots of other companies are watching to see how well it works.

It IS a good transitional method to sever the link between employment and health insurance coverage, and that probably is an improvement.

The Medicare Part D drug benefit actually came in under projected cost from the outset, you know...the only program of its kind in US history that ever did, and this new program uses the same kind of mechanisms.

[unofan]

Re: The Sad Case of the Patient Protection and Affordable Care Act

http://online.wsj.com/article/SB1000...LEFTTopStories

Gee, that sounds almost identical to Paul Ryan's plan for Medicare...

So which is it, Fishy? A great idea, or a horrible thing?

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

This death panel thing makes me crazy. Any hospital of a decent size and I would hazard to guess all teaching hospitals have ETHICS panels who review care of those who are very ill. This was something that was developed to protect the patients from overzealous Drs and families. The object of these panels is to consider whether it is ethical to continue to treat the patient when there is no hope of recovery. They attempt to limit the needless treatment/use of modalities
that could cause pain/ suffering with no hope of benefit in people who had no hope of recovery. Ex- comatose, patient with profound brain injury and the Dr wants to do multiple tests to fully define the condition but this won’t change the treatment plan. The side effect of omitting testing/treatment with no help to the patient is we do not spend money on.

The original Bill had a provision to encourage Drs to discuss the prognosis and ascertain the wishes of the patient before they were in extremis. It also provided for reimbursement for the discussion. Any Dr worth their salt has this discussion (which is time consuming) but currently they have to do this gratis. This was added to the Bill because research showed patients having frank discussions regarding dx/ end of life care not only lived longer but had higher levels of satisfaction with quality of life (especially if they chose palliative care) than the people who went with the full court press without the benefit of discussion. This result shocked many in the medical community but has been reproducible.

Perhaps we have different definitions on "death panels". From what I understand, the argument stems ENTIRELY upon the panel-represented body's ability to pay, and in most cases, that's the government. Because the government is only able to provide limited funds, such as with Medicare, there are two ways to address this. One is to cut the reimbursement amount, and the other is to ration the amount of care provided. Combine this with the fact that the Medicare contract states you may only use them as a source of payment plus any co-pays involved, not to mention that any year after retirement costs more to enroll, and you are not able to collect social security without joining Medicare, and you have an issue. This is why I have been pushing the patient payment hybrid alternative. If there's any way for the govenrment to save money on this money-sucking program, it should be considered.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Death panels is more of a long-term effect. This isn't so much of a tax as it is a price ceiling. Obviously, insurance companies will look to charge more because not only is the product now inelastic, but they will now need to cover what may be some very unhealthy people. However, now the government has effectively set a demand price, as the people will demand to pay for their insurance the amount of the tax, plus the price of avoiding rationed care (e.g. emergency room). Eventually, we will get to a point where the government is providing funding for all care because of the lack of affordability for insurance, and it will then be rationed in order to stay within budget.

This death panel thing makes me crazy. Any hospital of a decent size and I would hazard to guess all teaching hospitals have ETHICS panels who review care of those who are very ill. This was something that was developed to protect the patients from overzealous Drs and families. The object of these panels is to consider whether it is ethical to continue to treat the patient when there is no hope of recovery. They attempt to limit the needless treatment/use of modalities
that could cause pain/ suffering with no hope of benefit in people who had no hope of recovery. Ex- comatose, patient with profound brain injury and the Dr wants to do multiple tests to fully define the condition but this won’t change the treatment plan. The side effect of omitting testing/treatment with no help to the patient is we do not spend money on.

The original Bill had a provision to encourage Drs to discuss the prognosis and ascertain the wishes of the patient before they were in extremis. It also provided for reimbursement for the discussion. Any Dr worth their salt has this discussion (which is time consuming) but currently they have to do this gratis. This was added to the Bill because research showed patients having frank discussions regarding dx/ end of life care not only lived longer but had higher levels of satisfaction with quality of life (especially if they chose palliative care) than the people who went with the full court press without the benefit of discussion. This result shocked many in the medical community but has been reproducible.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Mrs. Les,

One of the problems we have to deal with is inaccurate information.

The Big Lie: people with pre-existing conditions can't get coverage under the current system. Not quite true: if you have pre-existing conditions and want coverage, you merely have to get hired by a company that provides health insurance, you are automaticaly covered as long as you enroll when first eligible.

The Truth can Set You Free: use that insight; you don't need a mandate (which now is unconstitutional on the federal level anyway*); what you need is Open Enrollment Windows (hmm...like the existing health plan for Federal employees...). If we break the link between employment and health insurance coverage, everyone who wants health insurance can buy it no questions asked as long as they do it during the open enrollment period, insurance companies can price it properly. The problem is merely exacerbated by PPACA (as it now stands) because it still allows people to buy insurance after they get sick.

Another Big Lie: if health care costs go up faster than inflation, we must have a problem.

Not completely true; much of health care is elective, and you'd expect people to consume more of it as their incomes rise. If I'm poor and my kids have crooked teeth, too bad for them....if I have some discretionary income I can send my kids to the orthodontist. If I'm poor and I need glasses, I get a cheap functional pair; if I have some discretionary income, I can get contact lenses or designer frames.

I could continue this list for awhile....PPACA is all command-and-control, "anything not mandatory is forbidden." There is no incentive for innovation, no incentive for cost control. A far better solution would be to sever the link between health insurance and employment, allow a combination of high-deductible insurance and a HealthCare Spending Account (FSA) that can be rolled over from year to year (how stupid is it that if we don't use our FSA this year we forfeit the money?), have periodic open enrollment windows, and while that doesn't "solve" the problem of a person with no coverage using the emergency room, it surely helps mitigate it substantially.





* apparently, many people don't realize that there is a huge difference between what states are allowed to do and what the federal government is allowed to do. States do have the authority to regulate people directly; states can impose a mandate if they want. It is now clear that the federal government does not have the power to regulate people; the mandate is unconstitutional, the federal government can only regulate behavior.

First, I am not arguing for or against the current Bill. I think we can all agree that medical cost needs to be addressed. In response to your post-
- you merely have to get hired by a company that provides health insurance… This is either a willfully ignorant or disingenuous thing to say. Are you assuming all people chose to be in a situation that does not get them the coverage they need? Some ‘facts’- Not all employers insure people (ex.- small businesses, part time workers). Depending on the size of the employer they may not cover pre-existing conditions. Not everyone can chose an employer that will have the ‘right’ insurance. You cannot assume everyone who is unemployed is that way by choice.

- Open enrollment does not address the suck on the system that occurs when the purposefully uninsured utilize the system with no hope of reimbursement. These people have no intention of paying in and many times can’t pay the bills when they get the service. The easiest thing would be to have them sign something that says they accept the risk of not being covered and the hospital is not required to treat them without payment. This is not realistic. We need to deal with the fact that hospitals can’t absorb the cost of giving these people care indefinitely. In Mass the number of hospitals is shrinking d/t financial problems. In the city next to me there used to be 3 hospitals and 2 acute psych facilities in the space of 5 miles. They were always full. There is now 1 hospital and the nearest treatment ctr for emergent psych is 20 miles away. Sometimes people sit for a few days in the local ER before they have a bed on the floor or a place at the psych facility. (no, this really isn’t an exaggeration. Sometimes they get treated and released after a few days in the ER at massive cost, without ever getting access to a floor bed.)

- much of health care is elective,- I must be reading this wrong. I am sure you can’t be implying that the majority of our expense is because of frivolous expenditure. The examples you use are odd. Without the Cadillac version of supplemental insurances braces aren’t covered, glasses may be covered but usually with a limit. If people are spending money on this they aren’t the ones that are going to cost us cash. It is the person with chronic illness with multiple comorbidities that will cost us the serious cash if they are undertreated and land in the ER, ICU etc. A few hundred $ to pay for meds/testing every month beats the 100K of ER, ICU, surgery, etc. They don’t tell someone in the unit they can’t afford the surgery or meds. They give them and worry about reimbursement later.

- allow a combination of high-deductible insurance and a HealthCare Spending Account… and while that doesn't "solve" the problem of a person with no coverage using the emergency room, it surely helps mitigate it substantially. I agree it is stupid to lose the $ at the end of the yr. In theory this sounds wonderful. In reality a high deductible is a barrier to care for the person who is working a few jobs to make ends meet.. Most people do not have 3K to burn before coverage kicks in. In Mass this has been a real problem. Insurance costs about 350$/month for the cheapest plan. That is a lot of cash. For many that means they have nothing left to save to pay the deductible. In my practice I can’t count how many times the patient cannot afford the deductible so can’t be seen/refuses an appt, can’t afford generic meds, basic testing, or the recommended screening for things like diabetic retinopathy. My visit isn't spent advising the appropriate care. It is strategizing what is least likely to cause harm when the patient can't afford what is needed.

I repeat the question -what the plan is to deal with the aftermath of not covering people while we wait to work something out?

[Tiggsy]

Re: The Sad Case of the Patient Protection and Affordable Care Act

3) Roberts ruled that the Federal government does have the power to impose a tax on people who do not purchase health insurance. He said it quite explicitly: "people have the option either to purchase health insurance or to pay the tax."


You somehow keep defining # 3 as a "mandate" while I have been using the word "mandate" in the more conventional dictionary sense. Once we recognize we have been using two different definitions, any apparent discrepancy disappears.

I don't see how this is not a mandate.

http://dictionary.reference.com/browse/mandate?s=t
verb (used with object)
10. to authorize or decree (a particular action), as by the enactment of law.

Either you follow the law or pay the price. If you refuse to pay the price long enough, as with income taxes, you could go to jail.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

All well and good, although I will say with #2 nowhere was there ever a push to punish people with jail for not getting health insurance. The stick in the carrot and stick approach was always a fine/tax/levy/whatever. Maybe a nitpicking distinction, but with some of the falsehoods flying around over this legislation (death panels for example) its one that needs clarification.

Death panels is more of a long-term effect. This isn't so much of a tax as it is a price ceiling. Obviously, insurance companies will look to charge more because not only is the product now inelastic, but they will now need to cover what may be some very unhealthy people. However, now the government has effectively set a demand price, as the people will demand to pay for their insurance the amount of the tax, plus the price of avoiding rationed care (e.g. emergency room). Eventually, we will get to a point where the government is providing funding for all care because of the lack of affordability for insurance, and it will then be rationed in order to stay within budget.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Fishy you just proved my point for me, so thanks for digging up the quotes. He said the mandate is unconstitutional under the commerce clause (a 5-4 decision) but constitutional under the taxing power. So, its constitutional. The law was written so that those who didn't comply (as in get insurance) would have to pay a penalty (a tax for Roberts purposes). The law didn't advocate jail or beatings for non-compliance, just what was upheld - a monetary payment for not carrying insurance.

What I laugh and laugh about is the continued "heads we win, tails you lose" mindset out of conservatives on this one. As the law was envisioned, you will either get insurance or pay for noncompliance. That's what Roberts agreed with. Whether he did so due to Commerce or Tax clause reasons is irrelavent for all practical purposes. Upon Obama's re-election the ACA will be enacted in full. Even the more sane cons like joecct are falling into this absurd trap, in that case with the notion that there's a penalty that won't be enforced, sorta like jaywalking fines. Uh, no. If this "loss" was really a victory for you guys, why is Scalia still going berserk over it?

Rover,

The IRS has said it is not going to use its agents to enforce the collection provisions of the ACA (you're not going to like the source, but with a quick google, it was all I could find).

I don't like the Federal Government getting more and more involved into "stuff" that have been the purview of the states. Massachusetts passed a health care law, goody for them. If I did not like it, I could have moved to New Hampshire. But unless I want to leave the country, I no longer have an option on health insurance.

[Rover]

OK, let's parse the ruling exactly as it was presented without using that problematic word:

1) Roberts explicity ruled with no equivocation that the Federal government does not have the power to compel people to purchase health insurance
2) Roberts ruled that the Federal government does not have the power to impose a "penalty" on people (except in one very narrow sense of the word): it can not threaten people with jail time if they do not buy health insurance, it can not make it illegal to go without health insurance. People have the right to choose whether they buy health insurance or not.
3) Roberts ruled that the Federal government does have the power to impose a tax on people who do not purchase health insurance. He said it quite explicitly: "people have the option either to purchase health insurance or to pay the tax."


You somehow keep defining # 3 as a "mandate" while I have been using the word "mandate" in the more conventional dictionary sense. Once we recognize we have been using two different definitions, any apparent discrepancy disappears.

All well and good, although I will say with #2 nowhere was there ever a push to punish people with jail for not getting health insurance. The stick in the carrot and stick approach was always a fine/tax/levy/whatever. Maybe a nitpicking distinction, but with some of the falsehoods flying around over this legislation (death panels for example) its one that needs clarification.

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I'm not saying you have to like the ruling, just that's what it was.

OK, let's parse the ruling exactly as it was presented without using that problematic word:

1) Roberts explicity ruled with no equivocation that the Federal government does not have the power to compel people to purchase health insurance
2) Roberts ruled that the Federal government does not have the power to impose a "penalty" on people (except in one very narrow sense of the word): it can not threaten people with jail time if they do not buy health insurance, it can not make it illegal to go without health insurance. People have the right to choose whether they buy health insurance or not.
3) Roberts ruled that the Federal government does have the power to impose a tax on people who do not purchase health insurance. He said it quite explicitly: "people have the option either to purchase health insurance or to pay the tax."


You somehow keep defining # 3 as a "mandate" while I have been using the word "mandate" in the more conventional dictionary sense. Once we recognize we have been using two different definitions, any apparent discrepancy disappears.