It is becoming increasingly clear that the average American cannot really figure out the details of healthcare reform. Obviously, if an individual has a pre-existing condition or suffers from an illness which he/she fears will approach his/her policy’s lifetime limits, healthcare reform may be like winning the lottery. When we look at it from a national perspective, however, we hear divergent views from the Democratic camp (extolling the virtues of their legislation) and the Republican camp (claiming that it is the death knell of America).

How is the average citizen supposed to formulate an opinion? I believe that, currently, it would be very difficult as the legislation is extremely complex and virtually all the commentators choose particular aspects of the law to buttress their particular position.

After giving some thought to the recent legislation, reading various reports, and recognizing the difficulty of synthesizing the totality of this most voluminous legislation, I think I may have stumbled on some real truths regarding understanding the benefits and possible burdens of our future healthcare.

Obviously, the first question to be answered is how will Americans benefit? Even this question is a bit more complex than it seems at first blush. Obviously, increased benefits, and the increased millions of people that will finally have health coverage is part of the benefit.

However, many young healthy Americans have chosen not to purchase health insurance reasoning that the odds are significantly in their favor that they will not need any medical care. Even if they have to visit a doctor for something minor, it would still be much cheaper than insurance premiums. Under the new legislation, though, they will not have this choice but will be forced to purchase insurance, or their employers will be forced to purchase insurance for them.  Apparently, the math is correct. As Anthem Blue Cross of California explained, the outsized increase in their insurance rates was because a significant number of lower-cost younger subscribers had opted not to purchase insurance leaving a pool of insured individuals that were both older and more costly. The question remains whether there is a true benefit to the people whose freedom of choice has been taken away and are now forced to subsidize older and costlier subscribers. I think that it may be dependent on basic differences in Democratic and Republican ideology and the question of the propriety of forcing a redistribution of wealth. I hasten to point out that increased taxes or a more equal redistribution of wealth might be more beneficial than forcing younger people who may not have significant means to subsidize the healthcare of older people.

The second question is at what cost? This question can be broken up into direct cost and indirect cost. Even with the projected direct costs there seems to be very different opinions. On the one hand, because President Obama drew a line in the sand that the cost could not exceed $1 trillion over the next decade, the numbers were jiggled and tweaked until the Congressional Budget Office (a nonpartisan agency) issued a projection that the cost in the next decade would be $940 billion. Hooray!

A former congressional budget office official has stated, however, that the way in which the $940 billion projection was achieved was in part by starting taxes and other offsetting revenues sooner than the costlier parts of the legislation take effect. In more simple language, what he is saying is that the government decided to delay the implementation of many parts of healthcare reform so that there would be fewer years of greater expense in the next decade while collecting money for many more years of the coming decade. If he is right, the second decade may be much more expensive than any Democrat wants to talk about.

If that was not enough, an analysis by RAND, an independent think tank, suggests that the reforms will actually increase America’s overall health spending–public plus private–by about two percent by 2020 (so much for savings).

The Cato Institute, a libertarian think tank, points to the Massachusetts health care reform of a few years ago which is similar to Obamacare. It finds that the law has not improved people’s health, and claims that estimates understate the law’s cost by at least one third.

So much for the direct costs. In the next segment, I will continue with the indirect costs.

Last night the House passed transformative healthcare reform which is expected to be voted on by the Senate and signed by the President sometime this week.

The legislation promises to eliminate issues of pre-existing conditions, and provide insurance to the tens of millions of Americans that currently do not have insurance coverage.

While details of the bill will emerge in the future and will answer questions such as the government’s role, the real cost, who will pay for it, and behind-closed-doors promises that were made, I think that some time is needed to digest the thousands of pages and hundreds of amendments that are part of this voluminous legislation.

At this juncture, there appear to be a number of issues that warrant discussion even if we do not yet know the content of the bill.

While this healthcare legislation is heralded as being the current day equivalent of the enactment of Social Security, Medicare and Medicaid, there are distinct differences. In the case of Social Security, Medicaid and Medicare, the legislation was passed by significant margins of both the Democratic and Republican parties. In the case of current healthcare reform, the last few weeks of negotiation, fighting and alleged arm-twisting was solely within the Democratic Party. In fact, none of the House votes were Republican. Speaker Nancy Pelosi’s claim that this legislation is bipartisan because there are some amendments that were suggested by Republicans seems disingenuous.

Virtually every poll I have seen indicates that the majority of Americans are against the current healthcare legislation.

As I understand it, “reconciliation” must be used to pass this legislation despite the fact that many scholars believe that this was not the intent of reconciliation. They view it as an abuse of a tool that was created to be used for minor fiscal impasses, not for legislation that is reported to take control of one-sixth of our economy.

Pro-life legislators, many of whom were elected because of their views on abortion, allowed legislation to pass with the promise of an executive order. I am sure they are well aware of the fact that executive orders can be rescinded at any time by the President that ordered them as well as any succeeding President. If I recall correctly, President Obama’s first act in office was to rescind President Bush’s ban on foreign aid to the extent that it paid for any abortions. President Obama’s rescinding of that order demonstrates his deep-rooted belief in being pro-choice. Can one really blame the pro-life people who feel that they were sold out by the very legislators on whom they relied?

The majority of the states have not only voiced their displeasure with the legislation, but have promised to sue the federal government seeking a ruling that the legislation is unconstitutional.

I have repeatedly said that I believe that the current healthcare situation in the United States cannot continue as it is. The question is how it should be changed and when it should be changed.

Considering everything in this post, however, the question is if the end (even according to those who believe that the current legislation is the right way to go) justifies the means? Is it proper to pass monumental legislation without the will of the majority of Americans, without the will of the majority of the states, without the will of at least part of both of our parties, and absent a lot of lobbying, individual payoffs to constituencies and an apparent healthy dose of arm-twisting, with not even a clear mandate from the Democratic Party?

I recently read an article in the Washington Post entitled “Group Appointments Give Patients Better Access to Physicians,” which I found intriguing. The URL for that article is appended below.

Essentially, the article touts the benefits of doctors simultaneously treating groups of patients. The benefits seem to be shorter wait times, more face time with the doctors (albeit with many other patients), and more patient involvement in their own care. Most intriguing was the apparent willingness of patients to share possibly embarrassing health issues in a group as compared to patients’ reluctance to share embarrassing information with their doctors in a one-on-one setting. The article further sites a 2006 review of nearly 20 studies published in the Journal of the American Board of Family Medicine calling group appointments “a promising approach.”

Both as an attorney and a person involved in medical billing, the first question that came to mind was how does this group setting for the practice of medicine and the sharing of private information, not only with a doctor and his or her medical staff but with other patients, mesh with HIPAA – HITECH? The second question that came to mind was why there was no mention of the potential pitfalls in the article?

Of course, my first reaction was that any medical group embarking on group care would have the patients sign HIPAA waivers which would warn the patients that inherent in their agreement to be treated in a group treatment setting was their agreement to waive certain privacy rights they would otherwise have in a one-on-one doctor consultation.

The idea is that patients who agree to group treatment settings should understand that they are relinquishing certain privacy rights even without any explanation from the doctors or requirements to sign special waivers. There is this part of me, however, that still questions what happens when a patient says something that is truly embarrassing and that information is disseminated. It is not hard to imagine what type of information this might be in an OB/GYN practice, although there are many other areas of medicine where the same could occur.

Assuming the medical practice had crossed all the “t”s and dotted all the “i”s with regard to potential financial liability, they should eventually prevail after a thorough audit either by the government for a HIPAA violation or by a civil lawsuit.

In any event, if a medical group decides to embark on group treatment, I think they should have very clearly drafted documents as well as an orientation session, preferably by video. This way they can amply demonstrate that the patient was fully informed of the inherent loosening of patient privacy, as well as offer the patient the alternative of one-on-one treatment.

The question is if the benefit outweighs the potential risks that doctors and medical practices face. I am not a doctor and I am not in a position to offer an opinion except to say that in doing any analysis of this sort, it is best to recognize that there is a potential for embarrassing information to be disseminated. There is also a potential that the person who feels aggrieved may seek recourse either through government intervention or through a civil lawsuit and even though the doctor may win, the win may be obtained at significant cost.

As an aside, to the extent this is done to maximize practice revenue, it is entirely possible that as this method of treatment gains popularity, third-party payers will adjust their reimbursement schedules accordingly.

http://www.washingtonpost.com/wp-dyn/content/article/2010/03/08/AR2010030802945.html

I recently read an article that at first glance was somewhere between comical and absurd but upon reflection is truly troubling. I have appended the URL below so that you can read one of the articles reporting this story.

Apparently, Assemblymen Felix Ortiz, a Democrat from New York, introduced legislation that would for forbid restaurants to add salt to the food they prepare. For violations of this act the restaurateurs would be liable for a $1000 fine for each violation. The articles I have read do not specify if the fine is per batch of food to which salt is added, per dish of salt contaminated food that is served to patrons of the restaurant, or if each shake of the salt shaker in the kitchen adds $1000 to the tab.

The apparent rationale behind this legislation is based on the premise that salt is unhealthy and that consumers should have the option of how much salt their food contains. Obviously, the assemblymen did not consider the option of customers choice of which restaurant they patronize based on their acceptance of the food the restaurant serves.

When reading this story the words that reverberated in the back of my mind were “what was he thinking.” The more I focused on “what was he thinking” the more troubling the article became.

I began to question the assemblymen’s underlying rationale for introducing the legislation. How far does he think the government should be involved in the private choices individuals make. Let’s face it, salt is not arsenic. The American Heart Association encourages people to monitor their salt intake. However salt in and of itself is not poisonous. Similarly troubling is the way in which this unwarranted intrusion is couched in terms of offering freedom of choice. Essentially what he is saying is that we should ban salt in the preparation of restaurant food BECAUSE we want to give consumers free choice regarding the amount of salt they want in their food.

It is clear that this assemblymen and I differ on how much governmental intervention we need in our lives. It is also clear that he does not have a refined palate, as he apparently doers not know the difference between the taste of salt that is added during the cooking process and salt that is added thereafter. What do you think.

http://www.myfoxny.com/dpp/news/local_news/new_york_state/chefs-call-proposed-new-york-salt-ban-absurd-20100310-akd

Virtually all medical practices are involved with medical billing. Currently, the language of medical billing is ICD-9, which is 3 to 5 digits in length with either the letters V or E as the only alpha characters used in ICD-9.

On January 16, 2009 the Department of Health and Human Services (HHS) published a regulation requiring the replacement of the ICD-9 code set with the ICD 10 alternative as of October 2013. The ICD 10 promises greater specificity and the ability to identify disease etiology, anatomic site and severity with the additional characters in ICD 10 allowing for the identification of the body system, root operation, body part and device involved in the procedure.

The question is how this transition will impact on your medical practice. As it currently appears, the transition has the capacity to wreak havoc for the following reasons. The ICD-9 code set has approximately 4,000 line items while ICD 10 has approximately 5 times as many line items. The increased number taken in conjunction with a certain lack of compatibility between the two protocols has difficulty written all over it. Recent reports indicate that the learning curve from ICD-9 to ICD 10 will be significant. Aside from the thousands of new codes that will be introduced, apparently, just 5% of all ICD 10 codes map directly to ICD-9 codes, and conversely, only 26% of ICD-9 codes map to ICD 10 codes.

While the current compliance date for ICD 10 is October 2013 and that date is not etched in granite, this is not the type of transition that happens with the flick of a switch. Billing staff, whether working for in-house or outsourced medical billing companies will need significant training. Failure to be properly trained and prepared may cause serious disruption to a medical practice’s revenue cycle management, or in simple English, the cash flow of medical practices may be (at least temporarily) very seriously disrupted.

Medical billing companies must start planning for training and developing internal protocols to ensure that their clients are not left with gaping holes in their collections. Let’s face it, the insurance carriers will not be upset if they have the opportunity to delay or deny significant numbers of claims.

Medical practices must decide if they want to retrain their staff and the drain on their current resources that this training will cost. They must also decide if they are willing to take the risks for incomplete, untimely, or inefficient transition. Similarly, if they timely train their staff, those employees will be in great demand that may lead to very attractive offers from other medical providers and medical billing companies.

For those who wait for the last minute and are not currently thinking about how to navigate this massive change, the results are almost certain, and they are not encouraging. I believe that every billing company and medical practice that currently has in-house billing must listen to the wake-up call and prepare accordingly or suffer the consequences.

One of the hallmarks of our great country is that we are a DEMOCRACY. To effect a proper administration of the will of the people and the good of the nation, we have a very detailed electoral process and a rather sophisticated checks and balances system at both the state and federal levels.

The question I pose to you is if, during the time that they are in political office, elected officials receive the mandate from their constituents empowering them to act at their sole discretion irrespective of what the constituency truly wants. Or is the expectation that the elected officials will use their best judgment in making decisions to the extent that they understand what the people who elected them want and the elected officials are, therefore, morally if not legally bound to follow the will of the people.

Depending on your understanding of the democratic process, it follows that you will have a differing view on the purpose of the many polls that sitting elected officials conduct to gauge the attitudes of their the people they represent. In the first case, one might assume that polling is primarily done to prepare for reelection runs and to make sure elected officials stated policies comport with the expectation of the voters. In the second case, one might assume that the reason was to better understand the will of the people and to properly represent them. Even in the latter case, though, reelection planning might still be part of the calculus. I believe that this question goes to the root of our understanding of democracy.

Now for the applicability to healthcare.

It is readily apparent that America cannot (on a forward-going basis) afford its own healthcare. With health-care spending at approximately 17% of GDP (meaning that 17% of every dollar we produce goes to healthcare), and with all estimates of future healthcare costs rising quicker than projected inflation or projected increases in GDP, we know that, ultimately, the cost of healthcare will strangle us.

The real question is not IF we need healthcare reform, but HOW it can be accomplished. In addition, because of other possibly more pressing economic challenges e.g. our current deficit, unprecedented levels of debt, high unemployment etc.,  is this the right time to enact sweeping health-care reform, which brings us to the question of WHEN.

When internecine fights were going on in the House and in the Senate, one could chalk that up to the regular ying and yang of the political process. It started to become uncomfortable when the elusive 60th vote was needed in the Senate. There were those who thought that the rules should be changed, but in the end the vote was bought.

Thereafter, the Massachusetts race, which took everyone by surprise, further complicated the bought-and-paid-for 60th Senate vote. This left a few alternatives — either get the house to approve the Senate version (which proved undoable), try to get a new 60th Senate vote (which similarly proved to be undoable) or use “reconciliation.” This last approach is a method by which only 51 votes are needed to modify legislation as long as it is done, not for the substance of the law, but for minor revisions relating to the dollars and cents of the bill and how it relates to the budget. Reconciliation was never intended to ram major legislation through the Senate without the otherwise requisite 60 votes.

There were reports that members of Congress were upset that senators from less populous states had the same vote as senators from the larger states. Isn’t that the reason why we have a House of Representatives that tracks the population and a Senate that tracks the rights of the states and together the idea is that we will get a true voice of both the people and their respective states? To argue that the Senate is unfair when things go against you seems to be arguing that if you don’t get what you want our system of government is to blame.

What I found particularly troubling were reports that Speaker Nancy Pelosi asked members of the House to vote for healthcare even if it might cost them the midterm elections. In my own humble opinion I think that she was asking them to “take one for the team.” My question is who is the team? Is it the Democratic Party, President Obama, or the people that elected them to Congress? My logical conclusion is that if he/she could lose an election for voting for healthcare, that particular member of Congress was not voting the will of his constituents.

Virtually all of the polls I have seen show that America is deeply divided over pending health-care reform. I believe that I have a simple solution.

Why don’t we go back to the basics—good old democracy?

Why don’t we ask the Democrats to prepare their version of healthcare reform and ask the Republicans to do the same? Thereafter, it can be posted on the Internet and a national referendum should be held so that the will of the people prevails.