(12-17-2009 09:36 PM)jh Wrote:  No explanations, because I have no doubt the proposed plan will be a bad one, but I do have a question about pre-existing conditions.

I've worked for my current company for ten years. During that time the company has switched insurance carriers two or three times, so my current insurance company is at least the third different one that I've had. If I develop a condition now, and my company decides to change carriers again, can I be denied on the basis of a pre-existing condition (and lose my insurance through no fault of my own)? Or does this only apply to individuals attempting to purchase insurance?

(12-18-2009 12:21 AM)Hambone10 Wrote:  If I'm not mistaken, when you go to work for a larger company, pre-existing conditions are generally waived. In other words, the ability to spread that risk across a much larger pool will take care of the price risk. Clearly this is going to cost a bit more... but I just don't see that it can cost more than we waste on "public" healthcare when spread across 250mm people.

I think the plan is completely misguided and a power and money grab... but I can certainly see how to make it work.

a) decide on what will be covered for all
b) have existing insurance companies negotiate with Congress on an "it will cost this much" proposal.
c) have the government pay that much per person from existing funds paid for healthcare for everyone in the country...
d) The governments only other job is to ensure that the items on the list are actually covered and that the people on the rolls exist. Not much room for debate
e) let the insurance companies compete with more or fewer doctors (like HMO and PPO's today) or additional services for the same price for the basic plan... and also "add-ons" paid by employers or individuals in order to spread their risk as far as possible.

We won't necessarily solve the guy who needs 20k/month in care, but he'll have coverage for basic healthcare, and I'm willing to bet that it costs us significantly less than what we spend now... which will make things like that situation easier to handle.

(12-18-2009 12:59 AM)OptimisticOwl Wrote:  Sounds good to me. But tens of thousands of people have better plans than the one(s) the Dems are trying to pass. I am just shocked, shocked I tell you, that no liberals have stepped forward to defend the Dems plan(s) and explain how and why they will work. I thought maybe I was missing something, but I guess not.

(12-18-2009 09:24 AM)Owl-88 Wrote:  

(12-18-2009 12:59 AM)OptimisticOwl Wrote:  Sounds good to me. But tens of thousands of people have better plans than the one(s) the Dems are trying to pass. I am just shocked, shocked I tell you, that no liberals have stepped forward to defend the Dems plan(s) and explain how and why they will work. I thought maybe I was missing something, but I guess not.

Since The Plan seems to be a constantly shifting thing I don't know how you can expect anyone to defend it. It changes by the day, and the House and Senate would still have to reformulate it once the Senate passes their version (if they do).

(12-18-2009 09:33 AM)Owl 69/70/75 Wrote:  

(12-18-2009 09:24 AM)Owl-88 Wrote:  

(12-18-2009 12:59 AM)OptimisticOwl Wrote:  Sounds good to me. But tens of thousands of people have better plans than the one(s) the Dems are trying to pass. I am just shocked, shocked I tell you, that no liberals have stepped forward to defend the Dems plan(s) and explain how and why they will work. I thought maybe I was missing something, but I guess not.

Since The Plan seems to be a constantly shifting thing I don't know how you can expect anyone to defend it. It changes by the day, and the House and Senate would still have to reformulate it once the Senate passes their version (if they do).

But isn't that kind of an artful dodge?

We can't defend it, so we'll keep changing it. We keep it a moving target so none of the criticisms will stick.

Kind of a sleazy way to do business, don't you think?

(12-18-2009 12:31 PM)texd Wrote:  For example, say a new procedure comes out that completely cures Tex D's Syndrome.

(12-18-2009 12:31 PM)texd Wrote:  The key to requiring coverage of pre-existing conditions is to mandate health coverage. If coverage is mandated then the insurers are not worried about you being uncovered until your back goes out on you and then you call up and say "yes, I'd like to sign up for insurance... and by the way, I'm scheduled for surgery next week."

The Medicare savings proposed are not to be made in across the board cuts to fees, but targeted cuts. Specifically:

1) phased in cuts to Medicare Part A (hospital) Disproportionate Share (DSH) payments. DSH payments are payments over and above standard Medicare Part A payments made to hospitals in low-income communities. The rationale for DSH payments to these hospitals is that the poor tend to be both sicker and less insured than the middle class or wealthy. The rationale for cutting these payments under reform is that if everyone is required to have insurance and the poor have their insurance subsidized, there should be less disparity in health and insurance profile based on socioeconomic status over the long term.

2) Cuts to Medicare Advantage plans. Medicare Advantage plans are the private insurance plans which a medicare eligible individual may enroll in to replace traditional Medicare. For each patient covered by an MA plan, the feds pay the plan, on average (it varies from plan to plan), 114% of what it would cost to cover an average of patient in Traditional Medicare. In exchange the plans have some benefits (some have vision or dental, some have Medicare part D gap insurance to cover the infamous drug plan doughnut, some just offer the convenience of having the same plan for medical Medicare and drug Medicare) and some downsides (the fact that they generally pay providers about 80-90% of traditional Medicare fees and are a much bigger PITA for providers in terms of unpublished payment policies and unexplained denials, they tend to have a more limited panel of providers). The inefficiency of the premium is exacerbated by the fact that they target younger, healthier Medicare recipients in there advertising, so while the pay is 14% more than the AVERAGE Medicare recipient would cost the system, their patient actually use less health care, thus making the difference even greater. The rationale for the 14% premium was that it would last for just a couple years to ramp up MA and get it to be an accepted model and that after that, the greater efficiency of the private sector would mean the feds could pay LESS than 100% of an average Medicare patient cost to the MA plans. Problem there is that Medicare as a whole runs at a 97% Medical Loss Ratio (MLR - The percentage of total cost that goes to patient care vs Administrative). MA plans vary widely, but generally run at 75-87% (Aetna is 77.9%) MLR. The other 10-25% goes to administration and corporate profit. The result is that for every $100 spent on a traditional medicare patient, $97 is going directly to care for the patient; for every $100 spent on a Medicare Advantage patient, $76 or less is going directly to care for the patient.

3) Cuts on payments related to quality control issues: These are decreases in payments for things such as hospital readmission or disease caused by healthcare (e.g. hospital-acquired infection) -- these cuts include cutting altogether federal Medicaid matching funds to cover for healthcare caused disease.

4) Increase the drug manufacturer rebate for the Medicaid Drug Rebate Program: Currently drug manufactures must rebate 15 and 11 percent (brand name/generic) of average sales price on drugs sold to Medicaid to the states for states that participate (which I think all do). The Senate bill would divide that first tier up into rebates of 23 and 17% and the generics would go to 13%

5) Expand the Physicans Quality Reporting Initiative to offer more differential payments for evidence-based medicine. There are some major kinks in the original PQRI system that they'll have to work out for this to work (basically, you currently get a Pass/Fail grade and get paid the extra as a lump sum or you don't; there's no data provided to the failing providers to tell them where they came up short). There are some other value-based payment shifts on which I'm not fully versed.

6) Independent Medicare Advisory Board to recommend specific cuts for procedures. The idea behind this is to address issues such as "sticky prices." Sticky prices are a result of early adoption and subsequent defense of those prices. For example, say a new procedure comes out that completely cures Tex D's Syndrome. The procedure requires 3 surgeons, an anesthesiologist, and round-the-clock nursing for the first five days post-op. It's expensive. Now, three years later, further innovation has got it down to 1 surgeon and quarter-time nursing. But the price has yet to be dropped to fully reflect the reduced resources required. Think of it as the same as the problem with pre-season rankings. The problem with the IMAB, however, is that (a) it cannot possibly be representative of all specialties, and given its independence, there's no check on its decisions like there is with the existing Medicare Payment Advisory Comittee and CMS make a decision and (b) as written, the IMAB has initial control over only certain sectors of healthcare (mainly physicians) for the first few years, meaning that regardless of where they SHOULD be making cuts for their first 5 years of existence, they WILL be making cuts from physicians, even if it makes more sense to cut on a drug or facility side of things.

7) They're looking to cut payments to physician-owned facilities on the theory that self-referral is a major driver in healthcare costs. This ignores that most physician-owned facilities (especially surgery centers since they're generally in competition with hospital OPDs) operate far more efficiently than their corporate and even non-profit analogs.

8) Medicare Fraud and Abuse - This should not be too huge an issue for physicians as the majority of F&A falls in the ancillary care areas of Medicare: Home Health, Mobility Scooters, Durable Medical Equipment, etc. That's where you can reap millions without raising too much suspicion. A physician who takes in $10mln in Medicare payments in a year is a MAJOR red flag. A company that sells home medical equipment that takes in $10mln in Medicare payments in a year is an average player. Overaggressive enforcement tactics in this arena can cause headaches for physicians due to the overflow (for example onerous restrictions on DME can hit optical shops or the ability to provide crutches, etc.; and we have yet to see what kind of damage the new Recovery Audit Contractors for Medicare are going to have... they already exist, but CMS is still in the contracting phase them.)

As to the last issue, the dems say it's deficit neutral over 10 years and deficit reducing over 20. The reason for that, despite the disconnect you point out in when we start raising/saving money for the plan vs when we start spending it is the anticipated startup costs. When you suddenly insure 30million new people, healthcare costs will go up; that bad hip or abdominal discomfort or fading eyesight that they don't think has been worth spending money on a diagnostic doctor's visit just to tell them they couldn't afford the treatment, will immediately become more pressing business for many of those 30 million people. Once a person has been insured a while, such costs will not be backed up. That part is true. The other part of this is that the savings for things such as evidence-based medicine and killing off sticky prices will not only be found, but will continue to be found. That part is highly debatable.

(12-18-2009 12:31 PM)texd Wrote:  The key to requiring coverage of pre-existing conditions is to mandate health coverage. If coverage is mandated then the insurers are not worried about you being uncovered until your back goes out on you and then you call up and say "yes, I'd like to sign up for insurance... and by the way, I'm scheduled for surgery next week."

The Medicare savings proposed are not to be made in across the board cuts to fees, but targeted cuts. Specifically:

1) phased in cuts to Medicare Part A (hospital) Disproportionate Share (DSH) payments. DSH payments are payments over and above standard Medicare Part A payments made to hospitals in low-income communities. The rationale for DSH payments to these hospitals is that the poor tend to be both sicker and less insured than the middle class or wealthy. The rationale for cutting these payments under reform is that if everyone is required to have insurance and the poor have their insurance subsidized, there should be less disparity in health and insurance profile based on socioeconomic status over the long term.

2) Cuts to Medicare Advantage plans. Medicare Advantage plans are the private insurance plans which a medicare eligible individual may enroll in to replace traditional Medicare. For each patient covered by an MA plan, the feds pay the plan, on average (it varies from plan to plan), 114% of what it would cost to cover an average of patient in Traditional Medicare. In exchange the plans have some benefits (some have vision or dental, some have Medicare part D gap insurance to cover the infamous drug plan doughnut, some just offer the convenience of having the same plan for medical Medicare and drug Medicare) and some downsides (the fact that they generally pay providers about 80-90% of traditional Medicare fees and are a much bigger PITA for providers in terms of unpublished payment policies and unexplained denials, they tend to have a more limited panel of providers). The inefficiency of the premium is exacerbated by the fact that they target younger, healthier Medicare recipients in there advertising, so while the pay is 14% more than the AVERAGE Medicare recipient would cost the system, their patient actually use less health care, thus making the difference even greater. The rationale for the 14% premium was that it would last for just a couple years to ramp up MA and get it to be an accepted model and that after that, the greater efficiency of the private sector would mean the feds could pay LESS than 100% of an average Medicare patient cost to the MA plans. Problem there is that Medicare as a whole runs at a 97% Medical Loss Ratio (MLR - The percentage of total cost that goes to patient care vs Administrative). MA plans vary widely, but generally run at 75-87% (Aetna is 77.9%) MLR. The other 10-25% goes to administration and corporate profit. The result is that for every $100 spent on a traditional medicare patient, $97 is going directly to care for the patient; for every $100 spent on a Medicare Advantage patient, $76 or less is going directly to care for the patient.

3) Cuts on payments related to quality control issues: These are decreases in payments for things such as hospital readmission or disease caused by healthcare (e.g. hospital-acquired infection) -- these cuts include cutting altogether federal Medicaid matching funds to cover for healthcare caused disease.

4) Increase the drug manufacturer rebate for the Medicaid Drug Rebate Program: Currently drug manufactures must rebate 15 and 11 percent (brand name/generic) of average sales price on drugs sold to Medicaid to the states for states that participate (which I think all do). The Senate bill would divide that first tier up into rebates of 23 and 17% and the generics would go to 13%

5) Expand the Physicans Quality Reporting Initiative to offer more differential payments for evidence-based medicine. There are some major kinks in the original PQRI system that they'll have to work out for this to work (basically, you currently get a Pass/Fail grade and get paid the extra as a lump sum or you don't; there's no data provided to the failing providers to tell them where they came up short). There are some other value-based payment shifts on which I'm not fully versed.

6) Independent Medicare Advisory Board to recommend specific cuts for procedures. The idea behind this is to address issues such as "sticky prices." Sticky prices are a result of early adoption and subsequent defense of those prices. For example, say a new procedure comes out that completely cures Tex D's Syndrome. The procedure requires 3 surgeons, an anesthesiologist, and round-the-clock nursing for the first five days post-op. It's expensive. Now, three years later, further innovation has got it down to 1 surgeon and quarter-time nursing. But the price has yet to be dropped to fully reflect the reduced resources required. Think of it as the same as the problem with pre-season rankings. The problem with the IMAB, however, is that (a) it cannot possibly be representative of all specialties, and given its independence, there's no check on its decisions like there is with the existing Medicare Payment Advisory Comittee and CMS make a decision and (b) as written, the IMAB has initial control over only certain sectors of healthcare (mainly physicians) for the first few years, meaning that regardless of where they SHOULD be making cuts for their first 5 years of existence, they WILL be making cuts from physicians, even if it makes more sense to cut on a drug or facility side of things.

7) They're looking to cut payments to physician-owned facilities on the theory that self-referral is a major driver in healthcare costs. This ignores that most physician-owned facilities (especially surgery centers since they're generally in competition with hospital OPDs) operate far more efficiently than their corporate and even non-profit analogs.

8) Medicare Fraud and Abuse - This should not be too huge an issue for physicians as the majority of F&A falls in the ancillary care areas of Medicare: Home Health, Mobility Scooters, Durable Medical Equipment, etc. That's where you can reap millions without raising too much suspicion. A physician who takes in $10mln in Medicare payments in a year is a MAJOR red flag. A company that sells home medical equipment that takes in $10mln in Medicare payments in a year is an average player. Overaggressive enforcement tactics in this arena can cause headaches for physicians due to the overflow (for example onerous restrictions on DME can hit optical shops or the ability to provide crutches, etc.; and we have yet to see what kind of damage the new Recovery Audit Contractors for Medicare are going to have... they already exist, but CMS is still in the contracting phase them.)

As to the last issue, the dems say it's deficit neutral over 10 years and deficit reducing over 20. The reason for that, despite the disconnect you point out in when we start raising/saving money for the plan vs when we start spending it is the anticipated startup costs. When you suddenly insure 30million new people, healthcare costs will go up; that bad hip or abdominal discomfort or fading eyesight that they don't think has been worth spending money on a diagnostic doctor's visit just to tell them they couldn't afford the treatment, will immediately become more pressing business for many of those 30 million people. Once a person has been insured a while, such costs will not be backed up. That part is true. The other part of this is that the savings for things such as evidence-based medicine and killing off sticky prices will not only be found, but will continue to be found. That part is highly debatable.

(12-18-2009 02:00 PM)georgewebb Wrote:  

(12-18-2009 12:31 PM)texd Wrote:  For example, say a new procedure comes out that completely cures Tex D's Syndrome.

Here's the definition:
Tex D's Syndrome: a neurological disorder characterized by pathological devotion to Rice sports. Often manifested in compulsive tendency to road trip and/or tailgate. Susceptible to temporary remission but generally considered incurable. Usually associated with well read, intelligent, socially adept people and much maligned by those unfortunate enough to have not contracted it yet.

(12-19-2009 02:00 PM)Owl75 Wrote:  Currently I am in the Texas "risk pool" because of prexisting condition that prevents me from getting regular insurance. They charge 2x regular premiums.

(12-19-2009 07:02 PM)Owl 69/70/75 Wrote:  So my question is this--If we really want to improve health care, why are we looking at bad systems for our model, instead of looking at the GOOD systems elsewhere?