HCR -- More Dry Reading

By John Ballard

There is no getting around it. Healthcare Reform discussions are getting old and worse as time passes. Passage of PPACA was an important step in the right direction but everyone agreed it was only a start. If by some magic opponents became supporters, there would still be bitter disagreements about what should happen next. Rather than drone on about the downside, here is a collection of links to check out. Some are informative, others not so much. But this is today's snapshot.

?Anti-abortion legislation flanks repeal vote. This is among the latest from Fierce Healthcare News, one of several exaggerators trolling the internet.

Almost immediately after the vote this week to repeal the health reform bill, congressmen introduced a pair of anti-abortion bills that show just how serious House Republicans are about changing the current healthcare culture.

Of the two bills introduced Thursday, the "No Taxpayer Funding for Abortions Act (H.R. 3)," sponsored by Rep. Chris Smith (R-N.J.), aims to outlaw any tax dollars from going toward abortions. The "Protect Life Act,"sponsored by Rep. Joseph Pitts (R-Pa.), aims to ban government funding for abortions under the Affordable Care Act. House Speaker John Boehner (R-Ohio) deemed the bill that would cut taxpayer funding for abortions "common-sense legislation."

Note: This and the next two links carry additional links for the interested reader.

Without missing a beat, the GOP keeps whipping a dead horse with the image of dead babies, keeping alive the anti-choice hopes of that part of their base. How better to gin up enthusiasm for repealing PPACA than tying it once again with theh inflammatory abortion issue.

I was unaware until I read this that the Hyde Amendment is only that, an "amendment" to some other piece of legislation that expires every year.  H.R.3 (notice the small number, which indicates that it is the third-highest priority of the new House majority right after its attempt to repeal the Affordable Care Act) codifies the limitations of the Hyde Amendment, encrusting it further with additional language further limiting abortion coverage.

Whether this move turns out to be more than symbolic remains to be seen. My own view is that the sooner we get the arguments out in the open the sooner the question of abortion will get settled.
My own position that abortions are morally reprehensible but should never be criminalized is not represented by any quarter of politics except the DFH or anarchist caucuses.
The national picture is a crazy mixture of various state policies that taken together are a mess. My hope is that sooner rather than later the question will be federalized, formalized and fit with reasonable limitations, probably along the original lines of Roe, the language of which fairly begged the states to come up with restrictions that make sense, starting with the third trimester.

?House Judiciary Committee looks into medical liability reform. The first thing I saw on TV this morning was a C-SPAN video of a House Committee yammering on for two hours about "tort reform." the loaded buzzword which in most vocabulary means "liability caps" on medical malpractice suits.

One of the ongoing arguments against PPACA is that it only set in motion "study groups" to explore the issues complicating medical malpractice. At the heart of the argument is nothing less than the very American inalienable right to a jury trial, which in the case of malpractice lawsuits invariably puts a medical professional on trial for a medical catastrophe leaving the plaintiff in such bad shape that a jury of the meanest people in the country is moved to tears, awarding outrageous punitive damages way past the economic damages incurred. I'm trying (but not very hard) not to be cynical for two reasons. First, the actual amounts of award damages for malpractice are a minuscule part of the overall problem of healthcare costs and healthcare inflation.  And second, most of these lawsuits are settled out of court.

That said, no one can argue that the costs of "defensive medicine" ARE heavy drivers of health care costs. No medical professional will be criticized for "doing everything possible" or "going the extra mile" or making sure" that a patient is being cared for with no safety precaution left to chance. Never mind that with a fee-for-service billing model extra consultations and/or tests also happen to result in swelling the revenue streams of both the physician who orders them and those to whom the referral is tossed.

Go to the video for a study in watching a discussion in which a group of people talk past one another with no one offering any middle ground. That applies to the panel of experts as well as the Committee members.
I couldn't watch more than a few minutes without getting frustrated. I want to yell at the TV "What about ACO's? Does anyone know the meaning of the terms Accountable. Care.  Organization.???"
How about the idea that if an organization will be accountable and subject to getting sued?

Another proposal usually not mentioned is a special court, something like a bankruptcy court, specialized and tasked with handling malpractice claims. 

There are a number of ways for this issue to be addressed. And last year's SOTU speech tossed out an invitation for Congress to address it. But like so many of the president's proposals, that one was ignored along with the rest. A GOP-controlled House has a good chance to advance some constructive alternatives and sell them as "tort reform" but as long as the term remains a synonym for "damage caps" there will be no progress.

?Home healthcare siphons off patients from hospitals. This one interests me because I'm in a non-medical allied field as a senior care-giver.

Home healthcare has taken a bite out of the hospital market, based on a study by Frank Lichtenberg, a business school professor at Columbia University.

Lichtenberg estimates the U.S. saved up to $25 billion in hospital payroll costs in 2008 due to the growth of the home health sector. And further savings are likely if home healthcare continues to grow.

The findings suggest that the quickly growing population of senior citizens will not necessarily lead to an expanded hospital market.

To see whether home healthcare could serve as a substitute for hospital care, Lichtenberg's study looks at employment and payroll growth in the two sectors, as well as other factors such as length of stay and share of patients discharged to home healthcare.

"An important reason why home healthcare may serve as a substitute for hospital care is that the availability of home healthcare may allow patients to be discharged from the hospital earlier," Lichtenberg writes in his abstract.

This has been and will continue to be a trend.  There are multiple reasons for this trend, from the costs of hospital care versus home care to reducing patients to hospital-acquired infections and diseases.  Arguments for and against the trend are endless, but when costs become the driver, home care trumps hospital care every time. A patient at home not only has the care and support of people he knows, but food, housekeeping, utilities, secondary insurance and other maintenance costs not added to the medical charges. Even with home health nurses and aides home health care comes out ahead.

I read somewhere that hospitals in Sweden are proud when they have empty beds because it indicates they are taking care of a healthy population. That is, of course, an alien idea in this country where every capital investment is expected to yield a monetary return at least equal to its depreciation schedule. Even so-called not-for-profit entities like many hospitals cannot endure the idea of empty beds.

The goal of a hospital is very much like that I once had as a cafeteria manager. We called it "line speed." At mealtime the only limitation on how fast the money came in was how rapidly we could move the line. A well-trained line of servers with the right production staff could easily serve over a hundred meals every fifteen minutes. And you can be sure we did everything possible to make that happen because people on a lunch break don't have time to waste and need to get in and out as quickly as possible.

Am I the only one who thinks there is an incestuous, symbiotic relationship between not-for profit hospitals and the very much for profit providers which they typically serve? As you study the issue of home health care, ask yourself whether money or medicine is the greater metric. In fact, go back and read the above quote one more time.

?A Family Physician's EMR Experience

This one's a quickie.
A doctor tells first hand how electronic health records have streamlined his job, even to the point where he can go missing nearly a week and return without being covered up with unfinished business.

Sultan Rahaman graduated from the University of the West Indies Medical School in Kingston, Jamaica and completed his Internship and Residency in Family Medicine at the Jackson Memorial Hospital/University of Miami medical center in Miami, Florida. He is a full time Family Physician in solo private practice in Longwood, Florida. Dr. Rahaman has been a member of Doctors for America since 2008, where this post first appeared.

...Recently I had to make a sudden trip to South America for a funeral. Besides the obvious emotional distress, I worried about my practice coverage while overseas. I still had a hospitalist covering me for hospital cases. However, I was anxious that a local family physician would not be able to effectively cover other routine issues with patients whom she was not acquainted. The EMR circumvented many of my worries. Because the software and data storage are Internet-based, my laptop essentially provided me with all the functions as if I were in the office. The main thing lacking is that I cannot examine the patient in person. From the time I reached the departing airport I was able to start reviewing my prescription refill requests, all fax communications, lab reports and all phone call messages documented by my staff. While in South America I also logged into my EMR software in the morning and at night and performed those tasks. For emergency communications my office was able to contact me by text messaging. When I returned to the office after this 'hurricane' 5 day trip I was relieved to see that there were no stacks of charts waiting for my attention, and because of the ability to seamlessly perform work on the road, I did not have any backlog of work on my computer/EMR system. What was stunning is that even though a family physician was backing up my practice, she did not have to be contacted even once! My competent staff and the EMR system worked wonderfully.

?A Surgeon Stands Up To His Peers, and Fights for the Physician Payment Sunshine Act -- (Part 2 of �On the Road to Reform�)

This one's NOT a quickie. I'll let Maggie Marhar's summary do the parsing. For the details go to the link and try to remain calm as you read. This a tawdry tale that's not made up.

In part 2 of this post I focus on Dr. Charles Rosen, a spine surgeon at the University of California at Irvine who has had the courage to speak out about the use of surgical devices that are not helping patients. In part 1, Bloomberg quoted Rosen questioning fusion; in part 2 I explain that he gained notoriety within his profession a few years earlier, when he publicly expressed his concerns that a very popular artificial spinal disc, Charite, was hurting patients.

Rosen also is concerned about the consulting fees that device-makers pay some surgeons. He believes that when companies pay physicians who write about new devices and procedures, the transactions should be made public. �I don�t care if someone is making $1 million or $2 million he told me. I don�t want to restrict payments�I just think they should be transparent.�

Today, Rosen is no longer a lone voice in the wilderness. In 2006, he founded the Association for Medical Ethics, a group of 300 physicians dedicated to highlighting the repercussions of the for-profit health care industry�s influence on health care. Most of them are spine surgeons.

Meanwhile, he has helped win a major battle for transparency. In 2010, Congress passed the Physician Payment Sunshine Act as part of the health reform package.

?Repeal, replace, renew, revise, revisit - what the bloggers say

Joe Paduda's blog, Managed Care Matters, is hosting a healthcare reform carnival. Maggie Mahar's post above is among those listed, but the collection covers all kinds of topics.
I want to highlight two items since most readers will not have the time or inclination to read them all.

(1.)   How to Fix Medicare�s Doc Fix Problem by Jeff Goldsmith is an accountants nightmare. Accounting and politics go together like oil and water.I love Paduda's description.

Jeff Goldsmith's contribution comes by way of the Heath Affairs Blog, where he suggests a solution to the Medicare physician reimbursement  mess  debacle  conundrum  disaster. Jeff suggests "writing off the SGR "debt" to the federal budget as "uncollectable" and demanding both sacrifice and reform from the physician community in exchange." While I am most certainly reluctant to challenge someone as insightful and knowledgeable as Goldsmith, my inner cynic tells me 'no way'.

(2.) And finally this.

The creepiest entry I've ever read comes from David Williams, who's dug out the news that two sisters' life sentences in Mississippi were suspended on the condition that one donate a kidney to the other.

(This last piece illustrates why those of us who live in Georgia still sometimes say "Thank God for Mississippi."  That was always a reassuring thought when we looked at the national statistics about education. As bad as I think I have it, I am well aware that I would be even worse off politically if I had to live in Mississippi.)