It is a moral and religious imperative for Medicare to encourage physicians to propose a voluntary discussion about their patients’ wishes for end-of-life care

Politicians or other government leader who are against Medicare providing an incentive for physicians to propose a voluntary discussion about their patients’ wishes for end-of-life care don’t care about patients. Our leaders are afraid to admit that commitments made to the 80 million baby boomers entering the Medicare system starting this coming year cannot be met without destroying our global competitiveness. But we can begin to acknowledge reality by considering the patients’ personal religious and moral desires regarding the extent and kind of resources they wish to be deployed by the medical-industrial complex as they near the end of their life.

It is inhumane to facilitate a system that often expends far more resources than would be consistent with a patient’s wishes for extending their lives. Anyone who has had a parents’ “life” extended without consideration of their parents’ wishes knows that the system is not set up to deliver anything less than the “maximum level of care” paid for by Medicare benefits. It is a moral outrage for our society to tax its young people to support paying for life-extending invasive care provided to older people that can exceed the desires of the very people whose lives are being extended.

This is not a partisan issue; it is a moral and religious imperative that our public funds devoted to health care are for services that are within the desires of the patients. Patients may wish to have more “heroic” measures deployed to extend their lives than their next of kin; Denying an incentive for physicians to help patients understand their options makes it unlikely that the patients wishes can be respected. Any honest public leader confronting the demographics of the baby-boom on Medicare should support the system being structured to determine and implement a patient’s wishes for care at the end of their lives.

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Pfc Manning & Wikileaker Assange Aren’t The National Security Risk: Poor Information System Design Of Data Access Policies Is To Blame

Lady Gaga performing "Paparazzi" on ...

Image via Wikipedia

Who is losing their job in information systems security design at the firm that decided on a “one-level” data access policy? While there was clearly too little sharing of data before 9/11, it’s difficult to fathom that a decision was made to make the most-sensitive government documents easily available to an army with the lowest rank possible. If it wasn’t Pfc Manning, it would have been someone else.

Many people view what Pfc Manning did as “treason,” and I wouldn’t have done it. But the real treason was implementing a data access system that made everything available to everyone. Any information technology expert worth their salt knows that it is possible to set up levels of data access. And that levels of data access need not necessarily reduce information sharing and the ability to discern trends to “connect the dots.”

Why isn’t their more media focus on the Kindergarten level information systems design that created this National Security Risk? It’s almost as bad as the media’s failure the shame the Senate into passing the Zadroga (9/11 First Responders Illness) bill. Well hopefully Jon Stewart managed to focus the appropriate shame on Mitch McConnell, Jon Kyl and Co.

Maybe the Pentagon could use some advice from the Department of Health and Human Services information technology people. They have held sensitive patient information in computer form since Medicare was enacted, and, to my knowledge, have never had a security breach like the “Lady Gaga CD” caper.

BTW, Everything about the private who downloaded the diplomatic cables says that it was stolen using a CD labeled Lady Gaga. Can all of that data have fit on a single CD? Perhaps it was a DVD…Little technical detail, but all that in under a gigabyte?

So…Let’s try and keep our National information systems data security used by the military to a level at least as good as that in place at the Department of Health and Human Services. With levels of access. Not “you’re cleared, you now have access to everything.”

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Medicare Costs Are The Most Important Issue In Long-Term Deficit Reduction

The least solvable part of our long-term deficit crisis is the infinite demand for medical services committed to the baby boom generation through the Medicare Program.

Social Security long term financial stability can be achieved through mathematical and actuarial adjustments. Continue to increase the full benefit age, increase income subject to the FICA tax, and make minor downward adjustments to benefit payments and viola, Social Security can be fixed for most of the 21st century.

But Medicare…Bernanke and Greenspan have gingerly mentioned that Medicare costs are the real long-term threat to our Nation, but they haven’t really been as explicit as will be necessary to change our thinking about Medicare.

Ah, Medicare. That great financial commitment created when it seemed like a good idea to implement a social contract that essentially said: “if you are eligible for this benefit, you are entitled to the best state of the art medical care available, essentially unlimited, for however long you live.”

Although the Medicare social commitment was made before the following now common but very costly procedures became ubiquitous:

Coronary artery bypass grafts, hip, knee, and shoulder replacements, implantable electronic defibrillators, biologically engineered drug therapies, bone marrow transplants, heart, liver, lung, cornea, kidney transplants, etc. etc.

We accept, as a society, that wealthy people ‘get better stuff’ than the rest of us. Mercedes automobiles are the safest cars on the road. We accept, however, that not everyone can afford the most expensive and safest car. A small segment of the population can afford the level of safety that a Mercedes provides, while everyone else that can afford to drive, drives cars that aren’t as safe. But when it comes to health care, our standard is essentially: everyone gets everything they want, regardless of its’ expense or its’ actual improvement in the quality of the ‘covered persons’ life.

With 25% to 35% of Medicare dollars being spent on the last six months of life, it is difficult to make the case that we’re getting much value from a huge proportion of program costs. Yet when the common-sense idea of paying physicians to discuss end-of-life care desires with their patients was proposed as a part of health insurance reform, the idea was torpedoed by ‘fiscally conservative’ Republicans as ‘Death Panels.’

Until we come to terms with the idea that we can’t afford to pay the costs of giving everyone the best of everything (in terms of medical care), we won’t ever begin to confront the menace that Medicare costs are to our survival as a Nation.

35 million people are today enrolled in a program that has an unsustainable growth rate in costs. But over the next 20 years, that 35 million people will become 80 million people as the baby boom age cohort enters the Medicare entitlement social contract.

The ‘adult conversation’ that politicians keep talking about having with the American People needs to be focused on this: We can’t afford to give everyone the best of everything with regard to Medicare benefits. Wealthy people will be able to get whatever they want, but the rest of us are going to have to get by with some limits on what resources are spent on their care.

If we don’t accept limits to Medicare costs, which means everyone won’t get the best of everything, then we are financially doomed…

Future posts will include some ideas as to equitable ways of implementing limits, but if we don’t accept the basic idea that limits need to be set, then there’s no point in seeking out ethical methods to determine how to best allocate the available resources.

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The Virginia Supreme Court Decision & ObamaCare

Well I’m not sure where this is headed, but I’m going to start using the zero-cost of publishing feature of the Internet and do some blogging…

Although I’ve spent 25 years on the “payor/administrator” side of the health insurance system, my skills sets and thinking extend to other areas…

My latest thinking has to to with ObamaCare, and the recent Virginia Supreme Court ruling that the Right seems to be crowing about: Invalidating the albeit weak “mandate” requiring American citizens to “be covered” by some form of health insurance. Here’s the deal:

People don’t like insurance companies refusing to cover people for pre-existing conditions (yet they seem to understand why you can’t buy homeowners insurance while your house is in flames). But the only way to allow people with pre-existing conditions to enroll in health insurance plans is if everyone is required to be enrolled…

Eliminating the idea of requiring universal enrollment makes it even less likely that ObamaCare will succeed from an “insurance” perspective. This concept was originally understood by Republican legislators as a critical feature of any plan that “fixes” the problem of what to do about people who have pre-existing conditions not being able to get covered.

Why is it constitutionally legal for most States to require drivers to buy liability insurance, but constitutionally illegal for the Federal Government to require citizens to buy health insurance?

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Dear Republican Party Proponents of “Repeal & Replace”: Here’s Some Practical Low Cost Ideas For What To “Replace” ObamaCare With…

Dear incoming Republican Majority House Members-

What follows are some ideas if you’re seeking to put forward policy about the the “replace” part of “repeal and replace…”

It just isn’t possible to “make the case” that employers have been steadily dropping health insurance coverage from what used to be called “fringe benefits.” At best, many of these people get “limited coverage plans,” which basically put them back into the ranks of the uninsured if they ever are admitted to a hospital or have a serious injury of almost any kind. As a Nation, we can’t just ignore the growing ranks of the uninsured. But…the main problem with access to health insurance is cost; not any other “lack of access” (except for people with pre-existing conditions):

Census data chart showing how employers are dropping coverage

ObamaCare primarily universally ignored cost (the hard stuff) and focused only on the “coverage” issue. Not easy, but NOT REALLY THE PROBLEM.

People lack access mostly because of the cost of coverage. The cost of coverage is so high not because of the impact of the often-demonized “profit-seeking publicly held health insurance companies;” it is because the care costs so much. Health insurance companies, particularly those with stockholders, just try to make profits by staying a little ahead of the cost curve:


Making fundamental changes to a part of the American economy which is on track to comprise roughly 20 percent of the Gross National Product by the year 2012, is a task that should not and can not be dealt with in town-hall meetings. Even President Obama supporters are beginning to question how the nation will ever be able to afford the continuously increasing costs that are the root of the “health insurance problem.”

Before I continue, it is appropriate for ‘full-disclosure’ to make it clear that my perspective comes from my 25-year career as a health insurance executive. Although unlike most health insurance companies today, the one’s I’ve worked for have been either ‘mutual companies,’ or not-for-profits,’ making them immune to delivering Wall Street profit objectives (more on this important distinction below).

As most economists acknowledge, the current recession will likely continue longer and deeper than any contraction since the end of World War II. With this in mind, it would make a lot of sense to return to the long-standing American concept of incremental social-policy change in health care.

The suggestions that follow are not particularly futuristic or visionary, neither do they really address the fact that it is the cost of health care that dictates the cost of health insurance. However, these suggestions will significantly improve the existing system without creating any incremental tax costs for the American taxpayer.

Obamacare takes people who were getting “uncompensated care” (for which hospitals and doctors were “shifting costs” with higher fees for people with employer-sponsored health coverage), into people with “compensated care.” But most of the costs for people who were previously uncompensated were supposedly already in the system. So…Are hospitals and doctors going to lower their rates to insurance companies since they will have far less uncompensated care? Never gonna happen…

OK, back to ideas on the “replace” side of “repeal and replace:”

These are simple, no-nonsense, and low-cost solutions to solving key problems within the existing system, The barriers that have prevented these ideas from already being implemented are familiar: Political will and special-interest lobbying. On the chance that the Obama Administration and Congress may be returning to the idea of incremental reform; the following problems and solutions should be considered in the process:

The First Problem: Regulation & Red Tape. The current private health insurance system is regulated differently, depending on whether coverage is “self-insured,” mainly large companies of 100 employees that are financially able to pay for most of the costs of health care for their employees and dependents, or “insured” – small employers, some large employers and all individuals who buy their own health insurance.

The Situation: There exists a maze of 50 regulatory bureaucracies, which are state departments of insurance, controlling the “insured” market. Yet since the early 1970’s a Federal Tax regulation that was not intended to impact health insurance coverage, “ERISA,” (The Employee Retirement Income Security Act) has served as a “magic loophole” that eliminates most state insurance department oversight of the “self-insured” market. “Self-insured” employers, by the way (which are “responsible for” about half of all people who have health insurance, are blissfully not subject to most of the byzantine spiderweb of State regulatory oversight.

Lawyers and corporate financial wizards call this loophole the “ERISA-exemption,” in the sense that self-insured companies are “exempt” from state regulation and are only subject to the Federal laws that apply to health insurance.

Although there have been attempts to standardize state insurance regulation, nearly every state in the Union has a department of health insurance, each with its own set of rules and regulations about how health insurance coverage works. This creates much confusion and poses many questions. Why should anyone need to navigate different regulations for health insurance coverage based upon a topographical feature, say, a river, that has nothing to do with health care?

Does anyone believe that people on two sides of a state border have different health care needs because of which side of the border they live or work on? If not, why should they have different health insurance regulatory structures?

The Solution: Abolish state level oversight of health insurance in lieu of a Federal structure to serve all Americans. Regulate insurance and self-insured companies through a Federal Department of Health Insurance, within the Department of Health & Human Services, which currently regulates Medicare programs through a single set of Federal rules applied by the Centers for Medicare and Medicaid Services.

The Second Problem: The Challenges of Choice. Confusion and high administrative costs result from an overabundance of so-called “choice” in health insurance benefit designs.

The Situation: Among the reasons for the original Medicare program’s lower administrative costs (than privately administered insurance plans) is the fact that 85 percent of Medicare beneficiaries who are enrolled in the program all have a single, easy to understand “benefit design” – more commonly known as coverage, exclusions, and cost-sharing. Doctors and hospitals all know what is in the Medicare benefit design, and there is little confusion over which services will be paid by Medicare. Even the private market for supplements to the basic Medicare plan were standardized to just seven “benefit designs,” that are the same throughout the USA.

Contrast the simplicity of a single benefit design for 30 million Medicare beneficiaries with private health insurance companies’ tens of thousands of benefit designs – all of them equipped with their own definitions and variations of coverage, exclusions and cost-sharing provisions. This is clearly “choice” taken to ridiculous proportions. These tens of thousands of benefit designs create the need for doctors and hospitals to have staff that does nothing but figure out which insurance has what coverage. Does anyone believe that the cost or availability of health insurance coverage is improved by having tens of thousands of benefits in place? Choice is important, but one size does not fit all in health insurance needs. However, tens of thousands of choices? Hardly.

The Solution: Over a three-year period, the nation could shift from an unlimited number of health insurance “benefit designs” to, at most, one hundred plans. At the end of the phase-in period, every health insurance plan for groups or individuals would need to conform to one of those plans. A hundred plans is still a lot, but as long as we place such a high value on “choice,” it is far better than tens of thousands. There is no doubt that a reduction in administrative costs and complexity would result from changing the existing system of unlimited “choice,” to a much smaller menu of plans.

The Third Problem: “U.S.A.” – Uninsured Sickly Americans. Some people cannot afford health insurance because of cost, and others because insurance companies “underwrite” prospective buyers. Underwriting, a form of predicting and calculating the costs of a person’s health care needs based on a number of factors, also allows insurance companies, in many cases, to reject applicants for coverage based on their health status.

The Situation: This problem exists because under the current system, many people, for many reasons, don’t pay for health insurance coverage, and would buy it “only when they need it.” It’s the same reason you can’t buy homeowners insurance after your home has already been flooded or burned. Insurance works because the cost of providing health care is spread across the populace. In any given year of the past twenty years, 80 percent of people are responsible for 30 percent of health care cost, while just 20 percent of the people incur 70 percent of those health care costs.

The Solution: If health insurance companies had their costs for a single person limited by creation of several multi-state risk pools for the entire American population, then they could also be prohibited from excluding people from coverage for “pre-existing conditions.” This would eliminate a major reason why some people can’t buy health insurance on their own because of their health status. This “fix” would enable many more people to get health insurance on their own.

The Fourth and Final Problem: The Woes of Wall Street. A huge factor in high health insurance cost is that most health insurance companies are publicly-held and at the whims and mercies of a highly-volatile stock market. In addition to covering the cost of health claims and their administrative expenses, publicly-held health insurance companies are also expected to provide dividends and other forms of investment returns to their stockholders.

The Situation: After President Truman’s implementation of wage and price controls in 1948, health insurance became a fringe benefit of employment and until the late 1990’s, most companies bought their health coverage from mutual insurance companies. The most well-known of these are the formerly mostly mutual structured Blue Cross and Blue Shield plans.

While publicly-held, stock-driven health insurance companies existed prior to the late 1990’s, it was not the way most American’s received their health coverage. But after most of the Blue Cross and Blue Shield affiliated companies shifted to Wall Street listed stocks, the majority of people today receive their coverage from companies that have investor returns among their primary objectives. Mutual companies, while still oriented toward not losing money, have very little incentive to “make money” beyond that needed for their“ reserves” (the amount of funds they would need to pay for the health care costs of their insured populations for a given time period), and to cover their costs of administering the claims.

The Solution: We should return to a model where private health insurance is delivered by mutual insurance companies, or at least companies that are not driven by the need to produce returns for their investors.

The way most Americans got their health insurance coverage in the 1970’s and 1980’s was far better than the way most of us are insured today. Back in the 1970’s, “mutual” insurance companies, without Wall Street investment return demands, provided most health insurance.

Health insurance, like the rest of health care economics, differs from the rest of the economy for many reasons. Adding a shareholder’s demand for a tidy stock return to a health insurance companies’ expectations is contradictory to the objective of reducing health care costs.

And isn’t reducing health care costs at the root of what we are all arguing about?

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