It seems difficult to understand why all Americans aren't clamoring for health care insurance reform. But, if I reflect on the fact that our current dysfunctional system of health care 'delivery' has been dominated by 'insurance delivery priorities' for the past three decades, it gets easier to understand how many Americans don't 'understand' a different reality.
Doctors aren't supposed to work for health insurance companies, but, to the draconian way health insurance 'delivery' is administered that is exactly whom they work for and they feel impuned at delivering the best care to their patients.
Health care delivery at one time was not as heavily weighted on insurance 'permission' to treat so much as appropriate diagnosis and the power of physicians and surgeons to deliver care. A 'fiscal' constraint was placed on hospitals and doctors in the 1980s called DRGs and that was a game changer.
Then, for the first time in American Medical History, the insurance companies had more power than the physician or surgeon. DRGs literally dictated the length of a patient stay and their course of treatment. In actuality, it was an outrageous reality that was subscribed to by allowing CEOs to determine the diagnosis and outcomes of patients. Not all people are created exactly the same. There are complications depending on genetics, wellness and physical condition. Why is it that a 60 year old with Congestive Heart Failure has a poorer prognosis than a 25 year old trauma victim with a flailed chest? The reason is the age, physical condition and ability to heal without complications, that is the difference.
According to Wiki, in 1991, the top 10 DRGs overall comprising 30% of DRGs were: normal newborn, vaginal delivery, heart failure, psychoses, cesarean section, neonate with significant problems, angina pectoris, specific cerebrovascular disorders, pneumonia, and hip/knee replacement. Of the top ten, four or forty percent are regarding the birth of a newborn. There is dearly little that can be done to change childbirth.
One would think that after 18 years of consistent use of these DGRs they would be a 'science' by now, but, they aren't. We have witnessed the drastic lack of compassion by CEOs toward women giving birth which required legislation to correct. We know that Pre-Mature delivary of an infant takes tens of thousands of dollars US to achieve a viable human being that can live off a neonatal unit. Strokes are still an issue in the society requiring more rehab today than ever. We learned through medical research that long term rehab literally retrains the brain to function. There are more hip and knee replacements today than ever in an active society that demands to have access to their lives through ambulation and activity. There are no drugs or livestyles that stop arthritis.
The point is, CEOs haven't got a clue as to the future of 'health care delivery' in the USA. They didn't know in the 1980s and they don't know today. The 'state of American health care' is fluid and not a 'commodity.' The development of DRGs were punitive. It stated that hospitals and doctors and surgeons didn't know what they were doing and they needed to be focused and controlled. Basically, the Health Care Insurance Companies took on a 'patriarchal' approach to doctors, physicians and patients. It was draconian and uncompassionate. They had no right to 'talk down' to MDs and yet still today they do exactly that.
I don't mind if society wants to streamline recordkeeping to limit repeated tests, it is better we aren't exposed to repeated blood draws or x-rays; but; don't get in the way of a physician that feels as though there is a need for a repeated test when someone's well being is on the line. I don't know of many MDs that actually disregard 'the cost' to a patient when writing perscriptions or ordering diagnostics or treatments. They are people that care for people and while some might have bedside manners not of the best finishing school, they do interact with piers that will inform them of their demeanor and potential misstep.
The DRG experience in the USA took away the 'trustworthiness' of the Medical Profession and Professional and stated Corporate America knew better how to administer care than they did. It is the biggest farce for money this country has ever experienced and it has gone on from the 1980s through 2009. Three decades of 'managed' care through insurance companies that throw off their enrollments those people that aren't producing a 'profit.'
There is greatness in this country. There is greatness within the practice of medicine. There is greatness in the hands of a surgeon and I want this mess to stop and I want it to stop now. Women were protected from draconian insurance CEOs when they needed a hospital and MD to assist their infant to life outside the womb with a legislative action, it is time to recall the draconian form of 'insurance delivery' of health care and put it back in the hands of the physicans and surgeons that best understand it and the person they administer their art.
I think I life off with Page 775 of the House Bill:
There is a delineation to "presumed" eligible for a State policy and "determined" to be qualified. I mentioned this before. In the case of a newborn, it is considered eligible for any assistance at the time of birth, until qualified for disqualified for public assistance with their health insurance needs. On page 776, lines 1 thorugh 8 it states there is 30 days from what I call a percipitating event to move from 'presumptive' to 'qualified.'
‘‘(3) APPLICATION FOR MEDICAL ASSISTANCE.—In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance by not later than the last day of the month following the month during which the determination is made.
During the coarse of this bill there are repeative statements to bring the law to bear. One of those 'repeative statements' is called a 'Conforming Amendment.' It states where in existing law the words will be changed. Page 776, lines 22 through 25 and Page 777, lines 1 through 5 is one of those statements. So, I'll include it here as an example:
(2) CONFORMING AMENDMENTS.—
(A) Section 1902(a)(47) of the Social Security Act (42 U.S.C. 1396a(a)(47)) is amended by inserting before the semicolon at the end the following: ‘‘and provide for making medical assistance available to individuals described in subsection (a) of section 1920C during a presumptive eligibility period in accordance with such section’’.
Relatively mondane, boring and standard issue of wording. Why would the wording appear in a Medicare law? Because it is these laws that are being extended to 'eligible' individuals under age 65 in the Public Option. It has nothing to do with people already eligible.
Sorry, interruptions happen. Page 778. ;lines 9 and 10:
Subtitle C—Access
SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.
There are some language adjustments in this section, but, basically the reimbursement to them will be 80% of applicable services. That is a good rate of payment as far as I am concerned.
Page 778; lines 21 through 25 and page 779; lines 1 through 11:
‘‘(C) payment for primary care services (as defined in section 1848(j)(5)(A), but applied without regard to clause (ii) thereof) furnished by physicians (or for services furnished by other health care professionals that would be primary care services under such section if furnished by a physician) at a rate not less than 80 percent of the payment rate applicable to such services and physicians or professionals (as the case may be) under part B of title XVIII for services furnished in 2010, 90 percent of such rate for services and physicians (or professionals) furnished in 2011, and 100 percent of such payment rate for services and physicians (or professionals) furnished in 2012 or a subsequent year;’’.
This provision goes on to include more explanations of services, some reimbursalbe at 100%. The rates of payment or reimbursement are not less than 80%. States will be allowed to apply for a Medical Home Pilot Program that can have a life of upto 5 years.
Page 781, 7 through 18:
(1) IN GENERAL.—A pilot project is a project that applies one or more of the medical home models described in section 1866E(a)(3) of the Social Security Act (as inserted by section 1302(a)) or such other model as the Secretary may approve, to high need beneficiaries (including medically fragile children and high-risk pregnant women) who are eligible for medical assistance under title XIX of the Social Security Act. The Secretary shall provide for appro16
priate coordination of the pilot program under this section with the medical home pilot program under section 1866E of such Act.
The section is followed by definitions, evaluations, reports and provisions for interpretor services. Accurate interpretors are vitally important. Here is a story, it is profoundly truthful and does not have to do with HIV/AIDS.
There was a Hispanic woman, about 62 years old came in the hospital for a hysterectomy. She was evaluated by the physicians and an irregularity was found in the EKG of her heart. She was referred to a cardiologist who did a cardiac catherization. It was found she had coronary artery disease and it would have to be dealt with in open heart surgery before any other surgery could be performed.
The evening before her surgery her son came to visit with her. He happened to stop at the desk on his way out off the unit and asked when his mother would be going for her hysterectomy.
I was called to speak to him as he spoke perfect English. I reviewed the chart and realized she was going to have open heart surgery. The consents were signed and witnessed by an employee from the kitchen of the hospital that was supposed to have spoken Spanish well. I asked him what made him believe his mother was going to have a hysterectomy. He stated that is why she came to the hospital and it was his understanding that was what was to occur.
I asked him if he spoke Spanish well enough to speak to his mother and we went into the room. It was a double occupancy room. The husband to the woman was at her bedside. The son asked his mother what kind of operation was being conducted that she consented to and she and her spouse stated a hysterectomy. No lie.
I called around to the nursing units in the hospital until I found a Spanish speaking RN and she reported to the patient's room. She conversed with the patient and the husband who had been at her side the entire time. She stated, the patient and her spouse was under the impression she was having a hysterectomy in the morning.
I then telephoned the surgeon and explained the consent that was signed was invalid because the interpreter was not a licensed individual and did not convey the brevity of the expected surgery to the patient. He immediately cancelled the surgery. The next day, a certified interpretor was ordered in his orders and the hospital had to secure one from a nearby university that had a few on staff.
The woman would have had surgery on her heart, been admitted to a SICU after surgery and the spouse would have never realized that a minor procedure was actually a major surgical procedure that was far more life threatening than a minor procedure.
Needless to say if the son hadn't stopped to visit his mother before her surgery there would have been drastic consequences to any of the surgery because it would have occurred and the following orders without prior consent. There probably would have been legal issues as well as ethical ones.
So, the 'idea' that accurate and certified interpreters are a luxury and not a requirement in any medical setting is hideous.
Page 783, lines 19 and 20:
SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
The option to experience a birth outside a hospital is an option. Page 784, lines 7 through 18:
‘‘(29) freestanding birth center services (as defined in subsection (l)(3)(A)) and other ambulatory services that are offered by a freestanding birth center (as defined in subsection (l)(3)(B)) and that are otherwise included in the plan; and’’; and (2) in subsection (l), by adding at the end the following new paragraph:
‘‘(3)(A) The term ‘freestanding birth center services’ means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)), including by a licensed birth attendant (as defined in subparagraph(C)) at such center.
There are definitions and effective dates that follow.
Page 785, lines 13 and 14:
SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE VACCINES FOR CHILDREN PROGRAM
I think that is fairly self explanatory. Page 786 is a new major Subtitle, lines 1 through 3:
Subtitle D—Coverage
SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-INFECTED INDIVIDUALS.
There are no extra allowances for HIV infected people. They have to meet the same requirements for service as everyone else. The provision does state a specific time frame for enactment of this portion of the bill which is no later than January 1, 2013. There are exceptions for USA Territories. They can qualify individuals differently and somewhat more generously. There is a two year extention for Transitional Medicaid Assistance (TMA) until December 31, 2012 simply to allow States to get their act together.
Page 789, lines 1 and 2:
SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER CERTAIN CHIP PROGRAMS.
This states that once a child is found to be eligible for Medicaid recertification does not take place for a year. The idea is to cut down on 'middle management' costs. Rarely do these children move off assistance that quickly anyway. The parents or guardians are required to report changes in circumstances and income during that period of time anyway. It is a requirement of receiving assistance. They have to report those changes or there can be consequences, but, they don't have to be scrutinized by government.
Page 789, lines 19 through 21:
Subtitle E—Financing
SEC. 1741. PAYMENTS TO PHARMACISTS.
(a) PHARMACY REIMBURSEMENT LIMITS.—
Page 790, lines 1 through 6:
‘‘(5) USE OF AMP IN UPPER PAYMENT LIMITS.—The Secretary shall calculate the Federal upper reimbursement limit established under paragraph (4) as 130 percent of the weighted average (determined on the basis of manufacturer utilization) of monthly average manufacturer prices.’’
That is fair reimbursement. What that states is the manufacturer charges whatever they charge for the medication and the pharmacist can charge 30% above what it cost them. So if a drug cost $1.00 per pill the pharmacist can charge $1.33 per pill.
There are other cost provisions by manufacturers that are to be reported within 30 days to the Secretary that help sculpt the Average Manufacturer Price (AMP) to whole distributors, including mail order pharmacies that are not open to all members of the public, such as rebates from manufacturers, discounts or price concessions so long as they are not passed through to the retail pharmacist or cost reimbusement for the return of defective or damaged medications.
The idea here is to prevent higher prices to the consumer when in fact there are lower prices to wholesalers.
There is a transparency provision for the public. There is also rebates allowed for 'single source' medications. Single source are new formulations under patent. There are provisions that they will be allowed to provide rebates to enhance the marketability of the initial introduction to the market. The States are going to be required to attend to all this recordkeeping. They want to know the public monies used in Medicare are within reason while still allowing physicians to order the necessary and perhaps new medication if the patient needs it.
Page 797, lines 5 through 12:
‘‘(C) REPORTING ON MMCO DRUGS.—On a quarterly basis, each State shall report to the Secretary the total amount of rebates in dollars received from pharmacy manufacturers for drugs provided to individuals enrolled with Medicaid managed care organizations that contract under section 1903(m).’’; and (3) in subsection (j)—
Page 797, lines 21 and 22:
SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION
Page 798, lines 5 through 8:
‘‘(1) IN GENERAL.—The term ‘medical assistance’ includes payment for costs of graduate medical education consistent with this subsection, whether provided in or outside of a hospital.
Page 798, lines 13 through 24:
‘‘(A) the State submits to the Secretary, in a timely manner and on an annual basis specified by the Secretary, information on total payments for graduate medical education and how such payments are being used for graduate medical education, including—
‘‘(i) the institutions and programs eligible for receiving the funding;
‘‘(ii) the manner in which such payments are calculated;
‘‘(iii) the types and fields of education being supported;...
This provision goes beyond just three topics of interest, but, what it boils down to is a reporting by the States of monies spent on medical education and where the money is going including the 'specialty' areas being pursued. It is a 'tracking' of the trends in medical education to insure the country have enough graduates to fill the need, in the areas where need is expressed.
The Secretary and the Advisory Committee on Health Workforce Evaluation and Assessment then reviews the information and then make changes in where funds will be distributed to further enhance graduates to choose fields of greater need.
Page 801, lines 4 through 8:
Subtitle F—Waste, Fraud, and Abuse
SEC. 1751. HEALTH-CARE ACQUIRED CONDITIONS.
(a) MEDICAID NON-PAYMENT FOR CERTAIN HEALTH CARE-ACQUIRED CONDITIONS
This provision takes nosocomial infections beyond the hospital into 'health care acquired' conditions. I've discussed before the dangers and increased costs to infections and conditions acquired due to exposure to the hospital environment.
I'll end here for today. There are a total of 1018 pages, so its nearly complete.
