| Five Reasons Obamacare Legislation Failed; The Worst Legislation Money Can Buy; Putting the Patient in the Driver's Seat Posted: 31 Oct 2013 08:06 PM PDT Here's an exceptionally well written, on-target email from Claudette, an occupational therapist from Michigan, in response to my post Physical Therapist in NY Chimes in on Health Care Costs. Claudette wants to " Put the Patient in the Driver's Seat". Claudette writes ... Hello Mish
I do not disagree with the PT who wrote to you about consolidation of hospital systems resulting in increases in cost of care, but there are other pertinent problems to consider.
For example, in the current system, the physician and hospital make more money if they perform more services...so there is an incentive to order more tests, do more therapy and generally "do more to make more".
Under the ACA, there should be one bundled payment per diagnosis/incident.
What I suggest is not new, or radical. Medicare instituted DRGs or Diagnosis Related Groups with inpatient day and dollar limits per diagnosis 38 years ago (I was just beginning to work as an OT then).
DRGs drastically cut the cost of inpatient care and spawned the development of new service models including inpatient rehabilitation centers, Homecare and rehab in nursing homes, none of which fell under the constraints of the inpatient DRG.
Was this good? Yes, getting out of the hospital earlier is less expensive and healthier. There is no better place to get really sick than in a hospital.
Healthcare will not be truly competitive or cost effective until the patient is the one in the drivers seat. The patient should be informed, empowered to make care decisions and should pay the bill.
The bill should be discussed and agreed upon before service, whenever possible. Service prices should be posted so that consumers can comparison shop.
Right now patients are the point of service but are not part of the decision process. ACA did not change that and, in my mind, that is its greatest shortcoming.
Claudette Obamacare, the Worst that Money Can Buy As I reflect on all the emails that I received, it is readily apparent that numerous healthcare professionals understand precisely what is wrong with the current system. So, how come none of the numerous existing problems were fixed? Five Reasons Obamacare Legislation Failed - Lobbyists wrote the ACA legislation. When Nancy Pelosi stated "We have to pass the health care bill so that you can find out what is in it", she was referring to you , me, and Congress. An extremely tiny number of people knew what was in the bill: lobbyists for hospitals, lobbyists for insurance companies, lobbyists for HMOs, and lobbyists for major pharmaceutical companies.
- President Obama was more concerned about his legacy than anything else. He wanted Obamacare at any and all costs and was willing to sign any piece of legislation, no matter how poor.
- Politicians in general do not have the public's vested interest in mind. They have their own reelection efforts in mind. That statement holds true regardless of which political party you support.
- Lobbyists and industry PACs donate massive amounts of money to politicians from both parties. That is why we do not allow drug imports from Canada. That is why there is an explicit law that prevents government from bargaining with drug companies on prescription drugs. That is why the US pays the highest drug costs and highest healthcare costs of any nation on the planet.
- Republicans for the most part were more concerned over stopping Obamacare than improving the healthcare of citizens of the United States. The irony here is Obamacre is essentially the same as Romneycare.
So here we are, stuck with the worst legislation imaginable. As Claudette suggests, we need to put the patient in the driver's seat. Unfortunately that is in the vested interest of only the patient. Who speaks on behalf of the patient? The sad answer is all too apparent: no one that the president or Congress listens to. They are all beholden to lobbyists, their legacy, and their reelection campaigns. Mike "Mish" Shedlock http://globaleconomicanalysis.blogspot.com |
| Hollande's Tax Everything Plan Blows Sky High With Riots by Farmers; Hollande Backs Down on Ecotax, on a Tax on Savings, On Corporate Earnings; Something For Nothing Posted: 31 Oct 2013 08:50 AM PDT President Francois Hollande wants to balance the French deficit by taxing the rich, taxing the poor, taxing trucks, raising the VAT, and increasing the tax on corporations. That policy blew sky high this week in a storm of riots by Brittany farmers. Please consider French Gov't Backs down on Truck Tax After Riots French Prime Minister Jean-Marc Ayrault on Tuesday indefinitely suspended the introduction of a green tax on trucks following riots at the weekend in the Brittany region.
The move comes three days after a protest by hundreds of food producers, artisans and distributors in the western Brittany region ended in the worst riots in the area in years.
One person was seriously injured in clashes between police and a group of around 1,000 demonstrators, who blocked a national road with convoys of vehicles and tonnes of produce on Saturday in protest over the tax.
Bretons say the levy will squeeze the already wafer-thin margins of the region's struggling chicken, pork and other food producers.
The protests were seen as the expression of growing frustration nation-wide with the escalating tax burden on businesses and households.
Taxes have risen 70 billion euros (96 billion dollars) in the past three years, as France battles to shrink its budget deficit.
The truck tax, which is to apply to all vehicles of over 3.5 tonnes that use French roads, aims to raise 1 billion euros a year towards the development of rail and river transportation. French Way of Getting Your Message Across Mr. Ayrault denied that the government had caved in to the protesters. " To be courageous is not to be obstinate; it's to listen and understand," he said after a meeting with Breton lawmakers and several Cabinet Ministers. In France, riots, strikes, and mass protests work. This is the second time this week, and third time in a month that France rolled back a tax. Hollande Backs Down on Ecotax, on a Tax on Savings, On Corporate Earnings Bloomerg reports Tax Revolts Hit Hollande as Farmers, Soccer Clubs Protest. French President Francois Hollande's taxes, among the world's highest, have made strange bedfellows out of the country's soccer clubs and farmers in Brittany.
Revolts against a series of levies have erupted with protests by farmers in Brittany against a trucking tax on Oct. 27 leaving several people injured, and soccer clubs refusing to play a round of league matches in November to oppose a tax on salaries of more than 1 million euros ($1.38 million). Hollande has said he won't budge on the millionaire tax, while Prime Minister Jean-Marc Ayrault said today he's suspending the levy on truckers transporting agricultural products for now.
The Socialist president, who turned to increased taxes to narrow the country's budget gap, has backed down on other levies in the face of objections. On Oct. 27, he gave up on a plan to lift taxation on savings, just weeks after backing off a new levy on corporate earnings.
"The cumulative effect of these retreats is that they confirm in many voters' eyes that the government is struggling to govern," said Bruno Jeanbart, a director of Paris-based pollster OpinionWay. "Even Hollande's own supporters question if he's up to the job. The problem for the president is that every time there's good news, it's marred by political errors."
Hollande's ratings in polls have sunk, making him the country's most unpopular president. A BVA poll published last night showed Hollande's approval rating dropping six points in the past month to 26 percent, the lowest level for any president under France's current constitution.
The revolts reflect discontent with taxes that have risen by 70 billion euros in three years. France's tax burden was 46.3 percent of gross domestic product last year, up two percentage points from 2011 when it was already the third-highest in the world behind Belgium and Denmark, according to the Organization for Economic Cooperation and Development.
"There's no more room to raise taxes," said Laurent Dubois, a professor at the Institute of Political Studies in Paris. "The French feel taxes are going up and purchasing power is going down. They voted for Hollande thinking they'd afford austerity; that the rich would pay. They realize now that that's not possible. There aren't enough rich people." Not Enough Rich People to Tax Socialists are all in favor of raising taxes (on somebody else). When Hollande ran out of rich people to tax, he simply taxed everybody. Those generally supportive of tax hikes then revolted in a riot of "not me" protests. Support for Tax on Soccer Players is 83% Apparently there are not enough soccer players to matter. By a massive margin, the "Not Me" protesters support Hollande's 75% tax rate on millionaire soccer players. On soccer clubs, Hollande has said he intends to hold his ground on a pledge to tax salaried earnings of more than 1 million euros at a rate of 75 percent for two years. French soccer clubs said last week they won't play a round of league matches during the last weekend in November to protest the tax.
For some unprofitable clubs, the extra burden is a threat to survival, according to the Ligue de Football Professionnel.
"The consequences of this measure will be dramatic," said Frederic Thiriez, head of the LFP, said in a statement. "France must be the only country that taxes money-losing companies."
The clubs, which are canceling matches between Nov. 29 and Dec. 2, are asking the government to abandon the tax.
The million-euro salary levy is one that is popular. About 83 percent of French say the soccer strike is unjustified, according to a poll by Opinion Way for LCI television. For now, Hollande says he is not backing down on taxing soccer players. I guess there are not enough of soccer players to matter (at least until games are cancelled, tax revenue plunges, and people who want to see the games riot). French Want Something For Nothing Hollande has promised to cap the deficit mostly by shrinking spending next year. That won't make the French happy either, said Emmanuel Riviere, a pollster at TNS Sofres in Paris. "The French want the deficit addressed and spending reduced but they don't want to give up their services and social protection," he said. "Faced with this contradiction, Hollande has been ambiguous. The result is that the French are now suspicious that the government isn't telling them the truth." Making a Choice "If we don't have the tax we can no longer restart public works projects, renovate roads including the high-speed train links that all lawmakers are asking us for," he said. "We will have to make a choice. We will have to find an agreement." said Industry Minister Arnaud Montebourg. Well, perhaps Montebourg should ask if people want tax hikes to support those things. Then again, the answer would likely be "Yes, But ... Not On Me!" Mike "Mish" Shedlock http://globaleconomicanalysis.blogspot.com |
| Physical Therapist in NY Chimes in on Health Care Costs Posted: 31 Oct 2013 01:52 AM PDT Reader "Chris", a physical therapist in private practice in New York, pinged me about Obamacare and rising health care costs in general. Chris writes .... Hello Mish
I wanted to comment on your recent posts regarding Obamacare. Most of the criticism from you, and others, has focused on the issues and difficulties surrounding the website, dropped coverage, legal disputes, and rising costs you called "Obamashock!"
As a healthcare provider, I would like to point out a seldom heard critique regarding competition and hospital consolidation.
A cornerstone of ACA (Obamacare) is promotion of Accountable Care Organizations (ACOs) intended to be fully integrated systems, capable of taking patients through a complete continuum of care.
Allegedly, ACOs would reduce price.
However, a recent study on the Impact of Hospital Consolidation by the Robert Wood Johnson Foundation found the opposite was true.
Providers and the specialty groups remain in isolated silos. The hospitals merge simply to increase their market share and ability to leverage higher fees from insurers, which they have done.
Four Points From the Study
- "The Patient Protection and Affordable Care Act (ACA) promotes Accountable Care Organizations (ACOs) and the bundling of payments across providers for an episode of care (bundled payments), both of which encourage consolidation between hospitals and physician practices."
- "Hospital consolidation generally results in higher prices. This is true across geographic markets and different data sources. When hospitals merge in already concentrated markets, the price increase can be dramatic, often exceeding 20 percent."
- "Hospital competition improves quality of care. This is true under both administered price systems, such as Medicare and the English National Health Service, and market determined pricing such as the private health insurance market. The evidence is more mixed from studies of market determined systems, however."
- "Physician-hospital consolidation has not led to either improved quality or reduced costs. Studies find that consolidation was primarily for the purpose of enhanced bargaining power with payers, and hence did not lead to true integration. Consolidation without integration does not lead to enhanced performance."
Contrary to the success of these hospital systems in raising their rates, private practice physical therapy, the sector that I work in, has seen inflation adjusted reimbursement down 40% between 1992 and 2012.
Medicare has cut physical therapy reimbursement an additional 16% more since 2012.
Private payers (insurers) also continue to cut our reimbursement each year. The difference between private practice and these large hospital systems remains the relative leverage they each have in negotiating for higher reimbursement rates.
Private practice has no leverage and major systems have an unreasonable amount of leverage. This is why physicians across the US have migrated in record numbers towards hospital systems.
Competition of private practitioners and smaller hospital systems has historically kept prices lower. That competition is now being done away with by Obamacare in the name of cost savings, but it is having the opposite effect.
Obamacare is a disaster on so many levels its frightening.
Regards,
Chris Mike "Mish" Shedlock http://globaleconomicanalysis.blogspot.com |
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