CHAPTER 12
STATUTORY CHANGES
“Bad laws are the worst sort of tyranny.” - Edmund Burke
“A pirate was captured and brought before Alexander the Great.
Alexander asked the pirate:
'How dare you molest the people?'
The pirate replied: 'And how dare you molest the entire world? I am called a thief because I do it with a little ship only. You do it with a great navy and you are called an Emperor!'”
§ 12.1.0 HEALTH CARE ACCESS FOR ALL
§ 12.1.1 In Virginia, 71% of businesses are small – 48% of small businesses provide health insurance and 62% of all employers provide insurance.
§ 12.1.2 As health insurance premiums have skyrocketed, small businesses are finding it increasingly difficult to offer health insurance to employees and compete.
§ 12.1.3 In 2000, 1% of people had to pay a $1,000 deductible or more. In 2008, 18% of people had to pay a $1,000 deductible or more. Inflation hasn’t increased that much, now!
§ 12.1.4 Having to pay that first $1,000 makes me really think, “can I afford to do without this procedure?” Thus, it is doing what private insurance companies designed it to achieve.
§ 12.1.5 For profit companies must fund health insurance for all employees equally, based upon some standard, such as $1,800 a year plus 5% of salaries, bonuses, profits, and investments. It must be affordable, so, these figures ought to be negotiated. Of course, employers in a position to contribute more can do so. These contributions would take the form of vouchers given to each employee. Risk would not be based on the individual nor would it be based on the employer. All risk would be divided equally across the 300 M Americans. Each employee would then select insurance plans best for him or her, with that voucher, augmented, if need be, by their own resources or by the federal government.
§ 12.1.6 Start-up corporations without profits or bonuses and with certain average salaries and within targeted investments ought to pay significantly reduced health insurance premiums for the first, say, 3 years, and the government would pay premiums for employees while the start-up business gets established. If that start-up business is sold or transferred, the government might have the right to assess it for health care costs that it paid for employees, assuming the sale or transfer results in profit.
§ 12.1.7 Not-for-profits must fund health insurance for all employees equally, based upon some standard, such as at least 6% of salaries AND bonuses plus 3% of investments.
§ 12.1.8 More is always ok, and, when recruiting highly sought employees, it might be necessary.
§ 12.1.9 All premiums and medically necessary expenses will receive a full tax rebate. Medically recommended expenses will receive a deduction, and elective procedures might be subject to a modest excise tax. All companies, charitable organizations, and governments must make the same contribution for health care for each of its employees. This would not apply when an employer provides additional assistance or transfer of vacation / sick days when employees are ill, provided that that additional assistance or transfer is equally available to all.
§ 12.1.10 – The government would reach up and pay premium difference for those whose employer can only contribute small amounts.
§ 12.1.11 - Individuals who receive an amount greater than the cost of the insurance plan they purchase can put balances in an untaxed, roll-over Health Savings Account (HSA) (interchangeable for college savings and retirement) that can be transferred upon death for use by dependents for their HSA, college, or retirement.
§ 12.1.12 - Everyone would have an HSA and the excess payments from a HFC, say $5 a day that it is used, would be placed in their HSA. If the policy they select costs less than the insurance contributions from their employer or from the government, then the balance would be placed in an HSA.
§ 12.1.13 - We could purchase into plans offered by the government, private for-profit sector, and private not-for-profit sectors. Each of these plans would be available across state lines. These plans could be mix-matched by each American.
§ 12.1.14 - Employees working 1 hour a week could purchase health insurance and their employer would contribute, say, 90 cents a week while the government and individual would pay the difference. The CEO of United Health, earning $8 M would contribute $640,000 into the employee health insurance account. If he obtained a $1.6 B bonus, the $128 M would be put into the account.
§ 12.1.15 - 36% of people who applied for health insurance were denied coverage due to a pre-existing condition! If they try to obtain coverage and the private insurance companies deny coverage, why do we continue to blame all of the 47 M without health insurance?
§ 12.1.16 - 20,000 rescissions by health insurance companies saved them $300 M in that year alone! Dropping people who in good faith have purchased insurance with your company and then need service is not always fair. I must agree with insurance companies, however, that when the evidence is proven that one knew of a major health condition and denied it on their application with intent to defraud the insurance company, then the insurance company should not have to pay for that person’s medical care.
§ 12.1.17 - Every 3 months, insurers will send a postcard written at the 6th grade reading level, that shows how much the total revenues were for that specific policy category (say vision), the medical costs, the administrative operations, and the profits.
§ 12.2.0 YOUNG ADULTS
§ 12.2.1 At the age of 18, persons who have been found mentally retarded or otherwise unable to gainfully obtain health insurance ought to have coverage through the government, immediately. That transition period can sometimes be difficult.
§ 12.2.2 Students who attend college must purchase a group health policy through that college.
§ 12.2.3 The remaining young adults ought to purchase insurance when they are employed, and, when they are in between employment, as frequently occurs, they ought to be covered by their parents’ health insurance through the age of 26. If they are completing doctoral studies or another terminal degree and they are unable to purchase college policies (say, unemployed and finishing their doctoral dissertation, internship, or residency, a 3 year extension ought to be granted to age 29.
§ 12.2.4 - Insurance companies must –
§ 12.2.4.1 – Not drop high end users
§ 12.2.4.2 - Not decrease coverage once contracted
§ 12.2.4.3 – Not impose unreasonable cost increases
§ 12.2.4.4 – Cover pre-existing conditions (after one year after initial application). First year coverage ought to be mandatory for all public policies.
§ 12.2.4.5 – Not impose lifetime, annual, or specific disease or procedure caps
§ 12.2.4.6 - Cover life partners and all dependents
§ 12.2.4.7 – Fully cover preventive medical procedures, OP visits, procedures, mammograms, rectal exams, screenings, dental exams, vision exams, behavioral health intakes without co-payments.
§ 12.2.4.8 - Premiums must be only 4 pages.
§ 12.2.4.9 – Premiums must be written to be understood – say at the 6th grade level, written for consumers and not lawyers. (My insurance policy is 120 pages long, written in fine print, by lawyers and for lawyers!)
§ 12.2.4.10 - Modest risk premiums (10%) or, modest risk co-payments would be permitted based on history of abuse, elevated risk based on choice behaviors (e.g., smoking, obesity (more costly than heart disease or cancer)), or future costs.
§ 12.2.4.11 - Requiring pre-authorization for an ambulance or visit to the ER is illogical. Excessive use of pre-
authorizations must be reined in. At the same time, I have known some people I could envision calling for an ambulance ride to the ER twice a week for the attention.
§ 12.2.5 - The government must establish maximum out-of-pocket payments that include costs of premiums, assistance on premiums, co-payments, co-insurances, deductibles, and caps. These maximums might be modified by the type of insurance program individual’s buy.
§ 12.2.6 - Presently, health insurance companies, Medicaid, and Medicare only pay for services performed by providers who are willing to accept their low pre-determined payment schedule. If you want to see a great doctor, you pay out of pocket. Let me translate this into English – this is rationing! We have rationing in America!!! Rationing, whether it is by government or private insurance companies, must stop now.
§ 12.2.7 - Public health insurance programs must cover their own costs and must pay providers fees that are competitive and meet their costs.
§ 12.2.8 - All health insurance premiums and health care costs must be tax deductible or tax rebatable by employers or employees.
§ 12.3.0 SLOWING THE INCREASE OF CONSUMER PRICES
12.3.1 Measures reducing ADMIN costs, taxing excess profits, reducing defensive medicine, and reducing medical errors, will reduce health care costs, and, presumably, profits. Over the first 5 years, there will be substantial decreases in costs to insurance companies, government, and, presumably, the people who pay premiums.
AFTER THE FIRST 5 YEARS:
§ 12.3.1.1 - With everyone contributing to the pool, where 17% now don’t, much more risk and payments are shared. Frankly, including younger, healthier people will reduce our average cost.
§ 12.3.1.2 - Health care costs must be contained. President Nixon was the last president to use price controls. I believe that health costs ought never increase more than 10% over the DoL rate of inflation. For example, if general inflation is 3.00%, health care costs might be permitted to increase 3.30% PP. This would still mean, however, that when the number of Alzheimer’s Disease cases also increases 10% a year, costs of AD will increase 13.3%.
§ 12.3.1.3 - With keen competition between private insurance companies, not-for-profit organizations, and government, costs ought to be reduced.
§ 12.3.2 Doctors are unique in that they profit from the more services they decide you need. They might put you on pills they own stock in. The radiologist who reads your MRI might own the MRI clinic.
§ 12.4.0 EXPERIMENTAL PROCEDURES
§ 12.4.1 Many private health insurance plans now exclude coverage for experimental drugs, procedures, and surgeries. When new, these drugs, procedures and surgeries might be extremely intensive and costly.
§ 12.4.2 We want providers and researchers to experiment and develop things that improve our lives. Thus, we don’t want to completely exclude these procedures.
§ 12.4.3 Risk aversive insurance companies should not have to pay the whole costs of developing new procedures.
§ 12.4.4 Experimental drugs and procedures approved by the FDA for experimentation would share costs between the insurance company, patient, provider, health service organization, and government.
§ 12.5.0 EXPAND TRADITIONAL MEDICAID
§ 12.5.1 Most of the 50 M uninsured can be covered through expanding the eligibility for Medicaid. This might somehow reduce concerns about socialized medicine, since it is already an established program. Of course, I advocate elsewhere that Medicaid ought to be a federal program, operated by Medicare, as it would reduce administrative costs by $19 billion a year.
§ 12.6.0 ERISA
§ 12.6.1 Patients who are harmed due to medical HMO malfeasance must be permitted to file law suits without exclusion due to ERISA.
§ 12.7.0 TAX IMPLICATIONS
§ 12.7.1.1 - “Medically necessary” procedures ought to be eligible for tax rebate. As some people would not be able to pursue these medically necessary procedures without upfront tax rebates, the federal government might provide advances.
§ 12.7.1.2 - “Medically recommended” procedures ought to be eligible for full tax deduction.
§ 12.7.1.3 - “Elective” procedures might be discouraged through implementation of a modest excise tax.
§ 12.7.2 A Citizen’s Panel ought to review procedures and determine necessary, recommended, or elective, based on recommendations of health care providers and never should they base decisions on the economic benefits to the government.
§ 12.8.0 INSURANCE MEANS TEST OR FEE
§ 12.8.1 Some individuals might have other means. If a family has liquid assets of $10 M, perhaps a means test would be satisfied. If they require health care, they must pay out of pocket if they have chosen the means test exclusion. If they are agreeing to pay for all of their own health expenses, they should not be subjected to paying a non-insurance fine.
§ 12.8.2 Regarding non-insurance fines, liberals propose percentage fees (2% of $7.50 an hour is $312). Conservatives propose a fixed fee, say $2,500. Regardless, health insurance must be documented.
§ 12.8.3 What if religious beliefs forbid the purchase of health insurance – it is a form of legalized gambling. Ought they to be penalized? What could be the costs to society and how much voice does society have?
§ 12.9.0 IMMIGRATION POLICY
§ 12.9.1 Immigration applicants with personal or family histories of health problems might be subjected to a cost / benefit analysis to determine whether potential merits (Nobel laureate) might offset potential health costs – at least for the time being. Ill residents not making educational progress might be granted temporary extensions but, if medical needs are not pursued and educational progress is not made, individuals must be deported.
§ 12.10.0 PREVENT PRICE GOUGING
“All that is required for evil to triumph is that good men do nothing”. – Edmund Burke
§ 12.10.1 - Medical fees must be no more than 20% different across third party payers. Hospitals now over-charge, sometimes 3 times what they charge insurance companies, to indivduals from who they don’t expect to collect, so that, after they show due diligence and it goes uncollected, they write off the entire inflated figure. This tax write down benefit has driven up bankruptcies and reduces corporate income tax paid to the IRS and is paid for by the taxpayer.
§ 12.10.2 - A study of NY hospitals determined they overcharged patients without health insurance $1 B a year. If similar results are throughout, this practice of hospitals padding the bills of the uninsured totals $20 B a year.
§ 12.10.3 - Overcharging is done because: (1) capitalism, and (2) CMS doesn’t pay rates that cover costs so these losses must be made up elsewhere.
§ 12.10.4 - Insurance companies will only be allowed to drop an individual (or, depending on the program that the congress adopts) if premiums go unpaid for more than 45 days, unless the individual is having a health crisis.
§ 12.10.5 - Insurance companies’ premium increases will be limited to no more than 10% more than the general rate of inflation. Again, if DoL determines a rate of 3.0%, the insurance company might be permitted to increase fees by 3.3%.
§ 12.10.6 - Bonuses of insurance company, health care provider, and pharmaceutical manufacturers will be contained ithin reason, directly based on the performance of the company, providers, or medications. These bonuses must be submitted to the PHS and SEC for authorization. Excessive bonuses will be subject to the excessive health care profits tax.
§ 12.10.7 - Each insurance company must hold tele-conferences with providers and patients in order to identify medical, procedural, and ADMIN concerns. Logs will be submitted to the PHS outlining steps to implement cost saving and life enhancing procedures.
§ 12.11.0 MEDICAL BANKRUPTCY (MB) § 12.11.1 - Congress passed legislation making it more difficult to file for bankruptcy. Still, more than 1 bankruptcies are filed each year. 60% are MBs.
§ 12.11.2 - The cost of filing for MB must be reduced and federal court fees waived. If someone is the victim of domestic violence, we don’t make them pay a fee to report the abuser or file a protection order, etc. People who are the “victim” of cancer and who must file for bankruptcy ought to not be charged for the legal procedure.
§ 12.11.3 - I realize these suggestions would tend to increase MBs and the dollars “expunged” from the system. For individuals facing MB with chronic or terminal health conditions, this will be beneficial. Responsible universal coverage will reduce MBs and it will reduce the billions of dollars expunged from the economy. Patients will no longer feel like criminals.
§ 12.11.4 - Prompt filing of MBs and close communication with creditors can reduce expenses $3 B a year.
§ 12.11.5 - Protected assets ought to include health equipment and handicapped vehicles.
§ 12.11.6 - Loosing the 1st home makes a person homeless. People with 3 homes don’t need MB! MB must allow greater “inaccessible” amounts on the first home, cash that will be used to pay MB expenses, 6 months’
worth of living and health care costs, protected savings for college, HSAs, and retirement. Shouldn’t a second home and stocks be ineligible for protection?
§ 12.11.7 – When physicians and judges have determined that the bankruptcy is due to medical problems, then there ought to not be a restriction imposed, such as waiting 7 years to re-file.
§ 12.11.8 - 1.5 M Americans face foreclosure of homes due to medical bills yearly. Efforts must be made to assist people in keeping their homes throughout medical tragedies and MBs. I propose a program to loan / grant monies to pay toward rents or mortgages during medical emergencies. I propose that over the next 5 years, health insurance must provide some degree of housing / costs of living, during a patient’s illness.
§ 12.11.9 - Providing full health coverage will reduce MBs and the amount of money that providers and health care corporations lose.
§ 12.12.0 DETERMINATION OF PAYMENTS
“If you climb up a tree, you must climb down the same tree.” - African Proverb
§ 12.12.1 - Throughout this paper, I suggest modifications in payments for various services. Sometimes I suggest increases. Sometimes I suggest decreases.
§ 12.12.2 - CMS ought to have access to IRS documents, so that wages or profits can be identified. If the public system is paying clinical psychologists $56 an hour and 20,000 clinical psychologists are reporting an average income to the IRS of $24,000, then I would suggest that, perhaps, that salary is too low for a doctorally prepared licensed clinical psychologist.
§ 12.12.3 - On the other hand, an orthopedic surgeon in my region earns $3 million a year. Sure, he probably works more than 50 hour work weeks, but, still, it seems like a little more than what I want my tax dollars to pay.
§ 12.13.0 CENTERS FOR MEDICARE AND MEDICAID (CMC) REQUIRE SIGNIFICANT MODIFICATIONS
§ 12.13.1 - Medicare patients must pay 50% of psychiatric costs but only 20% of all other care, yet, psychotropic medications are covered at the same rate as others. CMS discrimination is wrong. Interestingly, CMS’ most under-paid programs are in the areas in which the US performs most poorly – NH, pediatrics, and MI. These are populations in which the victims cannot speak up for themselves. Payments must be just and competitive. Medical and social costs / benefits must be included in CMS equations and must no longer be allowed to be the basis for discrimination.
§ 12.13.1.1 - Studies compellingly report to CMS that treating MI/SA reduces the need for medical care by half, saving $300 B a year. Again, I urge that CMS must enter both social and medical costs and benefits in their determination of the value of medical procedures. Given that 2/3rds of the most common killers of Americans have strong and direct behavioral components, behavioral health counseling must be encouraged as a preventive measure and CMS must pay competitive compensation.
§ 12.13.1.2 - The Virginia Tech shooter, who killed 33 people, received inadequate MI care. Virginia courts could not assure treatment, lacking funds.
§ 12.13.1.3 - CMS Board consists of only physicians and no other providers. A whole team is needed.
§ 12.13.6 - Interestingly, these physicians who earned an average of $225,000 gave themselves a 3% increase by decreasing pay to other providers who earn an average of $65,000. While most physicians are, indeed, underpaid by Medicare, so are all other providers who most need Medicare increases to pay for bread rather than cruises.
§ 12.14.0 MI/SA COURTS
§ 12.14.1 - MI/SA courts must be designated in all state and federal judicial districts.
§ 12.14.2 - All staff ought to receive special training.
§ 12.14.3 - Goals ought to be treatment, rehabilitation, vocational training, and restitution.
CHAPTER 13
LOBBYING & CAMPAIGN FINANCE REFORM
§ 13.1.0 EVERYTHING IS RELATED
Does money upset the hearts of learned men?
He answered, "men whose hearts are changed by money are not learned" - abu Hamid al Ghazali
§ 13.1.1 It almost seems that some government bureaucrats and politicians vote or regulate based, not on duties andobligations to the American public, but to their future employer who has promised them a job making ten times greater salary.
§ 13.1.2 Lobbying serves an important function. Lobbying organizations provide legislators with important information. Lobbying provides corporations with a voice to explain their positions, a voice they are entitled to use but they cannot vote.
§ 13.1.3 Lobbying provides money to political campaigns needed to win that otherwise would be left unfunded by the public that has lost interest in politics.
§ 13.1.4 I am not going to make specific recommendations regarding lobbying and campaign finance reform. That’s another matter that must be addressed fully to assure that the interests of representative’s constituents are primary and that reform result in justice and transparency.
§ 13.1.5 The top twenty pharmaceutical companies and their two trade groups, Pharmaceutical Research and Manufacturers of America (PhRMA) and Biotechnology Industry Organization, lobbied on at least 1,600 pieces of legislation between 1998 and 2004. According to the Center for Responsive Politics, pharmaceutical companies spent $900 M lobbying between 1998 and 2005 (more than any other industry). They donated $90 M to federal candidates and political parties, giving 3 times more to Republicans as to Democrats. According to the Center for Public Integrity, the 18 months through June 2006 alone, pharmaceuticals spent $182 M on federal lobbying. It has 1,274 lobbyists in Washington.
§ 13.1.6 In 2004, U.S. health insurers directly employed 470,000 people averaging $61,409 totaling $29 B a year. Employment related to all forms of insurance totaled 2.3 M at about $150 B a year. Average wages for full-time civilian workers as of June 2006 were just $41,231. The insurance industry lobbies a lot. For 2008, insurance ranked 8th in size of political contributions to members of Congress, giving $28,654,121 (that’s an average of $54,000 for each member of congress).
§ 13.2.0 GREATEST THREAT TO DEMOCRACY
“If you run after two hares you will catch neither.” - African Proverb
Chinese Symbol for Inability
to Judge Right from Wrong
§ 13.2.1 Companies and special interest groups spend over $2 B a year in lobbying the federal government. That’s over $3 M for each member of Congress. If you received $1 million from one special interest group, could you vote against them? Imagine the kind of pressure that someone like Senator Baucus must feel with the millions of dollars in donations and gifts yet, perhaps, he struggles knowing that his constituents and the American people need just, effective, and comprehensive health care reform.
§ 13.3.0 POLITICAL INFLUENCE
“Never forget that turning a blind eye to oppression and watching from the sidelines is itself oppression.” - Harun Yahya
§ 13.3.1 Each American would like to believe that his or her congressman / senators are above reproach. For the most part, most, ultimately, seek the best available option.
§ 13.3.2 I’ve attached a few pages that provide an example of who gives what to whom.
§ 13.3.3 Campaign donations are required by the Federal Election Commission (FEC) to be fully disclosed to the public. That’s a step in the right direction. If I hop on the internet, I can tell you the name of every campaign donor.
§ 13.3.4 Lobbying financial records are more covert. They are not fully accessible to the public. Special interest groups might do undocumented things like hire prostitutes, buy a bottle of champagne, employ a senator’s cousin, or donate to their favorite charity … There are hundreds of loop-holes in present lobbying regulations that benefit politicians and businesses at the expense of American voters.
§ 13.3.5 Who influences congressmen the most?
Spouses and Family Their Political Party Peers and Friends
Staff Members Lobbyists Voters
§ 13.3.5.1 Spouses and Family
§ 13.3.5.1.1 - I remember once reading about the 19th Amendment that gave women the right to vote. It passed Congress and many states. Southern states blocked its passage. It all came down to Tennessee. In that
legislature, a young representative found a note tucked in his pocket that morning from his mother saying, “be a good boy … and vote for women’s suffrage”. He voted for his mother and it passed by one vote. Close, but enough.
§ 13.3.5.1.2 - There is no known method of assuring that our elected officials are not influenced by family. Even if we sequestered them (which advocates of term limits might appreciate), they would still be influenced by their memories and knowledge (say, dad fought on Normandy beach or mom died of breast cancer). This access often leads congressmen to appreciate the needs of citizens.
§ 13.3.5.2 Their Political Party
§ 13.3.5.2.1 - In the last 50 years, the two political parties have become increasingly hostile toward one another and vote in blocks against the other rather than voting on the issue and voting on behalf of the people who elected them. In an era where an increasing number of Americans identify themselves as “Independents”, this rigorous party unity among elected representatives will ultimately lead to the loss of power by those parties.
§ 13.3.5.3 Peers and Friends
§ 13.3.5.3.1 - Our peers influence us. In congress, as one walks from the office to the chamber, s/he horse trades with fellow congressmen – if you vote for this legislation giving my district $10 M today, I’ll vote tomorrow to give your district $10 M.
§ 13.3.5.4 Staff Members
§ 13.3.5.4.1 - Who else do congressmen work with? Staff exist to help the electorate and to help elected officials comprehend matters and to do the right thing. Congressmen depend on staff. With thousands of phone calls, letters, and emails; tens of thousands of pages of material to read every week; and, public appearances, the phrase “relies upon staff” is not enough. Staff members usually try to do the right thing. They are often strongly influenced by what they know is the legislators’ predilections. Sometimes staffers are influenced by others – their own spouses, clergy, or friends. Staff members may leave congress one day and join a lobbying firm the next. With access to all of their old friends, they make very influential lobbyists.
§ 13.3.5.5 Lobbyists
§ 13.3.5.5.1 - K Street, North West, is now an infamous setting for lobbying organizations. Some work is good. They fund research, accumulate data, and summarize information. Truth has been said to be the first casualty of war. Almost always, lobbying groups are paid by a special interest group. Thus, facts are usually skewed so that they bolster the positions of those who pay their salaries.
§ 13.3.5.5.2 - Every state capital has lobbyists, usually paid less than in DC. The median salary for US lobbyists was $96,000! While most lobbying analysts earn half that, the smooth, well-connected bread winners earn much more than the median.
§ 13.3.5.6 Voters
§ 13.3.5.6.1 - The American voter’s opinions are also factored into decisions by lawmakers. Of course, as voters, we must make certain that our elected officials hear from us. The recent obstructions posed at town halls present a lop-sided picture of the wishes of the voters. Our representatives walk away fearing for their lives and hearing loud opposition to health care reform. Supporter of health care reform must be heard equally effectively, albeit respectfully.
§ 13.4.0 LOBBYING & DONATIONS BY HEALTH CARE PROVIDERS & CORPORATIONS TO CONGRESS
“If you're not part of the solution, you're part of the problem.” - African Proverb
“ … a hoarseness caused by swallowing gold and silver.” - Demosthenes
§ 13.4.1 A few critical points:
§ 13.4.1.1 - Health care providers, hospitals, insurance companies have spent, this year alone, over $500 M to lobby Congress. 2:1, these monies are spent to oppose change.
§ 13.4.1.2 - Most of the formerly biggest lobbyists, Chamber of Commerce, American Medical Association, all of the pharmaceutical groups, medical device companies have ramped up lobbying in 2009.
§ 13.4.1.3 - There are over 5,000 people employed as health care lobbyists. That’s almost 10 lobbyists for each member of Congress.
§ 13.4.1.4 – Spending billions of dollars on legislative lobbying is redundant and wasteful. These excessive costs are passed onto the American consumer who pays, on average, about $7 more for the direct services of health care services or insurance companies. Indirectly, they pay $4,000 more for the continuing wasteful spending in health care that is pushed by these lobbyists. So, if you guaranteed that my $7 investment would turn into $4,000, I’d be pouring money down this wide, greedy drain.
§ 13.4.1.5 – In the Appendix, I provide a little data on lobbying and campaign donations. Much of this information is readily available on the internet, from sites such as www:opensecrets.org. My solitary intent in providing this information is to show the reader that every member of Congress has a vested interest in health care one way or the other. Every congressman hopes their decisions (or poised waiting) will result in large contributions. As voting Americans, we still have a voice in our democracy and our voices must be heard, whether you as an individual are in favor of reform or you oppose reform. We must objectively read health care reform plans, discuss them, make decisions, and inform our elected officials of our opinions.
§ 13.4.1.6 - Notice that when the republicans are in power, more donations are made to republicans. When democrats are in power, more donations are made to democrats.
§ 13.4.1.7 - Notice that liberal groups tend to give more to democrats, but, they still donate to republicans.
§ 13.4.1.8 - Notice that conservative groups tend to give more to republicans, but, they still donate to democrats.
§ 13.4.1.9 - Notice that every member of congress accepts money from at least one of these organizations.
§ 13.4.1.10 - Notice that organizations give more money to politicians with more influence. High on the list of almost every organization are the house and senate leaders and the chairs and ranking members of the various committees that have jurisdiction over health care.
§ 13.4.1.11 - The shear number of lobbyists and the amounts of campaign donations on health care is numbing. The American people must stand up and assume an assertive non-violent voice in this democratic debate. The special interests of the biggest companies and those who spent the most on lobbying efforts will be looked after and the American people will be left with higher price gouging, moderate increases in access to inferior quality care, and continuing decline in the quality of health care services, increased disease, and shorter longevity unless the people speak up. This is, literally, a matter of life and death.
CHAPTER 14
HEALTH CARE PROVIDERS PART ONE: REDUCING COSTS
“In nothing do men more nearly approach the gods than in giving health to men.” - Cicero
§ 14.1.0 TRANSPARENCY
§ 14.1.1 All health providers, physicians, clinics, hospitals, insurance companies, drug companies, health equipment companies must prominently disclose their relationships to other organizations as well as financial interests. If I go to my doctor’s office, I ought to know that he receives $375,000 in research funding from the drug company that makes the drug he wants to prescribe to me. Likewise, all academic, political, and government information ought to contain disclosures on potential conflicts of interest.
§ 14.1.2 I propose that every Congressman, the White House, and senior administrative staff ought to have a page of their web site that posts every donation or donation in kind or promise of future employment within a week as well as tying together each donation to related votes.
§ 14.1.3 The people contact legislators and the White House tens of thousands of times every day expressing their positions on issues up for vote before the congress. I would love to see it required that on each web page, federal politicians and senior administrators summarize statistically the total number of contacts and the positios of the American people.
§ 14.2.0 COLLEGE HEALTH SERVICES TRAINING PROGRAMS
§ 14.2.1 In order to contain expenses and meet growing demand for health providers, educational programs focusing on military, inner cities, rural, geriatric, and pediatric populations are needed.
§ 14.3.0 MALPRACTICE INSURANCE FOR HIGH RISK FIELDS
“In the sick room, ten cents' worth of human understanding equals ten dollars' worth of medical science.” - Martin Fischer
14.3.1 While the need for a federal malpractice insurance program for high risk fields, such as OB-GYN (especially in rural communities) will decrease with effective medical tort law reform, the immediate need for and benefits of such a program is recognized over the next 5 years.
§ 14.4.0 INCREASING PROVIDERS IN UNDERSERVED RURAL COMMUNITIES AND THE INNER-CITIES
§ 14.4.1 What is the one thing that poor farmers from the middle west and minorities in Atlanta have in common? It’s elevated eligibility for public health insurance – Medicaid and Medicare. As it pays far less than costs, doctors are not enticed to locate to these underserved regions. As stated throughout this paper, public insurances must pay on par with private insurances or, at least, cover costs. Increasing payments of lower paid providers will reduce later need for most costly procedures. Imagine a nation in which doctors are motivated to serve the poor in the mid-west, the south, Appalachia, and inner-cities, because they’ll be able to earn a living. A ton educational loans repayment program by the NHSC is charming but it is ineffective in comparison to doing the moral and capitalistic thing, paying competitively for services in underserved regions so that more providers serve there.
§ 14.5.0 FIRST RESPONDER PROGRAMS
§ 14.5.1 Since the first moments following a trauma are most critical, I place great emphasis upon these services. By increasing the speed of first responders and their efforts, there is decreased fire destruction, fewer and less traumatic injuries of civilians. Increased funding for training, equipment, and salaries ought to be provided. Air transport costs 3 times more than land transportation; however, greater use might introduce greater efficiencies, reduce per unit costs, and improve outcomes. First responders’ access to medicines that must be administered in the first moments following a stroke or heart attack must be enhanced. I encourage strong support of first responders and 911 phone centers. All together, I suggest that First Responder Programs will cost an additional $15 B a year. I suggest that increased investment in these programs will save $15 B a year in reduced costs of lost lives, reduced damage, and enhanced safety.
§ 14.5.2 In most cases, the very first responders are family, co-workers, and other members of the community. Given that 1.5 M people have a heart attack or stroke and more than 100 M traumas report to the ER each year, that means that about 1 in 3 of us will suffer a heart attack or stroke in our lifetimes. And, on average, each of us will be a “first responder” who can help another in an emergency countless times across our lifetime. First aid, life saving, CPR, and EHD use ought to be taught to all Americans. This program is elaborated upon elsewhere.
§ 14.6.0 CONTINUING EDUCATION (CEPs)
§ 14.6.1 FHCs ought to provide CEPs for all providers. How do we sift through the information glut? Central authoritative sources would be helpful.
§ 14.6.2 CEPs are increasingly critical as our knowledge base is growing exponentially. CEPS must be more
efficacious.
§ 14.6.3 My wife worked for a non-university business that gave sabbaticals every 5 years. I like the thought of requiring at least a 9 day CEP workshop every 2 years for providers in order for them to “get back into the groove of medical education”.
§ 14.6.4 All providers ought to communicate with a professional group on a daily or weekly basis.
§ 14.7.0 PROVIDER ACCESS TO COST & PATIENT FINANCE INFORMATION
“God heals, and the doctor takes the fee.” - Benjamin Franklin
§ 14.7.1 All providers must review with the patient the prescription, benefits, costs, side-effects, outcomes, exact prices, expected patient compliance behaviors, and review insurance coverage before going on to the next patient. This information ought to be instantly available via IT. By providers and patients researching together and discussing options, costs will decrease. One study found that costs did not decrease when patients were given two options (e.g, surgery or chemotherapy), but, costs did decrease when patients were given three options (e.g., surgery, chemotherapy, or radiation therapy). At that point, it seems, patients began to also consider costs.
§ 14.7.2 Financial insulation of physicians worsens this problem. The multi-millionaire surgeon whom I visit has little concept of the difficulties the person earning minimum wage faces when he orders an $8,000 wheelchair. Even if he knows the cost, 1.6% of his income versus, say, 45% of mine insulates him from my circumstances.
§ 14.8.0 COST SHARING OF PROVIDERS’ MALPRACTICE INSURANCE
§ 14.8.1 If providers had to make a co-payment of even 5% on malpractice insurance for tort awards or settlements, all providers might be motivated to quickly obtain training that rectifies the problem and, hence, they learn more quickly to not repeat errors. Of course, that would then require their participation in the settlement process.
§ 14.8.2 Multiple studies indicate that a small percentage of providers within specialties account for about 80% of patient complaints and litigation. Why? Perhaps, following a patient complaint or lawsuit, those providers ought to undergo a period of supervision, the goal of which is to reduce re-occurrence of medical errors and patient complaints and give that provider up-dated knowledge or patient skills. That’ll reduce medical errors!
§ 14.9.0 PAYMENT FOR STUDENTS & LESS COSTLY PROFESSIONALS
§ 14.9.1 My region has 40% of the physicians we should. So, I welcome NPs and PAs.
§ 14.9.2 Specializations in geriatrics, pediatrics, and psychiatry must increase for NPs and PAs.
§ 14.9.3 Pychopharmacologists and clinical psychologists, with advanced training, could safely and efficaciously prescribe and ought to be permitted to do so by federal legislation covering all states. While highly successful in the military, I suggest that all federal health care programs reimburse for services offered by “less costly professionals” who are licensed in a state and who have completed an authorized prescription program. FHCs might employ these providers.
§ 14.9.4 Government and insurance companies might provide coverage at reduced rates for students’ services in medical, nursing, dental, dental hygiene, allied health schools, and clinical psychology internship programs.
§ 14.9.5 For low-risk, specified pharmaceuticals that patients have received for longer than a year, pharmacists ought to be permitted to prescribe continuing use of those medications, as long as the physician prescribing the drug does not object. This could reduce by millions the number of visits that are needed for physicians.
§ 14.10.0 CONSULTATION BY TECHNOLOGY
§ 14.10.1 - Over one-third of Americans do not have access to a given specialist within an hour’s drive. All Americans ust have access to health professionals through IT. Such consultations and MI services would consist of the rural patient visiting an IT center where a PA or NP meets them, the patient is connected via IT to an eye doctor at Johns Hopkins or a psychiatrist at the University of Pittsburgh, a remote examination is made using the combination of the specialist’s expertise and the PA or NP’s eyes, ears, and hands. MI sessions could be conducted through IT with the local provider only coming back at the end of the session for prescription instructions or re-scheduling. Of course, many consultations could not be carried out in this way. Such sessions will be more costly, sometimes paying for 2 providers plus IT costs, but, these must be covererd in order to assure that Americans in rural communities have access to health care.
§ 14.11.0 OUTSOURCING SOME MEDICAL TECHNOLOGIES
§ 14.11.1 - Many health services must be done close to home. If I have a heart attack or stroke, the first cardiologist I see is probably the one I’ll take. I doubt I’d even question his credentials.
§ 14.11.2 - Some, less time sensitive, procedures can be performed on an outsourced basis at great savings, benefiting from substantially decreased costs in Canada, Mexico, or the Carribbean and benefiting from the use of an economy of scale.
Procedure # % # x % Savings
Heart 4.5 M 20% 0.9 M $4.5 B
Endoscopy 1.5 M 33% 0.5 M $0.5 B
Cesarean Section 1.3 M 25% 0.3 M $1.6 B
Orthopedics 1.3 M 40% 0.5 M $2.6 B
MRIs 10.0 M 25% 2.5 M $2.5 B
4.7 M $11.7 B
§ 14.12.0 BLENDING BEHAVIORAL HEALTH AND PRIMARY CARE
“Our prayers should be for a sound mind in a healthy body.” - Decimus Junius Juvenal
§ 14.12.1 - Studies demonstrate increased positive outcomes, reduced need for medical services, better QOL, reduced
mortality, and substantial savings by integrating medical and behavioral health services within the physical structure of primary care practices and through professional integration of services and fields.
§ 14.12.2 - Now with real-time video feeds on computers, costly psychotherapy offices may become less necessary while also increasing access for rural patients to therapists from around the country.
§ 14.12.3 - I told every patient: “here is my home telephone number, call me anytime you need me, I’d rather you called me at 3 AM than you suffer a crisis by yourself.” I received less than12 calls a year but I was told hundreds of times that, knowing that I cared and was available, it lessened ER visits, psychiatric hospitalizations, and patient distress. Ironically, by trusting patients with my telephone number and to call only in emergencies, it empowered them and they did not abuse it.
§ 14.13.0 REGRESSION TOWARD THE MEAN FOR DOCTOR SALARIES
“Restore a man to his health, his purse lies open to thee.” - Robert Burton
§ 14.13.1.1 - The second most expensive health care related service is physicians. In 2003, physicians’ services cost $539 B, or $700,000 per physician ($1,800 PP). The average fee for a GP visit was $100 whereas the average fee for visiting a specialist was over $200. § 14.13.1.2 - Keep in mind the many provider expenses – a building ($500k), a receptionist ($35k), nurse ($90k), malpractice insurance ($30k), continuing education ($2k), medical records ($30k), billing ($80k), compliance ($50k), and equipment ($250k). Costs will vary by specialty and location, but, we all agree that many physicians face enormous expenses.
§ 14.13.1.3 - While free in most countries, US doctors pay $100,000 - $300,000 for higher education and medical education. Given that higher education is free in most EOCD / European nations, this amounts to a tremendous expense. However, the ROI is equally tremendous.
§ 14.13.1.4 - US doctors earn more than doctors in the other OECD nation, yet they are seen less often than in 22 of 29 other OECD nations.
§ 14.13.1.5 – US physician specialists earn 6.6 x the US GDP PP and US GPs earn 4.2 times the US GDP PP. Other
OECD specialists earn 4.0 times the GDP PP and GPs earn 3.2 times the GDP PP. We pay our typical physician specialist $105,600 more and our typical physician GP $48,000 more than OECD comparisons would suggest may be merited.
§ 14.13.1.6 - US radiologists are paid around $420,000, twice what they are paid in other OECD nations. They’re paid above the trend line for US physicians, as well. Payment reductions would be warranted. Some diagnostic services could be performed anywhere, shipping jobs overseas could reduce costs 40% or $3 B.
§ 14.13.1.7 - The 13,800 orthopedists earn $403,000 and perform 225 procedures each per year, on average.
§ 14.13.1.8 - Cardiovascular surgeons invest significant time in education and training but earn tremendous salaries with little evidence supporting costly procedures. Tenet Health settled out of court on allegations that it performed heart surgeries on healthy patients in order to bill them for the procedure. It couldn’t have been the people who swore by the Hippocratic oath who performed those needless heart surgeries?
§ 14.13.1.9 - Regression of physician salaries to mean and toward salaries of other OECD nations will reduce physician costs substantially. Reduced risk (e.g., lower overhead, malpractice insurance, felt need to practice defensive medicine, and ADMIN) will make most physicians willing to adjust incomes.
§ 14.13.2.1 - I would pay my doctor anything if he could keep me healthy and alive for another 100 years. However, the US has a shorter life expectancy than the other 29 OECD nations by an average of 5 years! 5 years longer lifespan didn’t seem that much when I was 16, but, now, it suddenly means oh so much more. Our infant mortality rate is 72nd according to a WHO study!
§ 14.13.2.2 – Why do our doctors spend less time with US patients? US doctors invest more time in teaching, research, reviewing new products by medicine distributors and product manufacturers.
§ 14.13.2.3 - MOST IMPORTANTLY: US physicians spend 3 times more of their time in ADMIN, billing, and authorization justifications than doctors in other countries with purported paper-pushing addictions. They didn’t teach that in medical school! Reducing administrative demands would free providers to see patients, save money, see 15% more patients thereby reducing growing demand, and vastly improve physicians’ QOL. It seems ironic that opponents to health care change argue that fewer doctors will be available, when, the current bureaucracy imposed by private health insurance companies is greater than that imposed upon physicians in the other 29 OECD nations that practice “socialized medicine” and these private insurers impose more bureaucratic hurdles than Medicare, America’s current public system.
§ 14.13.2.4 - Freeing up one-half of that time would add the equivalent of 75,000 physicians! That would meet the increased need created by covering the uninsured and it would reduce unmet demand by one-half.
§ 14.13.2.5 - Reducing felt need of physicians to practice defensive medicine would increase savings.
§ 14.13.2.6 - GPs look at the whole person, increasing longevity, if only slightly. Need is increasing, but, with salaries averaging $150,000, few medical school graduates enter this desperately needed field. GPs merit more.
§ 14.13.2.7 - US infant mortality is 27th of 30 OECD nations and 72nd in a study by the WHO. The problem is caused by unhealthy lifestyles including SA, lack of prevention information or efforts, insufficiently equipped hospitals for neonatal care, delivery complications, and pediatric diseases. US pediatricians are paid second lowest of all specialties, $145,000, and less than what pediatricians are paid in other OECD nations. We must attract the brightest. Provider payments must be increased significantly in this field, if we really value our children.
§ 14.14.0 DENTIST SALARIES
§ 14.14.1 - US dental care expenditures total $100 B / yr. Ironically, that averages the same gross income as all physicians. US dentists earn significantly higher salaries than dentists in OECD nations and much higher than the US salary trend line would predict. Salary modifications for dentists could reduce expenses.
CHAPTER 15
HEALTH CARE PROVIDERS PART 2: MEETING INCREASED FUTURE DEMANDS
§ 15.1.0 MEETING DEMAND FOR RNs
“For tomorrow belongs to the people who prepare for it today.” – African Proverb
§ 15.1.1 As 7 M in US are unemployed in July 2009, 135,000 nursing positions remain vacant. Capitalism’s not working right here, why? The demand for RNs is estimated at 1 M in next decade. RN salaries, at $62,000 per year are higher than the average B.A. ($52,000) and, they often command higher wages than doctoral psychologists. How can we meet RN demand?
§ 15.1.2 Increase salaries? Since nursing schools can’t increase graduates, traditional supply and demand strategies, such as increasing salary beyond the 19% premium for their degree, are not useful. Some facility administrators see that nursing salaries have increased more than inflation in last 50 years and they’re reluctant to further increase nursing salaries. So, what is restricting the number of RNs available to us?
§ 15.1.3 One problem is very practical. We must offer child or elder care; housing for young nurses without families (especially when first moving to rural communities); and, transportation in bad weather. FHCs might offer some such services.
§ 15.1.4 Some positions will always be difficult to fill (e.g., night nurse at a home for aggressive teens). Offering longer sabbaticals, safer or less stressful working conditions, greater appreciation, and more competitive wages will increase applicants.
§ 15.1.5 RNs enter the field older and retire younger, restricting nurse availability. Why do they retire 5 years younger? By knowing why, we might better meet those needs, and reduce RN demand by 80,000.
§ 15.1.6 RNs are designated caregivers within families, so, they are more likely to care for sickly or elderly family members or grandchildren. By shifting burdens through elder care or child care programs, MI day programs, HHC, HHs, ALFs, NHs, and hospice, we could increase RN availability.
§ 15.1.7 Nursing has great demands, high stress, and too much paperwork. Orders may be barked out leaving nurses to feel underappreciated. IT, sensitivity training, stress management programs, and paperwork reduction might help keep many nurses in the field and reduce turnover rates. Organizational Development interventions might build the sense of teamwork, increase physicians’ respect, and reduce nursing stress.
§ 15.1.8 With women’s liberation since the 1970s, more professional opportunities are available to women who once were essentially restricted to nursing and teaching. Nursing competes now with other professions, medicine, law, clergy.
§ 15.1.9 Programs to recruit more nurses to the field at younger ages might result in nurses staying in the field longer and might result in starting salaries lower than those of older RNs. Programs that combine the senior year of high school with 3 years of college might recruit some students. Condensing 4 year programs into 3 years with summers might recruit some students. Also, condensing NP / MSN programs into 5 years might be beneficial.
§ 15.1.9.1 - Recruitment of male nurses and specializations in geriatrics, pediatrics, and MI are needed.
§ 15.1.9.2 - Programs that feed registered ILs into RN programs could further meet demand.
§ 15.1.9.3 - Recruitment must begin in high schools.
§ 15.1.9.4 - Coordinated recruitment will reduce duplication of nursing shortage studies and recruitment. This is inefficient and these investments could be invested on recruiting nurses.
§ 15.1.9.5 - One nationalized study that addresses the needs of nurses, providers, patients, and colleagues in financial, interpersonal, familial matters, would be more cost-effective and ought to be conducted by one organization such as the Public Health Service (PHS).
§ 15.1.10 - By introducing EMRs, administrative reductions, and automated dispensing, an efficiency of 15% could be realized - the equivalent of 300,000 RNs. While much of the time savings would be spent on improved quality, and reduced medical errors, the financial savings would be only partially realized, perhaps meeting the need for 100,000 nurses.
§ 15.1.11 - A federal nursing school could meet much demand for nurses, hiring master teachers, and broadcast courses globally through IT.
§ 15.1.12 - Payment by third party payers for basic services by nursing students will increase the availability of practica sites, revenues to nursing schools, increase faculty, students, graduates, and nurses.
§ 15.2.0 MEETING DEMAND FOR NURSING SCHOOL FACULTY
“Education is our passport to the future, for tomorrow belongs to the people who prepare for it today.” - El-Malik el-Shabbaz (Malcolm X)
§ 15.2.1 The 1,700 RN programs must increase production of RNs by 15 students per year, each, on average. Most RN programs can not accept qualified applicants due to the shortage of faculty. RN faculty are hard to recruit, as the positions demand more education and offer lower salaries.
§ 15.2.2 Increased faculty salaries are just and needed.
§ 15.2.2.1 - In capitalism, universities would increase nursing faculty salaries; but, that is not happening. Why not?
§ 15.2.2.2 - Many nursing schools are in public, lower salaried, community colleges and teaching colleges. Salaries are not easily increased and depend on government infusion.
§ 15.2.2.3 - This field was “acceptably” underpaid 50 years ago and this bias contributes to reluctance of administrators to increase salaries of nursing faculty today.
§ 15.2.2.4 - Nursing programs are not provided enough resources for costly programs.
§ 15.2.2.5 - Graduates do not provide comparable endowments as do doctors, lawyers, and dentists.
§ 15.2.2.6 - Federal funds must increase salaries of 20,000 nursing faculty by $25,000 a year. This will attract more, better qualified faculty to nursing schools. Funding might remain flat over 15 years, increasing the proportion paid by schools. This would cost about $550 M a year.
§ 15.2.2.7 - There could be a federal mandate that all schools receiving federal loans or funds will increase nursing faculty salaries by $25,000.
§ 15.2.2.8 - Increasing CDC / NIH grants could enhance salaries of grant recipients by $40,000.
§ 15.2.3 Nursing schools might use more adjunct faculty.
§ 15.2.4 Graduates of nursing programs that can produce faculty (master’s and doctoral programs) have decreased. Why? Recruitment shifts or competition?
§ 15.2.5 USE “IT” in nursing education. The very finest nursing professor from the best university could teach a human anatomy class and broadcast it across the globe, augmenting local nursing courses. This would increase efficiencies, consistency, and decrease work demands for local faculty, allowing admission of more students and result in less instructional costs on average per student. Even some lab instruction and testing could be performed on the computer, often with greater precision, optics, detail, options, and decision making queries. Computer access will lead to less but more expeditious use of fewer labs.
§ 15.2.6 The Federal Nursing School might recruit master nursing teachers and provide IT support for global broadcasting.
§ 15.2.7 Insufficient clinical practica sites –
§ 15.2.7.1 - FHCs could provide housing and experience for 40,000 nursing students.
§ 15.2.7.2 - Students can’t afford to travel 40 miles, but, offering travel funds might increase student ability to travel. If a couple thousand dollars is all that stands between a student becoming an RN, I’ll pay the gas money. Programs ought to accommodate 4 -10 hour days.
§ 15.2.8 Nursing remains a female dominated field. Women are more likely to make sacrifices for families and are less likely to re-locate. It sounds anti-feministic, but, male nurses will be more likely to move their families to underserved communities and they ought to be recruited into the field.
§ 15.2.9 I see restrictions in enrollment in all of the best paying health professions leading to escalating increases in wages. The fields without restrictions have seen salaries unchanged or lowered, with escalating educational loans.
§ 15.3.0 MEETING THE DEMAND FOR LPNs
§ 15.3.1 Electronic records could save 1/3 of 15%, $2.5 B, or reduce the need for 47,500 LPNs.
§ 15.3.2 Programs that feed registered IAs into LPN programs could further meet demand.
§ 15.3.3 IT based education would be more efficient and increase the impact of local faculty and increase students.
§ 15.3.4 Median LPN = $39,000 / yr - an excellent ROI.
§ 15.3.5 The projected increased demand for LPNs over the next 10 years is 100,000.
§ 15.3.6 Offer LPNs tax rebates, particularly in underserved rural communities and inner cities.
§ 15.3.7 A federal LPN school could hire master teachers to broadcast courses and labs globally, using IT.
§ 15.3.8 Payment for basic services by LPN students ought to increase the availability of practica, students, faculty, graduates, and LPNs.
§ 15.4.0 MEETING THE DEMAND FOR NURSING ASSISTANTS (NAs)
(1) NAs typically have 2 weeks’ training.
(2) Minimal training increases medical errors.
(3) Medical errors are costly and lethal.
(4) NHs and HHC programs are mostly staffed by NAs.
(5) NA salaries are near minimum wage.
(6) Do I care more about my French fries than my mom?
(7) NA turnover (quitting or firing) is great.
Greater responsibility, education, and salaries are profoundly demanded.
FHCs ought to provide standardized training for NAs of eight weeks’ length (320 hours), followed by a 3 month period of on-site supervision and ongoing FHC classes (4 hrs / wk).
· NA program tuition might be incurred by NAs but paid by employers in exchange for service.
· NA salaries must increase 33% to be competitive; however, that’s not possible with low CMS payments.
· Programs that feed registered IAs into LPN programs could further meet demand.
§ 15.5.0 MEETING THE DEMAND FOR PHYSICIANS
§ 15.5.1 The US has about 80% of the physicians per capita as the average OECD nation. If we were as healthy a people as they are, we would still deserve 25% more doctors, about 175,000. This shortage of physicians might be why they command higher salaries in the US. It might also relate to our 5 years’ shorter life span. Why the shortage? Medical schools are not producing enough physicians. While medical schools must ensure quality standards, the skeptic in me wonders if the bottle hold might be by design to assure a shortage of physicians.
§ 15.5.2 Admission is more competitive at the limited number of US medical schools. As more baby boomers age and more physicians are needed, the federal government might mandate that all schools educate more physicians.
§ 15.5.3 Constriction on physicians is not amenable to salary increases, except in, say, OB-GYN.
§ 15.5.4 Americans see their physicians about 20% less often as citizens from other OECD nations. Given that we have fewer doctors, that seems logical.
§ 15.5.5 Increasing the number of medical school graduates will lead to increased competition and decreased salaries. Keeping the pool of physicians restricted will allow increased fees and income.
§ 15.5.6 Enhancing efficiency is key. By reducing by one half the amount of time that a physician spends on ADMIN, we can increase the availability of 50,000 physicians. IT and similar technologies must be pursued in order to increase efficiency in the practice and at the medical school. Increased use of IT at the medical school will allow for more students, fewer instructional faculty, and less costly education.
§ 15.5.7 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.5.8 Increased payment schedules for GPs would increase its attractiveness over specializations. As it stands now, about 40% become PCPs.
§ 15.5.9 Direct payment incentives for the study of GP would increase their numbers.
§ 15.5.10 - A federal medical school will address much of the unmet demand for physicians that the Uniformed University was intended to fulfill, introducing consistencies, improve quality, greater efficiency, re-allocation of resources. Master teachers could broadcast courses globally with IT support.
§ 15.5.11 - Additional medical schools might be developed in underserved communities BUT special programs must be developed so that internships and residencies are offered in the same underserved communities.
§ 15.5.12.1 - PAs, NPs, and other practitioners might increasingly be utilized, especially in underserved rural communities, inner cities, NHs, hospices, HHs, HHCs, prisons, long term hospitals and training centers, VAMCs, schools, etc. These professionals are easier to recruit and cost one-half to one-fourth the cost of a physician. Of course, physicians are always available for difficult to treat and borderline diagnostic cases. By increasing the production of PAs and NPs, we can reduce the growing need for physicians by two-thirds, at least 100,000. Further, as the payments for services offered by these professionals is $30 less per visit, a savings of $9 B per year would be realized.
§ 15.5.12.2 - I propose that a federal school for PAs and NPs which hires master teachers and broadcasts lessons via satellite would introduce efficiencies. There are presently 140 PA programs and an estimated 850 NP programs. Programs that access these feeds could shift much of the teaching burdens to research, increase the number of students in the programs, and reduce per student costs of instruction.
§ 15.5.12.3 - I propose that the federal government provide $2 million per PA program for infrastructure investments and $4 million per year for operations. I propose that the 140 existing PA programs increase graduates by 10,000 per year. By increasing the average payment for PA services by $5, the average PA salary and benefits package could be increased by $30,000, enough to attract additional students.
§ 15.5.12.4 - I propose that the federal government provide $2 million per NP program for infrastructure investments and $4 million per year for operations. I propose that the 850 existing NP programs increase graduates by 57,000 per year. By increasing the average payment for NP services by $8, the average NP salary and benefits package could be increased by $48,000, enough to attract additional students.
§ 15.5.13.1 - Payment for basic services by medical, NP, and PA students ought to increase the availability of services and they might be reimbursed at lower rates, lowering costs.
§ 15.5.13.2 - PA and NP programs ought to offer specializations for individuals who will locate in rural communities, inner-cities; those who will specialize in fields such as anesthesiology, delivery, pediatrics, geriatrics, prisons, etc. and these programs ought to provide incentives for students who study in these fields and go on to practice in these fields.
§ 15.5.13.3 – A nurse anesthetist’s median pay is $145,000 whereas the anesthesiologist’s median pay is $314,000. This is $170,000 a year less for the nurse anesthetist who can provide many services at half the cost. Psychiatry nurse specialists earn half what psychiatrists earn. Pediatric nurses earn two-thirds what pediatricians earn. Geriatric nurse specialists earn half what geriatricians earn. In many cases, the services of the nurse specialist can be equal to that of the highly trained physician, they often show superior commitment and empathy, and they cost a fraction of what physicians cost. As such, their services ought to be sought for basic care. I would argue that NPs might serve a role in providing care in NHs and other long-term care facilities, prisons, school districts, etc.
§ 15.6.0 MEETING THE DEMAND FOR DENTISTS
§ 15.6.1 Admission is becoming more competitive at the limited number of American dental schools.
§ 15.6.2 Constriction on dentists is not susceptible to salary increases.
§ 15.6.3 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.6.4 A federal dental school will address much of the unmet demand for dentists that the Uniformed University was intended to fulfill. The use of IT programs will introduce consistencies, improve quality, introduce efficiencies, and relocate resources.
§ 15.6.5 Dental hygienists might increasingly be utilized in underserved rural communities, inner cities, NHs, hospices, HHs, HHCs, prisons, long term hospitals, training centers, VAMCs, etc. These professionals are easier to recruit and cost 1/4th the cost of dentists. Of course, dentists are always available for difficult to treat and borderline diagnostic cases.
§ 15.6.6 Payment for basic services by dental hygiene and dental students ought to increase the availability of services and they might be reimbursed at lower rates, resulting in lower costs.
§ 15.7.0 MEETING THE DEMAND FOR ALLIED HEALTH PROFESSIONALS
§ 15.7.1 Admission is more competitive at the limited number of allied health schools.
§ 15.7.2 Constriction on providers is generally not susceptible to salary increases.
§ 15.7.3 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.7.4 A federal allied health professions school will address much of the unmet demand for providers. Use of IT broadcasting globally will introduce consistencies, improve quality, introduce efficiencies, and relocate resources.
§ 15.7.5 Reliance upon assistants (e.g., physical therapy assistants) will increase service and reduce costs.
§ 15.7.6 Payment of basic services by students and doctoral psychology interns ought to increase the availability of services and they might be reimbursed at lower rates, resulting in lower costs.
§ 15.8.0 ACCESSING FOREIGN STUDENTS
§ 15.8.1 Graduates from health sciences universities throughout the world could be tapped to provide services in the US, increasing access to providers at reduced costs.
CHAPTER 16
QUALITY ASSURANCE (QA) IMPROVEMENT “All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.”
- Martin Luther King, Jr.
“Work is love made visible. And if you cannot work with love but only with distaste, it is better that you should leave your work and sit at the gate of the temple and take alms of those who work with joy.” - Kahlil Gibran
§ 16.1.0 QUALITY ASSURANCE (QA): FROM CLERICAL FUNCTIONS TO ADVANCED STRATEGIC ANALYSIS
“Laws are like cobwebs, which may catch small flies, but let wasps and hornets break through.” - Jonathan Swift
§ 16.1.1 Did you use perfect spelling and grammar on your last email? If not, your fine is $100, but, we’ll “review” all 30,000 emails you sent in the last ten years. Ten minutes later, “22,877 are not in compliance. You owe us $2,287,700 immediately. This is fraud and you face criminal prosecution.” This kind of strong armed technique is used to extort billions of dollars from small providers caring for Medicaid patients. This tactic provides Medicaid will billions of dollars, but, it also helps it achieve its other unstated goal. The more health care professionals they put in prison, the fewer health care professionals will tread into the web of providing care for Medicaid patients, and, thus, Medicaid costs are decreased. Gee, I wonder why Medicaid patients can’t get services?
§ 16.1.2 Sadly, the above is what is now called QA. The low payments combined with the increased probability of monitoring for frivolous records transgressions called fraud keeps many providers from accepting public health insurance. Can things change?
§ 16.1.3 Most QA consists of rules assuring compliance with insignificant clerical tasks – putting names on each entry, date and time, name and signature of provider, date (again) next to provider’s signature. Use SOAP format and address each of the 27 goals on pages 14 to 41. If you didn’t dot your “I”, you get paid nothing for that service, even if it had been a $20,000 surgery. Thus, one learns quickly to dot the “I”’s for Medicaid.
§ 16.1.4 For this low quality QA, we pay $50 B a year. Frankly, I don’t care if my dad’s doctor didn’t write the date before his entry AND after his signature. I care that he correctly diagnosed the problem and prescribed logical, helpful medicine and he cares for my dad. QA so often doesn’t even consider these factors.
§ 16.1.5 Imagine an IT system assures mundane punctuation and grammar is satisfied automatically. QA would become more sophisticated. Monitoring, QA could, in real time, examine rates and types of medical errors committed by different practitioners and flag those with high rates, procedures that are ineffectual, assure treatment fidelity, quality decision making, examine relative costs, efficiency, utilization of statistical prediction and decision making models, and appropriate prescriptions. Does a doctor send all patients to the CAT scan clinic in which he is 25% owner? This kind of QA might actually result in health care savings, reductions in medical errors and abuses, and truly enhance quality. Potential fraud could be identified almost immediately.
§ 16.1.6 QA costs will be unchanged, but, technicians and clerical staff will be replaced by IT professionals, economists, and health care professionals. Credit card company security divisions know how to spot possible fraud and we might contract for such services as records become electronic.
§ 16.1.7 By getting on the internet, I can tell you the average salary of graduates across different schools, tuition, room and board, financial aid, quality, and I can devise a formula for selecting the school with the best return for my investment. Yet, I can’t find cogent centralized outcomes or satisfaction data on doctors, PTs, therapists, hospitals, etc. Quality and Outcomes must be made transparent to all consumers up and down the health care “food chain”. As a patient, I ought to receive a form that shows how my doctor’s patients are satisfied with his services compared to other doctors in that specialty or region or state-wide or nation-wide. Wow! If I knew that my patients would see how I compared to my colleagues, in terms of quality or satisfaction, I’d tend to work even harder for them. The use of EMR’s will make this task easy to complete, with daily updates. Transparency of quality and outcomes is ultimately how to get the US health care system to thrive.
§ 16.2.0 SAVINGS THROUGH USE OF ONE SET OF REGULATIONS
“Almost all quality improvement comes via simplification of design, manufacturing ... layout, processes, and procedures.”
- Tom Peters
§ 16.2.1 A single set of procedures, available on-line with prompt customer service could save provider time. Now, providers who accept 20 different forms of patient insurance keep 30 to 60 manuals, with which they are expected to be intimately familiar. When doctors are now working a health care assembly line, they don’t have time to think about the differences in ADMIN regulations. Simplification of these systems by adopting one set of regulations, one set of authorization panels that are tied in to licensing boards would make sense.
§ 16.2.2 I generally have to wait about 20 minutes for an insurance representative to discuss the needs of one of my patients. If insurance companies had to pay providers for wait times, insurance companies would answer their phones immediately. As the current system now exists, providers must employ about twice as many billing managers for the same number of procedures as 2 decades ago, as individual third party payers have each adopted unique procedures required for billing.
§ 16.2.3 I live in one state and I am within a 50 minute drive of 3 other states. I would argue that the functions of a physical therapist are the same whether practicing in one state or another. As the insurance companies want centralization for competition’s sake, I suggest that the federal government ought to regulate all health care services and professions. This would save $15 B per year over the duplication of services by individual states. Individual providers who move from one state to another must re-apply for licensure and re-submit forms, transcripts from 40 years ago, letters of recommendation, at a cost to them of another $10 B per year that would no longer be necessary if the federal government assumed leadership for this function.
§ 16.3.0 BALANCING SPEED WITH QUALITY
§ 16.3.1 Standards of quality of care and efficiency of service must be balanced and ought to be specifically articulated by CMS for all Americans whether they are in private or public programs.
Study after study reveals a troubling pattern. Patients at private clinics or hospital pay more and receive inferior quality of care than patients at public facilities.
CHAPTER 17
PHARMACEUTICALS PROGRAMS
“No amount of experimentation can ever prove me right; a single experiment can prove me wrong.” - Albert Einstein
“It is easy to get a thousand prescriptions but hard to get one single remedy.” - Chinese Proverb
§ 17.1.0 TOP DRUG COMPANIES - NAMES, RANKS, REVENUES & PROFITS
§ 17.1.1 The top 12 drug companies found in the Fortune 500 are listed 2 pages below. Their revenues posted in July 2007 totaled $383 billion and profits totaled $79 billion. Of each dollar they took in, 21 cents was designated “profit”. For each American, they had revenues of $1,276 and profits of $265.
§ 17.1.2 If we compare the profitability of drug companies to the whole of the Fortune 500, we find that they are more than 3 times as profitable as the whole Fortune 500.
§ 17.1.3 If we examine profitability, we see that while the whole of America and many companies have felt the economic recession of 2008-09, the profitability of drug companies remains untouched in a time when the revenues and profits of most Fortune 500 companies are turning to losses.
§ 17.2.0 DOLLARS INSIDE BIG PHARMA
§ 17.2.1 For every dollar that big Pharma receives
§ 17.2.1.1 - It spends only about 15 cents on drug development. Some of these services are provided to satisfy
mundane and outdated requirements of the FDA, some of which are senseless and ought to be removed. Some FDA requirements are essential for the very safety of the American public.
§ 17.2.1.2 - It spends about 30 cents on marketing and ADMIN! Drug representatives monitor which doctors prescribe their medicines and they reward physicians with junkets, novelty items, speaking fees, and research dollars.
§ 17.2.1.3 - 20 cents is spent on shareholder equity, also known as profit.
§ 17.2.1.4 - It spends about 35 cents on production, distribution, and direct ADMIN of these functions. Also, within this 35 cents, drug marketing companies offer very generous programs for patients in need of their medications but who make low or no income.
§ 17.2.1.5 - R&D expenditures of 15 percent is not robust, although for many years the percentage of their budgets devoted to R&D was significant. I’m all for bigger and more profitable pharmaceutical companies! If they’d develop vaccines for cancer, heart disease, MS, Parkinson’s Disease and Alzheimer’s Disease, I’d pay them a bundle. Big Pharma profitability must be done within the budget of Americans while vastly improving longevity and QOL. Greater investments in R&D and less spending on marketing ought to be an objective of all private and public insurance programs.
§ 17.2.1.6 - Marketing and general ADMIN total $115 B a year.
§ 17.3.0 BIG PHARMA LOBBYING
§ 13.1 One report summarized the first quarter spending of Big Pharma lobbying at $126 million (or $504 million a year). That’s its own safety net. After all, what politician who receives $100,000 a year from big Pharma would vote against big Pharma? As for investments in changing the opinions of the public, Big Pharma is spending nearly $1.5 million a day on public advertising while health care reform is being debated.
§ 17.4.0 MEDICATION ERRORS COSTS
§ 17.4.1 One study reported the number of US deaths due to adverse reactions to medications totaled 100,000 and resulted in 2.1 M serious injuries. This estimate did not include prescription errors, accounted for elsewhere. The costs of medication errors to society (death, life insurance, lifetime of lost income, re-hiring and training, changed family dynamics) and the health care system (e.g., surgery, ICU / CCU, lengthened hospitalizations and greater doctor visits) is tremendous.
§ 17.4.2 $320 B in costs from errors when we’re only paying $244 B a year for medications grabs my attention, especially when longevity is still so low. The unknown variable is the costs to society and health care if the medications were not administered.
§ 17.4.3 EMRs will significantly reduce medication errors.
§ 17.4.4 Constant, real time monitoring of medical records would assure faster identification of potential medical concerns and warnings would be issued much faster.
§ 17.5.0 PRESCRIPTION DOSE CHANGE RECOMMENDATION
§ 17.5.1 Dosages ought to be prescribed factoring in the patient’s weight and, perhaps, metabolism, and liver function. The disparities were not all that significant in the 1940s when most every adult weighed between 100 and 200 pounds. Now, the range, with Anorexia and obesity, is 80 to 300 pounds and, when factoring in children, the minimum can decrease to 5 pounds. Once a medication has been successfully introduced, especially those used on a long term basis, monitoring frequency might be reduced.
§ 17.6.0 POLYPHARMACY
§ 17.6.1 As we age and more things go wrong with us, physicians start prescribing us more medications. Isolated specialists that treat diseases instead of whole people can add medicines without checking for possible interactions. As a patient visits multiple specialists over the years, the number of medications builds up. Polypharmacy’s effects are especially prevalent among the elderly, chronically ill, alcoholics, persons with liver disease, and children.
§ 17.7.0 FOOD AND DRUG ADMINISTRATION (FDA)
§ 17.7.1 I introduce several programs for which I urge expansion of FDA authority and monitoring activities that will save Americans and pharmaceutical manufacturers money.
§ 17.7.2 FDA must be granted the authority to regulate generic biological drugs. I’m amazed that biologic drugs have been on the market for 20 years and this is now the first time that I’ve heard that the FDA doesn’t even have a program in place to regulate such drugs. Why did they not develop such a program in the previous 2 decades? Authority ought to be able to be granted by executive order. But, political lobbying is greater with these excessive profits, calculated at $20 B a year.
“Let advertisers spend the same amount of money improving their product that they do on advertising and they wouldn't have to advertise it.” - Will Rogers
§ 17.7.3 FDA ought to regulate direct marketing of drug and health care companies to potential patients, reducing “demand created advertising”, through imposing fees in combination with regulation.
“Advertisers in general bear a large part of the responsibility for the deep feelings of inadequacy that drive women to psychiatrists, pills, or the bottle.” - Marya Mannes
§ 17.7.4 Approved medications or procedures in some other nations ought to be considered class B. Americans ought to be allowed to purchase these products, provided the items have satisfied a lowered threshold of safety and information is openly provided to potential US consumers. US doctors might provide class B procedures or prescriptions for patients who provide informed consent, especially when they face chronic, debilitating, or terminal illnesses. Federal agencies will provide assistance to assure narcotics and drugs are not distributed. This will provide US patients with more alternatives and reduce costs of some items.
§ 17.7.5 Drug development costs are borne by US but must be shared with OECD nations. By partnering companies and nations to invest in drug development, we could increase efficiencies, accessibility, quicken development time, and increase treatments. We must permit a streamlined review process. If drug development costs were limited to only money, that would be nice. Some costs include the lives of Americans.
§ 17.7.6 FDA should regulate disclosure laws for providers and service associations. Before allowing one’s neurologist to prescribe “x” drug, one ought to be informed that the doctor receives a $375,000 a year research grant from that company.
§ 17.7.7 FDA ought to require / fund long term studies of safety, efficacy, side-effects, and interactions. The use of an electronic medical records system could make such studies inexpensive.
§ 17.8.0 CENTRALIZED PHARMACY & HEALTH CARE PURCHASING CENTER
§ 17.8.1 The US spends (in 2003) $752 per person on medication, $3,008 for a family of four, and twice the OECD average.
§ 17.8.2 At $244 B (in 2003), it’s the third biggest part of health care. Still, we die young.
§ 17.8.3 The US pays more than other OECD nations for same medicines, partly to pay for development.
§ 17.8.4 A centralized pharmacy could negotiate competitive, fair prices with each drug manufacturer. In English, the process of negotiating fair prices is a critical part of what is called capitalism.
§ 17.8.5 An economy of scale would add to savings.
§ 17.8.6 If the US spent only half more than other OECD nations, we would save $60 B a year.
§ 17.8.7 This could be managed, through bid-contract, by a health insurance company or pharmacy.
§ 17.9.0 DOCTORS NEED UNBIASED INFORMATION ON DRUGS
§ 17.9.1 American doctors spend much more time evaluating drugs’ effectiveness and potential dangers than do physicians from other OECD nations. Part of the reason is that we get the latest products whereas those in other OECD nations get more “proven” products and benefit from our experimentation. Doctors must individually read and examine research studies on drug benefits provided to them by the drug companies themselves. Even with tremendous levels of oversight by FDA, doctors have marginal confidence in the results of these studies. Unbiased, trustworthy articles providing information on drugs studied by objective researchers must be available. The “objective” research of drug developers, academicians, and physicians with financial interests in the drug are not as likely to induce confidence.
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