Author: the holy handgrenade

The question I hold tonight is: Shall we? Can we possibly reach and maintain peace?

I don’t know…..but sometimes it’s hard to be optimistic….

Cross posted at Daily Kos

What I do know is that peace cannot exist without two things: love and respect.

If we cannot respect those who are different than us, we cannot be at peace with them. Far too many of us find it too easy to fall into the trap of dehumanizing those who are different, an attempt to justify our lack of respect for them. We find it too easy to drag out those terms that denigrate others. Too easy to call someone a “fag”, a “nigger”, a “kike”, a “bitch”, whatever…

I know that I grew up falling into that trap far more often than I would like to admit. I would like to think that I have grown up, that I have learned something in my life to know how wrong this is, that the we as a people have learned how wrong this is, yet…I still hear the words of my father, when he said to me; just this past Tuesday; that his “neighborhood is being overrun by niggers”…

I was appalled. I wanted nothing more than to scream in his face, to ask him if he has learned nothing from life. Instead, I found myself rationalizing his behaivor by blaming his generation, by blaming the way he was brought up. But, I was brought up by him, so how do I know that this is wrong and he doesn’t?

Has he not learned to respect people, to treat everyone as a human being deserving of respect, regardless of what makes them who they are?

Apparently not…

Now, I look down at my baby girl, hoping that she will not learn this hatred from him, that she will learn to love her fellow beings, that someday, she can carry on the mission of peace between the races, and eventually peace between the nations…

It is obvious that those who currently run our country have not learned to respect others. They wage wars, illegal wars, wars based on greed and hatred, claiming to spread democracy throughout the world. Yet, how can we force our ideals on others and call it a mission of freedom? How can freedom come from the barrel of a scared kid’s M16; a kid who is being taught not to respect those whose country he’s “fighting for”?

I find myself boiling over with hatred for those in power, this administration. Does this make me less of a human being? Can I be someone who hopes for peace, yet feels hatred towards my fellow humans, even if they are evil to the core? Am I rationalizing my hatred the way a racist, a sexist, a homophobe rationalizes their hatreds? I would like to believe the answer is no, but how can I be sure….

So, I find that, while I believe we should respect eachother, at the same time, I find that this may not be possible in all cases.

But what about love?

Isn’t love powerful enough to move us forward, to bring about peace?

I sure as hell hope so, ’cause right now, it seems like all I got to give….

Today’s column will focus on possible reductions to the Medicaid roles in North Carolina, hospital closings, the uninsured and core blood collections.

(more below the flip)

First up Today is an item from The News and Observer, out of the Raleigh/Durham region of North Carolina, titled 57,000 Might Lose Medicaid Benefits. In an effort to meet state budget requirements, the North Carolina Department of Health and Human Services has proposed a Medicaid budget that would lower the income levels that are used to determine Medicaid eligibility.

The budget also imposes a freeze on reimbursement levels for hospitals and physicians, as well as nursing homes and pharmacies.

These cuts would focus on the dual eligible Medicaid recipients (those eligible for Medicare as well as Medicaid). These members would lose access to services that Medicaid traditionally covers the Medicare co-insurance amounts, such as home nursing services and, in the case of younger, disabled recipients, their prescription coverage.

United HealthCare Posts Strong Earnings from Higher Premiums

The next item is one that I find more than just a bit troubling (as someone who deals with managed care payers on a daily basis). It is illustrative of the current trend in managed care in the healthcare industy.

In an article titled UnitedHealth Profit Up on Higher Premiums, Yahoo indicates that United HealthCare (UHC) has reported a 41% increase in first quarter earnings, far exceeding expectations. The profits are based on UHC’s increased premiums and cost cutting.

The reason I find UHC’s profits troubling is due to their current negotiation strategy with physician groups. UHC has taken the tactic that any non-participating provider will not be paid directly, instead sending payment to the member. This creates a difficult situation for both the provider and the patient and is used as a strong arm to force providers into participation status. A participation status that is usually accompanied with sub-par reimbursement rates.

UHC’s negotiation tactics, coupled with their recent purchases of Oxford Health and MAMSI (a large managed care payor in Maryland),  have put providers at a distinct disadvantage, creating cash losses that are generally shifted to other charge paying payors and the uninsured population.

It is disturbing to think the United HealthCare is reaping great rewards at the expense of providers, their members and patients unaffiliated with UHC.

Shifting Burden of Uninsured ER Care

The next item for today is an article from the LA Times titled Study Sees Shift in ER Care. A report by the National Health Foundation reviewed the trends in uninsured emergency department visits in Los Angeles County for the five year period of 2000 – 2005. The report indicates that, while insured care at the four county public hospitals has dropped by 27% during the sample period, the number of uninsured patients treated at private hospitals jumped by a third. This shift from non-profit public hospitals to for-profit private hospitals is a major factor in the closure of nine private emergency departments in LA County during the last few years.

The study also indicates that more than 2 million LA County residents are currently without health insurance, falling mainly in the 19-64 year old demographic. This is one of the highest percentages of uninsured versus overall population of a major metropolitan area in the country. Many of the uninsured in LA County are employed, just with jobs that do not provide healthcare, or cannot afford the premiums for healthcare their employers are offering.

GOP Turning on Bush’s Medicaid Cuts

In a Yahoo article titled House GOP Balk at Size of Medicaid Cuts. In what is a welcome surprise, 44 GOP reps feel that the Medicaid cuts put forth by Bush’s budget proposal are excessive.

Considering the dire situation that most state’s Medicaid programs are facing, it is refreshing to see that both sides of the floor are prepared to fight the Bush administration’s attempts to gut the program.

The money quote in the article comes from Nancy Pelosi:

The final budget will most likely contain some level of cuts to Medicaid funding. Hopefully a bi-partisan effort can prevent a catastrophic dismantling of the system.

Call for Federal Program Overseeing Use of Cord Blood

Finally, we have an article from the NY Times titled Group Calls for U.S. Program to Oversee Use of Cord Blood. A call for a new federal program to oversee the promotion and use of umbilical cord blood (a by-product of healthy childbirth) has been made by Congress’s main medical advisory group. As opposed to trying to explain cord blood usage myself, I’ll defer to the text of the article:

The recommendation is for another 100,000 units to be harvested. The main stumbling block of this effort is the high cost of the collection process, about $1,100 per unit collected. Of course, many insurers will not cover this process (speaking from experience here, I paid out of my own pocket to have this done when my daughter was born almost five years ago). Many samples collected currently are stored solely for the private use of the infant’s family (as are the samples collected in my case).

The goal is to create a public bank of cell samples, much like the current blood bank system. This is an issue that I will be watching very closely, especially considering the current administration’s stance on embryonic stem cell collection.

More Below the Fold.

The cuts were originally halted by a decision by a federal judge in Nashville. That decision has since been overturned by the 6th US Circuit Court of Appeals. The courts have yet to determine the methodology for removing these recipients from the system, as well as, how these recipients will be notified of their new-found ineligibility.

It is well documented that the TennCare program (one of the finest Medicaid programs in the country) has put a tremendous strain on Tennessee’s annual budget, but I can’t help but feel that dropping over 300,000 state residents into the realm of the uninsured will be anything but catastrophic.

Next up is an article from the Washington Post regarding poor disciplinary response to DC area physician misconduct entitled D.C. Council Hearing Planned on Oversight of Doctors. The DC city council is planning a hearing to review the DC Board of Medicine’s response to physician misconduct within the city’s medical community. The council’s review of the board’s disciplinary actions indicated that there are more than a dozen physicians whom had not been suspended or reprimanded in DC while having received disciplinary action in Maryland or Virginia for sexual misconduct, criminal convictions or questionable medical practices.

Councilman David Catiana is leading the charge in this investigation.

The result of this type of lack of oversight is an across the board spike in malpractice premiums, as opposed to charging more to those who have blemishes on their records. This causes those physicians who practice in good faith to pay higher overhead costs to remain in practice in the DC metropolitan area, which are then passed on to the consumer (patients), many of whom are part of DC’s very large uninsured population.

Next up is an article from the New York Times entitled Hospital Business in New York Braces for a Crisis. This article outlines the chilling situation regarding hospital availability in New York. In the last 27 months, 12 New York hospitals have closed their doors, with many others shutting down wings and non profitable departments. Many of the facilities in financial danger suffer due to low Medicaid rates in the state and traditionally poor paying managed care payers who have made NY their stomping grounds (HIP, GHI, etc).

What this means is that in due time, there will be a shortage of available facilities in areas where their services are more greatly needed. When a hospital closes its doors, along with it goes the emergency department. When a community loses an emergency department, wait times and quality of care suffer at the remaining facilities.

The main reason why I am personally concerned by this trend in New York is that it will also become an issue in other areas of the country, due in part to the expected Medicare and Medicaid cuts, as well as, the ever growing uninsured population.

I am finding it more difficult to dismiss the doom and gloom crowd in regards to the latest impending emergency healthcare crisis.

Physicians of all specialties can expect Medicare payment rate decreases of 5% per year, beginning in 2006 and continuing until 2013, creating a decrease in excess of 30% by the end of this period.

As the focus of my experience is in emergency medicine, I will only provide my analysis of the effects of the impending cuts on that aspect of medical care.

In a normal emergency department, approximately 20% of the patient volume is comprised of Medicare recipients. This percentage is significantly higher in areas with larger Medicare populations (Florida, New York, California and Arizona). While a cut to payments for 20% of the patient population may not seem to be a catastrophic loss, it must be taken into account the effect these cuts will have on reimbursement for the remaining 80% of the patient volume.

Managed Care Patients Affected

Many managed care insurance carriers (Aetna US Healthcare, United Healthcare, Cigna, Oxford, Humana, etc) base their reimbursement rates on a percentage of the Medicare rates. These percentages will vary by market and negotiations on behalf of the physicians, but generally run between 110% and 160% of the Medicare rates. It must be understood that, unlike the Medicare program, participation in these plans in normally voluntary for emergency physicians.

While voluntary in the technical sense, participation is a way of life for emergency providers because of the tactics employed by these payers. Because only a handful of states have enacted mandatory assignment laws (laws designed to force insurance carriers to pay physician fees directly to the provider as opposed to paying the patient), many carriers will pay non-participating provider’s claims to the patient, forcing the physicians (or their billing agents) to exhaust valuable resources in chasing the payment down from the patient.

What all this means is that, the cuts in Medicare payment rates will also result in drops in payments by managed care plans. This would normally account for an additional 20-25% of the patient volume in an average hospital emergency department, bringing the total impacted patient base to 40-45%.

Other Payers Impacted

Along with the hits to the Medicare and managed care patient base, emergency providers will also see reductions in other government and regulatory payer payments. Among those would be claims for recipients of Tricare (Champus), which is the benefit plan for retired military personnel and their families. Champus payments are based on the Medicare fee schedule and will be cut as well. Unlike managed care plans, emergency physicians will not opt out of Champus participation, as this would mean no payment at all.

It is also quite possible that many states will follow the Medicare fee reductions and reduce fee schedules for the state run Medicaid programs.

Probably the biggest area of concern for emergency providers in regards to these cuts is the various Blue Cross/Blue Shield plans throughout the country. Many BCBS carriers base their reimbursement on the Medicare rates and are not open to negotiation with providers for premium fees. Much like managed care plans, non-participation in BCBS plans means that the patients will be paid directly, creating a burden on the patient and a politically difficult situation for the provider of service.

How This Effects You

I can imagine that many who have read this far are thinking “That sucks for the emergency healthcare providers, but, how does this affect me and why should I care?”…

These cuts to Medicare payment rates will be felt by anyone who wanders into an emergency room. Many providers will be forced to terminate participation with plans that follow Medicare reimbursement methodology to offset the losses that can not be avoided in the Medicare population. This will result in higher out of network co-pays and deductibles for members of these plans, or payments being made directly to the patient.

Emergency room physicians will also be forced to seek alternate sources of revenue to offset losses brought on by the cuts. This is usually done in the form of higher fees charged for services rendered. The higher fees will not increase revenue from Medicare or payers using Medicare as their basis for payment. Those directly affected by the increased fees will be those without insurance, the self-pay population, those that normally cannot afford the already pricey services in the first place.

Increases in emergency physician fees will be analyzed by insurance carriers when they review what they charge for member premiums. This is one of the many factors carriers take into account when determining what to charge their members for coverage. Which is why you’ll see your BCBS premiums increase, while reading that your local BCBS carrier is carrying surpluses in the tens of millions of dollars (see Carefirst in Maryland and Highmark in Pennsylvania). It is a dangerous catch-22 that leaves the patient in the middle.

Conclusion

While many may not be sympathetic to the “plight” of emergency physicians, it must be taken into account that, unlike pretty much every other specialty, emergency room physicians cannot turn a patient away based on their ability to pay or what type of insurance coverage they have. So while primary care physicians can limit the number of new Medicare patients they treat each year, ED physicians do not have that luxury. ED physicians also pay among the highest premiums for malpractice insurance (along with OBGyns) as well as serving what may be the most grueling aspect of the medical community.

One must also remember, during the seven year duration of these cuts, emergency physician practice expenses are expected to rise at a rate of 3-5% per year, based on recent history.

Please bear in mind that the statements and figures above are based on my years of experience in emergency physician billing, from many aspects of the process. I have worked in accounts receivables, regulatory affairs and managed care contract negotiations.

I’m not sure what the solution is, outside a complete revamp of the payment system…