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Duke Professor's Analysis of HR 3200

(HT to Shawn Floyd)

This following is authored by John David Lewis, a visiting associate professor of politics, philosophy and economics at Duke University. Here is his analysis.

What does the bill, HR 3200, short-titled ‘‘America’s Affordable Health Choices Act of 2009,” actually say about major health care issues? I here pose a few questions in no particular order, citing relevant passages and offering a brief evaluation after each set of passages.

This bill is 1017 pages long. It is knee-deep in legalese and references to other federal regulations and laws. I have only touched pieces of the bill here. For instance, I have not considered the establishment of (1) “Health Choices Commissio0ner” (Section 141); (2) a “Health Insurance Exchange,” (Section 201), basically a government run insurance scheme to coordinate all insurance activity; (3) a Public Health Insurance Option (Section 221); and similar provisions.

This is the evaluation of someone who is neither a physician nor a legal professional. I am citizen, concerned about this bill’s effects on my freedom as an American. I would rather have used my time in other ways—but this is too important to ignore.

We may answer one question up front: How will the government will pay for all this? Higher taxes, more borrowing, printing money, cutting payments, or rationing services—there are no other options. We will all pay for this, enrolled in the government “option” or not.

....

1. 1. WILL THE PLAN RATION MEDICAL CARE?

This is what the bill says, pages 284-288, SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS:

‘(ii) EXCLUSION OF CERTAIN READMISSIONS.—For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.

and, under “Definitions”:

‘‘(A) APPLICABLE CONDITION.—The term ‘applicable condition’ means, subject to subparagraph (B), a condition or procedure selected by the Secretary . . .

and:

‘‘(E) READMISSION.—The term ‘readmission’ means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.

and:

‘‘(6) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of— . . .

‘‘(C) the measures of readmissions . . .

EVALUATION OF THE PASSAGES:

1. This section amends the Social Security Act

2. The government has the power to determine what constitutes an “applicable [medical] condition.”

3. The government has the power to determine who is allowed readmission into a hospital.

4. This determination will be made by statistics: when enough people have been discharged for the same condition, an individual may be readmitted.

5. This is government rationing, pure, simple, and straight up.

6. There can be no judicial review of decisions made here. The Secretary is above the courts.

7. The plan also allows the government to prohibit hospitals from expanding without federal permission: page 317-318.

2. Will the plan punish Americans who try to opt out?

What the bill says, pages 167-168, section 401, TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE:

‘‘(a) TAX IMPOSED.—In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of—

(1) the taxpayer’s modified adjusted gross income for the taxable year, over

(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer. . . .”

EVALUATION OF THE PASSAGE:

1. This section amends the Internal Revenue Code.

2. Anyone caught without acceptable coverage and not in the government plan will pay a special tax.

3. The IRS will be a major enforcement mechanism for the plan.

3. what constitutes “acceptable” coverage?

Here is what the bill says, pages 26-30, SEC. 122, ESSENTIAL BENEFITS PACKAGE DEFINED:

(a) IN GENERAL.—In this division, the term ‘‘essential benefits package’’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security . . .

(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:

(1) Hospitalization.

(2) Outpatient hospital and outpatient clinic services . . .

(3) Professional services of physicians and other health professionals.

(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care . . .

(5) Prescription drugs.

(6) Rehabilitative and habilitative services.

(7) Mental health and substance use disorder services.

(8) Preventive services . . .

(9) Maternity care.

(10) Well baby and well child care . . .

(c) REQUIREMENTS RELATING TO COST-SHARING AND MINIMUM ACTUARIAL VALUE . . .

(3) MINIMUM ACTUARIAL VALUE.—

(A) IN GENERAL.—The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).

EVALUATION OF THE PASSAGES:

1. The bill defines “acceptable coverage” and leaves no room for choice in this regard.

2. By setting a minimum 70% actuarial value of benefits, the bill makes health plans in which individuals pay for routine services, but carry insurance only for catastrophic events, (such as Health Savings Accounts) illegal.

4. Will the PLAN destroy private health insurance?

Here is what it requires, for businesses with payrolls greater than $400,000 per year. (The bill uses “contribution” to refer to mandatory payments to the government plan.) Pages 149-150, SEC. 313, EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE

(a) IN GENERAL.—A contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to 8 percent of the average wages paid by the employer during the period of enrollment (determined by taking into account all employees of the employer and in such manner as the Commissioner provides, including rules providing for the appropriate aggregation of related employers). Any such contribution—

(1) shall be paid to the Health Choices Commissioner for deposit into the Health Insurance Exchange Trust Fund, and

(2) shall not be applied against the premium of the employee under the Exchange-participating health benefits plan in which the employee is enrolled.

(The bill then includes a sliding scale of payments for business with less than $400,000 in annual payroll.)

The Bill also reserves, for the government, the power to determine an acceptable benefits plan: page 24, SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

5 (a) IN GENERAL.—A qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage.

EVALUATION OF THE PASSAGES:

1. The bill does not prohibit a person from buying private insurance.

2. Small businesses—with say 8-10 employees—will either have to provide insurance to federal standards, or pay an 8% payroll tax. Business costs for health care are higher than this, especially considering administrative costs. Any competitive business that tries to stay with a private plan will face a payroll disadvantage against competitors who go with the government “option.”

3. The pressure for business owners to terminate the private plans will be enormous.

4. With employers ending plans, millions of Americans will lose their private coverage, and fewer companies will offer it.

5. The Commissioner (meaning, always, the bureaucrats) will determine whether a particular network of physicians, hospitals and insurance is acceptable.

6. With private insurance starved, many people enrolled in the government “option” will have no place else to go.

5. Does the plan TAX successful Americans more THAN OTHERS?

Here is what the bill says, pages 197-198, SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS

‘‘SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

‘‘(a) GENERAL RULE.—In the case of a taxpayer other than a corporation, there is hereby imposed (in addition to any other tax imposed by this subtitle) a tax equal to—

‘‘(1) 1 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $350,000 but does not exceed $500,000,

‘‘(2) 1.5 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $500,000 but does not exceed $1,000,000, and

‘‘(3) 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000.

EVALUATION OF THE PASSAGE:

1. This bill amends the Internal Revenue Code.

2. Tax surcharges are levied on those with the highest incomes.

3. The plan manipulates the tax code to redistribute their wealth.

4. Successful business owners will bear the highest cost of this plan.

6. 6. Does THE PLAN ALLOW THE GOVERNMENT TO set FEES FOR SERVICES?

What it says, page 124, Sec. 223, PAYMENT RATES FOR ITEMS AND SERVICES:

(d) CONSTRUCTION.—Nothing in this subtitle shall be construed as limiting the Secretary’s authority to correct for payments that are excessive or deficient, taking into account the provisions of section 221(a) and the amounts paid for similar health care providers and services under other Exchange-participating health benefits plans.

(e) CONSTRUCTION.—Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.

EVALUATION OF THE PASSAGES:

The government’s authority to set payments is basically unlimited. The official will decide what constitutes “excessive,” “deficient,” and “efficient” payments and services.

7. Will THE PLAN increase the power of government officials to SCRUTINIZE our private affairs?

What it says, pages 195-196, SEC. 431. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES.

‘‘(A) IN GENERAL.—The Secretary, upon written request from the Health Choices Commissioner or the head of a State-based health insurance exchange approved for operation under section 208 of the America’s Affordable Health Choices Act of 2009, shall disclose to officers and employees of the Health Choices Administration or such State-based health insurance exchange, as the case may be, return information of any taxpayer whose income is relevant in determining any affordability credit described in subtitle C of title II of the America’s Affordable Health Choices Act of 2009. Such return information shall be limited to—

‘‘(i) taxpayer identity information with respect to such taxpayer,

‘‘(ii) the filing status of such taxpayer,

‘‘(iii) the modified adjusted gross income of such taxpayer (as defined in section 59B(e)(5)),

‘‘(iv) the number of dependents of the taxpayer,

‘‘(v) such other information as is prescribed by the Secretary by regulation as might indicate whether the taxpayer is eligible for such affordability credits (and the amount thereof), and

‘‘(vi) the taxable year with respect to which the preceding information relates or, if applicable, the fact that such information is not available.

And, page 145, section 312, EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND DEPENDENT COVERAGE:

(3) PROVISION OF INFORMATION.—The employer provides the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements of this section.

EVALUATION OF THE PASSAGE:

1. This section amends the Internal Revenue Code

2. The bill opens up income tax return information to federal officials.

3. Any stated “limits” to such information are circumvented by item (v), which allows federal officials to decide what information is needed.

4. Employers are required to report whatever information the government says it needs to enforce the plan.

8. 8. Does the plan automatically enroll Americans in the GOVERNMENT plan?

What it says, page 102, Section 205, Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan:

(3) AUTOMATIC ENROLLMENT OF MEDICAID ELIGIBLE INDIVIDUALS INTO MEDICAID.—The Commissioner shall provide for a process under which an individual who is described in section 202(d)(3) and has not elected to enroll in an Exchange-participating health benefits plan is automatically enrolled under Medicaid.

And, page 145, section 312:

(4) AUTOENROLLMENT OF EMPLOYEES.—The employer provides for autoenrollment of the employee in accordance with subsection (c).

EVALUATION OF THE PASSAGES:

1. Do nothing and you are in.

2. Employers are responsible for automatically enrolling people who still work.

9. 9. Does THE PLAN exempt federal OFFICIALS from COURT REVIEW?

What it says, page 124, Section 223, PAYMENT RATES FOR ITEMS AND SERVICES:

(f) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.

And, page 256, SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

‘‘(C) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting—

‘‘(i) the identification of a county or other area under subparagraph (A); or

‘‘(ii) the assignment of a postal ZIP Code to a county or other area under subparagraph (B).

EVALUATION OF THE PASSAGES:

1. Sec. 1123 amends the Social Security Act, to allow the Secretary to identify areas of the country that underutilize the government’s plan “based on per capita spending.”

2. Parts of the plan are set above the review of the courts.

(Originally posted on Southern Appeal)

Comments (36)

"3. The government has the power to determine who is allowed readmission into a hospital."

My head just exploded. The person needing readmission will be treated. The hospital doing an unacceptable number of early discharges will eat the cost. This has nothing to do with rationing and everything to do with bean counting. The good professor should stick to his classics.

Here is the full subsection,

" `(4) AGGREGATE PAYMENTS, EXCESS READMISSION RATIO DEFINED- For purposes of this subsection:

`(A) AGGREGATE PAYMENTS FOR EXCESS READMISSIONS- The term `aggregate payments for excess readmissions' means, for a hospital for a fiscal year, the sum, for applicable conditions (as defined in paragraph (5)(A)), of the product, for each applicable condition, of--

`(i) the base operating DRG payment amount for such hospital for such fiscal year for such condition;

`(ii) the number of admissions for such condition for such hospital for such fiscal year; and

`(iii) the excess readmissions ratio (as defined in subparagraph (C)) for such hospital for the applicable period for such fiscal year minus 1.

`(B) AGGREGATE PAYMENTS FOR ALL DISCHARGES- The term `aggregate payments for all discharges' means, for a hospital for a fiscal year, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such fiscal year.

`(C) EXCESS READMISSION RATIO-

`(i) IN GENERAL- Subject to clauses (ii) and (iii), the term `excess readmissions ratio' means, with respect to an applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of--

`(I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to the applicable period; to

`(II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period.

`(ii) EXCLUSION OF CERTAIN READMISSIONS- For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.

`(iii) ADJUSTMENT- In order to promote a reduction over time in the overall rate of readmissions for applicable conditions, the Secretary may provide, beginning with discharges for fiscal year 2014, for the determination of the excess readmissions ratio under subparagraph (C) to be based on a ranking of hospitals by readmission ratios (from lower to higher readmission ratios) normalized to a benchmark that is lower than the 50th percentile."

This makes it obvious that the Section is about financial sanctions not rationing.

`"(7) MONITORING INAPPROPRIATE CHANGES IN ADMISSIONS PRACTICES- The Secretary shall monitor the activities of applicable hospitals to determine if such hospitals have taken steps to avoid patients at risk in order to reduce the likelihood of increasing readmissions for applicable conditions. If the Secretary determines that such a hospital has taken such a step, after notice to the hospital and opportunity for the hospital to undertake action to alleviate such steps, the Secretary may impose an appropriate sanction."

**How will the government will pay for all this? Higher taxes, more borrowing, printing money, cutting payments, or rationing services—there are no other options. We will all pay for this, enrolled in the government “option” or not.**

Liberalism (also 'Progressivism'): a political/economic system in which virtue is seen as the ability/desire to spend the money of others on various causes and programs, and to deem these programs successful based on their intent rather than their results.


This makes it obvious that the Section is about financial sanctions not rationing.

I suggest my fellow commentators and readers read that sentence from our commentator Al again. Go on. Read it again. Heck, Al, _you_ read it again. Simply amazing. This is about financial sanctions not rationing. I just love it. Right: Punishing the hospital for readmitting people "too often" for a given condition has no relation to rationing. Because, you know,

The hospital doing an unacceptable number of early discharges will eat the cost.

Well, no, it's the hospital doing an unacceptable number of readmissions. That's why, y'know, they call it "excess readmissions." Of course, you can't get a readmission without a discharge, but if they just treat the person from home rather than readmitting him, even if readmitting would have been medically indicated, they can avoid having excess readmissions. This isn't exactly rocket science. It's creating an incentive to the hospital to ration readmissions and to think of the patient in relation to the aggregate.

But why am I explaining that to Al? I explained it already in another thread. I've never yet see Al admit that he was wrong, even when evidence was given. But it's an interesting insight into the liberal mindset. The liberal thinks the government can punish hospitals for treating too many people in some particular context, but this has nothing to do with rationing!

Pearls before swine Al. These folks are happy in their paranoia and ignorance.

This makes it obvious that the Section is about financial sanctions not rationing.

Let's apply that to the Soviet supermarket: it's obvious that the lack of bread in the aisle is absent for a financial reason and not because of rationing. Here's the problem, Al: rationing is the final cause, not the efficient cause. It reminds me of that old Steven Wright joke:

Policeman: Why were you speeding?
Wright: My foot was to the floor.

Of course, the policeman was looking for a final cause while Wright gave him an efficient one. But both can be present in the same event. In the same way, financial necessities are the efficient cause while rationing is the final cause.

To employ yet another analogy: I ask you why Jane is so skinny and you say, "because she burns more calories than she takes in." But suppose I followed up and asked, "But why is that?" You could answer in one or two ways. One way could be, "That's how our anatomy works." Another could be, "Jane wants to be skinny." In the same way, "financial sanctions" and "rationing" are complementary causal accounts of the same event. They are not rivals.

Frank:

The point you've made about "complementary causal accounts" is applicable to a wide range of philosophical and theological issues. E.g., in the evolution debate, one can affirm genetic mutation/natural selection in terms of efficient causation while also affirming telic guidance of the same process in terms of divine intent. On the filioque issue with the Orthodox, one can affirm that the Father is the sole efficient cause of the Spirit's procession while also affirming the Son as final cause, i.e. he for the sake of whom the Father as Father breathes forth the Spirit.

Best,
Mike

Mike:

Thanks for your comments. In fact, I'm working on an article for the St. Thomas Journal of Law & Policy entitled, "How to Be Anti-Design Advocate." It's modeled after Al Plantinga's famous "How to Be an Anti-Realist." One of my criticism of the ID folks is that they see final causes as rivals to efficient causes. That, I believe, is Paley's fallacy. More later.

Frank

Badger:

Pearls before swine Al. These folks are happy in their paranoia and ignorance.
lol are you serious, or are you just playing dumb? Al just spent about 60 lines saying that cutting off funding for re-admissions is allowing those re-admissions.

Do you also think that if I cut off the air to your lungs by holding your mouth and nose, I'm still allowing you to breathe? After all, you could get air by other means, like cutting a hole in your throat.

"Your Honor, I was still allowing him to breathe, just not by the only viable way of breathing. Get it?"

Lydia and Frank,

Thank you, thank you, thank you for pointing out to Al that he is deeply confused about public policy and how scare resources are allocated. My favorite Al quote came from the infamous Liberty Counsel post in which he said the following:

"We have three things going on here; folks who want a more rational system of health care, folks who see problems, real or imagined, and a political party that is willing to lie, cheat, and steal in order to regain power even if their actions render the nation ungovernable."

The key behind Al's thinking (and my guess is President Obama and many of the well-meaning technocrats working for him) is this idea that Al is on the side of the angels because he wants "a more rational system of health care". This is the dream behind all collectivist thinking and reminds me of the classic old story about the visiting Soviet official to the U.S. who walked into multiple bakeries full of bread and asked his hosts who made all the decisions to bake the bread. The Americans responded that it wasn't anyone's individual responsibility but left up to the individual bakery owners to decide how much to bake. The Soviet official was incredulous because he couldn't imagine a system that was "rational" being left up to the decentralized decisions of free individuals.

My head just exploded.

You should go to a hospital and get that fixed. The miracles of modern medicine never cease, as long as you've got the insurance to pay for it.

So maybe the rationing portion is somewhat of a stretch but how do we pay for this when half the country ends up going to the public plan because businesses would rather pay an 8% tax than offer private plans? Medicare, Social Security, Medicare already has 100+ Trillion in unfunded promises. We can't even afford our health insurance commitments to our poor and elderly and they want to "fix" the rest of our health care system? The health care industry is highly competitive as shown by its low profit margin of 3-4%. This bill will put our country further in the hole. The Congressional Budget Office agrees that this plan will cost us 1 Trillion dollars over 10 years.

"but if they just treat the person from home rather than readmitting him, even if readmitting would have been medically indicated, they can avoid having excess readmissions"

So the hospital discharges me too early, I then need to be readmitted and the hospital refuses to treat me for a problem they have caused. According to Lydia they may try to treat me at home for a problem that needs hospital care.

Oh, can I be that person. Please let me be that person. Since my doctor would have to conspire with the hospital in order for this to happen, I now am able sue him and the hospital. The hospital is going to staff my residence with 24 hour nursing? What if I need a scan. The hospital is going to ferry me back and forth? What if I need an anesthesiologist? What if I code? We are now talking manslaughter minimum.

What are hospitals and doctors going to do? Perhaps they will enter into criminal conspiracies, break numeruous state and federal laws, and create huge liabilities as well as ignoring professional canons.

Or, perhaps they will devise protcols that reduce the number of too early discharges to an acceptable level.

Think, think, think. Which is more likely?

You all complain about costs and then you spin any attempt to control costs into a new plan to give us an abundance of soylent green. Yum, soylent green.

BTW, Lydia, just to be clear, in order to do what you suggest several people would have to conspire to falsify records and misappropriate funds. They have turned an administrative penalty borne by the hospital in its capacity as a corporation into multiple felonies as well as civil liabilities that will fall on them. I will be happy to admit error when that happens but so far this like shooting fish in a barrel.

in order to do what you suggest several people would have to conspire to falsify records and misappropriate funds

Rubbish. There are plenty of conditions for which whether to admit in the first place is a judgement call. I have just had such a condition myself (foot infection). One doctor in the ER said that if it spread and I had to come back, I would be admitted. I had to come back, and the doctor in the ER that time treated it with IV antibiotics in the ER rather than admit. He was very open about the fact that he was attempting to avoid admitting me. I overheard him talking to another patient and doing the same thing, telling the patient that in this way the patient could tell his insurance company that he hadn't been admitted to the hospital. *In the particular case*, it worked out all right, and I didn't mind it, because a) it made sufficient sense to me that the IV in the ER might take care of it with follow-up oral antibiotics and my own subsequent office visits, b) I am an on-the-ball person who would know warning signs of further problems and would get myself seen immediately, and c) I had a husband free and on the spot over the next few days to drive me around if necessary. Had I been 85 years old and living alone, it probably would have been an inappropriate decision on his part, but then again, he might not have made the decision under those circumstances. But nobody had to falsify any records. Another example: My mother has multiple myeloma, is on chemotherapy, and occasionally gets pneumonia. After several instances of pneumonia, her doctor began choosing to admit her more aggressively when he hadn't fully decided whether it was pneumonia or not, as a preventative measure.

There was no need to falsify records in my case, and had my mother's doctor continued to be hesitant about admitting her as he was before, there would have been no need to falsify records. It would just have been a matter, as it was in my case, of making a different judgement about how to treat.

I can see no reason why something similar would not be the case with respect to readmission. There are plenty of conditions and situations where there is a moment when some doctor weighs things up and decides whether to admit you or not. Once this penalty for the hospital is in place, that will put an additional consideration into effect to influence the doctor, just as the doctor I encountered in the ER was influenced by concern over the _patient's_ costs.

Or, perhaps they will devise protcols that reduce the number of too early discharges to an acceptable level.

"To an acceptable level"? Al, to an acceptable level?

When you are the one bearing the brunt of the mistake, how many mistakes are acceptable to you? We are not talking about revising protocols to reduce inappropriate early discharges - an obviously good idea. We are talking about refusing to use the clear evidence in hand about a particular person who is ill, refusing to treat them, purely because a statistic says they fall in a statistical grouping that is not desired - because the hospital wants its totals to come out right.

Al, people are not statistics. Setting up procedures to ignore the known condition of a person because someone else made a mistake by discharging them is not dealing with them as persons. It is treating them as units of health care consumption.

There is a very important line between planning and preparing for overall costs and consumption of deliverable goods, and applying those goods to specific persons in actual usage. Every hospital, clinic, and insurance program does the former. We have (up to now) generally denied the right of a hospital to refuse to treat a specific person merely on account of a statistical pattern. Now we want to have the federal government mandate this?

I don't think so.

I had thought that the current debate was simply one more step on the continuum of liberal vs conservative disagreement - until I started reading the actual bill. At this point I no longer think so. This is NOT health care reform. The real purpose of the bill is to ramrod federal hands into as many spheres of human life as can be excused under the concept "health care". This purpose seeps out everywhere you look at the bill. The mandatory provisions, the way it cancels out the private sector, the way it manhandles patients as objects, the way it uses completely separate parts of life to control us (tax records), and so on. There are LOTS of ways to reform health insurance that don't require such methods, such a ham-fisted approach to changing American life. The fact that they want this bill says a lot about what they really want.

This is not reform, it is communism. Obama was telling the truth when he said he wants to remake America so that it no longer looks anything like its former reality. He wants it to look like the Soviet Union.

No fair, Lydia. If the patient can be properly treated on an out patient basis, he should be. We are talking about necessary readmissions where out patient treatment would be be clearly improper. Pushing the envelope on admissions and discharges is how we got into this.

Your first point wasn't about judgment calls, it was about hospital administrators and doctors entering into a conspiracy to evade state and federal regulations. You may not have realized that you were writing that, but you were.

All this is besides the point. This section isn't about rationing, it is about accounting. You and the Professor are creating a causation chain that ignores variables that are inconvenient to your arguments or of which you are unaware.

I also have had some experience here. A few years ago I talked my doctor into doing a couple of in office IVs for a serious infection resulting from a spider bite and giving me a script for a course of injectable as well as oral antibiotics, saving me extra trips to his office. The last place I wanted to be with an infection was a hospital but had I presented at an ER in that condition they would have insisted on admitting me.

"Al, to an acceptable level?"

Yes. You have apparently bought into the rationing meme. This is an accounting section. The algorithms set up to enforce this section will have to filter out the noise and allow for unavoidable human error. No human run system is perfect.

Tony, it doesn't matter who is administering health care - insurance companies or the government, statistical analysis is the only way to handle things once the population reaches a certain point.

You obviously haven't read many bills that deal with complex matters. Before you judge this bill, go into the U. S. Code and read through some of the sections. For that matter, read all the way through your credit card agreement or your health insurance policy (not the summary you get - the whole thing).


"In the same way, "financial sanctions" and "rationing" are complementary causal accounts of the same event. They are not rivals."

Dr. Beckwith, your underlying assumption is that nothing can be done to correct the problem of readmissions due to too early discharges hence the only outcome of financial sanctions can be rationing of some sort.

If one assumes that hospital administrators are currently playing a numbers name in which there is no downside to early discharges and huge benefits for engaging in them, it becomes reasonable to assume that increasing their risk will influence their behavior and decrease the risks currently borne by the patients and taxpayers.

You obviously haven't read many bills that deal with complex matters.

Al, I have occasion to read various pieces of Title 26 of the US Code every work day of my life. And the regulations attached thereto. And some of Title 29, and a little of Title 5. I must do a certain amount of dabbling in various state codes and regulations, though not much.

In addition to reading them and understanding them, my employer also expects me to read proposed regs and comment on them, and ask for improvements thereto, with some frequency, and to participate in public hearings on them. And to read newly passed bills to prepare our responses to the new law. Been there, done that. You might want to ascertain facts before you throw your ignorance around.

My daily job also deals intimately with using statistics for projections. I know the difference between using statistics to forecast future needs and setting up reserves for them (that's kind of the heart of my job), and coming along after the fact and dealing with specific events that are (or are not) in line with projections. When an life insurance company finds that a person they insured dies 30 years earlier than expected, they don't say: we have experienced too many early claims this year, your claim is unacceptable. They pay it, even if it represents a loss. When a hospital finds a person who needs readmission and decides that readmitting them will result in non-payment for the readmission, the hospital will pressure the parties involved to not readmit.

`(I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to the applicable period; to

`(II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period.

Al says this is about accounting rather than "rationing". I don't really care whether the first effect of the provision is an accounting policy or something else. The long run effect of this sort of accounting policy will be just about EXACTLY like one of the things we don't like about insurance companies and make us willing to consider reform in the first place: refusal to pay for health care on a basis that SIMPLY WON"T LOOK AT THE INDIVIDUAL, and instead looks solely at statistics that may or not be applicable in this case.

If the patient can be properly treated on an out patient basis, he should be. We are talking about necessary readmissions where out patient treatment would be be clearly improper.

By no means are such decisions always that cut and dried. A little light doesn't go on on the patient's head if out patient treatment would be improper. As I pointed out already, even in the kind of situation I (and you) have faced, a whole lot of factors about the patient are relevant including even such things as how intelligent and observant the patient is, what other activities the patient is likely to engage in if you send him home, and so forth. The punishment to hospitals for excess readmissions throws another consideration into the mix as a whole that simply should not be there, as the consideration of the patient qua individual should be the only consideration when the patient presents with a problem.

Dr. Beckwith, your underlying assumption is that nothing can be done to correct the problem of readmissions due to too early discharges hence the only outcome of financial sanctions can be rationing of some sort.

False dichotomy. Might such punishments result inter alia in additional, proper caution about early discharge? Yes, they might indeed. Are they likely _as well_ to result in scale-tipping for not readmitting in individual cases, which _should not be the case_, because that consideration _should not be influencing_ the decision whether or not to readmit? Obviously so.

"By no means are such decisions always that cut and dried."

I agree and I believe I made that clear. Your first statement didn't differentiate between wobblers and those who clearly need readmission. The bill's authors also recognize that some hospitals may improperly try to reject those who need readmission and that is why we have, "(7) MONITORING INAPPROPRIATE CHANGES IN ADMISSIONS PRACTICES- The Secretary shall monitor the activities of applicable hospitals to determine if such hospitals have taken steps to avoid patients at risk in order to reduce the likelihood of increasing readmissions for applicable conditions. If the Secretary determines that such a hospital has taken such a step, after notice to the hospital and opportunity for the hospital to undertake action to alleviate such steps, the Secretary may impose an appropriate sanction."

Tony, if you can navigate the tax code you can clearly understand this bill. I may have interpreted your comment in the light of the professors qualifications in his introduction. If you meant the scopem that's a legitimate disagreement. I don't think meaningful reform is possible without a comprehensive bill that deals with insurance and begins to deal with Medicare cost issues. How else would we deal with this?

I don't get your problem with statistical modeling but we may be talking past each other due to unstated assumptions on the part of either or both of us.

It seems both you and Lydia believe that the penalties in the section may well alter the early discharge patterns of offending hospitals but that we will still have problems at some point in the future. If the hospitals change their discharge policies then won't they be off the "list" and no longer subject to penalties? How we get from there to the rationing you fear puzzles me.

I may have too much faith in our system but I don't believe we are justified in going beyond a facial reading of these sections.

Perhaps the bill is not at this level of detail yet (something to be done by regulation?) but does it have any limtiations for re-imbursement based on length of stay for particular conditions? Most insurance policies, for example, limit re-imbursement for the amount of time for hospitalization for a normal pregnancy. Are there similar provisions in this bill, which would then seem to really put the squeeze on hospitals - you won't be reimbursed for a patient hospitalized beyond X days for Y condition, and then you will not be re-imbursed if he gets re-admitted because this episode of the condition happened to be an outlier (statistically).

As Wesley J. Smith puts it, this is the skeleton of a bill, to be filled out by bureaucrats. By my recollection, the Committee is empowered to put those kinds of limitations in place.

"Al says this is about accounting rather than "rationing". I don't really care whether the first effect of the provision is an accounting policy or something else. The long run effect of this sort of accounting policy will be just about EXACTLY like one of the things we don't like about insurance companies and make us willing to consider reform in the first place: refusal to pay for health care on a basis that SIMPLY WON"T LOOK AT THE INDIVIDUAL, and instead looks solely at statistics that may or not be applicable in this case."

It's both rationing and accounting - and obviously so. Further, it's extraordinarily disingenuous for anyone who's informed to imagine otherwise. Further still, it's not only inextricably related, it's premeditated as such, the rationing aspect and the "accounting" controls, and that too should be apparent.

"[Doctors take the Hippocratic Oath too seriously], as an imperative to do everything for the patient regardless of the cost or effects on others" Ezekiel J. Emanuel, MD, chief advisor to the admin. and brother of Rahm Emanuel, Journal of the American Medical Association, 6/18/08

"Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years" E. J. Emanuel, Principles for Allocation of Scarce Medical Interventions, Lancet, 1/31/09

"Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely 'lipstick' cost control, more for show and public relations than for true change." E. J. Emanuel, Health Affairs 2/27/08

"[Medical care should be reserved/rationed for the non-disabled, not given to those] who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia" E. J. Emanuel, Hastings Center Report, Nov/Dec '96

If the country, the citizens thereof, desire a massive, central statist and, in essence, decidedly leftward and "social justice," communitarian conception to be deployed, to be institutionalized via a federal bureaucracy, legal mandates, cooptations of a huge portion of the economy and the country's ethos in general, etc., then the administration should, in the spirit of transparency and openness to review and critique, explicitly advertise it in that vein. We remain, hopefully, a representative democracy in the lineage of classical liberal republics. But neither the administration nor legislators and others in favor of this centralized, "social justice" system are doing so. Instead its been a flim-flam presentation with basic deceits being leveraged, a matador and red cape presentation throughout, as such, a rank and overarching display of contempt for the citizen as such.

h/t Defend Your Health Care

And, Bill Whittle, in this video and applied to the administration in general, enlarges nicely and with effect on the flim-flamming deceits alluded to above.

HR 3200 should be scraped in its entirery immediately. The whole process should start over from scratch starting with fixing Medicate deficiencies.

I don't think meaningful reform is possible without a comprehensive bill that deals with insurance and begins to deal with Medicare cost issues. How else would we deal with this?

How indeed? That is the very heart of the matter. What this bill proposes is this: health care cost/payment/delivery/allocation is not satisfactory, so we should take approximately 1/7 of the entire economy and turn it into a federal fiefdom to make it work well.

Why, oh Why, must we jump from an admittedly not perfect system to one so completely different, one so completely at odds with American principles of free enterprise, in one swell foop? Rather than ASSUME that lesser modifications can't work and must be leapfrogged, why not TRY them, or try several of them, piecemeal, while you find components that DO work. And then use that information to craft a really intelligent system that USES free enterprise and the kinds of things government is good at side by side? The "findings" portion of the bill is incredibly thin as a legal basis for taking over a huge private industry.

Al,

Thank you for your feedback because -through the head explosions and stuff- it gives me insight in to the underlying justification for and logic of this clause.

If I'm reading you correctly, the concern with the present system is that too many hospital administrators are rigging the system and prematurely discharging patients. Those early discharges are a) running up unnecessary costs when the sick are re-admitted and b)preventing folks from getting healthy.

To resolve this problem, HR 3200 proposes to incentivize the hospitals to do the right thing (extend the original stays in hopes that they prevent unnecessary re-admissions) by capping the re-admissions. The premise is that the hospitals will be forced to re-admit those sick folks that they did not cure in the first place, and eat the cost of those superfluous re-admissions.

I've still got to dig further to really understand if/how the hospitals will eat those costs without passing them on to the patient, but I'll take your word for it.

Assuming my understanding is correct, here are my thoughts:

a) Your original premise that there is an epidemic of hospitals (presumably with the consent of the doctors) that are knowingly releasing patients prematurely in order to make a buck leaves your argument in a precarious position. For one thing, this practice would require a grand conspiracy between hospital administrators, doctors and insurance companies to allow enough obviously sick people out the door to make it worthwhile. (you already stated your skepticism about such a complex conspiracy)

Assuming the logistics of such scams are workable, you are also demeaining the integrity of the medical professionals. The fundamental issue is whether doctors are intentionally releasing sick people. Regardless of the administrative pressures or other -as the White House characterizes them - "perverse incentives", if you think that the doctors are willing to ignore their own training and knowingly ignore people's health, then the newly proposed incentives are doomed to failure. Rather than incentivizing the doctors to keep people in the hospital longer, these same old money-grubbers are just going to find ways to deny health on the back end.

While preventable re-admissions might be a legitimate issue, it is more likely a problem with inefficient processes rather than perverse incentives. It seems logical to focus our resources on streamlining administrative processes rather than trying to penalize hospitals and patients under the assumption that they are knowingly cheating the public.

b) I think it is more than reasonable that people would characterize this clause as Rationing of health care. That is, they are using rationing (aka capping re-admissions) in hopes of shifting the incentive away from re-admissions. The White House denies that the reforms will lead to rationing, but I think it would be more useful for them to admit that the reforms are all about rationing.

The framers of this bill should make the case why their rationing is somehow more useful and more palletable than the current rationing under private insurance companies. I doubt that they could make such a case, but it would certainly allow the rest of us to discuss the merits rather than spending days and days trying to interpret the actual intentions and methods being proposed.

Rationing or not, this bill is a bad one and should burned.

The number of people liberals claim to be without INSURANCE is misleading. Some are young and healthy and would rather spend their money on a new car or a trip around the world. (Obama needs these people to be forced into the system so that the healthy can pay for the sick, thus denying them their new car or that trip around the world.) Some are eligible for Medicare but don't know it. Some are between jobs. Many of them are illegal aliens. Only a very small group of people fall between the cracks of having no health insurance because they don't fit the above categories. But let me remind you of this: they still do have ACCESS to health care. They just have to pay out of their own pockets. Usually hospitals try to work out a plan for those people who cannot afford the bill. (And yes, some do have to file bankruptcy like millions do every year for other reasons.) Maybe Obama and his gang should try to figure out how to get those few people without the ability to pay for health insurance eligible for Medicare and leave the rest of us the hell alone.

Al, I work in an ER, and have worked as an RN for years. You say you "talked my doctor into doing a couple of in office IVs for a serious infection resulting from a spider bite and giving me a script for a course of injectable as well as oral antibiotics, saving me extra trips to his office." Are you a doctor? If not, what educational background did you use to justify your expertise in treatment options? Are you an RN? Or an LPN? If not, how in the world did you legally give yourself antibiotic injections without going to an office or hospital and having a licensed professional do them? Injectable antibiotics can have serious reaction issues; did you have a plan and equipment in place to deal with them? How does your doctor feel right now, knowing you broke the law, coerced him into doing the same and then bragged about it in a national forum? Had your infection worsened (I may be going out on a limb here, but I'm betting on staph, since that's what the majority of "spider bites" actually are), would you have sued yourself for malpractice? Or your doctor? I wonder....

Well, Sean, he did say "in-office." To be fair.

Questions...How extensive will the needed administrative bureaucracies be for ObamaCare? Will we have more czars? How will the 'secretary' monitor all of this? How are we to train all of the new doctors that will be needed to handle the influx of patients? Are the answers somewhere in the 1000 plus pages? Do lawyers even understand all of this?

I was interested by the first comment by Al regarding the HR3200's penalty for re-admissions by hospitals. To be sure, the wording seems to penalize the hospitals for injudicious early discharge by not reimbursing the hospital when, in the questionable judgement of a bureaucratic administration, the hospital is "guilty" of premature discharge of patients. It seems, in a shallow analysis, that only the hospital will face the penalty.

However, if the hospital knows that it will not be reimbursed, it has little incentive to re-admit a patient. Furthermore, hospitals extend the PRIVILEGE of admitting patients to the doctors. These privileges can be revoked without the patient having any knowledge of the revocation. A physician without admitting privileges at a hospital is virtually unable to practice medicine. This leaves the patient, in the end, unable to get treated by his own physician and likely unable to be re-admitted without changing doctors. No other doctor will want to accept such a new patient when he or she may also face sanctions from the hospital.

So, while the legislation is, I hope, to punish hospitals for poor treatment, the unintended consequence is that the patient will ultimately lose even his primary physician and be left without any medical tratment. This is not just rationing, it is outright denial of coverage for patients.

This is not a theoretical analysis. Doctors do lose admitting privileges for a number of administrative reasons and must meet certain criteria (imposed by the hospital and medical boards) to regain the right to admit a patient.

Professor Lewis's analysis may actually understate the problem.

I gather that the refusal of reimbursement for readmission is only for such-and-such many readmissions for some particular condition--that is, for a condition where the hospital has had "too many" readmissions in the applicable period (a year, or whatever). So I doubt, myself, that the hospital would be likely to pass the pain down the line by denying a physician admitting privileges altogether as a result. This is all the less likely as I foresee a doctor shortage over the coming years, this whether or not Obamacare is enacted but definitely exacerbated if it is.

It took me little time to recognize that the quoted lines from the bill are taken out of context.

The very first interpretation of the code is completely off.

The code refers to an additional allowance above the base rate. It refers to the aggregate admissions for the year, not the payment for a single individual. The section actually quoted actually restricts what readmissions can be excluded from the additional allowance.

Totally off.

The code, when read from the beginning, reduces the additional allowance above the base operating DRG payment for readmission in excess of what would be normally expected for the condition and the quoted section actually restricts certain readmissions from being considered for exclusion.

Just as well, the section refers to the aggregate payments made in the year, not a specific payment made for a specific patient. In general, it is reasonable to expect that a hospital making reasonable effort to reduce patient readmission will have an average number of readmissions that are consistent with the applied measure of what can be reasonable expected.

Lastly, the note that the there are limitations on the administration or judicial review of the method of measurement for the determination of the number of readmissions for a specific condition at a specific hospital is as minor as this sentence is long.

I was really hoping to find a good evaluation of HR3200 so I could make some reasonable assessment of the economic impact. I'm just disappointed, though not surprised, that the professor is a dolt. I've had many and can tell you that the more they know, the less in touch with reality they are.


"1. This section amends the Social Security Act"

Duh, what's your point?

2. The government has the power to determine what constitutes an “applicable [medical] condition.”

The words only apply to a very restrictive addition to the SS Act which determines how much extra a hosptial will receive above the base allowance for the procedure.

3. The government has the power to determine who is allowed readmission into a hospital.

The section says nothing about determining anything about anyone. It only applies to aggregate payments for the year.

4. This determination will be made by statistics: when enough people have been discharged for the same condition, an individual may be readmitted.

Again, the section has absolutely nothing to do with an individual. It has everything to do with the average number of people over the year. And, even if the hospital does have an average number of readmissions in excess of the measure, they still get paid, they just don't get paid EXTRA.

5. This is government rationing, pure, simple, and straight up.

Not even close. To conclude this, statements 1 through 4 would have to be even reasonably true.

6. There can be no judicial review of decisions made here. The Secretary is above the courts.

Based on what, that there is a restriction on review on the use of a methodology for measure? Who cares.

Dolt.

In general, it is reasonable to expect that a hospital making reasonable effort to reduce patient readmission will have an average number of readmissions that are consistent with the applied measure of what can be reasonable expected.

So, you _endorse_ the push from the government by punishing hospitals that have "too many" readmissions for the applicable condition. I don't endorse that. I think that's a problem and pressures hospitals to ration readmissions. Yeah, it's done by groups of patients, not by individual patient. You think that means it won't affect individuals? Unless I'm confusing this thread with another old thread (I don't have time to re-read it), I have discussed this at length, above. I know I've discussed it at length somewhere on this blog.

Here is my discussion at my own blog. See especially the update (headed in bold) in the center of the entry.

http://lydiaswebpage.blogspot.com/search/label/health%20care

I hope you find it interesting and useful. But please don't come to my personal blog and act like a jerk, or I will delete your comments with prejudice. I'm a tyrant over there.

Will this analysis and plans approve by the government? or is it ok to our community? i think all the benefits of this is will go the big companies and strong personalities. I wish all of this will be for good and for the sake of our community.

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