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Diagnosis: Obamacare , what now?

Diagnosis: Obamacare , what now? . An independent physician’s prognosis and prescription. David Stein, MD CV. Medical Director, Milwaukee Pain Treatment Services since 1997 Specialty in Pain Management: Interventional and medical management

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Diagnosis: Obamacare , what now?

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  1. Diagnosis: Obamacare, what now? An independent physician’s prognosis and prescription

  2. David Stein, MD CV • Medical Director, Milwaukee Pain Treatment Services since 1997 • Specialty in Pain Management: Interventional and medical management • Diplomate: American Board of Anesthesiology, American Board of Pain Medicine • Nicolet HS, UWM • UW-Madison Medical School • Cleveland Clinic residency in anesthesiology

  3. What is Obamacare? • Passed in Congress in 2010, this law attempts to provide universal coverage for Americans. • It was funded by various taxes, reductions in Medicare spending. • The central feature of the law is the creation of “exchanges” which are privately administered insurance plans offered through the state or federal government which meet federally specified levels of coverage and eligibility. • All citizens are required to meet one of the following conditions: exemption, have qualified insurance, purchase insurance on the exchange or pay the tax/penalty as administered by the IRS.

  4. What is Obamacare? 11,588,500 Words: ObamacareRegs 30x as Long as Law It will be of little avail to the people that the laws are made by men of their own choice if the laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood. - James Madison

  5. What are the risks associated with Obamacare for the individual? • High cost • Loss of privacy, security • Rationing of treatment through IPAB • Reduced access to providers

  6. What is the effect on Medicare recipients? • Over $700 billion was taken from the Medicare program to fund Obamacare with cuts to Medicare advantage plans • The health care law created the Independent Payment Advisory Board (IPAB), otherwise known as the “death panel” • The stimulus bill created “comparative effectiveness research” (CER) which endorses the concept of the “complete lives system” as advocated by Obamacare advisor Zeke Emmanuel. Health care resources are to be prioritized for those with the most productive potential, in other words, those between 15-50 years.

  7. Independent Payment Advisory Board (IPAB) IPAB: President Obama's NICE Way To Ration Care To Seniors, Forbes 10/21/12, Scott Atlas • IPAB’s lack of accountability for such authority over the personal decisions of Americans by government appointees is unprecedented.  • Beginning January 15, 2014 and every year thereafter, the law requires the board to submit specific recommendations to the President and Congress to “slow the growth” in national health expenditures. However, decisions by the panel are not simply recommendations to Congress; if the Senate, the House, and the president do not concur on an alternative proposal, or if Congress does not act at all, the HHS Secretary is required to implement the board’s recommendations.

  8. Medicare cuts: Replacement plans/Advantage plans cutSusan K. Livio, NJ Star-Ledger, 10/23/13 • The nation’s largest health insurer, UnitedHealthcare, claims the Affordable Care Act is responsible for forcing it to boot doctors from its Medicare Advantage program that serves thousands of elderly patients in the New York metro region. • A UnitedHealthcare spokeswoman said the company is dropping 10 to 15 percent of its physicians nationwide, although she declined to say how many are affected in New Jersey. Doing so will save money and improve care, spokeswoman Mary McElrath-Jones.

  9. Meet Zeke EmanuelBetsy McCaughey, NY post, 7/29/09 • Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel. He has already been appointed to two key positions: health-policy adviser at the Office of Management and Budget and a member of Federal Council on Comparative Effectiveness Research. • Emanuel, however, believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved 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 • Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others"

  10. Complete lives systemLancet vol 373, 423-431, January 2009, Ezekiel Emanuel

  11. Why is Obamacare so expensive? • Lots of mandates, coverage requirements that insurance companies must follow • Regulatory burdens • Guaranteed issue, no pre-existing disease exclusion • No cost limitations

  12. Why is Obamacare expensive?AAPS News December 2012 - Is ObamaCare Here to Stay? Dec 5, 2012 • According to the American Action Forum, 85 new rulemakings due to ObamaCare have imposed $20.4 billion in costs on private entities and $7.2 billion on state budgets. According to the Federal Register, the paperwork will take about 60 million hours. For a benefit of $0, the cost: benefit ratio is infinite.

  13. Why is Obamacare so expensive?New Mental Health Mandate Forbes, Merrill Matthews, 11/13/13 • The Council for Affordable Health Insurance used to publish an annual chart tracking the number of state mandates, and health actuaries provided a general estimate of how much various mandates added to the cost of a basic health insurance policy.  Depending on what it required, mental health parity was one of the most expensive mandates, adding between 5 percent and 10 percent.  • 72 Absurd Items ObamaCare Requires Your Health Insurance to Cover Conservative HQ,Ben Hart 11/08/13

  14. What's wrong with the website? • It doesn’t work • It creates significant security risks to those individuals creating accounts • No reasonable expectation of privacy

  15. What's wrong with the website? PrivacyWeekly Standard Blog, Jeryl Bier 10/14/13 • “You have no reasonable expectation of privacy regarding any communication or data transiting or stored on this information system.  At any time, and for any lawful Government purpose, the government may monitor, intercept, and search and seize any communication or data transiting or stored on this information system.  Any communication or data transiting or stored on this information system may be disclosed or used for any lawful Government purpose.”

  16. What's wrong with the website? Security.SharylAttkisson, CBS News, 11/06/13. • Henry Chao, HealthCare.gov's chief project manager at the Centers for Medicare and Medicaid Services (CMS), gave nine hours of closed-door testimony to the House Oversight Committee in advance of this week's hearing. • Chao said he was unaware of a Sept. 3 government memo written by another senior official at CMS. It found two high-risk issues, which are redacted for security reasons. The memo said "the threat and risk potential (to the system) is limitless." • The author of the security memo, Tony Trenkle, retired from CMS last week; no reason was given.

  17. What's wrong with the website? Security.ObamaCareHackathon: Healthcare.gov May Expose Social Security Numbers, Zero Hedge Tyler Durden10/25/2013 • When an American signs up for Obamacare online, they must enter a good deal of personal information to verify identity—including name, Social Security number, phone number, email address, income, and employer—and identifying information for their family members. In the majority of states, Americans will enter this information directly into the Healthcare.gov website. • The website, reportedly, has a coding problem that could allow hackers to deploy a technique called "clickjacking," where invisible links are planted on a legitimate web page. • "Common clickjacking would be a popular method to attempt to exploit [the site]" says Wilhoit. "Hackers could use this information in the creation of fake identities, fake credit cards, and fake accounts very easily

  18. What's wrong with the website? More warningsJoe Campana, Madison Headlines Examiner • Kitty Rhoades, Wisconsin Department of Health Services Secretary, warned of possible fraud and identity theft associated with Obamacare. • Rhoades especially warned senior citizens not to provide personal information such as a Social Security Number to anyone who contacts them concerning enrollment into Obamacare. • Last week, Health and Human Services Secretary Kathleen Sebelius admitted that it is possible that Obamacare navigators could be convicted felons in questioning by Senator John Cornyn (R-TX) during Senate Finance Committee hearings

  19. What are navigators?Worker Centers Exploit Lack of Scrutiny for ACA Navigator ProgramTown Hall, Ryan Williams, Oct 23, 2013 • Navigators receive taxpayer funds to support their efforts and earn $58 for every person they enroll. • As part of their responsibilities, navigators have access to enrollees’ personal information. • Navigators are instructed to only offer general guidance, restricted from even recommending one health insurer or plan over another

  20. Who are the navigators?Daily Caller, Michael Volpe 10/14/13 • Obamacare ‘navigator’ in Kansas has outstanding arrest warrant • Rosilyn Wells — theDirector of Outreach and Enrollment for the Heartland Community Health-care (HCHC) – is “the only full-time Affordable Care Act navigator in Lawrence,” according to the Lawrence Journal-World. • Wells was certified as an Obamacare navigator despite her financial history, which includes a bankruptcy in 2003, a 2007 civil charge from a local check cashing business called Midwest Checkrite for writing a bad check, being more than $1700 behind on her state tax bill, andhaving an outstanding arrest warrant in nearby Shawnee County.

  21. How much do the Obamacare exchanges cost?Nick Novak, MacIver Institute, 10/25/13

  22. Could the exchanges collapse? • A “death spiral” is possible because the monthly premiums and deductibles are very expensive and guaranteed issue – no pre-existing disease refusal. • If only very sick and expensive patient sign up for the exchanges, insurance companies will be forced to raise rates which will discourage most people from signing up. • A Gallup survey (11/09/13) found that only three in 10 uninsured Americans are familiar with the insurance marketplaces created by the health care reform law, while just 18 percent of the country’s 48 million uninsured — roughly 8.6 million — have attempted to visit an exchange website.

  23. Could the exchanges collapse?FORBES Scott Gottlieb Contributor Pharma & Healthcare 10/28/2013 • Under the law, insurers who offer policies inside the Obamacare exchanges are required to treat their enrollees inside and outside the exchange as a single risk pool. Among other things, this provision was meant to reduce the chance that insurers would steer healthier patients into plans sold outside the exchanges. • But the law doesn’t prevent insurers from offering plans exclusively outside the exchange. If they are entirely outside the exchange, they get to create their own risk pool, and aren’t subject to the same pricing that burdens plans inside the exchange. • As the pool inside the exchange becomes older, sicker, and costlier, more plans will have an economic incentive to get out of the Obamacare market altogether.

  24. Will I be able to keep my doctor? • It depends … • The exchanges have been constructed to restrict the number of network physicians and hospital providers as a way to reduce access and control costs • Doctors are not signing up for the exchanges • More physicians are hospital employed and less productive • Physicians average age is increasing, and likely to be retiring earlier • Baby boomers are aging • DOCTORS HATE IT!

  25. Will I be able to keep my doctor? SurveyDoctor Patient Medical Association Foundation, December 2011 • 90% say the medical system is on the WRONG TRACK • 83% say they are thinking about QUITTING • 61% say the system challenges their ETHICS • 85% say the patient-physician relationship is in a TAILSPIN • 65% say GOVERNMENT INVOLVEMENT is most to blame for current problems • 72% say individual insurance mandate will NOT result in improved access care • 49% say they will STOP accepting Medicaid patients • 74% say they will STOP ACCEPTING Medicare patients, or leave Medicare completely

  26. Will I be able to keep my doctor? ConsolidationAAPS News December 2012 - Is ObamaCare Here to Stay?12/05/12 • Hospitals now employ about 20% of practicing physicians directly, and many more in group practices owned by health systems. Employed physicians worked an average 53.1 hours per week, compared with 54.1 for physicians in private practice, and saw 17% fewer patients. “We know that an employed physician is less productive than a practice owner,” said Mark Smith of Merritt Hawkins (AM News 10/8/12). The effect of these changes could be the equivalent of losing 44,000 physicians over the next 4 years.

  27. Will I be able to keep my doctor? ExchangesPoll conducted by the New York State Medical Society, Carl Campanile, NY Post, October 29, 2013 • Only 23 percent of the 409 physicians queried said they’re taking patients who signed up through health exchanges. • Nearly eight in 10 — 77 percent — said they had not been given a fee schedule to show much they’ll get paid if they sign up. • “I get screwed from insurance companies already. I refuse to get screwed any longer,” one doctor said. • “I am seriously considering opting out of all insurance plans including Medicare because of [ObamaCare].” • “This is so poorly designed that a lot of doctors are afraid to participate,” said Dr. Sam Unterricht, president of the 29,000-member organization. “There’s a lot of resistance. Doctors don’t know what they’re going to get paid.”

  28. Will I be able to keep my doctor? Coding AAPS News December 2012 - Is ObamaCare Here to Stay? Dec 5, 2012 • Dr. John Natale, 63, a vascular surgeon from Arlington, Ill., has started serving a 10-month term in federal prison after conviction on two counts of “making false statements” in connection with surgeries performed between August 2002 and October 2004. He had saved the lives of five patients who had an expected 90% mortality, using an aneurysm repair procedure for which no precise CPT code exists. The government had also discovered, in some 2,400 operative reports, two inaccurate statements. • At sentencing, Judge Rebecca Pallmeyer stated: “It’s hard for me to imagine that there was some motivation other than to pad the bill in Dr. Natale’s operative notes.” Natale’s attempt to explain how he had made the errors was considered to be “obstruction of justice.” Cross-examination at trial revealed that a transcribed dictation was missing the preposition • The prosecutor urged the judge to impose prison time because of the need to deter Medicare fraud, and the need for the sentence to reflect the seriousness of the crime and respect for the law. “My sense is, still today, that the doctor doesn’t really believe that he actually committed an offense.”The Judge referred to “just a razor-thin margin on the Supreme Court upholding the recent Affordable Healthcare Act [sic].” Because the federal budget is so compromised, accurate coding is of extraordinary importance.

  29. Will I be able to keep my doctor? Manpowerjcommins@healthleadersmedia.com • The timing really could not be worse. One out of three practicing physicians in the United States is over the age of 55, and many of them are expected to retire in the next 10 or 15 years. • Meanwhile, U.S. medical schools have not provided for the loss of 33 percent of the nation’s physician work force. A number of studies have estimated that by 2020 the United States will be short anywhere from 24,000 to 200,000 physicians. • A multitude of aging baby boomers in need of healthcare will only worsen the situation. The first of the boomers turn 65 in 2010, and the U.S. Census Bureau estimates that the nation’s population over the age of 62 will increase from about 46 million now to about 83 million by 2030.

  30. Will I be able to keep my doctor? LoopholeObamacare Leaves Doctors On the Hook for Deadbeats, Reason, Tori Richards Nov. 9, 2013 • People who receive the federal subsidy to be part of Obamacare will be allowed to incur a three-month “grace period” if they can’t pay their premiums and then simply cancel their policies, stiffing the doctors and hospitals. • Under Section 156.270 of the Affordable Care Act the insured needs to pay a premium for just one month before qualifying for the three-month grace period. The insurance company must pay the claims during the first month of the grace period; during the second and third month doctors and hospitals are left to collect unpaid bills • “For instance, an oncology practice generally purchases the drugs to be used in a course of chemotherapy up front — which can run into the tens of thousands of dollars — and is then reimbursed by the payor as part of the medical service. Costs such as these are on top of the costs of displacing other patients with coverage.”

  31. Who is exempt from the Obamacare exchange? • Medicare, Medicaid, government insurance – Tri-Care • Native Americans, Amish, Mennonites, legal and illegal aliens, US citizens living overseas. • Qualified employer-sponsored health insurance • Self-insured, employer-based plans • Congress, staff, president

  32. What are the penalties for not having qualified insurance? • The penalty is phased-in over a three year period. • In 2014, the penalty will be the greater of 1.0% of taxable income or $95 per adult and $47.50 per child (up to $285 per family). • In 2015, the penalty will be the greater of 2.0% of taxable income or $325 per adult and $162.50 per child (up to $975 per family). • In 2016, the penalty will be at the greater of 2.5% of taxable income or $695 per adult and $347.50 per child (up to $$2,085 per family).

  33. What are the penalties for not having qualified insurance?Business Insider, Henry Blodget 7/2/12 • Less than $9,500 income = $0 • $9,500 - $37,000 income = $695 • $50,000 income = $1,000 • $75,000 income = $1,600 • $100,000 income = $2,250 • $125,000 income = $2,900 • $150,000 income = $3,500 • $175,000 income = $4,100 • $200,000 income = $4,700 • Over $200,000 = The cost of a "bronze" health-insurance plan

  34. What are the penalties for not having qualified insurance?The Motley Fool, Keith Speights, 10/23/13 • The IRS could take it out of any future tax refunds. If your taxes are withheld through your employer, the agency could also get the money through that route. However, it can't press criminal charges or assess further financial penalties for not paying. The IRS also can't place a lien on property as it can when seeking payment of overdue taxes.

  35. Will health savings accounts (HSAs) continue to survive?Health Savings Accounts Will Survive ObamaCare -- At Least For Now, Forbes, Merrill Matthews, 3/27/13 • HSAs are employer-sponsored, tax-advantaged accounts that are fully owned by employees and used to fund out-of-pocket health-care expenses. • HSA plans combine high deductible health insurance coverage, to protect against major accidents and illnesses, with a tax-free savings account used for smaller and routine health expenditures.   • ObamaCaregives health plans a little wiggle room: plus or minus 2 percent.  That wiggle room allows some federally qualified HSA plans with the highest deductibles (around $6,000) to barely meet the ObamaCare standards, according to Ramthun.

  36. What are some alternatives to the exchanges? Christian health Ministries (CHM) is not insurance but rather a Major Medical faith-based cost sharing ministry. • Once your Personal Responsibility is satisfied C.H.M. pays 100% of the remaining balance up to $125,000 per need.Bills less than $500 will always be your personal responsibility. • Gold - $500 Personal Responsibility per person annuallya) any condition requiring diagnostic testingb) any condition that creates a hospital billc) $150 p/p - per month - $450 for family of 3 or more. • Silver- $1000 Personal Responsibility per incidenta) any condition that creates a hospital billb) $85 p/p - per month - $255 for family of 3 or more. • Bronze - $5000 Personal Responsibility per incidenta) any condition that creates a hospital billb) $45 p/p - per month - $135 for family of 3 or more

  37. What are some alternatives to the exchanges? Christian health Ministries (CHM) www.chministries.org • Qualifications for members: • Christians living by biblical principles, including the use of alcohol • Follow biblical teaching on the use of alcohol an abstain from tobacco and the illegal use of drugs (1Cor. 6:19-20) • Attend group worship regularly if health permits.

  38. What if I want to pay for health care on my own? • Yes, you still can, for now • Determine the price up front with the provider • This is typically easier accomplished with independent clinics, laboratories and radiology facilities • Comprehensive price lists for providers will eventually be compiled • Medibid, a national company that allows consumers to bid on medical services • More privacy, paper medical records • Medicare patients must see providers that have “opted out” of Medicare if they want to pay for services out-of-pocket • If all fails, go abroad

  39. Are there legislative approaches at the state level that could protect individuals from the effects of Obamacare? • Require State insurance commissioner’s office to perform background checks on navigators • Protect WI citizens from IRS liens for failure to pay penalty/tax

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