MaxedOutMama
Sunday, November 29, 2009
It Was A Working Holiday
Through a series of flights, drives etc, my immediate family all managed to end up together for Thanksgiving in the Ne. That was the great part. The weather was not great.
The difficult part was that my brother the TechnoBuddha was scheduled (while he was in the area) for a checkup with the doc. That's my doc - SuperDoc. And I had gotten the Chief an appointment with SuperDoc the day after Thanksgiving. (SuperDoc seems afraid to take more than one day off at a time, I suppose because when you are a SuperDoc you don't like abandoning your medical salvage projects to lesser docs.)
I had tested TechnoBuddha's blood sugar in April while he was with me for Easter, and he was close to veering into Type II. So I then gave him a series of instructions and shipped him off to SuperDoc, and this was a followup for that. (TechnoBuddha has lost a TON of weight since then, and is progressing nicely with his exercise program, and his blood sugars have plummeted way out of the iffy range.)
So when TechnoBuddha arrived for his appointment at 7:30 AM (SuperDoc likes to crank them through early, which leaves more time for screaming at insurance companies all afternoon, I suppose), he discovered a very frantic SuperDoc whose network was down. Apparently the guy who normally works on it fled to Europe or went there on vacation or something.. So TechnoBuddha spent most the day on Wednesday getting him at least up, which finally involved buying new cable to connect the server and the router and reprogramming the router (which cable is now duct-taped across the back office). The router was new. The network is totally undocumented - even the cables are unlabeled, and you just can't start pulling cables at random to find out what is connected to what..
SuperDoc asked TechnoBuddha to come back on Friday to fix some other problems with two computers (Vista) that had apparently never been working right since they were put in.
So TechnoBuddha asked me to come with him on Friday to work on the problem, which was pretty dire. If I had been trying to work on those two machines, and if I were not computer literate, their broken and bleeding carcasses would long ago have been found by the side of a country road. I would have considered it justifiable homocide in self-defense. Those two PCs were a crime against humanity, and I am not exaggerating.
And we were at it most of Friday before we traced enough of the network to find where everything was hooking up and what the problem really was. I am sure we looked like a couple of bumbling idiots, but when there is no documentation and no cable labelling it is hard to even find the device locations much less figure out what to change, so I spent considerable time crawling around on the floor looking at connections. Commandments 1 - 10 of dealing with computer problems can be summed up with "Always wear pants and comfortable shoes". Friday night late I downloaded manuals and researched enough to figure out possible fixes for the problem, but Saturday we ended up pinging all possible addresses to find the freakin' IP addresses to get in there to get the information we needed to fix the freakin' problem.
Both Friday and Saturday we had to do all of this while the office was running and treating patients, so it was hardly an ideal situation.
We did finish those two machines on Saturday. I think whoever fled to Europe might not want to come back. SuperDoc had been instructed to buy Windows 7 and put it on the two machines which were so problematic, but that wouldn't have fixed the problem - IMO it was the way that they were hooked up to the network devices that appeared to be causing most of the nightmare. SuperDoc is having Comcast come in to rewire the building in a few weeks, so that may help. However his network has other problems - it needs to be documented and have a bunch of things done to it for safe operation. I am writing up all of what we did and learned, and there is a lot that still needs to be done.
Of course in the middle of this, SuperDoc had looked at the Chief's records from his recent hospitalization (which were not easy to get). The Chief has an emergency appointment at the hospital up here tomorrow, because according to SuperDoc the Chief was treated by "A person with an elementary school education and a cardiologist's degree" in South Georgia. SuperDoc said it was clear that even the hospitalist had doubts, and SuperDoc advised me that it could have been possibly lethal if I had not shooed the Chief in for his SuperDoc grease and oil job. SuperDoc hasn't said much, but he seems quite agitated and he told me to be sure to go in and talk to the doctor at the hospital. So I am nervous.
Tomorrow morning early I have to go to SuperDoc's to make sure his network comes up properly, and then I rush back and get the Chief and go to the hospital. As soon as I get a clear Chief day, I have to go back to SuperDoc's and work on his computer situation some more.
So you can safely assume that blogging will be light this week. SuperDoc and the Chief come first. More than a decade ago SuperDoc administered medication to me to try to save my failing brain. He opened up his office every day for months to do it - including Sundays. Including Easter Sunday. My situation then was totally dire, and I was one of those salvage projects. I would crawl across broken glass for SuperDoc, and I know darned well he isn't earning much. He has old-fashioned medical principles and does a lot of free medical care. He won't take most Medicaid patients, because it costs him more to treat them than if he were doing it for free, but he will treat people for free, including people like me that current medical protocols consign to the "untreatable" category. There is a divine sort of symmetry involved in applying my salvaged brain to straighten out his computer situation. SuperDoc said quite plaintively that he had had about five people in to work on it, but of course you will not get good results when the thing is undocumented. .
Before I get back to network diagrams, I would like to point out this profoundly stupid op-ed by Nicholas Kristof in the NY Times Are We Going To Let John Die?. I do not believe that even the SuperDoc and the Shrink combined could sort out Kristof's mind - I think this is self-inflicted, willed mental suicide in action. The basic points are:
But what is Kristof's point? Does Kristof know himself? The facts of this case seem to justify the senators who are asking questions and demurring on the health care bill rather than those who are willing to go ahead with it.
Under any of the current bills I've read (which is why I read them), John's coverage would not change as a result of the bill. He'd still have Medicaid; whatever his current situation, it would continue as is. If anything, some of these bills would make John's situation much, much worse due to the liability problem and the failure to pass tort reform. See NOFP's post on the subject. NOFP quotes Critical Care:
Perhaps you all may now better understand why I am so concerned about these bills, and why I may end up leaving this country if they pass in order to go to a country that doesn't have universal care and in which I can pay for my own care. Without tort reform, patients such as John and myself are likely to be in more jeopardy rather than less. With tort reform, we are liable to have expanded access to high-quality health care. See Nixon's column on medical liability and Christus Health's experience. Please note that while Massachusett's health reform attempts have produced patients without doctors and in many cases cuts in services provided specifically for those on public insurance, tort reform in Texas has produced more doctors, expanded access, and more services for people like John.
Obviously I would wish not to have the disease I do have. Unfortunately, some of the results of the disease I have are so similar to John's problem that I found it very painful to read of his situation. But I have been treated, and it is largely because I was wise enough never to fall for the sucker bait that is public insurance. It is a lie.
However, because I have been so ill, I have spent a great deal of time exposed to doctors, and the one thing I can tell you is that most of them are very good. They also like to do it. If you remove the impediments (such as crashed networks), they doc. If you just get out of their way, they doc. If you just promise not to sue them, they doc. Doctoring is what they do. The better they are, the more fanatical they are about it - and the US has some incredibly good doctors and a large mass of exceedingly good doctors. The US has doctors so damned committed to treating their patients that they have stripped themselves of all their assets and continued to treat patients without malpractice insurance. Obviously, the limit there is on how good the doc's marriage is. I do not think we wish to perpetuate a system in which the only doctors who can continue to treat large numbers of high-risk patients are those with extremely good marriages.
When even a profoundly altruistic SuperDoc has to draw the line at taking Medicaid patients that he cannot treat effectively because they will not get ancillary care, and they cost more for him to treat than free patients, one must understand that the FIRST step in health care reform should be to change our medical torts system.
These are health care reforms that will not work:
Payment by diagnosis rather than payment for service. ( This is what just happened to the Chief down in GA. He got the amount of treatment that would be reimbursed, and no more. No use ranting about private insurance companies - he is considerably older than me and is now on Medicare )
Mandated practice standards by some stupid government board. Guidelines are helpful, but in fact medicine is highly individual. All this BS about medical boards is going to be worse than useless - it will be used as a means to deny care to those who need it most (like John).
Paying doctors less if their patients are more expensive. This punishes doctors who are ordinarily the best in their particular specialities. These doctors are known to other doctors, who refer them their difficult cases. SuperDoc is on such a list, and I notice he seems to be treating a lot of other doctors. Needless to say, those cases may require more diagnostics and more treatment than the average person with that particular named condition. However, the rewards and cost-savings of effective treatment (such as I received) are disproportionate as well. Medicaid would have paid for me to die very slowly and expensively, but it will not pay for the rather inexpensive treatment (generally less than 4K a year) that allows me to run around and fix desperate SuperDoc's computers so he can doc. Of course, it is so cheap because the doc trained me in some stuff that is often done by medical personnel, but still, there is something wrong with this.
Allowing insurance or boards to mandate which tests/diagnostics should be used: TechnoBuddha had useless surgery this summer for precisely this reason. Because of a possible problem, SuperDoc wanted to send him for certain tests before letting him ramp up the exercise. One of them the insurance company would not pay for - they wanted him to have another, more expensive test which their guidelines said was better. However, for some SuperDoc reason that I do not understand, SuperDoc knew that test was usually better but was likely to generate a false positive in TechnoBuddha's case. But SuperDoc could not get through to anyone at the insurance company who could understand what he was saying, so TechnoBuddha had the insurance company's test, it rendered a false positive, and TechnoBuddha then had useless surgery to treat the condition that he did not have. At some point, we just need to all give up and realize that if our doctors are that incompetent, insurance companies fiddling are bound to make it worse rather than better. (The GIGO principle rules the world. If the average doctor is incompetent, the information pool used to generate the guidelines will also be skewed. Sometimes doctors use the inexpensive, old-fashioned test FOR A REASON.)
Mandating that unneeded coverage be purchased. We have accepted the reality that we can't provide cheap Cadillac medical treatment to everyone. Thus, should the federal government be requiring that everyone purchase coverage for, say, in vitro fertilization? It strikes me that such coverage is quite useless for persons such as the Chief and I. And mandating certain dollar levels of coverage is stupid too; it makes all medical care cost more. The old major medical policies were far more cost effective. If poorer people cannot afford the initial costs of regular treatment, then the obvious way to deal with that is to directly fund them individually, rather than making the entire population adopt an economically inefficient method of paying for health care. One of the reasons we had to work all weekend to deal with SuperDoc's computers is that a staggering amount of software, manpower and electronic filings are needed just to deal with simple doctor's visits. That is one of the reasons why going to a doctor costs so much more than it used to.
Setting up a vast medical bureacracy. Krauthammer's comments on the Senate health care bill cover this issue well. I found the bill unexpectedly arresting - comic even - and spent some rather happy hours calculating the total cost before the news of the Chief's premature clearance came through. If all those boards and new studies are going to be properly funded, they would cost over a hundred billion dollars. I suspect they won't be, which will produce more medical dogma garbage, but it will still cost a lot. Every dollar you spend on overhead is a dollar not spent treating a person.
I hope I have added something to this debate. Perhaps not. However I do know that the time I spent on the SuperDoc's floor fumbling around with cables at least allowed him to continue to treat patients.
Kristof's dingbat column has an accompanying blog post. I found reading the comments to be an exercise in disbelief; almost no one comments on the fact that the man has insurance already or the other discrepancies. Here is one exception:
The difficult part was that my brother the TechnoBuddha was scheduled (while he was in the area) for a checkup with the doc. That's my doc - SuperDoc. And I had gotten the Chief an appointment with SuperDoc the day after Thanksgiving. (SuperDoc seems afraid to take more than one day off at a time, I suppose because when you are a SuperDoc you don't like abandoning your medical salvage projects to lesser docs.)
I had tested TechnoBuddha's blood sugar in April while he was with me for Easter, and he was close to veering into Type II. So I then gave him a series of instructions and shipped him off to SuperDoc, and this was a followup for that. (TechnoBuddha has lost a TON of weight since then, and is progressing nicely with his exercise program, and his blood sugars have plummeted way out of the iffy range.)
So when TechnoBuddha arrived for his appointment at 7:30 AM (SuperDoc likes to crank them through early, which leaves more time for screaming at insurance companies all afternoon, I suppose), he discovered a very frantic SuperDoc whose network was down. Apparently the guy who normally works on it fled to Europe or went there on vacation or something.. So TechnoBuddha spent most the day on Wednesday getting him at least up, which finally involved buying new cable to connect the server and the router and reprogramming the router (which cable is now duct-taped across the back office). The router was new. The network is totally undocumented - even the cables are unlabeled, and you just can't start pulling cables at random to find out what is connected to what..
SuperDoc asked TechnoBuddha to come back on Friday to fix some other problems with two computers (Vista) that had apparently never been working right since they were put in.
So TechnoBuddha asked me to come with him on Friday to work on the problem, which was pretty dire. If I had been trying to work on those two machines, and if I were not computer literate, their broken and bleeding carcasses would long ago have been found by the side of a country road. I would have considered it justifiable homocide in self-defense. Those two PCs were a crime against humanity, and I am not exaggerating.
And we were at it most of Friday before we traced enough of the network to find where everything was hooking up and what the problem really was. I am sure we looked like a couple of bumbling idiots, but when there is no documentation and no cable labelling it is hard to even find the device locations much less figure out what to change, so I spent considerable time crawling around on the floor looking at connections. Commandments 1 - 10 of dealing with computer problems can be summed up with "Always wear pants and comfortable shoes". Friday night late I downloaded manuals and researched enough to figure out possible fixes for the problem, but Saturday we ended up pinging all possible addresses to find the freakin' IP addresses to get in there to get the information we needed to fix the freakin' problem.
Both Friday and Saturday we had to do all of this while the office was running and treating patients, so it was hardly an ideal situation.
We did finish those two machines on Saturday. I think whoever fled to Europe might not want to come back. SuperDoc had been instructed to buy Windows 7 and put it on the two machines which were so problematic, but that wouldn't have fixed the problem - IMO it was the way that they were hooked up to the network devices that appeared to be causing most of the nightmare. SuperDoc is having Comcast come in to rewire the building in a few weeks, so that may help. However his network has other problems - it needs to be documented and have a bunch of things done to it for safe operation. I am writing up all of what we did and learned, and there is a lot that still needs to be done.
Of course in the middle of this, SuperDoc had looked at the Chief's records from his recent hospitalization (which were not easy to get). The Chief has an emergency appointment at the hospital up here tomorrow, because according to SuperDoc the Chief was treated by "A person with an elementary school education and a cardiologist's degree" in South Georgia. SuperDoc said it was clear that even the hospitalist had doubts, and SuperDoc advised me that it could have been possibly lethal if I had not shooed the Chief in for his SuperDoc grease and oil job. SuperDoc hasn't said much, but he seems quite agitated and he told me to be sure to go in and talk to the doctor at the hospital. So I am nervous.
Tomorrow morning early I have to go to SuperDoc's to make sure his network comes up properly, and then I rush back and get the Chief and go to the hospital. As soon as I get a clear Chief day, I have to go back to SuperDoc's and work on his computer situation some more.
So you can safely assume that blogging will be light this week. SuperDoc and the Chief come first. More than a decade ago SuperDoc administered medication to me to try to save my failing brain. He opened up his office every day for months to do it - including Sundays. Including Easter Sunday. My situation then was totally dire, and I was one of those salvage projects. I would crawl across broken glass for SuperDoc, and I know darned well he isn't earning much. He has old-fashioned medical principles and does a lot of free medical care. He won't take most Medicaid patients, because it costs him more to treat them than if he were doing it for free, but he will treat people for free, including people like me that current medical protocols consign to the "untreatable" category. There is a divine sort of symmetry involved in applying my salvaged brain to straighten out his computer situation. SuperDoc said quite plaintively that he had had about five people in to work on it, but of course you will not get good results when the thing is undocumented. .
Before I get back to network diagrams, I would like to point out this profoundly stupid op-ed by Nicholas Kristof in the NY Times Are We Going To Let John Die?. I do not believe that even the SuperDoc and the Shrink combined could sort out Kristof's mind - I think this is self-inflicted, willed mental suicide in action. The basic points are:
- This guy named John in Oregon has a very nasty growth of abnormal blood vessels in his brain. More general info here.
- The only real treatment to stop the pain and the incremental brain damage is brain surgery.
- But John can't get brain surgery, because, according to the OP-ED: Without insurance, John has been unable to get surgery or even help managing the pain. When he collapses or suffers particularly excruciating headaches, Esther rushes him to the emergency room of one hospital or another, but an E.R. can’t do much for him. One hospital has told them not to come back unless he gets insurance, they say.
- Kristof wants those senators raising questions about health care reform to feel very guilty, repent and immediately vote for it, because: If a senator strolled indifferently by as John retched in pain, we would think that person pitiless. But isn’t it just as monstrous for politicians to avert their eyes, make excuses and deny coverage to innumerable Americans just like John?
He hasn’t been able to find a doctor who will accept him as a patient for surgery, apparently because the reimbursements are so low. Doctors tell him that his condition is operable — but that they can’t accept him without conventional insurance.I am extremely sympathetic to John, considering that I too, know what it is to vomit because the headache is so bad. My last such episode was not that long ago. Last night I only slept about four hours because I was in so much pain. Pain is a feature of my daily life. I do not suffer, but I do feel pain and my body experiences the stress of it. However, what I get (and what John is not getting) is the best possible treatment that gives me the maximum of achievable functionality. I wouldn't be getting that care if I were on Medicaid, which explains some of my hostility to these bills.
But what is Kristof's point? Does Kristof know himself? The facts of this case seem to justify the senators who are asking questions and demurring on the health care bill rather than those who are willing to go ahead with it.
Under any of the current bills I've read (which is why I read them), John's coverage would not change as a result of the bill. He'd still have Medicaid; whatever his current situation, it would continue as is. If anything, some of these bills would make John's situation much, much worse due to the liability problem and the failure to pass tort reform. See NOFP's post on the subject. NOFP quotes Critical Care:
Section 261 (p. 149–150) of Speaker Pelosi's bill puts physicians in an impossible conundrum. Doctors will only be reimbursed that amount for which the health-care commissioner determines is the appropriate treatment for a particular set of symptoms. However, doctors may still be held legally liable for failing to give that care which they could or should have given if additional care is actually more appropriate for the patient's well being.And that is a big part of why John is not getting the surgery he needs, and a big part of why many doctors will do free work, but not Medicaid work, and won't be able to do much for certain patients that they would otherwise treat. If patients won't get the ancillary care because it is not funded by public insurance, it is useless to perform a dangerous operation. And unless a surgeon can get a hospital and other doctors to commit to performing the extra care, it may be very dangerous to operate on the patient and leave him in worse condition. And that would expose the doctor to a lawsuit - word has it John Edwards has some pretty big alimony to pay and that he is looking for just such patients. Medicaid reimbursements are frequently so low that a doctor does not just lose money on the time spent treating them, but if a doctor accepts a lot of Medicaid patients, that doctor may not be able to afford the cost of the malpractice insurance to cover them. (Malpractice premiums vary by specialty and by patient count.) Still, I think there is something wrong with the story as told in this column. I am pretty sure that John can get treatment in Oregon provided his condition seems treatable.
So doctors are left with a choice between providing care that they know will benefit the patient but for which they may not be reimbursed, or providing limited care for which they will be reimbursed but quite possibly also sued by the patient.
Perhaps you all may now better understand why I am so concerned about these bills, and why I may end up leaving this country if they pass in order to go to a country that doesn't have universal care and in which I can pay for my own care. Without tort reform, patients such as John and myself are likely to be in more jeopardy rather than less. With tort reform, we are liable to have expanded access to high-quality health care. See Nixon's column on medical liability and Christus Health's experience. Please note that while Massachusett's health reform attempts have produced patients without doctors and in many cases cuts in services provided specifically for those on public insurance, tort reform in Texas has produced more doctors, expanded access, and more services for people like John.
Obviously I would wish not to have the disease I do have. Unfortunately, some of the results of the disease I have are so similar to John's problem that I found it very painful to read of his situation. But I have been treated, and it is largely because I was wise enough never to fall for the sucker bait that is public insurance. It is a lie.
However, because I have been so ill, I have spent a great deal of time exposed to doctors, and the one thing I can tell you is that most of them are very good. They also like to do it. If you remove the impediments (such as crashed networks), they doc. If you just get out of their way, they doc. If you just promise not to sue them, they doc. Doctoring is what they do. The better they are, the more fanatical they are about it - and the US has some incredibly good doctors and a large mass of exceedingly good doctors. The US has doctors so damned committed to treating their patients that they have stripped themselves of all their assets and continued to treat patients without malpractice insurance. Obviously, the limit there is on how good the doc's marriage is. I do not think we wish to perpetuate a system in which the only doctors who can continue to treat large numbers of high-risk patients are those with extremely good marriages.
When even a profoundly altruistic SuperDoc has to draw the line at taking Medicaid patients that he cannot treat effectively because they will not get ancillary care, and they cost more for him to treat than free patients, one must understand that the FIRST step in health care reform should be to change our medical torts system.
These are health care reforms that will not work:
Payment by diagnosis rather than payment for service. ( This is what just happened to the Chief down in GA. He got the amount of treatment that would be reimbursed, and no more. No use ranting about private insurance companies - he is considerably older than me and is now on Medicare )
Mandated practice standards by some stupid government board. Guidelines are helpful, but in fact medicine is highly individual. All this BS about medical boards is going to be worse than useless - it will be used as a means to deny care to those who need it most (like John).
Paying doctors less if their patients are more expensive. This punishes doctors who are ordinarily the best in their particular specialities. These doctors are known to other doctors, who refer them their difficult cases. SuperDoc is on such a list, and I notice he seems to be treating a lot of other doctors. Needless to say, those cases may require more diagnostics and more treatment than the average person with that particular named condition. However, the rewards and cost-savings of effective treatment (such as I received) are disproportionate as well. Medicaid would have paid for me to die very slowly and expensively, but it will not pay for the rather inexpensive treatment (generally less than 4K a year) that allows me to run around and fix desperate SuperDoc's computers so he can doc. Of course, it is so cheap because the doc trained me in some stuff that is often done by medical personnel, but still, there is something wrong with this.
Allowing insurance or boards to mandate which tests/diagnostics should be used: TechnoBuddha had useless surgery this summer for precisely this reason. Because of a possible problem, SuperDoc wanted to send him for certain tests before letting him ramp up the exercise. One of them the insurance company would not pay for - they wanted him to have another, more expensive test which their guidelines said was better. However, for some SuperDoc reason that I do not understand, SuperDoc knew that test was usually better but was likely to generate a false positive in TechnoBuddha's case. But SuperDoc could not get through to anyone at the insurance company who could understand what he was saying, so TechnoBuddha had the insurance company's test, it rendered a false positive, and TechnoBuddha then had useless surgery to treat the condition that he did not have. At some point, we just need to all give up and realize that if our doctors are that incompetent, insurance companies fiddling are bound to make it worse rather than better. (The GIGO principle rules the world. If the average doctor is incompetent, the information pool used to generate the guidelines will also be skewed. Sometimes doctors use the inexpensive, old-fashioned test FOR A REASON.)
Mandating that unneeded coverage be purchased. We have accepted the reality that we can't provide cheap Cadillac medical treatment to everyone. Thus, should the federal government be requiring that everyone purchase coverage for, say, in vitro fertilization? It strikes me that such coverage is quite useless for persons such as the Chief and I. And mandating certain dollar levels of coverage is stupid too; it makes all medical care cost more. The old major medical policies were far more cost effective. If poorer people cannot afford the initial costs of regular treatment, then the obvious way to deal with that is to directly fund them individually, rather than making the entire population adopt an economically inefficient method of paying for health care. One of the reasons we had to work all weekend to deal with SuperDoc's computers is that a staggering amount of software, manpower and electronic filings are needed just to deal with simple doctor's visits. That is one of the reasons why going to a doctor costs so much more than it used to.
Setting up a vast medical bureacracy. Krauthammer's comments on the Senate health care bill cover this issue well. I found the bill unexpectedly arresting - comic even - and spent some rather happy hours calculating the total cost before the news of the Chief's premature clearance came through. If all those boards and new studies are going to be properly funded, they would cost over a hundred billion dollars. I suspect they won't be, which will produce more medical dogma garbage, but it will still cost a lot. Every dollar you spend on overhead is a dollar not spent treating a person.
I hope I have added something to this debate. Perhaps not. However I do know that the time I spent on the SuperDoc's floor fumbling around with cables at least allowed him to continue to treat patients.
Kristof's dingbat column has an accompanying blog post. I found reading the comments to be an exercise in disbelief; almost no one comments on the fact that the man has insurance already or the other discrepancies. Here is one exception:
I am not completely certain but I believe your column distorts the facts. Under EMTALA a hospital cannot mandate insurance coverage as a condition of treatment. Under HIPAA laws the maximum length of time John’s wife can exclude coverage to John is twelve months. Oregon is one of the highest paying States for Medicaid reimbursements.Here is another comment that seems to bear out my suspicions that John can get treatment if surgeons believe it will help him. There may be details about his case that make success problematic; I note that Kristof did not speak to any doctors. One commented on the blog:
I was a physician who accepted Medicaid. They would pay me $120 for a bunion operation. I would have to pay for all the supplies, sutures, injectables and fixation devices. So if I wanted to use a titanium screw to fix the surgical fracture of bone necessary for the surgery, I would have to pay more for the screw set than the surgery paid. Plus the surgery included a 90 day global period. Meaning that the first 90 days I would receive no more fee than the original $120. And all of this because I chose to do the surgery in my off ice operatory rather than waste time admitting a patient to the hospital for a simple procedure under local. Health care reform needs to start in the doctor’s office and not in the insurance company’s bank account.This entire debate is being conducted in an atmosphere of indignant evasion of reality. It seems that no one but the persons involved in actually treating patients are taking this seriously. The result is likely to be very bad. See also a neurosurgeon's comment here.
Wednesday, November 25, 2009
Happy Thanksgiving
Among those climate "science" files hacked and distributed were a bunch of programming files.
WUWT has a set of comment segments. My favorite "
WUWT has a set of comment segments. My favorite "
What the hell is
supposed to happen here? Oh yeah - there is no 'supposed', I can make it up. So I have :-)"
The loneliness of the long distance climate programmer.
Mechanics I
Yesterday's GDP update for Q3 was more in line with what I had, and it implies that Q4 should show continued growth, and perhaps more growth than Q3.
So why am I so relatively pessimistic about 2010? Well, the first reason is compounded of some of the signs from Asia, which is improving. But growth in China is sustained mostly on a huge stimulus and a huge asset boom, and that has a known ending. Nor will it continue for years - by the end of 2010 some of their banks are going to be in trouble, and China's regulators are aware of the risks. Even rumors that banks will have to raise capital produce a massive fall in Chinese assets - so they appear to be in a tight spot.
Japan's growth is reported as good, but in nominal terms, Japan's economy is still shrinking. Workers' incomes have fallen 2.6% in nominal terms over the last year, and disposable income has fallen 2.9%. Of course CPI is falling as well, but their incomes are still declining in real terms, and the problem should be obvious. Singapore is not much better - take a look at the latest stats from Singapore and tell me what YOU think. I am not hugely bullish on Asia; India and China have maintained GDP growth with a lot of money infusions, but Chinese CPI is down, which makes me think they have a circulation problem. India is the bright spot, but they are now suffering inflation, especially in food.
Incomes are dropping quite hard in almost all of Europe's ring of fire. Ireland and Spain are in unambiguous depressions, as are some of the Baltics. The larger ex Soviets have experienced hard recessions, but one of the main future worries are that incomes are often dropping and there are a lot of foreign currency loans. Things will slowly improve on manufacturing, but those loans are a big worry for consumers; industrial production is no where near its former levels, and government debt is becoming an even bigger worry. Hungary is hard-hit, but Czech auto exports are falling, causing more concern, although by any measure Czech prospects for 2010 are better. Poland is the stand-out for 2009; the Polish economy generates pretty healthy internal demand. For a broader read on Europe, see the Q3 flash. Unemployment stats here. I am still working through Europe, so I don't have a conclusion.
For the US I have done much more, and I am still not very optimistic due to the basic mechanical structure.
The problem is that our current downturn is most similar to the 79-82 period, during which the US went through two periods of declining GDP. Click on this graph and open it up in another tab or window.
Note the Fed Funds rate in the late 70s-early 80s graphed against the producer price index, the consumer price index and the unemployment rate.
Raising rates suppressed the underlying rate of producer price increases, which restored the ability of companies to make money. But it came at the cost of crushing credit (who can borrow at those rates?) and produced a very difficult recession with an extraordinarily high unemployment rate. However, once inflation had been crushed economic growth and credit growth could resume, and there was no protracted drag on the US economy.
This graph shows how we got out of the 80s recession by looking at household sector debt (mostly mortgages at that time), housing starts and total gross private domestic investment. Debt is shown as the percent change from a year ago (left axis), and housing starts and GPDI are shown in units (right axis).
Because interest rates had fallen so sharply from their peak, housing affordability increased suddenly and very significantly, which sparked a round of building, which created jobs..... Etc.
This graph is the same as the one above but it includes the Fed Funds rate.
But we will not have the same dynamic this recession, because we are maxed out on consumer debt (even with a staggeringly low Fed Funds rate). Now we have to depend on the business sector or government for growth in GPDI, and it is hard for either to generate the same type of domestic boom.
Worse yet, if the Fed stops buying mortgage securities, mortgage interest rates are due to rise significantly. Also there is no doubt that mortgage lending standards will have to tighten; the agencies (especially FHA) are experiencing horrendous defaults. Low rates plus high losses = debt no one but the government will buy. And then those housing credits are due to expire....
So basically the housing outlook over the next couple of years is worse than it has been over the last few months. Beyond that, we can only hope for consumer boosts from must-have buying, irrational exuberance, or lower debt loads. Incomes are not increasing for most workers as tax receipts show; the retirement bulge is hitting; and overall taxable wages are still declining. There will therefore be only a marginal consumer pickup.
Needless to say no one is making a lot of money off interest. And worse yet, cost inputs for production are still rising. True, we have reached the Schumpeter turn according to tax receipts - corporate profits are rising - but will that provide enough carrying wave of growth to overcome the real income drops among consumers?
What you see in the latest update to CFNAI is a signal showing that the carrying signal is just not there:
Compare the CFNAI signals from the 1980s downturn to our current downturn. The 1982 recession ended in November. (Recession dating, NBER)
These are the one month CFNAI indexes for the end of the 1982 recession:
Nov: -1.03
Dec. -0.77
Jan. +1.37
Feb. -0.66
Mar. +0.83
Coming to the present:
Now you will note that one month CFNAI has been headed down for a while, and the three month average has now followed.
Postulating that the current growth cycle started in June (many have it in July), here are the comparable months:
May: -2.42
June -1.81
July -0.37
Aug. -0.63
Sep. -1.01
And now October came in at -1.08. We just never climbed out of the hole.
The Fed can fiddle with the timing of the next leg down a bit, but it appears to be coming. Any theory (and it is the Fed's theory) that increased business profits will spark a slow steady growth cycle appears to be foundering on compressed business profit margins, meaning that many large companies are still cutting to try to bolster up profits. Because:
Incomes are not rising (right scale, indexed to 12/2007) and real retail sales (left) are going sideways, and producer prices are slowly rising (right). This is not a recipe for profits, especially since the value of commercial real estate is dropping.
The next impetus that could really help us are consumer debt defaults and writedowns. Once people clear enough debt, they'll have more income left for other things. However that takes years, and the collapse in incomes (aggregate matters less than median) means that the go-to number keeps sliding down a bit.
If people can't spend from rising incomes, and if they aren't able or willing to borrow, and if input costs are rising, the only place companies can look for sustained growth is to external sales. It is not necessarily true that investment related to external sales will be put into the US, which means that GPDI probably will fall next year. And that is the horror scenario.
PS: Happy Thanksgiving, and here is an updated pretty graph of CFNAI:
So why am I so relatively pessimistic about 2010? Well, the first reason is compounded of some of the signs from Asia, which is improving. But growth in China is sustained mostly on a huge stimulus and a huge asset boom, and that has a known ending. Nor will it continue for years - by the end of 2010 some of their banks are going to be in trouble, and China's regulators are aware of the risks. Even rumors that banks will have to raise capital produce a massive fall in Chinese assets - so they appear to be in a tight spot.
Japan's growth is reported as good, but in nominal terms, Japan's economy is still shrinking. Workers' incomes have fallen 2.6% in nominal terms over the last year, and disposable income has fallen 2.9%. Of course CPI is falling as well, but their incomes are still declining in real terms, and the problem should be obvious. Singapore is not much better - take a look at the latest stats from Singapore and tell me what YOU think. I am not hugely bullish on Asia; India and China have maintained GDP growth with a lot of money infusions, but Chinese CPI is down, which makes me think they have a circulation problem. India is the bright spot, but they are now suffering inflation, especially in food.
Incomes are dropping quite hard in almost all of Europe's ring of fire. Ireland and Spain are in unambiguous depressions, as are some of the Baltics. The larger ex Soviets have experienced hard recessions, but one of the main future worries are that incomes are often dropping and there are a lot of foreign currency loans. Things will slowly improve on manufacturing, but those loans are a big worry for consumers; industrial production is no where near its former levels, and government debt is becoming an even bigger worry. Hungary is hard-hit, but Czech auto exports are falling, causing more concern, although by any measure Czech prospects for 2010 are better. Poland is the stand-out for 2009; the Polish economy generates pretty healthy internal demand. For a broader read on Europe, see the Q3 flash. Unemployment stats here. I am still working through Europe, so I don't have a conclusion.
For the US I have done much more, and I am still not very optimistic due to the basic mechanical structure.
The problem is that our current downturn is most similar to the 79-82 period, during which the US went through two periods of declining GDP. Click on this graph and open it up in another tab or window.
Note the Fed Funds rate in the late 70s-early 80s graphed against the producer price index, the consumer price index and the unemployment rate.
Raising rates suppressed the underlying rate of producer price increases, which restored the ability of companies to make money. But it came at the cost of crushing credit (who can borrow at those rates?) and produced a very difficult recession with an extraordinarily high unemployment rate. However, once inflation had been crushed economic growth and credit growth could resume, and there was no protracted drag on the US economy.
This graph shows how we got out of the 80s recession by looking at household sector debt (mostly mortgages at that time), housing starts and total gross private domestic investment. Debt is shown as the percent change from a year ago (left axis), and housing starts and GPDI are shown in units (right axis).
Because interest rates had fallen so sharply from their peak, housing affordability increased suddenly and very significantly, which sparked a round of building, which created jobs..... Etc.
This graph is the same as the one above but it includes the Fed Funds rate.
But we will not have the same dynamic this recession, because we are maxed out on consumer debt (even with a staggeringly low Fed Funds rate). Now we have to depend on the business sector or government for growth in GPDI, and it is hard for either to generate the same type of domestic boom.
Worse yet, if the Fed stops buying mortgage securities, mortgage interest rates are due to rise significantly. Also there is no doubt that mortgage lending standards will have to tighten; the agencies (especially FHA) are experiencing horrendous defaults. Low rates plus high losses = debt no one but the government will buy. And then those housing credits are due to expire....
So basically the housing outlook over the next couple of years is worse than it has been over the last few months. Beyond that, we can only hope for consumer boosts from must-have buying, irrational exuberance, or lower debt loads. Incomes are not increasing for most workers as tax receipts show; the retirement bulge is hitting; and overall taxable wages are still declining. There will therefore be only a marginal consumer pickup.
Needless to say no one is making a lot of money off interest. And worse yet, cost inputs for production are still rising. True, we have reached the Schumpeter turn according to tax receipts - corporate profits are rising - but will that provide enough carrying wave of growth to overcome the real income drops among consumers?
What you see in the latest update to CFNAI is a signal showing that the carrying signal is just not there:
Compare the CFNAI signals from the 1980s downturn to our current downturn. The 1982 recession ended in November. (Recession dating, NBER)These are the one month CFNAI indexes for the end of the 1982 recession:
Nov: -1.03
Dec. -0.77
Jan. +1.37
Feb. -0.66
Mar. +0.83
Coming to the present:
Now you will note that one month CFNAI has been headed down for a while, and the three month average has now followed.
Postulating that the current growth cycle started in June (many have it in July), here are the comparable months:
May: -2.42
June -1.81
July -0.37
Aug. -0.63
Sep. -1.01
And now October came in at -1.08. We just never climbed out of the hole.
The Fed can fiddle with the timing of the next leg down a bit, but it appears to be coming. Any theory (and it is the Fed's theory) that increased business profits will spark a slow steady growth cycle appears to be foundering on compressed business profit margins, meaning that many large companies are still cutting to try to bolster up profits. Because:
Incomes are not rising (right scale, indexed to 12/2007) and real retail sales (left) are going sideways, and producer prices are slowly rising (right). This is not a recipe for profits, especially since the value of commercial real estate is dropping.
The next impetus that could really help us are consumer debt defaults and writedowns. Once people clear enough debt, they'll have more income left for other things. However that takes years, and the collapse in incomes (aggregate matters less than median) means that the go-to number keeps sliding down a bit.
If people can't spend from rising incomes, and if they aren't able or willing to borrow, and if input costs are rising, the only place companies can look for sustained growth is to external sales. It is not necessarily true that investment related to external sales will be put into the US, which means that GPDI probably will fall next year. And that is the horror scenario.
PS: Happy Thanksgiving, and here is an updated pretty graph of CFNAI:Friday, November 20, 2009
AGW Info Just Wants To Be Free
See Shrinkwrapped, Watts Up, The Reference Frame. ClimateAudit is unobtainable, but will have lots good. www.climateaudit.org.
I'm still reading the healthcare bill, so I can't really read this massive group of files, but this is hawt:
In other words, there ain't no science in climate science. The reason for this attitude can be explained by the flood of grant money it produces. It is easy to believe anything when you get millions of dollars for believing it.
This is no surprise to anyone who has been watching the mutatis mutandis of official climate records over the last decade. It's merely very entertaining.
Also see James Delingpole and Andrew Bolt who both have a bunch of excerpts.
Langmuir's "Colluquium On Pathological Science" is online at this site, and may be relevant. This talk was given in the 1950s. I had heard about it and read an excerpt but I had never encountered the whole lecture. I got the link from comments on this Althouse post.
Symptoms of Pathological Science:
I'm still reading the healthcare bill, so I can't really read this massive group of files, but this is hawt:
From: Tom Wigley [...]The ah, implicit mind set is that they can do anything with the data they want - there is no respect for whatever the real measurements may be - but the result should be plausible.
To: Phil Jones [...]
Subject: 1940s
Date: Sun, 27 Sep 2009 23:25:38 -0600
Cc: Ben Santer [...]
Phil,
Here are some speculations on correcting SSTs to partly explain the 1940s warming blip. If you look at the attached plot you will see that theland also shows the 1940s blip (as I’m sure you know).
So, if we could reduce the ocean blip by, say, 0.15 degC, then this would be significant for the global mean – but we’d still have to explain the land blip. I’ve chosen 0.15 here deliberately. This still leaves an ocean blip, and i think one needs to have some form of ocean blip to explain the land blip (via either some common forcing, or ocean forcing land, or vice versa, or all of these). When you look at other blips, the land blips are 1.5 to 2 times (roughly) the ocean blips—higher sensitivity plus thermal inertia effects. My 0.15 adjustment leaves things consistent with this, so you can see where I am coming from.
Removing ENSO does not affect this.
It would be good to remove at least part of the 1940s blip, but we are still left with “why the blip”.
In other words, there ain't no science in climate science. The reason for this attitude can be explained by the flood of grant money it produces. It is easy to believe anything when you get millions of dollars for believing it.
This is no surprise to anyone who has been watching the mutatis mutandis of official climate records over the last decade. It's merely very entertaining.
Also see James Delingpole and Andrew Bolt who both have a bunch of excerpts.
Langmuir's "Colluquium On Pathological Science" is online at this site, and may be relevant. This talk was given in the 1950s. I had heard about it and read an excerpt but I had never encountered the whole lecture. I got the link from comments on this Althouse post.
Symptoms of Pathological Science:
- The maximum effect that is observed is produced by a causative agent of barely detectable intensity, and the magnitude of the effect is substantially independent of the intensity of the cause.
- The effect is of a magnitude that remains close to the limit of detectability; or, many measurements are necessary because of the very low statistical significance of the results.
- Claims of great accuracy.
- Fantastic theories contrary to experience.
- Criticisms are met by ad hoc excuses thought up on the spur of the moment.
- Ratio of supporters to critics rises up to somewhere near 50% and then falls gradually to oblivion.
Thursday, November 19, 2009
Senate Health Care Bill
Update: While I'm reading, go check out Carl at NOFP's post on how many Americans are really uninsured. I believe the data he cites to be good, and my conclusion on these bills has so far been that they would raise, not lower, the number of uninsured Americans. The reason for this is that they will all raise the cost of insurance and mandate additional coverage; the inevitable result will be that many Americans will lose coverage. End Update.
Patient Protection and Affordable Health Care Act, now substituted for the original text in 3590. You can read it here.
I copied the table of contents below. I am going to concentrate on the revenue section first. I highlighted all the sections I'm going to read with special attention.
Curiosity drives the interest in the hospice programs and the "nondiscrimination" provisions relating to assisted suicide (coverage?). Hospices that don't manage to shuffle their patients off to the mortuary have been under severe pressure lately; people think that hospices save a great deal of money, but they often don't. It will be interesting to see what they come up with next. My guess is they want 'em dead within two weeks. The problem is that sometimes terminally ill people recover on their own or experience substantial remissions, so the only way to accomplish the two week plan is basically to off the hospice patients by giving them enough drugs to suppress their breathing, knock 'em out, no liquids - they die quickly from pneumonia.
Patient Protection and Affordable Health Care Act, now substituted for the original text in 3590. You can read it here.
I copied the table of contents below. I am going to concentrate on the revenue section first. I highlighted all the sections I'm going to read with special attention.
Curiosity drives the interest in the hospice programs and the "nondiscrimination" provisions relating to assisted suicide (coverage?). Hospices that don't manage to shuffle their patients off to the mortuary have been under severe pressure lately; people think that hospices save a great deal of money, but they often don't. It will be interesting to see what they come up with next. My guess is they want 'em dead within two weeks. The problem is that sometimes terminally ill people recover on their own or experience substantial remissions, so the only way to accomplish the two week plan is basically to off the hospice patients by giving them enough drugs to suppress their breathing, knock 'em out, no liquids - they die quickly from pneumonia.
‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS
‘‘SUBPART II—IMPROVING COVERAGE
‘‘Sec. 2711. No lifetime or annual limits.
‘‘Sec. 2712. Prohibition on rescissions.
‘‘Sec. 2713. Coverage of preventive health services.
‘‘Sec. 2714. Extension of dependent coverage.
‘‘Sec. 2715. Development and utilization of uniform explanation of coverage
documents and standardized definitions.
‘‘Sec. 2716. Prohibition of discrimination based on salary.
‘‘Sec. 2717. Ensuring the quality of care.
‘‘Sec. 2718. Bringing down the cost of health care coverage.
‘‘Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B—Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting
condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify affordable
coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C—Quality Health Insurance Coverage for All Americans
PART I—HEALTH INSURANCE MARKET REFORMS
Sec. 1201. Amendment to the Public Health Service Act.
‘‘SUBPART I—GENERAL REFORM
‘‘Sec. 2701. Fair health insurance premiums.
‘‘Sec. 2702. Guaranteed availability of coverage.
‘‘Sec. 2703. Guaranteed renewability of coverage.
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination
based on health status.
‘‘Sec. 2705. Prohibiting discrimination against individual participants and
beneficiaries based on health status.
‘‘Sec. 2706. Non-discrimination in health care.
‘‘Sec. 2707. Comprehensive health insurance coverage.
‘‘Sec. 2708. Prohibition on excessive waiting periods.
PART II—OTHER PROVISIONS
Sec. 1251. Preservation of right to maintain existing coverage.
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Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers
and group health plans.
Sec. 1253. Effective dates.
Subtitle D—Available Coverage Choices for All Americans
PART I—ESTABLISHMENT OF QUALIFIED HEALTH PLANS
Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.
PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH
HEALTH BENEFIT EXCHANGES
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III—STATE FLEXIBILITY RELATING TO EXCHANGES
Sec. 1321. State flexibility in operation and enforcement of Exchanges and related
requirements.
Sec. 1322. Federal program to assist establishment and operation of nonprofit,
member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS
Sec. 1331. State flexibility to establish basic health programs for low-income individuals
not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one State.
PART V—REINSURANCE AND RISK ADJUSTMENT
Sec. 1341. Transitional reinsurance program for individual and small group
markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and small
group markets.
Sec. 1343. Risk adjustment.
Subtitle E—Affordable Coverage Choices for All Americans
PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Sec. 1401. Refundable tax credit providing premium assistance for coverage
under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health
plans.
SUBPART B—ELIGIBILITY DETERMINATIONS
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Sec. 1411. Procedures for determining eligibility for Exchange participation,
premium tax credits and reduced cost-sharing , and individual
responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and
cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an exchange and
State Medicaid, CHIP, and health subsidy programs.
Sec. 1414. Disclosures to carry out eligibility requirements for certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded
for Federal and Federally-assisted programs.
PART II—SMALL BUSINESS TAX CREDIT
Sec. 1421. Credit for employee health insurance expenses of small businesses.
Subtitle F—Shared Responsibility for Health Care
PART I—INDIVIDUAL RESPONSIBILITY
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
PART II—EMPLOYER RESPONSIBILITIES
Sec. 1511. Automatic enrollment for employees of large employers.
Sec. 1512. Employer requirement to inform employees of coverage options.
Sec. 1513. Shared responsibility for employers.
Sec. 1514. Reporting of employer health insurance coverage.
Sec. 1515. Offering of Exchange-participating qualified health plans through
cafeteria plans.
Subtitle G—Miscellaneous Provisions
Sec. 1551. Definitions.
Sec. 1552. Transparency in government.
Sec. 1553. Prohibition against discrimination on assisted suicide.
Sec. 1554. Access to therapies.
Sec. 1555. Freedom not to participate in Federal health insurance programs.
Sec. 1556. Equity for certain eligible survivors.
Sec. 1557. Nondiscrimination.
Sec. 1558. Protections for employees.
Sec. 1559. Oversight.
Sec. 1560. Rules of construction.
Sec. 1561. Health information technology enrollment standards and protocols.
Sec. 1562. Conforming amendments.
TITLE II—ROLE OF PUBLIC PROGRAMS
Subtitle A—Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified gross income.
Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
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Sec. 2006. Special adjustment to FMAP determination for certain States recovering
from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B—Enhanced Support for the Children’s Health Insurance Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C—Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health Insurance
Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations
for all Medicaid eligible populations.
Subtitle D—Improvements to Medicaid Services
Sec. 2301. Coverage for freestanding birth center services.
Sec. 2302. Concurrent care for children.
Sec. 2303. State eligibility option for family planning services.
Sec. 2304. Clarification of definition of medical assistance.
Subtitle E—New Options for States to Provide Long-Term Services and
Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based services
against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F—Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual eligible
beneficiaries.
Subtitle I—Improving the Quality of Medicaid for Patients and Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.
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Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J—Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.
Subtitle K—Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B
services furnished by certain indian hospitals and clinics.
Subtitle L—Maternal and Child Health Services
Sec. 2951. Maternal, infant, and early childhood home visiting programs.
Sec. 2952. Support, education, and research for postpartum depression.
Sec. 2953. Personal responsibility education.
Sec. 2954. Restoration of funding for abstinence education.
Sec. 2955. Inclusion of information about the importance of having a health
care power of attorney in transition planning for children aging
out of foster care and independent living programs.
TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF
HEALTH CARE
Subtitle A—Transforming the Health Care Delivery System
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE
MEDICARE PROGRAM
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation
hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities
and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measurement.
Sec. 3015. Data collection; public reporting.
PART III—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 3022. Medicare shared savings program. (739)Sec. 3023. National pilot program on payment bundling.
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Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
Subtitle B—Improving Medicare for Patients and Providers
PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER
SERVICES
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions to the
practice expense geographic adjustment under the Medicare
physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain physician
pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care hospital services
and of moratorium on the establishment of certain hospitals
and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital extended care
services.
Sec. 3109. Exemption of certain pharmacies from accreditation requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II—RURAL PROTECTIONS
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical
diagnostic laboratory tests furnished to hospital patients in certain
rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment
adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community health integration
models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care
providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital services.
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.
PART III—IMPROVING PAYMENT ACCURACY
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform. (page 836)
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH)
payments.
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Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced imaging
services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the calculation
of the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Subtitle C—Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment
transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and
MA–PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income
benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under
prescription drug plans and MA–PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility for lowincome
assistance.
Sec. 3305. Improved information for subsidy eligible individuals reassigned to
prescription drug plans and MA–PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans and
MA–PD plans with respect to certain categories or classes of
drugs.
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in
long-term care facilities under prescription drug plans and
MA–PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan complaint
system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans
and MA–PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian
Health Service in providing prescription drugs toward the
annual out-of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
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Subtitle E—Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation of productivity
improvements into market basket updates that do not
already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F—Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement technical
assistance.
Sec. 3502. Establishing community health teams to support the patient-centered
medical home.
Sec. 3503. Medication management services in treatment of chronic disease.
Sec. 3504. Design and implementation of regionalized systems for emergency
care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk information.
Sec. 3508. Demonstration program to integrate quality improvement and patient
safety training into clinical education of health professionals.
Sec. 3509. Improving women’s health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING
PUBLIC HEALTH
Subtitle A—Modernizing Disease Prevention and Public Health Systems
Sec. 4001. National Prevention, Health Promotion and Public Health Council.
Sec. 4002. Prevention and Public Health Fund.
Sec. 4003. Clinical and community preventive services.
Sec. 4004. Education and outreach campaign regarding preventive benefits.
Subtitle B—Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized
prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant
women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C—Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention
and wellness programs for Medicare beneficiaries.
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Sec. 4203. Removing barriers and improving access to wellness for individuals
with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants.
Sec. 4206. Demonstration project concerning individualized wellness plan.
Sec. 4207. Reasonable break time for nursing mothers.
Subtitle D—Support for Prevention and Public Health Innovation
Sec. 4301. Research on optimizing the delivery of public health services.
Sec. 4302. Understanding health disparities: data collection and analysis.
Sec. 4303. CDC and employer-based wellness programs.
Sec. 4304. Epidemiology-Laboratory Capacity Grants.
Sec. 4305. Advancing research and treatment for pain care management.
Sec. 4306. Funding for Childhood Obesity Demonstration Project.
Subtitle E—Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V—HEALTH CARE WORKFORCE
Subtitle A—Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B—Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
Subtitle C—Increasing the Supply of the Health Care Workforce
Sec. 5201. Federally supported student loan funds.
Sec. 5202. Nursing student loan program.
Sec. 5203. Health care workforce loan repayment programs.
Sec. 5204. Public health workforce recruitment and retention programs.
Sec. 5205. Allied health workforce recruitment and retention programs.
Sec. 5206. Grants for State and local programs.
Sec. 5207. Funding for National Health Service Corps.
Sec. 5208. Nurse-managed health clinics.
Sec. 5209. Elimination of cap on commissioned corps.
Sec. 5210. Establishing a Ready Reserve Corps.
Subtitle D—Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine, general pediatrics,
and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration project.
Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric
education.
Sec. 5306. Mental and behavioral health education and training grants.
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Sec. 5307. Cultural competency, prevention, and public health and individuals
with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.
Subtitle E—Supporting the Existing Health Care Workforce
Sec. 5401. Centers of excellence.
Sec. 5402. Health care professionals training for diversity.
Sec. 5403. Interdisciplinary, community-based linkages.
Sec. 5404. Workforce diversity grants.
Sec. 5405. Primary care extension program.
Subtitle F—Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in outpatient settings and allowing flexibility
for jointly operated residency training programs.
Sec. 5505. Rules for counting resident time for didactic and scholarly activities
and other activities.
Sec. 5506. Preservation of resident cap positions from closed hospitals.
Sec. 5507. Demonstration projects To address health professions workforce
needs; extension of family-to-family health information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G—Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and criteria
for designating medically underserved populations and health
professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for
Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based mental
health settings.
Sec. 5605. Key National indicators.
Subtitle H—General Provisions
Sec. 5701. Reports.
TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A—Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician
referrals for hospitals.
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Sec. 6002. Transparency reports and reporting of physician ownership or investment
interests.
Sec. 6003. Disclosure requirements for in-office ancillary services exception to
the prohibition on physician self-referral for certain imaging
services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B—Nursing Home Transparency and Improvement
PART I—IMPROVING TRANSPARENCY OF INFORMATION
Sec. 6101. Required disclosure of ownership and additional disclosable parties
information.
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing
facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
PART II—TARGETING ENFORCEMENT
Sec. 6111. Civil money penalties.
Sec. 6112. National independent monitor demonstration project.
Sec. 6113. Notification of facility closure.
Sec. 6114. National demonstration projects on culture change and use of information
technology in nursing homes.
PART III—IMPROVING STAFF TRAINING
Sec. 6121. Dementia and abuse prevention training.
Subtitle C—Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and Providers
Sec. 6201. Nationwide program for National and State background checks on
direct patient access employees of long-term care facilities and
providers.
Subtitle D—Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness research.
Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under Medicare,
Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity and
Protection Data Bank and the National Practitioner Data
Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to not
more than 12 months.
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Sec. 6405. Physicians who order items or services required to be Medicare enrolled
physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on referrals to
programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before physicians may
certify eligibility for home health services or durable medical
equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics,
orthotics, and supplies competitive acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F—Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if terminated
under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain ownership,
control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to
register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under MMIS
to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located outside of
the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G—Additional Program Integrity Provisions
Sec. 6601. Prohibition on false statements and representations.
Sec. 6602. Clarifying definition.
Sec. 6603. Development of model uniform report form.
Sec. 6604. Applicability of State law to combat fraud and abuse.
Sec. 6605. Enabling the Department of Labor to issue administrative summary
cease and desist orders and summary seizures orders against
plans that are in financially hazardous condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential communications.
Subtitle H—Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
Subtitle I—Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL
THERAPIES
Subtitle A—Biologics Price Competition and Innovation
Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
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Sec. 7003. Savings.
Subtitle B—More Affordable Medicines for Children and Underserved
Communities
Sec. 7101. Expanded participation in 340B program.
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B program.
TITLE VIII—CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for purchasing
community living assistance services and support.
TITLE IX—REVENUE PROVISIONS
Subtitle A—Revenue Offset Provisions
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2.
Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and Archer
MSAs not used for qualified medical expenses.
Sec. 9005. Limitation on health flexible spending arrangements under cafeteria
plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical
manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D
subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health insurance
providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.
Subtitle B—Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments.
Sec. 9022. Establishment of simple cafeteria plans for small businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
