CHAPTER 12
STATUTORY CHANGES
“Bad laws are the worst sort of tyranny.” - Edmund Burke
“A pirate was captured and brought before Alexander the Great.
Alexander asked the pirate:
'How dare you molest the people?'
The pirate replied: 'And how dare you molest the entire world? I am called a thief because I do it with a little ship only. You do it with a great navy and you are called an Emperor!'”
§ 12.1.0 HEALTH CARE ACCESS FOR ALL
§ 12.1.1 In
§ 12.1.2 As health insurance premiums have skyrocketed, small businesses are finding it increasingly difficult to offer health insurance to employees and compete.
§ 12.1.3 In 2000, one percent of people had to pay a $1,000 deductible or more. In 2008, 18 percent of people had to pay a $1,000 deductible or more. Inflation hasn’t increased that much, now!
§ 12.1.4 Having to pay that first $1,000 makes one really think, “can I afford to do without this procedure?” Thus, it is doing what private insurance companies designed it to achieve. At least, it does so in January among the poor.
§ 12.1.5 For profit companies must fund health insurance for all employees equally, based upon some standard, such as $1,800 a year plus five percent of salaries, bonuses, profits, and investments. It must be affordable, so, these figures ought to be negotiated. Of course, employers in a position to contribute more can do so. These contributions would take the form of vouchers given to each employee. Risk would not be based on the individual or employer. All risk would be divided equally across the 300 million Americans. Each employee would then select insurance plans best for him or her, with that voucher, augmented, if need be, by their own resources or by the federal government.
§ 12.1.6 Start-up corporations without profits or bonuses and with certain average salaries and within targeted investments ought to pay significantly reduced health insurance premiums for the first, say, 3 years, and the government would pay toward premiums for employees while the start-up business gets established. If that start-up business is sold or transferred, the government might have the right to assess it for health care costs that it paid for employees, assuming the sale or transfer results in profit early in its operation.
§ 12.1.7 Not-for-profits must fund health insurance for all employees equally, based upon some standard, such as at least six percent of salaries AND bonuses plus three percent of investments.
§ 12.1.8 More is always ok, and, when recruiting highly sought employees, it might be necessary.
§ 12.1.9 All premiums and medically necessary expenses will receive a full tax rebate. Medically recommended expenses will receive a deduction, and elective procedures might be subject to a modest excise tax. Employers may provide additional assistance or transfer of vacation / sick days when employees are ill, provided that that additional assistance or transfer is equally available to all when they are in need.
§ 12.1.10 – The government would reach up and pay premium difference for those whose employer can only contribute
small amounts or whose average employer salaries only merit small employer contributions, based on the
employee’s salary, number of dependents, and regional medical costs.
§ 12.1.11 - Individuals who receive an amount greater than the cost of the insurance plan they purchase may place
balances in an untaxed, roll-over Life Savings Account (LSA) (interchangeable for health, college savings, and retirement) that can be transferred upon death for use by dependents for their LSA, college, or retirement.
§ 12.1.12 - Everyone would have an LSA and the excess payments from a HFC, say $5 a day that it is used, would be
credited to their LSA. A monthly HFC fee would be taken from their LSA for as long as they remain members of that HFC. If the policy they select costs less than the insurance contributions from their employer and / or government, then the balance would be placed into an LSA.
§ 12.1.13 - We could purchase into plans offered by the government, private for-profit sector, and private not-for-profit
sector. Each of these plans would be available across state lines. These plans could be mix-matched by each American. As plans would be available across state lines, the federal government would now regulate the health insurance industry and it would be subject to provisions of the Sherman Anti-trust Act.
§ 12.1.14 - Employees working 1 hour a week could purchase health insurance and their employer would contribute, say,
$1.25 a week (1/40th that of other employees) while the government and individual would pay the difference. The CEO of United Health, earning $8 million would contribute $640,000 into the employee health insurance account each year, to be divided among UH’s 75,000 employees equally, netting them $8.53 each. If he were to obtain a $1.6 billion bonus, the $128,000,000 would be put into the employee healthcare pool and the 75,000 UH employees would net an extra $1,706.63 each that year.
§ 12.1.15 – An astounding 36 percent of people who applied for health insurance were denied coverage due to a pre-
existing condition! If people are trying to obtain coverage and the private insurance companies deny coverage, why do we continue to blame all of the 47 million people without health insurance?
§ 12.1.16 – One study found 20,000 rescissions by health insurance companies in just one year saved them $300 million
in that year alone! Dropping people who in good faith have purchased insurance with your insurance company and make good faith payments and then have insurance rescinded does not seem fair. Some of the reasons cited for rescissions seems like a stretch (e.g., denying cancer care because five years earlier when the consumer applied for insurance, they did not cite a case of acne 15 years earlier). If there is intent to defraud the insurance company or that the pre-existing condition were known, where very recent, and directly related to the condition for which rescission is offered, then rescission would seem reasonable.
§ 12.1.17 - Every year, insurers ought to send a one page letter, written at the 6th grade reading level, that shows the
total revenues for that specific policy category (say vision), medical costs paid, administrative operations, gross profits, taxes, and net profits. One the next line, the total number of consumers ought to be reported. Then, these elements ought to be averaged by the number of consumers. Then, the insurance company ought to report these elements for that individual as well.
§ 12.2.0 YOUNG ADULTS
§ 12.2.1 At the age of 18, persons who have been found mentally retarded or otherwise unable to gainfully obtain health insurance ought to have coverage through the government, immediately. That transition period can sometimes be difficult currently.
§ 12.2.2 Students who attend college must demonstrated proof of coverage through their parents or else they must purchase a group health policy offered through a consortium of colleges.
§ 12.2.3 The remaining young adults ought to purchase insurance when they are employed, and, when they are in between employment, as frequently occurs, they ought to be covered for brief periods (one month for each year of employment) by previous employers and next by their parents’ health insurance through the age of 26. If the student is completing doctoral studies or another terminal degree and they are unable to purchase college policies (say, unemployed and finishing their doctoral dissertation, internship, or residency), a 3 year extension of their parents’ policy ought to be granted to age 29.
§ 12.2.4 - Insurance companies must –
§ 12.2.4.1 – Not drop high end users
§ 12.2.4.2 - Not decrease coverage once contracted
§ 12.2.4.3 – Not impose unreasonable cost increases
§ 12.2.4.4 – Cover pre-existing conditions.
§ 12.2.4.5 – Not impose lifetime, annual, or specific disease or procedure caps
§ 12.2.4.6 - Cover life partners and all dependents
§ 12.2.4.7 – Fully cover preventive medical procedures, OP visits, procedures, mammograms, rectal exams, screenings,
dental exams, vision exams, behavioral health intakes without co-payments.
§ 12.2.4.8 – Policy agreements / contracts must be fully summarized into four pages.
§ 12.2.4.9 – Policy agreements / contracts must be written to be understood – say at the 6th grade level, written for
consumers and not for lawyers. (My insurance policy is 120 pages long, written in fine print, by lawyers and for lawyers!)
§ 12.2.4.10 - Modest risk premiums (ten percent) or, modest risk co-payments would be permitted based on history of
abuse, elevated risk based on choice behaviors (e.g., smoking, obesity (more costly than heart disease or cancer)), or future costs.
§ 12.2.4.11 - Requiring pre-authorization for an ambulance or visit to the ER is illogical. Excessive requirements for pre-
authorizations and authorization procedures by insurance companies must be reined in. While they might have initially been implemented for the purpose of limiting misuse of that procedure, it is now used simply to reduce costs to insurance companies. What person who is having a heart attack is first going to consult his 120 page contract to see the precise procedures expected of him before he calls for an ambulance? In fact, I might argue that expecting anyone to read the details of that policy written in legaleze, fine print, and profusely, is unreasonable.
That said, I have known some people I could envision fitting into the original category, calling for an ambulance ride to the ER twice a week for nothing more than the attention. Utilization patterns ought to be reviewed regularly and when a potential abuse is identified, that person must be confronted on that abuse and therapy or special limitations might be imposed. I would envision this to be extremely rare, less than one percent of consumers at any time over their lifetime, and I would envision that the evidence of misuse ought to be compelling (e.g., 6 ambulance calls in the last 2 weeks). Restrictions might include – ambulance calls must be made for that patient by a staff member … While emergency services ought to normally be performed without cost to the patient, abusers of such services ought to incur an immediate “cost” for excessive use in the form of co-payments that might be triple that of usual co-payments.
§ 12.2.5 - The government must establish maximum total costs to consumers within a given policy bracket, that would
include premium, co-payments, co-insurances, deductibles, and caps (which I advocate elsewhere in this proposal to eliminate).
§ 12.2.6 - Presently, health insurance companies, Medicaid, and Medicare only pay for services performed by providers
who are willing to accept their low pre-determined payment schedule. That is not capitalism, that is oligopolistic socialism! If you want to see a great doctor, you pay out of pocket. Let me translate this into English – this is rationing! We have rationing of health care right here in
§ 12.2.7 - Public health insurance programs must cover their own costs and must pay providers fees that are competitive
and meet their costs.
§ 12.2.8 - All health insurance premiums and health care costs must be tax deductible or subject to tax rebate by
employers or employees other than “elective” procedures.
§ 12.3.0 SLOWING THE INCREASE OF CONSUMER PRICES
§ 12.3.1 Measures reducing administrative costs, taxing excess profits, reducing defensive medicine, and reducing medical errors, will reduce health care costs, and, presumably, corresponding levels of profits. Over the first 5 years, there will be substantial decreases in costs to insurance companies, government, and, presumably, the people who pay premiums.
AFTER THE FIRST 5 YEARS:
§ 12.3.1.1 - With everyone contributing to the pool, where 17 percent now don’t, much more risk and payments are
distributed more evenly. Frankly, by including younger, healthier people from among those uninsured, it will further reduce the average cost and be beneficial to older people currently holding insurance policies.
§ 12.3.1.2 - Health care costs must be contained. President Nixon was the last president to use price controls. I believe
that health costs ought never increase more than ten percent over the Department of Labor’s published rate of inflation. For example, if general inflation is 3.00%, health care costs might be permitted to increase 3.30% PP. This would still mean, however, that when the number of Alzheimer’s Disease cases also increases five percent a year, costs will increase 3.465%.
§ 12.3.1.3 - With keen competition between private insurance companies, not-for-profit organizations, and government,
Medical costs, administrative costs, profits, and payments made, ought to be reduced modestly, counting
inflation, over years 6 to 10.
§ 12.3.2 Doctors are unique in that they profit from the more services they decide you need. They might put you on pills they own stock in. The radiologist who reads your MRI might own the MRI clinic. Regulations are, of course, required to assure inappropriate behaviors.
§ 12.4.0 EXPERIMENTAL PROCEDURES
§ 12.4.1 Many private health insurance plans now exclude coverage for experimental drugs, procedures, and surgeries. When new, these drugs, procedures and surgeries might be extremely intensive and costly.
§ 12.4.2 As a society, Americans all want providers and researchers to experiment and develop things that improve our lives, or, at least, the lives of our own children. Thus, we don’t want to enact regulations that prevent medical advances.
§ 12.4.3 Risk aversive insurance companies should not have to pay the whole costs of developing new procedures. Then again, if other best practices have been utilized without benefit, then, if an experimental procedure is available, should it not be up to the physician and patient whether it is used? What if the medicine costs $500,000 a month for that one patient? I conclude that insurance companies have a moral and contractual obligation to provide some level of care, at least comparable to the cost of similar procedures commonly used today. But, insurance companies are not in the business of creating new medicines or procedures, so, their liability ought to be limited to the maximum typical cost of alternative, best-practices.
§ 12.4.4 Experimental drugs and procedures must receive an initial authorization, provided relatively quickly, by the FDA. Upon authorization, costs for experimental procedures ought to first be covered up to the maximum of alternative practices by the insurance company. Then, the patient, provider, health service organization, and government must provide the balance. As time is so often of the essence in such cases, the government ought to guarantee coverage and then bill the insurance company for the alternative maximum and then negotiate the difference between parties of interest.
§ 12.5.0 EXPAND TRADITIONAL MEDICAID
§ 12.5.1 Most of the 47 million who are uninsured can be covered through expanding the eligibility for Medicaid or, better still, Medicare. This might somehow reduce concerns about socialized medicine, since it is already an established program. Of course, I advocate elsewhere that Medicaid ought to be a federal program, operated by Medicare, as it would reduce administrative costs by $19 billion a year.
§ 12.6.0 ERISA
§ 12.6.1 Patients who are harmed due to medical HMO malfeasance must be permitted to file law suits without exclusion due to ERISA.
§ 12.7.0 TAX IMPLICATIONS
§ 12.7.1.1 - “Medically necessary” procedures ought to be eligible for tax rebate. As some people would not be able to
pursue these medically necessary procedures without upfront tax rebates, the federal government might provide advances.
§ 12.7.1.2 - “Medically recommended” procedures ought to be eligible for full tax deduction.
§ 12.7.1.3 - “Elective” procedures might be discouraged through implementation of a modest excise tax.
§ 12.7.2 A Citizen’s Panel ought to review procedures and determine necessary, recommended, or elective designations, based on recommendations of health care providers. They never should base decisions on the economic benefits to the government.
§ 12.8.0 INSURANCE MEANS TEST OR FEE
§ 12.8.1 Every American will have the resources with which to purchase health insurance. Thus, having coverage is mandatory.
§ 12.8.2 Some individuals might not choose to have insurance due to having alternative means. If a family has liquid assets of $10,000,000, perhaps a means test would be satisfied. If they require health care, they must pay out of pocket if they have chosen the means test exclusion and they are not eligible for filing medical bankruptcy. If they are agreeing to pay for all of their own health expenses, they should not be subjected to paying a non-insurance fine.
§ 12.8.2 Regarding non-insurance fines, liberals propose percentage fees (2% of $7.50 an hour is $312). Conservatives propose a fixed fee, say $2,500. Regardless, health insurance must be documented. As everyone will have the means to purchase health insurance, public, private for profit, or private not for profit, no one ought to be without insurance. There are those among us, most unfortunate, who often fall between all cracks and have no home or job and are extremely confused. Help must be provided for them and a fine would be senseless. On the other hand, the other group least likely to possess health insurance would likely be individuals who are resistant to change and who wish to protest legislation of mandatory health insurance. I would argue that individuals have the right to free speech and assembly and protest but their rights do not exclude them from lawful legislation while they protest.
§ 12.8.3 What if religious beliefs forbid the purchase of health insurance – as it is a form of “legalized gambling”. Ought they to be penalized? What could be the costs to society and how much voice does society have in enforcing lawful legislation that would interfere with one’s practice of religion?
§ 12.9.0 IMMIGRATION POLICY
§ 12.9.1 Immigration applicants with personal or family histories of health problems might be subjected to a cost / benefit analysis to determine whether potential merits (Nobel laureate) might offset potential health costs – at least for the time being. Ill resident aliens not making educational progress might be granted temporary extensions but, if medical needs are not pursued and educational progress is not made, individuals must be deported.
§ 12.10.0 PREVENT PRICE GOUGING
“All that is required for evil to triumph is that good men do nothing”. – Edmund Burke
§ 12.10.1 - Medical fees must be no more than 20 percent different across third party payers. Hospitals now over-
charge, sometimes three times what they charge insurance companies, to indivduals from whom they don’t expect to collect, so that, after they show due diligence and their fee goes uncollected, they write off the entire inflated figure. This tax write down benefit has driven up bankruptcies and reduces corporate income tax paid to the IRS and is paid for by the taxpayer.
§ 12.10.2 - A study of NY hospitals determined they overcharged patients without health insurance $1 billion a year. If
similar results are throughout, this practice of hospitals padding the bills of the uninsured totals $20 billion a year.
§ 12.10.3 - Overcharging is done because: (1) capitalism, and (2) CMS doesn’t pay rates that cover costs so these
losses must be made up elsewhere.
§ 12.10.4 - Insurance companies will only be allowed to drop an individual (or, depending on the program that the
congress adopts) if premiums go unpaid for more than 45 days, unless the individual is having a health crisis.
§ 12.10.5 - Insurance companies’ premium increases will be limited to no more than ten percent more than the general
rate of inflation. Again, if DoL determines a rate of 3.0%, the insurance company might be permitted to increase fees by 3.3%.
§ 12.10.6 - Bonuses of insurance company, health care provider, and pharmaceutical manufacturers will be contained
within reason, directly based on the performance of the company, providers, or medications. These bonuses must be submitted to the PHS and SEC for authorization. Excessive remuneration of any kind will be subject to the excessive health care profits tax.
§ 12.10.7 - Each insurance company must hold tele-conferences with samples of providers and patients and they must
summarize satisfaction and success measures and the must identify medical, procedural, and administration concerns. Logs will be submitted to the PHS outlining steps to implement cost saving and life enhancing procedures.
§ 12.11.0 MEDICAL BANKRUPTCY (MB)
§ 12.11.1 - Congress passed legislation making it more difficult to file for bankruptcy. Still, more than 1 million
bankruptcies are filed each year. Most (60% to 80%) of bankruptcies are due to medical bills.
§ 12.11.2 - The cost of filing for MB must be reduced and federal court fees waived for individuals for whom bankruptcy is
justified. If someone is the victim of domestic violence, we don’t make them pay a fee to report the abuser or file a protection order, etc. People who are the “victim” of cancer and who must file for bankruptcy ought to not be charged for this legal procedure and is in violation of their due process rights under the 14th Amendment.
§ 12.11.3 - I realize these suggestions would tend to increase MBs and the dollars “expunged” from the system. For
individuals facing MB with chronic or terminal health conditions, this will be beneficial. Responsible universal coverage will essentially eliminate MBs, lessen the burden on federal courts, and it will reduce the billions of dollars expunged from the economy. Patients will no longer feel like criminals. If one is labeled or treated like a criminal, they might tend to act like one.
§ 12.11.4 - Prompt filing of MBs and close communication with creditors can reduce expenses $3 billion a year.
§ 12.11.5 - Protected assets ought to include health equipment and handicapped vehicles.
§ 12.11.6 - Loosing the 1st home makes a person homeless. People with three homes don’t need MB! MB must allow
greater “inaccessible” amounts on the first home, cash that will be used to pay MB expenses, 6 months’
worth of living and health care costs, protected savings for children’s college, LSAs, and retirement accounts. Shouldn’t a second home and stocks be ineligible for protection?
§ 12.11.7 – When physicians and judges have determined that the bankruptcy is due to medical problems, then there
ought to not be a restriction imposed, such as waiting 7 years to re-file. Cancer flair-ups are not a choice, like
gambling, and they should not be treated in the federal courts like they are. As medical conditions can resume at any time, MB DUE TO MEDICAL CONDITIONS ought to be permitted to re-file at any time.
§ 12.11.8 - 1.5 million Americans face foreclosure of homes due to medical bills yearly. Efforts must be made to assist
people in keeping their homes throughout medical tragedies and MBs. I propose a program to loan / grant monies to pay toward rents or mortgages during medical emergencies. I propose that over the next 5 years, health insurance must provide some degree of housing / costs of living, during a patient’s illness, when that illness results in loss of income.
§ 12.11.9 - Providing full health coverage will reduce MBs and the amount of money that providers and health care
corporations lose.
§ 12.12.0 DETERMINATION OF PAYMENTS
“If you climb up a tree, you must climb down the same tree.” - African Proverb
§ 12.12.1 - Throughout this paper, I suggest modifications in payments for various services. Sometimes I suggest
increases. Sometimes I suggest decreases.
§ 12.13.0 CENTERS FOR MEDICARE AND MEDICAID (CMC) REQUIRE SIGNIFICANT MODIFICATIONS
§ 12.13.1 - Medicare patients must pay 50 percent of psychiatric costs but only 20 percent of all other care, yet,
psychotropic medications are covered at the same rate as others. CMS discrimination is wrong. Interestingly, CMS’ most under-paid programs are in the areas in which the
§ 12.13.1.1 - Studies compellingly report to CMS that treating MI / SA reduces the need for medical care by half, saving
$300 billion a year yet it costs $20 billion and reduces a medical condition. Given that 2/3rds of the most common killers of Americans have strong and direct behavioral components, behavioral health counseling must be encouraged as a preventive measure and treatment measure and CMS must pay competitive compensation.
§ 12.13.1.2 - The Virginia Tech shooter, who killed 33 people, received inadequate MI care.
assure treatment due to their lack of funds. That very next year, the
§ 12.13.1.3 – The CMS Board consists of only physicians and no other providers. A whole team is needed.
§ 12.13.6 - Interestingly, these physicians who earned an average of $225,000 gave themselves a 3% increase by
decreasing pay to other providers who earn an average of $65,000. While most physicians are, indeed, underpaid by Medicare, so are all other providers who most need Medicare increases on occasion.
§ 12.14.0 MI/SA COURTS
§ 12.14.1 - MI/SA courts must be designated in all state and federal judicial districts.
§ 12.14.2 - All staff ought to receive special training.
§ 12.14.3 - Goals ought to be treatment, rehabilitation, vocational training, and restitution.
§ 12.14.4 - Special funding might be $1 billion per annum.
CHAPTER 13
LOBBYING & CAMPAIGN FINANCE REFORM
§ 13.1.0 EVERYTHING IS RELATED
Does money upset the hearts of learned men?
He answered, "men whose hearts are changed by money are not learned" - abu Hamid al Ghazali
§ 13.1.1 It almost seems that some government bureaucrats and politicians vote or regulate based, not on duties and
obligations to the American public, but to their future employer who has promised them a job making ten times greater salary.
§ 13.1.2 Lobbying, indeed, served an important function. Lobbying organizations provided legislators with important information. Lobbying provided corporations with a voice to explain their positions, a voice they were entitled to use but lobbying groups still could not vote.
§ 13.1.3 Lobbying provided money to political campaigns needed to win that otherwise would be left unfunded by the public that has lost interest in politics.
§ 13.1.4 I am not going to make specific recommendations regarding lobbying and campaign finance reform. That’s another matter that must be addressed fully to assure that the interests of representative’s constituents are primary and that reform result in justice and transparency.
§ 13.1.5 The top twenty pharmaceutical companies and their two trade groups, Pharmaceutical Research and Manufacturers of America (PhRMA) and Biotechnology Industry Organization, lobbied on at least 1,600 pieces of legislation between 1998 and 2004. According to the Center for Responsive Politics, pharmaceutical companies spent $900 million lobbying between 1998 and 2005 (more than any other industry). They donated $90 million to federal candidates and political parties, giving three times more to Republicans as to Democrats (remember that it was republicans who held the power and control of the house, senate, and white house at that time). According to the Center for Public Integrity, the 18 months through June 2006 alone, pharmaceuticals spent $182 million on federal lobbying. It has 1,274 lobbyists in
§ 13.1.6 In 2004,
§ 13.2.0 GREATEST THREAT TO DEMOCRACY
“If you run after two hares you will catch neither.” - African Proverb
§ 13.2.1 Companies and special interest groups spend over $2 billion a year in lobbying the federal government. That’s over $3 million for each member of Congress every year. If you received $3 million from one special interest group, could you vote against them? Imagine the kind of pressure that someone like Senator Baucus must feel with the millions of dollars in donations and gifts that have flowed into his hidden coffers, yet, perhaps, he struggles knowing that his constituents and the American people need just, effective, and comprehensive health care reform.
§ 13.3.0 POLITICAL INFLUENCE
“Never forget that turning a blind eye to oppression and watching from the sidelines is itself oppression.” - Harun Yahya
§ 13.3.1 Each American would like to believe that his or her congressman / senators are above reproach. For the most part, most, ultimately, seek the best available option.
§ 13.3.2 I’ve attached a few pages that provide an example of who gives what to whom.
§ 13.3.3 Campaign donations are required by the Federal Election Commission (FEC) to be fully disclosed to the public. That’s a step in the right direction. If I hop on the internet, I can tell you the name of every campaign donor.
§ 13.3.4 Lobbying financial records are more covert. They are not fully accessible to the public. Special interest groups might do undocumented things like hire prostitutes, buy a bottle of champagne, employ a senator’s cousin, or donate to their favorite charity … There are hundreds of loop-holes in present lobbying regulations that benefit politicians and businesses at the expense of American voters.
§ 13.3.5 Who influences congressmen the most?
Spouses and Family Their Political Party Peers and Friends
Staff Members Lobbyists Voters
§ 13.3.5.1 Spouses and Family
§ 13.3.5.1.1 - I remember once reading about the 19th Amendment that gave women the right to vote. It passed
Congress and many states. Southern states blocked its passage. In the
§ 13.3.5.1.2 - There is no known method of assuring that our elected officials are not influenced by family. Even if we
sequestered them (which advocates of term limits might appreciate), they would still be influenced by their memories and knowledge (say, dad fought on
§ 13.3.5.2 Their Political Party
§ 13.3.5.2.1 - In the last 50 years, the two political parties have become increasingly hostile toward one another and vote
in blocks against the other rather than voting on the issue and voting on behalf of the people who elected them. In an era where an increasing number of Americans identify themselves as “Independents”, this rigorous party unity among elected representatives will ultimately lead to the loss of power by those parties.
§ 13.3.5.3 Peers and Friends
§ 13.3.5.3.1 - Our peers influence us. In Congress, peers affect members. Sometimes, one might support a bill today so
that their district benefits from a bill tomorrow.
§ 13.3.5.4 Staff Members
§ 13.3.5.4.1 - Who else do congressmen work with? Staff exist to help the electorate and to help elected officials
comprehend matters and to do the right thing. Congressmen depend on staff. With thousands of phone calls, letters, and emails; tens of thousands of pages of material to read every week; and, public appearances, the phrase “relies upon staff” is not enough. Staff members usually try to do the right thing. They are often strongly influenced by what they know is the legislators’ predilections. Sometimes staffers are influenced by others – their own spouses, clergy, or friends. Staff members may leave congress one day and join a lobbying firm the next. With direct access to all of their old friends, they make very influential lobbyists for the next several years.
§ 13.3.5.5 Lobbyists
§ 13.3.5.5.1 - K Street, North West, is now an infamous setting for lobbying organizations. Some work is good. They
fund research, accumulate data, and summarize information. Truth has been said to be the first casualty of war. Almost always, lobbying groups are paid by a special interest group. Thus, facts are usually skewed so that they bolster the positions of those who pay their salaries.
§ 13.3.5.5.2 - Every state capital has lobbyists, usually paid less than in DC. The median salary for US lobbyists was
$96,000! While most lobbying analysts earn half that, the smooth, well-connected bread winners earn much more than the median.
§ 13.3.5.6 Voters
§ 13.3.5.6.1 - The American voter’s opinions are also factored into decisions by lawmakers. Of course, as voters, we
must make certain that our elected officials hear from us. The recent obstructions posed at town halls present a
lop-sided picture of the wishes of the voters. Our representatives walk away fearing for their lives and hearing loud opposition to health care reform. Supporter of health care reform must be heard equally effectively, albeit respectfully.
§ 13.4.0 LOBBYING & DONATIONS BY HEALTH CARE PROVIDERS & CORPORATIONS TO CONGRESS
“If you're not part of the solution, you're part of the problem.” - African Proverb
“ … a hoarseness caused by swallowing gold and silver.” - Demosthenes
§ 13.4.1 A few critical points:
§ 13.4.1.1 - Health care providers, hospitals, insurance companies have spent, this year alone, over $500 million to lobby
Congress. 2:1, these monies are spent to oppose change.
§ 13.4.1.2 - Most of the formerly biggest lobbyists, Chamber of Commerce, American Medical Association, all of the
pharmaceutical groups, medical device companies have ramped up lobbying in 2009.
§ 13.4.1.3 - There are over 5,000 people employed as health care lobbyists. That’s almost 10 healthcare lobbyists for
each member of Congress.
§ 13.4.1.4 – Spending billions of dollars on legislative lobbying is redundant and wasteful. These excessive costs are
passed onto the American consumer who pays, on average, about $7 more for the direct lobbying services of health care or insurance companies. Indirectly, Americans must pay $4,000 more each year, per person, for the continuing wasteful spending in health care that is pushed by these lobbyists. So, if you were guaranteed that your $7 investment would turn into $4,000, you’d be pouring money down this wide, greedy drain, too, I’d imagine. If you could get better quality care and save $16,000 a year for your family, would you consider it?
§ 13.4.1.5 – I provide a little data on lobbying and campaign donations. Much of this information is readily available on
the internet, from sites such as www:opensecrets.org. My solitary intent in providing this information is to show the reader that every member of Congress has a vested interest in health care one way or the other. Every congressman hopes their decisions (or poised waiting) will result in large contributions. As voting Americans, we still have a voice in our democracy and our voices must be heard, whether you as an individual are in favor of reform or you oppose reform. We must objectively read health care reform plans, discuss them, make decisions, and inform our elected officials of our opinions.
§ 13.4.1.6 - Notice that when the republicans are in power, more donations are made to republicans. When democrats
are in power, more donations are made to democrats.
§ 13.4.1.7 - Notice that liberal groups tend to give more to democrats, but, they still donate to republicans.
§ 13.4.1.8 - Notice that conservative groups tend to give more to republicans, but, they still donate to democrats.
§ 13.4.1.9 - Notice that every member of congress accepts money from at least one of these organizations.
§ 13.4.1.10 - Notice that organizations give more money to politicians with more influence. High on the list of almost
every organization are the house and senate leaders and the chairs and ranking members of the various committees that have jurisdiction over health care.
§ 13.4.1.11 - The shear number of lobbyists and the amounts of campaign donations on health care is numbing. The
American people must stand up and assume an assertive non-violent voice in this democratic debate. The special interests of the biggest companies and those who spent the most on lobbying efforts will be looked after and the American people will be left with higher price gouging, moderate increases in access to inferior quality care, and continuing decline in the quality of health care services, increased disease, and shorter longevity unless the people speak up. This is, literally, a matter of life and death.
§ 13.5.0 LOBBYING AND CONGRESSIONAL VOTING
§ 13.5.1 – There is a strong relationship between the REPORTED amount of lobbying donations given to a
Congressman and his or her subsequent voting on related issues. Money by lobbyists is a stronger predictor of how a Congressperson will vote than are the wishes of constituents (as polled), region, or even political party affiliation.
§ 13.5.2 – All of the democrats AND republicans on the Senate Finance Committee had voted in favor of the federal
public option of property insurance for floods yet they vote against a public option for health care. The reason?
Money?
CHAPTER 14
HEALTH CARE PROVIDERS PART ONE: REDUCING COSTS
“In nothing do men more nearly approach the gods than in giving health to men.” -
§ 14.1.0 TRANSPARENCY
§ 14.1.1 All health providers, physicians, clinics, hospitals, insurance companies, drug companies, health equipment
companies must prominently disclose their relationships to other organizations as well as financial interests. If I go to my doctor’s office, I ought to know that he receives $375,000 in research funding from the drug company that makes the drug he wants to prescribe to me. Likewise, all academic, political, and government information ought to contain disclosures on potential conflicts of interest.
§ 14.1.2 I propose that every Congressman, the White House, and senior administrative staff ought to have a page of
their web site that posts every donation or donation in kind or promise of future employment within a week as well as tying together each donation to related votes or administrative decisions.
§ 14.1.3 The people contact legislators and the White House tens of thousands of times every day expressing their
positions on issues up for vote before the Congress. I would love to see it required that on each web page, federal politicians and senior administrators summarize statistically the total number of contacts they have with people from their jurisdiction, outside their jurisdiction, lobbyists (and which ones advocating what), and the positions of the American people.
§ 14.2.0 COLLEGE HEALTH SERVICES TRAINING PROGRAMS
§ 14.2.1 In order to contain expenses and meet growing demand for health providers, educational programs focusing on military, inner cities, rural, geriatric, and pediatric populations are needed.
§ 14.3.0 MALPRACTICE INSURANCE FOR HIGH RISK FIELDS
“In the sick room, ten cents' worth of human understanding equals ten dollars' worth of medical science.” - Martin Fischer
§ 14.3.1 While the need for a federal malpractice insurance program for high risk fields, such as OB-GYN (especially in rural communities) will decrease with effective medical tort law reform, the immediate need for and benefits of such a program is recognized over the next 5 years.
§ 14.4.0 INCREASING PROVIDERS IN UNDERSERVED RURAL COMMUNITIES AND THE INNER-CITIES
§ 14.4.1 What is the one thing that poor farmers from the middle west and minorities in
§ 14.5.0 FIRST RESPONDER PROGRAMS
§ 14.5.1 Since the first moments following a trauma are most critical, I place great emphasis upon these services. By increasing the speed of first responders and their efforts, there is decreased fire destruction, fewer and less traumatic injuries of civilians. Increased funding for training, equipment, and salaries ought to be provided. Air transport costs three times more than land transportation; however, greater use might introduce greater efficiencies, reduce per unit costs, and improve outcomes. First responders’ access to medicines that must be administered in the first moments following a stroke or heart attack must be enhanced. I encourage strong support of first responders and 911 phone centers. All together, I suggest that First Responder Programs will cost an additional $15 billion a year. I suggest that increased investment in these programs will save $15 billion a year in reduced costs of lost lives, reduced property damage, and enhanced safety.
§ 14.5.2 In most cases, the very first responders are family, co-workers, and other members of the community. Given that 1.5 million people have a heart attack or stroke and more than 100 million traumas report to the ER each year, that means that about 1 in 3 of us go to the ER each year and 1 in 3 will suffer a heart attack or stroke in our lifetimes. And, on average, each of us will be a “first responder” who can help another in an emergency countless times across our lifetime. First aid, life saving, CPR, and EHD use ought to be taught to all Americans. This program is elaborated upon elsewhere.
§ 14.6.0 CONTINUING EDUCATION (CEPs)
§ 14.6.1 FHCs ought to provide CEPs for all providers. How do we sift through the information glut? Central
authoritative sources would be helpful.
§ 14.6.2 CEPs are increasingly critical as our knowledge base grows exponentially. CEPS must be more efficacious.
§ 14.6.3 Faye worked for a non-university business that gave sabbaticals every five years. I like the thought of requiring at least a 9 day CEP workshop every two years for providers in order for them to “get back into the groove of medical education”.
§ 14.6.4 All providers ought to communicate with a professional group on a daily or weekly basis.
§ 14.7.0 PROVIDER ACCESS TO COST & PATIENT FINANCE INFORMATION
“God heals, and the doctor takes the fee.” - Benjamin Franklin
§ 14.7.1 All providers must review with the patient the prescription, benefits, costs, side-effects, outcomes, exact prices, expected patient compliance behaviors, and review insurance coverage before going on to the next patient. This information ought to be instantly available via IT. By providers and patients researching together and discussing options, costs will decrease. One study found that costs did not decrease when patients were given two options (e.g, surgery or chemotherapy), but, costs did decrease when patients were given three options (e.g., surgery, chemotherapy, or radiation therapy). At that point, it seems, patients began to also consider costs.
§ 14.7.2 Financial insulation of physicians worsens this problem. The multi-millionaire surgeon whom I visit has little concept of the difficulties the person earning minimum wage faces when he orders an $8,000 wheelchair. Even if he knows the cost, 1.6 percent of his income versus, say, 45 percent of the indigent patient insulates him from the real life circumstances of his patients.
§ 14.8.0 COST SHARING OF PROVIDERS’ MALPRACTICE INSURANCE
§ 14.8.1 If providers had to make a co-payment of even 5 percent on malpractice insurance for tort awards or settlements, all providers might be motivated to quickly obtain training that rectifies the problem and, hence, they learn more quickly to not repeat errors. Of course, that would then require their participation in the settlement process. Insurance companies do not want that involvement, because the more things cost to them, the more they can charge in malpractice premiums.
§ 14.8.2 Multiple studies indicate that a small percentage of providers within specialties account for about 80 percent of patient complaints and litigation. Why? Perhaps, following a patient complaint or lawsuit, those providers ought to undergo a period of supervision, the goal of which is to reduce re-occurrence of medical errors and patient complaints and give that provider up-dated knowledge or patient skills. That’ll reduce medical errors! The insurance company that carries the provider has two financial incentives to settle – (1) it reduces the rate of actual litigation and wildly unforeseen circumstances in the courtroom and (2) the more it pays in settlements, the more it can charge next year and make a corresponding jump in profits.
§ 14.9.0 PAYMENT FOR STUDENTS & LESS COSTLY PROFESSIONALS
§ 14.9.1 My region has 40 percent of the physicians we should. So, I welcome NPs and PAs.
§ 14.9.2 Specializations in geriatrics, pediatrics, and psychiatry must increase for NPs and PAs.
§ 14.9.3 Psycho-pharmacologists and clinical psychologists, with advanced training, could safely and efficaciously prescribe and ought to be permitted to do so by federal legislation covering all states. While highly successful in the military, I suggest that all federal health care programs reimburse for services offered by “less costly professionals” who are licensed in a state and who have completed an authorized prescription program. FHCs might employ these providers.
§ 14.9.4 Government and insurance companies might provide coverage at reduced rates for students’ services in medical, nursing, dental, dental hygiene, allied health schools, and clinical psychology internship programs.
§ 14.9.5 For low-risk, specified pharmaceuticals that patients have received for longer than a year, pharmacists ought to be permitted to prescribe continuing use of those medications, as long as the physician prescribing the drug does not object. This could reduce by millions the number of visits that are needed for physicians.
§ 14.10.0 CONSULTATION BY INFORMATION TECHNOLOGY
§ 14.10.1 - Over one-third of Americans do not have access to a given specialist within an hour’s drive. All Americans
must have access to health professionals through IT. Such consultations and MI services would consist of the rural patient visiting an IT center where a PA or NP meets them, the patient is connected via IT to an eye doctor at Johns Hopkins or a psychiatrist at the University of Pittsburgh, a remote examination is made using the combination of the specialist’s expertise and the PA or NP’s eyes, ears, and hands. MI sessions could be conducted through IT with the local provider only coming back at the end of the session for prescription instructions or re-scheduling. Of course, many consultations could not be carried out in this way. Such sessions will be more costly, sometimes paying for two providers plus IT costs, but, these must be covererd in order to assure that Americans in rural communities have access to health care. Ultimately, these procedures are much less costly than requiring a patient to drive or fly several hours, stay overnight at a hotel, etc.
§ 14.11.0 OUTSOURCING SOME MEDICAL TECHNOLOGIES
§ 14.11.1 - Many health services must be performed close to home. If one has a heart attack or stroke, the first
cardiologist seen is probably the one to be taken. I doubt that anyone would even question his credentials.
§ 14.11.2 - Some, less time sensitive, procedures can be performed on an outsourced basis at great savings, benefiting
from substantially decreased costs in
economy of scale.
Procedure # % # x % Savings
Heart 4.5 M 20% 0.9 M $4.5 B
Endoscopy 1.5 M 33% 0.5 M $0.5 B
Cesarean Section 1.3 M 25% 0.3 M $1.6 B
Orthopedics 1.3 M 40% 0.5 M $2.6 B
MRIs 10.0 M 25% 2.5 M $2.5 B
4.7 M $11.7 B
§ 14.12.0 BLENDING BEHAVIORAL HEALTH AND PRIMARY CARE
“Our prayers should be for a sound mind in a healthy body.” - Decimus Junius Juvenal
§ 14.12.1 - Studies demonstrate increased positive outcomes, reduced need for medical services, better QOL, reduced
mortality, and substantial savings by integrating medical and behavioral health services within the physical structure of primary care practices and through professional integration of services and fields.
§ 14.12.2 - Now with real-time video feeds on computers, costly psychotherapy offices may become less necessary while also increasing access for rural patients to therapists from around the country.
§ 14.12.3 – Patient access and trust reduces misuse through empowering them.
§ 14.13.0 REGRESSION TOWARD THE MEAN FOR DOCTOR SALARIES
“Restore a man to his health, his purse lies open to thee.” - Robert Burton
§ 14.13.1.1 - The second most expensive health care related service is physicians. In 2003, physicians’ services cost $539 billion, or $700,000 per physician ($1,800 PP). The average fee for a GP visit was $100 whereas the average fee for visiting a specialist was over $200.
§ 14.13.1.2 - Keep in mind the many provider expenses – a building ($500,000), a receptionist ($35,000), nurse ($90,000), malpractice insurance ($30,000), continuing education ($2,000), medical records ($30,000), billing ($80,000), compliance ($50,000), and equipment ($250,000). Costs will vary by specialty and location, but, we all agree that many physicians face enormous expenses.
§ 14.13.1.3 - While education is free in most OECD countries, US doctors pay $100,000 - $300,000 for higher education and medical education. Given that higher education is free in most EOCD / European nations, this amounts to a tremendous expense. However, the ROI is equally tremendous.
§ 14.13.1.4 - US doctors earn more than doctors in the other OECD nation, yet they are seen less often than in 22 of 29 other OECD nations.
§ 14.13.1.5 – US physician specialists earn 6.6 times the US GDP PP and US GPs earn 4.2 times the US GDP PP.
Other OECD specialists earn 4 times the GDP PP and GPs earn 3.2 times the GDP PP. We pay our typical physician specialist $105,600 more and our typical physician GP $48,000 more than OECD comparisons would suggest may be merited.
§ 14.13.1.6 – Surveys of physician salaries revealed the following:
§ 14.13.1.6.1 –Anesthesiologists are typically paid $275,000 although anesthesiologists who specialize in pain
management are paid $370,000. This seems reasonable.
§ 14.13.1.6.2 – Cardiologists are typically paid $395,000 to $468,000, although some are paid as much as $811,000. I
would suggest that cardiologists’ median income might be reduced by $125,000 per year. The reduction in unnecessary procedures by 25 percent will address most of the increased projected need for cardiologists (e.g., obesity) that is fueled by higher salaries that is being fueled by more cardiology residents that fuels more cardiac bypass surgery and angioplasties. Greater, wiser utilization of PAs, NPs, and health educators could also augment much of that “unmet-need”. Recommendations herein would reduce costs by $10 billion per year. Tenet Health settled out of court on allegations that it performed heart surgeries on healthy patients in order to bill them for the procedure. It couldn’t have been the people who swore by the Hippocratic oath who performed those needless heart surgeries?
§ 14.13.1.6.3 – Critical care physicians are typically paid $215,000 and Emergency Medicine physicians are paid
$216,000. I would suggest that the median income of EM physicians might be increased $25,000 per year, costing $250 million per year.
§ 14.13.1.6.4 – Family Practice physicians typically earn $135,000 whereas FPs who also provide obstetrical care are
paid $204,000. Elsewhere, it is reported that FP’s now earn $150,000. The often look at the whole person with all organ systems being integrated, and consider drug interactions. Thus, they have a slight advantage over specialists in that visits to FP’s is related to slightly elevated longevity. I suggest that median income of FP’s ought to increase $50,000, resulting in a net cost of $3 billion. I would also advocate the increase in the number of FP’s from 62,000 to 75,000. The cost of this second recommendation would be $3 billion.
§ 14.13.1.6.5 – Gastroenterologists typically earn $349,000, although some are paid as much as $590,000. GI’s might
have their median income reduced by $75,000 a year. This would save $900 million per year.
§ 14.13.1.6.6 – Hematologists / oncologists (cancer) typically earn $246,000, although some are paid as much as
$685,000. I would not recommend modification.
§ 14.13.1.6.7 – Opthalamologists typically earn $314,000, although some are paid as much as $511,000. In general, I
would not recommend significant modification.
§ 14.13.1.6.8 - Opthalamologists who specialize in Retina procedures typically earn $469,000, although some are paid
as much as $716,000. These specialists might have their median income reduced by $100,000 per year. This would save $500 million per year.
§ 14.13.1.6.10 – Orthopedic surgeons typically specialize in surgical procedures on specific parts of the body. They
typically earn, depending on the part of the body in which they specialize, between $392,000 to $670,000. Some are paid as much as $1,352,000. It seems noteworthy to me that spine surgeons earn $670,000 to $1,352,000 whereas neurosurgeons earn $541,000 to $936,000. I would think that spinal surgeons ought to be earning 20 percent less than neurosurgeons, not 20 percent more. Back pain costs more than $100 billion annually in the
§ 14.13.1.6.11 – Psychiatrists typically earn $169,000 a year and prized child and adolescent psychiatrists typically earn
$189,000 a year. Psychiatrists might earn as much as $265,000. As 75 percent of psychotropic drugs are now prescribed by GP’s, FP’s, OB-GYNs, and pediatricians, this field is undermanned and underfunded. I recommend increasing the median income of psychiatrists by $50,000 per year. The
§ 14.13.1.6.12 -
(WHO). The problem is caused by unhealthy lifestyles, including substance abuse, lack of prevention information or efforts, insufficiently equipped hospitals for neonatal care, delivery complications, and pediatric diseases. US pediatricians are paid second lowest of all specialties, $145,000, and less than what pediatricians are paid in other OECD nations. We must attract the brightest or, at least, attract bright enough specialists who will provide exceptional care and reduce the indicators of poor pediatric quality of care nation-wide. Provider payments must be increased significantly in this field, if we really value our children. I suggest that a salary of $200,000 for pediatricians might be reasonable.
§ 14.13.1.6.13 – Plastic surgeons typical earn $411,000 a year and might earn as much as $820,000. A large portion of
plastic surgery is “elective” in nature and would not apply to many insurance plans. Not elective plastic surgeries ought to be reduced in payment by $25,000 resulting in the savings of $250 million a year.
§ 14.13.1.6.14 - US radiologists are paid around $420,000, twice what they are paid in other OECD nations. They’re
paid well above the trend line for US physicians, as well. Payment reductions are warranted. Some diagnostic services could be performed anywhere, transferring jobs overseas could reduce costs 30 percent or $2 billion and would result in reduced income to $310,000.
§ 14.13.2.1 – Why do our doctors spend less time with US patients?
§ 14.13.2.2 - MOST IMPORTANTLY: US physicians spend 3 times more of their time in administrative functions, billing, and authorization justifications than doctors in other countries with “purported socialistic paper-pushing addictions”. They didn’t teach paper pushing in medical school! Reducing administrative demands would free providers to see patients, save money, see 15 percent more patients thereby meeting growing demand, and vastly improve physicians’ own QOL. It seems ironic that opponents to health care change argue that fewer doctors will be available, when, the current bureaucracy imposed by private health insurance companies is greater than that imposed upon physicians in the other 29 OECD nations that practice “socialized medicine” and these private insurers impose more bureaucratic hurdles than Medicare, one of America’s current public systems, in addition to the VA, IHS, military, intelligence, and Medicaid.
§ 14.13.2.3 - Freeing up one-half of that time would add the equivalent of 75,000 physicians!
§ 14.13.2.4 - Reducing felt need of physicians to practice defensive medicine would increase savings.
§ 14.14.0 DENTIST SALARIES
§ 14.14.1 - US dental care expenditures total $100 billion per year. Ironically, that averages the same gross income as all physicians, at $700,000 each. US dentists earn significantly higher salaries than dentists in OECD nations and much higher than the
CHAPTER 15
HEALTH CARE PROVIDERS PART 2: MEETING INCREASED FUTURE DEMANDS
§ 15.1.0 MEETING DEMAND FOR RNs
“For tomorrow belongs to the people who prepare for it today.” – African Proverb
§ 15.1.1 As 7 million people in the
§ 15.1.2 Increase salaries? Since nursing schools can’t increase it’s numbers of graduates, traditional supply and demand strategies in capitalism find their efficacy mitigated. Further increasing the salary beyond the 19% premium for their degree will generally not be useful for further attracting many nurses. Some facility administrators see that nursing salaries have increased more than inflation in last 50 years and they’re reluctant to further increase nursing salaries. So, what is restricting the number of RNs available to us?
§ 15.1.3 One problem is very practical. We must offer child or elder care; safe housing for young nurses without families (especially when first moving to rural communities); and, transportation in bad weather. FHCs might offer some such services. Most costs ought to be covered by private providers. Public contributions might be $4 billion per year.
§ 15.1.4 Some positions will always be difficult to fill (e.g., night nurse at a home for aggressive teens). Offering longer sabbaticals, safer or less stressful working conditions, greater appreciation, and more competitive wages will increase the numbers of nurses available in these difficult to fill fields.
§ 15.1.5 RNs enter the profession older and retire younger than colleagues in medicine, dentistry, and allied health fields. This restricts nurse availability. Why do nurses retire 5 years younger? By knowing why, we might better satisfy those needs, and reduce the RN unmet-demand by 80,000! The Health Research Agency ought to be conducting research on this topic.
§ 15.1.6 RNs are designated caregivers within families, so, they are more likely to care for sickly or elderly family members or grandchildren. By shifting burdens to elder care or child care programs, MI day programs, HHC, HHs, ALFs, NHs, and hospice, we could increase RN availability, if, but, modestly.
§ 15.1.7 Nursing has great demands, high stress, and too much paperwork. Orders may be barked out leaving nurses to feel underappreciated. IT, sensitivity training, stress management programs, and paperwork reduction might help keep many nurses in the field and reduce turnover rates. Organizational Development interventions might build the sense of teamwork, increase physicians’ respect, and reduce nursing stress.
§ 15.1.8 With women’s liberation since the 1970s, more professional opportunities are available to women who once were essentially restricted to nursing and teaching. Nursing competes now with other professions, medicine, law, clergy, dentistry, etc. What do we need to offer in order to attract the brightest? I believe that more nursing positions in hospitals, NHs, even doctor’s offices ought to require the MSN / NP. Funding ought to be provided to pay at least 250,000 master’s level nurses an additional $25,000 per year, costing $7.5 billion a year (FICA and benefits).
§ 15.1.9 Programs to recruit more nurses to the field at younger ages might result in nurses staying in the field longer and might result in starting salaries lower than those of older RNs. Programs that combine the senior year of high school with 3 years of college might recruit some students. Condensing 4 year programs into 3 years with summers might recruit some students. Also, condensing NP / MSN programs into 5 years might be beneficial.
§ 15.1.9.1 - Recruitment of male nurses and specializations in geriatrics, pediatrics, and MI are needed.
§ 15.1.9.2 - Programs that feed registered ILs into RN programs could further meet demand.
§ 15.1.9.3 - Recruitment must begin in high schools.
§ 15.1.9.4 - Coordinated recruitment will reduce duplication of nursing shortage studies and recruitment. This is inefficient
and these investments could be invested on recruiting nurses.
§ 15.1.9.5 - One nationalized study that addresses the needs of nurses, providers, patients, and colleagues in financial,
interpersonal, familial matters, would be more cost-effective and ought to be conducted by one organization such as the Public Health Service (PHS).
§ 15.1.10 - By introducing EMRs, administrative reductions, and automated dispensing, an efficiency of 15% could be realized - the equivalent of 300,000 RNs. While much of the time savings would be spent on improved quality, and reduced medical errors, the financial savings would be only partially realized, perhaps meeting the need for 100,000 nurses.
§ 15.1.11 - A federal nursing school (FNS) could meet much demand for nurses, hiring master teachers, and broadcasting courses globally through IT. I suggest that this FNS might have a budget of $1,200 million per year. It would maintain major US east coast and west coast campuses as well as multiple smaller campuses in at least three other needy countries. Part of the funding for the international components would be through the increased tax on nicotine exports. The FNS would have a nursing faculty of about 4,000! The FNS would have an enrollment of 4,000 LPNs, 32,000 RNs, and 16,000 MSN / NPs / Ph.D.’s. IT broadcasting to private schools world-wide would augment revenues by $200 million per year. Tuition, room, and board would provide revenues of $600 million per year. International funding would provide revenue of $300 million. Federal revenues of $100 million per year would be required. The FNS would require infrastructure investments of $400 million per year for 5 years. The foreign campuses of the FNS would require infrastructure investments paid by the nicotine export tax of $400 million per year for 5 years.
§ 15.1.12 – By permitting Medicare, Medicaid, and private for-profit and not-for-profit payers to make payments for basic
services provided by nursing students will increase the availability of practica sites, revenues to nursing schools, increase faculty, students, graduates, and nurses.
§ 15.2.0 MEETING DEMAND FOR NURSING SCHOOL FACULTY
“Education is our passport to the future, for tomorrow belongs to the people who prepare for it today.” - El-Malik el-Shabbaz (Malcolm X)
§ 15.2.1 The 1,700 RN programs must increase production of RNs by 15 students per year, each, on average. Most RN
programs can not accept qualified applicants due to the shortage of faculty. RN faculty are hard to recruit, as the positions demand more education and offer lower salaries.
§ 15.2.2 Increased faculty salaries are just and needed.
§ 15.2.2.1 - In capitalism, universities would increase nursing faculty salaries; but, that is not happening at many nursing
schools. Why not?
§ 15.2.2.2 - Many nursing schools are in public, lower salaried, community colleges and teaching colleges. Salaries are
not easily increased and depend on government infusion.
§ 15.2.2.3 - This field was “acceptably” underpaid 50 years ago and this bias contributes to reluctance of administrators
to increase salaries of nursing faculty today.
§ 15.2.2.4 - Nursing programs are not provided enough resources for costly programs.
§ 15.2.2.5 - Graduates do not provide comparable endowments as do doctors, lawyers, and dentists, as such, the
university spending more money on these “cost center” programs is not perceived to be a wise allocation of
capital.
§ 15.2.2.6 - Federal funds must increase salaries of 20,000 nursing faculty by $30,000 a year. This will attract more,
better qualified faculty to nursing schools. Funding might remain flat over 15 years, increasing the proportion paid by schools. This would cost about $700 million a year.
§ 15.2.2.7 - There could be a federal mandate that all schools receiving federal loans or funds will increase nursing
faculty salaries by $30,000. This, however, would pass costs onto young nurses who are in shortage anyways.
§ 15.2.2.8 - Increasing CDC / NIH / NSF grants could enhance salaries of grant recipients by $40,000.
§ 15.2.3 Nursing schools might use more adjunct faculty. Adjunct faculty often provide more realistic clinical insights but are often less scholarly and academically trained.
§ 15.2.4 Graduates of nursing programs that can produce faculty (master’s and doctoral programs) have decreased. Why? Recruitment shifts or competition? A federal program ought to be implemented immediately to provide scholarships for MSN / NP / Ph.D. nursing students of $25,000 a year for 20,000 students, at an additional cost of $500 million per year. The efficacy of this program ought to be evaluated in 8 years and, at that time, funding may gradually decline.
§ 15.2.5 USE “IT” in nursing education. The very finest nursing professor from the best university could teach a human anatomy class and broadcast it across the globe, augmenting local nursing courses. This would increase efficiencies, consistency, and decrease work demands for local faculty, allowing admission of more students and result in less instructional costs on average per student. Even some lab instruction and testing could be performed on the computer, often with greater precision, optics, detail, options, and decision making queries. Computer access will lead to less but more expeditious use of fewer labs.
§ 15.2.6 The Federal Nursing School might recruit master nursing teachers and provide IT support for global broadcasting.
§ 15.2.7 Insufficient clinical practica sites –
§ 15.2.7.1 - FHCs could provide housing and experience for 50,000 nursing students (20 students at a time).
§ 15.2.7.2 - Students can’t afford to travel 40 miles, but, offering travel funds might increase student ability to travel. If
practica sites, nursing programs, and / or the government provided travel funds, even at 10 cents a mile, many students would be more likely to consider further distances for practica sites. Programs ought to accommodate 4 -10 hour days.
§ 15.2.8 Nursing remains a female dominated field. Women are more likely to make sacrifices for families and are less likely to re-locate. It sounds anti-feministic, but, male nurses will be more likely to move their families to underserved communities and they ought to be recruited into the field.
§ 15.2.9 I see restrictions in enrollment in all of the best paying health professions leading to escalating increases in wages. The fields without restrictions have seen salaries unchanged or lowered, with escalating educational loans.
§ 15.3.0 MEETING THE DEMAND FOR LPNs
§ 15.3.1 Electronic records could save 1/3 of 15%, $2.5 billion per year, or reduce the need for 47,500 LPNs.
§ 15.3.2 Programs that feed registered IAs into LPN programs could further meet demand.
§ 15.3.3 IT based education would be more efficient and increase the impact of local faculty and increase students.
§ 15.3.4 Median LPN = $39,000 / yr – a very good ROI.
§ 15.3.5 The projected increased demand for LPNs over the next 10 years is 100,000.
§ 15.3.6 Offer LPNs tax rebates, particularly in underserved rural communities and inner cities.
§ 15.3.7 A federal LPN school could hire master teachers to broadcast courses and labs globally, using IT.
§ 15.3.8 Payment by third party payers for basic services provided by LPN students ought to increase the availability of
practica, students, faculty, graduates, and LPNs.
§ 15.4.0 MEETING THE DEMAND FOR NURSING ASSISTANTS (NAs)
(1) NAs typically have 2 weeks’ training.
(2) Minimal training increases medical errors.
(3) Medical errors are costly and lethal.
(4) NHs and HHC programs are mostly staffed by NAs.
(5) NA salaries are near minimum wage.
(6) Do I care more about my French fries than my mom?
(7) NA turnover (quitting or firing) is great.
· Greater responsibility, education, and salaries are profoundly demanded.
· FHCs ought to provide standardized training for NAs of eight weeks’ length (320 hours), followed by a 12 month period of on-site supervision and ongoing FHC classes (4 hrs / wk).
· NA program tuition might be incurred by NAs but paid by employers in exchange for service.
· NA salaries must increase at least 33% to be competitive; however, that’s not possible with low CMS payments. CMS must increase payments to hospitals, doctors, and hospitals minimally to cover this cost.
· Programs that feed registered IAs into LPN programs could further meet demand.
§ 15.5.0 MEETING THE DEMAND FOR PHYSICIANS
§ 15.5.1 The
§ 15.5.2 Admission is more competitive at the limited number of US medical schools. As more baby boomers age and more physicians are needed, the federal government might mandate that all schools educate more physicians.
§ 15.5.3 Constriction on physicians is not amenable to salary increases.
§ 15.5.4 Americans see their physicians about 20% less often as citizens from other OECD nations. Given that we have fewer doctors, that seems logical.
§ 15.5.5 Increasing the number of medical school graduates will lead to increased competition and decreased salaries. Keeping the pool of physicians restricted will allow increased fees and income.
§ 15.5.6 Enhancing efficiency is key. By reducing by one half the amount of time that a physician spends on ADMIN, we can increase the availability of 75,000 physicians. IT and similar technologies must be pursued in order to increase efficiency in the practice and at the medical school. Increased use of IT at the medical school will allow for more students, fewer instructional faculty, and less costly education.
§ 15.5.7 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.5.8 Increased payment schedules for GPs would increase its attractiveness over specializations. As it stands now, about 40% become PCPs.
§ 15.5.9 Direct payment incentives for the study of GP would increase their numbers.
§ 15.5.10 - A federal medical school will address much of the unmet demand for physicians, introducing consistencies,
improve quality, greater efficiency, re-allocation of resources. Master teachers could broadcast courses globally with IT support. I propose a
§ 15.5.11 - Additional medical schools might be developed in underserved, rural communities BUT special programs
must be developed so that internships and residencies are offered in the same underserved communities,
otherwise, as soon as a medical student goes off to the city and sees the attractive lifestyle of a surgeon earning $500,000 a year, small town practice generating $125,00 a year doesn’t seem quite as appealing.
§ 15.5.12.1 - PAs, NPs, and other practitioners might increasingly be utilized, especially in underserved
rural communities, inner cities, NHs, hospices, HHs, HHCs, prisons, long term hospitals and training centers, VAMCs, schools, etc. These professionals are easier to recruit and cost one-half to one-fourth the cost of a physician. Of course, physicians are always available for difficult to treat and borderline diagnostic cases. By increasing the production of PAs and NPs, we can reduce the growing need for physicians by two-thirds, at least 100,000. Further, as the payments for services offered by these professionals is $30 less per visit, a savings of $9 billion per year would be realized.
§ 15.5.12.2 - I propose that a federal school for PAs as well as NPs (described elsewhere) which hires master teachers
and broadcasts lessons via satellite would introduce efficiencies. There are presently 140 PA programs and an estimated 850 NP programs. Programs that access these feeds could shift much of the teaching burdens to research, increase the number of students in the programs, and reduce per student costs of instruction. The total cost of a FPAS would be approximately $500 million. A total of 1,600 faculty would be hired. A total of 12,000 PA students would be served. Total revenue from IT programs would be $25 million per year. Total revenue from tuition, room, and board would be $200 million. Total revenue from international development programs from the
§ 15.5.12.3 - I propose that the federal government provide $2 million per PA program for infrastructure investments and
$4 million per year for operations. I propose that the 140 existing PA programs increase graduates by 10,000 per year. By increasing the average payment for PA services by $5, the average PA salary and benefits package could be increased by $30,000, enough to attract additional, highly qualified students. This would cost $280 million in the first year for the first proposal; $560 million per year for the second proposal. Scholarship assistance for the additional 10,000 students per year would equal $500 million.
§ 15.5.12.4 - I propose that the federal government provide $2 million per NP program for infrastructure investments and
$4 million per year for operations. I propose that the 850 existing NP programs increase graduates by 57,000 per year. By increasing the average payment for NP services by $8, the average NP salary and benefits package could be increased by $48,000, enough to attract additional students. This would cost $1.7 billion for the first proposal; $3.4 billion per year for the second proposal. Scholarship assistance for the additional 10,000 students per years would equal $500 million.
§ 15.5.13.1 – Payment by third-party payers for basic services performed by medical, NP, and PA students ought to
increase the availability of services, they might be reimbursed at lower rates, and they might lower costs.
§ 15.5.13.2 - PA and NP programs ought to offer specializations for individuals who will locate in rural communities,
inner-cities; those who will specialize in fields such as anesthesiology, delivery, pediatrics, geriatrics, prisons, etc. and these programs ought to provide incentives for students who study in these fields and go on to practice in these fields.
§ 15.5.13.3 – A nurse anesthetist’s median pay is $145,000 whereas the anesthesiologist’s median pay is $314,000.
This is $170,000 a year less for the nurse anesthetist who can provide many services at half the cost. Psychiatry nurse specialists earn half what psychiatrists earn. Pediatric nurses earn two-thirds what pediatricians earn. Geriatric nurse specialists earn half what geriatricians earn. In many cases, the services of the nurse specialist can be equal to that of the highly trained physician, they often show superior commitment and empathy, and they cost a fraction of what physicians cost. As such, their services ought to be sought for basic care. I would argue that NPs might serve a special role in providing care in NHs and other long-term care facilities, prisons, school districts, etc.
§ 15.6.0 MEETING THE DEMAND FOR DENTISTS
§ 15.6.1 Admission is becoming more competitive at the limited number of American dental schools.
§ 15.6.2 Constriction on dentists is not susceptible to salary increases.
§ 15.6.3 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.6.4 A federal dental school will address much of the unmet demand for dentists. The use of IT programs will introduce consistencies, improve quality, introduce efficiencies, and relocate resources. Again, I propose a multi-campus FDS.
§ 15.6.5 Dental hygienists might increasingly be utilized in underserved rural communities, inner cities, NHs, hospices,
HHs, HHCs, prisons, long term hospitals, training centers, VAMCs, etc. These professionals are easier to recruit and cost 1/4th the cost of dentists. Of course, dentists are always available for difficult to treat and borderline diagnostic cases.
§ 15.6.6 Payment for basic services by dental hygiene and dental students ought to increase the availability of services
and they might be reimbursed at lower rates, resulting in lower costs.
§ 15.7.0 MEETING THE DEMAND FOR ALLIED HEALTH PROFESSIONALS
§ 15.7.1 Admission is more competitive at the limited number of allied health schools.
§ 15.7.2 Constriction on providers is generally not susceptible to salary increases.
§ 15.7.3 Increased investments in CDC and NIH will increase grants, faculty, and students.
§ 15.7.4 A federal allied health professions school will address much of the unmet demand for providers. Use of IT broadcasting globally will introduce consistencies, improve quality, introduce efficiencies, and relocate resources. Again, the campus ought to be multi-disciplinary.
§ 15.7.5 Reliance upon assistants (e.g., physical therapy assistants) will increase service and reduce costs.
§ 15.7.6 Payment of basic services by students and doctoral psychology interns ought to increase the availability of services and they might be reimbursed at lower rates, resulting in lower costs.
§ 15.8.0 ACCESSING FOREIGN STUDENTS
§ 15.8.1 Graduates from health sciences universities throughout the world could be tapped to provide services in the
CHAPTER 16
QUALITY ASSURANCE (QA) IMPROVEMENT
“All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.”
“Work is love made visible. And if you cannot work with love but only with distaste, it is better that you should leave your work and sit at the gate of the temple and take alms of those who work with joy.” - Kahlil Gibran
§ 16.1.0 QUALITY ASSURANCE (QA): FROM CLERICAL FUNCTIONS TO ADVANCED STRATEGIC ANALYSIS
“Laws are like cobwebs, which may catch small flies, but let wasps and hornets break through.” - Jonathan Swift
§ 16.1.1 Medicaid uses strong armed techniques to recapture some of its initial expenditures. This kind of strong armed technique is used to extort billions of dollars from small providers caring for Medicaid patients. This tactic provides Medicaid with billions of dollars, but, it also helps it achieve its other unstated Herculean goal of providing care with insufficient resources. The more health care professionals put in prison, the fewer will tread into the web of providing care for Medicaid patients, and, thus, costs are decreased. This adversely affects the services and quality of services that Medicaid patients can obtain.
§ 16.1.2 Sadly, the above is what is now called QA. Can things change?
§ 16.1.3 Most QA consists of rules assuring compliance with insignificant clerical tasks – putting names on each entry, date and time, name and signature of provider, date (again) next to provider’s signature. Use SOAP format and address each of the 27 goals on pages 14 to 41. If you didn’t dot your “i”, you get paid nothing for that service, even if it had been a $20,000 surgery. Thus, one learns quickly to dot the “i”’s for Medicaid.
§ 16.1.4 Frankly, I don’t care if my dad’s doctor didn’t write the date before his entry AND after his signature. I care that he correctly diagnosed the problem and prescribed logical, helpful medicine and he cared for my dad. QA so often doesn’t even consider these factors.
§ 16.1.5 Imagine an IT system assures mundane punctuation and grammar is satisfied automatically. QA would become more sophisticated. Monitoring, QA could, in real time, examine rates and types of medical errors committed by different practitioners and flag those with high rates, procedures that are ineffectual, assure treatment fidelity, quality decision making, examine relative costs, efficiency, utilization of statistical prediction and decision making models, and appropriate prescriptions. Does a doctor send all patients to the CAT scan clinic in which he is 25% owner? This kind of QA might actually result in health care savings, reductions in medical errors and abuses, and truly enhance quality. Potential fraud could be identified almost immediately.
§ 16.1.6 QA costs will be unchanged, but, technicians and clerical staff will be replaced by IT professionals, economists, and health care professionals. Credit card company security divisions know how to spot possible fraud and we might contract for such services as records become electronic.
§ 16.1.7 By getting on the internet, I can tell you the average salary of graduates across different schools, tuition, room and board, financial aid, quality, and I can devise a formula for selecting the school with the best return for my investment. Yet, I can’t find cogent centralized outcomes or satisfaction data on doctors, PTs, therapists, hospitals, etc. when my life depends on it!!! Quality and Outcomes must be made transparent to all consumers up and down the health care “food chain”. As a patient, I ought to receive a form that shows how my doctor’s patients are satisfied with his services compared to other doctors in that specialty or region or state-wide or nation-wide. Wow! If I knew that my patients would see how I compared to my colleagues, in terms of quality or satisfaction, I’d tend to work even harder for them, focusing every moment on their needs. The use of EMR’s will make this task easy to complete, with daily updates. Transparency of quality and outcomes is ultimately how to get the
§ 16.2.0 SAVINGS THROUGH USE OF ONE SET OF REGULATIONS
“Almost all quality improvement comes via simplification of design, manufacturing ... layout, processes, and procedures.”
§ 16.2.1 A single set of procedures, available on-line with prompt customer service could save provider time. Now, providers who accept 20 different forms of patient insurance keep 30 to 60 manuals, with which they are expected to be intimately familiar. When doctors are now working a health care assembly line, they don’t have time to think about the differences in ADMIN regulations. Simplification of these systems by adopting one set of regulations, one set of authorization panels that are tied in to licensing boards would make sense.
§ 16.2.2 I generally have to wait about 20 minutes for an insurance representative to discuss the needs of one of my patients. If insurance companies had to pay providers for wait times, insurance companies would answer their phones immediately. As the current system now exists, providers must employ about twice as many billing managers for the same number of procedures as two decades ago, as individual third party payers have each adopted unique procedures required for billing.
§ 16.2.3 I live in one state and I am within a 50 minute drive of 3 other states. I would argue that the functions of a physical therapist are the same whether practicing in one state or another. As the insurance companies want centralization for competition’s sake, I suggest that the federal government ought to regulate all health care services and professions. This would save $15 billion per year over the duplication of services by individual states and it would improve accountability. Individual providers who move from one state to another must re-apply for licensure and re-submit forms, transcripts from 40 years ago, letters of recommendation, at a cost to them of another $10 billion per year that would no longer be necessary if the federal government assumed leadership for this function.
§ 16.3.0 BALANCING SPEED WITH QUALITY
§ 16.3.1 Standards of quality of care and efficiency of service must be balanced and ought to be specifically articulated by CMS for all Americans whether they are in private or public programs.
Study after study reveals a troubling pattern. Patients at private clinics or hospitals pay more and receive inferior quality of care than patients at public facilities.
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