GEHA's Seven-Year "Glitch"

In a little piece of legislation known as the Affordable Care Act, preventive services are mandated to be covered with no out-of-pocket expense to consumers.  According to the Healthcare.gov website, approved insurance plans must cover a “list of preventive services for children without charging a copayment or coinsurance.”  Number 18 on that preventive care list is:  childhood immunizations for children from birth to age 18, acknowledging regional variation in the standard recommendation schedule.  After all, vaccinations are the cornerstone public health achievement of the last century and have saved countless pediatric lives. 

Alas, all fairy tales must come to an end.  For government employees choosing GEHA insurance coverage, that type of prevention comes at a definitive out-of-pocket cost.  According to Wikipedia, GEHA is a self-insured, not-for-profit association providing health and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits Program (FEHBP) and the Federal Employees Dental and Vision Insurance Program (FEDVIP). According to the US Census Bureau 2014 statistics, Washington State has approximately 341,000 state and local government employees.  My hometown has three very large installations, the Puget Sound Naval Shipyard, Naval Undersea Warfare Center Keyport, and the Bangor Naval Submarine Base employing a large number of full-time employees and contractors.   Many of these individuals have health insurance coverage provided by the Government Employees Health Association (GEHA) insurance plan. 

Surely, the benevolent executives at GEHA are familiar with the Affordable Care Act and its preventive provision mandate.  They must also realize immunizations for children under 18 years of age qualify under the umbrella of preventive care.  So what seems to be the problem? 

For the past fifteen months, EVERY single explanation of benefit (EOB) paperwork mailed to physicians who are practicing in the Pacific Northwest and patients who are employed by the government shows $50-100 of “out of pocket” cost per visit for immunizations and their administration being kicked to patients.  Isn’t it terrible the government can no longer afford comprehensive health insurance coverage in compliance with the ACA for the hardworking men and women they employ? 

Can you imagine what will happen to these families when GEHA continues to operate unchecked and refuses to bear the costs of cholesterol testing, diabetes screening, or annual mammograms?  Washington State already has a mumps outbreak which is massively out of control.  Forcing employees of the federal government to fork over for each and every vaccination for their child is certainly not going to help improve health outcomes. 

After reviewing more than 100 EOB’s personally, a clear and definitive pattern of fraud emerges demonstrating GEHA makes every single patient responsible for $50-100 in out-of-pocket costs for immunizations.  Language in our GEHA contract clearly states we must follow their specifications according to each EOB we receive.  Being the diligent small pediatric office we are, a bill for the amount is sent off to the patient each and every time. 

At first, families would call to inquire why they were “responsible” for “out-of-pocket” preventive care costs.  My answer was simple.  “It violates the central statute of the ACA, but no one can stop the government from ignoring the law of the land.”  Underneath it all, the GEHA fraud is likely just another one of those oversights “allowed” to continue while the federal government looks the other way. 

One meticulous parent called GEHA to figure out what the problem was. GEHA was “shocked” about this small, insignificant computer “glitch” and the customer service representative assured her the mistake would be corrected.  (That was 15 months ago with still no correction in sight.)  The mother forced GEHA to send us a corrected EOB reimbursing us properly for preventive services provided in accordance with ACA guidelines and removing the balance from the patient responsibility category. 

Over the last 15 months, despite many employees complaining to their respective HR departments, patients complaining to the GEHA customer service line, and my office complaining to provider relations about the difficulty getting paid correctly for preventive visits the first time, all of our efforts have been in vain.  The mysterious “glitch” simply cannot and will not be fixed.  (My guess is it may be the same incompetent information technology team who were involved in the healthcare.gov site debacle working on this befuddling “glitch.”)

It got me to wondering about the number of offices who miss the fact GEHA is shorting them by $50-100 per patient well child check-up?  And then I realized the indirect benefits of the GEHA “glitch” to the insurance company.  GEHA must be saving an awful lot of money this way.  This indomitable “glitch” might even be occurring nationwide, in which case, it is saving millions upon millions of cold hard cash. 

Slowly the realization dawned on me that the chance GEHA will fix their innovative money-saving “glitch” is about the same chance a man with a wooden leg has of escaping a forest fire.  I can tell you exactly who the one-legged man in the forest fire is – it is the primary care physician.  Why does the insurer always get to strike the match, start the forest fire, and watch us burn?  When will GEHA be forced to comply with the provisions mandated in the Affordable Care Act and who pray tell is going to enforce the law of the land?

Dear President Trump

I hope you read this letter.  I doubt you will.

I know you’re busy rebuilding Washington, reshaping the international order, and doing a lot of other weighty stuff.  Full disclosure, I voted for you.  Not because you promised to repeal the Affordable Care Act, or because you tweeted at me about it, but because our healthcare system is hopelessly broken and requires an overhaul that does not simply convert over to a single payer system.

Recently you were quoted in an interview with Reuters: “I loved my previous life… I had so many things going… this is more work than my previous life. I thought it would be easier." Yes.  I did too.  Welcome to the frustrating world of shaping health care for a nation.  It should be about making others’ lives better, but instead it is about padding lobbyist pockets. 

There are people who say you’re the wrong man for this job. I am undecided on this.  You’re famous for your hatred of complicated solutions.  They annoy you. They annoy you because you know they’re a waste of time and energy.  Time and energy that can be put into more important things.

You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. There are more experts in healthcare than any other area of the economy.  Does that tell you something? I think it should.

If you want any chance of being re-elected next go around, we must get cracking on building the healthcare infrastructure from scratch.  It is not going to be easy, but you already learned this lesson per your statement above.  So how do we streamline health care reform and get ‘er done? 

There are two main problems:  access (coverage) and runaway cost.  The Affordable Care Act provided coverage to many and coupled it with cost control to no one.  This made affordability unachievable for the long-term and things will continue to get worse. 

Congress is currently on the wrong track headed to an empty station.    The general approach of the American Health Care Act is to decrease costs by cutting coverage to the people.  Please go back to the drawing board and start again.  Throwing support behind the American Health Care Act is just flogging a dead horse.  People in this country want affordable healthcare choices and freedom from fear of no access for chronic conditions and unforeseen catastrophic events.  They no longer want to worry about health issues bankrupting them.  Struggling families are one catastrophic illness away from losing their American Dream and that must change.  Step back and take in the big picture. 

Stop focusing on the minutiae.  Instead, start small to overhaul healthcare one phase at a time.  Develop a system which provides immunizations, annual screenings, and simple but necessary medical interventions to every person in the country.  Call it basic care.  You can expand the Community Health Clinic model or utilize the existing Public Health system which is sorely underfunded and underutilized, yet remarkably cost-effective.  Physicians are not required to administer immunizations, take blood pressure, and check cholesterol levels.   Save money by putting mid-level providers in these roles. 

Some basic specialty care could be provided at the public health facilities or community clinics and mid-level specialty providers could fill these positions.  If an individual becomes severely ill or injured and requires more specialized care, needs hospitalization, or surgical intervention, then their catastrophic insurance plan will kick in to cover these needs. 

This is how insurance was created to work, by covering the expense of unanticipated events. Embrace the idea that health insurance should be for:  cancer, heart attacks, car accidents, and other unexpected issues.  The cost of health insurance would decrease considerably if it functioned more like actual insurance and less like a system to reimburse physicians for routine, expected health maintenance.  Third party payers distance patients and physicians from being cognizant of real cost. 

Finally, allow the free market to play a role by giving people options.  80% of healthcare can be handled in a Direct Primary Care practice, where patients pay the physician and enter into a more contractual relationship.  This provides the options many physicians and patients are afraid of losing in a single payer system, an idea that was extremely unpopular in the past.  Health savings accounts could be set up to cover out-of-pocket costs for those who are interested in care outside of the public health system or name brand medications, which are more expensive than generics.

Last but not least, ignore the special interest groups for the time being.  No one else has tried to overhaul health care without kowtowing to them and it is high time someone with big (Ahem) aspirations just went for it.  You are the right person for an unconventional approach.  The Big Four are:  the AMA ($20 million on lobbying in 2016), the American Hospital Association ($20 million), the American Health Insurance Plans (AHIP, $7 million), and Pharmaceutical Research and & Manufacturers of America (PhRMA, $20 million but the industry total was $240 million altogether.)  Special interests cannot help you cultivate the Public Health system or grow the network of community clinics.  Leave them out of it.

I realize the longer this letter becomes, the less likely it will be read, so I will close by saying healthcare is the SINGLE most important task you must accomplish to have any hope of being re-elected.  You have nothing to lose by giving something simple a chance.  The AHCA is trying to pound a square peg into a round hole.  Find the round peg and with it, the right solution. 

Sincerely,

Niran S. Al-Agba, MD

(just google me if you want to talk more)

What is the Cost of a Single Hospital Bed in Kitsap County? $225 Million

May 1^st, the Washington State Department of Health will rule on the Certificate of Need (CON); whether or not CHI closes hospital operations in Bremerton and moves all services to Silverdale. CHI will invest $680 million to expand campus size and build a state-of-the-art facility; they will save $9 million annually in improved efficiency.  It will take just 75.5 years to recoup the cost. 

To put the size and expense of this project into perspective, Becker’s Hospital Review compiled a list of the most expensive hospital expansion projects in the nation for 2016.  CHI is listed at number 13 because the cost prediction was initially $530 million; however, expenditures are now predicted at $680 million, bringing CHI up to the 6^th most expensive project in the United States. 

Reviewing the list of the top 20 carefully, a few trends emerge.  Most expansion projects involve demolishing aging facilities and building new structures with more beds, private rooms, ER bays, and goals of enhancing the “hospital” experience.  NOT ONE other hospital expansion involved closing the doors and walking away from an “aging” structure, leaving it empty, and never looking back. 

The “aging” facility in Bremerton has an assessed value of $72 million and a property tax bill of approximately $950,000, from which CHI is currently exempted, as they provide charitable care to the uninsured.  The whole idea of exempting nonprofits from paying taxes is based on the belief these entities provide charity for the underserved and underinsured and value the facilities in which they provide healthcare for communities.  This will no longer be the arrangement for CHI and the City of Bremerton.

Hospital bed availabilities are expressed in number of beds/1,000 population.  According to the Kaiser Foundation, Washington and Oregon are the two lowest states in the nation with bed ratios at 1.7 bed/1000 population.  After the 6^th most expensive hospital expansion project in the United States is complete, Kitsap County will have a mere 1.3 beds/1,000 population.  The expansion does nothing to help this important disparity in our region, which is considerably underserved. 

The most expensive hospital expansion of 2016 is at Jackson Health in Miami, Florida which will spend $1.8 billion for new facilities and adding 20 beds.  That works out to $90 million/bed.  Florida has 2.6 beds/1,000 population, twice that of Kitsap County.  The most frugal expansion being completed is at the University of Virginia Medical Center, adding 80 beds for $394 million, which works out to $4.9 million/bed.  Virginia has 2.1 beds/1,000 populations.

At both Harrison Hospital campuses, there are currently 347 beds, 24 of which are NICU designated.  Once the $680 million expansion project is complete, the final bed tally will be 350 beds.  Kitsap County will gain 3 beds for the 680 million dollar expenditure, which is about $225 million per bed in cost. 

There are THREE core issues with walking away from the hospital facility in Bremerton:  1) no charity care will be provided in exchange for the generous tax exemption of almost $1 million provided by the City each year and 2) there has been no definitive provision for emergent, urgent, and primary care for the populace within the city limits and 3)  the aging facility on 7 acres of unusable land being vacated and leaving environmental hazards such as asbestos and legionella with no plans for its future. 

To look from another angle, we should ask what Kitsap County is gaining from this $680 million expansion? All services will be in one place. 

Non-Profit Hospitals are a Fairy Tale

Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations.  3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax.  An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.

The idea of exempting nonprofits from paying taxes in the first place, is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand.  As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question. 

Many nonprofit hospitals calculate their charitable care by using something known as “chargemaster” pricing; exorbitant, non-negotiated prices which are inflated many times higher than what private insurance or Medicare would pay.  This allows facilities to overstate their provision of “charity care,” calculated as revenue loss by the hospital in exchange for their lucrative tax exemptions. In a patient evaluated with  chest pain, the allowable for Medicare is $3600; however, in an uninsured patient, the hospital may “write-off” an inflated $25,600 in uncompensated costs, which is 8 times higher than actual cost of care provided.  Nonprofit hospitals should be required to meet a higher standard by providing true (non-inflated) charity care.

A study, conducted by Zack Cooper (Yale), Stuart Craig (University of Pennsylvania), Martin Gaynor (Carnegie Mellon), and John Van Reenen (London School of Economics), evaluated the way nonprofit hospitals charge.  “Not-for-profit hospitals don’t price any less aggressively than for-profits. We subsidize not-for-profits to the tune of $30 billion annually, in the form of tax exemptions, and we have to ask what that money is getting us,” says Cooper, co-author of the study.

So what is the tax exemption getting us if not to “real” charity care for those in need?  A significant amount of nonprofit hospital revenue is being spent on executive salaries and benefit packages, reinvestment in new state-of-the-art facilities, and expanded healthcare services for those who can afford it. 

According to Becker’s Hospital Review in 2012, the combined compensation of the top executives at the 25 most profitable non-profit hospitals totaled almost $58 million. The highest paid nonprofit hospital CEO in the nation is Jeffrey Romoff, at the University of Pittsburgh Medical Center (UPMC.)  An article in The Pittsburgh Post Gazette found his 2015 compensation was $6.43 million dollars;  he has topped $6 million for the last four years, plus notable perks, such as access to a private chef, chauffeur, and a jet.  Additionally, the Gazette found 31 UPMC executives and physicians earned at least $1 million in 2015, six of whom received more than $2 million each. 

In 2013, Pittsburgh Mayor Luke Ravenstahl unsuccessfully sued UPMC to collect more taxes on the grounds his city was losing $20 million annually as a result of the tax exemptions.  CBS News aired a segment after investigating the financial details.  UPMC brought in $948 million in profit over the 2 year period 2011-2012, while providing a mere 2% of its budget in charity care, and yet was saving $200 million after tax exemption. Imagine what that could pay for in the way of healthcare for the poor, disabled, and elderly, not to mention the funding for teachers, police officers, and firefighters?

The idea nonprofit hospitals should be paying property taxes has been gaining traction ever since.  In 2015,  a New Jersey judge ruled that Morristown Medical Center should be responsible for paying property taxes because it acted more like a for-profit organization than one devoted to the provision of charity care.  He said, “modern nonprofit hospitals are essentially legal fictions;” kind of like a modern day fairy tale.  Ultimately, Morristown Medical Center reached an amicable agreement with the city to pay $1 million in the way of taxes, but multiple cities have followed suit, challenging the tax exempt status of nonprofit hospitals in the state.  

Illinois is the latest battleground for the property tax exemption controversy.  A 2009 report by the Center for Tax and Budget Accountability found the property tax exemptions for 47 Chicago-area nonprofit hospitals were worth $279 million. In Illinois, a charity was originally defined as an organization generating revenue from donations and providing services to those in need.   In 2010, the Illinois Supreme Court ruled Provena Covenant Medical Center was not entitled to a property tax exemption because they were not a charity, as most of their revenue was generated from fees for service.

In 2012, the Illinois Hospital Association lobbied hard to expand the definition of charity in state law.  The state legislature passed a provision—buried in the Medicaid Reform Bill 2194-- allowing property tax exemptions for hospitals providing charity care in the equivalent amount to their tax liability.  Medicaid reimbursements, considerably lower than private insurance payments, were allowed to count toward the “charity care” tabulation. 

The Carle Foundation Hospital is the 10^th most profitable hospital in the nation, according to the May 2013 article in Health Affairs.  They filed a request to have a property tax exemption after the controversial 2012 law was enacted.  The City of Urbana argued Carle had revenues approaching $2 billion annually, functioned more as a for-profit organization than nonprofit, and caused the city to lose $6.3 million in property taxes, necessitating a rate increase for other city properties as a result.  Last year, the 4^th Distric Appellate Court ruled the 2012 state law unconstitutional. 

Dissatisfied with the outcome, Carle Foundation Hospital appealed to the Illinois Supreme Court.  On March 23, 2017 the Supreme Court of Illinois vacated the ruling of the Appellate Court, but would not consider constitutionality of the 2012 law;  Carle will be entitled to the property tax exemption for now.  The Supreme Court recommended reconsideration in the lower courts as to the question of constitutionality, so the debate remains ongoing.

The days of charitable establishments singularly devoted to comforting and caring for the poor and suffering are long gone.  Most nonprofit hospitals are vast profit machines bearing little resemblance to the charitable organizations of the past.  By reinvesting in state-of-the-art facilities with unnecessary “bells and whistles,” nonprofits are currently dominating city landscapes, becoming the largest local employers, and bringing in more revenue than the cities in which they are located. 

By sidestepping  property tax payments to the county or city in which nonprofit hospitals reside, they are shifting the financial burden for essential services and infrastructure onto the backs of individual citizens and small business owners, who should not bear the costs alone.  Stricter criteria should be applied to determine whether a hospital meets a “charity care threshold” in order to retain the lucrative nonprofit designation.  This is a vital step toward ensuring cities and counties collect adequate revenue for developed land, while ensuring vulnerable populations have somewhere to go when in need of healthcare, which is rapidly becoming unaffordable for us all. 

A Mountain of Evidence Against Hospital Consolidation

There is a growing body of evidence that hospital mergers lead to higher prices for consumers, employers, insurance, and government.  It is vital to educate patients, their communities, and our lawmakers as to how hospital consolidations raise costs, decrease access, eliminate jobs, and reduce the quality of healthcare. 

A study published by the National Bureau of Economic Research and Zack Cooper at Yale University sheds light on the real cost of reduced hospital competition: prices are 15.3 percent higher in markets with one hospital as compared to markets with four or more hospitals, a cost differential of $2000 per admission. “I have never seen a study that says consolidation makes things better,” says Cooper. Neither have I, despite researching this topic extensively.  Hospital consolidation increases costs and does nothing to improve healthcare quality. 

The ACA created incentives for health care facilities to coordinate under accountable care organizations (ACOs); this hindered the ability of regulators to block hospital mergers.  As a result, across America, we have seen a dramatic increase in hospitals gobbling up independent providers and becoming powerful regional monopolies, cautionary tales which should be used to guide local decision makers.  Since the Affordable Care Act went into effect the rate of hospital consolidation has increased by 70 percent. 

Harrison Medical Center is the hospital in which I was born, raised (following my father on rounds to the nursery as a child), and practiced medicine as a new community physician.  Since CHI “acquired” Harrison, they have bought local independent medical practices at a rapid pace. Recently, the largest independent multispecialty physician group in the county, the Doctors Clinic, merged with CHI, as did the last independent orthopedic group. 

Prior to these mergers, 65% of physicians in Kitsap County were independent.  That number has plummeted to a mere 27%.  Kitsap County is losing choice for the consumer, employer, and physicians, which will ultimately reduce access to care. 

Physician groups merging with CHI Franciscan are restricted from utilizing the local ambulatory surgery center (ASC) for outpatient procedures; they are encouraged to use hospital facilities instead.  It is well accepted costs at hospital facilities are substantially higher when compared to identical procedures completed at ASCs. Much of that difference is accounted for by the “facility fee” (room rental charge at hospital-based clinics and operating rooms.) 

A recent study conducted by Leemore Dafny (Northwestern), Kate Ho (Columbia), and Robin Lee (Harvard) provides solid evidence that prices increase when hospitals consolidate.  “If you are [consolidating] because you think in the long run it will serve your community well, you should think twice,” said Dafny, a health and hospital expert at Northwestern University.   

The case for hospital consolidation is strongly supported by the American Hospital Association, the leading industry trade group, which spent $15 million on lobbying in 2015.  They want you to ignore the fact increasing competition among hospitals is a scientifically proven cost-control measure.  The AHA contradicted data published by both Zack Cooper and Leemore Dafny by suggesting access and quality improve in a monopolistic system, yet they have no solid research to back up their assertions. 

The bottom line is studies have shown cities with higher premiums on the ACA insurance exchanges tend to be in cities with the higher priced hospitals.  Higher prices in less competitive markets lead to higher premiums, increased costs of which are passed on to employers, followed by higher out-of-pocket payment demands for individuals and families who have high-deductible health insurance plans.    Additionally, when hospitals consolidate into monopolies, they leverage their advantageous market position to negotiate more aggressively with insurers and employers.  This drives costs up by as much as 15-20%. Are we prepared to levy this substantial increase onto the backs of Kitsap County citizens?

Avvik Roy, a journalist and health policy analyst, gave a presentation on “How Hospital Mergers Increase Health Costs” in 2012.  He concluded that communities and government must do more to fight consolidation among hospitals.  He is right. As an independent physician in private practice, I care a great deal about our people, our patients, and healthcare delivery in Kitsap County.  The fact hospital consolidations do not economically benefit patients is backed by a mountain of scientific evidence.  While those in charge may decide merging is ultimately the best course of action, it will be imperative we stand up as a unified community and hold CHI accountable for ensuring the cost savings they have promised materialize.

#BoycottUnited Airlines for Condoning Unrepentant Violence

Watching events unfold at United Airlines over the last few days have filled me with shock, awe, and horror.  As a result of this public relations disaster, their motto “flying the friendly skies” has turned into “not enough seating, prepare for a beating.” America stands as a beacon of freedom from oppression.  United Airlines was an iconic American company until last Sunday, with a responsibility to uphold the intent of the immortal words in the Declaration of Independence, “all men are created equal, that they are endowed by their Creator with certain unalienable Rights that among these are Life, Liberty and the Pursuit of Happiness.” 

In my opinion, much of the backlash was initially a result of the lackluster attempt at an apology from the CEO of United Airlines, Oscar Munoz.  Despite three attempts, he still appears rather oblivious to the real suffering of Dr. Dao.  Physicians have been taught that the best thing to do in the face of a medical error is to be honest, forthcoming, and apologize; it must be genuine and from the heart -- acknowledge our blunder, take responsibility for our mistake, and convey our sincere regret.  Executives at United Airlines would do well to heed these words.

According to scientific research, there are six ingredients which constitute a proper apology – 1. Expression of regret, 2. Explanation of what went wrong, 3. Acknowledgement of responsibility, 4. Declaration of repentance, 5. Offer of repair, and 6. Request for forgiveness.  The request for forgiveness is missing from apologies offered by this corporation. 

Describing the violence caught on video as “re-accommodating customers” was offensive.  Engaging in “blaming the victim” by describing the man who was dragged, while screaming and bleeding, up the aisle and off the airplane as both “disruptive and belligerent” made matters worse.  However, as United Airlines watched their market value plummet by $250 million, this story began to take on an even more shameful context. 

Does the background of a fare-paying passenger matter when evaluating an infringement on his rights?   No.  His “troubled past” should be completely irrelevant as to how United Airlines handled the forcible removal of a ticketed passenger unwilling to give up his seat.  United Airlines actions are reprehensible and unjustified.   We must not allow ourselves to be distracted by the salacious details of Dr. Dao’s life story; unless we are ready to risk exposure of our own personal secrets should we refuse to give up our paid seat someday. 

The victim in this story is the passenger and could have just as easily been any one of us.  More troubling to me is the thought Dr. Dao might be suffering from PTSD, in my opinion, based on the video footage.  The fear conveyed in his guttural scream coupled with his passive demeanor as he was dragged down the aisle of the airplane indicated Dr. Dao seemed familiar with the brutality of forced compliance. At no point on the video is Dao seen attacking the security officers.  In fact, he was later observed standing in the aisle saying quietly, "I want to go home, I want to go home."

However, Dr. Dao’s hometown paper, the Courier-Journal, capitalized on the opportunity to break a story, noting he was convicted of a drug-related offense more than a decade ago.  As if implying United Airlines was vindicated in their mistreatment of him; in effect, victimizing him twice.  His medical license was suspended by the Kentucky Board of Medical Licensure and reinstated in 2016.  Public documents indeed confirmed Dr. Dao carries a diagnosis of PTSD stemming from his traumatic childhood and additional distress experienced while working as a physician after coming to America. 

Dr. Dao initially agreed to disembark the overbooked flight, from news reports, and when he discovered the next flight was not until Monday afternoon, he expressed the need to return to work.  He is recorded on video saying “I can’t be late, I’m a doctor.  I’ve got to be there at 8am tomorrow.”  His license is restricted with supervisory requirements.  It is highly likely unexplained absences could harm his chances of a full return to an occupation he dearly loves. 

Research has found (Blair, 2000), 85% of Asian refugees had experienced horrible traumas prior to immigrating to the United States, including starvation, torture, and losing family members to war.  A report released by the Surgeon General’s Office in 2001, reveals the effect culture, race, and ethnicity can have on mental health.  Suffering from a mental health disorder can be highly stigmatizing and reflect poorly on one’s “family honor,” making it difficult to accept.  Historical events and circumstances many individuals of Asian descent have lived through can be extremely traumatic.  One study found as many as 70% of Southeast Asian immigrants suffer from PTSD.

Dr. Dao graduated from the University of Medicine of Ho Chi Minh City in Vietnam, in 1974, a tumultuous time in Vietnam before the fall of Saigon in 1975.  He very likely has had experiences many of us born and raised in America cannot fathom.  His lawyer confirmed as much this morning on a live news conference.  This man is the father of 5 children, four of whom are physicians, and he is married to a pediatrician.  He has clearly worked very hard and overcome numerous obstacles in his life.  He has atoned for his own missteps while holding his head high and that deserves our respect.  According to public record, he complied satisfactorily with The Kentucky Board of Medical Licensure recommendations for rehabilitation and requirements to have his license reinstated.  Dr. Dao embodies a quintessential American story.

Let us return for a moment to United Flight 3411 last Sunday evening where this man was physically assaulted as he was forcibly removed from the airplane he had been initially allowed to board.  Can you imagine his fear and anxiety as he was “selected” to be evicted?  When three large men returned to force him from his seat, what was HIS subjective experience?  Even, the passengers who stood up for Dr. Dao were emotionally disturbed witnessing this horrifying event.

How more emotionally provocative would it be if one already suffered from PTSD, anxiety, or depression?  If the airline industry cannot make allowances for individuals in this country who are singled out unfairly on the basis of age, race, or even disability, then everyday Americans must stand up for those individuals being victimized who are unable to do so for themselves.  This could have happened to any one of us. 

Nelson Mandela once said, “To deny people their human rights is to challenge their very humanity.”  A second hero in this story, in addition to Dr. Dao, is the woman who said, “No.  This is wrong.  Oh My God.  Look at what you are doing to him.”  Thank you for lending your support to someone being mistreated. 

If we as a nation lose sight of our humanity, we will lose everything for which we stand.  Corporations are not people.  We should bring United Airlines to their knees until they truly comprehend the damage they have done, mentally, physically, and emotionally to this innocent 69 year old physician and man.  United Airlines should do more than apologize profusely; they should ask forgiveness of Dr. Dao, his family, our nation, and the world. 

 

 

You've Got Facility Fees!

ACA Medicaid expansion resulted in unanticipated negative consequences for many patients and physicians in rural, underserved, or medically isolated communities across America. Consolidation of healthcare entities was financially incentivized by the ACA and slowly my beloved corner of the Pacific Northwest is becoming a medical wasteland. 

In a beautiful community on the Olympic peninsula, just north of where I live and practice, it happened again; another private clinic sold to a large medical corporation.  Peninsula Children’s Clinic was a bustling pediatric office meeting the vital complex healthcare needs of children in Port Angeles, WA for the commercially insured as well as Medicaid patients.  Why were they forced to close? A phone call with their office manager six months ago foreshadowed the outcome, “we are losing a great deal of revenue seeing Medicaid patients making it difficult to survive.

Peninsula Children’s Clinic was unable to remain financially solvent, so they were purchased, like a horse on the auction block, by the Olympic Medical Center.  Their website recently posted the following:

“Peninsula Children's Clinic is now licensed as part of Olympic Medical Center.

Patients seeking care at these hospital-based clinics may receive a separate billing for a facility-fee. This fee could result in higher out-of-pocket expenses for patients.

Patients should contact their insurance company to determine their coverage for hospital-based clinic facility charges.”

Hospital-based clinics tack on “facility fee” charges, which are separate from the bill for the doctors’ services, for the use of the room in which the patient was seen. One hospital administrator told me to think of it as “room rental.”

Facility fees bring in a considerable flow of cash and have the secondary benefit of incentivizing hospitals to buy independent practices because then the hospital can charge two to five times more.  Buying independent practices, like Peninsula Children's Clinic, expands the hospitals’ market share and allows greater leverage when negotiating reimbursements. 

Payers must acquiesce and pay the facility fees.  As the payers are forced to pay more to the hospitals and hospital-based clinics, guess where they make cuts? They cut their fees to the independent private practice physicians, already struggling to make ends meet.  My practice was notified of the impending 50% cut in reimbursement from Kaiser Permanente for specific codes just last week for private providers.  In the meantime, as the government incentivized hospitals, are costs getting lower? Are consumers spending less? Are outcomes improving at record speed? Nope, and they won’t be anytime soon.

Medicare pays double the amount for office visits at hospital-owned clinics as compared to private physician offices, according to 2012 and 2014 reports by the Medicare Payment Advisory Commission (MEDPAC), an agency that guides Congress on Medicare spending. For example, Medicare paid $453 for an echocardiogram at hospital-owned facilities, yet the same test performed at an independently owned physician office costs, on average, $189, according to the 2014 report. In its 2012 report, MEDPAC found Medicare paid 80 percent more for a 15-minute visit at a hospital-based clinic compared to one at a private practice.

Based on the prediction Medicare spending would increase $2 billion by 2020, MEDPAC lobbied Congress to equalize payments between hospital-based and private physician offices by eliminating the onerous facility fee. Eliminating the facility fee and setting hospital reimbursement equal to that of independent physicians for 66 procedure groups, results in $900 million per year in savings on Medicare costs.  However, eliminating the charges has proved daunting, for $3 trillion “reasons.”

Although MEDPAC has long promoted the idea of “site neutral payments,” the hospital lobby deafened Congress to this important recommendation.  The American Hospital Association opposes MEDPAC’s recommendations on several grounds, including facility fees are warranted because they create the financial incentive hospitals “need” to shore up “loss leaders” like the ER, where they are obligated to treat everyone, regardless of ability to pay. Hospitals say the money helps make up for low government reimbursement rates and pay expenses outside of patient care, ranging from electric bills to hospital administrator salaries.

Consumer groups, such as Health Watch USA , say hospitals are charging patients, insurance companies and Medicare more without reason.  Their board chairman, Kevin Kavanagh, has emphasized in many newspaper articles and publications that these fees are “essentially double billing”, without improving quality or patient outcomes.  Many watchdog groups believe the fees have persisted to promote mergers between hospitals and clinics.  Organizations, like the Association of Independent Doctors has emphasized facility fees add “zero value” for the additional cost.   

The facility fee adds billions of dollars to the nation’s health-care costs. Patients with private insurance are responsible for as much as a 15% portion of the facility fee. One family in Port Angeles accustomed to paying $125 in out-of-pocket costs for doctor visits saw their costs skyrocket to more than $500 overnight.  The increase reflects the new “facility fee” charge.  Now, this family drives 2 hours each way to see me, because after accounting for gas and time, it costs less to visit my office than to visit Olympic Medical Center.

The movie, “You've Got Mail,” succinctly illustrates the differences between small and large practices. Meg Ryan closes the doors to her specialty bookstore, Little Shop Around the Corner, for the last time and wanders over to the newly opened big-box Fox Books to browse the children’s section.  In one memorable scene, a desperate mother runs in asking an employee where to find the “Shoe series” of books for her daughter. The hapless clerk blankly repeats “Shoe books?” Meg rolls her eyes and rattles off a list of multiple books in the series from memory, including her recommendation of which to read first, to which the mother was extremely grateful.

I am the Little Shop Around the Corner, as are many surviving, independent physicians across this great nation.  We know our patients, their healthcare, and are effective, efficient, well-oiled machines.  Facility fees must be made transparent for patients or abolished, like they did by law with Public Act No. 15-146 in Connecticut.  Studies continually show small clinics provide better quality care for lower cost, have fewer hospital admissions, and keep patients healthier than the hospital-based clinics.  We must eliminate the onerous facility fee to level the playing field, eliminate the incentive for hospitals to create monopolies, and save Americans 100s of billions of dollars per year.

"Let Obamacare Explode"

Last week, the AHCA was pulled from the House floor after not enough votes could be secured in favor of its passage.  A Washington Post article reported President Trump’s thoughts on the matter.  “We couldn’t get one Democrat vote, not one. They [Democrats] own Obamacare.  So when it explodes…we make one beautiful deal for the people.”  Journalist Robert Costa asserted “there was little evidence that either Trump or House Republicans made a serious effort to reach out to Democrats.”  Well Robert, I sure did. And I did not get very far. 

In the interest of full disclosure, over the past 20+ years, I have been a Democrat, Republican, and just about everything in between.  I recently reached out to lawmakers on both sides of the aisle, yet the responses were lopsided.  A recent entry myself into the political physician realm, I gave a presentation last week on lowering Medicare drug costs to the National Physicians’ Council for Healthcare Policy (NPCHP), in the Energy and Commerce Committee Hearing Room in Washington DC.  This phenomenal group of physicians was assembled by Congressman Pete Sessions (R) from Texas; and they are innovative, engaged, and working to improve the lives of their patients and fellow physicians. 

Six weeks prior to my Washington DC visit, I reached out to three local lawmakers in the interest of discussing healthcare:  Congresswoman Cathy McMorris-Rodgers (R), Congresswoman Jaime Hererra-Beutler (R), and my own local Congressman (D), who I am not naming because of the story below.  Both Congresswomen responded and met with me briefly; they were gracious, honest, and forthright about their support or lack thereof for the AHCA.   Despite three attempts to set up a meeting with my own Representative, I have yet to receive a response. 

In my opinion, not engaging with practicing physicians on the subject of health care reform is a lost opportunity.  There was very little chance my Democratic Representative would vote in support of the AHCA (which is perfectly acceptable), but why is it not worth his time to exchange ideas with a local practicing physician? 

Eighteen months ago, my Representative and I were both in attendance with our respective extended family members at a local theatre production watching our children perform.  During the event, I responded as a Good Samaritan for a relative of my Congressman.  Without a second thought, I jumped up quickly to respond.  To qualify for Good Samaritan protection, you must meet three qualifications:  there must be an emergency, aid must be rendered outside a hospital or a place with medical equipment, and care provided must be voluntary.   In the interest of privacy, suffice it to say, this particular situation met all three criteria and I rendered all necessary and appropriate treatment. 

Partisanship has no place in the rendering of health care services and should play no role in the work of advancing health care reform.  Regardless of party affiliation, lawmakers should solicit recommendations from local practicing physicians whenever they are able.  Both Representatives McMorris-Rodgers and Herrera-Beutler set aside time to speak with a concerned physician from their home state about impending healthcare legislation.  They are both strongly committed to ensuring the populations of Washington State have timely access to healthcare.  I realize their time is precious.  So is mine.

Practicing physicians are partially to blame for not insisting our voices be heard by lawmakers.  As a group, we willingly lend our expertise assisting others in our offices, our communities, and our country, yet we accept the status quo as second class citizens when it comes to having a place at the proverbial healthcare policymaking table.  This MUST change.  Lawmakers who passed the foundering ACA and burdensome MACRA legislation consulted very few practicing physicians on the front lines, and their legislative plundering is destroying our once noble profession. 

The last independent pediatric group in my local Congressmans’ hometown was recently purchased by a hospital conglomerate as a direct result of the ACA legislation he supported. Everyone seeking pediatric care in that county will see their costs rise significantly as a result of the mandatory “facility fee” imposed by the hospital for primary care services. This is a loss of affordable access for his community.

After pulling the AHCA bill last Friday, Trump said, “As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. “  I agree with him.  It will ultimately result in a better healthcare plan for us all.  First and foremost, however, lawmakers responsible for ACA and MACRA legislation must be held accountable for the unanticipated consequences resulting from “coverage with no access to care;” the folly of which is unfolding before our very eyes. 

Physicians care deeply about our patients and our communities. Physicians must ensure they have input on the next healthcare go-around.  Meaningful healthcare reform will require pragmatism, diligence, compromise, and patience.  Working across the aisle is vital to developing better health care legislation for the American people. 

It is time lawmakers consider front-line doctors as the ‘industry experts’ best positioned to contribute to the development of effective and enduring health care reform rather than relying on the renderings of lobbyists who are padding their own pockets as well as those of legislators.  In response to Robert Costa at the Washington Post, I believe President Trump when he said they could not obtain one single Democratic vote.  My own Democratic Representative would not spend five minutes discussing healthcare legislation with me, a practicing physician from the district he represents in Congress.  It is time to roll up our sleeves, shake hands, and get to work.