Is misogyny (distrust of women) on the move in these three states?

Datelines California, Indiana, and Michigan, 12/26/13

The California Supreme Court refused to halt same sex marriages when it poured cold water on a legal challenge to ban  these marriages. Californians know the story: proposition 8 passed in 2008. Same sex marriages were supposed to be banned because that's what the citizens voted for. But in 2010 the ban was ruled unconstitutional. In June of 2013 the U.S. Supreme Court let the ruling stand -- the ban was gone, same sex marriages were on. Governor Brown ordered that county clerks could begin issuing marriage certificates. That's how that matter stands now.

It appears that antipathy to transgender issues has taken its place: As of 1 January 2014 transgender students will be allowed to use the locker rooms and washrooms that match up with the genders to which the students identify. One need not stretch the imagination to understand why issues of genitalia are confusing to parents and coaches alike. Opponents to the new law want to repeal it and have mounted an effort to get the issue on the November election ballot. It is in its own way a revisit of Proposition 8.

The argument that misogyny applies to California's effort to stop same sex marriages probably fails on the basis that the proposed legislation is equally unfair to all who apply, does as much harm to men as to women, excludes both sexes from participation in joint healthcare insurance, prevents both sexes from enjoying the tax benefits of marriage, and generally discriminates equally against both sexes. The currently proposed separate-by-sex restrooms and lockers equally inconveniences both sexes as well as transgender persons. So misogyny isn't an accurate label since the proposed legislation is equally unfair to both sexes as well as to transgender persons.

The Indiana legislature, meanwhile, is preparing to vote on HJR-6 which would amend the state's ban  on same sex marriage. Meanwhile, proponents of the ban on same sex marriage want to extend the ban to include anything similar to marriage, e.g., tax exemptions, shared health insurance, and civil unions. Indiana's proponents of banning same sex marriage go beyond California's Prop. 8.

This bill takes a serious swipe at same-sex anything. Not only does HJR-6 outlaw same sex marriage, it also takes an extra step by refusing to recognize legal alternatives to same-sex marriage, e.g., it would deprive same-sex couples of any status that could be deemed substantially similar to marriage such as civil unions and domestic partnerships.

The irony is that Indiana law already makes same-sex marriage illegal. If enacted HJR-6 would actually change the state constitution and tie the hands of future legislatures to prevent passage of legislation that would allow same-sex marriage.

One may reasonably argue that HJR-6 is mean-spirited but not that it is misogynous. It is equally unfair to everybody.

Not so In Michigan where a legislator recently spoke out against a push for what opponents are calling "rape insurance." The legislator disclosed more than a passing interest in the matter when she revealed in public that she'd been raped 20 years ago and that had the proposed "rape insurance" law been in effect at the time she could have faced untenable consequences.

Here's the scenario in brief along with our conclusion that the Michigan law is misogynous. The Michigan legislature just passed legislation banning health insurance plans from covering abortion unless it can be shown that the woman's life is in danger. The impact of this change in the law is that it means women and/or their employers will be obliged to buy separate insurance policies or "riders" to their insurance policies if rape or incest result in pregnancy. Opponents call this law "rape insurance" and argue that women who wouldn't want an abortion under any circumstances shouldn't pay for it since so doing enables abortions by others.

Although this law passed the Michigan legislature last year, it was vetoed by Governor Rick Snyder. If the law passes the legislature again this year, it becomes law without having to run the gubernatorial gauntlet a second time. In effect, under Michigan state law this move is a way to sneak one past the governor despite the popular will of the people (polls show widespread popular opposition).

This bill meets our definition of misogyny: it is directed against women. That is why State Representative David Knezek, State Senator Gretchen Whitmer, and others have called it "misogynistic." We also find it misogynistic.

We call your attention to an editorial entitled "The Most Misogynistic Law I've Ever Seen" by Sen. Whitmer, posted 12/23/13, published in Huff Post, 12/26/13. The opening line should knock your socks off even if you're not wearing any.

 

 

YOUR DOCTOR ISN'T IN THE PLAN ANYMORE. NEITHER IS YOUR PLAN.

"I'm sorry," tolls the receptionist in a bored voice, "but your doctor isn't in our plan anymore."

Senator Reid opts out: click on comments at end of this editorial re Reid's Obamacare snub

Item A concerns a doctor whose healthcare policy was abruptly canceled when her own physician announced he was quitting the health care plan, would no longer accept insurance, and would henceforth require monthly "concierge" style payment, plus a cash fee for office visits, and that she'd have to have separate insurance for hospitalization whether needed or not.  As for the healthcare plan he was leaving -- the plan would either be disbanded or taken over by doctors who could speak English.

Note: for the uninitiated, "concierge" style practices require advance payment arrangements such as monthly, quarterly, or annual payments plus fees applicable to the services patients use. Medications are not included. Insurance plans are not accepted.

Item B is about several doctors in various settings who have in common that they've sold their practices to corporate entities, foundations, exchanges, or other business groups. It works like this: the corporate entity buys the practice, then employs the doctor or somebody else to run it on a day-to-day basis. The corporate entity pays the staff, the rent, and the expenses. To recoup its money, and to make more money, the practice is required to double or triple its volume. To accomplish this task, the time spent with  each patient must be reduced, say, to a few minutes. That'll be the job of the staff who now no longer works directly for the doctor or the patient but who instead is responsible to the employer. In this plan, insurance is still accepted, in fact, is welcome. If the on-site managing doctor and his staff can't meet these goals, they'll be replaced.

Healthcare Plans that cover patients, doctors, and insurers vary widely. They may assign doctors to multiple plans and keep track of so-called "production," how many patients each doctor sees and how long the average visit takes. Doctors whose "production" numbers are profitable to  the company will have a higher rate of retention providing they don't rock the corporate boat in other ways (then they're called "disruptive" and get fired anyway).  What procedures and surgeries are allowed will be a corporate decision dependent on cost-benefit ratios, not patient need.

Healthcare Plans may be narrow and include a minimal number of specialists and no highly sub-specialized surgeons. It's your  personal out-of-pocket lookout if services not included in your medical provider network are sought.

Utilization Review (UR) is already used in California for injured workers who may be denied access to specialized care by a UR doctor who is not licensed in California and who has never seen the patient. The UR doctor's judgment may nonetheless overrule the California-licensed primary treating physician's judgment even though the primary physician has spent hours with the patient.

In this way, UR in California and the ACA throughout the USA are joined -- see our previous editorials on the Independent Payment Advisory Board (IPAB) which was originally rejected for Medicare under its previous name, the Independent Medicare Advisory Board (IMAB). Some pundits assert that the ACA under the guise of Obamacare is actually a nationwide watered down HMO and that to keep it that way it's necessary to eliminate as many hospitals and specialized centers as possible, and as many doctors as possible, while making the remaining doctors act like cattle herders trying to avert a stampede.

Stay tuned. These issues have long legs.

References

"How to practice medicine without a license," San Francisco Chronicle, 8/29/08

OBAMACARE: FURIOUS BACKPEDALLING DETRACTS FROM ALREADY DIMINISHED CREDIBILITY

When is the last time that an American president asked to have the law set aside so that presidential credibility might be restored? How about right now?

Even though California Insurance Commissioner Dave Jones has indicated that California should go along with the president's request to allow older insurance policies that don't meet the required criteria of the Affordable Care Act (ACA) to be extended, Covered California Executive Director Peter Lee says no dice because the state of California cannot force the insurance companies to grant extensions. Covered California voted 5 to 0 that allowing these older policies to continue would undermine the ACA even though President Obama himself, in a spectacularly furious backpedalling gesture, asked for just that. In so doing the president hoped to restore his diminished credibility when he promised so loudly and so often that if you liked your current doctor or your current policy you could retain either or both.

All the same, as of this writing, the ACA is doing well in California. About 80,000 persons have signed up for policies. Nevertheless,  about 220,000 non-compliant policies in California may be extended despite Peter Lee's exhortations otherwise. The reason, however, isn't as much the presidential plea for mercy as it is the insurance companies' assertions that they didn't have enough time to notify clients and don't have enough time anymore to make necessary adjustments.

By now it has become evident that ACA-compliant policies are likely to cost more than the non-compliant policies they replace -- we've already seen the example of the woman who congratulated the president on Obamacare and then found out that she couldn't afford it and would now be worse off than before when she had a non-compliant policy. Now she has none. Evidently, Peter Lee thinks that "none" is a suitable alternative for her. Lee may turn out to be even more of an ideologue than the president himself. It took a while for the president to acknowledge his mistake, but, in due course, he did just that. Meanwhile the ideologues stomp ahead, trampling opposition, no matter how small and desperate they are.

In general, the idea of insurance for all should take hold, but not in an atmosphere of partisan bickering, party affiliation, and ultimate hypocrisy where Congressional representatives, as one of their perks, may seek medical care at any American military hospital on a "prn" basis.

Yessirree,"prn" is the abbreviation for "pro re nata," which means according to need, their needs, not ours. Once again Congress looks out for itself first. Citizens like us get promises, then dregs, then raised premiums that push the ACA into offering policies that often turn out to cost more than the policies they replace. The risk now is that the ACA will protect us out of more health care than it'll provide in return. We hope not lest the ACA become known as the Unaffordable Care Act (UCA).  

"Keep Your Health Plan Act of 2013" clears the House of Representatives

HEALTH COVERAGE BILL PASSES WITH 39 DEMOCRATS CROSSING OVER. HR 3350 sponsored by Representative Fred Upton from Michigan passed 261 to 157 with 39 Democrats voting with the Republican majority and 4 Republicans crossing over to vote with the Democrat minority. The Senate is not in session today -- the pot is boiling but doth not yet runneth over. The simmering pot revolves about the three dozen plus three Democrats who have signaled by their crossover that they don't support President Obama who has promised a veto if the bill makes it through Congress.

The four Republicans who also crossed over to the Democrat side could eventually play a larger role. The Republican vote for this bill envisions not only allowing the rescinded health care plans to be returned to their buyers but also extends to the insurance companies the right to sell the  policies to new customers. This latter provision could wreak havoc with the Affordable Care Act (ACA) whereas the lesser proposal by the President to allow the already purchased policies to stay in effect for another year is seen as a healing measure to buy time even though this proposal also has its own troubles since it flies in the face of legislation already signed into law.

In California Insurance Commissioner Dave Jones has stated that he'll go along with the President's attempt at ACA repair. Proponents of the ACA feel that HR 3350 (Upton) is a not-so-subtle attempt to undermine Obamacare altogether. Stay tuned, stay informed!

OBAMACARE: "NOT ENOUGH IS BEING DONE IN WASHINGTON THAT HELPS ME WITH MY LIFE!"

No doubt about it, President Obama heard the criticism and has responded in kind.  His announcement today that the individual mandate would be postponed by one year is designed to assuage the millions of subscribers who were satisfied with their health plans because they'll now be enabled to keep them for another year even if they're not compliant with the Affordable Care Act (ACA).

When queried by press about his constant reaffirmations of the original plan to promote the ACA in the face of a failed internet sign-up program, the president spoke to the people's hearts when he said "I'm not stupid enough" to have promoted an internet program had he known in advance that it was about to be an abject failure. He admitted the "fumble." Now that's language we can understand although we'd still like to know who in our capitol was stupid enough to have left the president holding the bag. In private business, such persons get reassigned to life-at-home although we've become inured to their walking away with golden parachutes.

Issues that weren't faced up to entirely include why increased cost may be an inevitable outcome. One argument we've used in this blog is that the ACA requires 60 year old grandmothers to purchase policies that include maternity care. Ridiculous? Maybe not. The same ACA requires 27 year olds to pay a rate that'll include prostate disease coverage for older men. That's just how all inclusive insurance works.

There's no denying that  private insurers used to dump patients once sickness and injury claims were filed and that previous administrations tolerated this rueful practice. There's no denying that some insurers used to resurrect claimants' healthcare histories and retroactively cancel a claimant's policy because the applicant had acne that came under medical treatment at age 17 and wasn't reported at the time the applicant bought insurance coverage -- but that, too, was tolerated. 

There's no denying that annual limits and lifetime limits would often ensnare the very sick into bankruptcy -- but this egregious insult and harm was also allowed by previous administrations. Obama's credit is that he sought to resolve these inequities but in his eagerness failed to keep  his eye on the ball and misled the public. He is now gradually trying to dig himself out of the hole he dug -- today's step is a shovelful in the right direction.

But will a one-year postponement do enough or will it just give everybody breathing room until the inevitable cancelation catastrophe one year from now?

One problem is that pro-private-insurance interests opposed to the ACA are rooting for failure and will inevitably point out that President Obama is unilaterally suspending the law to recoup his own popularity with midterm elections pending. Proponents will support the president or seek further enabling legislation.  

California will be a statewide workshop since we're being told on the one hand that  in California one million cancelations have been sent out and will now need to be rescinded -- what will be the cost of that and who will pay for it? On the other hand, we're also told that California leads the nation in ACA sign ups.

Political pundits will notice that today's discussions have so far not mentioned the Independent Payment Advisory Board (IPAB) -- that is Sections 3403 and 10320 of the ACA that'll allow cancelation of benefits once the ACA  gets too expensive. The IPAB is to be staffed by appointed bureaucrats at $165,000 per year. They will not need to report to Congress. Now there's something to worry about! Ask your Congressional representatives about it -- if they're making a beeline for legislation, tell them to take this item under advisement to strip the IPAB of its power to take away our increasingly hard-won benefits.

PRESIDENT OBAMA APOLOGIZES AND PROMISES TO INTERFERE WITH CARE YOU DON'T NEED!

"I am sorry that they are finding themselves in this situation based on assurances they got from me" is as much of an apology from President Obama as we're likely to get. This apology isn't abject but it's a remarkable turn around from the president's previous wholehearted support of the Affordable Care Act (ACA). It's a far cry not only from his June 2009 promises but also from his September 25th statement in Maryland where he ringingly declared, once again, that "if you already have health care, you don't have to do anything."

By now we know that millions of  policy holders have been skunked because private plans purchased directly from insurance companies have been arbitrarily and unilaterally cancelled by the insurance companies that so eagerly sold them in the first place. These plans have conveniently been declared non-compliant with the ACA. The convenience is that the same companies can now turn around, create ACA-compliant health care plans, and sell them to their own customers at a hefty mark-up. It may not quite be double-billing, but it sure as Hades qualifies as "double-selling."

Here's what another one of our knowledgeable sources says:
"It's not the ACA doing this, it's the insurance industry using the ACA as an excuse to institute more advantageous plans for themselves." Right on! Too bad the president and his devoted inner clique didn't tumble to that in time  or didn't speak out. In fact, that millions of people would lose their health-care plans was actually reported in the Federal Register in June of 2010. Therefore, the obligation of public disclosure was technically met. Too bad, isn't it, that President Obama and Secretary Sibelius didn't read it or decided to ignore it while they steamrolled the public instead.

Our source whom we'll call Josefina points out that "the insurance companies were allowed to set up and offer whatever they wanted as long as they include no cap, no discrimination for pre-existing conditions, and some basic care inclusions such as maternity care and mammograms."

In fact, given these required inclusions, it can be argued with reasonable medical assurance that the ACA-compliant policies are probably superior to the plans that are now being pulled off the market. On the other hand, the buyer lost his choice of product.

Here's what happened to Josefina: first, Blue Cross cancelled her  health care plan. Blue Cross blamed the ACA. Then Blue Cross told Josefina they would send her a replacement policy that needed to be accepted by December, 2013 "in order to delay implementation of the ACA provisions at the same rate of $1427/month. They made it sound like that would be a good thing for me when the advantage is all theirs, including being able to max me out of my plan." A reasonable argument can be made that Blue Cross is complying with the ACA by offering a superior replacement policy even though such plans in the future are expected to cost more.

Josefina, who understands insurance, pointed out how the new plan could be ACA-compliant while also decreasing other coverage included in her previous plan but which isn't mandated by the ACA. By now our reading public knows that the ACA compliant plans include mandatory coverage of mental illness and maternity care even for 60 year old grandmothers. So the public finds it has to buy superior plans that cost more in order to cover the previously uninsured population estimated to be around 22 million persons.

Here's Josefina's summary: "They (the insurance companies) blame it on the ACA (Obamacare) but it actually (is) the insurance company industry manipulation while pretending that it's the ACA." 

Our conclusion: we agree with this assessment but feel obliged to point out that the Federal Government knew about the scam as early as June of 2010 -- that's when the president and Secretary Sebelius should have told the rest of us what was cooking in a pot that was shortly to boil over and burn millions of people who believed the presidential assurances from as early as 2009 and as recently as September of 2011.

One can only be dismayed at such deception unless we buy the argument  that the president and his staff were simply incompetent. Remember, this president is the same one who also promised in a speech on health reform in 2009 that he would make sure that "no government bureaucrat gets between you and the care you need." 

Although President Obama admitted that "we weren't as clear as we needed to be in terms of the changes that were taking place," he did not acknowledge that he knew at the time, or should have known at the time, that millions of persons would lose their private healthcare plans. Now we see a welcome reversal of field: "we've got to work hard to make sure that we're going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this." Our information is that the president has instructed his staff to "close some of the holes and gaps in the law" and to find out to what extent he can help as many persons as possible who lost their insurance.

Is that a promise to interfere with policies that foist insurance plans on us that we don't need? Sometimes there's no winning strategy. Instead, there's  a chance for restorative damage control. That could be the ultimate winning strategy in this otherwise fiasco of healthcare reform.

References

"User's Guide to the Affordable Care Act (Obamacare) and the Independent Payment Advisory Board (IPAB)," 6/28/2012, http://totalcapitol.com/?blog

"What Obama should've said about health reform," The Hill, Washington, D.C., 9/16/09

OBAMACARE: "IF IT HASN'T CHANGED SINCE THE LAW WAS PASSED..."

By now we all know the story: "water, water everywhere, but not a drop to drink," or, in its latest revision, "words, words everywhere, but not a syllable of truth anywhere."

"If you like your doctor, you will be able to keep your doctor. Period. If you like your healthcare plan, you will be able to keep your health care plan. Period."

Ooops, not 'zackly "period," more like a comma from a president who must have been in a coma when he misspoke so badly and so carelessly on 15 June 2009 when he recklessly promised so much only to deliver so little four years later.

The new version of "period" is "if it (your health care plan) hasn't changed since the law was passed." The president's awkward attempts to shred and parse his previous language are downright embarrassing particularly to those among us who trusted him at the time.

Here's the latest horror story we have, relayed by a subscriber who has asked us not to publish his name but whose revulsion at the deception he's been offered is palpable.

Joe B, we'll call him, had an individual policy with Blue Shield in which he enrolled in 2012 and which he intended to keep especially since his president told him that if he liked his health-care plan he could keep it, "period!"

Joe B's plan was HSA compliant with high deductibles, $4,000 individual, $8,000 family-embedded. There was no so-called "lifetime maximum." Joe B recently was advised by Blue Shield that the health-care plan he liked and expected to keep would not be available after 12 December 2013. He was told that the plan he liked and had intended to keep was not compliant with the Affordable Care Act, that his new premium for a plan he didn't want would be increased by 40%,  that his deductibles would go up by 12.5%, and that his co-pays after the deductible was met would, in Joe's own words, "skyrocket."

Next Joe B  checked out CoveredCA. Too bad for Joe B, because CoveredCA did not offer him any HSA compliant plans. Joe B's conclusion, sadly on target, is that "the lies which were told that both got the law passed and got many elected or re-elected (Obama) are insidious and cause for great concern for our country."

Next, Joe B learned about the IPAB (Independent Payment Advisory Board) from our blog and finds that  provision of the ACA "cause for great additional concern."

Joe B's conclusion: "Stealthily setting up a plan to redistribute income through the healthcare system is what is resulting, and it's just not right."

Our conclusion: if the president wants to ease into a more socialized system, or a single-payer model, he should have the intestinal fortitude to tell that to the voting public.  What he is doing now is an attempt to deceive the public and re-write history. It is likely that the computer glitches in the sign-up process will eventually be fixed, but Joe B has just found out that the HSA compliant health care plan that he liked and was told he could keep is out the window -- that, my friends, is not a computer glitch. It was false when the promise that Joe B could keep his health care plan was initially floated and remains so today -- a sad commentary and severe blow to our ability to trust our president's promises on healthcare or anything else.




 

OBAMACARE: IF YOU LIKE YOUR DOCTOR OR YOUR HEALTH-CARE PLAN ...

In 2009 President Obama declared that "I will ensure that no government bureaucrat gets between you and the care you need."

In fact, on 15 June 2009 President Obama declared that "if you like your doctor, you will be able to keep your doctor, period." That's when the president also promised that "if you like your health-care plan, you will be able to keep your health-care plan, period."

Now, four years later, as the ill conceived website for Obamacare crashes, and as more financial infusion and taxes are needed to float the Affordable Care Act (ACA), the president confesses, "Oh yeah, we did raise some taxes." Admittedly, that the website was badly conceived does not necessarily mean that the ACA itself was a mistake. The ACA boasts its own internal mistakes, one of which is the Independent Payment Advisory Board (IPAB).

Readers of this blog may recall our discussions of Sections 3403 and 10320 of the ACA which establishes the legal  basis for the IPAB. President Obama said that the IPAB would be composed of "doctors et cetera." The sad truth is that there is no provision whatsoever in the ACA that requires appointment of physicians. The IPAB will have the authority  to regulate the provision of healthcare and to restrict access to care -- here's how: the IPAB's job will be to make economic judgments and decide which diagnostic and  treatment protocols will be covered. Your doctor can prescribe diagnostic tests and treatment but an unelected panel will decide what is actually authorized. Patients can pay out of pocket for the rest. The IPAB panel is expected to include about 15 political appointees who, conveniently, won't be annoyed by such pesky requirements as reporting to Congress. IPAB board members are expected to be paid $165,000 per year, total cost to the public of about $2.5 million.

Spokespersons and publicists for the ACA do not mention the IPAB -- it's too sensitive.  When it was previously known in older legislation as the Independent Medicare Advisory Board it was reviled as a "death panel" for the elderly.

In California where Covered California is out-performing equivalent programs in other states, the meaning is that most, not necessarily all, Californians who are citizens or legal residents can get coverage. Of course, as companies drop the health care coverage citizens or legal residents already have, the premiums are likely  to go up -- so the ACA may not be so "affordable" after all. On the other hand, it won't have pre-existing condition preclusions and there won't be so-called "lifetime limits" or annual benefit limits.  Mental health benefits, often not included in employer owned programs, will be included. Expectedly, the cost of premiums is likely to go up.  Four basic programs are anticipated, bronze, silver, gold, and platinum. Bronze will have the lowest premium cost and the highest out-of-pocket co-pay. Platinum will have the highest premium and the lowest co-pay.

 Doctors have already been summarily dropped by Medicare Advantage programs in New York. CBS reported in California that Kaiser Permanente canceled policies covering 150,000 persons. In Florida, 300,000 persons have lost their health care coverage. They weren't asked if they preferred to keep the doctors or health care plans they already had.

References

"What Obama should've said about health reform," THE HILL, Washington, D.C., 9/16/09, Robert L. Weinmann, MD

"User's Guide to the Affordable Care Act (Obamacare) and the Independent Payment Advisory Board," http://totalcapitol.com/?blog, posted by bobweinmann, www.politicsofhealthcare.com,
June 28, 2012

"Affordable Care Act Loses Debate," The Weinmann Report - politicsofhealthcare.com, 10/04/12

"Obamacare: Separating Fact from Fiction...", www.politicsofhealthcare.com, 9/20/13

"Congress Keeps its Subsidies," www.politicsofhealthcare.com, 9/30/13

GOVERNOR BROWN SIGNS INTERPRETER BILL (AB 1376)

AB 1376 got the support from Governor Brown it deserved when he signed it into law on the last day available to him -- we did not feel the bill needed to have been the cliffhanger that it turned out to be but, in the words of the bard, "all's well that ends well." Kudos go to many supporters who worked on the bill and to the sponsors of this legislation, particularly Jesse Ceniceros, Board Chair, Voters Injured at Work (VIAW). VIAW was the chief sponsor of this legislation that will enable injured workers to have access to interpreters during medical visits. The bill was one of equity, allowing the deadline for certification of interpreters to be extended to 1 March 2014. Why a bill that passed the last legislative step without opposition in the legislature and clearly had bipartisan support had to wait until the last day of the session for the Governor to sign it intrigues political pundits -- was it just political theater or was there serious backroom efforts to get a veto? It intrigues us. We'll be getting back to SB 863 soon, too -- that's the bill that enables Independent Medical Review to be done by doctors who aren't licensed in California, just like Utilization Review doctors. That's the bill that promised injured workers more than it delivered and embarrassed the California Labor Federation. That's the bill that Senator Beall sought to revise this year via SB 626 which got pulled midway through the session. We'll be poised to pounce if SB 626 comes back in January for the 2014 legislative session. Our editorial from this past summer remains available (see references below).

References

SB 626 (Beall) Tackles SB 863 (Deleon), www.politicsofhealthcare.com, 4/15/13

SB 626 (Beall) Restores Equity and Balance, ibid,  2/24/13

SB 626 Alert, ibid, 2/23/13

CONGRESS KEEPS ITS SUBSIDIES

Dateline, Washington, DC, 2 AM, 1 October 2013 -- In our earlier blog on 9/30/13, we mentioned Rep. Langford's last ditch effort to scuttle subsidies and create an even playing field for Obamacare. The idea, to impose a one year delay in the requirement of the Affordable Care Act that individuals buy health insurance, was also supposed to deny federal subsidies to MOCs (Members of Congress), to staff employees of Congressional offices, to members of the Executive Branch, to White House staff, and to both the president and vice president for the same length of time. It turns out that that was a "No Fly Zone." When asked about it, Speaker Boehner said the Constitution mandates that Congress be paid. Yes, maybe so, but there's nothing in the Constitution that says MOCs and their Capitol Hill staffers must have subsidies in addition to salaries. In a masterpiece of hypocrisy, both sides of the aisle have managed to cause a shutdown. Military is excluded and will be funded but not necessarily all of their civilian counterparts at the Pentagon. We will want to stay tuned: today's fight isn't over and the debt ceiling conflict is just around the corner.

Dateline, Washington, D.C. 3:50 PM, 9/30/2013 MOC James Langford now wants to pull all individual exemptions in Obamacare while leaving intact current business exemptions. He points out how at first Congressional exemptions were proposed and then replaced by mandatory participation and then in turn how subsidies snuck into the game with the result that individual exemptions blossomed for the favored few on both sides of the political aisle leaving the befuddled middle class out in the proverbial cold. At this writing there's still 8 hours to go to shutdown.

OBAMACARE: separating fact from fiction in the Affordable Care Act (ACA)

On 20 September 2013, President Obama stated that Obamacare would enable millions of Americans who were locked out of the system to get quality health care. He did not mention Section 10320 of the Affordable Care Act (ACA) that can be implemented when the government feels that costs are getting too high -- at this point the Indpendent Payment Advisory Board (IPAB) is enabled by law to bypass Congress and simply eliminate or disqualify specific services from coverage. While we understand the fiscal imperatives of this Section of the ACA we also feel that the public should be properly advised how such a provision might work, for instance, insulin injections for patients over 80 years of age could be denied payment, so could dialysis coverage for patients over 75 years old, or surgery for brainstem tumors in children. When push comes to shove, it will be of interest to notice if there's equity in denials of care, for instance, will Congressional representatives and staff be subject to the same denials of coverage that will be imposed on rank and file citizens? These questions have come to the surface since our original posting. The ACA under the IPAB Section is empowered to delete coverage under the act, not to tell citizens they can't pay independently for care denied coverage under the ACA. For many patients denial of coverage is tantamount to denial of care. Previously, we've touched upon whether or not Obamacare (ACA) exempts Congress and staff from the full effect of the law as Representative Jim Jordan, R-Ohio, claimed in his August 8th statement which asserted that Congress was getting "special treatment." Jordan stated that Obamacare "exempted Congress and their staff from the full effect of the law." True or not? The Office of Personnel Management says that the federal government usually pays around 75% of employees' health insurance premiums. Newly issued rules regarding payment of employees' health plans bought on the exchange won't be more than the government's contribution for other federally insured workers. Congressional representatives will decide who is employed by the "official office" as opposed to Congressional committees -- the former will be obliged to buy insurance from the exchanges whereas staffers retained by committees will not be obligated to buy from the exchanges. The group hired directly by a Congressional office will be eligible for up to 75% reimbursement or contribution to premium costs. The fact is that "all full-time and part-time employees employed by the official office of a Member of Congress" will be obliged to buy insurance through the exchanges. These employees are eligible for the Congressional co-pay which the Office of Personnel Management says is between 72 and 75% of its employees' health insurance premiums. So what's the uproar about? It is clear that there is a difference in how Congressional employees get treated under the ACA. A large part of the credit or blame for this difference goes to Senator Grassley's amendment to the ACA: it was Senator Grassley whose amendment specified that Congressional staffers "fully participate in the exchange by picking a plan, paying for it on their own, and perhaps qualifying for subsidies (italics added)." This reference to "subsidies" bothers Jordan and others who believe that the ACA is not equitable. The fact is that others besides Congressional employees will also be entitled to subsidies. Hence, the ACA is equitable although it may be more expensive than had been originally envisioned. It is also doubtful that Congressional persons will ever suffer from arbitrary decisions by the IPAB. In a nutshell, Congress and staff are not exempt from the ACA. Co-pays and subsidies are allowed but are not limited to Congress and staff.

My opinion: Grassley intended his amendment to be a poison pill that Democrats wouldn't swallow. He was wrong. The Democrats gulped it down and then shoved it down Republican throats. The real problems will be access to coverage for care. The ACA creates employment worries about full-time versus part-time employment, secretive denials of care by the IPAB under the guise of fiscal restraint whereby specific services are denied or made subject to increasingly onerous rules and regulations. Rising private insurance coverage costs with increasingly higher required deductibles are expected, e.g., middle America will find itself trapped between policies that cover too little and adequate private coverage that costs too much and requires high deductibles. In this scenario, the only winners are the insurance companies.

Credits: Paige Robbins was Chief Research Associate for this piece.

References: The Plain Dealer, PolitiFact.com; News release, Jim Jordan, 8/08/13; Lima News, "Jordan said challenging Obamacare is his top priority," 8/14/13; Office of Personnel Management press release, 8/07/13; News release, Sen. Charles Grassley, "Grassley amendment makes Congress obtain coverage from health care plan established in reform bill," 9/30/09.

AB 1376 DESERVES SUPPORT ...

This bill is intended to make sure that the California workers' comp system continues to have enough interpreters to enable access to care for injured workers who are obliged to rely on interpreters to explain the details of their injuries, how they were incurred, what impairments have been caused, and what level of disability is being experienced. It seems like an easy call -- vote for the bill. In fact, the California legislature did vote for the bill. It passed handily without significant opposition. Now it sits on the Governor's desk as an item of enrolled but not signed legislation. We recommend that Governor Brown sign AB 1376.

Nurse practitioner bill, SB 491 (Hernandez), is down but not out

In part because of its own hypocrisy, the nurse practitioner bill has for the present taken an inglorious swan dive. Nonetheless, we believe it'll come to the surface again. But first, let's get to the juicy hypocrisy.

 

Political readers on healthcare will no doubt recall the nurses' efforts this summer to stop schools from allowing teachers and parents to administer insulin injections to diabetic students. The argument the nurses used was that teachers and parents weren't educated and trained to recognize when insulin injections should be given, what harm might occur were such injections not timely given or withheld, and what adverse side-effects might be expected, let alone treated.  It was a "safety" issue, nothing to do with job preservation.

Physicians identified with these arguments because these arguments were the same that the physicians' lobbies were using to fend off passage of SB 491 (Hernandez).  That the nurse practitioner lobby let itself use these arguments on one hand while arguing against them on the other hand turned out to be the very essence of poor political timing. We doubt they'll repeat the mistake when the bill resurfaces which, in due course, we think it will. So the word we issue to the CMA and its allies is CAVE CANEM (beware of the dog, the sign that was found in the Roman rubble of an ancient eruption of Mt. Vesuvius).

 

In essence, relying on the idea that Obamacare will cause a shortage of physicians, emboldened by Senator Hernandez' willingness to take on the traditional physicians' organizations, the nurse practitioners (NPs) sought the right to practice at levels beyond their education and training and to do so without physician supervision. One argument the NPs used was the shortage of sophisticated medical care in rural  areas. What they didn't say was that the NPs would actually populate these areas and stay there. They  didn't promise to accept lower pay, either. In fact, why  should they?  If the NPs are licensed to practice medicine as physicians, shouldn't they then be entitled to equivalent remuneration? That, we say, would be the logical next step for the nursing lobby. But first it was necessary to get SB 491 passed and signed into law. That is why it's inevitable that the NPs will try again sooner or later.

 

The California Medical Association (CMA) successfully argued that quality and safety in medical care was dependent upon proper education and training. Physicians well know that it's hard enough  to make diagnoses and render treatment even with 12 to 15 years of college, medical school, and advanced internship and residency training.

 

The Union of American Physicians and Dentists (UAPD) weighed in heavily on the side of the CMA. The UAPD  and the CMA acknowledged the importance of nurse practitioners but stopped short of allowing their level of education and training to be legislated as equivalent to physicians' level of education and training. Both organizations argued that the right way to fix anticipated physician shortage problems would be to expand post-graduate residency training positions for newly minted physicians and to expand the number of medical schools. The key  is to provide "properly trained individuals," not simply to invoke a "quick fix" by giving higher priority to the number of licensed professionals as opposed to the quality of the education and training of those professionals.   

 

Other organizations that helped to  oppose SB 491 included the California Neurology Society (CNS), California Academy of Family Physicians, Diabetes Coalition of California, California Society of Anesthesiologists, Blind Children's Center, California Academy of Eye Physicians and Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, Latino Physicians of California, Chinese Medical Dental Association, Let's Face it Together, Minority Health Institute, Dream Machine Foundation, Canvasback Missions, Lighthouse Mission, Time for Change Foundation, Here 4 Them, Osteopathic Physicians and Surgeons, etc (if we've left out your organization, just let us know).

 

References

 

See our blog of 6 August 2013 and references

 

The Daily Journal, San Mateo County, "A Slipper (sic) Slope Indeed," Robert L. Weinmann, MD, 8/13/13

Sacramento Bee, "Expanding role of nurses a recipe for malpractice lawsuits," Robert L. Weinmann, MD, 4/24/13 

 

 

New Post on Obamacare IPAB (Section 10320, ACA) is in preparation -- we are endeavoring to expose  the latest Congressional dodges none of which are a surprise to political pundits, e.g., congressional subsidies to cover themselves.  Nevertheless, we're still looking into it.  We had intended to cover Bill Clinton's talk on the ACA this September 4th, but we didn't find what he said especially revealing, not up to his own standard. We heard him say the expected about persons not currently covered but didn't notice any emphasis on how the program is expected to tout high-deductible policies or that Middle Income people will watch their rates rise in order to finance the newly covered.  Our background research continues -- don't hesitate to comment directly to our blog if you wish.  -- rlw, editor, www.politicsofhealthcare.com
 

SB 491 (Hernandez) Gets Stopped  in  Assembly Committee on Business Professions and Consumer Protection

A united coalition including the California Medical Association (CMA), the Union of American Physicians and Dentists (Local 206 of the American Federation of State, County, and Municipal Employees, AFL-CIO),  the California Society of Physical Medicine and Surgery (CSPM&R),  the California Neurology Society (CNS), and several others helped to convince the committee that allowing healthcare professionals, no matter how well intentioned, to practice beyond their levels of education and training was unwise and a recipe for disaster. Accordingly,  SB 491 failed today to clear the Assembly Committee on Business Professions and Consumer Protection. The name of the game was consumer protection.

In one of our previous blogs we pointed out that nurses and/or nurse practitioners (NPs), once enfranchised to practice medicine without physician supervision, already well disciplined and organized into a proper union would be well poised to negotiate for equal pay. It was not expected that the newly enfranchised nurses would rush to the hinterlands of California where medical back-up in the form of well trained physicians and surgeons would be lacking or that the nurses would rush to places where resources and money were scarce.

One should not expect the nurses to quit this quest. A new campaign should be expected as soon as the old wounds have healed and their  regenerative powers have been regained.

References and a footnote

"SB 491 (Hernandez) clears committee," www.politicsofhealthcare.com, 5/17/13

"If the work is equal, shouldn't the pay be equal?" www.politicsofhealthcare.com, 4/26/13

"No, no, no on SB 491, 492,  493," www.politicsofhealthcare.com, 4/18/13

Footnote: notice that in this instance an AFL-CIO union was on the same side as the CMA  and other traditional physician organizations -- editor.



 

Obamacare, AB 76, SB 71 -- government deception

Governor Brown's veto message for AB 76 is a  sublime essence of deception. Here is the actual  text: "I am returning Assembly Bill 76 without my signature. This bill is unnecessary as I am signing a similar measure, Senate Bill 71. A Constitutional Amendment has also been introduced that will preserve the existing Constitutional and statuatory requirements of the California Public Records Act. -- Sincerely, Edmund G. Brown, Jr.

Readers of this column already know that Brown signed SB 71 while vetoing AB 76. Our readers also know that SB 71 is a mirror image of AB 76. So Brown didn't veto anything. Instead, he has contrived to project an appearance of preserving access to public records with a huge cutback in the only significant benefit injured workers managed to wrangle out of last year's SB 863.

Both bills were run through the legislature at the same time, one in the Assembly, the other, in the Senate. When I spoke to one of the Senators who seemed well disposed to calling the Assembly bill, AB 76, into question no mention was made of the parallel bill on the Senate side, SB 71, lurking around the corner although both bills had the same anti-injured worker provision about return-to-work.

SB 71 pays lip service to the provision in SB 863 that appropriated $120,000,000 per year to pay for a return-to-work program for injured workers. The slap in the face to injured workers is the provision of SB 71 that was also included in AB 76: "the program applies only to injuries that occur on or after January 1, 2013."

When SB 863 was passed this $120,000,000 benefit was applied to all injured workers, not just  injured workers whose injuries occurred on or after January 1, 2013.  It was a key reason why this otherwise hostile bill to injured workers got support from the California Labor Federation which collaborared  with big business (Grimmway Farms) to get it passed. 

Although it is unlikely that this sophisticated a plan was entirely worked out in advance, it has turned out to be stunningly successful for Big Business.

As for Obamacare, we'll next discuss how the Independent Payment Advisory Board (IPAB) will be empowered to work first to limit the franchise to the elderly and then to restrict access to care to all participants while Congress and possibly even IRS fight to remain exempt from its alleged protections.

UNDER COVER OF AB 76, SB 71 GETS SIGNED INTO LAW

SB 71: a stealth move that worked. Governor Brown shrugs off public input ... again!

When AB 76 was hot and heavy, rendering or denying public access to public documents and records,  this column and others exposed the hypocrisy. When I met with one of our State Senators last week, I was advised that the legislature heard the hue and cry and that AB 76 was pulled from the Governor's desk. The expectation was that the bill would return, keeping the language on page 61 that cut benefits from injured workers despite prior legislation awarding them those benefits, but that the language threatening citizens' ability to use the California Public Records Act (CPRA) would be amended out of the bill.

Wrong. Instead, Governor Brown signed SB 71, another "trailer bill,"  which will also allow local governments to restrict access to these records and the information therein. One method will be to let the local agency decide in what format to release electronic data if they release it at all. Local governments will be allowed to deny written requests for public records -- they will not be required to state the reason for denial. Appeals wlll be hard to formulate if no reasons are given for denial.  Transparency in California's open-government law will be sliced and diced.

Has the Governor snubbed the public?

He kept in the language that snubs injured workers and makes SB 863 from last year even more confiscatory than it already is. SB 71 acknowledges that "existing law appropriates $120,000,000 per year" to pay for a return-to-work program but then states "the program applies only to injuries that occur on or after January 1, 2013." One of the few benefits that one could have argued for with reference to last year's SB 863 was that it appropriated $120,000,000 for a return-to-work program. This benefit, presumably, is one reason why Angie Wei, California Federation of Labor, worked so hard to get the bill passed. That benefit has now evaporated for all injuries prior to 1/01/2013.

Did the California Labor Federation,  workers  injured  before 1/01/2013, and all of their supporters get out-maneuvered by Governor Brown? It turns out that AB 76 and SB 71 were mirror bills and that the technical  reason AB 76 got vetoed was because SB 71 was already in the  process of being signed. Either bill was sufficient to take away the benefits from injured workers that had been bestowed on them by SB 863 from 2012. Two weeks later (as of 7/17/13) we  still haven't heard an outcry from the original supporters of SB 863. It does not  appear that this loss of benefits concerns  the labor unions.

AB 76, a Trailer Bill that Makes a Difference

AB 76 is a 120 page trailer bill that made it through the legislature to the Governor's desk without a public hearing. Trailer bills are expected to be limited to technical changes and are not expected to contain substantive language that should be presented in public hearings.

AB 76 was introduced on January 10, 2013 by the Committee on Budget.  It was amended in the State Senate on June 12, 2013.  In between these dates there were no public hearings.

On page 61 there is mention of "a return-to-work program administered by the director, funded by one hundred twenty million dollars ($120,000,000) ... for the purpose of making supplemental payments  to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss. Moneys shall remain available for use by the return-to-work program without respect to the fiscal year."

The bill then says "eligibility for payments and the amount of payments shall be determined by regulations adopted by the director  ... subject to review at the trial level of the appeals board  upon the same grounds as prescribed for petitions of reconsideration ... on or after July 1, 2013, all civil penalties collected pursuant to this chapter shall be deposited in the Labor Enforcement and Compliance Fund."

AB 76 deprives  injured workers of benefits if they were injured prior to 2013. The bill states re eligibility that "this section shall apply only to injuries sustained on or after January 1, 2013." 

We are at a loss to explain why language of this importance wasn't deemed worthy of a public hearing. We notice that all of the Democrats voted for the bill while all of the Republicans voted against it.  So the bill passed on partisan or strict party lines -- nothing astonishing about that, is there? What's quizzical in this instance is that organizations representing injured workers did not testify at public committee hearings since there weren't any.  All of the Democrats voted for the bill, all of the Republicans voted against, a traditional and routine party-line vote.   Pundits who find that the language on page 61 is harmful to injured workers should seek comment from organizations that represent injured workers such as the California Labor Federation.  

In the meantime, it can be stated with reasonable political probability that page 61 and the interests of injured workers weren't of top concern  in the consideration of this bill.  Injured workers took back seat to everything else in the other 119 pages.

"Equal Work with Unequal Pay" Revisited

In a recent communique sent privately, I was asked about the meaning of  "equal work with unequal pay" from an earlier blog about pending legislation in California re SB 491, 492, and 493 where nurse practitioners, optometrists, and pharmacists would be equated with physicians. The writer asks "in what sense is the work of a nurse practitioner ever quite the same as the work of a board-certified neurologist?" The writer said "I personally would not be willing to pay a nurse practitioner as much as I would cheerfully pay my neurologist. How about you?"

I agree with the challenger that nurse practitioner education and training is not comparable to the training of a physician, much less  to a physician who  has also done additional specialty training. I agree with the writer.  I would not expect to pay the same for the lesser trained practitioner.

But since that wasn't the point of my editorial I'll take another whack at it. My point is that if SB 491 et al pass in California, the decision as to who gets paid and at what rate will pass into new and untested hands. Unless the nurses' union is asleep at the switch, once SB 491 passes, it can be expected that the nurses' union will lobby to make sure that the newly minted nurse-physicians get paid the same as graduate physicians. The argument will be a legal one, namely, that the legislature, having designated nurses as equivlalent to physicians, is now obligated to see that they get equivalent pay.

In this case I asked my challenger to explain why a certain physicians and surgeons organization wasn't lobbying against SB 491. I was told that the group was "focused on other things." My response is that if the Hernandez series,  SB 491, 492, and 493 get signed into law it won't be long before there are no "other things" on which to focus.

Physicians' groups should oppose SB 491 et al in the interest of making sure that optimal medical care remains the goal, not watered down versions thereof.  So far we know that the California Medical Association, the Union of American Physicians and Dentists, and the California Neurology Society have taken up the campaign and so have many individual physicians.

Why Is Private Practice On the Road to Obsolesence?

Physicians have always wielded a certain amount of power in hospitals by being able to control admissions of patients to hospitals on which they participate as medical staff members.  

Hospitals compete to have as many physicians on staff who will admit as many patients as possible to highly competitive hospitals. Physicians pay medical staff dues on an annual basis  for admitting privileges (that's the privilege to admit one's patients to a specific hospital) and become medical staff members as independent contractors. They are not employees or salaried.  Generally, physicians seek admitting privileges  to more than one hospital and decide to which hospital to admit patients. The choice is presumably based on which hospital the physician feels will best serve the needs of his patients. But that's not the only criterion.

Because of a corporate practice prohibition in California, hospitals, with some exceptions, for instance state hospitals,  may not employ physicians. The reason is potential conflict of interest, e.g., the worry that some physicians might succumb to pressure from hospitals for rapid patient turn around or to unnecessary admissions to enhance corporate profit for the hospital. The corporate practice prohibition is supposed to make sure that physicians remain responsible to the patient, not to the corporate entity.

That is why corporate entities want to reduce the power of individual physicians to influence the hospital's corporate bottom line and to find an alternative way to admit patients. That problem  has been solved: one way to get around the corporate practice act is to hire a physician to develop a department and to have that physician choose the physicians who'll work at the hospital. In this scenario a chief physician hires other physicians. This scenario doesn't violate the corporate practice prohibition.

Patients can buy insurance policies that tie them to large corporate entities such as foundations,  exchanges, or Accountable Care Organizations (ACOs).  These business entities  may then hire physicians and assign them to groups of patients at designated locations such as clinics or hospitals and get around the corporate practice prohibition. It also takes away the authority of physicians to select their own patients and to admit them to a wide choice of hospitals. This method gives increased power and ultimately increased financial remuneration to the foundations, exchanges, and Accountable Care Organizations (ACOs) and to a lesser extent to each individual hospital since the hospitals will be obliged to affiliate with increasingly larger corporate entities which will compete with each other.

The physician is now an expense to the foundation,  exchange, or ACO. It makes corporate sense for the foundation,  exchange, or ACO  to negotiate the lowest possible remuneration for  physicians who are salaried workers and who will be as obliged as any other worker to negotiate for higher pay, health care insurance, vacation pay, and retirement benefits. Physicians are subject to "economic credentialing," i.e., a corporate record that compares how much each physician spends on diagnostic tests and treatment for each patient. At the end of the year, if Physician A has ordered diagnostic testing and treatment averaging $25,000 per patient  while Physician B has made the hospital or foundation pay $50,000 per patient, the physician who made his plan pay twice as much for patient care is less likely to be offered a renewal contract.

As the provision of healthcare becomes an expense to the business plan, it also becomes an impediment to corporate profit. Physicians, in this scenario, are the gatekeepers to their employers' banks. That is why physicians are quitting private practice -- they can't keep up with advances in healthcare at the same time as they need to compete economically with each other and also with increasingly better oiled business organization.

Health Care Corporation of America is HCA on the New York Stock Exchange (NYSE).  In Northern California, in Santa Clara County, HCA owns Good Samaritan Hospital and Regional Medical Center. UnitedHealth Group is UNH on the NYSE and purchased Monarch Health Group in Southern California while its Optimum business group bought ApplcCare Medical Group and Memorial HealthCare.  Meanwhile, Humana, listed on the NYSE as HUM, took over Metropolitan Health with its network of physicians who render care to Medicare patients and Concentra with 300 clinics in 40 states. Health  Management Associates, listed as HMA on the NYSE, recently featured on CBS' 60 Minutes, is under investigation. In this environment, individual physicians whose primary attention is to comparatively small groups of patients may be sliding into obsolescence.

ALERT re AB 889 (Frazier)                                                              

AB 889 has just passed the Assembly Floor vote victoriously. The next procedural stop for this bill is the state senate. This bill is unique in that it'll remove stepwise medication requirements for patients generally but will still leave room for the insurance companies to  impose stepwise prescribing for injured workers pursuant to SB 863. In other words, it will give benefits to patients who are privately insured or who are dependent upon HMOs, PPOs, and managed care that will not be made available to injured workers who will still be subject to stepwise prescribing by dint of SB 863 since they will remain subject to the whims of MPNs (Medical Provider Networks) empowered to make their own decisions and whose power under the law has been increased by last year's passage of SB 863. If AB 889 makes it through the Senate, it'll still be subject to Gubernatorial veto -- the Governor vetoed similar legislation  last year. Proponents of AB 889 need to start now to work the state senate and also the Governor's office. Some legislators who favor AB 889 are the same legislators who voted for SB 863 -- their votes now for AB 889 may be an act of contrition or a call of conscience. Either way it's a good start. Now we need the state senate  to come on board and for the legislature to convince Gov. Brown not to veto the bill if it passes the legislature.

Proponents of this legislation are currently reported to include groups as diverse as the California Medical Association, the Union of American Physicians and Dentists, and the American Federation of State, County and Municipal Employees. We expect that Assemblyman Frazier's website will reflect a larger list.

THE 9th U.S. CIRCUIT COURT OF APPEALS LAST FRIDAY REJECTED THE ATTEMPT TO RESCIND THE 10% PROVIDER RATE CUT FOR TREATING THE POOR AND IMPOVERISHED. 

The lawsuit in favor of repealing the 10% cut would have undercut Governor Brown's austerity budget. The Brown administration believes that the state will save about $508 million over the next two years based on implementation of the 10% cut.  We are not surprised that the adnimistration is reconsidering the accuracy of this amount.  We are not as surprised as once we would have been that Governor Brown's administration delivered a kick in the butt to California's poor and impoverished and that this position, which would have done honor to Marie Antoinette of "let them eat cake" fame, has now been upheld by the Appeals Court.

SB  640 (Lara) is currently on the legislative docket and could cure the 10% cut. In its original form the bill is unlikely to pass. This bill is stalled in committee. Lara may be obliged to accept amendments that gut his bill or get nothing at all. One possible amendment is allowing the legislation to rescind the 10% cut for skilled nursing facilities while keeping the 10% cut in place for physicians and hospitals.  If the 10% cut is kept in the bill, the likelihood is that even more money will be saved as physicians drop out of the program and hospitals lay off workers. Lives will be lost, morbidity will increase, but the budget will have been balanced.

AB 900 (Alejo) has already been amended to limit the bill to restoration of the 10% to skilled nursing facilities. This ploy splits the opposition by appeasing one faction at the expense of the others.  Proponents of these two bills to date have included the California Medical Association, as sponsor, with support from the Service Employees International Union,  the Union of American Physicians and Dentists, the California Hospital Association, and the California Neurology Society, among others.

Physicians and other providers including hospitals and their Medi-Cal patients stand to lose signficantly if the bills fail because retroactive payments may be sought since the court case has already failed. The cuts are expected to include clawbacks for two years based on the delay in implementation of the cuts since 2011. Part of the current reason for amendments that agree to limit the bill to skilled nursing facilities is to allow the Governor just enough daylight  not to veto the bills should they pass. We'll see. Just don't hold your breath especially if you're a patient dependent on Medi-Cal.

MEDI-CAL PROVIDER CUTS: SB 640 AND AB 900

When does austerity mean tossing sick people under the bus?

Answer: anytime there's a government shortfall.

SB 640 (Lara) and AB 900 (Alejo) are designed to prevent the 10% Medi-Cal provider cuts that are now in the legislative hopper.  California is short of money. Apple's Tim Cook is now under the gun for sequestering money abroad in order to avoid taxes in the USA.  Last we looked, Cook was not only from America, but also from California. Not to worry. There's another way to get some money into California: cut down on the money spent on the sick and poor, especially citizens who are sick and poor at the same time.  That definition is fulfilled by Medicaid patients. In California, that program is called Medi-Cal.  

Medi-Cal has always had a sordid reputation in California. In 1981 Medi-Cal had to be coerced to  get back nearly a million dollars it carelessly overpaid to a single recipient for double-billing  (that was when a million dollars was still thought of as money).  The ante has  gone up since then but the program remains a conduit for channeling less and less money to  Medi-Cal patients. The impetus is to reduce Medi-Cal provider payments by 10% even though it's understood that such a move will drive providers out of the system.  Fewer providers plays into the hands of those who want more than the 10% cut. If enough providers opt out the cut in provider fees will considerably excced 10%.  Doctors will get blamed for not participating in a widespread system of moral bankruptcy and financial irresponsibility.

SB 640 and AB 900 will reverse the 10% cut providers and their patients suffer as a result of the 2011-2012  state budget. The California Medical Association has challenged the cuts in court and gets credit for sponsoring these bills.  We recommend support for SB 640 and AB 900.

SB 491 (Hernandez) CLEARS COMMITTEE

NURSES WIN KEY COMMITTEE VOTE

First, the facts

In a stunning victory for Nurse Practitioners SB 491 (Hernandez) cleared the Senate Appropriations Committee by a 4 to zero vote (DeLeon, Hill, Lara, and Steinberg). There were
no votes against the bill (Walters, Gaines, and Padilla were not recorded to have voted). No matter, the measure needed only the 4 votes it got.  

The California Medical Association, opposed to the bill, said in its Hot List that "this bill gives nurse practitioners independent practice" because "nurse practitioners will no longer need to  work pursuant to standardized protocols and procedures or any supervising physician and  would basically give them a plenary license to practice medicine."

One of the arguments by Senator Hernandez that proved particularly attractive to proponents was his assertion that allowing Nurse Practitioners to practice medicine "can reduce the cost of medical care by allowing lower-cost workers to  do more routine tasks in place of higher-paid MDs." In this blog, we have already asserted why this fanciful concept may well prove to be illusory. The nurses are well organized and have a strong union. In the opinion of this author the nurses' unions would be asleep at the switch were they to stand idly by while their colleagues got paid less than physicians for doing the same work.

Milton Lorig, MD, Union of American Physicians and Dentists, wrote in the Sacramento Bee that "physicians like myself have undergone far more rigorous training" and that he doubted that a mid-level practitioner "would have made the diagnosis of NMDA-Receptor Autoimmune Encephalitis" that he recently treated. Lorig argued that "patients deserve ready access to providers who are adequately trained." He did not, however, persuade DeLeon, Hill, Lara, or Steinberg -- just one would have been sufficient to save the day for optimal care.

Author's amendments may still be introduced, for instance, a provision to delete the authority for nurse practitioners to make diagnoses of patients and to perform procedures. Allowing expanded use of skilled nurses should not be done by lowering practice standards that physicians, nurses, and scientists have worked centuries to develop.
 

SB 494 REDUCES PHYSICIANS' ABILITY TO PROVIDE OPTIMAL CARE AND COUNSELING

LEGISLATION ALERT

SB 494 DILUTES ACCESS TO QUALITY  HEALTH CARE

SB 494 was introduced by Senator Monning and enjoys having Senator Ed Hernandez as the principal co-author. Their bill was heard in Sacramento this morning.

SB 494 would increase the number of health plan enrollees or insureds to primary care physicians. The original bill was introduced on 2/21/13 and was amended on 4/03/13 to allow "the assignment of up to 2,000 enrollees or insureds to each full-time equivalent primary care physician and would authorize the assignment of an additional 1,750 enrollees or insureds" to each primary care physician if that physician supervises one or more nonphysician medical practitioners.

The bill threatens that "willful violation ... would be a crime."

Senator Hernandez has also proposed enlarging the scope of practice for nurses, optometrists, and pharmacists (SBs 491, 492, 493). Diluting the quality of health care, Hernandez evidently feels, will improve access to health care generally. SB 494 is a companion bill that will make it impossible to do anything else but reduce the quality of physician-time spent with patients. Physicians will be penalized for having assistants by having their workloads increased. That maneuver by itself will chop down the amount of time physicians can spend counseling patients. If this bill is signed into law, patients will yearn for the day then they were allowed a whole ten or fifteen minutes with their doctors.

SB 494 is intended to bully physicians because it makes willful violation a crime. Physicians may not be in charge of whether or not they have assistants since assistants may be hired by HMOs, Accountable Care organizations, Foundations, hospitals, and managed care plans generally. This proposed legislation damages physicians' chances to provide optimal diagnostic and counseling efforts. 

At the hearing today, no testimony was offered by physicians' organizations.  

IF THE WORK IS EQUAL, SHOULDN'T THE PAY BE EQUAL?

Senate Bills 491, 492, and 493 (Hernandez) would allow RNs with advanced training, optometrists, and pharmacists to practice medical care without the pesky obligation of going to medical school, doing internships, or submitting to residency programs under the supervision of faculty. Indeed, most surgery would remain out ot bounds (not all surgery, mind you!).  The nurses, optometrists, and pharmacists would be allowed to undertake primary care. The RNs with advanced training would be qualified as Nurse Practitioners.  Proponents argue that this largesse will reduce medical costs because lower-cost workers would take over some of the tasks done by physicians. Just where to draw the line is one of the problems. For instance, how does one "draw the line" when the differential diagnosis of, say, "numbness" is the chief complaint?  Should an evaluation  for multiple sclerosis be considered? The patient who is misdirected to the lower level diagnostician will find out the hard way.

The San Jose Mercury News, in an editorial on April 12, 2013, said "these bills ... would allow nurse practitioners to establish indpendent practices and deliver limited care without a doctor's oversight." It has also been argued that the lesser-level practitioner would be paid less. Herein lies a problem: if the NP, optometrist, or pharmacist is delivering medical care equal to or on a par with physicians, shouldn't the lesser level practitioners be paid at the same level?

The Affordable Care Act is supposed to expand access to care, not to water it down.

Recently, we learned that the Union of American Physicians and Dentists negotiated a raise for physicians by showing that a  group of nurses was being paid more than their physician counterparts. The opportunities in Hernandez's  legislation make it worthwhile for physicians, nurses, optometrists, and pharmacists to organize into collective bargaining units lest the Hernandez package be used to create equal work with unequal pay. 

If the Hernandez  package is passed,  the nurses' unions would be asleep at the switch if they did not seek equal pay for equal work.

AB 889 (FRAZIER) UP TO BAT while SB 626 (Beall) strikes out

SB 626 (Beall) would have put one helluva crimp in SB 863 (DeLeon). Now that SB 626 has been pulled, perhaps, to be continued next year as a two-year bill, the business community can focus its laser like interests elsewhere, e.g., onto AB 889 (Frazier). 

AB 889 (Frazier) would impose specified requirements on health care service plans or health insurers. AB 889 would require insurers to have "an expeditious process in place to authorize exceptions to step therapy." Step therapy is the process whereby patients are required by their insurance companies to try specified generic medications before being allowed to try newer, better, and probably more expensive medications. Cost control comes before patient care according to this protocol.

Similar legislation, AB 369 (Huffman) was vetoed last year by Governor Brown. Here's what the Governor said about AB 369 in his veto message: "this bill would prohibit a health plan or insurer from requiring a patient to try and 'fail' more than two medications before allowing a patient to have the pain medication prescribed by his or her doctor."

Governor Brown stated that "independent medical reviews are available to resolve differences in clinical judgment when they occur, even on an expedited basis."

We now know that the independent medical review law derived from SB 863 allows the identities of independent medical reviewers to be kept secret and that the law specifies that neither the Workers Compensation Appeals Board (WCAB) nor the courts can alter an independent medical reviewer's decision just because it's wrong, no matter how incredibly wrong it may be. Brown put his foot (well, both feet) further into it when he also said "any limitations on the practice of 'step-therapy' should better reflect a health plan or insurer's legitimate role in determining the allowable steps." Translation: a health-plan's profit center has a "legitimate role" in overruling doctors' medical decisions

Governor Brown should be interviewed about these comments repeatedly.

We recommend support for AB 889 (Frazier). We recommend early lobbying of the Governor since last year he sided with insurance company interests and vetoed a similar bill.  

Update: We are advised that AB 889 (Frazier) is scheduled to be heard by the Assembly Health Committee on April 30th, 1:30 PM, Room 4202. Interested parties, especially those who would like to attend or testify, need to stay alert to possible changes in time and/or date.

A BONANZA OF MALPRACTICE LITIGATION IS IN THE OFFING

STATE SENATE BILLS 491, 492, AND 493 ARE BILATERAL TRIPLE MALPRACTICE BONANZAS FOR TRIAL LAWYERS -- ON BOTH SIDES.

Senator Ed Hernandez's bills to promote expanded scope of practice for nurses, optometrists, and pharmacists,  scheduled for hearing on April 22nd, got pulled from committee just hours before the hearing.

In our previous post on this topic we pointed out, as did others, that these bills lower the level of education and training for healthcare professionals especially with reference to  differential diagnosis and selection of diagnostic and treatment modalities. If it is determined that a lower level of education and training is acceptable, then the same level of reduced education and training should also be acceptable for physicians. Since these bills allow reduced levels of required education for the same or similar services, we should expect increasing levels of malpractice litigation should any of these bills get voted into law -- a boon to  both plaintiffs' and defense bars, a veritable bonanza of malpractice litigation.

Late notice: we're advised that the Hernandez bills will be brought up in committee on April 29th.

NO, NO, NO ON SB 491, 492, AND 493!

Do we as citizens agree to reduce the level of education and training of our physicians while increasing the number of healthcare providers by expanding the healthcare pool to include nurses and others? Some say the Hernandez Trio, SB 491, 492, and 493 would do just that. The critical question is whether so doing  would be advantageous or detrimental to the provision of healthcare generally.

SB 491 would let Nurse Practitioners (NPs) practice medicine on their own, just as physicians do. The argument for so doing is that there is a dearth of physicians especially in rural areas that NPs could fill.
The counter argument is that physicians are better educated and trained in terms of diagnostics, differential diagnosis, and therapeutics, that is, how to distinguish what may seem to be an inocuous illness as opposed to the harbinger of a medical catastrophe. The issue is whether or not the exchange is worth the candle. The probable result of passage of SB 491 is that NPs, once licensed, will skedaddle from rural practice as fast as their physician colleagues and will set up shop where the money is and compete with their more advanced and more highly trained counterparts. THAT'S the underlying issue. The rest is window-dressing.

SB 492 would allow optometrists to act as ophthalmologists without the pesky interval of real honest-to-gosh medical education and training. Under SB 492 optometrists would be allowed to administer and prescribe drugs including controlled substances. Never mind that right now at the same time various task forces are trying to make it increasingly difficult even for well trained physicians to prescribe narcotics. SB 492 implies that full blown medical education is not necessary for safe ophthalmology practice. If one believes that then SB 492 isn't a problem.

SB 493 would allow pharmacists to dispense medications. In some cases, as when a renewal isn't attended to promptly by a physician, pharmacists already do just that. Their argument is that their training in pharmacology is actually more than most physicians get. On the other hand, conveniently ignored is that pharmacists aren't educated or trained in physical diagnosis and often are not equipped to deal with the adverse consequences of medications. The upshot is that they may prescribe and leave it to some physician somewhere to deal with the complications.

Commentary

"Nurse practitioners battle for right to treat patients" is the title of a piece by Shannon Pettypiece, Bloomberg Businessweek reporter. She describes the predicament of Christy Blanco, Nurse Practitioner in El Paso, who has a doctorate degree in nursing practice. Blanco asserts competence in treating diabetes, asthma, high blood pressure, and other conditions. Blanco's problem is that in Texas she is required to contract with a doctor to sign off on medical charts. By contrast no such requirement  exists in New Mexico so Blanco is considering moving there. In her suboptimally used El Paso office she states she is "spending money and making no profit." Ruefully, she adds, "it is a business."

Yessirree, "it is a business," one that has been learned by managed care organizations and corporate American generally and is about to be upgraded by Accountable Care Organizations and pharmacies that are opening their own clinics to be staffed by nurse practitioners and, maybe, even by some physicians (we don't say "even by some doctors" since in due course the NPs will have doctorate degrees in nursing practice).

Competition is not precluded by Hernandez' three bills. Physicians usually leave Nursing Plans in the hands of nurses. They're not required by law to do so. So if competition is the name of the game, one possibility is for physicians to add nursing practice to their own armamentaria. So doing makes more sense than trying to maintain the status quo. We can expect that universities, ever on the prowl for profitability, just like corporate America anywhere, will hire physicians to teach the nurses and then award them "Equivalency Certifications" suitable for framing and display. Physicians can also construct practices entitled to collective bargaining so they can be on equal footing with the nurses who've developed significant enough clout to be direct members of the AFL-CIO (meanwhile, not far behind, is the Union of American Physicians and Dentists, otherwise known as the UAPD or Local 206 of AFSCME, the largest union within the AFL-CIO).

A little known fact, recently revealed by Stuart Bussey, MD, JD, president of the UAPD is that in 2012 the doctors' union was obliged to negotiate with San Francisco County to raise the salaries of the doctors to equal the salaries of the FNPs. The predicament was a kudo for union power on both sides. Unfortunately for the doctors, their preferred professional associations and societies are not unions and are not allowed to negotiate collectively. The nurses don't suffer from this form of erudite elitism.

Professional education has always been considered the democratic equivalent of royal titledom.  We defer to titles, e.g., "doctor. " The nurses' and optometrists' answer is to upgrade alternative forms of education so that the "doctor" title can be bestowed.  Pushing the fact that the higher education and training that physicians get has intrinisic worth is held to be an elitist argument. The answer is to downgrade elitisim. That's where we're headed: less education, less training, equivalency certification, upgraded titles, and a race to the bottom where money lies in tempting repose.

The Affordable Care Act is supposed to upgrade healthcare for all. The expanded application of SB 491, 492, and 493 will downgrade healthcare for all but will expand access to some form of care. This triumverate of bills allows otherwise well trained professionals to work beyond their levels of training. We anticipate in the long run malpractice premiums will increase to accommodate the addition of suboptimally trained new professionals. We recommend a no vote on SBs 491, 492, and 493.