Monday, September 29, 2014


It  is not commonly realized by participants in health care plans sponsored by health insurance exchanges derived from the Affordable Care Act (ACA) that these plans are subject to changes allowed under the law.  The meaning is that a plan purchased this year may have been compliant with the ACA (Obamacare) at the time of purchase but may not remain compliant with changes that the ACA allows these plans to make (including the annual premium which may be raised annually if that's what the executives of these plans want). 

We understand that the ACA and the exchanges have dealt death blows to many longterm relationships between patients and their doctors.  It is not uncommon to see posters in clinics that state that the clinic and its doctors do not accept Covered California subscribers. 

Take a look at what it means to buy into a Bronze, Silver, Gold, or Platinum Plan. These plans reflect "actuarial values" which means the percentage of the covered benefits that each of the plans is expected to pay, e.g., Bronze Plan subscribers pay the least in annual premiums while paying the highest co-pays. Conversely, Platinum Plan subscribers pay the most for their annual premiums and in return pay the lowest co-pays. 

Currently, the Bronze Plan covers about 60% of health care costs. The Silver Plan covers about 70%. The Gold Plan covers about 80%. The Platinum Plan covers about 90%. The unpaid gap is the subscriber's co-pay, highest for patients who are strapped for cash and are obliged to purchase the lowest price plan, lowest for patients who can afford the Platinum Plan. That means that doctors, clinics, and hospitals who have a high percentage of Bronze Plan participants are most likely the ones who'll be stiffed on required co-pays. 

Here's the rub: each of the plans has a range that it's supposed to cover, e.g., at the time of this writing the Bronze Plan is reported to cover from 58 to 62 percent. It is expected that as time marches on there will be changes, even favorable changes in these plans. Because of how the ACA is written and because of how the exchanges function, a Bronze Plan that now covers 60 percent may at some time in the future cover 65%. The rub is that the next step up in the ACA division is the Silver Plan which starts coverage at 68 percent which means that your Bronze Plan no longer qualifies as a Bronze Plan but also doesn't qualify as a Silver Plan. So your plan is no longer valid under the ACA. 

What may be even harder to understand is that the Platinum Plan also has limits. It cannot cover more than 92 percent. So doing is not legal under the ACA.

So where does Proposition 45 which is on the November ballot in California fit in? Proponents of the ACA or Obamacare fear that passage of Proposition 45 could prove harmful to the ACA since the Covered California exchange recently negotiated a rate increase for its over one million plus enrollees. 

The ACA makes purchase of healthcare insurance mandatory but does not regulate premium prices. Covered California, like other insurers, does not want to have rate increases it can currently negotiate subject to being rescinded by an insurance commissioner. Proposition 45 would  empower the insurance commissioner to do just that. The Insurance Department in California is reported to have found that rate increases from 2013 to 2014 are from 22 to 88 percent (the Covered California board has not voted a position one way or the other on Propostion 45 as of the date of this article).  

References for this piece: 

1) THE HILL Newspaper,  Washington, D.C., "What Obama should've said about healthcare reform," 9/16/09, by Robert L. Weinmann, MD;
2) POLITICO, "GOP govs could gum up Obamacare," 2/10/10 ("I will ensure that no government bureaucrat gets between you and the care you need"), by Robert Weinmann, MD; 
3) John C. Goodman ( Goodman, 9/23/14 ("if you like your insurance you can keep it");
4) SAN JOSE MERCURY NEWS, "Measure creates odd alliances," Tracy Seipel, 9/26/14;
5) Editorial, Robyn G. Young, MD, President, CALIFORNIA NEUROLOGY SOCIETY, 9/17/2014 ( these three points are emphasized:
  a) Prop 45 will require public disclosure of hearings re health inssurance rates;
  b) Prop 45 will require approval of changes in health insurance rates by the California Insurance Commissioner;
  c)  Prop 45 will require sworn statements about the accuracy of information submitted to the insurance commissioner to justify proposed rate changes.

  Comment: Prop 45 proposes transparency that the ACA (Obamacare) has consistently denied, e.g., Pelosi's laughable comment that the ACA had to be passed so we could see what's in it and then an Independent Payment Advisory Board (IPAB) that by law need not include even a single physician. The Covered California board likes the murky mists of non-transparent legislation. THAT is what Prop 45 seeks to change. THAT scares insider deal-moguls to the very core of their existence.  

Thursday, September 18, 2014


From the Association of American Physicians and Surgeons, AAPS News, September, 2014, we learn that the Florida Medical Association passed the following resolution, namely, "that the FMA advocates that the lack of specialty board recertification (italics added) should not restrict the ability of the physician to practice medicine in Florida." 

In a feisty letter-to-the-editor, Ellen McKnight, MD, Pensacola, writing over the title, "FMA Passes Anti-MOC Resolution,"  stated that "hospital employed physicians should immediately use this to remove MOC requirements from hospital medical staff bylaws."

In a previous editorial in this blog, "How Physicians Eat Their Young," 2/12/14, we showed how the specialty boards use MOC and  re-credentialing to convert their previously august and professional objectives into money-making opportunities for themselves. We recommended taking a look at each board's IRS Form 990, not only for what is reported, but also for what is not reported, e.g., individual compensation arrangements.

We provided references for interested parties. Among the juice-laden items we revealed was that as of 2011 the American Board of Internal Medicine reported total assets of $57, 586, 843 -- so what, dear reader, for what purpose do you think ABIM needs nearly $60 million? 

We informed our readership that as of 2011 the ABIM board chair was remunerated about $800,000. We revealed that recertification costs for an allergist were $2,700 and that MOC costs for an allergist were $2,850. 

Do not think for a moment that FMA's resolve to reduce the necessity for recertification will go unnoticed by the boards -- the huffing and puffing are still to come. We await and expect similar resolutions from other state medical associations, unions, and professional societies. 

Peer-reviewed journal  references are appended to our 12 Feb 14 editorial entitled "How Physicians Eat Their Young." 

Thursday, September 11, 2014


The Los Angeles Times Data Desk report on 61 closed California hospital emergency rooms is ominous. Some hospitals closed altogether, e.g, Saint Louise Mental Health Center in 1999, San Jose Medical Center in 2004, and Martin Luther King Jr -Harbor Hospital in 2007

Now we're waiting to see if a similar fate will overtake Doctors Medical Center in Contra Costa County. A Contra Costa Times editorial dated 8/28/14 provided a dismal outlook and, said, yes, it was the fault of the "nurses and physicians." The newspaper's editors said the nurses and physicians were "more concerned with protecting unsustainable jobs than ensuring adequate emergency service." The nurses and doctors were at fault because they were trying to maintain the hospital as a "full-service hospital." 

The newspaper, in a masterpiece of misunderstanding, opined that keeping a full-service hospital wasn't "realistic." On its side, the paper was able to state that "the district borrowed to keep Doctors running the past few years." The editors said that this effort was burying West County taxpayers deeper in debt." The editors didn't mention that this effort also saved countless lives over the years and if properly funded would continue to do so. 

But, then, the CCTimes is no friend of the hospital. In 12/01/13 the editors opined that "death for Doctors Medical Center is only a matter of time" and that the emergency room service at DMC was already on life-support. The editorial board opined that DMC wouldn't make it past the Spring of 2014. While matters are still rough at DMC, the editors should take note that the Harvest Moon Festival from The Fall of 2014 is already behind us and the medical and nursing staffs are still soldiering, still doing good for many, and even saving lives.

The issue is whether or not patients come first, or profits. 

The main problem according to  CCT is revenue shortfall (that's the lingo financial people use for going broke). CCT pointed out that in 2011 the West Contra Costa Healthcare District which operates the hospital won a $47-per-house tax increase. Declining hospital inpatient volume was and is a serious problem. What do do?

Richard Stern, MD, DMC Chief of Staff, issued a statement wherein he said that "the county's effort to support the medical needs of West County residents has been the equivalent of providing ... fire extinguishers. This will not help when the next Chevron fire ignites homes and there is no infrastructure to fight the fire." Stern has a point when he says "it is time for the politicians to respond to the needs of the entire county and for the Contra Costa Times editorial staff to educate itself on the real issues here and its role in fomenting this human tragedy."