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11/28/2014

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Emanuel didn't mention Medicaid expansion because that wasn't his topic. He's written and spoken frequently about "reinventing American health care" and I believe that's what he was doing at this conference. By the way, his book on the subject:

http://www.amazon.com/Reinventing-American-Health-Care-Outrageously/dp/1610393457

Hospitals are among the most expensive elements in our health system, and a more rational system would send us to the hospital less often. Emanuel's point is that hospitals now provide many services that can be provided more efficiently by clinics and primary-care physicians, and that the ACA includes provisions to change some of those adverse incentives.

A few years ago, a colleague and I studied ER data from the Cone Health system and found that the costs run up by the most expensive patients weren't due to their time in the ER. It wasn't because of the ER, per se. It was because they came to the ER with multiple or very serious illnesses and had to be admitted to inpatient hospital stays. Hospital care was the huge expense, and the implication was that costs could be better controlled if more patients saw primary-care physicians often rather than forgoing such care and coming to the ER with serious illnesses.

So yes, the ACA includes incentives to make American health care more efficient, and doing so will cause some hospitals to close. But that doesn't mean Medicaid expansion isn't doing the same thing. Pungo appears to be due to Medicaid expansion, not the ACA incentives that are only now beginning to take effect.

So we have two factors, and per usual, you've told only half the story. One half is that the ACA will lead to hospital closing by making health care more efficient, thereby holding costs down. One would think that'd be a good thing on balance. The other half is that in states that don't expand Medicaid, hospitals will close because they're starved of the funds they need to serve the poor and uninsured. One would think that'd be a bad thing.

Let me get my arms wrapped around the message you are transmitting, Andrew. It is OK for hospitals to close if it is due to Obamacare; but it is not OK for hospitals to close because the states decline to expand a charity program. Is that your position, in a nutshell?

BTW, it is not at all clear that Pungo was closed because of the factor that you mentioned. From the article linked above:

"The president of Community Health Hospitals, Roger Robertson, says there was just not enough patients to maintain the hospital. They say they've had just four people per day come to the Belhaven hospital in 2013 needing critical acute care. It fell to two per day in 2014."

You need a certain amount of volume to make a hospital viable. Pungo did not even come close to having it. The administrators, in addition, were likely anticipating the future changes in the economic environment for health care delivery being spurred by Obamacare. It is not inconceivable that Pungo was among the 1000 that Emanuel was predicting.

It's okay for hospitals to close if it's due to improved efficiency and care. It's not okay if it's due to state governments acting against their people's best interests and harming the poor in the process. Yeah, that's my position.

So if Pungo had closed because of "improved efficiency and care" forced by Obamacare, then that would have been OK. Is that your position?

If so, would it also have been OK for the hospital to close, for instance, because of efficiencies spurred by a truly free market?

(Of course, this is a very hypothetical question, because the health care sector was heavily socialized even before Obamacare was passed.)

Hello gentlemen. I actually worked for UHS (now Vidant) on and off for over a decade - culminating in a four-year assignment in Ahoskie covering weeks-to-months of 24/7 inpatient Pediatric call at a time.

For brevity's sake, we'll just say that once again, I was "rewarded" with a "voluntary" boot-in-the-ass after challenging working conditions that can only be described as abusive to the point of being inhumane.

Pediatricians should be seen and not heard - for hospital Pediatrics doesn't make any money you see.

And neither did Pungo - which functioned as a glorified clinic for a number of years. But it did save some lives (including one of my cousins), and I don't think anyone died in the back of an ambulance waiting on care while they were open (not very "efficient" if you asked me).

Critical access hospitals generally don't make money.

Then came Vidant (under new-and-not-so-improved senior management - OBTW David Herman is on his way OUT - cue the Hallelujah Chorus) . . . riding into Belhaven and making a lot of promises to the local populace that it clearly had no intention of keeping.

Vidant actually wanted to build a multi-million-dollar clinic a few blocks up the road . . . while diverting the emergencies to Washington and/or Greenville. Plainly put, the suits in Greenville did not want any competition.

For supposedly smart people who "anticipated the changes brought on by Obamacare", Vidant executives sure spent a lot of time sucking up to (and shilling for) the "reform" (before it was passed) that would ultimately bury their more rural operations.

If you were employed or contracted by Vidant and openly opposed Obamacare (because expanding a long-broken program - that would be Medicaid - made NO FISCAL SENSE), you were toast.

Boyd, I'm wondering (in the wake of your "study" of Cone - a completely different practice environment) how patients in these more rural areas are going to find doctors - given that the MBA's running our community hospitals in NC have long made it sport to treat primary care physicians like crap/pawns on their chessboard of greed (THE REASON I landed in the blogosphere in the first place - not that any of the "progressives" here cared or could be bothered) . . . and we are facing severe shortages in smaller/rural communities - because doctors (particularly Pediatricians) are walking away from hospitals in droves.

Hospitals are expensive because they are top-heavy with high-dollar management (too many chiefs - not enough Indians) - often run by local cabals that are more interested in politics than good medicine. Moreover, they're horribly inefficient because many of those well-meaning reforms you champion (like, I dunno, embracing EMR) have proven to be fiscal disasters - lowering productivity and draining resources - actually taking practitioners AWAY from the bedside.

But the thing is we have to have hospitals - especially critical access hospitals - because that's where lives are saved. And we have to staff them with doctors and nurses who know what they're doing. Everybody cannot make it to the medical meccas (as an aside, it would be nice to see an experienced/seasoned hospital Pediatrician taking never-ending call make at least a quarter of what some of the 9-5 executives/lawyers pull in for running these places into the ground).

Your hallowed reform, Andrew, did NOT fix ANY of the things that really need to be fixed. You did not LISTEN to the boots on the ground. You worshiped at the wrong altars.

But hey, as long as the suits can rake in their millions and float on their parachutes . . .

. . . and the Cones of this world keep their seats on the board.


Brod conveniently leaves out the most important reason many of these hospitals have found it difficult to continue operation: The significant reduction of Medicare and Medicaid reimbursement rates to hospitals, an integral part in making the bogus financial assumptions of his beloved health care "reform" seem to be reasonable.

http://www.usatoday.com/story/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/

FTA:

"The closings threaten to decimate a network of rural hospitals the federal government first established beginning in the late 1940s to ensure that no one would be without health care. It was a theme that resonated during the push for the new health law. But rural hospital officials and others say that federal regulators — along with state governments — are now starving the hospitals they created with policies and reimbursement rates that make it nearly impossible for them to stay afloat.

Low Medicare and Medicaid reimbursements hurt these hospitals more than others because it's how most of their patients are insured, if they are at all. Here in Stewart County, it's a problem that expanding Medicaid to all of the poorest patients -– which the ACA intended but 23 states including Georgia have not done, according to the federal government — would help, but wouldn't solve.

'They set the whole rural system up for failure,' says Jimmy Lewis, CEO of Hometown Health, an association representing rural hospitals in Georgia and Alabama, believed to be the next state facing mass closures. 'Through entitlements and a mandate to provide service without regard to condition, they got us to (the highest reimbursements), and now they're pulling the rug out from under us.' "


As usual in situations like this, Brod's "position" on these things is justified only by the excessive massaging of facts necessary to support an unsupportable policy position.

The fact that we are arguing the effects of a law that was put into place based on lies and deception, is absurd. On that we should all agree, whether you are left or right on the political scale.

Do you not think that the "powers that be" didn't know this would happen? Divide and conquer is the MO.

Make no mistake. It's NOT about helping the poor get treatment or making it "affordable" for you or me. It's about CONTROL. Alla- the complete lives system! And dare I say AGENDA 21.

Bob, I am loathe to put any faith in the CEO's (particularly "non-profit" ones) who have bled the system dry with their self-serving infrastructures that have had the effect of raising businessmen to God-like/untouchable status - while slowly and methodically devaluing the services of the doctors and nurses who actually provide the care.

The middle-men of medicine are what cost so much. That and catering/pandering to millions of Americans who've been bred to expect everything for nothing. You simply cannot blame the fiscal black hole on doctors - or unnecessary tests - any more. And if you do want to blame it on unnecessary tests - then WHY didn't the ACA come with some real tort reform?

A good example of just how bad things got is the "disproportionate-share" program (Medicaid) - a reimbursement plan designed to compensate hospitals for providing services to the uninsured & medically-under-served. Over a period of years, the program was defrauded by North Carolina hospitals (some of our biggest/best) - depending on which source you consult/cite - to upwards of a billion dollars. It wound up being the equivalent of a Federally-funded candy store plundered by men-in-suits fancying themselves captains of industry (never mind that their "industry" was heavily subsidized/socialized).

The Feds investigated and found fault. But the money was long gone - poured into fancy cancer centers, new buildings and big salaries. The money was "repaid" . . . with pennies on the dollar. No one was prosecuted. And the story barely got two days of coverage by our progressive state newspapers - so determined to sell snake oil to a gullible/increasingly entitled public.

My point is this: A lot of these hospitals/their CEO's and boards richly DESERVE having the "rug pulled out from under them". But even now, I've not seen ANY evidence that it has induced anyone to clean up their acts. I have yet to encounter a hospital leadership "team" that was worth the millions they skim off the top - away from services and patients.

Andrew Brod and his ACA-loving cohorts are just WRONG about so many things pertaining to "reform"-that-wasn't. The law was passed and we found out what as in it - and what wasn't.

What I really love is that the House-of-God's house-of-cards is falling in on itself much faster than I ever dreamed it would.

Mary, Bob, Tommy-- I think all three of you are right. The things you are saying are by no means mutually exclusive.

The reason the federal reimbursement rate to hospitals was reduced was precisely because the ACA would, through Medicaid expansion, get those reimbursements to hospitals in another form. That's the whole point! It's beyond illogical to blame that on the ACA, though I'm not surprised to see it on this page.

Andrew, it is really too bad that Justices Ginsburg, Breyer, Sotomayor and Kagan ruled that requiring the states to expand Medicaid was unconstitutional. All of these Democrat-appointed Supreme Court justices held that "the ACA" was flawed from this standpoint:

http://en.wikipedia.org/wiki/National_Federation_of_Independent_Business_v._Sebelius#Chief_Justice_Roberts.27_opinion

And it's too bad that an economist does not understand why expanding a beyond-broken, broke, horribly-overseen program (that would be MEDICAID) should not be expanded.

It's a bad law, Andrew. Excuse me, TAX. Rhammed down our throats. Gave EVERYTHING to the insurance companies. Based on a pack of lies.

And now you admit, the ACA robbed Peter to pay Paul.

Keep 'em coming.

"The reason the federal reimbursement rate to hospitals was reduced was precisely because the ACA would, through Medicaid expansion, get those reimbursements to hospitals in another form."

Oh, of course. The old "volume is better than margin" fallacy so beloved of those who can rationalize anything to fit the agenda.

What could possibly go wrong? (SMH)

Let's not forget the ample evidence from Oregon's experience that shows Medicaid expansion accomplishes very little for money spent.

http://www.cato.org/blog/oregon-study-throws-stop-sign-front-obamacares-medicaid-expansion

FTA:"There is no way to spin these results as anything but a rebuke to those who are pushing states to expand Medicaid. The Obama administration has been trying to convince states to throw more than a trillion additional taxpayer dollars at Medicaid by participating in the expansion, when the best-designed research available cannot find any evidence that it improves the physical health of enrollees. The OHIE even studied the most vulnerable part of the Medicaid-expansion population – those below 100 percent of the federal poverty level – yet still found no improvements in physical health.

If Medicaid partisans are still determined to do something, the only responsible route is to launch similar experiments in other states, with an even larger sample size, to determine if there is anything the OHIE might have missed. Or they could design smaller, lower-cost, more targeted efforts to reduce depression and financial strain among the poor. (I propose deregulating health care.) This study shows there is absolutely no warrant to expand Medicaid at all."

We won't discuss the other reasons why Medicaid expansion is a sucker's bet for the states smart enough to refuse the losing proposition.

Here's a strategy being considered by certain states who have made the mistake of expanding Medicaid: Freezing additional enrollments.

FTA:

"Policymakers and taxpayers are right to want to reduce the government dependency Obamacare seeks to create. Obamacare’s Medicaid expansion creates a new entitlement for able-bodied adults. By and large, these adults have no dependent children at home to care for and no disabilities keeping them from meaningful employment. And the peer-reviewed evidence is clear: expanding Medicaid to this new class of able-bodied adults will discourage them from working and, as a result, shrink the economy. Able-bodied childless adults have never been considered among the most vulnerable, which is why they do not typically qualify for other types of welfare, including cash assistance and long-term food stamps.

But lawmakers are also wise to take a careful approach at unwinding this Obamacare disaster. Freezing enrollment allows states to begin the hard work of reducing dependency, but allows them to do it a thoughtful way.

Poverty is a short-term situation for most Americans. According to the latest data from the U.S. Census Bureau, nearly half of individuals in poverty will increase their incomes and exit poverty within four months. Nearly three-quarters of them will increase their incomes and exit poverty within a year. In fact, the median length of time an individual spends in poverty is just 6.6 months. By closing the front door to expansion, enrollees will gradually transition off of these welfare programs as their incomes naturally rise – just as they would anyway."

Read the article to see how this strategy worked previously.

http://www.forbes.com/sites/theapothecary/2014/12/03/welfare-to-work-how-states-can-unwind-obamacare-expansion-and-restore-the-working-class/

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