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UPDATED: NE Journal of Medicine: RomneyCare: 18% increase in Administrators–No Significant Increase in Doctors/Nurses

UPDATE: Another problem discovered. To help pay for RomneyCare, reimbursements to doctors for Medicaid patients were cut.

Because of its own rising costs, the state government has cut payments to doctors and hospitals. According to family physician Dr. Katherine Atkinson, the state insurance reimbursements often do not cover her expenses: “Every time I have a Medicaid patient it’s like handing them a $20 bill when they leave.”

This has caused physicians to:

This week’s issue (June 16, 1011) of the

New England Journal of Medicine contains (updated) study which found that two-thirds of callers posing as mothers of children on Medicaid and/or S-CHIP were denied an appointment with a specialist for an urgent medical problem. Only 11% of those posing as having private insurance were denied an appointment.

UPDATE 2: Let me also add, Romney’s bad decision making continues…Romney has proposed allowing Health Savings Accounts to pay for traditional health insurance. This is the opposite of what the health care market needs. We need more people watching their bills, shopping around, and less time spent by doctors filling out insurance paperwork.

 

The Health Care reforms instituted by Governor Romney increased administrators by 18.4% compared to 8% for country but non-administrative positions grew at same rate as states without health reform. according to a report in the New England Journal of Medicine

From 2005–2006 to 2008–2009, employment per capita in administrative occupations grew by 18.4% in Massachusetts, as compared with 8.0% in the rest of the country (P=0.015). These administrative occupations include management, business and financial operations, and office and administrative support (including medical records and health information technicians). In contrast, employment levels in nonadministrative positions in Massachusetts increased by 9.3% after health care reform, an increase similar to that of 8.6% in the rest of the United States (P=0.796).

These data suggest that enactment of reform in Massachusetts was associated with more rapid growth in health care employment, primarily in administrative occupations and (perhaps) patient care support occupations rather than among physicians and nurses

Obviously, government health care requires lots of paperwork:

More important, our analysis supports physicians’ concerns about the administrative burden of health care reforms, an issue that will have to be addressed as the ACA is implemented.

So what happens when you add 400,000 people to health roles but not any more doctors/nurses as the rest of the country? It is no wonder that according to the Cato Institute:

As goes choice, so goes quality. Statistics on waiting times for specialist care in Massachusetts read like a dispatch from Canada. (emphasis mine) In 2004, Boston already had the longest waits among metropolitan areas. By 2009, waits had generally shortened in other metro areas (outside of Mass.) (average wait: less than three weeks) but lengthened in Boston (average wait: seven weeks), according to the Merritt Hawkins survey.

Really seven weeks!!! OK. So wait times increased but surely the quality is the same?

Voters who believe the Massachusetts law reduced the quality of care outnumber those who believe it helped by nearly 3-to-1 (29 percent to 10 percent).

OK. So more administrators, lower quality, and long wait times but at least it made health care more affordable and reduced costs?

“Premiums are growing 21 to 46 percent faster than the national average, in part because Massachusetts’ individual mandate has effectively outlawed affordable health plans.

OK. So longer waits, more administrators, lower quality, and reduced affordability of private insurance. But surely the government by being a bulk purchaser of health care can purchase at lower costs?

Since Massachusetts has covered just 432,000 previously uninsured residents, the cost of covering a previously uninsured family of four — at least $20,000 — is well above the average cost of an employer-sponsored family policy (about $13,000)

OK. So longer waits, more administrators, lower quality, reduced affordability, and greater cost; but according to Romney the people of Massachusetts know the costs and US taxpayers are not helping to pay for Romney’s experiment?

Had state officials not done their level best to hide those costs — the individual mandate pushed 60 percent of the cost off-budget, while expanding eligibility for Medicaid pushed another 20 percent onto the federal budget — no one would be hailing Massachusetts as a model.

OK. So longer waits, more administrators, lower quality, reduced affordability, greater cost, hidden costs to taxpayers in Mass and US taxpayers; but at least this will keep Massachucetts from going down the path to European single payer system that rations care?

To cope with the cost of its reforms, Massachusetts created a legislative commission that has recommended moving the entire market to a single, Canadian-style payment system that would encourage doctors and hospitals to ration care.

The mainstream media do not seem to understand why so many conservatives do not want Romney. My reason is simple: I want my parents, my kids, and my fellow Americans to have the best health care possible. Liberals and some Republicans like Romney have argued that we will not end up with the long lines and bureaucracy of europe with health reform. I hope this post helps people understand why I do not support Romney.

COMMENTS

  • turkeyotooley

    I knew Romneycare was bad, but you successfully illustrate how bad it is.

    Hopefully, caucus voters will pay attention. The Des Moines Register would have been well served to read your diary entry before making their ridiculous endorsement for Romney.

    Nice job.

  • JSobieski

    The issue of Romneycare and Obamacare illustrates yet another example of how our public discourse is inadequate.

    The legal cases on Obamacare focus on the “mandate” because that is likely the strongest argument for overturning Obamacare in court. However, the mandate is not the primary reason why Obamacare is a bad idea.

    The data cited above is why Obamacare and Romneycare are bad ideas.

    Increase costs
    Increase wait times
    Make it harder for insurance companies, hospitals, and providers to behave as businesses
    Move further away from capitalism
    Discredit capitalism in the eyes of the public–have people begging for a government option, and ultimately single payor

    Arguments on mandate ultimately help the government option/single payor types. There is no “mandate” if taxes are increased to pay for a government option.

    • quill67

      Suppose we allow people to get a tax rebate for private insurance. You buy private insurance and instead of getting a tax deduction, you get the same amount put into an HSA. Spend $10,000 on private health insurance, say and instead of not having to pay tax on that $10,000 probably averaging 20%, you get a 20% rebate into your HSA. So that 10K policy would give you $2,000 of your money to spend without filling out any claims.

    • quill67

      Suppose we allow people to get a tax rebate for private insurance. You buy private insurance and instead of getting a tax deduction, you get the same amount put into an HSA. Spend $10,000 on private health insurance, say and instead of not having to pay tax on that $10,000 probably averaging 20%, you get a 20% rebate into your HSA. So that 10K policy would give you $2,000 of your money to spend without filling out any claims.

      • lineholder

        Sorry, I’m not gung-ho over it, but that’s because I see other areas of health care as being a higher priority for the time being.

        One of the biggest challenges we’re facing is access to care at the primary care provider level. There are two areas where this hurts us the most, i.e. responsiveness to chronic illness management and keeping Medicare/Medicaid patients in areas where access to PCPs is limited out of the emergency room. (You would not believe the number of cases coming through the ER directly associated with these two root causes, quill67. It’s astronomical, and if something isn’t resolved soon re: PCP access, it’s going to get worse).

        So, if we’re going to invest political capital or any type of tax rebate “perks” into the system, that’s just where I personally think we should start.

        • quill67

          It has been strange. When we lived in Texas, you could find a 24 hour clinic (AM/PM for example) with really cheap services on every corner. But when we lived in PA and now in TN, they are almost non-existent, and so people go to emergency rooms.

          There are a couple of reasons this happens. In Texas there is a large population of people who do not have health insurance and these clinics are an inexpensive. But as paperwork costs have increased staff requirements, doctors find it difficult to operate independently.

          Another interesting issue is that many offices contract out their doctors to private companies. Patients seeking drugs have learned that if a doctor does not give them the drugs, they fill out nasty evaluation forms so those doctors will lose their contracts. Fearing this, doctors have told me that they write prescriptions for people that in the past they would have told to” take a hike”.

          If you know of other reasons, for the shortage let me know. I know malpractice plays a role and that nurse practioners and PAs are helping but would like any info you might have (even if anecdotal)

          • lineholder

            is simply that specialists make more money that PCPs do. So students are more inclined to pursue a path of specialty rather than general medicine.

            Following directly behind that is the fact that third-party payers are inclined to pay lower rates to PCPs than to a specialist. (That’s part of what feeds into the point above)

            Malpractice insurance does play into the element of costs, even for specialists. For example, the malpractice costs for OB physicians has become very high. It discourages OB practice in the area.

            EMTALA

          • lineholder

            Under EMTALA, hospitals aren’t allowed to turn anyone away from the ER. Under the current Medicare structure (and I think this applies to Medicaid as well) hospitals get additional payment for being what is called a “disproportionate share hospital”, meaning that if they get extra payment for the number of indigent patients they treat to offset the costs. In inner city areas, this doesn’t exactly encourage PCPs to set up practice, because patients just go to the ER for treatment.

            I’d really like to see us consider some things that haven’t been tried before, such as expansion of case managers to follow up with patients who have chronic illnesses. The more we can get patients directly involved in their own healthcare, the better chronic illnesses can be managed. But case management, per se, isn’t something that is differentiated within the payment structure, so even though a lot of DRs might consider it as being a way to approach health care, they aren’t actually going to pursue it unless it can be justified economically.

            It would be an easier change to go to clinical case managers (upgrade from nursing) rather than trying to draft doctors into the system (which is what O-care is trying to do with Internation Medical Graduates)

          • lineholder

            is that as long as hospitals continue to get DSH payments, they’re not necessarily motivated to pursue helping the patient to apply for insurance that might be available to them (such as Medicaid). You have to really stop and think it through as to why they wouldn’t do so. Some hospitals are beginning to take the initiative on this, though.

          • lineholder

            right now, the number and scope of regulatory measures coming out of DC is hitting the health care industry head on. So hospitals are faced with their share of uncertainty and inability to do cost projections in the accounting method they are accustomed to using.

            The big challenge for right now is EMRs. CMS went overboard with “meaningful use” requirements, which is putting a lot of providers in a bind. Then as soon as providers get past that hurdle, they have transition to ICD-10-CM coming up late in 2013. Much higher specificity than our current coding terminology system. All sorts of challenges on that one. Directly relates to “clear claims” and suspension or denial of billing claims.

            Yeah…there’s a lot going on right now.

          • lineholder

            *

          • quill67

            used for all transactions–small and large treatments or simply for more expensive treatments?

            Reason I ask is that if it applies to all, this is just another reason why we should move the country to a high deductible environment so we don’t get bogged down with the small stuff.

            Imagine we had to buy Big Macs like we buy health care. We would go to the counter, they would ask us for proof of insurance. We would wouldn’t bother asking them how much it cost and they probably would not be able to tell us anyway. We would fill out our forms and they would promise to bill us. Sometime over the next month, we would get a separate bill from the lettuce provider, bun provider, etc. McDonalds would then apply their service charge adjusted for whether we are in network or out and whether the costs were appropriate. We would probably find that they miscoded are big mac as the much more expensive club deluxe but figure it was not worth the time calling to complain since we didn’t have to pay bill anyway.

            Then we would wonder why our food insurance bills were going up.

          • lineholder

            ICD-9-CM is currently being used for coding. Yes, it all applies to all contexts. The diagnoses codes recorded on a patient’s medical record identify what condition or illnesses the patient is being treated for, called “chief complaint”.

            Third-party payers review the diagnoses codes to determine whether or not the service provided is (1) medically necessary and (2) covered under policy.

            If the diagnosis code provided doesn’t substantiate evidence for the services for provided, charges for services can either be suspended until the provider submits more data substantiating the claim or denied, depending on the scope of what’s allowed under policy coverage.

            In 2013, that coding system changes to greater specificity. Getting specificity out of Drs can be like pulling eye teeth…they don’t want to mess with the documentation…they just want to be a doctor and treat the patient.

            When the specificity expands, the most significant impact it is likely to have is to provide another potential obstacle that disrupts the revenue cycle.

            But it’s coming on the heels of other regulatory measures that have the potential to disrupt the revenue cycle as well. So what we’re looking at is accumulative disruptions, and health care orgs can only see so much of it before it start taking its toll.

            We’ve signed an agreement with WHO (World Health Organization) to take on Clinical Modification expansion of the coding system. But I will say this…the one area where using the expanding coding does help us is in advancement of technology.

          • lineholder

            Let me put it this way, quill67. As it currently stands, payment rates for specialists are disproportionately higher than payment rates for PCPs. That doesn’t allow many med students to come out of school with high loans and the loan payments that go along with it to go into general med.

            Without PCPs, we lose the continuity of care for patients. There is no one to act as gatekeeper in managing overall patient care without a PCP. Where this hurts us the most is with management of chronic illnesses.

            We’ve started making use of PAs and NPs for specific tasks, which takes the burden of time off the PCPs that we do have. And payment rates for PAs and NPs have been incorporated into the third-party payer system.

            But we still have a gap in continuity of care, because we don’t have enough PCPs, PAs and NPs to meet full demand of what would be required to treat patients AND to manage chronic illnesses in a substantial way.

            If we found a way to incorporate clinical case managers into the mix in a way that could be justified (i.e., it’s less costly to use a team concept including clinical case managers at the gatekeeper level than it is to pay either specialists or ER for repetitive elements of primary care pertaining to chronic illnesses), then it could be justified via third-party payers and has strong potential to reduce most costly visits being incurred for this reason.

            Providing PCP access in inner city areas is more of a challenge, I think. There are provider organizations that are beginning to try to find ways to meet this challenge. For example, via mobile treatment facilities, particularly when it comes to treatment of patients with chronic illnesses.

            But for the everyday citizen in an inner city area (or even some rural areas) that gets an ear-ache after hours (or even during hours for that matter), they may still end up going to the ER for treatment. We just don’t have access for enough PCPs incorporated in those areas.

          • lineholder

            O-care expands preventive care requirements, putting more demands on the PCPs we do have.

            It’s a mess.

          • runner12

            and/or 24 hour clinics that exist as an alternative to the ER. Many are being set up by large healthcare systems. Several are putting clinics in Wal-Marts with a visible breakdown of costs upfront.

            I think that this is beneficial, but there are still people who will go to the ER because they view it as “free” treatment. One solution could be to set up a 24 clinic inside the hospitals next to the ER. This way patients could be triaged accordingly and reduce the overcrowding in the ER. This would seperate real emergencies from those who are just seeking PCP-type treatment.

            While EMTALA had good intentions, its’ unforseen consequences have been disastrous for our health care system.

          • lineholder

            some of our local hospitals. We also have free-standing urgent care services and a few clinics. And I personally know of a physician’s practice that has expanded their operating hours to try to meet demands within the community. So there are options that exist, with new ones on the horizon, such as integrated health care orgs.

            Integrated health care organizations that include both hospitals and physicians practices are trying to make the effort to shift some of the costs outside of the more costly hospital environment. Any and/or all of these options can help to minimize some of the trends that we’ve been seeing for over-utilization of ER services for simple illnesses.

            But when it comes to continuity of care (and especially in reference to dealing with long-term chronic illnesses), our health care system is designed in such a way that it is the role of PCPs to act as gatekeepers and promote long-term continuity of care for a patient. It is the role of hospitals and free-standing urgent care centers to focus on episode of care (with little emphasis on long-term care beyond the scope of that particular episode). Specialists ride the middle of the spectrum,. They focus heavily on episode of care, but they have more emphasis on long-term continuity of care than hospitals do.

            When medical students started turning more to specialty practice than going into general medicine, the emphasis on and ability to meet the demand for long-term continuity of care fell through the cracks of the system.

            That’s when people began relying more heavily on the ER for services associated with either continuity of care or peaks in chronic illness treatment that could have been resolved at the PCP level if we had the PCPs to meet the demand.

            What’s started happening is that in an effort to try to reduce some of the costs associated with repetitive peaks in chronic illness, the government is expecting hospitals to take on greater responsibility and the accountability for a patient’s long-term continuity of care outside the scope of that episode of treatment. These policy folks in DC may mean well, perhaps, but the simple fact is that those efforts would be far more effective at the PCP level, not the hospital level.

  • carolynr

    What is it going to take for this STUPID world to wake the heck up. The TPM…what happened to you and your ideals…did you leave them at the door…for any TP reading this.

    God…THE LAST PERSON YOU WANT INTO THIS PARTY IS ROMNEY.

    Doc’s solution…Let Newt KO Romney…and then let’s see what’s left of Newt. If I had to pick…Freddie Mac and all…it would be Newt. However…where is my guy Perry…He should be in SC…Newt’s on a vacation…and Romney is suffering in SC something terrible. Time for the slot to open.

    • carolynr

      For anyone that reads my posts…here’s the plan. I will repeat it again. Romney…I bet you…dollars to donuts will allow private insurance companies to insure people…BUT IT WILL BE ADMINISTERED BY THE FEDS. Let’s hope this thing gets overturned and we can go back to across state buying and MEGA competition.

      • circlegranch

        “Romney’s Cronyism Problem is Emblematic of Contemporary Politics” by Benjamin Domenech, managing editor of “Health Care News”.
        www.dailycaller.com/2011/12/16/romneys-cronyism-problem-is-emblematic-of-contemporary-politics/

        According to this article, The Heritage Foundation uncovered some cronyism issues with Romneycare but the information has remained little known. Given the fact this article is essentially buried in the weeds at Daily Caller, it’ll probably stay that way…..until he becomes the nominee and is laid bare in the general.

  • lineholder

    I am studying for a health-related career field (health information, or management of the data obtained from medical records, if you prefer to call it that). Those studies involved evaluating various types of health care systems used internationally.

    Nation after nation that has implemented this type of health care system has run into the same type of problems. This type of system has major systemic faults.

    When gov’t is the middleman (or the primary payer), it doesn’t always focus on true costs of operating the system…it assumes “bottomless pockets” of citizens will pay for it. And it’s been seen time after time that gov’t has a tendency to follow the lead of “new, improved, advantageous benefits to health care” that “experts” put forth (LOL, it’s almost WORSE than global warming is in that respect).

    Since funding for operations within the system all come from the same “pocket”, if any effort is made to keep costs low, as costs in other areas (like administrative costs) rise, it must be balanced by increased revenues or decrease expenses in other areas, i.e. increase in premiums or decrease in provision costs, the latter of which can lead to rationing of care.

    Some of the ideas these “experts” have are good ideas. It’s the method of implementation, the fact that when gov’t is the middleman it goes for overkill, and the manner in which managed capitalism interferes with free-market principles that ultimately does more harm than good.

    For example, implementation of electronic medical records is a good idea. Anyone who has worked in a completely paper-based system will tell you this. Going with EMRs streamlines the process, providing data to multiple areas of the health care process in real-time, which facilitates speed and efficiency in providing care to a patient.

    But when gov’t adds other things into the process that don’t necessarily have to be there in order for the process to succeed…it’s like spending money on a luxury rather than a necessity, and when funds are tight, that isn’t the best way to go about it. That’s what gov’ts mandate providers do…spend money on the luxury.

    There’s so MUCH of this that people just don’t know. Layer upon layer of it. We do have other options that could be considered but aren’t, mostly because public officials associated with health care policy go with the newest trends and fads.

    Thank you for getting the word out!!! This is a good piece!

    • carolynr

      This comes down to sloth…I mean it. Can’t we get some type of innovation. Do we want a nanny state…look at the rest of them…we just sent $7.7 TRILLION of our money to bail them out in Europe.

      • lineholder

        If it comes down to Romney or Obama, I’ll back Romney, with everything I’ve got in me, because it is that important to get Obama out of there.

        But Romney had ample evidence available to him from the trends and patterns that existed in other nations showing that this type of health care system has major systemic faults, and he chose to implement it anyway rather than fighting to break new ground and develop a type of system that WORKS!

        Then he talks about if he’s elected President, he’ll “repeal the bad and keep the good” of O-care? Excuse me, but there’s no way I’m of a mind to trust his judgment on differentiating between “good” and “bad”. Not when he could have fought for something much better by far than this and didn’t do it!!

        Backing away from it won’t be easy, not at this point, because there is so much of the “nanny state” interventionist mentality and “having gov’t fix it” that has become incorporated into the system over the years.

        I genuinely and sincerely believe that if we could find a way to back away from some of that interventionist type of policy-making, we might have a chance to reduce costs AND improve quality of care and access to care at the same time.

        I just don’t believe Romney will do that.

        • circlegranch

          then we should all do some research into that and get the word out. One thing in Newt’s favor I have to say; if he loses this, I have a feeling he’s going to delve into the machine effort behind Romney and write one heck of a book to expose it.

          • lineholder

            This is a horrible, HORRIBLE piece of legislation, and we need to fight tooth and nail to get rid of it now.

            It’s just like JSobieski said in another thread…once it becomes entrenched in a society (and part of the policy “status quo”), it’s next to impossible to get rid of it. Other countries have actually tried, but you can’t just wave a magic wand and undo the damage that has been done. It just doesn’t work that way. All they’ve got available to them is the option to nibble around the edges and that’s it.

            I want more for our nation than that. Period.

      • http://redmerrimack.blogspot.com/ charliebravoNH

        people have been using the argument that to beat Romney you link Obamacare to Romneycare. The truth is you don’t have to.Call Romneycare what it truly is, SOCIALIZED MEDICINE.

        http://www.redstate.com/charliebravonh/2011/01/05/michael-merlina-mitt-romneys-joe-the-plumber/

        • lineholder

          That’s exactly what we should be saying. LOL, even if me, I’ve alluded to it when I’ve used the phrase “type of health care system”, but I’ve not out-and-out said “socialized health care system”. I’ll pay more attention to that in the future.

          It’s truly amazing. I don’t know how many people in our country are aware of what’s gone on in other nations where socialized health care systems are concerned. But many of them went strongly for single-payer systems, realized that it wasn’t sustainable economically or that it had dire unintended consequences, then they backed away from it and fought tooth and nail to maintain elements of private insurance incorporated into the system in one way or another. Australia is actually paying incentives to their citizens to purchase private health insurance! Ironic, isn’t it?

          It’s the system itself that just doesn’t work. Too many flaws. Too many expectations. Far too many governmental fingers in the “pie”. And once they make a commitment to it, it’s next to impossible to back out of it.

  • romansdaughter

    He wants to revise Obamacare and yes, Charlie it’s a socialized health care system plain and simple. So in otherwords Willard wouldn’t repeal it but like everything else just tinker around the edges…is that what he was saying with Greta? Rick Perry, please come to our rescue…we don’t want Willard.

    • http://redmerrimack.blogspot.com/ charliebravoNH

      group of victims in MA who have to pay fines because they don’t have health insurance. Many are young or self employed and are leaving the state. With Obamacare, which is much worse there is nowhere to go.

  • romansdaughter

    nt.

  • Carol Tarasewicz

    Willard Mitt Romney is responsible for the huge health insurance premiums we’ve had in MA since he signed that law. It’s a fact. I will only vote for him if he is the nominee, but I hope he is not.
    What is wrong with these people endorsing him? Do they owe him something?
    The Des Moines Regiser endorsement was a huge disappointment to me.

  • runner12

    Thank you for pointing out that it is nothing more than socialized medicine.

  • quill67

    Otherwise he would say how bad his Health Bill has turned out and be MAD AS **LL

  • westcoastpatriette

    a liberal progressive in Republican clothing.

  • Mike Ferguson

    (nt)

  • lineholder

    If I remember correctly, you’re a nurse. True? Have you gotten into “meaningful use” of EMRs yet where you work?