Bill Kessler’s Article “The EntitltedGeneration” in the NY Times poses thought provoking issues regarding
“entitlements.” The root of opposition
to cuts in Social Security, Medicare and Medicaid entitlements is growth of the
proportion of the population that qualifies and needs such services, combined
with the overall gross inequities in other entitlements in our economy. Republicans have opposed these programs since
Roosevelt and Johnson first introduced them. They voted against them in 1965 when the Social Security Act went into law. They have said no such “entitlements” should exist, while defending
their own entitlements (which is legally the correct term) in the form of
extensive tax deductions, credits, deferrals and avoidance through tax
shelters. Despite the shortcomings of Kessler's article, he is correct that there are problems with the growth of these
programs that must be addressed.
A first major problem is that
wealthy people generally do not need Social Security benefits, Medicare or
Medicaid. That has to stop. Where there
are specific exceptions, such as people with life time severe disabling
conditions, there can be exceptions but those are the exceptions not the rule.
Policy wonks like to talk in very big
picture, broad stroke terms, like percent of GDP and statistical ratios, but as
the 19th century German poet Heinrich Heine, aptly noted, that, “You
cannot feed the hungry on statistics.”
The reality is that most of the solutions are not in denying sick or disabled people essential services, it is in eliminating overbilling, duplication and waste
within the services delivered and eliminating services with no measurable benefit. Policy
wonks have a penchant for denying people services, while people in the trenches
like me, prefer finding out what is working well and what isn’t and fixing them. Let's have a go at that.
Many of the problems stem from piling-on and conflict
of interest by health care providers, and proliferation of ineffective
“treatments” which are billed routinely to Medicare and Medicaid.
There is a very long list of so-called "treatments" that are routinely paid for by Medicare and other private health insurances that have no objectively demonstrated
benefit whatsoever. None, nada. If a person decides
they wish to have such treatments, right now Medicare nearly always pays for them whether they do any
good or not. If people want magic, they should pay for it themselves.
Secondly, the medical
billing system is inherently corrupt. It designed by physicians to benefit physicians and hospitals. Doctors have sliced and diced every
conceivable medical service into ever smaller pieces, so each slice can be
billed separately so the sum is far more than the original total item billed. What used to be a
single service is now five or six services, each with a price tag. There are currently around 9,000 medical billing codes, which could easily reduced by half. Secondly, there is an enormous conflict of
interest between physicians making referrals and laboratories or specialized
testing and treatment centers in which they are part owners. There is far too much incentive to refer their patients for testing or treatments at facilities that benefit them. This has to stop.
Here are a few suggestions.
1.
Anyone not paying taxes because of use of tax shelters
should be exempt from receiving Social Security, Medicare and Medicaid. Zero, none, no exceptions. If you have money in Grand Cayman or Switzerland don't ask the American people for a hand out. If you're not willing to pay into the system, you're on you're own.
2.
People with annual retirement income through the date of their estimated deaths of greater than $500,000
per couple should be precluded from collecting Social Security benefits. They don't need them.
3.
People with annual retirement income greater than $500,000
per couple should be required to pay significant graduated Medicare co-pays
proportional to their annual retirement income. The more your retirement income, the more your co-pay for each service.
4.
Age for Social Security benefits should be gradually
raised to 70 years over a 10-year period with the exception of people with
significant medically diagnosed disabilities or disorders. Roosevelt and
Johnson did not anticipate people living relatively healthy lives as long as
they do today.
5.
Medical health insurance billing is completely out of control. The notion that for profit private insurance companies can be more efficient and save money is a complete sham. Medical health insurance billing should be managed by
a private non-profit agency not connected with any insurance company contracted
through the US Department of Health and Human Services. There is an inherent conflict of interest in
allowing insurance companies to control access to medical services. Such an independent non-profit organization
should be subject to monitoring and review by an oversight group consisting of health care, governmental,
insurance industry and private health advocacy groups. Please don't bother me with your whining about government inefficiency. The administrative cost of the IRS is 4 tenths of one percent and 93% accuracy, and of Social Security administrative cost is from 0.6% to 2.3% depending on the program. Show me a private company with such low administrative cost.
6.
The American Medical Association Current Procedure Terminology (CPT) medical insurance billing code
system used to determine what medical services will be paid for by insurance of
Medicare, is inherently steeped in conflict of interest. It should be totally revamped and managed by
an independent non-profit organization with representatives of medical and
allied health specialities, federal health agencies and non-profit health
advocacy groups. Physicians and other
health professionals directly benefitting from such billing codes should not have final
say in approving or disapproving of billing codes. The current CPT system is designed to benefit
medical sub-specialities promoting the proliferation of billable procedures and
precluding inclusion of other effective procedures that may not benefit their
professions.
7.
Physician practice groups should be prohibited from
owning a controlling a share in medical services such as pathology
laboratories, radiology facilities, pharmacies, specialty health stores (e.g.
rehabilitation equipment, sleep stores), or other testing facilities to which
physicians may refer patients, to avoid conflict of interest.
8.
Reimbursement for interventions for which there is inadequate
objective evidence of their effectiveness for any condition or illness, should
be prohibited. See Special Committee on Questionable and Deceptive Health Care
Practices; Federation of State Medical Boards of the United States, Inc. http://www.fsmb.org/pdf/1997_grpol_Deceptive_Health_Care_Practices.pdf and QuackWatch , scroll to Questionable Products, Services, and Theories.
9.
Allocation of Medicaid Waiver funds by state or county
agencies for services to appropriately qualified individuals, but for which objective
evidence of benefit can NOT be shown, should be prohibited. These funds are used by people with chronic disabilities to supplement typical medical services, but are grossly misused by some. Your hair would stand on end of you saw some of the stuff people buy with Waiver money. Currently Social Workers employed by county
agencies decide whether requested services are eligible for Waiver reimbursement, and
generally have no idea whether they have any benefit. Decisions are idiosyncratic and often irrational.
10.
Physicians and other licensed health providers should
be prohibited from owning a significant share of any medical or rehabilitative residential treatment
facility (e.g. Alzherimer’s, substance abuse, psychiatric) to which those
physicians or their practice partners refer patients for care and treatment, to avoid
conflict of interest.
11. Use of costly medical equipment
such as MRI scanners, proton beam cancer treatment devices, etc. should be coordinated regionally by groups of referring
physicians and hospitals, rather than a competitive fee-for-service model which encourages each hospital and clinic to develop it's own facilities. Once a hammer has been created, far too many patients become nails. The current system promotes
over-utilization. Physicians making such
referrals should not be permitted to own shares in the devices to which they refer patients for
testing or treatment.
12.
The most costly medical procedures should be carefully
evaluated by independent groups of medical specialists and treatment research evaluators to determine the relative
benefits, risks and costs, as well as possible less expensive
alternatives. These procedures have frequent costly complications and pose quality of life questions, especially among older patients. In some cases they may be
deemed essential and life sustaining and others a matter of choice. Among the most costly services are heart,
liver, lung, pancreas and kidney transplants.
These surgical procedures are done in critically ill patients. The quality of life and survivability in
patients nearing the end of life who undergo such procedures are not
inconsequential issues.
Any discussion of entitlements will go nowhere until there is equity in what is defined as an entitlement.
