Chapter 11, Part II: Managed Rationing
“–Managed care plans have prospered chiefly as a result of policies pursued by the federal government for more than 60 years.? The main distortion is the tax preference to employer-provided health insurance.? Under current tax law, only one kind of health spending is tax- exempt money spent to pay health insurance premiums, and only those premiums provided by an employer.? Given the high rate of taxes, that provides a powerful incentive to have as much health care delivered through employer-provided health insurance, and as little paid out of pocket, as possible.? With government, insurance companies, and businesses picking up most of the direct costs of health care, it stands to reason that they will want to make most of the decisions about care.†? [1]
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hose who feel a sense of relief that Congress did not pass
As I read the Preliminary Plan Summary of
1. preventive care =? pregnancy? ? ? prevention? = contraceptives, also for minors? without parental consent.
2. family planning? =? abortion, contraception? and population control? to meet “health†goals found in Healthy People 2000.
3. pregnancy-related care = abortion.
4. preventive screening = pregnancy screening? provided through school health screenings and Medicaid’s EPSDT.? In an effort to improve health services, “Federal block grants? that support community health centers, family planning? clinics–and maternal and child health programs will continue.? New initiatives include funding for school-based clinics.†? [3]
In addition are a host of other services that are to be covered, which appears similar to the list of services covered by Medicaid.
The question is:? WHO DECIDES what is medically necessary or appropriate?? The October 19, 1993, issue of the National Right To Life News gives us a glimpse in its article titled “Quality Of Life Basis For Treatment Denial, First Lady Tells Congress.â€? The article states: “Under the Clinton? Healthcare Rationing? Plan people ‘will know that they are not being denied treatment for any reason other than it is not appropriate–will not enhance or save the quality of life,’ Hillary Rodham Clinton? told the Senate Finance Committee September 30†(emphasis added).
“As an example, she suggested that heart surgery would be denied certain older people.? TIME’s October 4, [1993] issue said the
“Among those to whom the Clinton? Healthcare Rationing? Plan would deny treatment are children born with disabilities.? In an October, 1, article in the St. Paul (Minnesota) Pioneer Press, the Newhouse News Service reported that Clinton Administration officials acknowledge the plan would deny therapy to children with ‘cerebral palsy, cystic fibrosis and other congenital and chronic disabilities’ because such treatment is considered too costly.
“Physical, occupational, and speech therapy would be cut off after 60 days, although many such children require it for years.? At the same time, the
We read in the paper that area hospitals are consolidating, merging and forming alliances.? Doctors tell us that hospitals are buying out their practices, and that treatment is expected to conform to physician practice guidelines, in a kind of “canned†approach.? Gone is the patient/doctor relationship that once existed.? As one hospital employee put it, “the doctors say they feel like indentured servants.â€
Practice guidelines which tell a doctor what the “standard†practice is expected to be, may undermine the doctor’s best interest for his patient.? If he consistently varies from practice guidelines, he may be the subject of suspicion, even though he is doing what is in the best interest of his patient.? Such guidelines may hinder the doctor’s ability to practice medicine as he sees fit.? As medical associations become more and more tolerant of euthanasia, so will practice guidelines.? How will this effect doctors who believe that their first responsibility as physicians is to first do no harm?
“The National Health Board? consists of seven members appointed by the President with the advice and consent? of the Senate.? The National Health Board assumes certain responsibilities for administering the new health care system, while existing federal agencies assume others.? The Board:
- Sets national standards for state plans and ensures access to health care for all Americans.
- Interprets and updates the comprehensive benefits and recommends to the President and Congress changes in the health care system.
- Establishes a new performance-based quality management program and develops valid measures of health outcomes? to be used in annual performance reports for health plans.
- Develops and implements standards for a national health information system, using a public-private network to support quality improvement and collects enrollment data? and comparative information about cost.
- Implements the safety net of the national health budget.
“STATE RESPONSIBILITIES
“States ensure that all eligible individuals enroll in a regional or corporate alliance and have access to a health plan that delivers the guaranteed comprehensive benefit.? Each state must implement plans approved by the National Health Board? by January 1, 1997.
“States may begin to implement the new system as early as January 1, 1995.? Implementation involves adopting federal standards? and establish health alliances.?
“Within the broad federal guidelines, states exercise flexibility in the design and governance? of regional health alliances.? States have the option to implement a single-payer system.
“States certify health plans–Only certified plans may offer health coverage through alliances.†? [5]
We not only have Outcomes-Based Education (OBE) but Outcomes-Based Healthcare.? The question to ask is: what are the outcomes, and who decides?!
The answer is:? “quality of life,†“appropriate†health care, and population control? as defined by the government.?
A hospital ethics committee is one vehicle used to decide if care is “appropriate†for those patients who are considered “high needs.�
What are the chances of an ethics committee making decisions that will not be in conformity with practice guidelines? and federal mandates? if it means the hospital will lose federal money or its membership in the alliance?
“The principal manner by which the Clinton? plan would lead to the rationing? of lifesaving medical treatment to those with a “poor quality of life†is this:? By capping health insurance premiums at a rate of growth far below that of health care cost inflation, the Clinton Rationing? Plan would make less and less money (in “real†or health inflation-adjusted dollars) available to pay for health care each year.? That would force insurance and health care providers to gradually cut back on the care provided, which would require them to ration treatment.? Given the climate of opinion among bioethicists and medical providers today, this selective denial of treatment would largely be based on quality of life? judgments — an approach the First Lady clearly favors.†? [6]
This brings to mind a newspaper article titled “
“The traditional health insurance industry will ‘disappear.’�
‘Insurance companies now spend a lot of time and money looking for only healthy people to insure’ Magaziner? said, promising that the administration will get rid of the practice.? ‘The current insurance industry as risk-assessors and underwriters will disappear’–Instead, he said, the insurance industry might become ‘care managers’ if they can persuade consumers to buy their services–In general, as Magaziner? painted it, the administration plans a health-care system with a core of guaranteed benefits set by the federal government and supervised by the states.? Patients would belong to ‘health alliances’ that would pay for the care from money that comes from government, employers and workers.? As Magaziner? outlined it, some elements of the health-care plan include:
- Medicare
- Medicaid, the tax-supported insurance program for the poor would merge into the main health-care system
- Some long-term care for the elderly and disabled would be included–But the administration plans a separate health system for more general long term care needs, chiefly because of its costs.
‘You’d get killed on the cost’ of including it in the core benefits package, Magaziner? said.†? [7]
I’ll BET the administration plans a separate health system for long-term care!? Could it be called RATIONING????
The Missouri Department of Social Services, Division of Medical Services, as well as state population controllers such as Health Policy Institute, are promoting a managed care? program called MC+ or Managed Care Plus.? The program is being marketed to? Medicaid? clients. ? [8]
A call to the MC+ hotline at 1-800-348-6627 revealed that the seven managed care? providers who have agreed to provide most of the services covered under the Missouri Medicaid program include (or did include at one time): GenCare, Humana, Health Care USA, Care Partners, Mercy? MC+,? Community Care Plus? and Prudential.
Medicaid is merging into the general health care system, and is to become the universal health-care coverage, just like Ira Magaziner? and Dr. Joycelyn Elders? said.
“Under managed care, the insurance company not only finances the care, but picks the doctors and decides to a large degree what treatments are acceptable.? Even traditional insurance companies, moreover, are beginning to exercise more control over what treatments get delivered, through a process called ‘utilization review’.†? [9]
“Performance measures for doctors in HMOs depend heavily on how much they cost the plan rather than by any measure of patient satisfaction.? According to the Group Health Association of America, which represents HMOs, 49% of HMOs use cost experience to adjust doctor payments, while only 20% use customer satisfaction.? In addition, managed care? plans employ utilization review boards, which can second-guess treatments.? If the board decides the prescribed treatment isn’t necessary, the plan can refuse to reimburse the costs.†? [10]
Words like utilization review and practice guidelines? are vehicles through which HMO’s managed care? programs employ rationing.
Some say we already have rationing, since those who cannot afford lots of health care are denied care.? However, such persons are helped by organized charities, hospitals and doctors who write off millions of dollars in health care they donate to those who cannot pay, and good people who donate to special funds? set up for those in need.? Yes, there are those who STILL fall through the cracks, but those cracks are not intentional.? How much WORSE for the government to intentionally ration care to those in need through government standards, practice guidelines? and socialized health care designed to provide only APPROPRIATE care as defined by the federal government!
“According to the Congressional Budget Office? (CBO), Medicare and Medicaid payments to hospitals are 70.3% and 62.5% of private patient payments respectively.? While the uninsured pay less - on average 30% of the care they receive according to the CBO - their impact on health spending is dwarfed by the volume of Medicare and Medicaid.
“These government programs account for fully 75% of uncompensated health care in the
Dr. Lois Copeland? is an internist and primary care physician in
“First, physicians will be forced by the price controls in the alliance system to ration health care.? Since the
“Second, the independent judgment of physicians will be constantly challenged by bureaucrats who are not health care professionals.? Second opinions will come not from other physicians, but from government bureaucrats whose chief concern will be meeting budget targets.? Necessary treatment may be denied to a patient if the local alliance has already spent its budget.? The bureaucratic nightmare of paperwork, hassles, threats, and intimidation so common today with Medicare and Medicaid will increase exponentially.
“Third, we primary care physicians will not have the back up we need from specialists.? Since the number of physicians allowed to specialize will be drastically curtailed under the
“Finally, the
“The
HMOs pay their PCPs (Primary Care Physicians, which may include General Practice, Family Practice, Internal Medicine, and Pediatrics) a fixed monthly amount for each of its HMO members that have selected him/her.? This is called a Monthly Primary Care Capitation.? For this fee, the HMO member receives various services.?
HMOs also have a “referral? fund, [which is] a separate budgeted amount established for hospital and specialist referrals based on the age and sex of the individual members.? Hospital services must be authorized by the PCP–Professional services are paid from the Referral Fund directly to the specialists who provide care.?
“Services that are referred to a specialist are paid by a Referral Fund.? This is separate from the monthly primary care capitation.
“All referral fund surpluses will be shared equally between–[the] HMO and the PCP’s.? An individual PCP’s referral fund must be in a surplus position to share in the community referral fund surplus.†? [13]
“American Medical News reports that a primary care physician who cuts hospital stays by 25% for the 1,000 patients he manages could generate an annual savings of $312,500 for the health plan, which will share some of this windfall with the physician.†? [14]
This gives physicians associated with HMOs a financial incentive NOT to refer patients to specialists such as surgeons for needed care !!!?
Newsweek’s October 23, 1995, issue carried an article in its Focus On Your Money section titled “Beware Your HMO.†The article stated, “Some can be counted on in a pinch, but many delay or deny crucial care if you require expensive tests or procedures.? Here’s how to protect yourself.â€? The article tells the stories of people who didn’t receive the care they needed.? One man lost the use of his legs because needed surgery was delayed.? Another man “claims his wife died because doctors did not refer her to a specialist.â€? A woman “died after her HMO refused to authorize a bone-marrow transplant, despite the fact that its contract? covered such treatment.? Her family later collected $89 million in damages.â€
This Newsweek? article offers the following suggestions on how “to get the best care possible out of your HMOâ€:
1. “If possible, don’t sign an HMO contract? requiring you to arbitrate a dispute.
2. “Find out how your HMO compensates your doctor.? Ask it to provide you with an unaltered provider contract.
3. “Get copies of claims filed on your behalf.
4. “If (your doctor) won’t order a test or refer you to a specialist who can get to the root of your symptoms, let him know that you know how he’s compensated.
5. “Go outside the network for a second opinion.
6. “File an immediate appeal.
7. “Consider paying for the test yourself.
8. “File a formal complaint with your state’s department of corporations or department of insurance.
9. “Hire a lawyer who specializes in ‘bad faith’ claims or insurance matters.
10. “If your employer offers an old-fashioned fee-for-service indemnity plan, consider switching.â€
Socialized medicine is here.? Missouri is implementing Clinton’s? Health Care Rationing? Plan through: HMOs; PPOs; parish nurses; school/community-linked services; public/private partnerships; and school-based clinics? funded with Medicaid money through a Medicaid Interagency Agreement? between schools and the state Division of Medical Services.?
The International Anti-Euthanasia Task Force’s January/ February 1992 issue of the IAETF Update, wrote of an exhibit at the National Museum of Health and Medicine in Washington, D.C. titled “The Value of The Human Being: Medicine in Germany? 1918-1945.� The exhibit illustrated how groundwork for the Nazi atrocities was paved with good intentions.? The
A doctor and his wife, who is a nurse, are quoted as sharing the following:
“Several years ago on a lecture tour in Europe, we were privileged to hear the world-famed Geneticist, Professor Jerome Lejeune, of the
“Many years ago my father was a Jewish physician in
? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? B. & J.W.â€[15]
The lessons we fail to learn from history have a tendency to repeat themselves.
[1] “The Trouble With `Managed Care’ Making Money By Denying Health Care,†Consumers’ Research, Sept. 1994, p. 15.
[2] “Health Security Preliminary Plan Summary,†Benefits, I, p. 9.
[4] National Right To Life News, Vol. 20, No. 16; Oct. 19, 1993; pp. 1, 15.
[5] “Health Security Preliminary Plan Summary,” pp. 5, 11, 15, 19, 20.
[6] “Quality Of Life’ Basis For Treatment Denial, First Lady Tells Congress,†National Right To Life News, Vol. 20, No. 16; Oct. 19, 1993; pp. 1, 15.
[7] “
[8] “Just for You!
[9] John W. Merline “The Trouble With `Managed Care’ Making Money By Denying Health Care,†Consumers’ Research, Sept. 1994, p.10.
[10] “How Do Plans Manage Care?,†Consumers’ Research, Sept. 1994, p.11.
[11] “Calling All Consumers; The Big Cost Shifters,†Consumers’ Research, Sept. 1994 p.? ? ? ? ? 43.
[12] “A Doctor’s Perspective-the Clinton Health Plan: A Prescription for Big Government,†Special Report; The Heritage Foundation; 214 Massachusetts Ave. N.E.; Washington, D.C. 20002-4999; (202) 546-4400; p. 3.
[13] “HealthLink HMO Program Description,†“Primary Care Physician Agreement,†Addendum to “Primary Care Physician Agreement,†“Lab Selection Form.â€
[14] “Questionable Cost Savings; The Trouble With ‘Managed Care’ Making Money By Denying Health Care,†Consumers’ Research, Sept. 1994, p.13.
[15] “A Genetic Choice?†Right To Life Of Greater Cincinnati, Inc. Newsletter, Jan. 1996.