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Contents Bulletin Scripting in shell and Perl Network troubleshooting History Humor

Slightly skeptical view on programmers and system administrators health issues

News Skeptisim and PseudoScience Recommended books Recommended Links Medical Industrial Complex The Audacity of Greed Overuse of Cardiac Stents Linked to Patient Deaths
Health insurance Ambulances overcharges Medical Overbilling Notes on Diabetis Type II Flat feet  Quality of Life Controlling your Weight
Coronary Artery Disease Hypertension Paroxysmal supraventricular tachycardia (PSVT) Ultrasonic humidifiers Fighting nasal congestion Basics of Preventing RSI for programmers and sysadmins Vision
Haggling with doctors and health insurers Six ways to say No and mean it

First, do no harm

Personal health insurance plans  Overload Dumbing down america Coping with the toxic stress in IT environment
Hospital overcharges Medicare Insurance fraud Short Introduction to Lysenkoism Conformism pressures in large organizations BPH  Techno-fundamentalism
Cargo Cult Science Scientific Fraud Pseudoscience and Scientific Press Toxic managers Quotes Humor Etc

Programmers and system administrators are mass profession. There were approximately 435K programmers in the USA in 2006. I think number of system administrators are roughly the same so we can speak about the labor army of one million people.

Contrary to superficial impression of individual cubicles and nice environment, IT is actually very unhealthy profession. With a high chance to be unemployed after 50.  More often then not, there are periods of considerable stress. Some are caused by catastrophic failures of hardware equipment, some by unrealistic schedules and workloads, some by own errors of particular programmer or sysadmin.

Overtime is common. Job security is deteriorating as outsourcing is rampant.  Employment after 50 is not guaranteed. Environment changes way too fast, and not always for good. Fashion rules (remember The Devil Wears Prada). Toxic managers are common (remember Office Space ;-)

So sooner of later a programmer need to face "medical-industrial complex" of the USA. And this is a dangerous "for profit" beast with tremendous appetite which maims and kills annually considerable amount of people. Living under Neoliberalism with its "greed is good" mentality and "homo homini lupus est" slogan is indeed dangerous  and requires knowledge of elementary "self-defense". Hippocratic oath no longer applies to medical profession in the USA. Most doctors still follow it, but there real sharks among them (with some ending their careers in jail like regular criminals) and you need to hope for the best but  prepare for the worst.  Especially rampant abuse is with cardiac stents (Overuse of Cardiac Stents Linked to Patient Deaths) with around a dozen of cardiologists serving jail terms (see for example Stent doctor Salisbury stent doctor sentenced to federal prison )

As USA Today reported (Doctors perform thousands of unnecessary surgeries):

Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures, according to a USA TODAY analysis of the U.S. government's National Practitioner Data Bank public use file, which tracks the suits. About half the doctors' payments involved allegations of serious permanent injury or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands, of victims.

Journal of the American Medical Association reviewed records for 112,000 patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support installing the devices.

"Don't just take a doctor's word," says Patty Skolnik, who founded Citizens for Patient Safety after her son, Michael, died at 22 from complications in what she says was unnecessary brain surgery. "Research your doctor, research the procedure, ask questions, including the most important one: 'What will happen if I don't get this done?'"

A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. A 1997 study in the Journal of the American College of Surgeons looked at 5,601 patients recommended for surgery and found that second opinions found no need for the operation in 9% of the cases. Among those who got the countervailing second opinion, 62% opted not to have the operation.

But many patients simply aren't inclined to question their doctors.

"We expect the physician to know what's best for a patient," says William Root, chief compliance officer at Louisiana's Department of Health and Hospitals. "

We put so much faith and confidence in our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can do a lot of damage."

Chronic stress, overload, long hours, unhealthy diet  and other environmental factors  deeply and negatively affects the lifestyle of programmers and system administrators.  So there is nothing surprising that despite pretty comfortable work conditions many programmers/system administrators suffer from assortments on various diseases. Like other workers who spend long periods in front of a computer terminal typing at a keyboard, programmers are susceptible to:

Additional health problems are typical for those who experience constant stress and/or are typical "diseases of civilization". Among them

Also many programmers/sysadmins works as contractors and either do not have health insurance or have very basic health insurance. This is typical for young programmers and those who are over 50 and were let go on their previous jobs die to outsourcing

Low and middle income US citizens  spends far more on health care than any other country but gets only mediocre care in return for its investment. The U.S. national average score on 37 separate measures of health care falls far short when compared either to a few centers of excellence within the country, or to other countries, the report from the Commonwealth Fund found. And that's true not only in terms of mortality statistics but also in terms of quality of life.

The main problems with US healthcare are:

Programmers and system administrators can do much better is maintaining their health. And they are naturally equipped for dealing with complex system and thus able to navigate the maze of the USA "medical industrial complex"

A lot of outcomes depends on the level of individual knowledge. Knowledge is power both for avoiding unnecessary procedures (with some causing irreversible damage) , unnecessary overprescribed drugs, and when negotiating with health care providers.

Some facts:


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Old News ;-)

[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Feb 01, 2017] The dangers of repeal of obamacare

Feb 01, 2017 | economistsview.typepad.com
EMichael : January 31, 2017 at 05:34 AM
Meanwhile, have you noticed this from Drum?

"I've written before about the possibility that repealing bits and parts of Obamacare-which is all Republicans can do-will destroy the individual insurance market. Not just the Obamacare exchanges, but the entire market. Insurers would still be required to insure everyone who applies for coverage, but there would be no subsidies and no mandate. The result would be a flood of super-expensive patients like me, and virtually no healthy people to balance out the pool. If that happens, insurers will simply exit the individual market rather than take huge losses

Here's the only reaction I could find from the insurance industry:

"At a time when the individual market faces challenges, we need as many people as possible to participate - so that costs go down for everyone," said Kristine Grow, spokeswoman for America's Health Insurance Plans.

This wasn't even a reaction to Obamacare repeal, either. It was a reaction to the Trump administration's childish attempt at sabotaging signups for 2017. Basically, the insurance industry has been curiously quiet about the whole thing.

Why? They know the stakes better than anyone. Recent premium hikes hold out the promise that after years of losses, their Obamacare business will finally turn profitable this year or next. But a ham-handed repeal effort does just the opposite. The individual market would become massively unprofitable, and insurers would have to decide whether to ride it out for a year or two, or simply abandon the individual market altogether. These are really lousy alternatives."

http://www.motherjones.com/kevin-drum/2017/01/insurance-industry-curiously-quiet-about-obamacare-repeal

I think I know the reason for the insurance company's silence. They want to go back to the old way. Sure, if the ACA stays in place as it is, they are OK and will profit once they find the proper premium levels. But with what the Reps have already done to the ACA they doubt the program can move forward, especially now.

But even if the Reps just let it stand(which they won't), the insurance companies have figure out that they would be far better off with the old private markets of high deductibles, pre existing condition bans, recissions and cancelling of policies once the holder gets sick.

Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies.

So they stay silent(in public anyway) cause no matter what happens they make out, and this way it seems like they are just following orders and working to "help" the public.

Peter K. -> EMichael... , January 31, 2017 at 05:44 AM
Don't people argue that if we go back to the old way, that the entire system will collapse and we'll get single payer eventually after many painful years?

Trump and that clown Stephen Moore keep talking about competition across state lines but I don't see that happening.

DeDude -> EMichael... , January 31, 2017 at 06:38 AM
ObamaCare required a lot of things, including that they didn't use more than 20% of the premiums on profits. They couldn't just be a scam collecting premiums and kicking people off their plans if/when they got sick. In the old model it was a lot easier to make fat profits out of the asymmetrical knowledge between them and the marks.
EMichael -> DeDude... , January 31, 2017 at 06:54 AM
If the insurance companies thought that medical loss ratios would make it into the bill, they would never have allowed Lieberman to break the filibuster.

Meanwhile, over at Angry Bear, Run has a great post.

http://angrybearblog.com/2017/01/38918.html

I am not sure whether the House is the only one that can change their rules to avoid a CBO analysis. Trying to find out.

DeDude -> EMichael... , January 31, 2017 at 07:22 AM
Yes banning the CBO from scoring repeal and revealing that it is a big budget buster - was a classic GOP trick (keep the people uninformed before you screw them). I agree that it is a little surprising that democrats have not yet gotten the big guns our and pointed out how MediCare will go bankrupt when ACA is repealed. There must be some tactical calculation there. They probably want that perfect storm of scared seniors to call their Senators at a specific time when it will be most likely to tip over the wagon.
DeDude -> DeDude... , January 31, 2017 at 07:26 AM
The GOP repeal of ACA will bankrupt MediCare and Paul Ryan doesn't want you to know about it !!!!!!!!!!!!!!!

Write your Senators and write your representative demanding that they reveal all the details of their nefarious plans.

pgl -> DeDude... , January 31, 2017 at 08:30 AM
"more than 20% of the premiums on profits"

Gross or operating? Operating profit margins are only 8% (4 times greater than a competitive return). Gross margins include the bloated operating expenses. Think X-inefficiency.

pgl -> EMichael... , January 31, 2017 at 08:29 AM
"Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies."

One minus the medical loss ratio is the gross profit margin for these oligopolists. This margin should be less than 10% for reasons I have noted before. But wait - they now exceed 20%. What one gets when one allows unfettered monopoly power.

EMichael -> pgl... , January 31, 2017 at 08:45 AM
No, they do not exceed 20%. That is the max in the private market, 15% in the employer market.
DeDude -> EMichael... , January 31, 2017 at 09:13 AM
I should have been a little more precise. "The 80/20 rule requires insurance companies to rebate any excess premium charged if they spend less than 80% of premiums on medical care and efforts to improve the quality of care"

https://www.cms.gov/CCIIO/Resources/Files/Downloads/mlr-report-02-15-2013.pdf

So it includes everything including administration.

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 21, 2017] Assessing Obama healthcare track record

Jan 21, 2017 | www.jacobinmag.com
Over his two terms, Barack Obama signed a number of major health-care bills into law, most significantly the Affordable Care Act of 2010 (ACA), though also more recently the 21st Century Cures Act of 2016. Though the GOP's coming assault on health care is likely to be heartless - and though resistance to it must be resolute - we would be better served by a sober assessment of Obama's health-care legacy than by triumphalist acclaim of such laws.

The ACA, passed without any Republican votes, has had a significant impact on health-care access: mainly through the expansion of Medicaid together with the subsidization of private health insurance, it achieved a partial reduction in the number of the uninsured, from 48.6 million in 2010 to 28.4 million in early 2016 (still an enormous number!), according to National Health Interview Survey estimates . Other provisions of the law, like those eliminating co-payments for some preventive care or banning preexisting condition discrimination, benefited many more.

Yet those who trumpet such gains while scratching their heads at the law's relative unpopularity are missing the crux of the problem: despite President Obama's reforms, the health-care system continues to fail much of the nation.

One example: in Canada, physicians and hospitals are free when you use them. In the United States, co-payments and deductibles for such care (which average $7,474 for a family marketplace silver plan) often rations medical care by economic status. Studies have shown that those with inadequate insurance avoid going to the ER even when they need it, delay care when in the throes of a heart attack , and face financial strain and sometimes bankruptcy when sickness strikes. Such injustices preceded the ACA, but because the law failed to fix them, it is blamed - fairly or unfairly - for their persistence.

More recently, Obama signed the 21st Century Cures Act into law, which among other things incrementally reduced the rigor of the Food and Drug Administration's drug approval process. These provisions were tantamount to a generous handout to the pharmaceutical industry, which had lobbied heavily for the bill. Not surprisingly, it also did precisely nothing about sky-high drug costs .

This is a decidedly mixed legacy. The gains of the ACA are evident: indeed, for some of those who gained coverage, it was lifesaving. Its shortcomings, however, are equally evident: some twenty-eight million uninsured, persistently high cost-sharing, inequalities in access, uncontrolled drug prices, and so forth.

Of course, Republican designs, whether repeal and/or modification, will only make things worse. When that happens, we should dub the resultant fiasco GOP-Care, and blast it for all its injustices. However, it should also be clear that "Let's go back to 2016" will not be a winning campaign slogan for Democrats in coming elections: people want - and deserve - real change.

To defeat GOP-Care, we will need a more powerful weapon than Obamacare. For this reason, the time to push for universal single-payer health care is right now

-Adam Gaffney

[Jan 18, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 18, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 16, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 16, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 15, 2017] Michael Moores movie Sicko. In it he talks to people in Canada, Britain, France about their experiences with their health care systems

Notable quotes:
"... "According to Sicko, almost fifty million Americans are uninsured while the remainder, who are covered, are often victims of insurance company fraud and red tape. Furthermore, Sicko points out that the U.S. health care system is ranked 37 out of 191 by the World Health Organization with certain health measures, such as infant mortality and life expectancy, equal to countries with much less economic wealth. Interviews are conducted with people who thought they had adequate coverage but were denied care. Former employees of insurance companies describe cost-cutting initiatives that give bonuses to insurance company physicians and others to find reasons for the company to avoid meeting the cost of medically necessary treatments for policy holders, and thus increase company profitability." ..."
Jan 15, 2017 | economistsview.typepad.com

RGC said...

I just watched Michael Moore's movie "Sicko. In it he talks to people in Canada, Britain, France about their experiences with their health care systems.

It is a bunch of little anecdotes, but if you watch it, be prepared to be ticked-off at the US system.

The most compelling point for me was when one of the Americans living in France mentioned that the big difference she noticed was that the French government is afraid of the people, while in the US the people are afraid of the government.

https://freedocumentaries.org/documentary/sicko Reply Saturday, January 14, 2017 at 11:14 AM

pgl -> RGC...

"According to Sicko, almost fifty million Americans are uninsured while the remainder, who are covered, are often victims of insurance company fraud and red tape. Furthermore, Sicko points out that the U.S. health care system is ranked 37 out of 191 by the World Health Organization with certain health measures, such as infant mortality and life expectancy, equal to countries with much less economic wealth. Interviews are conducted with people who thought they had adequate coverage but were denied care. Former employees of insurance companies describe cost-cutting initiatives that give bonuses to insurance company physicians and others to find reasons for the company to avoid meeting the cost of medically necessary treatments for policy holders, and thus increase company profitability."

Great movie.

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.

[Jan 15, 2017] The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States

Jan 15, 2017 | economistsview.typepad.com
JohnH -> anne... , January 14, 2017 at 08:00 AM
The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States.
'
This is only the beginning of Democrats' appeasement of Trump and Republicans...it will be stunning to watch how much damage Republicans can do during Trump's first 90 days with only a slim majority in the Senate. During the first 90 days under Obama, who had a true electoral mandate and big majorities in both houses, Democrats basically sat on their hands, blaming Republicans for their unwillingness to do much for the American people.
Observer -> anne... , January 14, 2017 at 08:50 AM
So if we matched Canada, we'd see a 30% decrease, of a segment which comprises 10% of health care spending, or 3% overall decrease.

"PwC's Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate."

So reaching Canadian spending levels would counter ~ 6 months of health care cost increases. Reaching OECD levels buys you another couple of months.

Put another way, reaching OECD levels for drug spending closes 10% of the US-OECD spending gap.

Not nothing, but "fixing" drug prices seems more like an emotional (i.e. political) talking point than a real silver bullet for health care costs.

http://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html

pgl -> Observer... , January 14, 2017 at 11:17 AM
Ever noticed that marketing costs are 30% of revenue? This is a by product of the monopoly power in this sector. Dean Baker has often noted we could have the government do the R&D and then have real competition in manufacturing.
libezkova -> Observer... , January 14, 2017 at 10:40 PM
Don't be a lobbyist for Big Farma.

You forgot that those researchers often produce useless or even dangerous drags, which are inferior to existing. Looks as scams practiced with hypertension drugs.

This rat race for blockbuster drugs is the same as corruption in financial industry.

http://www.alternet.org/story/148907/15_dangerous_drugs_big_pharma_shoves_down_our_throats

pgl -> anne... , January 14, 2017 at 11:16 AM
Actually the industry profile is very relevant but goes in a different direction - if US firms were compelled to charge market (not monopoly) prices, we would better compete with foreign firms.
pgl -> Observer... , January 14, 2017 at 11:14 AM
Any excuse to charge sky high prices for drugs that don't cost that much to manufacture? If these monopoly profits were not so high, we would buy more drugs and employ more people.
Observer -> pgl... , January 14, 2017 at 12:57 PM
Do you think we would really buy materially more drugs if prices were lower? Particularly enough more, at those (30-50%?) lower prices, to generate the funds to employ more people?

(If that actually generated at much or more funds, it would seem like the pharma companies, seeking to make as much money as possible, would have already set prices at that lower per unit level.)

In any case, that seems like a LOT more drugs.

Perhaps Anne has data on the number of scripts per person in the US vs OECD.

pgl -> Observer... , January 14, 2017 at 01:06 PM
There are lots of poor people who don't take drugs because they can't afford them. This will become especially true if the Republican repeal Obamacare.
anne -> Observer... , January 14, 2017 at 09:05 AM
The point of course is wildly exploiting ordinary people in need of healthcare in every possible way, or a reflection of what we have come to. Returning now to the market...

[Jan 15, 2017] Lasik is a good demonstration of what is wrong with the US medical-industrial complex.

Jan 15, 2017 | economistsview.typepad.com
Observer -> anne... , January 14, 2017 at 09:16 AM
Well, for some services, clearly yes. Here's a Yelp review for Lasik, 4.5 star rated by users provider, with prices "Starting as Low as $250 an Eye".

https://www.yelp.com/biz/lasikplus-vision-center-chicago-2

It can also work when the consumer is only indirectly in the loop. I was reading a presentation on Skilled Nursing Care yesterday, where they were pointing out hospitasl that were getting more selective in discharging to only highly rated SNFs. (The people making this point were the highly rated SNFs.)

Would I do price shopping for cardiac surgery? No. MRI for a troublesome shoulder? Yes, I've actually done that, and seen 5X or more cost deltas from facilities on the insurance "approved" list.

ilsm -> Observer... , January 14, 2017 at 07:05 PM
Lasik is like liposuction .........

cosmetic.

libezkova -> ilsm... , January 14, 2017 at 10:30 PM
Lasik is a good demonstration of what is wrong with the US medical-industrial complex.

Vision is one of the most important functions for a person and some effects of Lasik are highly negative, especially on your night vision.

You get a halo.

One of the most common Lasik complications is dry eye.

https://www.symptomfind.com/procedures-tests/lasik-complications/

libezkova -> libezkova... , January 14, 2017 at 10:33 PM
See also
http://www.mayoclinic.org/tests-procedures/lasik-eye-surgery/basics/risks/prc-20019041

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 13, 2017] What was at stake why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine

Jan 13, 2017 | economistsview.typepad.com
anne -> Observer... , January 13, 2017 at 07:39 AM
https://twitter.com/lhfang/status/819677587408568320

Lee Fang ‏@lhfang

What was at stake & why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine:

https://theintercept.com/2017/01/12/cory-booker-joins-senate-republicans-to-kill-measure-to-import-cheaper-medicine-from-canada/

BERNIE SANDERS INTRODUCED a very simple symbolic amendment Wednesday night, urging the federal government to allow Americans to purchase pharmaceutical drugs from Canada, where they are considerably cheaper.

2:49 PM - 12 Jan 2017

Peter K. -> anne... , January 13, 2017 at 09:33 AM
Cory Booker, another progressive neoliberal....
pgl -> Observer... , January 13, 2017 at 09:37 AM
Very good. On health insurance, they get 20% gross margins. I have argued many times we can cut this to 10%.

[Jan 12, 2017] Almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 12, 2017] Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

Jan 12, 2017 | www.nakedcapitalism.com
Benedict@Large , January 12, 2017 at 2:53 pm

Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

RUKidding , January 12, 2017 at 3:26 pm

After spending day time hours publically going after Jeff Sessions (good), Booker uses the cover of darkness to reveal who he really works for.

Here's a clue: it isn't any of the 99%, whether in NJ or elsewhere.

Talk's cheap, but money walks – eh, Booker?

EndOfTheWorld , January 12, 2017 at 3:40 pm

Somewhere I saw that Bernie praised Trump taking on Big Pharma.

curlydan , January 12, 2017 at 3:33 pm

'specially if you're from Jersey. Kind of like Biden, Delaware, and credit cards. The strings on the puppets are awfully tight.

[Jan 12, 2017] 200PM Water Cooler 1-12-2017 naked capitalism

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"Hierarchies aren't natural phenomena within the human race. Outside of parenting, human beings aren't born with the inclination to be ruled, controlled, 'managed,' and 'supervised' by other human beings" [ The Hampton Institute ]. Hierarchies are artificial constructs designed to serve a purpose. They are a necessity within any society that boasts high degrees of wealth and power inequities. They are a necessity for maintaining these inequities and ensuring they are not challenged from below."

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of sehnsucht ("inconsolable longing"). For example, in 'Sad Strains of a Gay Waltz,' Stevens writes of American southerners (although the words just as easily apply to their author) as 'voices crying without knowing for what, / Except to be happy, without knowing how.' The object of Stevens's inconsolable longing changed over time. In his early professional days, when he first moved to New York City, it was his hometown of Reading, Pa. Writing to his future wife, Elsie, Stevens lamented that he 'lost a world' when he left there" [ The American Conservative ].

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 11, 2017] the DEPRAVED nature of the American "Health Kare" system

Jan 11, 2017 | www.nakedcapitalism.com
clarky90 , January 10, 2017 at 6:12 pm

For me, often it is the "small crimes" that exemplify the DEPRAVED nature of the American "Health Kare" system. (See the right hand panel of The Last Judgment Bosch triptych) https://en.wikipedia.org/wiki/The_Last_Judgment_(Bosch_triptych)

US drugmaker charges 200 times UK price for common worm pill

A US drugmaker has put a price tag of more than $800 on a pinworm treatment - 200 times more expensive than the equivalent medicine on British pharmacy shelves, in the latest example of "price gouging" in the world's largest healthcare market.
Impax Laboratories (Bastards!) started selling mebendazole this year at an average wholesale price of $442 per pill, according to figures seen by the Financial Times, which were checked with several US pharmacy chains including Walgreens and CVS.

Most cases of pinworm, a parasitic infection also known as threadworm, require two pills, meaning a course of treatment costs about $884. The drug is available prescription-only in the US but can be bought over the counter in the UK, where Boots, a British chemist chain, charges £6.99 for a pack of four pills, or £1.75 each.

The pinworm parasite, which is common in children, affects 200m people a year worldwide and up to 40m in the US. It is recommended that family members are treated for the highly contagious infection at the same time, meaning a household of five's treatment costs more than $4,400.

https://www.ft.com/content/f0080fe4-c3ad-11e6-9bca-2b93a6856354

"Mebendazole came into use in 1971, after it was developed in Belgium.[4] It is included in the WHO Model List of Essential Medicines, the most important medications needed in a basic health system .[5] Mebendazole is available as a generic medication.[6] The wholesale cost in the developing world is between 0.004 and 0.04 USD per dose .[7] In the United States a single dose is about 884.00 USD as of 2016.[8]

https://en.wikipedia.org/wiki/Mebendazole

[Jan 11, 2017] TrumpCare, Pre-Existing Conditions, and Continuous Coverage naked capitalism

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... 'Do not go without health insurance, because if you get sick, you won't be able to afford any'. ..."
"... why isn't Bernie jumping up and down for Medicare expansion? ..."
Jan 11, 2017 | www.nakedcapitalism.com
By Lambert Strether of Corrente .

Let me begin by summariing (from thi s excellent post by Jane Timm of NBC ) what we might politely call Trump's intellectual journey on health care policy:

As GOP lawmakers begin the process of repealing President Obama's landmark legislation, it's worth taking a look at the eight times Trump has changed his position on Obamacare since announcing his bid for president more than a year and a half ago:

1. Repeal Obamacare. Look to Canada for inspiration.
2. Repeal Obamacare. Cover everybody.
3. Repeal Obamacare, but 'I like the mandate'
4. Repeal Obamacare. Replace it with something.
5. Repeal Obamacare. Not everyone will be covered.
6. I do want to keep parts of it, we might just amend it.
7. Begin to repeal on day one.
8. 'Be careful' - don't take the blame!

Do Trump's views even matter? Some answer no, arguing that Trump will just delegate everything to Mike Pence, Tom Price, and the rest of the Republican nomenklatura . We'll see, but I don't think The Donald sliced through not one but two party establishments like a hot knife through butter with the goal of handing off power to the Mikes and Toms of this world. So Trump's views matter. We just don't know what they are! Interestingly, Zeke Emmanuel met with Trump on health care policy. His reaction : "I found him engaged, curious, and he asked a lot of thoughtful questions and had a lot of opinions, as you might expect." So, whatever the reasons for Trump's shifting positions, I don't see them as random. Or focus-grouped, either. So there's that).zd

That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that's sensible, since pre-existing conditions skew old , and Trump's base is older . Covering pre-existing conditions is also the right thing to do, as Trump himself seems to recognize :

Trump has consistently supported requiring insurers to cover those with pre-existing conditions, a regulation called guaranteed issue. "I would absolutely get rid of Obamacare," Trump said in a February 25 during the Republican primary, but "I want to keep [the provision regarding] pre-existing conditions. It's the modern age, and I think we have to have it."

Code Name D , January 9, 2017 at 6:21 pm

I don't agree. The "free rider" problem distorts the issue of afordabity. Young people do not buy coverage because they can not aford it – regardless of weather they want it or not. Issurance is so expensive its pricing people out of the markets.

So called "continus coverage" is a typical market solution. "Can't aford it? Well we will keep raising rates until you can. If you can aford it, we will keep rasing rates until you can't."

There still are no price controles.

Frank Stain , January 9, 2017 at 2:00 pm

Are people that hate the mandate because it's government coercion really going to like the Continuous Coverage imperative? The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance. The imperative of Continuous Coverage says: 'Do not go without health insurance, because if you get sick, you won't be able to afford any'.
This replaces the soft nudge of the mandate with the the very firm stick of inevitable financial ruin and uncurable sickness if you make a mistake and get sick when you didn't expect to. Why is this preferable to a mandate? Because you can still gamble?
A subsidiary point: are junk catastrophic plans going to count for purposes of Continuous Coverage once they ditch community rating? Those plans aren't going to provide anything like the $$ in the system that allow for coverage of pre-ex conditions.

ProNewerDeal , January 9, 2017 at 2:30 pm

"The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance"

The mandate is an ATROCIOUS penalty that penalizes people who cannot afford to purchase a crapified health insurance premium, or those that can "afford the premium" but don't have $6K in emergency savings with which to pay the annual deductible – e.g. can NOT afford to actually use the "insurance". Reminder: US personal adult median income is ~$30K, & net wealth is ~$37K, so this would cover a large portion if not a majority of USians that you are poor-shaming by saying "fail to be good citizens".

Frank Stain , January 9, 2017 at 2:49 pm

I was sort-of quoting the elite liberal line, not trying to poor-shame. But surely it makes sense to call a financial penalty 'soft' in comparison to the much harder penalty of financial ruin + incurable sickness if you mess up by gambling you won't get sick, and then you do.

Roger Smith , January 9, 2017 at 2:56 pm

Atrocious indeed. It is a way to divert attention from the real problem and blame the perceived personality faults of random people you do not know. With all the talk of Trump being some variation of fascist, I cannot figure out how people reconcile this mandate (or forced auto insurance mandates).

I have noticed that a lot of the Obama administration's "legacy" or general work was made by fudging numbers and not actually solving any of the problems at hand. Charging people for not buying a service they already could not afford as a way to punish them into making your numbers look good seems to fit the bill.

J , January 9, 2017 at 3:19 pm

The insurance is for 'catastrophic' coverage only. There are many, many scenarios where you could have an MI, stroke, major trauma, cancer, etc. and end up with surgical, hospital, nursing home and rehab costs running into the $1M+ range. The insurance prevents you from complete financial wipeout; it doesn't exist to make your PCP appointments or Lipitor "free" every month.

Second point, we can argue all we want about who's going to pay for healthcare in this country – the individual, the employer, the government, or some combination thereof. Healthcare will be unaffordable to a large degree based on how fat and sick the US population is. It doesn't matter who's paying when the average healthcare consumer is now 50+ years old with a BMI of 30+, has diabetes, hypertension, sleep apnea, asthma, and continues to smoke, eat fast food, not exercise and has no intention to change.

Last point, we do not ration care at the end of life like other countries with single payor systems do. Most of a person's total lifetime cost of care comes in the last 6 months of life. An enormous amount of savings could be achieved by stopping futile care at the end of life. In my experience, hardly any Americans die at home, everyone dies in an ICU on a ventilator, with multiple IV drips running, often on dialysis too. This is insane. We as a society have to find somewhere to draw the line where certain things shouldn't be done – like dialyIng 90 year olds

steven , January 9, 2017 at 6:10 pm

I don't think anyone is addressing frank's point which is:

In what way is creating a penalty, which tells people who cannot maintain consistent coverage that they can be permanently locked out of the market, better than the individual mandate? The brunt of both approaches is borne by the same people and both approaches inflict pain to coerce behavior. The mandate is a penalty that can be removed at any time by buying a subsidized guaranteed issue policy and the ACA had mechanisms in place to make it feasible to get into coverage. Under repeal, If you have a coverage gap you then face much higher premiums or refusal of needed coverage with no mechanism(such as substantial enough subsidies) to ever be able to afford to get back into the market. Saying that this is better because the government isn't forcing you to buy insurance, when no one goes without insurance if they can afford it in the first place, seems rather silly. Pushing these people into high risk pools has been tried numerous times in this country and has never worked out as the costs are always enormous and there is never the public will to subsidize the pools to the extent needed to keep them afloat.

We know perfectly well that the republicans have no intention of providing the level of subsidy that is necessary to get everyone covered because they don't believe that doing without health insurance/health care is a problem that government should be trying to fix.

As for lambert's statement about trump not shaking things up in order to hand power to others:

Trump doesn't care about policy and has no views on how his power should be used other than to aggrandize his own name. He is a dreaming narcissist whose views change 10 times in a day depending on what he thinks is expedient. He is the perfect malleable president for congressional republicans, an amoral blank slate driven only by his vision of himself as benign dictator. There is no way to counter the clear and organized agenda of the republican establishment, that now completely controls congress, unless you have some coherent policy view of your own. Donald Trump is going to rubber stamp the republican party's agenda and then claim that everyone's problems are solved and most of his supporters will be stupid enough to believe all their problems have disappeared because their all powerful proto-fascist daddy figure waved his big d!#k around and said it is so.

KK , January 9, 2017 at 2:07 pm

How clever is the American system, no work, no medicine

Tom , January 9, 2017 at 2:14 pm

Excellent, excellent snapshot of where we stand during this moment of calm before the storm (or rather, this moment between the current storm (ACA disintegration) and the next, bigger storm (ACA replacement).

Waldenpond , January 9, 2017 at 2:40 pm

This was for voteforno6

Here's what I found:

[There is no Constitutional provision explicitly giving the president the power to issue executive orders. Article II, Section 1 ("The executive power shall be vested in a President of the United States of America.") and Article II, Section 3 ("he shall take Care that the Laws be faithfully executed) have been cited as a grant of this power. Even so, presidential executive orders have the legal force of law if made pursuant to an Act of Congress. The authority for such orders can be either inherent or implied. The power is inherent when the executive order is derived from the powers conferred upon the President as commander-in-chief or, in international situations, as head of state; the power is implied when the order represents a reasonable interpretation of the powers expressly granted to the President under the Constitution.]

and

[Only two Presidential executive orders have been overturned by the courts. The first involved a 1952 presidential order issued by President Truman, Executive Order 1034, placing the nation's steel mills under federal control in order to prevent labor strikes from affecting steel production and thus hurting the national economy.[1] The U.S. Supreme Court determined that the Truman Order was unconstitutional because it overstepped the boundary between executive and legislative powers, holding that President's power to issue the order must stem either from an act of Congress or from the Constitution.[2].

The second executive order overturned by a court was issued by President Clinton. Executive Order 12954 prevented the federal government from entering into contracts with organizations that hire replacements for striking employees.[3] The court determined that the Order was regulatory in nature and preempted by the National Labor Relations Act, which guarantees employers the right to hire permanent replacements.[4]]

My understanding is the executive orders are legitimate if congress has not acted. With all the talk of mcr for all, basic income, ubi, unions, outsourcing, taxing the parasite class and guillotines, that movement needed to win or it will be crushed and I imagine the Ds and Rs will quickly rectify this in the next 2 to 4 years so if the wealthy were unfortunate enough to get someone like Sanders who might do something like this, it will be off the table.

grayslady , January 9, 2017 at 3:40 pm

Executive orders mostly work for issues that don't require congressional funding approval. Based on your excellent brief summary, Trump could probably lower the age of Medicare by Executive Order, but then he would have to find a way to pay for it. My memory may be faulty, but I believe that only Congress can impose taxes, not the President, so Trump would still need to propose a method of paying for Medicare-for-all that Congress would approve. Even if he found a way to pay for healthcare that didn't require congressional funding approval, if the funding source was considered to be too outrageous, Congress could impeach him.

ProNewerDeal , January 9, 2017 at 2:42 pm

0bamaBots & H1llaryB0ts spent years trashing Social Democrats/Sanders voters as "unrealistic" "far-left" "fair-dusty" "un-pragmatic".

Perhaps it was psychological projection, because IMHO 0bama & H1llary were un-pragmatic.

Imagine if 0bama earnestly tried to implement MedicareForAll in 2010? 0bama could've stayed sold-out to the other monopolistic industries that own US pols. Even the most strident left 0bama critics like say Glen Ford would have to say, "look, 0bama is a war criminal, has dictator-murdered US citizens without due process, tried to raise the social security age for GenX & younger, pursued the TPP; but 0bama deserves 1 prop for implementing MedicareForAll & saving 45K USians/yr per Harvard Public Health".

But no, 0bama & H1llary insist on staying sold-out to all major BigBiz groups. Fighting even 1 of them ala FD Roosevelt "I welcome their hatred" to investment bank$tas, is excessively pragmatic for these DLC neoliberal Reagan-clone scumbags.

Clive , January 9, 2017 at 3:07 pm

From an insurance industry point of view, certainly in the U.K. market which I doubt is significantly differently to the U.S., insurers hate complex underwriting. They either want scheme-compliant customers or, if those customers turn up and are found to be wide of scheme, they'd simply rather not have them as customers.

If an insurer is forced to take whatever business rolls up at its door, one way of avoiding having to specialist underwriting is to simply use pricing to deter anyone with a functioning brain cell from ever actually buying a policy. In other words, the fact that you genuinely need underwriting is used to whack the premium or the co-pay up. Okay, technically you are not denying coverage but in practice that's exactly what you are doing because most people will (certainly under the ACA) just pay the fine.

What the politicians - who know diddly squat about insurance product design - hadn't counted on though is, as noted though (correctly) above, you still get a death spiral because a lot of just-above-impoverished and slightly to moderately-severe unwell people will still enter the pool because they realize that even expensive (in-effect catastrophe) insurance is still better than pay-as-you-go. What you're going to deter is a mass market of impoverished or just-above-impoverished but slightly unwell (some sort of pre-existing condition which probably won't result in huge claims - a significant proportion of the potential pool will be this class of customer) potential customers who, in bulk, would contribute the vast proportion of your float (the reserves to pay out claims), because they think, usually correctly, they won't make a mega huge claim and are paying money for nothing.

If any changes in U.S. healthcare policy is considered which involves, to some extent, insurance (assuming Single Payer is off he table, which, however lamentable, sounds like reality) then policy makers really must consult with insurance marketing experts. Failure to understand consumer behavior in this industry will result in policy failures - yet again. None of this is new or not throughly understood - travel insurance has a vast trove of market and customer data to determine who chooses to take out medical expenses cover, who doesn't and why they don't (i.e. chose to spin the roulette wheel and risk not having coverage).

All of which makes me think - remind me again what is so wrong with Single Payer?

oho , January 9, 2017 at 3:19 pm

' remind me again what is so wrong with Single Payer?'

Of all the black swans out there--I'd bet that the most likely black swan is Trump expanding Medicare to under-65's in some form.

Seriously. Nixon to China >>> Takes a jingoistic, nationalistic, hotelier w/massive health insurance bills to like the idea of dumping those costs onto the government.

Trump is already on record liking drug re-importation from Canada and sticking it to Big Pharma.

(but again, it's the most likely of unlikely events) and I'm not holding my breath

Carla , January 9, 2017 at 8:53 pm

' remind me again what is so wrong with Single Payer?'

It treats everybody the same, something the 1% absolutely cannot abide.

A decade ago, I was traveling in Italy with a friend. When we were staying in the beautiful walled city of Lucca, he developed an infection in his index finger. We asked at our B&B where he might get treatment and were directed to the ER of a hospital about 2 blocks away. We joined a couple of other people in the waiting room and after about 5 minutes, someone came and took my friend to an examining room. Nobody in the ER spoke English and we had no Italian. About 10 minutes later, my friend emerged with a neatly bandaged finger and a prescription for antibiotic ointment written in Italian. He explained to me that they had lanced the finger, drained the pus, applied a disinfectant, and bandaged him up. When he took his credit card out to pay, they smilingly waved it away. You see in Italy, if you are hurting, you receive care and treatment because you are a human being.

American one-percenters just can't stand that. Apparently it somehow robs them of their specialness.

Thor's Hammer , January 9, 2017 at 11:09 pm

During my first week of employment in Vancouver Canada the financial secretary of the company called me into the office. "Have you received your Care Card yet?

"I'm a f--ing Yank– Don't I have to become a landed immigrant to apply?

"You are in a civilized country now– we don't allow anybody to go without health care."

I filled out a single page form and was immediately covered for all medical expenses including my pre-existing cancer. Administrative cost for universal coverage– a fraction of the bureaucratic overhead doctors face in the US in order to comply with the ACA & Medicare regulations.

During my stay in Canada I never stood in a line waiting to see a doctor or was placed in a room awaiting a fly-by visit by a doctor seeking to maximize his "production" as is often the case in the USA.

grayslady , January 9, 2017 at 3:46 pm

The favorite method of U.S. insurers to avoid paying for true insurance is to eliminate potential service providers. For example, under your Obamacare policy, all forms of contraception are supposed to be covered; but if no gynecologist in your network performs IUD insertions, then, essentially, you are denied coverage. Happens here a lot with surgical specialties, wherein no doctor in a particular network is qualified to perform certain surgeries even though Obamacare allows for coverage.

sj , January 9, 2017 at 8:47 pm

You know, I'm getting rather tired of the argument that Medicare payments are so abysmal. Doctors will leave, boo-hoo, yadda yadda.

Under the system we have now, those potential losses just get shifted to the uninsured. I just had a medical procedure and reviewed the billing from the hospital.

Cost of the procedure: $6600. Write off for insurer: $5564 Payment by me (since I had not met the deductible) $1036. My insurance company paid nothing.

Now, I'm lucky. I have insurance, and I had been stashing money into an FSA account and so I actually had the $1K. But in what world is it okay to penalize those unable to afford insurance by charging them six times as much as they write off for an insurance company. I

The whole healthcare-for-profit business is obscene. It's the "for profit" part that is subsuming the time of doctors and their staffs. Not the "patient care" part.

The so-called doctor exodus is a red herring. If someone becomes a doctor so that they roll in the money, I don't want to be their patient. Let them leave. Maybe we can actually get back to a healer model.

--
Lot's of interesting articles to be found with this search:

https://www.google.com/#q=how+much+time+to+doctors+spend+working+with+insurance+companies
--
I'm not even going into the fact that so often doctors start out so deep in debt they might feel the need to gouge their patients. That a different, if related, issue.

John k , January 9, 2017 at 3:25 pm

Trump's base is 50+. So what if he drops Medicare to 50+? Even somebody 45 would be happier thinking he would be covered in five years. And 50-65 is more in need than 35-50.
Midwest would be happy, and lots of reps from Midwest just trump proposing this would give it a life of its own and make dems look like pikers.

Course, this would someday be expanded, dooming health insurance does trump owe them anything? Didn't that industry donate to her?
Meanwhile, other corps should be happy to get their sickest workers covered always puzzled other industries haven't lobbied for Medicare expansion.

And with talk of changing Obamacare, why isn't Bernie jumping up and down for Medicare expansion?? Do all dems have undying fealty to insurance?

reslez , January 9, 2017 at 3:41 pm

> why isn't Bernie jumping up and down for Medicare expansion?

Clearly Bernie hasn't learned the art of the deal. But I think everyone figured that out after the primary.

As many problems as there are with Medicare I honestly believe expansion is the only way for Trump to square this circle. In addition it's the best solution for the country in the short-term. Think of how many billions of dollars will be saved on administrative overhead alone.

I don't see how Trump or the Republicans can get around Obamacare repeal, it was a core campaign promise. He can drag Congress along with promises of privatizing it in the future. That's a battle I'm willing to fight. Maybe they'll try to privatize it at the same time, though. I think they'd have to preserve a "public option" either way, simply because there are tons of seniors the health insurers won't touch with a 50 foot pole.

MyLessThanPrimeBeef , January 9, 2017 at 4:06 pm

Contrasting with Medicare for all, Medicare from 50+ on is the lesser of 2 evils (the other being keeping the status quo).

In the spirit of 'not letting good be the enemy of perfect,' i am interested and would like to know more if more people are advocating this.

Why should people die because they can't afford healthcare? Why should people go into debt to get treated? This is more important than no college education without free tuition.

Carla , January 9, 2017 at 9:04 pm

I agree. In the spirit of 'not letting the good be the enemy of perfect,' we should only let people 49 and under die because they can't afford healthcare.

Who needs people 49 and under, anyway?

james wordsworth , January 9, 2017 at 7:46 pm

The crazy thing is that Medicare for all has a solid business argument in its favor (although not for the AMA or big pharma, or big insurance). All companies pay similar amounts for coverage per employee (no more time spent wasted with analyzing plans), so a level playing field, while not as good as a field tilted in your favor, is better than one tilted against you. Great for small companies trying to get new employees, Individuals can start their own businesses without having to worry about losing health benefits (or the high costs of small plans). Everything about medicare for all screams economic efficiency (you know, having doctors doctor, not spending 50% of their time arguing with insurance companies).

Of course this all flies in the face of the american mantra of self reliance and that is where a great economic argument gets destroyed by the reality of a messed up culture in a modern world. Self reliance is great, but in an urban modern world, cooperation works better.

ProNewerDeal , January 9, 2017 at 8:16 pm

+1 IIRC 1 of the US auto mfgers explicitly claimed that the factories in Canada were more cost efficient for them, solely due to the health care costs.

It is as if US business leaders are adherents to neoliberal religion, that for-profit businesses will ALWAYS in ALL product/services provide a better product/svc per $ cost than a government or nonprofit private org can.

The same scenario exists with info tech, ppl wil bitch about Microsoft as OS vendor or office suite software vendor, when they could pay for corporate-level support from Ubuntu Linux or LibreOffice. They bitch about getting jacked by Oracle or SAP ERP, when say 10 MNCs could found a nonprofit dedicated to creating industrial/MNC-level ERP software that could be installed on-site or cloud-computing hosted. Etc.

Dr Duh , January 10, 2017 at 1:23 am

My idea, which helps ameliorate but doesn't solve the problem of the uninsured is to incentivize physicians to provide charity care. As it stands, you take significant risk for minimal to no reward.

The uninsured don't pay and Medicaid pays pennies on the dollar compared to private insurance. To make matters worse these are typically the sickest and the unhealthiest patients, i.e., they put off coming in so their disease is often at a crisis point and have bad nutrition, obesity, tobacco addiction and weak social support systems. They are bad outcomes waiting to happen. To cap it off, they are the most likely to sue you, they have stronger economic incentives to do it and have less social trust in physicians.

I know plenty of people (mostly anesthesiologists) who routinely complain about being paid despite being compelled to do all this work and take all this risk (including non-trivial risk to their own health from needle sticks and the like). I think that a big part of the resentment is that they are compelled to provide charity care as a condition of maintaining their privileges at the hospital.

Instead, let physicians write off charity care at their standard rates, i.e., I normally get $903 to come in at midnight and take out someone's ruptured appendix then take care of them in hospital for a week and provide follow up care for 90 days, but if the person is uninsured, I can deduct the $903 from my adjusted gross income as if it were a charitable donation. Further, physicians could be protected from civil liability for charity care. Though they would still be subject to criminal liability for criminal misbehavior and professional sanctions for substandard care, a bad outcome would not lead to a lawsuit.

I think the most important thing is that this would remove the compulsion to work for free. Most physicians and certainly anyone who has started in the past 10 years didn't do it for money. There's far more money and less stress in finance or tech. Most physicians like taking care of people. It's certainly the best part of my day, but being forced to do something sticks in the craw.
While this would certainly push up physician income.

meeps , January 10, 2017 at 2:14 am

Thanks for the extra detail regarding the 'continuous coverage' conditions.

The 18 month contract term reeks of post-ACA era grandfathered plans (my spouse's employer has a 12 month no coverage contract term) which is the very feature that prices us out of it. People who were priced-out under Obamacare are in for another brain-freeze should the incoming administration order up another self-licking ice cream cone.

I'm concerned that Pence will declare that having two X chromosomes is a pre-existing condition, but that's a subject for another post.

Trump seems to have some opportunity to cultivate an image as the 'most beautiful deal-maker ever' if he can deliver an improved Medicare For All plan. Of course, there's a risk that Republicans will crapify it first and then claim they delivered. But that strikes me as equally risky for Trump and the Republicans. Obama should never have staked his name and the reputation of the Democrats on Romneycare. They lost all credibility and the party is going extinct. I have a low opinion of Trump's branding but I suspect he thinks it's just great! It'd be inept beyond measure to sully it with something even worse than Obamacare. I'll refrain from placing odds just now

dejavuagain , January 10, 2017 at 8:48 am

In the old pre-existing conditions day, the other game played by the insurance companies was to challenge insureds for failing to disclose pre-existing conditions to the insurance company. Even if the insured was not aware of the existence of the pre-existing condition, the insurance company would deny coverage. So, in every big claim, the insurance company would simply deny coverage. Good luck.

And, I was the victim once of an insurance company "losing" my check, and cancelling my health insurance. Scary walking around without health insurance for a few months.

[Jan 11, 2017] Obamacare Republican Leaders Trying to Quell Revolting Senators

Notable quotes:
"... as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians. ..."
Jan 11, 2017 | www.nakedcapitalism.com
At least some Republicans seem mindful of the concept, "If you break it, you own it."

Even though Obamacare polls as having more opponents than supporters (see here and here ), many of the people who have benefitted from the program are strong supporters. In addition, those who have gotten coverage via Medicaid expansion may not realize that the ACA is the reason. And even with a majority of the public typically polling as not liking Obamacare, only 20% are willing to ditch it with no replacement .

So it should not come as surprise to find that the Republicans, finding themselves in the unexpected position of being able to end Obamacare, are in a squabble over what to do about the, um, opportunity. Obamacare repeal was not a Trump priority and as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

But it appears that regardless of what Trump is willing to do regarding Obamacare, he seems cognizant of the risk of creating disarray and being blamed for it a concern he oddly does not have on other issues. It's likely that this caution is purely cynical: that he understands how complicated implementing a replacement or even a stopgap would be, and he does not want Congress spending time on the Republican party bete noire of Obamacare to the detriment of pushing through Trump's priority items, particularly early in his term when he has the best chance to take ground quickly.

And the Republicans are divided enough to potentially forestall quick action. Politico and Bloomberg put different spins on the same story. Politico goes with the party line: GOP leaders vow to plow ahead with Obamacare repeal . The wee problem is that GOP leadership isn't what it is cracked up to be. Remember how Boehner was repeatedly unable to bring the unruly Tea Party faction to heel? And one of the first acts of the incoming House, to gut its own ethics office , turned into a PR disaster and was quickly scuttled. dbk , January 10, 2017 at 6:42 am

as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

I get the impression T is clued in about how popular a "Canadian-style" health care plan could potentially be.

That there are this many R senators in doubt/on the fence about this particular repeal might lend hope to the possibility that there might be divisions re: other issues, including key nominees. Let's hope the D's have their staffs working full-time on who might be willing/inclined to break ranks for particularly problematic nominations.

My personal concerns here are those for AG (someone who has emerged straight out of 1963) and the Dept of Education, but the list is long and opinions may differ about priorities.

Normal , January 10, 2017 at 7:53 am

They need the lobbyists to write the replacement law ASAP. Then they can proceed with reckless abandon.

Kemal Erdogan , January 10, 2017 at 8:53 am

But, the trouble is the obamacare is more or less what lobbyists wanted.

So, no I see a real trouble here. However militant the republicans seem they would not shoot themselves in the foot. My take is that they will claim that they replaced the law with something better while not touching anything meaningful at the core of it for the simple reason that for such a system to work, it must be more or less the same as what obamacare is. Think how M. Romney's plan looks very similar to Obama's.

The fact is the other workable alternatives are far too much to the left for their liking. So once such a low is introduced that even marginally helps the mid-lower classes, they tend to stick, unless the country falls into open dictatorship that is.

Code Name D , January 10, 2017 at 11:33 am

Ding ding ding!!! That's the billion-dollar observation here. Obamacare is Free-market economics at its best. For it to fail would generate an intellectual crisis among neo-liberals and libertarians alike. To repeal the ACA is to admit that free markets don't work.

For the industry, their bottom line is literally – the bottom line. That ACA is failing is already apparent. So, something must be done to stabilize the ACA before it collapses completely, and give single payer advocates even more political clout than they already have. Wait too long, and single payer might -gasp- be placed on the table.

But I am seeing some odd behavior from the Democrats. They seem to be actively pushing the healthcare battle onto the floor. Keep in mind they are convinced the ACA both works and is extremely popular. If they can get Republicans to repeal the ACA, then they win the mid-term elections and retake congress.

Trump may act the buffoon. But his election proves he is smarter than most people suspect. You underestimate Trump at your own peril. Sending out mixed messages is probably Trumps version of his poker face, while at the same time he is able to read his opponents projections as they react to various seemingly random messages. The further the ACA descends on its death-spiral, the more clout he will acquire to compel changes according to his vision.

Art Eclectic , January 10, 2017 at 12:07 pm

Actually, I don't think the Dems think the ACA works an is extremely popular, I think they see the opportunity to nuke the thing and get single payer on the table. With Trump on records as admiring the Canadian system, that provides an opening (real or not) that would simply not be possible with any other political figure in the oval office. Not even HRC could have pushed through single payer against Republican opposition, Obama did the best he could with Romneycare. The only shot at single payer comes in the form of forcing Trump's hand, so they might as well take their shot.

Sound of the Suburbs , January 10, 2017 at 7:59 am

In a globalised world you just have to look around to see how expensive the US healthcare system is.

Check international league tables and copy someone else's cheaper and better system.

It's that easy.

DJG , January 10, 2017 at 8:43 am

President Susan Collins, as Atrios used to refer to her. And here she is again, a wise elder on health care. Sheesh. The flashbacks of her wondrous bipartisanship and moderation are starting to overwhelm me already.

And President John McCain, who has squandered whatever moral authority he may ever have gained from his stay in the Hanoi Hilton, telling us how to deal with Boris and Natasha.

And Ron Johnson, the most clueless man in Wisconsin except for Scott Walker.

They don't have two synapses to rub together among the three of them. Not one of them has a sense of political economy. They mainly react, and not well. They will end up making Trump look like a statesman. And, ironically, they would have taken the same positions with Hillary Clinton.

So Obama and Trump are not transitional or tranformational. We are marking time as the roofing tiles drop off the buildings from neglect.

Eclair , January 10, 2017 at 8:58 am

Colorado, one of the states that fully embraced the ACA, extending Medicare to hundreds of poor and disabled residents (the state's uninsured rate dropped from 15.8% in 2011 to 6.7 percent in 2015), is bracing for impact, according to the Denver Post.

Of course, the state's voters overwhelmingly rejected a proposed health care cooperative that would have provided residents with universal health coverage a la Canada in last November's election.

Thankfully, we can all saunter over to our neighborhood pot store and stock up. Who needs doctors anyway.

marym , January 10, 2017 at 9:11 am

AHIP demands for Obamacare replacement – The first link to TPM shows a screen shot. Haven't found an actual link to an AHIP publication. The second link to NYT has a discussion of some of the items.

http://talkingpointsmemo.com/dc/insurer-trade-group-lists-its-demands-of-republicans-in-obamacare-repeal-fight

http://www.nytimes.com/2016/12/06/business/health-insurers-obamacare-republicans.html

Code Name D , January 10, 2017 at 11:07 am

Hahahah! They only THINK they are working on it. The TPM is your typical corporate boardroom speak. "Seek solutions for this, that, and the other thing. Send the right messages. Reassure the confidence fairy. Don't rock the boat." In other words, they delegate solutions to minions to figure out while they pose for the camera.

marym , January 10, 2017 at 11:29 am

Agreed on your general assessment of TPM, but not sure I understand your comment. The screenshot is presented as a copy of the actual demands from AHIP, the insurance industry. It does use some pseudo-caring-about-"consumers" language, and I'm no expert, but generally these demands seem to say – keep the money coming; don't send us too many poor/sick people; don't make any rules; or at least none that we don't write.

PKMKII , January 10, 2017 at 9:30 am

The dogs chasing the car finally got it, and now they don't know what to do with it.

RUKidding , January 10, 2017 at 10:36 am

It's to laugh, otherwise we'll all cry and/or pound our heads against brick walls.

It's my understanding that CA has used ACA in a useful way that is benefitting citizens who otherwise would be really up the creek with no paddle. So be it.

ACA is what friggin' BigPharma, BigHospital, BigInsurance, et al, wanted. IOW a Republican's wet dream of a "health care" insurance system. But because the Blackity Black black black Kenyan Muslim got the credit for it, rather than RMoney well then it's simply terrible. If RMoney had enacted the exact same thing, the R Team would be extolling it's virtues 24/7/365.

The impact on me, personally, is smallish. I get that it's been a worthless POS for many, but there are the 20 to 30 million who truly benefitted from it. I know some people personally in that category, and I read comments in blogs from others.

Of course, the most draconian of TeaPartiers simply want to repeal ACA and that's the end of it. You're on your own is their Ayn Randian rally cry. Frankly what's always bugged the sh*t out of me is that the R Team wasted the last 8 years endlessly (was it 60 times?) attempting to vote out ACA, but they spent not one iota of a second in devising a replacement. They have zip, zilch, nada, bupkiss to offer. What a worthless group of grifters.

I doubt that Trump gives a stuff what happens to his voters, other than that he probably has a notion that he'll need their fealty and votes in 4 years. Therefore, Trump may try to get something that has some minimum usefulness enacted.

I can't wait. /s

[Jan 06, 2017] Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Notable quotes:
"... They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. ..."
"... They spoke anxiously about rising premiums, deductibles, copays and drug costs. ..."
Jan 06, 2017 | economistsview.typepad.com

Chris Lowery said... January 05, 2017 at 06:42 AM And an interesting take on Trump voters' views on healthcare
http://www.nytimes.com/2017/01/05/opinion/the-health-care-plan-trump-voters-really-want.html?ref=opinion

The Health Care Plan Trump Voters Really Want
By DREW ALTMAN•JAN. 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump - people who are enrolled in the very health care marketplaces created by the law - one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.

Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.

The Kaiser Foundation organized six focus groups in the Rust Belt areas - three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance - for which they were eligible for subsidies - saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called "chaos" if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, "a smart businessman like Trump would let that happen." Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.

There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as "un-American."

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.

In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.

Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
Reply Thursday, January 05, 2017 at 06:42 AM pgl said in reply to Chris Lowery ... Excellent story. Yesterday Pence and Paul Ryan lied to us. They are basically assuming Trump supporters are really stupid. This says these supporters are smarter than the GOP frauds assume:

But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept. Reply Thursday, January 05, 2017 at 06:53 AM JohnH said in reply to pgl... The partisan hack opines...oblivious to the fact that people might have good reason to be angry at skyrocketing prices for what used to be known as catastrophic coverage.

Sad that there seems to be no one but Bernie and his supporters to stand for real health care reform. Instead the debate gets left to partisan hacks, who have nobody's interest in mind except the party's. Reply Thursday, January 05, 2017 at 07:42 AM Peter K. said in reply to JohnH... Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Know-nothing Republicans hate it because Obama signed it into law.
Reply Thursday, January 05, 2017 at 07:45 AM pgl said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

As in reigning in the monopoly power of Big Pharma. We should also reign the doctor cartel. And of course end the oligopoly power of the health insurance sector. Of course Paul Ryan is in the pockets of the latter - so it ain't gonna happen under his "leadership". Reply Thursday, January 05, 2017 at 06:55 AM EMichael said in reply to Chris Lowery ... Now is not the time to ignore what was actually the "real" problem.


" Republicans Hate Obamacare Because _______


I'm not one to defend the worst parts of Obamacare and those who find themselves on the receiving end of the mandate with no subsidies have some genuine complaints, but generally the bit that goes in the blank there is "it was the blah president's signature legislative achievement."

http://www.eschatonblog.com/

And yes those whose incomes are too high for subsidies do have a complaint.

But for the most part, the single most important "problem" with the ACA is that healthcare in the US is incredibly expensive.

One day people will stop attacking the ACA because of something the ACA had absolutely nothing to do with.

I am thinking that will be when it is gone, and people will then be shocked to see that healthcare in the US is very expensive. Reply Thursday, January 05, 2017 at 07:31 AM JF said in reply to EMichael... Yes, it is expense. This results from pricing that is free from any real market balances or alignments. The incentives are all misaligned.

Need to stop using the word, 'cost' so much. It is all about a non-market space where pricing is unfettered.

Normally, the public brings in uniform rules of Commerce to apply here, or the public does the services directly. Alas. Reply Thursday, January 05, 2017 at 09:07 AM Peter K. said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

Why don't the Democrats do this?

Progressive neoliberalism.... Reply Thursday, January 05, 2017 at 08:44 AM pgl said... "Michigan's expansion of Medicaid health insurance coverage has boosted the state's economy and budget, and will continue to do so for at least the next five years, according to a new University of Michigan study."

When Mike Pence and Paul Ryan appeared together to declare Obama's medical reforms a complete failure, it is odd that they never mentioned Michigan - which seems to be a success story. Reply Thursday, January 05, 2017 at 06:50 AM

[Jan 05, 2017] Chris Lowery

Notable quotes:
"... They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. ..."
"... They spoke anxiously about rising premiums, deductibles, copays and drug costs. ..."
Jan 05, 2017 | plus.google.com
said... And an interesting take on Trump voters' views on healthcare --


http://www.nytimes.com/2017/01/05/opinion/the-health-care-plan-trump-voters-really-want.html?ref=opinion

The Health Care Plan Trump Voters Really Want
By DREW ALTMAN•JAN. 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump - people who are enrolled in the very health care marketplaces created by the law - one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.

Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.

The Kaiser Foundation organized six focus groups in the Rust Belt areas - three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance - for which they were eligible for subsidies - saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called "chaos" if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, "a smart businessman like Trump would let that happen." Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.

There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as "un-American."

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.

In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.

Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
Reply Thursday, January 05, 2017 at 06:42 AM pgl said in reply to Chris Lowery ... Excellent story. Yesterday Pence and Paul Ryan lied to us. They are basically assuming Trump supporters are really stupid. This says these supporters are smarter than the GOP frauds assume:

But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept. Reply Thursday, January 05, 2017 at 06:53 AM EMichael said in reply to pgl... These Trump voters will quickly become convinced that whatever happens to the ACA due to Trump and the GOP's actions, it will be the fault of Obama.

That is why they are stupid. Reply Thursday, January 05, 2017 at 07:24 AM JohnH said in reply to pgl... The partisan hack opines...oblivious to the fact that people might have good reason to be angry at skyrocketing prices for what used to be known as catastrophic coverage.

Sad that there seems to be no one but Bernie and his supporters to stand for real health care reform. Instead the debate gets left to partisan hacks, who have nobody's interest in mind except the party's. Reply Thursday, January 05, 2017 at 07:42 AM Peter K. said in reply to JohnH... Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Know-nothing Republicans hate it because Obama signed it into law.
Reply Thursday, January 05, 2017 at 07:45 AM anne said in reply to JohnH... The partisan hack opines...
The partisan hack opines...
The partisan hack opines...

[ Enough personal attacks. Enough. ] Reply Thursday, January 05, 2017 at 07:48 AM pgl said in reply to JohnH... I think even your dog just went "snore". Reply Thursday, January 05, 2017 at 08:18 AM pgl said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

As in reigning in the monopoly power of Big Pharma. We should also reign the doctor cartel. And of course end the oligopoly power of the health insurance sector. Of course Paul Ryan is in the pockets of the latter - so it ain't gonna happen under his "leadership". Reply Thursday, January 05, 2017 at 06:55 AM EMichael said in reply to Chris Lowery ... Now is not the time to ignore what was actually the "real" problem.


" Republicans Hate Obamacare Because _______


I'm not one to defend the worst parts of Obamacare and those who find themselves on the receiving end of the mandate with no subsidies have some genuine complaints, but generally the bit that goes in the blank there is "it was the blah president's signature legislative achievement."

http://www.eschatonblog.com/

And yes those whose incomes are too high for subsidies do have a complaint.

But for the most part, the single most important "problem" with the ACA is that healthcare in the US is incredibly expensive.

One day people will stop attacking the ACA because of something the ACA had absolutely nothing to do with.

I am thinking that will be when it is gone, and people will then be shocked to see that healthcare in the US is very expensive. Reply Thursday, January 05, 2017 at 07:31 AM JF said in reply to EMichael... Yes, it is expense. This results from pricing that is free from any real market balances or alignments. The incentives are all misaligned.

Need to stop using the word, 'cost' so much. It is all about a non-market space where pricing is unfettered.

Normally, the public brings in uniform rules of Commerce to apply here, or the public does the services directly. Alas. Reply Thursday, January 05, 2017 at 09:07 AM Peter K. said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

Why don't the Democrats do this?

Progressive neoliberalism.... Reply Thursday, January 05, 2017 at 08:44 AM pgl said... "Michigan's expansion of Medicaid health insurance coverage has boosted the state's economy and budget, and will continue to do so for at least the next five years, according to a new University of Michigan study."

When Mike Pence and Paul Ryan appeared together to declare Obama's medical reforms a complete failure, it is odd that they never mentioned Michigan - which seems to be a success story. Reply Thursday, January 05, 2017 at 06:50 AM Fred C. Dobbs said... A Threat to US Democracy:
Political Dysfunction
http://nyti.ms/2hOJ9AB
NYT - Eduardo Porter - Jan 3

Is American democracy broken?

There are precedents around the world for the kind of political jolt the United States experienced in November. They usually include a political firebrand who promises to sweep away a system rigged to serve the powerful rather than the interests of ordinary people. They usually end badly, when the popular champion decides to read electoral victory as an invitation to bend the institutions of democracy to the force of his will.

Most Americans, I'm sure, never expected to worry about that sort of thing in the United States. And yet concern is decidedly in the air (*). Did a combination of globalization, demographic change, cultural revolutions and whatever else just upend America's consensus in support of liberal market democracy? Did American democracy just succumb to the strongman's promise?

(* Is Donald Trump a Threat to
Democracy? http://nyti.ms/2hNr32N )

I'm skeptical that the United States is about to careen down the path taken by, say, Venezuela, governed by the whim of President Nicolás Maduro - the handpicked successor of the populist champion Hugo Chávez, who was elected in the late 1990s on a promise to sweep away an entrenched ruling class and proceeded to battle any democratic institution that stood in his way.

Still, the embrace by millions of American voters of a billionaire authoritarian who argues that the "system" has been rigged to serve a cosmopolitan ruling class against the interests of ordinary people does suggest that American democracy has a unique credibility problem.

The United States resisted the temptations of Nazism, fascism and communism that beguiled Europe in the first half of the 20th century. Extreme parties like France's National Front or the United Kingdom Independence Party never established an American toehold. Populist candidates running as outsiders - Pat Buchanan, Ross Perot, Ralph Nader - could only tip the balance between the two parties of the establishment.

And yet, when the 21st century brought about a populist insurrection, the United States government was quick to cave.

"What makes the United States so distinctive?" wrote Ronald Inglehart, a political scientist at the University of Michigan, in a somewhat prescient article a few months before the election. "One reason may be that in recent years U.S. democracy has become appallingly dysfunctional."

Working Americans have suffered disproportionately from the economic shocks of our time. Income inequality in the United States far exceeds anything seen in other advanced nations. Families from the middle on down have suffered stagnant or declining incomes for years. And the nation's threadbare social safety net remains the weakest in the industrialized world, providing only the most meager insurance to working families undercut by globalization and technological change.

But for all the reasons Americans may have to rebel against the status quo, what made the political system so vulnerable to a populist insurrection in November was that - for all its institutional strengths - the political system itself has come to be seen by too many voters as illegitimate.

"There is persistent lack of confidence in U.S. political institutions which allows populists to make hay," said Pippa Norris, a political scientist at the Kennedy School of Government at Harvard and the University of Sydney in Australia. "And the institutions need a major overhaul because some, like elections, are badly broken."

This is not just about the Electoral College system, which awarded the presidency to the candidate who lost the popular vote. It is not just about money's growing influence in politics, though that plays a part, too.

The problems are embedded in the design of America's political institutions - with all their checks and balances ostensibly designed to slow down policy-making and prevent political extremists from swiftly taking over the gears of government. These institutions have produced a polarized government, paralyzed by partisan gridlock, unable to govern effectively. They have built a system easy to demonize as rigged.

The Electoral Integrity Project, run by Professor Norris and colleagues from Harvard and the University of Sydney in Australia, surveys thousands of election experts to assess the quality of hundreds of elections around the world. They are asked to rate how well district boundaries are drawn, whether voter registration procedures are adequate, and the effectiveness of campaign finance regulation, among other things.

Based on the average evaluations of the elections in 2012 and 2014, the United States' electoral integrity was ranked 52nd among the 153 countries in the survey - behind all the rich Western democracies and also countries like Costa Rica and Uruguay, the Baltic states, and Cape Verde and Benin in Africa.

A paper by Professor Norris on these results, titled "Why American Elections Are Flawed," describes the major problems with American electoral institutions, perhaps the most critical of which is partisan control over electoral institutions, which has subjected the integrity of elections to the distortions of a partisan lens.

( https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2844793 )

The fact that each state has its own set of electoral regulations - covering things like the type of technology used and opening hours of the polls - means that Americans' voting rights can change substantially from state to state. And the party polarization that has gripped statehouses across the country has stymied attempts to build sensible, effective electoral regulations and bred mistrust.

The patchwork of electoral systems - run by politically appointed local officials managing part-time workers - is hardly a recipe for competence. "Among mature democracies, the nuts and bolts of American contests seem notoriously vulnerable to incompetence and simple human errors," Ms. Norris notes. ...
Reply Thursday, January 05, 2017 at 06:53 AM kthomas said in reply to Fred C. Dobbs... Gerry Mander.

Oh, and let's not forget the Corporations have Constitutional rights. Reply Thursday, January 05, 2017 at 07:29 AM Peter K. said... All of the political, partisan progressive neoliberals are pretty pessimistic about Trump: DeLong, Krugman, Vox, etc.

(the same people that assured us Clinton was a great candidate who would win easily...)

And it's funny how the stock market is booming (despite the looming trade wars) and all of the establishment type neoliberals are pretty optimistic! (DeLong here questions Olivier Blanchard)

http://www.bradford-delong.com/2017/01/should-read-disagreeing-with-olivier-my-chances-of-success-are-surely-less-than-50-50-nevertheless-as-i-read-the-e.html

DeLong: January 04, 2017 at 06:44 AM

Should-Read: Disagreeing with Olivier, my chances of success are surely less than 50-50. Nevertheless...

As I read the evidence, the short-run fiscal multipliers (1) from government purchases are rather high, (2) from transfer payments to the liquidity-constrained are moderate, and (3) from high-income tax cuts are next to zero. At the moment it looks like effectively all of the Trump fiscal initiative to be will take the form of (3). Some of it will be direct tax cuts. The rest will be tax credits to businesses that are not currently cash-constrained but rather, at the margin, in the share buyback business.

But they will produce a stronger dollar.

Thus I expect next to no effective fiscal stimulus. I expect a larger capital inflow (trade deficit). And I am told we now expect the trade war to start soon.

Thus I do not see why Olivier Blanchard is so optimistic.
Where is he coming from? What does he see that I do not?

... Reply Thursday, January 05, 2017 at 07:12 AM Peter K. said in reply to Peter K.... The "stronger dollar" seems to be the go-to criticism.

I agree that tax cuts and deregulation alone won't do much (see the Bush years) except blow more asset bubbles.

I just don't get the theory of a larger capital inflow and strong dollar. Aren't those good things?

All of the comfortable progressive neoliberals' vacations in foreign countries will be cheaper. Their multinational corporate sponsors now can purchase more for the dollar in foreign lands, whether it be labor, assets, whatever.

Yes the export sector will be hurt, but they've never really cared about the export sector or unionized manufacturing jobs. The Fed will create more jobs as necessary. Plus it's mostly automation which can't be stopped. What, are you a Luddite?
Reply Thursday, January 05, 2017 at 07:17 AM Peter K. said in reply to Peter K.... Olivier Blanchard:

https://piie.com/blogs/realtime-economic-issues-watch/light-elections-recession-expansion-and-inequality

"To the extent that both growth and interest rates are higher, the dollar is likely to appreciate, leading, ironically, to larger US trade deficits, which Donald Trump the candidate indicated he wanted to fight. This leads me to trade issues and trade measures."

Isn't that what Clinton wanted? Higher growth and interest rates? That would also lead to a stronger dollar.

But absent tax cuts for the rich and deficits, interest rates wouldn't be so high.

Seems like progressive neoliberals and mainstream macro economists are slaves to the bond vigilantes. See Bill Clinton dropping his middle class spending bill campaign promise.

"ncrease the demand for domestic goods, and increase output (although, even then, as pointed out by Robert Mundell more than fifty years ago, the exchange rate may appreciate enough to lead to lower output in the end). But the "by themselves" assumption is just not right: Tariffs imposed by the United States would most likely lead to a tariff war and thus decrease exports. And the decrease in imports and exports would not be a wash. On the demand side, higher import prices would lead the Fed to increase interest rates further. "

So tariffs are bad because they cause retaliation. That's politics, not economics. And again the Fed is brought in to tell us that something good is actually bad.

High growth causes the Fed to kill the economy. Same would happen under Democrats.

Neoliberal BS.
Reply Thursday, January 05, 2017 at 07:24 AM kthomas said in reply to Peter K.... Da, comrade! Reply Thursday, January 05, 2017 at 07:30 AM Peter K. said in reply to kthomas... Where is our Miss Manners, Chris Lowrey? Reply Thursday, January 05, 2017 at 07:34 AM anne said in reply to kthomas... Da, comrade!
Da, comrade!
Da, comrade!

[ Ceaseless crazed destructiveness. ] Reply Thursday, January 05, 2017 at 07:42 AM Fred C. Dobbs said... (Harding redux?)

The Trump Administration
http://tws.io/2iFd3rC
via @WeeklyStandard
Nov 28, 2016 - William Kristol

Who now gives much thought to the presidency of Warren G. Harding? Who ever did? Not us.

But let us briefly turn our thoughts to our 29th president (while stipulating that we're certainly no experts on his life or times). Here's our summary notion: Warren G. Harding may have been a problematic president. But the Harding administration was in some ways an impressive one, which served the country reasonably well.

It was possible to say, before Warren G. Harding was elected, that he wasn't particularly well-qualified to be president. And he did turn out as president to have, as we say nowadays, some issues. But his administration was stocked with (mostly) well-qualified men who served with considerable distinction.

Andrew Mellon was a successful Treasury secretary whose tax reforms and deregulatory efforts spurred years of economic growth. Charles Dawes, the first director of the Bureau of the Budget, reduced government expenditures and, helped by Mellon's economic policies, brought the budget into balance. Charles Evans Hughes as secretary of state dealt responsibly with a very difficult world situation his administration had inherited-though in light of what followed in the next decade, one wishes in retrospect for bolder assertions of American leadership, though in those years just after World War I, they would have been contrary to the national mood.

In addition, President Harding's first two Supreme Court appointments-William Howard Taft and George Sutherland-were distinguished ones. And Harding personally did some admirable things: He made pronouncements, impressive in the context of that era, in favor of racial equality; he commuted the wartime prison sentence of the Socialist leader, Eugene V. Debs. In these ways, he contributed to an atmosphere of national healing and civility.

The brief Harding administration-and for that matter the eight years constituting his administration and that of his vice president and successor, Calvin Coolidge-may not have been times of surpassing national greatness. But there were real achievements, especially in the economic sphere; those years were not disastrous; they were not dark times.

President-elect Donald J. Trump probably doesn't intend to model his administration on that of President Warren G. Harding. But he could do worse than reflect on that administration's successes-and also on its failures, particularly the scandals that exploded into public view after Harding's sudden death. These were produced by cronies appointed by Harding to important positions, where they betrayed his trust and tarnished his historical reputation.

Donald Trump manifestly cares about his reputation. He surely knows that reputation ultimately depends on performance. If a Trump hotel and casino is successful, it's not because of the Trump brand-that may get people through the door the first time-but because it provides a worthwhile experience thanks to a good management team, fine restaurants, deft croupiers, and fun shows. If a Trump golf course succeeds, it's because it has been built and is run by people who know something about golf. The failed Trump efforts-from the university to the steaks-seem to have in common the assumption that the Trump name by itself would be enough to carry mediocre or worse enterprises across the finish line.

To succeed in business, the brand only gets you so far. Quality matters. To succeed in the presidency, getting elected only gets you so far. Governing matters.

It would be ironic if Trump's very personal electoral achievement were followed by a mode of governance that restored greater responsibility to the cabinet agencies formally entrusted with the duties of governance. It would be ironic if a Trump presidency also featured a return of authority to Congress, the states, and to other civic institutions. It would be ironic if Trump's victory led not to a kind of American Caesarism but to a strengthening of republican institutions and forms. It would be ironic if the election of Donald J. Trump heralded a return to a kind of constitutional normalcy.

If we are not mistaken, it was Georg Wilhelm Friedrich Hegel (though sadly unaware of the phenomena of either Warren G. Harding or Donald J. Trump) who made much of the Irony of History. But how Hegelian it would be if the thesis of the Bush and Clinton dynasties, followed by the antithesis of a Trump victory over first a Bush and then a Clinton in 2016, were to produce an unanticipated synthesis: a Trump administration marked by the reconstruction of republican normalcy in America. In its own way, that would be a genuine contribution to making America great again.

(Harding-Coolidge-Hoover were a disastrous triumvirate
that ascended to power after the Taft & Wilson administrations, as the GOP - then the embodiment
of progressivism - split apart due to the
efforts of Teddy Roosevelt.)
Reply Thursday, January 05, 2017 at 07:40 AM Peter K. said in reply to Fred C. Dobbs... Kristol is mad Trump lambasted the Iraq war.

Was Putin against the Iraq war? I think the whole world was except for the "Coalition of the Willing."

You'll never see the UK back another war like that. Reply Thursday, January 05, 2017 at 07:56 AM EMichael said... Sad, sad day for NBC News.

" Megyn Kelly had a good 2016. Between her news-making stint as a Fox News debate moderator, a flattering profile in Vanity Fair, and a lucrative book deal, she cemented her reputation as a talented and no-nonsense journalist-one of the most highly paid in the industry. And now she's making the jump to NBC News, where she will anchor a Sunday evening news show, host a daytime show, and cover major political events. "Megyn is an exceptional journalist and news anchor, who has had an extraordinary career," said NBC News Chairman Andrew Lack in a statement. "She's demonstrated tremendous skill and poise, and we're lucky to have her."


Another thing Kelly has demonstrated is racist demagoguery, which defined much of her tenure at Fox News....

The NBPP "controversy" represents a particular fixation of Kelly's, but it was not her only racist display. In 2013, in reaction to my colleague Aisha Harris' Slate piece, "Santa Claus Should Not Be a White Man Anymore," the Fox anchor infamously claimed that both Santa Claus and Jesus of Nazareth were white men. "Jesus was a white man, too ... he's a historical figure and that's a verifiable fact, as is Santa." (The truth is that "white" as a political or racial category didn't exist in either 1st century Palestine or 3rd and 4th century Turkey-and that Santa's not real.) In 2015, Kelly insisted that the racist emails exchanged by officials in Ferguson, Missouri-which included a joke about a man seeking "welfare" for his dogs because they are "mixed in color, unemployed, lazy, can't speak English and have no frigging clue who their Daddies are"-were normal."

http://www.slate.com/articles/news_and_politics/politics/2017/01/megyn_kelly_is_a_racial_demagogue.html
Reply Thursday, January 05, 2017 at 07:40 AM Peter K. said... It's now democratic socialists versus progressive neoliberals.

The progressive neoliberals have failed the world over.

Hillary Clinton, a competent, knowledgeable establishment politician, lost to a laughable reality TV star clown.

Think about it. Mull it over in your mind. It's hilarious how cocky and confident the neoliberals were throughout the election. It's amazing how wrong they were. Trump's victory is almost worth it. Not quite.

http://www.commondreams.org/views/2016/02/26/we-are-not-denmark-hillary-clinton-and-liberal-american-exceptionalism

Published on
Friday, February 26, 2016
by Common Dreams

"We Are Not Denmark": Hillary Clinton and Liberal American Exceptionalism

by Matthew Stanley

Several months removed, it now seems clear that the Democratic debate on October 13 contained an illuminating moment that has come to embody the 2016 Democratic Primary and the key differences between its two candidates. Confronting Bernie Sanders's insistence that the United States has much to learn from more socialized nations, particularly the Nordic Model, Hillary Clinton was direct: "I love Denmark. But we are not Denmark. We are the United States of America."

The implication behind this statement-the reasoning that ideas and institutions (in this case social and economic programs) that are successful in other nations are somehow practically or ideologically inconsistent with Americans and American principles-speaks to a longstanding sociopolitical framework that has justified everything from continental expansion to the Iraq War: American exceptionalism. Rooted in writings of Alexis de Tocqueville and the mythology of John Winthrop's "City Upon a Hill," the notion that the history and mission of the United States and the superiority of its political and economic traditions makes it impervious to same the forces that influence other peoples has coursed through Abraham Lincoln's "Gettysburg Address," the Cold War rhetoric of John F. Kennedy and Lyndon Johnson, and the foreign policy declarations of Barack Obama.

espite particular historical trends-early and relatively stable political democracy, birthright citizenship, the absence of a feudal tradition, the relative weakness of class consciousness-historians have critiqued this "American exceptionalism" as far more fictive than physical, frequently citing the concept as a form of state mythology. Although different histories lead naturally to historical and perhaps even structural dissimilarities, America's twenty-first century "exceptions" appear as dubious distinctions: gun violence, carbon emissions, mass incarceration, wealth inequality, racial disparities, capital punishment, child poverty, and military spending.

et even at a time when American exceptionalism has never been more challenged both by empirically-validated social and economic data and in public conversation, the concept continues to play an elemental role in our two-party political discourse. The Republican Party is, of course, awash with spurious, almost comically stupid dialogue about a mythic American past-"making America great again"-the racial and ethnic undertones of which are unmistakable. Those same Republicans have lambasted Obama and other high profile Democrats for not believing sufficiently in their brand of innate, transhistoric American supremacy.

But this Americentrism is not the sole province of the GOP. We need look no further than bipartisan support for the military-industrial complex and the surveillance state to see that national exceptionalism, and its explicit double-standard toward other nations, resides comfortably within the Democratic Party as well. Russian President Vladimir Putin and Ecuadorean President Rafael Correa censured Obama's use of the term in the fall of 2013, with the latter likening it to the "chosen race" theories of Nazi Germany. Hyperbole notwithstanding, academics often do associate American exceptionalism with military conquest. It does, after all, have deep roots in the Manifest Destiny ethos that spurred the Mexican War, drove continental and trans-Pacific expansion, and emerged as a paternalistic justification for voluminous military interventions in Latin America, Africa, and the Middle East. As Dick Cheney suggests, "the world needs a powerful America." In this unilateral missionizing zeal Clinton proves most typical. As historian Michael Kazin argues in a recent piece for The Nation: "Hillary Clinton is best described as a liberal. Like every liberal president (and most failed Democratic nominees) since Wilson, she wants the United States to be the dominant power in the world, so she doesn't question the massive sums spent on the military and on the other branches of the national-security state."

But Clinton's brand of American exceptionalism goes beyond the issue of American military dominion and into the policy potentials of mid-century social liberalism and, more specifically, the neoliberalism that has since replaced it. Indeed, since George McGovern's failed presidential bid of 1972, neoliberals, moving decidedly rightward on economic issues, have consistently employed exceptionalist code to fight off movements, ideas, and challengers from the left. The victims include leftist efforts toward both American demilitarization and the expansion of a "socialistic" welfare state. Socialist feminist Liza Featherstone and others have denounced Clinton's uncritical praise of the "opportunity" and "freedom" of American capitalism vis-à-vis other developed nations. "With this bit of frankness," Featherstone explains, referring to the former Secretary of State's "Denmark" comments, "Clinton helpfully explained why no socialist-indeed, no non-millionaire-should support her. She is smart enough to know that women in the United States endure far more poverty, unemployment, and food insecurity than women in Denmark-yet she shamelessly made clear that she was happy to keep it that way." Indeed, Clinton's denunciation of the idea that the United States should look more like Denmark betrayed one of the glaring the fault lines within the Democratic Party, and between Clintonian liberalism and Sandersite leftism. It also revealed a more clandestine strain of American exceptionalism common among liberals and the Democratic Party elite in which "opportunity" serves as a stand-in for wider egalitarian reform. As Elizabeth Bruenig highlighted in The New Republic: "Since getting ahead on one's own grit is such a key part of the American narrative, it's easy to see how voters might be attracted to Clinton's opportunity-based answer to our social and economic woes, though it leaves the problem of inequality vastly under-addressed. Indeed, a kind of American exceptionalism does seem to underpin much opportunity-focused political rhetoric."

This preference for insider politics (rather than mass movements involving direct action) and limited, means-tested social programs speaks to a broader truth about modern liberalism: it functions in a way that not only doesn't challenge the basic tenets of American exceptionalism, it often reinforces them. Whether vindicating war and torture and civil liberties violations, talking past the War on Drugs and the carceral state, or exhibiting coolness toward the type of popular protest seen during of Occupy Wall Street, with its direct attacks on a sort of American Sonderweg, establishment Democrats are adept at using a more "realistic" brand of Americentrism to consolidate power and anchor the party in the status quo. Now the 2016 Democratic Primary has seen progressive ideas including universal health care, tuition-free college, and a living minimum wage, all hallmarks of large swaths of the rest of the developed world, delegitimized through some mutation of liberal exceptionalist thinking. These broadminded reforms are apparently off limits, not because they are not good ideas (though opponents make that appraisal too), but because somehow their unachievability is exceptional to the United States.

All this is not to exclude (despite his "democratic socialist" professions) Sanders's own milder brand of "America first," most evident in his economic nationalism, but to emphasize that American exceptionalism and the logical and practical dangers it poses exist in degrees across a spectrum of American politics. Whatever his nationalistic inclinations, Sanders's constant reiteration of America's need to learn from and adapt to the social, economic, and political models of other nations demonstrates an ethno-flexibility rarely seen in American major party politics. "Every other major country " might as well be his official campaign slogan. This bilateral outlook does not fit nearly as neatly within Clinton's traditional liberal paradigm that, from defenses of American war and empire to the, uses American exceptionalism tactically, dismissing its conservative adherents as nationalist overkill yet quietly exploiting the theory when politically or personally expeditious.

In looking beyond our national shores and domestic origin-sources for fresh and functional policy, Sanders seems to grasp that, from the so-called "foreign influences" of the Republican free soil program or Robert La Follette's Wisconsin Idea or even Lyndon Johnson's Great Society, American high politics have been at their most morally creative and sweepingly influential not only when swayed by direct action and mass movements, but also when they are less impeded by the constraints of ethnocentrism and exceptionalism. The "We are not Denmark" sentiment might appear benign, lacking as it does the bluster of Republican claims to national supremacy and imaginary "golden age" pasts and what economist Thomas Picketty has termed a "mythical capitalism." But it is the "seriousness" and very gentility of liberal Americentrism that underscores the power, omnipresence, and intellectual poverty of cultural dismissal. "I still believe in American exceptionalism," Clinton has proclaimed in pushing for U.S. military escalation in Syria. Indeed she does, and it is by no means relegated to the sphere of foreign policy.
Reply Thursday, January 05, 2017 at 07:42 AM Peter K. said in reply to Peter K.... "Socialist feminist Liza Featherstone and others have denounced Clinton's uncritical praise of the "opportunity" and "freedom" of American capitalism vis-à-vis other developed nations. "With this bit of frankness," Featherstone explains, referring to the former Secretary of State's "Denmark" comments, "Clinton helpfully explained why no socialist-indeed, no non-millionaire-should support her. She is smart enough to know that women in the United States endure far more poverty, unemployment, and food insecurity than women in Denmark-yet she shamelessly made clear that she was happy to keep it that way." Indeed, Clinton's denunciation of the idea that the United States should look more like Denmark betrayed one of the glaring the fault lines within the Democratic Party, and between Clintonian liberalism and Sandersite leftism."

Is it better to ignore this fault line and try to paper it over or is it better to debate the issues in a polite and congenial manner?

Of course the progressive neoliberals in this forum regularly resort to ad hominem to any ideas or facts that don't line up with the agreed-upon party line.

And then our Miss Manners Chris Lowrey complains about all sides.
Reply Thursday, January 05, 2017 at 07:52 AM EMichael said... Survival guide for those opposed to Trump and just plain tired of the Sarandonistas of the world.


Indivisible
A practical guide For resisting the Trump agenda

Former congressional staffers reveal best practices for making Congress listen.

https://www.indivisibleguide.com/ Reply Thursday, January 05, 2017 at 07:53 AM Peter K. said... http://stumblingandmumbling.typepad.com/stumbling_and_mumbling/2017/01/economists-in-an-alienated-society.html

January 05, 2017

ECONOMISTS IN AN ALIENATED SOCIETY
by Chris Dillow

"The social power, ie the multiplied productive force", wrote Marx, appears to people "not as their own united power but as an alien force existing outside them, of the origin and end of which they are ignorant, which they thus cannot control."

I was reminded of this by a fine passage in The Econocracy in which the authors show that "the economy" in the sense we now know it is a relatively recent invention and that economists claim to be experts capable of understanding this alien force:

As increasing areas of political and social life are colonized by economic language and logic, the vast majority of citizens face the struggle of making informed democratic choices in a language they have never been taught. (p19)

This leads to the sort of alienation which Marx described. This is summed up by respondents to a You Gov survey (pdf) cited by Earle, Moran and Ward-Perkins, who said; "Economics is out of my hands so there is no point discussing it."

In one important sense such an attitude is absurd. Every time you decide what to buy, or how much to save, or what job to do or how long to work, economics is in your hands and you are making an economic decision.

This suggests to me two different conceptions of what economics is. In one conception – that of Earle, Moran and Ward-Perkins – economists claim to be a priestly elite who understand "the economy". As Alasdair MacIntyre said, such a claim functions as a demand for power and wealth:

Civil servants and managers alike [he might have added economists-CD] justify themselves and their claims to authority, power and money by invoking their own competence as scientific managers (After Virtue, p 86).

There is, though, a second conception of what economists should do. Rather than exploit alienation for their own advantage, we should help people mitigate it. This consists of three different tasks:

- We should help people make better decisions for themselves. This needn't consist of "nudging". We might do it by increasing their information. Or we might do it by warning people to avoid the most common errors of judgment. This is what I do in the day job. By this standard, Martin Lewis is one of country's leading economists.

- We shouldn't engage in futurology. That's the job of soothsayers, necromancers and charlatans*. Instead we should help build resilience to shocks. At the individual level, this consists in helping people to make choices, such as in building well-balanced portfolios. And at the social level it means helping to build institutions which allow people to bear risk: this can be private insurance markets as well as a welfare state.

- We can undermine the justifications for inequalities of wealth and power by pointing out that bosses and bankers' claims to them are often plain wrong.

The difference between these two conceptions has been highlighted, inadvertently, by Jeremy Warner. He says economists have had a "terrible year" because their warnings of a Brexit shock were wrong. Maybe, maybe not. But this allegation only applies to economists as priests. In our second conception, economists have had a good year. For example, most actively managed UK equity unit trusts have under-performed trackers, which supports our longstanding advice in favour of passive management.

I should stress here that the distinction between economists as priests and economists as dentists is separate from the heterodox-orthodox distinction. Orthodox economics, when properly used, can both serve a radical function and help inform everyday decisions.

You might object here that my distinction is an idiosyncratic one. Certainly, economists as dentists earn less than economists as priests: I know as I've done both. But there are reasons for that, which have little to do with economists' social utility.

* OK, I do it sometimes – but only to keep my editor happy.
Reply Thursday, January 05, 2017 at 08:05 AM RGC said... The US nomenclatura is embarked on a massive media campaign to divert and reframe the election issues away from the economic and inequality concerns expressed by the Sanders campaign. No "break up the banks", no "free public college", no "medicare for all", no campaign funding reform.

For a while we had the Russian hacking accusations, which have suddenly gone dormant (will we ever get proof?). Now we have divide and conquer identity issues. But no proposed alternatives to Trump for curing our economic malaise along the lines suggested by Sanders.

We are headed back to business as usual, with the right fighting the so-called center left (our two neoliberal factions) for dominance. Apparently conditions have not deteriorated enough yet for a populist uprising. How much more does it take before we reach a critical mass? Reply Thursday, January 05, 2017 at 08:16 AM Peter K. said... From Thomas Edsall's NYTimes column:

"At the moment, the Democratic Party is structurally fragile and its members have shied away from the kind of radical upheaval Republicans have been forced to embrace. Nonetheless, Democrats will soon face enormously risky decisions.

Does the party move left, as a choice of Keith Ellison for D.N.C. chairman would suggest? Does it wait for internecine conflict to emerge among Republicans as Trump and his allies fulfill campaign promises - repealing Obamacare, enacting tax reform and deporting millions of undocumented aliens?"

It's funny how there has been no discussion of the DNC chair contest, and yet the progressive neoliberals here still whine that the forum isn't an echo chamber which reflects their views. And then they fantasize about banning people with whom they disagree. Reply Thursday, January 05, 2017 at 08:20 AM Denis Drew said... State governments famously (or infamously) give away billions in tax breaks to lure in firms that make jobs. 19 Republican governors -- by rejecting Medicaid expansion -- have rejected TAKING IN federal tax money to generate good medical jobs, not to mention the multiplier effect of new spending ...

.. and it's the states' own money that they sent to the federal government that they don't want to TAKE BACK ...

... oh, almost forgot; it's good for uninsured poor people too (almost forgot about that). Reply Thursday, January 05, 2017 at 08:27 AM pgl said in reply to Denis Drew ... Nice point. My DINO governor (Cuomo) was smart enough to take the Medicaid funding but he gives all sorts of stupid supply-side breaks to businesses. Reply Thursday, January 05, 2017 at 09:05 AM Peter K. said... http://www.nytimes.com/2017/01/04/business/economy/federal-reserve-minutes-interest-rates.html

Fed Officials See Faster Economic Growth Under Trump, but No Boom

By BINYAMIN APPELBAUM
JAN. 4, 2017

"Ms. Yellen has warned that fiscal stimulus, like a tax cut or a spending increase, could increase economic growth to an unsustainable pace in the near term, resulting in increased inflation. The Fed quite likely would seek to offset such policies by raising interest rates more quickly."

Progressive neoliberalism...

And Alan Blinder said Hillary's fiscal plans wouldn't be large enough to cause the Fed to alter its path of rate hikes.

And Trump promised more better infrastructure like clean airports.

And Trump won.
Reply Thursday, January 05, 2017 at 08:39 AM Peter K. said in reply to Peter K.... I'm now thinking that Trump will have conflict with the Fed.

He lives for conflict and drama. Reply Thursday, January 05, 2017 at 08:41 AM pgl said... An update on the Chevy Cruze controversy. US consumption was 194,500 vehicles with 190,000 made here in the US. That's 97.7% of them being produced locally. Tweet that.

[Jan 04, 2017] Study suggests route to improve artery repair

Notable quotes:
"... People with any form of diabetes are at greater risk of developing cardiovascular conditions than people without the disease. Moreover, if they undergo an operation to open up a clogged artery by inserting a "stent" surgical tube, the artery is much more likely to clog up again. ..."
"... Surgical stents for artery repair are typically coated with slow-releasing drugs that aim to suppress excessive regrowth of the surrounding smooth muscle cells. This approach to release drugs locally might work for drugs that boost SHP-1 expression, King speculates. ..."
Jan 04, 2017 | www.eurekalert.org
BOSTON - (January 4, 2017) - People with any form of diabetes are at greater risk of developing cardiovascular conditions than people without the disease. Moreover, if they undergo an operation to open up a clogged artery by inserting a "stent" surgical tube, the artery is much more likely to clog up again.

However, researchers at Joslin Diabetes Centers now have uncovered an explanation for why these procedures often fail, which may lead toward better alternatives.

An enzyme known as SHP-1, which can suppress the growth of smooth muscle cells lining the inside of blood vessels, plays a crucial role in stent failure, says George King, M.D., Joslin's Chief Scientific Officer and senior author on a paper in the journal Diabetologia describing the work.

Stents coated with a drug that activates SHP-1, and thus slows the accelerated growth of these vascular cells, might help in treating arterial disease in diabetes, says King, who is also Professor of Medicine at Harvard Medical School.

His team's research began with experiments among mice fed a high-fat diet and rats that were genetically modified to display insulin resistance and related metabolic conditions related to diabetes. "We found that SHP-1 expression was decreased in the arteries from all of these animal models," says Weier (Glorian) Qi, co-lead author on the paper. "We also found that SHP-1 expression dropped in the arteries of patients with type 2 diabetes."

Next, the scientists created mice that were genetically engineered to over-express the protein in their vascular smooth muscle cells. When the scientists fed these mice a high-fat diet that clogged their arteries and performed a procedure similar to stent insertion, they found that the arteries in these animals were less clogged than in normal mice given the same procedure.

The researchers went on to demonstrate that SHP-1 is reduced in mouse vascular smooth muscle cells primarily by the high levels of lipids in the blood associated with diabetes and related conditions, rather than the high levels of glucose also present in those conditions.

Following up on these findings may help to address a major research puzzle in diabetic complications, says King: Each type of tissue seems to react differently to the disease.

For example, he explains, smooth muscle cells grow thicker in large blood vessels like arteries, but similar type of contractile cells begin to die off in tiny blood vessels in the eye.

"These opposite cell growth patterns are an enigma," King comments. "They also make it difficult to develop therapeutics, because we would want to deactivate SHP-1 in the eye and activate it in large arteries."

Surgical stents for artery repair are typically coated with slow-releasing drugs that aim to suppress excessive regrowth of the surrounding smooth muscle cells. This approach to release drugs locally might work for drugs that boost SHP-1 expression, King speculates.

"We hope our research encourages ideas about how to address this problem for people with diabetes," he adds. ""The more ideas that come up, the greater the chances that we can achieve such a needed treatment."

Joslin's Qian Li1 was the other co-lead author on the paper. Joslin contributors also included Christian Rask-Madsen, Samuel Lockhart, Yu Xia, Xuanchun Wang and Mogher Khamaisi. Chong Wee Liew of the University of Illinois at Chicago; Lars Melholt Rasmussen of Odense University Hospital in Odense, Denmark; and Kevin Croce of Brigham and Women's Hospital also were co-authors. Lead research support came from the JDRF, the American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases.

[Jan 04, 2017] Mediterranean diet may have lasting effects on brain health

Jan 04, 2017 | www.eurekalert.org
MINNEAPOLIS - A new study shows that older people who followed a Mediterranean diet retained more brain volume over a three-year period than those who did not follow the diet as closely. The study is published in the January 4, 2017, online issue of Neurology ®, the medical journal of the American Academy of Neurology. But contrary to earlier studies, eating more fish and less meat was not related to changes in the brain.

The Mediterranean diet includes large amounts of fruits, vegetables, olive oil, beans and cereal grains such as wheat and rice, moderate amounts of fish, dairy and wine, and limited red meat and poultry.

"As we age, the brain shrinks and we lose brain cells which can affect learning and memory," said study author Michelle Luciano, PhD, of the University of Edinburgh in Scotland. "This study adds to the body of evidence that suggests the Mediterranean diet has a positive impact on brain health."

Researchers gathered information on the eating habits of 967 Scottish people around age 70 who did not have dementia. Of those people, 562 had an MRI brain scan around age 73 to measure overall brain volume, gray matter volume and thickness of the cortex, which is the outer layer of the brain. From that group, 401 people then returned for a second MRI at age 76. These measurements were compared to how closely participants followed the Mediterranean diet.

The participants varied in how closely their dietary habits followed the Mediterranean diet principles. People who didn't follow as closely to the Mediterranean diet were more likely to have a higher loss of total brain volume over the three years than people who followed the diet more closely. The difference in diet explained 0.5 percent of the variation in total brain volume, an effect that was half the size of that due to normal aging.

The results were the same when researchers adjusted for other factors that could affect brain volume, such as age, education and having diabetes or high blood pressure.

There was no relationship between grey matter volume or cortical thickness and the Mediterranean diet.

The researchers also found that fish and meat consumption were not related to brain changes, which is contrary to earlier studies.

"It's possible that other components of the Mediterranean diet are responsible for this relationship, or that it's due to all of the components in combination," Luciano said.

Luciano noted that earlier studies looked at brain measurements at one point in time, whereas the current study followed people over time.

"In our study, eating habits were measured before brain volume was, which suggests that the diet may be able to provide long-term protection to the brain," said Luciano. "Still, larger studies are needed to confirm these results."

[Jan 02, 2017] U.S. Healthcare Is A Global Outlier (And Not In A Good Way)

Jan 02, 2017 | www.zerohedge.com

Historically, the United States has spent more money than any other country on healthcare.

In the late 1990s, for example, the U.S. spent roughly 13% of GDP on healthcare, compared to about a 9.5% average for all high income countries.

However, as Visual Capitalist's Jeff Desjardins notes, in recent years, the difference has become more stark . Last year, as Obamacare continued to roll out, costs in the U.S. reached an all-time high of 17.5% of GDP . That's over $3 trillion spent on healthcare annually, and the rate of spending is expected accelerate over the next decade .

HIGH COSTS, HIGH BENEFIT?

With all that money being poured into healthcare, surely the U.S. must be getting better care in contrast to other high income countries.

At least, that's what one would think.

Today's chart comes to us from economist Max Roser (h/t @NinjaEconomics ) and it shows the extreme divergence of the U.S. healthcare system using two simple stats: life expectancy vs. health expenditures per capita.

Courtesy of: Visual Capitalist

THE DIVERGENCE OF U.S. HEALTHCARE

As you can see, Americans are spending more money – but they are not receiving results using the most basic metric of life expectancy. The divergence starts just before 1980, and it widens all the way to 2014.

It's worth noting that the 2015 statistics are not plotted on this chart. However, given that healthcare spend was 17.5% of GDP in 2015, the divergence is likely to continue to widen. U.S. spending is now closing in on $10,000 per person.

Perhaps the most concerning revelation from this data?

Not only is U.S. healthcare spending wildly inefficient, but it's also relatively ineffective. It would be one thing to spend more money and get the same results, but according to the above data that is not true. In fact, Americans on average will have shorter lives people in other high income countries.

Life expectancy in the U.S. has nearly flatlined, and it hasn't yet crossed the 80 year threshold. Meanwhile, Chileans, Greeks, and Israelis are all outliving their American counterparts for a fraction of the associated costs. buckstopshere , Jan 1, 2017 10:02 PM

A shorter life expectancy makes Social Security look more solvent.

Cooking the books.

junction buckstopshere , Jan 1, 2017 10:08 PM
The chart shows that Monsanto and the New World Order are succeeding, that more glyphosate herbicide in the food, more toxic chemtrails and more unneccessary operations are having the desired effect, to cull the American population. Helped immeasurably by the cocaine and heroin flown into the USA by the Bush Crime Cartel on Air Force cargo planes.
cheka junction , Jan 1, 2017 10:10 PM
nyc runs US health care. that tells one all he needs to know.
Pinch Dog Will Hunt , Jan 2, 2017 12:58 AM
Republitards and Freedumb-lovers need to watch Michael Moore's movie about this called "Sicko"

https://www.youtube.com/watch?v=thkBLpRwdSM

You need MORE socialism, not less.

Tards.

Chief Wonder Bread balolalo , Jan 1, 2017 10:42 PM
Australia, Norway, Switzerland, Germany, South Korea, Japan, Italy, U.S.

Which of these countries is not like any of the others? Haha. Multiculturalism is such a fantastic deal. Some "cultures" just don't make good lifestyle decisions such as thinking that grape drank and swisher sweets are healthful choices.

philipat cheka , Jan 1, 2017 10:35 PM
It is, of course, in part a "Lifestyle" issue but the US system is grossly inefficient because there are adverse incentives built in (Adverse selection etc.). The US still uses a "Fee for service" model which has never been able to control costs anywhere in the world. On top of that, high pharmaceutical prices in the US account for up to 90% of total Big Pharma profits ane Medical Malpractise insurance not only directly adds large costs but indirectly forces the use of an unnecessary number of tests and the use of the newest drugs etc. Without any sensible controls at any point in the system it will only continue to get further out of control, as ACA has illustrated.
Ballin D philipat , Jan 1, 2017 10:41 PM
What's the alternative to "fee for service?" Seems pretty standard to charge for services rendered.
philipat Ballin D , Jan 1, 2017 11:47 PM
Except that more services = more fees = higher costs. Hence multiple tests, multiple procedures and multiple drugs = higher costs and higher fees = inefficiency bias and higher still costs. Physicians are human and the Healthcare providers have become experts at maximising costs to breaking point. There are many alternative models within which to control costs through negotiated standard procedures and fixed costs for each procedure and drug formularies (including the use of generic drugs) etc. Single payer is used by much of the developed world where the supplier agrees to supply at a negotiated price or doesn't get to participate, which focuses their attention nicely. The benefits of scale, in whatever system is used, should result in lower prices but don't in the US where USG is already the largest single provider of healthcare (Medicare/Medicaid etc).
Canoe Driver philipat , Jan 2, 2017 12:36 AM
A lot of people, certainly not just doctors, are making a lot of money from this dysfunctional medical system. That is the difference no one is talking about. The money is not disappearing down a rabbit hole. It is being pocketed by thousands of multi-millionaires. It is a profit-based system. Medicine is the one field where Capitalism has no hope of efficiency. Why? Because the demand is infinite and inelastic. A recipe for the financial rape of millions.
dogsandhoney2 junction , Jan 2, 2017 12:43 AM
yeah,
and it also shows the effect of a
30% increase in psychological stress since 1980.
stress = ^stress hormones = stressed immune system =
anxiety/depression/cardiovascular disease/hyper inflammatory response/etc..

all to be treated by those in the stressed-out health care system,
usually with hyper-cost pharmaceuticals.

it's well past due date for the u.s. to become civilized by starting
single payer medical plans.

health insurance corporations = the terror.

sinbad2 heresy101 , Jan 1, 2017 10:48 PM
I wouldn't count on it.

Private healthcare and insurance is very profitable 2 of the 3 trillion the US spends on healthcare would go to shareholders and management of healthcare companies.

Mr Trump is a businessman and a realist. The media would be calling him a commie if he tried to fix it.

sinbad2 , Jan 1, 2017 10:38 PM
Americans would not have it any other way.

The countries that have the most cost effective healthcare, are countries that provide government run health insurance.

Americans would never tolerate claiming helthcare costs back from a Government run health providor, like in Australia, or waisting taxpayers money building hospitals.

Americans have to pay for their belief that private for profit health insurance is cheaper and better than government provided insurance.

Xena fobe sinbad2 , Jan 1, 2017 11:41 PM
Americans would accept single payer. But insurance companies would not.
TheEndIsNear I Write Code , Jan 2, 2017 12:05 AM
250,000 deaths in 2015 were due to medical error, the third leading cause of death in the U.S.
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medica...

38,300 people were killed on U.S. roads in 2015.
http://www.newsweek.com/2015-brought-biggest-us-traffic-death-increase-5...

33,636 deaths due to "Injury by firearms" of which only 11,208 were homicides, 21,175 were self inflicted suicides, and the remainder were due to accidental/negligent discharge of a firearm or "undetermined intent".
https://en.wikipedia.org/wiki/Gun_violence_in_the_United_States

brooklinite8 , Jan 1, 2017 11:07 PM
When I was visiting India I saw few women administer a baby birth basically in few minutes with bare hands, water, oil and some sarees. Here in the US I believe the bill comes around 5-10k at the least. Did we ever ask the question as to why do we need insurance to afford health care? Did we ever ask how has it become so out of control? Why has healthcare become such a big business? Where are the morals of humanity?

In USA the welfare of the state takes precedence to the welfare of the people. Human beings are valued at no different rate in USA than India. Welcome to the Land of the Free, Home of the Brave. Good Old USA. We are outliers and Everything we do should be an outlier. If not we will revisit and make sure it becomes an outlier. Lol

Canoe Driver brooklinite8 , Jan 2, 2017 12:57 AM
The total cost per childbirth in the US is said to be $50-65k. This figure is so outrageous that it is impossible to correlate it with the cost of providing the services. It is simply a bunch of profiteers taking their cut. And the profit can be several hundred percent of the underlying cost, precisely because the "customer" has no choice at all. Capitalism, which works well in many contexts, fails miserably in medicine. Demand is infinite and inelastic in the medical field.
hairball48 , Jan 1, 2017 11:15 PM
A shitty diet of sugar laden, high carbohydrate fast food products is what contributes to most Americans' shorter life spans, not "poor health care".

Health care is expensive because it's run by a de facto "health care mafia". I worked in the technical field of health care for 28 years. Excessive regulation is but just one reason health care is so expensive in the USA. Barriers to entry are another. Try to establish a medical school. See how long it takes. Fewer docs, the higher the price of docs. ECO 101. Don't look for a change anytime soon.

hairball

Miffed Microbio... hairball48 , Jan 2, 2017 12:14 AM
When I was an intern for clinical microbiology they gave us $300/month as a stipend. Today an internship costs $24k. This is on top of the 4 years degree. Plus the mechanization of the lab is continuing every year to the point there will be fewer jobs in the future. Hate to say it but my field is fucked. Much of my time is spent meeting regulatory compliance and it gets worse every year.

Miffed

tyberious , Jan 1, 2017 11:52 PM
Me, 20 years in Healthcare BS, MSPH, , started in reference labs, then trauma center, biotech and now in healthcare insurance quality improvement (Medicare). 1st of all the money is in the government, we all know that!

But my main response to the article is that the America sheep are being sheared! The assault starts at birth with 21 vaccines by adulthood( infant mortality), hormones in the food (preteen secondary sex characteristics)(breast cancer)(prostate cancer) , HFC (diabetes, heart diseases, and other complications) GMO's, glycophosphates, glutens, and the multitude of useless pharmaceuticals.

My point is Americans are being poisoned, not so much intentionally, but through fascist business models.

So recap: Chronic preventable illnesses, extensive bureaucracy, poor food choices (# 1 in my book), and a government that cares zero fucks about you!

chosen , Jan 2, 2017 12:18 AM
Doctors are way overpaid. Hospitals charge ridiculous prices that have no relation to reality. Insurance companies screw us even more.

The US medical system is worse than the university system. Both are scams whose main goal is to make the providers more and more money, and the users poorer and poorer. It is sick.

Canoe Driver chosen , Jan 2, 2017 1:12 AM
Basically, you are right. The idea is that the price is all the funds the "customer" has in the world, every time there is significant illness. This is because the demand for healthcare is essentially infinite and inelastic. If you want to live, pay us everything you have, then declare bankruptcy. That is what happens naturally in a for-profit medical system.

[Dec 30, 2016] Payment for Emergency Ambulance Services.

Dec 30, 2016 | dfs.ny.gov
The Office of General Counsel issued the following opinion on June 7, 2006, representing the position of the New York State Insurance Department.

Payment for Emergency Ambulance Services.

Re: Payment for Emergency Ambulance Services.

Questions Presented:

1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization ("HMO") has made partial payment of a bill?

2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization has denied payment entirely?

Conclusions:

1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the ambulance company may not bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract that provides major medical or similar comprehensive-type coverage. However, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the patient directly for the balance of the bill.

2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies available to the patient.

Facts:

This inquiry is general in nature.

Analysis:

N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See N.Y. Public Health Law § 4406(1) (McKinney 2002).

N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:

(aa)(1) Every contract issued by a hospital service company or health service corporation which provides major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law.

(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided pursuant to this subsection, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms of the policy.

(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.

(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection. . . .

N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney Supp. 2006), which applies to individual accident and health insurance policies issued by commercial insurers contain identical provisions.

In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge, which shall not be excessive or unreasonable.

Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.

Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the patient.

If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's Consumer Services Bureau.

Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies. For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.

This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation of the New York Insurance Law. No opinion is rendered on any other laws.

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.


1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36, dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.

[Dec 30, 2016] 20 things to know about balance billing

Notable quotes:
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
"... Montana Public Radio ..."
"... Sunshine State News ..."
"... The New York Times ..."
"... The New York Times ..."
Dec 30, 2016 | www.beckershospitalreview.com

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Here are 20 things to know about balance billing.

1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

2. Balance billing complaints are up 1,000 percent in Texas . According to the Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in 2015, an increase of 1,000 percent.

3. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times .

4. Emergency room services to blame, in part. A Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not. For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a 2015 study from the Centers for Public Policy Priorities in Austin.

5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient. When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance .

6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News . During a billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare, the patient was balance billed $1,170 for a total of five stitches.

7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

8. Payers have sued providers for 'excessive' out-of-network fees. Aetna has sued a half dozen out-of-network physicians in recent years, alleging gross over charging for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635.

9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of balance billing his account for an out-of-network rate after the patient submitted in-network payment rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation, Matthew Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However, Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.

10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. Those in rural areas often must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest after PacificSource contributed a policy cap of $13,000.

11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider-based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying a $30 copayment for in-network care with a Cleveland Clinic chiropractor, Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her insurance plan refused to cover.

12. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation does not apply to existing outpatient centers that already engage in the practice, however.

13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. The administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network.

14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.

15. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. The states of Illinois and New Yorkhave arbitration methods in place, and Florida , Washington and Pennsylvania are currently considering a similar resolution methods.

16. New York has some of the strongest consumer protection laws. Under New York law , consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes.

17. Florida state legislature is currently embroiled in a fight to pass balance billing laws. Legislation to outlaw balance billing in Florida has continued to creep through the state legislature since last fall. Introduced in both the house and senate, the bills have sparked conflicting and outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement rates, reports Sunshine State News .

18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from balance billing who went to in-network facilities for emergency services, reports Consumerist . In non-emergency cases, it would require providers to notify patients within 24 hours if an out-of-network specialist will be involved in an episode of care.

19. Consumers don't know how to navigate the legal waters. According to a Consumer Union report, 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn't know their rights to fight the bills. An overwhelming majority (87 percent) did not know which agency or department in their state government is tasked with handling complaints about health insurance. "So many times, people just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR .

20. The New York Times dedicated a series to consumer encounters with surprise healthcare bills. Elisabeth Rosenthal's series in The New York Times entitled Paying Til it Hurts examined the personal and financial implications of excessive, unexpected medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments often feature individuals with unaffordable balance bills like Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant he never knew was present during surgery.

[Dec 26, 2016] IBMs Watson Used In Life-Saving Medical Diagnosis

Dec 26, 2016 | science.slashdot.org
(businessinsider.co.id) 83
Posted by EditorDavid on Sunday December 11, 2016 @09:34PM from the damn-it-Jim-I'm-a-doctor-not-a-supercomputer dept.
"Supercomputing has another use," writes Slashdot reader rmdingler , sharing a story that quotes David Kenny, the General Manager of IBM Watson:
"There's a 60-year-old woman in Tokyo. She was at the University of Tokyo. She had been diagnosed with leukemia six years ago. She was living, but not healthy. So the University of Tokyo ran her genomic sequence through Watson and it was able to ascertain that they were off by one thing . Actually, she had two strains of leukemia. They did treat her and she is healthy."

"That's one example. Statistically, we're seeing that about one third of the time, Watson is proposing an additional diagnosis."

[Dec 26, 2016] New Google Trusted Contacts Service Shares User Location In Real Time

Dec 26, 2016 | tech.slashdot.org
(onthewire.io) 89 Posted by msmash on Monday December 05, 2016 @11:00AM from the interesting-features dept. Reader Trailrunner7 writes: Google has spent a lot of time and money on security over the last few years, developing new technologies and systems to protect users' devices. One of the newer technologies the company has come up with is designed to provide security for users themselves rather than their laptops or phones .

On Monday Google launched a new app for Android called Trusted Contacts that allows users to share their locations and some limited other information with a set of close friends and family members. The system is a two-way road, so a user can actively share her location with her Trusted Contacts, and stop sharing it at her discretion. But, when a problem or potential emergency comes up, one of those contacts can request to get that user's location to see where she is at any moment. The app is designed to give users a way to reassure contacts that they're safe, or request help if there's something wrong.

[Dec 26, 2016] Are Psychiatric Medications Hurting More Patients Than They Help?

Notable quotes:
"... Scientific American ..."
Dec 26, 2016 | science.slashdot.org
(scientificamerican.com) 431

Posted by EditorDavid on Sunday December 18, 2016 @01:34PM from the depressing-anti-depressant-news dept.

An anonymous reader quotes Scientific American 's Cross-Check blog :

Two new posts on this website have me contemplating, once again, the terrible possibility that psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013, almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."

This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University of South Carolina, acknowledges the "inconvenient truth" that Americans' mental health has, according to some measures, deteriorated ...

It's all more evidence of something their blogger wrote in 2012. "American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis -- harmful medical treatment -- in history ."

[Dec 26, 2016] Google Successfully Uses Machine Learning To Detect Diabetic Retinopathy

Dec 26, 2016 | news.slashdot.org
(betanews.com) 30 Posted by BeauHD on Tuesday November 29, 2016 @05:40PM from the medical-breakthrough dept. BrianFagioli writes from a report via BetaNews: Diabetic eye disease is caused by retinopathy. Affected diabetics can have small tears inside the eye, causing bleeding. Over time, they can lose vision, and ultimately, they can go blind. Luckily, Google has been trying to use machine learning to detect diabetic retinopathy. Guess what? The search giant has seen much success. Not only are the computers able to detect the disease at the same level as ophthalmologists , but Google is actually slightly better! "A few years ago, a Google research team began studying whether machine learning could be used to screen for diabetic retinopathy (DR). Today, in the Journal of the American Medical Association , we've published our results: a deep learning algorithm capable of interpreting signs of DR in retinal photographs, potentially helping doctors screen more patients, especially in underserved communities with limited resources," says Lily Peng , MD Ph.D., Product Manger at Google. She goes on to say "our algorithm performs on par with the ophthalmologists, achieving both high sensitivity and specificity . [...] For example, on the validation set described in Figure 2, the algorithm has a F-score of 0.95, which is slightly better than the median. F-score of the 8 ophthalmologists we consulted (measured at 0.91)."

[Dec 26, 2016] Japanese City Tags Elderly Dementia Sufferers With Barcodes

Dec 26, 2016 | science.slashdot.org
(japantimes.co.jp) 115 Posted by EditorDavid on Sunday December 11, 2016 @03:34PM from the scans-of-the-setting-sun dept. "The Japanese city of Iruma has introduced scannable adhesive barcodes to tag fingernails of senior citizens with dementia who are prone to getting lost as a way to help concerned families find missing loved ones," writes HughPickens.com , citing this article from Japan Times : The adhesive QR-coded seals for nails -- part of a free service launched last month and a first in the country -- measure just 1 cm (0.4 inches) in size. "Being able to attach the seals on nails is a great advantage," says a city worker. "There are already ID stickers for clothes or shoes but dementia patients are not always wearing those items." If an elderly person becomes disorientated, police will find the local city hall, its telephone number and the wearer's ID all embedded in the QR code. Japan is grappling with a rapidly aging population , with senior citizens expected to make up a whopping 40 percent of the population around 2060 .
The article describes Japan as "a country where 4.8 million people aged 75 or older hold a license... Last month, police started offering discounts for noodles at local restaurants to elderly citizens who agreed to hand in their driving licenses."

[Dec 26, 2016] 'Fatal' Flaws Found in Medical Implant Software

Dec 26, 2016 | tech.slashdot.org
(bbc.com) 38 Posted by msmash on Thursday December 01, 2016 @07:35PM from the security-woes dept. Security researchers have warned of flaws in medical implants in what they say could have fatal consequences . The flaws were found in the radio-based communications used to update implants, including pacemakers, and read data from them. From a BBC report: By exploiting the flaws, the researchers were able to adjust settings and even switch off gadgets. The attacks were also able to steal confidential data about patients and their health history. A software patch has been created to help thwart any real-world attacks. The flaws were found by an international team of security researchers based at the University of Leuven in Belgium and the University of Birmingham.

[Dec 26, 2016] New Study Shows Marijuana Users Have Low Blood Flow To the Brain

Dec 26, 2016 | science.slashdot.org
(eurekalert.org) 560 Posted by BeauHD on Wednesday November 30, 2016 @08:00AM from the time-for-a-check-up dept. cold fjord writes: State level marijuana legalization efforts across the U.S. have been gaining traction driven by the folk wisdom that marijuana is both a harmless recreational drug and a useful medical treatment for many aliments. However, some cracks have appeared in that story with indications that marijuana use is associated with the development of mental disorders and the long-term blunting of the brain's reward system of dopamine levels . A new study has found that marijuana appears to have a widespread effect on blood flow in the brain. EurekAlert reports: "Published in the Journal of Alzheimer's Disease , researchers using single photon emission computed tomography (SPECT), a sophisticated imaging study that evaluates blood flow and activity patterns, demonstrated abnormally low blood flow in virtually every area of the brain studies in nearly 1,000 marijuana users compared to healthy controls, including areas known to be affected by Alzheimer's pathology such as the hippocampus. According to Daniel Amen, M.D., 'Our research demonstrates that marijuana can have significant negative effects on brain function. The media has given the general impression that marijuana is a safe recreational drug, this research directly challenges that notion. In another new study just released, researchers showed that marijuana use tripled the risk of psychosis. Caution is clearly in order.'"

[Dec 26, 2016] 5 Ways to Lower Your Medical Bills Personal Finance

Notable quotes:
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Nov 29, 2007 | US News

Insurance companies aren't the only ones who can negotiate a lower price -- you can, too. Here's how.

By U.S. News & World Report

Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another ailment: medical bills.

Six hours in an operating room, two knee replacements, medications and a five-day hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist, physical therapy, additional medicines and special exercise equipment to help him recover.

"One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills."

Luthra's insurance company was able to negotiate with the hospital so that it paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.

But individual patients can haggle for lower medical bills, too. Here are tips on how to go about it.

Work up the courage to ask. It's not just insurance companies that can negotiate.

"The typical insurer gets about a 60% discount," says Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and ask the chief financial officer , you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the CFO how much they or the person in the billing office are willing to give you."

Although it's common to negotiate with a real-estate agent or car salesperson you probably never will see again, it's much more difficult to negotiate with a doctor you trust to make you well and to provide continuing care for your family. Only 31% of Americans have tried to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated. But of those who tried, 93% have been successful at least once, and more than a third saved more than $100.

Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get a fair price as well as you do.

But even though almost 80% of physicians will prescribe a generic medication over a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey of physicians by the Center for Health System Change and the University of Chicago

If money is an issue, you need to ask your doctor if cheaper, medically sound options are available. The trick is to keep it friendly and ask nicely. For minor health ailments such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating required.

Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in other billing issues, so you need to find a person with the ability to adjust your bill.

"I would suggest the consumer go to the office manager," says Timothy Cahill, a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients. The office manager should be able to direct you to the person in charge of billing.

Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.

"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and the chief technology officer of Vimo.com, a company that uses public records to figure out what prices insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing terms, paying credit card transaction fees and sending collection agencies after patients who fail to pay.

Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your insurance should cover and try to negotiate a discount off the sticker price.

"As a consumer, just like a detective, you have to really understand the specifics of your insurance benefit plan, take the initiative of setting up conference calls (including yourself, the hospital and your insurance company) proactively, and you have to document everything," says Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just pay the bill as is."

This article was reported and written by Emily Brandon for U.S. News & World Report.

[Dec 26, 2016] How to avoid and handle surprise medical bills

Notable quotes:
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
thehill.com
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

When these out-of-network providers send you a bill for their services, you may have to pay the full amount out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill that your insurance fails to cover. And the balance bill generally requires you to pay more than the out-of-pocket amount you would have owed if you had been treated by an in-network provider.

Emergency rooms are one of the most common locations where healthcare results in surprise bills.

As detailed recently in an article by two Yale scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER visits to an in-network facility involved out-of-network physicians. The average balance billed to patients was $622.55, though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills.

Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill.

Several states have already enacted laws to protect consumers against surprise bills, although some of the statutes protect patients only in the case of balance bills for out-of-network ER services for a serious medical emergency. Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps you can take to protect yourself from such surprises.

Prevent surprise bills

The best defense against a surprise bill is prevention. If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available.

However, for a planned surgery or other procedure, you probably have time to speak up. Make sure that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask your physician and your hospital in advance if they can arrange to have only in-network providers treat you.

Some hospitals may have no in-network specialist for care you might require. Find out if another hospital in your area can provide all your necessary services on an in-network basis. In some areas, there may be no in-network specialists available of the type you need. In that case, inform your plan that its network lacks necessary services and find out if the terms of the plan or state law provide you protection from large balance bills in such circumstances.

Always refer to your plan by its exact official name. Often insurers have multiple plans with similar names but different networks. If you use the wrong plan name when inquiring about a plan's network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you have documentation. Ask for the names of the providers who will be involved in your care, and check with your insurer and with the providers themselves to see if they are all in your plan's network.

Check if your state protects consumers

If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services. Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.

At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.

If your state does not provide protection

If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate.

If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org, to estimate what the procedure typically costs in your locality. If your plan's reimbursement is based on an amount that is less than the typical charge, you can use this information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider's charge is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above the typical market rate.

If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth

[Dec 25, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
"... This piece is by Drew Anne Scarantino ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

How You Can Avoid Outrageous E.R. Bills (Really!)

When it comes to a trip to the E.R., the reality is that there's usually no time to shop around and compare prices in advance. But if you do some research before an emergency happens, you could potentially keep costs significantly down.

The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of dollars in savings shaved off a potentially outrageous E.R. bill.

This piece is by Drew Anne Scarantino.

[Dec 04, 2016] The goal of the majority of providers is to increase total sales by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance and is not necessarily indicative of a purely capitalistic motive.

Notable quotes:
"... The goal of the majority of providers is to increase total "sales" by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance and is not necessarily indicative of a purely capitalistic motive. ..."
www.amazon.com
Dwight Clark on May 1, 2013
An author that really knows and understands the complexities of the healthcare (sickcare) industry

I was a practicing cardiologist in the US for over 30 years. I, as most other practicing cardiologist, was trained and fully believed the prevailing methods of diagnosis and treatment were not only correct but absolutely necessary. Several decades of experience taught me this is not close to being accurate. The majority of medical tests, and much of the treatment, is not only unnecessary, but harmful and/or dangerous. The goal of the majority of providers is to increase total "sales" by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance and is not necessarily indicative of a purely capitalistic motive.

David Goldhill is one of the few authors that have experienced this travesty and is educated and intelligent enough to understand the consequences of this nationwide epidemic and the needless, wasteful, and dangerous care. His ability to sort through all of the "noise" prevalent in the governmental and media diatribe and isolate the real problem as full insurance for everyone is unique. This system is doomed for failure. There will never be enough resources to fund medical care as long as the consumer is not the payer. They will always demand more and the providers are happy to accommodate them.

I have left the US and am presently living in Beijing, China, attempting to establish purely preventive heartcare clinics. This is more general education regarding diet, smoking, sedentary lifestyle, and alcohol abuse. than traditional western medicine. Less income, but certainly more satisfying.

[Dec 04, 2016] Overuse of Cardiac Stents Linked to Patient Deaths

About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David Brown of Stony Brook University School of Medicine
Notable quotes:
"... About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a year, and controversy surrounding this practice has spurred nationwide litigation and a federal investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice. ..."
"... Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked – a condition called in-stent thrombosis. ..."
"... Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur. ..."
"... Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson. ..."
"... Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson. ..."
"... Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said. ..."
medstak.com

About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a year, and controversy surrounding this practice has spurred nationwide litigation and a federal investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice.

For the most part, stenting procedures are relatively low in risk and moderately safe. However, as with any surgical procedure – even a minimally invasive one – there is a risk of developing complications. Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked – a condition called in-stent thrombosis.

Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur.

Additionally, manipulating arteries with a stent or any other sort of medical procedure can lead to the walls of the blood vessel becoming injured or damaged. The innermost layer of coronary arteries, known as the endothelium, is particularly susceptible to this sort of damage; the result can be the formation of scar tissue in the area of the stent, and this too can lead to the artery re-narrowing in a process known as restenosis. Treating Restenosis can involve an additional stenting procedure, though in severe cases where a stented artery recloses it may be necessary to have a patient undergo a coronary artery bypass to remedy the condition.

Overuse of cardiac stents leads to patient deaths

Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson.

After suffering chest pain, Peterson paid a visit to cardiologist Dr. Samuel DeMaio, who inserted 21 stents in his patient's chest over a period of eight months, including five mesh tubes in a single artery. Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson.

She later sued DeMaio for cardiac stent malpractice – an increasingly common charge in a Dr. Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine Healthgrades.comqaDr. Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine Healthgrades.com

Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said.

Cardiac stent problems cost $2.4 billion a year

The U.S. health care system spends an estimated $2.4 billion a year caring for patients that received unnecessary cardiac stents, says Dr. Sanjay Kaul, of Cedars-Sinai Medical Center. Patients face a much greater risk for complications like coronary scar tissue, blood clots and uncontrolled bleeding from anticoagulant medications – all of which can be life-threatening. Jim Simecek told Bloomberg that he is on blood-thinning medicine for the rest of his life to prevent clots in the cardiac stents he received from a Cleveland doctor who is currently the subject of a federal probe.

Sixty-four year old Monica Crabtree's cardiac stent problems caused a torn artery, which resulted in an infection and her death, according to her husband. He also pursued legal action after it was determined by another cardiologist that Monica's stent was completely needless. The surviving spouse recovered $240,000 in a malpractice settlement brought against the surgeon.

FDA reports hundreds of deaths attributed to cardiac stents

Some 773 patient deaths linked with cardiac stents were logged with the FDA last year, according to Bloomberg. Though this figure has jumped more than 70 percent since 2008, with recent media coverage on cardiac stent overuse and ongoing federal investigations, cardiologists may be using fewer stents and only on suitable patients.

John Harold, president of the American College of Cardiology said the doctors who have been charged with cardiac stent malpractice or fraud are essentially "outliers" in their community, and that these surgeons fail to represent the "overwhelming majority."

[Nov 27, 2016] The likely death toll from Voixx had actually been several times greater than the FDA estimate

Nov 27, 2016 | www.unz.com
Author James Bovard has described our society as an "attention deficit democracy," and the speed with which important events are forgotten once the media loses interest might surprise George Orwell.

Consider the story of Vioxx, a highly lucrative anti-pain medication marketed by Merck to the elderly as a substitute for simple aspirin. After years of very profitable Vioxx sales, an FDA researcher published a study demonstrating that the drug greatly increased the risk of fatal strokes and heart attacks and had probably already caused tens of thousands of premature American deaths. Vioxx was immediately pulled from the market, but Merck eventually settled the resulting lawsuits for relatively small penalties, despite direct evidence the company had long been aware of the drug's deadly nature.

Our national media, which had earned hundreds of millions of dollars in advertising revenue from Vioxx marketing, provided no sustained coverage and the scandal was soon forgotten.

Furthermore, the press never investigated the dramatic upward and downward shifts in the mortality rates of elderly Americans that so closely tracked the introduction and recall of Vioxx; as I pointed out in a 2012 article , these indicated that the likely death toll had actually been several times greater than the FDA estimate. Vast numbers Americans died, no one was punished, and almost everyone has now forgotten.

[Nov 26, 2016] Fat is the Cause of Type 2 Diabetes

Notable quotes:
"... We can decrease insulin resistance, however, by decreasing fat intake. ..."
Nov 26, 2016 | nutritionfacts.org

We can also do the opposite experiment. Lower the level of fat in people's blood and the insulin resistance comes right down . If we clear the fat out of the blood, we also clear the sugar out. That explains the finding that on the high fat, ketogenic diet, insulin doesn't work very well. Our bodies become insulin resistant. But as the amount of fat in our diet gets lower and lower, insulin works better and better-a clear demonstration that the sugar tolerance of even healthy individuals can be impaired by administering a low-carb, high-fat diet. We can decrease insulin resistance, however, by decreasing fat intake.

[Nov 24, 2016] Cost of an Angiogram - Consumer Information

Nov 24, 2016 | health.costhelper.com
What People Are Paying - Recent Comments
Angiogram of heart
Amount: $55,150.00
Posted by: Pamela Garrett in Palm Springs, FL. Posted: September 1st, 2015 07:09PM
Physician: Medical Center: Jfk medical center
Had this procedure done to check heart due to abnormal stress test. Did not need any stents or any other procedure as everything was negative. I about had a heart attack when I opened the bill!!!
Was this post helpful to you? yes no Report prohibited or spam
Angiogram
Amount: $30,000.00
Posted by: StubbsMagoo in Richland, WA. Posted: January 20th, 2015 08:01PM
Physician: Doctor Korimerla Medical Center: Kadlec Medical Center Richland, WA.
My angiogram was done through the wrist area, with no stents, and was over in 20 minutes. 30 k ...really? I wish I was one of the millions in the U.S. that had no insurance to rape, then I could have gotten it for free. So now I am looking at 2k I owe immediately!!!!! This price is ridiculous and Kadlec Medical Center in Richland Washington should be ashamed and the community should be appalled. Shame on you Kadlec!!!!
Was this post helpful to you? yes no

[Nov 24, 2016] More young people contracting old-age conditions including varicose veins due to sedentary lifestyles The Independent

Nov 24, 2016 | independent.co.uk
People in their 20s and 30s are being treated for varicose veins, knee joint problems and other conditions usually associated with old age.

Bad postures and sedentary lifestyles have led to a rise in the number of younger people experiencing complaints such as back pain and haemorrhoids, according to analysis by Bupa.

Data from more than 60,000 medical procedures in 2015 was compiled by the private healthcare group .

[Nov 24, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

[Nov 24, 2016] Legislature's ambulance bill is too costly

Notable quotes:
"... Price-gouging by ambulance services, including those run by municipalities, was always a disreputable exercise, preying on people who suffer emergency illnesses or injuries. ..."
"... The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the Legislature is right to go above it. But 300 percent is too high. ..."
The Boston Globe

When the Legislature finally produced a measure to prevent ambulance companies from gouging out-of-network patients and their insurers, it set a limit of 300 percent of the federal Medicare reimbursement rate or the ambulance's regular fee, whichever is lower. This is a ceiling that might function more like a floor, pushing ambulance firms to raise their rates to 300 percent of Medicare. It's a bad idea.

Price-gouging by ambulance services, including those run by municipalities, was always a disreputable exercise, preying on people who suffer emergency illnesses or injuries. And when insurers decided to fight back by reimbursing patients a set amount, rather than pay whatever the ambulance demanded, they, too, threw patients under the wheels: Ambulances expected the patients to make up the difference between the insurers' rate and the ambulance's. Few situations better illustrate patients' frustrations with the health care system.

So the unwanted task of deciding on an appropriate level of reimbursement fell to the state. And it should surprise no one that both insurers and ambulance services are lobbying for the best possible deal, while grumbling about government interference. Fire departments and other municipal offices that operate ambulances are hoping their friends in the Legislature can deliver a generous fee.

The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the Legislature is right to go above it. But 300 percent is too high. Patrick should veto the bill and ask the House and Senate to send it back to him with a lower price ceiling.

[Nov 23, 2016] 7 Tips For Fighting And Paying A Big Hospital Bill

Notable quotes:
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Sep 17, 2013 | www.forbes.com

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

2. Vigilantly review the bills. "It's very common for hospital bills to contain errors and overcharges, so make sure you've actually received the services they said you did," Detweiler says.

Candice Butcher, vice president of Medical Billing Advocates of America, says if you're discharged in the morning (as most patients are), protest if you're socked with a full daily-room rate for the date you left the hospital.

And if you brought your medications with you, make sure you weren't charged for them by the hospital. "This frequently happens," Butcher says.

Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily-room charge, because, Butcher says, they are "considered the cost of doing business."

3. Challenge your health insurer's decisions, when warranted. Keep track of any hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy. If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections.

4. Negotiate bills once you know how much you'll have to pay out of pocket. If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital or clinic business office staff to arrange a payment plan."

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the advocacy firm Copatient.com, which charges 30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.

Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges no more than $3,000. Attorneys often charge 30% of the savings they achieve.

... ... ...

Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter TWTR -0.69% @consumermayer.

[Nov 23, 2016] How Can I Negotiate A Sky-High Ambulance Charge On My Medical Bill

Notable quotes:
"... My husband suffered a heart attack when we were on vacation, and I called an ambulance. He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As it turns out, the ambulance service wasn't in our health insurer's network, so they paid only a small portion of the bill. We're making small payments on the balance, but the initial bill seems so high. The collector calls all the time to demand we pay the balance in full. Is there anything we can do to get the bill looked at and possibly lowered? ..."
"... Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate a lower balance. ..."
"... I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges, inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing department immediately. ..."
"... Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost. ..."
"... Medicare negotiates, on average, a 73% discount. ..."
"... Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be persistent. If your efforts prove fruitless, you can always consider hiring a professional ..."
| www.forbes.com

... ... ...

Question:

My husband suffered a heart attack when we were on vacation, and I called an ambulance. He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As it turns out, the ambulance service wasn't in our health insurer's network, so they paid only a small portion of the bill. We're making small payments on the balance, but the initial bill seems so high. The collector calls all the time to demand we pay the balance in full. Is there anything we can do to get the bill looked at and possibly lowered?

Answer:

I'm glad to hear your husband is recovering, but I am sure the stress of an unexpected medical bill isn't helping him heal. Ambulance bills are notoriously costly, but yours seems to be inflated. Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate a lower balance.

I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges, inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing department immediately.

Even if the bill is correct, you should still set up a time to speak with someone in the billing office-someone with the authority to negotiate on your balance. Go into the conversation equipped with the knowledge that Medicare and insurance companies rarely pay the hefty price tags that consumers see.

Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost. In the case of inpatient hospital bills, for example, a NerdWallet study found Medicare negotiates, on average, a 73% discount. While the ambulance service may not agree to such a large discount for you, coming to any negotiation equipped with such knowledge will put the company on notice that you aren't going to lay down and take its bullying or an inflated bill.

... ... ...

Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be persistent. If your efforts prove fruitless, you can always consider hiring a professional . A medical billing advocate is able to represent clients' interests much in the way an attorney would advocate for you in a courtroom. Their experience and expertise in the field can sometimes prove more effective (and less stressful) than taking on a stubborn provider alone.

See also

[Nov 23, 2016] 7 Steps in Appealing a Health Insurance Denial

Notable quotes:
"... As a practicing physician who is fed up with the way insurance carriers have managed to take over the delivery of health care in this country, my comments, I warn you, will be brutally frank. The way the game is played, the providers of health care bill as much as they believe they can get away with. ..."
"... That's because they are in business to make money - that's why it's called "for profit" health care. The insurance carriers try their damn best to find excuses to not pay as many of these charges as they can. Same reason. These two conspirators become co-conspirators when they play the game of "crap runs down hill". ..."
"... So here's my advice. Don't pay any "balance billing" no matter what they choose to call it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for specifics as to the balance billing. ..."
Nov 23, 2016 | blogs.nytimes.com
MJ Columbus OH July 12, 2011

Unfortunately sometimes the only way to get around denial of precertification is to ask your doctor to lie. I had an MRI after a fainting episode that showed possible MS, which runs in my family. All other diseases were excluded. The medical recommendation is to get a follow-up MRI in 6-months. Because I wasn't having active symptoms, the follow-up MRI was not precertified when ordered by my neurologist. I went to my family physician for help, she requested the MRI, saying I was having headaches (everybody gets one occasionally, right?). I immediately got the necessary MRI and am now being treated. I think the insurance company didn't really want to deny the MRI, they wanted to delay expensive treatment, which was the likely outcome.

o'keefe illinois July 12, 2011

I am currently appealing a claim with HealthLink. Too long to go into but it involves an Intensive Outpatient Treatement program for my 20 year old son. There own guidelines state that this may well be the best initial choice for treatment. However, they advised us when they would not precertify that he needs to fail at out patient treatment and community support. Really? So I get to the External appeal process. Healthlink contracts with MCMC to provide the physician to do the reveiw. Can we say conflict of interest? She spits out the same verbage used to deny the precertification but mentions criteria that is no longer being used to asses such cases. Or and then there is the mention of my son's "wearable cardioverter defibrillor" has nothing to do with our case. So I appeal to the State of Illinois (eye roll) and am told I cannot appeal a denial of a precertification. I must have a denied claim. OK, but I can't get to the denied claim as HealthLInk won't even percert the care. Who are these people?

Clint N. NYC July 12, 2011

I recently had to deal with the insurance company VS primary care provider VS patient VS lab test provider. Its a cluster-expletive. Even trying to keep track of who said what when is difficult. Not too mention the hours upon hours of your precious time it *will* consume.

Short summary:

I had a severe flu (possibly swine flu) and made a doctor's appointment. They were very busy and couldn't see me for 2 weeks. When I came in for my appointment, I had recovered from the flu. My appointment was reclassified as well-care. My job's health insurance plan was revised two months prior to exclude well-care. I was now on the hook for 100% of the cost of the visit. The doctor ordered a full blood work since I was a new patient.

I realize it was my fault that I didn't know well-care wasn't covered. Lesson learned - I've read my EOB a couple times now, cover to cover. Unfortunately, I still only kind of know what is covered.

Anne Marie Bryn Mawr, Pa. July 12, 2011

As a practicing physician who is fed up with the way insurance carriers have managed to take over the delivery of health care in this country, my comments, I warn you, will be brutally frank. The way the game is played, the providers of health care bill as much as they believe they can get away with.

That's because they are in business to make money - that's why it's called "for profit" health care. The insurance carriers try their damn best to find excuses to not pay as many of these charges as they can. Same reason. These two conspirators become co-conspirators when they play the game of "crap runs down hill".

That's when they come up with things like "co-pays", "deductibles", "co-insurance", and a whole host of creative ways of attempting to coerce the patient to pick up the tab.

So here's my advice. Don't pay any "balance billing" no matter what they choose to call it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for specifics as to the balance billing.

Don't accept their response. Write again. Write to the insurance carrier and appeal.

Then write the provider with the appeal number from the insurance company. Keep it going round and round. If contacted by a collection agency, write back explaining your appeals and that your financial condition won't allow you to pay without getting a disposition from your claim, and a better explanation from the provider as to why the procedure wasn't covered. Tell them to not contact you again. Tell them that you refuse to pay until you get a decent explanation. Dare them to sue you. CC a law firm on all correspondence. Make the providers get hurt enough to fight against the carrier. Bust up their friendship. Neither will hire a lawyer to get you. The publicity is the only thing they are afraid of.

KR NYC July 11, 2011

I am in the process of filing a claim for the first time ever. Cigna denied coverage for an operation after the fact. This was not even a marginal case, it was an obvious medical need. I suspect that insurance companies simply play the odds, deny and spread the costs to hospitals, surgeons, patients and maybe themselves. A lot less than paying the whole thing. This has nothing to do with medicine, as I have discovered. It is about how to boost revenues and damn fairness and the patient. Plan to fight and publicize my fight. This is as clean cut a case that can be found.

Walter San Diego, CA July 11, 2011

Having handled over 4000 health care appeals over the past 15 years, this article is a pretty good basic overview (so long as most of the Comments are ignored). The Affordable Care Act may ultimately be helpful in making this hodgepodge of rules more uniform, but that remains to be seen. The ultimate message for patients must remain clear: It is imperative to FIGHT for the care you need using all available resources and expertise at your disposal!

Frederick Willman Madison, WI July 11, 2011

One more reason why we must furiously resume pushing for medicare for all to replace the GOP health solution of just die folks.

FW
Madison, WI.

Lisa NYC July 11, 2011

#7 is correct: it is a game to the health insurance companies. They routinely deny perhaps 40% of all claims thinking that most people will just shrug off the denial and go away. The key is to keep calling, resubmitting and fighting the portion that they have denied. I have received initial denials for the most ludicrous reasons: the doctor retired; there is no such doctor at that address, etc... It is a game designed for the health insurance companies to win UNLESS you fight back.

Mollace Toledo, Ohio July 11, 2011

"If you feel too frail or overwhelmed to pursue an appeal yourself, nonprofit groups like the Patient Advocate Foundation can provide guidance for free."

A single person battling a life-threatening illness or condition is, of course, going to be overwhelmed and frail. Insurance companies bank on it. My suggestion is to start with advocacy first. Insurance companies make things difficult because they are in the business of making money, not helping patients. They want you to give up. When you have another person or two in your corner everything moves along better. Especially when the advocate knows how to fight hard and isn't afraid to speak frankly. There are witnesses to what is happening and you are taken more seriously.

It is ironic that there is now Health Proponent, a company that will fleece you in order to "advocate" for you. Only in America, folks.

Susan is a trusted commenter Eastern WA July 11, 2011

I had to have all my teeth extracted before I could begin treatment for throat cancer. I did not have enough dental insurance, and the oral surgeon's office told me that medical had informed them it would not pay the remainder.

I contacted mymedical insurance company, which recommended that I wait for a denial and then appeal. I pointed out that by that time I would be quite sick from the radiation, and would like to deal with it while I was still capable. Turns out there is a board that considers these things, so I had both of the oral surgeons, my oncologist, and my ENT all write letters to this board. The medical insurance company paid for the whole thing, since it was proven to be a medical necessity.

Now, if we could just get the oral surgery place to refund all that we paid, plus the dental insurance, so that the dental insurance can in turn use my benefit to help repay us for the dentures . . .

Michael in Vermont North Clarendon, VT July 11, 2011

This happens all the time. There are gajillions of codes used by the insurance companies. If your healthcare provider uses an incorrect code, then the insurance company won't pay the bill. Call the insurance company and find out what the codes should be. Then call or visit your health care provider and bring them up to date on the codes. Blue Cross and Blue Shield have all of their codes listed on their Internet site.

tough old bird Virginia July 11, 2011

sounds like Chinese water torture.

Harry St. Louis, MO July 11, 2011

You start off with the most important thing in any claim or grievance, and in almost any business deal - get it (and put it) in writing!

All the phone calls in the world will not help you but just trip you up. (And if you have to hire an attorney, this will save time and money.)

Robert Leff Cambridge, MA July 11, 2011

I have a friend who broke his back in a car accident and as a result has had ongoing medical issues. He told me that he treats the denials as a game. You submit the entire claim, they reject part of it, you resubmit the rejected part, they pay part and reject part, and you keep on going until you get your money. It seems cruel, but an insurance company's profit is the amount of money each year that they do not pay out in claims, so the incentive to deny is very strong.

Caught in the Middle Tenafly, NJ July 11, 2011

After some back and forth, Medicare paid its share of a claim that I, rather than my doctor, submitted,
I then submitted the claim to my secondary insurer who, after further back and forth, said that it could not pay the claim because it had been agent for my former employer and no longer had access to the employer's funds. The employer in turn, after more back and forth, says it plans tosubmit this and other claims to the current secondary employer for payment rather than pay them directl y. The process seems to go on forever.

mary browning is a trusted commenter miami beach, FL July 11, 2011

Good heavens, why should it take instructions that would require a graduate degree? In other countries none of this mess would be required. Disgraceful.

If you are sick and don't feel up to doing things, how, indeed could you do what you are said to do to simply get what is required or due to you?

George Eliot Annapolis, MD July 11, 2011

Stop. Just sue them and put them on the defensive. Denial of claims is the way the criminal health insurance companies provide record salaries to the gangsters who run the companies, and big dividends to their share holders.

All hail the American Plutocracy!

Barry New Jersey July 11, 2011

Appealing a health insurance denial which involves a substantial financial liability can be viewed like any other do-it-yourself endeavor. If you are comfortable handling a matter upon which, say, $75,000 or more is at stake (which is not uncommon), good luck. On the other hand, if the stakes are high, you may want consider having it handled by an attorney who specializes in this area of practice

TB is a trusted commenter Philadelphia July 11, 2011

As someone who went through this process recently, I would make the following suggestions:
1) Be very legalistic in your approach to the appeal, and quote appropriately from the policy and from law (this of course assumes you have a solid legal basis for your appeal).
2) Inform the insurance company in writing that if they require a full appeal, you will hire legal counsel to research and document your appeal.
3) Remind the insurance company that under ERISA, if you ultimately win, you are entitled to reimbursement of your legal fees and expenses.

This won't win obviously if you are on shaky legal ground. But if the insurance company is on shaky ground and just trying to avoid paying a claim (which was the case with us), this sort of saber rattling can help resolve the question quickly before you end up in a formal appeal. The insurance company doesn't want you to hire a lawyer if you have a good chance of winning.

stevesw1 Baltimore, MD July 11, 2011

Assistance with appeals and grievances from denials of health insurance claims is a service that many state Attorneys General provide for free, so check with your Attorney General's office before paying someone to assist you with the process.

[Nov 22, 2016] Hiring a Guide to the Medical Bill Maze

Notable quotes:
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
Apr 29, 2013 | Bloomberg

When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based financial planner. "All of a sudden we were getting bills for over $30,000."

As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate. It negotiated with the physician's health-care group to reduce her bill to $7,000.

More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy because of illness have some form of health insurance. So hiring a medical billing advocate can be an essential part of the cure to financial ills.

Yet finding the right advocate can be tough, and those in the direst situations can ill afford the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson, co-president of the Alliance of Claims Assistance Professionals (ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people willing to pay you to help them." Despite long experience, Stephenson herself has trouble making a good living purely from advocacy, so she supplements her income by serving as an expert witness in medical lawsuits.

Employees working at sizable companies may already have access to a health advocate. Just over half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner, a senior consultant for Mercer's Total Health Management practice. Many employees don't know the benefit exists, he says, and the services generally aren't as customized as those of an independent billing advocate.

Credential Check

Unlike with more established professions such as accounting or law, there is no standard credential to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate has certifications in medical bill coding from either the American Academy of Professional Coders or the American Health Information Management Association.

Many people with those designations aren't advocates, however, working instead for hospitals or insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care system, you'll need someone who specializes in your specific kind of billing problem.

A good place to start is Claims.org, ACAP's website. It lets you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers' compensation and insurance for special needs children.

Privacy Issues

The best way to find the right specialist is to ask the advocate for a resume and references. This can be tricky, because laws about disclosing private medical information are so strict that some advocates have difficulty providing references. In order to do so, their clients must agree to discuss their medical history.

Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy firm VersaClaim in 2002, she ran an organization that helped doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.

A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible with my medical experience in real life?" she says. "Do the charges look realistic, or is there an $85 Tylenol?"

Location Matters

Another important factor to consider is an advocate's location. State laws vary in how they regulate insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty much universal, so the client's location doesn't really matter."

For a patient negotiating a lower bill directly with a local hospital or private insurer, having an advocate who knows the specific state regulations helps. State rules for advocates can also vary dramatically. Florida has some of the strictest. "Due to the large senior population in our state, we have a strong urge to make sure our people adjusting medical claims are licensed, competent and held to a high standard," says Matthew Guy, a spokesman for Florida's Division of Agent and Agency Services, which licenses and regulates advocates.

The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster, we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters must pass an exam and take 24 hours of continuing education classes every two years.

Contingency Basis

A handful of advocates will work on contingency if they think you have a negotiable claim. Most will impose strict conditions to ensure they get paid if they win. "When I started my practice, I did everything on contingency but learned very quickly that a lot of consumers who want you to take their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate at Life Bridge Solutions in Naples, Florida.

Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical bill savings.

Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of medical billing problems, including those of the uninsured. She has 25 years of experience in the health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says. For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors who have lost their capacity or desire to manage daily finances.

Instead of being a member of ACAP, Samotin is a member of the American Association of Daily Money Managers, a trade group for generalists. Only a handful of the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says. Nor does she expect rapid growth in the field.

"Because this is a disorganized profession, people entering the field have to be entrepreneurs," she says. "They have to hang out their shingle and go out and get clients. In my experience, the majority of people who are good medical analysts and advocates are not necessarily good business getters."

So until the profession matures, finding a good advocate will remain difficult, no matter how vital the service is.

(Lewis Braham is a freelance writer based in Pittsburgh.)

To contact the editor responsible for this story: Suzanne Woolley at swoolley2@bloomberg.net

[Nov 22, 2016] Negotiating can cut hundreds off your medical bills

Notable quotes:
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
13 WTHR Indianapolis
But you can fight back against skyrocketing medical costs.

"I've heard discounts up in the area of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program development with Consumer Credit Counseling.

She says it's possible to negotiate down your medical bills - everything from ambulance rides to surgery. She says you can also bargain with your dentist, the lab that does your blood tests, the eye doctor - even the company that makes you prescription medication.

"Each company has a specific number you can call to fill out an application and many times, you'll get a discount, or you'll get the product free through the drug companies, if you qualify financially," Perron said.

All you have to do, with or without insurance, is make a call. Each case is handled differently. In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital. They'll work with you to make sure the cost is paid.

So how do you pay less?

There are a number of options:

Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill out hardship paperwork.

"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses and your other bills that you have to pay every month," said Perron.

Sholar called Indianapolis EMS.

"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people who drive the ambulance. That's just the way it is'," he said.

But he didn't give up.

"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor'," Sholar said. "The supervisor's name is John. John wasn't too happy."

Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed, but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.

"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't received a bill for that," he said.

But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling 911.

"I would have put a rag over it and got a ride here," he said.

Tips to Negotiate Your Medical Costs

Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:

First and foremost be informed. Understand what type of medical insurance coverage you have and what your co-pays or financial responsibilities are. Some insurance companies have contracts with certain medical providers to offer a discount if you receive treatment from a "preferred provider." We encourage individuals to meet with their Human Resource department or contact their insurance company to speak with a representative about their coverage and benefits prior to receiving medical treatment. This could reduce your financial responsibility significantly.

Apprisen recommends for you to review your itemized statement from your medical provider. If you feel there are discrepancies or charges in question, contact your medical provider to meet with their Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part of resolving your issues. Simply ignoring communication from your medical provider will not resolve the issue and could potentially lead to a negative impact on your credit rating if resolution is not reached.

Whether you have insurance or not, you are encouraged to contact your medical provider prior to treatment (if possible) to discuss costs associated with your treatment and to work out the possibility of negotiating those costs down. Many medical providers will consider giving discounts to individuals who are willing to pay the balance in full upon services rendered or within a short period of time after receiving treatment. If you find yourself in a position where you are not able to pay the balance in full, consider negotiating with your medical provider for a monthly repayment plan interest free. You are encourage to analyze your personal budget to insure you are able to make the financial commitment to your medical provider. Negotiating your medical bill then failing to follow through with the financial payment arrangement could negate your hard effort to reduce your medical bill.

If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision maker" to see if you qualify for any financial hardship programs. Most hardship programs require you to provide evidence of your financial situation and the award is based on financial need. Be prepared to give a full budget disclosure in order to be considered for the hardship program.

Apprisen's mission is "To help people improve their financial well-being through counseling, community outreach and financial education."

You can call Apprisen at 1-800-355-2227 or visit apprisen.com.

There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. You can find out more about those companies at objectivedx.com.

[Nov 21, 2016] Pharmaceutical Executives Indicted: Protectionism Leads to Corruption

Notable quotes:
"... Every economist in the world can quickly explain how a 10 percent tariff on imported steel will lead to corruption. The same logic applies to drug patents, although since they are the equivalent of tariffs many thousand percent (they typically raise the price of protected drugs by factors of ten or even 100 or more), the incentives for corruption are much greater. ..."
"... kickback scheme between a major drug manufacturer and a mail order pharmacy. ..."
"... Gary Tanner, the former Valeant executive, entered into a secret relationship with Philidor's chief executive, Andrew Davenport, federal authorities said. ..."
Nov 19, 2016 | economistsview.typepad.com

anne : November 18, 2016 at 05:00 AM , 2016 at 05:00 AM

http://cepr.net/blogs/beat-the-press/pharmaceutical-executives-indicted-protectionism-leads-to-corruption-43-641

November 18, 2016

Pharmaceutical Executives Indicted: Protectionism Leads to Corruption #43,641

Every economist in the world can quickly explain how a 10 percent tariff on imported steel will lead to corruption. The same logic applies to drug patents, although since they are the equivalent of tariffs many thousand percent (they typically raise the price of protected drugs by factors of ten or even 100 or more), the incentives for corruption are much greater.

This is why every economist in the world should have been nodding their heads saying "I told you so" when they read this New York Times article * about a kickback scheme between a major drug manufacturer and a mail order pharmacy. Unfortunately, there were no economists mentioned in this piece. And, it is quite possible that most economists support this form of protectionism, in spite of the enormous inefficiency and corruption that results. (Yes this is a major point in my free book, "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer." ** )

* http://www.nytimes.com/2016/11/18/business/valeant-philidor-fraud-kickback-scheme.html

** http://deanbaker.net/books/rigged.htm

-- Dean Baker

anne -> anne... , November 18, 2016 at 05:06 AM
http://www.nytimes.com/2016/11/18/business/valeant-philidor-fraud-kickback-scheme.html

November 17, 2016

Former Valeant and Philidor Executives Charged in Kickback Scheme
By KATIE THOMAS and MATTHEW GOLDSTEIN

Gary Tanner, the former Valeant executive, entered into a secret relationship with Philidor's chief executive, Andrew Davenport, federal authorities said.

[Nov 07, 2016] The Cigna CEO took home $49 million in total comp last year – and wasn't the highest paid Cigna executive

www.nakedcapitalism.com

Knifecatcher November 7, 2016 at 2:59 pm

Today our HR department revealed the "new and improved" 2017 benefits package… and it's massively crapified. But good news! The "High Deductible Health Plan" is now a "Consumer Driven Health Plan" thanks to our good friends at Cigna, who kindly reminded us that we just haven't been doing our part as active health care consumers to help reduce health care costs. Because the real problem with health care today is obviously branding.

Knifecatcher November 7, 2016 at 3:27 pm

The consultant they brought in to dump this on us actually said "most people spend more time shopping for the best price on shoes than they spend shopping for the most cost-effective health care."

I had the temerity to point out what I've learned from firsthand experience – that there is NO WAY TO KNOW what a provider will charge for a particular procedure beforehand. The response was that they'd follow up with me later. :)

Apropos of nothing, the Cigna CEO took home $49 million in total comp last year – and wasn't the highest paid Cigna executive.

Waldenpond November 7, 2016 at 5:26 pm

Have you seen the commercial where a female basketball player is goofing off for her child in the house… falls and injures herself. Later she's in a sling and grabbing a small trampoline and in response the 'husband' is on the phone. I guess the inference is he's calling the insurance company but I think it makes more sense to be calling for a price check.

The next time you have a compound fracture, remember to stay calm, and get the best price.

Tvc15 November 7, 2016 at 3:28 pm

And my company is offering a new 2017 "benefit"; Critical Illness Insurance to provide financial protection for an illness such as cancer, stroke or heart attack.

Uh, okay, I thought that is why I pay $6,000 / yr for my high deductible medical plan, not including company subsidy, dental or vision.

Maybe they should have asked marketing to help with the branding.

jrs November 7, 2016 at 3:38 pm

I think it's not actually for medical costs in most cases. It's for the cost of say not being able to work due to cancer and so on. Or that's what I've seen out there, obviously I don't know about your particular plan.

Waldenpond November 7, 2016 at 5:33 pm

Check the policy. Some policies are very specific in that they will include specific cancers and exclude others. The additional can cover illnesses not covered by the initial contract, lost wages, support, and unemployment in case your employer fires you. It may apply to Cobra costs in case of job loss so a person can maintain continuity of care.

Knifecatcher November 7, 2016 at 4:03 pm

We got that too, along with a number of other optional programs. My assumption is that once you get past medical, dental, and vision all those other post-tax "benefits" (pre-paid legal, long term care insurance, etc) are just profit centers, and that the provider gives the employer a kickback for allowing them access to a captive customer base – with payments automatically deducted from each paycheck! I don't know that for sure, but it's the only explanation I can see as to why HR pushes those so hard.

[Nov 01, 2016] Guillotine Watch, Health Care Edition

Nov 01, 2016 | www.nakedcapitalism.com
allan November 1, 2016 at 8:36 pm

Guillotine Watch, Health Care Edition

Divorce trial 'lifestyle analysis': Ex-wife needs $5 million a year [Chi Trib]

With multiple homes, a full-time private chef, vacations, entertainment and $746 for pet care, Alicia Stephenson needs more than $400,000 a month to meet her living expenses, according to testimony from a financial expert who specializes in divorces.

Cathleen Belmonte Newman, a certified divorce financial analyst, said she completed a "lifestyle analysis" to determine that Stephenson would need $433,991 "net" in monthly maintenance to keep up a standard of living similar to what she had during her marriage to Richard Stephenson, the multimillionaire founder of the Cancer Treatment Centers of America hospital network. …

Much of the trial, now in its third week, has featured testimony from Alicia Stephenson's friends and business associates who have outlined her lavish lifestyle during the marriage: trips on private jets, several homes complete with staff and high-end furnishings and artwork, millions of dollars in jewelry, couture clothing, fancy parties, expensive vehicles, motorcycles and yachts. …

All paid for by cancer patients and, truth be told, by their insurance companies.

Edit: from a comment on the article, a story about CTCA:

http://scienceblogs.com/insolence/2013/03/07/the-cancer-treatment-centers-of-america-cherry-picked/

[Nov 01, 2016] The private market has rejected the government sponsored private/public partnership

Nov 01, 2016 | economistsview.typepad.com

JohnH : November 01, 2016 at 03:42 PM

The private market has rejected the government sponsored private/public partnership. The government should return the favor and reject the private market, which has shown that it can't deliver, either by itself or in partnership.

Time to bring back the public option...or just nationalize the health insurance cartel.

Reply Tuesday, November 01, 2016 at 03:42 PM

[Oct 29, 2016] The monthly premium you paid in 2016 was $315.62. Beginning January 1, 2017, your monthly premium will change to $520.59 for the coverage plan you have been automatically renewed into

www.nakedcapitalism.com

Pat October 26, 2016 at 3:56 pm

Caught part of the View this morning including their section on the admission from the Administration that premiums are going to increase in double digits some high for the next year. After some defense of it and info about one of the problems of it (including a somewhat dissonant outburst from Clinton's biggest fan Joy Behar about why should health care be for profit) Goldberg went on a rant. After her starting the defense part of it, it was interesting to hear her go on about paying more and more for less and less and never seeing any kind of rebate because she hadn't used the insurance she paid for for over a decade. She has almost realized she has been had.

Joseph Hill October 26, 2016 at 4:49 pm

In my inbox today courtesy of CareFirst Blue Cross Blue Shield:
"Your premium: The monthly premium you paid in 2016 was $315.62. Beginning January 1, 2017,
your monthly premium will change to $520.59 for the coverage plan you have been automatically
renewed into.
Please understand that premium rates are approved by State regulators pursuant to strict federal and
state rules. We deeply regret increases, but these rates realistically reflect the actual costs of providing
care to you and all other individuals who have bought coverage under the ACA. "
65% annual premium increase (and an deductible increase as well). Absolute F**king disaster.

jrs October 26, 2016 at 4:59 pm

They are telling you a way to change it though. The premium rates are approved by State regulators, means the states should push back.

Joseph Hill October 26, 2016 at 5:11 pm

Right. I'll call my lobbyist.

Skip Intro October 27, 2016 at 8:30 am

That's what I call an October Surprise!

[Oct 28, 2016] Neoliberals believes the problem with the ACA lies with deadbeats who refuse to purchase a substandard product despite a government-imposed penalty. Thier solution? Make the government-imposed penalty higher. What comes next?

Oct 28, 2016 | www.nakedcapitalism.com

Waldenpond October 27, 2016 at 2:39 pm

It's not just premiums. Health care penalty to double. http://newyork.cbslocal.com/2016/10/26/obamacare-premiums-penalties/

Societies that keep ramping up law and punishment are a sign of what?

Jim Haygood October 27, 2016 at 2:45 pm

Thank you, 0bama!
Thank you, John Roberts!

MyLessThanPrimeBeef October 27, 2016 at 3:35 pm

I can see the headlines now – the higher the health care penalty and premiums, the bigger Hillary's landslide victory.

Pat October 27, 2016 at 2:59 pm

Funnily enough, I'm pretty damn sure that the eventual response to this is going to be "pound sand". There is lots of information out there about how to derail that penalty.

The real fix is, of course, single payer and a highly regulated health care market. That said, I'm pretty damn sure that if I were to read the fix article I could pick it apart without much problem, and not just because it has taken the obvious solution off the table. And everyone of my 'solutions' would be ignored because they would come from the point of view that the first goal will be to provide HEALTH CARE and the profits of insurance companies, pharma and private medical are the least important part of the equation.

temporal October 27, 2016 at 3:04 pm

According to the IRS, shared responsibility payments will jump to $695 per adult and $347.50 per child, with the family maximum not to exceed $2,085 or 2.5 percent income above the filing threshold. That's up from $325 per adult and $162.50 per child, with a maximum of $975 per family for the 2015 tax year.

According to the IRS, the national average premium for a bronze level healthcare plan on the Obamacare marketplace was $2,484 a year, or $207 per month for individuals, and $12,240 a year, or $1,020 per month for a family of five or more.

The article compares last years ACA bronze cost to this year's penalty. Not quite valid.
The NY ACA website shows current catastrophic coverage to be $5500 a year with a $6500 per person deductible, so two grand looks like a bargain unless you have some sort of serious medical condition. And two grand is probably only a few months worth of groceries so what's not to like?

OIFVet October 27, 2016 at 3:12 pm

It is still cheaper to pay the penalty than to pay large premiums for a plan that covers practically nothing and has a small provider network. From the NYT article, the 0bama administration argues that having worthless insurance is not paying for nothing, because even people with monster deductibles have "protections against catastrophic costs." Did I miss the part where the 0bama administration instituted out of network maximum on out of pocket costs? There are no out of pocket maximums on out of network costs, and given the small and ever shrinking networks, the administration's contention that crappy policies provide people with "protection" is an utter BS. Yet 0bama has the temerity to insist that we ought to be thanking him for this travesty. It is worth noting that many of my acquaintances who were strongly in favor of 0 care have now began to admit that it does not work. But they don't blame 0bama for it, they blame the republicans. Which is part of their justification for voting for Hillary, because apparently she will "fix 0 care". It is driving me nuts, this willful blindness and unwillingness to question democrat orthodoxy.

Pat October 27, 2016 at 3:19 pm

My personal opinion is that until ALL emergency room coverage is covered regardless of network including hospitalization until transfer (at insurance company cost) is medically feasible, these plans are largely useless. Although there could be a good business in emergency medical jewelry that tells paramedics/EMTs the hospital(s) where they can take you and those you most avoid no matter what the circumstances. Especially since those would need to change yearly, if not more often.

OIFVet October 27, 2016 at 3:41 pm

Emergency rooms are half of it. The other problem is that given the small networks, it is quite possible that these networks do not include specialists in particular specialised care that might be needed. Then there is the very high probability that one is operated by an in-network surgeon in an in-network hospital, but the anesthesiologist is out-of-network, as is the post-op nurse. It is not going to be easy for anyone to sort these things out even in case of non-emergency care. This is where the outrage about the increasing high deductibles and huge premium hikes is doing a disservice to the people, beciause I hardly ever see any article that mentions the fact that these increases are accompanied by large shrinkage of provider networks, and then goes on to mention the unlimited out of network costs and links it to the shrinking networks. It is an effing travesty, the whole lot of it.

I am very much incensed on the issue of access to medical care and how 0 care did not improve it one bit for most people. I could easily just lean back and not give a sh!t because I got mine through the VA, so to hell with everyone else. But I can't, my father died for lack of access to care in this "great, exceptional" country of ours. It is a hurt that will never go away, particularly as the democrat party continues to defend this monstrosity and 0bama callously pats himself on the back. Every time he intones "Thanks 0bama" I feel it as a direct affront on our collective dignity and our basic human right to receive healthcare. An effing narcissist and a sociopath is what he is

Tom October 27, 2016 at 4:22 pm

F*ck Yeah!

craazyboy October 27, 2016 at 4:24 pm

Hillary mentioned there were a couple or two thingies with it that needed fixing. Thanks in advance, Hillary!

With prices compounding at 20-40% annually, Hillary better move fast.

JohnnyGL October 27, 2016 at 4:49 pm

Here comes the magic sparkle pony "public option" dressed up to hide the fact that it'll actually be a massive bailout!

The fines/penalties associated with the "individual mandate" are like the duct tape that holds the whole ACA marketplaces together. The duct tape is looking a bit worn.

craazyboy October 27, 2016 at 6:29 pm

Then the provider network gets narrowed down to a few local barbershops.

A friend told me his doctor told him he was "re-focusing" his practice on "corporate accounts", which is apparently what it sounds like, and my buddy had to look for a new doc.

Jim Haygood October 27, 2016 at 3:58 pm

" There could be a good business in emergency medical jewelry … especially since those would need to change yearly, if not more often. "

Your emergency bracelet or necklace needs to be connected to the IoT (Internet of Things).

Then your EMT can just press a button to find out where you're "covered" today.

Thank you, 0bama!

Tom October 27, 2016 at 4:26 pm

Ha! The patient's medical jewelry would sync with the EMT vehicle's nav system:

Nav Voice: "The nearest hospital in your cardiac arrest patient's network is … 20 miles away. Based on your patient's vital signs, the prognosis is not good. Would you like to recalculate your route? The nearest mortuary is … 2 miles away."

tgs October 27, 2016 at 3:30 pm

Lost my full time job and insurance in August of 2015 (along with over a hundred colleagues). I determined that I would pay a penalty of around $300 if I didn't get Obamacare. On the other hand, I would have paid over $800 for a bottom level policy that I would never use for the four final months of 2015.

So, I will be paying the penalty in 2016 unless I manage to find a job that gives me coverage. I have a little over a year until I quality for medicare.

Tom October 27, 2016 at 4:30 pm

Now that's having some skin in the game!

P.S. I emphathize with your plight. I went without insurance for 2 years after my business tanked in 2009 and it is no fun to have to make that decision and live with it.

Katharine October 27, 2016 at 2:46 pm

Here's a howler from the Guardian:

African revolt threatens international criminal court's legitimacy
https://www.theguardian.com/law/2016/oct/27/african-revolt-international-criminal-court-gambia

The US refusal to participate didn't threaten its legitimacy, of course, because it was always supposed to be for other people, but when they start refusing to be judged–well, really! What's the world coming to? Its senses?

JohnnyGL October 27, 2016 at 4:53 pm

tgs and Tom,

Don't think you're missing out on much. Over here, my employer has been dishing out ACA-style, high-deductible plans with hefty co-insurance since WAY back before it was cool.

Even if you have coverage, the Insurers don't actually pay for stuff. My family as a whole has about $10K in bills backlogged and all four of us are perfectly healthy.

I can only imagine what actual, sick people have wracked up.

dk October 27, 2016 at 3:26 pm

… some think that whether they send hundreds of dollars to the I.R.S. or thousands to an insurance company, they are essentially paying something for nothing.

The opportunity to select my own treatments and providers, and negotiate payment? That's not nothing. But having to pay extra for it is quite an insult.

different clue October 27, 2016 at 3:27 pm

Well, when the penalty costs as much or more than the ObamaCare crapsurance itself, then the boycotters can give in and buy the shitsurance. Perhaps the boycotters will have exterminated Obamacare with death spirals by then anyway.

polecat October 27, 2016 at 4:08 pm

perhaps the public should just quit filing their taxes …. en mass !

THAT might send a message !!

dk October 27, 2016 at 4:43 pm

Doesn't work so good for people paying in through their wages, and filing to get a refund.

Sammy Maudlin October 27, 2016 at 4:05 pm

From Jonathan "Stupidity of the American Voter" Gruber's appearance on CNN :

Look, once again, there's no sense of oh it just has to be fixed. The law is working as designed; however, it could work better, and I think probably the most important thing experts would agree on is that we need a larger mandate penalty. We have individuals who are essentially free riding on the system . They're essentially waiting until they get sick and then getting health insurance. The whole idea of this plan which was pioneered in Massachusetts was that the individual mandate penalty would bring those people into the system and have them participate. The penalty right now is probably too low and that's something ideally we would fix.

In other words, he believes the problem with the ACA lies with "deadbeats" who refuse to purchase a substandard product despite a government-imposed penalty. His solution? Make the government-imposed penalty higher. What comes next? Hmm, let's set the wayback machine to November 27, 2013 and see if anyone has any ideas…

Lambert Strether
November 27, 2013 at 1:41 am

Then again, perhaps I wasn't cynical enough. If you don't assume ObamaCare is about health care, a lot falls into place.

Sammy Maudlin
November 27, 2013 at 10:55 am

It's obviously not about "health care." Where's dollar one towards nutrition education? Subsidies for organic farming? Tax breaks towards gym membership and/or the purchase of exercise equipment? Why are health savings accounts being gutted?

Nope, it's about creating a captive market for the health insurance companies consisting of every American citizen. You don't buy health insurance, there will be tax consequences courtesy of your federal government. Currently, those consequences are minimal. However, how long will it be before ACA "deadbeats" (who aren't paying their "shared responsibility" and costing the rest of us!) are in the crosshairs of the government and a media campaign is launched to repeal the ban on criminal liability for non-compliance?

If I were more cynical, it might look like a protection racket to me.

I'm still not that cynical because they are not asking for criminal penalties yet. But I'm getting there.

polecat October 27, 2016 at 5:03 pm

This is exactly the kind of clueless rhetoric that has caused uprisings in the past ….

I was speechless having read that transcript …… I mean …I read that as … "lets BLEED THEM EVEN MORE !!!"

Jim Haygood October 27, 2016 at 5:27 pm

We had to destroy the consumers in order to save them.

jawbone October 27, 2016 at 7:39 pm

All of which comments above indicate that the Dems have firmly joined the "Hurry Up and Die" as set forth by the Repubs.

ObamaCare, while it has been good for some portion of those insured by it, is essentially a Profit Protection Plan for The Bigs.

EmilianoZ October 27, 2016 at 4:43 pm

Is being on Medicaid better than being on 0bamacare?

timbers October 27, 2016 at 2:42 pm

Health Care

From I think the same NYT article:

The I.R.S. says that 8.1 million returns included penalty payments for people who went without insurance in 2014, the first year in which most people were required to have coverage. A preliminary report on the latest tax-filing season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a return for people uninsured in 2015.

How can any sane person ignore that as a failure warning as are Obama and Clinton?

The same folks who see Iraq, Afghanistan, Libya, Yemen, Somalia, Syria, and Ukraine as not failures also think Obamacare a success. Higher penalties, more subsidies to rich gigantic insurance corporation is what Hillary will fight for. Oh…and more Iraqs, Libyas, Syrias, and Ukraines, too.

MyLessThanPrimeBeef October 27, 2016 at 3:47 pm

Are penalty payments considered taxes?

If so, they are destroying money with this law.

ProNewerDeal October 27, 2016 at 4:06 pm

fw http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

Marie Antoinette-level out of touch Matthew Yglesias, claims the ACA could be solved by making the Individual Mandate needs to be "much bigger" & "generous special exemptions" should be removed.

Matthew Yglesias, making an attempt at being the Douchiest Bag.

Adult median income is ~29K. 75% of workers live "paycheck to paycheck", their pay barely meets purchase of essentials like housing rent & food. Student loan debt topped $1 Trillion & is the biggest consumer debt, yet many student loan debtors are Type 1 &/or Type 2 Underemployed, adding another extra cost.

People are already getting insulted by paying the Individual Mandate, or the Tax on Time waiting on hold for IRS Customer No-Service to possibly get a form indicating a "generous exemption". But to Yglesias, if the Mandate was "much bigger", that would compel them to purchase ACA.

Yglesias doesn't mention what "much bigger" Mandate Penalty means. Is it double? Is it half of what a Bronze plan premimums is, & what would that be, ~5X the current Mandate Penalty?

Yglesias makes no mention that many ACA policy holders cannot afford to actually use the insurance, due to the high ~$6K deductibles.

Yyglesias makes no mention of having the Nostradamus Jan 2018 & predict calendar 2017 income, despite many jobs becoming increasingly unstable, gig economy'd or otherwise crapified & unpredictable.

Yglesias makes no mention of the heinous Medicad Estate recovery.

Yglesias does at least suggest that his "bigger Penalty" should be accompanied by a "public option" health insurance.

BTW I recall Yglesias fellow dbag, 0bot Lawrence O'Donnell condescendingly smugly claim on msDNC that the "Indivdual Mandate Penalty" is optional. AFAIK, O'Donnell has never apologized or corrected his incorrect claim.

[Oct 27, 2016] Justice has begun to oppose Hospital Mergers because it has been shown to drive up Health Care Costs, when Hospital Systems consolidate and control larger share of the local market medical prices go up

Oct 27, 2016 | economistsview.typepad.com
pgl : , October 26, 2016 at 08:05 AM
Brad and Michael DeLong make a strong case for more vigorous anti-trust enforcement re the health insurance sector:

https://www.project-syndicate.org/commentary/us-health-insurance-mergers-by-j--bradford-delong-and-michael-m--delong-2016-09

Of course a public option would also lead to more vigorous competition. This needs to be on the top of President Clinton's agenda come January 2017. Trump on the other hand thinks we should just get rid of Obamacare and offer "more choices" whatever that means. Of course Trump has no idea what any of this means.

im1dc -> pgl... , -1
The Obama Administration Justice Dept has been asleep until this past year on Medical competition/consolidation.

Justice has begun this past 9 months to oppose Hospital Mergers b/c it has been shown to drive up Health Care Costs, i.e., when Hospital Systems consolidate and control markets medical prices go up.

Justice is opposing the merger of the only two Hospital Systems in my MSA, regardless the merger is still on.

If it goes through there will be one provider which will control health care costs in a 50+ mile radius in East TN and Western Virginia, although they pledge not to, of course.

Competition works, consolidation does not, even in Healthcare. Consolidation makes some people very wealthy and powerful at the expense of everyone else.

[Oct 25, 2016] New York Times Reports on Sharp Slowing of Insurance Costs Under Obamacare

Oct 25, 2016 | economistsview.typepad.com

anne : October 25, 2016 at 05:32 AM

http://cepr.net/blogs/beat-the-press/nyt-reports-on-sharp-slowing-of-insurance-costs-under-obamacare

October 25, 2016

New York Times Reports on Sharp Slowing of Insurance Costs Under Obamacare

Just kidding. Actually, insurance costs have slowed sharply in the years since the Affordable Care Act was passed, but it is unlikely many readers of the NYT would know this. Instead, it has focused on the large increase (not levels) in premium costs for the relatively small segment of the population insured on the exchanges. In keeping with this pattern, it gives us a front page piece * telling readers about the 25 percent average increase in premiums facing people on the exchange this year. There are two points to keep in mind on this issue.

First, the focus on premiums is exclusively on the relatively small segment of the population getting insurance through the exchanges and specifically through the exchanges managed through the federal government. According to the latest numbers, 12.7 million people are now getting insurance through the exchanges ** (roughly 4.0 percent of the total population). This article refers to the premiums being paid by the 9.6 million people insured through the federally managed exchange (3.0 percent of the total population). Many states, such as California, have well run exchanges that have been more successful in keeping cost increases down.

There are two reasons that costs on the exchanges have been rising rapidly. The first is that insurers probably priced their policies too low initially. Even with the increases this year premium prices are still lower than had been expected in 2010 when the law was passed. In fact, there has been a sharp slowing in the pace of health care cost growth in the last six years. While not all of this was due to the ACA, it was undoubtedly a factor in this slowdown. In the years from 1999 to 2010, health care costs per insured person rose at an average annual rate of 5.7 percent. In the years from 2010 to 2015 costs per insured person rose at an average rate of just 2.3 percent.

[Graph]

The other reason that premiums on the exchanges have risen rapidly is that more people are stiill getting insurance through employers than had been expected. The people who get insurance through employers tend to be healthier on average than the population as a whole. The Obama administration expected that more employers would stop providing insurance, sending their workers to get insurance on the exchanges. Since they have continued to provide insurance, the mix of people getting insurance through the exchanges is less healthy than had been expected.

Note that this has nothing to do with the "young invincible" story that had been widely touted in the years leading up to the ACA. The problem is not that healthy young people are not signing up. The problem is simply that healthy people of all ages are getting their insurance elsewhere. The overall percentage of the population getting insured is higher than projected, not lower as the young invincible silliness would imply.

* http://www.nytimes.com/2016/10/25/us/some-health-plan-costs-to-increase-by-an-average-of-25-percent-us-says.html

** https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-04.html

-- Dean Baker

[Oct 25, 2016] Cholesterol Down Ten Simple Steps to Lower Your Cholesterol in Four Weeks--Without Prescription Drugs

Oct 25, 2016 | www.amazon.com
by Janet Brill

5.0 out of 5 stars /span> By Kelly Jadon on September 28, 2008 Format: Paperback

10 Simple Steps To Naturally Lower Your Cholesterol From: [...]

Book Review: Cholesterol Down by Dr. Janet Brill

Cholesterol Down is for the 105 million Americans who have high cholesterol. The author, Dr. Janet Brill, a registered and licensed dietitian/nutritionist, exercise physiologist, and certified wellness coach has spent years counseling patients on cardiovascular disease prevention, researching, and writing on the subject of cholesterol. Her work has been published in the International Journal of Obesity and the International Journal of Sport Nutrition.

Cholesterol Down provides readers with the information they need regarding cholesterol -- what it is and how it works both for and against the body. It is significantly endorsed by Dr. Jennifer H. Mieres, the National Spokesperson for the American Heart Association. She states, "The simple, consistent, and inexpensive lifestyle therapy outlined in her {Dr. Janet Brill's} Cholesterol Down Plan could be the most important investment you make in your future health." Dr. Brill explains LDL, the bad portion of cholesterol, and offers an effective combination therapy of foods, scientifically based, that are as effective as statins. Besides lowering LDL, the following ten-step program also offers further health benefits.

First, eat 1 cup of oatmeal every day. The U.S. Department of Agriculture recommends three whole-grain servings daily. This is linked to reduced risk of heart disease, stroke, type 2 diabetes, obesity, some cancers, lower blood pressure, and improved bowel movement. Oatmeal lowers LDL, may raise HDL--the good portion of cholesterol, and studies show that the more consumed, the greater the benefit.

Second, eat a handful of almonds daily, approximately 30. Read more › 2 Comments 238 people found this helpful. Was this review helpful to you? Yes No Sending feedback... Thank you for your feedback. Sorry, we failed to record your vote. Please try again Report abuse

5.0 out of 5 stars /span> By Dr. Jonathan Dolhenty on February 17, 2007 Format: Paperback
Must Reading for Those Interested in Their Health I have a personal interest in this particular subject so I was pleased to be asked to read and review "Cholesterol Down," a book which definitely should be read by anyone with a current cholesterol problem and, for that matter, by anyone in the younger set who wants to prevent such a problem from occurring in his or her future. If I had had this information many decades ago, I probably could have prevented or at least delayed the coronary problems I am now fighting. After my first heart attack five years ago, I had to face the fact that some extraordinary changes were necessary and at the top of that list was diet. I was placed on a "Mediterranean" diet which is very similar to the diet which Dr. Brill recommends in her book.

Dr. Brill suggests ten simple steps to lower one's cholesterol without resorting to prescription drugs. I am all in favor of that because nothing disturbs me more within the medical area of my life than the taking of prescription drugs. I try to avoid that sort of thing like the plague. I much prefer to utilize "natural" remedies whenever and wherever possible. So far I've been fairly successful, having to take only one prescription medication (an anti-clotting drug) and only because I have found no comparable natural remedy.

This book is divided into two parts plus an appendix. The first part of the book provides the reader with information about cholesterol and heart disease, basically the scientific foundations upon which Dr. Brill's ten-step plan is based. This can be read first but it is not necessary. I read the second part first, which actually describes the ten-step cholesterol down plan, because I was specifically interested in reviewing what the author suggests; one can always go back to the scientific rationale later. Read more › 27 Comments 502 people found this helpful. Was this review helpful to you? Yes No Sending feedback... Thank you for your feedback. Sorry, we failed to record your vote. Please try again Report abuse

5.0 out of 5 stars /span> By Tom Bruce on November 25, 2007 Format: Paperback Verified Purchase
Good for what ails you The book promises "10 Simple Steps to Lower Your Cholesterol" and it delivers. The first section of this book deals with what cholesterol is and what it does, and as this reader-friendly author suggests, "If science is not your cup of tea, simply cut to Part II." Part II is the meat of the book, listing the ten simple - and they are - steps to lowering your cholesterol. Not only simple, but affordable, too - much more so than prescribed medicine. With each step, the good Doctor explains how each process helps us reach our medical goal, gives the medical proof that exists for each, presents case histories, and lists further options and tips on how to additionally simplify each step. Yet, if you're not into the medical jargon, this section of the book is formated so you can skip over much of the material presented and get the basic information you need in a few short paragraphs. She does make it easy. The third and final section of the book offers charts to help you follow this course, if you're into such regimentation. There are also a few dozen healthful recipes, few of which appealed to me. Now here's the bonus part: as Brill explains, each of these steps will also help in lowering blood pressure, aiding diabetics, fighting obesity, forestalling aging, even stopping hair loss. So, if you suffer from any of these ills and more, you can't go wrong with this basic recipe for good health. After five weeks on this regimen, my cholesterol numbers were back to normal. The one problem I found with this diet, it was almost too much to eat. Well, not too much, but very filling. I have followed a modified version of the plan, mainly keeping in the oatmeal and heart-friendly orange juice, and my numbers continue to be where they should be months later. Comment 61 people found this helpful. Was this review helpful to you? Yes No Sending feedback... Thank you for your feedback. Sorry, we failed to record your vote. Please try again Report abuse

[Oct 25, 2016] Rates Up 22 Percent For Obamacare Plans, But Subsidies Rise, Too

Oct 25, 2016 | economistsview.typepad.com

Fred C. Dobbs -> anne... October 25, 2016 at 09:19 AM

(Just because Robert Pear does a piece
about the problem doesn't mean it's
not a real one.

Would you believe NPR?)

Rates Up 22 Percent For Obamacare Plans, But Subsidies Rise, Too
https://n.pr/2eokAZG

October 24 - All Things Considered - Alison Kodjak

The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017, according to information released by the Obama administration Monday afternoon.

Still, federal subsidies will also rise, meaning that few people are likely to have to pay the full cost after the rate increases to get insurance coverage.

"We think they will ultimately be surprised by the affordability of the premiums, because the tax credits track with the increases in premiums," said Kevin Griffis, assistant secretary for public affairs at the Department of Health and Human Services.

The 22 percent rise reflects the average for all insurance marketplaces, both federal and state-based exchanges for which data are available. For insurance purchased through the federal HealthCare.gov exchange the rise will average 25 percent.

During a media briefing Monday, Griffis said the 2017 rates are roughly at the level the Congressional Budget Office forecast when the law was proposed. "The initial marketplace rates came in below costs," he said. "Many companies set prices that turned out to be too low." ...

(Assuming Clinton is in the White House,
and enough Dems are in Congress next year,
this had better be dealt with pronto.)

EMichael -> Fred C. Dobbs... , October 25, 2016 at 10:26 AM
No, there is a problem, but Pear has no idea what it actually is and spends no time in putting it in perspective.

These increases were certainly expected, as were the decreases expected in the areas that had them. This is a totally unknown insurance pool. There is no experience with these people at all. To make it worse, the first people to sign up were the people who had been denied insurance because of pre existing conditions who really need medical care and could not afford it.

It'll calm down, but people like Pear are not interested in facts at all, and certainly not interested in perspective.

Why don't people like Pear state, "even with these premium increases insurance through the exchanges will be be less expensive than insurance through employers"? Nah, not the right message.

Or how about, "while the percentage increases are high, more than 3/4 of the insured will not have those kind of increases?" Nah, that doesn't sound that bad.

Or how about finding out what the average premium payments are under the exchanges and putting the increases into perspective? Something like, "Most new enrollments were for low premium policies. Phoenix is going to have some of the highest increases, in some cases going up as high as 111%. Last year a 30 year old single with no subsidy paid, at that low premium level, $60 a month in premiums, or $720 a year. Now that will be $120 a month or $1440 a year. Meanwhile that same person, if he had employer provided insurance would have paid an average premium of(between him and his employer) $6435 a year". Nah, that doesn't say what he wants to say.

Course, deductibles are different in all of those cases. Max out of pocket is fixed under the ACA at $7150 per person. So that 30 year old in Phoenix is going to pay a minimum of $1440 a year for his healthcare. If he gets seriously injured or sick he will pay at most, $8590.

Lot of money, no question. But the guy with employer provided insurance is going to pay a minimum of $6435 a year. His deductible will be around $1478 a year and then add in the out of pocket max that varies drastically, with 14% having less than $2000 as the OOP max and 18% having an OOP max of more than $6000.

http://kff.org/report-section/ehbs-2016-summary-of-findings/

You tell me which is cheaper, which you would rather have, especially if you were a healthy 30 year old.

One more thing. The exchange numbers are for 2017, the employer numbers are for 2016.

Charlatans like Pear are no better than the front page of the National Enquirer. He should not be paid attention to for any reason. And he has been doing it for decades.

DeDude -> anne... , October 25, 2016 at 05:55 AM
Just put a public option on each of these exchanges.
anne -> DeDude... , October 25, 2016 at 06:26 AM
Just put a public option on each of these exchanges.

[ Important, though I would argue not a permanent solution:

http://www.pnhp.org/news/2016/february/clintons-%E2%80%98public-option%E2%80%99-is-a-diversion-we-need-single-payer-medicare-for-all

February 25, 2016

Clinton's 'Public Option' is a Diversion: We Need Single Payer, Medicare for All
By Don McCanne, M.D. ]

EMichael -> anne... , October 25, 2016 at 06:50 AM
It is not a diversion, it is part of the process.

A public option would lead to single payer.

Adamski -> EMichael... , October 25, 2016 at 07:15 AM
If Congressional Dems chicken out of single payer due to the power of the insurance and drug lobbies, then the same lobbies will oppose a public option as they did when the ACA was being debated. Either policy needs the determination to defeat those lobbies, so the same Dems might as well pass single payer. That's why a public option is both a diversion and unlikely to pass.

When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!

EMichael -> Adamski... , October 25, 2016 at 07:23 AM
As bad and uninformed as your entire post is, this takes the cake:


"When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!"

That comment has no basis in reality. You really should not talk with such certainty(even using an exclamation mark)on a subject that you surely have no knowledge.

JohnH -> Adamski... , October 25, 2016 at 07:37 AM
Agreed...EMichael always tries to find a way to let corrupt Democrats off the hook. Democrats have become past masters at explaining away their ineptitude in 2009. Fact is, they really didn't have any intention of accomplishing much for the American people, and their big majority put them in an embarrassing situation that exposed their 'liberal' agenda as being little more than hot air.

More troubling yet...if Democrats couldn't pass a public option with 60 votes in their Senate caucus, how will Hillary be able to pass any positive health care reforms with a bare majority in the Senate...if she even gets that? Overall Democrats will be happy, because they will have a plausible explanation for doing nothing...

pgl -> JohnH... , October 25, 2016 at 07:57 AM
Getting the facts right is letting corruption off the hook? I would say you've lost your mind but me thinks you never found it in the first place.
Dan Kervick said in reply to Adamski... , October 25, 2016 at 07:57 AM
Both would be very difficult to pass. But single payer would be much more difficult, by many orders of political magnitude, since it involved putting the entire private health insurance industry out of business; moving many, but not all, of the workers in that industry into the new public health insurance bureaucracy; and creating new jobs for the people dislocated by the transition.

Since Clinton has not run as a single payer advocate, and thus will have no popular mandate to pass it, it is difficult to imagine her being able to mobilize the huge political effort that would be needed for such a gargantuan political task, even if she wanted to do this.

At this point, the best that can be hoped for is a public option that is then grown and expanded over time, by steps, into a single payer system.

JohnH -> Dan Kervick... , October 25, 2016 at 09:17 AM
The best way to provide single payer would be to nationalize the health insurance industry, which would not be that hard, since it is rapidly consolidating into an oligopoly consisting of a few big firms. And it wouldn't cost that much either.

But, as your say, that's politically impossible...and we're not supposed to entertain that possibility, even though economists love to entertain themselves with pie in the sky stuff like helicopter money.

pgl -> JohnH... , October 25, 2016 at 09:37 AM
"The best way to provide single payer would be to nationalize the health insurance industry".

This is like saying the best way to drink coffee is to drink coffee. I guess you do not know what single payer means.

Dan Kervick said in reply to pgl... , October 25, 2016 at 09:46 AM
It's clear JohnH means that the industry is first nationalized as is, and then methodically consolidated over some period of time to transform it into a lean and proper single payer system..
Tom aka Rusty said in reply to pgl... , October 25, 2016 at 09:49 AM
Actually, there is a difference.

There could be single payer insurance without nationalizing health care services.

Dan Kervick said in reply to Tom aka Rusty... , October 25, 2016 at 10:21 AM
Sure, I guess there could be a privately run health insurance monopoly. But who is advocating for that?
Dan Kervick said in reply to Dan Kervick... , October 25, 2016 at 10:24 AM
JohnH didn't say anything about nationalizing health care services. He said we could nationalize the health *insurance* industry.
pgl -> Dan Kervick... , October 25, 2016 at 10:39 AM
Again - exactly my point. Someone today actually ate his Wheaties and can read with precision.
Dan Kervick said in reply to pgl... , October 25, 2016 at 10:57 AM
Sorry, I have no idea what your point was.
pgl -> Dan Kervick... , October 25, 2016 at 10:38 AM
No one. Exactly my point. Leave it to Rusty to advocate a private monopoly for health insurance.
Tom aka Rusty said in reply to pgl... , October 25, 2016 at 11:11 AM
Huh?

You apparently do not understand the difference between a government single payer insurance and a government monopoly provider.

Julio -> Dan Kervick... , October 25, 2016 at 09:31 AM
Oh, nonsense. Just give Republicans their wishes. Ability to sell across state lines. Deregulation. Non-enforcement of antitrust.
We'll have a single payer in no time.
Peter K. -> Julio ... , -1
Yggies suggests a combo harsher penalities for the Bernie Bros and Gals with a public option.

http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

[Oct 25, 2016] The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017

Oct 25, 2016 | n.pr

October 24 - All Things Considered - Alison Kodjak

The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017, according to information released by the Obama administration Monday afternoon.

Still, federal subsidies will also rise, meaning that few people are likely to have to pay the full cost after the rate increases to get insurance coverage.

"We think they will ultimately be surprised by the affordability of the premiums, because the tax credits track with the increases in premiums," said Kevin Griffis, assistant secretary for public affairs at the Department of Health and Human Services.

The 22 percent rise reflects the average for all insurance marketplaces, both federal and state-based exchanges for which data are available. For insurance purchased through the federal HealthCare.gov exchange the rise will average 25 percent.

During a media briefing Monday, Griffis said the 2017 rates are roughly at the level the Congressional Budget Office forecast when the law was proposed. "The initial marketplace rates came in below costs," he said. "Many companies set prices that turned out to be too low." ...

(Assuming Clinton is in the White House,
and enough Dems are in Congress next year,
this had better be dealt with pronto.) Reply Tuesday, October 25, 2016 at 09:19 AM EMichael said in reply to Fred C. Dobbs... No, there is a problem, but Pear has no idea what it actually is and spends no time in putting it in perspective.

These increases were certainly expected, as were the decreases expected in the areas that had them. This is a totally unknown insurance pool. There is no experience with these people at all. To make it worse, the first people to sign up were the people who had been denied insurance because of pre existing conditions who really need medical care and could not afford it.

It'll calm down, but people like Pear are not interested in facts at all, and certainly not interested in perspective.

Why don't people like Pear state, "even with these premium increases insurance through the exchanges will be be less expensive than insurance through employers"? Nah, not the right message.

Or how about, "while the percentage increases are high, more than 3/4 of the insured will not have those kind of increases?" Nah, that doesn't sound that bad.

Or how about finding out what the average premium payments are under the exchanges and putting the increases into perspective? Something like, "Most new enrollments were for low premium policies. Phoenix is going to have some of the highest increases, in some cases going up as high as 111%. Last year a 30 year old single with no subsidy paid, at that low premium level, $60 a month in premiums, or $720 a year. Now that will be $120 a month or $1440 a year. Meanwhile that same person, if he had employer provided insurance would have paid an average premium of(between him and his employer) $6435 a year". Nah, that doesn't say what he wants to say.

Course, deductibles are different in all of those cases. Max out of pocket is fixed under the ACA at $7150 per person. So that 30 year old in Phoenix is going to pay a minimum of $1440 a year for his healthcare. If he gets seriously injured or sick he will pay at most, $8590.

Lot of money, no question. But the guy with employer provided insurance is going to pay a minimum of $6435 a year. His deductible will be around $1478 a year and then add in the out of pocket max that varies drastically, with 14% having less than $2000 as the OOP max and 18% having an OOP max of more than $6000.

http://kff.org/report-section/ehbs-2016-summary-of-findings/

You tell me which is cheaper, which you would rather have, especially if you were a healthy 30 year old.

One more thing. The exchange numbers are for 2017, the employer numbers are for 2016.

Charlatans like Pear are no better than the front page of the National Enquirer. He should not be paid attention to for any reason. And he has been doing it for decades. Reply Tuesday, October 25, 2016 at 10:26 AM DeDude said in reply to anne... Just put a public option on each of these exchanges. Reply Tuesday, October 25, 2016 at 05:55 AM anne said in reply to DeDude... Just put a public option on each of these exchanges.

[ Important, though I would argue not a permanent solution:

http://www.pnhp.org/news/2016/february/clintons-%E2%80%98public-option%E2%80%99-is-a-diversion-we-need-single-payer-medicare-for-all

February 25, 2016

Clinton's 'Public Option' is a Diversion: We Need Single Payer, Medicare for All
By Don McCanne, M.D. ] Reply Tuesday, October 25, 2016 at 06:26 AM EMichael said in reply to anne... It is not a diversion, it is part of the process.

A public option would lead to single payer. Reply Tuesday, October 25, 2016 at 06:50 AM Adamski said in reply to EMichael... If Congressional Dems chicken out of single payer due to the power of the insurance and drug lobbies, then the same lobbies will oppose a public option as they did when the ACA was being debated. Either policy needs the determination to defeat those lobbies, so the same Dems might as well pass single payer. That's why a public option is both a diversion and unlikely to pass.

When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option! Reply Tuesday, October 25, 2016 at 07:15 AM EMichael said in reply to Adamski... As bad and uninformed as your entire post is, this takes the cake:


"When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!"

That comment has no basis in reality. You really should not talk with such certainty(even using an exclamation mark)on a subject that you surely have no knowledge. Reply Tuesday, October 25, 2016 at 07:23 AM JohnH said in reply to Adamski... Agreed...EMichael always tries to find a way to let corrupt Democrats off the hook. Democrats have become past masters at explaining away their ineptitude in 2009. Fact is, they really didn't have any intention of accomplishing much for the American people, and their big majority put them in an embarrassing situation that exposed their 'liberal' agenda as being little more than hot air.

More troubling yet...if Democrats couldn't pass a public option with 60 votes in their Senate caucus, how will Hillary be able to pass any positive health care reforms with a bare majority in the Senate...if she even gets that? Overall Democrats will be happy, because they will have a plausible explanation for doing nothing... Reply Tuesday, October 25, 2016 at 07:37 AM pgl said in reply to JohnH... Getting the facts right is letting corruption off the hook? I would say you've lost your mind but me thinks you never found it in the first place. Reply Tuesday, October 25, 2016 at 07:57 AM Dan Kervick said in reply to Adamski... Both would be very difficult to pass. But single payer would be much more difficult, by many orders of political magnitude, since it involved putting the entire private health insurance industry out of business; moving many, but not all, of the workers in that industry into the new public health insurance bureaucracy; and creating new jobs for the people dislocated by the transition.

Since Clinton has not run as a single payer advocate, and thus will have no popular mandate to pass it, it is difficult to imagine her being able to mobilize the huge political effort that would be needed for such a gargantuan political task, even if she wanted to do this.

At this point, the best that can be hoped for is a public option that is then grown and expanded over time, by steps, into a single payer system. Reply Tuesday, October 25, 2016 at 07:57 AM JohnH said in reply to Dan Kervick... The best way to provide single payer would be to nationalize the health insurance industry, which would not be that hard, since it is rapidly consolidating into an oligopoly consisting of a few big firms. And it wouldn't cost that much either.

But, as your say, that's politically impossible...and we're not supposed to entertain that possibility, even though economists love to entertain themselves with pie in the sky stuff like helicopter money. Reply Tuesday, October 25, 2016 at 09:17 AM pgl said in reply to JohnH... "The best way to provide single payer would be to nationalize the health insurance industry".

This is like saying the best way to drink coffee is to drink coffee. I guess you do not know what single payer means. Reply Tuesday, October 25, 2016 at 09:37 AM Dan Kervick said in reply to pgl... It's clear JohnH means that the industry is first nationalized as is, and then methodically consolidated over some period of time to transform it into a lean and proper single payer system.. Reply Tuesday, October 25, 2016 at 09:46 AM Tom aka Rusty said in reply to pgl... Actually, there is a difference.

There could be single payer insurance without nationalizing health care services. Reply Tuesday, October 25, 2016 at 09:49 AM Dan Kervick said in reply to Tom aka Rusty... Sure, I guess there could be a privately run health insurance monopoly. But who is advocating for that? Reply Tuesday, October 25, 2016 at 10:21 AM Dan Kervick said in reply to Dan Kervick... JohnH didn't say anything about nationalizing health care services. He said we could nationalize the health *insurance* industry. Reply Tuesday, October 25, 2016 at 10:24 AM pgl said in reply to Dan Kervick... Again - exactly my point. Someone today actually ate his Wheaties and can read with precision. Reply Tuesday, October 25, 2016 at 10:39 AM Dan Kervick said in reply to pgl... Sorry, I have no idea what your point was. Reply Tuesday, October 25, 2016 at 10:57 AM pgl said in reply to Dan Kervick... No one. Exactly my point. Leave it to Rusty to advocate a private monopoly for health insurance. Reply Tuesday, October 25, 2016 at 10:38 AM Tom aka Rusty said in reply to pgl... Huh?

You apparently do not understand the difference between a government single payer insurance and a government monopoly provider. Reply Tuesday, October 25, 2016 at 11:11 AM Julio said in reply to Dan Kervick... Oh, nonsense. Just give Republicans their wishes. Ability to sell across state lines. Deregulation. Non-enforcement of antitrust.
We'll have a single payer in no time. Reply Tuesday, October 25, 2016 at 09:31 AM Peter K. said in reply to Julio ... Yggies suggests a combo harsher penalities for the Bernie Bros and Gals with a public option.

http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

[Oct 16, 2016] How to Make Healthier Food Choices

Oct 16, 2016 | familydoctor.org
handout for more tips. Try a Mediterranean Diet for one of the healthiest approaches to eating we know about.

[Oct 15, 2016] Nuclear Stress Test Side Effects Side Effects Guide

Oct 15, 2016 | www.sideeffectsguide.org

Before saying anything about nuclear stress test side effects, let's explain nuclear stress test first. This test is designed to show your heart details. This way your doctor can determine irregularities regarding your heart or arteries.

How does this test actually look like? First, metal electrodes are attached to the chest and back of the patient; then the patient will have to run on a treadmill. While he is running, the electrocardiogram is recording the entire activity. After that, the patient will get an injection and then the pictures of his/her heart will be taken. This injections contain small amounts of radioactive substances which is a reason why people believe this test is harmful for the body. However, experts agree that these amounts are too small to harm any patient.

Although this test is useful for many reasons, it also has its side effects. Some of the following effects may occur:

Headache – it can be mild or quite severe and last for a couple of hours. This side effect is common among patients. It can be accompanied by nausea.

Pain in chest – another common side effect which appears shortly after the test, but soon disappears.

Breathing difficulties and heart rate changes – both of which come to normal after a while.

Some of the patients may experience bitter taste in their mouth.

All of these side effects are just temporary and they vanish in relatively short time. But before going for this test, make sure to follow your doctor's instructions. He will probably tell you not to drink or eat anything 4 hours before your test begins. Also you will be told not to take any medicines and to wear sports clothes appropriate for running. If you are pregnant , consult your doctor before deciding to take this test. Also, if you are very ill, talk to your doctor about some other option.

[Oct 15, 2016] NIH What To Expect During a Nuclear Heart Scan

Oct 15, 2016 | nhlbi.nih.gov
Many nuclear medicine centers are located in hospitals. A doctor who has special training in nuclear heart scans-a cardiologist or radiologist-will oversee the test.

Cardiologists are doctors who specialize in diagnosing and treating heart problems. Radiologists are doctors who have special training in medical imaging techniques.

Before the test begins, the doctor or a technician will use a needle to insert an intravenous (IV) line into a vein in your arm. Through this IV line, he or she will put radioactive tracer into your bloodstream at the right time.

You also will have EKG (electrocardiogram) patches attached to your body to check your heart rate during the test. (An EKG is a simple test that detects and records the heart's electrical activity.)

During the Stress Test

If you're having an exercise stress test as part of your nuclear scan, you'll walk on a treadmill or pedal a stationary bike. During this time, you'll be attached to EKG and blood pressure monitors.

Your doctor will ask you to exercise until you're too tired to continue, short of breath, or having chest or leg pain. You can expect that your heart will beat faster, you'll breathe faster, your blood pressure will increase, and you'll sweat.

Tell your doctor if you have any chest, arm, or jaw pain or discomfort. Also, report any dizziness, light-headedness, or other unusual symptoms.

If you're unable to exercise, your doctor may give you medicine to increase your heart rate. This is called a pharmacological stress test. The medicine might make you feel anxious, sick, dizzy, or shaky for a short time. If the side effects are severe, your doctor may give you other medicine to relieve the symptoms.

Before the exercise or pharmacological stress test ends, the tracer is injected through the IV line.

During the Nuclear Heart Scan

The nuclear heart scan will start shortly after the stress test. You'll lie very still on a padded table.

The nuclear heart scan camera, called a gamma camera, is enclosed in metal housing. The camera can be put in several positions around your body as you lie on the padded table.

For some nuclear heart scans, the metal housing is shaped like a doughnut (with a hole in the middle). You lie on a table that slowly moves through the hole. A computer nearby or in another room collects pictures of your heart.

Usually, two sets of pictures are taken. One will be taken right after the stress test and the other will be taken after a period of rest. The pictures might be taken all in 1 day or over 2 days. Each set of pictures takes about 15–30 minutes.

Some people find it hard to stay in one position during the test. Others may feel anxious while lying in the doughnut-shaped scanner. The table may feel hard, and the room may feel chilly because of the air conditioning needed to maintain the machines.

Let your doctor or technician know how you're feeling during the test so he or she can respond as needed.

[Oct 15, 2016] The Breakaway insurance plan amounted to a reverse Ponzi scheme where unsuspecting employers expecting to buy affordable policies instead bought costly reinsurance requiring them to cover each others losses

Notable quotes:
"... Breakaway, with about 300 employees, accused Berkshire and Applied of "siphoning" premiums through a web of illegal shell companies, with diverted premiums going to unlicensed out-of-state insurers, the wire agency said. ..."
"... The plan amounted to a "reverse Ponzi scheme" where unsuspecting employers expecting to buy affordable policies instead bought costly "reinsurance" requiring them to cover each other's losses, leaving taxpayers on the hook for shortfalls when too many workers are injured on the job, Breakaway said. ..."
Oct 15, 2016 | www.nakedcapitalism.com

Cry Shop September 13, 2016 at 1:11 am

Class Warfare:
http://www.ejinsight.com/20160913-buffett-flagship-sued-over-workers-compensation-siphoning/

Breakaway, with about 300 employees, accused Berkshire and Applied of "siphoning" premiums through a web of illegal shell companies, with diverted premiums going to unlicensed out-of-state insurers, the wire agency said.

The plan amounted to a "reverse Ponzi scheme" where unsuspecting employers expecting to buy affordable policies instead bought costly "reinsurance" requiring them to cover each other's losses, leaving taxpayers on the hook for shortfalls when too many workers are injured on the job, Breakaway said.

[Oct 15, 2016] How Accurate Are Omron Blood Pressure Monitors And Cuffs

Oct 15, 2016 | diabeteswell.com
It is essential to know the instructions on how to use an omron blood pressure monitor. It is vital to get accuate readings. Omron makes sure that you have the equipment correctly fitted before use because there is a light or sign telling you that it is attached correctly. It is also important that your posture is correct when taking such readings. For example, position your hand of the bp device on the other elbow when using a wrist monitor. Once again full details and diagram instructions are provided with their equipment. They make blood pressure readings simple and you will quickly incorporate these into your weekly routine. Important – Take a morning and evening reading

You should choose a certain day of the week in terms of regularly checking your blood pressure and stick with it. The procedure is very simple and straightforward. You should take your first reading around one hour after waking up. Note the rating and then take a second reading around one hour before going to bed. This will help get an accurate reading of what your levels are.

We have asked the question; how accurate are Omron blood pressure machines? Now let's ask a much more general question that all of you should understand the answer to;

Why do I need to bother with blood pressure readings?

Hypertension may well be the medical term given for high blood pressure, but the name you should associate it with is one which is widely used. That is "The Silent Killer". Many people are unaware that they actually have high levels of blood pressure. They feel the odd twinge or headache, but simply put this down to feeling a little under the weather.

The fact is that although possible symptoms such as severe headaches, fatigue, chest pains, or a feeling of confusion could affect you, many feel that such symptoms are not associated with high blood pressure, or they simply do not get very many of these symptoms.

Consider this; Hypertension is the biggest cause of strokes known, it also has a massive say in the amount of heart related problems we suffer from.

If that is not enough reason for you to take blood pressure readings seriously then I feel nothing will persuade you.

How can you keep those blood pressure levels in the 'healthy zone'?

Those who are overweight are increasing their risk of high blood pressure and the more overweight you are the bigger your problems. This makes blood pressure monitors particularly important for this group of people. You really need to address your weight issues, lifestyle and exercise regimen if you are to get yourself back on track. It cannot be overstated just how important looking after yourself is if you are to avoid high blood pressure problems.

Those of us who smoke, drink alcohol to excess and generally eat a poor diet are also leaving ourselves wide-open to high blood pressure.

One diet in particular should help you!

There is a really effective diet for those with high blood pressure which is known as the DASH diet. If you have home blood pressure equipment such as the wrist monitor versions that Omron provide and you find that your blood pressure is creeping up the wrong way please ask your doctor about this excellent diet.

It has been devised specifically to bring your blood pressure levels down, and if you follow it to the letter it should have you back to normal in around 2 weeks of use.

Those 2 weeks could be the difference between a new you and a very poorly you!

One of the wisest investments you will make in terms of health

There may be lots of gimmicks or unnecessary bits of equipment for your health available today, but please rest assured that home monitors for blood pressure are not gimmicks and they are highly useful. So useful they could actually save your life. Try putting a price on that!

This is the other thing, the price of such equipment really is trifling in terms of how low it is, and the peace of mind it will give you and your loved ones will pay for such a purchase many times over.

Hopefully the above has shown you the answer to our question; how accurate are Omron blood pressure machines, and you will use this advice to purchase one of their extensive range to suit your needs. Remember; it could be a life saver!

[Oct 15, 2016] How Big Pharma's Industrial Waste Is Fueling the Rise in Superbugs Worldwide

Oct 15, 2016 | www.truth-out.org
Sep 22, 2016 | www.truth-out.org
Written by The Bureau of Investigative Journalism | Report Pharmaceutical companies are fuelling the rise of superbugs by manufacturing drugs in factories that leak industrial waste, says a new report which calls on them to radically improve their supply chains.

Factories in China and India -- where the majority of the world's antibiotics are produced -- are releasing untreated waste fluid containing active ingredients into surrounding areas, highlights the report by a coalition of environmental and public health organisations.

Ingredients used in antibiotics get into the local soil and water systems, leading to bacteria in the environment becoming resistant to the drugs. They are able to exchange genetic material with other nearby germs, spreading antibiotic resistance around the world, the report claims.

Ahead of a United Nations summit on antimicrobial resistance in New York this week, the report -- by the European Public Health Alliance (EPHA) and pressure group Changing Markets -- calls on major drug companies to tackle the pollution which is one of its root causes.

They say the industry is ignoring the pollution in its supply chain while it drives the proliferation of drug resistant bacteria -- a phenomenon which kills an estimated 25,000 people across Europe and globally poses "as big a threat as terrorism," according to NHS England's Chief Medical Officer Dame Sally Davies.

If no action is taken antimicrobial resistance (AMR) will kill 10 million people worldwide every year -- more than cancer -- according to an independent review into AMR last year led by economist Professor Jim O'Neill.

Changing Markets compiled previous detailed reports and conducted its own on-the-ground research looking at a range of Chinese and Indian drug manufacturing plants making products for some of the world's biggest pharmaceutical companies. One of the world's biggest antibiotic production plants, in Inner Mongolia, was found in 2014 to be "pumping tonnes of toxic and antibiotic-rich effluent waste into the fields and waterways surrounding the factory," according to Chinese state television.

In India, where much of the raw material produced by Chinese factories is turned into finished drugs, various studies have found "high levels of hazardous waste" and "large volumes of effluent waste" being dumped into the environment. About a quarter of UK medicines are made in India.

[Oct 14, 2016] Deaths Linked to Cardiac Stents Rise as Overuse Seen

Notable quotes:
"... Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). ..."
"... The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention. ..."
"... "It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her." ..."
"... "I do believe that Bruce was a guinea pig," she said. "That was the way it was done." ..."
Bloomberg

When Bruce Peterson left the U.S. Postal Service after 24 years delivering mail, he started a travel agency. It was his dream career, his wife Shirlee said.

Then he went to see cardiologist Samuel DeMaio for chest pain. DeMaio put 21 coronary stents in Peterson's chest over eight months, and in one procedure tore a blood vessel and placed five of the metal-mesh tubes in a single artery, the Texas Medical Board staff said in a complaint. Unneeded stents weakened Peterson's heart and exposed him to complications including clots, blockages "and ultimately his death," the complaint said.

DeMaio paid $10,000 and agreed to two years' oversight to settle the complaint over Peterson and other patients in 2011. He said his treatment didn't contribute to Peterson's death.

"We've learned a lot since Bruce died," Shirlee Peterson said. "Too many stents can kill you."

Peterson's case is part of the expanding impact of U.S. medicine's binge on cardiac stents -- implants used to prop open the arteries of 7 million Americans in the last decade at a cost of more than $110 billion.

When stents are used to restore blood flow in heart attack patients, few dispute they are beneficial. These and other acute cases account for about half of the 700,000 stent procedures in the U.S. annually.

Among the other half -- elective-surgery patients in stable condition -- overuse, death, injury and fraud have accompanied the devices' use as a go-to treatment, according to thousands of pages of court documents and regulatory filings, interviews with 37 cardiologists and 33 heart patients or their survivors, and more than a dozen medical studies.

'Marching On'

These sources point to stent practices that underscore the waste and patient vulnerability in a U.S. health care system that rewards doctors based on volume of procedures rather than quality of care. Cardiologists get paid less than $250 to talk to patients about stents' risks and alternative measures, and an average of four times that fee for putting in a stent.

"Stenting belongs to one of the bleakest chapters in the history of Western medicine," said Nortin Hadler, a professor of medicine at the University of North Carolina at Chapel Hill. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to lose it, he said.

Stenting abuse is by no means the norm, but neither is it a rarity. Federal cases have extended from regional medical centers in Louisiana, Kentucky and Georgia to a top-ranked metropolitan hospital system in Ohio.

Asset Seizure

A doctor practicing at a hospital owned by the Cleveland Clinic, rated the premier heart center in the country by U.S. News and World Report, had his assets seized by federal agents in a stent investigation, according to federal court filings in April. The Clinic has not been accused of wrongdoing, and says it's cooperating with the investigation.

Two out of three elective stents, or more than 200,000 procedures a year, are unnecessary, according to David Brown, a cardiologist at Stony Brook University School of Medicine in New York. That works out to about a third of all stents.

Brown said his estimate is based on eight clinical trials of 7,000 patients in the last decade, which he analyzed in the Archives of Internal Medicine last year. Two cardiology researchers who have studied the use of stents say the number could be as low as about half Brown's estimate, and one said it is probably larger.

Costs, Risks

Even the low end of these estimates translates into more than a million Americans in the past decade with implants in their coronary arteries they didn't need, said William Boden, chief of medicine at a Veterans Administration hospital in Albany, New York. Boden was the principal investigator of a 2007 study known as Courage that found stents added no benefit over medicines, exercise and dietary changes in stable patients.

Unnecessary stents cost the U.S. health care system $2.4 billion a year, according to Sanjay Kaul, a cardiologist and researcher at Cedars-Sinai Medical Center in Los Angeles. Patients who received them are living with risks including blood clots, bleeding from anti-clotting medicine and blockages from coronary scar tissue, any of which can be fatal, Kaul said.

Monica Crabtree died at age 64 after one of her arteries was torn in a stent procedure that led to infection, according to her widower, Gary Crabtree. He received at least $240,000 from a 2011 settlement of his lawsuit against her doctor, after a second cardiologist reviewed the case and told him the stent wasn't needed. Crabtree choked up speaking about his late wife and showed pictures of their 47 years together.

Worried Shaving

"It wasn't just a simple mistake," said the retired auto worker in Largo, Florida. "If the stent was something she really needed, I could have handled it. But it was a total loss of life that didn't need to happen."

Jim Simecek, of Medina, Ohio, said he worries every morning that a nick from shaving could bleed out of control. Simecek, who works at a Ford dealership, said he has to take blood-thinning medicine for life to ward off clots in the six stents he received from a Cleveland-area cardiologist who's under federal investigation for his stent work.

"It's as if your heart was open and somebody was sticking a knife in," said Rhonda McClure, 54, referring to eight stents she received from a Kentucky cardiologist who agreed in June to plead guilty to a federal Medicaid-fraud charge for falsifying records used to justify a stent he placed.

Patient Letters

Cardiac stents were linked to at least 773 deaths in incident reports to the U.S. Food and Drug Administration last year, according to a review by Bloomberg News. That was 71 percent higher than the number found in the FDA's public files for 2008. The 4,135 non-fatal stent injuries reported to the FDA last year -- including perforated arteries, blood clots and other incidents -- were 33 percent higher than 2008 levels.

The FDA declined to comment on whether the reports were a cause for concern. It said adverse-event reports tied to medical devices have increased overall due to agency efforts. It also said the data can contain incomplete and unverified accounts from reporting parties.

More than 1,500 patients have gotten letters from hospitals since 2010 alerting them that their stents may have been unnecessary. In Philadelphia, the University of Pennsylvania Health System sent 700 such notices in April.

Stenting Decline

At least 11 hospitals have settled federal allegations of charging for needless stenting and other misdeeds in the catheterization labs where the procedures are performed. Federal probes of stenting practices continue in at least five states. In Louisiana and Maryland, cardiologists went to federal prison last year for implanting the devices and charging for them without medical justification. A third doctor has agreed to do time in a plea bargain.

"There is a huge financial incentive to increase the number of these procedures," said Jamie Bennett, a former assistant U.S. Attorney in Baltimore who handled stent investigations. "The cases we have seen to date are just the tip of the iceberg."

Since Boden's Courage study, stenting procedures have declined by about 20 percent. Still, this July, a panel of experts convened by the American Medical Association and the Joint Commission, a hospital accreditor, named elective stenting as one of five overused treatments that too often "provide zero or negligible benefit to patients, potentially exposing them to the risk of harm."

Better Choices

Doctors are using fewer stents and choosing more-appropriate patients than they were a few years ago, according to John Harold, president of the American College of Cardiology, the specialty's main professional group. Harold said that "real-world clinical practice" and research indicates Brown probably overestimated how many people with coronary artery disease could be handled initially only with drug-based treatment.

He said there are examples of inappropriate use and the ACC is taking steps to "address and correct the imbalance" with treatment guidelines and by urging more hospital oversight. Cardiologists who've been accused of fraud or are serving prison time are "outliers" who don't represent the "overwhelming majority."

Lawyers for John McLean, a Salisbury, Maryland, cardiologist convicted of billing for unwarranted stenting, argued in a federal appeal last year that inappropriate usage is widespread and their client was prosecuted for behavior that's the industry norm.

Lost Appeal

They cited a 2011 study in the Journal of the American Medical Association that found only half of elective stent procedures nationally were appropriate under usage guidelines written by societies of heart specialists. The study found 12 percent were inappropriate, and 38 percent fell into the uncertain category of the guidelines.

"The study demonstrated clearly that a large number of stable patients receive coronary artery stents that are later found to be inappropriate or questionable," the appeal argued. "The same was true of the patients in Dr. McLean's practice." McLean's appeal was denied in April. He is serving an eight-year sentence.

Elective-stent patients typically see rapid quality-of-life improvements, including in their ability to work and be active, according to Ted Bass, president of the Society for Cardiovascular Angiography and Interventions, whose members specialize in cardiac implants. The Courage trial found stents, compared to medication and lifestyle changes, were better at relieving chest pain for as long as two years after placement -- a benefit that ended by 36 months.

Profit Centers

First used in Europe in 1986, cardiac stents took off in the 2000s as cardiologists found them to be more effective in heart attacks than angioplasty. In that earlier technology, a small balloon is inflated to widen blood passages and then withdrawn. Stenting facilities, known as "cath labs," spread at hospitals and became profit centers.

Hospitals receive an average payment of about $25,000 per stent case from private insurers, according to Healthcare Blue Book, a website that tracks reimbursements. The federal Medicare program pays less. Doctors who implant stents earn a separate fee that averages about $1,000 and ranges from $500 to $2,850, according to Medicare and Blue Book data.

The procedure typically involves inserting the stent with a catheter through a small incision in the groin area or wrist and snaking it through to heart vessels. It usually takes less than 45 minutes.

Kickbacks Alleged

Stony Brook's Brown, and Boden, who led the Courage study, argue that many elective patients should be getting medical therapy before they risk stents. Only 44 percent try medication and lifestyle changes before stenting, a 2011 study in the Journal of the American Medical Association found.

At least five hospitals have reached settlements with the Justice Department over allegations that they paid illegal kickbacks to doctors for patient referrals to their cath labs. St. Joseph Medical Center in Towson, Maryland, paid the government $22 million without admitting liability.

Prosecutors alleged the hospital paid kickbacks to a practice co-founded by Baltimore cardiologist Mark Midei for stent referrals. His doctor's license was revoked in 2011 when the Maryland Board of Physicians found he falsified records to justify unwarranted stents.

St. Joseph told 585 of its patients they may have received unnecessary stents. In May, 252 patients reached a settlement with the hospital under confidential terms, according to Jay D. Miller, an attorney for the plaintiffs.

Plea Agreement

The hospital settled the government's case "to avoid the expense and uncertainty of litigation," it said in a statement. Spokeswoman Julia Sutherland said the hospital declined to comment on any patient lawsuits.

In an interview, Midei denied he stented without medical need. He took issue with experts who deemed many of his stents needless, and said disagreement among cardiologists on cases is common. Midei was not a party to the federal settlement. The government has said its investigation of the case continues.

In June, Sandesh Patil, a cardiologist practicing at another St. Joseph hospital -- this one in London, Kentucky -- agreed to plead guilty to charging Medicaid for a stent that wasn't medically warranted under the program's rules. (Although both hospitals were once owned by the same parent, the one in Maryland has been sold.)

Catheterization procedures multiplied at St. Joseph in London after Patil began practicing there in 2000, when the hospital had a different name. In that year, the type of procedure used for stents was done 210 times. They climbed to 929 by 2009, state data show.

Multiple Stents

Stenting income from Medicare alone was more than a sixth of the hospital's 2009 operating income, based on data from American Hospital Directory, a research firm. When Patil left London in 2010, catheterization procedures fell 34 percent from their 2009 high. Using the midpoint of the directory's price range for such procedures, the decline would have cost the hospital about $15 million. David McArthur, the hospital's spokesman, declined to comment on its revenues.

Rhonda McClure, one of Patil's patients, had her arteries catheterized 18 times by him and his partners over four years, according to her deposition and other filings in a lawsuit she and 361 other patients have brought against Patil, St. Joseph and other doctors who practiced there. She said she received eight cardiac stents. The defendants deny the negligence and fraud allegations against them.

McClure's deposition says a cardiologist who reviewed her case after the stents told her that scarring caused by "too many procedures" was her main problem.

Short Breath

McClure said she suffers from chest pain and shortness of breath, and has been told by her new doctor that she may need more stents and surgery to keep her coronary arteries from closing. She said she gets so tired she needs to sit and rest after walking down the stairs.

St. Joseph-London repaid Medicare $256,800 for unnecessary procedures and is cooperating with federal prosecutors, McArthur said. He said Patil was never employed by St. Joseph and lost his privileges to practice there in December 2010. Patil's attorney said his client had no comment.

Under his plea bargain, Patil agreed to serve 30 to 37 months in federal prison. He forfeited his Kentucky medical license for five years. In 2012, he told a family court judge his monthly income was $53,300.

"Thirty-seven months is nothing for all the injuries he done for money," McClure said.

Message Balancing

After the Courage trial shed doubt on stents' effectiveness for stable patients, stent-implanting cardiologists felt unfairly attacked and organized a campaign to "better balance the messaging," said Bonnie Weiner, who was president of the Society for Cardiovascular Angiography and Interventions at the time.

The society hired a public relations firm and paid it more than $300,000 a year to help publicize the benefits of stents, according to the group's filings with the Internal Revenue Service. The firm helped launch a consumer website for SCAI, SecondsCount.org, which has published several articles, including one under the headline, "For many patients, open arteries are better than closed arteries."

SCAI collected $2.7 million in donations for "public education" between 2008 and 2011 from stent makers Abbott Laboratories Inc., Boston Scientific Corp., Cordis Corp. and Medtronic Inc., its Web site says. Manufacturers' sales of cardiac stents were about $5.5 billion globally last year, down 5 percent from 2011, according to the Health Research International consulting firm.

High Median

Medtronic spokesman Joseph McGrath said grants to SCAI for patient education are "unrestricted," and SCAI is solely responsible for how the funds are used. Spokesmen for Abbott, Boston Scientific and Cordis declined to comment.

Interventional cardiologists, the specialty SCAI represents, earn a median income of $562,855 a year, as compared to $207,117 for family doctors, according to Medical Group Management Association, which surveys physician practices. The interventionalists ranked 13th among 118 specialties tracked by MGMA.

Michigan Death

Mehmood Patel, a Lafayette, Louisiana, cardiologist who went to prison last year on 51 counts of charging for needless stents, made over $16 million in one three-year span, evidence in the case showed. Prosecutors said he was driven by the desire to be the busiest cardiologist in town.

He unsuccessfully argued that he used his best medical judgment in every case and lost an appeal. Patel is serving a 10-year sentence in a federal penitentiary.

Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel).

The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention.

"It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her."

False Claims

Kovach said that when she told the chief operating officer of the hospital where Patel worked about the death, the executive, Karen Chaprnka, diverted the conversation. Reached recently by e-mail through a hospital spokesman, Chaprnka said she "disagreed with the allegations made by Dr. Kovach."

"He's their cash cow," said Kovach, now co-director of a clinic that treats congenital heart disease at the Detroit Medical Center. "They're not about to turn him in."

Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of $4 million to settle the federal charges. Kovach was awarded $760,000 as a whistle-blower under the U.S. False Claims Act. Allegiance disagreed with the allegations and settled the claims to avoid "lengthy litigation," it said in a statement.

Patel continues to practice at the hospital and must improve record-keeping to substantiate cardiology procedures, Allegiance said. In the settlement, Patel agreed to hire a consultant to oversee treatment of his patients and an auditing firm to monitor billings. He didn't return phone messages.

Cleveland Raid

In Ohio, Simecek, the worker at the Ford dealership, grew suspicious after his sixth stent from cardiologist Harry Persaud at the Cleveland Clinic's Fairview Hospital in 2011. Simecek said he went for a second opinion and was told he didn't need any of the stents. Now he said he has to take blood thinners the rest of his life.

"With the littlest cut, the blood starts running," said Simecek. "What if I am in an auto accident?"

Persaud is under criminal investigation for health care fraud, mail fraud and money laundering, according to federal court filings. Last October, Federal Bureau of Investigation agents raided his office and removed financial records and patient files for procedures at three Cleveland-area hospitals. The government has seized $343,634 from his and his wife's bank accounts, alleging the funds represent the proceeds of fraud related to a "significant number" of unnecessary stent procedures.

Multiple, Elongated

The Cleveland Clinic found "problems related to the use of stents in some patients" at Fairview and reported them to the government, according to spokeswoman Eileen Sheil. She would not say how many patients were affected. Persaud resigned from the hospital staff last year.

At least 64 of Persaud's patients at St. John Medical Center in suburban Westlake received letters from the hospital saying they may have received an unnecessary stent between 2010 and 2012, according to spokesman Patrick Garmone, who said Persaud no longer practices there.

Persaud denied wrongdoing in court filings and said his stent procedures were proper. Neil Freund, his attorney in lawsuits filed by patients alleging unwarranted stents, said "it is our intent to defend these cases." He had no comment on the federal investigation.

Final Order

In Texas, the state medical board's final order in DeMaio's case found that the cardiologist placed "multiple, elongated, overlapping" stents in patients in areas of "insignificant or only moderate disease." Peterson, the retired mailman, was identified only as Patient C in the staff complaint. No patient was mentioned in the final order.

Peterson was thriving in his new career in the travel business, his wife Shirlee said. He had a heart attack in 1997, which didn't crimp his love of travel and dance, she said. "He was an awesome man who never met a stranger," she said.

After his death, Shirlee Peterson said a friend told her she had a cardiologist who refused to do multiple stents.

"I do believe that Bruce was a guinea pig," she said. "That was the way it was done."

DeMaio said Peterson was extremely sick when he came to him. He said it was significant that the board's final order didn't use the word "excessive" in describing his stent work. That included 31 stents stretching for 14 inches inside the arteries of Patient B in the staff complaint.

"Any patient of mine who received a full metal jacket" -- interventional cardiology's term for such extensive work -- "would have been turned down by at least one, if not multiple surgeons," DeMaio said. He said he doesn't use stents as much these days because standards have changed and he doesn't see as many seriously ill patients.

[Oct 12, 2016] Managing hyperlipidemia means controlling cholesterol and triglycerides.

Aug 01, 2021 | www.heart.org

Hyperlipidemia is a mouthful, but it's really just a fancy word for too many lipids – or fats – in the blood.

That can cover many conditions, but for most people, it comes down to two well-known terms: high cholesterol and high triglycerides . Our bodies make and use a certain amount of cholesterol every day, but sometimes that system gets out of whack, either through genetics or diet. Higher levels of the "good" HDL cholesterol are associated with decreased risk of heart disease and stroke. HDL helps by removing cholesterol from your arteries, which slows the development of plaque. The "bad" LDL cholesterol, on the other hand, can lead to blockages if there's too much in the body.

What's the treatment?

If you are diagnosed with hyperlipidemia, your overall health status and risks will help guide treatment . Making healthy diet choices and increasing exercise are important first steps in lowering your high cholesterol . Depending on your overall risk, your doctor may also prescribe medication in conjunction with healthy eating and regular exercise.

"The combination of diet and regular physical activity is important even if you're on medication for high cholesterol ," said Dr. Vincent Bufalino, an American Heart Association volunteer. "It's the most critical piece."

Consulting a doctor is important, since each condition has it quirks. For people with high triglycerides, for example, alcohol can be particularly dangerous. But for those with high cholesterol, a daily glass of wine or other alcohol, along with healthy eating and exercise, may actually help, Dr. Bufalino said.

Once I have it, can I reverse it?

Hyperlipidemia can be improved in many cases through healthy eating and regular exercise.

Here are some tips on how to manage your risk of high cholesterol. Learn more about cholesterol:

[Oct 12, 2016] What You Need to Know about the New Cholesterol Guidelines CHI Health Blogs

Feb 25, 2015 | blogs.chihealth.com

In late 2013, after an extensive review of evidence, the National Heart, Lung and Blood Institute updated cholesterol guidelines. Why did they do this? These new guidelines better identify those at risk of atherosclerotic cardiovascular disease (ASCVD), and also better diagnose people who already have ASCVD. Patients who have ASCVD are more likely to suffer a heart attack or stroke.

To determine if someone is at risk of developing ASCVD a risk estimator is available through Cardio Source. Information including Systolic Blood Pressure, a patient's race, HDL Cholesterol and more are entered.

Depending on the level of risk, patients should take different courses of action. For all patients who are determined to be at risk for ASCVD there are behavioral modifications they should implement. These include: eating a heart-healthy diet, regularly exercising, avoiding tobacco products and maintaining a healthy weight.

For lower risk individuals, there are other items to take into account on whether they are likely to develop ASCVD. These include a family history of premature ASCVD, LDL greater than 160, high sensitivity C-reactive protein, Coronary calcium score and Ankle/brachial index.

For those with a high likelihood of developing ASCVD and for those individuals who already have ASCVD, statins should be taken. The guidelines have also been updated. There are non-statin medications also available for those patients unable to take statins (due to side effects or drug interactions). Talk with your doctor to determine which medicine is best for you.

[Oct 12, 2016] Doctors Behaving Badly

Notable quotes:
"... Doctors Behaving Badly ..."
Oct 12, 2016 | blogs.chihealth.com

CHI Health Blogs CHI Health Heart

Cardiology
Eric Van De Graaff, M.D.
May 14, 2012 As odd as this might sound, my mother was upset when I declared my intention to go to medical school.

It wasn't the mountain of debt I was sure to incur since I'd already figured out how to get Uncle Sam to pick up the bill (a small deal that put me in a military uniform for a decade). It wasn't the fact that medical school would delay the litter of bouncing grandbabies she wanted to fawn over. And it certainly wasn't because she'd miss me-she'd already seen too much of me and my dirty laundry on weekends during college.

No, my mother was legitimately disappointed in me for choosing to enter the medical profession simply because she had a deep-seated disdain for doctors. I could almost envision her sad disgrace as she chatted with the neighbors during my final year as a resident in brain surgery:

Mom: "What's little Festus up to these days?"

Neighbor 1: "Oh he's doin' real good. He's got hisself a carwash business up in Magna that pulls in a couple hundred a week. Lookin' to buy a bass boat for him and the misses."

Mom: "And Cletus?"

Neighbor 2: "Almost done with his ten years up at the state pen in Bluffdale. Won an award for license plate stampin'. Trixie and the boys are real proud of him."

Neighbor 1: "And what's Eric doing?"

Mom: "He's still not married."

My mother never told me why she disliked doctors so much. I'm left to assume that she'd had a number of bad interactions with them over the years, but she never bothered to back up her expressions of disapproval with any sort of details. It took several years for my mother to warm up to the idea that I had not turned to the dark side by becoming a doctor. I think a lot of it had to do with inertia-by the time she finally decided to express any acknowledgement of my career decision, two more of us boys were in medical school and I supposed she realized she couldn't be disappointed in all of us.

Now that I've been in practice a number of years I've finally learned what it was that so intensely turned my mother off about doctors: they can be arrogant, condescending and impolite. Of course, many of my readers are at this moment wondering if I'm also going to reveal other mysteries such as "birds fly" and "dogs bark."

I had a roommate in medical school who was a great guy. He studied hard, didn't party too much, and always managed to put the toilet paper on the right way (rolling out from the top down, in case you were wondering). Years after we graduated and had gone our separate ways I had a phone conversation with a physician assistant who'd gone to work for my old roommate. "It must be great working for Dr. X," I added. A pause on the phone. "No," he said slowly, "he's a total jerk. Everybody hates him."

I have two theories. One is that all medical students believe they will go on to become an Albert Schweizer in their field-kind, self-sacrificing, benevolent-but somewhere along the way a certain fraction of them let the glory of their career go to their heads and begin to treat patients and underlings like chewing gum on a movie theater floor. What constitutes that percentage is in the eye of the beholder. For my mother it was some where around the 98% mark. I'm a little more generous-I'll say 20%.

My second theory is that all doctors believe themselves to be noble, kind, and beloved by all. Rarely do I come across an arrogant doctor who recognizes him- or herself as such. Rather, almost all of us think we're appropriately mannered. And we are . . . most of the time.

The rubber hits the road, though, when job-related stress enters the picture. A physician who ends up an hour behind in a busy clinic can become snappy at his nurses and receptionists. A surgeon who is elbow-deep in a case gone awry will turn her anger toward the anesthesiologist and scrub techs. In both cases, the doctors in question feel they were simply reacting appropriately to the situation: "Of course I yelled at my nurse. Doesn't she realize she is making me later than I already am?" or "Of course I hurled the Metzenbaums across the room. Am I the only one in the OR who cares what happens to this patient?!"

As any nurse will tell you, the true measure of a doctor's demeanor is not how he or she acts during times of ease. Instead, the nature of a physician's soul is uncovered precisely during those times when he or she has the most right to explode in a volcano of vulgarities and instrument-throwing. A doctor who can keep cool while juggling 3 phone calls, a clinic filled with patients, and a patient exsanguinating on the operating table is both rare and worthy of high esteem.

In fellowship I had the misfortune to work under a cardiologist described by all other fellows thus: "She's fun socially but awful to work with." This proved to be true: at a staff party she was great to have around, but when faced with the challenge of rounding on 15 patients in a two-hour period she transformed into Medusa. Yet, I'm sure, if asked, she would maintain that she is polite, kind, and patient-as long as the situation doesn't demand otherwise. The problem is that her definition of "situation" was pretty much every day at work.

We doctors have chosen professions that are inherently filled with stress, deadlines, and treading in deep emotional waters. None of that grants us a free pass to behave like spoiled toddlers. As I see it, doctors should always follow 2 simple rules:

Rule #1: It is simply not allowable to be impolite, mean, nasty or snippy with staff or patients even when you are in a stressful situation.

Rule #2: Whatever is stressing you is probably stressing those around you as much or more. Under those circumstances you have to go out of your way to be kinder and more understanding. As a doctor, you control the mood in the clinic and operating room even if you can't control the situation.

I freely admit I am unable to always adhere to these rules but I at least recognize them and intend to spend the rest of my career trying to do better. My mother passed away many years ago but I'm hoping that somewhere up there she can look down and see that I didn't turn out to be so terrible after all.

This entry was posted in Cardiology . Bookmark the permalink .

8 Responses to Doctors Behaving Badly

  1. Loan Eby says: May 15, 2012 at 4:26 pm Bedside manner
    I was with my mom when her doctor told her she had Stage IV pancreatic cancer. After learning my mom had 6-months to live, I remember walking out of Good Sam in Kearney and running into my high school friend who was a nurse there. My friend greeted me with a smile because she had not seen me in years. I told her the devastating news and how awful the doctor was to my mom. She told me he was one of the best oncologists around. If he was the best round, I would have hated to see their worst. Thank you for your post.
  2. Nikki says: May 15, 2012 at 4:44 pm It's refreshing to read Dr. Van De Graaff post. I have worked with many Dr. and nurses in my time in the medical field. Sometime you get the nice fun loving Dr. / nurse or sometimes they are possessed, as a clinic worker it's my job ( and I take pride in it) to not let it get so bad in the clinic and if it does everyone better start doing their best to make the situation the best they can. I don't think that there is a day that goes by we aren't laughing even when we are all a little crazy. It's nice to know that when you behave badly you know you shouldn't….
  3. Lance Taylor says: May 15, 2012 at 10:53 pm Treat other how you would expect to be treated, and all will be well.
  4. Sandra says: May 18, 2012 at 8:42 am My mother also had the same attitude towards physicians. However, my mother took everything in stride and always voiced her opinion. A few times she would bluntly express to the physician/nurse when they were not very nice and did not answer her questions. It was interesting to see the look on the physician/nurse's faces; it is evident that they were not aware how they come across to their patients at any given time. Sometimes it is up to the patient to express to their care provider how they are treating the patient. I saw first handed how their attitudes changed each time my mother came into the clinic for the chemo/radiation treatments. I would advise others to ask the provider/nurse how is your day going, it is amazing how their attitude can fall into a positive manner when someone shows interest in them as a person not just a physician/nurse. Thanks for sharing your story Dr. V.
  5. RS says: June 26, 2012 at 11:00 am I have to say, your mother raised you right! Its not everyone that knows the correct way to put the toliet paper on! Your attitude is refreshing and you make your profession proud! Your well written article should be a reminder to everyone that we should all treat those around us with dignity and respect.
  6. Leslie says: August 13, 2012 at 10:22 am I am a retired respiratory therapist, my father was a pharmacist who owned his own pharmacy and I have 3 cousins and an uncle who are physicians. I say that because I want you to know that I have been around physicians all of my life. All that being said I would come alot closer to your mother's 98%(probably around95%) than your generous 20%. That would include my uncle. To find a physician who is both a good dr and a good person is rare indeed. For decades I had to endure tamtrum throwing doctors. Now we have added millions of doctors from middle eastern countries who have NO respect for women, zero manners and have such thick accents the poor little old people have no clue what the physician just said, let alone who he actually was(no name, no specialty, no time for questions, no business card).
    My opinion has been for years that if you can't keep your cool under stressful conditions then you need to be a plumber. Anyone who doesn't think that every level of healthcare is extremely stressful-think again. Yelling at people who have done no wrong only makes them more nervous and more likely to really make a mistake. Yep, a plumber. You can make as much money(perhaps more). You can make your own hours. No insurance companies to deal with.
    Think about it. Some people make everyone happy by entering a room…and others by leaving.
  7. Jonathan hersch says: August 14, 2012 at 2:05 pm I find that my patients say the same thing about other doctors as your mother. Certainly many have let this career go to their head. I have many techniques to control my anger and frustration when things are going bad in the operating room. It's hard but a must.

    I find myself hanging out with doctors who are like myself. Laid back and don't take life too serious. The rest are hard to get along with. Patients feel the same.

  8. KEITH BARKLEY says: April 10, 2013 at 9:34 am I had the privelege of meeting DR. van de Graaf after a trip to the hospital via rescue squad. These people really saved my life.I was near death and Dr van de Graff helped preform a miracle for me.I haved been exposed to many medical people over the past 80+ years and I will critisize few of them – – but Dr van de Graff is truly a special person – as well as Dr.

[Oct 12, 2016] The American Heart Association -- Protecting Industry Not Patients

Dec 16, 2013 | www.huffingtonpost.com
The American Heart Association (AHA) and the American College of Cardiology (ACC) recently released new cardiovascular disease prevention guidelines . They are an egregious example of much that is wrong with medicine today.

The guidelines propose a vast expansion of the use of statins in healthy people, recommending them for about 44 percent of men and 22 percent of healthy women between the ages of 40 and 75. According to calculations by John Abramson, lecturer at Harvard Medical School, 13,598,000 healthy people for whom statins were not recommended based on the 2001 guidelines now fall into the category of being advised to take moderate or high intensity statin therapy.

The American Heart Association (AHA) is a nonprofit organization with a mission to "build healthier lives free of cardiovascular disease and stroke." Yet in its 2011-2012 financial statement , the AHA noted $521 million in donations from non-government and non-membership sources and many well-known large drug companies, including those who make and market statins, contribute amounts in the $1 million range.

Even as many in the medical community suspected the guidelines were a ploy to help the AHA's drug partners sell statins, it was revealed that the guideline's online calculator to determine cardiac disease risk over predicts risk by an astonishing 75 to 150 percent. But the guideline writers are standing firmly behind their faulty calculator.

Seven of the 15 authors disclosed ties to industry. Originally, the panel chair, Neil J. Stone, MD of Northwestern University, declared that he has had no ties to industry since 2008. Jeanne Lenzer, writing in the British Medical Journal (BMJ) last month, interviewed Dr. Stone who said: "When I was asked by NHLBI [National Heart, Lung and Blood Institute] to chair the [cholesterol] panel, I immediately severed ties with all industry connections prior to assuming my role as chair." However, prior to 2008, he accepted funding and consultancy fees from multiple pharmaceutical companies, including Abbott, AstraZeneca, Pfizer, Merck, and Schering-Plough among others. Dr. Stone also told the BMJthat he will "definitely" not take any industry funding for two years. Are we to believe that by severing his ties in 2008 his mind became an instant tabula rasa, completely devoid of any conscious or unconscious bias towards the drug companies which had been paying him? To do so strains the bonds of credulity past the breaking point.

The financial ties between large pharmaceutical companies and the AHA are numerous and very remunerative for the AHA, including huge donations from Abbott, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb (BMS), Eli Lilly, Merck and Pfizer. BMS, along with Merck and Pfizer are national sponsors of AHA's Go Red For Women> heart disease awareness campaign whose web site tells patients "If your doctor has placed you on statin therapy to reduce your cholesterol, you can rest easy-the benefits outweigh the risks" The site also proclaims that "Zocor and Pravachol - have the fewest side effects," and "statins may only slightly increase diabetes risks." The Women's Health Initiative , a federal study of over 160,000 healthy women to investigate the most common causes of death, disability and poor quality of life in postmenopausal women, showed that a healthy woman's risk of developing diabetes was increased 48 percent compared to women who were not on a statin. And contrary to what statin apologists say about statins only increasing diabetes risk in people who are at high risk of developing it anyway, for example the obese, women on statins in the Women's Health Initiative who were of normal weight increased their risk of diabetes 89 percent compared to same weight women not taking a statin.

In 2010, AHA received $21,570 from statin maker AstraZeneca to run an AHA course about "emerging strategies with statins" at the Discovery Institute of Medical Education and almost $100,000 for learning projects including "debating controversial topics in cardiovascular disease." The AHA defended the deceptively marketed and controversial cholesterol drug Vytorin. Did that have anything to do with the $2 million a year the AHA was taking from marketer Merck/Schering-Plough Pharmaceuticals?

The AHA also rakes in millions from food companies which are also million dollar donors and which pay from $5,490 to $7,500 per product to gain the "heart-check mark" imprimatur from the AHA, renewable, at a price, every year. The foods so anointed have to be low in fat, saturated fat, and cholesterol yet Boar's Head All Natural Ham somehow made the cut as did Boar's Head EverRoast Oven Roasted Chicken Breast . Such processed, high-sodium meats raise blood pressure, the risk of cardiovascular disease and the risk of diabetes. A review of almost 1,600 studies involving one million people in ten countries on four continents showed that a 1.8-ounce daily serving of processed meat raised the risk of diabetes by 19 percent and of heart disease by 42 percent.

The new guidelines might make sense if statins were truly as effective as their proponents claim, and if they had no adverse effects. But they have an increasing list of side effects, which affect at least 18 percent of people who take them. These range from muscle pain, weakness and damage to cataracts, cognitive dysfunction, nerve damage, liver injury and kidney failure.

As Jerome Hoffman, M.D., Professor Emeritus of Medicine at UCLA wrote recently with regard to these guidelines: "How did we arrive at a place where conflicted parties get to make distorted semi-official pronouncements that have so much impact on public policy?" How indeed? By Barbara Roberts, M.D. is an Associate Clinical Professor of Medicine at the Alpert Medical School of Brown University. She is the author of The Truth about Statins and How to Keep from Breaking Your Heart: What Every Woman Needs to Know about Cardiovascular Disease . Martha Rosenberg is a health reporter and author of Born with a Junk Food Deficiency.

[Oct 11, 2016] Doctors perform thousands of unnecessary surgeries

Notable quotes:
"... A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. ..."
"... "We expect the physician to know what's best for a patient," says William Root, chief compliance officer at Louisiana's Department of Health and Hospitals. "We put so much faith and confidence in our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can do a lot of damage." ..."
Oct 11, 2016 | www.usatoday.com
June 20, 2013 |

Jonathan Stelly was 22, a semi-pro baseball player aiming for the big leagues, when a fainting spell sent him to his cardiologist for tests. The doctor's office called afterward with shocking news: If Stelly wanted to live to age 30, he was told, he'd need a pacemaker.

Stelly knew it would be the end of his baseball dream, but he made a quick decision. "I did what the doctor said," he recalls. "I trusted him."

Months after the surgery, local news outlets reported that the Louisiana cardiologist, Mehmood Patel, was being investigated for performing unnecessary surgeries. Stelly had another doctor review his case. Then another. And another. They all agreed: He needed blood pressure medication, but he never needed the pacemaker.

Today, Patel is in prison, convicted of billing Medicare for dozens of unnecessary heart procedures. Stelly, now 34, still has the pacemaker – but the doctors shut it off years ago.

"Baseball was my life, and he took that away," Stelly says. "For nothing."

... ... ...

Tens of thousands of times each year, patients are wheeled into the nation's operating rooms for surgery that isn't necessary, a USA TODAY review of government records and medical databases finds. Some, such as Stelly, fall victim to predators who enrich themselves by bilking insurers for operations that are not medically justified. Even more turn to doctors who simply lack the competence or training to recognize when a surgical procedure can be avoided, either because the medical facts don't warrant it or because there are non-surgical treatments that would better serve the patient.

... ... ...

Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures, according to a USA TODAY analysis of the U.S. government 's National Practitioner Data Bank public use file, which tracks the suits. About half the doctors' payments involved allegations of serious permanent injury or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands, of victims. <

... ... ...

A 2011 study in the Journal of the American Medical Association reviewed records for 112,000 patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support installing the devices.

... ... ...

"Don't just take a doctor's word," says Patty Skolnik, who founded Citizens for Patient Safety after her son, Michael, died at 22 from complications in what she says was unnecessary brain surgery. "Research your doctor, research the procedure, ask questions, including the most important one: 'What will happen if I don't get this done?'"

... ... ...

A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. A 1997 study in the Journal of the American College of Surgeons looked at 5,601 patients recommended for surgery and found that second opinions found no need for the operation in 9% of the cases. Among those who got the countervailing second opinion, 62% opted not to have the operation.

But many patients simply aren't inclined to question their doctors.

"We expect the physician to know what's best for a patient," says William Root, chief compliance officer at Louisiana's Department of Health and Hospitals. "We put so much faith and confidence in our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can do a lot of damage."

[Oct 10, 2016] Report Highlights Prevalence of Diagnostic Errors

medstak.com
"Everyone will experience one meaningful diagnostic error in their lifetime," Dr. John Ball recently told NBC News. Ball, who chairs the Committee on Diagnostic Error in Medicine, helped draft a report on the alarming rates of late or misdiagnosis in U.S. healthcare settings – the consequences of which are often catastrophic if not fatal for some patients.

Prevalence of medical misdiagnoses

According to the study:

In sum, the majority of American adults will suffer the effects of misdiagnosis or diagnostic error at some point in their lives.

Doctors afraid to admit their mistakes

The report suggests that better training and guidelines can help reduce incidence of diagnostic errors in clinical settings. However, we live in a culture where doctors and hospitals are not always willing to speak freely about mistakes, making it that much more challenging to learn from near misses.

"If people are afraid to speak up, then bad things can continue to happen," Ball said.

This sentiment was echoed back in 1998 by The Institute of Medicine, which found that medical errors and surgical mistakes claimed the lives of tens of thousands of American patients each year. The organization also called for a "culture of confession" in the hopes that healthcare professionals wouldn't be afraid to fess up their blunders. With a more open dialogue among medical providers regarding botched surgeries and missed diagnoses, new approaches could be developed to help prevent the same errors from repeating themselves.

Ball also says that pathologists and radiologists should get more involved in clinical care and patient diagnosis for more accurate testing.

Real life examples of diagnostic errors

The life-altering consequences of diagnostic mistakes are all too familiar to Susan Sheridan of Boise, Idaho. Sheridan's husband died after his doctors failed to diagnose an aggressive cancer in his spine, and her child – who is now an adult – was rendered permanently disabled after physicians failed to treat his infant jaundice.

In 1995, her newborn son Cal developed a dangerous condition known as kernicterus which is caused by high levels of bilirubin. At just a few days old his skin had turned a bright orange, but Sheridan's concerns were continually dismissed by pediatricians. By the time the correct diagnosis was finally made, Cal had suffered extensive brain damage leading to cerebral palsy. He is both hearing and speech impaired, uses a walker and will need medical care for the remainder of his life.

Sheridan hopes that other families will never have to endure similar heartache and loss and has since become the director of patient engagement for the Patient-Centered Outcomes Research Institute (PCORI). Still, Sheridan laments that there is no organization or system where medical errors can be logged and tracked.

"The first thing I wanted to do was tell somebody, so they could make sure that will never happen again."

[Oct 10, 2016] The FDA is compromised and they can't be trusted

Oct 10, 2016 | www.nakedcapitalism.com

patrick October 10, 2016 at 7:27 pm

The FDA is compromised and they can't be trusted. http://ssrn.com/abstract=2282014

[Oct 10, 2016] The moment you see the phrase 'surrogate outcome' you know they aren't looking at the disease anymore

Oct 10, 2016 | www.nakedcapitalism.com

paul October 10, 2016 at 10:26 am

The moment you see the phrase 'surrogate outcome' you know they aren't looking at the disease anymore.

Gee October 10, 2016 at 10:50 am

Absolutely.

See page 6 for a good summary of the ways surrogates can be problematic.

http://depts.washington.edu/ssbiost/PRESENTATIONS/DeMets.pdf

SpringTexan October 10, 2016 at 7:16 pm

Great reference with good list of trials that make the point; thanks!

[Oct 10, 2016] Is it any coincidence that the US is one of the few developed countries that allows drug advertising on television

Notable quotes:
"... Is it any coincidence that the US is one of the few developed countries that allows drug advertising on television ? I've lost count of the number of times I've wanted to throw something at the TV when I hear the phrase " … ask your doctor whether Drug X is right for you !". ..."
"... Better yet, just avoid the TV at all costs. You are simply being manipulated. ..."
"... If you did not choose to put something in front of your eyeballs, you can be highly confident that somewhere, there's a serious conflict between the message being delivered and your best interests. ..."
Oct 10, 2016 | www.nakedcapitalism.com

JustAnObserver October 10, 2016 at 1:04 pm

Is it any coincidence that the US is one of the few developed countries that allows drug advertising on television ? I've lost count of the number of times I've wanted to throw something at the TV when I hear the phrase " … ask your doctor whether Drug X is right for you !".

OTOH maybe that's a plus. If its being promoted on TV then avoid it at all costs until you've read the independent trial evidence.

Anonymouse October 10, 2016 at 3:09 pm

Better yet, just avoid the TV at all costs. You are simply being manipulated.

If you did not choose to put something in front of your eyeballs, you can be highly confident that somewhere, there's a serious conflict between the message being delivered and your best interests.

And even if you did choose it, be careful what the producer's motives were…

[Oct 10, 2016] When profit motive replaces Hippocratic oath terrible things happen

Notable quotes:
"... We are talking about "medical industrial complex" here. So this is a systemic problem: Dangerous drugs, "blockbuster drugs" are just the tip of an iceberg. ..."
"... Hospitals became more of a money making machines and the duration of your stay in hospital often is determined by the insurance you have and doctors financial motives, not by your disease. ..."
"... First step of the government take over all pharmaceutical research could be government paying for all clinical trials. What could the industry object? It would mean much less financial risk for the firms - an incentive. ..."
"... Read more about this for profit fantastic here - I think I've got it right: http://ontodayspage.blogspot.com/2016/06/will-500000-americans-year-die-for-lack.html ..."
Oct 10, 2016 | www.nakedcapitalism.com

likbez October 10, 2016 at 1:30 pm

We are talking about "medical industrial complex" here. So this is a systemic problem: Dangerous drugs, "blockbuster drugs" are just the tip of an iceberg.

When profit motive replaces Hippocratic oath terrible things happen. And this is what happened under neoliberalism. "Greed is good" is the new morality.

That include useless surgeries, such as cardiac stenting (which is a mass practice in the USA).

See

Actually any area where control is difficult and the same doctor recommends the procedure and later does the surgery is suspect. When you're a hammer everything looks like a nail.

Hospitals became more of a money making machines and the duration of your stay in hospital often is determined by the insurance you have and doctors financial motives, not by your disease.

Denis Drew October 10, 2016 at 1:43 pm

First step of the government take over all pharmaceutical research could be government paying for all clinical trials. What could the industry object? It would mean much less financial risk for the firms - an incentive.

No matter who pays for the research it is the same university researchers doing the work - as far as I know. Government could fund the whole thing without any need for greed.
* * * * * *
Right now, 10,000 Americans die weekly (!) of heart failure. Formerly there was no improvement and certainly no cure. In 2012 a small clinical trial or a balloon inserted around the heart to assist pumping ended with 5 actual cures, most improved and a few held steady. A much larger trial of 200 is being attempted to get FDA approval …

… but is in Limbo (from my reading) by inability to get investors to pony up for more than 100 of the 200 - $30 million short being the reason. The flip side of profit based research ripoff.

I'm sure today's 5 million heart failure sufferers in the US would gladly pony up $6 apiece. Maybe one of them should start a go-fund-me for $30 million. Maybe investors would not want them to.

Read more about this for profit fantastic here - I think I've got it right: http://ontodayspage.blogspot.com/2016/06/will-500000-americans-year-die-for-lack.html

* * * * * *
Gilead - the same company that brought us Sovaldi - now has developed a drug that claims to be 95% effective against all versions of hepatitis: Epclusa. At $75,000 a treatment (that may only cost them $150 to manufacture) X 300 million worldwide sufferers, that comes to $22.5 trillion (with a "t") to treat all. I'm sure they need most of that for future research (or divert it to pay for the living and business expenses for every man, woman and child in the US, Canada and Mexico for one year).

http://www.marinij.com/article/NO/20160710/FEATURES/160719994

[Oct 10, 2016] Never to take any drug that hasn't been on the market for at least 5 years. The FDA is toothless and is corrupt

Notable quotes:
"... A pharmacist friend of mine told me never to take any drug that hasn't been on the market for at least 5 years. The FDA is toothless and is corrupt just like every other regulatory agency in this country. Big pharma is primarily concerned with huge profits like "blockbuster" (expensive) and drugs that you have to take over a long period of time and this is probably one reason why a lot of research on superbugs isn't being done. There's no money in it. ..."
Oct 10, 2016 | www.nakedcapitalism.com

Elizabeth October 10, 2016 at 3:14 pm

A pharmacist friend of mine told me never to take any drug that hasn't been on the market for at least 5 years. The FDA is toothless and is corrupt just like every other regulatory agency in this country. Big pharma is primarily concerned with huge profits like "blockbuster" (expensive) and drugs that you have to take over a long period of time and this is probably one reason why a lot of research on superbugs isn't being done. There's no money in it.

[Oct 10, 2016] Why Useless Surgery Is Still Popular

Notable quotes:
"... An accompanying editorial came to a scathing conclusion: The surgery is "a highly questionable practice without supporting evidence of even moderate quality," adding, "Good evidence has been widely ignored." ..."
"... "We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense and potential complications." ..."
"... What decisions in medicine today give priority to what is best for the patient? Unnecessary surgery is only one component of patient care taking a back seat to money. Pharmaceutical companies remove lower-priced drugs from market and set sky-rocketing prices for drugs that remain. Devices, such as morcellators that spread cancer during surgery and vaginal mesh that can irreversibly ruin a woman's health, are still being used despite their terrible impacts because of the money in it for the device makers and doctors who use them. ..."
"... Capitalism works when consumer protection laws are enforced to protect consumers from predatory suppliers. American consumers have been left to fend for ourselves. We must not trust our doctors to provide sound health care. Instead, we are forced to do our own research and draw our own conclusions from credible, independent sources, to the extent they still exist. ..."
"... DO NOT look to news articles for medical advice! And lastly, know that medical doctors are often biased too much against surgery, while surgeons are often biased too much in favor of surgery. ..."
"... As a physician, and this is me speaking for myself, I feel that unnecessary surgeries, procedures, and diagnostic tests are a byproduct of a culture where people would prefer a pill or surgery to behavioral change and where doctors are compensated well to provide this (called the "perverse incentive." ) ..."
"... Patients demand surgery, demand an MRI and feel upset if physical therapy doesn't fix their problem instantly. Ironically, I am a physician who eschews any diagnostic or procedure that I don't deem necessary, but some patients will complain if they don't get their quick fix and will deem you a bad physician. If orthopedic surgeons perform fewer of arthroscopies they will see their salaries slashed. ..."
"... One of my former surgical professors, the head of the department of surgery in a major New York teaching hospital once told me "Asking a surgeon if you need an operation is like asking a barber if you need a haircut." Obviously it is more complicated than that and I am not suggesting that surgeons do not carefully consider the needs of the patients. It is true that when your background and training is in surgery, or any particular discipline, that becomes the lens through which you view the world. ..."
Oct 10, 2016 | www.nytimes.com

Before a drug can be marketed, it has to go through rigorous testing to show it is safe and effective. Surgery, though, is different. The Food and Drug Administration does not regulate surgical procedures. So what happens when an operation is subjected to and fails the ultimate test - a clinical trial in which patients are randomly assigned to have it or not?

The expectation is that medical practice will change if an operation turns out not to help.

If only.

It looks as if the onus is on patients to ask what evidence, if any, shows that surgery is better than other options.

Take what happened with spinal fusion , an operation that welds together adjacent vertebrae to relieve back pain from worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The conclusion : Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.

The studies were completed by the early 2000s and should have been enough to greatly limit or stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health and Sciences University. But that did not happen, according to a recent report . Instead, spinal fusion rates increased - the clinical trials had little effect.

Spinal fusion rates continued to soar in the United States until 2012, shortly after Blue Cross of North Carolina said it would no longer pay and some other insurers followed suit.

"It may be that financial disincentives accomplished something that scientific evidence alone didn't," Dr. Deyo said.

Other operations continue to be reimbursed, despite clinical trials that cast doubt on their effectiveness.

In 2009, the prestigious New England Journal of Medicine published results of separate clinical trials on a popular back operation, vertebroplasty , comparing it to a sham procedure. They found that there was no benefit - pain relief was the same in both groups. Yet it and a similar operation, Kyphoplasty, in which doctors inject a sort of cement into the spine to shore it up, continue to be performed.

Dr. David Kallmes of the Mayo Clinic, an author of the vertebroplasty paper, said he thought doctors continued to do the operations because insurers pay and because doctors remember their own patients who seemed better afterward.

"When you read a study, you reflect on whether it is representative of your patient population," Dr. Kallmes said. "It is easy to conclude that the answer is 'no.' The mean age in the study is different or 'I do it differently.'"

"I think there is a placebo effect not only on patients but on doctors," Dr. Kallmes adds. "The successful patient is burned into their memories and the not-so-successful patient is not. Doctors can have a selective memory that leads them to conclude that, 'Darn it, it works pretty well.'"

The latest controversy - and the operation that arguably has been studied the most in randomized clinical trials - is surgery for a torn meniscus , a sliver of cartilage that acts as a shock absorber in the knee. It's a condition that often afflicts middle-aged and older people, simply as a consequence of degeneration that can occur with age and often accompanying osteoarthritis . The result can be a painful, swollen knee. Sometimes the knee can feel as if it catches or locks. So why not do an operation to trim or repair the torn tissue?

About 400,000 middle-aged and older Americans a year have meniscus surgery. And here is where it gets interesting. Orthopedists wondered if the operation made sense because they realized there was not even a clear relationship between knee pain and meniscus tears. When they did M.R.I. scans on knees of middle-aged people, they often saw meniscus tears in people who had no pain. And those who said their knee hurt tended to have osteoarthritis, which could be the real reason for their pain.

Added to that complication, said Dr. Jeffrey N. Katz, a professor of medicine and orthopedic surgery at Harvard Medical School, is the fact that not everyone improves after the surgery. "It is not regarded as a slam-dunk," he said. As a result, he said, many doctors have been genuinely uncertain about which is better - exercise and physical therapy or surgery. That, in fact, was what led Dr. Katz and his colleagues to conduct a clinical trial comparing surgery with physical therapy in middle-aged people with a torn meniscus and knee pain.

The result: The surgery offered little to most who had it. Other studies came to the same conclusion, and so did a meta-analysis published last year of nine clinical trials testing the surgery. Patients tended to report less pain - but patients reported less pain no matter what the treatment, even fake surgery.

Then came yet another study , published on July 20 in The British Medical Journal. It compared the operation to exercise in patients who did not have osteoarthritis but had knee pain and meniscus tears. Once again, the surgery offered no additional benefit.

An accompanying editorial came to a scathing conclusion: The surgery is "a highly questionable practice without supporting evidence of even moderate quality," adding, "Good evidence has been widely ignored."

So what should patients be told? Should they even be offered the surgery?

Patients should be told that physical therapy is a good first-line therapy for pain relief, Dr. Katz said, but that surgery also relieves pain. Pain relief can take longer with physical therapy, he says. With surgery, he said, patients have to recover from the operation but are likely to be back at work within two weeks.

"At the end of the day," he said, "patients ought to choose."

Of course, how they choose might depend on how the choice is presented.

Here's how Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University in Hamilton, Ontario, who wrote the editorial in The British Medical Journal, would deal with the clinical trial data:

"I personally think the operation should not be mentioned," he says, adding that in his opinion the studies indicate the pain relief after surgery is a placebo effect. But if a doctor says anything, Dr. Guyatt suggests saying this: "We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense and potential complications."

Hearing that, he says, "I cannot imagine that anybody would say, 'Go ahead. I will go for it.'"

Sandra Adams Half Moon Bay, CA August 5, 2016

Dr Deyo's comment, "It may be that financial disincentives accomplished something that scientific evidence alone didn't," may be the biggest understatement made about how modern medicine works.

What decisions in medicine today give priority to what is best for the patient? Unnecessary surgery is only one component of patient care taking a back seat to money. Pharmaceutical companies remove lower-priced drugs from market and set sky-rocketing prices for drugs that remain. Devices, such as morcellators that spread cancer during surgery and vaginal mesh that can irreversibly ruin a woman's health, are still being used despite their terrible impacts because of the money in it for the device makers and doctors who use them.

Capitalism works when consumer protection laws are enforced to protect consumers from predatory suppliers. American consumers have been left to fend for ourselves. We must not trust our doctors to provide sound health care. Instead, we are forced to do our own research and draw our own conclusions from credible, independent sources, to the extent they still exist.

MD NY August 5, 2016

Invasive treatments require careful scrutiny of the risk/benefit ratio and an individual approach. While the risks are fairly easy to quantify, this article just begins to skim the surface of an incredibly complex research problem: how to evaluate the benefit and effectiveness of a surgical intervention such as knee surgery? what do you compare it to? medicine? physical therapy? a sham procedure? all of the above? How do you measure quality of life? functional outcome? While the author hits upon some real issues in health care, I would issue this statement of caution: Medical research is full of bias that is usually invisible to the lay audience.

The conclusions of such research can be overblown by the media looking for sensational content. DO NOT look to news articles for medical advice! And lastly, know that medical doctors are often biased too much against surgery, while surgeons are often biased too much in favor of surgery.

C Fu California August 4, 2016

As a physician, and this is me speaking for myself, I feel that unnecessary surgeries, procedures, and diagnostic tests are a byproduct of a culture where people would prefer a pill or surgery to behavioral change and where doctors are compensated well to provide this (called the "perverse incentive." )

Patients demand surgery, demand an MRI and feel upset if physical therapy doesn't fix their problem instantly. Ironically, I am a physician who eschews any diagnostic or procedure that I don't deem necessary, but some patients will complain if they don't get their quick fix and will deem you a bad physician. If orthopedic surgeons perform fewer of arthroscopies they will see their salaries slashed.

The US has one of the least cost effective medical systems in the world, and despite all of the money spent, we still have some of the worst preventative care and highest infant mortality rates in the developed world. I used to work in private practice and now work at an HMO because I was tired of being asked to recommend more studies or surgeries to make more money. Our healthcare needs and overhaul, but the American people also need to shift their beliefs about what is good healthcare. More is not always better.

Jeffrey New York, NY August 4, 2016

One of my former surgical professors, the head of the department of surgery in a major New York teaching hospital once told me "Asking a surgeon if you need an operation is like asking a barber if you need a haircut." Obviously it is more complicated than that and I am not suggesting that surgeons do not carefully consider the needs of the patients. It is true that when your background and training is in surgery, or any particular discipline, that becomes the lens through which you view the world.

[Oct 09, 2016] Data Also Shows Increased Stent Thrombosis for Bare Metal Stents

Data Also Shows Increased Stent Thrombosis for Bare Metal Stents
Oct 09, 2016 | ptca.org

DAPT Study Extended Treatment After Stenting Lowers Stent Thrombosis and Heart Attacks

"Longer is better."

That's what Dr. Dean Kereiakis told Angioplasty.Org when characterizing the results of the long-awaited Dual Antiplatelet Therapy (DAPT) study, which were presented today at the annual American Heart Association Scientific Sessions in Chicago.

Dr. Kereiakes is the co-principal investigator for this five year study of 10,000 patients, which adds to the knowledge base of whether long-term treatment with aspirin and a thienopyridine, such as Plavix, after stent implantation is beneficial to patients.

[Oct 09, 2016] Do You Really Need a Stent for CAD

Apr 13, 2016 | www.verywell.com
Reviewed by a board-certified physician. Updated We have all heard the claims that cardiologists are inserting too many stents in patients with coronary artery disease (CAD) . And the fact is that this happens much more often than we would like to think.

So what should you do if your doctor says you need a stent? Are you one of those people who actually do need a stent - or should your doctor be talking to you about medical therapy instead?

If your doctor tells you that you need a stent, it is likely he or she will attempt to explain why. But the issue can be quite complicated, and your doctor may not be entirely clear in his/her explanation. And you may be too stunned by the news that you need a stent to concentrate completely on what you are being told.

Fortunately, if your doctor says you need a stent, there are three simple questions you can ask which will tell you what you really need to know. If you ask these three questions, you stand a much better chance of getting a stent only if you really need one.

Question One: Am I Having A Heart Attack?

If you are in the early stages of an acute heart attack, the immediate insertion of a stent can stop the damage to your heart muscle, and can help reduce your chances of suffering cardiac disability or death. If the answer to this question is "yes," then a stent is a very good idea.

No need to go on to Question Two.

Question Two: Do I Have Unstable Angina?

Unstable angina , like an actual heart attack, is a form of acute coronary syndrome (ACS) - and therefore it should be considered a medical emergency. The early insertion of a stent can stabilize the ruptured plaque that is producing the emergency, and can improve your outcome.

If the answer to this question is "yes," placing a stent is most likely the right thing to do. No need to go on to Question Three.

Question Three: Isn't There Medical Therapy I Can Try First?

If you get to Question Three, it means that you are not having an acute heart attack or unstable angina. In other words, it means you have stable CAD. So, at the very least, placing a stent is not something that needs to be done right away. You have time to think about it, and to consider your options.

It is the patients with stable CAD who, according to the best clinical evidence available, are receiving far too many stents. In stable CAD, stents turn out to be very good at relieving angina , but they do not prevent heart attacks or reduce the risk of cardiac death. So, the only really good reason to insert stents in people with stable CAD is to relieve persistent angina when aggressive treatment with medication fails to do so.

The Best Approach For Stable CAD

The best treatment for people with stable CAD is to take every step that is available to stabilize plaques in the coronary arteries -- that is, to keep the plaques from rupturing.

(It is the rupture of a plaque that produces ACS in the first place).

Stabilizing plaques requires the control of cholesterol , blood pressure , and inflammation, no smoking , regular exercise, and making clotting less likely. Aggressive drug therapy will include aspirin , statins , beta blockers , and blood pressure medication (when necessary). If you are having angina, adding nitrates , calcium channel blockers , and/or ranolazine will usually control the symptoms.

If your angina persists despite this kind of aggressive medical therapy, then by all means a stent is something that should be strongly considered. But keep in mind that a stent only treats one particular plaque, and that most people with CAD have several plaques. Furthermore, while most of these plaques are considered "insignificant" by traditional measures (since they are not producing much blockage in the artery), it now appears that the majority of cases of ACS occur when one of these "insignificant" plaques suddenly ruptures.

What this means is that, whether or not you end up getting a stent for your stable CAD, you still will need aggressive medical therapy to prevent the rupture of one of those "other" plaques, the "insignificant" ones, the ones for which too many cardiologists may express little or no interest.

Summary

If you are told you need a stent, you can quickly determine how badly you need one, if at all, by asking three simple questions. These questions are so easy for your doctor to answer - generally with a simple yes or no - that there will be no excuse for his/her failing to take them up with you.

But if it turns out that you have stable CAD, and therefore a stent is at least not an emergency, you are owed a full discussion about all your treatment options before you are pressured into a stent.

[Oct 09, 2016] Unnecessary stents costing millions

Notable quotes:
"... MJA ..."
"... The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents, had long been in the practice of rewarding Dr Midei financially for being a high-volume user of its stents. ..."
"... "Stenting in stable angina is open to debate in some circumstances as to whether it reduces mortality but every study done shows it is effective in relieving symptoms," he said. ..."
"... New England Journal of Medicine ..."
"... Journal of the American College of Cardiology ..."
"... There is also another interesting dynamic operating here. In the days when the cardiologists did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy. The dynamics have now changed with interventional cardiology – there is no gatekeeper to interventional therapy – cardiologists self-refer for intervention – procedures from which they derive considerable profit. It would be difficult to argue that this has had no influence on the stent rate. ..."
"... As an interventionist, I unfortunately know of at least one cardiologist who stents clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It is very hard to prove though. ..."
Oct 09, 2016 | doctorportal.com.au
13 December 2010 MJA InSight

UP TO one-third of coronary stents inserted in patients with stable coronary artery disease (CAD) in Australia each year ― about 3500 stents - may be unnecessary, potentially harmful and costing the nation millions of dollars, according to a leading cardiologist.

Professor Richard Harper, emeritus director of cardiology at MonashHeart, Monash Medical Centre in Melbourne, said any experienced interventional cardiologist would admit that many coronary lesions with 50‒70% stenosis were being stented in Australia without certain knowledge that the particular lesion was causing ischaemia.

Medicare statistics show that, last year, there were 22 383 operations for insertion of a stent or stents in Australia (20 780 in 2008 and 21 204 in 2007), for which Medicare paid $6.78 million ($6.24 million in 2008 and $6.2 million in 2007).

These payments do not include the cost of a coronary angiography, radiological services and preparation, or aftercare.

The average cost of coronary angiography with stent insertion, including hospital stay, is $18 300 of which Medicare pays $1647.

Professor Harper said about 50% or more of stents were inserted in stable CAD patients and the remainder were in patients with acute heart attack, for which stenting was almost always warranted.

A rapid online publication of a detailed paper written by Professor Harper on the use of stents in CAD patients has been published by the MJA .

He was commenting after the issue of unnecessary stenting hit the headlines in the United States, with the revelation that Baltimore cardiologist Dr Mark Midei may have implanted 585 stents that were medically unnecessary from 2007 to 2009.

An article in theheart.org , the website for cardiovascular health professionals, said a US Senate Finance Committee report called the Midei imbroglio "a clear example of potential fraud, waste, and abuse". (1)

The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents, had long been in the practice of rewarding Dr Midei financially for being a high-volume user of its stents.

However, many US cardiologists believe Dr Midei is being treated unfairly.

The Cardiac Society of Australia and New Zealand (CSANZ)'s Interventional Council chair, Associate Professor Andrew MacIsaac, said any fraud or criminal behaviour by a cardiologist, as was being alleged in the US, was appalling and would be totally unacceptable.

However, he had never heard of it occurring in Australia and it was different from doctors having a diversity of opinion over the appropriate indications for coronary stenting.

"Stenting in stable angina is open to debate in some circumstances as to whether it reduces mortality but every study done shows it is effective in relieving symptoms," he said.

Professor Harper said the problem with what he considers to be unnecessary stents in Australia "lies in our system of reimbursement for coronary procedures".

He said patients often had more than one coronary lesion and the only sure way to tell which one was the cause of the myocardial ischaemia was by measuring fractional flow reserve (FFR) - or the effect of the narrowing on blood flow - during coronary angiography.

However, FFR was not commonly undertaken in Australia because the flow wire was costly and not adequately reimbursed in either the public or private system.

The procedure was also fiddly, took time and resulted in fewer stent insertions - a procedure which attracted a much higher fee.

"Faced with a 50-70% coronary stenosis, it is easier and more remunerative for an interventional cardiologist to stent the lesion rather than measure FFR - particularly when there is a two-thirds likelihood that the result will show no need for the stent," Professor Harper said.

Medicare statistics show that, last year, only 385 procedures for FFR were carried out in Australia (234 in 2008 and 131 in 2007).

Professor Harper said the health system should be restructured to make it more financially viable to measure FFR.

He said a pivotal randomised study in the New England Journal of Medicine last year, of 1000 patients with multi-vessel coronary artery disease, showed that routine measurement of FFR in patients undergoing percutaneous coronary intervention with drug-eluting stents significantly reduced the rate of death, non-fatal myocardial infarction and repeat revascularisation compared with patients who had stents inserted on the basis of angiography alone. (2)

The patients who underwent FFR had fewer stents implanted at a lower cost.

The results were replicated in a follow-up study at two years, which was reported in the Journal of the American College of Cardiology . (3)

Professor MacIsaac said CSANZ had been lobbying for more than 10 years for the establishment of a national registry of coronary interventions to audit outcomes and quality assurance.

However, it was still waiting for federal and state funding.

"A database has essentially been prepared but there is no funding mechanism to implement the collection or analysis of the data," he said.

"If we really want to be assured that everything is fine, that would be the way to go."

A Medicare spokeswoman said the unnecessary insertion of cardiac stents had not been identified as a specific compliance issue.

"However, health professionals should be aware that when Medicare Australia has a concern that items are being claimed without meeting the item requirements, an audit may be conducted," she said.

Medicare Australia treated all allegations of non-compliance seriously and encouraged anyone who suspected potential fraud or non-compliance under the Medicare program to call the Australian Government Services Fraud Tip-off Line on 131 524.

  1. Sue says: December 14, 2010 at 11:52 am

    There is also another interesting dynamic operating here. In the days when the cardiologists did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy. The dynamics have now changed with interventional cardiology – there is no gatekeeper to interventional therapy – cardiologists self-refer for intervention – procedures from which they derive considerable profit. It would be difficult to argue that this has had no influence on the stent rate.

  2. Rick says: December 14, 2010 at 5:45 pm

    Very interesting and informative article with some good comments – need more like this.

    • – Highlights a long-standing major problem with Medicare failing to keep up with technology, but would interventionalists change their habits if Medicare changed? In the public sector the Medicare rebate usually doesn't matter; in private they'll charge (and should charge) what they feel is the appropriate fee. What is needed is proper peer review and clinical governance in both sectors.
    • – Probably highlights the need for better funding of cognitive work compared to intervention.
    • – As far as MIBI scans go, not all labs are equal. If I can, I get mine done in hospital labs with regular through-put where they regularly correlate results with angiography.
    • – Predictable response from the Medicare bureaucrat, but not understanding the issue at all (nothing to do with fraud, and everything to do with delivering a better outcome more cheaply).
  3. Stewart mair says: December 15, 2010 at 9:49 am

    Myocardial perfusion studies are well reimbursed and are an arm's length procedure. It is also rumoured that stress echo, not an arm's length procedure, works.

  4. Stenter says: December 15, 2010 at 12:50 pm

    The emperor has no clothes!

    As an interventionist, I unfortunately know of at least one cardiologist who stents clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It is very hard to prove though.

  5. Brett Forge says: December 15, 2010 at 11:56 pm

    The article makes some very important and quite radical points about diagnosis and assessment of chest pain and atherosclerosis.

    But they then assert that in patients with ischaemia, revascularisation improves outcomes, and that patients with significant ischaemia should have invasive angiography.

    This is unproven. All the randomised trials of stable angina show that revascularisation may reduce short term angina but does not reduce mortality or myocardial infarction rates.

    If they want to reduce the cost and wastage in modern cardiology just restrict PCI to those patients in whom angina is limiting or in whom an adequate trial of medical therapy has failed to control symptoms.
    This will reduce the numbers of interventions by far more than 30%.
    If and when FFR measurements are shown to reduce mortality or AMI then the conclusions of this article will be evidence based. At the moment they are not.
    Whilst many procedures are beneficial to patients, vast numbers of procedures are performed on patients in whom no proven long-term benefit has been demonstrated.
    Has there been a greater racket in the history of medicine?

  6. Anonymous says: December 19, 2010 at 2:45 am

    Hasn't MIBI scanning been providing this info for the past 20 years already?
    It's arms length and much more reliable than stress echoes.

  7. Rick says: December 19, 2010 at 8:53 pm

    The MJA article also states that stenting non-ischaemic lesions (ie with normal FFR) worsens the prognosis. This is of concern.
    The article also suggests abolishing the item number for MIBIs and using CT coronary angios to diagnose CAD – not sure that this is a viable option for patients with significant renal failure or even in areas where CT coronary angio is relatively new; seems like an exclusively teaching hospital perspective.

  8. Surgeon says: January 17, 2011 at 9:23 pm

    And this overuse does not cover the large number of patients having multiple stents and ending up with a definitive operation some time and multiple infarcts later

  9. prof Montage says: January 18, 2011 at 8:42 pm

    I was late to look at this dialogue.
    Brett Forge has it spot-on.
    He usually does!

  10. john langdon says: November 12, 2012 at 3:17 pm

    John.
    This is happening in australia now. Have 3 drug eluting stents fitted with no tests prior,same niggles of exertional pain continued at start of exersise then dissapeared for duration of 1.5 hours bike ride after stents.niggles of chest pain lasted approx 4 months after stenting. Never breathless/overweight/or smoked,very athletic. Father 100 years old no cardiac history. Have had conformation of my angiogram confirmed that there were no restrictions by leading USA medical institution, that needed intervention. Qld cardiologist also falsified his files, where do I go now?.

[Oct 09, 2016] Many Stent Procedures Unnecessary

Mar 26, 2007 | www.webmd.com

Hundreds of thousands of Americans may undergo unnecessary angioplasty and stent procedures to open clogged heart arteries each year, a landmark study suggests.

The long-awaited results show that people with stable coronary artery disease who got common medications to lower blood pressure and cholesterol levels were no more likely to die or to have a heart attack over the next five years than those who also underwent angioplasty with stents .

Of the more than 1.2 million angioplasty procedures performed each year, at least 50% of them are done on an elective basis in people with stable coronary artery disease, says Stephen Nissen, MD, president of the American College of Cardiology (ACC) and head of cardiovascular medicine at The Cleveland Clinic.

In people with coronary artery disease, plaque builds up in the arteries, making it harder for blood to get through, thereby depriving the heart muscle of oxygen. This can lead to chronic chest pain that worsens during exercise and to heart attacks .

During angioplasty, a balloon at the end of a long tube is threaded through an artery in the groin. The doctor shimmies the probe up through the patient's leg and into the arteries of the heart, inflating the tiny balloon at the spot where the vessel has narrowed.

To keep the vessel open, doctors usually add a stent to the end of the balloon catheter. These metal, mesh-like tubes prop open clogged arteries to restore blood flow.

Angioplasty Still Best for Some

The study's results do not apply to people who get stents because they are in the midst of a heart attack or whose chest pain suddenly gets worse, doctors stress. For them, angioplasty is a proven lifesaver.

Additionally, angioplasty is better at relieving the chest pain associated with angina , says researcher William Boden, MD, of Buffalo General Hospital/Kaleida Health in Buffalo, N.Y.

"For an individual patient, angioplasty may still be the best option," he tells WebMD. "But there has been an implication that if you give patients drug therapy rather than angioplasty, you're giving them less than optimal treatment.

"Now we know that if you opt for medicine, you are not putting patients at risk," Boden says.

The study, known as COURAGE, was released at the annual meeting of the American College of Cardiology and simultaneously published online by The New England Journal of Medicine .

Stent Patients as Likely to Die, Have Heart Attack

The researchers studied 2,287 people with stable coronary artery disease who experienced chest pain for about two years, with an average of 10 episodes per week. All had at least a 70% blockage in one or more heart arteries.

All participants were put on optimal drug therapy, which includes nitroglycerin to control chest pain, beta-blockers to control heart rate , ACE inhibitors for lowering blood pressure, and statins to lower cholesterol . Everyone was also urged to exercise more and lose weight and quit smoking , if needed.

Then, about half the participants also underwent angioplasty, usually with stents.

Over the next five years, 19% of those in both groups died or had a heart attack. Similar numbers of people in both groups -- about 12% -- were hospitalized for heart problems.

However, there were some benefits to angioplasty. People who had the procedure were 40% less likely to need another procedure to open up blocked heart arteries. And, particularly in the first two years, they reported better quality of life and less frequent episodes of chest pain.

But over time, some of the differences started to dissipate. By five years later, 74% of people who had angioplasty were angina-free vs. 72% of those who got drugs alone, a difference so small it could be due to chance.

Results Stun Medical Community

Boden notes that COURAGE is "the first properly-sized study to answer the question of whether angioplasty and stents reduce the risk of death and heart attacks in people with stable coronary artery disease."

The results came as a shock to many in the cardiology community -- even to the researchers themselves.

"The study was designed with the hypothesis that the combination of angioplasty and optimal medical therapy would be superior," Boden says. "But the results do not support its benefit in reducing heart attacks and death when used as an initial management strategy."

So why would so many doctors recommend a costly procedure without strong evidence it works?

The average cost of having an angioplasty was $38,000 in 2003, according to the American Heart Association.

Nissen thinks it's because "it seems so intuitively obvious: If you open up a block artery, you'll fix the problem."

American Heart Association President Raymond J. Gibbons, MD, chief of cardiology at the Mayo Clinic, adds that there's a financial incentive for doctors. "People get paid for how many procedures they do," he tells WebMD.

But this study "clearly shows there is no advantage to PCI [percutaneous coronary intervention, or angioplasty] as an initial strategy. It's unnecessary," Gibbons says. "Angioplasty should be reserved for patients [who can't be helped] by medical therapy."

Adds Nissen, "This study will change a lot of thinking. The benefits of angioplasty in people with stable chest pain is very modest, at most. It should be reserved for patients for intolerable symptoms."

Results Questioned

But many doctors who perform angioplasties say the procedure's proven benefits in relieving angina, or chest pain, is getting lost in the shuffle.

Donald Baim, MD, chief medical officer of Boston Scientific, a manufacturer of drug-eluting stents, says, "COURAGE is not a catastrophic failure. [It shows that angioplasty plus stents] improves symptoms."

Marty Leon, MD, of Columbia University Medical Center, says, "There are so many deep flaws in the way this study was executed and planned. It was rigged to fail," and it did. "This study should not affect treatment patterns."

Boden says the criticism is unfounded, pointing out that the researchers purposely studied people at medium to high risk of having a heart attack or dying -- "the very people you would expect to benefit most from the procedure."

[Oct 09, 2016] Medicares second highest-paying doc performed unnecessary heart procedures

Notable quotes:
"... Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments. ..."
"... Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare program ..."
"... Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013, he made $16 million, more than seven times the amount received by the next highest earning Florida cardiologist, according to data collected by ProPublica. ..."
"... Unnecessary cardiology procedures have been a focal point for government investigators over the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary surgeries. ..."
Jul 05, 2016 | www.insurancefraud.org
, Washington, DC - One of the country's highest paid physicians agreed to a three-year exclusion to settle claims that he billed Medicare for medically unnecessary cardiac procedures, according to the Department of Justice.

Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments.

Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare program , prompting support from a Super PAC of former patients who were "disgusted and distressed" by the government's portrayal of Qamar.

In addition to a three-year exclusion from Medicare, Qamar will pay $2 million and forgo an additional $5.3 million in suspended claims.

Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013, he made $16 million, more than seven times the amount received by the next highest earning Florida cardiologist, according to data collected by ProPublica.

Unnecessary cardiology procedures have been a focal point for government investigators over the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary surgeries.

Source: Fierce Healthcare

[Oct 09, 2016] Stent Scandal A Shocking Story, But Not News Health Beat by Maggie Mahar

Oct 09, 2016 | www.healthbeatblog.com
Posted on December 8, 2010 by Maggie Mahar Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report .

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.

Although St. Joseph's has not admitted to any wrongdoing, last month it agreed to pay a $22 million fine to settle charges that it paid illegal kickbacks to Dr. Midei's medical practice in exchange for patient referrals. In other words, it seems that the hospital encouraged the doctor to implant those tiny mesh tubes in his patients' arteries. Certainly, hospital executive knew that they were making handsome profits on Midei's stent procedures. This is why they paid him those "bonuses" to shepherd unwitting patients to their cath-lab where doctors can diagnose heart attacks, and quickly open arteries. Midei was a rainmaker.

Clinical guidelines generally suggest that an artery be at least 70 percent blocked before a stent is used to open it up, and St. Joseph's rules consider anything less than 50 percent blockage to be "insignificant." But court documents allege that some of Midei's patients were told they had blockages in the 90 percent range, while a subsequent review of their records shows blockages closer to 10 percent or less.

Medical Journals Have Been Telling Us This for Years

But what I find most disturbing is that the story about Dr. Midei is not new; nor is it "news." As Dr. Nortin Hadler , author of Worried Sick , argues in his guest-post below, medical research suggests that stents have been overused, nationwide, for years , exposing patients to needless risk and exorbitant expense.

In January of 2006, an article published in the journal Circulation observed that although there has been a dramatic increase in artery-opening procedures in order to prevent heart attacks over the last 10 to 15 years, the rate of heart attacks stayed relatively constant. The findings came from two studies, one done in the U.S. and one done in Canada.

At the time Dr. Thomas Graboys, a professor of medicine at Harvard Medical School, told the Center for Medical Consumers that stents "are virtually useless, in stopping the progress of the disease itself." "The public is looking for a magic bullet," Graboys warned. "Go to a non-hospital-based doctor in the community. A well-trained internist can take care of the lion's share of people with coronary heart disease. The vast majority of people do well on medication-cholesterol-lowering drugs, antihypertensives, low-dose aspirin ."

For an expert opinion on "the best" and most persuasive of the many studies that raise serious questions about invasive heart procedures, see Dr. Hadler's post below.

Nevertheless, as the Center for Medical Consumers reported in 2006 : "The number of people undergoing artery-opening procedures continues to rise not only because they are huge money-makers , but they are also very effective at relieving the severe chest pain of angina, which is a common symptom of heart disease." Patients like the "quick fix" of the stent treatment for angina. Medication doesn't work as rapidly.

Writing about the Midei case over at Kevin M.D,. Bob Wachter , Professor of Medicine and Chief of the Division of Hospital Medicine at the University of California, San Francisco, comments on the patient response: "Most of his patients were probably quite content – many had chest pain and a stent undoubtedly seemed like an appropriately aggressive, high-tech cure. 'He put two stents in almost immediately,' said one grateful patient. 'I felt relief.'

"Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for stenting), she was unfazed," Wachter observes. "No one can ever tell me that I didn't need that stent,' she told the Baltimore Sun. 'I feel like [Dr. Midei] saved my life.'

" Moreover, I'm guessing that Dr. Midei's complication rate was quite low ," Wacther continues, " as it usually is when one does procedures on healthy people . He probably followed all the protocols mandated by accreditors and the relevant specialty societies. (Oh yeah, except for the ones regarding professionalism.)

"The problem is this," he concludes, "as long as the cardiologist reading the cath is the one who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem."

"Gizmo Idolatry"

What may be most troubling about the Medei imbroglio is that it highlights how our infatuation with high-tech medicine tempts us to ignore medical evidence. The popularity of stents is all part of a mindset that Drs. Bruce Leff and Thomas E. Finucane have termed " gizmo idolatry ."

Back in June of 2006, a few months before I began HealthBeat, I wrote a post about our use of stents for The Health Care Blog. It was titled: " Tech: Is Newer Better? It's a Coin Toss ." Below, an excerpt :

"Last week The Annals of Internal Medicine roiled the medical world by publishing a study suggesting that the drug- coated stents produced by companies like Boston Scientific and J&J may not be quite as miraculous as first advertised . (You will find the abstract here ) Following a two-year study, researchers at the Cedars-Sinai Medical Center in Los Angeles are now suggesting that the 'putative superiority' of drug-coated stents is founded on questionable premises.' Or as The Wall Street Journal put it, the clinical trials of drug-coated stents (mostly funded by manufacturers), may 'have exaggerated their real-life advantage.' [Dr. Midei was using a new generation of drug-coated stents.]

"Stents, you may remember, are those tiny metal scaffolds that cardiologists use to prop arteries open after they have been cleared of fatty deposits. Since they were approved in the early 1990s, manufacturers have made a fortune peddling the devices which, they say, can prevent a future heart attack while avoiding riskier and more invasive bypass surgery. Today, stents are used in 85% of all coronary interventions in the United States .

"Before turning to the new Cedars Sinai study, it should be said that THCB has long harbored doubts as to whether these cunning devices represented the best solution for quite so many patients. Back in 2003, THCB quoted a Stanford study which suggested that, over the long term, patients with multi-vessel disease would achieve better outcomes, at a lower cost, if they opted for the bypass operation. In 2005 THCB questioned the cost-effectiveness of the new, improved "drug-coated" stents that are designed to prevent the growth of scar tissue inside the artery. . .

Yet "drug-coated stents have become wildly popular, thanks in part to what The Annals of Internal Medicine describes as 'aggressive marketing' and the unbridled expectations of patients. Wall Street likes them too. At $2300 a pop (vs. a mere $700 for the uncoated, bare-metal variety), the newer stents are far more profitable. Despite the hoopla, nine months ago THCB was once again forced to ask 'Are Stents A Waste of Money?' after reading about a study of 826 patients, published in Lancet , which suggested that the drug-coated stents made by J&J and Boston Scientific aren't cost-effective for all patients and should be restricted to those at highest risk for heart attack.

"A second 2005 study, published in The New England Journal of Medicine , added to the uncertainty about the widespread use of stents by reporting that patients suffering minor heart attacks do equally well with drug therapy . 'In a study colliding with established practice, recovery from small heart attacks went just as well when doctors gave cardiac drugs time to work as when they favored quick, vessel-clearing procedures ," the NEJM reported. "The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans annually who have small heart attacks – the most common kind. Most previous studies support the aggressive, surgical approach. . . . Meanwhile, just last fall, Dr. Eric Topol, chairman of the cardiology department at the Cleveland Clinic, warned Consumer Reports : 'Unfortunately, the extensive use of such stents is far ahead of the data that can be cited to support them .'

"But it's not just that manufacturers over-estimated the benefits; they underestimated the new risk that the coated stent introduces. For after reviewing outcomes research, Cedars Sinai's clinicians found that the drug-coated stents increase the danger that a blood clot will form inside the stent– months, or even years after the procedure. Such clots can be life-threatening . . .

"The stent story illustrates a major problem in our money-driven health care system. When a product is very profitable, it is promoted to the skies-and, in such cases manufacturers tend to put the very best face on their clinical research . A startling study published last month in the Journal of the American Medical Association comparing clinical trials funded by for-profit entities to clinical trials fund