Let’s keep up the fight, and let the libs know that we are not backing down!

Robert M. Johnston, M. D.

In my thirty-five years of being a reliable and independent voter, I have never before felt compelled to contact any of my representatives.

I want you to know that I voted for you because I thought you would exercise independent thought.

I have been very concerned with our fiscal policies, namely; runaway spending, record deficits and debt levels, and the impact that several proposed pieces of legislation would have on our economy and deficit. For the first time in our history, we’ll likely leave the next generation worse off than we are.

By voting for one of the largest spending bills in our history without even reading it, let alone understanding the consequences (intended and unintended) and more recently, your vote in support of cloture for the healthcare bill, you have sorely disappointed me.

While health care reform always sounds good, I believe we must be extremely cautious when injecting the government into an industry which represents approximately 13% of our economy.

This bill utilizes ten years of revenues to pay for approximately six years of expenditures, yet it is being represented as defecit neutral. Do you really believe the populace is that stupid?

To achieve this purported neutrality, this bill assumes a 20% reduction in physician reimbursements for Medicare patients. I have spoken to several physicians I know, and they tell me that physicians who primarily see Medicare patients can not survive at the current reimbursement level. With a further cut of 20%, what will attract the best and brightest to this critical vocation? Why would the best and brightest incur the rigors and massive cost and related indebtedness of medical school when it is obvious that they would be unable to earn as high a return on their investment as those in other professions?

Additionally, over the last four years, Congress has shown no inclination to allow the previously enacted Medicare reimbursement reductions to take effect, yet those very reductions are at the heart of this reform bill, accounting for almost half the cost of the bill. Is not the inclusion of such savings in this bill therefore fraudulent? I can not imagine the Congressional outcry if companies (AIG, for one example) even attempted such obfuscations!

This legislation leaves untouched the most obvious areas ripe for savings such as tort reform, elimination of health insurers’ anti-trust exemption, prescription drug re-importation and the ability to purchase insurance across state lines (as we can for other kinds of insurance).

Instead, it creates massive new bureaucracies, increases taxes and adds significant burdens to the Internal Revenue Service. Based on that, it appears that Congress is unwilling to even try free market approaches and rather, rule by fiat. I am vehemently opposed to such an approach.

I have had people tell me that should their taxes be raised, they’ll stop making money. Who will then pay the costs of this bill? Whose taxes will you then increase? Have we not yet learned that when taxes are raised, revenue receipts diminish? Have we not learned from the Kennedy and Reagan tax reductions that tax reductions stimulate the economy and ultimately increase tax receipts to the Government?

Now, as we near the end votes, we see that politicians’ votes are being bought and an extremely unpopular bill which will have a huge impact upon our national economy and health care is being rushed through with early morning votes and false deadlines such that there is insufficient time to fully understand the consequences, and unintended consequences of this legislation. There is also insufficient time to hear fully from your constituents, presumably to avoid a repeat of the August recess debacle. To me, this is an act of political cowardice.

Early this morning, you voted for cloture on a bill which places the people you purport to represent in the position of subsidizing the populations of Nebraska, Louisiana, Vermont and Massachusetts. I demand you explain why you sold out those you purport to represent! Why should Virginians not be treated every bit as well as any other state’s residents?

I urge you to change your record and represent those who elected you. Senator Webb, I promise that should you continue to vote in favor of this legislation, I will not only contribute to your future electoral opponents, I will work for them to ensure that your votes do to your political aspirations what they will do to this Country.

Season’s Greetings to All.

The only way we can bring any sense out of this abysmal situation is for reasonable people who truly have no ulterior self-serving motives to sit down and discuss differences, and not spend all their efforts criticizing the opposition. Both parties are guilty and my esteem for our elected officials keeps going lower and lower. Remember my 3 C’s: communicate, collaborate and cooperate.

The Dutch and Swiss systems with the strong private insurance models along with good regulation and universal coverage is now the latest flavor of the week.

I have some faith that if passed it will move us toward progress in next decade. Calling it socialistic makes me wonder whether you have run out an argument for your side of the argument, John?

To correct the problems with the DRG system CMS has now introduced the severity-based DRG system. It is based on the novel idea that patients who are really sick might cost more to treat, and recognizes that paying average cost for all (the idea behind the original DRGs) creates an incentive to deny the sickest patients the care that they need.

Various trade publication articles claim that the new DRG system requires even more detailed coding, which will likely lead to even more detailed billing. Hospitals must still submit itemized bills to their Medicare fiscal intermediary so that it can categorize the patient in the new Medical Severity Diagnosis Related Group.

The DRG payment is still just a starting point. It is then adjusted for a host of other factors that may or may not have anything to do with the cost of patient care. These include location, percentage of low-income patients treated, indirect medical education payments, payments for technology add-ons, and high cost cases. High cost cases are determined by arcane formulas that would have made the USSR’s GOSPLAN proud.

This is not the kind of bundled payment system that exists in cash for care healthcare. In cash for care, patients get a price up front. In Medicare MS-DRGs, providers learn what they will be paid after they submit the kind of itemized bills that originated in the 1930s.

The system is so complex that even CMS gets the DRG payments wrong. A June 3, 2009, Federal Register posting corrects CMS’s application of Medicare severity long-term care diagnosis-related group relative weights for payment. They were calculated incorrectly for the entire federal fiscal year due to the “misapplication of our established methodooly in the calculation of the budget neutrality factor.”

CMS isn’t paying up–unlike the private sector, the government typically isn’t held accountable for its errors.

I don’t understand Uwe R’s hubris regarding the fact that government can create DRG’s along with big holes in the ground. Government controls both the treatment and the price of Medicare DRG’s. Thus among other things we have hospitals competing to create open heart units because the Medicare system creates big buck advantages for those hospitals doing a lot of open heart surgery. Do we see as many hospitals doing the same for diabetes treatment etc.?

Government controlled DRG payment variations become incentives that can be both good and bad. Would we want to see computers produced in the same manner?

Read again what I wrote in response to Ms. Gorman’s comment, but, please, more carefully this time:

“Evidently she has not kept up with hospital pricing since the 1930s. In 1983, for Medicare, Ronald Reagan’s administration introduced a sharp departure from the fee-for-service payment then still in vogue in the private sector, namely, the DRGs. These are, in fact, bundled payments, albeit only for hospital care.”

Did you see that, John? “In 1983, for Medicare ….”. What I meant by that is for Medicare, not for private insurance.

I am not on Medicare. I have private health insurance. And yes, you are right, John, nothing is bundled there – it’s all piece-rate payment, and it is driving me nuts.

But let me repeat: I wrote that payments have been bundled into DRGs for Medicare patients. Medicare is run by the government.

Happy holidays!

Uwe