The Phony Claims About Medicare
Excerpts from a 9/19 Washington Post editorial by E. J. Dionne
"The Great Medicare Debate threatens to be at least as impenetrable and demagogic as last year's health care fight... a lot of phony claims have to be swept off the table."
"The Republicans should admit that the Medicare fight is not primarily about the threatened "bankruptcy" of the Medicare system... They also have to stop denying that there's a link between their tax cutting plans and the Medicare cuts. It's simply true that they need huge cuts in Medicare (and Medicaid) to finance their budget balancing promises and their tax cuts."
"Given the Republicans' shucking-and-jiving, the Democrats should be unapologetic about trying to force them to tell the truth. But to do that, the Democrats need to tell more truth themselves... One truth involves admitting what President Clinton himself has said repeatedly: The federal budget will never be brought under control -- and there will never be room for new initiatives -- until health costs (that's Medicare and Medicaid) are brought under control. Republicans are cutting more than makes sense, but some cuts have to happen."
"Another truth is that health costs are killing every other level
of government. It's not just Medicaid. The basic costs of providing health
coverage for public employees bulk ever larger in state and local budgets."
"The third truth is that the Republican cuts in Medicaid may be more dangerous -- to the health system, if not politically -- than those to Medicare. Deep cuts in Medicaid could increase the already rising number of uninsured Americans and endanger the poorest among the elderly and the disabled -- the two groups getting the bulk of Medicaid resources."
"The last truth is that the debate cannot focus solely on the elderly or poor. If Medicare and Medicaid cuts are too deep, hospitals and doctors will shy away from serving the elderly and poor, or will try to push costs to the non-elderly, which could further increase the number of uninsured. Or the quality of the whole system will decline. The basic issues are how much health coverage we all want, how much we are willing to pay and how far are we willing to go to share the costs across the whole society."
RWHC Responds To House Speaker
Last Thursday, the Republican's controversial Medicare reform proposal was unveiled and Wisconsin's Congressman Steve Gunderson met with House Speaker Newt Gingrich. In response to this discussion, we have again been asked for input and we have refaxed to Washington the thirteen key recommendations prepared for July's House Ways and Means Medicare Hearing--Medicare's Disproportionate & Inequitable Impact On Rural Health.
Shalala's Rural Advisors Set Agenda
The National Advisory Committee on Rural Health, staffed by the Federal Office of Rural Health Policy held a strategic planning retreat this month in Annapolis to determine a work plan for the next eighteen months, assuming that it would still be funded. Objectives were chosen based on a combined weighting of perceived importance to rural communities as well as consideration of what practically could be accomplished. The topic priorities related to:
Antitrust Needn't Limit Cooperation
An ad hoc group in Wisconsin has been working to find a mechanism that will allow the State to supersede federal antitrust barriers in those particular circumstances where it feels that it is in a community's or region's best interest to do so. A near consensus has been reached and draft legislation is being prepared for introduction in the near future to amend an existing that would govern the application process for state exemption.
The August issue of Integrated Health Care Delivery Systems contains a good description of this increasingly common policy as recently adopted in Wyoming: "The new legislation grants state and federal antitrust protection, in theory, to health care providers that enter into collaborative agreements. It allows the state to exempt collaborative health care arrangements from antitrust law. This objective is achieved by imposing active supervision over such collaborative arrangements. Wyoming's policy 'will be significantly enhanced by cooperative arrangements including joint ventures and similar enterprises, and contracts... that might otherwise be prohibited by federal and state antitrust laws if undertaken without government involvement. The formation and operation of cooperative arrangements will be subject to government regulation by the state, and 'state regulation [will] be substituted for the marketplace and market competition.' The law requires that 'approval of cooperative arrangements... be accompanied by appropriate conditions and ongoing supervision of the cooperative arrangement in order to protect against abuses and to effectively except the actions of approved and regulated cooperative arrangements from state and federal antitrust liability."
"The (State) will not approve an application unless it is determined that 'the arrangement is more likely to result in a better overall promotion of the quality of health care, access to health care, a lower cost for health care and the increased availability of a comprehensive health care system in the state than would otherwise occur...' "
At the same time, RWHC has been working with the federal Department of Justice to receive approval to its request for a Business Advisory Letter, i.e. their permission to negotiate collaboratively with regional HMOs and third party payers.
Our basic position is that there is very little competition among RWHC hospitals, particularly when compared to the much larger competition from urban providers in rural markets. We are now in the process of further documenting the level and impact of this urban -rural competition. If Justice agrees with our analysis we will be able to proceed without dependence on a request for a state exemption.
Getting Rural Health's Big Picture
The death rate due to motor vehicle injuries in the rural counties served by RWHC members is 64% higher than Wisconsin's urban counties, suicide is 41% higher and "other injuries" is 30% higher.
Typically these major challenges to the health of rural communities have been masked inside statewide numbers and not accessible at the local county level due to the problem of small numbers and statistical significance. That is about to change with the state's distribution of The Wisconsin Information Manager.
A six computer disk package (based on software from the US Centers for Disease Control and Prevention) was recently distributed by the Wisconsin Division of Health to county departments of public health. This software has made it possible for all of us to more easily quantify the public health issues that pose a special risk in rural areas. Preferably, a more extensive dissemination of this valuable tool will occur in order to facilitate the expansion of community and regional assessments and interventions.
From Sam Roberts' Who We Are: "... 67,000 people were
injured by exercise equipment in 1990, or about twice as many as were injured
in accidents involving television sets."
Rates are for all deaths in disease group per 100,000 population of county group based on 1990 U.S. census and 1993 Wisconsin death files. Age adjusted mortality rates were calculated and displayed only if based on 50 or more deaths total in the RWHC counties.
RWHC rural counties include those counties that are served by RWHC hospitals and that are not in one of Wisconsin's Metropolitan Statistical Areas: Adams, Clark, Columbia, Crawford, Dunn, Grant, Iowa, Jackson, Juneau, Lafayette, Richland, Sauk & Vernon.
Urban counties include those counties that comprise Wisconsin's Metropolitan Statistical Areas: Brown, Dane, Calumet, Chippewa, Douglas, Eau Claire, Kenosha, La Crosse, Marathon, Milwaukee, Outagamie, Ozaukee, Racine, Rock, St. Croix, Sheboygan, Washington, Waukesha & Winnebago.
Marshfield Wins Most Of Appeal
The Blue Cross antitrust federal district court decision against Marshfield Clinic was reversed this month on most points by the and Seventh Circuit Court of Appeals decision substantially reversing an earlier federal district court decision in an antitrust case filed by Blue Cross Blue Shield United of Wisconsin in 1994. All previous awards against Marshfield were nullified and the Clinic was awarded its costs for the Appeal from Blue Cross.
Seventh Circuit Court Chief Justice Richard Posner found that Marshfield Clinic and Security Health Plan are not "monopolies" and that no separate "HMO market" exists, as contended by Blue Cross. Judge Posner wrote: "...Security is not a monopolist of HMO services because HMOs are not a market, and the Marshfield Clinic, its parent, is not a monopolist either because it does not control its independent contractors (physicians) ... the Clinic does not have a monopoly of physician services in the north central region or in any parts of the region other than parts too small to support more than a handful of physicians."
In my opinion, Judge Posner was somewhat less than judicious when he went on to give the unsubstantiated opinion that: "Twelve physicians competing in a county would be competing to provide horse-and-buggy medicine. Only as part of a large and sophisticated medical enterprise such as the Marshfield Clinic can they practice modern medicine in rural Wisconsin."
The Court of Appeals did find that in agreeing to "divide the market" with Wausau-based North Central Health Protection Plan (NCHPP), the Clinic and SHP acted incorrectly. However the justices stated that: "the burden will be on Blue Cross to show (in a trial) how much less it would have paid the Clinic had the Clinic refrained from that illegal practice."
Whether Blue Cross will try to take this case to the U.S. Supreme Court or decide to use this decision to its advantage in other markets remains to be seen. While it is good news that millions of dollars will not flow from a rural health system to Blue Cross shareholders, there is reason to be concerned that some systems may misinterpret this decision as a green light for to engage in more aggressive behavior to take-over rural health providers.
October is National Co-op Month. The nation's 47,000 cooperatives are big and small. They serve 120 million people in all 50 states. And, they're located everywhere--cities, towns, suburbs and throughout rural America.
Providing goods and services as economically and efficiently as possible is their first order of business. And as locally owned and controlled businesses, co-ops are unique because of their commitment not only to the people they serve but also to their communities.
You'll find co-ops for credit and financing, electric and telephone services, insurance, housing, day care, health care, food, farm marketing and supply, news services, florists and much more.
For years co-ops have been expanding horizons for the people they serve. In their own words: "It's just good business, and it works for the benefit of our neighbors, our communities and for our country too."
How About Fed.'s Own Hospitals?
From "Public Lives" by Joe Klein in 9/18 Newsweek:
"... (Senator Bob) Dole might have confronted his fellow vets with an inconvenient reality: the (federal) V.A. Hospital system is a disaster, a scandalously wasteful and ineffectual way to provide care for needy veterans. It should be privatized. The Heritage Foundation (a conservative think tank) has estimated that $1.6 billion per year could be saved and better services provided if the hospitals were sold off and eligible veterans given vouchers for private care."
Urban Folks Now Back Rural Equity
As HMOs have become a key element in Medicare reform, states that would receive low payments under Medicare's archaic "AAPCC" capitation formula have begun to see the world in a way long familiar to rural providers. As reported last month, Wisconsin's average monthly AAPCC ranks fourth lowest in the nation with an intra-state variation of $211 (Vernon County) to a high of $398 (Milwaukee).
The "Coalition for Fairness in Medicare" is a newly organized initiative by state hospital associations and HMOs from Iowa, Massachusetts, Minnesota, Oregon, the state of Washington, Utah and soon the Wisconsin Hospital Association. They are trying to get Congress to adopt a plan to narrow the wide variation in federal payments to HMOs over a seven year transition.
An example of their proposal is as follows: each year, area reimbursement rates that are less than 85 percent of the national norm would be increased by 11.0%, those between 85 and 95 percent by 7.5%, those between 95 and 105 percent by 5.0%, those between 105 and 120 percent by 2.5%, and those over 120 by 0.5%.
If the federal government wants to reduce windfalls for HMO expansions in states with high AAPCC rates and encourage them in states with low rates, this proposal or one that would give comparable results is clearly necessary.
The Enemy Of Intimacy
Emily Friedman gave the keynote address at the Wisconsin Hospital Association's 75th annual convention. She is the Section Editor for health policy of the Journal of the American Medical Association and a regular contributor to a number of other national journals.. To some, her AMA post is a strange credential for one who is arguably one of the clearest and strongest moral voices in American health care.
Last week in Milwaukee (at the Pfister Hotel where the WHA was born) she spoke to a packed house on ethical issues for emerging "integrated delivery systems." Why long an advocate for major reform of our traditional fragmented "system," she spoke of her concern that unlike initiatives earlier in the century aimed at making health care easier to afford and more available, today's efforts are often driven more by provider, insurer profit seeking and employers' need to reduce costs.
In harmony with the position long taken by the Cooperative she warned of the natural tendencies for large regional or multi-state systems to have their primary allegiance not to patients but to the CEO and when for-profit, to the stockholders and not to the community but to the system itself. Her most controversial statement may have been:
"the (large) size of many systems or
institutions is the enemy of intimacy."
She reminded us that the personal nature of health care requires a professional intimacy between a provider and patient, an intimacy that she believes is inherently in conflict with the nature of large institutions and systems.
On the other hand, she strongly dismissed the typical creeps verses angels characterization of the growing wars between for-profits and non-profits. The litmus test for who can claim the high moral ground is equally applicable to both:
Cause Of A Third Party Candidate?
From an editorial in 8/25 Washington Post:
"The voters want a balanced budget and a government that works, but they are wary of a wholesale dismantling of protections for the poor, the elderly and the environment. But the Democrats who are talking against such moves have failed to convince voters of their own capacities for leadership or initiative. The voters, in short, don't agree with the Republicans and don't respect the Democrats. Is it any wonder the public's mood is so sour?"
Bachelor's Program For Rural RN's
Due to the endurance and hard work of Pat Lasky, a senior member and associate dean of the UW-Madison School of Nursing, a long-standing request of rural nursing and RWHC is finally to be answered.
According to September's Nursing matters, five campuses of the UW System are collaborating in offering a bachelor's degree in nursing to meet the needs of students who have limited access to a campus. The Collaborative degree is a joint effort of the schools of Nursing on the campuses at Madison, Eau Claire, Oshkosh, Milwaukee and the department of Nursing at Green Bay.
Extensive use will be made of distance education technology with ten remote sites around the state. Students will select a "home" campus for student related services and except for one "unique capstone experience," attend classes at the outreach sites.
The first two courses in the nursing curriculum will be offered beginning in January 1996. Call 800-442-6459 for more information.
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