Obama plan to pay for health reform

**Prince** · 06-13-2009, 09:13 AM

Obama plan to pay for health reform

President Barack Obama says he's now found savings that will pay almost all the costs of a massive overhaul of America's health care system.

Obama on Saturday is announcing an additional $313 billion in new proposed savings that he says would bring the total funding available for his top-priority health insurance reform to nearly $950 billion over 10 years.

White House officials insisted the new savings were rock-solid, but also acknowledged they had yet to settle on a specific mechanism to achieve lower prescription drug costs that make up nearly one-quarter of the new savings.

“Any honest accounting must prepare for the fact that health care reform will require additional costs in the short term in order to reduce spending in the long term,” Obama says in his weekly radio and Internet address. “Today, I am announcing an additional $313 billion in savings that will rein in unnecessary spending, and increase efficiency and the quality of care.”

The new proposals from Obama came as the drive for health care reform reaches a pivotal juncture in Congress. On Monday, the Senate Finance Committee is scheduled to receive Congressional Budget Office estimates on a slew of health-care options. On Wednesday, the committee is expected to unveil proposed legislation.

In advance of those milestones, the White House was moving aggressively to counter public criticism that funding plans for the health reform effort are unrealistic, particularly in the face of an expected 10-year pricetag of $1 trillion or more. Some analysts have faulted the White House for being overly optimistic about savings and tone-deaf to which tax-raising proposals are likely to fly in Congress.

In his address Saturday, Obama refers to a 10-year total of more than $600 billion in “savings” for health care. However, he does not explain in his latest comments that, under his revised budget released last month, $326 billion of that amount would come from tax hikes on Americans making over $250,000 a year, “loophole closers,” and higher fees for some government services.

In a conference call with reporters Friday, Office of Management and Budget Director Peter Orszag said the latest announcement signaled that the White House had met its obligation to identify funding sources for a broad-based effort to make health insurance more affordable and more widely available.

“We are making good on this promise to fully finance health care reform over the next decade,” Orszag declared.

The bulk of the new $313 billion in savings would come from cutting or reducing the growth of payments to hospitals, medical equipment manufacturers and laboratories — though the major cuts don't target doctors, Orszag said.

Over the next decade, $110 billion is slated to come from reducing reimbursements to take account of what Orszag described as the ability of providers to improve their efficiency. “Health care services should be able to achieve and do achieve productivity improvements over time,” he said. According to a fact sheet released by the White House, future increases in such Medicare payments would be reduced based on an assumption that health care providers achieve half the productivity increases seen elsewhere in the economy. The budget official said the reductions would take place even if providers failed to garner the projected efficiencies.

Another $106 billion would come from cuts in so-called disproportionate share payments the federal government makes to hospitals with large numbers of uninsured patients. “As the ranks of uninsured decline under health reform, those payments become less necessary,” Orszag said.

About $75 billion is slated to come from lower payments for prescription drugs. However, Orszag said the White House was “in discussions with stakeholders over the best way of achieving that $75 billion.”

Notwithstanding that ambiguity, Orszag asserted that the White House had put forward $950 billion in budgetary offsets that could be use to fund health reform. He called the proposals "hard" and "scoreable," meaning that they were sufficiently certain and specific to pass muster with CBO officials who formally tally the cost of budget items.

Asked about the discrepancy, Orszag said, “There’s been continuous skepticism that we will come forward with detail….The detail on the $75 billion for prescription drugs will be forthcoming in the very near future and I will rest my reputation as a former CBO director on the fact that there are multiple ways in which those savings can be achieved and we are committed to achieving that level of savings in this package.”

There were signs that the announcement of the additional $313 billion of savings may have been rushed. In addition to the vagueness about the $75 billion in lower drug costs, the White House’s health care reform coordinator, Nancy-Ann DeParle, did not join a conference call with reporters to announce the new proposals. Her presence had been advertised in advance, but a spokesman said she was in another meeting and could not participate.

The cuts and savings are likely to engender warnings from providers that de-facto rationing will occur as patients in some areas find themselves unable to find providers willing to perform lab tests, X-rays and the like, due to the lower reimbursement rates.

Hospitals are also likely to protest that the disproportionate share payments, which are targeted for cuts of 75 percent, are vital to maintaining hospitals in costly urban centers, and to keeping teaching hospitals viable.

“It is unlikely to be an exact match on a hospital-by-hospital basis but what we believe will occur is that the remaining DSH payments that will still exist can be better targeted to the hospitals most in need,” Orszag said.

source

**danzik17** · 06-13-2009, 08:36 PM

How about this. Don't do this healthcare bullshit and use that 100 billion to pay down some of the ridiculous foreign debt we've accrued.

**bio-chem** · 06-13-2009, 09:43 PM

LOL this is all a joke. we are so fucked

**bandaidwoman** · 06-14-2009, 08:31 AM

A lot of generalities and very low on specifics

It is estimated that defensive medicine costs us 100 billion dollars a year.
The single best way to lower health care costs without even changing much of anything else is tort reform, so that docs are not over ordering tests and procedures due to fear of malpractice...

Defensive medicine documented | DB’s Medical Rants
Is the Defensive Use of Diagnostic Tests Good for Patients, or Bad? -- DeKay and Asch 18 (1): 19 -- Medical Decision Making

Defensive Medicine: Cautious Or Costly? - CBS News

.....Yet the irony is that as we continue to struggle with exploding expense – which most experts agree is the single biggest threat to the success of health care reform – we continue to spend billions on defensive medicine.

Reducing and even (in the best of all possible worlds) eliminating the practice of defensive medicine would significantly curtail our overuse of resources and unnecessary spending....

Physicians practice defensive medicine because they don’t trust the system, regarded by many to be dysfunctional for both patients and physicians, and one that breeds secrecy and mistrust and impedes safety efforts.

Every doctor does this, especially in the er , almost every single person with a headache or belly pain will not leave an er now without an expensive cat scan ( used to be plain films and ultrasound was adequete)

Although I voted for obama, he like most democrats, just don't understand how this is part and parcel of any health reform that lowers cost. Georgia has a democratic represenative scott davis, who understands this, probably because he went to the Warton school of business.

**bio-chem** · 06-14-2009, 10:49 AM

Originally Posted by bandaidwoman

Every doctor does this, especially in the er , almost every single person with a headache or belly pain will not leave an er now without an expensive cat scan ( used to be plain films and ultrasound was adequete)
.

I would kind of like to see some statistics backing this one up.

**bandaidwoman** · 06-14-2009, 05:02 PM

did you look at the massachusets study?

UConn Advance - February 23, 2009 - Study shows defensive medicine widespread

The study, “Investigation of Defensive Medicine in Massachusetts,” is the first to specifically quantify defensive practices across a wide spectrum and among a number of specialties.

It also is the first to link defensive practices across a number of medical specialties – anesthesiology, emergency medicine, family medicine, internal medicine, general surgery, neurosurgery, orthopedics, and obstetrics/gynecology – directly with Medicare cost data.

Or how about this one from 2005 jama
JAMA -- Abstract: Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, June 1, 2005, Studdert et al. 293 (21): 2609

Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances...

Or this one with a link to nonpartisan entity funding studies that support the jama conclusions. https://www.conquerchiari.org/subs%2...ine%203(6).asp

For those that don't beleive it even when it comes from the horse's mouth:

This one done in the social sciences literature by some business analysts
SSRN-Do Doctors Practice Defensive Medicine? by Daniel Kessler, Mark McClellan

Defensive medicine" is a potentially serious social problem: if fear of liability drives health care providers to administer treatments that do not have worthwhile medical benefits, then the current liability system may generate inefficiencies many times greater than the costs of compensating malpractice claimants. To obtain direct empirical evidence on this question, we analyze the effects of malpractice liability reforms using data on all elderly Medicare beneficiaries treated for serious heart disease in 1984, 1987, and 1990. We find that malpractice reforms that directly reduce provider liability pressure lead to reductions of 5 to 9 percent in medical expenditures without substantial effects on mortality or medical complications. We conclude that liability reforms can reduce defensive medical practices.

I can tell you this, I order tests and procedures to cover my ass all the time. ask any doctor.

There is also a very nice side effect of tort reform that most citizens and most doctors and lawyers don't realize, transparency of errors. Right now there is such anatagonism between lawyers and doctors , patients and doctors, hospital and potentially suing patient that when errors occur, nobody wants to tackle it openly and honestly to improve patient outcomes in the future..

The studies don't even come close to approximating how much it really costs.

**bio-chem** · 06-14-2009, 05:28 PM

Originally Posted by bandaidwoman

did you look at the massachusets study?

UConn Advance - February 23, 2009 - Study shows defensive medicine widespread

Or how about this one from 2005 jama
JAMA -- Abstract: Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, June 1, 2005, Studdert et al. 293 (21): 2609

Or this one with a link to nonpartisan entity funding studies that support the jama conclusions. https://www.conquerchiari.org/subs%2...ine%203(6).asp

This one done in the social sciences literature by some business analysts
SSRN-Do Doctors Practice Defensive Medicine? by Daniel Kessler, Mark McClellan

I can tell you this, I order tests and procedures to cover my ass all the time. ask any doctor.

The studies don't even come close to approximating how much it really costs.

I don't deny that defensive medicine is practiced. I read the links to what you posted. It's the assertion that almost all ER patients with a headache get a cat scan that I have a problem with. You only see CT machines in the ER in large, high level trauma facilities. Further many small community, rural hospitals (many of which are in your back yard of the south) don't have the volume to own a CT machine in their imaging department let alone the ER. opting to schedule all such scans maybe once a week with a mobile service. Something that would make ordering CT scans on ER patients an impossibility. Another obstacle to the scenario you paint is the fact that hospitals are in the business of making money and ordering scans that they know they can not get reimbursed for is not a very common practice for those hospitals trying to remain financially viable. Especially considering how these economic times have effected hospitals

**bandaidwoman** · 06-14-2009, 05:32 PM

Originally Posted by bio-chem

I don't deny that defensive medicine is practiced. I read the links to what you posted. It's the assertion that almost all ER patients with a headache get a cat scan that I have a problem with. You only see CT machines in the ER in large, high level trauma facilities. Further many small community, rural hospitals (many of which are in your back yard of the south) don't have the volume to own a CT machine in their imaging department let alone the ER. opting to schedule all such scans maybe once a week with a mobile service. Something that would make ordering CT scans on ER patients an impossibility. Another obstacle to the scenario you paint is the fact that hospitals are in the business of making money and ordering scans that they know they can not get reimbursed for is not a very common practice for those hospitals trying to remain financially viable. Especially considering how these economic times have effected hospitals

I practice in a rural hospital, we cat scan all the time. We have rented both the MRI and ct scanner on a full time basis now ( despite the economy) , and yes , we are hemmoraging money as I am also medical director. In our meetings we have decided that ordering the necessary ( and maybe overly necessary) tests even in the uninsured is more cost effective than one multi mult million dollar lawsuit, (Right now 10/ 15 lawsuits they are dealing with now are from the ranks of uninsured.) I also practice in an academic hospital, when I am on call I am asked to accept patients who cannot get the workup needed at the local hospital, My malpractice e carrier has told me that with the economy and the loss of insurances, many are looking to recover costs by sueing so we cannot let our gaurd down. I am sure I am not the only one who got a call from our malpractice carrier about this....

unfortuneatly there is a saying in the ER " You never get sued for the ct scan you ordered, only the one you didn't" With that kind of thinking....

for the record these are the first three thoughts that go through every doc's mind when coming up with a differential disease process...

"What does my gut ( and physical exam and history) tell me this person likely has wrong with them?
What do I need to do to reasonably establish the diagnostic impression?
What do I need to do to cover my ass in case I am wrong? "

**bio-chem** · 06-14-2009, 05:50 PM

Originally Posted by bandaidwoman

I practice in a rural hospital, we cat scan all the time. We have rented both the MRI and ct scanner on a full time basis now ( despite the economy) , and yes , we are hemmoraging money as I am also medical director. In our meetings we have decided that ordering the necessary ( and maybe overly necessary) tests even in the uninsured is more cost effective than one multi mult million dollar lawsuit, (Right now 10/ 15 lawsuits they are dealing with now are from the ranks of uninsured.) I also practice in an academic hospital, when I am on call I am asked to accept patients who cannot get the workup needed at the local hospital, My malpractice e carrier has told me that with the economy and the loss of insurances, many are looking to recover costs by sueing so we cannot let our gaurd down. I am sure I am not the only one who got a call from our malpractice carrier about this....

unfortuneatly there is a saying in the ER " You never get sued for the ct scan you ordered, only the one you didn't" With that kind of thinking....

What percentage of these patients so you feel you are admitting that you you normally wouldn't? What is the hospital and your staff doing to help offset these costs in other areas? how do you expect the obama money and the still undefined "meaningful use" to impact this problem? Are you doing any data analytics right now on outcomes, and if so do you think this will help reduce the amount of unnecessary scans ordered in the future?

Sorry for all of the questions, but i really am curious.

**bio-chem** · 06-14-2009, 05:55 PM

another question. How is this effecting the technology that hospitals are utilizing? more specifically with CT's of the heart 64 slice and greater machines are utilized. In a rural hospital that normally would not have a 64 slice but more commonly a 16 or 32 or even potentially lower, do you feel that this problem will force smaller hospitals to speed up their adoption of these newer technologies or perhaps even slow it down?

**KelJu** · 06-14-2009, 09:00 PM

Goody goody goody, give me some money.

**bio-chem** · 06-14-2009, 09:40 PM

Originally Posted by KelJu

Goody goody goody, give me some money.

you're doing health care IT? good field to be in for the for the future.

**bandaidwoman** · 06-15-2009, 09:28 AM

Originally Posted by bio-chem

What percentage of these patients so you feel you are admitting that you you normally wouldn't? What is the hospital and your staff doing to help offset these costs in other areas? how do you expect the obama money and the still undefined "meaningful use" to impact this problem? Are you doing any data analytics right now on outcomes, and if so do you think this will help reduce the amount of unnecessary scans ordered in the future?

Sorry for all of the questions, but i really am curious.

The hospital is offsetting costs by cutting employee benefits ( the hospital insurance now no longer pays for any routine physicals)... I know bad place to cut benefits in terms of prevenative health but I am not the hospital administrator,

both the er and hospital have gone 100% fully electronic so we can start tracking and monitoring problem patients, procedures etc. I have my office electronic records link up with the hospital which is good for continuity of patient care ( readmissions are costly to both hospital and patient.) etc.

As to what percentage of admission, don't have those but here are a few facts...Admissions are so much higher than it was 14 years ago, our hospital is almost always full it is on diversion on a constant basis. ( due to growing population, aging and declining healthy patients , growing ranks of uninsured who wait till they are very very sick before seeing a doctor ( in this case the hospital).

When on call I used to admit only 5-6 patients a night. The other night I admitted 20 patients between 10 pm and 3 am and lost track of the additional admissions after that since I was so tired. That is the usual number for me now.

I think obama's agenda for calling for electronic information systems is fabulous, I already see the cost differance in terms of preventing medical errors, reording tests that have already been done etc, things that I have my EMR designed to harvest information the way I need it to avoid costly medical interactions etc.to remind me when tests have been done etc.

His agenda for a national health insurance coincides with those of us ( physicians for national health insurance) who agree that it is time. In fact the JAMA showed that a majority of us ( including general surgeons) believe a national health insurance is mandatory. I believe this will help the bottom line in hospital in rural areas where the uninsured overutilize and bankrupt the hospitals.Physicians for a National Health Program - Health Care is a Human Right

**Dale Mabry** · 06-15-2009, 02:26 PM

Originally Posted by bandaidwoman

I think obama's agenda for calling for electronic information systems is fabulous, I already see the cost differance in terms of preventing medical errors, reording tests that have already been done etc, things that I have my EMR designed to harvest information the way I need it to avoid costly medical interactions etc.to remind me when tests have been done etc.

Watch the Obama praise in here, you will be labeled a socialist

His agenda for a national health insurance coincides with those of us ( physicians for national health insurance) who agree that it is time. In fact the JAMA showed that a majority of us ( including general surgeons) believe a national health insurance is mandatory. I believe this will help the bottom line in hospital in rural areas where the uninsured overutilize and bankrupt the hospitals.Physicians for a National Health Program - Health Care is a Human Right

So wait, I thought every single Doctor and nurse in the U.S. would immediately get his or her pay cut in half if we went with "Socialized" healthcare. This would obviously lead to people no longer trying hard to be Doctors and without the competition involved with a capitalistic healthcare program, we would immediately revert back to bloodletting as a cure for every disease within the first 5-6 months.

I wouldn't be able to guess it from your post, but I suspect that the under/uninsured are more of a problem to hospitals than the politicians are letting on.

**bio-chem** · 06-15-2009, 02:46 PM

Can anyone name an industry that has benefited from a lack of competition?

**min0 lee** · 06-15-2009, 02:49 PM

Cable TV

**bio-chem** · 06-15-2009, 02:51 PM

Originally Posted by min0 lee

Cable TV

there is more competition now than there has ever been.

**min0 lee** · 06-15-2009, 02:52 PM

Joking, it sure took a while.

**NeilPearson** · 06-15-2009, 02:57 PM

... cable TV has lots of competition, and it still sucks

**Dale Mabry** · 06-15-2009, 03:07 PM

Originally Posted by NeilPearson

... cable TV has lots of competition, and it still sucks

No it doesn't. Verizon, DirectTV and Comcast is hardly a lots of competition. The second Fios is available in my building I am jumping ship.

And Bio, there will always be competition, not every person's driving force in life is money. Some people just do things to be the best at something. I would have to think most, if not all, scientific discoveries came from someone wanting to discover something, not someone who said, "How can I make the most money...Oh yeah, I will claim the sun is the center of the universe and prove it..." The problem comes in the form of getting the grant to fund your research. If money were the driving factor they would all get belly-button rings and learn to lip-synch like Britney Spears.

**bio-chem** · 06-15-2009, 04:57 PM

Originally Posted by Dale Mabry

No it doesn't. Verizon, DirectTV and Comcast is hardly a lots of competition. The second Fios is available in my building I am jumping ship.

And Bio, there will always be competition, not every person's driving force in life is money. Some people just do things to be the best at something. I would have to think most, if not all, scientific discoveries came from someone wanting to discover something, not someone who said, "How can I make the most money...Oh yeah, I will claim the sun is the center of the universe and prove it..." The problem comes in the form of getting the grant to fund your research. If money were the driving factor they would all get belly-button rings and learn to lip-synch like Britney Spears.

new medicines by and large come from american pharmacetical companies. and it is almost entirely profit driven.

Toshiba right now has a 320 slice CT. and these things can do amazing stuff. trust me it is because they want to beat GE, Siemens, and Philips.

Right now american hospitals have to compete with each other. It is a major cause of them adopting new technologies. Don't believe me? next time you drive by a billboard count how many are for hospitals proclaiming a new imaging device they have. 3T MR anyone? When it comes to healthcare americans shop around. Digital mammography is a big deal right now because women will drive to a different hospital or imaging center to receive a digital image over a film. keeping up with the jones' drives technological adoption in hospitals.

Compare this to hospitals in canada. Hospital administrators do not choose which imaging equipment they get. The government dictates if a new MR is warranted. another thing mammography CAD is not reimbursed by the canadian government. want to take a guess on how many times CAD is used in canada?

**quadluver** · 06-15-2009, 05:59 PM

Originally Posted by bio-chem

Can anyone name an industry that has benefited from a lack of competition?

Industries don't benefit, companies do. The real beneficiaries are the consumers, because they get to decide.

**maniclion** · 06-15-2009, 07:31 PM

Originally Posted by Dale Mabry

we would immediately revert back to bloodletting as a cure for every disease within the first 5-6 months.

Sounds more logical than the, "Here try this pill that I get paid to hand out like lollipops. It might cause your sphincter to itch like crazy, your finger nails turn to a sloppy goopy glue like mess so that when you go to scratch your butthole your fingers get stuck and you either rip them away taking skin and ass hairs or you can walk around like a booty-scratching monkey......"

**maniclion** · 06-15-2009, 08:07 PM

I see Band-aid womans point of view from the patient side. I gave up trying to figure out why I have back pain because after one doc gave up I'd go to a new one and he would have me do the same Xrays and scans that I'd just had done with another doc. I had to pay a good chunk of change for them and I figured just showing up each month to get a prescription was less expensive than keeping doing these tests over and over....

**bio-chem** · 06-15-2009, 09:09 PM

Originally Posted by maniclion

I see Band-aid womans point of view from the patient side. I gave up trying to figure out why I have back pain because after one doc gave up I'd go to a new one and he would have me do the same Xrays and scans that I'd just had done with another doc. I had to pay a good chunk of change for them and I figured just showing up each month to get a prescription was less expensive than keeping doing these tests over and over....

this just helps prove in my mind how important competition and patient choice is to me. not all x-ray machines or MRI's are the same. image quality varies just like radiologist/physician skill does.

**danzik17** · 06-15-2009, 09:10 PM

Interestingly enough leeches and maggots actually do as good a job or better than some medications/procedures to handle things like debriding (sp?) tissue or stopping blood clots in extremities.

It's just pretty freaking disgusting.

**Dale Mabry** · 06-16-2009, 08:48 AM

Originally Posted by bio-chem

this just helps prove in my mind how important competition and patient choice is to me. not all x-ray machines or MRI's are the same. image quality varies just like radiologist/physician skill does.

How does that show you the importance of competition? It shows me that someone is not getting the level of care they need because a hospital can't justify the cost of a piece of equipment. That more shows how fucked up the system is than giving support for it.

**ZECH** · 06-16-2009, 09:45 AM

I don't see National Health care EVER working. And from what I see on TV, most Doctors and special interests are against it. I don't ever see it passing.

**bio-chem** · 06-16-2009, 10:08 AM

Originally Posted by Dale Mabry

How does that show you the importance of competition? It shows me that someone is not getting the level of care they need because a hospital can't justify the cost of a piece of equipment. That more shows how fucked up the system is than giving support for it.

because with competition an informed consumer can choose the level of care he needs. Competition forces hospitals to adopt newer, better technology faster. I have already given examples of this and compared it to canada.

**Dale Mabry** · 06-16-2009, 11:58 AM

Originally Posted by bio-chem

because with competition an informed consumer can choose the level of care he needs. Competition forces hospitals to adopt newer, better technology faster. I have already given examples of this and compared it to canada.

An informed consumer cannot choose the level of care they want, an informed consumer can choose the level they can best afford. What good is top of the line technology when no one can afford it? I think the average faily pays 12k a year for medical insurance, and half of the people who file for bankruptcy from medical expenses have insurance. So tell me now, how is this good for Americans? It's not, Insurance companies are in business to make money, and once somebody becomes less profitable as an insured, they are dropped. Now, this is the way you want the people providing your healthcare to think?

Not a single one of you who is against national healthcare would be saying it wouldn't work if you had a child dying of cancer who had been denied coverage. The exact same reason why Nancy Reagan was for fetal stem cell research and Dick Cheney is against a constitutional ban on gay marriage, once it affects you personally it becomes a priority. Honestly, who's to say that there can't be basic coverage for all and supplemental coverage for those who want better care? Why does someone who has strept throat need to pay an MD $2000 to find this out when it is relatively easy to diagnose and the test is probably about 50 years old?

An even better question is how can you justify spending $1 trillion on the Iraq war to bring democracy to Iraqis and not spend the same on your own people who can't afford healthcare. Only a fool would use the WMD excuse now, they obviously never had them.

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