Rationing spelled out in HR3200? And what if it is?

I received an email with a link to an analysis of HR3200 in which the blogger quotes the specific language in the bill that leads him to conclude that HR3200 does indeed ration care. Of course, we all know that private insurance also rations care, so that's not the issue here, at least not directly. What I'm wondering is how you can change someone's mind when they have -- dispassionately, even -- read the bill and drawn this conclusion?

Anyhow, here's the link I was sent. What do you all make of it?

http://www.classicalideals.com/HR3200.htm


The person who sent me the email also noted that one of Obama's chief medical advisers, Dr. Ezekiel Emanuel, has written numerous times in the past about personal physicians needing to serve the greater good of society (i.e. rationing), which may not always be the best thing for the patient in question. He linked to this article:

http://online.wsj.com/article/SB10001424052970203706604574374463280098676.html


I honestly don't know how to respond. The blog and the article both seem to make good points. All I've got is, "But private insurance rations, too," which sounds a bit childish after a while. Does it all really just boil down to the question of, who do we want to be rationing our care: faceless private insurance bureaucrats, or faceless government bureaucrats?

were enacted tomorow there would not be enough health care professionals available to meet the demand for care. Single payer would immediately add another 50 to 100 million uninsured/underinsured patients to our existing health care system. A health care system where competent doctors are currently not lacking patients.

The problems in our fucked up health care system go far beyond affordable health insurance.

by a good nurse practitioner. Colds are just one example.

to be treated by a NP. They have much better bed side manner, ime. Many specialists employ them in their own offices as well.

I have NO problem with that whatsoever, if that's what they are calling "rationed care".

http://factcheck.org/2009/08/twenty-six-lies-about-hr-3200/

I've read the bill too, (How geeky is that?).

My take on "preventable" readmissions. They are talking sbout follow up care and maybe doing it right the first time so the patient doesn't have to go back to the hospital for the same thing.

Sometimes, for example, cancer does not show up until several months after the patient first notices that something somewhere is wrong. That is not really common, but it can happen, especially when a patient has a number of things wrong or when the symptoms are generalized or confusing for one reason or another. There are lots of reasons for readmissions. Drug abuse for which the abuser refuses treatment is another cause for readmissions. Also, many diseases by their very nature get progressively worse. Then there are the cancer patients who have to come in repeatedly for certain problems.

for Medicare now, they have approved home visitations. What in the world is wrong with that? It cuts down on admissions but the patient still receives care! That's probably what this is all about.

has to do with discouraging sending people home too soon. As I recall the discussions, there will be penalties imposed on hospitals with too many discharges and near-immediate readmissions because the person discharged was not yet ready to go home. That recollection is consistent with the title: REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS (i.e. just keep them in until they are well, rather than sending them home only to be readmitted in a very short period).

You'd need to read the bill INCLUDING whatever other sections it references or amends to sort this out. Both sides of the debate have been reading the text of the bill in isolation - it doesn't work that way. Since much of what the bill does is amend existing law, it is impossible to understand the bill without tracking the references to what is being amended.

OK. I got curious and dug out the bill: Here is what is being amended - part of the Medicare statute: ‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR EXCESS READMISSIONS.—

In other words, if you insist on kicking out patients too early and they bounce back, you're not going to get paid for the re-admission. The patient gets treated - but the hospital doesn't get to double dip because it caused or contributed to the problem.

I haven't had the time to peruse everything in context, unfortunately.

They knew this would play on people's emotions.It is called
"dark populism" at which the GOP are expert.

It is difficult to try to stop it now. If something is not
nipped in the bud, and it sticks. (people pick up on it and
believe it--whew.)

The truth is Insurance Companies simply deny coverage if they
believe a procedure is not medically necessary. People challenge
these and often and win. Just this week, Bernstein said he
had been denied an MRI by his Insurance Co. He planned to challenge.
I think Bernstein would have some good Insurance. People can
call this rationing.

I must say this is a hard one.

That alone calls its credibility into question. As you're probably aware, she's the one who started spreading the idea that having Medicare pay for optional end-of-life counseling between a patient and doctor is actually a secret government plot to kill off the elderly.

As for the excerpt:
This is indeed in the bill, but it is taken out of context. If you look earlier in the same section, the bill says this:


Now, I'm no expert in legalese, but my interpretation is that this would reduce Medicare payments to hospitals for excess readmissions for the same condition. It would not PROHIBIT such readmissions, but would reimburse them at lower rates. The goal, I believe, is to discourage hospitals from sending patients home before they're ready, only to have them come back a week later for the same problem.

Discouraging hospitals from sending patients home before they're ready sounds like a more likely goal. The blogger's take on this, of course, is that, "when enough people have been discharged for the same condition, an individual may be readmitted."

The legalese of that section is what must be leading him to that conclusion; note the underlined part: "excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number... of discharges for such applicable condition for the applicable period and such hospital." So maybe it doesn't mean what he thinks it means, but how does that relate to not sending patients home too soon?

It seems to say that the restrictions on excess readmissions will not apply if the number of discharges is BELOW a certain minimum level. Once the number of discharges exceeds that level, the lower reimbursement rates will kick in.

It's not clear to me if this refers to the total number of patients discharged at the hospital for a given condition, or the number of times an individual patient is discharged for a given condition within a certain period. The latter would seem to make more sense.

... Section 1886 of the Social Security Act is being amended to add a sub-section (p) called “Adjustment to hospital payments for excess readmissions.” Therein, the new language describes excess readmissions, where hospitals will be reimbursed at a reduced rate for readmissions considered to be “excessive.”

The new language goes on to include the part that the blogger quoted: “excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.”

SO... does that basically say that a readmission for Disease X won’t be considered excessive IF, for that hospital, a certain minimum number of Disease X patients have not yet been discharged that year? In other words, the readmission for each illness type has a threshhold for excessiveness that is determined individually for each hospital?

Yep, that's what it sounds like to me in context. Hadn't thought about if such threshhold applies to an individual patient or to the hospital as a whole. Good question.

Does it all really just boil down to the question of, who do we want to be rationing our care: faceless private insurance bureaucrats, or faceless government bureaucrats?

If that was the decision the choice of what is best would have to be based on the character of the people in each group, and who they support most, and how they get into the position to make that decision. There is an argument that neither government nor corporations can decide, you could say they both have too many flaws, but if that was true, which group would be easier to replace?

Much of the reason for money first doctrine of some groups is to defend money. In other words they make the claim that people are rich because of some special characteristic that makes them best to choose social policy. They have to claim superiority to be able to further their dominance, because without that claim it is obviously wrong, since what ever they think of the unwashed masses they have to think of people in their own group also.



In a representative governance that choice is made by a proxy representative of the people, so in theory the decision is by most people about who can get care, not based on who has the most money. Assuming people are given information to understand the problems and the fixes for those problems.

The idea of checks and balances and democracies is there so most people decide, if it is thwarted by stolen elections, propaganda, deceptions, or many other ways, then it is not a democracy but an extension of the people doing those things to remove democracy.

It is possible governments can be so corrupted that they are an extension of money. They can also be an extension of a social class. In some histories they were an extension of a religious or racial class. In those cases they would be defending a subset of society, some on the right fear that very thing because of some biases they have. That is why they promote the idea of republicans not getting care. Although if any system is transparent, no doctors or nurses would allow that, so that is a bad argument about our government. In other words that counter argument is not valid if we protect our democracy, or are able to have an informed citizenry.

What government actually is determines much of whether they are a better choice, so if they are an extension of most people, and you believe all people have equal dignity and value, then they decide better. If you believe some people are better, then you have to suppress the many so that few can make the decisions for people in their group.



But on a better more hopeful note. As productivity continues to rise compared to demand, jobs can be made by wars, consumerism, planned obsolescence or other profit first methods. Or the demand that already exist things like health care, since by mentioning rationing you make the statement demand is higher then supply, can be answered with increase in health capability.

Inside our situation it is just not profitable to do some things that most think are good. It is not profitable to treat an elderly person with comfort and compassion in their latter years. But it can be done because most of society likes that idea, so if their is scarcity of care, and the private sector does not make all the decisions, jobs can be created and demand lowered in many sectors. There would be less profit for many sectors since demand supply ratio determines profit, scarcity raises profit, but more people will be treated.

To make it clearer, society can increase health coverage by making jobs in that sector, new clinics and even hospitals, and more nurses and doctors. That would lower the profit of that sector of course, but it could be done by society wanting it, it would not be done by profit wanting it. Profit needs scarcity to keep profit margin higher.

I'm trying to explain this. Making an elderly person treated and comfortable for a few years at end of life has no productivity or profit in it. It has zero gain in money or productivity and actually cost money and resources from society. Think about it, it cost money to give health care. So 'profit first' drops as much care as they can. And the drop of care is based partly on how much money you have, not how much you need the care.

Society can get together and say we want more people to have care, we want people to be treated, we don't want profit to decide, so elderly people got medicare. Not for profit, it is not there for profit, but because it is right and compassionate and it is who we want to be.


In the same way their is little profit to treat a seriously ill younger person, there is little profit in getting someone well. But in society we want people to get treated, it is not about profit, so we need a system that does not just look for profit in the equation. And as far as society goes, if people do get treated some return to work, but with high unemployment again that is not a profitable thing, there are other workers that can do the job.

See how profit does not want to help people, it has no reason to, only society can add compassion to the argument. People can demand that they want to be a society that cares.

It should be noted many people in private sector, the profit side, can and do want to help people, but they are under the control of the corporate charter that they must make as much money possible or be fired by shareholders. In that, many people in private sector want government regulation so they can act within a compassionate bounds. They don't want it to be no rules, they want everyone to have the same rules so that it is not a race to the bottom of who can deny the most care.

Those are some of the things I discuss on that topic.

I just say, "well, it's not working right now, so I'm game for trying something else."

be rationed. There are some other health care procedures that at this time have to be rationed. Stem cell research, of course, may change that.

That's basically what it comes down to. I don't want to make it fairer for you if it means I have to give up anything. At least that's what people are saying.