Friday, July 31, 2009
Even before they will try to hammer out a common bill there are other contentious items facing both Congressional Houses. At this point they seem to be getting a handle on cost by ignoring all years except the first of the estimated $245 billion 10 year increase in Medicare costs. How much subterfuge will there be in the final bill?
Until September when Congress reconvenes there will be little overt action towards a workable plan. Probably the Times is the best source of in formation at this time. Any analysis I could possibly do would just be pure speculation, therefore the subject will be on my back burner until September.
Meanwhile my priorities over the next few days will be focused on children (4), grandchildren(3), and great grandchildren(5). Local stimulus money, tax abatements, sewer charges, politics will have to wait.
Thursday, July 30, 2009
My memory is faulty. I have obtained a copy of the new paperback edition of "The Soprano State"and although Senator Lesniak's name appears 5 times (pages29,39,82,101-4,224-225) much of it was regarding his relationship with former Governor McGreevey and his maneuvering to prevent a special election after McGreevey's announced plan for election so that Senator Cody would be the acting Governor.
Other "powers" wanted a special election to place Corzine in power. We owe Lesniak a token of graditude for sparing us a few months of Corzine mismanagement.
The book in one place refers to Lesniak as being the Union County boss.
Wednesday late afternoon I was again scanning the print Ledger's 1st section and to my amazement there was an article about 18 New Jersey towns receiving $26.8 million stimulus money for additional police.
Elizabeth in Union County received $4.96 million for 17 new cops,East Orange $3.247 mil for 14 new police,Paterson $3.747 mil,Trenton $2.959mil, PLAINFIELD there was no such town listed. Oh yes Brooklawn got$350,081, Frenchtown $204,618, Wildwood $819,120.00 but NO PLAINFIELD.
Obviously we have enough police and no gang or crime problem. Or did we not apply for COPS money because the recipients would only receive enough funds for a three year period and then be obligated to fund the 4th year itself?
Or were we one of the approximately 24 towns that were turned down? Among them were Newark and Camden for past violations. Officials said that these agencies accepted the 3 year ban instead of repaying money owed to the government for misuse of funds. Will we ever know?
Perhaps, our focus for "stimulus money" was centered on a withdrawn request for $15 million to fund another "developer's " plan for condos or apartments without parking space in the center city area. Or maybe there is no tax abatement in policemen.
Or could it mean that the County political powers have more influence in Trenton then our own local Assembly persons? I believe but my memory may be faulty, that the book "Soprano State" mentions a close relationship between Governor Corzine and State Senator Lesniak. .
I am not referring to the weather, which for the past two days have been typical New Jersey summer. One literally walked through the humidity Wednesday morning. People with respiratory problems were in danger when venturing outside.
Instead, I allude to the bogger's world. Either the provocative bloggers are losing their touch or what is more likely the readers are having an acute attack of ennui. The number of comments posted have dropped to almost none. That is not due to blogger censorship, since our Plainfielders post everything even critical of themselves. Yes there are some that are in bad taste, or slanderous, or not germane to the subject that are dropped. That is the bloggers right and in my opinion obligation.
Other blogs written by "politicos" rarely if ever posts a contrary comment. In fact there is one that had only one comment posted since its inception and that was a supportive one in a controversial situation . Of the other four on CLIPS,one posts multiple commentaries, another only a few which are usually position supportive. Others post rarely, although there is one whose author I respect but who doesn't seem to have enough impact on readers to generate any commentary. At least I have read none regarding his latest posting.
This Dog Day syndrome has affected my Health Care analysis. No time will be lost since it seems that the Blue Democrats are leaning to a compromise with the House leadership on a Bill they will support. The payback is that no action will be taken until after the recess.
This Wednesday it was reported that the bipartisan Senate group of 6 has reached agreement on most of the items in the Senate version and that too will be acted upon when the Senate reconvenes. Again these are only rumors, nothing has been released.
At the same time Obama apparently has shifted from a 100% person covered federal insured health plan stand to one with subsidies to the private insurers. Any plan that he finds acceptable will only cover about 95% of the population. He also seems to have veered from his proclamation that there would be no extra financial burden on the middle class to pay for the new Health Care Plan to one that will be at the expense of sacrificing things that don't make them healthier. That probably means entitlements supported by tax money or increased taxes to pay for them including schools, police etc. will suffer from the lack of funding unless taxes are raised for their use".
A final digression; Monday night at the Council/PMUA Working Session Council President Burney mentioned in passing that a meeting between several Council members and PMUA executives had resulted in the roll back of certain charges like open lids and time which the containers had to be off the street. A few citizens near me wondered whether such a meeting was in violation of the Open Public Meetings Act. In N.J.S.A. 10:4-6 (1973) there is a statement to the effect that'"a public meeting is one held by a public body of any level of government-state,county or local-with the intent to discuss or act as a body on public business. A meeting may be in person,by telephone conference call, or by other means of electronic communication."
It is my non legal opinion that this type of meeting is in a grey area since in can only recommend some action by one of the participants and not perform any action. There is also a very interesting problem created by this definition of a public meeting; How can the public participate in a telephone conference call or email meeting? Anybody have any idea on how to solve the logistics?
Maria; All our wishes for a speedy recovery.
Tuesday, July 28, 2009
Health insurance runs from basic vanilla coverage to highly expensive "Cadillac" plans. According to the Congressional Budget Office; the average employer-sponsored insurance. has a premium of about $5000 for individual coverage and $13,000 thousand dollars for family coverage. (NY Times 7/28/09.)
There is the question whether part time employees at any level should be recipient of any of these perks. In New Jersey's civic positions part time employees with multiple jobs receive pension benefits from all. Too9 often there is a revolving chair in commission, authority or agency appointments all giving perks including early vesting in pension plans. There are examples in the "Soprano State".
PMUA mentioned plans to completely automate its trash and recycle clean ups. This will reduce the number of employees per truck to 1 or2. Who will write t he legislation prohibiting street parking on pick up days? Or will there be alternate street side pickups? What will happen to the handicap or elderly who at present are exempt from curbside placement of the PMUA containers?
Other unanswered questions included; Is there any planned cut in services to weekly pickups?
With the drop in prices for recycles, as a result of the recession is the service loosing money and who will make up the shortfall? This is important since Mr. Watson stated that the designated recycle facility is months behind in its payments to various authorities including PMUA.
There was no exploration of how the Sewer Charges and the so called ' Shared Services" costs could be collected through taxes.
Since the subject of absorption of the PMUA by the city was not broached Monday night there remains a question of responsibility for the PMUA bonds. The public needs information if that road is to be pursued.
Since all the above is supposed to be public information London said a copy would be placed in the City Clerk's office.
Council President Burney noted that there had been preliminary meetings between Council members and the PMUA executives. A few in the audience privately raised the question but did not ask if these meetings were subject to the Sunshine laws.Perhaps not if they were not scheduled and were just informal.
It was noted that PMUA was required by county and state rules [laws] to use the County's Incinerator in Linden whereas private haulers were using at a savings out of state landfills. PMUA has a 25 year favorable rate contract with UCUA not available to those who have not opt in. Further questioning elicited that there was a cap on the amount of tonnage.Above that the rate would be similar to that charged to others.
The shared services provided by the interlocal agreement included clearing of the downtown area, city property,city parks, cleaning up after municipal events, trash services for municipal buildings. etc at no charge to the "city". When questioned, how the costs for this service was met the answer was that it was that portion of the ratepayers bill.
During the public commentary Plainfielder Albert Pittis noted that the "shared services" charged business properties was based on "lot" and not on the building's space area.
Therefore a multistory property paid the same fee as a single story on the same size lot.
Other citizens remarked that PMUA was providing a municipal service that should be part of the City's operating costs and therefore a budget item which would be part of the tax base. Instead property owners are deprived of that deduction or any voice in the cost of the service.
PMUA counsel London stated that the Sewer Charge on the rate payers bill was determined by an adopted "methodology" which she refused to clarify because of "pending litigation" . She did state that the bill was determined on the volume of water used not on the water companies charges.
Prior to the formation of PUMA sewerage charges were also part of the tax bill.
The availability of the compensation received by PMUA's executives is open to the public and not unreasonable. What is not stated are perks including health and dental insurance, pension plan, travel and meeting reimbursement. The inference was besides the Commissioners $4,500.00 annual gratuity, they received the same perks as the Authority's executives.
A member of the public wondered why there had to be 7 commissioners and not two or three. Perhaps a reference could be had in the "Soprano State".
All the above is anecdotal and subject to correction which is welcomed. I do urge reading any newspaper report in print or on line, as well as Plainfield Plaintalker.
Someone asked the other day, 'What was your favorite fast food when you were growing up?'
We didn't have fast food when I was growing up,' I informed him. 'All the food was slow.'
'C'mon, seriously. Where did you eat?'
'It was a place called 'at home,'' I explained. ! 'Mum cooked every day and when Dad got home from work, we sat down together at the dining room table, and if I didn't like what she put on my plate I was allowed to sit there until I did like it.'
By this time, the kid was laughing so hard I was afraid he was going to suffer serious internal damage, so I didn't tell him the part about how I had to have permission to leave the table.
But here are some other things I would have told him about my childhood if I figured his system could have handled it :
Some parents NEVER owned their own house, wore Levis , set foot on a golf course, traveled out of the country or had a credit card.
My parents never drove me to school. I had a bicycle that weighed probably 50 pounds, and only had one speed, (slow).
We didn't have a television in our house until I was 27. It was, of course, black and white, and the station went off the air at midnight, after playing the national anthem and a poem about God; it came back on the air at about 6 a.m. and there was usually a locally produced news and farm show on, featuring local people...The station was Dumont that and NBC weret he only two in this area.
I never had a telephone in my room. For most the only phone was on a party line. Before you could dial, you had to listen and make sure some people you didn't know weren't already using the line.
Pizzas were not delivered to our home... But milk was. All newspapers were delivered by boys and all boys delivered newspapers --who had to get up at 6AM every morning.
Movie stars kissed with their mouths shut. At least, they did in the movies. There were no movie ratings because all movies were responsibly produced for everyone to enjoy viewing, without profanity or violence or most anything offensive.
If you grew up in a generation before there was fast food, you may want to share some of these memories with your children or grandchildren. Just don't blame me if they bust a gut laughing. Growing up isn't what it used to be, is it?
MEMORIES from a friend :
My Dad is cleaning out my grandmother's house (she died in December) and he brought me an old Royal Crown Cola bottle. In the bottle top was a stopper with a bunch of holes in it.. I knew immediately what it was, but my daughter had no idea. She thought they had tried to make it a salt shaker or something. I knew it as the bottle that sat on the end of the ironing board to 'sprinkle' clothes with because we didn't have steam irons. Man, I am old.
How many do you remember?
Head lights dimmer switches on the floor.
Ignition switches on the dashboard.
Pant leg clips for bicycles without chain guards.
Soldering irons you heat on a gas burner.
Using hand signals for cars without turn signals.
Older Than Dirt Quiz :
Count all the ones that you remember not the ones you were told about. Ratings at the bottom.
2.Coffee shops with tableside juke boxes
3.Home milk delivery in glass bottles
4. Party lines on the telephone
5.Newsreels before the movie
8. Howdy Doody
9. 45 RPM records
11. Metal ice trays with lever
12. Blue flashbulb
15. Wash tub wringers
If you remembered 0-3 = You're still young
If you remembered 3-6 = You are getting older
If you remembered 7-10 = Don't tell your age,
If you remembered 11-15 =You're older than dirt!
I might be older than dirt but those memories are some of the best parts of my life.
Don't forget to pass this along!!
Especially to all your really OLD friends....
The first 2+ hours were devoted to the PMUA's presentation and questions from the Council members. along with personal remarks from Council President Burney as to his view of the session's scope and goals. The public question and commentary period lasted about 40 minutes.
Suffice to say most of the public speakers focused on "Sewer charges", "Shared Services", and operating costs including compensation matters.
Later today when I have a chance to scan my memory and insufficient handwritten notes- if any one has ever tried to read a doctor's handwriting he will know that means that most of the notes are undecipherable- I shall post my impressions of the meeting. I advise all to read Bernice's report when available and Mark Spivey's report which at the earliest will be in print tomorrow.
Monday, July 27, 2009
Comics are in several forms which is why some appeal to different audiences. Very few are targeted for children. There are the social commentary, the political cynic, the almost true to life, and the soap operas among others. Some strips are produced in the UK, others reflect life in Canada. Some have such dark humor that they are not comprehensible. Others are so obtuse that the point is easily lost. To each his own but let not the vanishing comic page be another landmark of 21st Century America.
By the way, my thousand year old 7-8 am breakfast routine is to scan the Courier's 1st section for news items of interest especially local, gaze at the editorial/letters page read the comics and the daily bridge column, read the Ledger's sports page (Still one of the best in the country) and the comic pages. If time permits I will scan the news section and also look for names in the obituary pages. I reserve the Times for Lunch and afterwards.
I also often when first getting up if the cats permit look at early Internet news items. That is one advantage of being retired; time.
The official city site gives no information about the Council's working session tonight with the PMUA. Plainfield today as of 7am list City hall library at 7:30 pm, whereas Plaintalker has it to b e at *pm in the Court House. If I were a betting man I would pick the Court House; more public room.
Why can't we have reliable information from our city site? WE pay for it.
In New Jersey the bribery scandal involving political leaders in Hudson County as well as in the State Government structure has demonstrated again the dangers of the "pay to play" practices of local, county and state governments. I and others have consistently expressed our opposition to the awarding of contracts to "approved providers' without competitive bidding. Citizens interested should study the agenda acted upon at Council meetings. I am not accusing the members of our City Council of wrong doing but trying to point out the inherent dangers in this practice.
On a national level both the President and Vice President made damaging gaffes; the President overreacted to an incident involving the police and an Afro-American Harvard professor. How effective damage control will be remains to be seen. Let us hope that there will not be too great a negative reaction affecting his popularity among all ethnic groups. Until all the facts are known and made public we can not determine that it was racial bias as the sole provocation for the police officer's inappropriate action.
When bias issues arise it would be helpful if all concerned would not act in haste and not exhibit a thin skin and react aggressively creating escalation of the situation. Unfortunately, ethnic groups tend to be insular, defensive and resentful. It would help all if every one could establish personal relationships with members of other racial, religious or ethnic affiliations. Perhaps then there would be a better understanding of others and less incidents too often tragic.
Vice President Biden seems to be suffering from foot in the mouth disease. The latest was his demeaning remarks about Russia which smack of the same self authoritative image characteristic of the Cheney Vice Presidency. He certainly did nothing to smooth relationships between Russia and us. Pallin would have made a better VP, and that ain't saying much.
On a pleasant note, as of this writing two of the Councilors have posted their views on tax abatements. I urge you to read them. This is transparency in government.
(note; last night I posted a second post on health care financing)
Sunday, July 26, 2009
There are other groups that are lobbying Congress in favor of certain changes in the way they are paid. Among them are the hospitals and other clinics who see the possibility of surviving in a new world, where they can count on an income sufficient to meet all expenses and create a profit. No longer will they have to have multiple levels for reimbursement, often with the individual without insurance having it to pay an excessively high fee. No longer will hospitals have to offer treatment without hope of reimbursement. No longer, if they can craft the bill properly, will they have to accept payment from a program such as Medicaid that does not cover the basic expenses.
This is also applicable to those that provide home health services, emergency rescue services, physical therapy, hospice programs etc..
The pharmacy industry is also taking an active role in lobbying to attempt to set payment for medications in order that they can make a profit while discouraging the mandatory substitution of generic medications. Advancements in care is the result of research, trial, overcoming failures and dead ends. The generic manufacture does not have to absorb these costs, in fact many of the generics are produced with low cost labor over seas in countries like China .
Finally, the insurance industry sees a golden opportunity to profit if they can be the beneficiaries of government-sponsored plans. This industry has made a profit by operating subsidized Medicare programs under contract even in competition with the federally sponsored program. They were given that opportunity because even with a subsidy ,they were more cost efficient then the feds themselves. If the industry can either block a government-sponsored plan for those that have not or can not receive insurance or becomes contractual operators to run the new plan,. it will extremely benefit financially .
Since some of the Democrats are listening to these groups their influence will be vital upon the final bill as it is presented to the President for signature. There are probably many compromises before there is a mutual agreement between both houses Congress.
I realize that this presentation of the problems related to reimbursement is sketchy. Before any health care bill may become law this issue will be one of one of the most difficult to be solved. The possibilities are great that the final draft will not be consistent with President Obama's desires. Moreover I prognosticate that there will still be a segment of the population that will still not be covered.
Saturday, July 25, 2009
I hope that I can address this issue in the next few entries. I am going to begin with an over view of physicians.
Even though I am retired and have been for over 20 years. I still have a deep interest in how physicians work and how they are compensated. Up until the 70s almost 100% of physician's practiced on a fee-for-service basis. With the development of clinics, franchised ER services and highly specialized in hospital practices such as critical/ intensive care etc, hospitals developed contractual arrangements with doctors. Some were straight salary, others allowed physicians to earn on a fee for service basis up to a certain level beyond which all extra money went to the institution. Obviously, the latter reduced incentive to do more then needed.
Still, most physicians in private practice were reimbursed by fee-for-service. Most were very ethical in their relationship to patients. The services they provide were simple what was needed in the patients care. Often there were unnecessary tests and procedures simply to protect the physician in the litigious society.
Unfortunately, there were so some that had "all the moneymakers" and use them for financial advantage. This minority also were able to find ways to game the system.
Physician practices mostly consisted of a single person or at most a two man group.However larger groups began to develop. In most groups In these groups reimbursement was based on productivity a practice that is common in the legal profession. A few groups like the Mayo Clinic, for example did reimburse their physicians with a salary commensurate with the income level. common to that specialty. The attraction to joint such groups was the benefit of security and retirement plans. There was also the freedom from financial worry and the ability to concentrate on the patient's care.
The change from "private fee for service practice" was accelerated by the emergence of walk-in clinics and the Emergency Room staffing which was commonly franchised to a group with salaried doctors. A new breed of doctors, many of foreign training, was emerging. They relished the definitive hours of work and the freedom to go home without a worry in the world. Gradually hospitals increased the number of staff physicians on salary in even the common specialties..
A recent report suggested that nowadays nearly 40% of physicians today are salary. The day of the individual or small private practice is disappearing. Therefore, I am convinced
that any Health Care program that comes out of Washington requiring set reimbursements for all doctors receiving federal funds will not be resisted by the Medical profession.
The problem will depend on the reimbursement. If it is too low the incentive for highly qualified individuals to enter the medical profession will be gone. There will be other fields that offer a greater financial inducement to these individuals and ultimately the public will suffer. This has already taken place in the past few decades where there has been a brain drain into the space and electronics fields as well as facets of the financial industry.
The danger is real. Under Medicare there is already exists a disproportionate difference between the fees allowed a primary care [family] physician and a specialist. The result is a tendency for medical school graduates to train for specific specialties Unless the family doctor or group can have a lifestyle equal to that of the specialist there is a danger in any new federal program to accelerated is this trend.
Any program that Washington it produces should make sure that our brightest youngsters are not discourage from going into medicine . My great fear is that the economies desired will be at the expense of all medical personnel, while monies will be wasted in bureaucratic personnel.
This issue of medical reimbursement is one of the prime stumbling blocks slowing the creation of a workable Health Care plan.
It was a pleasant but not really a surprise to read Adrian Mapp's blog this morning, reiterating his stand on the the Monarch tax abatement ordinance.
I know that there will be comments from anonymous readers who will blast his position, as politically motivated and anti-Jerry Green. I will erroneously be criticized for favoring Counsilor Mapp . What I am praising, is his publicly taking a position which is in agreement with my concept of what is best for Plainfield.
Of course I am only one voter. Would only others on the council consider this ordinance, along with other gifts that in the past few decades Plainfield's government has bestowed on favorite entrepreneurs . This includes so-called PILOT programs.
Anyhow, we have up to the Agenda Setting Session in August for an indication how administration and Council will be acting.
This past week the emphasis has been on Health Care Reformation:
I have reviewed the transcript of President Obama's last Wednesday's news conference . My overall impression is that the conference was well scripted , the questions appeared to be scripted as were the responses. The net result was that nothing new was said.
President Obama learned from Hillary Clinton's Health Reform failure in Congress. She had presented a completed package produced by a secret committee action. Instead President Obama decided to give Congress only general instructions without specifics .
This too seems to have been an error in judgment. There are too many dedicated interests in Congress to come up with a plan that satisfies all. Ultimately, there has to be a meeting of the minds or, once again nothing will be accomplish. Undoubtedly, as is customary in Congress, there will be buried in the 1000 pages of the bill enough pork bellies to waste millions of dollars.
One question, that is holding up action in Congress is how the program is going to be financed. The prospect of making up any new deficit by a surtax on the so-called "Rich" is great. However, I will bet you a nickel to your penny that any change in income tax will in short order be reflected upon the middle-class.
The second problem program, which has received a great deal of negative comment in both Houses of Congress from the insurance industry is the so-called public insurance pool or program. It is supposed to be competitive to the plans offered by commercial carriers. It is obvious that anything subsidized by the federal government will have such an advantage that the other programs can not be competitive and survive. The net result is feared to be,despite Administration denials, a single payer Federal run Health Program.
A third program which even the blue Democrats in the House are objecting, is a mandatory requirement for employers to offer insurance to all full time employees ,or pay a 8% penalty payroll tax,. The worry is will it drive small or marginal companies out of business, with the resulting unemployment.
All the above is subject for more discussion in the near future. Be assured that there will be some form of a plan this year, but not until after the November elections despite the fact that no House or Senate seats up for election.
Friday, July 24, 2009
In response to readers' unanswered questions at Council meetings; on 7/23/09 Plainfield Plaintalker printed a list of the types of tax exempt properties in Plainfield All these properties have a total listed assessed value of $254,134,000. which would at present rates bring in approximately $15,194,671.86 in taxes if my math is ok. $16 million off the top that we other tax payers have to provide. This does not include all the properties that have reduced payments through tax abatement or Pilot Programing. That is not chicken feed.
Let us review the classes of tax exempt properties, Some we can not change as a result of existing laws. Others we can challenge and perhaps get a clarification of the law. Still others probably do not meet a strict interpretation of existing indications. These must be taxed. Yes it will mean litigation, but we need every dollar that is due us.
- Homes of disabled veterans; those that served are country deserve such consideration. Would it not be nice if the city could receive some federal grant to help defray the costs. Where are a legislatures?
- Schools; The municipal schools run by the Plainfield Board of Education are part of the civic operation. The school buildings and all properties needed for operation of the programs must be exempt. However is this extended to private schools and/or colleges? If so, why? Is there federal or state legislation mandating this gift to profit making enterprises mandatory? Is the property being used for municipal needs and are freely available to the public?
- City owned properties and municipal buildings: It goes without saying that if the property is being used for municipal needs it would be ridiculous for the city to tax itself. There could be a case to tax property owned by the city but being used by a profitable enterprise
- Cemeteries: If any of the residents are on the city voting rolls, their plot should be taxed
- Houses of worship and parsonages; this is traditional not to be touched. BUT the exemption can be granted for only that building or portion that is used for the purpose designated. Buildings owned by a religious body and rented to others should be taxed appropriately.
- Public housing; Clarification should be made as to whether the terminology is generic or specific. A profit making entity running a supposedly public housing project should not be exempt.
- State and Federal owned buildings, we have no choice.
- Railroad properties; an archaic curse that should not be valid in this age. The exemption was granted to encourage the building of the railroad for the community's benefit. This same `error c an be compounded in tax abatements for construction of new condos "to bring people onto the community"
- Hospitals; Again only that part of the property that is for the use of Health Care needs. not rental or other income ares.
- Social Agencies: A strict definition as to their role. If solely for profit, should be taxed.
- PMUA properties; This is an autonomous body over which the citizens have no control. It can b e argued that it should pay property taxes.
- Lodges and Fraternal organizations: Only those that offer unrestricted membership to all can merit such a benefit. If any part of the building is used for a profit oriented enterprise it can not be tax exempt. If there are any qualifying ethnic, religious, or financial limitations for membership it should not have the tax benefit. I question if any such organization merits such taxpayer support.
- Union County College; are all institutions of higher education offered tax exemption by State law? If so OK but if the non state private on es are subject to taxation so should this organization.
If administration,the Common Council, or a special empowered civic committee does not review the entire situation this Fiscal Year then the citizen's interests are not being protected. Either Administration with the approval of the council or the Council on its own can create such a "commission" and act on its findings. This is as important as a review of all the city's ordinances and charter provision.
The Challenge is to the Council for they represent all the people in the community. If the Council can not stand its own two feet, then as its members come up for reelection they should be replaced by others who are not looking over their shoulder in fear of offending the boss.
Thursday, July 23, 2009
"Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences"
Purpose: We undertook an in-depth exploration of the unintended consequences of pay-for-performance programs In England and California.
Methods: We interviewed primary care physicians in California (20) and England (20) and compared unintended consequences in each setting. Interview recordings were transcribed verbatim and subjected to thematic analysis.
Results: Unintended consequences reported by physicians varied according to the incentive program. English physicians were much more likely to report that the program changed the nature of the office visit. This change was linked to a larger number of performance measures and heavy reliance on electronic medical records, with computer prompts to facilitate the delivery of performance measures. Californian physicians were more likely to express resentment about pay for performance and appeared less motivated to act on financial incentives, even in the program with the highest rewards. The inability of Californian physicians to exclude individual patients from performance calculations caused frustration, and some physicians reported such undesirable behaviors as forced disenrollment of noncompliant patients. English physicians are assessed using data extracted from their own medical records, whereas in California assessment mostly relies on data collected by multiple third parties that may have different quality targets. Assessing performance based on these data contributes to feelings of resentment, lack of understanding, and lack of ownership reported by Californian physicians.
Conclusions: Our study findings suggest that unintended consequences of incentive programs relate to the way in which these programs are designed and implemented. Although unintended, these consequences are not necessarily unpredictable. When designing incentive schemes, more attention needs to be paid to factors likely to produce unintended consequences.
To improve health care quality, payers are increasingly using financial incentives to reward physicians and medical groups that meet specific performance targets. There has been a rapid recent growth in the number of these pay-for-performance programs, which provide financial incentives for quality improvement, in primary health care. In the United Kingdom an ambitious and costly pay-for-performance program -- Quality and Outcomes Framework (QOF) -- was introduced for all primary care physicians in 2004. In the United States, almost all pay-for-performance programs include incentives for primary care physicians, and the largest physician incentive program, a statewide initiative in California, involves even more physicians than in the UK program. In California many primary care doctors participate in larger physician organizations (such as prepaid multispecialty medical groups and independent practice associations, or IPAs,[5,6] which contract with health plans on their behalf), and incentive payments are made to these larger organizations as opposed to individual physicians or practices. In England, payments are made directly to practices, which are mostly groups of between 1 and 10 primary care physicians. These payments contribute as much as 30% of practice income. In most (but not all) of the California settings, the amount received by physicians is much lower.
Although pay-for-performance programs may deliver on their stated goals,[7,8] they could have unintended effects on other aspects of care or on physician motivation. These effects include encouraging physicians to avoid sicker patients, exacerbating disparities,[10,11] and neglecting types of care for which quality is not measured. It is therefore important when designing incentive programs to consider unintended effects in addition to desired benefits. A combination of theory and empirical data can provide important lessons to inform the design of pay-for-performance programs. Because externally imposed incentive programs can undermine internal motivation,[14,15] careful attention should be paid to the manner in which incentive programs are implemented. Although economic and psychological theories alert us to potential unintended effects of external incentives, there has been no assessment to date of the extent to which such effects are manifest in practice in the California initiative and only limited assessment within English primary care.[17,18] We pay particular attention to unintended consequences in each setting.
My apology for delaying any personal in depth comment is sort of medical. I have had several nights of sleeplessness. Rather than a full night (5hrs for me) I was sleeping in about 1 to 2 hour segments and then being awake for another hour or so. Naturally I would fall asleep in the afternoon for an hour and/or after dinner.
I am not an advocate of sleeping pills because the prolonged or hangover effect is a real problem at my aged. Despite this I took one of the newer in fashion medication with supposedly a short "life" last night. The results were a little short of miraculous; it took me an hour to fall asleep, I awoke in am hour and then after my usual awake interlude fell asleep for almost 3 hours. My alarm clock awoke me and all seemed well for another two hours when I felt the need for a "nap". So; Thursday morning was shot. By the way the "Wake up pill" does not counteract the prolong effect of the sleeping pill.
For those that wonder about dosage, I have always been an advocate of minimal effective medication. Overkill can be that.
If any one is interested in this retires practitioner -not provider- concerns of medical care planned programs, it is coming in dribs and some drabs starting later today.
Wednesday, July 22, 2009
The hot subject for Plainfield's bloggers this week has been the proposed tax abatement for the condos in the Monarch project. Everyone has written at least one post on the subject. The number of comments received, especially by Plainfield Today and Plainfield Plaintalker should indicate to both Administration and the members of the Council of public sentiment.
We voters would certainly appreciate those elected officials who have a blog with access from CLIPS to give some indication of their opinion regarding offering a tax abatement to new unsold residential construction.
Additionally, the recently proposed granting of a replacement Pilot Program for the Cedar Brook, Senior Citizens Apartment to the prospective new owners seems to me to be inappropriate and another affront to the taxpayers of the city.
The principle is to say the same. There is no reason for taxpayers to subsidize someone else's for-profit investment. It makes no difference if it is residential or commercial construction or stocks and bonds. All have a risk which is inherent in any investment. No one has offered to have the public mitigate the losses suffered by General Motors or Citi Group stockholders some which could be their retirement savings. There is no difference.
(for the record I never owned any GM stock and had no Citi Group stock when it went into free fall.)
The public is entitled to know the terms of the agreement, the percentage tax being paid or fix sum so in lieu of tax.
A concerned citizen at Monday's Council meeting asked, not for the first time, what properties including governmental buildings, school district sites, "not for profit" agencies which includes Solaris, religious organizations, and others entitled by law to tax exemption are on Plainfield's books. Of course he could go to the Tax Accessor's office and check the books himself but he and we should be entitled to a public response.
That was not the first time he had asked that question and this writer has not only requested the same information but suggested that the not for profits holdings be examined to see if they are being used for income generating purposes, not charitable.
There are several buildings which are owned by the religious organizations that are not used as a parish home. If they are being used for income producing purposes for the organization or not intimately involved in its mission, I would question if they are entitled to exempt status. I believe that it is in the grey area that a separate residence for a spiritual leader that is not contiguous to the house of worship should qualify.
There are other facilities that have been built in Plainfield by qualifying agencies that have subsequently changed ownership once or more. If they have become "for profit" have they maintained their tax exempt status? Has anyone checked?
Regarding the proposed ordinance passed on first reading for a tax abatement for the condos at the Monarch I feel that it is inappropriate unless the same perk is granted to every new purchaser of a home in the city.
Plainfield already has given the developer a sweetheart deal by selling the land for $1.00. WE taxpayers do not need to further subsidize his investment. Additionally, since we have been in effect threatened that if the condos are not sold-I don't believe that they will be- he will turn the units ito rental apartments, why are not taxes being levied on the entire structure. What is delaying the CO? How can he sell condos if the building does not have a certificate of occupancy? Since the Senior Citizens Center can not be used without the CO is the city responsible for its reported 14% of the buildings operating costs? Will we ever get any answers to any of these questions.
One more thought, when a tax abatement is granted are there any specified time or use restrictions in the agreement ?
Finally, a new Pilot Program for the Cedarbrook Senior Citizen's Apartment Building!. My own personal opinion is that it is not appropriate.
The original 47 year Pilot program was granted in 1976 as part of the requirements of the Federal backed agencies mortgage requirements. The City was in effect becoming a partner in the development of a needed building. The original investors have made a profit on their investment in part due to our required subsidisation. With the sale of the property the original mortgage will be paid off and the city's obligation finished.
New ownership is not buying a building with developmental risks, the income is assured and the purchase purpose is for profit. The building is no longer a community responsibility. We do not have to facilitate the sale or purchase of the property. I am sure that somewheres in the deed to the apartment is a clause that it was constructed for Seniors and that there are specific rental regulations. Has our legal arm researched this and given an opinion before any action is sought on this program? I hope that will be addressed when the new Pilot Program next is up for action.
Tuesday, July 21, 2009
The panel consisted initially of the Mayor,Assemblyman Green, Assemblywoman Stender, Council Chairman Burney, Corporation Counsel Williamson, and from the State; an Assistant Commissioner whoes name I did not get.
It was obvious from the questions and the discussion that CAG will have no real function or purpose except to make suggestions to the Commissioner's office about the Plainfield situation. Since the group function appears to be window dressing and will have no authoritative status it is really an exercise in futility I left early.
Of interest in answer to a question it was stated that CAG was not an official government organization and thus was not subject to open public meeting laws.
I hope for a will post comments on the "road status" portion of the meeting.
The Courier had a reporter at the Public Forum, his report is 1st page top. (9.00am)
There has not been to my knowledge a presentation of the agreement between the City and the State about this highway.
Somewheres in the not too distant past I think it was mentioned that the State maintained West Front Street as well as Plainfield Ave north of 5th St. Is that true?
We have been told that the agreement is somewheres but we have never been shown it. Last Monday night Corporation Counsel Williamson in the absence of Administrator Dashield mention a possible date of 1928 or at least several decades ago when the agreement took effect.
Since in my antiquity I seem to recall that it was after WWII That the concept to make 4th and 5th streets one way streets was enacted. I believe that a deal was made with the State at the time for that stretch of Highway to become a city responsibility because the State would not otherwise permit the diversion of traffic.
Route 28 is a State Highway. In Plainfield it has always run Eastbound from the Dunellen City line along West Front St. to Plainfield Ave Then it goes south to West Fifth Street and turns east to the Fanwood City line. Along the stretch the street becomes East 5th St. and then South Ave.
To go westbound the route is the reverse along South Ave, East 5th St to Roosevelt Ave.The next section is a deviation from the original highway. At Roosevelt it goes North one block to the 4th St. extension turns left to East and then West 4th St to Plainfield Ave , turning North along the original route.
Incidentally; Plainfield Ave south of 5th St. is a County Road.
We have had too much beating about the bush. No more I believes. Let us know the facts. Let us also not continue to cover over the failures and errors which were the responsibility of the city that led to the substandard construction of that portion of South Ave.
Let us not forget that the city made a million dollar error in the reconstruction of North Ave during the same period, an error we tax payers ate.
Hurt feelings: Last night at the public participation portion of the Council meeting I asked two questions and received no reply to either. #1 Who is responsible for Plainfield Ave and West Front Street?; #2 This was complex and that may be why it was ignored. If the building has not received its Certificate of occupancy can the Condos be sold for occupancy? If they are granted a CO is the rest of the building still 'under construction" and exempt from taxes? If A completed building but empty free from taxation why would not a landlord of a vacant commercial property be exempt?
I think those questions deserve an answer, don't you?
At last nights Council meeting a resolution was introduced on first reading granting P&L Management,LLC who seems to be a successor to developer "Dornoch Plainfield LLC," a 5 year tax abatement. Although the abatement is supposedly to apply only to the condos when sold,. The Tax abatement is supposedly to result in a 40% tax on the condo.
The impression received at the meeting was that the developer Dornoch was in effect given the property in exchange of including a Senior Center. Since the building has not yet received a Certificate of Occupancy , it is not considered a taxable asset.
When asked when it would be taxable as a building if the CO is delayed the opinion was that would be up to the tax assessor. That seems to be place an enormous amount of power in the hands of a manciple employee.
Also no one has opined as to the status Of The Senior Citizens Center. Can it be occupied if the Building itself has not received its CO? Can each unit reeive an individual CO if the Building itself does not have one? Since only 8(12%) of 63 condos have been sold when will the pruchasers be able to take possession. Do their sale contracts have an out clause? If no more condos rfae sold will the propety become rentals? If so will the "owners" have on out?
One more question, are the principles of "P&F Management" different from "Dornoch Plainfield, LLC.Is the change a real transfer or bookkeeping shenanigans?
The other action was an Resolution authorizing payments in lieu of taxes for the Cederbrook Apartments- a Senior Citizens supoposedly rent restricted, and directing the mayor and city clerk to execute a pilot agreement!
In 1976 when the building was opened a 47 years Pilot agreement was permitted to expire in 2023, the new one would expire in 2039 or an additional 16 years of not sharing the tax burden.
Are we permitting fly by night entrpreneurs to make money at the house owners expense.
Administration last week cancelled a special meeting which would have given anothe devloper $15 million for his project. Is there a pattern?
I find it hard to buy that all of this is for the good of Plainfield.
The other interesting non action was the Administration's request to withdraw Councilmatic Resolution 302-09 regarding the employment of James Mangin as CFO. No reason was given but h e had not met with the Council. Or has there been some other development? We certainly miss the presence of a financial officer. Per haps Mr. Mapp would be interested.
Missing from the meeting besides CN reporter Mark Spivey, was City Administrator Dashields leaving Corporation Counsel as the only Administrative Repreaentives.
I will post something later.
Meanwhile; Michelle Obama has become one of the Obama administration’s most visible surrogates on health care, announcing the release of $851 million in federal financing for health clinics, calling for tougher nutritional standards in the government’s school lunch program and urging Democrats to rally around the president’s efforts to revamp health care.
She has chosen to deliver her recent remarks in more traditional settings for a first lady — at a clinic, a playground and in the White House garden. Her aides say she will promote policy, not make it, and will continue to concentrate on children and families. They say they do not expect her to be accused of overstepping her bounds as Hillary Rodham Clinton was when she tried to remake health care as the first lady.
On Friday, the budget office’s director, Douglas W. Elmendorf, said the bill would add $239 billion to the national deficit over 10 years, partly because of an increase in Medicare spending to avert sharp cuts in payments to doctors. (This is much less than the $591 reported by the joint Senate committees-see yesterday. I will discuss doctor’s payments anon)
Mr. Orszag said taking out those doctor payments with a new policy would make the bill “deficit-neutral” over 10 years. On Saturday, President Obama in a radio address said he would reject any health legislation that would increase the deficit.
The House bill provides subsidies to offset premium costs and out of pocket spending for household below 400% of the poverty level, with those of the lower end receiving more.
SUBSIDIES TO EMPLOYERS: The Senate bill provides tax credits to employers with fewer than 50 full-time workers who pay at least 60% of their employee’s health insurance premium. Credit amounts are based on a few factors, including the size of the employer and the type of coverage provided, and is available for up to three consecutive years.
The House bill provides tax credits to employers with fewer than 25 full-time workers. The credit can be up to 50% of the premium costs, dependent upon the size of the employer and the average wages, and is not offered for employees earning more than $80,000 per year.
EXPANSION OF MEDICAID: The Senate bill; extends Medicaid to all individuals with income up to 150% of the poverty level [$16,245 a person]. Currently Medicare covers millions of low income older Americans, people with disabilities, pregnant women, children and some parents, low income childless adults are generally not eligible.
The House bill; expand Medicaid to all individuals with incomes up to 133% of the poverty level about $14,400.
FINANCING: The Senate; estimated the 10 year cost to be about $1 trillion. The bill does not include financing proposals, because the Health Committee does not have the authority over taxes or Medicare or Medicaid. By Constitution all revenue raising legislation originates in the House.
The House bill estimates the ten-year cost about $1 trillion. To raise $544 million over 10 years by imposing an income surtax of families with incomes over $350,000 and individuals with incomes over 287. Raise much of the remainder by lowering spending on Medicare and other health care savings.
My future postings will deal with the objections from interested and pressure groups to various elements in the bills as they are as of this date. There will be no timetable for their posting. I hope this series has been of some value.
Monday, July 20, 2009
The Children's Health Insurance Program is jointly financed by the Federal and State governments and is administered by the States. Within broad Federal guidelines, each State determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures. CHIP provides a capped amount of funds to States on a matching basis. Federal payments under title XXI to States are based on State expenditures under approved plans effective on or after October 1, 1997.
The Bush administration would have permitted the program to expire. but the Democrat Congress temporarily extended it until President Obama signed the Re-Authorization Act earlier this year.
Briefly the program is designed to provide insurance coverage for children whose family has no insurance and are not eligible for Medicaid. Each state sets the upper limits for eligibility and benefits. New Jersey will enroll children within a family limit income of $77,175.00. This is only exceeded by New York, all others are lower. However N.J. is 10th in the number of children enrolled. This could be because the program is not as well known as it should be.
Some states are experiencing sever financial problems and are being forced to cut back on the program. California which has the most serious financial problem in the country had almost 1.7 million children enrolled in 2007. This state has had to put a moratorium on enrollment.
The attraction to the states for this program is that the Federal government will pay the states up to 70% of the costs whereas in Medicaid it is only 57%. However, the states need to find funding for their portion of the program
A recent joint report from the Congressional budget office and the Joint Committee on Taxation dated 7/2/09 noted that the proposed new bills would only cover an additional 20 million of the 65 million that are either uninsured or lack adequate basic insurance.
This would be at the expense of a national deficit increase of $591 billion from 2010 to 2019. That is after measures to reduce the costs by over $100 million are in place. This is giving some of the Washington hierarchy reason to pause for a second look.
That is one of the factors that may delay any bill from being completed before the August recess.
To return to the present two versions; in the matter of the Insurance Market Place; the Senate would require every state to have an insurance exchange where small employers and individuals uninsured through work or a public program could buy insurance. The Senate bill would also allow states to form regional insurance exchanges.
The House bill is more federally centered by creating a national insurance exchange for the same purpose. It could be open to large employers over a period of time. It would also allow states to opt out and operate their own exchange under federal rules.
It is obvious that the Senate is still concerned with state’s rights and the House is leaning to a national health plan.
In the area of a Public Plan; the Senate would offer a new public plan to compete with the private insurers in the insurance exchange. This public plan would only provide the essential health benefits an is described in their bill.
The House bill calls for a new public plan to compete with the private insurers in the exchange. This plan would initially pay providers at rates that are pegged to Medicare rates which are lower than those from private insurers. They would offer different levels of coverage through this plan; “basic, enhanced and premium”.
It is obvious that from all elements of the Health Care industry that serve patients there has been considerable opposition to this plan. Physicians, Home care, Rehab services and especially the Hospitals would suffer economically. We have personally felt the results of reduced cash flow to hospitals. Even if they could stay open, it would be at the expense of reduced care and services.
Sunday, July 19, 2009
Cook School, 1st Tuesday November 2008. You all got out then, do it again this November
Rural scene Bavaria.
An old castle partly in ruins with vineyards below; Moselle River Germany.
My original intent was to summarize last year's posting on Health Care in various countries and discuss various options that have been suggested for America. However , the process has moved way beyond a theoretical stage and soonedr or later a definitive bill will b e sent to the Prersident for his signature. Therefore, I now going to post the differences between the p[lans that are for vote in each house and I will also keep up with new developoments including objections for various sectors that will be affected by any plan put into effect.
As of 7/18/09 there are three different health care bills working their way through Congress: The Senate Committee on Health, Education, Labor, and Pensions (HELP) approved its 651 page bill this past week. The Senate Finance Committee is working on a bipartisan bill. The House Democrats in three committees are working on a single plan. Both “Ways and Means” and ‘Education and Labor” committees have approved the over 1000 page House version. The House Energy and Commerce committee must still approve the bill before it can reach the floor for a vote.
Within the past few days there has been an undercurrent in Congress questioning the potential negative impact on employment as well as costs if the bills are past as presently constituted.
The present Senate version requires employers with 25 or more workers to contribute at least 60% of the premium cost for their full time workers. There is a penalty of $750 for each full time worker and $375 for each part time worker not cove red.
The proposed House version requires employers with an annual payroll larger than $$250,000 to contribute 72.5% of the premium for full time workers and 65% for the families. The penalty for the employer with an annual payroll of $400,000.00 is a payroll tax of up to 8%.
In the realm of Individual mandates both require most individuals to have a minimum level of insurance. The Senate b ill exempts American Indians and those who can’t afford insurance e or live in states without insurance exchanges. There is a penalty for non compliance up to $750 a person each year.
The present House bill Exempts those who cannot afford insurance, dependents, and those with religious objections. The penalty is 2.5% of adjusted gross income over a certain level (example; $18,000.00 for a childless couple.)These are two of at least eight distinct items covered in the bills. I intend to do a few more each posting.