Tuesday, December 1, 2015


As we enter the 12th month of 2015 the day is as dreary as the future seems to have become.

I may not be an expert on national politics or our nation’s role in international affairs but after 55 years of active involvement in health care I can consider myself as sort of a Maven. Never the less my lifetime of experiences does give me as much authority as most of the columnist to publicly express my opinions.

With that in mind sometimes my daily (?) blog is a true potpourri designed for information or for discussion.

This is the time of the year for Medicare recipients to renew their supplemental insurance policies as well as those insured in the “Exchanges”. The dead line for 2016 is Dec. 7, 2015

As a retired physician I have considered the ACA as a health care disaster. Universal health care costs money. If the government is going to subsidize it has to be met by taxes. If the consumer-you and me-will be paying for it the cost of premiums will be increased. If the provider has to bear the burden the quality of services will be limited by the need to make a profit.

Since no politician wants to raise taxes the insured’s premium is going up or carriers like United Health Care are exiting from the "Exchange" field. In some cases such as Health Republic a nonprofit cooperative insurer in New York or CoOpertunity Health a nonprofit cooperative insurer in Iowa and Nebraska have defaulted on millions of dollars of claims and have been shut down by the state authorities.

The providers in Iowa and Nebraska were fortunate in that in their states their claims were covered by the states’ insurance guarantee. The doctors and hospitals in New York are not as lucky because that state’s insurance guaranty association does not cover claims of a health-insurer company only if it is also a life insurance company.

There is an unanswered question that may end up in court. What is the obligations of the policy holders in a cooperative insurer? Will they potentially have to satisfy the unpaid claims?

There is no question that the pending mergers of the big commercial insurance carriers will create pseudo-monopolies and with it a rise in premiums.

Contributing to the ongoing deterioration of American health care is the tendency of hospitals to merge into networks and their absorbing of providers as employees to deliver care

In New Jersey that has led to Horizon contracting with certain hospital groups as Tier 1 who will accept a lower reimbursement. That is reflected in the patients co pay. Yes the other hospitals will be reimbursed but the co-pays will be higher, perhaps enough to force the patient to go to the Tier 1 hospital.

Accepting the concept that one never gets more than what has been paid for; if certain hospitals receive less money than others there has to be an accommodation in services delivered.

This can be accomplished by a decrease in the quantity or quality of care being provided, adjusting the number or qualifications of personnel employed, stricter enforcement of hospital stay according to a cook book formula not the patient’s physical and mental wellbeing.

There is also delegation of physician’s services to `individuals with a lower level of training. Plus the demands of a heavier workload in a time period; seeing more patients per hour.

Health care today has become a big box operation in which profit not the patient’s welfare is the goal.

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