What To Do About Broken

California Healthcare News first published this article “What To Do About Broken” on October 9, 2018.

iStock_000010152161Small-150x150“All of our reasoning ends in surrender to feeling.” – Blaise Pascal

An adjective, the word “broken” encompasses a multitude of meanings, most of which identify a magnitude of concern, while very few provide comfort.  Recognizing that which is broken often remains elusive, creating a daunting challenge when facing this dangerous combination. Even when a solution presents itself, the ability to surrender remains a most formidable foe. Navigating through this labyrinth, individually and as a society, is also sometimes referred to as “life.”

It is no coincidence that life usually starts and ends in a hospital. With almost 5,500 hospitals in the United States today, only by the middle of the twentieth century did these institutions become symbols of hope, slowly creating an inextricable dependence upon which the sick and infirm rely. Nearly a score into the twenty-first century, the hospital represents the primary solution when there is a threat to health. What would happen if the basket holding all of society’s proverbial eggs breaks (assuming this container is not already broken)? … Read more →

Health Care and the Laws of Nature

The Daily Journal first published this article, Health Care and the Laws of Nature, on August 8, 2018.

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“If there is no God, everything is permitted.” – Fyodor Mikhailovich Dostoevsky

The Laws of Nature

When science prevails over the laws of nature, controversy is near. Stories from antiquity warned against such hubris, like poor Icarus who plunged to his death during a maiden voyage with wings made from feathers and wax. Zeus intervened twice on the side of nature, first when he sentenced Prometheus to eternal torment for delivering the gift of fire to humanity, and again when he struck down love-stricken Orpheus with a bolt of lightning before Orpheus escaped from Hades.

Whether divine warnings or stories told to invoke fear, science celebrates similar transgressions as evidence that God may be man-made. Whether we live in a universe forged over billions of years or in just under seven days, what are the malleability of nature’s laws? In 1903 Orville Wright elevated above the ground for 12 seconds in a gasoline-powered, propeller-driven biplane, but his legacy exists today in the context of war, travel and commerce. The impact from fire on an evolutionary timeline often omits reference that 10,000 years ago a spark may have transformed tuberculosis from an environmental microbe to a deadly disease that has killed more than 1 billion people. When science finally resurrects the dinosaurs, we can ask them about nature’s resilience. … Read more →

Health Care’s Latest Pissing Contest

California Healthcare News first published this article, Health Care’s Latest Pissing Contest, on August 7, 2018.

iStock_000016579707Small“I dwell in possibility.”  — Emily Dickinson

Episode 5: Insurance Strikes Back

Last March dozens of insurance companies filed suit in Florida against a hospital, a laboratory and a medical claims collection agency for more than $100 million.  Earlier in March Anthem initiated an action to recover $13.5 million against a small hospital in Sonoma County, California allegedly creating an illegal pass-through arrangement for laboratory claims. In April UnitedHealthcare sued the owners of two laboratory companies in Texas for supposedly orchestrating a similar pass-through scheme that resulted in reimbursements of $44 million.

Across the nation, insurance companies and health care providers battle over the by-product of metabolism in humans. Historically used to make gunpowder, clean, tan leather and dye textiles, urine not only has a role in the earth’s nitrogen cycle, but the $8.5 billion spent in 2014 just testing the excretion exceeded the Environmental Protection Agency’s annual budget. Lately, clinical laboratories and health care providers have joined forces to test almost anything the human body can produce and/or eliminate, but at the center of health care’s recent controversy is a staggering 44 billion annual gallons of potential contraband, most of which usually goes to waste.  A new gold rush has hit the United States health care system like a tsunami, although this liquid gold retains its color and has nothing to do with dinosaurs. … Read more →

Health Care in F Minor

This article, Health Care in F Minor, first appeared in California Healthcare News on July, 10, 2018.

baby-grand-piano_135“When we are no longer able to change a situation – we are challenged to change ourselves.” – Viktor Emil Frankl

The Opening

With four flat notes, the scale of F minor celebrates sadness while commanding infinite visceral responses to all seven tones.  The English language, on the other hand, offers only a handful of anagrams for these same seven letters, although its best effort can only make use of five. Music creates emotional snowflakes, so we forego the need to reconcile different sounds made by the piano and its 2,500 parts.  The Scrabble enthusiast, however, best performs with only two combinations, each scoring a paltry 11 points.

Comparing expression through word or song does not reveal one better than the other, although it may present certain challenges when the piano holds a conversation with the clerk at the neighborhood market.  My five-year old son offers at least one solution, even if he is unable to spell the two high-rolling Scrabble words “decaf” and “faced.” Upon hearing an F minor scale for the first time, he turned to me and said: “Papa, that is so sad.”

Second Movement: The Problem

If health care was a piano, acute care hospitals and their 14,400 different codes under the International Statistical Classification of Diseases and Related Health Problems, tenth edition (“ICD-10”) practice C major scales on a regular basis. … Read more →

HOSPITALS GIVE UNTIL IT HURTS

This article, Hospitals Give Until It Hurts, first appeared in California Healthcare News on April 10, 2018.

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“The formula ‘two and two make five’ is not without its attractions.” — Fyodor Dostoevsky

A 2005 report surveyed 1,771 personal bankruptcy filings, half of which cited medical expense as the cause.  For those suffering from an illness that preceded bankruptcy, individual out-of-pocket medical expenses averaged close to $12,000, and those qualifying as “medical debtors” were 42% more likely to experience lapses in health insurance coverage. This serves as the backdrop to what is commonly known in health care as “charity care” or “hospital fair pricing policies.”  Consumer advocates blamed hospitals as the cause of this financial epidemic, fueled by the absence of any law or regulation regarding the prices that uninsured and underinsured consumers/patients paid for health care, not to mention the collection practices employed by those entities insisting upon payment for services rendered.

Health Care By Robin Hood

Fundamentally there should be nothing wrong with accepting from those patients without financial means less money than wealthier patients for similar services. Certain laws are inconsistent with this medical benevolence, such as one federal statute that prohibits health care providers from submitting a bill for payment substantially in excess of that entity’s usual charges for these items or services.  The penalty for violating this law, 42 U.S.C. § 1320a-7(b)(6), is possible exclusion from Federal health care programs such as Medicare and Medicaid. The California Court of Appeal, Fifth District, offered another reason why hospitals should refrain from such generosity, specifically after the seminal 2014 decision in Children’s Hospital of Central California v. Blue Cross of California (226 Cal. App. 4th 1260). After decades of fighting between non-contracting providers and insurance companies, the best advice the judicial system had to offer in defining “reasonable value” was past agreements to pay and accept a particular price.

Nevertheless, legislators believed the ways in which hospitals should bill the uninsured could not be left to chance, and in 2005 California passed Assembly Bill 774 which required hospitals to develop a policy specifying how it will determine financial liability for services rendered to financially qualified patients and those patients without any insurance.  In part, AB 774 (1) placed limitations on billing and collection practices for hospitals as well as their billing agents, (2) required hospitals to submit to the Office of Statewide Health Planning and Development (OSHPD) their plan to comply with the new obligations, and (3) charged the Office of the Attorney General with enforcing transgressions. … Read more →

The Upside to Broken

This article The Upside to Broken first appeared in California Healthcare News on January 9, 2018.

iStock_000020087330LargeThe world breaks everyone, and afterward, some are strong at the broken places.”  — Ernest Hemingway

When in Colorado

Just outside Aspen, Colorado, an elevated system dependent upon variations in tension on a rope that bends and flexes over sheaves and around bullwheels transports trusting passengers 1,500 feet up the side of a mountain. Each of these sky travelers has a front-row seat to the possible danger and calamity that can at any time strike immediately below, but only an observant few notice Aspen Valley Hospital during their journey upward. Fewer still realize this health care facility is an outpatient department of neighboring Aspen Valley Hospital. Located in rural Snowmass Village, Colorado, this tiny adjunct treats most injuries and illnesses that manifest on the mountain, leaving everything else typically handled by an acute care hospital to the main facility eight miles away in Aspen proper. Heedless of weather conditions and current events, Aspen Valley Hospital soldiers on in its commitment to honor the Hippocratic Oath.

Death by Taxes

As it does so, the American health care system finds itself on the defense against yet another partisan attack, this time in the form a massive tax code overhaul. In the process of implementing record-breaking tax cuts throughout the national economy, the Tax Cuts and Jobs Act effectively eliminates the Individual Mandate provisioned under the Affordable Care Act (the “ACA”). Five years ago, in the seminal decision National Federation of Independent Businesses v. Sebelius, Chief Justice John Roberts and the United States Supreme Court upheld the constitutionality of the ACA’s Individual Mandate. This was not accomplished through the Commerce or Necessary and Proper Clauses of the U.S. Constitution, but rather through Congress’s authority to lay and collect taxes (U.S. CONST., art I, § 8, cl. 1).  While not quite the same beast as the repeatedly failed “repeal and replace” challenges the nation’s health care system withstood earlier in 2017, this most recent foray is at least legally proper. The question that still remains, however, is exactly how will health care in the United States change in 2018, when fiscal repercussions end against those Americans who fail to maintain minimum essential health insurance coverage?

In a universe where the actuarial resides, eliminating the Individual Mandate is a death sentence that will ultimately collapse the ACA’s fiscal sustainability. In other, more practical realms, a health care system within which younger, healthier patients have no motivation to obtain insurance totally undercuts the already diminishing number of payers to wreak havoc in the form of health insurance premium hikes, necessary or not. The nation’s already depleted health care arsenal against such a response from payers is practically useless, as it is left with only unthinkable options such as the return of preexisting conditions and elimination of premium parity restrictions, the justification for which is either “some lose” or “everyone loses.” This is hardly an enviable position from which to defend itself. … Read more →