A ‘Fox’ in the IRS’s Henhouse

When President Nixon waved goodbye to his staff on the steps of the Marine One helicopter that would carry him off the White House lawn for the final time, it was the culmination of the Watergate scandal. A break-in at the Democratic National Committee headquarters, orchestrated by individuals in the Nixon administration (G. Gordon Liddy, Jeb Magruder, John Mitchell, E. Howard Hunt, John Dean and James McCord), and the attempted cover-up by the President and his staff that resulted in the President’s resignation from office, rather than face almost certain impeachment. One piece of evidence that was central to the case against the President was an 181/2minute gap in a tape recording from the Oval Office, allegedly between Nixon and his Chief of Staff H. R. Haldeman. According to the President’s secretary, Rose Mary Woods, she made ‘a terrible mistake’ during her transcription, resulting in the gap in the recording. It wasn’t what was in the recording, but what was not, that raised the country’s suspicion that Nixon was complicit in the operation and the cover-up— a level of distrust and doubt that ultimately forced him out of office.

In 2013, the Internal Revenue Service (IRS) made public that it had targeted ‘selected’ political action groups applying for tax-exempt status between 2010 and 2012 for ‘intensive’ scrutiny, based on their names or political themes. Appearing before the Congressional House Ways and Means Committee, acting IRS commissioner, Danny Werfel, testified that IRS officials inappropriately flagged progressive groups seeking tax-exempt status, in addition to tea party and conservative groups.

In a letter to Representative Sandy Levin, the top Democrat on the Ways and Means Committee, from J. Russell George, the Treasury inspector general for tax administration (TIGTA), George revealed that there were 298 political groups brought up for a closer review between May 2010 and May 2012. Of the six that had the words progress or progressive in their name, one-third were singled out for further scrutiny. He continued by pointing out “in comparison, our audit found that 100% of the tax-exempt applications with Tea Party, Patriots, or 9/12 in their names were processed during that timeframe.”1

The impetus for this investigation appeared to have had its roots when the U.S. Supreme Court handed down a ruling in Citizens United v. Federal Election Commission on January 21, 2010. It overturned most previous restrictions on political campaign spending and permitted nearly unlimited and usually anonymous spending by corporations and other groups that often influenced election outcomes.

The New York Times reported: Almost all of the biggest players among third-party groups in terms of buying television time in House and Senate races in August, have been 501 (c) organizations, and their purchases have heavily favored Republicans…2

Shortly after the New York Times article was published, Senator Max Baucus, Democratic chair of the Senate Finance Committee, asked the IRS to look at nonprofit organizations’ compliance with IRS rules.

During the review period, the IRS did not deny any applications of organizations with Tea Party, patriots or 9/12 in their names, but only 4 were approved.  During about that same period, several dozen organizations whose name included progressive, progress, liberal or equality were approved. For many of the conservative or Tea party leaning organizations, their applications were placed in an ‘Emerging Issues’ category by the IRS, which was flagged for additional questioning and months, even years, of further delay on their final disposition.

Steven Miller, the IRS’s acting commissioner, and Lois Lerner, director of the agency’s exempt-organization division have claimed that the IRS officials began the scrutiny of these politically leaning groups after they found a surge in the number of applications for status as 501(c) ‘social welfare’ organizations. Both officials claimed there was an increase from 1,500 applications in 2010 to almost 3,500 in 2012. Several points appear to contradict their assertion: First, Lerner originally attributed the increase in reviews to low-level workers in the Cincinnati IRS office, but those workers told Congressional investigators that they “were acting on orders from Washington.” Second, the increased reviews, starting March 2010, began before any significant increase in filings by these ‘social welfare’ groups could have been detected. Finally, the actual number of 501(c) applications was less in 2010 than in 2009.3

Chairman Darrell Issa and his fellow Congressmen on the Oversight and Government Reform Committee are trying to determine exactly who gave the orders for IRS agents to target these groups. Lois Lerner, who retired from the IRS in September 2013, has ended up at the center of focus in the IRS scrutiny scandal. “(Lerner) was in a powerful position and could have been acting alone,” quotes Issa. He further explains that Congressional documents suggest that she was under political pressure to ‘orchestrate’ the targeting.

Lerner admitted, at a legal conference the previous year, that the agency improperly targeted groups to added scrutiny only because they had the words tea party or patriots in their names. In May 2013, Lerner appeared before the House committee and invoked the Fifth Amendment when questioned, but not before giving an opening statement that she “broke no laws.”  In a follow up to the request by the committee for further testimony, Lerner’s attorney, William Taylor said his client would testify on Capitol Hill only if compelled by a federal court, or if given immunity for her testimony. Subsequently, Lerner was issued a Congressional subpoena to reappear before the committee, but, when she failed to comply, was found to be in contempt. Attorney General Eric Holder and the U.S. attorney for Washington will now be asked to refer Lerner to the Justice Department for disposition of her subpoena.

In the spring of 2014, IRS Commissioner, John Koskinen, promised to turn over Lerner’s emails to the committee for their investigation into her involvement. Then came the bombshell early this summer when Lerner’s attorney, revealed to the House Ways and Means Committee, that a ‘trove’ of Lerner’s emails, including those she sent to other federal agencies, were lost when her computer crashed in 2011. Lerner’s losses were not the only ones, when it was reported that six other employees in that department encountered similar problems. Although the extent of their losses was not reported, the revelation, which raises even more questions, was that one of those employees was Nicole Flax, who was chief of staff for the acting IRS commissioner at the time, and a frequent visitor to the White House and the Eisenhower Executive Office Building, The lost emails, reportedly covering from 2009 through mid-2011, closely coincided with the May 2010 to May 2012 increased IRS review period.

Tempers, on both sides, have risen to a fever pitch. The Republicans on the Congressional Oversight and Government Reform Committee feel the IRS Commissioner, John Koskinen, has not been forthcoming with Congress, because it took more than a year after the investigation had begun for the IRS to reveal the loss of Lerner’s emails. They also question Koskinen’s objectivity because it has been reported he donated nearly $100,000 to Democratic candidates and the party’s organizations over the last forty years.4

Representative Issa has made his reservations clear that someone (Lerner), with 30 years of working experience in the federal government, would not know to follow the guidelines that require emails to be printed. “We will probably never know what really happened since the IRS destroyed the hard drive,” he said.

According to Lerner in 2011, communication from the field director for the IRS headquarters’ Customer Support center, as well as, a forensic lab, confirmed that the lost data could not be recovered. “It does seem quite suspicious that these employees engaged in the controversial activities here had computer crashes, as opposed to there being a systemic crash,” said Daniel J. Metcalf, the founding director of the Justice Department’s Office of Information and Privacy. “And it is awfully suspicious that the agency has been unable to reconstruct, through a back-up system, what it says it lost.”

It is clear that Lois Lerner broke the law by not making hard copies of her emails as backup. The IRS leadership also broke the law when it failed to report Ms. Lerner’s broken hard drive and lost emails. “Any agency is required to notify us when they realize they have a problem that could be destruction or disposal,” reported David S. Ferriero, head of the National Archives and Records Administration, when he testified before the House Oversight and Government Reform Committee.

By their own admission, the IRS employees in the Cincinnati office overstepped their authority. The consequences of their illicit activities may have changed many outcomes of the 2012 elections, all the way up the line from the city, county and state house races, to the office of the Presidency itself. Impeding the voices in the electoral process should be held to the same standards as stuffing ballot boxes, or not counting votes, which are Federal crimes.5

It’s hard to imagine that the ‘intensive’ scrutiny and the ‘lost’ emails were not part of an orchestrated effort! There is a fox somewhere in the IRS henhouse, maybe several more, which gave the go-ahead for the agents in the Cincinnati office to proceed with the selective review process. And, like Watergate, possibly a skulk in the White House that was in on it too!

 

 

References:

 

1. http://www.cbsnews.com/news/irs-progressive-groups-flagged-but-tea-party-bigger-target/

2. Luo, Michael; Strom, Stephanie, Donor names remain secret as rules shift, The New York Times, September 20, 2010.

3. http://philanthropy.com/article/IRS-Rationale-for-Tea-Party/1392771

4. http://www.newsmax.com/Newsfront/attorney-lois-lerner-missing-emails/2014/06/27/id/579767/

5. http://soundpolitics.com/archives/008248.html

Houston: We Have Had a Problem!

The Russians are intruding into the Ukraine. The radical Sunni insurgents from Syria and Iraq are forming a caliphate. The injustices of Veterans Administration are just now being addressed. The political subterfuge by the Internal Revenue Service may never be fully known because of the apparent loss of Lois Lerner’s emails. All these problems potentially affect the path this country follows in the future. However, collectively, these untoward events don’t compare to the potential problems that are streaming across our southern border. Unchecked, this deluge of illegals is turning into an invasion, rather than a humanitarian crisis as described by our administration in Washington, DC.1

The players in this battle are the Mexican drug cartels, the gangs and even potential terrorists on one side. Trying to fend off this onslaught, on the U.S. side, are the outnumbered U.S. border patrol agents and the citizens of the border communities whose resources, agencies and health care facilities are being overrun. Surprisingly, it’s been difficult to determine Homeland Security’s position, except as a facilitator for the Obama administration. On the sidelines are the President and the Congress, who are apparently not willing or able to enforce current immigration laws or pass legislation that could resolve this critical situation. The pawns that are being used to wage this war are the children from third world countries to our south, who want nothing more than to grow up in an environment that is not corrupted by violence.

For the most part, this problem is by our own doing. Money has been allocated to build a fence between the United States and Mexico. For a myriad of excuses, from outright dereliction by our current and several recent past Presidents and our Congressional representatives, to political posturing, only 685 miles of this 1954-mile border has been completed. Much of the this so-called ‘fenced’ border consists of barbed-wire, vehicle barriers and inadequate materials that provide only minimal impediment for those who want to enter this country. Properly constructed fencing does work. Israel has proven that a security fence has decreased terrorist intrusions across the Gaza Strip by over 95 percent.

A decade ago, Nobel prize-winning economist Milton Friedman warned, “It’s obvious you can’t have free immigration and a welfare state.”

In 2007, senior research fellow at The Heritage Foundation, Robert Rector, published a further explanation that Friedman’s comment should be viewed as applying not merely to means-tested welfare programs such as food stamps, Medicaid, and public housing, but to the entire redistributive transfer state. “In the transfer state,” he writes, “government taxes the upper middle class and shifts some $1.5 trillion in economic resources to lower-income groups through a vast variety benefits and subsidies.”

Rector goes on to explain that the transfer state redistributes funds from those with high-skill and high-income levels to those with lower skill levels. Low-skill immigrants become natural recipients in this process. Appearing to agree is Julian Simon, the godfather of open-border advocates, who acknowledged that imposing such a burden on taxpayers was unreasonable, stating, “immigrants who would be a direct economic burden upon citizens through the public coffers should have no claim to be admitted into the nation.”

Getting to the crux of the matter, Rector points out that “elections in modern societies are, to a considerable degree, referenda on the magnitude of future income redistribution. An immigration policy which grants citizenship to vast numbers of low-skill, low-income immigrants not only creates new beneficiaries for government transfers, but new voters likely to support even greater transfers in the future.

The granting of citizenship is a transfer of political power. Access to the U.S. ballot box also provides access to the American taxpayer’s bank account. This is particularly problematic with regard to low-skill immigrants. Within an active redistributionist state, as Friedman understood, unlimited immigration can threaten limited government.”2

Looking at the pictures of the thousands of unaccompanied minors crowded into temporary shelters until their fate can be determined, I am reminded of the very effective ads put out by the ASPCA depicting abandoned animals whose only hope is being adopted by a loving owner. The desperate situation and gut wrenching stories of these displaced children tug at our heartstrings.  Looking for new opportunities and unrestrained freedoms, brave souls, not unlike these children, built this country. So why the concerns over the virtual flood of new individuals who want those same freedoms and opportunities? The simple answer centers around affordability and available resources. This country has finally come to realize that we can no longer be the world’s policeman. Now, the social issue that is dividing this nation is this country’s continuing role as a safe haven.

The consensus opinion from Washington feel the nidus for this huge influx arose when President Obama issued an executive order on June 15, 2012, creating the Deferred Action for Childhood Arrivals (DACA) program.3 There are those who feel he was chiding Congress for not passing the controversial DREAM Act.

Apparently, by the time the news of President Obama’s DACA program filtered down to South America, the message took a different twist. Instead of those who were already in this country, Obama’s mandate appeared imply that once minors were able to gain entry to this country by any means available, it was likely that they would be allowed to remain for some indeterminate time. Until the recent uproar, it seems the administration made no or very little attempt to clarify this misunderstanding. Since many of these minors arrive with no papers, it will be up to the immigration courts to determine their eligibility. Additionally, while they are waiting for their court date, they are being placed with relatives, at the government’s expense. It is estimated that between 75-95% of these children fail to show up for their court date and disappear into the existing Hispanic community.

Not everyone agrees with the explanation put out the Obama administration!

“This is not a humanitarian crisis. It is a predictable, orchestrated and contrived assault on the compassionate side of Americans by her political leaders that knowingly puts minor illegal alien children at risk for purely political purposes,” is a quote in a press release by the National Association of Former Border Patrol Officers. Representatives of this same organization went on to claim, “certainly, we are not gullible enough to believe that thousands of unaccompanied minor Central American children came to America without the encouragement, aid and assistance of the United States government.”

Although the effects of the onslaught of unaccompanied minors are rippling across the country, two states in particular are shouldering the brunt of the exodus— Texas and Arizona. On March 7, 2014, Texas Governor Rick Perry said, “We either have an incredibly inept administration, or they’re in on it, somehow or another. I hate to be conspiratorial, but how do you move that many people from Central America across Mexico and then into the United States without they’re being a fairly coordinated effort?” He went on to add that his state has already used $500 million of Texas taxpayers’ dollars to assist with the influx of illegal immigrants.

Controversial Arizona Sheriff Joe Arpaio, already a high-profile critic of the current federal immigration policy, said, “I got my own theory… I think the White House sometimes is incompetent, but I can’t imagine them doing this (transporting many of the unaccompanied minors from Texas to Arizona) without realizing that there was going to be controversy.” He went on to criticize the way the media and some of our elected representatives have been given only limited access to the refugee camps that are springing up to house the children. “Why are they hiding these kids from the media? … Well, I think I have a theory here. I don’t think they’re all young kids. I would bet there are 16-, 17-year-olds. How do we know they’re not members of a gang coming across?”

“It’s time for the U.S. to get serious about immigration,” quoted Zack Taylor, Chairman of the National Association of Former Border Patrol Officers. “We can start by taking away their incentives to be here. All benefits: medical, food stamps, public housing, education, everything… Our government is encouraging foreign nationals to come into our country illegally and stay.”

Recalling his recent experience standing on the banks of the Rio Grande River and witnessing small pontoon boats ferrying load after load of illegals across to the U.S. side of the border, independent filmmaker, Dennis Michael Lynch said, “I just watched our country and the future of our own children officially fall off the cliff, and I don’t know what to do…”

Maybe, the answer to Lynch’s plea of frustration was uttered 44 years ago. Struggling to maintain his composure in the cramped Lunar Module, Apollo 13 Commander James Lovell put out a call for help to the Houston Space Command Center after an explosion crippled his spacecraft.  Although his message, was brief and to the point, it reflected the dire circumstances the Commander and his crew faced if they had any hope of coming back alive. Lovell’s message of controlled desperation endures: “Houston, we have had a problem.”

We can only hope our President and the members of Congress are listening!

 References:

  1. A humanitarian crisis is defined as a singular event or a series of events that are threatening in terms of health, safety or well being of a community or large group of people. Then doesn’t this same definition also apply to the citizens and support systems (law enforcement, health care facilities, welfare agencies, schools, etc.) in those communities where this flood of illegals is occurring? Also shouldn’t the elected officials of these communities have a say in the disposition of these individuals who have entered our country illegally?
  2. Rector, Robert, Look to Milton: Open Borders and the Welfare State, The Heritage Foundation, June 21, 2007.
  3. To be eligible for DACA, the individuals had to be born on or after June 16, 1981, have come to the U.S. before their sixteenth birthday, lived continuously in the U.S. since June 15, 2007 and been present in the U.S. on June 15, 2012 and on every day since August 15, 2012. Those that qualify are eligible to file for a work authorization permit, obtain a social security number or tax ID number and are protected from deportation for two years. There is the stipulation that the status has to be renewed every two years.

The ‘Perfect Storm’ at the Veterans Administration

The VA’s ‘perfect storm’ is the result of the idealists in Washington and the upper echelons of the Veterans Administration imposing their wishes on the pragmatists in the trenches. While the focus of the recent attention seems to be directed toward the VA employees who participated in scheduling infractions, the true blame probably rests in the unachievable obligations of the VA system itself. ‘Heads have already started to roll’, and more are sure to follow. But just because some VA rule mandates that patients have to be seen within a predefined time, doesn’t mean it can be done— at least be done without making sacrifices in other areas.

Now that the issues within the VA have been pushed center stage, it is important to keep the issues of limited access of patients into the system separate from the other concerns such as bloated salaries for VA employees and prioritization of expenditures. These concerns are important and can be discussed in a further posting, but dilute out the importance of fulfilling the acute needs of the eligible VA population.

In an imaginary example, a physician working in a VA clinic regularly sees four patients an hour— the time that physician feels is adequate to take a proper history, perform an adequate physical examination and prescribe an appropriate course of therapy based on any diagnostic results. Because of pressure from the ‘powers-that-be’, that physician is now told his/her new allotment will be six patients per hour. In this scenario, although the physician is mandated to work harder and longer, usually with no increase in pay, it is the patients who suffer. They suffer because they have less time with their doctor to address their unanswered concerns and undiscovered needs when their doctor has to move on to the next patient.

All health care systems have limited manpower and resources. When the patient demands exceed resources, there are only two alternatives that keep the system functioning: decrease the quality of care given to certain or all patients, or decrease access to the system.

The ethical dilemma raised by allocation of limited manpower and resources by the VA hospitals is rationing. The VA has adopted the limiting access position as have Canada and England with their single payer delivery models.

It’s a simple enough question: Given there is a fixed amount of resources, in the short term, how are those resources most ethically distributed? Divide them evenly, so that each party gets the same amount, or give more to some and less to others? Make health care services the limited resource. Does a delivery system then offer less than optimum care to all the eligible patients or does the system give optimum care to some, while delaying or denying access to others?

The U.S. Veterans’ Administration hospitals have a rule that medical care is to be provided to military veterans in a timely manner within 14-30 days. Due to the chronic deficiencies in staffing and inability to always comply with the 30-day rule, certain personnel in some VA facilities sought out tactics ‘to game the system’.  In 2010, then the VA’s Undersecretary for Health Operations and Management, William Schoenhard, released a memo outing the strategies used to get around complying with the appointment rule and ordered them stopped.

These practices were recently brought to light at the Phoenix VA hospital, where allegedly at least 1700 veterans were victims of rigged lists when the wait time for an average appointment was 115 days. Additionally, allegations were levied that more than 40 veterans had died while waiting for their appointment. Allegedly, these practices are not just occurring at one VA facility, but were and are still pervasive in other facilities within the VA system. Due to these recent allegations, Congress has undertaken hearings with much of the attention directed toward Veterans’ Secretary Eric Shinseki, who recently submitted his resignation over the scandal.

Twenty years ago, annual performance reviews were instituted that seemed to have created perverse incentives to ‘cook-the-books’, with respect to the policy scheduling violations. “Fear was instilled in lower-level employees by their superiors, and those superiors did not want long wait times”, said Florida Congressman Jeff Miller, chairman of the House Veterans Affairs Committee. “Bonuses were tied directly to the waiting times of the veterans, and anybody that showed long wait times was less likely to receive a favorable review”.

A review of the inner workings of the VA system sheds more light on the complexities within the Veterans Administration’s health care facilities. The eligible veteran United States population is 21.8 million, with about 9 million enrollees currently in the system. To service the needs of that population, there are 153 VA hospitals, 773 outpatient treatment centers and 260 counseling centers, where 6.5 million patients were seen in 2012-2013. Patient costs are free for veterans with low incomes, former POWs and those with severe disabilities. Veterans who served in combat zones are also eligible for free care for two years after their discharge because of an illness or injury that may have been service related. For the rest, they are responsible for a $15 co-pay/visit and $50 for most visits with a specialist, or for certain tests. Hospital stays can be as low as $236 for the first 90 days.1

Some experts feel that many of the problems arise from an acute shortage of physicians, mostly those in primary care. The VA’s projected needs are 5,500 primary care doctors, and currently they are 400 positions shy of that goal. In the last three years, the VA claims the number of primary care doctors has grown by 9 percent, while the demand for primary care appointments has grown by 50 percent. According to David Cox, the National President of the American Federation of Government Employees, the theoretical responsibility for each primary care VA doctor should be about 1200 patients. In reality, that number is now close to 2000. Although most medical complexes are struggling to find enough primary care doctors, the VA’s problems are compounded by their lower pay scale of $98,000 to $195,000/ year for these positions, while the average was $212,000 in the private-sector in 2012.2

The latest census data for the population in Canada came in at over 35 million. Reportedly, there are 1365 hospitals located that supply care for our neighbors to the north. Similar to the VA system, they function under a single payer health care delivery model. Although there is a great deal of variance across the Canadian provinces, the average waiting time between referral from a general practitioner and the receipt of elective treatment is 18.2 weeks (127.4 days). The waiting time between referral by a general practitioner and consultation with a specialist has risen to 8.6 weeks (60 days).

Britain’s National Health Service (also a single-payer model) has similar problems. In 2010, about one-third of England’s NHS patients, considered sick enough by their family doctor, waited more than a month to see a specialist. Realizing the critical nature of their inefficient system, where the mortality rate from heart disease was 36% higher than in the U.S., the ‘NHS Constitution’ enacted a policy that “no patient should wait beyond 18 weeks (126 days) for treatment after a General Practitioner referral”.

The Fraser Institute, a pro-free market Canadian think tank, reported that even a one-week increase in the wait time from a referral by a general practitioner to the receipt of treatment was associated with an increase of approximately three female deaths per 100,000 population. The report also determined, that over the 15-year period from 1994-2009, increases in the wait times in the Canadian heath care system for cardiovascular care were associated with approximately 662 potentially avoidable deaths. Overall, they projected during that same period, increases in wait times for medically necessary elective treatment may have been associated with 44,273 additional female deaths.3

The acuteness of the shortage of resources, beds and staffing is not new in the VA system. At least several recent administrations in Washington and probably most members of Congress have been aware of these problems for years. Some members of Congress have even advocated for solutions, but to no avail. That was until a number of our veterans reportedly died because of delays in receiving appropriate care. What is new is the awareness of these problems by the public.

Increased morbidity and mortality due to delay of care is a tragedy, no matter the circumstances. Avoidable delay of appropriate care borders on being criminal.

In looking at the big picture, as to the whys, there are at least four significant areas of concern at VA facilities: 1. A system that chronically is pushed to its maximum by unrealistic expectations with its current staffing level and patient load. 2. Very little patient restraint because patients assume little to no responsibility for their ‘first-dollar health care expenses’. 3. Lack of accountability by the VA employees for violations of protocol, or think their work is over when their shift ends, verses the private sector mindset of when the task is completed. 4. Chronically overworking and under-paying their primary care physician staff.

One long-term solution would be to increase the physician staffing and the number of treatment centers within the system. On a more immediate basis, act on the growing call to refer certain patients with acute problems into the private sector for their care (a voucher system). The state Exchanges created by the ACA legislation could be another vehicle. A more radical approach recommended by a few, would be to get the VA out the acute care business altogether and, focus on what they do best— long-term care and rehabilitation.

The American public is shocked and dismayed when they hear about a 115-day waiting period for some of our veterans, while both Canada and England, also with single-payer models, experience almost the same delays on a regular basis.

When Obamacare is fully implemented and if the Exchanges drive the competing private insurers out of the market, only the federal programs will remain. Then those wait times of 115 days for all patients will become the norm!

References:

1.The Associated Press, The Dallas Morning News, May, 31, 2014.

2. Oppel, Jr., R A., Goodnough A., The New York Times in The Dallas Morning News, May 30, 2014.

3. Hospital wait times may have cost 44,273 women their lives over 16-year period: Fraser Institute/ Politics – Yahoo News Canada.

Border Boondoggle

Except for infiltration by terrorists across the Canadian border, the most discussed ‘border’ issues all concern Mexico. With the United States’ insatiable appetite for illicit drugs, and hopes for a better life, our southern border has turned into a virtual war zone. Increasing border patrol presence, construction of a fence in some areas and stepped up surveillance have only made a dent in the flow of problems. Until the root causes are addressed this country will be in a losing battle.

Washington is in gridlock because the Republicans are afraid of losing the Hispanic vote and the Democrats are holding out for more illegals, before the problems are resolved. The flaw in the Republicans’ concern seems unfounded. As an example, even after President Reagan signed into law The Immigration Reform and Control Act in 1986, which granted amnesty to 3 million illegal aliens, George H. Bush still only garnered 35% of the Hispanic vote, when he ran for President in 1989. The problem of foot-dragging by the Democrats is causing an increasing dilution of this country’s identity, spiraling costs of health care incurred by these uninvited residents, escalating violence that have direct ties to Mexican gangs and rampant drug trafficking.

Three areas must be addressed if a solution is to be found: elimination of the ‘anchor’ baby legislation, effectively closing our border and some form of amnesty.

‘Anchor babies’ is a term given to those infants who are born within the borders of the United States and are granted automatic citizenship, even though neither parent is a legal citizen. As background, this automatic birthright citizenship first arose after the Civil War as a Constitutional provision clause of the 14th Amendment in 1868. It was a way to undo the Dred Scott ruling and ensure citizenship for former slaves born on U.S. soil.

Analysis of Census Bureau data reveals that an estimated 340,000 births (‘anchor babies’) in the United States were born to parents of undocumented immigrants in 2008. That extrapolates out to 8 per cent of the births in this country. Carrying the extrapolations of all the costs out further, at an average of $25,000/birth, which also includes prenatal, delivery and post-natal care for both the mother and the newborn child, costs to the health care system would be predicted to be 8.5 billion dollars in 2008. Add to that another $10,000/year for 12 future years of required public educational costs, Medicaid, CHIP, Perinatal CHIP, welfare, Supplemental Nutrition Assistance Program (formerly food stamps), Section-8 housing through Temporary Assistance to Needy Families (formerly AFDC) and the costs generated by those who care for them, the costs rise exponentially.

It is estimated that since The Immigration Reform and Control Act of 1986, at an average of 170,000 ‘anchor babies’/year over those 24 years, adjusting for inflation, have generated costs of $165,000/child or 673 billion dollars total. In more understandable terms, babies born to non-documented parents have generated costs to the United States of over two-thirds of a trillion dollars in the last 24 years and at a current rate of 58 billion dollars/year for just their birth and education.1 These cost estimates only take us through 2008.

Even if a ‘hardened’ fence were to extend from border to border and 100 miles out into the both oceans, there would still be some drugs and illegals that would continue to get through— but a lot less! To be even reasonably effective, the border closure should directly coincide with some form of amnesty. After that specified time, everyone will be sent back with virtually no exceptions.

Realistically, this country is not going to be able to send 11-20 million people back to their home countries. As soon as the anti-amnesty supporters get over this premise, the sooner a solution can be reached. The only REASONABLE solution, mentioned in back corners of the debate, is to give those who are already in this country illegally, before a predetermined date, some sort of legal status. This new legal status would allow them to work, pay and receive benefits from social security, participate in the other entitlements programs and require them  to pay federal and state income taxes. For those who come in after a predetermined date, they go back to their country of origin and fall in line after those who are already in line through the normal immigration practices.

Continuing along this same scenario, the other stipulation would be those, who accept legal status for residency, but entered illegally, will never have the right to vote or hold public office. Controversial, as that might sound, this is the same stipulation afforded in some states to convicted felons, even after they have served their sentence. Looking at it from a more pragmatic way, these uninvited guests came this country or remained here under illegal pretense. Why should they be afforded these same rights of citizens, who are in this country legally?

A caveat, that could be offered to these current illegals, would be for them to voluntarily return to their country of origin and apply for legal immigration to this country. If and when they then return legally, they would have the right to vote and hold elected office.

Until the discordant voices unite and realize that a compromise is vastly better than the status quo, there will be no answer to the subject of illegals. Tina Grego, a journalist for the Denver Rocky Mountain News, published a column in October 2007, titled Mexican Visitor’s Lament that explained the costs incurred by illegals better than anywhere else that I have read.

What Ms. Greco concluded was, with at over a half a trillion dollars a year of incurred costs, this country can no longer turn a blind eye to our ‘uninvited guests.’

1. Tenery, R., Birthright Citizenship: The Silent Costs, Echoes for the Future, http://robtenerymd.com, December, 2010.

2. Grego, T., Mexican Visitor’s Lament, Denver Rocky Mountain News, 10/25/07.

The Reverend Jessie Jackson and Geronimo

What would be the response be from the Muslim community if a health care insurer decided that it would decrease the reimbursement for hospital care of their Muslim policyholders, if they were readmitted for the same diagnosis within thirty days of their last discharge? Incidentally, the insurer did not apply that same rule to their Christian patients. Would not the Muslim clerics loudly protest or worse?

What if only black patients, and not any other patients, who were admitted to hospitals for observation and limited diagnostic studies, had to comply with the ‘two-midnight’ rule for their health care insurance to cover their stay? Would the Reverend Jessie Jackson and other leaders in the black community stage a protest march in Washington?

Would the leaders in the ‘gay’ community be silent if practitioners were reimbursed 25% less when they treated gay patients?

Would the women’s lib contingency stand idly by if health plans that specifically targeted medical issues in females faced disproportionate funding decreases while other plans went untouched?

Finally, what if the patients of the Indian Health Service were forced to use preferred pharmacy networks even though their out of pocket costs would be significantly higher? Do you wonder if the leaders of the Native American Community might consider closing all the roads, including the Interstate highways, through their reservations to public transportation in protest?

Although each of these examples seems farfetched, they are close to the truth. The only difference is that these individuals from the Muslim, black, gay, female and Native American communities are limited to the seniors in their community— the seniors who are enrolled in the Medicare program. For each of them, all of these five scenarios are potentially real. The difference is their needs go almost unnoticed, not because of their religious preference, color of their skin, gender or ethic background, but because they are over 65.

For most senior citizens the Medicaid, Medicare and Medicare Advantage programs are single-payer models that are run by the federal and state bureaucrats under the auspices of the administration through the Centers of Medicare and Medicaid Services (CMS). As the ‘only game in town’, they promulgate these discriminatory rules, because they can.

 Where is the outcry on behalf of the seniors? Where is the Reverend Jessie Jackson, a Gloria Steinem or a Geronimo to come to their rescue?

It’s not AARP! Their members were thrown ‘under the bus’ when AARP’s Board of Directors threw their support behind President Obama’s health care plan. They didn’t seem to care that over $700 billion would be diverted away from projected Medicare funding over the next ten years. To the Board of Directors of AARP, it has always been about the money. Through its subsidiary company, AARP was one of the main suppliers of Medi-gap insurance, a privately purchased coverage that picked up where Medicare benefits left off. The George W. Bush administration passed the Medicare Advantage program that was a lower-cost alternative to the Medi-gap coverage. More than 11 million seniors took advantage of the program that significantly cut into the AARP Medi-gap revenues. President Obama eliminated subsidies for the Medicare Advantage program that made the more-expensive Medi-gap coverage more competitive.

What about the American Medical Association (AMA) and the American College of Physicians (ACP)? Current AMA policy supports adequate funding for the Medicare program and opposes further reductions of current Medicare limiting charges.  However, it seems that both of these influential organizations felt that achieving a permanent fix to the Sustainable Growth Rate (SGR) was more important than fighting to block this diversion of projected Medicare funding away from the seniors and to the ‘newly’ insured under Affordable Care Act. As a side note, have these organizations achieved their goal of a permanent fix for the SGR by throwing their support behind the President’s health care plan? No!

So who fights for the seniors’ interests? The answer is the seniors themselves, who really have no effective organizational model after AARP traded their best interests for company profits. They do have the representatives that they elected to their statehouses and Washington DC— these same representatives that were also elected by and are also beholding to many other interests in the community.

These discriminatory regulations by CMS and mandates under the authority of the ACA are examples of how sectors of underrepresented populations fall prey to the dictates of a few when competition is eliminated from the marketplace. Today, it is the seniors.

Tomorrow, who knows?

The Surgeon General— Where’s the Beef?

The President’s nomination of Vivek H. Murthy, M.D. for the office of Surgeon General reveals how the current administration selects individuals to help run this country. Past Presidents have not always supported the most qualified candidate for a particular position, but one who more closely aligns with their particular point-of-view. Recently, the nomination of Dr. Murthy, a Harvard College, Yale Medical School graduate and residency trained Internist at the Brigham and Women’s Hospital in Boston, has drawn both praises and criticism from differing sectors of the community.

Often referred to as ‘the Nation’s Doctor’, the Surgeon General is the operational head of the U.S. Public Health Service. The person who holds that position is also the leading spokesman on public health matters in the federal government.

After completing his residency in 2006, Dr. Murthy joined the faculty of Brigham and Woman’s Hospital as a Hospitalist and Instructor in Medicine at Harvard Medical School. Despite his pristine academic credentials, it is his activities outside direct patient care that appear to have garnered him the President’s nomination for Surgeon General.

Dr. Murthy’s career in advocacy began when he co-founded and served as president of Visions Worldwide in 1995. It was an organization that concentrated on AIDS education and prevention in the U.S. and India, the homeland of his parents. He went on to co-found TrialNetworks, a cloud-based optimization system that would allow clinical trials to bring new drugs to the market more quickly and safely. In 2008, he started Epernicus, a collaborative networking platform for scientists to improve their research productivity. In that same year, he co-founded Doctors For Obama, which was later renamed Doctors for America, where he served as the national chairman. In 2011, Dr. Murthy was appointed by President Obama to the U.S. Presidential Advisory Council on Prevention, Health Promotion, and Integrative and Public Health within the HHS.

Outside of the medical community, the most controversy with Dr. Murthy’s nomination comes from the supporters of the ‘right to bear arms’. Contained in a Twitter posting in October 2012, the nominee wrote, “Guns are a health care issue.”  With his support for Obamacare (the ACA) and apparently gun control, two of the most controversial domestic issues being pushed by our President, Dr. Murthy’s nomination comes as no surprise.

His academic credentials and interests in improving world health and medical research are laudable. However, the major concerns, voiced by some members of the medical community, are based on Dr. Murthy’s lack of clinical experience— being exposed to and responsible for direct patient care. The experience of titrating oxygen levels in an elderly patient with advanced emphysema or getting up in the middle of the night to comfort a family member who has just lost a loved one to a terminal disease. These are the kind of experiences that earns one the right to be called ‘the Nation’s doctor’.

Even though the main responsibility of the Surgeon General is to be the spokesman for public health and disease prevention, Dr. Murthy’s two plus year tenure on the President’s Council on public health and his early participation in AIDS awareness give him only minimal credentials in this area.

Dr. Murthy’s expertise is in political advocacy, not patient care. He is an idealist, much like our President. Although he should be commended for his medical training and activism, these do not automatically translate into being a good doctor. That comes from ‘being there’!

If he becomes Secretary General, Dr. Murthy rounds out three of the most important members of President Obama’s healthcare team: Ezekiel Emanuel, M.D., PhD, purported to be the leading architect of the Obama care legislation, stayed in academic medicine and held the position as associate professor at Harvard Medical School. Upon entering the public sector, he joined the National Institutes of Health where he was Chief of the Department of Bioethics. Currently, he holds the position of Special Advisor for Health Policy to Peter Orszag, the Director of the Office of Management and Budget. Although she has announced her retirement, current secretary of Health and Human Services, Kathleen Sebelius’ credentials are a B.A. in political science, a Master’s degree in Public Administration, former Governor of Kansas and former lobbyist for the Kansas Trial Lawyers Association.

With these three individuals, that have helped to create, are in charge of implementing and will act as spokespersons for President Obama’s agenda to transform this country’s health care delivery system, there seems to be a pattern— a pattern of exemplary credentials, passionate idealism of what should be, but very little experience in the ‘trenches’ of actual health care delivery— one that appears to closely follow the path of President Obama himself.

The often-quoted line, first appearing in an advertising campaign for a national hamburger chain, seems to succinctly wrap up the concerns of many members in the medical community about the President’s health care team— Where’s the beef?

This country deserves better!

Complacency, Acceptance Then Dependency— A Master Plan?

Maybe, I’ve been watching too many spy movies and TV series where the plot is to cause a government downfall, but events over the last several years have made me question my previous position of it couldn’t happen to us. My belief has been that our nation’s leaders, no matter who holds this country’s highest office, have similar goals to that of our forefathers.

The long-standing structure of tripartite governance of checks and balances that prevents one branch of the government from taking over, is being put to the test with our current administration. To a certain extent, this occurs with most Presidents. But the efforts seem more concerted with President Obama, as if there is some of some sort of master plan that will take this country in a different direction— as he promised just prior to taking office.

Four events appear to be the major factors that have contributed to the stark changes that seem to be leading this country today:

9/11 shattered this country’s naïve belief that, despite what was happening in other parts of the world, the United States was, in some way, immune to threats from those outside our borders. Now, privacy and independence are being pitted against personal safety. Although heightened airport security is the prime example, the growing reach of the National Security Agency (NSA) and the Central Security Service (CSS) are potentially even more intrusive into the privacy rights of the individual citizen.

The roots of the 2008 recession (July, 2011, @ http://robtenerymd.com) go back to the Community Reinvestment Act of 1977 that was enacted during the Carter administration. In attempting to provide affordable housing to a population that couldn’t afford it, the House of Cards finally came crashing down despite the efforts of every administration since President Carter. We have not yet fully recovered from this protracted economic downturn, and much of the free world was dragged down with us.

This country has failed to address the consequences of a virtually open border with Mexico. Not only do we face the economic problems of supporting many of these illegals who fill our schools, hospitals, jobs and jails, but also the growing political power they exert as their numbers continue to increase. Both political parties have failed to reach a conclusion for somewhat different reasons. The Republicans, even when they had the opportunity, failed to do much more than give lip-service to a meaningful resolution. The Democrats, hoping to gain a larger share of the legal Mexican voters, are in no hurry to tackle the hard questions surrounding amnesty and actually closing the border.

It is naïve, and in some cases unrealistic, to support sending all illegals currently residing in this country, back to their native country. A pathway to citizenship, or some form of legal status, is the only solution. The haphazard methods of enforcement not only feed this country’s appetite for illegal drugs, but have turned the Mexico/United States border into a war zone, where countless lives are threatened and lost every day. Meaningful border closure, whether it is virtual or real, must be accompanied by a firm date, after which there are almost no exceptions— no amnesty, no getting back in line, just automatic extradition for all those who are apprehended.  Finally, put an end to automatic citizenship (December, 2010 @ http://robtenerymd.com) for those who are born in this country, unless, at least one parent is a legal citizen at the time of their birth.

The last event that has changed this country is the election of a President who fundamentally believes that the United States should move in a different direction. Even those who agree with the President’s principles can’t disagree that he told prospective voters of his plans for the United States even before he was elected to this country’s highest office. Many of those who voted for then Senator Obama just didn’t believe he would be so intent and effective in carrying out his pledges.

Not that the President alone has created these events while he has been in office, but he has either created or allowed a culture in Washington that has fostered these changes: Under the Obama administration, this country is rapidly moving toward an entitlement society. Why work when individuals can get almost as much out of the entitlement programs than from a job? The explosion of the food stamp program is the ‘poster-child’ example.

Prior to the passage of the Affordable Care Act (Obamacare, ACA) over 45+ million of or citizens were without some type of health care coverage.  Even after an almost total transformation of this nation’s health care delivery system, the uninsured are still only projected to be reduced to 30 million.  Several trillion dollars later, one has to ask, “Are the congregate of patients in this country better off?” My guess, the answer will be a resounding no!

The scary scenario is if the President’s experiment doesn’t work and all the private health care payers move on to other markets, the only recourse will be a single payer system.  “Vladimir Lenin, one of the founders of socialism and communism, said that socialized medicine is the keystone of the arch to the socialist state. In other words, you’ve got socialized medicine as the foundation because it gives you control of the people. Once you have control of them, you can do whatever you want,” a Ben Carson, M.D. quote on The Kelly File on October 9, 2013.

The apparent expansion of the scope of authority of the Department of Homeland Security (DHS) is alarming. Consolidation of this new cabinet department came after passage of the Homeland Security Act of 2002, during the George W. Bush Administration. The original premise was to ‘prevent terrorist attacks within the United States, reduce the vulnerability of the U.S. to terrorism and minimize the damage from attacks that do occur.’

However, worrisome are: The 1.6 billion rounds of ammunition that the DHS has reportedly already stockpiled. The March 3, 2013 report of the 2,717 mine resistant, armor protected vehicles (MRAP) that have been retrofitted for the streets here in this country. The 704 million more rounds of ammunition (a significant number which are .40 caliber hollow-points) that the DHS has contracted to purchase over next four years. The 300 acre ‘fake city’ that the U.S. Army has constructed at a cost of $96 million in Virginia which was ostensibly built to prepare U.S. troops for occupation of cities abroad.

The President’s Affordable Care Act calls for the Ready Reserve Corps that is directed to ‘assist full-time Commissioned Corps to meet both routine public health and emergency response missions.’ Even before he was elected to the Presidency, then Senator Obama called for the creation of a ‘civilian national security force that’s just as powerful, just as strong, just as well funded as the U.S. military.’

With every horrific mass shooting by some deranged outcast, the administration and their supporters in the Congress push for stricter laws on gun ownership, background checks, automatic weapons and magazine capabilities. Using the tragedies brought on by a few malcontents, some of whom are probably acts of terrorism, there appears to be a push to disarm the American people. However, only the opposite is occurring as more Americans, fearing for their own safety, are violating state laws (example is Connecticut) and stockpiling weapons and ammunition in even larger numbers.

The most recent revelation is the projected defense budget cut, just released by Defense Secretary Chuck Hagel, that would decrease military operations to Pre-World War II levels, even in the face of Russia’s recent take over of Crimea. Granted the world has changed. Domestic terrorism now is more likely than a full-scale invasion from a foreign power. Advances in surveillance, weapon technology and mobility have changed the battlefields of today. ‘Feet-on-the-ground’ is being replaced by satellite surveillance and drones in the sky. President Reagan’s success that brought down the Berlin Wall, and Russia to the brink of financial ruin, carries a price that this country can’t afford. Even the most hawkish agree that the United States can no longer be the world’s policeman. Hopefully, we have also learned that becoming involved in ‘culture wars,’ such as in Iraq, is almost always futile in the long run.

A change in our military agenda was predictable. But how far the United States should back off its deterrent posture to a more protective position may only be answered if we are put to the test. Unfortunately, by then it could be too late.

This country must stand ready to defend its allies and its best interests abroad. At the same time, guard its citizens on their home soil. Whether the Obama administration has chosen the right balance between deterrence and protectionism will ultimately be judged by the historians.

Even those, who are behind President Obama’s vision for this country, must recognize several troubling trends. The privacy provisions our citizens have enjoyed are being sacrificed for more protectionism. There appears to be a purposeful ‘redistribution of the wealth.’ The explosion of the entitlement programs of ‘cradle-to-grave’ government support is threatening to turn the United States from the world’s economic leader into an extension of the European community. We, the people, are being stripped of the power to defend ourselves both at home and abroad, and we are losing our voice in Washington as the Executive Branch assumes more and more control. With the President and his administration essentially abandoning many of the principles that make up our Constitution, the culture, the opportunities and the freedoms that were the foundation of this country are quickly being diluted into a sea of complacency, acceptance and dependency.

History tells us that democracies follow a predictable arc of rise and fall. As they reach their zenith, those with less elect to public office those that promise them more. When the desires of those with less rise to the level that they become the voting majority, one of two, or both, scenarios ensue: Unaffordable debt is incurred to be funded by future generations, or the wealth of those with more is redistributed to those with less. When the standard of living falls, as it does in either situation, the arc is completed.

Then sometime off in the future, the capitalistic incentives will be born again in the hopes of those who are willing to raise themselves above those who are just content to go along.

Are the changes that are taking place in the United States a part of some master plan or just the normal evolution of a democracy? The upcoming two elections, this fall and in 2016, could stop this country’s slow slide into socialism. But only if enough voters are willing to look beyond their own pocketbook, skin color and professed political party.

Sadly, I doubt that will happen!

Does Bedside Manner Matter Anymore?

“My doctor is really good.” Contrast this to another comment, “My doctor must be good.” The former statement is positive, while the latter conveys a lingering doubt. Both quotes connote a continuing ownership in the relationship. In the latter, the doctor has failed to make a connection and the patient is looking for reassurance. If the physician’s competence is also in question, patients often look elsewhere. The bridge to make that connection is what is called the ‘art’ of medicine. This art, which takes the relationship to a higher level, is often referred to as the physician’s bedside manner.

The term compassion is frequently used to describe this art of medicine. Caring not just about the malady, but caring about the patient. Caring that they do not suffer, caring that they do not recover alone and caring that those who love them are also suffering. Compassion without outwardly demonstrating that sensitivity is without meaning.

The art is in being able to show this higher level of involvement. It is a willingness to be more than just a scientist by giving of one’s self rather than just a ‘peddler of pills.’ It demonstrates an investment in one’s patients and not just in what is wrong with them. That ability to practice this art is often the single most important factor that elevates one physician above another.

The art is more encompassing than just showing compassion. It is about showing respect. It is about remembering that each physician is also a representative of the medical profession— those who have gone before and those who will come after. It is not just about commitment to one’s patients, but to the patients of others as well. It is an appreciation of being part of the medical profession.1

Although much is written about medical ethics, very little mention is given to medical etiquette. The two disciplines are similar and frequently overlap, but clearly not the same. Although open to interpretation, medical ethics predominately deals with the concerns of right versus wrong. While etiquette is the discipline that addresses the variances in the individual’s personal approach, it is best framed with terms such as demeanor, conduct, body language and deportment. It is about how physicians act, react and the manner in which they dialogue not only with their patients, but everyone they encounter in their role as a physician.

The pioneers of medicine were introduced to this profession in an era when taking care of patients was considered an act of beneficence and not just a transaction. When undesirable outcomes were accepted as ‘acts of God’ and not misdiagnoses. When medicine was a calling to most and not just a vocation. Advances in the science, third-party payment systems, marketing and fear of reprisals have changed all that. Unfortunately, there is no going back!

What have not changed are the patients. Although they are no longer all accepting, they are still afraid. They still are in pain. They still want their physicians and the other medical professionals who care for them to care about them too.

The term bedside manner is not just about making the correct diagnoses and prescribing the most appropriate treatments. That is the science. It is also not just about the ethics of ‘right versus wrong.’ Bedside manner is more about how physicians conduct themselves and how they relate to those that they are around. Their demeanor and how they adhere to the rules of etiquette. How they connect! Bedside manner is about the ‘art’ of medicine.

In the broader sense, bedside manner is not just about one patient, but realizing that physicians are part of a community of patients and other caregivers. What they say and do reflects on all of those who are part of the family of medicine. It is about not losing sight of the lessons they have learned from those who came before them. Finally, it is about giving back to this noble profession that has given so much to them.

 

  1. Tenery, R., Bedside Manners: A Compendium of Physician Relationships. CreateSpace Independent Publishing Platform, 2014.*

 

* Now available through Amazon books in paperback and eBook, my hope is that Bedside Manners will find its way into all sectors of the medical community, especially into the hands of those who are beginning their journey into medicine. Cover-to-cover, the ‘little book’ takes no longer than a short seminar to read, but lays out a lifetime of lessons and experiences that can guide physicians and all caregivers in their roles as practitioners, mentors, teachers and role-models.

Outcome Measurements Could Be a Two-Edged Sword

 

In 2007, with the purported intent of ‘promoting high-quality, patient–centered care and accountability,’ the Centers for Medicare and Medicaid Services (CMS) and Hospital Quality Alliance (HQA) began making public each hospital’s 30-day mortality outcomes for acute myocardial infarction and heart failure. The reporting was extended to pneumonia, in 2008. To add even more impetus, a federal program, called Value-Based Purchasing, was created that assigned penalties in Medicare reimbursement to hospitals that didn’t meet CMS’s stipulated clinical-care measures, while giving bonuses to those hospitals that exceeded them. Although the percentages of the penalties were most often far less than one percent (maximum of 1.25%), the losses mounted to hundreds of thousands in revenue to the so-called under-performing hospitals. In a report by Fierce Health Care in August of last year, 2,225 of the nation’s 5,700 hospitals will receive Medicare payment reductions totaling $227 million starting October 1, 2013.

More recently, under section 3025 of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) was established which requires CMS to reduce payments to IPPS hospitals (those that participate in the Medicare part A funding) with excess readmissions, beginning on October 1, 2012. Under the dictates of the program, CMS began reimbursing hospitals less if a Medicare patient is readmitted for the same problem within 30 days of discharge. Although less touted than the goal of improving the quality of heath care, the leadership of CMS, and those that dictate their policies, have come to the decision that one of the ways to control this country’s spiraling health care costs is by reimbursing health care services based on outcomes. The assumption is that by rewarding good results, or, more often, penalizing poorer results, the outcomes will be better.

On the positive side, these CMS requirements will most likely create better discharge planning, and efficiencies in the utilization of diagnostics and the prescribing of therapeutics. However, this goal to increase efficiency, and thus cost savings, using outcome measurements, introduces the potential for several disturbing consequences. It also casts disparaging insinuations on a profession that prides itself on quality, dedication and beneficence.

The inference that physicians and hospitals will only give their full measure unless incentivized by rewards or face penalties, is not only degrading but inflammatory. The premise also potentially cheapens the patient/doctor relationship from professional to one of prostitution— pay more to get more. It works for ‘the trade,’ but in the professional world, that must deal with the unpredictable science of medicine, third party mandates and a sue-crazy public, the premise does not always hold true.

In the case of the recent CMS HRRP program, the use of perverse incentives doesn’t necessarily reward the institutions and the physicians that have better measurable outcomes (fewer readmissions), but more often penalizes those who have a higher readmit rate. Varying age, education and severity demographics play significant roles in outcomes, but tend to distort the results. More than that, it discourages physicians and health care institutions from moving or expanding into locales where the sickest patients often congregate.

A recent study by Health Service Research reported that hospitals that treat more poor seniors who are both Medicare and Medicaid have higher rates of readmission.  Lane Koenig, Ph.D., president of KNG Health Consulting in Rockville, MD, who was the author of the study, quotes, “While these hospitals are more likely to be hurt, they are also more likely to be struggling financially.”

What are the population demographics surrounding the referring area of the admitting institution? What about referral institutions such as city/county hospitals, heart hospitals and cancer centers? Should they be held to the same standards with respect to readmission criteria?

Koenig went on to say, “currently, CMS does not take socioeconomic status into account when calculating readmission rates. It is possible that adjusting HRRP calculations for socioeconomic data could mask disparities in quality of care. The counter argument is that by not adjusting it, you may be penalizing hospitals simply because they treat a potentially sicker or more-difficult-to-manage population.”

Often left out of the discourse, are the patients’ perceptions, when they see that the hospital they use when they are sick, is being penalized because of lack of compliance with Medicare’s so-called standards. Similar to the ‘best doctor’ lists periodicals often publish to sell more advertising space in their publications, it potentially raises doubts if the patient’s doctor is not on the ‘list.’ Then there are the liability concerns that arise with poor results, if patients feel that their care was below the standards rather than an ‘act of God.’

Also, there are the extra costs and resources necessary to insure compliance. (As an example, there are the projected 1000s of additional IRS agents necessary to enforce compliance of the Individual Mandate clause of the ACA). What party established the standards? It harkens back to the DRGs. With respect to the CMS readmit policy, is there a real difference between four weeks and five, except for the differing reimbursement levels?

More important, what parties suffer the most? The answer is easy— the sicker and more vulnerable patients and the very hospitals that they rely on to get them through their difficult times. It also raises concerns as hospital systems evaluate development in new areas or expansion of their current facilities. Why go to or grow areas with potentially sicker populations?

The desire to encourage better discharge planning and increase efficiencies is sound. But, as with DRGs, there are patients who are potentially put at risk. A past example is the mothers, and their newborns, whom would have benefitted by an extra day or two stay in the hospital. In this more recent case, it’s the most fragile elderly, often who return to their less protected environments.

The larger question that lurks in the background is what do outcome measurements and other government mandates such as electronic medical records, e-prescribing, DRGs and the upcoming ICD 10 requirements, that are being pushed onto medicine, have in common? One would like to think that they are to allow more efficient utilization of our limited health care resources.  To advance the level of health care services to a larger sector of the population. To control the escalating costs that threaten this country’s future financial viability.

The answer may be all three or none of the above. The chilling observation is that by controlling a country’s heath care system, the rest will soon follow was once considered Orwellian.

Now, I’m not so sure!

It Always Seems to Boil Down to Politics

In 2009, when the final vote was taken on The Patient Protection and Affordable Care Act (ACA, Obamacare), it was split along party lines. Since the Democrats held the majority in both Houses of Congress, they already had a distinct advantage.

But, it was the additional deals ‘arranged’ by the administration and the Democratic leadership that were necessary to insure the controversial legislation’s passage. They were the ‘not-so-secret’ promises to certain elected representatives and influential bodies in the health care industry.

There was Democratic Senator Mary Landrieu’s ‘Louisiana Purchase’— the provision that would provide $300 million in Medicare subsidies for people living in Louisiana. Senator Landrieu denied that her vote on health care reform was contingent on the Medicare subsidy. However, she did not publically commit to supporting the health care reform bill until the subsidy for her home state was included.

In early November, Senator Landrieu stated, in a speech on the floor of the Senate, that she had been mislead when she voted for the ACA in 2010. She was responding to the growing uproar as millions of patients across the country were losing their health care coverage as the dictates of the ACA were being implemented.

With Democratic Senator Ben Nelson, as a key holdout vote on the bill, Senate Majority Leader Harry Reid made a deal with him to allegedly secure his vote, giving the Democrats the 60 votes needed to kill a Republican filibuster. The deal, referred to as the ‘Cornhusker Kickback’ included language giving Nebraska 100 percent federal funding of the Medicaid expansion indefinitely. The deal drew so much fire from critics — who said it amounted to Nelson selling his vote – that he asked Senator Reid to remove the permanent Medicaid exemption from the legislation.

However, the real genius of the Obama administration, as opposed to the Clinton task force proposal in 1993, was in the President’s handling of the pharmaceutical industry, AARP and the AMA.

The drug industry backed, what would later be called Obamacare, in return, they were promised a 10-year limit of only an $80 billion cut in prescription drug costs. (A drop in the bucket of their almost $3 trillion in projected revenues over the next decade). They were also given assurances that the administration would continue to work against importing the lower-cost Canadian drugs. All the pharmaceutical industry had to do was put its formidable advertising budget at the disposal of the administration. Of the estimated $120 million spent lobbying for the passage of legislation, the drug companies funded $26.1 million of that total.

A subsidiary of the American Association of Retired Persons (AARP) was the supplier of Medi-gap insurance— a privately purchased coverage that picked up where Medicare benefits left off. The George W. Bush administration created the Medicare Advantage program that was a lower-cost alternative to the Medi-gap coverage. More than 11 million seniors took advantage of the program that significantly cut into AARP’s Medi-gap revenues. President Obama eliminated subsidies for the Medicare Advantage program that had made the more-expensive Medi-gap coverage more competitive.

Even though over $700 billion in projected funding for the Medicare program would be diverted to cover the new enrollees under the ACA, and although seniors would end up paying more money for their coverage, the leadership at AARP threw its support behind the proposed new law. Appearing to be more concerned with corporate revenues than abandoning the seniors, who comprised its membership, the leadership of AARP donated millions of dollars toward the advertising campaign and lobbying efforts in support of the proposed legislation. Referred to as ‘corporate cronyism’ much of their membership openly rebelled against its leadership.

When the Board of Trustees of the American Medical Association (AMA), and reaffirmed by its House of Delegates (HOD), openly supported the current administration’s proposal to solve the growing problem of the uninsured, it came as a shock to much of the physician-community. A survey by a physician recruitment firm, Jackson & Coker, revealed that only 13% of physicians surveyed agreed with the organization’s decision. Another study, the National Physicians Survey, reported that more than three times as many physicians believed that the quality of the American health care system would ‘deteriorate’ rather than ‘improve’ under the mandates of the ACA and nine out of ten physicians thought the proposed legislation would have a negative impact on their profession.

Several reasons have been floated for the AMA’s surprising support.  The major reason given to the AMA’s membership was that the President would throw his support behind a permanent ‘fix’ to Sustainable Growth Rate (SGR). Since the 1997 Balanced Budget Act first went into effect in 2002, the SGR formula, which is used to calculate levels of Medicare reimbursements to physicians, has not taken a realistic approach to increases in patient volume and the complexity of the science. Therefore, each year physician organizations across the country have groveled at the feet of the representatives in Washington, only to be granted a temporary reprieve from the fee cuts mandated in the Balanced Budget Act. Each year they had been promised a permanent fix. Each year there wasn’t. There was real hope that, with the President’s influence, this time it would be different. It hasn’t been, until possibly this coming year. The flawed SGR formula still looms over their heads. And, the AMA’s already dwindling membership has taken another hit.

The Supreme Court’s ruling, that the ACA was constitutional, as a tax but not a mandate, seemed to seal the fate of those who still held out hope that the controversial law could be overturned. That was until the Republican led House of Representatives decided to block funding for the new legislation. Although the House softened its demands to only delaying implementation of the Individual Mandate clause of the law for one year, Senate Majority Leader Harry Reid used his position so that the continuing resolution sent over by the House never even came to the floor of the Senate for debate. This apparently irresolvable divide was what led to the most recent government shutdown.

Giving him credit, Senator Reid was able to put together a temporary compromise, not necessarily to end the debate over the health care legislation, but to end the government shutdown and raise the debt ceiling. However, it only extends until February 7, 2014. He broke the logjam by eliciting the support of Senate Minority Leader Mitch McConnell. Unfortunately, the real differences between the two parties still exist, but thanks to Senators Reid and McConnell, the federal government is once again up and running.

Did I mention that the bill released by the Senate, passed by the House and signed by the President to end the most recent shut down also included an authorized spending increase of $1.2 billion for an already proposed $1.718 billion construction project on the lower Ohio River in Illinois and Kentucky— the state represented by Senator McConnell?

As implementation of the ACA chokes and sputters to ‘get out of the gate,’ and failing to meet its projected goals on most levels, the administration has issued exemptions and delays on almost a routine basis.  The ACA’s future appears to rest in the hands of the administration and of the results of the upcoming election in November.

These compromises, delays issued by CMS and Presidential mandates that appear to fly in face of the law and almost indiscriminate exemptions give us a peek into how things really work in our nation’s capitol.

And we just thought it was about the issues!