Back-End Games

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I found the above image on the internet.  It has been a while since I have picked on Obamacare.  I have left it alone despite all the unilateral “changes” that the President has made to some of the requirements.  It is beyond me how a bill can be constantly tweaked by the government and still called legal but we will let that go for now.   Anyway, four months ago I wrote the following:

Oh….my…..God!  According to Henry Chao, deputy chief information officer for Centers for Medicare and Medicaid Services, up to 40 percent of the technology needed to run the new Obamacare health insurance marketplace has not yet been built and will not be ready when insurance companies start sending in bills when coverage begins January 1.  So let me get this straight.  They started this thing without proving it can work…and it can’t.  And now they openly admit that 40% of the back-end technology is missing.  Are you kidding me?  And when Chao says 40% is he severely underestimating the real amount so save face?  I bet yes.  This is bad.  Real bad.  I still have not been able to get on the Healthcare.gov site.  It says I am locked up in verification purgatory.  And now they tell me that even when I do get something it could break down in January.  Where is a puke bucket?  I am going to get sick.

Why would they leave the back-end undone?  Well, right now the administration is bragging that the new health exchanges reached 5 million enrollees (wasn’t it supposed to be a lot more?).  Anyway, there is this huge debate on whether many of these enrollees were previously uninsured or not.  In other words, they could have been dumped from their old insurance and went scrambling to replace it on the exchange.  This replacement, in general, has been for a lot more money, by the way.  If this is true, that could knock down that 5 million number.  Surely the government can clear this up, right?  This just in:

In congressional testimony to the House Ways and Means Committee on Wednesday, Health and Human Services Secretary Kathleen Sebelius said that the government can’t track how many people have paid their premiums because the “back end” of HealthCare.gov that would allow insurers to reconcile enrollment and payment information with the government isn’t completed.

So now I know why the government didn’t have the back-end done.  I get it.  What happened to that whole transparency goal for this administration.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  15 comments for “Back-End Games

  1. Ben
    March 26, 2014 at 1:25 pm

    Two comments
    1. Last week I had a 25 year old working for cash under the table. Cut his FPL. No insurance. He was allowed to sign up for Obamacare. So for $50 or so he now gets insurance, after the injury. It will pay for the injury supposedly. But the insurance company has to pay the hospital $6000 for the $50 it gets from the patient and the $300 it gets from the government.
    What do you think will happen next? The insurance company gets hundreds of millions more from the government for their “losses”. They will raise premiums for the rest of us

    So I pay 4 times
    1. I have to pay $1400 a month for my familys insurance. Unlike Canada where everyone gets insured and everyone pays in through a provincial sales tax . Even though working under the table buy things and pay tax.

    2. My rates will go up
    3. I pay increased taxes to pay for his insurance.
    4. I probably wont be paid as the insurance company will state I did not preapprove the procedure. But because he is an insured by them, I cannot balance bill the patient anything.

    As a physician I am now in a 60% tax bracket. Federal 35%. Medicare 3.8%. Social security on the first 108k makes about another 5%. State taxes another 9%. Then really health insurance is another tax or another 10% of income. The reason it went through the way it did. Government workers, and unions get it covered by employer, so the Democrats made them happy. Poor people dont pay at all, so the Democrats are happier. If you make a million or more a year, 20,000 in health care costs is 2% of income or less so better to have paid health insurance than a 9% national sales tax, so the Republicans were mildly happy.
    But the rest of us self employed, that actually work for our money are paying 35 plus 3.8 plus 5 plus 9 plus 10% or 60% tax not including property tax, sales tax, disability insurance (after all if you are poor or a government worker the government picks up the tab for this), any insurance (has anyone realized that the upper half of society insures themselves while the bottom half has the government bail them out?
    Add to that no pension. Heck if I was California policeman I would be retired at age 52 at 100k a year pension.

    In response to the charity clinic that cant find a gastroenterologist to do a colonoscopy for less than $600. Do you realize what the doctors cost is? He is not running a charity clinic. His employees get paid, he does not get government grants. Unlike the farmers getting subsidized crop insurance (many of them worth multi millions) his malpractice is not subsidized. It cost me $2200 to get a tooth replaced, from the dentist. That doctor is not netting $600. $600 may be what he figured out his costs are and he is doing it for free.

  2. Stella Fitzgibbons MD
    March 26, 2014 at 8:49 am

    Excuse my pro-ACA attitude, but I’ll spend this morning at a clinic for the uninsured–part of it praying that nobody over 50 comes in with anemia & constipation, ‘cuz it is NOT POSSIBLE to find a nearby gastroenterologist who will do the colonoscopy for less than $600…even if there were a surgeon and cash-strapped hospital willing to operate on an early cancer, or an oncologist or radiation guy willing to do followup treatment. And I hope nothing neurologic comes in either, or any asthma patients I can’t manage without going beyond plain albuterol inhalers and p.o. prednisone, which are all the patients can afford unless the drug reps were extra generous this month. When I go to my ER tomorrow we will have to balance being open to everybody with what an ER visit can cost a guy who is working two jobs to pay the rent. Yeah, Obamacare has lots of problems, but quality medical care will always be expensive, and if it involves some cost-shifting you can shift some onto me.

    • Doug Farrago
      March 26, 2014 at 9:30 am

      Is that $600 cash? Does that include anesthesia? How about the consult? Is it at the hospital? Maybe the ACA will make people shop for prices because it seems EVERYONE (including myself) has a very high deductible (shitty plan) and an HSA. That actually would be a good thing. Right now, though, the hospitals and doctors are not giving discounts for cash which they need to be doing. When that happens, I will tip my hat slightly to Obamacare. Your other points. The ACA does NOTHING for the inhaled corticosteroid products as most of their plans don’t or hardly cover meds unless a deductible is met. And the ER visit is also not not covered until the deductible is met. No benefit from the ACA there. And define quality again? Hitting some unproven metric, being around for your patient, getting that patient into a specialist early because you made a phone call? These can all be called quality so throwing words around that have multiple meanings is, well, meaningless. Yes, the cost shifting will fall onto you but not just because you will be paying higher taxes (you will) but because you will have more bureaucratic work to do that pays nothing.

      • JRDO
        March 26, 2014 at 11:04 am

        And the realistic alternative to getting needed healthcare to those impoverished patients who need it is??

        • Doug Farrago
          March 26, 2014 at 11:35 am

          Impoverished? Define that again? Medicaid, a massive and abused safety net, is FREE. It is the middle class that gets hosed in healthcare.

          • JRDO
            March 26, 2014 at 12:12 pm

            My bad. Dr. Gibbons clearly stated ” the uninsured”. So let’s stick with that and I’ll rephrase it. And the realistic alternative to getting needed healthcare to those uninsured patients who need it is?

    • Randy
      March 26, 2014 at 11:44 am

      I think everybody agrees that the need is there for a plan that will help the uninsured, but that doesn’t excuse a poorly conceived, poorly executed plan, nor does it excuse secretiveness about how the plan is working.

      • JRDO
        March 26, 2014 at 12:37 pm

        Actually no, not everybody does agree that there is a need for a plan that will help the uninsured. And, some of those who do agree that there is a need for such a plan, and are critics of the ACA ,have no realistic alternative suggestion. That’s what all the hullabaloo over the universal mandate part of the ACA was. Do you not recall the Supreme Court case in which Justice Scalia compared the need for health insurance to the need for broccoli?

        • Randy
          March 26, 2014 at 1:36 pm

          Sorry, I’ll have to amend my comment to many people, maybe even most, but not all, agree there is a need for a plan to help the uninsured. Personally I think there is a need for such a plan.

          That doesn’t change the point though, which is that regardless of the all the good intentions there is no excuse for poor planning and execution, and unnecessary secrecy.

          • Stella Fitzgibbons
            March 26, 2014 at 1:47 pm

            Your cynicism is well justified. And keep in mind that the ACA would be about half as long were it not for all the favor trading, scratch-my-back and deal-making involved in getting it through Congress & Senate when it was first proposed. I really do not believe that an alternative program would have a snowball’s chance of acceptance, and am 100% sure that the Republicans would just shrug and claim that they tried but the voters just didn’t want it enough. I guarantee that everybody who’s been told their pre-existing conditions rule out any assistance would want it.

          • Doug Farrago
            March 26, 2014 at 4:04 pm

            Yes. The pre-existing condition rule out was a MAJOR advancement. Agreed. But both parties suck and we, as physicians, are also to blame for giving away control of medicine. I will let Pat tell you why as I am sure he knows it better than I

        • Pat
          March 27, 2014 at 2:42 pm

          JRDO, the apparent answer in all cases is naked force… Why does every answer to helping the needy always begin and end with force? Stella mentioned cost-shifting – that in itself is force and there is NOTHING charitable about it. When armies of coders, billers, auditors, and lawyers assault – yes I said assault – doctors in ever increasing numbers over progressively more inane and nonsensical items, then it is only to control us and profit off of us, all under the guise of compassion. The laws, guidelines, ICD/CPT’s, tax codes, NPI’s, UPIN’s, and all the rest are backed up by judicial, arbitrary, and ultimately, armed force. Think I’m being hysterical? Try not paying taxes or running your clinic lab counter without CLIA certification. I have personally talked with doctors falsely accused of Medicaid fraud whose homes were invaded by armed agents (who found nothing, but terrorized the man’s family).

          There are well-intentioned doctors aplenty who find merit in the ACA or who don’t mind accepting a loss of autonomy for “the greater good” or who simply demand that something be done for some without thought as to the consequences for others …. these doctors are being played for chumps, having their own consciences used against them while they themselves are used to club others.

          I do not intend disrespect to those who have walked the same hard path as I, have earned their perspective, and are really trying to help others in need. But I cannot accept force as either a proper tool for a physician, or as a compassionate way to deliver care.

    • Private Doc
      March 29, 2014 at 10:25 pm

      Wrong. The ACA is a complete sham and debacle. I have more uninsured now than before because people are not willing to pay the premiums and the copays and they were refused their previous insurance directly because of the not affordable care act.

      I have even begged them to please just pay one months premium so they can get the tests/interventions needed. Nope they would rather spend it on tattoos, tobacco products and whatever else they want but they are NOT going to spend it on health care.

  3. Randy
    March 24, 2014 at 2:14 pm

    The ACA was strong on hope and rhetoric, but weak on execution. I get the feeling that the folks in charge of this are much more interested in concept than the nuts and bolts of making it work. If we ran our offices like this we’d be out of business.

  4. Pat
    March 24, 2014 at 10:07 am

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