Dr O Brien Answers Unaddressed Questions

							          Unaddressed Questions from Thomas Timothy Smith, MD Program:
              Addressing Healthcare Reform: Reality, Myths and Distortions
                                What it Means for You

Who prepared estimates regarding anticipated 143 billion “savings”? GAO? In what year will
“savings” start to be realized? Ans: The $143 billion in deficit reduction was estimated by the
non-partisan Congressional Budget Office (CBO). The first reduction in the deficit will occur
in 2012.

Medicare (not Medicaid) is “neglected” in the PPACA. There is no provision to pay for cuts to
physician reimbursement rates. Instead, provisions are designed toward “savings” or cuts.
How will physicians afford to accept Medicare patients? Ans: I’m not sure I would use the
term “neglected”; both are pretty well affected by the legislation. But you are correct in noting
that the legislation does not address the scheduled reductions in Medicare payments to
physicians. The Sustainable Growth Rate (SGR) factor enacted in 1997 was not addressed.
However, typically when a date to apply it approaches, the Congress suspends it for a certain
time. The next date it would automatically go into effect is December 1, 2010. Therefore,
physicians will be looking for relief again during the “lame-duck” post-election session of
Congress.

Are the limits on, and eventual phasing out of, health savings accounts purely political moves
or do they have a legitimate justification? Is there any chance of restoring and promoting
health savings accounts or has the recent bill permanently buried it? Ans: Health Savings
Accounts (and Flexible Savings Accounts) are not phased out by the legislation. The tax-
deductibility was capped at $2500 and, as of 2011, untaxed dollars cannot be used to
purchase over the counter drugs unless prescribed by a physician.

Our country currently spends approximately 17% of GDP on healthcare, and I‟ve heard in
60% is government money (SCHIP, Medicare, etc). If we streamlined our system into 1
efficient unit, how much of our GDP (%) would a universal system cost? (Taiwan does it for
7.8%) Ans: This is an imponderable. It depends on many variables—GDP growth, growth of
health care costs, health care utilization, health of the population and others. If we could
reduce our costs of health care to that of the second most expensive system in the world, we
would spend about 8% of our GDP for health care. That also happens to be about the
median for all OECD nations.

For Dr. O‟Brien: How exactly will fraud and waste be reduced in Medicare? Why do you
think the government will stop fraud on a bigger program when it can‟t stop it now?
Fraud is cause? More, many more fraudulent claims and false clinics and false payments I
understand, than inspectors are able to investigate. How can this be fixed? I see no
expansion of inspectors to ferret out fraud. Ans: There are a number of enhancements
(including increased funding and staffing) for anti-fraud investigations, fraud detection,
sharing of data between state and federal programs and substantially increased penalties for
false claims.

Why does Obama care not have any significant support by the majority of the American
population? Ans: If one asks Americans about specific components of the bill, it is clear that a
large majority of Americans support nearly every aspect of the legislation. Further, a very
recent poll found that if those who stated they were in favor of repealing health care reform
were asked “What if repealing the law meant the insurance companies were no longer
required to cover people with existing medical conditions or prior illnesses”? about 40% of
them changed their minds and said it should not be repealed.

Where is government control? So many say this is at takeover by the government of health
care. What aspects of government control are these? Ans: The government defines the
benefit package that private insurers must offer in the exchanges, the exchanges will be
government (state) operated, though they may be contracted to private providers, annual and
lifetime limits will be eliminated.

Why are our Creighton insurance and insurance premiums already going up significantly?
Ans: Actually they are rising much less rapidly than employer provided costs nationally.
Costs are based on employee utilization of health care and the prices of the care. One way
to continue to keep our increases below those of other employers is to participate actively in
the Creighton Wellness Program.

I believe the budget office came out with new numbers since the March 2010 numbers your
site. I recall their early numbers were understated. Ans: No, the CBO has not revised its
estimates of costs and savings.

If someone is on Medicare and their health improves so they can go back to work (off
Medicaid now); is there any waiting period before they can buy insurance from an exchange?
Ans: No.

In regards to physician accountability, how will non-compliant patients be handled and what
will prevent physicians from dropping these patients? Ans: The legislation does nothing to
affect the way physicians deal with noncompliant patients.

How will this act affect those going into the healthcare field several years from now, or affect
those just graduating and continuing on to post-graduate education such as medical school?
Ans: It is likely there will be changes in the way health care delivery is organized,
administered, and reimbursed. The legislation contains funding for demonstration projects
that test the effects on quality and cost of Affordable Care Organizations (ACOs), organized
provider systems so that patients will have “medical homes,” and projects examining the
effects of bundling payments for services.

How do you address the argument that this health care reform will entice citizens to get on
Government provided healthcare? And would that reimbursement rate affect the quality of
healthcare in the US? Ans: The only government provided health care that someone
currently not eligible for it can get will be Medicaid because of the eligibility expansion. One
hopes that providers for Medicaid patients will have the integrity to provide quality of care
equivalent to that they provide all other patients.

Given that expanding access to healthcare is seen as an issue of justice, a la „the preferential
option for the poor,‟ how can we justify paying for it when the nation is in debt so that a future
generation funds our care? How can we be sure the future generation will not be more
impoverished then we are? If so, how is it just to make them pay for us? Ans: As noted in the
presentations, the CBO has estimated that deficits will be reduced in the future, thus resulting
in some alleviation of the burden that federal deficits impose on future generations.
Are there any taxes consequences to those that receive health care insurance as a benefit?
Ans: Only if they are beneficiaries of “Cadillac” plans provided by employers.

How does this act affect immigrant elders? Ans: if they have lawful immigrant status and
have contributed to Medicare as workers, they will be eligible for Medicare with its enhanced
benefits.

Is there a definitive source to find out what all is in this bill? It is to my understanding that they
are still deciding what it contains? Ans: Please see the sources of information provided at or
near the end of the PowerPoint presentations.

If insurance companies cannot look at health status, where does the incentive come for
lifestyle change? Ans: The fact that insurers can risk rate or reject clients doesn’t seem to
provide much incentive now. The best incentive is a desire to lead a full and healthy life. The
legislation does provide a number of measures in support of preventive care and workplace
wellness programs, in which employers provide incentives to participate.

Given the tremendous increase in patient load along with stark shortage of physicians
(~60K), how is the next generation of doctors being trained for this new environment? Ans:
Medical schools are expanding class sizes, some new medical schools have been and are
being established, and postgraduate training positions will be reallocated to primary care.
However, workforce concerns remain. They are addressed by a number of features of the
legislation including incentives for health professionals to enter specialties with shortages and
to practice in underserved areas. Further, there are incentives to train and utilize non-
physician providers and to increase the efficiency of care delivery.

Please speak to the impact of Healthcare Reform Act on hospice care and the delivery of and
utilization of hospice care. Ans: Hospice care will continue to be covered much as it is now
though the legislation enhances access to hospice care for Medicaid and Medicare
beneficiaries. It also funds demonstration projects to evaluate the impact on patient care and
quality of life. Whether new services will be covered will depend on the minimum benefits
package that ultimately emerges. It is also possible that hospice care will increase given
improved end-of-life planning.