Advice and Commentary on the World of Professional Consulting


chapman george updatedCost of care.  Everyone agrees it is just too expensive. We spend much more per capita on healthcare, (about $10,500) than any other developed country in the world. Healthcare is now 19% of our GDP and costs are rising faster than our economy grows. The federal budget is about 3.65 trillion. Healthcare accounts for the biggest chunk of the federal budget at 28% or $1.022 trillion. To put that into perspective, pensions account for 25%, defense 21%, welfare 9%, interest on debt 7%, education 3%, protection 2%, transportation 2%, other 2% and finally general government 1%.  2018 premiums are hard to project because of the uncertainly in the market created by the White House. The actual cost for care will increase around 12% due to factors like medical inflation, aging and morbidity adjustments, and the ACA tax to cover the medically indigent. Experts warn that the conflation of terminating the individual mandate (everyone buys insurance), terminating the subsidies for the indigent (who buy insurance on the exchanges), and just general uncertainty over what Washington is doing could cause rates to jump another 17%.

Coverage or who pays. Almost half of all Americans, 156.8 million people or 49%, are covered by their employer.    On average, employers pay for about two thirds of the employee’s premium. The other half is covered by some sort of government program. 64 million people, or 20% of us, are covered by Medicaid. Medicare covers 44.8 million seniors or 14% of us. 22.4 million or 7% of us are covered by non-employer groups. The 7 million people who purchase individual coverage on the exchanges are part of this group. The VA and federal employment cover 6.4 million or 2% of Americans. The remaining 26.6 million of us or 8% are still uninsured. If the federal government follows through on cutting the subsidies on the exchanges, most likely the uninsured rate will climb.

The culprits. Our costs are high mainly because of prices, (particularly for drugs and implantable devices), administration, inefficiently delivered and unnecessary services, fraud and emphasis on treatment versus prevention. All told, it is estimated that the above “culprits” cost us around $765 billion per year. Ironically, a contributing culprit could be we don’t see/use our physicians enough. We average 4.1 doctor visits a year. People in developed countries with far lower costs and better health status see doctors more often: Australia 6.7, Canada 7.4, France 6.8, Germany 9.7, and the U.K. 5 visits.  Our high deductible plans may be keeping us from seeing the doctor when we should. Drugs developed in the US are cheaper in most other countries. For example, in 2015 the heartburn medication Nexium sold in the US for about $215. It was $60 in Switzerland, $58 in Spain, $42 in England and $23 in the Netherlands.

Profit margins.  Most people believe the insurance companies are making the big money. Highly publicized CEO salaries and the president threatening to “cut the subsidies to greedy insurance companies” may contribute to this belief. The average profit margin for insurance companies is 3.2%. The ACA actually capped how much of the premium an insurer could retain for operations at 15%. If an insurer spent only 80% on claims, retaining 20%, they had to refund 5% of the premium to consumers. The 15% covers marketing, reserves, administration and profit. So after covering their operating expenses, the average profit was just 3.2% for insurance companies.  The average profit margin for drug manufacturers is 20.8%; medical instruments and supply companies average 12.5%; medical appliance and equipment sellers average 9.5%. Hospitals average 3.7%.  While profits are quite healthy for the drug and manufacturing companies, medical debt is the #1 for personal bankruptcies for people with insurance and without insurance. 62% of filings for personal bankruptcy are due to medical bills. Job loss, excess credit, divorce and unexpected expenses round out the top 5 reasons for personal bankruptcy.

Performance.  Ever since comparisons have been made, our healthcare system pales when compared to other developed countries. Based on a variety of measurable and accepted factors, the highly reputable World Health Organization ranks the US #37. Ahead of us are countries like France, Italy, Spain, Japan, the U.K., Germany, Canada, Australia, Greece, Norway, Ireland and Sweden.  The Commonwealth Fund compared 11 countries on things like: prevention, safety, coordination, accessibility, affordability, timeliness, administrative efficiency, equity throughout all income levels and nine measures of healthcare outcomes or status. We came in dead last behind #1 U.K., #2 Australia, #3 Netherlands, #4 New Zealand, #5 Norway, #6 Sweden, #7 Switzerland, #8 Germany, #9 Canada and #10 France.

Hospitals.  There are about 5,500 hospitals in the US with almost 900,000 staffed beds admitting 35 million of us per year. 80% of hospitals are not for profit. In NYS, all 195 hospitals are not for profit. 1,800 hospitals are located in rural communities and they are the most vulnerable financially in an increasingly competitive and volatile market. Hospital consolidation, through mergers and acquisitions will save many of the at risk rural and smaller suburban hospitals. The Accountable Care Act was the catalyst for increased M&A activity, encouraging larger, integrated, comprehensive and more efficient delivery systems. It will very rare in the near future to find an independent stand alone hospital. Most will become cogs in a huge clinical wheel. The FTC is keeping a wary eye on hospital consolidation. So far, consolidation has saved some failing hospitals and improved recruitment of physicians but it has not resulted in lower prices for consumers. If consolidation ultimately results in a virtual monopoly that won’t negotiate price with insurers, the FTC will step in and break it up.

Physicians.  More than half of all active physicians are now employed by a hospital or healthcare system.  As the business side of medicine becomes more regulated, confusing and complicated, the trend away from the hassle of private practice will continue. Depending on your source, the number of active physicians varies significantly. According to the Kaiser Family Foundation there are about 923,000 professionally active physicians. According to the Association of American Medical Colleges there are about 861,000. Dire predictions of a severe shortage of physicians seem to highly exaggerated.  If you split the above difference in the number of active physicians and call it 900,000, that would be about one physician per 360 of us. (US pop. about 323,000,000) About half the active physicians are in primary care. That would still be just 720 of us per primary care physician which seems more than manageable despite our aging population. Some of these self- serving predictions fail to account for or minimize the impact of 88,000 Physician Assistants, 160,000 Nurse Practitioners, technology, telemedicine and increased consumer involvement in our care.

The leading killers. The average life expectancy in the US is 79 years.  75% of all deaths can be attributed to just 10 causes. Heart disease is the #1 killer at 23% of all deaths. Cancer is #2 causing 23% of all deaths. Chronic lower respiratory disease (COPD) is 3# causing 5.6% of all deaths. The rest are: #4 accidents, #5 strokes, #6 Alzheimer’s; #7 diabetes; #8 flu and pneumonia; #9 kidney disease and #10 suicide. Moving quickly up the top killer list is overdose from opioid/heroine. 140 people a day or 51,000 a year die from overdosing on oxycodone, fentanyl, codeine, hydrocodone, etc. Once the prescription expires, addicts turn to cheaper heroine.    

Good health. 50% of good health is impacted by your “life”. That includes factors such as income, disability, education, social exclusion, social safety net, gender, employment or working conditions, race, diet, housing and sense of belonging to your community. 25% of good health is impacted by your healthcare including access to care, the system you choose and wait times. 15% of good health is affected by your biology and genetics. Finally, 10% of good health depends upon air quality and civic infrastructure. Of the factors you can control, keeping in contact with your primary care physician is the best thing you can do to reduce or mitigate, if not completely prevent, untoward health events.

Sandy Stefano of Sandler Training led the Professional Consultant's Association's October meeting on the topic titled Developing A Business Development Plan for 2018. Sandy was the perfect person to lead it because her company trains people on sales and prospecting... and it's literally her life.

Sandy Stefano Sandler TrainingShe started out asking the group what the definition of business development was. After a lot of responses, she defined it as "a Broadway show played by a psychiatrist". After the laughter died down, she reasoned that we as consultants, many sole proprietors, work on finding the need our potential clients have for whatever services we provide. We need to do this by using the process of asking questions to get the prospects talking so we can listen, like psychiatrists to find out where the pain might be laying.

Then we talked about the process of clearing the garbage out of our own minds so we can focus on the issue at hand. We all tend to question ourselves and have periods when we feel defeated, which she addressed with a triangle that showed how we should reorient our minds towards getting new clients. The idea of establishing a behavior that we can maintain along with refining our techniques helps all of us maintain a positive attitude... even when we're getting beaten down mentally.

Sandy laid down 3 things all of us need to work on attaining to help our careers go better. The first is partners, those who are willing to work with us in finding new clientele as well as offering support; the second is referrals from clients we've worked with who've appreciated what we've done for them; third is a list of potential clients, as many as you can who you believe should be your target market. The more the merrier, because you never know if a potential client might have a potential client for you.

She said a couple of things that resonated greatly with the audience. The first is that she's always prospecting because, no matter how good the work is they do, every year they lose around 35% of their customers, which means they need to refill the pipeline. The second is that it could take up to 8 attempts just to get through to a potential customer... not close a sale, just to reach them. That's daunting, but her position is that if we take care of the points of the triangle mentioned above that this becomes part of a process and removes all the emotional baggage from our heads.

Next on the list was our addressing 30-second commercials, something PCA does at the beginning of every meeting. She offered 3 things that every statement needs to have: your name and company name; the type of company you work for; what you do to help your clients. This is big because at least half the people in the room owned up to doing 2 out of 3 of these, with the last piece often missing. This is especially important if you're using the phone to reach contacts and need to leave a message. She agreed that it also helps to tell people on messages that you'll continue calling regularly, but if they wish you to leave them alone to ask them to call and say so. This is an important addition; if they call, tell them you'll leave them alone for a specified period of time, 6 months to a year, before trying to reach out to them again, and then see if they tell you not to bother or are open to hearing from you later on.

The finale of the presentation left us with 4 Sandler Rules we all should follow:

* You never have to like prospecting, you just have to do it
* A prospect who is listening is no prospect at all
* There are no bad prospects, only bad salespeople
* You can't lose anything you don't have

It was a wonderful presentation and we all learned a lot. We all thanked Sandy, who's also a member of PCA, for giving us this great information.

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by George Chapman, GW Chapman Consulting

ACA Update.  Five Republican and five Democrat senators put aside politics and gave their “common ground” testimony before the Senate’s Health, Education, Labor and Pension committee. In doing so, they encouraged the entire Congress to do the same and fix the ACA together. The 10 senators jointly recommended: funding the cost sharing reduction payments (that the President has threatened to terminate);  re-enforce the individual mandate and encourage more younger and healthier people to buy health insurance; give states greater latitude to experiment and tinker; and, finally, address soaring costs. In the meantime, the Senate’s parliamentarian has ruled that the fast track “filibuster proof” approach  used by Republicans to repeal the ACA, known as budget reconciliation, expires  September 30 which means (as this article goes to press) there probably won’t be a repeal do-over till October 2018.

Obesity progress.  After several years of rapid increases, national  obesity levels have leveled off in 2015 and 2016. Industry observers worry that the relatively “good” news may cause policy makers to become complacent and ease up on the accelerator. Efforts to help us lead healthier lives must be kept up at full speed. Colorado had the lowest obesity rate at 22% while West Virginia had the highest rate at 38%.  Obesity is defined as a Body Mass Index (BMI) of 30 or more. I BMI of 30 is about 30 pounds overweight. The highest concentration of obesity is in southeastern states.

ER usage.  Most payers and regulators have historically placed a lot of blame for our high cost of care on unnecessary or avoidable emergency room visits.  A recent study published in the International Journal for Quality in Healthcare has debunked the myth that too many people use emergency rooms needlessly. Researchers studied 115,000 records representing  424 million visits over a 5 year period and concluded just  3% of the total ER visits were “avoidable”.  A number of these visits were for things most ERs are not equipped to deal with like dental or mental health problems. About 7% of the avoidable visits were for alcohol or mood related disorders and about 4% of the avoidable visits were for dental issues. The researchers defined an avoidable visit as one that did not require diagnostic tests, screening procedures or medications. Researchers  concluded that the vast majority of  us do not use ERs for primary or routine care and that we need to focus on access to dental and mental conditions after normal business hours.

Physicians treat all the same.  Historically, government plans like Medicaid and Medicare have not paid  physicians as well as most private payers. (Although in recent years private payers have tended to drop their rates closer to Medicare rates.) It would seem that people with poorer paying plans might receive less or worse care than people with better paying plans. While “you get what you pay for” is true in most industries,  it is NOT in healthcare.  The vast majority of physicians treat the patient, not their insurance plan. While your plan may not pay for a certain test or procedure, it is of no concern to the physician who is going to do what is best for you in his/her clinical judgement.  A recent study proves this, even if in a roundabout way. The study was published in the Journal of the AMA Internal Medicine. It  found no difference in the rates that low value services were provided to Medicaid covered patients versus commercial/private covered patients. Physicians tend to order the same low value (almost useless) tests and services indiscriminately. Also, it does not appear that Medicaid patients are forced to see “lower quality” providers. While the bad news is providers are still ordering “low value” tests and services, the good news is that none of us are being discriminated against because of our health plan. Just about all providers make it clear up front what insurances they accept, so once you’re in the exam room your insurance is moot.    

CVS and Walgreens sued.  Consumers are claiming the two large pharmacy chains failed to inform them that it would be cheaper, less out pf pocket, to simply pay cash for certain medicines versus going through their insurance. Insurance copayment amounts often exceeded the actual cost of the drug.  This fraud is called a “clawback”.  For example, the consumer has a $50 copay on prescriptions, but the drug only costs $30.  According to the lawsuit, the pharmacy chains are in cahoots with the pharmacy benefits manager Express Scripts.   

Hospitals fail to meet expectations.  A report published by Kaufman, Hall and Associates revealed only 8% of 125 healthcare organizations surveyed met consumer expectations. The report found that while almost all organizations say improving the patient experience is a high priority, just 30% have the capability to do so. Only 15% are making a concerted effort to improve patient access with diverse locations and digital connectivity and less than 10% see price transparency as a high priority, The managing director of Kaufman concluded that in the age of Netflix and Amazon, consumers expect a lot more from their providers and “consumerism” should be a core capability as it will be a key to long term sustainability. (In fairness to healthcare organizations, they are highly regulated and have nowhere near the access to capital that Amazon and Netflix have.)

Aetna and Apple.  The health insurance and consumer technology giants are considering making the Apple watch available to Aetna’s 23 million members. Aetna already subsidizes the cost of an Apple watch for its 50,000 employees. This may be no more than more of a marketing ploy by Aetna to attract younger more tech savvy members than as most studies of person wearable fitness devices are at best inconclusive when it comes to showing any improvement in the health of the device wearer.  Proponents feel that anything that makes people more health conscious is a good thing while critics are concerned about the invasion pf privacy and the potential nefarious use of date derived by the insurer.

Aging.  The state of Washington leads the country when it comes to helping its seniors “age in place” according to a study by AARP and The Commonwealth Fund. Everyone prefers to live at home for as long as possible and to avoid a nursing home for as long as possible. The average cost of home care is $128 a day nationwide. The average cost of a nursing home is $230 a day nationwide. Washington State has made support for home and community based care a priority. It provides a adult day care, assisted living and even foster care as options for the infirmed elderly. This is far preferable to family care givers as well. Washington also empowers home health aides to provide more care. Through its “No Wrong Door Program”,  highly trained staff either answer your questions or direct you to the right place. Washington provides more housing alternatives to  nursing homes than most states. Nationwide, about 52 of 1,000 people over 75 reside in an assisted living facility. In Washington, it’s double that.

 

The first Professional Consultant's Association of Central New York meeting of the year was a roundtable discussion on the topic of writing and how important it is for your business. It was led by Mitch Mitchell of T. T. Mitchell Consulting, Inc (disclaimer; the writer of this article and most of the article's on this site are by Mitch Mitchell, but it's being intentionally written in 3rd party mode) and covered a host of topics relating to the writing process.

Mitch MitchellMitch began by showing some of the types of email and regular mail correspondence he receives on a regular basis from people hoping to work with him. Most of the letters suffer from multiple types of errors. The most common are misspellings, copied form letters (which means receiving the same exact letter from multiple companies) and letters that either refer to something he doesn't do or where they forget to mention his name. Some of the membership believed form letters going out to client isn't necessarily a bad thing as long as the letters are sent to specific people, but everyone got a chuckle realizing that the same exact letter with minor changes is a common thing many companies do.

Next he got into talking about 10 things that consultants should avoid when it comes to writing letters, blogs, articles or contracts. We spend the most time on contracts, where the discussion talked about a couple of different things.

The first was whether we should be writing the contracts or allowing our potential clients to put them together. There was no consensus on this except to say that it depended on the client and the work being requested. We did agree that if we write the contracts that not only should they be relatively short and easy to understand, but we should always explain the deliverables that the client should expect to receive from us. Contracts should also always have an area talking about price, and they should establish what they expect to be paid rather than dodging the issue; it's a waste of time not to discuss rates when you've gotten to the point where a contract is finally required.

The second was whether consultants should have lawyers reading contracts that come from clients where not only are they long but there's a lot of legal speak. This can be scary for newer consultants because they're worried that the client might decide to go a different route and we're all looking to work with paying clients. The group consensus was that if we're comfortable reading the entire contract that we probably don't need a lawyer, but if anything looks suspicious or dodgy that paying a lawyer to review it might be prudent. We also agreed that anything we see in a contract that we don't like should be brought to the attention of the client and somehow worked out. It's always better to address things up front to protect yourself rather than waiting for problems to occur and find out that you're trapped in the terms of a contract you signed.

The final piece was talking about ways writing could benefit all consultants in helping to brand their business or create publicity for themselves. Those six items were:

     * write a book

     * write a blog

     * write an article

     * write a white paper

     * create a digital product

     * create an online portfolio

As always, the roundtable presentation created a great discussion by the members of the organization, and hopefully everyone left taking away something they can use in the future. That's the best thing about working with consultants; everyone has enough ideas to go around.

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by George Chapman, GW Chapman Consulting

House repeals ACA.  It took over seven years, but the House finally managed to get enough votes, barely, to repeal the Affordable Care Act (ObamaCare) and replace it with the American Health Care Act (TrumpCare). The fate of the AHCA bill now is in the hands of a much more moderate Senate. Once enough votes were pledged, the bill was intentionally sent to the floor for a House vote before the Congressional  Budget Office could take a look at the bill and figure out what the financial and coverage consequences would be.

If you recall, the CBO estimated that the original version of the AHCA would cause 24 million people to lose coverage. The revised bill sets aside $8 billion for pre-exiting conditions or for high risk pools. That sounds like a lot, but it is only $1.6 billion per 5 years. According to industry experts, about 226,000 people had pre-exiting conditions covered by the ACA at a cost of $2.5 billion in 2011. So the $8 billion proposed by the ACHA would only cover about half the 226,000 people with pre-existing conditions. Employer plans could be impacted by the AHCA by a provision that could jeopardize the current cap on out of pocket expenses.

The bottom line is sicker people will pay a lot more for their insurance or go without. The latter option means hospitals and physicians will once again be faced with providing uncompensated care to the people who are the sickest and most vulnerable. Almost all of the industry’s major trade associations have expressed their concerns over potential reductions in insurance subsidies (cost sharing reductions) including: American Medical Association, American Nurses Association, American Hospital Association, and American Health Insurance Plans. The CBO analysis of the ACHA sent to the Senate should be out by the time you read this.     

AHCA pre-existing conditions. The list is far more extensive and pervasive (ridiculous?) than you think. The ACHA would allow all commercial insurers to charge more all their customers for the following: cancer, chronic obstructive pulmonary disease, Crohn’s disease, cystic fibrosis, depression, diabetes, down syndrome, eating disorders, epilepsy, glaucoma, gout, heart diseases, heartburn, high cholesterol, hypertension, kidney problems, mental health issues, sleep disorders, TB, and tooth disease among others. This issue, along with cost sharing reductions  will get the most attention when the Senate takes a look.

Drug prices. Americans use more drugs per capita than any other country. We also pay more for drugs than other country. Drugs now account for 10% of total healthcare spending. Recent accounts of price gouging by drug companies has brought the issue to the forefront. Even drugs made right here in the USA are cheaper in most other countries. The simple solution is already on the books. The FDA is empowered by the 2003 Medicare Modernization Act to allow drug imports to the USA, if they are deemed safe and less expensive. The drug lobby has been very effective at preventing anyone in the FDA or HHS from employing this provision. It is ultimately up to the President, who oversees HHS and the FDA, with one executive order.

VA closures. The VA is contemplating closing over 1,100 vacant and underutilized facilities in order to save $25 million a year and to shift more care to the private sector. President Trump recently signed a bill extending the period in which vets can seek medical care from private physicians and hospitals. The move towards privatization was recently accelerated by reports of long, often fatal, waits for care at certain VA facilities.

End of life.  According to an “end of life”  survey conducted by the Kaiser Family Foundation, half of the respondents believe they will not be in control over their own medical decisions towards the end of life. 56% said they are more likely to have serious discussions with a family member than with a physician. Only 11% of the respondents said they have discussed end of life wishes with their personal physician. 71% of the survey respondents said they would prefer to die at home, but only 41% expected to do so. 54% do not want their family members burdened by their care. 42% said once they are deemed terminal, they just want to be comfortable and pain free. Only 23% of respondents wanted to live as long as possible, no matter what it takes. It is natural to postpone or not even think about end of life decisions while relatively young, but one never knows what will happen in life. We are being encouraged to broach the subject with our primary care physicians, so when the time comes we will maintain control and our wishes will be honored.

Healthcare dilemma.  The healthcare industry has added a lot of jobs to the economy over the last ten years and most of the jobs are good paying jobs. The increase in hospital staffing has been in response to an aging population, increased regulatory burdens and increased demand for services as more people are insured. Reimbursements that have not kept up with  increasing costs and the uncertainly over the AHCA (TrumpCare) have caused even the largest hospital systems to reduce staff. Brigham and Women’s Hospital in Boston announced plans to offer buyouts to 1,600 employees. Catholic Health Initiatives will cut 900 positions through layoffs and buyouts. The Anderson Cancer Care Center in Texas plans to cut 1,000 jobs. NYC Health & Hospitals announced organizational restructuring that would eliminate 600 positions across their system. Before the ACA was repealed, the Urban Institute estimated even a partial repeal of the ACA, let alone a full replacement, would increase uncompensated care to providers by about $1 trillion a year for the next 10 years. Many hospitals will face credit downgrades if the ACHA causes millions to lose their insurance. To make matters worse, as staffing cuts are made, hospitals must deal with increasing physician and nurse burnout.

We’re #37. The World Health Organization ranks the healthcare systems in 190 countries. The rankings are based upon several factors including: the overall health of the population; health disparities within the population (poor v. rich; public insurance v. private insurance); system responsiveness/patient satisfaction; distribution of responsiveness within the population (uninsured v. insured; urban v. rural);  distribution of financial burden (who pays: government, employer, self). All things considered, the WHO ranks the US  #37. The top 5 countries are: France, Italy, San Marino, (an independent sovereign country within Italy); Andorra, (an independent  sovereign country between Spain and France), and Malta. Other notables are: UK #18, Germany #25, Canada #30, Russia #130, China #144. In last place at #190 is Myanmar. The US remains firmly entrenched as the #1 country for highest cost per capita at about $10,500 and percentage of GDP at about 18%. In the 1960s, healthcare was 5% of the US GDP.

Warren Buffett’s take.  At the annual meeting of Berkshire Hathaway, Buffett, the founder multi-billionaire and philanthropist was asked if the AHCA was a good first step in a broader strategy to relieve the tax burden on American businesses. Buffett responded that taxes aren’t the problem. If you want to make American businesses more competitive you have to fix what it costs us for healthcare. He labeled our healthcare costs/system “the tapeworm of American competitiveness”. It is 18% of our GDP. Other countries spend an average of 11%, so US businesses are at a huge competitive disadvantage. He advocates a single payer system to drive down costs and waste.   

House repeals ACA.  It took over seven years, but the House finally managed to get enough votes, barely, to repeal the Affordable Care Act (ObamaCare) and replace it with the American Health Care Act (TrumpCare). The fate of the AHCA bill now is in the hands of a much more moderate Senate. Once enough votes were pledged, the bill was intentionally sent to the floor for a House vote before the Congressional  Budget Office could take a look at the bill and figure out what the financial and coverage consequences would be. If you recall, the CBO estimated that the original version of the AHCA would cause 24 million people to lose coverage. The revised bill sets aside $8 billion for pre-exiting conditions or for high risk pools. That sounds like a lot, but it is only $1.6 billion per 5 years. According to industry experts, about 226,000 people had pre-exiting conditions covered by the ACA at a cost of $2.5 billion in 2011. So the $8 billion proposed by the ACHA would only cover about half the 226,000 people with pre-existing conditions. Employer plans could be impacted by the AHCA by a provision that could jeopardize the current cap on out of pocket expenses. The bottom line is sicker people will pay a lot more for their insurance or go without. The latter option means hospitals and physicians will once again be faced with providing uncompensated care to the people who are the sickest and most vulnerable. Almost all of the industry’s major trade associations have expressed their concerns over potential reductions in insurance subsidies (cost sharing reductions) including: American Medical Association, American Nurses Association, American Hospital Association, and American Health Insurance Plans. The CBO analysis of the ACHA sent to the Senate should be out by the time you read this.     

AHCA pre-existing conditions. The list is far more extensive and pervasive (ridiculous?) than you think. The ACHA would allow all commercial insurers to charge more all their customers for the following: cancer, chronic obstructive pulmonary disease, Crohn’s disease, cystic fibrosis, depression, diabetes, down syndrome, eating disorders, epilepsy, glaucoma, gout, heart diseases, heartburn, high cholesterol, hypertension, kidney problems, mental health issues, sleep disorders, TB, and tooth disease among others. This issue, along with cost sharing reductions  will get the most attention when the Senate takes a look.

Drug prices. Americans use more drugs per capita than any other country. We also pay more for drugs than other country. Drugs now account for 10% of total healthcare spending. Recent accounts of price gouging by drug companies has brought the issue to the forefront. Even drugs made right here in the USA are cheaper in most other countries. The simple solution is already on the books. The FDA is empowered by the 2003 Medicare Modernization Act to allow drug imports to the USA, if they are deemed safe and less expensive. The drug lobby has been very effective at preventing anyone in the FDA or HHS from employing this provision. It is ultimately up to the President, who oversees HHS and the FDA, with one executive order.

VA closures. The VA is contemplating closing over 1,100 vacant and underutilized facilities in order to save $25 million a year and to shift more care to the private sector. President Trump recently signed a bill extending the period in which vets can seek medical care from private physicians and hospitals. The move towards privatization was recently accelerated by reports of long, often fatal, waits for care at certain VA facilities.

End of life.  According to an “end of life”  survey conducted by the Kaiser Family Foundation, half of the respondents believe they will not be in control over their own medical decisions towards the end of life. 56% said they are more likely to have serious discussions with a family member than with a physician. Only 11% of the respondents said they have discussed end of life wishes with their personal physician. 71% of the survey respondents said they would prefer to die at home, but only 41% expected to do so. 54% do not want their family members burdened by their care. 42% said once they are deemed terminal, they just want to be comfortable and pain free. Only 23% of respondents wanted to live as long as possible, no matter what it takes. It is natural to postpone or not even think about end of life decisions while relatively young, but one never knows what will happen in life. We are being encouraged to broach the subject with our primary care physicians, so when the time comes we will maintain control and our wishes will be honored.

Healthcare dilemma.  The healthcare industry has added a lot of jobs to the economy over the last ten years and most of the jobs are good paying jobs. The increase in hospital staffing has been in response to an aging population, increased regulatory burdens and increased demand for services as more people are insured. Reimbursements that have not kept up with  increasing costs and the uncertainly over the AHCA (TrumpCare) have caused even the largest hospital systems to reduce staff. Brigham and Women’s Hospital in Boston announced plans to offer buyouts to 1,600 employees. Catholic Health Initiatives will cut 900 positions through layoffs and buyouts. The Anderson Cancer Care Center in Texas plans to cut 1,000 jobs. NYC Health & Hospitals announced organizational restructuring that would eliminate 600 positions across their system. Before the ACA was repealed, the Urban Institute estimated even a partial repeal of the ACA, let alone a full replacement, would increase uncompensated care to providers by about $1 trillion a year for the next 10 years. Many hospitals will face credit downgrades if the ACHA causes millions to lose their insurance. To make matters worse, as staffing cuts are made, hospitals must deal with increasing physician and nurse burnout.

We’re #37. The World Health Organization ranks the healthcare systems in 190 countries. The rankings are based upon several factors including: the overall health of the population; health disparities within the population (poor v. rich; public insurance v. private insurance); system responsiveness/patient satisfaction; distribution of responsiveness within the population (uninsured v. insured; urban v. rural);  distribution of financial burden (who pays: government, employer, self). All things considered, the WHO ranks the US  #37. The top 5 countries are: France, Italy, San Marino, (an independent sovereign country within Italy); Andorra, (an independent  sovereign country between Spain and France), and Malta. Other notables are: UK #18, Germany #25, Canada #30, Russia #130, China #144. In last place at #190 is Myanmar. The US remains firmly entrenched as the #1 country for highest cost per capita at about $10,500 and percentage of GDP at about 18%. In the 1960s, healthcare was 5% of the US GDP.

Warren Buffett’s take.  At the annual meeting of Berkshire Hathaway, Buffett, the founder multi-billionaire and philanthropist was asked if the AHCA was a good first step in a broader strategy to relieve the tax burden on American businesses. Buffett responded that taxes aren’t the problem. If you want to make American businesses more competitive you have to fix what it costs us for healthcare. He labeled our healthcare costs/system “the tapeworm of American competitiveness”. It is 18% of our GDP. Other countries spend an average of 11%, so US businesses are at a huge competitive disadvantage. He advocates a single payer system to drive down costs and waste.