RUSH: Here’s Stacy, somewhere in Georgia. Great to have you with us on the EIB Network. Hi.
CALLER: Dittos, Rush.
RUSH: Thank you.
CALLER: Hiding under a tree hoping I won’t be seen. I wanted to talk with you about how the government or how Obama is going to do that thing about quality versus quantity.
RUSH: Yeah, and the bundling the payments.
CALLER: Yeah. And I also wanted to say, I’ll say it for you, Obama is a liar. There is no such thing as preexisting condition exclusions for life. So, sorry, no better, you can’t pull that one off on me.
RUSH: Wait a minute, translate that one for people in the audience. There’s no such thing as permanent exclusions for preexisting conditions for life. What does that mean?
CALLER: That is true. Anyone who signs onto a group policy, which is 90% of all insured, sign on under the HIPAA law from ’96. The maximum waiting period for a preexisting condition is one year. That one year is reduced by the number of months in the previous calendar year you have coverage. For example, if you work for a company and you have insurance there, you change jobs, go to a different company, every preexisting condition you have is covered with a certificate of credible coverage from your previous insurance company. So Obama can’t pull that one on me. I know he’s a liar.
RUSH: I have to ask you how you know this.
CALLER: I work in insurance, which is why I’m hiding under a tree behind a car hoping nobody sees me.
RUSH: That’s what I would hope you would say. I wanted to make sure that you had credibility to know what it is that you’re saying and discussing.
CALLER: Well, sir, I’m a business systems analyst on a claim system, a medical claim system, so I’m very familiar with it.
RUSH: And you are at this very moment making this phone call hiding under the shade of a tree?
CALLER: In the parking lot, yes, sir. (laughing)
CALLER: I also wanted to talk about how Obama is going to do this and I can’t claim all the credit for this thought. This morning I saw on the news someone talking capitation, and that sounds exactly like what they are going to do. Capitation is where the doctor does not get paid by visits or procedures. Capitation is a primary care physician payment where they pay you per person you treat in a month. So if you have 50 patients, you get paid X-number of dollars for each patient each month.
RUSH: I gotta take commercial but I’ve got questions about this one.
RUSH: Can you hang on? Have you got enough time? Can you stay secret and secluded long enough?
CALLER: Will you give me a note for my meeting I’m going to miss?
RUSH: Yeah, absolutely, absolutely.
RUSH: We rejoin Stacy from a secluded, unknown location in Georgia. She is an expert in the health insurance business. She does not want to divulge her location because her industry and people in it have been demonized. And we were in the middle of a conversation on a decapitation of doctors. I want you to start — (laughing) — start again on this. This is about bundling.
CALLER: Yes. Capitation, folks who had HMO plans back in the eighties and early nineties will remember this. Capitation is where a doctor — you have to sign up with a primary care doctor. Your doctor submits a report that says I have a hundred people assigned to me as my primary care people.
RUSH: Submits that to the HMO?
RUSH: All right.
CALLER: Way, way back. So the company, or in the government’s case, the government would pay that provider X-amount of dollars, say $10 per patient, per month, regardless of whether he sees them or not.
RUSH: And regardless what it costs him to treat them if they need it?
RUSH: Will you explain something to me?
CALLER: Yes, sir.
RUSH: I don’t know how that ever survived. What doctor worth his salt would put up with that deal?
CALLER: Well, the thing is we can promote volume using that. I mean if you only have a hundred primary care doctors in a 200,000-person area you get volume so it’s Walmart deals for medical doctors.
RUSH: Okay. So this is what Obama is talking about, we’re going to change from quantity to quality?
CALLER: But now here’s the thing. Capitation also involves how many times a primary care physician has to refer a patient to a specialist and his payments are reduced when he has to do that. So a doctor has —
RUSH: Hey, now, wait, wait. Now, you’re a great, great source of information, and I got questions, so pardon my interruptions, but I just want to make sure I heard this right. I understand the capitation and a hundred patients get paid ten bucks whatever it was whether they were seen or not, but if a patient needs to be referred to a specialist for a test or something, based on a diagnoses, then the payment of $10 is reduced?
CALLER: Exactly. And it depends on how they want to do it, if they want to do it as a percentage, as a flatline fee, but that amount of capitation will be reduced.
RUSH: Okay, now, does that incentivize the doctor not to refer people who should be referred?
CALLER: It not only incentivizes that, but it also incentivizes the doctor not to see patients. Because if he brings a patient in and it costs him 50 bucks to do a visit, and he’s only get paid $10 for that visit he’s losing —
RUSH: But how can he refuse to see them? The patients needs to see the doctor, patient calls, ‘I’m coming in,’ the doctor says, ‘No, screw you?’
CALLER: Well, yeah, I mean they can say, ‘Well, it’s a three-week wait.’ If you’ve got the flu it’s over. I mean if it’s anything other than a serious condition it’s gone in three weeks, the things people go to the doctor for, the hangnails, the flus, the colds, it’s over by then. And, now, remember, you also in the eighties and nineties had a younger population structure. There weren’t as many elderly people with the chronic conditions. You didn’t have the diabetes issues that you have today. You didn’t have a lot of these things that are building now.
RUSH: Why not?
CALLER: Well, because the population as a whole was younger.
RUSH: Yeah, but type 2 diabetes, I mean type 2 diabetes can happen when you’re 25.
CALLER: Well, it can but it’s more common the older you get. The same thing with arthritis, the same thing with cardiac problems, the same thing with all these type of illnesses and conditions that come with getting older are going to necessitate more visits with more procedures. It’s just an average. It’s statistical.
RUSH: Okay, now, I’m going to tell you why this is so valuable to me, your information is.
RUSH: I’m very fortunate. I don’t use my insurance when I need to go to the doctor and I haven’t been to the doctor in, what, two years. I just don’t go for a flu, for the cold. The last time I went to the doctor was when I held out, I had some intestinal thing and I held out for three weeks. I just don’t go. I don’t like it, I’m not paranoid, I’m not a hypochondriac, I just don’t go. Now, people say, ‘You’re getting older, you need to get checkups anyway, do these colonoscopies, the prostate,’ I got that handled. But the story you’re telling me, my first question is, what doctor would put up with this?
CALLER: Well, like I said, it was the Walmart model until the population demographics changed and the procedures. Remember in the eighties, we didn’t have the blood tests, the MRIs, the CAT scans, all these things that we do now.
RUSH: I have heard doctors complain, because of sports stars getting MRIs 25 times a season, more and more people come in with a sprained knee and want an MRI.
CALLER: About what you said on Greta’s show, too, about the major medical —
CALLER: — about catastrophic. The HSAs with the high deductible health plan is an attempt to get back to that. The federal government and state governments have basically outlawed catastrophic coverage. The HSA with the high deductible health plan is an attempt to get around those rules —
CALLER: — but the patient still pays —
CALLER: — for the doctor’s visits —
RUSH: HSA is a health savings account —
RUSH: — for those of you in Rio Linda.
CALLER: Right. We would love to sell catastrophic. We would love to do these things, but we can’t. The law won’t allow us to do that. So the quality part will be how many times does the doctor send a patient to a specialist or how many times does patient end up in the ER with some condition and he will be penalized based on those counts. And because all of your medical records are now in Washington, DC, they can track this with precision accuracy.
RUSH: Yeah. By the way, am I also right when I postulate that for Obama to judge doctors’ work on a qualitative basis, quality basis rather than quantity, somebody in Washington is going to have access to everybody’s medical records to find out how the patient is being dealt with and treated, right?
CALLER: Oh, absolutely. That’s the first step in digitizing, that’s why they want to digitize everyone’s records.
RUSH: All right. Now, the next question may be a toughie but given all that you’ve seen and all that you do because it’s your business, if you were in charge of fixing all of this, do you have a blueprint, just a basic blueprint without getting into all kinds of details, what would you do to fix this?
CALLER: The first thing I’d do is scrap mandates, both federal, state, and, local. Allow groups to select the health plans that they want and that their people need. I’d do tort reform, of course. But the mandates I think are the biggest thing. You have mandates that cover all kinds of things, you know —
RUSH: All right, explain to people what a mandate is.
CALLER: A mandate is where your state government — typically it’s state but there are federal mandates — come in and say you must cover mammograms for people 35 and older. Well, that means that no insurer, no group who is self-insured that uses an insurance company for claims processing, they must cover that procedure, under those guidelines, so everybody has to pay for it. You could be a construction company hiring a hundred guys, not one of them needs a mammogram but you still have to pay for that coverage.
RUSH: That’s almost enough for a construction guy to go get an addadictomy operation.
CALLER: Well, if he’s a guy he doesn’t need one right? (laughing)
RUSH: Well, that’s true, it’s the other way around.
CALLER: So the takadickoffamy, maybe, but — (laughing)
RUSH: Yeah, we have a different name for it, but yours works. So the Obama plan’s got federal mandates all over the place and —
CALLER: Oh, he does.
RUSH: — and they’re largely political.
CALLER: Oh, absolutely. I guarantee you you will see sexual orientation drug therapy and surgical procedures covered. I was shocked, I read House bill 676 before I finally just decided to either blow my brains out or go back to work and they’re covering chiro, they’re covering podiatry, they’re covering all kinds of stuff we don’t cover because it’s not AMA approved, I mean all these things, you’re looking at it going, ‘How in the world are they going to cover all of that?’
RUSH: This is a ball game. Once they get this they are going to be able to regulate every aspect of everybody’s life.
CALLER: Oh, you know, and this nonsense he talks about, oh, well, you know, your insurance company is getting between and you your doctor? Bull crap. Because I tell you now if your insurance company says you don’t need an MRI for that sprained ankle, you know, wait a month if it’s still bad we’ll talk, you can still make your own appointment, go down there and pay for it yourself. When Obama’s stuff comes through you won’t have that option. You won’t have the option to say, well, I think I need it anyway so I’m going to pay it. Furthermore, insurance companies, the last thing we want to do is cut your claim. We want it to pass through our system without a human being ever looking at it, and pay as it should. That’s what we want.
RUSH: Don’t be offended here, Stacy, but something you just said just rolled right off of your lips, but, man, a red flag went up and I think it’s one of the big problems that we have. If I need an MRI or think I do, I want the doctor to tell me I don’t, not an insurance company. But, see —
CALLER: Well, sure.
RUSH: — since most people can’t pay for one of those themselves they are prisoners to a system that is dysfunctional.
CALLER: But that’s where the doctor has to have a say, he has to say, ‘Look, you’ve got a sprained ankle. Let’s get it on crutches, let’s do ice treatment, and if in a month it’s still bothering you we’ll look at an MRI.’
RUSH: But your example was the insurance company says you don’t need it, you don’t get it. Then you gotta wait a little while. The doctor weighs in second, not first.
CALLER: No, no, no, no, no, no. If the doctor puts a diagnosis down on a pretreatment estimate or on a referral or on a authorization that says this person has a history of osteoporosis, this person has had a week of swelling, and all of this, that will actually be authorized because there’s a medical reason behind it. If you’re a healthy 25-year-old, you come in with a sprained ankle and you tell the doctor you want it now, he has to get the auth, he’s not going to be able to sell it, and he knows better unless you have a reason for doing that test. So we’re not crazy. We know what conditions require what kind of treatments.
RUSH: Well, I know, so does Obama. He says we’re going to do what works.
CALLER: Well, you know what, if Obama was my doctor, I’d just go on ahead and shoot myself before I went to the doctor.
RUSH: Dr. Chicago. Okay, let me summarize, let me see if I can summarize for myself and the audience what I’ve learned from you.
RUSH: The bundling is that doctors are paid per patient whether they’re seen or not, flat fee, the charges can be based on age, gender, whatever, but it’s a fixed fee at a fixed time. Now, the question I have is, apart from the denial of services to patients and the long delays, you know, like you just said, the flu, don’t see the patient for three weeks, flu will be better, it’s a built-in cost cutter, how do you force doctors to live under these conditions —
CALLER: Well, that’s what you don’t do.
RUSH: — unless in the end they have to become quasi-employees of the government? It sounds like they already are. But how do you force them to do this?
CALLER: Well, that’s the thing. I already know providers who are saying they will not accept the public plan. I mean today a Medicare patient, a traditional Medicare, not Med Advantage, a Medicare patient is an automatic six-month wait for an appointment. They won’t take the public plan at all. If they are forced to, they have told me personally they will see six patients per doctor per day and that’s it because it’s not worth it to them.
RUSH: Exactly. I’ll tell you where this is going to lead. There’s only one place it can lead. Single payer government control of both patients and providers.
CALLER: That’s exactly right.
RUSH: That’s the only place this can end up.
CALLER: And the doctors will have no choice.
RUSH: They will then have no choice. The only choice they’ll have is to not become doctors.
CALLER: Exactly right. And we’ll be doing what England is doing now and bringing doctors in from China and India and foreign countries that we hope they have a good medical education.
RUSH: Don’t shoot yourself, Stacy. You’re too valuable.
CALLER: Well, thank you.
RUSH: All right. Thanks much. I have to run. You can now come out of hiding.
CALLER: Okay, bye-bye.
RUSH: Thanks very much. That’s incredible. It’s amazing. I’m sure a lot of you already knew that because you have to go through this garbage to access the health care system. But that’s Stacy from parts unknown in Georgia.
RUSH: Folks, I don’t want you to misunderstand when I asked her why should the insurance company be the first to sit and decide as to what kind of treatment is covered. Sometimes when the insurance company says no, they’re right. See, this is the problem. I mean, how can any business function…? You have to think of it this way. How can any business function if the paying party — in this case the insurance company — has no say on whether it pays or not? And, see, that is the problem with third-party payer systems. An employee generally receives insurance through their employer; they pay little attention to the cost of the policy.
At the user end, the employee as a patient believed that whatever treatment or drug or procedure is desired should be paid for because that’s where we are attitudinally. No questions asked! This is part of the problem. You know, the patients have their role here, too. Now, the American people have been led to believe that they’re entitled to all this, for nothing, because health care is a right. And you have people like Obama now promising them, ‘That’s what’s going to be in my plan! A couple of rich people, a couple millionaires are going to pay for it.’ Now, the answer here is not more government. The answer — as I have maintained from the outset of this because I am a capitalist, I understand markets. The answer is direct ownership of policies by patients. The answer is more patients paying for either their coverage or their treatment. That is the answer.
That’s why — and Stacy talked about it — health savings accounts are so crucial, and they are dead and buried in both the House and the Senate bill. More direct ownership: You buy your own insurance policy. That was my whole point with the catastrophic stuff. You know, you buy your own insurance coverage, whatever you want. But did you also hear her say they can’t sell policies they’d like to sell? She’s an in insurance agent! State law right now prevents companies from selling policies to patients that the patients would like to buy and that they would like to sell. Now, that’s a huge problem here. You cannot have any system of anything — health care, whatever, you cannot have any system — that is based solely on demand and have no rational restraints on it. You just can’t! Nowhere else in the private sector do we have that: Whatever you want, you get regardless of cost? Or that’s what you think you’re getting? It doesn’t work, it can’t work, and that’s why this is such a mess in the first place.