Dear President Bush,
You recall the joke with two men washed up on an island after their boat is wrecked in a storm. Captured by natives they are given two options, death or Ru-Ru. The first one chooses Ru-Ru knowing death to be certain and final. The tribe sodomizes the man. The second man, having seen the terrible treatment of his friend, decides he could not stomach such a consequence. When the leader approaches him with the same options, death or Ru-Ru, the man chooses death. The leader says “Death it shall be, but first a little Ru-Ru!”
This joke is similar to the interplay between your health care strategies and your recently announced bird flu plan. How do they interact to produce a greater horror? This requires an examination of your stated plans and their likely impact.
The overall health care market has demand exceeding supply. This is projected to grow worse as the population ages. By leveraging market forces the Bush administration’s health care strategies aim to cut prices, thus costs. This is accomplished by having more people under high deductible health plans. These folks will negotiate prices with their doctors and hospitals thus driving prices down rapidly.
The reality is two groups postpone needed care, those under high deductible health plans and the uninsured. Both are growing rapidly under your watch. This may reduce demand in the short run, but postponed care for chronic conditions has proven to result in expensive hospitalizations and procedures in the long run.
When these two groups need that high dollar care, hospitals will be on the hook to provide it. Most uninsured will not be able to pay for long hospitals stays or the costs of major surgeries, thus the hospital will eat the bill. Those on high deductible health plans may have funded their health savings account or not. Those who failed to do so will be on the hook for a $1,050 to $2,100 deductible, plus that 20% copay. This translates to growing hospital accounts receivable and bad debts at a time when safety net hospital’s profit margins are under pressure.
Hospitals have to take care of all who present regardless of ability to pay. Safety net hospitals have a much greater burden. Most of these are non profit community or governmental hospitals. In my town the non profit system provides 80% of the emergency care to the uninsured while the for profit hospital provides about 20%.
A private physician’s practice does not have to accept all who show up for care. Local multi-specialty clinics require a $100 deposit from patients without health insurance. No deposit, no doctor’s visit. You encourage sick people to see their doctor in your bird flu plan, yet almost 50 million folks have considerable difficulty making that happen.
Large clinics will treat the high deductible insured like the uninsured should they have no doctor visit benefits. Better pony up that $100 deposit! How long will doctor’s hold on to insured patients with a high deductible health plan? How large will they let their account grow before cutting them off, essentially firing the patient?
The likely impact of your plans is to reduce hospital and physician capacity even further as they fail to address the cost of caring for the nearly 50 million uninsured Americans. My prediction is older doctors will retire to avoid the hassles. Some safety net hospitals will close as their bad debts balloon and they lack the cash flow to pay their bills.
How do your bird flu plans address hospital and physician capacity, knowing the tremendous demand created by a pandemic? They bail on it as evidenced by Fran’s remarks the other day with Scott McClellan.
Q Yes, after World War II, we had a hospital system here under Hill-Burton where we made an estimate of how many hospital beds you need per population. Now we've long gone away from that system, and hospitals have been working on a more for-profit motive. But given the fact of a dangerous pandemic, wouldn't it be necessary to again look at this situation to make sure that especially in the rural regions -- it may hit in the rural regions, not in the big city -- there are hospital facilities available to be able to take care of that, otherwise, you'll have to move people from -- over long distances, thus increasing the dangerous threat of pandemic. Have you looked at this, and have you drawn any conclusions with regard to that in your report? Or do you intend to?
MS. TOWNSEND: I wouldn't say -- I don't think that there are conclusions drawn in the report directly related to that. I'd have to -- I may be wrong. I don't think so. But what I would say to you is, this goes directly to our planning with state and local officials.
You know, I'm fond of saying, having been a local myself earlier in my career, rarely will the solution itself to the practical problem faced in a community come from inside the beltway, come from Washington. The answer is, what we can do is give advice and guidance, the kinds of planning assumptions that they ought to look at, their capacity and how to increase the capacity and how to increase the capacity to meet local need.
And that's the sort of advice and guidance we're giving. We're working with state and local officials through Secretary Leavitt, and we will continue to do as part of the planning effort.
Q: …HHS has made it clear, repeatedly, that they consider the best planning to be at the local community hospitals, the state and local public health departments. But those departments and the hospitals, almost to the department and the hospital, have said, thanks for your advice, we appreciate it; we do not have -- do not have the resources to buy the ventilators, to buy the surge capacity, to buy all of the extra things that we're being told -- and the antivirals -- that we're being told that we need. Hospitals were here in Washington a couple of weeks ago -- Hopkins, Stanford, top hospitals in the country -- each one of them, all together, said the advice is great, there's no way for us to pay for it on our margins.
So that being the case, what is the advice for those hospitals, those public health communities to actually prepare?
MS. TOWNSEND: Well, just as you have a personal budget, I have a personal budget, the federal government has a budget, so do state and local communities. And it's a matter of setting priorities. We believe that this should be a priority for resource allocation and for planning, for policy implementation and planning. We believe those hospitals -- it's more that they need to do than simply buying things, whether it's anti-viral drugs and vaccine, or ventilators -- that's all very important, don't misunderstand me. But there are policies and procedures they need to put in place, in terms of essential personnel -- policies for absenteeism, how they will staff emergency rooms -- and all that planning needs to be done now while they look at the resource implications and plan for those, as well.
Punt! Fran bailed on hospital capacity, then when margins are mentioned she runs off the field altogether. Yes, Mrs. Townsend can keep a secret. She should be promoted to the Director of the CIA. A warning to Fran should she get the death of Ru-Ru question in the hearings. Answer with “Admit nothing, deny everything, and make counteraccusations”. It worked for the last guy in the job.
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