End to Medicare 'As We Know It' Already In The Works

Discussions for Patients, Family, and Friends HD For Patients
1

Even before the Super Committee convened – and failed to find a formula for reforming entitlements – Democrats wielded a familiar refrain to reject any Republican effort to save Medicare by offering competition.

“Put simply, it ends Medicare as we know it,” President Obama said earlier this year about GOP proposals.

Senate Democratic leader Harry Reid, D-Nev., also blasted Republican plans, and employed the same “end Medicare as we know it” phrase, before going on to say it would subject seniors to the rising costs of health care.

James Kvaal, Obama’s campaign policy director, threw the same stone at Mitt Romney, arguing that the Republican presidential candidate’s plan to offer both traditional Medicare and access to private plans would end seniors’ medical coverage.

But as it turns out, Obama himself sharply limits Medicare spending and Democrats actually voted for it in the new health care law, fundamentally altering the program “as we know it,” say analysts.

“President Obama ended it as we know it,” said James Capretta of the Ethics and Public Policy Center. “The one thing I don’t think the public really understands is that the health care law has already capped Medicare spending and President Obama was the proponent of that cap.”

In the new health care law, Medicare is slashed by $500 billion and growth in Medicare spending is capped to just 1 percent over growth in the overall economy.

In an 80-page message addressed to the Super Committee, Obama proposed another $250 billion in Medicare cuts along with lowering the limit on Medicare spending to gross domestic product plus 0.5 percent. He would cap spending at the lower number by reducing reimbursements.

Since Medicare typically grows 2 or 3 points more than GDP plus inflation, or at around 7-9 percent annually, seniors lose ground every year.

“Any time we have an arbitrary cap that’s not reachable, where benefits could be harmed, we would be opposed,” said David Certner, policy director for American Association of Retired Persons.

Some critics are concerned about how the president will enforce limits. He’d use the Independent Payments Advisory Board, or IPAB, created by the health care law. But it only has one power to hold down spending – impose price controls on providers.

“If there’s a cost that go above the cap, we’re going to be stopping care for that year and in essence lead to rationing of care,” Certner said. “So we can’t have arbitrary caps in the Medicare program.”

When doctors, surgeons or those who make knee or hip replacements are simply told they’ll be paid significantly less, what will they do? Capretta said he fears the worst.

“Eventually some of the providers of those services will drop out of the market and there will be issues in terms of accessing care,” he said. “That’s what the Medicare actuary has already predicted will occur under the health care law.”

Medical groups say they expect a shortage of some 90,000 doctors by the end of this decade, as 30 million baby boomers have begun to retire, making access to care even tighter.

Democrats resisted cutting Medicare in the now-defunct Super Committee negotiations, but the hospital trust fund will not be able to pay full benefits in 2024. That means far more will have to be done than some are willing to contemplate now if Medicare is to be preserved for future retirees, and if the nation wants to avoid not only ‘ending Medicare as we know it,’ but avoid ending it altogether.

Read more: http://www.foxnews.com/politics/2011/11/23/can-medicare-survive-efforts-to-end-medicare-as-know-it/#ixzz1ebFDJ957

2

Yeah…Fox would have you believe is that to save money in Medicare, the Obama administration is going to ration your healthcare. What Fox doesn’t report is that under Obama’s administration there have been stepped up efforts to address fraud and abuse in Medicare. You may be interested in this website:
http://www.stopmedicarefraud.gov/

Or you may be interested in this report from the Office of the Inspector General that says that in FY 2010 aloneover $4 billion was returned to the Medicare Trust Fund as a result of active investigation and prosecution of Medicare providers who committed fraud.

Or you may want to read how one recent strike in 2011 led to charges of 91 defendants in 8 states who had filed false claims that cost Medicare $295 million.
http://www.hhs.gov/news/press/2011pres/09/20110907c.html

There is more than one way to skin a cat. Hopefully more attention will be paid on preventing Medicare fraud and prosecuting criminals who are committing Medicare fraud to the fullest extent of the law to return money to the Medicare Trust fund and allow it to remain solvent without cutting benefits.

3

How does Health Reform Effect Medicare Spending (PDF LINK)

Most of the Medicare provisions in the ACA will reduce program spending, but some will increase it, and on net, Medicare spending will be reduced by an estimated $424 billion for the 10-year period from fiscal year 2010 through fiscal year 2019, a 6 percent reduction from spending that had been projected for that period

While this amount is not insignificant, it is also not unprecedented, and represents a smaller share of projected 10-year baseline Medicare spending than the spending reductions included in the Balanced Budget Act (BBA) of 1997. At the time it was enacted, the BBA was projected to result in a 12 percent reduction in projected baseline Medicare spending.

The ACA includes a number of provisions that are expected to reduce Medicare spending.

Reduced Payments to Providers and Medicare Advantage Plans
More than half the Medicare savings comes from two provisions: one that institutes a productivity adjustment which will reduce annual fee-for-service provider payment updates and one that makes changes to payments for Medicare Advantage plans. Additional savings come from reducing payments for preventable hospital readmissions and home health services. The annual increase in payment rates for various Medicare services, generally adjusted to reflect inflation, will be reduced by a measure of economy-wide productivity improvement. The compounding effect of this change will significantly reduce growth in program spending in perpetuity. The Medicare actuaries have questioned whether the savings will be sustainable for the long run, while others believe the baseline sets a new achievable target for promoting provider efficiency.

For Medicare Advantage plans, the ACA phases out payments made in excess of fee-for-service costs, consistent with recommendations of the Medicare Payment Advisory Commission. In addition, the 6 productivity adjustment and other Medicare fee-for-service payment changes generate additional savings from MA plans because plan payments are linked to fee-for-service spending levels.

Independent Payment Advisory Board (IPAB)
The newly-created IPAB is a 15-member panel charged with recommending a set of Medicare program changes, within certain constraints, if program spending growth exceeds specified targets, beginning in 2015. These targets are estimated to require IPAB to identify nearly $16 billion in savings for the years 2015 to 2019. The IPAB recommendations will be sent to the Congress under special procedures; disapproval will require a supermajority vote. They may not include changes to increase revenues, beneficiary premiums or cost-sharing; restrict benefits or modify eligibility criteria. Prior to 2019, certain providers are exempt from reductions.

Beneficiary Premiums
The ACA modified a provision in current law that requires higher-income Medicare Part B enrollees to pay a higher monthly Part B premium. The law temporarily eliminates the indexing of the income thresholds at which the higher premium must be paid. As a result, between 2010 and 2019, the share of Medicare beneficiaries paying an income-related Part B premium will rise from 5 percent to 14 percent.

In addition, the law established a new income-related premium for Medicare beneficiaries enrolled in Part D prescription drug plans, reducing government contributions for Part D coverage by increasing premiums for higher-income beneficiaries who are also subject to the income-related Part B premium. The thresholds for the Part B and Part D income-related premium are fixed at $85,000 for an individual beneficiary and $170,000 for couples through 2019.

Delivery System Reforms
Other provisions of the ACA are aimed at changing the health care delivery system in ways that seek to produce long-run efficiencies and program savings. A general theme of these provisions is to shift provider incentives away from increasing the volume of services toward incentives for improving quality and care coordination. Examples include establishment of a Medicare Shared Savings program for Accountable Care Organizations (ACOs) and bundling payments around a hospital stay. A new Center for Medicare and Medicaid Innovation will test additional innovative payment and service delivery models, a number of which are expected to focus on Medicare and Medicaid dual eligibles and other high-need populations.

Other Provisions That Increase Medicare Spending
Some provisions will increase program spending and partially offset the savings generated from the provisions discussed above. Most notably, the law gradually phases in coverage to close the Part D coverage gap (or “doughnut hole”) by 2020. The law also includes an annual wellness visit and other improvements in Medicare coverage of recommended preventive services.

Revenue Provisions
Finally, although not affecting program spending, the law included two provisions that will provide new revenue streams dedicated to financing Medicare benefits. These are an increase in the Medicare payroll tax on certain high earners (earnings more than $200,000 for an individual or $250,000 for a couple) and a new fee on drug manufacturers.

>>>>----<<<<

These changes don’t change the nature of the program, as compared to the so called Ryan plan which would reduce Medicare to something akin to a coupon program for premium support. The Ryan plans ends Medicare as it has existed for 45 years; the ACA sustains Medicare.

4

[QUOTE=Bill Peckham;21913]How does Health Reform Effect Medicare Spending (PDF LINK)

Most of the Medicare provisions in the ACA will reduce program spending, but some will increase it, and on net, Medicare spending will be reduced by an estimated $424 billion for the 10-year period from fiscal year 2010 through fiscal year 2019, a 6 percent reduction from spending that had been projected for that period

While this amount is not insignificant, it is also not unprecedented, and represents a smaller share of projected 10-year baseline Medicare spending than the spending reductions included in the Balanced Budget Act (BBA) of 1997. At the time it was enacted, the BBA was projected to result in a 12 percent reduction in projected baseline Medicare spending.

The ACA includes a number of provisions that are expected to reduce Medicare spending.

Reduced Payments to Providers and Medicare Advantage Plans
More than half the Medicare savings comes from two provisions: one that institutes a productivity adjustment which will reduce annual fee-for-service provider payment updates and one that makes changes to payments for Medicare Advantage plans. Additional savings come from reducing payments for preventable hospital readmissions and home health services. The annual increase in payment rates for various Medicare services, generally adjusted to reflect inflation, will be reduced by a measure of economy-wide productivity improvement. The compounding effect of this change will significantly reduce growth in program spending in perpetuity. The Medicare actuaries have questioned whether the savings will be sustainable for the long run, while others believe the baseline sets a new achievable target for promoting provider efficiency.

For Medicare Advantage plans, the ACA phases out payments made in excess of fee-for-service costs, consistent with recommendations of the Medicare Payment Advisory Commission. In addition, the 6 productivity adjustment and other Medicare fee-for-service payment changes generate additional savings from MA plans because plan payments are linked to fee-for-service spending levels.

Independent Payment Advisory Board (IPAB)
The newly-created IPAB is a 15-member panel charged with recommending a set of Medicare program changes, within certain constraints, if program spending growth exceeds specified targets, beginning in 2015. These targets are estimated to require IPAB to identify nearly $16 billion in savings for the years 2015 to 2019. The IPAB recommendations will be sent to the Congress under special procedures; disapproval will require a supermajority vote. They may not include changes to increase revenues, beneficiary premiums or cost-sharing; restrict benefits or modify eligibility criteria. Prior to 2019, certain providers are exempt from reductions.

Beneficiary Premiums
The ACA modified a provision in current law that requires higher-income Medicare Part B enrollees to pay a higher monthly Part B premium. The law temporarily eliminates the indexing of the income thresholds at which the higher premium must be paid. As a result, between 2010 and 2019, the share of Medicare beneficiaries paying an income-related Part B premium will rise from 5 percent to 14 percent.

In addition, the law established a new income-related premium for Medicare beneficiaries enrolled in Part D prescription drug plans, reducing government contributions for Part D coverage by increasing premiums for higher-income beneficiaries who are also subject to the income-related Part B premium. The thresholds for the Part B and Part D income-related premium are fixed at $85,000 for an individual beneficiary and $170,000 for couples through 2019.

Delivery System Reforms
Other provisions of the ACA are aimed at changing the health care delivery system in ways that seek to produce long-run efficiencies and program savings. A general theme of these provisions is to shift provider incentives away from increasing the volume of services toward incentives for improving quality and care coordination. Examples include establishment of a Medicare Shared Savings program for Accountable Care Organizations (ACOs) and bundling payments around a hospital stay. A new Center for Medicare and Medicaid Innovation will test additional innovative payment and service delivery models, a number of which are expected to focus on Medicare and Medicaid dual eligibles and other high-need populations.

Other Provisions That Increase Medicare Spending
Some provisions will increase program spending and partially offset the savings generated from the provisions discussed above. Most notably, the law gradually phases in coverage to close the Part D coverage gap (or “doughnut hole”) by 2020. The law also includes an annual wellness visit and other improvements in Medicare coverage of recommended preventive services.

Revenue Provisions
Finally, although not affecting program spending, the law included two provisions that will provide new revenue streams dedicated to financing Medicare benefits. These are an increase in the Medicare payroll tax on certain high earners (earnings more than $200,000 for an individual or $250,000 for a couple) and a new fee on drug manufacturers.

>>>>----<<<<

These changes don’t change the nature of the program, as compared to the so called Ryan plan which would reduce Medicare to something akin to a coupon program for premium support. The Ryan plans ends Medicare as it has existed for 45 years; the ACA sustains Medicare.[/QUOTE]

NDXUFan writes:
The Paul Ryan plan is also co-authored by Clinton staffer Alice Rivlin:

Honorable Paul D. Ryan
Ranking Member
Committee on the Budget
U.S. House of Representatives
Washington, DC 20515
Dear Congressman:

The attachment to this letter responds to your request for analysis of the proposal
that you and Alice Rivlin have put forward to substantially change federal
payments under the Medicare and Medicaid programs. CBO has conducted a
preliminary analysis of the major provisions of that proposal, the results of which
are summarized in the attachment.
I hope this information is helpful to you. If you have any questions, please contact
me or CBO staff. The primary staff contact for this analysis is Philip Ellis.
Sincerely,
Douglas W. Elmendorf

http://cbo.gov/ftpdocs/119xx/doc11966/11-17-Rivlin-Ryan_Preliminary_Analysis.pdf

5

Individuals who commit fraud against the Medicare program should be prosecuted to the full extent of law.

6

I think a better way to go about this is to style Medicare after the Federal Employee Health Benefits program. The dialysis industry is in serious need of competition. I am also concerned about the very, very sick folks that I have seen in the clinics, cutting their care is immoral. I could care less about the rich.

7

[QUOTE=NDXUFan12;21914]NDXUFan writes:
The Paul Ryan plan is also co-authored by Clinton staffer Alice Rivlin:

Honorable Paul D. Ryan
Ranking Member
Committee on the Budget
U.S. House of Representatives
Washington, DC 20515
Dear Congressman:

The attachment to this letter responds to your request for analysis of the proposal
that you and Alice Rivlin have put forward to substantially change federal
payments under the Medicare and Medicaid programs. CBO has conducted a
preliminary analysis of the major provisions of that proposal, the results of which
are summarized in the attachment.
I hope this information is helpful to you. If you have any questions, please contact
me or CBO staff. The primary staff contact for this analysis is Philip Ellis.
Sincerely,
Douglas W. Elmendorf

http://cbo.gov/ftpdocs/119xx/doc11966/11-17-Rivlin-Ryan_Preliminary_Analysis.pdf[/QUOTE]

Did you even read the letter you linked to? (my emphasis)

“Second, future beneficiaries would probably face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare. (For additional discussion of these issues, see CBO’sJanuary 2010 letter to Congressman Ryan about his “Roadmap” proposal.)”

The January 2010 letter gives more detail:

“Both the level of expected federal spending on Medicare and the uncertainty surrounding that spending would decline, but enrollees’ spending for health care and the uncertainty surrounding that spending would increase. Under the Roadmap, the value of the voucher would be less than expected Medicare spending per enrollee in 2021, when the voucher program would begin. In addition, Medicare’s current payment rates for providers are lower than those paid by commercial insurers, and the program’s administrative costs are lower than those for individually purchased insurance. Beneficiaries would therefore face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare. Moreover, the value of the voucher would grow significantly more slowly than CBO expects that Medicare spending per enrollee would grow under current law. Beneficiaries would therefore be likely to purchase less comprehensive health plans or plans more heavily managed than traditional Medicare, resulting in some combination of less use of health care services and less use of technologically advanced treatments than under current law. Beneficiaries would also bear the financial risk for the cost of buying insurance policies or the cost of obtaining health care services beyond what would be covered by their insurance”

You can see this in dialysis. If Medicare was not primary then the providers would charge more for the same services. Total healthcare spending would sky rocket under the Ryan plan, by much more than the federal government would save. For every dollar the federal government saved total healthcare spending would increase by more than two dollars. Again, the way dialysis is paid for makes this very clear.

You’ve been snookered.

8

Bill, the people who are complaining about the Ryan plan are driving spending thru the roof, it is estimated that the deficit in the next 10 years will be $44 trillion(Wall Street Journal) How do you propose to pay for that and how? If your answer is to “Raise those taxes” I have a nasty surprise for you. The top tax rate for a corporation is 46.7 percent, if you factor in Social Security and all other taxes(Wall Street Journal, Monday, November 28, 2011-Page A 16). In tax compliance, the United States ranks 69 out of 183 nations(World Bank International Finance Corp.) The United States has the second highest corporate income tax rate in the world, behind the United Kingdom(UK), Finland, Norway, Switzerland, and Ghana(World Bank). If you are curious about the highest corporate income tax rate, it is in Japan. The other countries of the world are slashing corporate tax rates and business makes location decisions based on those tax rates. My point is that the more the tax base shrinks, the less money there will be to pay for dialysis thru Medicare. Instead of increasing taxes to pay for dialysis, we need to make the United States tax base, much larger, by eliminating deductions and replacing that with very low tax rates, to generate revenue.

In addition, we need to deregulate health insurance and their monopoly to greatly reduce premiums. Bill, we have tried it your way for years, it is not working, health care is just too expensive for the majority of people. Freedom works, Bill, not big government and bureaucrats. You will never find enough money in taxes to regulate these people, use competition, much more effective and much less expensive.

9

You don’t actually lower healthcare costs by capping federal spending. It shifts spending but really the premise is flawed because there is nothing Ryan or anyone else can do to stop Congress in 2022 from increasing taxes to pay for healthcare for seniors.

In 2022 Congress will quickly cave to political reality and increase the value of the premium support. The only way the Ryan plan works is if future Congress doesn’t cave in to political pressure. Why would anyone believe that is likely?

If you eliminate Medicare you eliminate Medicare’s buying power. With less buying power the private insurers will have to pay more for the same services. But as anyone who uses dialysis must know, Medicare is not just a check writer.

The Ryan plan imagines that without Medicare, the free market will provide higher quality care without having to deal with all of Medicare’s regulations and inspections. That is farcical. Without Medicare’s rule setting, without the surveys do you really believe dialysis would be better?

Would dialysis be better if units didn’t have to submit data to the USRDS? That is a requirement that comes from accepting Medicare reimbursement. One of many large and small. Do you think Aetna is going to require providers to submit data?Hospitals have to treat people who are dying or giving birth as a condition of accepting Medicare. Will Group Health have their own Emergency Medical Treatment and Active Labor Act as a condition of coverage? That is unlikely.

The way to save healthcare dollars is through hard day to day work. It isn’t through cost shifting. It isn’t by just giving up and removing the federal government from the provision of healthcare is no solution. It is “social engineering” and “imposing radical change” which is not "a very good way for a free society to operate.”

As far as taxes when the marginal rate and the effective rate are as far apart as they are in the US there is an opportunity to eliminate tax deductions and lower rates while raising revenue. The federal government needs more revenue and there are a number of ways to do it but they all come at some cost. Not raising additional revenue will come at a greater cost.

The Republican’s are a muddle right now. They are unstrategic and myopic to a fault. Their nihilism has led to worse policies. The republicans have given up on their responsibility to govern. It should be obvious by now that had 6 Republican Senators joined with Democrats to pass health reform in January 2009 it would have been a bill more to republican liking. But as of now there is no reflection on what they could have done, there is only the singular focus on winning the next news cycle. The Ryan plan isn’t a serious plan if you are interested in governing, it is only a serious plan if you are interested in campaigning.

10

[QUOTE=Bill Peckham;21933]You don’t actually lower healthcare costs by capping federal spending. It shifts spending but really the premise is flawed because there is nothing Ryan or anyone else can do to stop Congress in 2022 from increasing taxes to pay for healthcare for seniors.

In 2022 Congress will quickly cave to political reality and increase the value of the premium support. The only way the Ryan plan works is if future Congress doesn’t cave in to political pressure. Why would anyone believe that is likely?

If you eliminate Medicare you eliminate Medicare’s buying power. With less buying power the private insurers will have to pay more for the same services. But as anyone who uses dialysis must know, Medicare is not just a check writer.

The Ryan plan imagines that without Medicare, the free market will provide higher quality care without having to deal with all of Medicare’s regulations and inspections. That is farcical. Without Medicare’s rule setting, without the surveys do you really believe dialysis would be better?

Would dialysis be better if units didn’t have to submit data to the USRDS? That is a requirement that comes from accepting Medicare reimbursement. One of many large and small. Do you think Aetna is going to require providers to submit data?Hospitals have to treat people who are dying or giving birth as a condition of accepting Medicare. Will Group Health have their own Emergency Medical Treatment and Active Labor Act as a condition of coverage? That is unlikely.

The way to save healthcare dollars is through hard day to day work. It isn’t through cost shifting. It isn’t by just giving up and removing the federal government from the provision of healthcare is no solution. It is “social engineering” and “imposing radical change” which is not "a very good way for a free society to operate.”

As far as taxes when the marginal rate and the effective rate are as far apart as they are in the US there is an opportunity to eliminate tax deductions and lower rates while raising revenue. The federal government needs more revenue and there are a number of ways to do it but they all come at some cost. Not raising additional revenue will come at a greater cost.

The Republican’s are a muddle right now. They are unstrategic and myopic to a fault. Their nihilism has led to worse policies. The republicans have given up on their responsibility to govern. It should be obvious by now that had 6 Republican Senators joined with Democrats to pass health reform in January 2009 it would have been a bill more to republican liking. But as of now there is no reflection on what they could have done, there is only the singular focus on winning the next news cycle. The Ryan plan isn’t a serious plan if you are interested in governing, it is only a serious plan if you are interested in campaigning.[/QUOTE]

Bill, I never once said or implied, nor do I believe, that you will cap health care costs by capping Federal spending. Again, how do you plan to pay for a deficit of $44 trillion in the next 10 years? If you think we can run that type of debt, you are not serious, nor are you living in the real world. In addition, there is not enough money on this earth to finance that type of spending. I do agree, Congress would cave, it is something that they do very well. The solution is not more government spending, it is private sector competition between dialysis providers, reducing costs as they do in every other sector of our economy. The reason that health care spending is out of control is a lack of competition between medical providers. I am sure you have heard of Fannie Mae and Freddie Mac, how did that turn out? Hong Kong has a flat tax rate of 17 percent and they have more money in their treasury that they know what do to with, I hate to tell you that temporary tax cuts do not work in the long term. Why do you need inspections, if we have private sector competition between dialysis providers, dialysis consumers will just change providers or leave and go to another provider, much cheaper and much less hassle.

11

Bill, your crowd on the left has tried social engineering and radical change for years and years, how has it worked? To be honest, it has been a disaster. The Founding Fathers were serious about governing and they did not seek to control everything and everyone, as Pelosi, Reid, and Obama have sought to do, I wonder what they would think about that trio, I can only imagine.

James Madison: "“I cannot undertake to lay my finger on that article of the Constitution which granted a right to Congress of expending, on objects of benevolence, the money of their constituents. Charity is no part of the legislative duty of the government.”

Only focused on winning the next election cycle? “The Republicans want Senior citizens to eat dog food and want students to starve without school lunches???” Do you remember that one, Bill?

“UPS and FedEx are doing just fine, right? It’s the Post Office that’s always having problems.” -Obama

“It’s not surprising, then, they get bitter, they cling to guns or religion or antipathy to people who aren’t like them or anti-immigrant sentiment or anti-trade sentiment as a way to explain their frustrations.” --explaining his troubles winning over some working-class voters. -Obama

The Democrats, for years, have not solved problems simply because they wanted a tool to use against Republicans, at election time. If you create wealth, the hospitals will have more than enough money to treat the poor and suffering. I am curious, have your good friends, Obama and Joe Biden ever met someone that was poor and suffering? Unlike the popular myth, Biden’s family was very white collar and I do not think Obama has ever lived near any poor people. Unlike Obama and Biden, Ronald Reagan’s family was dirt poor, so was the Nixon family. These families did not have the millions of the Kennedy family or the resources of the Carter family.

“Ronald Reagan and his family lived in a half-a-dozen places within a few years, one residence was a dreary flat over a bakery, without any indoor toliet facilities. The family had to give up chicken on Sunday and turn to liver, considered a pet food by the butcher, who would add a pound to the grocery order without asking questions. Soup, potatoes, bread were served daily in the Reagan household. On Sundays, since the cats ate the mice, they caught in the barn, anyway, the Reagans ate the cats’ liver dressed up with a slab of bacon and some homegrown onions.”

I wonder why the Kennedy’s and their famous compassion were not their to assist the Reagan family? Bill, I thought your party said that Reagan was the “rich man’s candidate?”

12

Private sector competition among dialysis facilities has not reduced costs to payers or patients. Instead it has resulted in reduced choices for patients through industry consolidation as the two largest providers have used their profits from charges to payers that are multi-times Medicare’s allowed rates to build up acquisition funds allowing them to acquire many small and medium sized providers. I don’t mean this as criticism of patients, but ask other patients, especially those who are elderly or poor on in-center HD, what other dialysis clinics exist in their area and I suspect many would have no idea. Those who don’t have the Internet may not realize there are government and other databases, including the one on Home Dialysis Central, that allow them to search for clinics. They may not realize they can look up their clinic on Dialysis Facility Compare and find out how their clinic is doing on certain outcomes. If patients realized this, patients in clinics where survival was worse than average might leave those clinics in droves. It hasn’t happened.

And about competition related to prices…Medicare as a primary payer limits dialysis-related charges and what a patient might pay is limited, especially when the provider accepts Medicare assignment as dialysis clinics must. However, commercial charges for dialysis-related services and what a patient may owe can vary if a patient has an employer group health plan, including COBRA and doesn’t have Medicare too. I wonder how many patients have been able to find out their charges from their clinic. I’ve talked with patients who haven’t been able to learn this information. Maybe they didn’t ask the right person or maybe the charges are now too hard to calculate. Facilities have to tell patients if charges aren’t covered by Medicare, but they don’t have to divulge their prices to patients in advance so the patient could decide where to go for treatment. One limiting factor may be if the patient’s insurance doesn’t contract with the dialysis clinic. In that case, the clinic would likely not admit them or transfer the patient to a clinic that does.

Although it seems like the general theories of economics would work, in my experience, healthcare economics don’t seem to like other business economics where competition and time a product is on the market brings prices down. Maybe it’s because there is a consistently growing market which makes demand high so dialysis clinics don’t worry much about losing a patient here or there.

13

Mark on the one hand I want to restate why your analysis makes no sense, line by line.

From the weird - “why the Kennedy’s and their famous compassion were not their to assist the Reagan family?”, that’s a new one, time travel is a tempting topic to discuss but this is HDC and that would be inappropriate - to the more mainstream idea that somehow competition and the free market is all that is needed to fix what ails the US healthcare system. However, that isn’t what I feel needs to be said and HDC is not the place to say it.

What I think needs to be said is how inappropriate your participation has been on Home Dialysis Central. I once tracked HDC posts - DSEN’s last discussion board report was in Feb '09 - and back then HDC would get scores of post a week. People who actually needed information about the fairly narrow topic of home dialysis. The Home Hemodialysis for Patients board was always the most active.

The Home Hemodialysis for Patients board was a god send to many people in the early days when few were using HHD and information was scarce. There was then and is now, no better resource for HHD information. Luckily, the HDC expert boards and the PD boards seem unaffected by your presence but I feel you have effectively shut down the HHD Patient board with your nattering of personal grievances and/or your personal political views. Your posts have, for the most part, been an energy suck, a net negative for the community.

The discussions you have initiated and your lack of posting etiquette has driven people off. It is not the only thing that has caused the waning of the HDC HHD Patients board, but it is the most visible.

What would it take for you to give us back the HHD Patients board? To let HDC serve the needs of the HHD Patient community once again.

I miss the community that was once here.