The Interview

Saturday, May 30, 2009
I ran into Corky and Lenny's to grab a quick lunch to take back to my office. I ordered a pint of chicken soup, broth only, and .20 of pickled tongue, no bread. A waitress overheard my order and whispered to the deli man "He must be a doctor". So he asked me ".20? Are you a doctor?" "No", I replied. "I'm an insurance agent, but somewhere in California my mother is smiling."

OK, I'm not a doctor, but I recently had the opportunity to spend a half an hour with a high ranking manager at the Cleveland Clinic. The gentleman was familiar with Medicare reimbursements. He asked not to be identified and I will, of course, comply. Our interest is to collect information.

My first question centered on patient demographics. I was told that the Cleveland Clinic's patients were approximately:
* Private Insurance - 50%
* Medicare - 40%
* Medicaid, self-pay, and charity - 10%

Those numbers are important. Even though the government paid care accounted for less than half of all patients, I was advised that the Cleveland Clinic spent 215 million dollars last year in charity care, Medicare and Medicaid subsidies.

The Wall Street Journal reported on May 1, 2009 that the federal government planned "to keep Medicare payments to hospitals essentially flat". There is even talk that doctor's payments may be reduced. Those were two topics my new friend wouldn't touch. Even an unidentified Cleveland Clinic employee wouldn't want to appear too negative. We could discuss the general concepts of Medicare payments.

I wanted to know how the Centers of Medicare and Medicaid Services (CMS) decided how much a particular service or procedure was worth. More importantly, why wasn't it enough?

What he explained is that CMS determines a cost for a region. Though a teaching hospital is paid slightly higher, but not nearly enough to cover the extra expenses, CMS doesn't recognize the "difference between Bedford Community Hospital and the Cleveland Clinic". And there is a difference. Doctors, training, technology - someone has to pay for all of that. Those costs are shifted to the patients with private insurance.

There is a hierarchy of payments:
* Private Insurance pays more than
* Medicare Advantage pays more than
* Medicare pays more than
* Medicaid.

Medicare Advantage, which provides better care,is reimbursed at a higher rate. Medicare pays less than 50 cents on the dollar. Again, where does the money come from?

My last question, as his secretary was dragging him to his next meeting, was "Who pays if there isn't private insurance to cover the balance?"

We're meeting at P F Chang's this week to discuss this further.



Monday, May 18, 2009
I used to smoke two packs of cigarettes a day. Some days I also indulged in a cigar or one of my pipes. I enjoyed smoking. This was at a time when smoking was permissible everywhere- work, restaurants, even while shopping. I found it calming. I would inhale deeply, especially from my beautiful natural burl pipes, and use those moments to center myself. Smoking was therapeutic. Smoking was a hobby. And, smoking was unhealthy.

We knew. I may have been in my late twenties, but I knew that smoking was a health risk. My father was smoking unfiltered Pell Mell cigarettes. He was addicted. There was no joy, no peace. He had a habit, a cough, and eventually a cancer that would cause great pain and death. I knew that I could end up just like him if I wasn't careful.

I also knew my triggers, the times or circumstances that caused me to reach for my cigs and a lighter. One of my most consistent triggers, something that would always force me to reflexively light a cigarette, was any commercial from the American Cancer Society. Their anti-smoking commercials drove my smoking.

I haven't determined whether it was the tone, the content, or simply the point of view, but to this day the American Cancer Society has this hugely negative impact on me. I stopped smoking cigarettes on January 1, 1985. I still avoid their commercials.

We are knee deep in the national health care discussion. As a life long Democrat who has served on numerous campaigns, I am well aware of one side of the debate. As a thirty year plus veteran of the insurance industry, I live the other side. The American public, addicted to open unfettered access to medical care largely paid for by someone else, is interested in the discussion, but not the commercials.

The strident, polarizing messages issued from both camps, parked conveniently on the extremes, do nothing to illuminate the issues. Chrysler didn't fail because of our health care system. Conversely, Canadians are generally pleased with their access to health care. There is a grain of truth buried within the ads from both the unions and the insurance agents. Will the American public patiently sift through the propaganda to find that truth.

There are people of good will on all sides of the health care debate. There are doctors desperately trying to balance patient and business needs. Insurance agents are intimately aware of our clients' desire for affordable comprehensive insurance and the competing challenge to finance the care. There are thoughtful government employees and elected officials whose only goal is to help the American public. And there are labor leaders and business owners convinced that one option or the another would be the best for their members or employees.

Where are these people of good will? You won't find them on the talk shows. Reasoned debate is not good TV. In fact, if television is your primary source for news and information, the only thing you know for sure is that there is a huge conflict and that eventually one side will win and one side will lose. And that's just not true. We can all lose. That would be easy. We can do nothing and let cost and access spin out of control. Or we can over-reach and ignore our strengths.
Can we all win? That should be our goal and it won't be easy.

This blog is an invitation to participate in the discussion. When those commercials come on your set, when the talking heads work harder to drown out the opposition than to advance understanding, when you feel like I did when I watched the anti-smoking ads on my television so long ago, don't shut down. Participate.

Our goals should be common ground and mutual success. What is in the best interest on the American people? How do we get there?


Quick addendum: I got stuck for two hours at a presentation by Stuart Browning, the Michael Moore wanna be from the other side. Full disclosure - I walked out before it was over. Still, I want to expose my readers to as much info as possible. Michael Moore's website is Stuart Browning can be found at He is known for his 6 minute movie A Short Course On Brain Surgery

Getting Directions

Saturday, May 2, 2009
Avenue or Street? Name or Number? Four quick details and you can find your way around in Phoenix in minutes. Numbered roads run north and south. If that numbered road is also a street, such as 24th Street, then it is on the east side of town. 19th Avenue is on the west side. Indian School Road runs east and west. A perfect grid, Phoenix is easy to navigate.

Have you ever tried to explain how to get from Westlake to University Heights?

The Phoenix grid was designed first. The city of Phoenix was built within that framework. Greater Cleveland is very different. Our communities are linked by our roads. Our street system, with its twists and turns, traffic circles, and five point intersections, is organic, reactive, and responsive. New Brainard Road quickly comes to mind.

I think about our lack of north - south streets and the joy of an efficient grid every time I am stuck in traffic on Richmond Road. We have all dreamed of a better way to get around town. We just have to decide which neighborhoods to bulldoze.

Creating a health care delivery system where none existed is a lot like planning a city's grid. With limited expectations and little to disrupt, the new program would face little opposition.

Think about the delivery and payment of health care in the US. Our system is organic and ever changing. Part action, part reaction, we have evolved from a system of community hospitals and doctor/entrepreneurs to regional medical centers who employ entire teams of professionals.

Just as the medical providers have changed, so too have the payers. Blue Cross and Blue Shield associations were originally created by doctors and hospitals as a means for the patients to prepay for medical services. Health insurance quickly followed. Over the last seventy years we've moved from indemnity policies to Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and even the occasional Point of Service Plan (POS). Insurers now research everything from the most efficient ways to deliver health care to drug interaction and disease management.

Medicare brought the federal government into our system. Almost overnight, Washington went from uninvolved to a key player. Medicare pays the majority of the cost for the care of our elderly and infirm. The government decides how much it will pay for a doctor's exam,test, or hospital stay. Less than the insurance companies, less than the self-pay, government payments are accept or reject. The medical provider either accepts Medicare and its rules, its limitations, and its millions of beneficiaries, or he/she doesn't. Most providers accept Medicare.

Providers, insurers, and governmental changes have significantly impacted the way health care is practiced in this country. In many ways we have lost sight of who pays for medical services.

There are commercials on TV for diabetic testing devices, lift chairs. and scooters that are FREE if you are on Medicare. They aren't free. We are paying, probably over-paying, for all of this.

Like a drive down Van Aken Boulevard, Congress is discovering that our health care delivery system isn't a simple north-south or east-west. The New York Times reported on April 26, 2009 that the shortage of primary care physicians is just one more unanticipated obstacle on the path of change. Our current system rewards specialists. A revenue neutral option would lower the reimbursements for specialists, freeing up money for the general practitioners. Needless to say, the orthopedic surgeons are not happy.

Action and reaction. Raise compensation? Add more doctors? The one thing most of us know for sure is that we can't tear down our existing system and start over from scratch. So as we debate change and what the final results will be, we must be certain that we don't neglect to map the road from where we are to that final goal.


Questions or suggestions for future topics?