Bear, I do hope you are writing your thoughts up for pub somewhere; even short
letters to the eds of various economic pubs.
Peace, Love, & Light,

Vidette Todaro-Franceschi RN, PhD.
Associate Professor & Specialization Coordinator
Adult Health Advanced Practice Graduate Program
Hunter-Bellevue School of Nursing
Hunter College, City University of New York
425 E 25th St
New York, NY 10010
vtodaro@...

*********************************
www.energy-enigma.com

"To see that everybody not merely depends on everybody, but actually everybody
is everybody in a deeper sense."
Bohm, On Creativity, 1998.




---- Original message ----
>Date: Sat, 20 Sep 2008 00:32:54 -0000
>From: "bear" <tc_spirit@...>
>Subject: [Martha_E_Rogers] An interesting week on Wall Street and some ursine
reflections...
>To: Martha_E_Rogers@yahoogroups.com
>
> Not for the faint of heart...
>
> I think most everybody is now well aware that there
> has been a severe
> economic crisis brewing for the last few years.
>
> There are still some who would like to imagine that
> nobody could have
> ever anticipated the unfolding of the mortgage
> market and its impact
> on the nation's and the world's financial markets.
> These are however
> the same people who could not imagine planes hitting
> buildings,
> hurricanes destroying major cities, and they are,
> unfortunately, also
> the people who will be blindsided when the
> disastrous situation we
> face with respect to health care finance mechanisms
> also unravels as
> it unfortunately will in the years (if not months)
> to come.
>
> The number of people who have really understood what
> I have been
> saying about capitation contracts, managed care, and
> the combining of
> health care providers and finance entities can, in
> all honesty, be
> counted on my fingers and toes. This may be the
> moment to help people
> understand what is coming in health care in the next
> few months/years.
>
> The mortgage situation developed because greedy and
> manipulative
> mortgage companies and brokers sold foolish people
> on the idea that
> with an income of $20,000 per year they could afford
> to live in a
> $600,000 house, drive a new car every year, have a
> second home, and go
> on vacations - all they needed to do was sign up for
> a 3 year ARM with
> no interest or principal payments and then in three
> years they could
> get another 3 year ARM based on the obvious future
> appreciation in the
> value of their houses.
>
> But it wasn't just really dumb people making $20,000
> who fell for this
> nonsense. Some of the dupes made very large
> salaries, had advanced
> degrees, but simply couldn't understand that the
> RVs, boats, and
> second and third homes they were buying with the
> equity in their
> overvalued houses simply could not have been
> sustained any longer than
> it has been. I won't begin to tell you how many
> colleagues I have
> urged not to avail themselves of ARMs in the last 5
> years. Eventually,
> when the only thing driving up prices is the next
> sucker standing in
> line willing to pay the price, markets inevitably
> collapse.
>
> As I have watched over the last couple of years the
> thought that has
> constantly run through my mind has been the
> ebullience that
> characterized the country just before The Great
> Depression.
>
> If the only people hurting were foolish people who
> signed such
> mortgages and the foolish people who bought
> supposedly high return
> mortgage derivatives, i could easily live with their
> pain. But the
> greed knew no limits, and in the end, it isn't these
> most foolish
> people who will shoulder the bulk of the burden of
> the bailouts, it is
> the ordinary, everyday people who live within their
> means and who
> avoided taking such risks who will ultimately pay
> the tens of
> thousands of dollars per person in deferred taxes
> that it will take
> us, our children, grandchildren, and
> great-grandchildren to pay off
> the massive debts being assumed by the federal
> government for its
> failures to stop the mortgage meltdown years ago.
>
> How does this relate to nursing and my work on
> Professional Caregiver
> Insurance Risk? Just as foolish people took the risk
> that they would
> not be able to secure refinancing on their
> overvalued properties,
> despite the fact that this risk was palpable to
> anyone paying
> attention, the sheep kept walking willingly to their
> future slaughter.
>
> But of concern to me is all the similar risks, in
> this case health
> insurance risks, that doctors, hospitals, nursing
> homes, and clinics
> have willingly accepted as they have signed on for
> managed care
> agreements, capitation contracts, and the worldwide
> use of Diagnosis
> Related Groups financial reimbursement formulae.
>
> Just as mortgage brokers preyed on the ignorance of
> borrowers,
> organizations that purport to be health insurers
> have effectively
> transferred the actual insurance risks involved in
> the legitimate
> practice of running an insurance company and
> transferred these risks
> to health care providers. Over the short run this
> worked out pretty
> well for a small number of greedy and predatory
> companies, executives,
> investors, and sales people. Individuals made
> hundreds of millions of
> dollars by limiting patient's choices and delaying
> diagnosis and
> treatment – the most fundamental cornerstones of
> "caring". After all,
> if you haven't figured out what sort of care your
> patient needs, how
> can you possibly provide that care?
>
> Who this massive transfer of insurance risks hasn't
> worked out too
> well for are the tens of millions of people who lost
> the benefit of
> separation between their health care provider's
> personal financial
> gain/loss and clinical and professional duties and
> responsibilities.
>
> If you walk into virtually any managed care or
> capitated group
> practice, you won't need a PhD and a research
> background to note that
> the offices are overcrowded, the staff are
> overworked, the waiting
> time is absurdly long, and the amount of time each
> patient spends with
> their physician or nurse practitioner is too short
> to provide
> comprehensive diagnosis, treatment, and "care".
> These providers are
> really good at giving low cost, immediate care, but
> they really
> perform badly when it comes to delivering care to
> people with complex
> needs – our best friends, the unitary human beings
> who have complex
> needs, require longer visits not shorter visits, and
> whose needs are
> not well addressed by a prescription pad and a pep
> talk...
>
> The consequence of this, of course, is that hundreds
> of millions of
> patients spend far too long waiting to be seen and
> even when they are
> seen, the "focused visit" supersedes clinical
> efficacy. If there was
> no financial gain or loss in this situation for
> providers we might
> just all rail about the declining quality of care
> and how overburdened
> practitioners are. But there is a financial benefit
> to providers in
> this situation.
>
> Providers (and obviously not all providers) who
> overbook themselves,
> their offices, and their staff in order to add more
> managed care
> patients to the office roster are doing so to
> maximize their revenues
> without regard to the declining quality of the care
> they provide. They
> chose to accept health insurance risks but they have
> not, by and
> large, stood up and accepted the inevitable costs,
> their needs for
> bigger offices, more equipment, and more staff. That
> is one side of
> the financial gain/loss picture, the other is
> nowhere near so pretty.
>
> The other way providers (Hospitals, nursing homes,
> group practices,
> integrated health care delivery systems) optimize
> their financial
> performance is by ignoring, even denying, the
> clinical needs of their
> patients. Over the last few decades more and more
> patients have not
> been diagnosed early and correctly. Even when their
> physicians and
> nurse practitioners have finally acknowledged their
> needs, they have
> often been denied the very treatments they so
> desperately needed as
> their providers tried to escape their obligations to
> cover these costs
> – precisely what they agreed to do when they
> signed up to assume
> health insurance risks. In the end, the very
> providers that patients
> need to be able to rely on unquestionably, have
> violated the trust of
> their patients, just as the people selling no
> interest/principal
> mortgages and mortgage based derivatives to unwary
> borrowers and
> investors, many health care providers have benefited
> financially in
> their actions by delaying and denying diagnosis and
> care – passing the
> risks on to their unknowing patients.
>
> That individuals, even very large aggregations of
> health care
> providers cannot effectively manage health insurance
> risks is sort of
> a no-brainer for anyone familiar with elementary
> sampling theory, the
> core of my work on professional caregiver insurance
> risk. Large
> insurers manage risk by knowing their business,
> aggregating millions,
> even tens of millions, of policyholders, thereby
> reducing the
> variation in their insurance operating costs.
>
> But when companies that act like, talk like, and
> walk like health
> insurers transfer their health insurance risks to
> various health care
> providers, the risk aggregation is undone. Mortgage
> companies evaded
> the small amount of risks of non-payment due to poor
> underwriting, by
> transferring the risks of future non-payment to home
> buyers by selling
> them mortgages they couldn't afford and for short
> terms that virtually
> guaranteed defaults. What the mortgage companies
> failed to recognize
> is that eventually the houses they would be
> repossessing wouldn't be
> worth anything.
>
> Similarly, year after year of mismanaged care has
> led to a situation
> where millions of patients needs have been ignored,
> tens of millions
> are completely uninsured (Though i would argue that
> we can probably
> count the number of Americans with real health
> insurance with a very
> small number of beads).
>
> When large "health insurers" transfer insurance
> risks to health care
> providers, they KNOW that the health care providers
> cannot manage
> these insurance risks as efficiently as insurers
> can. The consequence
> of this is that health care providers do the only
> thing they really
> can to cut costs – remember, if health care
> providers were making
> their operations more efficient we would already
> have electronic
> medical records, and your waiting time for an
> appointment would be
> moments not hours.
>
> Capitated providers clearly cannot operate their
> practices efficiently
> and this is the area of their presumed expertise.
> Insurance
> operations, a field considerably older and far more
> developed than
> modern medicine and nursing, is way out of the
> domain of expertise of
> health care providers. So what do health care
> providers do to manage
> the financial risks they face? They reduce the level
> of services they
> provide.
>
> It takes longer to get appointments. Even when you
> get to the
> office/hospital, they don't want to take care of all
> your needs, they
> want to take care of the easiest needs you have and
> have you come back
> some time in the future when you can wait too long
> for too little care
> again. Delaying costs is a common insurer practice.
> Obviously delaying
> costs for one policyholder doesn't mean much. But
> delaying payments to
> millions of policyholders, precisely what happened
> after Katrina and
> which will happen with Gustav and Ike, dramatically
> affects the bottom
> line, for a while anyway.
>
> It is, in my humble opinion, long past time for
> nursing to champion a
> restructuring of our failing health care finance
> system and way past
> the time when nurses should be talking about working
> with managed care
> systems. The consequence? If you own stock in a
> managed care company –
> bail out while you can!
>
> I know it is one of my long rants, but I would feel
> remiss if I didn't
> point out that one of the next big ripples in our
> financial services
> sector is our 'about to collapse' system of health
> care finance and,
> by extension, our wildly dysfunctional health care
> system.
>
> Health care providers, like mortgage derivative
> investors, signed up
> for risks that are simply unmanageable. It is time
> to stop a system
> that hasn't worked for providers or consumers.
>
> Selfishly, I don't want anyone on this listserver to
> ever say that
> nobody could have possibly anticipated what is so
> clearly coming...
>
> Bear
>
>