How I wish I had access to someone involved in the health reform process in Washington!!
I would slip them a memo with just a few provisions suggested, they would take the memo, take the suggestions, and just slip them in as provisions to the health insurance reform bill that comes out. It wouldn't be hard, they are just a few things that would make life a lot easier for doctors, if only I knew someone.
On a much smaller scale, I did it once before. Here's my War Story. (Then after the War Story is the memo I wish I had someone to deliver it to.)
After my internship I worked in D.C. with the Public Health Service, as a so-called "two year doctor." It turned out I stayed in the USPHS for six years because I liked it and got a great deal, but still, I was a two year doc. In the second year I became head of the Migrant Health Program for a year. What a mega-experience! Especially since halfway through the year we got a surprise additional appropriation that we had to spend in just a few months, and I was in charge. Not only did we get the money spent, but we changed the whole concept of the program, away from giving small grants to county health departments all along the so-called migrant stream, and instead establishing significant health centers that would cater to the migrant workers, rather than simply working them in as another duty of the health departments. To do this we had to get all our regional offices activated to find grantees, and I myself went out to the field and wrote a grant in Orange Cove, CA, then flew back to DC, received the grant I had written, and approved it. A lot of fun.
By that time I really knew a lot about health care policy and probably as much about migrant health care as anyone. My father said, Budd, you ought to write a book. My Dad. He found me downstairs at his house reading "Ball Four" by Jim Bouton instead of doing the book and said, "You should be ashamed." My father.
But, actually, while he wasn't right about my being ashamed, he was right that I ought to write a book. So I actually did. First I got my Masters degree at the Graduate School of Public Policy at Berkeley. I wrote the first chapter as my Masters thesis, promising more to come. The next year I spent at the Stockholm School of Economics, and in between learning Swedish and doing research on Swedish health care, I finished the first draft of the book that was eventually published in 1975 as "Health Care for Migrant Workers - Policy and Politics."
But before it was published, I thought that to really finish the job, I ought to see if we can get the Migrant Health Law changed so that the policies of large health centers would be mandated, and couldn't be reversed by the next denizens of the Public Health Service Migrant Health Division, with their long standing ties to county health departments. It happened that I could co it, because I had one more year in the USPHS, and I was going back to Washington. I wasn't supposed to be lobbying for anything, of course, that wasn't my job. But I was in Washington, I was young, it was the 70's, and that's just me, anyway.
I think it was my friend Jim Mongan, who was then a staffer on the Senate Finance Committee, who got me in touch with Brian Biles, who was a staffer for Bill Roy, MD, Congressman from Kansas, who was on the House Commerce Committee, with jurisdiction over Migrant Health. I showed the manuscript, which was hefty, to him and to Steve Nelson, I think his name was, staff aide to Paul Rogers, Chairman of the Committee. They heard my rap, they weighed the manuscript, Mongan had probably told them I was a smart, good guy, and they thought it made sense. So they ran with it. They wrote the bill with my help, and got the adherence of Bill Roy and Paul Rogers.
Ah, the good old days! The bill was about to be passed and there were final hearings. I wasn't supposed to be there, of course, but I went to the final hearings where Paul Rogers presided. I was there in the audience trying to keep a low profile. I'm not sure who else was there, but the old guard of the Migrant Health Program who had worked all those years with county health departments and shipped them money, to whom I was of course anathema, had to be there, too. I kept a low profile.
So, naturally, at the end, with the new legislation going to be passed, what does Paul Rogers do? He looks out in the audience and says, "Now, where is Budd Shenkin?"
I am aghast, I'm not supposed to be there, I wasn't supposed to do this, and I'm saying to him silently and with my hands, "No! Don't call me out!" But he mistakes my reticence to modesty, and says, "No, come on, stand up there! This young man has done a real service in ... ." Actually, I'm not sure what he said. I just reluctantly stood up and took a small bow to scattered applause and sat down and hoped no one really noticed.
I needn't have worried - after all, what were they going to do to me? I was leaving the next year anyway, and besides, no one pisses of Congress if they can help it, and I was their guy. Even today, by the way, the law prevails, and the health centers that we established still exist.
The whole thing, and especially that day at the hearings, sticks in my memory as one of those things we remember to the end, a mile marker. (Like the time I came in to the first JV basketball game of the season with two minutes to go and the score tied, and scored five points and had an assist and we won and finished the season 23-0 -- but that's another story.)
Anyway, we could do that in migrant health. It was a very low profile program, no press whatsoever, no powerful interest groups, virtually nobody watching, something you can kind of slip by. Brian and Steve and I did high fives and they said, it just goes to show what one squirrly guy can do if he sets his mind to it, and I thought they were great. We gloried in our accomplishment. In their world of Washington congressional aides, doing good was the equivalent of making money on Wall Street - or probably Main Street.
Health Reform couldn't be any more different from Migrant Health, of course. Everyone's watching. Still, I wish I had friends like Steve and Brian now. I bet we could just slip some stuff in! I'm no longer with the USPHS, and what I know now is different, since I have been a practicing pediatrician for thirty years (where did they go, one asks.) I've been dealing with health insurance for a long time. So, if I could, here are the little changes I would make. It is in a memo I wish I could slip to someone who trusted and respected me, as Brian and Steve did, with just a couple of provisions to control what the health insurance companies do. I so wish.
Here is the memo:
Health insurance reform is sorely needed. The first consideration has been the interest of the American people at large, many of whom are priced out of the market, or are subject to untoward restrictions on policies, or are subject to rescissions. The proposed Health Insurance Exchange, which entails many requirements on insurance companies to repair these problems, will remedy many of these problems.
Less prominent in the discussions, however, has been the fact that physicians face some of the same problems in dealing with the insurance companies as the public does. Physicians frustrated by these insurance practices, and they contribute to the notorious lack of efficiency of the entire system. Physicians and insurance companies alike have small army of employees who spend their time determining eligibility, determining co-pays and deductibles, coverage for specific services, submitting claims, rejecting claims, appealing claims, etc. These opposing armies fight over money and rack up overhead dollars to the ultimate advantage of neither, and to the disadvantage of the public.
The Health Reform legislation should and could address many of these problems of insurance company/physician relations at the same time as they address the insurance company/patient difficulties. Here is a small set of measures that could be easily entered into the current legislative proposals that would increase simplicity and decrease overhead on all sides.
• Eligibility determination. When a patient makes an appointment, the physician’s office needs to know if the insurance coverage is current in order to know how to deal with the patient. At present, the insurance companies maintain websites with lists of eligible patients that the offices can access, but which is sometimes out of date, and which often does not detail all the specifics of each policy. A physician office thus has to access the site for each patient appointment and guess at some coverage issues. If the website indicates incorre tly that the patient is eligible, the physician’s claims are rejected because the website data was not accurate. Solution – legislation should mandate that insurance companies maintain eligibility data in a standard format, and that software be supplied to physicians’ offices so that all the offices need do is submit name and birth date, and all relevant data will appear instantly. The insurance companies should be required to honor physician’s claims if their website data was inaccurate. This provision could be called instant verification of patient eligibility.
• Payment standardization. Physicians are required to submit bills according to strict rules of CPT coding. Yet insurance companies are free to ignore some billings, saying that they regard these services as “covered” by other codes perhaps, or just saying that they simply choose not to pay those codes. Insurance companies should be required to respect all official CPT codes and policies that an office bills.
• Prevention of false billing. Physician offices are not pristine; over-billing does occur, and it can be difficult for an insurance company to detect. Currently, the insurance companies frequently demand to see copies of encounter notes before paying bills, and frequently down-code visits presumptively. The result is a never-ending exchange of data, denial and defense, delay and consequent overhead escalation. As a remedy, insurance companies should be allowed to request encounter data on 2% of an office’s billings per year, and to pursue cases of over-billing only if this sample provides evidence of persistent errors.
• Standardization of code submission. Much of CPT coding regulations are straight-forward, but some are not. For instance, if an office does a screening test for postpartum depression, there is a standard CPT code to use, 96110. Some companies will accept the code as is, others require a modifier, and yet others require a different modifier. The physician’s office then has to remember which code goes to which payer, and when small errors are made, resubmit claims after a denial is made. Standard industry-wide policies for code submission should be established.
• Extension of timely filing. It is easy and common for insurance claims to be sent to the wrong address, because patients frequently change insurances, and many insurance companies have various addresses to submit claims to. Rectifying an incorrect address can take time, and when the bill finally arrives at the proper address, it is sometimes rejected for untimely filing. The insurance company should be required to pay the claim if proof can be produced that the claim was filed timely somewhere. In addition, the same requirement should hold if the original claim was somehow defective, even if sent to the proper address. A service properly rendered by the physician should be honored.
• Establishment of an administrative ombudsman. Disputes and misunderstandings are inevitable in the relationship between insurance companies and physicians. In addition, improvements will always be possible. Just as some proposed legislation will establish an ombudsman for the public, legislation should also establish an ombudsman for insurance company/provider relations. In addition to fielding complaints, the ombudsman could be a watchdog for this area, and recommend progressive steps to increase efficiency and fairness.
• Establishment of fair vaccine payments. One of the most important aspects of prevention is the administration of vaccines. Yet, insurance companies frequently pay for the vaccines barely at cost, leaving the physician to eat the cost of overhead. Similarly, the Vaccine for Children program (VFC) provides the physician offices with the vaccine but does not pay for overhead. Insurance companies should be compelled to pay for vaccines at a fair rate, which has been calculated to be about 125% of Average Wholesale Price of vaccines, plus the administration fee. Practices providing VFC vaccines to patients should be paid the same overhead rate as they are paid for commercial vaccines, since the overhead for commercial and VFC vaccines is about equal.
• Establishment of competing Public Options. The provider community has objected to a Federal Public Option because of the disproportionate power to price and contract on the side of the Public Option. If, however, each area were to have at least two alternative Public Options – Federal, state, and/or coop – the competition among public entities for provider network members would decrease the imbalance of power. This approach has been advocated by Mark Pauly of the Wharton School.
Of course there are many other provisions to health insurance reform that would help to streamline the system and make the insurance company/physician playing field more level, but I would submit that these incremental adjustments (except the Public Option provision, which is not incremental) would be rather easy steps forward.
Oh, how I wish.
Budd Shenkin
Saturday, August 22, 2009
Monday, August 10, 2009
A Tree Grows in Berkeley
It’s amazing what a city boy like me can do, just amazing. I spent my early years until ninth grade in West Philadelphia, about a mile west of the University of Pennsylvania, at 47th and Osage. There was a lot of concrete, I have to say. It was great to have a back alley to play ball in, and we did have a small back yard, but I’m not sure anything grew there.
Then we moved to the suburbs and my mother did start to plant things in the yard, flowers and maybe even tomatoes against a white picket fence, I think. Not quite bucolic, but some trees and grass and flowers, especially trees out on the Main Line where we lived. It was just great to drive under the trees in Merion and Gladwyn, and hear birds and everything.
But now I live in California, and even though we are in Berkeley, which is pretty urban, hey, it’s still California, and lots of things grow here! We have a big redwood in our small back yard, I’d say 9 foot circumference, so things get pretty shady, but still, things grow. And I have planted things and arranged things and gotten into bulbs and planted impatiens and lots of things, and it’s just amazing what a city boy can do.
So, I just noticed maybe three years ago that over by the fence, just beside where I had planted some of those little living Christmas trees about ten years ago that actually grew into little Douglas firs, that a little stalk had grown up and was growing some fruit! I looked closely and I realized that some years ago I had eaten a really good plum, and then I had planted the pit there. Amazing, now it was growing fruit!
So I watched it and plucked off a couple of plums and ate them. They were so good! I watched for the flowers to come out the next year, and they did, and then the plums, and then I ate them again!
This year, we got about 15 plums growing! Tasty! I wasn’t sure, I thought they had been the deep purple plums when I ate them originally, but now I realized they were the more yellow colored and reddish plums. Still, very good! Juicy!
But since we were going away for a week and there were about ten plums ready to eat, I thought I’d pick them and take them out for our staff to share at our Bayside managers meeting. So I did.
I just put them on the table when we were eating lunch, and people said what are they? I said, they’re plums from our tree. I planted the pit myself, and the tree just grew.
“Wow,” they said. “You know,” they said, “are you sure these are plums?”
“Sure,” I said, “I picked them myself.”
But somebody said, “Are you sure? Are you sure they aren’t nectarines?”
“Nah,” I said, “they’re plums!”
“Are you sure?” said Alan from down the other end of the table. “Isn’t the skin a little furry for plums?”
“Well,” I said, “I think they’re plums.”
Then a few people tasted them, and everyone said, “These are nectarines!”
So, isn’t it amazing? Here I am, a city boy, and I planted a plum pit, and now I have the only plum tree I know of that grows nectarines!
Then we moved to the suburbs and my mother did start to plant things in the yard, flowers and maybe even tomatoes against a white picket fence, I think. Not quite bucolic, but some trees and grass and flowers, especially trees out on the Main Line where we lived. It was just great to drive under the trees in Merion and Gladwyn, and hear birds and everything.
But now I live in California, and even though we are in Berkeley, which is pretty urban, hey, it’s still California, and lots of things grow here! We have a big redwood in our small back yard, I’d say 9 foot circumference, so things get pretty shady, but still, things grow. And I have planted things and arranged things and gotten into bulbs and planted impatiens and lots of things, and it’s just amazing what a city boy can do.
So, I just noticed maybe three years ago that over by the fence, just beside where I had planted some of those little living Christmas trees about ten years ago that actually grew into little Douglas firs, that a little stalk had grown up and was growing some fruit! I looked closely and I realized that some years ago I had eaten a really good plum, and then I had planted the pit there. Amazing, now it was growing fruit!
So I watched it and plucked off a couple of plums and ate them. They were so good! I watched for the flowers to come out the next year, and they did, and then the plums, and then I ate them again!
This year, we got about 15 plums growing! Tasty! I wasn’t sure, I thought they had been the deep purple plums when I ate them originally, but now I realized they were the more yellow colored and reddish plums. Still, very good! Juicy!
But since we were going away for a week and there were about ten plums ready to eat, I thought I’d pick them and take them out for our staff to share at our Bayside managers meeting. So I did.
I just put them on the table when we were eating lunch, and people said what are they? I said, they’re plums from our tree. I planted the pit myself, and the tree just grew.
“Wow,” they said. “You know,” they said, “are you sure these are plums?”
“Sure,” I said, “I picked them myself.”
But somebody said, “Are you sure? Are you sure they aren’t nectarines?”
“Nah,” I said, “they’re plums!”
“Are you sure?” said Alan from down the other end of the table. “Isn’t the skin a little furry for plums?”
“Well,” I said, “I think they’re plums.”
Then a few people tasted them, and everyone said, “These are nectarines!”
So, isn’t it amazing? Here I am, a city boy, and I planted a plum pit, and now I have the only plum tree I know of that grows nectarines!
Wednesday, August 5, 2009
Health Insurance Exchange and Public Option
OK, here's how far I have come in understanding health insurance reform:
The era of health care reform is here. The first big step will be health insurance reform. Health insurance is only part of the problem, so health insurance reform can only be part of the answer. Nonetheless, health reform will lift a significant burden for the nation, and if done correctly, will enable further reforms to happen in the rest of the health care system.
Understanding the Health Insurance Business
If the health insurance system were a true free market, we would expect the pubic to benefit as competition proceeded, courtesy of the “hidden hand.” But that is not how the health insurance business works. Instead, the market is structured so that as companies prosper the public suffers. The trick of reform will be to reshape the market so that as companies compete the public benefits. I think this can be done by the current proposal, the Health Insurance Exchange (HIE). I also think that adding a Public Option (PO), health plans sponsored by government in competition with private plans, would help positive competition even further. Let me explain why.
The Current System
In the current system, there is no fixed price for a given policy. Instead, the price of each insurance policy, whether group or individual, is set by negotiation. This is called “experience rating.” If there were a single price for all comers, it would be called “community rating.” Decades ago Blue Cross/Blue Shield had community rating. When private companies entered the field they used experience rating. The Blues then had to also do experience rating, or they would have gotten all the bad risks (“adverse selection”).
In the current system, health insurance is a highly concentrated industry, with only a handful of major players nationwide and few local competitors. In any local area or even a state, one company can have 80% of the business. Competition is thus very muted.
In a perfect market no one company or individual has power; that is a prerequisite for the market to work. In health insurance, the insurance companies frequently have very significant power, and so do the hospitals. Occasionally, so do other providers such as doctors, but not usually. Large buyers of insurance sometimes have power as well; individuals, of course, never do. Given this playing field, it is clear that the theoretical advantages of market competition don’t have a chance of being realized.
How Health Insurance Companies Make Their Money
So, how do the companies make money?
Vis-à-vis Patients
Most importantly, insurance companies seek to identify the best risks and insure them, and to reject the worst risks – this is called “cherry-picking.” The companies spend a great deal of money underwriting policies to identify who is a good and bad risk so they can price the policies differentially, and they can not offer policies at all to some. The companies can also frequently be “price givers” rather than “price takers,” because groups and individuals in an area often have little choice of company. So, prices rise, profits rise, and groups and individuals can find themselves without a choice at all.
The companies also make money by rejecting policies retroactively (this is called “dumping,” or “rescissions”). When a patient gets sick the insurance company withdraws the policy on the grounds of an unrevealed preexisting condition. Thus, an insured patient becomes uninsured and the insurance company is not liable for the medical expenses.
The companies also write policies cleverly, exploiting their superior knowledge of policy details. Policy purchasers are confused not only by the “small print,” but even by the basic terms of deductibles, coinsurance, and exclusions from coverage. When illness strikes, patients frequently discover that they are under-insured.
The companies reject specific procedures and treatments for patients. There is as yet no independent and authoritative authority to determine which treatments and procedures are valuable. Thus, practitioners make their decisions and the insurance companies get to authorize or reject. Insurance companies probably feel more defensive than offensive in trying to curtail the proliferation of tests and procedures, but the battle for authorization piles up overhead and patients are caught in the middle.
They neglect customer service. Concentrated industries offer few consumer alternatives and can get away with this.
They pay less when a patient chooses an out-of-network provider. This contract provision is rather straight-forward, but recent lawsuits have clarified that the companies have compounded their gain by illegally overestimating the amount the patient is compelled to pay by using faulty cost data.
They market their products either through brokers or directly themselves, using the usual marketing techniques. There is no reputable central source of information and evaluation of these policies for buyers to turn to, only salespeople. Again, overhead is significant.
Vis-à-vis Providers
The great majority of policies are now either HMO’s or PPO’s, both of which require the insurance company to assemble a roster of physicians, hospitals, laboratories, etc., that “accept” that insurance. The companies assemble their networks by contracts that specify payment rates.
In negotiating with physicians, there are usually only a few insurance companies in any single area. The physicians, however, are many, and are forbidden by anti-trust law from negotiating as a group. The insurance companies make their money here by tough negotiating against the atomized physicians.
After the contracts are established and services rendered, physicians try to maximize their billings but must adhere to detailed rules of coding their services. The insurance companies make money by delaying, denying, and down-coding (estimating a service complexity at less than the claim) payments. The physician/insurance battles are legendary; the overhead of personnel salaries on both sides funding this war is also legendary.
Some hospitals have local monopolies or oligopolies and can do very well in negotiating with the insurance companies. In other areas where there are many small hospitals, the insurance companies again make their money by being more concentrated than the providers. In either case, with small numbers of negotiators, efficiencies rarely result, and it is more common for both entities to take their advantage and simply boost the price to the public.
Administration-only Services
Large employers frequently self-insure and use insurance companies for their provider networks, policy benefit structures, and claims payments. In contrast to the above situations, this function appears to be more typical of the general business world.
In sum, then, we can see how little the health insurance market resembles the ideal of “perfect competition.” No hidden hand works to serve the public as the industry strives for profit, accumulates overhead, and doesn’t serve the public interest much at all.
Serving The Public Interest Better – The Health Insurance Exchange (HIE)
The whole point of a “Health Insurance Exchange” (HIE) would be to change competition into a system that actually worked for the benefit of the public. The HIE would present a menu of insurance choices to buyers, both individuals and groups. There would be Level I, Level II, Level III, and Level IV benefits, with each company offering complying with the benefit requirements at each level. There would be no “cleverness” allowed.
The costs would vary, and some offerings might have extra features above the specified level – add-ons, if you will. So at Level I you could choose company A with its network of providers, or Company B with its network, etc. The companies would be required to accept all comers at a common price (“community rating.”) Riskier groups and individuals would be subsidized (several techniques are available, from private and public sources), so no company would suffer adverse selection. Lower income individuals would be subsidized – in essence, they would have a modified voucher. The HIE would be available to individuals and small groups at first, and later to larger groups.
Just establishing this new exchange system would solve several of the health insurance problems. It would:
• Increase insurance accessibility, and thus greatly reduce the numbers of uninsured.
• Eliminate the problem of portability.
• Reduce under-insurance.
• Increase transparency of policy provisions, and thus protect patients from exploitation.
• Eliminate patient dumping.
• Reduce costs in the insurance system by:
o Eliminating the overhead of underwriting.
o Reducing the overhead of marketing.
Attracting patients would now center on price, additional coverage offered, patient service, and choice of provider networks. Profitability would center on efficiency of operations, both internal to the insurance company, and in the efficiency of care delivered by the company’s network.
On the other hand, the HIE would not fix some of the existing insurance problems:
• Conditions of negotiation with doctors and hospitals.
• Payment wars between providers and insurance companies.
• Insurance company\patient wars over coverage for procedures.
• Excessive concentration in the health insurance industry.
Still, even if there were still problems, one can see that having a HIE would be a great deal better than the current system. The HIE would not solve the problems of cost and quality – but changing the health insurance system cannot fix everything.
The Public Option
Now the question arises: given a HIE, would the public and the system of health care be even better served if one of the options were to be a government sponsored non-for-profit plan (the Public Option, or PO) that competed with the other offerings?
What do we mean by a PO? It is not yet decided what form Congress has decided the PO will take, but the most probable form would be a non-profit governmental entity governed by the same rules as the private companies. That is, the PO would have entries at each level of the HIE at a price decided on by the entity, but the price could not be so low as to cause a deficit in its budget.
What would be the virtue of a PO bound by the same rules as the private plans? The common explanation is that the public plan would “keep the private plans honest.” This must mean that the government plan would be honest, cut no special deals with any party, nor overpay its executives. Others have said the government could get “volume discounts.” It is hard to understand what this means, since commodities form very little part of health care. If it means that a large governmental plan could coerce favorable contracts with physicians because of size, that would be possible but not desirable, since short-lived profits from lower prices, as opposed to real efficiencies, would sooner or later cut into quality. With hospitals on the other hand, it may be that by combining payment systems with Medicare and Medicaid actual efficiencies in billings could be effected with resultant decreases in costs.
So let us assume that a government plan would differ from the private plans only in sponsorship. What is the virtue in that? First of all, it would lessen the degree of concentration of health insurance. Competition would thus be improved.
Second, private companies negotiate differently with providers than do governmental entities. The PO would probably offer a single price for services rendered to all providers, and accept all providers who wanted to sign up under those terms. The private companies might want to play the game differently – they might want to sign up only certain providers, as they would be freer to do so than would the PO. Thus, the private companies might have innovative plans with networks that would attract consumers, perhaps even at a higher price – there should be no law against paying for luxury. Some might pay primary care physicians more; others might pay specialists more. They might have different practice restrictions. Private companies could experiment with the Medical Home, with Accountable Care Organizations, etc. In this scenario, the HIE would allow for differentiation of product while at the same time ensuring a good quality lowest denominator. If the private plans were to go bankrupt and fail, the PO would always be there for the consumers who were with the failed plan.
Third, the PO might be more typically bureaucratic than some other private companies, who might be more innovative in their administrative functions. Thus, this private company could charge the same as the PO but still make a profit, and the public would be better served.
Fourth, before it sunk into traditional governmental mediocrity, the spirit of the PO might at first engender some innovations that the somnolent private companies were not capable of coming up with. If they could not match the PO, they would deserve to fade from the scene. If they felt themselves challenged to compete, counter-innovations might result.
Fifth, the PO might be better able to respond to national priorities than the private plans. For instance, there is a national shortage of primary care practitioners. The PO might be more likely than the private plans to respond to this priority by boosting the pay of primaries.
Conclusion
In sum, if pains were taken not to unduly advantage the PO, it might well be that including it in the HIE would result in a more vibrant competitive field that would wind up actually benefiting the public. In fact, the PO is such a good idea, it might be good to have multiple PO’s competing in one arena – one perhaps Federally sponsored, one state sponsored, and others cooperatives as have been mentioned in the Senate Finance Committee.
It is hard to see that too much competition at first among both private and public entities would be a problem. Everyone realizes that health insurance reform is only the beginning of health care delivery reform. Using the HIE and including a PO might well set the stage for further reform and evolution using free competition that actually works for, instead of against, the public interest.
The era of health care reform is here. The first big step will be health insurance reform. Health insurance is only part of the problem, so health insurance reform can only be part of the answer. Nonetheless, health reform will lift a significant burden for the nation, and if done correctly, will enable further reforms to happen in the rest of the health care system.
Understanding the Health Insurance Business
If the health insurance system were a true free market, we would expect the pubic to benefit as competition proceeded, courtesy of the “hidden hand.” But that is not how the health insurance business works. Instead, the market is structured so that as companies prosper the public suffers. The trick of reform will be to reshape the market so that as companies compete the public benefits. I think this can be done by the current proposal, the Health Insurance Exchange (HIE). I also think that adding a Public Option (PO), health plans sponsored by government in competition with private plans, would help positive competition even further. Let me explain why.
The Current System
In the current system, there is no fixed price for a given policy. Instead, the price of each insurance policy, whether group or individual, is set by negotiation. This is called “experience rating.” If there were a single price for all comers, it would be called “community rating.” Decades ago Blue Cross/Blue Shield had community rating. When private companies entered the field they used experience rating. The Blues then had to also do experience rating, or they would have gotten all the bad risks (“adverse selection”).
In the current system, health insurance is a highly concentrated industry, with only a handful of major players nationwide and few local competitors. In any local area or even a state, one company can have 80% of the business. Competition is thus very muted.
In a perfect market no one company or individual has power; that is a prerequisite for the market to work. In health insurance, the insurance companies frequently have very significant power, and so do the hospitals. Occasionally, so do other providers such as doctors, but not usually. Large buyers of insurance sometimes have power as well; individuals, of course, never do. Given this playing field, it is clear that the theoretical advantages of market competition don’t have a chance of being realized.
How Health Insurance Companies Make Their Money
So, how do the companies make money?
Vis-à-vis Patients
Most importantly, insurance companies seek to identify the best risks and insure them, and to reject the worst risks – this is called “cherry-picking.” The companies spend a great deal of money underwriting policies to identify who is a good and bad risk so they can price the policies differentially, and they can not offer policies at all to some. The companies can also frequently be “price givers” rather than “price takers,” because groups and individuals in an area often have little choice of company. So, prices rise, profits rise, and groups and individuals can find themselves without a choice at all.
The companies also make money by rejecting policies retroactively (this is called “dumping,” or “rescissions”). When a patient gets sick the insurance company withdraws the policy on the grounds of an unrevealed preexisting condition. Thus, an insured patient becomes uninsured and the insurance company is not liable for the medical expenses.
The companies also write policies cleverly, exploiting their superior knowledge of policy details. Policy purchasers are confused not only by the “small print,” but even by the basic terms of deductibles, coinsurance, and exclusions from coverage. When illness strikes, patients frequently discover that they are under-insured.
The companies reject specific procedures and treatments for patients. There is as yet no independent and authoritative authority to determine which treatments and procedures are valuable. Thus, practitioners make their decisions and the insurance companies get to authorize or reject. Insurance companies probably feel more defensive than offensive in trying to curtail the proliferation of tests and procedures, but the battle for authorization piles up overhead and patients are caught in the middle.
They neglect customer service. Concentrated industries offer few consumer alternatives and can get away with this.
They pay less when a patient chooses an out-of-network provider. This contract provision is rather straight-forward, but recent lawsuits have clarified that the companies have compounded their gain by illegally overestimating the amount the patient is compelled to pay by using faulty cost data.
They market their products either through brokers or directly themselves, using the usual marketing techniques. There is no reputable central source of information and evaluation of these policies for buyers to turn to, only salespeople. Again, overhead is significant.
Vis-à-vis Providers
The great majority of policies are now either HMO’s or PPO’s, both of which require the insurance company to assemble a roster of physicians, hospitals, laboratories, etc., that “accept” that insurance. The companies assemble their networks by contracts that specify payment rates.
In negotiating with physicians, there are usually only a few insurance companies in any single area. The physicians, however, are many, and are forbidden by anti-trust law from negotiating as a group. The insurance companies make their money here by tough negotiating against the atomized physicians.
After the contracts are established and services rendered, physicians try to maximize their billings but must adhere to detailed rules of coding their services. The insurance companies make money by delaying, denying, and down-coding (estimating a service complexity at less than the claim) payments. The physician/insurance battles are legendary; the overhead of personnel salaries on both sides funding this war is also legendary.
Some hospitals have local monopolies or oligopolies and can do very well in negotiating with the insurance companies. In other areas where there are many small hospitals, the insurance companies again make their money by being more concentrated than the providers. In either case, with small numbers of negotiators, efficiencies rarely result, and it is more common for both entities to take their advantage and simply boost the price to the public.
Administration-only Services
Large employers frequently self-insure and use insurance companies for their provider networks, policy benefit structures, and claims payments. In contrast to the above situations, this function appears to be more typical of the general business world.
In sum, then, we can see how little the health insurance market resembles the ideal of “perfect competition.” No hidden hand works to serve the public as the industry strives for profit, accumulates overhead, and doesn’t serve the public interest much at all.
Serving The Public Interest Better – The Health Insurance Exchange (HIE)
The whole point of a “Health Insurance Exchange” (HIE) would be to change competition into a system that actually worked for the benefit of the public. The HIE would present a menu of insurance choices to buyers, both individuals and groups. There would be Level I, Level II, Level III, and Level IV benefits, with each company offering complying with the benefit requirements at each level. There would be no “cleverness” allowed.
The costs would vary, and some offerings might have extra features above the specified level – add-ons, if you will. So at Level I you could choose company A with its network of providers, or Company B with its network, etc. The companies would be required to accept all comers at a common price (“community rating.”) Riskier groups and individuals would be subsidized (several techniques are available, from private and public sources), so no company would suffer adverse selection. Lower income individuals would be subsidized – in essence, they would have a modified voucher. The HIE would be available to individuals and small groups at first, and later to larger groups.
Just establishing this new exchange system would solve several of the health insurance problems. It would:
• Increase insurance accessibility, and thus greatly reduce the numbers of uninsured.
• Eliminate the problem of portability.
• Reduce under-insurance.
• Increase transparency of policy provisions, and thus protect patients from exploitation.
• Eliminate patient dumping.
• Reduce costs in the insurance system by:
o Eliminating the overhead of underwriting.
o Reducing the overhead of marketing.
Attracting patients would now center on price, additional coverage offered, patient service, and choice of provider networks. Profitability would center on efficiency of operations, both internal to the insurance company, and in the efficiency of care delivered by the company’s network.
On the other hand, the HIE would not fix some of the existing insurance problems:
• Conditions of negotiation with doctors and hospitals.
• Payment wars between providers and insurance companies.
• Insurance company\patient wars over coverage for procedures.
• Excessive concentration in the health insurance industry.
Still, even if there were still problems, one can see that having a HIE would be a great deal better than the current system. The HIE would not solve the problems of cost and quality – but changing the health insurance system cannot fix everything.
The Public Option
Now the question arises: given a HIE, would the public and the system of health care be even better served if one of the options were to be a government sponsored non-for-profit plan (the Public Option, or PO) that competed with the other offerings?
What do we mean by a PO? It is not yet decided what form Congress has decided the PO will take, but the most probable form would be a non-profit governmental entity governed by the same rules as the private companies. That is, the PO would have entries at each level of the HIE at a price decided on by the entity, but the price could not be so low as to cause a deficit in its budget.
What would be the virtue of a PO bound by the same rules as the private plans? The common explanation is that the public plan would “keep the private plans honest.” This must mean that the government plan would be honest, cut no special deals with any party, nor overpay its executives. Others have said the government could get “volume discounts.” It is hard to understand what this means, since commodities form very little part of health care. If it means that a large governmental plan could coerce favorable contracts with physicians because of size, that would be possible but not desirable, since short-lived profits from lower prices, as opposed to real efficiencies, would sooner or later cut into quality. With hospitals on the other hand, it may be that by combining payment systems with Medicare and Medicaid actual efficiencies in billings could be effected with resultant decreases in costs.
So let us assume that a government plan would differ from the private plans only in sponsorship. What is the virtue in that? First of all, it would lessen the degree of concentration of health insurance. Competition would thus be improved.
Second, private companies negotiate differently with providers than do governmental entities. The PO would probably offer a single price for services rendered to all providers, and accept all providers who wanted to sign up under those terms. The private companies might want to play the game differently – they might want to sign up only certain providers, as they would be freer to do so than would the PO. Thus, the private companies might have innovative plans with networks that would attract consumers, perhaps even at a higher price – there should be no law against paying for luxury. Some might pay primary care physicians more; others might pay specialists more. They might have different practice restrictions. Private companies could experiment with the Medical Home, with Accountable Care Organizations, etc. In this scenario, the HIE would allow for differentiation of product while at the same time ensuring a good quality lowest denominator. If the private plans were to go bankrupt and fail, the PO would always be there for the consumers who were with the failed plan.
Third, the PO might be more typically bureaucratic than some other private companies, who might be more innovative in their administrative functions. Thus, this private company could charge the same as the PO but still make a profit, and the public would be better served.
Fourth, before it sunk into traditional governmental mediocrity, the spirit of the PO might at first engender some innovations that the somnolent private companies were not capable of coming up with. If they could not match the PO, they would deserve to fade from the scene. If they felt themselves challenged to compete, counter-innovations might result.
Fifth, the PO might be better able to respond to national priorities than the private plans. For instance, there is a national shortage of primary care practitioners. The PO might be more likely than the private plans to respond to this priority by boosting the pay of primaries.
Conclusion
In sum, if pains were taken not to unduly advantage the PO, it might well be that including it in the HIE would result in a more vibrant competitive field that would wind up actually benefiting the public. In fact, the PO is such a good idea, it might be good to have multiple PO’s competing in one arena – one perhaps Federally sponsored, one state sponsored, and others cooperatives as have been mentioned in the Senate Finance Committee.
It is hard to see that too much competition at first among both private and public entities would be a problem. Everyone realizes that health insurance reform is only the beginning of health care delivery reform. Using the HIE and including a PO might well set the stage for further reform and evolution using free competition that actually works for, instead of against, the public interest.
Sunday, August 2, 2009
Love and Baseball
Yesterday I was with Ann and Sara at the Oakland Coliseum watching the ceremony to retire Rickey Henderson's number. Just terrific. One of those things you put in the memory bank. I feel the same way about the All Star Game at AT&T Park a couple of years ago with Nick. While across the Bay a huge pitchers' duel took place between the Phillies and the Giants, between Tim Lincecum, last year's Cy Young Award winner, and former Oakland A Joe Blanton. Lincecum won, but it was close. What a great thing to have two of my favorite three teams so good this year.
Since I'm from Philadelphia I try to get to a Phillies-Giants game every year when I can. This year it was on Thursday night, and I went with high school pal Jonny Fish from Philadelphia, college pal David Riggs from Philadelphia, and long time pal Sara Buckelew who went to Penn Med School. It was a fine game, close, with some scoring. Giants won. In the middle inning I went to get something to eat and stood in line for a brisket sandwich behind a big guy with a Phillies Utley shirt on. He told me that he was from New Jersey, just across the Walt Whitman Bridge and about 20 minutes from Citizen's Bank Park where the Phillies play, and that he tries to get out here every year if he can.
I mentioned to him that I heard that Utley was moving to San Francisco. The story was that Utley has married a San Francisco girl and I guess he likes the city. What's not to like? The Utley-shirted guy said, well, he's got a story. Seems a friend of a friend was living with a girl and they were going to get engaged, but before they did they were going to take separate vacations. The guy went to Cancun and the girl went to spring training in Arizona. So, they came back home and she said, "How was your trip?"
"Great," he said. "How was yours?"
She said, "Great. I'm going to marry Tim Lincecum."
Hope the guy had a really good time in Cancun.
Budd Shenkin
Since I'm from Philadelphia I try to get to a Phillies-Giants game every year when I can. This year it was on Thursday night, and I went with high school pal Jonny Fish from Philadelphia, college pal David Riggs from Philadelphia, and long time pal Sara Buckelew who went to Penn Med School. It was a fine game, close, with some scoring. Giants won. In the middle inning I went to get something to eat and stood in line for a brisket sandwich behind a big guy with a Phillies Utley shirt on. He told me that he was from New Jersey, just across the Walt Whitman Bridge and about 20 minutes from Citizen's Bank Park where the Phillies play, and that he tries to get out here every year if he can.
I mentioned to him that I heard that Utley was moving to San Francisco. The story was that Utley has married a San Francisco girl and I guess he likes the city. What's not to like? The Utley-shirted guy said, well, he's got a story. Seems a friend of a friend was living with a girl and they were going to get engaged, but before they did they were going to take separate vacations. The guy went to Cancun and the girl went to spring training in Arizona. So, they came back home and she said, "How was your trip?"
"Great," he said. "How was yours?"
She said, "Great. I'm going to marry Tim Lincecum."
Hope the guy had a really good time in Cancun.
Budd Shenkin
Saturday, August 1, 2009
Health Insurance Company rules
This is pretty true:
In three words – ‘insurance company rules’
www.youtube.com/watch?v=bVpX5fUvPlg
Budd Shenkin
In three words – ‘insurance company rules’
www.youtube.com/watch?v=bVpX5fUvPlg
Budd Shenkin
Budd's Excellent Adventure
So. a week ago my wife and I were about an hour and a half out of Honolulu coming back to Oakland on Hawaiian Air, and I had my earphones on. Ann nudged me and said, "They're looking for a doctor." Now, my Dad was a great and idealistic doctor, but he certainly had a jaundiced side. He taught me, when they come looking for a doctor, don't volunteer - you'll just get yourself in trouble! Knowing my Dad, this was the voice of experience, either personal or vicarious. But Ann doesn't come from a medical family, so she has always wondered about my attitude as a Samaritan. I take my father's advice seriously.
But on the other hand, I've always said, try this thought experiment. You are walking along and you see someone with an affliction by the roadside. The year is 1875 (the time of Dickens, say.) You can't do anything for the poor soul. Then, time travel forward to the present. You are a doctor, you have modern medicines, and you can go over and give him some medicine and cure him. What a mitzvah ("gift" - that's a Latin word.) Who wouldn't do it? Isn't it great to be a doctor!
So, you can understand how when she told me they were looking for a doctor, Ann looked at me with some expectation, but also with a question of what I would do. Since I hadn't personally heard the call or seen the flight attendants (where are those cute stewardesses of yesteryear??), I said, see if they call again, and back on went the headphones.
But the next thing I knew, I saw this young man I soon learned was 28 years old, a Pacific Islander of some sort, about 300 pounds as Pacific Islanders can be, lying supine at the bulkhead seat just in front of me and to the right, and an older lady (probably not as old as me, but time being what it is, still an "older lady") tentatively administering to him. So I went over and identified myself as a doctor.
"What are you?" she said.
"A pediatrician," I said. "What are you?"
"An internist," she said. "But I do hospice work for Kaiser, and I mainly tend to the website."
OK, it might have been her age group specialty, but I know acute medicine and I'm a guy, and as Ann says, there was no way I wasn't going to be in charge.
So the history was that Tony, the patient, thought he had an allergy to peanuts and had just eaten some cashews the plane had passed out. Guess it's not a peanut allergy (they don't cross react.) Way to go, Tony!
The internist had the airplane's blood pressure cuff and stethoscope, and she said his pulse was 160 and his blood pressure about 80/60. Classic anaphylactic shock, no doubt from the nuts.
It was a good thing the plane had an emergency tackle box that had epinephrine in it, because after all this is just the kind of emergency that happens, and can be treated readily and easily, a wonderful advance since 1875. Since the internist seemed a bit befuddled and hadn't even asked for the epi yet, I took the epi, tried to figure out how to use it - had to attach a needle, it looked like, but probably didn't have to, I just didn't know how to use it. The internist looked around for a nurse - doctors use nurses so much they don't know how to do so much any more - even the new pediatricians who come to our practice don't know how to give an immunization themselves, amazingly enough, let alone how to incise and drain a wound. Anyway, I gave the epi, then gave 50 mg. of Benedryl intramuscularly. All the while I was being a good doctor, reassuring Tony - who by this time was complaining it was hard to breathe, the cardinal sign of how these patients die, by airway obstruction. I hoped I didn't have to do anything heroic, like cutting into his trachea, lots of luck. Tony kept saying thank you, and breathed with some difficulty.
But his pulse came down and his BP went up in about 5 minutes and I thought he was turning around. Then a young, very young woman came up from the back and identified herself as a family doc from Maui. Where the hell had she been? This is really her specialty! She listened to him and thought he was wheezing. So did the internist. Well, he wasn't. He had upper airway sounds; I know wheezing when I hear it. He was so heavy and the plane was noisy so it was hard to hear anything, but they were worried about his wheezing. The FP wanted to give him something for wheezing so she shot in some terbutaline. Made him very tremulous. Then the fp went back to her seat, her magic done.
The internist said we should ask them to turn the plane around. I said I thought he was stabilizing and would be OK. I said if we turned around he would walk off the plane looking just fine and everyone would wonder what the fuss was about. He didn't complain about its being hard to breathe so much. I looked over at Ann and made a circular sign with my upraised finger and mouthed, "Turn around?" She shook her head decisively and mouthed back, "Unh-uh!" But she knew if we had to we would.
I talked to the captain on the phone and told him the difference of opinion, and I said I think he's stabilized so let's see. The captain talked to their contracted emergency service physicians on the radio and I guess they said stick with it because I didn't hear anything more. Tony's BP was up over 100 and his pulse down to 110. He was shivering a lot but that could be due to the terbutaline. I was on one knee beside him for about 45 minutes reassuring and monitoring. His BP came up to 120/80, then 140/100. Then his wife of one year, probably also about 225 pounds, asked if he could sit up. I said absolutely. He sat up, I took the oxygen away from him, and he slept sitting in a seat the rest of the way. Even with his weight, the Benedryl probably made him sleepy. We didn't turn around. There was an emergency crew waiting for him in Oakland and I quickly gave the history, and that's all she wrote.
So, I kept everyone cool and enjoyed being a real doctor, and Ann was very proud of me, and how I kep everyone calm.. I wondered what Hawaiian Air would do for me. It was interesting. When he went to the bathroom, the captain looked back and saw me and gave me a wink and a nod. The purser gave me a form to fill out and sign that I had attended to the patient. Aloha.
I suppose they figure, this is just what doctors do; there is a public trust. I didn't know whether to feel respected, or to feel like a sucker. Tony's wife did get my name - I gave her my card. She was very thankful and wanted to recognize me some way it seemed. Haven't heard from them.
I'm grateful that I didn't get into any trouble, that this particular good deed seems to have gone unpunished. O tempora, o mores.
Budd Shenkin
Ann and I were on the plane back home about 1.5 hours out from Honolulu when the attendants went looking for a doctor. Before I knew it a 300 lb. 28 yo Pacific Islander (I think) named Tony was lying on the floor of the plane in front of me with a pulse of 160, BP 80/60, complaining of difficulty breathing around the throat. Nuts had just been served. So there was this doc from Kaiser who did hospice work and drives their website, a very young FP who practices on Maui, a retired nurse, and me. So, we opened the crash box of the plane, I gave him epi and Benedryl, and the FP give terbuterol because she thought he had some wheezes. (I thought it was all upper airway - the guy was pretty heavy.) I talked to the captain, told him I thought Tony was stabilizing, we didn't turn the plane around, and the emergency crew waited for Tony at the Oakland airport, but he seemed pretty good by that time. You just never know what will happen.
But on the other hand, I've always said, try this thought experiment. You are walking along and you see someone with an affliction by the roadside. The year is 1875 (the time of Dickens, say.) You can't do anything for the poor soul. Then, time travel forward to the present. You are a doctor, you have modern medicines, and you can go over and give him some medicine and cure him. What a mitzvah ("gift" - that's a Latin word.) Who wouldn't do it? Isn't it great to be a doctor!
So, you can understand how when she told me they were looking for a doctor, Ann looked at me with some expectation, but also with a question of what I would do. Since I hadn't personally heard the call or seen the flight attendants (where are those cute stewardesses of yesteryear??), I said, see if they call again, and back on went the headphones.
But the next thing I knew, I saw this young man I soon learned was 28 years old, a Pacific Islander of some sort, about 300 pounds as Pacific Islanders can be, lying supine at the bulkhead seat just in front of me and to the right, and an older lady (probably not as old as me, but time being what it is, still an "older lady") tentatively administering to him. So I went over and identified myself as a doctor.
"What are you?" she said.
"A pediatrician," I said. "What are you?"
"An internist," she said. "But I do hospice work for Kaiser, and I mainly tend to the website."
OK, it might have been her age group specialty, but I know acute medicine and I'm a guy, and as Ann says, there was no way I wasn't going to be in charge.
So the history was that Tony, the patient, thought he had an allergy to peanuts and had just eaten some cashews the plane had passed out. Guess it's not a peanut allergy (they don't cross react.) Way to go, Tony!
The internist had the airplane's blood pressure cuff and stethoscope, and she said his pulse was 160 and his blood pressure about 80/60. Classic anaphylactic shock, no doubt from the nuts.
It was a good thing the plane had an emergency tackle box that had epinephrine in it, because after all this is just the kind of emergency that happens, and can be treated readily and easily, a wonderful advance since 1875. Since the internist seemed a bit befuddled and hadn't even asked for the epi yet, I took the epi, tried to figure out how to use it - had to attach a needle, it looked like, but probably didn't have to, I just didn't know how to use it. The internist looked around for a nurse - doctors use nurses so much they don't know how to do so much any more - even the new pediatricians who come to our practice don't know how to give an immunization themselves, amazingly enough, let alone how to incise and drain a wound. Anyway, I gave the epi, then gave 50 mg. of Benedryl intramuscularly. All the while I was being a good doctor, reassuring Tony - who by this time was complaining it was hard to breathe, the cardinal sign of how these patients die, by airway obstruction. I hoped I didn't have to do anything heroic, like cutting into his trachea, lots of luck. Tony kept saying thank you, and breathed with some difficulty.
But his pulse came down and his BP went up in about 5 minutes and I thought he was turning around. Then a young, very young woman came up from the back and identified herself as a family doc from Maui. Where the hell had she been? This is really her specialty! She listened to him and thought he was wheezing. So did the internist. Well, he wasn't. He had upper airway sounds; I know wheezing when I hear it. He was so heavy and the plane was noisy so it was hard to hear anything, but they were worried about his wheezing. The FP wanted to give him something for wheezing so she shot in some terbutaline. Made him very tremulous. Then the fp went back to her seat, her magic done.
The internist said we should ask them to turn the plane around. I said I thought he was stabilizing and would be OK. I said if we turned around he would walk off the plane looking just fine and everyone would wonder what the fuss was about. He didn't complain about its being hard to breathe so much. I looked over at Ann and made a circular sign with my upraised finger and mouthed, "Turn around?" She shook her head decisively and mouthed back, "Unh-uh!" But she knew if we had to we would.
I talked to the captain on the phone and told him the difference of opinion, and I said I think he's stabilized so let's see. The captain talked to their contracted emergency service physicians on the radio and I guess they said stick with it because I didn't hear anything more. Tony's BP was up over 100 and his pulse down to 110. He was shivering a lot but that could be due to the terbutaline. I was on one knee beside him for about 45 minutes reassuring and monitoring. His BP came up to 120/80, then 140/100. Then his wife of one year, probably also about 225 pounds, asked if he could sit up. I said absolutely. He sat up, I took the oxygen away from him, and he slept sitting in a seat the rest of the way. Even with his weight, the Benedryl probably made him sleepy. We didn't turn around. There was an emergency crew waiting for him in Oakland and I quickly gave the history, and that's all she wrote.
So, I kept everyone cool and enjoyed being a real doctor, and Ann was very proud of me, and how I kep everyone calm.. I wondered what Hawaiian Air would do for me. It was interesting. When he went to the bathroom, the captain looked back and saw me and gave me a wink and a nod. The purser gave me a form to fill out and sign that I had attended to the patient. Aloha.
I suppose they figure, this is just what doctors do; there is a public trust. I didn't know whether to feel respected, or to feel like a sucker. Tony's wife did get my name - I gave her my card. She was very thankful and wanted to recognize me some way it seemed. Haven't heard from them.
I'm grateful that I didn't get into any trouble, that this particular good deed seems to have gone unpunished. O tempora, o mores.
Budd Shenkin
Ann and I were on the plane back home about 1.5 hours out from Honolulu when the attendants went looking for a doctor. Before I knew it a 300 lb. 28 yo Pacific Islander (I think) named Tony was lying on the floor of the plane in front of me with a pulse of 160, BP 80/60, complaining of difficulty breathing around the throat. Nuts had just been served. So there was this doc from Kaiser who did hospice work and drives their website, a very young FP who practices on Maui, a retired nurse, and me. So, we opened the crash box of the plane, I gave him epi and Benedryl, and the FP give terbuterol because she thought he had some wheezes. (I thought it was all upper airway - the guy was pretty heavy.) I talked to the captain, told him I thought Tony was stabilizing, we didn't turn the plane around, and the emergency crew waited for Tony at the Oakland airport, but he seemed pretty good by that time. You just never know what will happen.
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