More on "Never Events"

What happens when the US government is itself at fault for a so-called "never event"?

I'm sure they hold themselves up to the same stringent standards that they expect the rest of us to follow...

Doctoring the Numbers for Socialized Medicine

My recent Washington Examiner OpEd on "health care czars" was the subject of a spirited discussion thread at LittleGreenFootballs.

My wife Diana brought this comment to my attention:

Funny. In Sweden, right now, the government has all the hospitals agree to this "guarantee of service" which means when you seek non-emergency care, you must be guaranteed to see a doctor within 7 days. And if the doctor sees it is needed, he will refer you to a specialist, and you must be seen within 90 days. Then if treatment is needed, you must be treated within 90 days.

Nice, but, the hospitals can't meet that arrangement, so hospitals are quietly asking their doctors not to issue referrals -- that way they get out of the 7-90-90 agreement, and the heavy fines imposed on the hospitals if they do not fill them.

This sort of "doctoring" of the numbers is not limited to Sweden.

Last year, a controversy erupted in the UK when it turned out that ambulance drivers were told to keep critically ill patients within the ambulance, even after the vehicle had pulled up to the hospital property just outside of the doors of the emergency rooms (called "A&E" for "Accident & Emergency" in Great Britain).

The patients were forced to wait within the ambulance so that their waiting time in the vehicle wouldn't count against the hospital's waiting time, thus allowing the hospitals to technically claim that their patients were treated within government-mandated standards of arrival within the hospital:

Scandal of patients left for hours outside A&E

Hospitals were last night accused of keeping thousands of seriously ill patients in ambulance 'holding patterns' outside accident and emergency units to meet a government pledge that all patients are treated within four hours of admission.

Those affected by 'patient stacking' include people with broken limbs or those suffering fits or breathing problems. An Observer investigation has also found that some wait for up to five hours in ambulances because A&E units have refused to admit them until they can guarantee to treat them within the time limit. Apart from the danger posed to patients, the detaining of ambulances means vehicles and trained crew are not available to answer new 999 calls because they are being kept on hospital sites.

If the US adopts government-run "universal health care", we will see American hospitals acting similarly and placing a higher priority on "doctoring their numbers" rather than their patients.

Rationing In Oregon

Oregon is the only state with formal medical rationing procedure on the books. Linda Gorman discusses its decision procedure.

She also notes:

The Oregon Health Services Commission Web site explains that the 2009 list emphasizes preventive care and chronic disease management because these services are less expensive and often more effective than treatment later in the course of a disease. However, there is no evidence that preventive care will reduce expenditures for the general population. Good evidence for the cost-effectiveness of disease management programs beyond those currently offered by physicians, individuals, insurers and patient groups also remains elusive.

What is driving the move away from procedures to save lives in immediate danger? Oregon's prioritized list is drifting toward increasing expenditures for politically popular care. This means preventive care for the healthy and treatment of diseases with active political constituencies. This drift in rationing appears to be unavoidable when political processes are given control over medical decision making.

Given that many of the supporters of "universal health care" at the national level are also plugging preventative care as an alleged source of savings, we may be on the verge of seeing this dynamic play out at the national level.

Hsieh OpEd in Washington Examiner

The February 23, 2009 Washington Examiner published my latest OpEd entitled, "America Doesn't Need a Health Care Czar". Here is the intro:

America doesn't need a 'health care czar'

By Paul Hsieh, MD, OpEd Contributor - 2/23/09

KEY DATA: Free market health reforms could reduce health insurance costs by over 50%.

TAKE HOME: President Barack Obama's plans for a "health czar" would represent an unprecedented and dangerous intrusion of government into the practice of American medicine.

Former senator Tom Daschle's withdrawal as President Barack Obama’s nominee for Secretary of Health and Human Services has left the White House administration scrambling to find a new "health czar" to implement their goal of government-run "universal health care."

But while the primary focus had been on Daschle's tax problems, Americans should also ask a more fundamental question: Why do we need a health czar in the first place?...

Read the rest here.

Atlas on American Medical Care

The February 18, 2009 Washington Times published the following OpEd by Dr. Scott Atlas. Atlas does some much needed "mythbusting" of the alleged problems with American health care. Here are a few excerpts:

Pardon The Interruption...

As politicians, economists, popular media and an ever increasing list of others convincingly proclaim cures for the ills of American health care, we Americans are subjected to a stream of opinion deriding as utterly miserable our health-care system compared to the rest of the developed world.

...In this interlude between health czar nominees, and before we legislate government as the solution and final arbiter of medical care, it may be a good time to consider a few unheralded facts about America's health-care system.

Dr. Atlas then cites (with references) the following facts:

(1) Americans have better survival rates from both common and rare cancers than Europeans

(2) Americans have significantly better survival rates from cancer than Canadians

(3) Americans have better access to treatment for chronic diseases than Canadians

(4) Americans have better access to preventive screening for major cancers than Canadians

(5) A marker for inequality of access and quality of health systems, the "health-income gradient" (i.e., that higher incomes achieve better health and lower incomes mean worse health) for adults 16 to 64 years old reveals a more severe disparity in Canada than in the United States

(6) In the United Kingdom and Canada, patients wait far longer than Americans (about twice as long, sometimes even more than a year) to see a specialist, have elective surgery like hip replacements or cataracts, or get radiation treatment for cancer

(7) Sixty percent of Western Europeans say their health systems need "urgent" reform

(8) More than 70 percent of Germans, Canadians, Australians, New Zealanders and U.K. adults (all countries in the survey except the Netherlands, with "only" 58 percent) say their health systems needs either "fundamental change" or "complete rebuilding"

(9) Although much maligned by economists and targeted by policymakers, an overwhelming majority of America's leading physicians themselves recently listed the computerized tomography (CT) scan and magnetic resonance imaging (MRI) as the most important medical innovations in improving patient care in the previous decade

(10) By any measure, the vast majority of all the innovation in health care in the world comes out of the U.S. health-care system

Read the whole thing here.

Surveys have shown that most Americans are satisified with the quality of their own health care. But because of the constant media drumbeat about the health care "crisis", too many are led to believe that everyone else is having a hard time and thus we need massive "reform" in the form of government-run "universal" care.

Articles like Dr. Atlas' will go a long ways towards countering these errors.

BTW, Dr. Atlas is both a senior fellow at the Hoover Institute with a focus on health care policy and also one of the top academic neuroradiologists in the country as a full professor of radiology at Stanford Medical Center. I used his textbook during my residency training as did many of my practice partners.

Hsieh LTE in Rocky Mountain News

The February 19, 2009 Rocky Mountain News printed my letter critical of yet another single-payer health care proposal for Colorado:

Single-payer health care has failed in every other country

Response to your story, "Dems' bill shoots for universal health care" from 2/5/2009 by Ed Sealover.

Single-payer health care has failed in every other country that has tried it. Canada controls health costs by forcing patients to wait months for MRI scans and cardiac surgeries that Americans can get in a few days.

Single-payer advocates mistakenly claim that health care is a "right".

Health care is a **need**, not a right. Rights are freedoms of action (such as the right to free speech), not automatic claims on goods and services that must be produced by another.

Instead of single-payer health care, America needs free-market reforms, such as allowing patients to purchase insurance across state lines and use health savings accounts for routine expenses. Insurers should be allowed to sell inexpensive, catastrophic-only policies to cover rare but expensive events.

Such reforms could reduce costs and make insurance available to millions who cannot currently afford it, while respecting individual rights.

"Comparative Effectiveness": The Path to Rationing

Lawrence Hunter discusses how the Obama Administration will use "comparative effectiveness ratings" (CERs) to introduce health care rationing. Here's an excerpt from his article:

The Hidden Healthcare Horror

...CER basically involves comparing different pharmaceutical drugs, medical devices, and other treatments in order to determine which is most cost-effective for fighting a particular disease. Theoretically, that sounds like a good program. But, in practice, CER will likely be used to justify rationing and restrict patient treatment options.

That's been precisely the result of CER programs in other countries.

Britain's comparative effectiveness agency, the National Institute for Health and Clinical Excellence (NICE), recently denied approval for the osteoporosis drug Protelos. NICE officials claimed that it was too pricey to be covered by the country's public insurance system. Never mind that research shows that Protelos's cheaper alternatives aren't effective for one out of every five osteoporosis patients. Countless Britons will now suffer from preventable bone fractures.

Canada's government-run healthcare system is equally stingy about approving state-of-the-art medical treatments. One recent example: A 57-year-old man living in Alberta went in for treatment for an arthritic hip. A specialist recommended he receive a cutting-edge surgery known as "Birmingham" hip resurfacing. Public bureaucrats denied the man coverage for the procedure, claiming he was "too old" for it. Worse still, they forbade him from paying for the procedure himself on the private market.

Virtually every government-run CER program ends up closing off patient access to the best treatments in the name of "cost consciousness." When bureaucrats are put in charge of medical care, cutting down on bills is prioritized over fighting disease.

Whenever government attempts to "guarantee" a service such as health care, it must also control it. This necessarily places bureaucrats in ultimate control of health care delivery, not physicians and patients.

Where Does Your State Rank?

The Small Business & Entrepreneurship Council has come up with a handy guide to rank the 50 US states (plus the District of Columbia) based on how badly their regulation raise the cost of health insurance. Some of the measures include the number of mandates, whether the state requires "guaranteed issue", community rating, and employer mandates, whether it allows tax-free use of Health Savings Accounts.

Here's their guide:

"Health Care Policy Cost Index: Ranking the States According to Policies Affecting the Cost of Health Care"

And their conclusions:

Among the 50 states and District of Columbia, the best 15 states in terms of state health care policies are: 1) Idaho, 2) Utah, 3) Iowa, 4t) Michigan, 4t) Ohio, 6) Alaska, 7) South Carolina, 8) South Dakota, 9) Pennsylvania, 10t) Nebraska, 10t) Wyoming, 12) District of Columbia, 13) Kentucky, 14) North Dakota, and 15) Oklahoma.

Meanwhile, the worst states are: 37) Minnesota, 38) New Hampshire, 39t) North Carolina, 39t) Rhode Island, 41) Florida, 42) New York, 43) New Jersey, 44) Colorado, 45) Maryland, 46) California, 47) Vermont, 48) Connecticut, 49t) Maine, 49t) Washington, and 51) Massachusetts.

Our elected officials talk a great deal about "solving the health care crisis." Unfortunately, the origins of the crises can largely be traced back to governmental policies that raise the costs of health care, and thereby limit the availability of health care coverage. If policymakers are serious about having a positive impact on health care, then significantly limiting the number of mandates and regulations makes sense at the federal and state levels.

Obviously, I wish Colorado ranked higher than 44th. But at least we have the examples of lots of other higher-ranked states to point to in the public policy debate!

(Via State House Call.)

Esmail: "'Too Old' for Hip Surgery"

The February 9, 2009 Wall Street Journal has published an OpEd by Nadeem Esmail warning of the health care rationing we'll be facing if we continue on our current course towards nationalized health care. Here is an excerpt:

'Too Old' for Hip Surgery

President Obama and Congressional Democrats are inching the U.S. toward government-run health insurance. Last week's expansion of SCHIP -- the State Children's Health Insurance Program -- is a first step. Before proceeding further, here's a suggestion: Look at Canada's experience.

Health-care resources are not unlimited in any country, even rich ones like Canada and the U.S., and must be rationed either by price or time. When individuals bear no direct responsibility for paying for their care, as in Canada, that care is rationed by waiting.

Canadians often wait months or even years for necessary care. For some, the status quo has become so dire that they have turned to the courts for recourse. Several cases currently before provincial courts provide studies in what Americans could expect from government-run health insurance...

For more discussion of problems with Canadian health care, click here.

Knope in Wall Street Journal

The February 14, 2009 Wall Street Journal has a major article on concierge medicine, featuring Dr. Steve Knope. Here's an excerpt:

Health Matters

Dale Haralson was the kind of patient some doctors would rather avoid. In 2005, the Tucson, Ariz., lawyer had a triple-bypass operation, then contracted an infection that spread to his chest, lungs, blood and bone. He needed more surgery and was told he would need a permanent feeding tube. But few surgeons wanted to take his complex case.

A former partner recommended that he see Steven D. Knope, a local primary-care doctor who treats a small group of patients in exchange for an annual fee. Dr. Knope took over Mr. Haralson's care, and found a skilled and willing surgeon and a pulmonologist who said that, instead of a feeding tube, he just needed to use an inhaler every day.

Today, Dr. Knope handles all the routine medical care for Mr. Haralson and his wife, Betty, and tracks the couple's general health and fitness. Together, they pay him $10,000 a year, and think it's money well spent. "All you need is one crisis and a good outcome and you know it's worthwhile," says Mr. Haralson, age 71, who exercises regularly, still practices law and still eats chocolate cake.

The kind of "concierge medicine" that Dr. Knope practices is gaining popularity across the U.S., particularly among older Americans with complex medical needs...

(Read the whole thing.)

In particular, there are a few points worth highlighting.

1) Concierge doctors take care of some complex, challenging patients whose needs could not be met in the standard fast-food medical model. If a doctor taking Medicare or conventional insurance has to average 7 minutes per office visit just to pay the overhead, there's no way he can do justice to his patient's medical needs.

2) Concierge medicine is not just for the wealthy. Those services are affordable to patients of modest means, if they are willing to budget for them and place a high priority on good medical care. It's no different from the fact that some parents who really value their kids' education will make it a priority to budget carefully and send their kids to a good private school rather than subject them to the harms of a government-run public school.

3) Both parties win because concierge medicine represents a shift towards free-market principles. Patients receive the care they need at a fair price. Physicians are able to practice according to their medical conscience, while being appropriately compensated. This is just an example of the broader virtue of free markets, where buyers and sellers exchange money for services on a purely voluntary basis. In a free market, the exchange occurs only if both parties deem it to be in their benefit. The concierge physician succeeds only by offering a genuine value to his patient. Hence, they are willing and eager to do so, as the many happy patients in the article can attest to.

If you want to protect yourself from the upcoming fiasco of "universal" Obama-Care, follow Dr. Knope's advice:

Maintain your private medical care if at all possible. If you are relatively healthy, look into a high-deductible health insurance plan linked to a Health Savings Account (HSA). Start putting money away in that HSA for a rainy day. Find a "concierge physician" or doctor with whom you can establish a direct financial relationship; someone who will act as your medical advocate in a system that is broken and will only get worse. You get what you pay for and medicine today is no different.

After all, it's your life at stake.

Concierge Physicians Vs. Maryland - Update

AP News reports that, "The Maryland Insurance Administration has issued a report clarifying the distinction between so-called 'concierge' medical practices and insurance providers who are subject to state regulation."

According to the article:

...[A]s long as the annual fee for a physical exam does not exceed the market value of the services, the business model would not be considered "insurance." For practices offering bundled fees for unlimited office visits, the report says contracts must define the services and use market values to avoid being considered insurance.

This may seem like a victory for concierge physicians. But the problem is that the current prices of most medical services are set directly or indirectly by government. Government explicitly sets prices for services rendered through programs like Medicare and Medicaid. And many private insurers peg their own rates to Medicare (e.g., paying for an ultrasound test at 125% of Medicare), thus increasing the scope of government influence in setting prices in the nominally private sector.

Hence, most medical "market values" are ultimately set by government, rather than by patients and physicians negotiating in a truly free market.

To illustrate the danger this poses to concierge physicians, consider what would happen if Medicare costs kept skyrocketing and the government decided that it must lower the payments for a Medicare patient's office visit from $50 to $25?

Yet suppose that concierge physicians decide they wish to still charge $50 (because they judge that's an appropriate price point that allows them to practice quality medicine) and their patients are glad to pay that amount (because they wish to receive that quality service)?

Because of the massive influence of the government in medicine, the "market value" of an office visit would be at or near $25, even though the concierge medicine price of $50 would be the actual price in a free market.

Hence, the government could then semi-plausibly claim that concierge physicians were "gouging" their patients by charging above-market rates, making them liable to be regulated as "insurers".

This is why concierge physicians must oppose in principle any claim whatsover by the government that it should regulate their fees. Any money that a concierge physician earns is based on a voluntary agreement between doctor and patient, where both sides judge that they are making a fair and rational exchange.

If concierge physicians value their ability to practice according to their best conscience, they should continue to oppose the state of Maryland's attempt to slip in this "market value" loophole.

Concierge physicians are the "market value" and they should be proud of that fact. They shouldn't let the government steal that noble designation from them.

(Via Dr. Steve Knope.)

My PajamasMedia OpEd on Cass Sunstein

The online political commentary website PajamasMedia.com has published my OpEd on Cass Sunstein, who is President Obama's new director of the Office of Information and Regulatory Affairs. Sunstein is one of the leading advocates of the philosophy known as "libertarian paternalism".

Although it's not directly related to health care, if his ideas were implemented, they could have an enormously destructive effect on American freedoms in many spheres including health care.

Here is the opening of my piece:

Obama's Regulatory Chief Believes in Paternalistic Government
February 10, 2009 -- by Paul Hsieh

The old joke runs, "I'm from the government and I'm here to help." Most Americans are appropriately skeptical of such a claim, just as they are skeptical when told that they've won $10 million in a Nigerian lottery. But President Obama's selection of Harvard Law professor Cass Sunstein to direct the Office of Information and Regulatory Affairs threatens to turn this joke into grim reality...

Read the rest here.

McCaughey on Government Controlled Medicine

Although Tom Daschle is no longer the nominee for Secretary of Health and Human Services, his ideas live on in the boondoggle "stimulus package".

In this Bloomberg News piece, Betsy McCaughey points out how the current stimulus bill calls for a "Federal Coordinating Council for Comparative Effectiveness Research" to essentially dictate how doctors should practice medicine. The government will decide what treatments are "most effective" and should therefore be paid for. If your doctor thinks a different treatment may be more appropriate for you, then he risks losing money and/or running afoul of the authorities.

Advocates of "universal health care" like to say that it would create a "compassionate" system in which money would no longer pose a corrupting influence on medical practice. Instead, doctors would be able to practice in their patients' interests free from economic concerns.

Of course, this is not possible. Any system of "universal health care" merely shifts the economic decision-making from the affected parties (doctors and patients) to government bureaucrats who will not necessarily have the patients' best interests in mind.

Free market health care is reviled by the leftists because it supposedly "puts a price on life". But as Betsy McCaughey points out, it is the government-run systems that actually do put a price on life and will explictly deny care to patients if it costs too much.

This is already the policy in Great Britain, as The Telegraph reported in its August 13, 2008 article, "Patients 'should not expect NHS to save their life if it costs too much'".

If we're not careful, it will soon be the policy in the US.

Government Interference With Insurance Markets

The February 8, 2009 Oklahoman points out some basic lessons from Economics 101:

Risk averse: State control affects insurance market

Here's what happens when governments assume too much control of the property and casualty insurance market: Private insurers are driven out, leaving taxpayers as the insurers of last resort.

Here's what happens when governments assume too much control of the group health insurance market: Premium prices are driven up, leaving some citizens uninsured...

Regulations on health insurers have driven away insurers in other states such as South Dakota. Those insurers returned only when those bad laws were repealed.

If we adopt such laws at the national level (as many universal health care advocates wish), then private health insurance may disappear altogether, leaving Americans with no choice but to rely on a government-run single-payer insurance system. When the government becomes the only health insurer, it has citizens by the throat and can take control over their lives in ways that private insurer would never dream of.

(Via Rob Abiera.)

Coverage vs. Care in Japan

Japan's universal health care system supposedly guarantees "coverage" for all residents. However, theoretical coverage isn't the same thing as actual medical care, as this unfortunate man found out:

Injured man dies after rejection by 14 hospitals

After getting struck by a motorcycle, an elderly Japanese man with head injuries waited in an ambulance as paramedics phoned 14 hospitals, each refusing to treat him.

He died 90 minutes later at the facility that finally relented -- one of thousands of victims repeatedly turned away in recent years by understaffed and overcrowded hospitals in Japan.

Paramedics reached the accident scene within minutes after the man on a bicycle collided with a motorcycle in the western city of Itami. But 14 hospitals refused to admit the 69-year-old citing a lack of specialists, equipment and staff, according to Mitsuhisa Ikemoto, a fire department official.

The Jan. 20 incident was the latest in a string of recent cases in Japan in which patients were denied treatment, underscoring health care woes in a rapidly aging society that faces an acute shortage of doctors and a growing number of elderly patients.

Nor is the problem one that would be solved by imposing a law like the US EMTALA statutes which force hospitals to accept and stabilize emergency patients. In the US, this has creating yet more overcrowding of emergency room. EMTALA has also driven away physicians from working at these hospitals. What cardiologist or neurosurgeon wants to take ER call if he isn't compensated for any care he delivers, but can still be sued for any alleged malpractice?

Instead, Japan's problems are more systemic and "is nearing collapse". When people are told they have a "right" to care without limit, costs will also rise without limit. Soon, the only alternative will be rationing, as is already commonplace in other countries like Canada and the UK.

Will the US be next?

(Via Gus Van Horn.)

Scandlen on Massachusetts Mandates

Greg Scandlen of the Heartland Institute has posted a brief article on the problems in Massachusetts entitled, "Mandatory Health Insurance Fails in Theory and in Massachusetts".

In addition to describing the bad economic outcomes caused by that state's policy of mandatory insurance, he concludes:

Mandatory insurance violates insurers’ and consumers’ right to act in their own best interests by forcing insurers to sell and customers to purchase insurance on terms and prices dictated by government decree. This destroys the very conditions that give insurance any value at all.

This is exactly on target and I'm glad he's highlighting that critical point.

(I'm also honored that he cites FIRM and my Objective Standard article, "Mandatory Health Insurance: Wrong for Massachusetts, Wrong for America".)

Gingrich: The Market Can Fix the Healthcare Problem

In the January 27, 2009 issue of US News & World Report, former Congressman Newt Gingrich explains why we need free market health care reforms:

...Yet oddly, there is sympathy for turning over our most private, personal decisions, not to mention one sixth of our economy, to the same unresponsive, anti-entrepreneurial culture that gave us the response to Hurricane Katrina. Our two largest government-run health programs--Medicare and Medicaid--are on fiscal crash courses that make Social Security seem like a model of solvency. Steep benefit cuts or much higher taxes will be required to sustain them anywhere near their current form.

The dwindling number of doctors who accept Medicare patients resent politicians and government bureaucrats threatening their fees and meddling with their judgment. This has aided the rapid expansion of private "concierge" medicine for seniors who can afford it and for physicians who demand more than what Medicare offers. In the mid-1990s, Tennessee's Medicaid's program went further than any other state toward the 1993 Hillary Clinton model of government-run healthcare. It proved so catastrophic that only the capable leadership of Democratic Gov. Phil Bredesen--who profoundly scaled back the experiment--saved the state.

More government bureaucrats involved in your healthcare would be destructive. Other countries with similar systems face lengthy and often deadly waiting lists. That is the only way to ration unlimited demand in the face of static supply. Go to YouTube and view the short films of Stuart Browning for a flavor of the Canadian system.

He makes many good economic points. When combined with fundamental moral arguments (such as government-run health care infringes on basic human freedoms), these can be extremely effective.

(Via David Catron.)

The Trojan Horse?

Is the Obama stimulus package a Trojan Horse for nationalized health care?

Joseph Smith warns about this possibility in this article in the February 2, 2009 American Thinker.

(Via Tom Olson.)

Update: Fixed bad link.

Lessons From Hawaii

Grace-Marie Turner explains how, "Hawaii's Keiko Crash Offers Lesson for All".

Fortunately, Hawaii's "universal coverage" plan for children collapsed quickly before it could destroy private insurance in the state. But it offered a good example of the phenomenon known as "crowd out".

Will the other 49 states learn the right lesson? Or will we duplicate this error on a national scale?

Massachusetts In A Nutshell

Grace-Marie Turner of the Galen Institute reports the following observation by one Massachusetts resident about their system of "universal health care":

"Before, I was uninsured and couldn't see a doctor. Then I made the sacrifice to buy insurance, but I still can't find a doctor who will see me. So I still don't get to see a doctor, but it's just costing me more now."