How Practice Guidelines Drive Up Costs

One of the assumptions behind ObamaCare is that government-driven "practice guidelines" will reduce medical costs and ensure more uniform quality of care.

However, this recent 9/29/2011 New York Times article suggests otherwise, "Why Doctors Order So Many Tests".

Of course, some of this is driven by defensive medicine (i.e., to avoid malpractice lawsuits) or by heightened patient expectations that the doctor "do something". But the article also notes this "unintended consequence":

Most notably, more than half the doctors believed that the current quality measures and clinical guidelines endorsed by health care experts and insurers as a way to rein in excesses were in fact having the opposite effect. The guidelines might, for example, require that patients with high blood pressure and diabetes have a specific blood test every three months and take high blood pressure medications as soon as their blood pressure exceeds 140. Because insurers are increasingly linking payment to these guidelines, physicians must strictly follow the quality measures to be paid, regardless of the patient's specific situation. Ironically, most of these quality measures are based on, well, more testing and treatments...

"Many doctors feel like they are on a treadmill and are running scared because of malpractice and having to check off all the checkboxes of quality measures," Dr. Chou said. "They feel like they are in an oppressive situation that they can’t do anything about."

Another interesting point is that these extra tests are not typically driven by physician greed (i.e., to generate extra revenue by ordering tests where they have a financial incentive).

It should be no surprise that costs rise the more that government handcuffs physicians and attempts to override their independent judgement with one-size-fits-all "practice guidelines". These practice mandates remove that physicians mind from the equation. Rigid bureaucratic thinking does not lead to innovation and savings in business. There's no reason to think that it will lead to innovation and savings in health care, either.

(Read the full text of "Why Doctors Order So Many Tests".)

Catron: Cain, Cancer, and Obamacare

David Catron discusses presidential candidate Herman Cain's claim that he'd be dead if ObamaCare had been in effect when he was diagnosed with cancer in 2006.

In particular, Catron discusses the numerous problems with the proposed new bureaucracies under ObamaCare, such as Accountable Care Organizations (ACOs). Here's an excerpt from his piece, "Cain, Cancer, and Obamacare":

The ostensible purpose of an ACO is to achieve high quality and efficient care by encouraging a group of hospitals, physicians, and other providers to work closely together on a particular population of patients. But, under the ACO rules proposed by Donald Berwick and his fellow bureaucrats at the Department of Health and Human Services (HHS), "quality" and "efficiency" will be measured in terms of money. "If the ACO is not successful it... is at risk of having to pay money back to CMS, and its participating providers may find that their own Medicare reimbursement is subject to recoupment by CMS."

This creates perverse incentives for doctors and hospitals to skimp on care in order to chase the promised rewards from the government. Furthermore, Catron notes:

Another distinctive feature of Obamacare's ACO system is "blind assignment." Unless someone imposes some sanity on the proposed rules, it is entirely possible that you could be retroactively assigned to an ACO without even knowing it. This means, in theory at least, that your doctor could be prescribing care according financial imperatives of his ACO rather than your best interests. Will he hesitate to send you to a pricey specialist or think twice before sending you to the hospital for an expensive diagnostic test, like an MRI or a CT scan? Will your doctor temporize if your symptoms are ambiguous, as they often are for patients with colon cancer?

(Read the full text of "Cain, Cancer, and Obamacare".)

There's a good reason that ACO's have been called "HMOs on steroids". But at least with HMO's, you knew in advance the deal you were getting. With ACOs, you might be unaware of the conflicts-of-interest your doctor faces when trying to juggling your medical interests with the demands of the ACO administration demanding greater cost savings.

As Megan McArdle noted in the 9/28/2011 Atlantic, the heavy-handed government approach inherent in the ACO concept explains why the "Poster Children for New Health Care Model Won't Participate in Model Program".

ACOs represent the old central-planner fallacy in a new guise. Fortunately, more Americans are waking up to this fact.

(And thank you, David, for citing FIRM and my earlier PajamasMedia piece in your article!)

Doctor Shortages in Ohio

The 8/29/2011 Cleveland Plain Dealer reports on doctor shortages in Ohio, even for "[m]ajor medical centers, including the Cleveland Clinic, MetroHealth System and University Hospitals".

The shortages run the gamut from "neurosurgeons, urologists, pediatric oncologists and other specialists" as well as "primary care doctors -- an umbrella term for family medicine, internal medicine, pediatrics, gynecology and general surgery".

Such shortages will become worse as more doctors try to flee the government-controlled system under ObamaCare. If even the world-renowed Cleveland Clinic has a hard time recruiting and retaining phpysicians, how difficult will it be for the rest of us?

Quick Links: Privacy, Price Controls, AMA

In the 9/23/2011 Washington Examiner, Congressman Tim Huelskamp (R-KS) warns how, "Obamacare HHS rule would give government everybody's health records".

The 9/22/2011 New York Times discusses, "One Small Group Sets Doctors' Pay".

In short, a "Specialty Society Relative Value Scale Update Committee" declares by fiat the worth of various physician services for Medicare. Because most private insurers peg their payment scales to Medicare, it affects most of American health care reimbursement. And as with all forms of economic central planning, the result is price controls and perverse economic incentives.

In the 9/26/2011 Forbes, Sally Pipes explains why "Doctor And AMA Split Over Contentious Issue Of ObamaCare". Key excerpt:

For more than 160 years, the American Medical Association has served as the self-appointed chief lobbying group for doctors. But the AMA's lofty status has been under threat over the last several years -- and is under attack today. In fact, the AMA now only counts about 17% of doctors as members.

According to a new survey, the majority of doctors do not believe that the AMA represents their views and interests. Much of that dissatisfaction stems from the organization's support for President Obama’s contentious health care reform package...

Some doctors are even dissociating themselves from the AMA. Of those who have terminated their membership, 47% cited the organization's continued backing of the health care law as the primary reason. Increasingly doctors are turning to associations like Docs4PatientCare and the Association of American Physicians and Surgeons that actually do represent their interests.

The reasons she lists are among the many that I'm not a member of the AMA.

Armstrong on Health Insurance and Personal Responsibility

The 9/24/2011 edition of PajamasMedia published Ari Armstrong's OpEd, "Health Insurance and Personal Responsibility".

Armstrong discusses the question asked by Wolf Blitzer to candidate Ron Paul in a recent GOP debate on who should pay for the health care of "a healthy 30-year-old young man [who] has a good job, makes a good living" but deliberately decides not to carry health insurance.

Although Blitzer framed the question as a false alternative between "society" paying for his care vs. "letting him die", Armstrong digs more deeply into issues of personal responsibility. In essence, if someone is able to pay for his own health insurance but chooses not to and instead "goes bare" on the risk, he should be help responsible for the bill (even if it might require a payment plan over time).

Armstrong then makes an important point:

But what about somebody who develops expensive health problems and truly cannot afford to pay? In those cases, hospitals and voluntary charity organizations remain free to step in and cover some or all of the costs.

Blitzer talks about "society" letting someone die, but whom does he mean? Each individual is part of society, so isn't the real question, "What are YOU going to do about it?" Treating "society" as some super-entity above and beyond the individuals who compose it causes two problems. First, it gives individuals an excuse to do nothing by their own initiative; second, it encourages many to ignore the actual victims of politicians' forced wealth transfer schemes.

This is a critical observation. Too much of current politics mistakenly reifies "society" as something above and beyond the individuals that compose it. This makes it too easy for politicians to propose policies which sacrifice individuals to a nebulous "collective good". Our numerous current political and economic problems are the consequence of this error.

The only way out of this trap is to recognize the primacy of the individual as the proper unit of political thinking, and to recognize that the proper function of government is to protect individual rights. Fortunately, more and more Americans are become aware that this is the critical issue.

Finally, Armstrong notes the following:

The deeper problem, the real reason a healthy 30 year old grows tempted to forgo health insurance, is that politicians have made the costs of health care and insurance ludicrously expensive.

Through destructive tax policies, the federal government linked health insurance to employment and encouraged the use of "insurance" for routine, every-day costs rather than for true emergencies. As a consequence, consumers have almost no incentive to seek economical care, and a considerable portion of each health dollar goes to insurance paperwork rather than actual care.

Today's politicians have taken dramatic action to turn health insurance into a gigantic wealth transfer scheme. That, indeed, is the entire premise behind the ObamaCare "mandate"; people must be forced to buy insurance because its artificially high costs subsidize the care of others. Consider, for example, the recent mandate from Health and Human Services that forces the insured who don't need birth control to pay for the birth control of others.

If we dismantled the federal controls over health care and moved toward a free market, that would put patients back in control of their health care, help contain costs, make insurance affordable again, empower more people to manage their health care costs, and ease the burdens on voluntary charity.

Armstrong's analysis is spot-on. It's not too late to reverse course, repeal ObamaCare, and move in the direction of genuine free-market health care reforms.

(Read the full text of "Health Insurance and Personal Responsibility".)

Catron: Obamacare's Last Best Hope

When is tax not a tax? When it's politically convenient for the Obama Administration.

David Catron discusses this in his new piece in the 9/23/2011 AmSpec, "Obamacare's Last Best Hope".

When ObamaCare was being debated in Congress, the administration insisted that the individual mandate was not a tax -- in order to get the votes. But now that it's being challenged in the courts, the same advocates are now claiming that it is a tax -- in order to get past the judges.

The degree of blatant intellectual dishonesty is breathtaking. But not surprising.

(Read the full text of "Obamacare's Last Best Hope".)

Rationing Abroad and At Home

Because of the debt crisis in Greece, government-run hospitals can't pay their bills.

Hence, patients aren't receiving medically necessary drugs. As Avik Roy notes, "Our future is Greece's present".

Closer to home, physician-blogger "Shadowfax" describes the proposed new indirect rationing system in Washington state.

Medicaid patients in WA are being told that if they use the ER for non-emergency purposes, then the state won't cover their costs. So this puts the hospitals and doctors in a tricky position.

The ER doctors could turn away those patients. But then they might run afoul of EMTALA laws which require the ER staff to evaluate the patient sufficiently to determine whether or not there is a genuine medical emergency.

Or they could see these patients and provide some level of services -- but risk not getting paid. (The hospital can attempt to bill these Medicaid patients, but realistically they almost certainly won't collect anything.)

So the proposed non-payment rules essentially put the ER doctor in a no-win position of rationer-by-proxy. The government will punish him financially if he doesn't save money for the government, but punish him legally if he fails to provide medically necessary emergency services.

To make matters worse, the list of supposedly "non-emergency" medical conditions the state won't cover includes:

Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia

Do you want the government deciding that a coma isn't a true emergency?

Or if a patient comes in with bad chest pain, neither the doctor nor the patient can always distinguish between something serious (like a heart attack) or something more benign (such as severe indigestion) without a variety of tests.

If it turns out that the patient's chest pain was just an unusually severe case of indigestion, the state gets to say to the hospital, "See it wasn't really anything too bad, so we won't pay you for performing all those unnecessary tests. They weren't really cost-effective use of scarce resources for indigestion."

Of course, the problem is that you don't know until after you run the tests that it wasn't anything too serious. The government gets to claim the benefits of 20-20 hindsight that it impossible for a doctor at the time the patient arrives in the ER.

Do we really want this kind of government-run medical system?

Wolf: Barack Obama’s desperate Hail Mary

Dr. Milton Wolf has a new OpEd in the Washington Times, "Barack Obama’s desperate Hail Mary".

He covers a lot of territory, but I wanted to highlight these two paragraphs:

Obamanomics has become its own parody, a disastrous amalgam of wildly increased deficit spending, central planning, bailouts, takeovers, unconstitutional mandates, overregulation, crony favoritism, debased currency and increased taxes. The "smartest guy ever to become president," as pundits used to call him, knows only one solution to every problem: Grow the government. Now his proverbial chickens have come home to roost and the landscape is littered with the results: Unemployment. High gas prices. Deficits. Food stamps. Poverty. Uninsured people. Foreclosures. Bankruptcies. Layoffs. Phony green jobs. Downgraded America. This is Obamanomics.

Obamacare has become emblematic of big government's arrogant incompetence. It's a 2,700-page monstrosity whose rules are still being written more than a year after its passage. Its supporters could not be bothered to read it before forcing it upon us, even as one of their own called it "a Ponzi scheme of the first order, the kind of thing Bernie Madoff would have been proud of." The landscape is littered with Obamacare's broken promises: Keep your doctor. Keep your insurance. Cut the deficit. Reduce premiums. Create 4 million new jobs. All lies. Instead, connected friends got Obamacare waivers while the rest of America has seen an increase in premiums and the roles of the uninsured actually have increased. This is Obamacare.

(Read the full text of "Barack Obama’s desperate Hail Mary".)

Despite these problems, the President is determined to "double down" and impose yet more government controls over the economy. More and more Americans are recognizing this is a recipe for disaster. And in 2012, they'll have a chance to make their opinions known.

Update: Reader C.A.P. just pointed out that Wolf's OpEd reminded him of this great cartoon:

Biddle on Rights and a Free Society

In the Fall 2011 issue of The Objective Standard, Craig Biddle has a new article entitled, "Ayn Rand's Theory of Rights: The Moral Foundation of a Free Society".

Biddle's article discusses the core philosophical issue that underlies all the current political battles over health care and (more broadly) the welfare state. Most of the political discussions presume some implicit or explicit understanding of the proper functions and limits of government, and the corresponding scope and limits of individual rights.

We're seeing similar discussions about rights and the proper scope of government as citizens ask politicians, "Out of every dollar that I earn, how much do you think I deserve to keep?"

During the ongoing health care debate, it's easy to get lost in the details of wonkish issues such as Medicare reimbursement policies, insurance regulations, and accountable care organizations, while losing sight of the broader issues of freedom, individual rights, and the proper scope of government.

Biddle's article does a nice job of covering those broader issues, while demonstrating their relevance to the current debates over health care, "entitlement" programs, the housing crisis, and our current runaway spending problem.

The full text of "Ayn Rand's Theory of Rights: The Moral Foundation of a Free Society" is available online for subscribers and non-subscribers. I highly recommend reading it and sharing it with others!

Problems With Japanese Universal Health Care?

The 9/10/2011 Economist describes growing problems with Japan's health care system: "Health care in Japan: Not all smiles".

An excerpt:

Doctors are too few -- one-third less than the rich-world average, relative to the population -- because of state quotas. Shortages of doctors are severe in rural areas and in certain specialities, such as surgery, paediatrics and obstetrics. The latter two shortages are blamed on the country's low birth rate, but practitioners say that they really arise because income is partly determined by numbers of tests and drugs prescribed, and there are fewer of these for children and pregnant women. Doctors are worked to the bone for relatively low pay (around $125,000 a year at mid-career). One doctor in his 30s says he works more than 100 hours a week. "How can I find time to do research? Write an article? Check back on patients?" he asks.

On the positive side, patients can nearly always see a doctor within a day. But they must often wait hours for a three-minute consultation. Complicated cases get too little attention. The Japanese are only a quarter as likely as the Americans or French to suffer a heart attack, but twice as likely to die if they do.

And despite Japan's image as a high-tech mecca:

The system is slow to adopt cutting-edge (and therefore costly) treatments. New drugs are approved faster in Indonesia or Turkey, according to the OECD. Few data are collected on how patients respond to treatments. As the Lancet says, prices are heavily regulated but quality is not. This will make it hard for Japan to make medical tourism a pillar of future economic growth, as the government plans.

(Read the full text of "Health care in Japan: Not all smiles".)

For some reason, most of this information doesn't make it into the American popular press.

FDA Restrictions On Free Speech

Gregory Conko and CEI have published a detailed article on FDA restrictions of free speech.

From their blog post:

What can you do if you learn you have a life-threatening illness but there is no Food and Drug Administration-approved medicine to treat it? Sometimes, there is nothing to do but hope. Very often, though, your doctor will be able to prescribe a drug or medical device that has been approved by the Food and Drug Administration (FDA) for a different condition. This practice, called "off-label" prescribing, is perfectly legal, commonly practiced within the medical community, viewed as an essential component of good medical care, and offers greater choice in treatment options for millions of American patients. It is not without controversy, however.

Because the safety and efficacy of off-label uses have not been certified by the FDA, some in government and the public health community have long criticized the practice. And the FDA has long forbidden drug and device makers from disseminating most information about off-label uses, often making it difficult for doctors and their patients to learn about important therapeutic options.

No federal statute explicitly forbids manufacturers from promoting or otherwise disseminating information about off-label uses of their drugs and devices. The FDA has, however, extended its authority over product labeling to encompass manufacturers’ speech in other contexts—including print and broadcast advertisements, brochures and pamphlets, websites, conferences and seminars, and face-to-face communication. The agency bars nearly all speech promoting an off-label use regardless of its veracity, and vigorously enforces this restriction even when the information is not being broadcast to lay audiences, but is provided directly to physicians with sophisticated medical training...

[A]s legal scholars have noted, if two physicians were to provide identical truthful and non-misleading information about off-label uses to an identical audience, one of them can be hailed as a medical pioneer and the other convicted of a federal crime solely on the basis of the second doctor's financial ties to a drug or medical device company. Naturally, this inconsistency has raised questions about the constitutionality of the FDA's treatment of off-label promotion.

In other words, there can be factually true, scientifically vetted, medically useful information that would benefit doctors and patients. Yet drugmakers (and sometimes physicians) are forbidden by law from telling treating physicians this information. In the name of "protecting" us.

For more information, see the full CEI article (PDF) "Hidden Truth: The Perils and Protection of Off-Label Drug and Medical Device Promotion".

Retail Clinics Are Booming

Retail clinics provide quality inexpensive basic health services for people on a tight budget. In the current economic climate, they are booming as people look for more ways to get the best health value for their dollar.

To the extent we allow a free market to operate, we can see more of these clinics proliferate to meet consumer demand. (Via Kelly V.)

Lehigh Valley Coalition Workshop on ObamaCare

[This looks like a very informative event, occurring Saturday 9/17/2011, 1pm - 5pm Eastern Time.  See below for details on how to watch the free live streaming video.   -- PSH]

 

 

The Lehigh Valley COALITION for Health Care Reform

proudly presents a free Constitution Day Educational Workshop

Everything You Wanted to Know About "ObamaCare"

(but didn't know who to ask)

Click here for details:

www.Meetup.com/Lehigh-Valley-COALITION-for-Health-Care-Reform

FREE and open to the public - Live Streaming Video

Go to:  http://www.ustream.tv/channel/health-care-reform---desales

Saturday, September 17, 2011

1 to 5 p.m.  (Doors open at Noon)

Gerald White Pavilion of the University Center

on the campus of DeSales University

2755 Station Avenue, Center Valley, PA 18034

Expert Presentations, Q&A, Breakout Sessions, Exhibits

Health care professionals, policy experts,

grassroots advocates, and legislative leaders

will explain how the Patient Protection and Affordable Care Act (PPACA),

also known as "ObamaCare," affects every American

FREE and open to the public - Live Streaming Video

Go to:  http://www.ustream.tv/channel/health-care-reform---desales

Topics include:

The Nuts and Bolts of "ObamaCare"

How "ObamaCare" affects Personal Liberty, Health Insurance, Health Care Choice, and the Uninsured

How "ObamaCare" affects Families, Children, and Seniors

How "ObamaCare" affects Medicare, Medicaid, Taxpayers, and the Deficit

How "ObamaCare" affects Businesses, Workers, Job Creation, and the Economy

How "ObamaCare" affects Doctors, Patients, Quality of Care, and Access to Care

How "ObamaCare" affects States, Efforts to Repeal and Replace "ObamaCare," and much more

Sponsored by: 

Docs 4 Patient Care (www.docs4patientcare.org)

Association of American Physicians and Surgeons - AAPS (http://www.aapsonline.org)

The Galen Institute (www.Galen.org)

Heritage Action for America (www.HeritageAction.com)

Americans for Prosperity - Pennsylvania (www.americansforprosperity.org/pennsylvania)

The Black Ribbon Project (www.theblackribbonproject.org)

M.D. News (www.MDNews.com)

V.S.A.S. Orthopaedics (www.vsas.com)

New World Aviation (www.NewWorldAviation.com)

Pennsylvania Chamber of Business and Industry (www.pachamber.org)

Pennsylvania Commercial Action Network - PA-CAN (www.pa-can.org)

The Ayn Rand Center for Individual Rights (www.aynrand.org)

and the

Lehigh Valley COALITION for Health Care Reform

www.Meetup.com/Lehigh-Valley-COALITION-for-Health-Care-Reform

 

FREE and open to the public - Live Streaming Video

Go to:  http://www.ustream.tv/channel/health-care-reform---desales

Please reserve your free seat online:

www.Meetup.com/Lehigh-Valley-COALITION-for-Health-Care-Reform

or call toll free: 1-888-698-4111 (Line 1)

Look for us on Meetup, Facebook, Twitter and LinkedIn!

For more information, email ObamaCareEvent@aol.com or call 1-888-698-4111 (Line 2) 

Directions: DeSales University Campus Map

www.desales.edu/assets/desales/CampusMap/DSUmap708.pdf 

  

Please join the Lehigh Valley COALITION for Health Care Reform if you'd like to support

ongoing efforts to educate the public and elected officials about the intended and unintended effects

of the Patient Protection and Affordable Care Act, aka "ObamaCare."

www.Meetup.com/Lehigh-Valley-COALITION-for-Health-Care-Reform

 

 

 

 

Doors Open at Noon
1 p.m. Welcome and Introduction

The Nuts and Bolts of ObamaCare — What Happens When? Donna Baver Rovito, Chair, Lehigh Valley Coalition for Health Care Reform

A Constitution Day Question — Is ObamaCare Constitutional? How ObamaCare Affects Pennsylvania PA State Representative Stephen Bloom (PA-199th)

How ObamaCare affects Families, Children, and Seniors and Why Doctors Oppose It Elena R. Farrell, D.O., Docs 4 Patient Care – PA Chapter Co-Founder

How ObamaCare affects Personal Liberty, Taxpayers, Medicare, Medicaid, and the Deficit K. Nicholas Pandelidis, M.D., Docs 4 Patient Care – PA Chapter Co-Founder

How ObamaCare affects Businesses, Workers, Job Creation & the Economy Samuel Denisco, Director of Gov’t Affairs, PA Chamber of Business and Industry

How ObamaCare affects Doctors, Patients, Access to Care, Quality of Care, and American Medical Innovation Richard A. Armstrong, M.D., F.A.C.S, Chief Operating Officer, Docs 4 Patient Care

 

IS ObamaCare Constitutional? Federal Efforts to Defund, Repeal, Replace ObamaCare Speaker: Rep John Shadegg (AZ-3), Retired

2:55 Ten Minute Break

What YOU Can Do to Help Defeat ObamaCare — Three Grassroots Efforts Right Here in PA     Pennsylvania Health Care Freedom Act (HB42) Terrence O’Connor, Esq.
    Nullification William Taylor Reil
    Health Care Compacts John Morningstar

Replacing ObamaCare: Why Separate Reforms Can Win the Day John F. Brinson, Chair, Lehigh Valley Tax Limitation Committee

Effective Solutions — What Would Be Better than ObamaCare? Alieta Eck, M.D., President Elect, Association of American Physicians and Surgeons (AAPS), Co-Founder, Zarephath Health Center

3:50 p.m. Break, Breakout Sessions, Visit Exhibits

Small breakout sessions will provide a rare opportunity to chat with our speakers in a more personal
setting and gain additional insight into their areas of expertise

4:10 p.m. Expert Panel

Speakers will reconvene for 45 minutes of discussion and Q & A from the floor and online viewers. Moderator: Donna Baver Rovito

4:55 p.m. Closing Remarks

Doors will remain open until 6 p.m

Quick Links: Readmission, Coding, Salaries

The 9/9/2011 Washington Post reports, "New data show difficulties in controlling patient 'rebound' at care facilities".

Controlling unnecessary readmissions is supposed to be part of ObamaCare's big Medicare savings. But if the federal government can't achieve these savings in the government-run VA Hospital system, is there any reason to think this will happen in the rest of the country?

The 9/13/2011 Wall Street Journal discusses the medical coding craziness at, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way".

This increases the bureaucratic burden on hospitals on doctors. Plus mis-coding is potentially a federal offense. The result will be even lower efficiency as providers spend more time on getting the paperwork right, and less time on patient care. (Via Martin B.)

Kevin Pho, MD, explains why, "Targeting physician salaries is a poor strategy for health care costs".

Hsieh/Minton OpEd: Durbin's Dietary Paternalism

The 9/13/2011 edition of HumanEvents.com has just published an OpEd co-authored by myself and Michelle Minton of the Competitive Enterprise Institute, "Durbin's Bill Is Dietary Paternalism".

Here is the opening:

"You can't have that. It's not good for you."

We've all heard parents say that to their children at the grocery store checkout line countless times. While it may be appropriate for a mother to say to her 10-year-old, it's simply the wrong way to treat adults. Yet that would be the effect of new restrictions on dietary supplements proposed by Sen. Richard Durbin (D.-Ill.)...

(Read the full text of "Durbin's Bill Is Dietary Paternalism".)

We discuss the dangers of the proposed new restrictions on dietary supplements, which would require many supplement manufacturers to submit proofs of safety to the FDA before they could be marketed -- including many that are already freely available in drugstores and supermarkets without a prescription. The new regulations would raise the prices of many supplements and force others off the shelves entirely.

On a personal level, I am taking some dietary supplements (in consultation with physician colleagues) to help with my hip fracture healing. So anything that would restrict my ability to purchase such supplements to promote my health greatly alarms me.

Many thanks to my co-author Michelle Minton and her colleagues at CEI for her excellent work and for facilitating the publication of this piece!

Wolf on Freedom, Jobs, and Health Care

Dr. Milton Wolf has a new OpEd in the 9/14/2011 Washington Times, "Hey Loser, Get a Job or Else".

In his piece, Dr. Wolf contrasts a positive conception of freedom as freedoms of action (as long as one doesn't violate another's right), and contrasts that with the leftists' view of "freedom" as forms of entitlements to goods and services that must be produced by another:

Freedom is man's power to exercise his own faculties as he chooses as long as he prohibits no other man from doing the same. Law exists to ensure that no man takes another man's life -- other than in self-defense -- or deprives him of his liberty or property. If it is wrong for one man to plunder, then surely it is equally wrong for a group of 20 men to plunder. And if it's wrong for 20 men to plunder, then it's equally wrong for 100 million men to plunder -' even if they have codified it into law.

In contrast, the false notion of "freedom" contains the seeds of its own destruction because of the inherent self-contradiction:

Liberals say that man is not free until he is free from want and so the government must guarantee his comforts -- everything from housing to health care, cellphones to sustenance. But this notion inherently contradicts itself. For the government to provide for all wants, or even just the important ones -- and our leaders know the difference -- they must plunder the property of other would-be free Americans. Worse yet, by attaching strings to every giveaway, they plunder the liberty of those on whom they lavish their largess. This notion of freedom destroys freedom.

Dr. Wolf then applies his analysis to both the ObamaCare health plan and to Obama's recently-announced "jobs plan".

He summarizes the basic issue as follows: "...[S]omething of liberty dies with each attempt to coerce a free man, especially when it comes with false promises of prosperity, be they jobs or health care."

I recommend reading the full text of "Hey Loser, Get a Job or Else".

And I greatly appreciate him citing FIRM and my recent PajamasMedia piece, "Let's Model ObamaJobs After ObamaCare!"

Catron: The Hypocrisy of Ron Paul

In today's AmSpec, David Catron discusses "The Hypocrisy of Ron Paul".

In particular, Catron notes that Ron Paul is not a principled defender of free markets, but rather has advocated some significant improper government interventions in the health care sector.

For more details, read the full text of "The Hypocrisy of Ron Paul".

(David Catron blogs regularly at HealthCareBS.)

Quick Links: iPad, HIPAA, Silence

The KevinMD.com medical website has posted my "thank you" essay to Apple and Steve Jobs, "My iPad and My Hip Fracture" (9/12/2011). Thank you, Dr. Kevin Pho!

KevinMD.com also posted Jared Rhoads' OpEd, "New HIPAA rules won’t enhance privacy, but they will burden physicians" (9/11/2011).

Rhoads' take-home point:

Many patients are rightfully concerned about the privacy of their health information. But the proper way to protect patient privacy is not to enshrine it as a new set of "rights" granted by regulators who seek to expand HIPAA. Instead, we should let hospitals and physicians win patient trust competitively through the demonstration of good practices and through the inclusion of clearly-worded contractual commitments to ensuring privacy. The courts are well-equipped to adjudicate such contractual issues. Let's use natural market incentives to secure our privacy, not government rule making processes.

In the 9/12/2011 AmSpec, Grace-Marie Turner describes "Obama's Strategy of Silence".

The Obama administration wants the public spotlight away from ObamaCare because they know it's a political loser. For this very reason, freedom-loving Americans should continue to keep it alive as a public issue. Sunlight is the best disinfectant. (Via David Catron.)

Quick Links: Bumper Sticker Tip, Medical Tourism, Job-Killing Taxes

Jared Rhoads of the Lucidicus Project has a nice activism tip for bumper stickers:



Interesting story on rising medical tourism within the United States. (Via Kelly V.)

The medical device industry warns ObamaCare-related taxes will cost 43,000 US jobs.

Never Forget

In Memoriam:

Duke University professor John Lewis offers this perspective in the Fall 2011 issue of The Objective Standard: "9/11 Ten Years Later: The Fruits of the Philosophy of Self-Abnegation".

In medicine, too often patients will succumb to otherwise-survivable diseases because they lack sufficient will or desire to live.

The same is true of civilizations. If a civilization lacks the equivalent of a healthy "self-esteem" and instead internalizes the cultural equivalent of "self-contempt", then it may not really think it deserves to survive when challenged. Whether 21st-century America falls in that category remains to be seen...

Wolf on Steve Jobs Vs. Obama

Dr. Milton Wolf has a nice new OpEd in the 9/9/2011 Washington Times, "Obama more telegraph than iPhone".

Here is the opening:

Steve Jobs, chairman of Apple Inc., became a billionaire not by force or manipulation but instead by understanding the central tenet of free-market capitalism: He served other people. Millions the world over have voluntarily handed over their hard-earned money in return for his high-tech smartphone, which ushered in a new age in communication. In some ways, the iPhone is, in fact, emblematic of America itself...

Dr. Wolf then contrasts the amazing innovations in the relative-free technology sector with the more heavily regulated sectors of the economy such as health care, energy, etc.

The failures of the various recent attempts at government crony capitalism (aka "public-private partnerships") are damning:

If you want to know what a government-created iPhone might look like, just take a look at a Government Motors Chevy Volt, the overpriced, short-range electric car nobody wants. Or take a look at Solyndra, the government-funded and now bankrupt solar-panel maker. Or Johnson Controls Inc. Or Evergreen Solar. Or SolFocus Inc. Or any other of President Obama's mergers of state and corporate power that are bankrupting our nation.

(Read the full text of "Obama more telegraph than iPhone".)

Whenever the government intervenes in the market place, all they do is thwart producers and consumers from acting freely on their best rational judgment. Americans are no longer allowed to spend their own money on what they deem best -- rather, their money is diverted directly or indirectly into the pockets of those with most political "pull". It should come as no surprise that the result is marketplace failure. But it's crucial to remember that the failure is due to government interference in the marketplace (rather than the free market.)

As George Mason University professor Peter Boettke once observed:

If you bound the arms and legs of gold-medal swimmer Michael Phelps, weighed him down with chains, threw him in a pool and he sank, you wouldn't call it a 'failure of swimming'. So, when markets have been weighted down by inept and excessive regulation, why call this a 'failure of capitalism'?

As one minor point of terminology, I personally would describe Steve Jobs relationship to his customers as "trading" rather than "serving". Jobs was a producer who expected to trade value-for-value with his customers. The beauty of a free market is that when compulsion is forbidden, trades must take place voluntarily, which means they happen when both parties deem it in their mutual interest. The natural result is a "win-win" transaction, compared to the "win-lose" (or "lose-lose") transactions which involve theft or government compulsion.

As this nice collection of Steve Jobs quotes shows, Jobs was not primarily driven by a desire to serve customers, but rather by a desire to produce good products according to his best vision and judgment. One example:

We think the Mac will sell zillions, but we didn't build the Mac for anybody else. We built it for ourselves. We were the group of people who were going to judge whether it was great or not. We weren't going to go out and do market research. We just wanted to build the best thing we could build.

Of course, Steve Jobs wanted to sell products. But in an important sense, "serving the customer" was secondary to his primary motivation of producing a great value.

The beauty of free-market capitalism is that it fosters and rewards precisely this kind of fiercely independent desire for innovation and production. Over time, the best producers rise to the top through the aggregate interactions of producers and consumers each seeking their best interests, exchanging value for value without compulsion.

The producers who become wealthy in such a system will have earned their wealth as the result of trading with willing consumers, rather than through political cronyism and clout. Ayn Rand once described this approach as the "Trader Principle". To the extent we have allowed this principle to operate, we have made America the wonder of the world.

UK Cancer Test Rationing

The 9/8/2011 UK Daily Mail reports, "GPs ordered to ration cancer scans".

From the article:

Family doctors have been ordered to ration the number of patients they send for life-saving cancer scans to save money.

They are being told to slash the number they refer to hospital for tests including ultrasounds, MRIs and CT scans commonly used to spot tumours.

Last night experts warned the cost-saving measures increased the risk of patients being diagnosed too late and dying unnecessarily.

Britain has one of the lowest cancer survival rates in Europe, and experts say late diagnosis is to blame...

(Read the full text of "GPs ordered to ration cancer scans".)

Despite the many claims of US admirers of the UK socialized medicine service claiming that the UK wasn't engaging in medical rationing, the truth is becoming clearer to all.

Of course, such rationing will save money for "the system". But it's unlikely to improve the already-dismal UK cancer survival statistics.

(Via D4PC.)

Catron: Flowers for Obamacare

David Catron's latest OpEd in the 9/7/2011 American Spectator, "Flowers for Obamacare", discusses how the Left's shifting "narrative" on Supreme Court Justice Clarence Thomas is driven by their political motives regarding health care.

Here's an excerpt from the opening:

For two decades, progressives have claimed that he is intellectually unfit to sit on the Court. They have repeatedly told us that Thomas is, as one commentator recently phrased it, "a dunce and a worm." However, as myriad constitutional challenges to Obamacare work their way through the courts toward an inevitable showdown before the Supreme Court, the dunce's intellectual powers have somehow improved. In fact, we are now advised that Thomas is not merely intelligent, but that he is an evil genius with an outsized influence on the rest of the Court.

For the left, the key problem is Justice Thomas' judicial philosophy favoring limited (rather than expansive) powers for the federal government.

As Catron observed in his related Facebook post, "It would appear that the closer ObamaCare gets to the Supreme Court the smarter Justice Thomas becomes."

Catron also discusses how many on the left are demanding that Justice Thomas recuse himself from ruling on any ObamaCare cases due to his wife's political sympathies for the Tea Parties. Yet they seem curiously unconcerned about "very real conflict of interest" involving Justice Kagan's pro-ObamaCare work when serving in the Dept. of Justice as an Obama appointee.

There's lots of good material in "Flowers for Obamacare", and I encourage folks to read the entire piece.

Hsieh PJM OpEd: Let's Model ObamaJobs After ObamaCare!

The 9/7/2011 edition of PajamasMedia has published my latest OpEd, "Let's Model ObamaJobs After ObamaCare!"

In this satirical piece, I discuss how President Obama could easily modify elements from his "universal" health plan to guarantee "universal" employment. Here's an excerpt:

1) Impose a "job mandate" requiring all companies with greater than 50 employees to add 10% new employees to their payrolls. So if a company currently has 50 employees, they would need to hire 5 new workers. If a company has 100 employees, they must hire 10 new workers, etc.

3) Of course, the government would have to closely specify what sorts of salaries, benefits, and job responsibilities must be included in any of these new government-created jobs, both within and outside the exchanges. We can't have those "millionaire and billionaire" employers exploiting their new employees. If a company needs, say, a Linux programmer, but the new worker has a "pre-existing condition" of not actually knowing Linux, the company should deal with it the best they can -- either by training him in Linux or finding him another job that he can do.

5) Of course, this idea of a "jobs mandate" is constitutional. Some old-fashioned pundits might mistakenly think that employers -- not the government -- should be free to decide whether and when to hire new workers, based on their own individual circumstances and requirements. But more enlightened scholars realize that "not hiring someone" is a form of "economic activity" that could affect commerce and economics across the country, especially when such individual "not hiring" decisions are considered in aggregate. Hence, by the Commerce Clause of the U.S. Constitution, Congress has the authority to limit or outlaw this widespread practice of "not hiring someone."

(Read the full text of "Let's Model ObamaJobs After ObamaCare!".)

Quick Links: Time, Retail Clinics, ACO Costs

Dr. Rick Donahue correctly notes that, "The secret to better patient care is time".

Note that this is one of the key values that a good concierge or "direct pay" physician offers the patient -- the ability to spend adequate time discussion problems and concerns. The current system dominated by 3rd-party insurance, Medicare and other forms of government-driven "coverage" put doctors in a position where they typically can spend only 15 minutes per patient.

Economist Mark Perry discusses the beneficial boom in "retail clinics". The partially-free market is doing well! (Via Kelly V.)

Other economists warn, "ACOs May Not End Wasteful Health Spending". But I'm sure the statists will be "shocked, shocked" when ACOs "unexpectedly" cost more than projected.

Quick Links: Haynes, Innovation, Bundling

Dr. Beth Haynes of the Black Ribbon Project and D4PC has a new OpEd in the 9/4/2011 TownHall, "Healthcare Rationing George Orwell-Style".

She exposes the double-speak and word games used to disguise the true nature of ObamaCare.

Fortune/CNN ask, "Is the FDA killing innovation?" (Via @TOSJournal.)

Short answer, "yes". Such regulations are another example of Bastiat's principle of "the seen vs. the unseen". We'll never know about the lives that could have been saved (but weren't) because of the FDA.

American Medical News reports on 9/5/2011, "Medicare unveils bundled payment models to start in 2012".

The 8/30/2011 Washington Times has a similar story, "Medicare testing new way to distribute funds to providers".

We've tried various forms of "capitation" in the 1980s and 1990s, and Americans resoundly rejected this approach as stealth rationing. Will they fall for it this time?

Deliberate Waiting in the UK

The 9/4/2001 Telegraph reports that the UK National Health Service (NHS) deliberately keeps patients waiting longer than necessary even though hospitals could see them sooner in order to lower patient expectations.

The NHS also keeps patients on the waiting lists longer than necessary in order to save money and/or shift the costs into future budget cycles.

As always, UK patients have theoretical "coverage". But that's not the same as actual medical care.

(Via @sonodoc99)

Ralston: Ready to Inform on Your Doctor?

In the 9/1/2011 Orange County Register, Richard Ralston of AFCM asks, "Ready to inform on your doctor?" He notes, "Government wants that, and already has doctors informing on patients".

Government-mandated electronic medical records will be a big part of tracking both patients and physicians.

And this proposed National Patient ID Card could make it much easier for the government to control what care patients may receive, and what kinds of treatments doctors can offer, all in the name of tracking and encouraging "provider savings". (Via @aapsonline.)

Health care in 2014 could become eerily similar to life in 1984, but with better technology on the government's side...

Open Letter to Apple: My iPad and My Hip Fracture

Dear Apple:

I've been a happy iPad2 owner since March 2011, but I never fully appreciated its value until I recently broke my hip in a bad fall and required subsequent hospitalization.

I am a physician, so I had already been using my iPad for my work, reading PDFs of medical articles, communicating with my colleagues via e-mail, etc. But when I broke my hip in an accident a few days ago, the iPad became my lifeline to the outside world:

Because I had my iPad with me at the time of the accident, I was able to immediately notify my friends and family of what had happened once I arrived in the ER.

In the ER, the iPad also helped keep my spirits up as I checked e-mail, followed my friends on Twitter and Facebook, and followed the regular world news. When my orthopedic surgeon presented my treatment options to me, he also e-mailed me some relevant medical literature in the form of PDF files which I could digest at my own pace on the iPad. And of course, I was also able to perform Google searches on my various surgery options, the complication rates, postoperative care requirements, etc.

Because of the specific nature of my fracture, I had to choose between two treatment options, each with its own pros and cons. I found it enormously helpful to be able to gather the relevant medical information literally "at my fingertips". Because of the iPad, I was able to more quickly make an informed treatment decision that I was comfortable with.

I did briefly leave my iPad with my wife during the surgery itself, but she gave it back to me immediately after the surgery. Other than that, it did not leave my side while in the hospital.

While in the hospital after my surgery, I used the iPad to read eBooks, check my e-mail, surf the internet, and keep up my regular blogging. It was a real morale booster to be able to continue as much of my regular online routine as possible, despite my impaired physical condition.

My wife also had her own iPad with her while I was hospitalized, which allowed her to update our friends and family in real time on my condition, as well as keep her occupied while I was asleep or in surgery.

And now that I'm at home recovering, my iPad is still at my side!

For someone such as myself with limited physical mobility, the iPad2 with its light weight and long battery life was perfect. A laptop computer simply would not have worked while in the hospital. The iPad was literally an emotional, medical, and physical lifeline for me during a difficult time in my life.

I know Apple has been in the news lately because of Steve Jobs' decision to step down as CEO. I just wanted to take this opportunity to publicly thank Mr. Jobs and Apple for creating such a wonderful, life-enhancing product.

In your advertisements, Apple has touted the iPad as "magical" and "revolutionary". To that, I would add the term "life-saver".

-- Paul Hsieh, MD

[Crossposted from GeekPress.]

The Battle In The States

The 8/25/2011 Washington Times reports, "Rebellion by states could be hazardous to health care overhaul".

(As the article notes, it's unclear that any state-level initiatives could override federal-level provisions of ObamaCare without consent of Congress and the President. But the state-level actions are an interesting reflection of popular political sentiment.)

In the 8/25/2011 Orange County Register, John Graham notes "Health insurers in states' cross hairs".

When state governments can accept (or reject) requested insurance rate increases, it turns the nominally-private health insurance companies into a variant of "public" utilities. Yet when it suits them, the states can shift the blame for increases on the insurers for political purposes.

Wolf and Scherz Double Treat

Two of my favorite physician-writers both published good OpEds recently:

Dr. Milton Wolf, Washington Times, "I'm exactly what's wrong with Barack Obama's America", 9/2/2011.

Ayn Rand once identified "the sanction of the victim" as the method by which bad guys kept exploiting the good guys:

The "sanction of the victim" is the willingness of the good to suffer at the hands of the evil, to accept the role of sacrificial victim for the "sin" of creating values.

It's nice to see some value-producing Americans decide to start withdrawing that sanction!

Hal Scherz of D4PC, Physicians News, 9/2011, "Doctors Will Remain A Target Until They Wake Up".

Let's hope American doctors (and patients) heed his warnings before it's too late.

Drug Shortages

A couple of analyses of drug shortages:

"Preventive Care, Obamacare Style", Robert Goldberg, AmSpec, 8/24/2011.

"The Perils of Price Control", Richard Epstein, Hoover Institution, 8/30/2011.

Hsieh PJM OpEd: How ObamaCare Plays Games with Your Life

My latest is now up at PajamasMedia: "How ObamaCare Plays Games with Your Life".

My theme is that under ObamaCare, people will succeed through cronyism, pull, and "gaming the system". In contrast, doctors who adopt the old fashioned approach of working for their patients' best medical interests will be punished for their virtues.

Here is the opening:

Whenever Congress attempts to "reform" the tax system by passing new laws, they inevitably create new winners and losers. But one group always wins -- the consultants and special interest groups best able to "game" the system to their advantage. The same is happening now with Obama's health care "reform," except this time the stakes won't just be money, but Americans' lives...

I also discuss Dr. Stewart Segal's related concept of the "ACO leper".

Will you be an "ACO leper" under the new system?

Wolf On Prosperity

Dr. Milton Wolf has a new WashTimes OpEd, "Prosperity starts with Americans, not Uncle Sam".

Although it's not directly related to health care, it's a good overview of some key points on free-market economics.

Given that the recent earthquake and hurricane have spurred more popular awareness of the "broken window fallacy", Dr. Wolf's piece is a nice contribution to this public discussion.

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