Frist: What My Doctor Thinks of ObamaCare

Former US Senator Bill Frist (and a cardiothoracic surgeon) discusses, "What my doctor thinks of ObamaCare".

Many of this internists' observations match what I've heard amongst my own colleagues.  And it shows the deep divide between doctors "in the trenches" and medical academicians and Washington lobbyists claiming to speak for doctors.

Here's an excerpt:

Frist: We hear the electronic health record (EHR) will solve much of what ails our health sector. 

Doctor: The EHR is not the savior of the medical system. In fact, it is effectively destroying the relational aspect of the art of medicine. Instead of talking with a patient and hearing her "story," we are being relegated to looking at a computer screen and pointing/clicking during the visit.  I know there are long-term benefits to an EHR,  but most internists who value the art of medicine will tell you it is killing the "story." And it is expensive. Physicians with EHRs see 15 to 30 percent fewer patients (and work later into the night). And yet with ObamaCare, we will be asked to take care of an additional 30 million patients... 

We are told that increased government regulation and monitoring will reduce waste.

Unnecessary regulations and increased paperwork are drowning us and reducing quality of care. We have allowed just "one more thing" to be added over and over again. The camel's back is now breaking. I have never seen physicians as depressed and stressed in my 20 years of practice. At each visit, I am required to tell the government whether the patient I am seeing had a flu shot last winter! Please help me understand how that improves care. I know the many quality metrics (i.e.: check this box) mean well, but they are having the opposite effect.  They are diminishing quality because they (the boxes) become the focus of each visit, rather than the human interaction...

But Washington tells us that "evidenced-based medicine" is the surest way to better outcomes.  

Quality care comes from a careful, professional analysis of a clinical situation that leads to a correct diagnosis and treatment for the particular patient at hand. Quality care will never be found by mindlessly marking boxes or following algorithms that are at the heart of what is being called "quality measures and evidence-based medicine."

(Read the full text of "What my doctor thinks of ObamaCare". Link via Dr. Megan Edison and Docs4PatientCare.)

UK Doctor Brain Drain

The 8/28/2012 Investor's Business Daily reminds us, "Socialized Medicine Is Enough To Chase Away British Doctors".

One excerpt:

More than 8,000 doctors have left since 2008, said the Financial Times. And it's not Britain's problem alone. Nearly 10% of Canadian-trained doctors end up in the U.S...

Yet it's obvious that Britain's socialized medicine is one of the chief reasons doctors are leaving, if not the top reason. The Financial Times reports that physicians have complained of "extensive 'goodwill hours' and coming in on days off." Younger doctors also "feel abused by the long hours" they put in.

When a government declares that it will provide "free" health care, there is no escaping the fact that such a system will one day be overwhelmed by demand and the providers -- the doctors and other professionals who are extensively and intensively trained -- won't be able to keep up. They will be overworked, underpaid and frustrated with the difficulties in performing the task they feel called to, namely healing the sick.

And what does this mean for those in the US?

While ObamaCare might not drive America's doctors elsewhere -- given that the U.S. is the world's last hope for freedom, opportunity and prosperity, there isn't any place to go -- it will cause deep problems. Rather than leave, today's U.S. physicians will simply retire early or change careers and tomorrow's will choose another profession, one less regulated and more remunerative.

(Read the full text of "Socialized Medicine Is Enough To Chase Away British Doctors".)

Fortunately, we still have time to change this.

(Via Dr. Evan Madianos.)

Quick Links: India, CA, Aspirin

Ari Armstrong: "Indian Patients Wait Weeks for Treatment -- Can You Guess Why?"

Orange County Register: "Repeal or not, California's stuck with Obamacare".

New York Times: "Regular Aspirin Use May Aid Prostate Cancer Recovery" (via Dr. Jonathan Cargan.) 

BTW: aspirin would never be approved by today's FDA.

WSJ: Cheesecake Factory Medicine

The 8/27/2012 Wall Street Journal discusses the government push towards top-down standardized health care in "Cheesecake Factory Medicine".

In particular, they discuss Dr. Atul Gawande's proposal that American health care should be modelled more like successful chain restaurants such as the Cheesecake Factory.

It is true that there are efficiencies to be gained by economies of scale in health care, as in many other industries.  But the WSJ notes:

No doubt health care could learn a lot about efficiency from a lot of industries, but to understand the core problem with assembly-line medicine, recall that ObamaCare actively promotes medical corporatism. The reason isn't to encourage business efficiency but for political control. Liberals believe in health-care consolidation because fewer giant corporations are easier for Mr. Orszag's central committee to control, and more amenable to its orders.

The writer Jonah Goldberg once described a similar strategy of government-driven economic consolidation during the New Deal:

[If] you want to use business to implement your social agenda, then you should want businesses themselves to be as big as possible. What’s easier, strapping five thousand cats to a wagon or a couple of giant oxen?

Similarly, it will be much easier for the federal government to regulate 100 large "hospital networks" or "accountable care organizations" (ACOs) than 10,000 small private practices.

In a separate article, the 8/27/2012 WSJ also noted that government-driven consolidation often drives up prices, because of decreased competition: "Same Doctor Visit, Double the Cost":

...[A] structural shift... is sweeping through health care in the U.S.—hospitals are increasingly acquiring private physician practices.

Hospitals say the acquisitions will make health care more efficient. But the phenomenon, in some cases, also is having another effect: higher prices.

As physicians are subsumed into hospital systems, they can get paid for services at the systems' rates, which are typically more generous than what insurers pay independent doctors. What's more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost...

In effect, the government is creating artificial monopolies (or near-monopolies) in many markets.

The hospital chains will then take advantage of this politically-favored position to raise prices.  This will then lead to calls for more government regulations to cut costs, accelerating the vicious cycle of ever-increasing central government control over medicine.  Controls breed controls.

It's time to get off this treadmill by repealing ObamaCare, decontrolling medicine, and allowing free-market reforms in American health care.

California Vs. Freedom of Contract

ER physician-blogger "White Coat" discusses the latest controversy over medical billing and freedom of contract in California, in his post: "Fair Payment?"

He cites a recent 8/17/2012 Los Angeles Times story, "State suing doctor over billing tactics".

Short summary of the basic facts:

A patient comes into the ER with an injured finger, requiring stitches.

The ER doctor is prepared to treat him, but the patient instead requests a plastic surgeon, because he wants "a professional" to do it.

The plastic surgeon (Dr. Martello) explains to the patient that her fee is more than the usual amount covered by his managed care plan for an ER repair.  The patient signs a form agreeing to pay the difference.

The surgeon performs the requested procedure. 

The state of California then sues the doctor, overriding her agreement with the patient and forcing her to accept what the state deems is an appropriate (and much lower) fee.  The state also attempts to revoke her medical license.

The LA Times notes that there is no dispute about the quality of the doctor's work.  Instead, the issue is about whether the doctor should be able to collect the agreed-upon fee:

Selesnick [Dr. Martello's lawyer] said the patients didn't want an emergency room doctor to stitch them up, so they waited for a plastic surgeon. "They wanted a professional," he said. He added, "No one is complaining that Dr. Martello did a bad job."

Selesnick argued that the state's case against his client underscores a larger problem: no one wants to pay for medical services. "Dr. Martello is definitely passionate about being a physician," he said. "She is equally as passionate about getting paid for the work that she did."

As Dr. "White Coat" notes:

The patients refused to have the emergency physician repair their wounds and demanded that they be treated by a “professional”. Now they’re accepting the “professional’s” services without planning on paying her the price that she asked?

Wonder why there are so many specialists who aren’t providing care to emergency department patients?...

I wonder if this whole “we’ll pay you what WE think is fair” line of reasoning would work when the doctor went to pay her California state taxes…

(Read the full text of his blog post, "Fair Payment?")

I'm especially encouraged by Dr. Martello's moral clarity.  She explicitly recognizes that she has the right to treat patients on her terms (mutually agreed to with the patient), and that the state has no right to dispose of her skill, training, and medical services by arbitrary decree.

The California courts may or may not agree with the doctor.  But I'm glad there are doctors like Dr. Martello fighting for her individual rights and for her freedom to contract.

(Link via Dr. Art Fougner.)

Doctor's Handwriting Font

A little humor to end the work-week: Doctor's Handwriting Font.

(Click on image to see it full size.)

Canadian Rationing Strikes Again

From Ontario Canada: "Last-hope prostate drug not funded".

Here's the opening of the article:

There are two tiers of men with advanced prostate cancer in Ontario: Those who get access to a remarkable drug through private insurance, and those who get a death sentence.

The grim news is often delivered at the London Regional Cancer Program to men whose shoulders sag and jaws drop when told Ontario's Health Ministry has for 15 months refused to pay for a medication covered by every other Canadian province.

"There's shock, fury and dismay," said oncologist Kylea Potvin. "Everyone thinks we have this wonderful universal health care system, but this is absolutely not the case. We've increasingly become a two-tier health care system where if you have money, you have access."

(Read the full text of "Last-hope prostate drug not funded".)

The US isn't there yet.  But we're moving there.

(Via Instapundit.)

Hsieh Forbes OpEd: Human Progress and Earned Wealth

My latest OpEd is now up at Forbes, "If You Want Human Progress To Stop, Institute A Maximum Income".

In this piece, I discuss the importance of making a moral defense of those who have earned wealth honestly, not just an economic defense.

Here is the opening:

Suppose a young medical researcher, Dr. Smith, discovered a safe, reliable vaccine for breast cancer. If a woman took a single pill at age 30, she’d never develop breast cancer. But the pill costs $1,000. How many American women would take that deal?

Most women would likely jump at the opportunity. For $1,000, a woman would be forever spared the expense and inconvenience of future annual mammograms. She’d never have to worry about her doctor calling to say, “Your mammogram showed a suspicious spot; please come in for a biopsy.” The 12% of women who would have developed breast cancer during their lifetimes would be spared the pain and risks of surgery, chemotherapy, and radiation therapy.

Each woman would gain an enormous value in terms of money saved, peace of mind, and potential added years of life, far exceeding the $1,000 cost. Roughly 2 million American women turn 30 each year. Assuming Dr. Smith made a 10% profit from each sale, he would earn $200 million a year. Most people would regard that as a completely fair outcome.

But not Hamilton Nolan...

(Read the full text of "If You Want Human Progress To Stop, Institute A Maximum Income".)

I'm also delighted to announce that Forbes has invited me to be a regular contributor, after my prior guest OpEds.  My focus will be primarily on health care, economics, and related issues, from a free-market perspective.

You can find my earlier Forbes OpEds here:

"The Federal Government's War On Medical Innovation" (8/8/2012)

"Is President Obama's Prostate Gland More Important Than Yours?" (7/5/2012)

"The Dangerous Synergy Between The Nanny State And Universal Health Care" (6/18/2012)

"Just Who Should Control Your Healthcare Spending?" (5/15/2012) 

I'd like to thank all my regular readers for their support and encouragement -- it means a great deal to me.

And thank you all for circulating my work by Facebook, Twitter, blogging, and e-mail!

Quick Links: Fascism, Tragedy, Medicaid

Medical student Ben Gallagher proposes: "In exchange for footing most of the bill for my medical training, the government should try to control how and where I practice in the future."

(If a private group wants to offer to fund a medical student's tuition in exchange for future services, that's perfectly legitimate. But Gallagher's proposal is dangerously fascistic. Link via Dr. Megan Edison.)

Grace-Marie Turner: "The Real Tragedy Of ObamaCare Has Yet To Be Felt By The Poor".

Scott Gottleib: "The closer one looks at Obamacare, the more it looks like Medicaid"

More Massachusetts Danger

In the 8/20/2012 Forbes, Sally Pipes describes how, "Gov. Deval Patrick's New Health Law Is Flat-Out Dangerous".

In particular, the state government will be imposing new cost controls enforced by new bureaucracies:

Healthcare providers that don't hit the government's new annual spending targets will face serious consequences. Two new state agencies -- the Health Policy Commission and the Center for Health Information Analysis -- have been created to discipline them.

Physicians who fail to reduce costs can be compelled to file "performance improvement plans." These filings are essentially designed to embarrass struggling hospitals. If providers don't adhere to their improvement plans, the agencies can fine them up to $500,000. And there don’t appear to be any means for appeal or judicial review of these fines.

Encumbering physicians with yet another layer of red tape is no way to reduce costs. Massachusetts Medical Society President Richard Aghababian has voiced misgivings that "the bill's very stringent reporting requirements" will be particularly burdensome to "the smaller medical practices in the Commonwealth," which generally lack the resources needed to shoulder such a hefty administrative burden.

The net result:

When costs go up for healthcare providers, they have to compensate somehow -- perhaps by laying off staff, restricting treatment options, or in the most severe cases, closing up shop entirely.

Ultimately, that leaves patients with fewer providers to treat them -- and thus substantially longer wait times. The Massachusetts Medical Society has predicted that Gov. Patrick’s law will force many hospitals to cut staff and result in delayed care for some patients.

Bay Staters already have to wait 45 days on average for an appointment with a family medicine doctor, according to the Society. That’s a 50 percent jump in wait time since 2010.

And there will be more problems to come unless the government takeover of medicine is reversed.

(Read the full text of "Gov. Deval Patrick's New Health Law Is Flat-Out Dangerous".)

Quick Links: Gray Market Drugs, FDA Magic, Dope and Chains

Given the critical shortage of some injectable drugs, it's no surprise that a "gray market" has arisen. (Via @OHPCenter.)

Dr. Steven Novella: "FDA Ensures Magic Rituals Are Done Properly"

David Catron has a new American Spectator piece not specifically on health care, but taking a broader perspective: "From Hope and Change to Dope and Chains"

Quick Links: Free Care, Gaming, Medicare Exodus

Dr. Edwin Leap: "Why must medical care be provided for free?", KevinMD, 8/16/2012.

(Dr. Leap asks a very relevant question, using his septic tank as a springboard for discussion.)

Sarah Kliff: "How doctors could game Obamacare", Washington Post, 8/15/2012.

Dr. Shabbir Hossain: "Beating the 30 day readmission: Why there’s little to celebrate", KevinMD, 8/16/2012.

(One trend to anticipate: Physicians will be under pressure by ACO and/or hospital administrators to delay such readmissions until after the 30-day "clock" runs out.  After all, the administrators won't bear the risk of trying to manage a patient in tenuous clinical condition as an outpatient.)

David Hogberg, "The Next Exodus: Primary-Care Physicians and Medicare", NCPA, August 2012.

Scherz: ObamaCare and Demonizing Doctors

Dr. Hal Scherz of Docs4PatientCare has a new piece in the 8/18/2012 TownHall, "Obama Says: Doctor, You Did Not Graduate From Medical School".

In particular, he notes how and why the Obama administration is demonizing doctors:

The healthcare system is being turned upside down with the federal government in charge of deciding who gets what kind of care, by whom, where and how much they will pay for it. Those who engineered Obamacare believe that they can do this because they feel that they own a piece of every doctor in America and that the government has a right to this work.

It becomes easier to do this by convincing Americans that healthcare is an entitlement, and consequently, someone has to provide that care for them. It becomes easier for people to feel that sense of entitlement, if they believe that their doctors are not the compassionate individuals that they thought they were, but rather, greedy opportunists like the President has depicted them.

On the current path, the worst is yet to come. Doctors are quitting in anticipation of government controlling their practices. Doctor shortages are here, but will soon reach epic proportions. Covert rationing of care is coming because there will not be enough doctors to see patients.

(There's lots more and I highly recommend reading the full piece: "Obama Says: Doctor, You Did Not Graduate From Medical School".)

Wolf: Barack Obama, Welfare King

Dr. Milton Wolf has a new Washington Times OpEd, "Barack Obama: The welfare king".

One excerpt:

Consider Obamacare. Despite his false promises, since President Obama has taken office, health insurance premiums have increased by more than $2,300 per family per year. But not to worry, Mr. Obama wants to give you free stuff! Obamacare provides "assistance" -- in reality, welfare -- to families earning up to $88,500 a year. Let that sink in. In Mr. Obama’s worldview, even families earning twice the nation’s median income should receive welfare.

Consider Mr. Obama's new welfare rules. In 1996, President Clinton and a Republican Congress implemented welfare-to-work requirements. It worked astonishingly well. Welfare caseloads dropped 70 percent. The American dream was restored for nearly 9 million Americans who worked their way out of poverty. Mr. Obama, however, prefers dependency and recently gutted the work requirements. More free stuff!

Of course, once people in the middle class are hooked on subsidies/handouts, the more politically entrenched they become.  Which is how we've gotten into our current entitlement mess.

(Read the full text of "Barack Obama: The welfare king")

It will take a bold politician to communicate to the voters how we got into this mess --and how we can get out.  In particular, he or she will would have to challenge the very premises of the entitlement state at both the moral and practical levels, and offer a viable alternative. 

We'll see if anyone can step up to the challenge.

Quick Links: MA, FDA, "Who Pays?"

Vuckovic: "Health law treats docs like villains" (Boston Herald, 8/14/2012).

Frezza: "How the FDA Stymies Progress -- and How to Get Around It" (Bio-IT World, 8/13/2012).

Nicely done interactive graphic: "US Health Care Spending: Who Pays?"

In particular, note how the government share of medical spending has increased dramatically over time. (Link via @IP4PI.)

Diana Hsieh on Medicine in a Free Society

In the 12 August 2012 episode of Philosophy in Action Radio, my wife Dr. Diana Hsieh discussed medicine in a free society.

The question was:

What would the practice of medicine look like in a free society? Today, the practice of medicine is highly regulated and controlled by the government, including in its business aspects.

How would medicine change if the government fully respected rights? What would remain the same?

Her Answer, In Brief:

While the particulars of a free market in medicine cannot be predicted, that free market would be far, far superior for doctors and patients than our current mixture of welfare and controls.

Download or Listen to Her Full Answer:

• Duration: 15:42
• Download: MP3 Segment

Tags: Business, Free Society, Medicine, Rights

Relevant Links:

• The Objective Standard:  The Virtue of Treating People Like Animals: Why Human Health Care Should Mirror Veterinary Health Care by Sarah Gelberg and A Prescription for America's Health Care Ills by Stella Daily Zawistowski
• Articles from FIRM

To comment on this question or Diana's answer, visit its comment thread.

A podcast of the full episode – where Diana answered questions on overcoming weakness of will, deductive reasoning, advertising to children, medicine in a free society, and more – is available as a podcast here: Episode of 12 August 2012.

Philosophy in Action Radio broadcasts every Sunday morning and Wednesday evening. For information on upcoming shows and more, visit the Episodes on Tap.

Quick Links: ACOs, Managed Care, Quagmire

Dr. Michael Kirsch, "Are ACOs merely repackaged HMOs?"

Herzberg and Fawson, "Accountable Care Organizations: Panacea or Train Wreck?" (NCPA, 8/14/2012)

WSJ: "Remember Managed Care? It's Quietly Coming Back" (8/2/2012)

Richard Epstein, "The ObamaCare Quagmire" (Hoover Institution, 8/14/2012)

Will Your Doctor Quit?

In this 8/12/2012 Forbes piece, Dr. Marc Siegel asks: "Will Your Doctor Quit? Obamacare Foretells Mass Exodus From Patient Care".

Dr. Siegel cites surveys demonstrating widespread physician discontent with ObamaCare, to the extent that many physicians are thinking of quitting.

There's no way to know (yet) how many physicians will actually follow through on such sentiments. And of course, much will depend on the results of the November 2012 election.

But I do know from personal experience that many doctors are quietly thinking about "exit strategies" to leave clinical practice if ObamaCare is not repealed. They may not talk about it with their patients, but they are talking about it with fellow physicians.

Maybe it's time that more Americans start asking this question as well.

(Read the full text of "Will Your Doctor Quit? Obamacare Foretells Mass Exodus From Patient Care".)

Will Paul Ryan Destroy Medicare? And Should He?

Now that Paul Ryan has been selected as the GOP VP nominee, we're hearing lots more discussion about his plans for revamping Medicare.

I do think it's important to keep in mind a few key facts about Ryan and Medicare:

* Medicare in its current form is unsustainable.

* Obama's plans for Medicare include draconian cost controls, including the infamous IPAB board which will use the power of the purse to impose de facto rationing. As I wrote last year for PJMedia:

If the IPAB sets the reimbursement rate for services below the cost of providing it, then hospitals and doctors could no longer afford to offer such services — even if the services are medically best for their patients. Life-saving medical procedures we currently take for granted, such as PET scans to detect early cancers or minimally invasive methods to safely open up blocked vital blood vessels without risky surgery, might no longer be available.

Although those services might still theoretically be "covered" by Medicare, in practice doctors would no longer offer them, and their patients would no longer be able to receive them.

* Paul Ryan will be lambasted by the Left as wanting to "end Medicare as we know it".   But David Catron reviews some of the dismal facts about the future of Medicare in his 8/13/2012 American Spectator piece "Paul Ryan as the Great Destroyer" and concludes:

All of which suggests that ending Medicare "as we know it" is a pretty good idea. How then, would Paul Ryan go about cleaning it up?

* If anything, Ryan's proposed systems of vouchers and premium supports don't go far enough.  That's because his stated goal is to "save Medicare", rather than to eliminate it as a government program.

* There are groups like Docs4PatientCare that also support some of the same intermediate-range ideas as Paul Ryan.  But they also frame their proposals in the broader context of "[u]ntil Medicare as we know it is phased out and the transition to private health insurance is accomplished".  In other words, they envision completely eliminating government interference in the health care market for senior citizens.  This is a praiseworthy goal which I fully support.

* Hence, Ryan's plans for Medicare do not go as far as I (or Docs4PatientCare) envision.  The current Obama approach will cause Medicare to crash in a catastrophic fashion.  The Ryan approach may buy it more time, but would leave in place an enormous government entitlement program.  Instead of either of those approaches, we should aim to end Medicare as a government program, but through a controlled landing rather than a crash.

* Hence, Paul Ryan's ideas may move us part way in the right direction, but not as far as we should go.   If the Romney/Ryan ticket wins the election, free-market advocates will still have much more work to do.

More Medicaid Woes

In the 7/31/2012 American Thinker, Dr. Zane Pollard warns, "Save American Medicine and Save Your Own Life".

In his piece, he discusses the frustrations he experiences daily dealing with the inflexible government Medicaid bureaucracy. Here's one example:

Recently, I operated on a 4-year-old who had esotropia (crossed eyes). I had obtained prior approval from Medicaid to do her surgery. On the day of surgery, I went to touch base with the child and family just before and noticed that the condition had changed since the original office visit. I now needed to perform a different surgery from that for which I had originally obtained permission.

The surgery went well, and the child had a very good result. Medicaid told me that since I had performed a surgery different from what I had requested, they were going to pay me nothing. In fact, the surgery that I performed was less costly to Medicaid than what I had originally requested.

Each of us, as a patient, trusts his physician to do the best humanly possible for him. We trust our doctors to change their minds to give what they feel is the best treatment at the time of delivery. How can anyone go to a doctor and trust him or her to do the best for us if the doctor knows that by changing the plan, he or she might be penalized?

Even worse, much of ObamaCare's expansion in "coverage" will involve moving people on the government Medicaid rolls.  Medicaid is already notorious for underpaying doctors (such that they lose money on each patient they see.)

In other words, Medicaid punishes doctors medically and financially. 

How long will doctors wish to keep working when their virtues are held against them?  And when these doctors leave medicine, what kind will remain?

(Read the full text of "Save American Medicine and Save Your Own Life".)

Another Canadian Warns Americans

James Hancock (an Canadian who now lives in the US) made the following comments about Canadian health care on Diana's blog.

He has graciously given me his permission to repost this slightly edited version here:

Welcome to Canadian healthcare folks, where 80% of all taxes from all levels of government got to healthcare and related fields. Where a hip replacement takes more than a year. Where chemotherapy takes 1 1/2 months of your 6 months to live. Where they're considering death panels like the father of socialized medicine, the UK.

By 2020 Canada's healthcare system will consume 120% of taxation. There are virtually no family doctors left because the pay is horrible and if you go to emerge and you're not dying on the gurney, it will take you at least 3 hours to see a doctor.

I sprained my ankle once. It took 4 hours to see the doctor to have him send me to x-ray. It took 2 hours in radiology to get the x-rays and then another 4 hours to see the doctor to look at the x-ray and tell me it wasn't broken (very bad sprain that might have been more).

Cut in my hand that got infected, 3 hours to see a doctor for a prescription for antibiotics.

2nd degree burns to my foot because of a corn pot tipping over, 3 hours to see a doctor for which the doctor prescribed pain killers that I'm allergic too, for which I told him directly I was allergic and my file also said so.  Another 3 hours to get a different prescription because I refused to leave until he fixed it. In the mean time, I'm just about passing out in pain.

The only people that get good medical coverage in Canada are celebrities. Even rich people have to come to the US for good healthcare because it's illegal to buy private healthcare in Canada. (soon to be overturned by the supreme court as a violation of our freedom of association, so Canada is about to get more free healthcare while the US gets less!) Everyone else waits, and waits and waits.

Get your passports ready folks! You're going to be going to Singapore and India for healthcare in the US soon.

James also pointed me towards this related recent news story: "Wait times for patients 'worsening'" (CBC News, 6/19/2012).

We have been warned.

Catron on Obama's Concept of "Fairness"

David Catron has a new piece in the 8/8/2012 American Spectator, "A Gut Check on What Obama Means by 'Fairness'".

Catron notes the hypocrisy of a president preaching "fairness", yet electing to avail himself of medical tests and procedures that likely would not be available to the general public once ObamaCare legislation is fully implemented.

For instance, President Obama was allowed to receive a CT colonography test (which can detect early colon cancers with much less risk than traditional colonoscopy). But Medicare denies coverage to senior citizens on the grounds that it's too costly and not a sufficiently-proven technology.

As Catron notes:

Take a moment to consider that. The President of the United States, a public servant paid by the taxpayers, followed the advice of his taxpayer-paid doctors that he should have a taxpayer-paid CTC.

Yet his health care commissars, also paid by taxpayers, have decreed that that it is too expensive to provide this very test to actual taxpayers when they retire and sign up for the Medicare program for which they have been paying all their working lives.

This perverse system, it should be remembered, is not merely presided over but taken advantage of by a man who incessantly lectures these very taxpayers about "fairness."

(Read the full text of "A Gut Check on What Obama Means by 'Fairness'".)

I'd also like to thank David Catron for citing my earlier Forbes piece on prostate cancer testing in his column and for promoting the FIRM blog!

Hsieh Forbes OpEd: The Federal Government's War On Medical Innovation

Forbes has published my latest OpEd, "The Federal Government's War On Medical Innovation".

I discuss how the government is hampering the development of life-saving medical technology through two methods: new taxes and FDA regulation.

Here is the opening;

The federal government is waging a stealth two-pronged war on medical innovation. And it will cost not just American jobs, but American lives.

The first prong is through new taxes. Recently, the Cook Medical company announced that it was canceling plans to open new factories because of the impending ObamaCare tax on medical device manufacturers scheduled to take effect in 2013. The 2.3% tax on total sales (not profits) will cost Cook $20 million dollars a year. As a result, the company will not be opening five plants that would have employed up to 300 people each.

Cook is not the only medical device company affected by the tax. Stryker (which makes artificial joints) will cut 5% of its workforce. Medtronic has announced the tax will cut into its investments in future products. Jonathan Rennert, chairman of Zoll Medical (which makes advanced cardiac defibrillators) has stated that the tax will mean “less innovation, fewer jobs, and fewer lives saved.”

The second prong of the war on innovation is through regulations...

I'd especially like to thank Cynthia for allowing me to quote her response to the FDA official who admitted to delaying the approval of digital mammography machines.

(Read the full text of "The Federal Government's War On Medical Innovation".)

Quick Links: Medicaid, PSA, Unnecessary Tests

"Nearly A Third Of Doctors Won't See New Medicaid Patients" (Kaiser Health News, 8/6/2012).

One big question is whether the government will compel doctors to see Medicaid/Medicare patients, perhaps as a condition of retaining their medical licenses.

"Metastatic disease reduced in PSA screening era" (American College of Physicians, 8/7/2012)

PSA screening may or may not be right for any individual patient. But doctors and patients should decide the medical appropriateness for themselves, rather than having a one-size-fits-all guideline imposed upon them by the federal government.  (And ICYMI, "Is President Obama's Prostate Gland More Important Than Yours?")

"Beware legal ramifications of unnecessary tests" (Medical Economics, 7/25/2012)

In other words, if a doctor orders a test deemed "unnecessary", they could be sued.  Of course, if they don't order one of those tests that in retrospect might have detected a serious problem, they can still be sued for "delay in diagnosis". 

So doctors face a potential"damned if you don't, damned if you do" medicolegal scenario with these "unnecessary" tests.  (Via Dr. Art Fougner.)

UK National Health Service Branch Bans Paperclips

Although it sounds more like a headline from The Onion, this story is apparently real: "NHS health and safety chiefs ban 'dangerous' metal paper clips".

From the article:

Manchester NHS Trust officials made the decision to stop the use of the metal stationary item after a member of staff cut their finger using one.

In a memo to staff, it was warned that the use of metal fasteners was 'prohibited' and the offending clips must be 'carefully disposed of immediately'.

'Due to recent incidents, NHS Manchester has decided to immediately withdraw the use of metal paper fasteners,' explained the memo featuring an accompanying picture of a paper clip - just to avoid any confusion.

   

'Please ensure any that remain in use be replaced by similar plastic fasteners. 'The use of metal fasteners is prohibited and must be carefully disposed of immediately. Thank you for your co-operation.'

The ban applies only to the employees of that NHS branch, not to the general public.

In other words, the NHS staff aren't considered competent to use metal paperclips safely. But they are deemed competent to make life-and-death medical decisions for UK residents.

Let's just hope no one tells NYC Mayor Bloomberg about this.

(Via @debbywitt.)

The Unreliability of Cross-Country Comparisons

One of the common criticisms levelled against American health care is that we supposedly spend too much money for such poor results. Typically, critics will also cite international comparison to show that the US fares poorly relative to other countries on a variety of supposedly objective metrics.

However, this recent paper from AEI by Frech, Parente, and Hoff provide some important context: "US health care: A reality check on cross-country comparisons".

In particular, they note that we have to be extremely careful about using standard OECD metrics such as infant mortality, life expectancy, and "premature mortality".

A few excerpts from their article:

For example, babies who are not viable and who die quickly after birth are more likely to be classified as stillbirths in countries outside the United States, especially in Japan, Sweden, Norway, Ireland, the Netherlands, and France. This is especially likely for babies who die before their birth is legally registered...

In the United States, however, nonviable births are often recorded as live births, making the US infant mortality rate appear misleadingly high. In a detailed study of medical records and birth and death certificates in Philadelphia, Gibson and colleagues found that infant mortality had been overstated by 40 percent, merely as a result of these nonviable births that were recorded as live births...

Furthermore:

There is another problem with using infant mortality to represent health care efficacy. US physicians often go to great efforts—at the prenatal and postnatal stages—to save a baby with poor survival chances. The additional prenatal care an American doctor provides may improve the odds of the live birth of a baby with poor survival chances, who is then likely to require extensive neonatal care.

Accordingly, the US uses substantially more neonatal intensive care units (NICU) than other industrialized countries. In this case, the additional health care may actually worsen reported infant mortality rates and misleadingly suggest poor care in the United States.

In other words, our willingness to expend greater resources on expensive neonatal care is held against us as a "proof" of our "inefficiency"!

Similarly, life expectancy comparisons can be skewed by differences in lifestyle as well as differences in accidents/trauma.  But even though such differences can be important, they don't necessarily reflect on the quality of a country's medical care system once a patient becomes ill.

The authors also point out this problem with mortality statistics:

Mortality data are an inadequate proxy for health system performance for another reason: they measure years of life, but do not reflect the quality of that life...

The OECD report, however, treats all years of life as the same, regardless of health status... The OECD report sticks with raw LE [Life Expectancy] —rather than using quality-adjusted versions—because of the wider availability of unadjusted LE data, but at the expense of conceptual accuracy.

As a result, the OECD report attributes no value to expenditures that permit people to enjoy a better life by, for example, being able to work or to be functional longer; it correlates expenditures only with mortality. Thus, money spent on knee replacements, for instance, would appear to be inefficient in that it does not decrease mortality, despite the obvious advantages of improved mobility and prevention of falls. Therefore, it is difficult to see mortality alone as an accurate measure of health system efficiency.

The US health care system does have some genuine problems as a result of decades of government interference.  And there is some validity to the argument that we spend money inefficiently -- a problem arising in large part by the government-driven third party payment system which creates perverse incentives to overconsume.  But these problems can be addressed by free-market reforms such as Health Savings Accounts.

And we should be especially careful not to base health policy on flawed statistical comparisons that paint us in a falsely bad light relative to other countries.

(Read the full text of "US health care: A reality check on cross-country comparisons".)

More Massachusetts Medical Controls

The 8/6/2012 Wall Street Journal has published an update on health care in Massachusetts, "RomneyCare 2.0".

They make two key take home points:

* Costs keep spiralling out of control

Health costs -- Medicaid, RomneyCare's subsidies, public-employee compensation -- will consume some 54% of the state budget in 2012, up from about 24% in 2001. Over the same period state health spending in real terms has jumped by 59%, while education has fallen 15%, police and firemen by 11% and roads and bridges by 23%.

* In response, the state will impose more overt controls over how doctors can practice medicine

[A]ll Massachusetts doctors, hospitals and other providers must register with a new state bureaucracy as a condition of licensure -- that is, permission to practice. They'll be required to track and report their financial performance, price and cost trends, state-sanctioned quality measures, market share and other metrics.

As the WSJ notes, this new "Health Policy Commission" will have the power to "to ensure that total Massachusetts health spending, public and private, grows no more than projected gross state product through 2017".  (Emphasis theirs)

Basically, if a doctor or hospital spends too much on a patient's care, they could be punished.

How hard will your doctor fight for your medical interests, if his medical license and his very livelihood are endangered whenever he spends more money than the government considers appropriate? Will he still be willing to order the MRI you need or prescribes the stronger (but more expensive) antibiotic to stop your life-threatening infection?

Of course the government will claim: "'We're not telling the doctors how to practice medicine -- that's still the physician's job. We're only establishing global economic guidelines. The doctor still makes the day-to-day medical decisions on his or her patients".

But in reality, the government will be using the power of the purse and the power of licensure to co-opt doctors into becoming its proxy agents of rationing.

As always, trends in Massachusetts under RomneyCare will foreshadow what will happen to the rest of the country under ObamaCare.  In particular, get used to hearing the term, "Accountable Care Organization".

(Read the full text of "RomneyCare 2.0".)

Quick Links: Defensive Medicine, Genetic Exceptionalism, Doctors Quitting

"The Vicious Cycle of Defensive Medicine".

From personal experience, I know that many ER doctors practice defensive medicine as a necessary evil in today's litigious society. (Via @sonodoc99)

"Misguided Genetic Exceptionalism".

Doctors should let patients have the choice to know about the genome, especially if it will give them valuable information about their disease prognosis.

"34% of doctors will leave profession within 10 years".

It's hard to know how reliable such reported numbers are.  Plus many doctors may consider quitting, but ultimately decide against it.  However, this is a disturbing news trend.

How the FDA Slowed Innovation for Breast Cancer Patients

The 8/2/2012 Wall Street Journal reported on a former FDA doctor under critical scrutiny for blocking approval of potentially more precise mammograms for 4 years(!).

Here is the opening of their story, "FDA Figure is Under Fire":

A Food and Drug Administration scientist blocked the approval of potentially more precise digital mammography machines for several years, a pattern that is coming under scrutiny after recent revelations that the man's computer was being monitored by the agency.

Robert C. Smith is being criticized by some breast-cancer doctors as well as some in the FDA for not approving the new machines during his nearly four-year tenure as a medical officer in the agency's radiological-devices branch.

(Read the full text of, "FDA Figure is Under Fire". If the link doesn't go to the full story, you can enter the article title into a Google search window, which will yield a link that takes you to the full text.)

The WSJ notes:

Five mammography machines using digital technology were approved by the FDA's radiological devices branch before Dr. Smith joined it. None were approved during his tenure. Six were up for approval in that time. There is no way of knowing whether any women had cancers advance because of the delays of digital technology

Smith's actions were especially frustrating for breast cancer specialists like Dr. Etta Pisano.  Pisano noted of Smith, "He began putting in obstacles to approval that were unreasonable" once he had the bureaucratic power to do so. 

(Dr. Pisano was co-author of a 42,760-patient study that appeared in the 2005 New England Journal of Medicine that demonstrated the reliability of digital mammography and showed that it was "'significantly better' than film in finding cancer in women under 50 and those before or during menopause".)

Dr. Smith's lawyer claims that Smith was merely following proper FDA procedure.  Smith's contention is that too many medical device manufacturers have an improper "cozy relationship" with FDA regulators, whereas Smith was merely being "an honest and rigorous regulator".

If that's true, that's alarming.  It would be bad enough if Smith were a rogue, overzealous regulator.  It would be even worse if Smith represents how the system is supposed to work.

As one breast cancer survivor noted in an online comment:

I just realized that if this particular bureaucrat had continued in his position, I probably wouldn't be here. My 3 year anniversary is coming up, so perhaps I should send him a "thank you for moving on" card.

But how many more Dr. Smiths are still at the FDA, delaying other vitally-needed medical innovations for American patients?

Another Medical Test Obama Got But You Might Not

A just-published article demonstrates that CT colonography is a good test for Medicare-age patients.

From the July 2012 issue of the American Journal of Roentgenology: "CT Colonography of a Medicare-Aged Population: Outcomes Observed in an Analysis of More Than 1400 Patients"

CT colonography is an excellent way of detecting early colon cancer (or excluding it), without the risks of a traditional colonscopy.

BTW, this is another medical test that President Obama was able to receive, but which many ordinary Americans with government medical insurance cannot: "President Obama Gets Virtual Colonoscopy (CT Colonography) But Medicare Denies CTC Coverage to Seniors".

(Related: "Is President Obama's Prostate Gland More Important Than Yours?", Forbes, 7/5/2012)

Hsieh Lecture on Medical Licensing Laws

My 20-minute lecture on "Milton Friedman and Medical Licensure" has now been posted:



I covered three main subjects:

* Milton Friedman's views of medical licensure
* Licensure and competence
* Licensing laws and ObamaCare

Towards the end, I cite Dr. Milton Wolf as one of the people promoting some good free-market reforms to move us in the right direction.

Thanks to Amanda Teresi-Muell for organizing this special Liberty On the Rocks event, as part of a commemoration of Milton Friedman's 100th birthday!

And thanks to Ari Armstrong for recording the video and for doing the video editing to intersperse the images of my slides within the footage!

(Note: I don't agree with Friedman on several issues. Friedman was not a fully-consistent advocate of free-market economics.  But on the topic of medical and occupational licensure, he was very good, and I wanted to highlight his excellent thinking on this particular topic.)

The Feds Can Regulate Your Stem Cells

FDA update: "U.S. District Court rules that stem cells are drugs".

From the article:

Treatments in which stem cells are harvested from bone marrow and injected straight back into the same patient are deemed part of routine medical practice - not regulated by the US government. But if the cells are subjected to more than "minimal manipulation", the FDA maintains that the therapy becomes a "drug", which must be specifically approved for use.

It's not quite, "All your cells are belong to us". But it's getting there...

Related: "Ruling frees FDA to crack down on stem cell clinics".

LAT Covers Concierge Medicine

The 7/29/2012 Los Angeles Times has a surprisingly balanced portrayal of the growing practice of "concierge medicine".

Here are some excerpts from their article, "Annual retainer fee buys patients more time with their doctors":

Concierge doctors often provide a comprehensive physical and extra screenings, as well as helping coordinate their patients' care with specialists or when they go to the hospital. Most doctors continue to take insurance, but others only take cash.

Everyone deserves to be healthy, but healthcare is a business, [Dr. Matt] Jacobson said. Unless they pay for it, everyone doesn't have the right to choose their provider, he said."

Some people view going to a private school as the most important thing," he said. "This is the same thing. Some people view healthcare as very important. They are going to cut their cable bill to see the exact doctor they want."

Similarly, the article discussed how it helped Dr. Robert Saltman:

He went from seeing between 20 and 25 patients a day to seeing between eight and 14, and he doubled the length of the appointments. Now, Saltman said he has the time to be proactive with patients and emphasize prevention and lifestyle changes. He hired a younger doctor to care for the primary care patients who chose not to pay the retainer.

Saltman said he didn't become a concierge doctor to increase his income. "I did it to continue to do something I love without being resentful," he said.

I especially liked this explanation from Dr. Saltman's patient Mitch Waks on the morality of choosing a concierge doctor:

Waks said he can justify the ethical dilemmas of paying his doctor extra for personalized medicine even as so many lack basic healthcare. "Is it bad that I am able to buy a BMW rather than a Chevy?" he said. "I don't think so."

Concierge medicine can be a win-win for both doctors and patients.

Doctors are able to practice good medicine according to their best judgment and conscience. Patients receive quality care with a minimum of interference from third parties such as the government or government-controlled insurance companies. I'm glad that more American patients and doctors are exploring this option.

(Read the full text of "Annual retainer fee buys patients more time with their doctors".  Article link via Dr. Matt Bowdish.)