Friday, September 28, 2012

NYT Openly Advocates Rationing

The New York Times recently published two OpEds openly advocating medical rationing.

The first was written by their economics columnist Eduardo Porter, "Rationing Health Care More Fairly" (8/21/2012).

His basic argument was that rationing was "inevitable", so the only question was how best to implement it.  In particular, he argued for a system like the UK's which doesn't pay for medical therapies costing more than $31k - $47k per year of life gained.  Similarly, he spoke approvingly of New Zealand's approach of not paying for vaccines if they cost more than $20,000 per year of life gained.

In other words, the only real argument (for Porter) was what exact dollar price the government should set on a year of an American patient's life.

The second piece was by Steve Rattner, an advisor to the Treasury secretary in the Obama administration, "Beyond ObamaCare" (9/16/2012).

Rattner admitted up front, "We need death panels".

Like Porter, he recommended stricter government controls to restrict medical spending.  His particular target was spending on the elderly, especially for people in their last year of life, which "consumes more than a quarter of the [Medicare] program's budget".

Of course, one big problem with this approach is that you often don't know what will be the patient's last year of life until after they've died.   It's easy for a bureaucrat to say after the fact, "Look at all that wasted money which didn't add much time to the patient's life".  But a physician on the ground doesn't always know if a patient will live or die from a surgery or procedure.  Should the government be deciding whether or not to try and save a patient's life?

These sorts of arguments are inevitable when the government controls medical spending, as it does for the Medicare population.  He who pays the piper calls the tune.  Under ObamaCare, such government control will quickly spread to the vast majority of the American population, not just the elderly.

I must admit to being surprised to see such open discussions of medical rationing so quickly.  Earlier in 2012, the New England Journal of Medicine still exhorted health policy analysts to avoid the "R-word" because it was such a political hot potato, and instead recommended using euphemisms such as "frugality". 

But if ObamaCare supporters are feeling confident enough to openly discuss rationing now, it means they'll be ready to put their plans into action if Obama wins a second term.

This coming November, American voters will have one final opportunity to decide whether or not to go down this road of "inevitable" government medical rationing.

At least the rationing advocates have given us fair warning of their intentions.  How we respond to that warning is up to us.

Thursday, September 27, 2012

Obama and Romney Health Policy Statements in NEJM

The New England Journal of Medicine has asked the Democratic and Republican presidential nominees, Barack Obama and Mitt Romney, to describe their health care platforms and their visions for the future of American health care.

Here are the links to their respective statements:
Obama: "Securing the Future of American Health Care"
Romney: "Replacing Obamacare with Real Health Care Reform"

Wednesday, September 26, 2012

Two From the NYT

The New York Times recently published two stories not directly related to ObamaCare, but which do highlight implications for patients if ObamaCare is fully implemented.

A 9/23/2012 story, "Study Divides Breast Cancer Into Four Distinct Types", describes some impressive scientific discoveries that will shake up doctors' understanding of the disease.
In findings that are fundamentally reshaping the scientific understanding of breast cancer, researchers have identified four genetically distinct types of the cancer. And within those types, they found hallmark genetic changes that are driving many cancers... 

Even within the four major types of breast cancer, individual tumors appear to be driven by their own sets of genetic changes. A wide variety of drugs will most likely need to be developed to tailor medicines to individual tumors. 
In other words, advances in genetic analysis could lead to tailored medical treatments.  This is exactly the opposite of the "one size fits all" medical treatment protocols favored by ObamaCare.  It would be a shame to see this promising line of research slowed down (or thwarted) by political considerations.

A 9/19/2012 story on kidney transplants, "In Discarding of Kidneys, System Reveals Its Flaws", describes problems with the current transplant allocation system leading to wasted organs.

One eye-opening excerpt:
Another factor, doctors and organ procurement officials say, is federal scrutiny of transplant success rates. 

In 2007, following revelations of lax government oversight of poorly performing transplant centers, the federal agency that manages Medicare, required that survival data for transplanted organs and recipients be made public. The figures are adjusted for relative risk factors and compared with expected survival rates. 

The penalty for underperformance can be severe. If the number of failures exceeds expected levels by 50 percent, transplant programs are flagged, explained Thomas E. Hamilton, director of survey and certification for the federal Centers for Medicare and Medicaid Services. If it happens twice in 30 months, the program’s administrators are given a brief probationary period to improve, or convince regulators that there were other factors. Otherwise, the program is decertified.

Because Medicare is the primary insurer for kidney transplants, such a ruling can effectively close a transplant program. Commercial insurers also use the survival ratings to make decisions on contracts.
Over five years, through June, 79 organ transplant programs had drawn oversight for repeatedly falling short and seven had been decertified, Mr. Hamilton said.

In interviews, dozens of transplant specialists said the threat of government penalties had made doctors far more selective about the organs and patients they accepted, leading to more discards.
“When you’re looking at organs on the margins, if you’ve had a couple of bad outcomes recently you say, ‘Well, why should I do this?’ ” said Dr. Lloyd E. Ratner, direct of renal and pancreatic transplantation at NewYork-Presbyterian/Columbia hospital. “You can always find a reason to turn organs down. It’s this whole cascade that winds up with people being denied care or with reduced access to care.”

Dr. Michael A. Rees, a transplant surgeon at the University of Toledo Medical Center, said his kidney program was cited by Medicare in 2008 after several unlikely failures. To save the program from decertification, he said he cut back to about 60 transplants a year from 100, becoming far choosier about the organs and recipients he accepted.

The one-year transplant survival rate rose to 96 percent from 88 percent, but Dr. Rees still bristles at the trade-off. “Which serves America better?” he asked. “A program doing 100 kidneys and 88 percent of them are working, or a program that does 60 kidneys and 59 of them are working? It’s rationing health care under the guise of quality, and it’s a tragedy that we are throwing away perfectly good organs.”
Remember that phrase: "rationing health care under the guise of quality". 

Under ObamaCare government "quality measures" will be imposed throughout all branches of medicine, not just transplant surgery.  These metrics will create powerful incentives for doctors to limit care in order to protect their practice statistics.  Doctors will be increasingly hesitant to perform the riskier heart surgeries or cancer surgeries on the sicker patients.  Instead of an incentive to practice medicine, doctors will be soon working under perverse incentives to not practice medicine.

And it will be the sickest patients who will suffer the most.

Tuesday, September 25, 2012

Quick Links: War, Outlawed Plans, Replacement Docs

Dr. Art Fougner: "The Coming War on Doctors".

Brian Schwartz: "Obamacare outlaws half of all individual plans sold".

Tweet of the day from Dr. Milton Wolf: "If you like the replacement refs in the #NFL, you'll love the replacement doctors in #ObamaCare." (Adapted from a line by Dr. Matthew Bowdish.)

Catron on Obama's AARP Speech

David Catron described how, "Obama's AARP Speech Broke My BS Detector".

In his 9/24/2012 American Spectator piece, Catron does some fact-checking on Obama claims, including:
"We've added years to the life of the program by getting rid of taxpayer subsidies to insurance companies that weren't making people healthier"

"[O]ver the next 10 years, we expect the average Medicare beneficiary to save nearly $5,000 as a result of this law"

"We lengthened the life of the trust fund by eight years"

"Their plan replaces guaranteed Medicare benefits with a voucher that wouldn't keep up with costs"
Read the full text of "Obama's AARP Speech Broke My BS Detector" for Catron's rebuttals.

(For the record, I believe Medicare should be eventually phased out and fully privatized, not "saved" as Romney/Ryan advocate.)

Monday, September 24, 2012

Gottleib on the Degradation of Medical Practice

Scott Gottleib of AEI discusses how, "Medicare reforms are degrading the practice of medicine".

In particular, he discusses three ways in which government control will hamper physicians' incentives to provide good clinical care:
1) Accountable care organizations and bundled payments
2) Pushing doctors to become salaried employees of large healthcare systems
3) An explicit cap on Medicare spending
The common thread in all these is that central planners in Washington can best manage how doctors "in the trenches" can and should treat patients.

Read the full text of "Medicare reforms are degrading the practice of medicine" for more details.

Saturday, September 22, 2012

Denver Debate: Gorman Vs. Emanuel

Independence Institute health economist Linda Gorman and key ObamaCare architect Dr. Zeke Emanuel recently participated in a debate over health care policy here in Colorado.

The Denver Post reports the highlights in its 9/21/2012 article, "Health care battle has plenty of fight left, Denver panel shows".

A few points by Gorman, as reported by the Denver Post:
The Affordable Care Act strips exactly the kind of freedom consumers need to make better care choices and reduce costs.

[T]he subsidies and patient-managing plans of "Obamacare" wipe consumer choice out of the picture. By contrast... procedures where buyers know the price and have real choice, like Lasik eye surgery and urgent-care centers, have seen costs come down through true competition.

Americans have tried that managed-care system in earlier decades, and many wound up hating the "capitated" model where they were denied care they wanted so they could save money... Such a system also pushes insurers to cherry-pick healthier patients to avoid high costs...
A few claims by Emanuel:
Our health care system is the fifth largest economy in the world and still tens of millions of Americans go without care...

Doctors and hospitals will join to manage each patient's care more efficiently, and win rewards from insurance funds if they save money and improve quality...
[T]he Romney-Ryan budget proposals would cut Medicaid funding up to 75 percent, a disaster for states and poorer patients.
More details at: "Health care battle has plenty of fight left, Denver panel shows".

Quick Links: New HMO, Standardized Medicine

Loren Heal of FreedomWorks: "Meet the New HMO -- Same as the Old HMO".

Dr. Don Dizon, an oncologist, on one-size-fits-all medicine: "Despite the best evidence, oncologists cannot dictate treatment".  Basically, they do not take into account patients' individual life preferences.

John Goodman: "Can Personalized Healthcare Survive Obamacare's Medicine Assembly Line?".

His critical observation:
Everything about ObamaCare — from its emphasis on pilot programs and demonstration projects to its faith in “evidence-based care” — is all about standardization. It’s about treating all patients with the same condition the same way. It’s about herd medicine. It’s about cookbook medicine. It’s about assembly line medicine. It’s as different from personalized care as different can be.

Friday, September 21, 2012

Obamacare Programs Exempted From Sequestration

The Washington Examiner notes, "Two Obamacare programs exempted from sequestration".

From the article:
Two programs in President Obama’s health care law were exempted by the White House from any potential cuts under sequestration. Sequestration will affect neither the Preexisting Conditions Insurance Plan nor the Consumer Operated and Oriented Plan (COOP), the White House report on sequestration noted today.

"Those programs were determined to be exempt," a senior administration official told reporters — citing a review of the relevant laws -- when asked why they were exempted even though they are not part of Medicare or Medicaid.'
For background on what will be cut, see "White House details substantial 'sequester' cuts for defense, Medicare".

(Via @sonodoc99.)

Thursday, September 20, 2012

ObamaCare Disarray

Scott Gottleib discusses how, "The emerging Obamacare truth is disarray".

In particular, he notes difficulties in implementing the various new bureaucracies and programs including:
* The temporary "high risk" pools 
* The CLASS Act
* Accountable Care Organizations
* Insurance regulations
For more details, read the full text of "The emerging Obamacare truth is disarray".

Quick Links: Denver, Challenge, Compliance

Denver Post covers new "direct-pay" primary care options in Colorado. (Via Brian Schwartz.)

New legal challenge to ObamaCare based on tax origination clause.  (Although this challenge can't hurt, IMHO ObamaCare can only be defeated at the ballot box at this point.)

Compliance costs with ObamaCare "Estimated at 80 Million Man-hours".

Wednesday, September 19, 2012

EMR Fail

An OpEd in the 9/17/2012 Wall Street Journal notes, "A Major Glitch for Digitized Health-Care Records".

In particular:
In two years, hundreds of thousands of American physicians and thousands of hospitals that fail to buy and install costly health-care information technologies—such as digital records for prescriptions and patient histories—will face penalties through reduced Medicare and Medicaid payments. At the same time, the government expects to pay out tens of billions of dollars in subsidies and incentives to providers who install these technology programs.

The mandate, part of the 2009 stimulus legislation, was a major goal of health-care information technology lobbyists and their allies in Congress and the White House. The lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually. Many doctors and health-care administrators are wary of such claims—a wariness based on their own experience. An extensive new study indicates that the caution is justified: The savings turn out to be chimerical.
Bottom line: "The savings claimed by government agencies and vendors of health IT are little more than hype."

(Via Dr. Richard Amerling.)

Tuesday, September 18, 2012

FreedomWorks: Health Reform in One Lesson

Freedom Works has posted a nice essay, "Health Reform in One Lesson".

Author Dean Clancy makes a very simple point:
Cut through all the bureaucratic jargon and mind-numbing acronyms, and there are only two basic ideas in health policy: HMOs and HSAs. That's it.

If you understand the essential difference between an HMO (health maintenance organization) and an HSA (health savings account), you will have acquired the only tool you really need to navigate the entire, complicated health policy debate and see through all the blah-blah of the so-called experts. It's a lesson so simple that housewives, janitors, and even many college professors can understand it...
Clancy then goes onto explain how all purported health care "reforms" really fall into one of those two categories.  The precise names may vary, but the basic principles are the same.

At root, either someone else (the government or some other third-party payor) decides how your health care dollar can be spent -- or you do.

The first option leads to increasing centralized control, whereas the second option leaves the control of your health care in your hands.

Clancy also has a nice discussion on how to move American health care in the direction of a fully free market.  For more details, read the full text of "Health Reform in One Lesson". 

(Link via Dr. Art Fougner. )

Related: "Just Who Should Control Your Healthcare Spending?", Forbes, 5/15/2012.

Monday, September 17, 2012

Dr. Keith Smith on Free Market Health Care

Dr. Keith Smith of the Surgery Center of Oklahoma was recently interviewed on "How the Market Can Cure the Health Care Crisis".

Three take-home points caught my attention:
1) By using price transparency and a "direct pay" business model, they can charge less than most hopsitals.

2) They don't take federal government money (e.g., Medicare), so their administrative costs are significantly lower.

3) The doctors working there have a powerful self-interested reason to maintain high-quality of care and not cut corners -- namely because their reputation and their economic viability are on the line.
(I wasn't as familiar with some of Dr. Smith's discussion about how hospitals and insurers "game the system" by overcharging patients with bills they don't ever expect to collect for tax purposes. His points seemed plausible, but I'd have to do more research to confirm them for myself.)

Many patients seeking high-quality affordable elective surgery are engaging in "medical tourism" overseas in countries like Costa Rica and India.  Dr. Smith's center could offer many of the advantages without the hassles of overseas travel -- basically a form of domestic "medical tourism".  In fact, Dr. Smith notes that Canadians already come to his center to avoid the long waits for surgeries under their "single payer" system.

Click here to learn more about Dr. Smith and the Surgery Center of Oklahoma.

(Video link via Dr. Megan Edison and Brian T.)

Sunday, September 16, 2012

Propagandizing ObamaCare

The 9/15/2012 New York Times reports on how government officials want Hollywood to promote ObamaCare in the plots of TV shows like "Grey's Anatomy" and "Modern Family".

Meanwhile Secretary of Health and Human Services Kathleen Sebelius has been cited for "illegally making political comments at an official event, which is a violation of the federal Hatch Act".

(The White House has announced  Secretary Sebelius will not be punished -- instead she will have to undergo "training".)

Saturday, September 15, 2012

Minton OpEd on NYC Drink Restrictions

Michelle Minton of CEI has a new OpEd in Fox News on the latest NYC law: "Sugary drinks ban begs the question -- who has the right to decide what you consume?"

An excerpt:
While it may be silly to worry about whether we can still get our super-sized sodas, it raises the very important question of who has the right to make choices about what an individual person consumes? And when governments adopt “nudging” policies that are meant to drive us to the choices lawmakers want us to make, when does that become control?

While any product if consumed in great enough quantities can cause negative health effects, the greater danger we face as Americans is in giving up the right to make our own choices...
 (Read the full text of "Sugary drinks ban begs the question -- who has the right to decide what you consume?")

Friday, September 14, 2012

Fogoros Book Published

Dr. Rich Fogoros (who runs the Covert Rationing blog) has finally published his e-book, Open Wide and Say Moo! The Good Citizen’s Guide to Right Thoughts and Right Actions Under Obamacare.

You can purchase a Kindle-format copy here at Amazon.

Overall, it was a very thought-provoking book with lots of good insights about the coming collectivization of American health care and what we can do to stop it.  I don't necessarily agree with every one of his points, but it was a good read and I learned a lot from him.

Wednesday, September 12, 2012

Government In Action

Washington Examiner: "Feds need 18 pages to define 'full-time' for Obamacare", (9/10/2011).

From the article:
In the latest indication of how complicated putting the Affordable Care Act into action will be, the Department of Health and Human Services and Internal Revenue Service issued 18-pages of regulations just to describe what a "full-time employee" is. Of note, to the Feds a full-time employee works an average of just 30 hours a week, not the normally accepted 40 hours.

The IRS rule is key because companies with more than 50 full-time employees must provide health insurance under Obamacare, or be fined. Business groups have been warning that small companies might try to replace full-time workers with part-time help to avoid being forced to offer health insurance in 2014, but the 30-hour full-time definition is likely to undermine those plans.

The lengthy 18-page definition caught some in the business world by surprise. "It's scary," said Randy Johnson, the U.S. Chamber of Commerce senior vice president for labor, immigration, and employee benefits. "It's just a small example of two words under our healthcare law of 2,700-pages," he said, adding: "It says to me things are awfully complicated."
(Read the full text of "Feds need 18 pages to define 'full-time' for Obamacare".) 

This is just the beginning of the bureaucratic expansions under ObamaCare.

Tuesday, September 11, 2012

Domenech on "Bigger Is Better"

Ben Domenech has a nice OpEd in the 9/6/2012 Daily Caller, "The Obamacare Fallacy: Bigger is better".

ObamaCare law explicitly drives increasing consolidation of doctors, hospitals, and providers.  Proponents argue this allows of increased efficiencies of scale. 

But the real agenda is that it allows greater government control.  It's much easier for the government to regulate 100 large "Accountable Care Organizations" than 100,000 individual hospitals and private practices.

Such consolidation is merely a continuation of a much older strategy. Jonah Goldberg’s book Liberal Fascism described how the Roosevelt administration sought similar consolidations of American agriculture and business during the New Deal. As Goldberg noted:
[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?
Bigger may be "better" for the government, but not for patients or doctors.

Monday, September 10, 2012

Pre-Existing Conditions and Free Markets

The Atlantic describes, "Why Pre-Existing Conditions Are a Tough Issue for the GOP".

Their analysis is correct in noting that Republicans feel obliged to "me too" the Democrats in advocating that the government compel insurance companies to cover customers regardless of any pre-existing conditions.

However, they are wrong in presuming that free markets can't address this issue. In fact, there are excellent free-market proposals that would tackle this issue, such as "health status insurance" proposed by University of Chicago professor John Cochrane.

We can't fix problems caused by earlier government controls with yet more controls.  Instead, we must repeal the earlier bad laws and allow the free market to operate properly.

For more detailed discussion on free markets and pre-existing conditions, see my article from the Fall 2009 issue of The Objective Standard, "How the Freedom to Contract Protects Insurability".

Quick Links: Catron, Orient, Romney Folding

David Catron: "The Charlatans of Charlotte", American Spectator, 9/7/2012.

Catron discusses the latest political demagoguing on Medicare. (I look forward to when politicians are seriously discussing how best to phase out Medicare.)

Dr. Jane Orient: "Health care coverage that kills" (Washington Times, 9/3/2012).

She notes: "[D]on't expect your life will have a higher priority than Obamacare's bottom line."

Will Romney fold on ObamaCare?  Tyler Cowen believes he will: "I’ve been predicting a Romney administration would block grant Medicaid, undo some or all of the Medicare savings in ACA, but essentially keep the mandate under a different label and then claim to have 'repealed and replaced.'"

If Romney continues to signal this, he could lose many votes from potential supporters.  And if Romney is elected, free-market advocates should recognize that this would only be the beginning (not the end) of the fight for genuine health are reform.

Saturday, September 8, 2012

Hsieh PJM OpEd: ObamaCare 2.0 and Global Spending Caps

PJ Media has just published my latest OpEd: "In Top Journal, Obamacare Boosters Push 'Global Spending Target'".

I discuss the latest push for a "global spending cap" on health care -- but public and private.

Here is the opening:
Free-market economists have long known that “controls breed controls.” In health care, leading Obamacare supporters are now proposing unprecedented new government controls over all medical spending — private as well as public — to “solve” problems caused by prior controls. Welcome to ObamaCare 2.0.

In a recent article in the New England Journal of Medicine (NEJM), several prominent Obamacare supporters have called for a binding “global spending target for both public and private payers.” In regular English, this means a government-enforced cap on how much Americans may spend in aggregate on their health care, both public and private.
The co-authors of this article include former Obama administration officials Dr. Ezekiel Emanuel (former White House health care advisor and brother of Rahm Emanuel, former White House chief of staff), Dr. Donald Berwick (former head of Medicare), and Peter Orszag (former budget director)...
 In particular, I cover 5 implications of this new approach.
1) This means rationing.
2) Get ready for the lobbyist feeding frenzy.
3) The government will exert increasing control over how doctors can practice.
4) Controls breed controls.
5) We need free-market reforms more than ever.
These "global spending caps" have already been enacted into law in Massachusetts. Under a second Obama administration, the rest of the US would likely follow.

(Read the full text of: "In Top Journal, Obamacare Boosters Push 'Global Spending Target'".)

Update: Thank you, Instapundit, for the link!

Friday, September 7, 2012

Phasing Out Medicare

Anders Ingemarson discusses, "Yes, We Can Get Rid of Medicare".

I'm glad to see more people discussing how to privatize Medicare, rather than how to "save" it. Once the end goal is agreed-upon, there's plenty of room to debate the exact methods and timing. I hope more policy groups and think tanks start working on this issue before it's too late.

Thursday, September 6, 2012

Fuchs: No Free Lunch

At, Dr. Albert Fuchs asks, "How will doctors handle the flood of newly insured patients?"

He opens with this analogy:
I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy. Tragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about forty years.

But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won’t work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears...
 After a detailed discussion of how this applies to health care, he then notes:
Sooner or later we will be forced to rediscover the credo that there’s no such thing as a free lunch. Shifting costs from one person to another doesn’t lower costs. A central plan to make something affordable always makes it unaffordable.
ObamaCare is unsustainable, because it attempts to guarantee too many free lunches to too many people. Such a system is impractical, because it's based on a flawed moral premise that giving away "free" lunches is the moral "right thing to do".

The only question is how long before people realize the truth.  Fortunately, more folks like Dr. Fuchs are sounding the alarms while there's still time to fix the problem.

(Read the full text of "How will doctors handle the flood of newly insured patients?")

Wednesday, September 5, 2012

Two From D4PC

Docs4PatientCare has just published two more OpEds:

"Obamacare -- The Real War on Women" (Dr. Hal Scherz and Dr. Tod Rubin, TownHall, 9/4/2012)

"Obamacare isn't the fix America needs" (Dr. Matt McCord, Detroit News, 9/4/2012)

In addition to critiques of ObamaCare, D4PC offers some good positive proposals that would move our health care in the right direction. 

For details, see their "The Physician's Prescription for Health Care Reform".

Tuesday, September 4, 2012

Hsieh Forbes OpEd: Will Obamacare Play Games With Your Actual Life?

Forbes has just published my latest piece, "Will Obamacare Play Games With Your Actual Life?"

My theme is that new ObamaCare rules on readmitting sick patients could tempt hospitals to "game the system" to your detriment.

Here is the opening:

Have you ever boarded an airplane, pushed off from the gate, then sat motionless on the runway for 45 minutes? This can happen for many reasons. But the federal Department of Transportation counts a flight as “departed” once it leaves the gate, not when it leaves the ground. Hence, airports have an incentive to “game the system” and artificially inflate their on-time departure statistics by sending planes from their gates even if they don’t go anywhere.

Under new ObamaCare rules, hospitals will have a similar incentive to “game” the system to improve their Medicare statistics, even at patient expense...

Read the full text of "Will Obamacare Play Games With Your Actual Life?"

Enforcing Standardized Health Care Via the Tort System

In a recent article in the New England Journal of Medicine (NEJM), several prominent ObamaCare supporters have called for a variety of new government controls over US health care as a follow-up to the current ObamaCare law. 

The co-authors of this article include former Obama administration officials Dr. Ezekiel Emanuel (former White House health care advisor and brother to Rahm Emanuel, former White House Chief of Staff), Dr. Donald Berwick (former head of Medicare), and Peter Orszag (former budget director).

One of their proposals caught my eye, because it's a clever way to use the tort system to ensure physician compliance with government practice guidelines:
A more promising strategy would provide a so-called safe harbor, in which physicians would be presumed to have no liability if they used qualified health-information-technology systems and adhered to evidence-based clinical practice guidelines that did not reflect defensive medicine. Physicians could use clinical-decision support systems that incorporate these guidelines. 
In other words, if doctors follow government practice guidelines (and use government-approved electronic medical record systems), they will be protected from malpractice lawsuits. But if doctors stray from those guidelines and anything goes wrong, they must take their chances in court. This will create tremendous pressure on physicians to practice government-approved “cookbook medicine.”

Given that physicians have been clamoring for many years for "tort reform" and other measures to alleviate the medical malpractice problems, I'm sure many will be very tempted by this "solution", even if they give up enormous clinical autonomy in the process.

And if you're a patient who is a clinical outlier (such that the standard treatment protocol doesn't work for your particular condition), you may have a harder time finding a doctor willing to diverge from those guidelines.

Standardization of treatments may sound good in theory.  But the problem is that patients don't come in standardized packages.

(Read the full text of the NEJM piece, "A Systemic Approach to Containing Health Care Spending".)

Monday, September 3, 2012

ObamaCare In One Sentence

Dr. Barbara Bellar, a family practice physician in Illinois, summarizes ObamaCare in one sentence:

Here's a transcript of her quote:
We're going to be gifted with a health care plan we are forced to purchase, and fined if we don't, which purportedly covers at least 10 million new people without adding a single new doctor, but provides for 16,000 new IRS agents, written by a committee whose chairman says he doesn't understand it, passed by a Congress that didn't read it but exempted themselves from it, and signed by a President who smokes, with funding administered by a Treasury chief who didn't pay his taxes, for which we will be taxed for 4 years before any benefits take effect by a government which has already bankrupted Social Security and Medicare, all to be overseen by a Surgeon General who is obese, and financed by a country that's broke.

So what the blank could possibly go wrong?
(Via Cynthia R.)

Fougner and Geraci-Ciardullo: Patient Care Is Not Meal Preparation

Dr. Art Fougner and Dr. Kira Geraci-Ciardullo have written a nice essay on the perils of "big medicine" entitled, "Patient care is not meal preparation".

In particular, they respond to the recent New Yorker piece by Dr. Atul Gawande urging that American medicine be run more like the Cheesecake Factory restaurant chain.

A couple of excerpts from the Fougner/Geraci-Ciardullo piece:
The Cheesecake Factory succeeds because of standardization and efficiencies, with complete control over purchasing and production. What recipes work become menu items throughout the chain. What recipes don’t work are soon discarded, much as a rancher periodically culls the herd.

The Cheesecake Factory model of care seems to work best for elective surgery. It is no coincidence that Dr. Gawande uses his mother’s knee replacement surgery as his example. Her orthopedic surgeon’s efforts over the years have produced standardization, efficiency and excellent outcomes...

There’s a problem, however. The same standardization so successful in elective surgery breaks down for most medical care situations. Even Dr. Gawande admits that “a person is not a steak.” Patients are not food items, they are not widgets in an assembly line.
Therein lies the fatal flaw for Cheesecake Health System’s doctors: the intrinsic variability of presentation, variability of response to treatment, and variability of co-morbidities.
 (Read the full text of "Patient care is not meal preparation".)

Yes, there is legitimate room for improving standardization and efficiency in health care, when it makes medical sense.

But too often, these can be a smokescreen for centralized government control over how doctors can practice and what services they can (or cannot) provide to patients.

Note: If you like this piece, you might want to subscribe to Dr. Fougner's Twitter feed.