Absurd Arithmetic

At PJMedia, Charlie Martin explains "The Arithmetic Absurdity of Obamacare".

I really like how he distills the basic issues of risk stratification, mandates, and cross-subsidies in terms anyone can understand. Instead of me quoting the whole thing, you should just go and read it at their website.

Reminder: Math always wins.

Three From McArdle

Megan McArdle has written three good analyses of ObamaCare at Bloomberg lately.

"Is Obamacare in a Death Spiral?" (10/21/2013)

The exchanges were also broadly understood to be needed to get young, healthy people into the system. Somewhat naturally, almost every story you’ve seen about a new enrollee -- including those told by the president this morning -- has focused on someone who couldn’t buy insurance before, or who had very expensive insurance. But it’s not surprising that those people are fighting through the system to get coverage; they would pull themselves to the top of Mount Rushmore using only their teeth if that’s what it took to get a cheap insurance policy. What we need to know is what is happening among the people who didn’t need Obamacare to help them buy insurance, because insurers would be perfectly happy to sell them a policy without it. Those are the folks whose premiums will cover treatment for the rest.

"Obamacare Fiasco Isn't a Single-Payer Conspiracy" (10/24/2013)

In response to the current ObamaCare launch difficulties, she notes:

The interesting thing is that people on both ends of the political spectrum seem to believe that the answer is the same: single payer. What Walter Russell Mead dubbed the “pivot" to single payer has begun as various folks point out that if we only had a total government takeover, these issues wouldn’t put the whole system in danger. I’ve seen more than a few progressive commenters suggest that maybe an epic fail will finally open the way to the single-payer system we should have had in the first place.

In private, and occasionally in public, conservatives are expressing the same fear. There’s a pretty popular conspiracy theory running around to the effect that this was the Barack Obama administration’s intent all along: Design this big Rube Goldberg apparatus that couldn’t possibly work, and when it fails, sweep in and “fix” things by enacting the single-payer scheme you wanted all along.

Perhaps they did want single payer all along, in their secret heart of hearts, but it’s ludicrous to think that they were capable of designing and pulling off a conspiracy of that magnitude...

(I do think that many on the political Left will use this as a "justification" to promote the single-payer system, regardless of the intentions of the initial legislators who passed the law.)

"Stopping Overtreatment Sounds Easy, Until It's Your Heart Attack" (10/25/2013)

I recommend reading the whole thing.  McArdle notes:

Is this to say that there is no way to save money in health care without hurting patients? Of course not. But we should be wary of asserting that it will be easy to save money without hurting patients as long as we simply follow the best evidence. Studies are, of course, the foundation of science. But they also have limits. The questions they can answer are often much narrower than the questions we would like to answer -- and often other studies give different answers. There’s a decent amount of evidence that hospitals which do more intensive interventions get better outcomes.

One point -- it's very easy for central planners to opine from their armchair about "best practices" for doctors and patients.  Yet such plans often run into trouble with real-life patients.

Allen Describes ObamaCare 2016

Dr. Bradley Allen, a pediatric heart surgeon, has an excellent OpEd in the Wall Street Journal on ObamaCare 2016 (from 10/22/2013).

He discusses the more fundamental structural problems with ObamaCare after the initial launch problems and how it will accelerate current ominous trends.  

The combination of the worsening doctor shortage, doctors opting out of Medicare, doctors opting out of Medicaid, and the migration of doctors out of private practice (due to regulatory overhead) will create tremendous problems for patients seeking medical care.

A few excerpts:

The loss of private practice is another big problem. Because of regulations and other government disincentives to self employment, doctors began working for hospitals in the early 2000s, leaving less than half in private practice by 2013. The ACA rapidly accelerated this trend, so that now very few private practices remain.

When doctors are employed like factory workers by hospitals, data from the Medical Group Management Association and others indicate, their productivity falls—sometimes by more than 25%. They see fewer patients and perform fewer timely procedures, exacerbating the troubles caused by physician shortages. Continuity of care also declines, since now a physician's responsibilities end when his shift is over.

Of those doctors still in private practice, many have taken refuge from the health-care law by going into concierge medicine, where the patient pays an annual fee (typically $500-$3,000 a year per individual) to a primary-care physician. This doctor provides enhanced care, grants quicker appointments and spends more time with each patient, working with a base of 300-600 patients instead of the 3,000-5,000 typical in the ACA era. Doctors and patients who can afford it love concierge medicine: It allows treatment to be administered as the doctor sees fit, instead of as if the patient is on an assembly line with care directed on orders from Washington.

Patients who can't afford concierge medicine but have seen their doctor take that route are out of luck: They have been added to the swelling rolls of patients taken care of by the shrinking pool of physicians. So even people with "private" insurance have found that the quality of their health care declined. Nowadays, many are forced instead to see a nurse or other health-care provider. The traditional doctor-patient relationship is now reserved primarily for those who can pay extra.

As a result, fewer bright young students will go into medicine:

With an average of $300,000 in student loans, eight years of college and medical school, and three to seven years as underpaid, overworked residents, a prospective physician in the ACA era would be starting a career at age 30 in a job that requires working 70-80 hours a week in an assembly-line fashion to earn perhaps $100,000 a year. No wonder so many qualified individuals these days are choosing careers on Wall Street or in Silicon Valley instead of medicine.

Dr. Allen paints a chilling scenario.  It's up to us to make sure this doesn't happen.

(Read the full text of "ObamaCare 2016: Happy Yet?")

KHN: I Don’t Have Children, So Why Do I Have To Buy Pediatric Dental Insurance?

Kaiser Health News fielded the following reader question, "I Don't Have Children, So Why Do I Have To Buy Pediatric Dental Insurance?"

Here's the question in full:

Q. My husband is self-employed and currently has an individual plan. I recently received a letter that said that he must purchase pediatric dental insurance, and if he doesn't provide proof that he has it they will automatically enroll him in a plan. We don't have children, so why would we have to have pediatric dental insurance?

Their answer begins:

A. Under the health care law, starting in January new individual and small-group health plans must cover 10 so-called essential health benefits. The list of required benefits was developed following a process that solicited input from consumer groups and members of the public, employers, states, insurers, and medical and policy experts. The final list reflects a core package of benefits that it was determined everyone should have access to, even though most people may not use every single benefit. It includes hospitalization and prescription drugs, maternity and newborn care, mental health and substance abuse services, emergency care and doctor visits, as well as pediatric services, including vision and dental services for children.  

KHN also notes that "people are not required to buy separate pediatric dental coverage if they buy a plan on the state health insurance marketplaces, or exchanges, unless their state specifically requires it."

So perhaps (paradoxically), someone can avoid this requirement by purchasing within the government exchange.

However, the broader problem of mandatory "essential health benefits" still applies.  Why should single men have to purchase maternity benefits?  Why should a teetotaller purchase substance abuse treatment benefits they don't need and will never use?

(Note: The problem of mandatory insurance benefits preceded ObamaCare, mostly enforced at the state level.  But ObamaCare partially federalizes this problem and expands this.)

Hsieh Forbes OpEd: "Northwestern University Did Right In Offering A Peanut-Free Football Game"

Forbes has published my latest OpEd, "Northwestern University Did Right In Offering A Peanut-Free Football Game".

Here is the opening:

2013, Northwestern University hosted the first known peanut-free college football game against Big Ten rival Minnesota. For that day, the school forbade peanut products from being sold or brought into the stadium. Groundskeepers even power-washed the 47,000 seats before the game to eliminate any peanut residue.

To my surprise, this aroused enormous controversy from some conservatives.  I discuss why their reasons are misguided and why I approve of Northwestern's decision.

I'd like to thank Diana Hsieh, Jenn Casey, and Dr. Matthew Bowdish for reading an earlier version of this piece. I'd also like to thank Alex Knapp for providing the quote at the end.

And as a followup, on 10/21/2013 the Daily Northwestern reported, "Students praise Northwestern's first allergy-conscious football game".

Electronic Medical Mess

Observers across the political spectrum are raising questions about the ObamaCare electronic medical records mandate. (Note: This is the physician side of electronic records, separate from the website problems reported by patients trying to sign up for insurance on the "exchanges".)

Dr. Dan Morhaim, who is both a physician and a Democrat representing Baltimore County in the Maryland House of Delegate, wrote the following in the Washington Post, in "An electronic medical records mess":

These systems tend to be fantastically complex. One doesn’t have to be intimately familiar with, say, Hertz or Enterprise to rent a car online. But many electronic health record systems have pull-down screens listing each of the 68,000 possible diagnosis codes in the World Health Organization’s International Classification of Diseases and 87,000 possible procedure codes.

Or consider what happens when I write a prescription: Every potential drug interaction or side effect listed generates a warning prompt. Inevitably, recognizing that the warnings are generally inapplicable and take time to sort out, clinicians start to bypass the alerts. Sooner or later, ignoring one will lead to serious complications...

Perhaps the most pernicious side effect is the erosion of the provider-patient relationship. When I first began working with electronic health records, I caught myself staring at the computer screen instead of engaging patients, who rightly felt ignored. Like many colleagues, I’ve reverted to the practice of talking with the patient and taking notes with pen and paper. After the evaluation is over and the patient has left, I type in the data. This takes much more time, but it is the only way to complete a proper history and exam....

Ideally, electronic health records would provide doctors with instant access to information and help patients track their medical histories. Such records should be a giant step forward in continuity and comprehensiveness of care. So far, the “cures” are worse than the disease.

Conservative columnist Michelle Malkin wrote the following in "Don't Forget Obamacare's Electronic Medical Records Wreck":

In June, the Annals of Emergency Medicine published a study warning that the "rush to capitalize on the huge federal investment of $30 billion for the adoption of electronic medical records led to some unfortunate and unintended consequences" tied to "communication failure, poor data display, wrong order/wrong patient errors and alert fatigue." Also this summer, Massachusetts reported that 60 percent of doctors could not meet the EMR mandate and face potential loss of their licenses in 2015. And a few weeks ago, the American College of Physicians pleaded with the feds to delay the mandate's data collection, certification and reporting requirements.

Dr. Hayward K. Zwerling, an internal medicine physician in Massachusetts who is also president of ComChart Medical Software, blasted the Obamacare EMR mandate in a recent open letter: "As the developer of an EMR, I sincerely believe that a well-designed EMR is a useful tool for many practices. However, the federal and state government's misguided obsession to stipulate which features must be in the EMRs, and how the physician should use the EMRs in the exam room places the politicians in the middle of the exam room between the patient and the physician, and seriously disrupts the physician-patient relationship." Zwerling's call to arms appealed to fellow doctors to pressure the feds to repeal the mandate. "It is past time that physicians reclaim control of their offices, if not the practice of medicine."

As I've mentioned previously, my own primary care physician in Colorado Springs quit her regular practice and converted to "concierge care" because of the EMR imposition. Dr. Henry Smith, a Pennsylvania pulmonary doctor, also walked away. "Faced with the implementation costs and skyrocketing overhead in general," he told me, "I finally threw in the towel and closed my practice"...

Dr. Michael Laidlaw of Rocklin, Calif., told EHR Practice Consultants that he abandoned the Obamacare EMR "incentive" program "when I realized that I spent the first two to five minutes of each visit endlessly clicking a bunch of garbage to make all the green lights show up on the (meaningful use) meter. I said to myself: 'I'm not wasting precious seconds of my life and my patients' time to ensure some database gets filled with data. I didn't go into medicine for this. It is not benefiting my patients or me. I hate it.' I actually refused to take the $10K-plus this year. I have even accepted that I would rather be penalized in the future. What is worth the most to me is AUTONOMY."  

Electronic medical records can be a tremendous benefit, if adopted organically by physicians and hospitals based on their needs and requirements.  But ramming them down the throats of doctors is merely hampering good patient care.

(Note: I also discussed electronic medical records in part 3 of my 4-part PJ Media series on the changing face of health care in , "The Eyes of Big Medicine: Electronic Medical Records".)

Update: Even kids know this is a problem.  Here's a drawing made by a 7-year old girl published in the 6/20/2012 issue of the Journal of the American Medical Association.

The article explains:

No one was more surprised than the physician himself. The drawing was unmistakable. It showed the artist—a 7-year-old girl—on the examining table. Her older sister was seated nearby in a chair, as was her mother, cradling her baby sister. The doctor sat staring at the computer, his back to the patient—and everyone else. All were smiling. The picture was carefully drawn with beautiful colors and details, and you couldn't miss the message.

(Click on image to see full size.)

Quick Links: Amerling, Catron

Dr. Richard Amerling explains why people should opt out of ObamaCare.

David Catron notes that Obamacare's "insurance marketplace" works just as well as everyother Soviet-style system.

Just remember: "Under ObamaCare, insurance cancels you!"

"

McArdle: Four Things We Think We Know About Obamacare

Megan McArdle writes the following in her post, "Four Things We Think We Know About Obamacare":

I’ve been seeing a few things floating around the blogosphere about Obamacare that aren’t true. They’re not really conservative or liberal talking points; they’re just misconceptions that people may have about how the health-care law works. So it seems worth pointing them out, especially because relying on some of these “facts” could get you into big trouble...

She then discusses 4 points of conventional wisdom that might not be fully correct:

You have until March 31 to buy health insurance.

The penalty for being uninsured next year is $95.

If the exchanges don’t work, as a last resort, we can always get people signed up through call centers.

The state exchanges are doing fine.

McArdle discusses each in more detail.  Read more at: "Four Things We Think We Know About Obamacare".

Armstrong Times Two

Ari Armstrong has a couple of noteworthy recent blog posts at The Objective Standard site:

ObamaCare: "What the Hell Kind of Reform Is This?" (10/18/2013)

"Government Shut Down and All I Got Was this Blog Post" (10/16/2013)

Hitler Learns About the Obamacare Exchanges

"Hitler Learns About the Obamacare Exchanges".  (Via Art Fougner.)

Update: Link was bad, now fixed!

Projections Vs. Reality

AP News reports, "Obama Administration Projected Strong Health Plan Signups".

Here's the opening:

The Obama administration's internal projections called for strong enrollment in the states in the first year of new health insurance markets, according to unpublished estimates obtained by The Associated Press. Whether those expectations will bear out is unclear...

Also:

"Why there is this reluctance to share internal estimates, I don't know," said health economist Gail Wilensky, who ran Medicare for President George H.W. Bush. "This kind of information has a way of worming its way out into the open, which makes it look like they have something to hide."

While consumer interest in the new health insurance markets has been undeniably strong, it's hard to get a sense of how many people have been able to navigate balky federal and state websites and successfully enroll. Numbers released by states running their own marketplaces suggest upward of 100,000 people have enrolled so far, out of millions of potential interested customers.

The administration refuses to release numbers for the 36 states in which it is taking the lead. Officials at first said the frozen computer screens and other issues were the result of a high volume of interest. They later acknowledged software and design issues were also to blame.

HHS belatedly rolled out a feature that allows consumers to get a look at health plans in their area without first establishing an account. The requirement that people set up an account before shopping was at odds with the normal way e-commerce websites are run, and was blamed for overloading the system.

Appearing earlier this week on MSNBC, former White House spokesman Robert Gibbs said the situation is "excruciatingly embarrassing" for the administration.

Reality has a funny way of confounding the best-laid plans of politicians.

Quick Links: Catron, Crovitz

David Catron: "Obamacare and the Edsel: A Tale of Two Lemons" (American Spectator, 10/14/2013).  Excerpt:

As the Edsel flop demonstrates, businesses in the free market are quite capable of making colossal mistakes. However, when they do so and the customer rejects their products, they make the necessary adjustments...

Whereas the potential buyers of the Edsel simply grimaced when they finally saw the thing and walked out of the showroom, the President and his congressional accomplices have arranged for you to be fined if you refuse to buy their ugly, overpriced, and dysfunctional product.

Gordon Crovitz: "ObamaCare's Serious Complications" (WSJ, 10/14/2013).  Excerpt:

Have you ever seen a price list in your doctor's office or at a hospital? Probably not, except for services like laser eye surgery and elective plastic surgery, which aren't covered by insurance. In these rare cases, there is price transparency and open competition.

As hospitals have merged to cope with the costs of increasingly complex regulation, competition has further diminished. This is a reminder of the truism that monopolies can only be sustained when government policy supports them.

Milton Wolf Running For US Senate

Dr. Milton Wolf has announced he'll be a candidate for the US Senate, challenging incumbent Pat Roberts in the GOP primary.

Here's his recent interview with Glenn Reynolds (aka "Instapundit"):



He has captured the attention of conservatives at the national level, as seen by this article, "Is Milton Wolf the next Ted Cruz?"

His campaign has a website at MiltonWolf.com and a Facebook page.  Here's his "Meet Milton Wolf" campaign ad.


You can also see a list of his columns for the Washington Times, many of which I've also linked to on this site.

I very much like his views on free-market health care reform.  (There are some issues on which we undoubtedly diverge, but that's not my focus at present.)  Overall, I'm glad he's a candidate and I encourage others who want to learn more to check him out!

Quick Links: Armstrong, Adalja, Goodman, Hillman

Because of other obligations, my blog posting may be lighter than usual this week. But here are a few links that readers might find interesting and/or thought-provoking:

Ari Armstrong: "ObamaCare Supporter: 'I Didn't Realize I Would Pay for It Personally'".

Dr. Amesh Adalja: "Obamacare's Onerous Rules Include A Blacklist Of America's Doctors".

John Goodman: "Community Rating".  (Via Dr. Richard Amerling.)

Mark Hillman: "What ObamaCare Means For Rural Colorado".

Benjamin Rush Institute Calendar

The Benjamin Rush Institute has revamped their website and their calendar.

If you're in the area for any of their conference, lectures, or debates, you should check them out!

Here's a sampling of some of their upcoming 2013 events:

Oct. 12 8:30 - 9:30 am Lee Gross, MD to speak on Epiphany Health at the AMSA fall conference in Stratford, NJ at Rowan School of Osteopathic Medicine.

Oct. 22 6:00 pm Rowan School of Osteopathic Medicine, Stratford NJ  (flier attached)

Debate/Discussion: US Health Care: Do we need to Reform the Reform?

Debaters:

• Dr. Alieta Eck, MD, past president AAPS
• Dr. Beth Haynes, MD, Executive Director, BRI
• Dr. William Thar, MD, Physicians for a National Health Plan
• 4th debater from Doctors for America, TBA

 

Oct. 23 5:30pm Icahn School of Medicine at Mt. Sinai, (NYC) Flier attached.

Debate: Medical Malpractice and Quality: Where to go from here?

Debaters:

• Michael Cannon, CATO
• Shirley Svorny, prof of Economics, CA State University
• Dr. Jeff Segal, JD/MD
• Dr. Ellen Carson, MD/JD.

Crashing The Health Care System

CNN reports, "Doctor shortage, increased demand could crash health care system".

One noteworthy quote:

"I think of (Obamacare) as giving everyone an ATM card in a town where there are no ATM machines," [ER physician Ryan] Stanton said. "The coming storm of patients means when they can't get in to see a primary care physician, even more people will end up with me in the emergency room."

What happened in Massachusetts in 2006 when the state's mandated health insurance rules went into effect illustrates the impending national problem.

When the Massachusetts law kicked in, wait times to get an appointment at primary care physicians' offices increased significantly, and they've remained high ever since, according to an annual survey from the Massachusetts Medical Society. And Massachusetts has the second highest physician-to-population ratio of any state...

 Also, "half the nation's physicians are over age 50 -- meaning many are at or near retirement age".

As always, "coverage" does not equal actual medical care.

McArdle On Faulty Obamacare Conventional Wisdom

Megan McArdle discusses, "11 Pieces of Obamacare Conventional Wisdom That Shouldn’t Be So Conventional".

Some of the interesting items on her list include:

1. Once Obamacare goes into effect, it will be impossible to substantially cut it back.
2. Accountable Care Organizations are certain to bring down overall health spending.
4. Emergency room use will decline.
5. People can game the system by going without insurance and then buying it when they get sick.
11. Obamacare will make bankruptcy a thing of the past, at least for the people who gain coverage. 

Click through to read more discussion of each of those (and other) items.

Physician Summit 2013: Speaker Profiles

The upcoming Physician Summit 2013 conference has posted their speaker profiles.

I won't be able to attend, but they have a good lineup, including Dr. Lee Gross and Dr. Kathleen Brown.

Click through to learn more about their program and how to register.




Speaker Spotlight The Physicians Summit 2013 is ramped up and underway for November 1-2 in Dallas.

We are pleased to present our Speaker Spotlight series — overviews of some of the excellent speakers you will hear at the Summit. In this, our first Speaker Spotlight installment, we’re honored to introduce Dr. Lee Gross, M. D., Co-Founder of Epiphany Health, National Executive Board member of Docs4PatientCare, and tireless champion for freedom and innovation in medical care and delivery.

It is also our honor to spotlight Kathleen M. Brown, M.D., Dermatologist, and owner of Oregon Coast Dermatology as our second speaker for the summit.