Hsieh Forbes OpEd: How ObamaCare Creates Ethical Conflicts For Physicians

Forbes has published my latest OpEd, "How ObamaCare Creates Ethical Conflicts For Physicians And How Patients Can Protect Themselves".

Here is the opening:

Do you trust your doctor? Most patients assume their doctor is working in their best medical interests whenever he or she orders a diagnostic test or recommends a particular treatment. Customers might wonder whether an unscrupulous auto mechanic is being truthful when he recommends a brake job or a new transmission. But most patients trust that their doctor isn’t recommending unnecessary surgeries merely to line his pockets.

The vast majority of doctors take their ethical responsibilities very seriously. Prior to ObamaCare, only a relatively few “bad apples” have chosen to compromise their professional ethics for financial gain. However, ObamaCare creates new ethical conflicts for doctors. We’ll examine some common physician conflicts of interest before and after ObamaCare, and discuss how patients can best protect themselves...

Prior to ObamaCare, physicians faced perverse incentives for overtreatment. Physicians might also be tempted to pad their income through inappropriate self-referral or business relationships such as "physician owned distributorships".

After ObamaCare, physicians will face perverse incentives for undertreatment, especially with "bundled payments" and government "appropriate use criteria".  The new "narrow networks" required by many ObamaCare exchange plans will exacerbate these issues:

To cut costs, many ObamaCare exchange plans also require “narrow networks” of providers, where patients may only receive treatment from a short list of approved hospitals and doctors. President Obama has repeatedly promised, “If you like your doctor, you can keep your doctor,” but many patients are learning the hard way that this isn’t true.

Such “narrow networks” also mean that many doctors will lose long-standing relationships with patients they’ve seen for years. Instead, doctors will be increasingly reliant on the government-run exchanges for new patients. This will create a powerful incentive for physicians to adhere to any treatment guidelines mandated by the government or by government-approved insurance plans.

I also discuss several ways patients can protect themselves from these old and new physician conflicts of interest.

For more details, see the full text of "How ObamaCare Creates Ethical Conflicts For Physicians And How Patients Can Protect Themselves".

Medical Malpractice and 3-Way Sex

As a change of pace from health policy, here's an excerpt from a recent Medscape article by Michael J. Sacopulos, JD, "5 Unexpected Ways You Could Get Sued":

Patient Not Warned to Avoid Physical Exertion; Dies During Threesome

A Lawrenceville, Georgia, jury awarded $3 million to the estate of William Martinez. Mr. Martinez was 31 years old in 2009, when he entered his cardiologist's office. There he complained of chest pain that radiated into his arm.

His cardiologist found that Mr. Martinez was at "high risk" of having coronary disease and ordered a nuclear test to be performed. The test was scheduled to take place 8 days after Mr. Martinez' initial appointment with his cardiologist. The cardiologist alleges that Mr. Martinez was instructed to avoid exertional activity until after the nuclear stress test was completed. The family of Mr. Martinez argues that no such instruction was given.

The day before his nuclear stress test, Mr. Martinez apparently engaged in some "exertional activity." In fact, Mr. Martinez engaged in a threesome with a woman who was not his wife as well as a male friend. During this encounter, Mr. Martinez died.

His family members then proceeded to bring a medical malpractice claim against his cardiologist and the cardiologist's practice. Presumably the family's thought was if William Martinez had been properly instructed to avoid high-risk activities, he certainly would have complied.

The family initially brought a claim for $5 million dollars, but this claim was reduced by a finding that Martinez was 40% liable for his own death. Note the mathematics: One would assume that engaging in a 3-way activity would make him one-third liable for his own damages, but apparently there were facts not known to me that increased his liability to 40%.

In August 2011, the New England Journal of Medicine reported that cardiologists are the physicians most frequently named in medical malpractice actions. In fact, cardiologists in the United States have a roughly 1 in 5 chance of being sued in any given year. Based on the Martinez case, you can see how these statistics can actually be true. The cardiologist's attorney indicates that an appeal will be taken. For now, we will all have to wait to see how the appellant court system of Georgia reacts to this case.

Lesson learned: Document every instruction. 

PJ Media: Federalizing Medical Conversations?

I have a short new blog post up at PJ Media, "Federalizing Medical Conversations?"

In it, I ask the question:

Will the federal government be taking a closer look at conversations between doctors and patients, in the name of protecting privacy? Here is an excerpt from a recent e-mail sent by a hospital administrator to physicians I know...

Click through to read the whole thing.

Canadian Surgeons and Patients End Runs Outside The System

The Calgary Herald reports, "Have scalpel, will travel: Alberta surgeons operate abroad to bypass wait times".

More Canadian doctors are practicing outside the country's borders (e.g., in the Caribbean) to provide patients with faster, better service.

In this case, a Canadian woman chose to have her knee surgery by a Canadian doctor in the Caribbean with only a 2-week wait (rather than a 7 month wait in the government socialized system).

This was after she got a private MRI scan (rather than waiting 8 months for a government-approved MRI scan.)

The article notes it's not merely the "super rich" exercising this option, but also many ordinary people who don't wish to wait.  In the case, the patient was totally reliant on her husband to get around, requiring pain medications that made her woozy.  For her, spending money to receive faster medical care made perfect sense.

This two-tiered system may be the future of American health care in a few years.

Dr. Milton Wolf Announces ‘PatientCare’

Dr. Milton Wolf (candidate for US Senate from Kansas) has published his 17-page alternative to ObamaCare.

I agree with many of his great ideas, and his plan would be a good start in moving us in the right direction.  Here's the direct link to the PDF.

Dr. Sotos' Model

The Pittsburgh Tribune has a nice profile of Dr. Peter Sotos in their article, "Walk-ins, cash discount set East Franklin surgeon apart".

Patients willing to pay cash receive good, timely, and affordable care. This is just one example of how health care can work when patients and physicians contract directly, without intermediaries such as the government or insurance companies.

(Via Dr. Amesh Adalja.)

Catron on Medicare and "Single Payer"

At the American Spectator, David Catron reminds us that we already have a "single payer" system for a large portion of the US population in the form of Medicare.  And BTW, it's also one of the most dysfunctional parts of our current health system.

In particular, he notes that:

* The Medicare system is economically unsustainable
* More physicians are declining to accept Medicare patients
* The government tracks intimate personal and health information on Medicare patients
* "Medicare patients have worse outcomes than patients with private health care insurance"

For more details on why we shouldn't move towards a "Medicare-for-all" system, read the full text of his piece, "Single Payer: We’ve Been There, Done That".

NYC Debate: Is ObamaCare Beyond Rescue?

On Wednesday 1/15/2014, Intelligence Squared will host a debate on the topic, "Obamacare Is Now Beyond Rescue":

With the disastrous launch of the HealthCare.gov website, critics of the Affordable Care Act, or “Obamacare,” were given more fuel for the fire. Is this political hot potato's inevitability once again at stake? And is the medical community really on board with the law, or resisting (rewriting?) it from the sidelines?

Panelists taking the "For" side include:

• 

  For

  Dr. Scott Gottlieb

  Practicing Physician & Former Deputy Commissioner, FDA
  
• 

  For

  Megan McArdle

  Writer and Columnist, Bloomberg View    

On the "Against" side:

• 

  Against

  Jonathan Chait

  Political Commentator and Columnist, New York Magazine
  
• 

  Against

  Dr. Douglas Kamerow

  Family Physician & Former Assistant Surgeon General
  
  

The debate will be moderated by 

• 
  

  MODERATOR

  John Donvan

  Author & Correspondent for ABC News

The website includes a "LiveStreaming" tab for folks to watch online.

H/T: Dr. Evan Madianos for the information!

He also adds:

We are organizing a Tweet chat on Twitter at UPenn in the hopes of making it more interactive and engaging. We are promoting it on twitter to the general public and to radiology groups, other doctors groups and health policy groups...

The hashtag will be : #IQChat.

Quick Links: Scribes, UK NHS

The New York Times describes how electronic medical records so diminish physician productivity that they have to hire scribes to do their data entry when seeing patients.

From the article:

“Making physicians into secretaries is not a winning proposition,” said Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans, in Dubuque, Iowa, who also researches physician dissatisfaction.

Dr. Sinsky, who was an author of the article in Health Affairs, has visited more than 50 primary care practices over the past five years, in the course of studying ways to stem high rates of physician burnout. She has found that physicians who use scribes are more satisfied with their work and choice of careers.

The inconsistency isn’t lost on health care experts. In most industries, automation leads to increased efficiency, even employee layoffs. In health care, it seems, the computer has created the need for an extra human in the exam room...

Dr. Scott Atlas reminds Americans of the horrible care patients can expect in the UK socialized system (NHS or National Health Service), and how American health care is moving in that directions.

Rethinking Health Insurance

Schultz, Atlas, and Cogan have a nice piece in the LA Times, "It's time to rethink health insurance".

Their basic takehome point is that, "Rather than using insurance to subsidize the consumption of all medical care, Americans should use it only for catastrophic expenses."

They also include some good concrete suggestions that would move us in the right direction.

(Note: I think "public financing" of health care should be eventually phased out.  But in our current political climate, that won't happen immediately.  For now, a helpful intermediate goal would be to make any such public financing as clear as possible, as opposed to being hidden in various insurance subsidies, so that taxpayers footing the bill can properly discuss and debate the scope of such financing.)

More Single Payer Drumbeat

Noam Scheiber at the New Republic makes a pretty cogent case, "How Obamacare Actually Paves the Way Toward Single Payer".

IMHO, the current awkward government-private hybrid insurance system is very unstable.

There are many folks still calling for repeal of ObamaCare and implementing (at least partial) free-market reforms, such as the updated Docs4PatientCare proposal.

Others are sounding a drumbeat for a full government-run "single payer" system. (Here's a typical piece from NYT columnist Paul Krugman.)

The "single payer" advocates correctly recognized that this was politically unrealistic in the initial debates of 2009-2010, but hope that the political climate is more favorable to them now.

Likewise, free-market advocates correctly see immense dissatisfaction with ObamaCare and hope the time is right for their ideas to gain more traction.

I don't know which way the balance will tip, but I do think this will be the next big battleground of ideas.

In the meantime, ordinary Americans should ask themselves two important questions:

1) If the government's partial takeover of the health insurance industry has gone so badly, do we think a more complete takeover will do any better?

Also, Noam Scheiber makes the standard moral argument about private health insurance, essentially a variation of the "profits over people" line:

For-profit health insurance is on some level morally offensive—at least when it’s practiced the way we Americans practice capitalism. With a few tantalizing but mostly unrepresentative exceptions, the longstanding aim of health insurers has been to weed out sick people, and to weasel out of paying for treatment if they somehow get insurance, so that the companies could boost their share price [and] lavish income on their executives...

Would a government-run health system really be any different?  We've already seen that government-run insurance systems in Canada and the UK also aim to limit care (and costs) for budgetary reasons. The rationales used include "cost effectiveness", "quality", etc.  But the end-point is the same -- they'll decide what medical care is considered "appropriate".  And if you don't like it, too bad.

Americans should therefore ask:

2) Why is "for profit" considered inherently evil, whereas "government-run" considered angelic and good?

Whichever side answers these two questions best to the satisfaction of ordinary Americans will will the cultural (and eventually the political) debate.

Quick Links: Medicare, Medicaid, Candidates

Washington Post: "Medicare pricing drives high health-care costs".

Hmm, central planners don't seem to get the prices right.

Peter Suderman: "No, Obamacare Won't Reduce Emergency Room Usage".

Boston Globe: "Physician-candidates running against health care law".

(BTW, one such candidate Dr. Milton Wolf, who is running for the US Senate from Kansas.)