Tuesday, April 14, 2015

Doc Fix Critiques

Three recent negative critiques of the Medicare "Doc Fix":

"House 'Doc Fix' Bill Makes Things Worse, Medicare Analysis Finds" (Chris Jacobs, Wall Street Journal)

"Medicare Doc Fix Bill Is IPAB-Lite" (David Hogberg, Daily Caller)

"Medicare fix needs fixing" (Theodore Marmor, Philadelphia Inquirer)

In particular, the Hogberg piece notes the perverse incentives that will pressure doctors skimp on care to patients as part of cost containment.  But all three are worth reading.

Monday, April 13, 2015

Perry: Lessons From Cosmetic Surgery Markets

Economist Mark Perry has a written a nice review, "What economic lessons about health care can we learn from the market for cosmetic procedures?"

In general, these services are not covered by insurance but rather paid for by the consumers themselves.  Hence, consumers have a keen interest in finding the best value for their medical dollar.

As a result, prices have essentially stayed stable (or decreased significantly) after adjusting for inflation.  In some case, the prices have gone down in nominal dollars as well!

As Perry notes:
Most importantly, none of the ten cosmetic procedures in the table above have increased in price by anywhere close to the 88.5% increase in medical care services since 1998.  [Emphasis his.]
Perry summarizes:
The competitive market for cosmetic procedures operates differently than the traditional market for health care in important and significant ways. Cosmetic procedures, unlike most medical services, are not usually covered by insurance. Patients paying out-of-pocket for cosmetic procedures are cost-conscious, and have strong incentives to shop around and compare prices at the dozens of competing providers in any large city.

Because of that market competition, the prices of almost all cosmetic procedures have fallen in real terms since 1998, and some non-surgical procedures have even fallen in nominal dollars before adjusting for price changes. In all cases, cosmetic procedures have increased in price by less than the 88.5% increase in the price of medical care services between 1998 and 2014.
In other words, the problem we've seen of skyrocketing prices in the traditional medical market can't be blamed on "fee for service". Rather, the issue is the 3rd-party payor system, a point also made by others such as Dr. Richard Amerling in his recent Wall Street Journal piece.

Proper treatment of a problem requires a proper diagnosis, in public policy as well as in medicine.  Perry's work is an important pointer in the right direction.

Wednesday, April 8, 2015

More MOC Controversy

Kurt Eichenwald of Newsweek has a new article on the controversy surrounding the American Board of Internal Medicine (ABIM): "A Certified Medical Controversy".

Here's the opening:
My wife is an internist. My brother is a pediatrician at a major academic institution. So was my father. My best friend is a surgeon. I regularly see an internist for my medical care, and I like her very much. I also should mention that this article is an opinion column. 

And it is my opinion that the American Board of Internal Medicine (ABIM) has hidden managerial incompetence for years while its officers showered themselves with cash despite their financial ineptitude and the untold damage they have inflicted on the health care system...
I applaud Eichenwald for asking some hard questions about the ABIM.

See also his earlier related story: "The Ugly Civil War in American Medicine". 

(Via Matthew Bowdish.)

Tuesday, March 31, 2015

Amerling Vs. Ginsburg on Fee For Service

The Wall Street Journal recently published a nice pair of columns on both sides of the issue, "Should the U.S. Move Away From Fee-for-Service Medicine?"

The anti-fee-for-service side was taken by Paul Ginsburg.  The pro-FFS side was taken by Richarad Amerling.

I basically agree with Dr. Amerling and I want to quote a couple of excerpts from his piece:
The real cause is the institution and growth of direct third-party payments. Inflation in health care was trivial until the mid-1960s, when Medicare and Medicaid were thrust into existence. The other big driver is the morphing of health insurance into a prepayment model, where even routine, low-cost care is covered. When neither the consumer nor the provider “feels” the cost of the service offered, it promotes overuse of medical services and high levels of spending. Government data show that 48% of health dollars were “out of pocket” in 1960. By 2008, this was down to 12%...

In other professions that feature fee for service but where third-party payments play a much smaller role, such as in law, dentistry or veterinary medicine, there is little excessive price inflation. Similarly, in areas of medicine outside the third-party-payment system, such as cosmetic surgery, Lasik eye surgery, and direct pay practices, prices have actually declined over time.

It is impossible to eliminate self-interest, which is embedded in human nature. But if some doctors and hospitals over time get away with unnecessary tests or padding bills, it isn’t because of fee for service. It’s because the patients are shielded from the impact by third-party payments.

Fee for service directly aligns payments with care, which is what most patients want, especially when facing serious illness. It’s incentive-based and increases the likelihood of quality care in a timely manner...
But I highly recommend reading both sides of this debate, "Should the U.S. Move Away From Fee-for-Service Medicine?"

Here is the related video.

Monday, March 30, 2015

Hsieh Forbes Column: 18-Year-Olds Should Be Allowed to Smoke

My latest Forbes column discusses the latest debate over raising the legal age for smoking: "Smoking Is Bad, But 18-Year-Olds Should Be Allowed to Smoke".

In particular, any debate on this should include the following three questions:
1) Is it the government’s job to stop legal adults from making unhealthy life choices?

2) Is it right for the government to restrict the freedom of adults over 18, because others under 18 might be more tempted to smoke?

3) Whose body is it, anyways?
People don't always make the best choices for themselves.  But in a free society, they should be able to do so, provided they aren't violating the rights of others.

Wednesday, March 25, 2015

Bad Health Tech

The New York Times recently ran a surprisingly good article, "Why Health Care Tech Is Still So Bad".

From the article:
A friend of mine, a physician in his late 60s, recently described a visit to his primary care doctor. “I had seen him a few years ago and I liked him,” he told me. “But this time was different.” A computer had entered the exam room. “He asks me a question, and as soon as I begin to answer, his head is down in his laptop. Tap-tap-tap-tap-tap. He looks up at me to ask another question. As soon as I speak, again it’s tap-tap-tap-tap.”

“What did you do?” I asked.

“I found another doctor."
The NYT piece correctly describes how mandatory electronic medical records are putting a barrier between patients and physicians, impeding good medical care.

And even some of the intended "safety" features, such as electronic alerts for wrong prescriptions can cause cognitive overload.  If you're faced with thousands of beeps and alerts each month, your brain quickly starts ignoring them.  It's the electronic equivalent of "crying 'wolf'".

(A related article from the technology field noted how, "MRIs show our brains shutting down when we see security prompts".  I wouldn't be surprised if the same thing happened with physicians coping with never-ending electronic medical record alerts.)

I'm not opposed to technological improvement.  But I am opposed to government mandates ramming technology into hospitals and medical offices based on bureaucrats' preferences, not in response to the genuine needs of physicians.  I love my smartphone --  but I don't think the government should use financial carrots-and-sticks to force everyone to own one.  Nor should the government use financial carrots-and-sticks to force physicians to adopt unwanted (and potentially harmful) electronic medical record systems.

Related stories:
"Can You Trust What's In Your Electronic Medical Record?" (Forbes, 2/24/2014)
"The Eyes of Big Medicine: Electronic Medical Records" (PJ Media, 9/18/2013)

NYT link via Dr. Matthew Bowdish, who also commented:
It breaks my heart whenever a patient tells me that one of the reasons they love our practice is that we look at the patients rather than a computer screen. Little do they know that we already have electronic health records although are holding on full implementation. Not only has the current EHR paradigm almost destroyed our business, it also risks robbing us of our humanity in caring for patients. The promise of technology is huge and necessary. These govt-mandated, tools of Big Insurance are not.

Monday, March 23, 2015

Patients Secretly Recording Doctors

The 3/12/2015 edition of JAMA (Journal of the American Medical Association) discusses "Ethical Implications of Patients and Families Secretly Recording Conversations With Physicians".

I don't think patients should record their physicians without their consent. However, I do strongly favor such recordings when both sides agree, as discussed in my February 2015 Forbes column, "Why You Should Record Your Doctor Visits".

But I also recognize that many states allow such surreptitious recordings with only "one party" (patient) consent.  Hence, I also agree with the JAMA piece that physicians should probably start communicating as if their words were being permanently recorded by the patient.

Tuesday, March 17, 2015

3 Good Things About US Health Care

US health care isn't perfect by any means. But Dr. Suneel Dhand gives us some much-needed perspective in this piece, "You’re lucky to be a patient in America. Here are 3 reasons why."

The three key points include:

1) Getting to see your attending physician every day.

2) Patient empowerment to choose.

3) Putting energy into customer satisfaction and good service in hospitals.

Dr. Dhand discusses each in more detail. For more info, please read the full text of  "You’re lucky to be a patient in America. Here are 3 reasons why."