Hsieh Forbes Column: Should Doctors Be Required To Tell The DMV If You Have Dementia?

My latest Forbes column is now out: "Should Doctors Be Required To Tell The DMV If You Have Dementia?"

This is another example in which a well-intended law may create perverse unintended consequences. As a friend noted, "Mandatory reporting laws of any kind are fraught with danger. One reason is that, from the patient's point of view, they can blur the lines between talking to your doctor/nurse and talking to a cop."

Hsieh Forbes Column: The Unsettled Science Of Covid-19

My latest Forbes column is now out: "The Unsettled Science Of Covid-19".

I discuss some recent controversies over Covid-19, including natural immunity, the efficacy of mask mandates, and the "lab leak" hypothesis -- and what that means for the concepts of "consensus" and "misinformation".

Hsieh Forbes Column: Perks And Incentives For Covid-19 Vaccination May Backfire

My latest Forbes column is now out: "Perks And Incentives For Covid-19 Vaccination May Backfire".

I discuss the proliferation of prizes and incentives being offered to get people vaccinated, and how this can sometimes create the opposite effect of making people more suspicious of the vaccine.

Assisted Suicide in California

News update: "Doctor-assisted dying will be legal in California from June 9th".

I recognize this is a controversial topic amongst many physicians. However, I support the basic idea in the interests of patient autonomy.

My own thoughts on this topic can be found in this January 2015 piece, "Does Your Right To Life Include The Right To Die?"

Coverage Vs Care in California

Today's "coverage does not equal care" story, this time from California:

"Getting A Medi-Cal Card Doesn’t Always Guarantee Health Care" (Kaiser Health News, 6/23/2015)

(Unfortunately, the article promotes the idea that the problem can be solved by more regulatory intervention.  I suspect that will only make things worse.)

Coverage But No Care in NJ, CA

Two recent news stories from New Jersey and California again highlight the fact that "coverage" does not equal medical care.

From the New Jersey Star-Ledger (2/5/2015): "Who will treat the flood of Obamacare Medicaid patients?"

From the San Jose Mercury News (2/7/2015): "Obamacare: Medi-Cal a waiting game for many low-income Californians".

In New Jersey, patient Justin Holstein said:

"You have a card saying you have health insurance, but if no doctors take it, it's almost like having one of those fake IDs," he said. "Your medication is all paid for, but if you can't get the pills, it's worthless."

Richard Holstein, his father, is a Long Branch psychologist who has watched his son struggle to get care. Yet he no longer accepts Medicaid in his own practice because the managed care payment of about $40 is half of what regular insurance pays, and a quarter of his full fee, he said.

Similarly, in California:

"We had a shortage of primary care doctors before this flood (of Medi-Cal enrollees) came about," said Dr. Steven Harrison, a veteran primary care doctor who directs a residency program for such physicians at Natividad Medical Center in Salinas. "Now we have a dire shortage."

A common theme in both stories: Patients were promised "coverage" under ObamaCare.  But they have a very difficult time finding a physician willing to see them, especially at the low rates that Medicaid pays.  Doctors essentially lose money on these patients, which means there is no way they can "make it up in volume".

The government even forbids Medicaid patients and doctors from reaching their own mutually-acceptable contractual arrangement to supplement Medicaid fees.  From the Star-Ledger piece:

Joanna DeProspero was desperate to find a pain management doctor for her adult daughter, who works part-time at Home Depot despite back pain. When she proposed paying cash, she learned it's illegal for a doctor to accept such a payment. Doctors who participate in Medicaid cannot bill a patient anything extra, said Downs, of the medical society -- even if that payment is freely offered by the patient.

 "I've literally cried at the end of the day after six or eight phone calls," said DeProspero...

One unfortunate side effect is that the patients end up going to the local emergency rooms instead (for care that isn't strictly an emergency), thus worsening the overcrowding situation in the ERs.

Supporters of the Affordable Care Act trumpet the increased "coverage" numbers provided by the law. But much of that increase is due to an expansion of Medicaid rolls, where the benefits are increasingly illusory for patients.

As we've seen throughout history, central planning and government fiats cannot create supplies of goods and services from thin air.  Instead, they merely create (or worsen) shortages.  Sadly, patients in New Jersey and California are paying the price for their lawmakers' ignorance of this lesson.

(New Jersey link via M.L.)

Mandates Killing California Solo Practice

The San Diego Union-Tribune reports, "Obamacare deals blow to one-doctor medicine".

One major problem has been the mandated electronic medical records.  From the article:

In a slow-motion version of the problems that crippled online insurance “exchanges” for months, doctors who see patients under Medicare and Medi-Cal programs have been forced by the phase-in of a 2009 federal "stimulus" law to install expensive, complex software systems that sharply reduce time for patients...

Nearly 70 percent of physicians say digitizing patient records has not been worth the cost, according to a survey by Medical Economics magazine. This negative cost-benefit view comes even after $27 billion in subsidies to health care providers for the systems.

One big problem is the dozens of systems don’t talk to each other, because the feds didn’t mandate interoperability before the rollout.

So communication gains among hospitals, clinics and doctors offices aren’t happening. Adding insult, doctors can be criminally liable if hackers get hold of patient data.

Worse is the hit to productivity. Doug says he once aimed to see four patients an hour for normal office visits. Now he struggles to see three each hour, and colleagues report much the same...

The article also notes: "Still, the mandates clearly shift advantage to large doctor groups and health systems that can amortize costs over more patients" and "So far, nobody knows if the move to factory-style medicine will improve the quality or cost of care."

We'll find out soon enough.

Quick Links: Catron, Rushing Patients, Poor Coverage

David Catron takes a closer look at the various claims that, "ObamaCare is working".

USA Today: "You're on the clock: Doctors rush patients out the door".

 (Note that this is a problem with the standard model, not with concierge medicine practices which allow doctors and patients ample time to discuss medical issues in depth.)

CBS San Francisco: "Some Covered California Patients Say They Can't See A Doctor".

(As always, "coverage" does not equal actual medical care. Politicians can promise the former, but can't decree the latter.)

Narrow Networks

Patients are starting to feel the pinch from ObamaCare's "narrow networks".  Two recent stories:

Los Angeles Times: "Obamacare enrollees hit snags at doctor's offices"
(2/4/2014)

Megan McArdle: "'Doc Shock' Reaches the Masses" (2/6/2014)

These narrow networks will also have a less-obvious effect on doctors, as I noted in my recent Forbes piece on the new ethical pressures on physicians caused by ObamaCare:

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.

Megan McArdle predicts that political pressures will cause insurers to loosen these narrow networks.  But then patients will have to pay higher premiums, instead.  Either way, patients will be paying some unpleasant price for this form of "universal" health care.

Quick Links: CA, Nonparticipation

David Catron: "California Schemin'".

Counterpoint from Cohn: "Anatomy of a Bogus Obamacare Argument", responding to an Avik Roy piece on CA.  Roy's piece includes multiple updates in response.

CNBC: "Two-Thirds of Americans Don't Know If They Will Insure Under Obamacare"

Adalja On Non-MDs And Licensing

Dr. Amesh Adalja notes that "Sometimes The Best Medical Care Is Provided By Those Who Aren't M.D.s" (Forbes, 2/10/2013).

From his piece:

...[F]or many conditions the expertise of a physician is not strictly required and an individual may be ably served by a nurse practitioner or the like. Expanded scopes of practice, in which a non-physician renders care independent of a physician, not only expand access to health care and have the potential to decrease the cost of healthcare, but also reflect a respect for the free market system.

Like Dr. Adalja, I support the elimination of licensing laws the unfairly restrict the ability of health professionals and patients to voluntary contract to their mutual benefit.

In a free market, patients might choose rationally some forms of medical care from an MD (and pay a higher fee) and other forms of care from a non-MD "mid-level provider" for a lower fee.  Provided that there is no fraud or misrepresentation by the provider to the patient, this can be a win-win for both parties.

(See also my related piece: "How Medical Licensing Laws Harm Patients and Trap Doctors", PJ Media, 10/1/2012)

However, we may also see state governments loosening some scope-of-practice laws for other, less-benign reasons.  The Los Angeles Times recently reported, "State lacks doctors to meet demand of national healthcare law" (2/9/2013).

The LA Times article notes:

There aren't enough doctors to treat a crush of newly insured patients. Some lawmakers want to fill the gap by redefining who can provide healthcare.

They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.

In this case, the motivation of the state of California is different.  The proposed changes in the laws are not driven by a respect for individual freedoms, but because of the growing problems of the government health program.

Patients won't be choosing between MDs and non-MDs for medical care in a free market, but instead obliged to accept care from whichever providers still willing to practice under ever-growing state control.

Considered in isolation, the specific concrete legal changes in California might be similar to genuine free-market reforms, but the larger context is very different.

Specialist Shortages

The 12/16/2012 Los Angeles Times reports, "Healthcare crisis: Not enough specialists for the poor".

As always, politicians can promise theoretical "coverage".  But they can't guarantee that patients will receive actual medical care.

It won't be long before the problems in California's government-run Medi-Cal program (which is their name for Medicaid) spread to the rest of the country.

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.

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.)

Quick Links: Ethics Corruption, White House, MA Costs, CA Shortages

Dr. Jeffrey Singer does a nice job discussing, "The Coming Medical Ethics Crisis". The subtitle: "How the government is putting the medical profession -- and your health -- at risk". (Via Brian Schwartz.)

Here is the White House PR strategy to defend ObamaCare in the coming weeks.

NPR and Kaiser Health News report that Massachusetts legislators still trying to figure out how to reduce rising health costs. Their solution: More government controls.

California legislators realizing that "coverage" doesn't equal actual care.

State Updates: MA, CA, CO

The 2011 report by the Massachusetts Medical Society notes that RomneyCare has resulted in, "Longer patient wait times, continued difficult access to primary care physicians,and gaps in physician acceptance of government coverage". (Via Scott K.)

The natural next question from Jared Rhoads, "How long until the Physician Mandate?"

Also in Massachusetts, an insurance company is being penalized $760,000 for selling policies that don't abide by the various state mandates.

(Or as Jared Rhoads noted on Twitter: "MA AG to insurance company: "STOP SELLING INSURANCE POLICIES THAT PEOPLE WANT! #governmentknowsbest")

John Graham's 5/6/2011 OpEd in the Orange County Register summarizes the main problem with the proposed new California law to impose Massachusetts-like controls over California's health insurance companies: "Politicians can't control health care costs". (Via Dr. Richard Armstrong of D4PC.)

Colorado Republican Amy Stephens continues to push for a state-run health insurance exchange, characterizing the government system as "free market", and calling opponents of her bill "anarchists". With "friends" like this... (Via Ari Armstrong.)

More California Dreaming

Now that a comprehensive national-level ObamaCare plan of "universal health care" is unlikely to happen, individual state governments will likely start working on their plans. Of course, the fact that they've failed in the past won't stop the true believers.

From California, we see the first stirrings.

The January 21, 2010 New York Times reports, "California Democrats Revive Universal Health Plan" -- with the explicit goal of imposing a "single payer" system on the state.

Apparently, they've learned nothing from the experience of other countries.

Along similar lines, the Associated Press reported on January 19, 2010 of new state rules that would create a "right to be seen by a doctor" for patients in HMOs (Health Maintenance Organizations).

From "California to Set Time Limit to See Doctors" (mirrored here):

California is poised to become the first state to set time limits for doctors to see patients, the Department of Managed Health Care said.

Regulations to be announced Wednesday require family practitioners in health maintenance organizations to see patients seeking an appointment within 10 business days. The deadline for specialists is 15 days.

Of course, if the government could conjure up immediate medical care by fiat, why not do the same for food, water, and housing?

Eventually, reality will catch up with even the most wooly-headed wishful thinking. But for now, California politicians keep dreaming...

Kurisko on Canadian Health Care

The non-partisan group Center of the American Experiment has published the following interview with Dr. Lee Kurisko, a radiologist who used to practice in Canada and who now practices in Minnesota, entitled "A Conversation about Canadian and American Health Care".

I highly recommend reading the whole thing, especially if you want a perspective from someone who has been in the trenches.

I've selected a few excerpts to highlight.

On inequality:

...I've seen more inequity and disparity in Canada than the United States, as far as access to care. As I mentioned, we had huge waiting lists. Our MRI waiting list was 13 months long. Our CT scan waiting list was seven months long. People in that system really were just left to suffer to a much greater degree than they are here in the United States.

One thing that you see that is not talked about very much is that Canadians with influence or connections tend to get medical attention more quickly. I would get telephone calls from various doctors requesting that their patients be moved up on the waiting list. If they made a reasonable case, I would do so, whereas there were other doctors who just referred people for imaging tests, and I never heard specific requests from those doctors. Their patients would just go to the end of the waiting list because they didn't have the same level of advocacy. The other thing -- and it's kind of a deep, dark secret -- is if you are connected to somebody in the medical system, you're much more likely to get your medical intervention done more quickly, whether by knowing a doctor, knowing somebody in the hospital administration, or whatever.

On the "dying in the streets" argument:

...In Canada there's a false perception, which I actually held for many years, that if you don't have health insurance in the United States, you literally do not get care. There's a perception in Canada that in the United States if you don't have insurance and you have a problem, you’re going to get turned away and that people are just dying in the streets for lack of health care. I've been in America for almost six years, and I've yet to see anybody who’s been turned away for health care -- at least in Minnesota. Whereas, the reality is that Canadians are turned away for health care in many different ways -- through waiting lists for access.

On central planning vs. the free market:

When I was working in Canada, we had this personnel meltdown when we had only three radiologists for 250,000 people. I was director of the department at the time, and I said to the hospital administration, "We need a rolloscope." A rolloscope is a device where the X-rays and CT scans are set up on the scope, and you can push a button and go from case to case to case. It really expedites your ability to read the cases promptly. I was reading about 40,000 cases a year at that time, which is just an enormous number, especially if you're reading without a rolloscope. The hospital said, "Well, you know, what? There's no money in the budget for us to buy your rolloscope. Perhaps, you could plead the case to the Ministry of Health. Perhaps, they can make a special dispensation of dollars so that you can get this rolloscope." The radiologists in Thunder Bay eventually got the rolloscope three years later, but there was no money to hire a clerk to load the films, so it just sat and collected dust for another year.

When I moved to Minnesota, I worked at St. Francis Medical Center in Shakopee, and we were seeing increasing volumes and just getting busier, and busier, and busier. My partner and I approached our organization, Consulting Radiologists Limited, and said, "We need a rolloscope. We've got these increasing volumes." They looked and said, "Hey, you guys are phenomenally productive. We want to facilitate your productivity. Here's your rolloscope." We had the rolloscope in a month, and we had someone to load it, too. That's the free market versus central planning.

On health insurance:

Certainly, I'm not against health insurance. I would never go without it, but, on the other hand, a lot of policies are not just insurance. They're prepaid medical plans. When everything is covered, then there's no restraint. I want insurance for the catastrophic illness that I may get or if I get in a bad car accident and I have really high costs. I don't really want to have to pay insurance for routine things like my daughter's sore throat or immunization or something like that, which is routine and expected.

A good analogy would be house insurance. House insurance is pretty reasonably priced, and it is because we have it for unexpected problems, like our house burning down or being robbed. My premiums reflect the fact that these are unlikely eventualities. On the other hand, if house insurance was based on all of my needs for my household -- floor wax, paint, dishwashing soap, new clothes, or whatever -- then, as a consumer, I would say, "The sky is the limit. Let's paint the walls every week. Let's put in new carpets every week." The cost for home insurance would be astronomical, and yet that is the exact situation that we have with the standard health insurance in the United States right now.

Dr. Kurisko also offers many insightful observations about tort reform, health savings accounts (HSAs), Medicare, and how government policies create artificial medical shortages.

I highly recommend reading the whole thing!

(Via StateHouseCall.)

Father of Canadian Health System Says It's In "Crisis"

The June 25, 2008 edition of Investor's Business Daily has an interesting article on the father of Canadian health care, Claude Castonguay, and his current views. Here are a few excerpts:

Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits

...Back in the 1960s, Castonguay chaired a Canadian government committee studying health reform and recommended that his home province of Quebec -- then the largest and most affluent in the country -- adopt government-administered health care, covering all citizens through tax levies.

...Four decades later, as the chairman of a government committee reviewing Quebec health care this year, Castonguay concluded that the system is in "crisis."

"We thought we could resolve the system's problems by rationing services or injecting massive amounts of new money into it," says Castonguay. But now he prescribes a radical overhaul: "We are proposing to give a greater role to the private sector so that people can exercise freedom of choice."

...What would drive a man like Castonguay to reconsider his long-held beliefs? Try a health care system so overburdened that hundreds of thousands in need of medical attention wait for care, any care; a system where people in towns like Norwalk, Ontario, participate in lotteries to win appointments with the local family doctor.

Years ago, Canadians touted their health care system as the best in the world; today, Canadian health care stands in ruinous shape.

Sick with ovarian cancer, Sylvia de Vires, an Ontario woman afflicted with a 13-inch, fluid-filled tumor weighing 40 pounds, was unable to get timely care in Canada. She crossed the American border to Pontiac, Mich., where a surgeon removed the tumor, estimating she could not have lived longer than a few weeks more.

The Canadian government pays for U.S. medical care in some circumstances, but it declined to do so in de Vires' case for a bureaucratically perfect, but inhumane, reason: She hadn't properly filled out a form. At death's door, de Vires should have done her paperwork better.

...Americans should know that one of the founding fathers of Canada's government-run health care system has turned against his own creation. If Claude Castonguay is abandoning ship, why should Americans bother climbing on board?

The author of this article, Canadian physician David Gratzer and author of The Cure: How Capitalism Can Save American Health Care, makes many excellent points.

One point that deserves further emphasis is the fact that the economic failures of the Canadian system are due to their fundamentally flawed premise -- that health care should be a "right". This point has to be explicitly challenged (and rejected) before genuine free market health care reform can take root in this country.

Hsieh LTE in Colorado Springs Gazette

The February 5, 2008 edition of the Colorado Springs Gazette printed my LTE, commenting on their good OpEd criticizing the 208 Commission (towards the bottom of the page):

BAD MEDICINE
Health care proposals will backfire on state

I want to thank The Gazette for its strong editorial against the ill-considered plan by the Colorado Blue Ribbon Commission on Health Care Reform ("Health care reform: It's a joke," Jan. 31). Their proposed system of mandatory health insurance already has been tried in Massachusetts and is failing. Costs there are already more than three times what was originally predicted, and the Boston Globe reports that it is expected to "cut payments to doctors and hospitals, reduce choices for patients, and possibly increase how much patients have to pay." The California state legislature has also just rejected a similar plan because it will cost too much.

These government-imposed plans violate the rights of individuals to freely choose what health insurance plans are best for them, and, as a result, lead only to rising costs and rationing. If Coloradans value their lives and their health, they will also reject this deadly proposal.

For more information on genuine free market health care reform for Colorado, please see www.WeStandFIRM.org.

Paul Hsieh, M.D.
Sedalia