Hsieh Forbes Column On Government Quality Metrics And Unintended Consequences

My latest Forbes piece is now out: "How Patients Pay The Price For Unintended Consequences Of Government Health Care".

I discuss how various government "quality" metrics intended to improve patient care can have the exact opposite effect.

This is an example of Goodhart's Law in action, sometimes phrased as, "When a measure becomes a target, it ceases to be a good measure."

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.

Catron: Drug Rationing for Seniors Begins

In the 2/24/2014 American Spectator, David Catron notes that, "Drug Rationing for Seniors Begins".

The latest restrictions for Medicare patients is alarming both the political Left and the political Right.  What the government giveth, the government can taketh away.

(This should be a warning for those advocating "Medicare for all".)

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".

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.)

Adalja on Medicare and End-Of-Life Care

Dr. Amesh Adalja has a new column up at Forbes: "Medicare Has Chained Us Together, Reliant On End-Of-Life Government Rationing".

A few excerpts from his piece:

As 25-30% of Medicare spending occurs in the last year of life, end of life care has become a rising issue in health care policy debates. End of life scenarios often place the ICU physician in the position of persuading designated surrogates of the patient to—after consulting the patient’s living will and stated wishes—withdraw care and allow the patient to succumb to their illness...

The growing fiscal burden of the program, not surprisingly, raises concerns regarding the costs and efficacy of the treatments paid for by Medicare. End of life care often takes place in ICUs and employs expensive state-of-the-art technology. Yet, in certain contexts, these advanced therapies are unable to alter the course of illness. Family members of gravely ill patients may have religious, financial, or other reasons to continue care and when an unseen 3rd party is responsible for the bill, costs of care are not a factor...

It is the increasingly socialized atmosphere of medicine that has created this scenario that puts physicians in a financial stewardship position creating a conflict with their role as an advocate for their patients. In any system where government pays for end-of-life health care, it will inevitably have to decide who receives it or not. In a free market, in which individuals control their own health care spending, individuals make these decisions for themselves... 

But you should read the full text.

Dr. Wes: A Case Of Fraud

Cardiologist/blogger "Dr. Wes" described an interesting medical ethics dilemma in his recent blog post, "A Case of Fraud".

In short, a cardiologist had to choose between doing what was right for the patient vs. following Medicare rules.

I don't know how often this happens. And I'm glad this particular doctor fulfilled his responsibility to his patient.

But we'll see more of these conflicts as Medicare imposes increasingly restrictive rules on how physicians are allowed to practice.  Many current doctors will still quietly do the right thing for their patients. But over time, we'll see a new generation of doctors more willing to comply with government edicts even if it goes against their Hippocratic Oaths to work for their patients' best medical interests.

And this isn't just abstract theorizing.

Some day, you might be that patient in the cardiac cath lab. On that day, you'd better hope you have a doctor still willing to act in your best interests.

(Read the full text of "A Case of Fraud".)

Quick Links: Docs Avoiding Medicare, Patients Avoiding ObamaCare, Fat In NZ

Wall Street Journal: "More Doctors Steer Clear of Medicare: Some Doctors Opt Out of Program, Frustrated With Payment Rates and Mounting Rules" (7/28/2013).

From the article:

The number of doctors who opted out of Medicare last year, while a small proportion of the nation's health professionals, nearly tripled from three years earlier, according to the Centers for Medicare and Medicaid Services, the government agency that administers the program. Other doctors are limiting the number of Medicare patients they treat even if they don't formally opt out of the system.

NPR: "Canvassers For Health Coverage Find Few Takers In Boca Raton" (7/29/2013)

BBC: "South African chef 'too fat' to live in New Zealand" (7/27/2013)

According to the New Zealand government, "It is important that all migrants have an acceptable standard of health to minimise costs and demands on New Zealand's health services..."

Medicare and Longevity

At Forbes.com, Christopher Conover asks an interesting question: "If Ray Kurzweil Lives Forever, Should Medicare Pay for His Health Care?"

Quick Links: Catron, Scherz, Preston

David Catron: "Obama Shafts Poor and Minority Seniors Again" (American Specatator, 3/18/2013).

He notes that, the "[l]atest cuts in Medicare Advantage hits those who can least afford it."

Dr. Hal Scherz: "Why Pay Physicians Anything At All For Providing Healthcare?" (Townhall, 3/18/2013).

(As Dr. Megan Edison astutely observed, "Why all this attention to 'doctor pay' when it is only 8.6% of healthcare costs? Because controlling doctors by changing their compensation structure is how to control 1/5 of the American economy.")

Bryan Preston: "Thanks to ObamaCare, You May Soon Get Serious Medical Treatment from People Who Lack Medical Training" (PJMedia, 3/7/2013)

Catron on Getting Hoist By Ones Own Petard

David Catron's latest American Spectator piece describes, "A Pimp for Obamacare Feels the Pain".

Specifically, he discusses a pro-ObamaCare supporter who is also an ER physician.  But as Catron noted:

He has finally discovered what I and others told him years ago: Medicare rules are, as he apparently now realizes, “arbitrary and disconnected from reality.” He has also noticed that, when a physician runs afoul of these bureaucratic vagaries, the government is the judge, jury, and executioner. The immediate cause of his disillusionment is Medicare’s trick of performing a superficial audit of a doctor’s billing practices and, based on a hopelessly flawed statistical sampling method, accuses him of fraud.

Read more at "A Pimp for Obamacare Feels the Pain".

And BTW, there are now 106 new ACOs (Accountable Care Organizations) for Medicare patients.

Here's the downloadable list (PDF format).

Medicare Whipsaw

ER doctor "Shadowfax" describes the Medicare whipsaw for physicians: "Medicare made the rules and now punishes doctors for following them".

The unintended consequences are due to a combination of coding rules, electronic medical records, payment rules, government definitions of "medical necessity", and presumption of guilt.

Atlas: Doctors Soon Won't Accept Medicare

In the 12/18/2012 Forbes, Dr. Scott Atlas explains that "Let's Be Honest -- Medicare is Insolvent And Doctors Soon Won't Accept It".

A few key take-home points:

Medicare is spiraling into bankruptcy, owing to both the demographics of America and the realities about health care.

An increasing proportion of doctors are already not accepting Medicare patients, and the primary reason is low payment for services.

There's an enormous difference between having insurance and achieving access to medical care.

Politicians can pat themselves on the back for guaranteeing "coverage", but their dictates cannot guarantee that patients receive actual medical care.  Coverage does not equal care.

Dr. Atlas also offers some partial reforms that can help in the interim while we continue the battle for free-market health care solutions.

(Read the full text of "Let's Be Honest -- Medicare is Insolvent And Doctors Soon Won't Accept It".)

Quick Links: HSAs, Exiting Medicare

Blogger "Mockerena": "I Need To Vent About Healthcare For A Minute, You Guys".

She underwent a very interesting psychological shift after she started using an HSA and became responsible for her own health spending.

Dr. Natasha Deonarain discusses, "Why I decided to opt out of Medicare as a provider".

Many more doctors will likely follow suit, for the reasons she describes.

Quick Links: Takeover, Taxpayers, Wales

From Patient Power Now: "Ten Reasons ObamaCare is a Government Takeover of Health Care"

Viard: "Both Parties Defend Medicare, None the Taxpayer" (Real Clear Markets).

I look forward to the day when the debate is over how to phase out Medicare, not how to save it.

Wales Online: "Lack of doctors in Wales causing NHS systems to 'break down'" (via Dr. Art Fougner and Dr. Richard Amerling.)

Quick Links: Bankruptcy, EMR, Sicker

Sally Pipes, "Medical bankruptcy: Fact or fiction?" (The Hill, 10/23/2012)

(Her conclusion: "The overwhelming body of research shows that medical costs play little or no role in the vast majority of U.S. personal bankruptcies."  Plus she notes that Canada has a nearly-identical bankruptcy rate as the US, despite the fact that Canadians have "free" government-provided health care.)

Dr. Anne Marie Valinoti,  "Physician, Steel Thyself for Electronic Records" (WSJ, 10/23/2012).

Dr. Charles Willey, "Government Meddling In Health Care Has Only Made Us Sicker" (IBD, 10/24/2012)

Will on IPAB and Rationing

In the aftermath of last week's debate, the issue of the ObamaCare IPAB board for Medicare rationing has resurfaced.

Supporters of IPAB are again claiming that the IPAB won't ration care. But in his 10/4/2012 column, George Will debunks this claim:

Beginning in 2014, IPAB would consist of 15 unelected technocrats whose recommendations for reducing Medicare costs must be enacted by Congress by Aug. 15 of each year. If Congress does not enact them, or other measures achieving the same level of cost containment, IPAB’s proposals automatically are transformed from recommendations into law. Without being approved by Congress. Without being signed by the president.

These facts refute Obama’s Denver assurance that IPAB “can’t make decisions about what treatments are given.” It can and will by controlling payments to doctors and hospitals. Hence the emptiness of Obamacare’s language that IPAB’s proposals “shall not include any recommendation to ration health care.”

By Obamacare’s terms, Congress can repeal IPAB only during a seven-month window in 2017, and then only by three-fifths majorities in both chambers. After that, the law precludes Congress from ever altering IPAB proposals.

Because IPAB effectively makes law, thereby traducing the separation of powers, and entrenches IPAB in a manner that derogates the powers of future Congresses, it has been well described by a Cato Institute study as “the most anti-constitutional measure ever to pass Congress.”

I'm glad George Will is emphasizing this point.

It's true that the IPAB won't directly tell individual doctors and individual patients what specific treatments they can or cannot receive. But it can set the prices so that a hospital can no longer afford to offer a specific service. For instance, if they say "Yes you can offer a PET-CT scan for detecting metastatic ovarian cancer, but you can only charge $100" (instead of $1000), then no one will offer that service and no patient would receive it.

It would be like the government telling grocers, "We won't ration food and we won't restrict what food consumers can purchase. But you must now all sell steaks for $1." 

Pretty soon, no one would sell steak at a loss and no one would be able to buy steaks either.

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.)

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.

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.