Take a provision in the Baucus bill that would punish any physician whose "resource use" is considered too high. Beginning in 2015, Medicare would rank doctors against their peers based on how much they cost the program—and then automatically cut all payments by 5% to anyone who falls into the 90th percentile or above. In practice, this rule will only apply to specialists.It'll be interesting to see how this all plays out. In the end, as dollars get pushed upstream to primary care physicians in favor of specialists and our older, experienced specialists retire, I wonder if the push to specialization will be as strong, leaving our seniors most affected by this policy. Yet, ironically, when the bean counters tally the health care cost tab at the end of the day, our policy makers will feel completely vindicated.
Since there will always be a missing chair when the music stops, every year one of 10 physicians will be punished if he orders too many tests, performs too many procedures or prescribes too many drugs—whether or not the treatments result in better patient outcomes. The 5% fine is substantial given that Medicare's price controls already pay only 83 cents on the private dollar.
In Medicare, meanwhile, the Administration is using regulation to change how doctors are paid to benefit general practitioners, internists and family physicians. In next year's fee schedule, they'll see higher payments on the order of 6% to 8%. The loose consensus is that the U.S. does have too few primary care doctors—less than 5% of medical students are entering the field—in part because they're underpaid.
Fair enough. But this boost for GPs comes at the expense of certain specialties. The 2010 rules, which will be finalized next month, visit an 11% overall cut on cardiology and 19% on radiation oncology. They're targets only because of cost: Two-thirds of morbidity or mortality among Medicare patients owes to cancer or heart disease.
. . .
One priority of the Baucus bill is to require the executive branch to wreak this kind of devastation every year, not just when a Democrat is President. It directs the Secretary of Health and Human Services to search out "potentially misvalued" RVUs, meaning those "for which there has been the fastest growth" or "that have experienced substantial changes in practice expenses." In other words, any specialty that grows too much must be targeted.
It's important to understand that these are "cuts" that don't actually cut any spending; the RVUs merely redistribute it from one medical bucket to another. In this case, Team Obama is sending a message to the medical community about its political priorities. The fee schedule is designed to avoid wild year-over-year payment swings, but HHS justified its decision with a flimsy survey whose data it won't release and whose results can't be replicated. (The President of the American College of Cardiology) Dr. Lewin told us that both HHS Secretary Kathleen Sebelius and budget director Peter Orszag refuse to meet with him to discuss the topic.
After all, it's our seniors who drive most of the cost for health care anyway and in the game of monetary musical chairs, someone has to ultimately sit out.
-Wes
My prediction on this whole health care reform thing from day 1 has been that the only thing that will get accomplished is the rearrangement of the pie slices between us docs. The insurers and big pharma and the hospital lobbyists are too strong to really allow any substantial change to affect them.
ReplyDeleteTBTAM-
ReplyDeleteI think the term is "re-arranging the deck chairs on the Titanic."
Wes,
ReplyDeleteOnce again, you ignore the examples of medicine as it is practiced abroad and engage in various doomsday senarios that have worked so effectively for interest groups in the past.
Every other indutrialized country has a ratio of primary care to specialists more akin to 75-25%, yet we do not see citizens dying in the streets. Of course there might be slight delays for such specialty treatment, but nobody goes unattended and most measures of health are better in these countries (maybe because they can actually spend more time engaged in proper exercise and can afford good nutritious food since they don't have the exorbitant insurance premiums we have here!)
How do they manage this!? Proper limitation of medical advancement that offer little benefit over older treatments, doctors who are plenty busy and don't need to make a buck by doing more and more testing and procedures to raise their income, and the lack of a litiginous society that can serve as the blame for why we have to order all these tests and procedures.
Until you answer how they manage to work this miracle at half the cost without having doom and destruction fall upon them, you've got a problem with your argument favoring the status quo.
Keith-
ReplyDeleteSo tell me, how low are you willing to let the government cut your salary in the name of fairness? Real number, please.
Wes,
ReplyDeleteI'll tell if you'll tell!
PS Secret to not getting your salary cut greatly; don't make alot to start with!
PPS Why don't I ever get an answer to how the Canadians and Europeans manage their health care systems at half the cost and actually manage to provide everyone with helath care?
Keith -
ReplyDeleteWhy don't I ever get an answer to how the Canadians and Europeans manage their health care systems at half the cost and actually manage to provide everyone with helath care?
Re: Canada - First, let me say, I am a doctor and not a health policy nerd. But here's what I understand. Canadians manage to give care to their populace by prioritizing diseases according to a central authority who determines what can be spent and prioritizes who gets care first, based, I presume, on perceived acuity. Unfortuately, these delays to care have resulted in increased deaths, prompting the emergence of private care in Canada ( a more recent article here). I already blogged on an interesting encounter I had with some nurses from Canada who struggled with having to decide which patients whould receive the 5 additional ICD's they were offered for an entire year. So while the central authority determines the amount of money spent, they make doctors have to decide who gets what. Doctors here have no legal cover for such a scheme and the moral issues are significant. Also, most of Canadians live remarkably close to the US border, and many have suggested the way Canadians maintain their system is because those unhappy can cross the border. Also, there are no private hospitals in Canada - they are government-owned - a much different model than here. Somehow I do not think American's are willing to permit the government to own their hospitals here - but that's just me. It is also interesting to note that Canada is struggling with increased costs, just like the US, much of it in part due to similar immigration problems to those we have here. Despite this, Canada's average tax rate is already 33% compared to the US's 28%.
So while the the Canadian system is in place, it's sustainability is just as tenous as ours, it costs it people indirectly though higher taxes and care delays that are more significant. Cheap cost, then, comes at a price. (Oh, and don't forget, the cost of people receiving care in the US are not accounted for in Canada.)
Canadian health care ain't as Utopian as you suggest.
I am not suggesting maintaining the status quo, either. I suggest transparency of pricing, portability of insurance options and reduced bureaucratic hoop-jumping by doctors as ways we might reach real reform. 'Til then, it's all just an expensive game of whack-a-mole.
Wes,
ReplyDeleteNever suggested it was utopian; just better than the disarray we have here in the states.
They ration ICDs by giving so many to each hospital, while we ration them by whether you have the means to pay or not. Some will argue that the poor middle class patients (not the absolute poor since they qualify for Medicaid) can still get the care they need, but usually they may be kicked around the health care system in our game of hot potato, eventually landing (if lucky) at our providers of last resort (usually one of those poorly run goverment facilities). So which means of rationing is more humane?
If people are dying in Canada as a result of delayed care, then how to account for their higher average life span? Possibly because they have better infant mortality as well due to universal prenatal care?
Too often this debate has been focused on anecdotal stories. This only shows that there is no perfect system of health care that will get it right 100% of the time, but the larger statistics suggest that a universal system that insures most basic health care needs and eliminates the experimental and fringe therapies and tests will serve us all much better.
Most telling is the fact that the creator of the Canadian health care system is held in high esteem in Canada and is considered a national hero. I guess our national hero here is Milton Freidman who professed unfettered capitilism and that all failures of the marketplace can be blamed on goverment.
This only shows that there is no perfect system of health care that will get it right 100% of the time, but the larger statistics suggest that a universal system that insures most basic health care needs and eliminates the experimental and fringe therapies and tests will serve us all much better.
ReplyDeleteAt worst, I would be dead under a system like you describe or in a wheelchair at best. Many of the soldiers, sailors and airmen that I served with in Gulf War I have already died because of the disconnect between VA health care and civilian health care, i.e. the VA tried to treat the symptoms, not the cause and they were discourage by the VA to seek civilian care (if they could afford it). I chose to seek civilian care because the VA's initial treatment of me seemed to give priority to my mental health over my physical health. To put it bluntly: The VA docs wanted to put me on antidepressants to help me "accept" my service connected disabilities rather than trying to treat those same disabilities.
The combined expense (out-of-pocket and private insurance) of my medical testing and treatment over the last 10 years stands at almost $400,000 so far. Those monies spent have allowed me to 1)stay alive (I've been dead on the ER table 5 times so far, 2)still be able to use my hands after my doctors thought I would lose the use of them last year due to muscle wasting and never dysfunction and 3)keep me out of a wheelchair and on my own two feet. Under the system that Keith seems to like my opinion is that I more than likely would have been denied the care that has maintained or improved my quality of life. I am 39 years old so my quality of life is important to, not only me but, my wife and pre-teen son.
I don't expect my healthcare to be free. My wife and I lost our house to foreclosure in 2005/2006 because of me being unable to work due to my worsening chronic health conditions and the VA stonewalling my disability claim, of which I currently have a 60% disability with four medical conditions still being disputed before the review board in Washington, DC for the last 5 years.
Under a rationing system I would be dead. I NEED my doctors to be able to run whatever medical tests they deem medically necessary without them having to worry if they are in the top 10% of "spenders" that Dr. Wes wrote about.
I guess our national hero here is Milton Freidman who professed unfettered capitilism and that all failures of the marketplace can be blamed on goverment.
Government, in general, does not produce innovation. Capitalism generally does. Just as the word "government" implies, it restricts. Capitalism is the antithesis of government.