The Tradeoffs of Obamacare

A few from above, from Saurabh Jha, MD (Twitter: @roguerad):

The biggest trade-off is between a constitutional republic, with all its checks and balances, and a centrally-planned healthcare.  The two are fundamentally incompatible.  The future will yield many more convulsions.  Many more Halbigs.

The optimism surrounding the ACA, summed up by President Obama's promise "if you like your doctor, you can keep your doctor," gave many the impression, myself included, that healthcare reform can be Pareto optimal; a win-win for all.

Regrettably, trade-offs are a fact of life.  Which means there are winners and there are losers.  This is not unusual.  But by not acknowledging the trade-offs we have created resentment in the losers, and widened the partisan chasm.

Read the whole thing.

-Wes

With Obamacare: Remember the Challenger

By now, the Obamacare insurance exchange debacle is old news. Our attention spans are so short, we're on to the next disaster.  So we sit before our TVs and enjoy the Humana ads with a smiling senior pointing to a whiteboards with their insurance plan name, or watch the news sponsored by Unitedhealth or Walmart's pharmacy department. Everyone's got a cheaper plan these days with more benefits than the other guy, and the good news never ends for you, according to our insurance companies.

Sign up people. No worries.

Even if they take you to the cleaners.

It was interesting reading the piece over at Kaiser Health News asking why a couple without kids has to buy dental insurance for children they don't have. Or  the free colonoscopy "catch" never discussed in the Obamacare ads that promoted by the law's proponents. More and more of these not-so-little details are not  as pretty and "free" as everyone had hoped, but it's what we as a nation have approved, hidden in the new law we never read.

Shame on us.

Shame on our legislators.

But we must take a different perspective now that it's becoming crystal clear what central control of health care delivery means.  I think most Americans have been incredibly tolerant of the rollout (and even appreciate the effort involved) since they have a rudimentary understanding of how complicated health care has become in America and how vital it is to our economy.

But I sense (like many others) that Americans' patience is growing thin.  People are wondering how will things be fixed?  How long will it take?  Will I have to pay a penalty for something so fraught with problems?  Who's responsible?  Whom can I call?  Can they be trusted?  Is this going to be how the rest of the health care coverage rollout happens? 

Years ago, millions of people watched the US space shuttle Challenger explode into a million tiny pieces on a crystal clear day shortly after its launch.  We were shocked at first, then deeply saddened, for our idealized notion of the space program so advanced and amazing quickly evaporated before our eyes.  We grieved with the crew's families as we watched in horror the events replayed on TV again and again and again. 

But then what happened?  Investigations followed.  Video tapes were reviewed.  A root cause analysis was undertaken.  Ideas were tested, the O-ring problem identified, and slowly, carefully, changes were made to the shuttle program.  New parts were engineered, other parts scraped.  More thorough testing than ever before occurred.  Then re-testing.  And slowly, cautiously, the shuttle program resumed, one baby step at a time.

And no one ever took a complicated shuttle launch for granted again.

So, too, should it be with our new health care law.

We should remember these lessons we learned from the Challenger disaster.  The Healthcare.gov rollout debacle was no less anticipated and certainly no less spectacular.  We need a root cause analysis of this mess.  We need to identify the problems and fix them if they can be fixed or scrap what can't.  We should stop and ask ourselves what of this law should continue, and what should be scraped.  We should ask the difficult questions and if it truly is in our best interest to proceed with certain parts, test and retest that which remains to make sure the systems are secure and the program functional.  And most of all, we should ask now if this whole grand health care idea is likely to be truly cost effective and sustainable for our nation before rushing ahead toward another disaster.

Because, like the Challenger, it's people's lives we're talking about here, not some stupid website catastrophe.

-Wes

Obamacare 2016: Happy Yet?

From Bradley Allen, MD in the opinion section of the Wall Street Journal this morning:

"The forecast shortage of doctors has become a real problem. It started in 2014 when the ACA cut $716 billion from Medicare to accommodate 30 million newly "insured" people through an expansion of Medicaid. More important, the predicted shortage of 42,000 primary-care physicians and that of specialists (such as heart surgeons) was vastly underestimated. It didn't take into account the ACA's effect on doctors retiring early, refusing new patients or going into concierge medicine. These estimates also ignored the millions of immigrants who would be seeking a physician after having been granted legal status.

It is surprising that the doctor shortage was not better anticipated: After all, when Massachusetts mandated health insurance in 2006, the wait to see a physician in some specialties increased considerably, the shortage of primary-care physicians escalated and more doctors stopped accepting new patients. In 2013, the Massachusetts Medical Society noted waiting times from 50 days to 128 days in some areas for new patients to see an internist, for instance.

But doctor shortages are only the beginning.

Even before the ACA cut $716 billion from its budget, Medicare only reimbursed hospitals and doctors for 70%-85% of their costs. Once this cut further reduced reimbursements, and the ACA added stacks of paperwork, more doctors refused to accept Medicare: It just didn't cover expenses.

Then there is the ACA's Medicare (government) board that dictates and rations care, and the board has begun to cut reimbursements. Some physicians now refuse even to take patients over 50 years old, not wanting to be burdened with them when they reach Medicare age. Seniors aren't happy."

Medicaid in 2016 has similar problems. A third of physicians refused to accept new Medicaid patients in 2013, and with Medicaid's expansion and government cuts, the numbers of doctors who don't take Medicaid skyrocketed. The uninsured poor now have insurance, but they can't find a doctor, so essentially the ACA was of no help.

The loss of private practice is another big problem. Because of regulations and other government disincentives to self employment, doctors began working for hospitals in the early 2000s, leaving less than half in private practice by 2013. The ACA rapidly accelerated this trend, so that now very few private practices remain."

Read the whole thing (subscription required, sorry).  Not surprisingly, it's not pretty.

-Wes

When We Conflate Health Care With Medical Care

From Marilyn M. Singleton, M.D., J.D.:

“Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” -Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

(Read the rest, especially the comments)

As I and others see the problems with "wellness initiatives" promoted by politicians and the insurance industry as cornerstones of our efforts to cut costs in our medical system, we should consider if institutional financial incentives will thwart any effort to achieve cost savings as physician productivity quotas are increasingly turned to as the driving force de rigueur for hospital profitability. Unfortunately, physicians are losing their ability to be stretched much further, especially as they struggle to keep up with the mushrooming number of inefficient certification and data-entry requirements, flooded e-mail in-boxes, and coding requirements necessary to continue practicing medicine in our new "reform" era. Then add the increasingly frequent hassles doctors are experiencing with their patients' insurance claim denials that go on for months. Medical care suffers as a result. Even our frontline force for quality medical care, nurses, are being stretched thin as many of their ranks are either let go or recruited as cleaning crews on top of their other patient care responsibilities.

Meanwhile, the insurance companies are recording record profits as Americans pay more and more into our system.

But, hey, thanks to the Electronic Medical Record and health care "reform" it sure is easy to order another colonoscopy in the name of "wellness" and "health care," right?

-Wes

The Costs of Not-so-Shared Decision Making

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:

"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."

What a nice, lovely, fuzzy bunny.  Who couldn't want such "shared" decisions in complex medical care?  Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement? 

And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim.  Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?

"Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:

• First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc.  In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").


• Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded  in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar.  Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings.  Then imagine for a moment if the cudgel for shared decision making is imposed.  The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians. 


• Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ).  Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?


• Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.


• Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care.  Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.

Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated. 

If that doesn' t matter to all of us, then share away.

-Wes