Some leftists are disturbed by Barack Obama’s failure to make a moral case for his signature legislation (ACA, the Affordable Care Act), writes John Goodman.
“How can there be a moral case for a 2,700-page bill that was shaped and molded by self-seeking interests, with no more regard for principle than one would find in a game of musical chairs?” he asks. It’s like asking for a moral case for the IRS code.
Economist Goodman states that ObamaCare is “self-evidently immoral.” Even if you believe that some of us have a moral obligation to help others with their medical care, “what does that belief have to do with legislation in which costs and benefits are strewn about with all the care of a drunken sailor?”
What moral code justifies the following, he asks:
- Forcing some people to pay more, and allowing other people to pay less, than the cost of their insurance
- Giving people in health insurance exchanges up to 10 times as much federal subsidy as those of the same income level who get insurance at work
- Forcing young people to pay two to three times the real cost of their insurance to subsidize older people with more assets
- Taking from people who need crutches or wheelchairs or pacemakers to give to…well, who knows?
Common law, Goodman writes, is focused on the question of “who owes what to whom, given that we are all equal before the law and each of us has the right to pursue his own interests.”
He challenges leftists to come up with a treatise on ethics that explains and justifies the what and why of forcible redistribution of wealth (http://healthblog.ncpa.org 7/6/11).
The Calculus of “Equity”
The promises of “healthcare reform” will fail, say supporters, if it does not “reduce disparities” in care. Appropriate data could allow consumers to choose plans on the basis of “providers’ track records in ensuring equitability of care” (NEJM 6/16/11).
Because of physician outrage, the Obama Administration put a “secret shopper” program on hold—for now. Fake patients would have checked whether doctors’ offices discriminated on the basis of type of insurance in making appointments. It is already known that they do: According to a 2008 survey by the Center for Studying Health System Change, only 4% of physicians decline to accept new privately insured patients, while 13% turn down new Medicare patients, and 27% new Medicaid patients (Avik Roy, National Affairs, summer 2011). For pediatric specialists, Medicaid acceptance is as low as 4% (NEJM 6/16/11).
To monitor, track, identify, and target the underlying causes of racial and ethnic disparities requires data. The HITECH Act requires physicians to record the race or ethnic background of at least half of their patients to receive incentives for implementing electronic records. Self-reporting is considered the gold standard, but imputing information based on surname or “geocoding” is proposed as an interim strategy (NEJM, op. cit.). There are no standards for percentage of genome needed to pass as a member of a particular group.
An acceptable, even required form of disparity is based on quality-adjusted life years (QALYs), plus intangibles including “social usefulness” and “reciprocity,” which reward patients for past exhibition of approved values. The model is the British National Institute of Health and Clinical Effectiveness (NICE), which has an international division for exporting its methods to 60 countries, including the U.S. Rationing is the cornerstone of the new redistributionist system. NICE is a faceless bureaucracy “empowered to tip the scales of suffering and death based on a set of arcane formulas and value judgments to which the public has neither access nor meaningful input,” writes Joe Herring (American Thinker 11/28/09).
Where Does the Money Go?
The first share goes to the top: for example, $10 billion to the Innovation Center, a real “gem” in the ACA, according to CMS head Donald Berwick. This “do tank” has the very special authority to report innovations that work to the Secretary of Health and Human Services, who can convert them into rulemaking without going back to Congress. We already know what “great care” is, states Berwick. The problem is that “payment systems aren’t aligned,” we lack the information we need, “we haven’t been trained to work in teams,” and “institutional structures are in our way.” The Center will “make things move really fast” by “releasing energy around the country” and by “commissioning work” (Medscape Internal Medicine 6/16/11).
The federal government wants to “give” states up to $50 million each to establish Exchanges; actually, ACA gives HHS power to tap a limitless amount. Exchanges will not reduce premiums. Their purpose is “to distribute taxpayer money to insurance companies on behalf of individuals who qualify for subsidies,” writes Dave Racer, thereby increasing dependency on government (www.alethospress.com).
Billions go to Medicaid managed care. One Arizona plan took in $652 million in 2010, and spent $554 million on “healthcare services.” We have no idea how many chest xrays, office visits, surgical procedures, or drugs this bought. But nearly $100 million did not buy any care for anyone. Money was taken from taxpayers and redistributed to…well, who knows?
Honest Prices, and the Uninsured
In his column “Universal Health Care with No Mandates” (Forbes 6/23/11), Peter Ferrara “just takes off the veil and calls the uninsured what it is,” writes John Dale Dunn, M.D. It’s a “phony issue, involving a concerted effort to make a crisis out of a series of anecdotes.” Dunn notes that the real cost of uncompensated care is surprisingly low, partly because the uninsured are largely young and healthy. Also, there’s the unspoken reality that the real marginal cost of charity care is far less than the uncollected, grossly inflated chargemaster charges.
Hospital prices—when obtainable—are typically three to six times higher than the prices posted at www.surgerycenterok.com, writes G. Keith Smith, M.D. “An amazing thing happened here in Oklahoma City,” he writes on the Center’s blog. An uninsured patient was given a fixed price up front—and it was exactly the same as the Center’s, except that the hospital’s did not include the surgeon and the anesthesiologist. This was a discount of $10,000 to $15,000—and the hospital still wanted the business!
RomneyCare Is Problem, Not Solution
Mitt Romney, “the guy whose turn it is to get the Republican nomination [for President],” writes Mark Steyn, is out defending his record. As Steyn sees the difference between their two plans, “Obama has a one-disaster-fits-all approach…, whereas Romney believes in letting a thousand disasters bloom.” The cost problem in Massachusetts was not caused by “deadbeats using the emergency room as their family doctor,” as Romney argued, “but by the metastasizing cost distortions of government intervention.” Three years later, ER use is higher than ever, 70% of the newly insured are all but entirely subsidized by the state, costs are 30% higher than the national average, and Boston has the longest wait time in the nation to see a new doctor.
We need a credible alternative, Steyn writes. However Congress votes, we’re rubbing against the real debt ceiling— “the willingness of the world to continue bankrolling American debauchery” (Investor’s Business Daily 5/13/11).
The Myth of Medicare Efficiency
Still frequently cited is the misleading comparison of Medicare’s administrative costs of 3% with 15% to 20% for employer-sponsored insurance. Unlike private insurers, Medicare has off-budget help: the IRS and Social Security Administration collect taxes and premiums, and HHS provides accounting, marketing, and more. Most importantly, Medicare beneficiaries are sicker, so the denominator of patient care costs is higher. The per person cost of Medicare administration, even with the extra help, is $509, versus $453 for private plans (Avik Roy, op. cit.).
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“Rulers have become owners…. We are…their wards, pupils, or domestic animals. There is nothing left of which we can say to them ‘Mind your own business.’ Our whole lives are their business…. We seldom had fewer rights and liberties nor more burdens: and we get less security in return. While our obligations increase, their moral ground is taken away…. [The new society creates] membership in a debased modern sense—a massing together of persons as if they were pennies or counters.” C.S. Lewis, quoted by Joseph Sobran
Committee Reports
Dr. Claud Boyd announces the following slate to be nominated at the annual meeting:
President-elect: Juliette Madrigal-Dersch, M.D., Austin, TX
Secretary: Charles McDowell, Jr., M.D., Johns Creek, GA
Treasurer: W. Daniel Jordan, M.D., Atlanta, GA
Directors: Curtis Caine, M.D., Brandon, MS; James Coy, M.D., Mt. Dora, FL; Adam Harris, M.D., San Antonio, TX; Wayne Iverson, M.D., San Diego, CA; George Watson, D.O., Park City, KS.
Resolutions are due by Aug 1: contact [email protected].
AMA Reaffirms Support for Mandate
In an overwhelming 2-to-1 vote, the AMA House of Delegates reaffirmed its support for the individual insurance mandate. Participation in the ObamaCare wealth redistribution scheme is called an “individual responsibility.” The goal, according to president Cecil Wilson, is to end cost shifting from the uninsured to the insured. The AMA also voted to work for repeal of IPAB.
ICD-10 Coming; CPT-5 Continues
A massive overhaul of health information systems is needed to move from the ICD-9 diagnosis coding system to the ICD-10 system, which will be a CMS requirement by Oct 1, 2013. CMS insists that this is a firm deadline. More complex than Y2K, the changeover will cost large health systems up to $20 million (Computerworld 6/13/11). ICD-10 increases the number of codes from 15,000 to 68,000, including 2,400 codes for a fracture of the femur. While hospitals will use the procedural coding in ICD-10, physicians will still have to use CPT-5; the AMA likely cut a special deal with HHS. The AMA bookstore is heavily advertising its new CPT-5 codebooks.
The accompanying AMA-designed E&M documentation guidelines continue unchanged, despite the recommendation to eliminate them made by HHS Secretary Tommy Thompson’s Advisory Committee on Regulatory Reform 10 years ago. Berenson et al. write that they create “serious and pervasive” problems, such as the design of electronic health records (EHRs) to produce excruciatingly detailed, often clinically irrelevant data dumps to satisfy auditors. Studies show that EHRs pay for themselves partly by facilitating coding to increase payments, not by increasing practice efficiency. They make the medical record an “ineffective source of communication.” Payment for $150 billion in E&M services is inextricably tied to this (NEJM 5/19/11).
AAPS Calendar
Aug. 6. Doctors’ Town Hall, Nashville, TN.
Sep 28-Oct 1. 68th annual meeting, Atlanta, GA.
Oct 4-6, 2012. 69th annual meeting, San Diego, CA.
ACTION OF THE MONTH
Do you know a medical student who should be introduced to AAPS? Scholarships are available for the annual meeting. The scholarship application form can be found at “https://aaps.wufoo.com/forms/z7p2z5/”> https://aaps.wufoo.com/forms/z7p2z5/
Perils of Health Information Technology
Expect more aggressive enforcement of HIPAA’s security rule, which usually begins with failure to notify patients of a breach. The Office of Civil Rights can go straight to a $1.5 million penalty; it is no longer required to resolve violations informally. Note that receiving an EHR incentive payment will put you on the Inspector General’s radar. And “meaningful use” requires administrative, technical, and physical safeguards of electronic protected health information (PHI).
If you dispose of hardware or media containing PHI, overwrite it twice—or crush the hard drive with a hammer. Maintain a record of movement of hardware or media and of the person responsible. Make an exact copy of electronic PHI, when needed, before moving it—that means even if you’re moving a computer from one exam room to another, advises Harry Rhodes of the American Health Information Management Association.
Medical devices such as an office MRI or a patient’s pacemaker contain PHI and often connect to networks. Lacking passwords or encryption, they are especially vulnerable to hackers or viruses, and can be used as a portal to infiltrate other devices. Such a security breach may violate both HIPAA and state laws.
There are also liability risks. In two instances, medical devices were deliberately hacked in order to harm epileptics. A pacemaker or infusion device can be reprogrammed by a person in the same room with the patient. The VA has suffered 173 known medical device infections since 2009 (MPCA 6/13/11).
The Compliance Revolution
Since 2007, the Strike Force of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) has charged more than 990 individuals for more than $2.3 billion of alleged false billings to Medicare. With ACA, compliance requirements are much amplified. “Quality” is now a compliance concern, and is increasingly integral to payment. Clinicians are expected to have systems for accurate and complete reporting of quality. Those who participate in new payment and delivery systems (such as medical homes, accountable care organizations, or value-based purchasing) need to address the fraud and abuse areas that these open up. Possibilities include “cherry picking,” “lemon dropping,” gaming of payment windows, and misreporting of quality or performance data (BNA’s HCFR 6/29/11).
Have you opted out yet?
Conscience v. Disparity and Quality
Once sacrosanct, physicians’ consciences are now perceived as a threat to “medical quality at a societal level.” We need a comprehensive framework to decide when conscience-based refusals (CBRs) to provide legal but morally controversial services should and should not be accommodated, write Douglas B. White and Baruch Brody (JAMA 5/4/11). It is a benefit for the profession to have some “morally serious persons…who are unwilling to just follow orders.” Yet “accommodating some CBRs results in an unfair distribution of burdens because only some patients will experience CBRs.” Then again, disallowing CBRs could make physicians less sympathetic to patients’ diverse moral views. How about limiting CBRs while “optimizing the burden-benefit ratio”?
Texas Medical Board Reform Passed
After years of effort by AAPS, some of the reforms of the Texas Medical Board (TMB) that we proposed are now law in Texas. The main provisions are:
- A 7-year statute of limitations on complaints;
- An end to anonymous, but not to confidential complaints;
- Disclosure to a physician when a complaint is filed by an insurance or pharmaceutical company;
- Allowing the recording of informal settlement conferences, thus reducing the abuse of power; and
- Requiring the TMB to accept the findings of fact and law by the administrative law judge.
We will continue to speak out publicly about the need for stronger reforms.
AAPS just filed a brief in district court arguing that the law does not moot most of our complaints in AAPS v. TMB, and asking that the TMB’s motion to dismiss be denied.
ObamaCare and Medicaid
In Florida v. United States, there’s a question just as important as the Commerce Clause issue: was Judge Roger Vinson correct in ruling that the federal government can force states to expand Medicaid as a condition of continuing to receive matching federal funds for the program?
Richard A. Epstein and Mario Loyola point out that the constitutional danger has long been recognized. In U.S. v. Butler (1936), the Supreme Court warned that if conditional federal grants were not restrained, the taxing and spending power “could become the instrument for the total subversion of the governmental powers reserved to the individual states.”
In South Dakota v. Dole (1987), the Court allowed Congress to condition receipt of 5% of highway funds on the state’s raising the drinking age to 21, holding that this modest penalty was mere persuasion, not coercion. It is, however, fundamentally wrong, argue these authors, to think of coercion as a matter of degree.
“The government always engages in coercion when it taxes money away from the citizens of the several states, only to return it to those states that abide by certain conditions” (WSJ 6/7/11).
Hedge Funds Finance Malpractice Litigation
An entirely new industry has recently cropped up, as speculators place bets on the lawsuit lottery. In 2010, hedge funds invested $1 billion in financing litigation. Payouts can reach tens of millions of dollars. Australia pioneered third-party financing of civil suits in the 1990s; the volume of litigation rose 16.5%. Some states prohibit this type of financing, and some state bars consider it unethical. But thanks to the trial lawyers’ lobby, Maine and then other states have enacted legislation that permits it. A typical firm is LawCash.net, write Jeff Segal et al. (Forbes 6/23/11).
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“The Court isn’t infallible. It just doesn’t admit mistakes, [which]become compounded…as they serve as precedents for further mistakes…. The rule of law is supposed to be predictable…. The clearest proof that we live under a government of men, not law, is that…if you want to guess how [the Court] will rule in a given case, reading the Constitution will be of no help.” Joseph Sobran, “Structures of Deceit”
Correspondence
Government Rewards. Physicians who anticipate reaping monetary rewards for meeting the “meaningful use” electronic health records (EHR) standards should take note of the rewards system the government instituted in 2007 for reporting “quality” information in the Medicare program. A lot of physicians did a lot of extra work collecting and reporting data, but to date about half received no “bonus” at all for doing so. According to CMS, in 2009 about 21% of eligible professionals participated, and 57% of them received a bonus averaging about $2,000.
It reminds one of the scam games at county fairs where hawkers hold out prizes that rarely anyone wins.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Is RomneyCare Different from ObamaCare? The plans are strikingly similar, and both represent the culmination of more than a decade of the same experiments in government-run health care funded and coordinated by large private foundations. The current mess in Massachusetts is clearly documented as a direct result of the ill-considered regulatory regime that Romney continues to defend.
Romney claims that Massachusetts was being crushed by having to spend $1 billion on care of the uninsured. In fact, there is evidence that a big chunk of spending from the uncompensated care pool went to subsidize Medicaid. The pool was a ripe target for hospitals set on using it as a health care ATM. In a 2005 report, the Inspector General found that 50% of emergency bad debt claims were paid without adequate documentation. One was for a routine physical exam on a visitor from Jamaica.
In short, the state was paying $1 billion for mismanagement rather than for uncompensated care. (See Health Alerts on http://healthblog.ncpa.org 5/18/11.)
Linda Gorman, Ph.D., Independence Institute, Golden, CO
Charity and Freedom. In all my years of practice, patients have rarely if ever appreciated free care to the point of being motivated to give back. In forced government quasi-charity programs, neither side (patient or physician) feels fulfilled or giving. In true charity clinics like Dr. Eck’s, there is a spirit of gratitude so that patients often voluntarily give their time and talents to help others. Both the physician and the patient can claim: “In these walls, nobody is a slave to government.” Neither is bound by government bureaucracy. It is amazing: Because of that freedom from obligation, both sides often give more. The more freedom in a society, the more there is giving.
Michael V. Riesberg, M.D., Pensacola, FL
One Way Out. I no longer think this economy, or this government—is capable of being reformed. I have asked every economist I know about how we get out of the mess we have created, including schools that don’t teach, growing numbers of people dependent on government handouts, a regulatory system that destroys entrepreneurship, and the impossible debt we have accumulated. Not one has offered anything approaching an answer. Not just a practical answer, but even any theoretical, dreamland answer. That means the entire house of cards will collapse. Maybe not for another 20 years, maybe just 10. By collapse I mean something close to an early Mel Gibson movie in which survival is the primary motive. A very large portion of our population has no practical skills. They may have advanced degrees or they may be great systems consultants and six sigma experts. But they don’t have a clue how to feed themselves, make clothes, build shelters, or fix a broken bone. After the collapse, the people who will prosper are those who can actually do something of value. We need to find a way that one patient and one doctor can find each other and work out a mutually beneficial relationship. Anything else is just noise.
Greg Scandlen, Hagerstown, MD
Board to Death. Using independent boards to strip us of our freedom appears to be the modus operandi of the Obama Administration. Consider just two of the many fiefdoms. The Consumer Financial Protection Bureau will use federal police powers to cajole unwilling contract-holders—mortgage lenders—to give up their legal rights. The Independent Payment Advisory Board (IPAB)—part of the ACA which will eventually be called the Absolute Coercion Act—will have a stranglehold on what may be paid for medical services. Political appointees of the current President, without the approval of a single elected official or a single citizen vote, will hold power over lending, shelter, life, and death.
Dave Racer, St. Paul, MN
It’s Not Your Money. The government considers Recovery Audit Contractors (RACs) a great way to reclaim funds. We got letters asking for money for two allegedly incorrect modifiers from bills for $150 paid in 2008. This will all get worse until all doctors opt out of Medicare, Medicaid, and all other insurance plans.
Craig Wax, D.O., Mullica Hill, NJ http://healthisnumberone.com
Not on the Pit Crew. Already I am seeing Dr. Gawande’s approach harm patients every day. He is part of a large plan to destroy doctors’ minds and turn us into rationing agents of the state.
David McKalip, M.D., St. Petersburg, FL
