Volume 64, No. 1 January 2008
STUPID IDEAS ON “HEALTH CARE
REFORM”
The American College of Physicians (ACP), the second-largest
physician group in the U.S., has repackaged its perennial call
for socialized medicine as “evidence based.” There’s an
“appalling lack of access to affordable health coverage,” an
impending crisis caused by a shortage of primary-care physicians,
excessive costs, etc. (www.acponline.org).
Despite the headline “Doctors Endorse Single Payer,” the ACP
stops short of saying that a system like Medicare is the best way
to achieve universal coverage. The current “pluralistic mix”
might be expanded, but everyone would be required to obtain
health insurance (Philadelphia Inquirer 12/4/07).
Elaborate plans offered by the ACP (Position Paper, Ann
Intern Med, January 2008), the AMA, or politicians all tend
to mix and match variants on several chronic, stupid ideas:
1. If one shop botches the job, keep taking your car (or
body or medical system or whatever) there for repairs.
If it looks as though various reform proposals are coming
out of the same shop, it s because they probably are. Ideas from
the gurus who created the current mess keep getting recycled from
one foundation, think tank, university, government agency, or
advocacy group to another. A lot of them are in the archives of
the Clinton Health Care Task Force.
For example, the ACP wants a “national workforce policy” to
ensure “an adequate supply of physicians trained to manage care
for the whole patient.” If trends continue, as few as 10% of
those training in internal medicine will practice as general
internists. And there’s “The Impending Disappearance of the
General Surgeon” (JAMA 2007;298:2191-2192).
The reason: “Medicine’s generalist base is disappearing as a
consequence of the reimbursement system crafted to save it the
resource-based relative value scale.” The AMA’s RUC (RBRVS Update
Committee), which meets behind closed doors, sets the policy
(Goodson J, JAMA 2007;298:2308-2310).
The solution: “reformulate” the same flawed process.
2. Give overstretched personnel more work to do.
“The right services appear to be carried out less than half
the time,” say experts on children’s medical care (N Engl J
Med 2007;357:1549-1551). Providing all recommended services
to a panel of 2,500 patients could require up to 7.5 hours per
day of physician time, Goodson writes. So while emergency rooms
are overloaded, and specialists are often unavailable to care for
the acutely sick or injured, we need to have more primary-care
doctors doing “prevention,” fixing “disparities,” and documenting
and checking compliance with “best practices.”
Everyone should have a “personal medical home” (the American
Academy of Family Physicians descriptor) or an “advanced medical
home” (the ACP’s “whole-person oriented,” “patient-centered”
model. There, the patient receives primary, principal,
coordinated, integrated, continuous, and comprehensive care with
enhanced access, quality, and safety, in a culturally and
linguistically appropriate manner, consistently using evidence
and decision-support tools. This is made possible by redirected
federal health care policy and a voluntary recognition process by
an appropriate nongovernment entity.
3. Fix an unsustainable system by forcing everyone into
it.
The ACP notes that government pays 46% of all U.S. medical
bills. “Despite repeated attempts to rein in federal expenditures
for Medicare and Medicaid, federal expenditures have continued to
increase much faster than inflation in the entire economy,” it
says. The two ACP options: single payer, or the current mix plus
more guarantees and subsidies.
4. Curb innovation and technology.
The ACP complains that the U.S. lacks a central authority
for ruling on the clinical or cost-effectiveness of new
technology, or for restraining its spread. Insurers are free to
cover, and physicians, patients, and hospitals are free to use
it.
5. Require use of prescribed health information
technology.
Interoperable data will help patients and physicians make
“informed decisions about the appropriate use of health care
services” and will “enhance monitoring of patient adherence,” ACP
states. Thus it will help curb use of diagnostic and healing
technology while enforcing use of certain approved preventive and
chronic disease monitoring technologies.
6. If people decline to buy a product, force them to; make
it “affordable” by making others pay.
This is basically the Massachusetts model. The ACP has not
awaited results from the Massachusetts experiment (see p 2).
While the ACP eschews the term “individual mandate,” that is
apparently what a “legal guarantee” of coverage means. As Paul
Krugman notes, speaking of universal coverage without a “so-
called mandate” is disingenuous and not serious; it would be like
making payroll taxes voluntary (NY Times 12/7/07).
These stupid ideas from the standpoint of improving U.S.
medicine or lowering costs are not put forth by stupid people.
Quality and spending are only pretexts. The ideas are well-
designed to further the real agenda. Bankrupt institutions and
damaged care create pressure for a government takeover.
The problem is that “expanding government authority over a
health care system that accounts for more than $2 trillion and
one sixth of the economy in a country that is ambivalent about
public power is…controversial.”
“No universal coverage plan, no matter how clever, can avoid
that ideological debate” (NEJM 2007;357:1677-1679).
The Evidence Base
The ACP pushes for “performance measures” to reduce errors
and improve quality. Here’s the evidence:
“More than 90% of the variation in reported risk-adjusted
30-day mortality rates for acute myocardial infarction,
congestive heart failure, and pneumonia is not explained by the
most evidence-based performance measures in use today” (Holloway
RG, Quill TE, JAMA 2007;298:802-804).
During the last 20 years, incentivized performance programs
have shown, writes Jeff Evans, that “what you measure generally
improves and what gets measured is generally what is easiest to
measure. But the ease of measurement does not necessarily define
the importance of the measurement” (Ob.Gyn.News
10/15/07).
Physician Manpower
The average age of physicians in New York State is 51
(MSSNYe-news 12/1/06). One of three practicing
physicians in the U.S. is over the age of 55. Anecdotal evidence
suggests that it may take two younger physicians to cover the
workload of one retiring physician, writes John Commins. Younger
physicians are less likely to work 80 hr/wk; and 24% of women
physicians under the age of 50 worked part time, in contrast to
only 2% of men (healthleadersmedia.com, October 2007). A Merritt Hawkins survey of
physicians aged 50 65 showed that 38% planned to retire from
clinical practice as soon as they could, and about half planned
to make changes that would at least reduce their patient load
within 3 years. Not a single physician indicated that recent
graduates were more dedicated and hard-working than physicians
their age, and 68% thought they were less so.
While some studies estimate that the U.S. will be short as
many as 200,000 physicians by 2020, Shannon Brownlee writes that
none of the presidential candidates has addressed the “flood of
new doctors coming down the pipeline,” which could wipe out all
the benefits of their plans by ordering tests and driving up
costs. Said Elliott Fisher of Dartmouth Medical School, “If we
sent 30% of the doctors in this country to Africa, we might raise
the level of health on both continents (“Overdose,” Atlantic
Monthly, December 2007).
A shortage of the “medical homes” touted by the ACP could
surely drive down expenditures, as in Canada, where 15.8% of the
population (29% in Quebec) has no primary physician. Without a
generalist, no one can get a referral to a specialist. About 25%
of Canada’s family doctors are foreign trained (www.stopgovernmentmedicine.com).
Per Capita and Out-of-Pocket Costs
According to Figure 3 in the ACP Position Paper (op. cit.),
the U.S. had the fifth lowest percentage (13.2%) of medical costs
paid out of pocket, compared with 27 other nations, in 2004.
France was lowest (7.6%), and Mexico highest (50.6%). The average
was 19.8%; Canada, 14.9%; Switzerland, 31.9%. It is noted that
U.S. OOP expenditures are highest in absolute terms but so is
U.S. income. Health spending increases at a constant rate of
about 8% for every $1,000 increase in GDP per capita (Wall St
J 11/13/07).
As OOP expenses declined (from 33% of personal health
expenditures in 1975), the share of GDP devoted to medical
expenses increased (N Engl J Med 2007;357:1793-1795).
The Evidence from Massachusetts
The free or nearly free (taxpayer-funded) health insurance
available to people with sufficiently low income is so popular
that the program may exceed its budget by $150 million. About
133,000 of 207,000 eligibles have signed up.
But only 10,000 of the 215,000 uninsured who are not
eligible for subsidies have obtained coverage through the
Connector. The rest either just remain uninsured or ask to be
exempted from the mandate (NY Times 11/25/07). Lawmakers
couldn’t repeal the reality that insurance is expensive because
care is expensive, exceeding the upper limit of 2.7% to 9% of
income for those earning between $15,000 and $50,000. And since
the government had run out of money for more subsidies, 20% had
to be exempted (Pipes SC, “HillaryCare the Preview,” Wall St
J 10/12/07). So much for universal coverage. And people who
have signed up for coverage are having trouble finding a doctor
who will see them.
Insurers were expected to increase rates in unsubsidized
plans by 10% to 12% next year, twice the national average. But
the Connector voted to press insurers to hold premium increases
to 5% without shifting the 8% to 10% increases in cost of care
to plan members. To enable insurers’ to meet their “target” of
5%, “providers are going to have to scale back their demands,”
said Marylou Buyse, president of the Massachusetts Association of
Health Plans (MAHP). Other suggestions by the Connector: steer
patients to lower-cost providers; encourage use of generic drugs;
and strengthen prevention programs for people with chronic
illnesses (Boston Globe 12/5/07).
Boston Medical Center HealthNet Plan is to be punished for
trying to “poach” beneficiaries from other plans, probably by
having the number of its insureds reduced (Boston Globe
12/4/07). Universal coverage was supposed to end “cherry
picking,” and choice and competition were to be encouraged, but
apparently marketing is not allowed (Consumer Power
Report 12/6/07).
The really ugly part of the Massachusetts plan is the out-
year costs. Officials projected that the plan would cost about
$1.4 billion per year for the first 3 years, and budgeted no
funds for subsequent years. According to the Kaiser Commission on
Medicaid and the Uninsured, “The state anticipates that no
additional funding will be needed beyond three years” (Hyman D,
Cato Policy Analysis No. 595, June 28, 2007).
100 Million Uninsured…
The number of Americans lacking disability coverage is about
100 million. And some 68 million lack life insurance, according
to the Life Insurance Marketing Association, writes Tim Pitcher.
The percentage of Americans without health insurance was at its
peak of 100% in 1930, and declined steadily until 1982, notes
Greg Scandlen, referencing the Source Book of Health
Insurance Data, 1990.
Maryland Court Checks Medical Board on Privacy
After more than 5 years of litigation, the Maryland Court of
Special Appeals held that psychiatrist Harold Eist, M.D., had not
failed to cooperate with a lawful investigation by demanding that
the licensure board justify its request for records of patients
who had refused to grant consent. An administrative law judge
(twice), two Maryland circuit judges, and now three appellate
judges have held that the prosecution of Dr. Eist was not
justified.
“At the heart of this case is the Maryland board’s assertion
that its power is absolute and is not answerable to patients,
physicians, legal precedents, or medical ethics,” write Janis G.
Chester, M.D., and Robert L. Pyles, M.D., (Clinical
Psychiatry News, November 2007). “It remained the board’s
position that issuance of a subpoena was not open to challenge.”
The court’s decision closely followed the legal arguments in
an amicus brief filed by AAPS and a number of other
organizations. It held that the medical board, like other
American governmental agencies, is subject to checks and
balances. If a physician or patient challenges its demand for
medical records, the burden rests with the board to prove that
its need to invade privacy outweighs the patient’s right to
privacy. The board must seek an independent court ruling.
The reaffirmation of a right to privacy is especially
important, given the rush to embrace electronic medical records
without adequate privacy protection.
AHA Claims Right to Defame with Impunity
In an amicus curiae brief filed before the Fifth Circuit
Court in the appeal of the jury verdict in Poliner v. Texas
Health Systems, the Health Care Indemnity Corporation, the
American Hospital Association (AHA), and others argue that the
Health Care Quality Improvement Act (HCQIA) bars damages based on
either tort or contract. Thus, it bars damages based on
violations of medical staff bylaws.
The AHA argues that bad-faith motives of peer reviewers are
irrelevant even outright fabrications are apparently acceptable.
In its brief, the AHA asserts that “Dr. Poliner has at all times
admitted his mistake.” Dr. Poliner insists that he did not make a
mistake, nor say that he did. All that is necessary to confer
immunity, the AHA says, is that reviewers’ statements meet some
sort of standard of “objective reasonableness” not a
“subjective” standard of good faith.
The AHA asserts that the court should not substitute its
judgment for that of the supreme hospital, notes Dr. Huntoon.
The AHA posted its brief at
www.aha.org. The AAPS amicus brief is posted at www.aapsonline.org.
P4P and Kickbacks
One way for physicians to get more money from a contract is
to meet performance measures in one of four categories: clinical
quality and patient safety, patient experience, business
operations, and utilization management. Under the last category,
physicians could be rewarded for switching to generic drugs. The
payments might be rationalized as compensation for the extra work
involved in making the shift. However, the AMA warns that such
payments could be construed as kickbacks. In 37 states,
antikickback laws also apply to private patients (BNA’s
HCFR 12/5/07).
On the National Provider Identifier
From the Healthcare IT Transition Group blog: Darrell
Pruitt, D.D.S., responds to IT professional Martin Jensen (http://blog.hittransition.com):
“[T]he NPI benefits nobody more than insurers and healthcare
IT stakeholders like you, whose careers depend on unraveling
expensive and dangerous artificial messes….
“By choice, I am not a HIPAA-covered entity….
“[T]he reason doctors have trouble getting paid in a timely
manner has nothing to do with identifiers. Delay-deny-lose is
just the way insurers traditionally operate. The NPI just makes
it cheaper for them because they save postage on denial letters.
“Do you mean to say that as desperately as our nation needs
doctors, they are going to be put out of business if they do not
get an NPI number?
“[T]he NPI…is integral to Pay-for-Performance an artifi-
cial…market force in the form of a doctor’s report card,
created and published by stakeholders…. The report card is
designed to replace a traditional free market, where consumers
determine who gets paid and how much. Like HIPAA, NPI is about
control of doctor-patient relationships.”
Peer Review Limbo
Suspended by a hospital in 2004, Dr. Jimmie R. Crow, a
surgical oncologist in Colorado, is still waiting for his initial
“fair hearing” in the hospital. In 2006, he sued the hospital. In
a unanimous opinion, the Colorado Supreme Court held that: “a
reviewing court cannot capably make that determination until the
administrative remedies have been exhausted and a complete record
has been developed to accomplish `meaningful’ review.” Dr. Crow
claimed that the hospital had repeatedly denied him access to
medical records that he needed to defend himself. Other states
that require exhaustion of all administrative remedies before
allowing access to the courts include Alaska, California, New
Jersey, and the District of Columbia (Amy Lynn Sorrell, AM
News 11/19/07).
Quota for Doctor Discipline
In 2004, the Texas legislature in its appropriations bill
expressed its expectation that 18% of complaints against
physicians should result in disciplinary action in 2006 and 2007,
an increase from the prior 10% (www.texmed.org). Only by
turning trivial and irrelevant complaints into “results” can an
agency comply with such an arbitrary request, notes a Texas
physician. One source of complaints is insurers who manufacture a
sham standard of care to support denial of benefits, and attack
physicians who provide denied care.
Deleting “Toxic” Doctors
Colorado Permanente Medical Group pulled itself out of the
red and reached all-time highs for physician and patient
satisfaction, using a process described in Business 2.0,
May 2007, by Jeffrey Pfeffer. Using a new evaluation process,
president Jack Cochran and medical director Patty Fahy began
removing 10 to 20 doctors per year, 2% of the total. The doctors’
“toxic behavior” infected the organization, they said. Since
attitudes were more important than skills, Fahy discovered,
anonymous surveys became an important part of the turnaround.
Correspondence
Managed Democracy. Parliamentary elections that
delivered a landslide (98%) victory to Vladimir Putin’s United
Russia party, were denounced by European officials. “Steered
democracy,” said the Swedish foreign minister. “Not a level
playing field,” said the European observer mission. “If Russia is
a managed democracy, these were managed elections,” said Luc van
den Brande, head of the Council of Europe delegation.
Putin’s party now has a large enough majority to amend the
constitution without the support of others. The victory at the
polls was a “sign of trust,” Putin said. “Russians will never
allow the nation to take a destructive path, as happened in some
other ex-Soviet nations” (Buffalo News 12/4/07).
Remember how advocates of managed care used to warn that
care previously provided by physicians was “unmanaged,” and by
implication reckless, inefficient, perhaps even dangerous? Is the
same true of an unmanaged what we might call “free” society?
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
The Ultimate Cost-Saver. It is quite true that costs
will be reduced if everyone accepts death. It is far cheaper to
kill people than to treat them, and that is why nationalized
systems are heading in that direction as fast as they can. This
is why we heard all the nonsense from experts of this and that
who claimed that Terri Schiavo’s death by starvation and
dehydration was peaceful, dignified, and painless. Apparently
they were unacquainted with Robert Conquest’s bone-chilling
descriptions of starving to death during Stalin’s Ukrainian
famine.
It is not true that the biggest portion of money is spent on
dying people. Recent Medicare figures show that the largest
spending occurs between age 65 and 75, not over 75.
Linda Gorman, Independence Institute, Golden, CO
Overhead. When I was born, my mother stayed in a
private room for two full weeks. At $5/day, I cost $75.
As HMOs try to tease out the part of deliveries that is
crucial and really expensive, they will eventually learn that the
true source of the heavy cost is overhead which will float
around and land on whatever is being paid for at the moment, and
typically will be something you don’t dare cut.
What is the justification? Perhaps some clue comes from
learning that my hospital sets aside 10% of revenues for new
buildings and equipment. It takes a very large team of managers
to do the planning, shift everything around during construction,
manage the confusion, hire new people, arrange early retirement
for obsolescent job descriptions, discover and respond to flaws
in the new development as they surface….
George Fisher, M.D., Philadelphia, PA
Beware of Medicare Advantage Plans. We had to refund
the better part of a year’s Medicare payments for a patient who
thought she was in standard Medicare but was actually in a
Medicare Advantage Fee-for-Service plan. We then had to bill the
FFS plan, and by so doing, agree to their rules. Since we’re the
ones who have to straighten out this mess, we contribute to
Medicare’s “low administrative overhead.”
Russell W. Faria, D.O., Newport, OR
Economic Fascism. I have been hooted down for
describing individual mandates as “fascism.” But an essay by
Thomas DiLorenzo 15 years ago explained how “corporatism” or
“industrial policy” an essential ingredient of the economic
totalitarianism practiced by Mussolini and Hitler had permeated
the Clinton Administration (Freeman, June 1994, www.fee.org). It is still very
much alive today .
Greg Scandlen, Consumers for Health Care Choices
Where Does the SCHIP Money Go? In Ohio, a lot goes to
CareSource, a highly profitable Medicaid HMO that is erecting a
$55 million building in downtown Dayton. The chairman of the
board is also CEO of Dayton’s largest hospital group. Many
CareSource enrollees are cancelling their commercial insurance.
Doctors can’t make a living on the 5% to 8% paid by CareSource.
So what is hailed as “coverage” means that services are no longer
available.
Kenneth D. Christman, M.D., Dayton, OH
Second-class Citizens. Medical professionals are no
longer full citizens with equal rights in what the late Milton
Friedman called the “socialist communist system of health care”
that exists now in the U.S. Almost all proposed plans will
increase medical communism. All physicians should refuse to serve
in any of the “plans,” as I will.
Samuel Nigro, M.D., Cleveland Heights, OH
Liberals Love Guns, Hate 2nd Amendment. Nationalized
medical care would be involuntary; thus it would depend on
government force, and ultimately on agents with guns. Without a
gun pointed at my head, I wouldn’t let the government take 15% of
my earnings for fraudulent Ponzi schemes. Who would?
Craig Cantoni, Scottsdale, AZ
All You Need to Know about Universal Healthcare. From
report GAO-08-17: “CMS and states do not prevent healthcare
providers who have federal tax debts [evaders] from enrolling in
Medicaid. CMS officials stated such a requirement for screening
providers could adversely impact the states’ ability to provide
healthcare to low income people.”
Frank Timmins, Dallas, TX
