Ugh. It’s impossible to watch the news these days. Whether you’re conservative, liberal, independent or non-committed, it’s impossible to avoid the political bickering these days as the U.S. Presidential campaign enters its final countdown. As a physician, seeing the video of Granny being pushed off a cliff is about all I can handle.
Seriously?
No politician I know has to deal directly with Granny, but I do. I have to look her in the eye. I have to talk to her. I have to be there when she comes in with a heart that’s not beating. I have to look at her struggling to breathe. I have to decide, based on the available information like her current and past medical history, social situation, family member concerns, prior surgical history, medications, lab tests, and a myriad of other variables whether to given granny a pacemaker or not.
Not you, Mr. Politician. Not Obamacare. Not my hospital. Not the insurance company. Not Big Data.
Me.
And for the moment, I’ve got granny’s back. No matter what, if she wants and needs a pacemaker, she’ll get it.
But everything that is being proposed to save costs in health care these days threatens my ability to make the right choice for granny.
For Democrats, they want a 15-member non-elected panel that might set a limit on certain aspects of when I can give granny a pacemaker despite what she and I might think. For Republicans, they want to allow insurance companys and their Big Data (or a pre-programmed supercomputer called ’Watson’) to tell be when I can or cannot give Granny a pacemaker despite what we might think. And both political parties want to do this in the face of a tort system that hasn’t had to change at all to account for these financially-imposed ultimatums for care.
In addition, both political parties seem to be aligning behind ideas that cut payments for what I do directly, and somehow pay me for my “outcomes” of care via ’bundles’ (or some other concocted payment scheme) that defines how to distribute the bundle to the various ’stakeholders’ in granny’s care, including me. Even more telling, we see another new initiative currently being rolled out: if Granny gets an infection despite perfectly acceptable care and comes back for follow-up management, guess who won’t get paid for her ongoing care after January 1, 2013? Neither my hospital nor me.
Talk about shifting risk!
So the risk of Granny’s pacemaker care in our current capitated ACO world is shifting ever-so-quickly from a company who is in the business of taking risk (insurers), to hospitals and me who are not in the business of taking risk. I am in the business of caring for patients and expecting I’ll get paid for that care. I do not have a big, fat, holding pen of reserves that people pay in to for assuming their health care risk like an insurance company. I just have a personal checking and savings account. (No wonder hedge funds are lining up behind insurance companies – it’s a win/win for their profits!)
This trend is only getting worse. In a piece entitled ’Tackling Rising Health Care Costs in Massachusetts’ that appeared recently in the online version of the New England Journal of Medicine, we find that the near-universal health care law in Massachusetts (upon which our current health care law is modeled and was sold as cost-cutting) has the “highest personal health care spending per capita of any state.” As a result, we also learn of a new law that was just passed to counteract this fact that contains measures that further shifts the cost risk further from insurers to the hospitals and doctors. In fact, as one former Boston hospital CEO has pointed out:
Even if you believe that capitated contracts are the best thing that could happen in health care, you should not and cannot believe that the transfer of risk inherent in such contracts should go unrecognized. The state’s failure to account for this gift to the insurance company represents an example of incomplete policy-making.
But doctors in Massachusetts have recognized the problem. The legislature there forgot to consider what doctors are actually doing in Massachusetts:
… they’re leaving.
Hey Granny! Maybe we should push the insurers and these well-funded politicians off the cliff.
By Dr. Westby G. Fisher
Dr. Westby G. Fisher is a cardiologist at NorthShore University HealthSystem who writes regularly at Dr. Wes.Visit website | More posts by Author
A few thoughts/comments:
The first is to note that the Independent Payment Advisory Board (IPAB--I presume this is the "15-member non-elected panel that might set a limit on certain aspects of when I can give granny a pacemaker despite what she and I might think" mentioned above) is directly prohibited from reducing Medicare costs via the rationing of care. "Because the health care law prohibits the board from rationing care, restricting benefits, or changing eligibility criteria, IPAB will be left with few options for its cost-cutting recommendations except such payment cuts." (from http://www.pbs.org/newshour/rundown/2011/07/whether-rationing-or-controlling-costs-medicare-board-draws-heat.html).
It is also worth noting that the IPAB only comes into play if Medicare costs increase at certain rates. If, as physicians and patients, we are able to find a way to provide good care that is less expensive, the IPAB never gets involved.
The article also seems to bristle at the idea that any outside influence should tell doctors what to do with/for our patients. However, it would seem to me that physicians have not usually been very good stewards of patient care decisions. From unnecessary cardiac catheterizations (for which HCA is currently under investigation) to physician influence from the pharmaceutical and medical device industries (see the ProPublica Dollars for Docs series--http://projects.propublica.org/docdollars/), we have an inconsistent record of providing the best, evidence-based, lowest cost care for our patients. If we do not change this, then outside organizations will continue to force limits on how we practice.
The fear of physician autonomy being reined in by outside influences seems to be to be less important than to make sure that we are providing the proper care at the proper time. We need to make sure we are not providing expensive care just because we can, and we need to redesign our system to ensure we are reimbursed for providing good quality care, not just high-volume care.
@nickdawson @Paulflevy @doctorWes ACO can be an acronym for Acquired Conflict Of interest.
@Paulflevy The IPAB (I presume this is the 15-member panel @DoctorWes mentions) is forbidden from reducing Medicare costs via rationing
@RichmondDoc @Paulflevy @DoctorWes I am from the government.and I am here to help u - 1st of 3 great lies.
@Healthmessaging @Paulflevy @DoctorWes Funny that the we fear gov't rationing, but little outcry re: established insurance co rationaing.
@Healthmessaging That's one of the reasons I like to get into some of these discussions. Maybe set a precedent for others. :)
@RichmondDoc I agree with you. Thanks for the energized discussion! Too bad more of that doesn't occur. SM isn't very social after all.
@Healthmessaging If the gov't is making noise about cutting costs, it is b/c our medical profession has failed in doing the job ourselves.
@Healthmessaging I think *physicians*, hospitals, etc need to play a major role in reducing costs. Estimated 1/3 of care = unnecessary
@RichmondDoc If we have to count on government to cut costs...or keep their promises...we are all goners.
@Healthmessaging As I note, IPAB may never meet if costs contained in other ways, cannot reduce benefits or ration care.
@Healthmessaging Second comment: IPAB prohibited by #ACA from rationing care, restricting benefits, increasing premiums or pt cost-sharing.
@RichmondDoc Thanks...I am truly scared and others should be as well what will happen if that provision of Obama care is implementsed
@Healthmessaging As a result, if we find other ways to reduce cost increases, IPAB never actually has any impact on anything.
@Healthmessaging First comment would be to say that IPAB only looks at Medicare, and only if Medicare costs increase at certain rates.
@Healthmessaging I am also reluctant to generalize too much on this answer, as I do not know details of your wife's condition/care.
@Healthmessaging I am glad to hear that your wife is doing well on the medication, and I wish her continued health.
@RichmondDoc @nickdawson Don't kid yourself or others that people will be thrown away by that or any other rationing body.
@RichmondDoc @nickdawson can u promise me 15 panel will not discontinue ins. reimbursement for her Rx because <5% of pts respond well to it?
@nickdawson This why organizations like #AHRQ and @PCORI are so important: they can honestly assess what care is most effective.
@RichmondDoc @nickdawson Listen..my wife is take an expensive Rx to manage her Stage 4 NSCLC - she's 8 yr survivor.
@nickdawson The problem is that there is little financial interest in investigating what kind of care is unnecessary: takes $ from someone.
@nickdawson If we don't study our assumptions or questions our beliefs re: care, then we will continue to provide uneneccesary care.
@nickdawson This question is at the heart of why we need patient-oriented outcomes research: what care is, actually, better?
@RichmondDoc I’m not arguing one way or another. It’s a conundrum. EG some cancers w/ no data on chemo after surg. Should we pay for chemo?
@Healthmessaging @nickdawson All jokes aside, spreading misinformation doesn't do much to improve honest dialogue re: #ACA.
@nickdawson So, then, they are not equivalent therapies. PT is not equal to surgery, and it seems right to cover surgery for ACL injuries.
@RichmondDoc Depends on activities. Forward movement, PT is just as effective. If I ever want to ski again, surgery is a must.
@nickdawson I'm not 100% up on ACL literature. Any evidence surgery benefits return to activities sooner, or other benefits?
@nickdawson I am looking forward to Medicine X at Stanford next month ...you?
@Healthmessaging @RichmondDoc ipso facto
@nickdawson @RichmondDoc I think ACL repair is #2 on 15 member panel hit list - particularly if you are close to 40 and speak latin...lol
@RichmondDoc My ACL is good example. Evidence says PT = surg outcomes for many. Should my ins pay? I say yes, but slippery slope.
@RichmondDoc @Paulflevy @DoctorWes Since when did the law matter to the current administration. Say goodby to covered ER visits for elderly.
@Healthmessaging Can you provide any proof for that assertion?
@Healthmessaging I reject this comparison. Implying the #ACA wills top paying for ER visits for seniors is irresponsible nonsense.
@RichmondDoc That's the same logic the 15-panel members will use to eliminate ER visits for seniors. Find a like scenario & generalize
@Healthmessaging Many already pay taxes for supporting things opposed to faith (Quakers and anabaptists paying for war), etc.
@Healthmessaging Other employers (like Jehovah's Witnesses) already forced to pay for care they disagree with (like blood transfusions).
@Healthmessaging If you can prove the #ACA will end ER visits for seniors, please share the resource. I don't think that is true.
@RichmondDoc Violating separation of church-state by forcing christian organizations yo provider for contraception for employees via premium
@Healthmessaging The 15-member IPAB is forbidden by the #ACA from reducing Medicare costs by reducing/rationing care to seniors.
@RichmondDoc Which one? Costly end of life care would move seniors to top of hit list for 15 member panel, including ER visits.
@Paulflevy Not sure I understand how reviewing therapies and emphasizing evidence-based care amounts to "rationing"...
@RichmondDoc @Paulflevy @doctorwes It’s a tricky topic to be sure. What about when there is no evidence?
@nickdawson @RichmondDoc @Paulflevy @doctorwes If evidence mattered docs would be more empathetic and better communicators. I
@RichmondDoc Good point. Pls comment on his page.That's one reason I tweeted it: An important distinction that raises resentment often.