Thursday, April 2, 2015

Obama, Doctors, and Health Reform

In 2009, my book Obama, Doctors, and Health Reform (IUniverse, Inc) appeared. It bore the subtitle “ A Doctor Assesses the Odds for Success, The Health System, from Top-Down to Bottom-Up, As Seen Through the Lens of Cultural Complexity.”

The odds for success, I believed then, as I do now, were not great.

I foresaw four major obstacles, which I called the four “Cs.”

-- Culture , American style, abhors the word “rationing.” Our health care culture cherishes unlimited choice, quick access to the latest and best in medical “cures,: and proven lifestyle restroing technologies. These traits conflict with a centralized, command-and-control, federal expansion of health care.

-- Complexities, American health care is a whirling Rubik’s cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxe to gore.

-- Costs, Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet scant evidence exists that these measures work. Proposed savings remain hypothetical.

-- Consequences , of curtailing health costs, may be worse than the cure, because health care constitutions and private practices in many communities are the fastest growing employer in town. Collectively, health care profoundly impacts most communities’ economies. Health care’s building blocks can’t be downsized quickly and dramatically.

To achieve reform goals, President Obama and his administration proposed four Medicare strategies.

One, initially investing heavily in ($44,000 to $64,000 per doctors) in Electronic Medical Recrods (EMRs) for doctors and hospitals.

Two, within five years, restricting or reducing Medicare payments to those doctors and hospitals that did not have EMRs.

Three, using Medicare-acquired data to pay doctors and hospitals, at the prevailing rates in the least expensive parts of the U.S., e.g. The same in urban New Jersey as rural Mississippi.

Four, stopping or reducing Medicare payments for expensive treatments that didn’t work, as determined by a federal Comparative Effectiveness Research Institute using EMR-generated Medicare data and implemented by an Independent Payment Advisory Board.

There you had it, a Medicare EMR-data-driven solution to America’s health care woes. I will leave it to the reader to judge how these obstacles and these strategies have worked out in the real world.

In the minds of the Obama administration the problems of the health system resided with the doctors and the medical-industrial complex. As economist David Leonardt explained in a Februar 2009 New York Times article (“The Big Fix: What Can Obama Do to Transform an Economy That Can No Longer Count on Wall Street or Silicon Valley.”)

“Doctors, drug makers and other medical companies persuaded the federal government to pay for expensive treatments that have scant evidence of being effective. These treatments are the primary reason the country spends s much more than any other on medicine. In these cases, and in others, interest groups successfully lobbied for actions that benefited them and hurt the larger economy.”

My response was: This is typical reform talk – those greedy doctors and their avaricious allies, drive overuse of unnecessary and expensive procedures. In reality, many patients expect these procedures to be done, since their health plans pay, and many procedures may restore a fuller lifestyle. In addition, patients and their families understandably want everything possible to be done, even though odds for success may be statistically slim.”

Fast forward to 2015. How have things worked out for those greedy doctors? Many are retiring early, not accepting or seeing fewer Medicare (24%), Medicaid (38%), and health plan exchange patients (25%), and nearly half (46%) give ObamaCare a “D”or “F” grade. This state of affairs could change , of course. Younger doctors are more accepting of ObamaCare than their older peers. The Supreme Court could drive a stake into the heart of ObamaCare in June. And the public may feel the drop in the number of uninsured justifies the costs, complexities, and consequences of ObamaCare.

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