Healthcare.gov Comedy of Errors: A One Act Play

Authors: President, Obama Administration, and Democratic Congress

Director:  Secretary of CMS (Centers of Medicare and Medicaid Services)

Cast:   The authors, Secretary of CMS,  members of  CMS information technology team,   the hub (7 federal agencies computer systems containing data determining eligibility and subsidies  for health exchange plans)

Plot:   Assume  cast knows what they are talking about when it comes to website development, assume you can fool most  of the people most of the time, assume public at large is computer literate and can easily  enroll in  health exchanges; and once enrolled, will grow to embrace health law.

Build Rube Goldberg-like site consisting of millions of lines of computer code, one line at a time. 

Delegate responsibility to CMS Secretary, meet with her one time in  3 ½ years to provide oversight and to check on progress of site.  Ask no questions. Assume everything is on track.

Delegate task of developing huge complicated  website  containing millions of lines of code to be assessed by hundreds of millions of Americans to Information Technology team members who act independently with centralized oversight.

Promise to meet impossible to meet political deadlines despite warnings by technological advisers that the site should be tested front-end to back-end before launch and might otherwise crash.

Launched anyway and collapses under stress and pressures of reality and inability of public to access, health plans to fund due to lack of accurate information and high error rate, and lack of overall workability.

Bring in political insiders to fix politically.

Meet with Silicon Valley executives, hire experienced Microsoft executive to examine what went wrong and to correct what may be uncorrectable.

Denouement: Go into full White House damage control mode with multimillion dollar public relations campaign  to explain the inexplicable.

THESE Are Last Two Weeks of 2013 and THESE Are The Polls Numbers

THESE

are the desolate, dark weeks

when nature in its barrenness

equals the stupidity of man.

The year plunges into night

and the heart plunges

lower than night.

William Carlos Williams MD (1883-1963),  These (1938)

THESE  are the last two weeks of 2013, and THESE are the for-against poll numbers  on Obama and ObamaCare.

Overall job approval, 43%/53%

Economic job approval,  39%/57%

Health law approval,   38%/52%

Direction of country, 30%/64%

Approval of young voters,  41%/54%

For President Obama and his administration,  THESE poll numbers are politically desolate, dark, and barren.  

People are losing heart because of repeated administration untruths and premature launching of an untested website for political gain.

But THESE numbers could improve, IF,

·         in the next weeks,  the website is fixed,  enrollment surges, and there are no more  surprises and snafus;

·          in the next 14 weeks, ending March 31, 2014,  7 million people, including 2. 7 million young invincibles, sign up and pay  for health exchange plans;

·         In the next 47 weeks,  ending November 9, 2014,  election day, healthcare.gov produces low cost,  reliable health plans,   and other  political events turn Obama’s way.

THESE are big IF’s.    Only one thing is certain.    Trust is a must, and trust, once lost,  is hard to regain.

Tweet:  To reverse downfall of ObamaCare and his administration,  President Obama must restore trust in competence and integrity of government

Future ObamaCare Shocks

Future shock – The shattering stress and dislocations  that we induce in individuals by subjecting them to too much change in too short a time.

Alvin Toffler (born 1928), Future Shock

Hold onto your hats and safety belts.   Future shock arrives on January 1, 2014,  when ObamaCare kicks in and descends into chaos.

Future shock will not be a single shock but a series of shocks including:

·         The “sticker shock” of new ObamaCare-qualified helaht plans with premiums averaging 30%  higher and out-of-pocket deductibles even higher,  often in the 50% to 100% higher range: said one new health plan recipient, ”It’s like having no insurance at all.”

·         Young people (18-34) “shock” when they learn to their dismay,  premiums and deductibles are often 3 to 4 times higher than before and their only choices are to pay the high plan piper, go onto Medicaid,   or opt out and pay the penalty.

·         Taxpayer “shock” when they are on the hook for billions of dollars of health insurers’ losses.

·         “I can’t keep my doctor “shock” as health exchange plans narrow your choice of doctors and your doctors isn’t on the list.

·         “I can no longer seek care”  shock at not being able to be seen at top hospitals and top specialists” because they haven’t survived the insurance company’s cut.

·         Back-end of the website “shock”   when you learn your doctor, hospital, or insurer has not been notified that you have enrolled  because of website errors and snafus. 

·         Health plan cancellations by mainstream employers,  outside the individual markets, “shock’ because they can no afford to cover you on ObamaCare compliant plans.

·         Long waits for hospital and doctor visits “shock” because of shortages of hospital beds and doctors.

·         Concierge and retainer fees of $1000 to $2000 per years “shock” in order to be seen promptly by a doctor.

·         Paying more for fewer benefits “shock”.

·         Part-time worker “shock” because employers put workers on 29 hours a week or less to avoid full-time worker penalties if they employers have 50 or more full-time employees.

·         Being told by doctors “shock”  when they tell you “We no longer accept Medicare, Medicaid, or health exchange health plan members.”

·         President Obama and Democratic congressional candidates “shock” as they delay or flee from cover from ObamaCare mandates.

Tweet: American health consumers and taxpayers and Democratic Congressional candidates: Brace yourself, health care future shocks are on the way.

Skepticism about Value-Based Physician Payments

The civilized man has the moral obligation to be skeptical, to demand credentials of all statements that claim to be facts.

Bergan Evans (1904-1978), The Natural History of Nonsense, XIV

I am skeptical about two ACA-related federal programs – PVBM (Physician Value Based Payment Modifier) and PQRS (Physician Quality Reporting System).

Both are designed to reward or punish physicians for delivering high-value low-cost care.   The response among physicians has been dismal, with less that 30% of physicians participating ,  either because of the time, expense, and hassle of entering data,  the meager financial  reward or punishment  (1-2%),  or the feeling that the programs are meaningless.

I am skeptical of those who would have us believe you can measure physician performance and reward them accordingly.  I am skeptical you can measure a physician’s value across the clinical spectrum.    I am skeptical you separate “volume,” i.e., the number of patients seen,  tests ordered , and procedures performed,  from the “value,” i.e.” quality” of the physician.

I agree with this statement in the November 28 New England Journal of Medicine by Robert Berenson, MD, of the Urban Institute and Deborah Kaye of Johns Hopkins,

“ Although we agree the value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid (CMS), despite heroic efforts, cannot accurately measure any physician’s  overall value,  now or in the foreseeable future.”

You can measure costs.  You can measure fees-for-service.  You can measure numbers of patients seen, tests ordered, procedures done, and to a lesser extent, you can measure outcomes.   But you cannot measure  “value” or “quality,” which are in the eyes of beholder.

Why not?   Part of the problem resides in the complexity of the physician-patient encounters  and complexity of medicine itself.  The typical primary care physicians 400 or more different clinical conditions each year, including  many patients with multiple chronic illnesses.    The variation between patients is enormous,  as is the variety of patient-doctor interactions.  You are dealing with a moving system with multiple moving parts over varying periods of time.   You are dealing with physicians with different clinical approaches,  different listening styles,   different personalities , different clinical reasoning, and different levels of empathy.   You are dealing with patients who have different physician expectations, and who expect or demand different physician skills.

To complicate matters, as a physician you see only  patient at a time,  at different intervals of time,  for different episodes of illness with different levels of severity,  with outcomes over which he or she has little of no control once the patient leaves the hospital or office.  Will patients change their life-long  habits,     will they change their eating habits, will they exercise, will they take their medicines?

Small wonder that physicians do not respect quality or value measures imposed from above.  Small wonder that  physicians willingly accept a 1-2% penalty for not participating in programs that measure only a fraction of what they do. 

You simply cannot measure, much less manage,  most complex clinical  situations, of the creativity and skills required to resolve or alleviate these situations.

Tweet:   Federal programs to measure physicians’  overall value through the use of data are destined to fail,  now and in the foreseeable future.

Sources:  A.T. Chien and M.B. Rosenthal, “Medicare’s Physician Value-Based Payment Modifier – Will the Tectonic Shift Create Waves?”:    R.A. Berenson and D.R. Kaye, “Grading a Physician’s Value -  The Misapplication of Performance Measurement,”  both in November 28 issue of New England Journal of Medicine.