Wednesday, November 30, 2011

The Doctor Fix and the Balloon Metaphor

Language is nothing but metaphor


November 30, 2011 – It’s here. Tis the season to battle over the annual doctor fix. The battle is more intense this year because of the super-committee's failure. The problem, as always, remains - how to fix the stupid macroeconomic Sustainable Growth Rate Formula (SGR) concocted in 1997 by Congress, but bypassed every year for the last ten years.

The “doc fix’, for the uneducated among you, is a temporary postponement of a legislatively mandated act- the SGR. If enacted this year, the SGR would cut doctor Medicare pay by 27.4%, or 29.4% if you throw in the 2.0% automatic cuts resulting from the super-committee's failure.

The SGR says the health inflation rate should be same as the general rate of inflation, although it never is because entitlement programs keep blowing up the federal balloon because people think health care is free, when it isn’t.

The trouble with SGR is if you cut doctors by 27.4%, you puncture the Medicare balloon. Doctors pull out of Medicare en masse. The balloon collapses because there are no more doctors to provide free care.

Back to health care as a political balloon. There are two schools of thought.

One, health care is a wonderful, infinitely inflatable balloon. It is a lifesaver, a rising boon for all citizens, a new new deal for which every progressive has waited a lifetime.

Two, health care is the Hindenburg. It is a socialistic death trap. It is death by mandate and will come crashing down to earth, gushing political debt gas as it falls.

These metaphors are both over-inflated. But I believe in the metaphor of the health system as a balloon, which when squeezed simply bulges out somewhere else.

You see these bulges in Medicare physician pay. Push down Medicare physician fees, and physicians will see more patients in less time, invest more in self-referral technologies, order more tests for which they know they will be paid, and practice more defensive medicine to avoid higher malpractice premiums.

Perhaps you could deflate the balloon by having doctors be rewarded only for good outcomes based on “evidence”, have them take more risks through ACOs for budget overruns, halt self-referrals and pay from pharmaceutical companies, reform malpractice, pay more for time spent with patients rather than for technologies.

And maybe, just maybe, you could puncture the balloon by paying for federal programs through vouchers, or block Medicaid grants to states, or private care through health savings accounts with high deductibles.

Don’t expect too much. The federal balloon still contains a lot of hot air, the government balloon is still rising, and balloons are still infinitely elastic and expandable.

I close with an Ogden Nash verse which I ought to apply to this blog.

One thing that literature would be
greatly the better for
Would be a more restricted employ-
ment by authors of simile and

Tweet: The Sustainable Growth Rate and the failure to fix it is a superb example of the balloon metaphor, squeeze it and it bulges out elsewhere.

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