Tuesday, April 5, 2016

Are We a Bottom-Up or Top-Down Health Care Nation?
Despite the conceits of New York and Boston, almost nothing starts there.  In the course of my daily work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society.  Trends are bottom-up, fads top-own.
John Naisbitt, Megatrends, 1982
Bottom-Up Thinking
Here I shall argue that America is a bottom-up,  not a top-down society;  that every health care organization,  large or small, rests on its own bottom;  that individual self-reliance beats government dependence;  that there are limits of government intervention into the health system; that government tyranny may  result from control of economic decision-making through centralized planning;  and that the chief danger of government economic omnipotence  is loss of individual enterprise  and serfdom.
America was founded on the belief  that government is best that governs least,  that the majority at the bottom rules over the minority at the top;  that equal opportunity trumps equal results;  that you cannot standardize individual behavior through government fiat; and that, in the end, market competition is more efficient than  government  coercion.
Top-Down Thinking
ObamaCare epitomizes top-down thinking.   It does this largely through a series of mandates – individual  mandates,  business mandates,  religious mandates,   and physician mandates. The physician mandates rest on  the thesis that one can calculate “value” through an interlocking system of electronic health records, that one can regulate physician behavior  through centralized planning, that  outside experts and managers, not physicians or patients,  and that government, not markets, know best.
The Other Side of the Argument
There is, of course, another side to this argument, namely,  that ObamaCare has ensured coverage to roughly 20 million previously uninsured people;   that Medicare and Medicaid and ObamaCare now cover roughly 150 million Americans and are widely popular and inextricable ;  that outcomes based on data are more objective than subjective judgments by patients and physicians;  that the people have spoken in favor of Obama in 2008 and 2012; and that government compassion for all should override passion for individualism, which generates greed and social inequities;  and that  economic populism, and business ethics  as exemplified by conservatives, has no. place in civilized society.
I  do not know how to resolve these differences  so I turned to  Topsy-Turvy,  my medical market guru,  for guidance.
 Topsy-Turvy: An Interview with a Medical Market Guru

Q: Why do you call yourself a Topsy-Turvy Medical Market Guru?
A: Because the medical markets are turning upside down. The top is where the bottom should be, and everything is inverted or reversed from where it ought to be. A guru, of course, is someone who knows everything about everything. That’s me.
Q: Explain. Please.
A: Well, everything is consolidating at the top, in hospitals, health exchanges, health plans, and government but they are decentralizing at the bottom in the form of patient-centered, consumer-driven care with removal of those “silos” between different parts of the health system. Everything in the future will be “coordinated” and dictated by data, evidence, and value, as defined from the top-down but resented from the bottom-up.
Q: Examples. Please.
A: Take hospitals. They’re getting bigger and bigger and will soon employ 70% of all doctors and 90% of young doctors, but hospitals are setting up offices and clinics outside their walls to make their services more convenient. Of course, all hospitals and all doctors will have electronic records. Meanwhile doctors at the bottom in private practice are a dying breed.
Take health exchanges. They are a perfect example of top-down government. By February 15, the end of their 2nd sign-up period, the exchanges will have 12.7  million members. Yet 250,000 doctors at the bottom have decided not to accept health exchange members.
Consider Medicaid. It is growing like Topsy. It will soon top 70 million membership. Even conservative states, like Indiana, are reeling in more Medicaid recipients. Yet some 30% to 40% of doctors, depending on the state, refuse to accept those in Medicaid or health exchange plans. And as many as 20% no longer accept new Medicare patients, who are growing in numbers at the rate of 10,000 a day. Bottoms-up are is down.
Think about ObamaCare as a whole. It’s a budgetary sink hole , the main driver of our soon-to-be $20 trillion national debt. Yet ObamaCare is approaching a state of no return, of not going back, of irreversible government gains. It is now a creature of the IRS, who will have every American filling out a form about their insured or uninsured status, and who will penalize 6 million of us for not having a health plan.
Q: So?
A: Well, the Republicans at the top want ObamaCare reversed or repealed, but they can’t because nearly 13  million uninsured are now being subsidized in federal health exchanges,.
Republicans say the top pillars of ObamaCare – individual and employer mandates – will collapse, and the whole thing will come tumbling down. Democrats claim "massive disruption" would ensue, and hospitals and health markets would suffer terrible economic consequences.
The GOP claims ObamaCare is like Humpty-Dumpty. Critics say once Humpty-Dumpty falls off the Wall, all the President’s horses and all the President’s men won’t be able to put Humpty-Dumpty together again.
Q: Do you buy that argument?
A: No. A Peter Pan analogy is better. Peter Pan was the story of a boy who never grew up. As long as he could fly and sprinkle magic dust on everything, everything would be “fair,” and everything would come out OK for everybody. Everyone would have their "fair share"of society's cake and could eat it too.
Six of 10 Americans believe in Peter Pan and magic dust. If the Supreme Court disassembles federal subsidies, 60% of people in a Kaiser poll say government should restore the subsidies and Humpty Dumpty can be put together again.
Q: Oh, Guru, are there other factors that may destroy these fairy tale myths?
A: Two.
One is the power of smart phones and the Internet. In the last quarter, 75 million people bought Apple smartphones. These people, many of whom are millenials and middle class and many of whom resent redistribution of their incomes and health benefits, may change the system bottom-side up by demanding return and evidence for their dollar.
Two is the behavior of physicians. Nearly 50%, actually 46%, give ObamaCare a D or F grade, another 30% to 40% aren’t taking Medicaid or Medicaid patients, and 20% have either switched to cash only practices, dumped third parties, or are contemplating doing both.
If a fairy tale sounds too good to be true, it usually is. Life, you see, isn't fair. You have to work to make it fair, and Government, as hard as it tries, can't speak or act for you. Only you can.






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