Sunday, October 25, 2009

Health-Care Reform: The Government Run Public Option is Rooted in the Intellectual Laziness of Congress and the Administration

Consider the following syllogism:
(1) To ignore (or refuse to consider) alternative solutions to health-care reform* is intellectual laziness.
(2) Other than expanding the government’s role in health-care, (public option, Medicare for all), the US Congress and Administration ignore alternative solutions to health-care reform.
(3) The US Congress and the Administration are intellectually lazy when they fail to consider alternatives to their government expanding health-care reform proposals.
* or any other problem for that matter

What are the purported purposes of the government run public option (GoRPO)?
The administration and Congress are correct when they point out that, to reduce individual costs for health-care and to insure the uninsured, we must have competition among health insurance companies. You’ll get no argument there from me or just about anyone else on this. Many members of congress, with clandestine support from the administration, declare that the only way to achieve these goals is through the GoRPO. That is, the GoRPO with lower insurance premiums because there is no profit motive, will serve as the prime nationwide competitor to all private health insurance providers. What government run program is known for efficiency and cost containment? Having worked for the federal government for 27 years, I can attest to the inherent inefficiencies and wasteful monetary practices. Sure, it would be simple to add another entitlement program further bloating the federal budget with attendant cost escalation (more government run health-care will never be budget neutral; is Medicare?). To expand federal government involvement in our health-care system while ignoring not only failures of state run systems but also the efficacy of alternatives is nothing less than intellectual laziness. Moreover, the intended and unintended consequences have severe repercussions for the future US health-care and the very fabric of US society.

In addition to desiring to insure the uninsured and reduce costs of health-care, a key intended (though rarely discussed) consequence of the GoRPO is the progression to a single-payer (government managed) health-care system for Americans (this has been stated publicly as desirous by some members of Congress). How can this happen? At the present time, the federal government manages or provides insurance for 33% of the US population. It would only be a matter of time, through GoRPO mission creep, that the government will be responsible for over 50% of US citizens. With this majority stake, the federal government will have the power to dictate rates and services for most Americans, effectively controlling all aspects of US health-care.

The unintended consequences of a GoRPO are numerous and include, but not limited to: cost overruns (as example – the government program Medicare will be bankrupt by 2017; the Massachusetts program is $9billion in debt), rationing (the only way to reduce escalating costs), higher taxes (income tax rates in western European countries range from 40% to 60% for the middle class), fewer new drug and device developments (from a decline in medical research and development – the government will be unwilling to pay for costly new products; e.g. the U.K. refuses to offer certain effective anti-cancer drugs because of cost), reduced citizen productivity (from loss of work while awaiting procedures), slowed or arrested progress in medical advances (e.g. fewer clinical trials testing new drugs or devices), dissolution of the private insurance industry, demise of private medical practices (all health-care providers will essentially be de facto government employees), government will be forced to pay for all medical education as is done in western Europe because individuals will no longer be able to repay loans for their medical education (the President seemed astonished this past summer when a Georgetown University medical student informed him that her debt after graduation will be $300,000), reduced quality of individuals seeking to enter medicine (in the UK for example, many physicians refuse to works nights and weekends), more claim denials (Medicare already denies a higher percentage of claims than any private insurer) and destruction of the medical profession as we know it.

Are there non-governmental alternatives to the GoRPO? Sure there are. We can insure those without access to insurance (6 to 14 million people by most reasonable estimates) by creating a privately managed member-owned pool consisting of the 6 to 14 million combined with employees of small businesses. Furthermore, such a large pool will have substantial clout in negotiating rates with insurance companies, thereby lowering costs. Another way to reduce cost is to allow companies and individuals to select insurance across state lines as is done for auto insurance. This approach will provide the needed competition and reduce health insurance costs. Proof that this is effective already exists. The 9 million participants of the Federal Employees Health Benefits Program have over 250 options from which to select and have enjoyed a lower rate of rise in insurance premiums when compared to the industry as a whole. Lastly, tort reform is an essential ingredient to reduce costs in any health-care reform proposal and must be applied across the country; billions of dollars will be saved annually.

Government intrusion into the American way of life must be the absolute last resort for resolving the issue of health-care reform, not the first solution we consider. An April 1959 memo from the Department of Health, Education and Welfare to congress is germane today:
In our society the existence of a problem does not necessarily indicate that action by the Federal Government is desirable. The basic question is: Should the Federal Government at this time undertake a new program to help pay the costs of medical care…, or should it wait and see [first if other options are effective]?

How many Nobel Prize recipients in Physiology or Medicine have been from the US? Since 1950, 58%. With a single payer system, future advances may never see the light of day in clinical practice. What nation other than the US can boast being responsible for bringing significant new technologies and drugs from the bench (laboratory) to the bedside (clinic or hospital)? That other nation doesn’t exist. The US has the distinct and singular honor for the primary development of new medical technologies not only for the US but for the entire human population.

The administration and congress have a mandate to establish health-care reform. But we want it done right, the first time. You know, sometimes neither the easy nor the get-it-done quick ways are the right paths. Don’t mess this up. Don’t be lazy.

This article may be downloaded from my website:

Friday, September 18, 2009

Health-Care Reform: A Center for Comparative Effectiveness Research is Redundant and Therefore Unnecessary

One legislative proposal for health-care reform in the US House of Representatives is to establish, through the Secretary of Health and Human Services in the Agency for Healthcare Research and Quality, a Center for Comparative Effectiveness Research (H.R. 3200: Division B, TITLE IV–QUALITY, Subtitle A–Comparative Effectiveness Research). This entity would be charged “to conduct, support, and synthesize research… with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically”. Furthermore, there will be an independent Comparative Effectiveness Research Commission “to oversee and evaluate the activities carried out by the Center [for Comparative Effectiveness Research]”. Moreover, the bill designates that funding will be allocated for and to be managed by the Center [“amounts in the Comparative Effectiveness Research Trust Fund (referred to in this section as the ‘CERTF’) under section 9511 of the Internal Revenue Code of 1986 shall be available, without the need for further appropriations and without fiscal year limitation, to the Secretary to carry out this section”]. It also establishes the fund (“For provision establishing a Comparative Effectiveness Research Trust Fund and financing such Trust Fund…”). Establishing these entities would divert precious dollars from and duplicate existing efforts.

Three critical comments about the proposed Center:
(1) Comparative Effectiveness is an alternate phrase for the existing medical practice of using Evidence Based Medicine in daily clinical decision making;
(2) The Center and attendant organizations will interfere with effective organizations presently in existence, e.g. the National Institutes of Health (NIH);
(3) Guidelines from the Center will be rigidly interpreted by Medicare and Medicaid personnel (based on near universal previous experience of physicians) with the egregious result of reducing patient-physician autonomy thereby negatively impacting our flexibility to manage patients on an individualized basis.

The NIH’s mission statement is quite clear –
“….[to realize its goals] the NIH provides leadership and direction to programs designed to improve the health of the Nation by conducting and supporting research:
• in the causes, diagnosis, prevention, and cure of human diseases;
• in the processes of human growth and development;
• in the biological effects of environmental contaminants;
• in the understanding of mental, addictive and physical disorders; and
• in directing programs for the collection, dissemination, and exchange of information in medicine and health, including the development and support of medical libraries and the training of medical librarians and other health information specialists”.

Within NIH’s purview are the funding and overseeing of clinical trials (testing new treatments and procedures with sound and ethical research methods) and determining best treatments (outcomes research).

Other Existing Oversight
In addition to the NIH, independent professional medical societies (e.g. American College of Physicians-Internal Medicine, American College of Surgeons, American Psychiatric Association, American Academy of Pediatrics, et al) establish diagnostic, treatment and follow-up guidelines for specific diseases. Furthermore, these guidelines are based on best available evidence (equivalent to “comparative effectiveness”) and expert opinion.

So who is asking for the Center for Comparative Effectiveness Research? Other than the authors of the legislation, the answer is not all that clear. The request for this Center certainly does not emanate from physicians, scientists or research administrators. It appears that this legislation is nothing more than a further attempt at outside control of medical practice with the (un)intended consequence of reducing autonomy of patients, clinicians (practicing physicians) and clinical investigators. This reduction in autonomy will negatively impact our flexibility to manage patients on an individualized basis. How so? With guidelines for medical practice mandated by the Center more rigidly interpreted by Medicare and Medicaid (one size fits all approach), individual patient differences cannot be incorporated into clinical decision making. Think this doesn’t happen now? It recently happened to me regarding the cancer pain management of a patient of mine insured by Medicaid. It can only get worse with establishment of the proposed Center.

If there are gaps in existing (e.g. NIH’s) health-care missions, then rather than create another level of bureaucracy let’s make programs like the NIH more robust by expanding and solidifying its critical mission for Americans. Though a well-meaning proposal, establishing a Center for Comparative Effectiveness Research and its attendant organizations (Comparative Effectiveness Research Commission and Comparative Effectiveness Research Trust Fund) would duplicate existing efforts of successful programs, divert precious dollars from such work and reduce physician and patient autonomy.

This article may be downloaded from my website:

Saturday, September 12, 2009

Health-Care Reform: Progression From a Government Run Public Option to a Universal Single Payer Health-Care System–By the Numbers (US Population)

Health-Care Reform: Progression From a Government Run Public Option to a Universal Single Payer Health-Care System – By the Numbers (Analysis of the US Population).*

What will be required for the federal government to take control of health-care in the US? A majority stake in US health-care is the answer. The proposed government run public option (GoRPO) is the first step in the process. This is the only possible conclusion upon analysis of health insurance data later combined with the GoRPO.

The US Census Bureau considers four major categories for Americans with health insurance: Medicare, Medicaid (includes the State Children’s Health Insurance Program; SCHIP), employment based (private) health insurance (includes the Federal Employee Health Benefits Program [FEHBP] and Tricare [covers active duty personnel, retirees and their dependants]) and self-pay. In addition to Medicare and Medicaid, the federal government is also responsible for insuring veterans (VHA) and Native Americans (IHA). Insurance data from the US Census Bureau show that 111 million Americans have their health-care insured and managed by the federal government (Medicare, Medicaid, VHA, IHA), about 33% (see Figure 1). [Note: The US Census Bureau realizes that many individuals with Medicare also have other insurance, but such data are not available).

Though not managed directly by the federal government, the health insurance coverage for Tricare beneficiaries and participants in the FEHBP (approximately 9 million Americans in each of these groups for a total of 18 million insured) is actually paid for by the federal government. Since the government is responsible for paying the health insurance for these individuals, the federal government in effect controls their health-care because the government negotiates with the entities to manage the health-care of those enrolled in either Tricare or the FEHBP. That is, the health-care of those enrolled in Tricare and the FEHP is de facto government run health-care. Rather than account for these 18 million individuals under the employer based (private) health insurance category, it would be more appropriate to include them as a government program (along with Medicare, Medicaid, VHA and IHA). Consequently, this now brings the total number of Americans whose health-insurance is controlled by the federal government to 129 million, an increase to 38% (see Figure 2).

Regardless of the veracity of the number of uninsured considered to be 47 million by the administration and much of congress, we will use this number as it seems to prevail in many discussions and speeches. If we now insure the 47 million presently uninsured in the GoRPO, this brings the total number of Americans whose health-insurance is controlled by the federal government to 176 million, an increase to 46% (see Figure 3).

Now let’s suppose, not an unrealistic supposition at that, that about 10 million individuals (21% or approximately one-fifth) who pay for their own insurance (the self-pay category) realize they are eligible to participate in the GoRPO [a rather conservative estimate, actually]…. and they elect to participate. This now brings the total number of Americans whose health-insurance is controlled by the federal government to 186 million, an increase to 49% (see Figure 4).

Some have predicted, and I think correctly so, that many businesses will find it far less expensive to pay a fee to the federal government than to cover their employee’s health insurance. Let’s make a conservative estimate (guess, if you will) that of the 159 million presently receiving employer based insurance, 20 million (or about 13%) find themselves seeking and receiving health insurance through the GoRPO. This now brings the total number of Americans whose health-insurance is controlled by the federal government to 206 million, an increase to 54%; that is, more than half of the US population (see Figure 5).

With the government providing for the health insurance of over 50% of the population, it would be the major health-care stakeholder in the US. Such control would, without question, directly lead to (A) terms dictating how health-care is managed in the US, (B) [initially] a two tiered health-insurance system, and (C) [eventually] a single-payer universal health care system. That GoRPO is the first step leading us toward a single-payer universal health care system is appreciated by REP Anthony Weiner D-NY who supports such a health-care system for the US. Given the example of Medicare and in an effort to control costs, health-care rationing on a fiscal basis is only a matter of time. (See my essay titled: Health-Care Rationing - A Practical Construct).

*Abbreviations in Figures:
GoRPO – Government Run Public Option
FEHBP – Federal Employees Health Benefits Program
IHA – Indian Health Affairs
VHA – Veterans Health Administration

This article may be downloaded from my website:

Monday, September 7, 2009

Health-Care Reform: Lessons Learned – A Brief History of Medicare Legislation and Its Relevance to the Health-Care Reform Debate in the 111th Congress

The proponents of the rush to complete a health-care reform bill for the purpose of meeting an arbitrary deadline have failed to visit the congressional efforts and legislative chronology for enacting an earlier albeit much smaller health-care reform: Medicare. The take home lessons from a review of pre-enactment history of Medicare include: (1) take your time [8 years, shy one month, from submission of the Forand bill to the signing by President Lyndon B. Johnson of the 1965 amendments to the Social Security Act which contained the Medicare and Medicaid legislation]; (2) success is incremental (many fits and starts in the process); and (3) congressional hearings are an integral part of the process (at least 6 major hearings between 1957 and 1965).

Though proposals for government run health-care, including a nationalized health-care system, preceded the enactment of Medicare legislation by decades, the introduction of the Forand bill is a reasonable place to start as it was the first serious attempt toward Medicare and because the key players in the end-game were in position.

When President Franklin D. Roosevelt signed into law the Social Security Act of 1945, there was no health insurance clause in the legislation. He correctly diagnosed that such a clause was unpopular with Americans and inclusion should wait for a later time. His successor, President Harry S. Truman wanted to incorporate national health-care into his Fair Deal program. This approach proved unsuccessful; however, the seeds were sewn for limiting government assisted health-care to those eligible for Social Security (that is, over age 65).

After ten years, false starts and much push by the AFL-CIO* as well as others, on August 27, 1957 REP Aime J. Forand D-RI of the House Ways and Means Committee introduced H.R. 9467 (health-care legislation targeting Social Security beneficiaries only) to the 85th Congress. As this was submitted at the end of the session, nothing further was done until the next session when Congressional hearings were held in June 1958. The bill was re-introduced on February 18, 1959 by REP Forand in the next Congress (86th) as H.R. 4700. From March 14, 1960 the House Ways and Means Committee held extensive sessions in an attempt to amend the Social Security Act. The Forand bill was defeated twice in committee: first on March 31, 1960 and again, this time with a stripped-down bill (hospital only benefits), on June 3, 1960 – however, these were the first official votes regarding health-care legislation ever held by the Ways and Means Committee. Between these defeats, hearings were held by the Senate Subcommittee on the Problems of the Aged investigating issues related to the health-care of the aged – these hearings further clarified the plight of the elderly. During the presidential campaign of 1960, candidate SEN John F. Kennedy D-MA and others popularized the moniker “Medicare”, later attached to health-care proposals for the elderly.

Soon after, REP Wilbur D. Mills D-AR introduced another health insurance bill H.R.12580 (the Mills bill) on June 13, 1960; the bill offered a program for States to provide medical care to elderly considered “medically indigent” and who did not meet State criteria for welfare – this was not a fully fledged insurance program. Sponsored in the Senate by SEN Robert F. Kerr D-OK, the bill was modified and became known as the Kerr-Mills bill. The bill passed both the House and the Senate, the first time health-care legislation reached a floor vote in the Senate. This bill was signed into law September 13, 1961 (Public Law 86-778).

On February 13, 1961, SEN Clinton P. Anderson D-NM and REP Cecil R. King D-CA introduced hospital insurance bills as S. 909 and H.R. 4222 in the Senate and House, respectively; known as the King-Anderson bill, it covered some hospital and nursing home costs. Hearings on the bill were held during July and August. A compromise health-care amendment (Anderson-Javits [SEN Jacob I. Javits R-NY] amendment) was attached to a welfare bill (H.R. 10606) on July 17, 1962; this bill was tabled by the Senate. The following year, revised King-Anderson bills were re-introduced as H.R. 3920 and S. 880 (February 21, 1963). The House Ways and Means Committee started hearings on the King-Anderson bill in November 1963; these were completed in January 1964 after being interrupted because of President John F. Kennedy’s assassination.

After postponing action on Medicare in June 1964, H.R. 11865 (which included amendments to Social Security but without a health-care component) was introduced July 7, 1963 and passed by the House on July 24th. The Senate Finance Committee took up H.R. 11865 and began hearings on August 6. The Senate attached Medicare as an amendment to H.R.11865 and the bill passed September 2, 1964. By October 2, it was clear the House-Senate Conference Committee could not reach a consensus to address differences in the House (without Medicare) and Senate (with Medicare) versions of the bill.

As the first bills in the new year, the King-Anderson bills were re-introduced as H.R. 1 and S. 1 in January 1965. On March 23rd, the House Ways and Means Committee replaced the King-Anderson bill with H.R. 6675 (the Mills bill) which was passed by the house on April 8th. From April through June, the Senate Finance Committee held further hearings; the Senate passed the bill on July 9th. The House-Senate Conference Committee met for one week (July 14 – July 21) and resolved differences in the House and Senate bills. Over July 27th and 28th, the report by the Conference Committee was passed by the House and Senate and included two amendments to the Social Security Act: Title 18 (Medicare; Parts A and B) and Title 19 (Medicaid). On July 30, 1965 President Lyndon B. Johnson signed the bill into law – Public Law 89-87.

The present health-care legislation before congress has not been adequately vetted with the American people. One month (August 2009) of scattered Town Hall meetings cannot adequately substitute for extensive hearings required of such comprehensive legislative measures.

The April 1959 report from the Department of Health, Education and Welfare (predecessor of the present Department of Health and Human Services) to the House Ways and Means Committee contains a segment that is germane today:

In our society the existence of a problem does not necessarily indicate that action by the Federal Government is desirable. The basic question is: Should the Federal Government at this time undertake a new program to help pay the costs of medical care…, or should it wait and see [first if other options are effective]?

Eight years were necessary to enact Medicare from the time REP Aime J. Forand D-RI submitted his bill to enactment into law. Medicare has serious issues with cost containment in large part because of fraud and waste; not anticipated by proponents and Congressional authors. Do we want to repeat this error?

*AFL-CIO: American Federation of Labor-Congress of Industrial Organizations; this group is lobbying hard for the present congress to steadfastly keep the public option.

This article may be downloaded from my website:

Friday, September 4, 2009

Health-Care Reform: A Government Run Public Option is Not An Option

The administration and most health-care reform bills pending in congress propose a government run public option (GoRPO) for the purposes of insuring the uninsured and reducing health-care costs by providing competition (“making insurance companies honest”). Such a proposal is hardly the panacea it is touted to be.

This essay (in bullet format*) will explore:
 the reasons to reject a GoRPO,
 the logic behind a GoRPO,
 the pathway to a government run universal national health-care system,
 failure of the Massachusetts system, and
 alternatives to a GoRPO that will insure the uninsured and, through competition among private health insurers, reduce health-care costs.
[*The bullet format best serves the purpose of this discussion].

There are substantial reasons to reject a GoRPO:
 A GoRPO will eventually lead to a universal nationalized health-care program, changing the face of American medicine, with the resultant (un)intended consequences (to include, but not limited to: raising taxes, rationing, reducing medical innovations [technology and pharmaceutical], decimation of private medical practices).
 The cost of a GoRPO will be significant and won’t be “budget neutral” (definition of budget neutral: won’t increase the cost to the government). The Congressional Budget Office has recently refuted the administration’s claim of budget neutrality for establishing and maintaining a GoRPO. Moreover, generally missed is the administration’s oft repeated statement that proposed health-care reform will be “budget neutral in the first ten years”. What happens after the first ten years? [During its development, Medicare was predicted to be “budget neutral”; it is not].
 The Massachusetts system, a GoRPO on a smaller scale, is a failure.
 Non-government alternatives to a GoRPO exist.
 Medicare recipients will suffer as the government takes Medicare funds (cuts in reimbursements to health-care providers and hospitals rather than reducing fraud and waste) to support a GoRPO.
 A GoRPO will place additional burdens on all hospitals (community and teaching hospitals alike) because low reimbursements to health-care providers for Medicare/Medicaid and GoRPO (Medicare rates) participants will lead to these individuals seeking their health-care at emergency departments and teaching hospitals. This will be especially detrimental to academic hospitals as work effort for their teaching and research missions is deflected to take care of the additional patient workload.
 Medicare recipients will experience reduced access to health-care as more practices decline to see these patients due to further lowering of reimbursements (a result of funds diverted from Medicare for support of a GoRPO and other Medicare budgetary reductions). Worse, many rural Medicare/Medicaid recipients will forego seeking medical care as the travel expenses to city hospitals will be prohibitive.

What is the true logic behind the GoRPO?
 Medicare spending is out of control.
 The administration and many members of congress want to control Medicare/Medicaid expenditures.
 There are grave difficulties in controlling Medicare/Medicaid spending when:
(a) Medicare/Medicaid enrollees expect the same benefit coverage for state of the art services as individuals with private health insurance, and
(b) there exists in Medicare/Medicaid unchecked waste and fraud.
 Medicare and Medicaid costs can be reduced if the US government is the primary (or near majority) insurer of US citizens.
 The opening to this is the GoRPO.
 [Don’t believe me? REP Anthony Weiner (D-NY), among many others, would like a nationalized health-care program as part of the overhaul but he will accept a GoRPO because he understands this to be the open door to a nationalized health-care program (on MSNBC’s Hardball)].

So what would be the path from a GoRPO to a nationalized health-care program?
 Individuals without health-care insurance will participate in a GoRPO.
 A GoRPO will offer premiums lower than those of private health insurers.
 Individuals with health-care insurance will gradually migrate to a GoRPO.
 Some employers will find it less expensive to pay a government fee than to provide health-care coverage for their employees and these employees will find it less expensive to participate in a GoRPO than to self-pay for insurance coverage.
 Over time, a GoRPO will grow in size.
 Combined with other government run (or funded) health-care programs (Medicare [includes SCHIP], Medicaid, Veterans Health Administration, Indian Health Service, TRICARE, Federal Employees Health Benefit Program), over time the US government will be the single largest, if not the majority, health-care insurer.
 The only possible outcome will be effective government control of medicine through mandates to health-care providers (physicians, nurses, etc), hospitals and pharmaceutical companies.
 Health-care providers and hospitals will effectively be government employees.
 [I’m not the only person to reach this conclusion (health-care providers as civil servants). Paul Gigot, news journalist, has said as much (on FOX News’ FOX News Sunday) – the discussion panel unanimously laughed at the inherent and unambiguous truth in this conclusion].
Is this truly what Americans want?

Established in 2006, the Massachusetts universal health-care system has reduced the number of uninsured to 2.6% of the state’s population. The system is a failure in every other respect:
 The insured have difficulty finding physicians because many practices have limited the number of individuals the see with this insurance as the practices cannot survive if a large percentage of their practice is comprised of individuals with this insurance – this is a direct consequence of low reimbursements to healthcare providers. This result should have been no surprise to the architects of the Massachusetts plan – similar issues have existed (and continue) for Medicare/Medicaid patients. [Will the federal government mandate, by statute or financial pressure on individual states, that physicians will be required to accept these patients?]
 Because of the difficulty in finding physicians, many insured continue to visit hospital emergency rooms for their health care.
 The budget of the Massachusetts system is $9 billion in the red, i.e. not “budget neutral”. It is most reasonable to investigate the failures of the Massachusetts system before the federal government embarks on a similar system albeit on a much larger scale.

Are there credible alternatives to the GoRPO? Yes there are. Some ideas I favor:
Reduce costs: Allow all citizens to seek insurance across state lines.
Insure the uninsured: Establish not-for-profit participant owned health insurance cooperatives.
These alternatives will force insurance companies to compete and “keep them honest” without the need for a GoRPO. In other words, a GoRPO is not required to force competition.

This article may be downloaded from my website:

Sunday, August 9, 2009

Health-Care Rationing - A Practical Construct

The concept of health-care rationing has not been adequately discussed in public because it’s a touchy subject, appropriately so. But a discussion of health-care rationing and treatment delays is imperative as these are serious long-term consequences of government run public and single-payer options. On a recent news program, Secretary Sebelius has indicated that rationing goes on all the time. Yes and no; i.e. not all forms of rationing are equivalent.

First of all, rationing must not be confused with good medicine. A physician’s decision not to order a test or perform a procedure not indicated for a patient’s symptoms or disease is not rationing; rather, it’s just good medicine. We can distinguish three types of health-care rationing: natural, self and fiscal. Natural rationing is a consequence of a limited biologic resource. An example would be limitations in the number of hearts available for heart transplants. Bottom line, not everyone who needs a heart gets one. Self rationing is when a patient’s clinical situation precludes interventional therapies. For example, an individual with a broken hip and advanced cancer of the pancreas with less than two months to live would not receive a hip replacement. Physicians make these decisions all the time. It is most disappointing, to say the least, to hear talking heads and politicians (who, by the way, know little to nothing of medicine) suggest that doctors are not doing this. Furthermore, no one would dispute this form of rationing. Lastly, fiscal rationing is the limiting of health-care because of arbitrary financial constraints; e.g. where an indicated treatment (surgery, chemotherapy etc) that will improve survival and/or quality of life is not provided because of arbitrary measures (generally fiscal, but others such as age would be considered) and/or inherent delays (e.g. insufficient number of physicians). It is this type of rationing that is not standardly practiced in the U.S. and scares Americans.

This article may be downloaded from my website:

Failures of Existing US Government Run Health-Care Programs


1) Medicare beneficiaries do not have the choice of physicians because many physicians elect not to participate in this program, mostly the result of the Medicare bureaucracy.

2) Many Medicare beneficiaries do not seek and/or receive adequate medical care. Medicare does not adequately cover medical expenses and must be supplemented by other insurance. Many Medicare beneficiaries often cannot afford the supplemental insurance. Government regulations will not allow Medicare beneficiaries to pay the difference; the Government’s assumption is that Medicare coverage alone is adequate. [NOTE: there is a television commercial where an elderly individual states that with Medicare AND her insurance she is able to get her motorized wheel chair].

3) The above will be compounded as Congress and the Administration take Medicare funds to offset some of the cost of the government managed public option.

TRICARE (The health-care benefits system for the US military)

TRICARE beneficiaries who have retired from the Armed Services (and their dependents) have even fewer choices in selecting their health-care provider than those in the Medicare system because TRICARE reimbursements to hospitals and health-care providers are less than those of Medicare. Consequently, many TRICARE beneficiaries live near heavily burdened military hospitals and clinics resulting in longer waiting times, effectively reducing access to care. This care is even further reduced for Medicare eligible patients – these folks are put at the bottom of the list for access to military clinics (yes, there is a cap) because they have (or could get) Medicare. A great way to treat our military retirees and their dependents!


VA beneficiaries encounter delays in their access to health-care. Case in point (true story): An elderly gentleman with advanced kidney cancer was given a prescription by his local medical oncologist for a medicine to be taken by mouth for his kidney cancer; the prescription would be filled at the local VA hospital. The VA refused to honor the prescription informing the patient he needed to see a VA medical oncologist. The patient died from his kidney cancer while waiting for his VA appointment; essentially, de facto rationing of healthcare. Nevertheless, you will hear elected officials tout the VA system as ideal.

So, you want another health-care program run by the U.S. government?

This article may be downloaded from my website:

Tuesday, July 28, 2009

While Doctors Slept

All Americans want health-care reform. Moreover, as the President and others have said, there is a mandate for such reform. However, there is no mandate to get it wrong.

Where is the physician leadership in this health-care debate? Why aren’t the physician members of Congress leading this discussion? Physicians must be positive forces in driving this health-care discussion.

The physician leadership in the United States, I will use the American Medical Association (AMA) as a point of reference, has completely rolled over in this health-care debate. Rather than taking a firm stand in support of the quality of health-care and drawing a line in the sand, leadership has accepted relatively insignificant scraps from the discussion table. The reasons for this I think are twofold. First, there is a fear that too strong a stand by physicians will appear self-serving with resultant backlash of opinion against physicians. This fear is unfounded. If we physicians argue poignantly and firmly about the quality service we continue to provide and the concerns that we have about the negative impact the present health-care reform bill will have on patient care, our point of view will be critical component of the health care reform debate. Our fiduciary responsibilities to our patients include not only practicing good medicine but also, and very importantly, publicly taking a stand ensuring the continued existence of quality health-care. And secondly, there is a sense as in years past that little will change and it is pointless to get all bothered up. This view is wholly incorrect and to ignore the winds of change will be detrimental to Americans.

In the prelude to Presidential Obama’s lecture to the AMA, AMA’s Board of Trustee member Dr. Nancy H. Nielson pointed out four areas on which physicians (read AMA) and the administration agree. Three are rather straightforward and would be considered low-hanging fruit: (1) Support for electronic medical records – the idea here is that medical records could be easily transferred between doctors and hospitals. Every hospital administrator and physician would agree this is a most worthy goal. One issue that hasn't been resolved is getting all the competing software products to intercommunicate. Are we to only have a single product? And why would the AMA wait for government guidance on this? The AMA ought to take the leadership role in this otherwise we may very well be forced to accept a product none of us want (such as DOD’s AHLTA system). (2) Comparative effectiveness research to enhance quality medical care. We already have this: these are called clinical trials and are routinely published on completion. Moreover, each medical specialty and subspecialty already has established rigorous (generally) guidelines published for all physicians and patients to review. We surely don't need to waste money on a government agency or another study by the Institute of Medicine to determine how physicians should practice. (3) An agreement between the AMA and the administration on medical liability (physician malpractice). Really? What auditory filter does the AMA leadership have? The President has clearly stated that he has no desire for tort reform. The fourth area involves Medicare reimbursement. Dr. Nielson indicated there is an agreement to use realistic numbers, i.e. dollars, in determining the true cost of treating Medicare patients and charting a new course to replace Medicare physician payments. Don't you believe it. This is lip service to physician concerns and a political ploy to get physicians on board – the Administration is already touting this achievement. The AMA is being taken for a ride – this is no less than the story of the gingerbread man.

In President Obama's address to the AMA, it is clear he and his administration understand neither physicians nor the practice of medicine. He discusses the needed change from quantity to quality of medicine. All the physicians I know practice quality medicine already and I know of none that practice “defensive medicine” or get extra tests. Physicians don’t benefit from ordering MRI or PET scans. He also addressed the newly popular concept of bundling reimbursement for a particular disease. For example, a patient with diabetes is admitted to the hospital for diabetic complications. With the bundling idea, rather than each physician and the hospital being paid individually for their services, a fixed lump sum will be submitted for the patient’s medical care. This will pit physicians and hospital against each other and make it easier for the government to reduce reimbursements; none of this is good for patient care. The President indicates there will not be an increased burden on the national budget. How so? He will borrow from Peter (Medicare) to pay Paul (public option); this can only hurt those on Medicare. The president demonstrated a paternalistic view toward physicians, at one point essentially instructing physicians not to worry about the business side; just leave it up to the government. [So lawyers who want to practice law shouldn’t be concerned about the business side of their law practice? Give me a break.] Whether in private practice or academic medicine, physicians are by now used to the business aspects of medicine – good medicine is good business. But a far more bothersome comment was when he had the temerity to instruct physicians on our motive for entering medicine. Wow! Tell that to any other professional organization. The AMA leadership ignored this (or maybe they looked to it as a form of penance).

The proposed public option will negatively impact health care in the United States, not immediately but definitely in the long-term. There are many reasons Americans must not support the public option:
1) There already exists two government programs (Medicare and TRICARE) with major unresolved issues. Why would we want a third such program? REP Joe Courtney (D-CT) has publicly stated that Medicare is efficient and therefore a model for the public option. If Medicare is so efficient, explain the more than $1 billion in fraudulent claims in the past few years.
2) Patients already receiving Medicare will have less choice in selecting a physician. This is a result of decreasing Medicare reimbursement to pay for the public option. More physicians in small private practices close to the patient’s home will see fewer patients with Medicare as their sole source of healthcare insurance. These patients will go to emergency departments for healthcare, travel long distances which many cannot afford, or will forgo medical care altogether.
3) With decreasing Medicare reimbursement to hospitals and imaging centers to pay for the public option, physicians in teaching and research hospitals will not be immune. They will be forced to see more patients in clinic and more patients will be admitted to these hospitals thereby reducing (a) clinical and basic science research, the fuel that propels medicine forward and makes US medicine sine pari, and (b) the time committed to training of the next generation of physicians.
4) More physicians in private practice will be forced to cap the number of Medicare patients the see in clinic, as many already do. As discussed above, this will be a hardship for these patients. Alternatively, the physicians will cram more Medicare patients into the clinic day with shorter visits and an overall reduction in the quality of care.
5) The cost savings to support the public option are to come from taxes (which I will not discuss), reduction in Medicare reimbursements (see above) and something completely new: government oversight of physicians practice habits. SEN Chuck Grassley (R-IA) indicated we could reduce costs by preventing patients from seeing a physician for several days on a daily basis. On numerous occasions I have followed a patient for several days as an outpatient so as to reduce costs by preventing a more expensive hospital admission. Physicians will not accept Federal oversight in their daily medical practice. [We may be willing to accept federal oversight if every other profession in the country would accept such oversight in their daily work: attorneys, plumbers, bakers, scientists, etc].
6) The law of unintended consequences and the myth of keeping your doctor are consequences of three key developments: (a) Premiums for the public option are predicted to be less than those of private insurers; (b) Hospital and physician reimbursements from the public options will not be any better than those of Medicare; (c) It is predicted that over time, individuals and families will convert to the public option. These developments will result in the following: (a) reduction in benefits as the government reigns in growing costs (Medicare and the public option combined); (b) inability of participating Americans to keep their favorite physician as practices cap the number of patients with government insurance; (c) physicians effectively become government employees as larger portions of reimbursements are federally managed and accompanied by mandated oversight; and (d) rationing of healthcare and worsening of a two-tiered healthcare system as experienced by citizens of countries with government run healthcare programs.

A government run public option is actually the easy solution, but also a more dangerous one for the long term health of US healthcare. We run the serious risk of damaging the quality of healthcare in this country. A more creative answer would take far longer to achieve and would require input from and participation of the private sector.

If the administration and supporters are indeed serious about the public option, they will demonstrate their leadership by example. The following amendment to the health-care reform bill is proposed: “For as long as a public option exists, all members of the executive branch and Congress must enroll in the public option and furthermore are not eligible for care at any military treatment facility”. Only in this way will Americans be assured of the feasibility and success of such an enterprise.

It’s worth specifically discussing health-care rationing and treatment delays as serious consequences of the eventuality of a government run program. On a recent news program, Secretary Sebelius has indicated that rationing goes on all the time. Yes and no. Rationing must not be confused with good medicine. A physician’s decision not to order a test or perform a procedure not indicated for a patient’s symptoms or disease is not rationing; rather, it’s just good medicine. There are three types of rationing: natural, self and financial. Natural rationing is a consequence of a limited biologic resource; an example would be limitations in the number of hearts available for heart transplants. Self rationing is when a patient’s clinical situation precludes interventional therapies. For example, an individual with a broken hip and advanced cancer of the pancreas with less than two months to live would not receive a hip replacement. Physicians make these decisions all the time. Financial rationing is the limiting of healthcare because of arbitrary fiscal constraints; e.g. where an indicated treatment (surgery, chemotherapy etc) that will improve survival and/or quality of life is not provided because of arbitrary measures and/or inherent delays. It is this type of rationing that scares Americans.

Why will Americans not accept financial rationing of health-care as mandated by a national run health program? This gets to our national psychology. Americans are of the mindset that anything is possible; after all we established a new nation and became the most productive nation on Earth with much hard work. We are an independent lot and believe the individual can accomplish whatever they set out to achieve. This psychology rolls over to what we expect from our medical care. We want everything reasonable to be done that will prolong survival and the quality of life. Countries that accept government health-care and rationing have a different history; a history of feudalism with largesse handed down at the discretion of a power elite (and little chance for advancement) as well as centuries of death from pestilence/disease/chronic wars with the result that dying before everything possible can be done is, though not acceptable, less unacceptable.

We hear over and over again that the cost of US health-care exceeds that of other countries and with poorer outcomes. This is far too broad a statement because it mixes apples and oranges (as well as and every other fruit). Sure the costs are higher here in the US. A major part of this is the cost of prescription medicines. It is eminently clear that the US is virtually the sole worldwide developer of new drugs that continuously make progress toward cures and improving the quality of life for the rest of world. Other countries don’t have the high costs because many drugs are just not allowed to be given (for example, some anti-cancer agents). It is very hard to think of any new drug development in other countries recently. Why? There is no incentive to develop a new drug if the government run health-care system won’t pay for its clinical use. Essentially, the US healthcare system subsidizes the world’s health-care! With regard to outcomes, let’s look at a cancer treatment example. Individuals with advanced breast cancer have, unfortunately, an incurable disease. Many countries with government run health-care programs limit treatment options. In the US, we give as many chemotherapy regimens as possible to prolong the patient’s life for years while maintaining the quality of that life. Sure the eventual outcome is the same, but the timing is different. I want to give that 38 year old mother of three with advanced breast cancer more time with her family.

Some (policymakers and non-practicing physicians) have argued that the US doesn’t have the best medical care in the world. Then why is it that people come from all over the world seek medical here? Conversely, why do Americans not seek health-care outside the US?

Physicians in the trenches taking care of patients have not been heard from. What we have are opinions of policymakers and talking heads who know little to nothing of the practice of medicine. Health-care professionals must speak up because this is not the time to hold back, our patients depend on us. We all know the potentialities when a driver falls asleep at the wheel.

This article may be downloaded from my website:

What Americans Want And Do Not Want In Their Medical Care

The Administration and Congress have established self-imposed deadlines for health-care reform. The major argument is that health-care reform is a mandate from the electorate. When the electorate was asked of we desire health-care reform, polls have convincingly demonstrated that the majority of Americans desire health-care reform. Who doesn’t want health-care reform? The problem is the following: Congress and the Administration have taken Am-ericans’ desire for reform as carte blanche to establish their version of healthcare reform. The question as to whether we want health-care reform is only the first step. The devil is always in the details.

Over the past few years, I have been asking my patients about their concerns regarding what they think should be included and excluded during considerations for improving health-care delivery in the United States. Below is a summary of their thoughts:

Americans desire the following in health-care reform:
• Affordable access to quality health-care for all – to include the uninsured, underinsured and those with pre-existing illnesses
• Adequate insurance coverage for health-care
• Competent physicians and other health-care providers
• Caring physicians and other health-care providers – health-care providers with a good bedside manner
• Choice of physician: primary care and specialty physicians [pending legislation to reduce Medicare/Medicaid reimbursements to support a government run health-care program will negatively impact Medicare and Medicaid patients in this regard]
• Choice of hospital
• Quality health-care close to home [pending legislation reduce Medicare/Medicaid reimbursements to support a government run health-care program will negatively impact Medicare and Medicaid patients in this regard]
• Research and programs for disease prevention – specifically, there appears to be quite a bit of interest in obesity and psychiatric disorders
• Improved coverage for psychiatric disorders – too often, inpatient services are cut short
• Improved end of life care
• Laws preventing private insurers from terminating coverage or drastically raising premiums on short notice
• Automatic health coverage, equivalent to previous coverage, for those who lose existing health insurance after losing their job or family member who carried the family insurance
• Health-care providers should be making medical decisions [corollary: neither insurance companies nor the Centers for Medicare and Medicaid Services should make such decisions]
Americans do not want the following:
• Delays in treatment – [Treatment delays are unacceptable when such delays would negatively influence survival (longevity), quality of life, or productivity {Scenario: A very healthy and previously active 54 year old woman, president and CEO of her manufacturing company, with painful arthritis of the hip must wait 6 months for hip replacement; this results in diminished productivity and quality of life because of limitations in mobility from the pain and requirement for strong pain medicines}].
• Rationing of health-care – [This is the elephant in the room topic; health-care rationing is unacceptable when such rationing would negatively impact survival, quality of life, or productivity {Scenario: A very healthy 73 year old woman previously very active in the community with painful arthritis of the hip is denied hip replacement because of age cut-off; this results in diminished quality of life, productivity and possibly survival}].
{This is not a “scare tactic” as some would suggest, but rather these scenarios are representative of some situations encountered in health-care systems in other countries by acquaintances or relatives of patients or colleagues of the author}.
• Denial of health-care for pre-existing disorders [citizens with pre-existing illnesses are the most in need of health-care coverage]

We’ve heard the often repeated argument that we have to do something and not do nothing. With the chance of doing something and getting it wrong? I think not. What is apparent is that the Administration and Congress have a deep rooted fear that there is a small window of opportunity to get health-care reform legislation passed, otherwise it’ll never happen. I think not. Congress and the Administration must be applauded for raising the issue of much needed health-care reform. Americans are bright and will not forget this issue; after all, health-care affects all of us, our loved ones and our financial solvency. So let’s take a deep breath and look into the details of what we as a nation want included in health-care reform. Let’s not rush to get something done for the sake of fulfilling a campaign promise. To get this wrong we run the risk of program failure while not delivering on the promise of health-care reform. Americans would prefer a well thought out plan for reform with all the above taken into account. Yes, health-care reform is an electoral mandate. It is not, however, an electoral mandate to get it wrong.

The issue of health-care reform is far too important to leave to Congress, the Administration and other policy makers. Rather, health-care reform, presented as a number of possible options, should be submitted after much discussion to the American electorate in the form of a national referendum. Then and only then can we say we got it right.

This article may be downloaded from my website: