Will The ObamaCare Plan Lead to Rationing?

Current public debate over the Obama/Congress health care insurance reform bill(s) has been increasingly fixated on whether or not health care "rationing" would result.

What is medical/healthcare rationing?

"To ration healthcare is to withhold at least some useful medical services from at least some of the people who would benefit from them." (per DrRich at covertrationingblog.com)

Does the Obama administration's plan include rationing?

Actually, we already have rationing, but it's not usually recognized.

Medical rationing comes in two flavors, covert and open/explicit.

Covert rationing occurs every day, as doctors and hospitals jump through the hoops required by government and insurances to treat people. The various delays, frequent rule changes, preauthorizations, unexplained denials & etc. are rationing methods covertly practiced on thousands of patients every hour. These techniques are designed to manipulate doctors and patients to change diagnosis and treatment plans for the benefit of the insurance company or government budget. Much of the disgust with insurance companies derives from these practices.

Covert rationing is both ineffective and destructive of the relationship people have with doctors. The additional medicrats required eat up any savings. Doctors become seen as a hurdle between the patient and some desired end. I have had many patients leave my practice angry at me when I have been unable to convince a stonewalling insurance company to pay for something. HMOs are a special type of covert rationing where the doctor performs rationing on behalf of the insurer and for the benefit of him/herself.

Open rationing occurs when an explicit decision is made to not cover a useful medical service ( e.g. no dialysis past age X) and is considered by many Americans to be distasteful, even evil. I practice in a state whose Medicaid system developed a controversial explicit rationing system in order save enough money to cover tens of thousands more people. It worked fairly well until the Federal medicrats put the screws to it. Open rationing is a common bogeyman in American politics.

The Congressional plans have no explicit language establishing open rationing. That means that covert rationing will be the main method of attempting to control costs in the system initially, and it will continue to be both ineffective and destructive. As long as people can make someone else pay for their medical care, no one will be able to quench the unceasing appetite of Americans for all possible care, all the time, immediately, for every ailment and symptom (The Happy Hospitalist often states: FREE= MORE MORE=BANKRUPT).

That is a huge flaw in the Obama plan. It can not control the costs because it cannot control the volume (this is a major problem with Medicare/Medicaid). The volume of services can only be controlled by external controls (rationing) and patient choice ( make 'em pay). Controlling waste and fraud are illusory solutions.

Initial attempts to control costs in a national system will follow the line of least political resistance using feeble and infuriating covert rationing, but in the long run will require explicit rationing as other nations have done. Yes, ObamaCare will have rationing, of the irrational kind.

An excellent source for discussions of these issues is DrRich at covertrationingblog.com, everyone interested in these issues needs to read his explanations and analysis.

AWOL

I'll be on a medical mission for the next two weeks with doubtful internet access for posting.

Until then, hassle Happy (see sidebar).

Treating Me In Dementia

I had a long-time patient tell me last week that she had a solution for her own future dementia.

She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.

A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.

I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.

Any other ideas?

Does Canada Really Make Patients Wait?

In the debate about a Government-run National Health Plan, impressions of the Canadian system loom over any proposal. The influence can be subtle, educated, or not. Often it degenerates into the exalted format of childhood arguments:"Does!" "Does not!" "Does too!" etc...

Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.

Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).

One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.

My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue. 

No national health care system can afford to pay for everything, for everyone, always.  All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert. 

When The Consultant Is Non-Compliant

Pay for Performance (P4P) and the Patient Centered Medical Home are two of the schemes being touted to save the nation from nefarious, inept and greedy doctors. Chief among arguments for these ideas are that more structured routine medical care will "increase quality" and "reduce health care costs". In essence, reward docs to do what 'someone' wants them to do (and imply future penalties if they don't).

An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.

I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.

The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!

Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?

Why Should I Care If Physicians Lose Autonomy?

How does the loss of the conscience clause threaten physician autonomy? How would that affect me?

The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.

The someone will be a government medicrat.

If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.

If the doctor is forbidden to provide a service, the patient cannot receive it.

Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.

Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.

No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?

Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.

Otherwise, expect your bladder difficulties to be treated by Vogon poetry.

Saving Medicare and Social Security

We need to encourage (=pay) all the Boomers to try this.

Doctor Automomy Vs. Patient Autonomy

What should happen when patient autonomy and physician autonomy appear to conflict?

What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?

The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.

Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.

My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?

"But doctor, don't you have a duty to provide what the patient wants"?

No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.

My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.

My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?

These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?

Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?

The patient is free to seek these services. I am free to decline.

As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Abraham Lincoln

Doctor Autonomy

Just as a patient has autonomy (self-rule) for health decisions, a doctor has autonomy in practice decisions.

A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.

Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment). 

When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.  

My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.

My next post will address one threat to this liberty. 

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