Wednesday, April 29, 2009

Al Gore on Conflict of Interest

The Institute of Medicine released a report excoriating drug and medical-device makers for sponsoring medical education and the like. Specialist medical societies immediately collaborated on a joint press release, where they basically prostrated themselves in apology for accepting funding from these industries. They would much prefer to be dependent on government, according to their statement.

It's not news: Many states have also introduced legislation to control industry's "influence" on medical practice, as written about here.

If and when they decide to stop grovelling before the agents of the state, the medical societies could learn from Al Gore, who enthusiastically defends his commercial interest in "green" technologies for which he lobbies the government for subsidies. This video shows an exchange between the former Vice-President and Rep. Marsha Blackburn (R-TN) at a Congressional hearing on April 24.

Mrs. Blackburn tries to nail Mr. Gore for being a partner in Kleiner Perkins, a venture-capital firm hoping to benefit from government hand-outs for "green" technology. Mr. Gore just laughs it off:

"If you believe that the reason that I have been working on this issue for over thirty years is because of greed, you don't know me." He continues: "I've been willing to put my money where my mouth is. Do you think there's something wrong with being active in business in this country?..... I'm proud of it."


Any doctor or scientist should respond similarly when agents of the state accuse her of "conflict of interest" for accepting funding from the pharmaceutical or medical-device industries.

(By the way, I note that the IOM does not burden itself with the same regulations it urges the government to impose on others. It notes that its report was funded by six sponsors. But it doesn't disclose how much money each sponsor paid, or how much it paid the individuals who wrote the report. Also, the first listed sponsor was the National Institutes of Health, a government agency. So, the IOM accepts government funding and issues a report demanding more government power. By the IOM's own standards, I'd call that a conflict of interest.)

Tuesday, April 28, 2009

A Frog Slowly Boiling in Water: The Recent History of Medicaid Payments

To keep doing the same thing over and over again and expect a different result is insane. Nevertheless, physicians still think that by lobbying the government for higher fees, they will succeed in improving the government's unwillingness to pay them adequately.

One would think that the history of Government health programs would lead physicians to conclude that they should be wound down, not ramped up. This is not the case. The American Medical Association, for example, calls upon Government to increase "outreach and enrolment" for Medicaid.

A new article in Health Affairs quantifies what we have known for a long time: Medicaid's payments to physicians are falling behind. They didn't even keep up with inflation during the period, increasing by 15% over the five years to 2008, versus inflation of 20%.

And yet doctors keep cheering when politicians fragment and hinder our access to coverage by expanding government-run health programs. It's remarkably self-destructive.

Friday, April 24, 2009

More Medical Price Fixing in Florida

Last year, the Florida Medical Association managed to get a bill passed that significantly tilted the playing field away from health plans and in favor of physicians. However, one of their key provisions was dropped before the bill landed on the governor's desk: forcing health plans to accept "assignment of benefits" for out-of-network physicians.

For the record, I think the current practice of health plans negotiating contracts with networks of providers is an absurd structure, relying on artificial economies of scale that exist only because of the tax-prejudice in favor of employer-based heath benefits. Nevertheless, it is what we're stuck with today.

I think the doctors' case is bunkum, both legally and ethically. I have previously proposed binding arbitration for the more difficult question of paying ER physicians. However, if a physician declines to join a health plan's network (and I congratulate him for doing so) then that gives him the opportunity to work directly for his patients. He has no right to demand that the state command the health plan to pay him directly.

This year, the FMA is trying to fix what it did not get in last year's reform bill by advocating a stand-alone bill, S1122, which would require health plans to execute assignment of benefits for out-of-network physicians.

But at what fee schedule? We know that doctors are displeased with the way health plans calculate fees for out-of-network providers. Well, Florida's health plans have managed to stymie S1122 by inserting an amendment that caves in on assignment of benefits but limits reimbursement to 80% of Medicare's fees, and forbids doctors from charging the patient extra ("balance billing). That won't make the doctors happy, and effectively kills the intent of the bill.
Which is fine by me, but it still doesn't address the challenge. If we had individual choice in health plans, and state legislators told the insurers and doctors to go and figure out this problem on their own, what would be the result?

I think that each health plan would eventually publish a "schedule of allowances" for out-of-network treatment. When a member presents a bill for a service on the schedule, which he's received from a doctor, the health plan pays the patient the amount on the schedule. If the doctor charges a fee higher than the schedule (which the patient has previously accepted), then the patient ends up paying the doctor somewhat more than his health plan has reimbursed him.

Because the schedules would be public, I anticipate that health plans would be happy to accept assignment of benefits on this basis, which doctors might demand because it would reduce their credit exposure to individual patients. Or, they could simply demand some fraction of their fee up-front.

This is not rocket science: It just requires less government intervention.

Wednesday, April 22, 2009

Making the Health IT Bailout Work for You!

Back on April 17, the Wall Street Journal's Elizabeth Williamson reported (online subscribers only) that "stimulus confusion frustrates business." It's a well written story about how businesses are increasingly finding their attention drawn to the question: "What the heck is the government going to do next?"

Not until this morning did I read the print version, which somehow hid itself behind a piece of furniture at home for the last few days. As often happens, the print version is longer. It's also worthy of note, describing how Perot Systems, potentially a big recipient of federal Health IT cash, is angling to get the biggest chunk possible:

“Perot has dedicated dozens of people to staff ‘war-rooms’ in its headquarters
in Plano, TX, and outside Washington, to monitor federal developments, both for
itself and for its clients ‘who don’t have the resources to have people sitting
around watching C-Span'."


This is the way bailout-stimulus spending works: crowding otherwise productive employees out of their real jobs in R&D, sales, or finance, and plunking them in front of TVs instead - so they can mainline direct feeds from the government.

We are living in an Ayn Rand novel. We just haven't experienced the train crash yet.

Curing Medicine of Government

My latest column in Freedom Politics discusses the Benjamin Rush Society's debate on the "right" to health care.

Friday, April 17, 2009

Treating Cancer in Oregon: When In Doubt, Let the State Decide

While health insurers pay for diagnosis, surgery, and intravenous chemotherapy for cancer patients, they balk at paying for oral anticancer pills dispensed by pharmacies, according to a New York Times story. Although the new drugs are expensive, the journalist figures that they are surely cheaper conventional alternatives. So here's the obvious question: "If the retail drugs are better and cost less than the office-based therapies, why wouldn't profit-maximizing insurers pay for them?"

One answer may be that the supposition is wrong. The new drugs may have side effects that the article never discusses. There may be benefits to having cancer patients come to a clinic or a doctor's office for treatment to ensure adherence to therapy.

Obviously impatient with such questions, the state of Oregon has come to the rescue, by mandating health benefit plan coverage for oral anticancer drugs if a plan also covers other cancer treatments.

How did the Oregon legislators decide this was a good thing to do? According to Oregon law, a sponsor proposing a new mandated benefit is supposed to provide a report on the costs, efficacy, and other effects of mandating the benefit. The purpose of the law is to ensure that the costs do not outweigh the benefits. I telephoned the sponsoring legislator's office, which (very kindly) informed me that the legislative counsel had advised that this mandate did not call for the legally required analysis.

So, we'll never know what the costs and benefits of this mandated benefit are. The pace of imposition of mandated benefits for health insurance has increased in recent years, with little critical examination by legislatures (or journalists). This legislative overreach has dramatically reduced Americans' scope of choice in health insurance.

Thursday, April 16, 2009

Business Groups & Health Reform: Conflicts of Interest?

I enjoy the research, news, and commentary produced by the Pacific Business Group on Health, with whose Executive Director for National Health Policy, Peter Lee, I've had the privilege of sharing a podium. PBGH represents fifty large, corporate purchasers of health care.

I have not yet met PBGH's other executives, but they are all very accomplished thought (and action) leaders in health care. Often, PBGH's publications are a little too loaded with "consultant-speak" for my liking, but they are data-rich and highly informative about the challenges businesses face when managing health benefits.

So, I have become a little distressed to read PBGH's appeals for a bigger role for Government in health care. The April 2009 newsletter, Spotlight, calls on "Congress and the Obama Administration to set national priorities for improving health-care quality," et cetera, et cetera.

I have not seen PBGH (or any of its sister groups) call for a significant expansion of Government as a payor, but there's a real drift towards accepting the idea that Government should decide quality.

If we accept that Government should define and measure quality, it's a very slippery slope to having Government controlling all health-care information, designing payment-incentives, and telling providers how to answer their professional calling. Indeed, PBGH's CEO, David Lansky, MD, has accepted an appointment to the federal health IT policy committee, which is funded by the American Recovery & Reinvestment Act (a.k.a. the "stimulus", "porkulus", or "bailout for anyone who hasn't been bailed out yet").

But my alarm-bells really started ringing when I read in the newsletter that the state of California has awarded PBGH the contract to execute the California Health Plan Report Card project for 2009-2010. This is an annual measurement of health plans' "quality."
So, PBGH now views Government as a customer. Can a group for which Government is a customer advocate impartially for health reform that gives health-care dollars and control to Americans, instead of to Government?

Maybe, but it sure looks like a conflict of interest to me.

Governments that Monopolize Health Care Deny It's A "Right"

This month's Capital Ideas column addresses the Canadian province of British Columbia's attacks on Dr. Brian Day's private orthopedic-surgical clinic. (It's a story I introduced in this blog entry.)

Wednesday, April 15, 2009

Medical Bankruptcy Solved! (Actually: All Bankruptcy Solved!)

The myth of medical bankrupcty persists. Perhaps it's due to aggressive advertising campaigns. But when President Obama parroted the nonsense that one third of personal bankruptcies are caused by medical debt, even the mainstream media couldn't swallow it.

Well, I give up. Let's even ignore the fact that the government contributes to medical bankruptcy, and just accept the numbers trafficked by the advocates of government take-over of health care. I have the solution!

I recently blogged about orthopedic surgeon Dr. Brian Day's struggle to compete against the Canadian provincial government of British Columbia. It's a fight that he might yet lose, despite a four-year old Supreme Court of Canada decision that government-monopoly health care violates Canadians' civil rights.

One of the things that people "admire" about Canadian health care is that "nobody goes bankrupt paying medical bills." You may die waiting for diagnosis or treatment, but at least you ain't gone bankrupt.

What a simple solution! Bankruptcy is the legal consequence of being unable to pay debts. If people are free to spend money on things that they prefer, some will borrow more than they can pay back. Clearly, prohibiting people from spending money on health care, and taxing it away from them to fund a government-monopoly health-spending mechanism eliminates bankruptcy!

I can't believe that I never thought of this before. Why stop at medical costs? Surely, the government can abolish all bankruptcy by prohibiting people from buying cars, houses, jewelry, or paying for higher education themselves. Just tax them and have the government provide the goods and services. Bankruptcy solved!

After all, I don't think there was much bankruptcy in the old Soviet Union, Cuba, or North Korea.

Should the Government Compete In Health Insurance? The Audacity of Hope Against Experience

One of president Obama's goals is to have a government health plan compete against private insurers to provide health insurance to all Americans. He and his supporters claim that this will inject competition to the market.

If that's all that the government wanted, then it would not have monopolized health care for Americans over 65-years old. Even in areas where the government does allow some competition in the fields that it occupies, such as mail delivery, it "cherry picks" the most profitable operations. We can expect the same - and worse - in health care. Read more in this month's Health Policy Prescription.

Friday, April 10, 2009

Health Care Not a "Right" Under Government Monopoly

It used to be, that advocates of government-run health care based their claims on the notion that health care is a "right". Indeed, when the Benjamin Rush Society hosted a debate on the resolution that "universal health care is the responsibility of the federal government," one of the speakers in favor of the resolution, Dr. Oliver Fein, represented the Physicians for a National Health Program, (PNHP), which includes the "right" to health care in its mission statement.

(Personally, I enjoy it when I'm speaking publicly on health reform and someone tries to make me look evil by asking: "Do you think that health care is a human right?" My answer is: "Yes, I believe that you have a right to spend your own money on health care of your choice, free of government interference.")

Indeed, most people surely believe that "health care is a right" is the slogan emblazoned on the cornerstone of the Church of Universal Coverage. So, what happens when a government actually monopolizes health care, under this claim?

Because governments are not competent to provide health care as a "right" (anymore than they would be competent to provide shoes as a "right"), people who define their right to health care like I do have to fight the state to recognize it.

In 2005, the Supreme Court of Canada found that elements of the province of Quebec's monopoly over health care violated citizens' human rights, because of the government's failure to deliver care. Since then, other Canadians have launched similar lawsuits in other provinces.

In British Columbia, the monopolistic provincial health plan is suing Dr. Brian Day, an orthopedic surgeon, for allegedly receiving direct payment from patients for performing surgeries in his clinic. Mindful of the 2005 Supreme Court decision, the province has adopted a novel legal tactic: claiming that health care is not a right! If that is the case, then the government's monopoly obviously cannot violate citizens' rights!

So what is government-monopoly health care all about then? Government greed? Lust for power over people's lives? One thing's for sure, once the state takes over, the citizen just hasn't got a chance.

Wednesday, April 8, 2009

"Universal Health Care is the Responsibility of the Federal Government"

I've been light on the blogging for a few days because I've been in New York City assisting at a debate on the resolution above, which was held at Columbia University College of Physicians & Surgeons.

I'm privileged to be on the Board of Directors of a new organization, the Benjamin Rush Society, whose mission includes promoting "the practice of medicine, free of government control,..." This year, a number of student-leaders are founding chapters at leading medical schools, and launching them with debates on the role of the government in health care.

At Columbia yesterday, two debaters spoke in favor of the resolution and two against. Each team had one physician and one non-physician (as you can see from the invitation).
The first speaker in favor of the resolution was a committed single-payer advocate, Dr. Oliver Fein of Cornell University. What impressed me about his presentation was that it was testimonial: He recited a litany of tragedies, resulting from his patients' inability to pay for health care because of some failure of health insurance. He emphasized the hassles that he and his office staff suffer through every day, as they struggle with health plans' obstacles to approve payment for care.

Dr. Fein would love nothing better than to get health insurers out of his face. And I agreed with him: He is an internist, not a specialist who usually delivers extremely expensive care. Like (too) many of his colleagues, Dr. Fein sees a desirable empty space in his practice without insurance companies, and believes that it has to be filled with government.

Why can't Dr. Fein see that the space is better off empty? Only the patient and the doctor should be in the practice, and consumer-driven reforms achieve that by returning health-care dollars to the patients who need them.

Local chapters of the BRS will be hosting three or four more debates this year in medical schools across the country. The BRS brings physicians and medical students a message of hope for a future of medicine free of undue government control. Please to to the website to sign up for news releases, so you don't miss an event when it happens at a medical school near you.

Friday, April 3, 2009

Hospitals Forced to Become Bill Collectors?

How about "patients control health-care dollars"?

The Minneapolis-St. Paul Star-Tribune ran an article with the above headline. The article addresses a new phenomenon: Twin Cities hospitals telephoning patients before scheduled procedures, and discussing how much they will owe out of pocket.

The reason: one in ten patients now have consumer-driven health plans, and the hospitals' bad debts are piling up. Call me crazy, but I think this is great news. Even one of the patients, who was scheduled for a C-section, got over her initial shock when others pointed out to her that this standard for any other facility providing a service.

Hopefully, patients will start engaging hospitals, figuring out how to save money by discussing the costs of their procedures beforehand. It shows a significant improvement over the situation I described a litte over two years ago, where a patient couldn't even discover how much he owed a primary-car doctor after he had paid him in full!

There's still a long way to go: Although a hospital featured in the article was able to discuss the price of its charges, it was unable to state how much the surgeon and anesthiologist charged. It's as if an airline could tell you how much they charged to rent you a seat during the flight, but not how much you owed the pilot and co-pilot!

This is largely due to a turf-protection privilege that physicians have lobbied for since time immemorial that prevents "the corporate practice of medicine". It is a medieval restriction, and I measure it in the Index of Health Ownership.

But with enough pressure from patients, this too shall pass.....

Wednesday, April 1, 2009

Health Policy Consensus Group's "Statement on Health Reform"

As President Obama and the Congress continue the health "reforms" that began in 1965, the Health Policy Consensus Group published a statement signed by 22 influential analysts who have grave concerns about the political class' unwillingness to change the way the government runs U.S. health care. (Yes, I am one of the signatories!)