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Nothing New: Same Old Stuff Spun Slightly Differently: Part 2

Stanley Feld M.D.,FACP,MACE

President Obama’s speech on healthcare reform to a joint session on congress added nothing new. It was just spun differently.

He continued avoiding the issue of healthcare rationing. Sarah Palin crudely called rationing “Death Panels.” It is an effective sound bite in our sound bite society.

President Obama called her out on it and followed with his own sound bite. He said his “healthcare reform bill is not going to stand between you and your doctor.” He is disingenuous. The plan is to establish a panel of independent experts that will decide on best practices. This panel will then pass on the information to a reimbursement panel that will decide to pay or not to pay.

Barack Obama really does want to come between you and your doctor.  More precisely, he wants to change the way your doctor practices medicine, says John C. Goodman, President, CEO and the Kellye Wright Fellow of the National Center for Policy Analysis.”

“Rationing Obama-style will be done indirectly, explains Goodman.  It will be the result of administrative decisions — all ostensibly made for the best of reasons: to eliminate futile and unnecessary care.”

Physicians will be penalized by non reimbursement if they do not practice the dictated best practices. As far as one can tell the best practices will be determined by the panel decisions on the most cost effective practice. The decisions are out of the patients’ hands and their physicians’ hands. It is a clear contradiction to the Presidents sound bite that “his healthcare reform bill is not going to stand between you and your doctor.”

President Obama does not understand the dynamics of medical practice. Medical information changes by at least 10% per year. Panels take at least 2 years to determine a single best practice guidelines as evidenced by the U.S. Preventive Services Task Force (USPSTF).

USPSTF is a subsidiary of the Agency for Healthcare Research and Quality. Its backgrounder states ;

All Americans benefit from safe, effective, and efficient health care. The Agency’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. In support of this mission, AHRQ is committed to improving patient safety by developing successful partnerships and generating the knowledge and tools required for long term improvement.”

The day USPSTF published best practices for osteoporosis it was out of date. Some guidelines have not been updated since 2002. Can the government move quickly on the best and safest medical practices?

The osteoporosis guidelines were published in 2007 by a panel of names unfamiliar to me as an osteoporosis “expert.” The guidelines were outdated on publication.

Guidelines should be a teaching tool and not a decision making and reimbursement tool. President Obama’s plan looks like it is going to dictate the way medicine is to be practiced. It will eliminate physician judgment and patient freedom to choose.

President Obama is seeking authority to make reimbursement decisions through these “independent” panels to force physicians to make treatment decisions. His goal is to force physicians to do fewer CAT scans, MRI’s, blood tests and operations. The government will not pay for procedures its panels consider questionable.

A retired physician leader sent me a note he wrote to a friend a few weeks ago. He has no political agenda. He is only interested in the best care for patients at the lowest possible price.

Dear H

Let’s agree that Medicare and Medicaid (including 79 million beneficiaries, and did you know that Medicaid coverage varies from state to state?), left as they currently operate, are fiscally untenable.

If we can do that, we must also agree that our wizards in congress (lower case intended) are responsible for that condition, having created it, and endlessly tinkered with it for nearly 50 years.

  Hang onto that thought, because whatever happens this year must be viewed as just the beginning of a work in progress headed who really knows where.

Who will tell us what "high quality health care at relatively low cost" looks like.  There are no current standards that define the terms, or that set the benchmarks to use when measuring them. 

Who decides whether a test is unnecessary?  Often one doesn’t know that until after the results are in. Some tests really are not necessary, I agree, and some doctors are fiscally driven, but they do not represent the majority of the profession, and the majority of the costs in the current situation.

The Dartmouth Atlas and the articles of Gawande do point the way to regional non-uniformities in the delivery of care, and not all of it can be blamed on the malpractice bar, but some of it can.

Doctors are rarely sued for doing too many tests, but they sure as hell are sued for doing too few.   I’m all for paying for value, but I doubt if the congressional wizards can define value any better than you can, or than many doctors can.

The bottom line needs to be getting sick people well as quickly as possible, and back to their normal lives, and preferably leaving them satisfied with the care and attention they received along the way.

As for "prevention", there is really very little doctors can do to prevent disease.  They can detect disease early with timely and appropriate examinations, some of the time. When they can detect disease early, chances are that outcomes will be better.

If patients want to stay well, they can improve their chances of doing so by not getting fat and not smoking, and that is about all there currently is to prevention.

Come back to your son-in-law to wind this up.  He was offered a procedure by his physician (doctors can sell people their own shoes, and often do) that is not yet an approved procedure.

Who does the approving?  A variety of entities do the approving. One being the Institute of Medicine, and one being the National Science Foundation. The National Science Foundation is always looking at new procedures.  There is not official, stepwise review and approval process, just the evolution of peer reviewed studies over time that eventually come to be recognized as representing an improvement in outcome.

There are large numbers of people walking around with a history of spinal fusions who have done quite well, so how one predicts a life of disability for someone is not clear to me. What is clear to me is that for a patient to opt for a procedure his insurer won’t cover is the same as having no insurance at all.

Dr. D

Think about it. President Obama’s solution to achieve his goals are wrong. His route will destroy physician judgment, patient choice and the physician patient relationship.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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