Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he’d get it and you wouldn’t, it’s rationing.
It may seem absurd to worry about whether wealthy or well-insured people get every last test and exotic or speculative treatment when millions of Americans have no health insurance and millions more have gaping holes in their coverage. But the well-insured happen to include virtually all the people making the key decisions about health-care reform — members of Congress and their staffs, the White House staff, Washington journalists, and so on. These people’s fears that they would lose the right to “choose my own doctor” (code for getting treatment with all the bells and whistles) helped kill Hillary Clinton’s attempt to reform health care in the early 1990s. Fear of rationing could kill Obamacare for the same reason.
Why is no one talking about health care reform from the doctor’s perspective?
When Doctors Opt Out
By MARC SIEGEL
Here’s something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn’t automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.
Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.
More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I’ve had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider — who they liked — abruptly stopped taking Medicare. One of the top mammographers in New York City works in my office building, but she no longer accepts Medicare and charges patients more than $300 cash for each procedure. I continue to send my elderly women patients downstairs for the test because she is so good, but no one is happy about paying.
The problem is even worse with Medicaid. A 2005 Community Tracking Physician survey showed that only 50% of physicians accept this insurance. I am now one of the ones who doesn’t take it. I realized a few years ago that it wasn’t worth the money to file the paperwork for the $25 or less that I received for an office visit. HMOs are problematic as well. Recent surveys from New York show a 10% yearly dropout rate from the state’s largest HMO, the Health Insurance Plan of New York (HIP), and a 14% drop-out rate from Health Net of New York, another big HMO.
The dropout rate is less at major medical centers such as New York University’s Langone Medical Center where I work, or Mount Sinai Medical Center, because larger physician networks have more leverage when choosing health plans. Still, I am frequently hamstrung as I try to find a good surgeon or specialist to refer one of my patients to.
Overall, 11% of the doctors at NYU Langone don’t participate in at least two insurance plans — Aetna or Blue Cross, for instance — so I end up not being able to refer my patients to some of our top specialists. This problem, in addition to the mass of paperwork and diminishing reimbursements, is enough of a reason for me to consider dropping out as well.
Bottom line: None of the current plans, government or private, provide my patients with the care they need. And the care that is provided is increasingly expensive and requires a big battle for approvals. Of course, we’re promised by the Obama administration that universal health insurance will avoid all these problems. But how is that possible when you consider that the medical turnstiles will be the same as they are now, only they will be clogged with more and more patients? The doctors that remain in this expanded system will be even more overwhelmed than we are now.
I wouldn’t want to be a patient when that happens.
Dr. Siegel, an internist and associate professor of medicine at the NYU Langone Medical Center, is a Fox News medical contributor.
“A woman died in labour in a hospital lavatory after her induction was delayed because of a lack of specialist staff, an inquest was told yesterday.”
I wonder if a private hospital who could be sued for medical malpractice would have had staff-on-hand to deal with this type of situation as opposed to a government-owned hospital where the only remedies are non-equitable (i.e., no tort or medical liability)?
Democratic blogger Ezra Klein appears to be positioning Dem health care reforms as a way to cut costs, on the grounds that a reformed system will be able to make “hard choices” and “rational” coverage decisions, by which Klein seems to mean “not providing” treatments that are unproven or too expensive–when “a person’s life, or health, is not worth the price.” Matthew Yglesias’ recent post seems to be saying the same thing, though clarity isn’t its strong suit. (He must have left it on Journolist.)
Isn’t it an epic mistake to try to sell Democratic health care reform on this basis? Possible sales pitch: “Our plan will deny you unnecessary treatments!” Or maybe just “Republicans say ‘yes.’ Democrats say ‘no’!” Is that really why the middle class will sign on to a revolutionary multi-trillion dollar shift in spending–so the government can decide their life or health “is not worth the price”? I mean, how could it lose?
The “rational,” cost-cutting, “hard-choices” pitch isn’t just awful marketing–I don’t even think it’s accurate. Put it this way: I’m for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling’s example of a young patient with cancer, where “the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200.” No “rational bureaucracy” would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life. But I think the government–faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public’s sentimental bias toward life–is less likely to be “rational” than the private sector.
That is to say, the government’s more likely to pay for the treatment (assuming a doctor recommends it). So it’s government for me.
Now, I understand that President Obama has chosen to sell his health care plan in the current budget as a way to control costs. How else to even colorably bill it as a policy response to the immediate economic crisis? That it won’t control costs seemed, initially, to be merely disingenuous–and what’s a little deception if that’s what it takes to get a good universal health care law passed? But on second thought, Obama’s strategy isn’t just disingenuous. In the not-so-long run it’s ineffective, a political loser.
Didn’t universal health coverage gain traction during the anti-HMO era, when voters began to see private-sector cost-cutting bureaucrats override the decisions of doctors to provide drugs and treatments to their patients? The evil HMOs tried to kick new mothers out of the hospital after a day! Politicians responded with laws mandating treatment, with a “patients’ bill of rights,” etc. But now, through a heroic, concerted effort at self-congratulatory Obamaist groupthink, the Dems are about to cast the government in the cost-cutting, treatment denying role and put themselves on the side of the heartless bureaucratic bean counters.
More broadly, haven’t liberals historically prospered when they promised and delivered more for the average American (more Social Security, health security, prosperity, clean air) in exchange for increased spending? Why not try the same with health care? Give pandering a chance.
Peter Orszag offers a can-do outlook on controlling health care costs.
The bottom line is that health care reform must be deficit neutral in the short run and deficit reducing in the long term. We have to have scoreable savings in the short term to finance additional benefits or coverage. But we must do more than that. We have to move aggressively to change the rules of the game so that we slow the growth in long term costs. Many of these things may not have substantial short-term savings, but over the long term will contribute to more efficient arrangements in the health sector.
I think he makes it sound way too easy to control health care spending. Let me give a semi-anecdote.
My oldest daughter is in her mid-twenties. She has a friend the same age who was stricken with cancer last year. She was treated with chemotherapy, Initially, the doctors thought this had worked, but now the cancer is back. My guess is that her prospects at this point are rather frightening.
That ends the anecdote. What follows is my imagination.
Imagine it were my daughter. What would be my attitude? I imagine that I would be walking into the oncologist saying, “Look. There has to be something you can try. I don’t know whether it’s bone marrow transplants or stem cells or some clinical trial somewhere. But we can’t just sit here and watch her die. Either you give us something that has a chance of working, or we’ll find another oncologist who will.”
Next, imagine that the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200. Would I want her to get that treatment? Absolutely.
But look at the issue from a rational, bureaucratic perspective. You have to treat 200 patients at a cost of $100,000 each in order to save one life, for a cost per life saved of $20 million. Is that what a rational bureaucracy would do?
A rational bureaucracy would not even tell the family about this treatment option. But I think that in the American culture regarding medicine, I would find out about it.
This semi-anecdote says nothing about free-market medicine vs. government health care. In my mind, free-market medicine is more likely to result in the treatment being attempted, but that is not necessarily an argument for or against free-market medicine.
My point is that I would be a lot less “can-do” than Peter Orszag in promising to rein in health care spending. I think that our cultural attitudes about medical services are such that attempts to bring rational cost-effectiveness to the system may not be so easy to implement.
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