I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.--Thomas Jefferson

Friday, April 22, 2011

Universal Health Care is Not the Solution


This article was first published in 2003 in the journal Orthopedics. It was written in response to a fellow Orthopedist's call for government single party payer.  Little did I know at the time how serious an attempt would be made within the next 7 years to "transform" medicine in America.

Lee D. Hieb, MD


Universal Healthcare Myths


Several superficially compelling reasons for universal healthcare are usually put forward. First, as the business of medicine becomes more complex, some physicians believe universal healthcare would be less of a hassle. Recently, a neurosurgeon commented, “I would be happy if the government would pay me $250,000 a year and took care of all running of the office so that I could see patients.” The second argument preys on physician ethics. It is often stated (and Dr Weiner discussed it in his article), that physicians under a capitalistic system fail to care for needy and sick patients. Presumably, universal healthcare, with the government looking after everyone, would somehow do charity better, and would “leave no patient behind.” The third myth is that the economy of scale would somehow cause medicine to cost less if run by a single-party payer. It is argued that the cost of the various insurance companies and government paperwork would be lessened if one unified form and one unified payer existed.

Universal Care Around the World


In the Soviet Union, medical care was free to all, but only the Polit Bureau (eg, high-ranking officials, their family, and friends) received any good care. When Boris Yeltsin required cardiac surgery, he went to a special hospital only for government officials, and was treated by American-trained surgeons. He even flew Dr Debakey from America to Russia to make judgements about his case. Why? Because he knew that he could not trust the physicians, nor the system he had helped create. As Ayn Rand wrote in Atlas Shrugged, “It is not safe to trust one’s life to a man whose life you have throttled.” According to Ann Ebeling (her husband, Dr Richard Ebeling, is President of the Foundation for Economic Education), who was raised in the Soviet Union, quality medical care was simply not available through state run medicine. To get help, patients would bribe doctors to come to their apartments and bring whatever equipment could be mobilized illegally from the hospital to perform lifesaving procedures. Black market private practice was the only effective medicine during the 70 years of economic decline and tyranny of Soviet Socialism.

Thursday, April 21, 2011

Immoral Medicine


The magician distracts the audience by doing meaningless but fascinating things with his right hand, while his left hand is doing the really meaningful activity unnoticed by the crowd.  The bigger the trick, the bigger the distraction required.

Democrats and President Obama should make David Copperfield proud.  With one hand they are distracting the American people with a nonstop barrage of bills and discussion:  What will happen to the budget? How many are really uninsured?  Is the Congressional Budget Office to be believed?

And for the ultimate distraction, Mr. Obama paraded a group of “doctors” in borrowed white coats for a great visual effect wholly devoid of  substance.  For all we knew, these guys could have been a group of actuaries at a DC convention bussed in as props for the day. (More likely they were doctors of the government paid variety, like Rahm Emanuels’s physician brother Ezekiel, sheltered in research institutions and teaching hospitals where they don’t have to run their own small businesses.)
While this diversion is going on, the real issues are hidden from the public -- the consequences of government funding of medical care on individual liberty and our moral compass.

Monday, April 11, 2011

Pay for Performance Treating the Well and Avoiding the Sick. (Letter to the Ft. Dodge Messenger)

Pay for Performance--Treating the Well and Avoiding the Sick.

On March 27th, a column in your paper appeared entitled “The one-word answer to health reform”.  For the most part I agreed with the sentiments and ideas expressed in the op ed, however I thought it ironic that under the heading of “Lowering Bureaucratic barriers”, the authors unwittingly touted a government program which will erect significant and immediate barriers that will affect the sickest among us.  Specifically they laud the idea that hospitals (and this will apply to individual physicians as well) will be paid for, as they put it, the “best care” not the “most care”. 

This program sounds good, as all government schemes do initially.  It is called P4P or Pay for Performance, and it seems reasonable that we should pay the better doctor and the better hospital more than we pay the bottom tier.  BUT, and this is a big but--how is this determined?  Government bureaucrats count what they can count, not what is ultimately important--very much like judging art by counting the brush strokes.  In the case of P4P, for example, doctors whose diabetic patients are under good control will be paid a higher fee than those with worse average monthly blood sugars.  The assumption is that the doctor totally controls the blood sugar.  The truth is that patients may choose to drink and eat bon bons, they may be too poor to get their medicine in a timely fashion, or may simply have very brittle diabetes that is difficult to control by even the best of doctors.  They may have learning deficits which make it difficult for them to be in perfect treatment compliance. What will happen to these people?  They will be discharged from the doctors’ “panels” because doctors have to run their offices and pay their increasing overhead, and they cannot afford non-compliant patients who will lower their “grade” and therefore their revenues.  Hospitals are already omitting the highest risk renal transplant candidates from the waiting lists because they will lower their “performance”.  In short, the people who least need a doctor will have one, and the sickest among us will be out in the cold. 

The other very bad aspect of P4P is its total lack of respect for the individual.  In an age when we have sequenced the human genome, and could deliver medicine tailored to the individual patient, government is enforcing a one size fits all program.  Under the rubric of “quality” we are forced into uniformity.  People become statistical ciphers.  As a surgeon, I am being told to treat patients by algorithms or face financial penalty, even when my individual patient may fall outside those guidelines.  (So far I have been able to dodge an out and out confrontation, but the shootout at the medical OK Corral looms large).

Ultimately, when you take the king’s dime, you take the king’s rules.  The only way to really give “Best Outcome to Every Patient Every Time” as written in the editorial, is to return the practice of medicine to patients and their doctors and hospitals.  Government medicine, wherever it has been applied increases cost, decreases quality, reduces patients options, and ultimately results in patients dying needlessly.  As Ronald Reagan said, “When government is the problem, more government is not the answer”.  For more information on medical economics please check out AAPSonline.org

Lee D. Hieb, MD