Most of the focus in the Obamacare debate has been on HB 3200. But Senator Max Baucus (D-MT) has been trying to forge a compromise package. Instead, he has upset both sides, the Left because it has no public option and the Right because it too contains provisions that would, in the name of cost cutting, put the expensive for whom to care at great medical hazard.
A Washington Times editorial points out one provision that I have been meaning to address. It seems that physicians who spend the top 10% in caring for patients each year will see their compensation reduced–no matter the cause! From the editorial:
Yes, there are death panels. Its members won’t even know whose deaths they are causing. But under the health care bill sponsored by Senate Finance Committee Chairman Max Baucus, Montana Democrat, death panels will indeed exist – oh so cleverly disguised as accountants. The offending provision is on Pages 80-81 of the unamended Baucus bill, hidden amid a lot of similar legislative mumbo-jumbo about Medicare payments to doctors. The key sentence: “Beginning in 2015, payment would be reduced by five percent if an aggregation of the physician’s resource use is at or above the 90th percentile of national utilization.” Translated into plain English, it means that in any year in which a particular doctor’s average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor’s payments by 5 percent.
Forget results. This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked. And because no doctor will know who falls in the top 10 percent until year’s end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.
This is simply unacceptable. It places doctors in a direct financial conflict of interest with their own patients, further undermining Hippocratic values, already under intense assault by the bioethics movement’s promotion of a quality of life ethic.
Time to steer a different course. Rather than try to remake everything, let’s focus on the cost of insurance and access to those with pre existing conditions. That can be done faster, cheaper, and without policies that undercut the equal moral value of all human life.
September 25th, 2009 | 11:21 am
What’s double-evil: no matter how well costs are ‘controled’, the top 10% of doctors get dinged anyway: you force down the 90% floor relentlessly by having all medical people play blind man’s bluff with the never-clearly-expressed goal. So people die sooner and cheaper and in more pain while doctors chase their tails trying to not be in the top 10%.
Gee, I’ve got a couple kids starting college in the next year or two – should I advise them to go into medicine?
(although I really like ‘our amatuer President’ as Obama’s informal title, I may need to switch to ‘our goals never clearly expressed President’ to more clearly acknowledge the only real result of his philosophical Pragmatism.)
September 25th, 2009 | 2:03 pm
You’re taking about an obscure cost control provision that will likely be gamed out of effectiveness. You could just as easily say that doctors will collude to use this clause to RAISE their fees overall, so even the ones that get dinged don’t feel much pain.
And you interpret THAT as death panels?
You are squandering what little credibility you have left on this issue with these hysterical anti -anything-Obama panicked rants.
September 25th, 2009 | 2:06 pm
[...] View original here: Obamacare: Death Panels by Proxy » Secondhand Smoke | A First … [...]
September 25th, 2009 | 4:01 pm
Padraig: Obscure, yes. That’s the problem. Unimportant? No. The purpose is to induce doctors to reduce patient costs. If an HMO did this, I would lead the charge. It is even more worrisome if government does it because you can’t sue.
September 25th, 2009 | 4:03 pm
I’ll grant that it’s easy to get overheated about Obama (in my case, it’s much less the President than the messianic treatment many of his followers give him that fuels my periodic overreactions). I’ll try to do better. But:
“obscure cost control provision that will likely be gamed out of effectiveness.”
If we grant this for this passage and any similar passage, then – well, then there’s no cost control, which means – what? That the system as proposed implodes, or that billions upon billions of dollars appears miraculously to keep it from imploding or – and this is the relevant point re: anti-Obama ranting – what Obama is selling here cannot possibly work in the real world as advertised, upon even rudimentary inspection.
And that’s the overall point – not that Obama is evil or wrong about everything (he is neither of these, as far as I can tell) but that he is disingenuous and, frankly, incompetent in his approach to health care reform.
September 25th, 2009 | 4:34 pm
Padraig:
Can you imagine the outcry if a private insurance company was found to have such a provision in their reimbursement rules? Just because the government runs a health care plan does not mean that it’s immune from budget pressure and the desire to force costs down – even at the expense of quality of care.
Also, don’t you think it’s a bit premature to assume that the provision will be “gamed out of effectiveness?” I don’t think you’d accept that as a defense if a private insurance company was proposing to institute this rule.
September 25th, 2009 | 9:28 pm
The provision under discussion is alarming. On the other hand, Medicare services are economically unsustainable at their current level. Isn’t the bottom line here that seniors are going to see their care cut either way?
September 25th, 2009 | 10:53 pm
Again, even if you all are right about the cost-cutting provision, how does this become “death panels”?
More neo-con fearmongering. Nothing more. Not much smoke and even less fire.
September 25th, 2009 | 11:40 pm
More “death panel” hogwash? I see you’re taking Goebbels to heart by telling a big enough lie often enough.
September 26th, 2009 | 1:00 am
penalty for spending too much money on patient = less money spent on patient = less care available to the patient = less choices = denial of wanted care = rationing = death panel. Enough said.
September 26th, 2009 | 9:30 am
” Enough said.”
No, not enough said, it’s just a cheap scare tactic unless you have an alternative that will prevent cutbacks. As noted above, Medicare under the current system is not that option.
September 26th, 2009 | 12:41 pm
I am a practicing general internist and have given these issues a great deal of thought.
At first I thought Palin’s “death panel” rhetoric was over the top; however, decreased funds for care for the elderly will mean less care, and some deaths. I believe many more American doctors will quit taking Medicare, and American kids will decline to go into medicine as a career. There’s nothing wrong with hiring foreigners for doctors (we already do to a significant extent), but we already have a shortage and expanding care will mean a worsening of the doctor shortage.
There is great variation in per-capita spending per Medicare beneficiary across the country; if the metric for the 5% cut is the spending of the top 10% nationally, then the doctors who take the cut will be concentrated in the Northeast, Southern Cal, Houston, and other places with big cities that tend to have lots more doctors and specialty care. I wonder how those members of Congress will handle the angry calls from their constituent doctors and patients? Interestingly, Baucus’ state (Montana) is not one with high per-capita Medicare spending.
September 26th, 2009 | 1:49 pm
Ken,
Consider three alternatives proposed here:
http://nrlcomm.wordpress.com/2009/06/13/hcrwebinar/
September 26th, 2009 | 2:33 pm
I can’t get too bent out of shape on this, compared to all the other issues surrounding Medicare and healthcare in general.
Insurers typically have a “reasonable and customary” clause, in which they set the reimburseable expense at the 85% percentile — anything above that the patient pays or the doctor swallows. (I think this is becoming less relevant than in the past, with negotiated rates.) Doctors who accept Medicare have already accepted being reimbursed substantially less than for non-Medicare patients. So I don’t know that this 5% ding will make a lot of difference — unless this has the effect of making it more difficult for an already sick individual to find a doctor to take them as a patient. Far bigger is the overall question of the level of doctor’s reimbursements, and the claim that this or that benefit will be funded by cutting Medicare costs.
September 26th, 2009 | 8:46 pm
Thank you for the link, Marc. I’ll give it a listen.
September 29th, 2009 | 7:10 am
No matter which way it goes, we’re still screwed. The government does not represent the best interests of the people and neither do the insurance companies. The best article I’ve read on the usurper’s healthcare nightmare as opposed to the present healthcare nightmare was in Rolling Stone magazine.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong
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