April 29, 2016
Under Obamacare, Government Is About To Start Dictating The Care You Receive
We’re getting to President Obama’s real goal behind heath care reform: having the government dictate the kind of care patients receive.
Obamacare was never just about covering the uninsured, which could have been done for a lot less money—not to mention fraud and political fallout. What Democrats really wanted was the government telling doctors how to practice medicine.
The notion that doctors can’t be trusted with their own craft has been around for decades. For example, those who pushed Health Maintenance Organizations (HMOs) complained that doctors were getting paid more for doing more and driving up health care spending.
But most people shunned HMOs because patients believed they were being denied care. Indeed, most states passed Patient’s Bill of Rights legislation in the 1990s to limit HMO denial-of-care practices.
And yet Obamacare created an even more aggressive version of HMOs called Accountable Care Organizations.
I was often asked in the ‘90s, especially since I was heavily involved in medical ethics issues, if I thought it was unethical for doctors to be paid more for doing more.
I answered that it was much better for doctors to be paid more for doing more than to be paid more for doing LESS, which is what the new system proposes. Especially when politicians and bureaucrats are setting the standards for what’s considered appropriate and inappropriate medical care.
Consider the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
The journal Health Affairs explains MACRA’s goal:
[T]he challenge extends to paying physicians in a way that promotes efficient, effective, and safe care; does not incentivize excessive and unnecessary care; and fosters the judicious use of medical resources since physicians order and direct the care that constitutes the lion’s share of total Medicare spending.
Of course, one person’s “judicious use of medical resources” can be another’s rationed care.
Health Affairs outlines how the government plans to achieve its goal under MACRA’s Merit-Based Incentive Payment System [MIPS]:
Physicians in MIPS must report performance measures to CMS [Centers for Medicare and Medicaid Services]. They’ll then be graded on four factors: quality of care (30 percent); resource use (30 percent); meaningful use of EHRs [electronic health records] (25 percent); and clinical practice improvement activities (15 percent). …High-scoring physicians will get a bonus, and low-scoring physicians will see their fees reduced. …Payment tied to performance must be 25 percent of a doctor’s or group practice’s Medicare revenue in 2019, increasing to 75 percent in 2022.
Heaven help the cancer patient if Dr. Government has determined that a new and promising, but also very expensive, drug isn’t effective enough. As Dr. Scott Gottlieb recently pointed out in the Wall Street Journal, Medicare makes seniors with a particular heart valve problem jump through hoops to get a therapy that is less invasive and less dangerous than open-heart surgery. “To limit their [heart valves] use, regulators created coverage rules based on a set of strained medical criteria. It was a budget prerogative masquerading as clinical reasoning,” writes Gottlieb.
Hoop jumping to get the proper medical care can be frustrating, but now Dr. Government can cut your doctor’s compensation for using an unfavored new drug or other therapy, and increase that compensation for using a less effective but government-favored drug or therapy.
See any ethical problems there?
Of course, doctors do make mistakes, and there is room to reduce waste, improve efficiency, and eliminate the perverse economic incentives that are rampant in the U.S. health care system. But the best way to do that is to give patients, not politicians and bureaucrats, more control over their health care dollars.
There are lots of professionals—e.g., lawyers, mechanics, plumbers, etc.—who get paid more for doing more. And consumers seem to adequately manage those systems.
The question is whether Dr. Government—which brought you our dysfunctional health care system, the Obamacare website disaster, and whined for decades about how bad butter and eggs were for your diet only to flip and say “never mind”—can make better clinical decisions than your doctor.
These reimbursement changes are not about better care; they’re about bigger government and more control over all health care decisions. You think the IRS has power over you? Wait until Dr. Government can make life or death decisions.