Friday, March 16, 2012

Ethics Crisis: What Government Is Doing to Healthcare

By Jeffrey A. Singer, M.D.
Reposted from Reason.com

For the past several years, the medical profession has been undergoing a disturbing transformation. The process was begun by the Centers for Medicare and Medicaid Services (CMS) in an effort to control exploding Medicare costs, and was accelerated by the passage of the Patient Protection and Affordable Care Act of 2010. As a surgeon in practice for over 30 years, I have witnessed this transformation firsthand. I fear that my profession will soon abandon its traditional code of ethics and adopt one more suited to veterinarians.

For centuries, my predecessors and I have been inculcated with what has come to be called the “Hippocratic Ethic.” This tradition holds that I am ethically required to use the best of my knowledge to recommend to my patient what I consider to be in my patient’s best interests—without regard to the interests of the third-party payer, or the government, or anyone else.

But gradually the medical profession has been forced to give up this approach for what I like to call a “veterinary ethic,” one that places the interests of the payer (or owner) ahead of the patient. For example, when a pet owner is told by a veterinarian that the pet has a very serious medical condition requiring extremely costly surgery or other therapy, the veterinarian presents the pet’s owner with one or more options—from attempt at cure, to palliation, to euthanasia—with the associated costs, and then follows the wishes of the owner.

Several factors in combination are bringing this ethical approach to my profession.

Since the mid-1980s, Medicare has imposed price controls on health care providers. Over the years, in order to accommodate increasing Medicare utilization, physician payments have steadily dropped.

Meanwhile, the regulatory burden on physicians has increased. In the last few years, CMS required all providers to adopt electronic health records or face economic sanctions from Medicare. It is the ultimate goal that every health care provider, including pharmacies, will have electronic databases that will be accessible to the U.S. Department of Health and Human Services (HHS).

In 2009, as part of the so-called stimulus bill, the Federal Commission for the Coordination of Comparative Effectiveness Research (FCCCER) was created. Its mission is to collect the data culled from all electronic health records and make recommendations regarding the comparative effectiveness of drugs, procedures, and therapies. In rendering advice, the FCCCER will essentially answer the following question: What is the most cost-effective way of allocating a fixed amount of resources among a population of roughly 310 million people?

With this same question in mind, the U.S. Preventive Services Task Force, a committee that reports to HHS, concluded in 2009 that mammogram screenings should not be recommended to women under age 50. This caused an uproar among both private health care providers and breast cancer advocacy groups, and the task force soon backed down. Similarly, in the fall of 2011, the task force recommended the abandonment of certain routine prostate cancer screenings. Once again, health care providers and cancer advocacy groups protested, and the task force rescinded its recommendation.

In 2010 the Patient Protection and Affordable Care Act established an Independent Payment Advisory Board (IPAB). Beginning in 2014, the 15 presidential appointees on this board will determine what therapies, procedures, tests, and medications will be covered by Medicare, using advice provided by the FCCCER. Such determinations will then be used to design the coverage packages for the non-Medicare insurance offered through the government–run exchanges. The decisions of the IPAB are not subject to Congressional oversight or judicial review.

Meanwhile, in an effort to control costs now, CMS has developed practice guidelines and protocols for physicians to follow. Committees of health care academics and statisticians developed these guidelines, using data from large population samples.

These protocols govern the therapeutic decisions made by the health care practitioner—right down to the pre-operative antibiotics a surgeon may order. Despite the fact that several recent peer-reviewed studies concluded that the protocols have had no positive effect—in fact, one study showed post-op skin infections increased since the protocols were instituted—CMS imposes financial penalties on hospitals that fail to get protocol compliance from their medical staff.

Medical students and residents are now being trained to follow federally-derived protocols and guidelines as a normal part of medical practice. As a result, this new generation of doctors will be less inclined to challenge the recommendations of federal task forces and agencies. Some academics also worry that “teaching to the protocol” might discourage independent thinking and the use of intuitive knowledge, two traits essential to the practice of good medicine.

In addition, decreased reimbursements and increased regulatory demands on physicians have led many to sell their practices to hospitals. The New England Journal of Medicine* estimates that 50 percent of the nation’s doctors are now hospital employees. As private medical practice becomes more economically untenable, look for the overwhelming majority of doctors to become salaried hospital employees—many working in shifts—in the next few years. Virtually every doctor now graduating a residency program is taking a position as a salaried hospital employee.

Ten thousand people will turn 65 every day for the next 19 years, placing an even greater fiscal burden on the Medicare program.

One way CMS is trying to deal with this is by penalizing hospitals and doctors who treat patients with resistant problems. Effective this year, any patient readmitted to a hospital within 30 days of discharge for the same or a related problem will be treated by the hospital without compensation. The plan is to implement the same policy with respect to the original treating physician in the near future.

To help deal with this more definitively, an old concept with a new name is being promoted and encouraged by the Affordable Care Act: the Accountable Care Organization (ACO). The ACO harkens back to the infamous HMO capitation system of the early 1990s over which the population rebelled.

In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain goals established by Medicare with respect to cost, length of hospital stay, re-admissions, or other “core measures,” they will get to share a portion of Medicare’s savings. If the reverse happens, they will face economic penalties.

Private insurance companies are currently setting up the non-Medicare version of the ACO. These will be sold in the federally subsidized exchanges mandated by the Affordable Care Act. In this model, there are no fee-for-service payments to providers. Instead, an ACO is given a lump sum, or “bundled” payment for the entire care for a large group of insurance beneficiaries. The ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: a surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.

In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally-planned practice guidelines are the primary goal. The hospital and provider networks will live or die by these objectives.

When almost all health care providers are salaried employees of hospitals, hospitals might then be able to get ACOs to work better than their ancestor HMOs. The hospital administrators will have more control over their medical staff. If doctors don’t follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the “problem” doctors.

So where does all this place the medical profession with respect to its ethical credo? In a few years, almost all doctors will be employees of hospitals and will be ordered to practice medicine according to federally prescribed guidelines—guidelines that put the best interests of the state ahead of the interests of individual patients.

When the physician’s primary obligation is to satisfy the wishes of the payer—ultimately the wishes of the state—how can patients be truly confident in their doctors’ decisions?

I submit that it all boils down to a question of professional ethics.

The medical profession must decide—and soon—which ethical doctrine to follow: Are doctors to be agents of their patients or agents of the state? All of us should dread the latter choice—because we will all be patients some day.

Jeffrey Singer practices general surgery in Phoenix, Arizona, writes for Arizona Medicine, the journal of the Arizona Medical Association, and is treasurer of the U.S. Health Freedom Coalition.

Friday, January 6, 2012

Doctors Going Broke


Doctors are leaving the profession, claiming bankruptcy, and/or ceasing to see Medicare patients due mainly to declining reimbursements. Once again, government is at the root of all of it. Combine this with the high costs of running a private practice, the threat of trial lawyers and the hundreds of thousands of debt accumulated in medical school and you've got a healthcare time bomb. When Obamacare goes into full effect, this could be the beginning of the end of American healthcare as we know it.

NEW YORK (CNNMoney) -- Doctors in America are harboring an embarrassing secret: Many of them are going broke.

This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists.

Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice. So if a cash crunch forces the death of an independent practice, it robs a community of a vital health care resource.

"A lot of independent practices are starting to see serious financial issues," said Marc Lion, CEO of Lion & Company CPAs, LLC, which advises independent doctor practices about their finances.

Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors' lack of business acumen is also to blame.

Loans to make payroll: Dr. William Pentz, 47, a cardiologist with a Philadelphia private practice, and his partners had to tap into their personal assets to make payroll for employees last year. "And we still barely made payroll last paycheck," he said. "Many of us are also skimping on our own pay."

Pentz said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue. "Our total revenue was down about 9% last year compared to 2010," he said.

"These cuts have destabilized private cardiology practices," he said. "A third of our patients are on Medicare. So these Medicare cuts are by far the biggest factor. Private insurers follow Medicare rates. So those reimbursements are going down as well."

Pentz is thinking about an out. "If this continues, I might seriously consider leaving medicine," he said. "I can't keep working this way."

Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.

Federal law requires that Medicare reimbursement rates be adjusted annually based on a formula tied to the health of the economy. That law says rates should be cut every year to keep Medicare financially sound.

Although Congress has blocked those cuts from happening 13 times over the past decade, most recently on Dec. 23 with a two-month temporary "patch," this dilemma continues to haunt doctors every year.

Beau Donegan, senior executive with a hospital cancer center in Newport Beach, Calif., is well aware of physicians' financial woes.

"Many are too proud to admit that they are on the verge of bankruptcy," she said. "These physicians see no way out of the downward spiral of reimbursement, escalating costs of treating patients and insurance companies deciding when and how much they will pay them."

Donegan knows an oncologist "with a stellar reputation in the community" who hasn't taken a salary from his private practice in over a year. He owes drug companies $1.6 million, which he wasn't reimbursed for.

Dr. Neil Barth is that oncologist. He has been in the top 10% of oncologists in his region, according to U.S. News Top Doctors' ranking. Still, he is contemplating personal bankruptcy.

That move could shutter his 31-year-old clinical practice and force 6,000 cancer patients to look for a new doctor.

Changes in drug reimbursements have hurt him badly. Until the mid-2000's, drugs sales were big profit generators for oncologists.

In oncology, doctors were allowed to profit from drug sales. So doctors would buy expensive cancer drugs at bulk prices from drugmakers and then sell them at much higher prices to their patients.

"I grew up in that system. I was spending $1.5 million a month on buying treatment drugs," he said. In 2005, Medicare revised the reimbursement guidelines for cancer drugs, which effectively made reimbursements for many expensive cancer drugs fall to less than the actual cost of the drugs.

"Our reimbursements plummeted," Barth said.

Still, Barth continued to push ahead with innovative research, treating patients with cutting-edge expensive therapies, accepting patients who were underinsured only to realize later that insurers would not pay him back for much of his care.

"I was $3.2 million in debt by mid 2010," said Barth. "It was a sickening feeling. I could no longer care for patients with catastrophic illnesses without scrutinizing every penny first."

He's since halved his debt and taken on a second job as a consultant to hospitals. But he's still struggling and considering closing his practice in the next six months.

"The economics of providing health care in this country need to change. It's too expensive for doctors," he said. "I love medicine. I will find a way to refinance my debt and not lose my home or my practice."

If he does declare bankruptcy, he loses all of it and has to find a way to start over at 60. Until then, he's turning away new patients whose care he can no longer subsidize.

"I recently got a call from a divorced woman with two kids who is unemployed, house in foreclosure with advanced breast cancer," he said. "The moment has come to this that you now say, 'sorry, we don't have the capacity to care for you.' "

Small business 101: A private practice is like a small business. "The only thing different is that a third party, and not the customer, is paying for the service," said Lion.

"Many times I shake my head," he said. "Doctors are trained in medicine but not how to run a business." His biggest challenge is getting doctors to realize where and how their profits are leaking.

"On average, there's a 10% to 15% profit leak in a private practice," he said. Much of that is tied to money owed to the practice by patients or insurers. "This is also why they are seeing a cash crunch."

Dr. Mike Gorman, a family physician in Logandale, Nev., recently took out an SBA loan to keep his practice running and pay his five employees.

"It is embarrassing," he said. "Doctors don't want to talk about being in debt." But he's planning a new strategy to deal with his rising business expenses and falling reimbursements.

"I will see more patients, but I won't check all of their complaints at one time," he explained. "If I do, insurance will bundle my reimbursement into one payment." Patients will have to make repeat visits -- an arrangement that he acknowledges is "inconvenient."

"This system pits doctor against patient," he said. "But it's the only way to beat the system and get paid."

Saturday, November 12, 2011

Obamacare to Cut Jobs of Artifical Hip, Knee Maker

Stryker, the Kalamazoo-based maker of artificial hips and knees, will cut 5% of its global workforce by the end of next year to reduce costs in the face of new fees on device makers required by the U.S. health care law.

The job cuts will reduce annual pretax operating costs by more than $100 million beginning in 2013, when the medical-device excise tax is scheduled to take effect, Stryker said Thursday in a statement. Stryker had more than 20,000 employees as of Dec. 31, according to Bloomberg News data.

Stryker expects to record $85 million to $95 million of the expense in the fourth quarter of 2011.

"These actions are part of our ongoing focus on quality, innovation and cost, and position the company to continue to provide strong, consistent growth in a changing environment," CEO Stephen MacMillan said.

Reposted from Freep

Tuesday, October 25, 2011

Obama Wants Your Health Records


By Kerri Toloczko, reposted from biggovernment.com

The federal government, as part of Obamacare implementation, is trying to figure out how to get its hands on everyone’s healthcare records.

It may seem like a small boat in the ocean of bureaucratic incursion that is Obamacare, but given the construction of the new law and the priority its authors and supporters place on “bending the cost curve,” allowing government access to American’s most personal records is a critical step in its effort to control healthcare costs at the expense of care.

The path to achieving this is to use treatment outcomes and other health data as instruments of rationing and denial of care through the Federal Coordinating Council for Comparative Effectiveness Research — created by President Obama — and based on European rationing boards.

There are several ways for the government to access our health records, and the U.S. Department of Health and Human Services is already contemplating options. One would be for the federal government to collect them directly. Another is mandating that the states, as part of Obamacare’s new healthcare exchanges, collect the information and pass it along to the federal government. A third would be to force private insurance companies to make the data available to the feds.

Notwithstanding any discussion of the government’s right to our private records, none of these are good ideas but not as bad as another option that some have floated; let a private contractor bid on the project to collect and maintain the information on behalf of the government.

Allowing a private company to access everyone’s healthcare records is an open invitation to disaster and a gross invasion of personal privacy. And more so as about the only company that could handle the job with any degree of competency appears to be Google.

Google’s business model is tracking and collecting preferred sites and other information from its users. Everything from favorite restaurants to marital status is fair game for the Internet behemoth, which uses sophisticated algorithms to identify who accesses the web in a given home — capturing birthdates, age, gender, imputed income and other information useful to determining what products and services might be of interest to a person when they go online.

Google collects and utilizes this information whether it has permission from the user or not, which is where the issue of private healthcare records comes into play.

Having those records, even if they are walled off and protected under law, does not mean they cannot be swept for information that is useful in other contexts. Everything from medical procedures you have had and their outcomes, medicines you take, your family health history, and details of your health insurance policy will be open to inclusion in Google data collection and marketing efforts through which the world’s largest search engine already generates much of its revenue.

Under a Google-driven collection of personal health data, there would be no “opt-in,” no “opt-out,” just your private records ripe for Internet picking.

The computerized healthcare record itself is helpful and useful. Many private studies have shown that electronic records can lead to enormous cost savings and cut down significantly on medical errors, helping to streamline costs and improve the quality of care available in hospitals today.

The problem is not that the information exists; it is how it can be used or, in this case, potentially abused. Even if no one can see the records, the possibility that they can be “data mined” if left in private hands is so strong that everyone should be concerned.

Medical records should be the property of the patient, and only the patient – an idea Congress and the states should aggressively seek to enshrine in law. Service providers and insurance companies need access to certain health information, but no outside entity should be allowed to touch them without a patient’s direct permission.

Google has turned the collection, analysis and recycling of personal information into an art form, and it shouldn’t be allowed to practice this art as the handmaiden of government with our health information. When it comes to records containing our private health data, a search engine should not be allowed any where near them. Nor, for that matter, should anyone else.

Friday, March 25, 2011

One Year Later…10 Things You Didn’t Know About Obamacare

Remember a year ago when VP Joe Biden was caught telling his boss that the massive Healthcare Reform Bill the President had just signed was (using Biden’s words) a ‘big f**king deal?’



Well folks, I hate to say this, but Joe Biden was right. This is a big deal. A big and expensive deal that still has not earned the support of more than half of America.
The as the bill was passed a year ago, a Gallup poll said:
only 49% of us think that passing healthcare reform was a ‘good thing.’
40% believe it was a bad thing

11% have no opinion
The people at Gallup asked the same question last week and not a whole lot has changed, except that more people DON’T like the idea:
only 46% support the healthcare reform bill
44% think it’s a bad idea
10% have no opinion
Maybe people just don’t know enough about what is in the bill. Remember then-speaker Nancy Pelosi telling us that we needed to pass the bill to find out what was in it?






As you know, they passed the bill, and now we know what is inside it. Bad stuff. Which might explain why even staunch Obamacare supporters like Congressman Anthony Weiner want a waiver for New York City.
But just how bad is it?

The folks at ‘Americans For Tax Reform’ have combed through the bill and found 10 Expensive Things You Did Not Know About Obamacare:

1. Did you know that . . . since Jan. 1 of this year (2011), you cannot use your flex-account at work (FSA) or health savings account (HSA) to purchase over-the-counter medicines?

2. Did you know that . . . since July 1 of last year (2010), Americans have been paying a 10 percent excise tax on all indoor tanning services?

3. Did you know that . . . starting in 2018, if your health insurance is “too good” or considered a “Cadillac” plan, then you will incur a new 40 percent tax on your health plan?

4. Did you know that . . . Obamacare has 21 new or higher taxes in it, totaling over $500 billion in increased taxes going to the government over 10 years?

5. Did you know that . . . beginning in 2014, individuals and families that do not purchase “qualifying” – as defined by federal bureaucrats — health insurance will be forced to pay a yearly tax penalty?

6. Did you know that . . . 7 tax hikes in Obamacare directly break President Obama’s “firm pledge” not to raise any form of taxes on individuals making less than $200,000 per year and families making less than $250,000 per year?

7. Did you know that . . . the capital gains tax rate under Obamacare will rise to 23.8 percent starting in 2012? That is a 59 percent increase from its current rate.

8. Did you know that . . . in 2013, those Americans facing the highest medical bills and the least ability to pay for them will find their ability to deduct medical expenses is further limited (medical expenses must be reduced by 10 percent of income under Obamacare, rather than current law’s 7.5 percent)

9. Did you know that . . . beginning in 2014, businesses with over 50 employees will be forced to offer health coverage for everyone, or pay a hefty tax for each employee?

10. Did you know that . . . in 2013, Obamacare caps the amount individuals and families can put in their flexible savings accounts at $2500? Currently there is no cap and these accounts are used for a myriad of health expenses including paying upwards of $14,000 in tuition to special needs schools for some parents?
I don’t know about you, but I‘m kind of nervous about what we will discover when this bill hits the ’terrible twos.’

(Source: The Blaze)

Sunday, February 20, 2011

Wisconsin Doctors Write Fake Sick Notes For Work-Ditching Teachers

We are seeing a wholesale disregard for the common good, the rule of law, and the right to self-government by the Left in the State of Wisconsin. It's very similar to the way those on the Left have tried to impose counterfeit marriage on other states.


1) An elected governor, and a majority in the State Senate, attempt to carry out their mandate.

2) In response the Democratic legislators flee their jobs and their state so that a vote (which they know they will lose) cannot be held.

3) Wisconsin teachers, and their supports, flood the capitol to try and intimidate the remaining Senators. The teachers walk off their jobs to do this, lying about being sick, thus forcing public schools to close.

4) Now, Wisconsin doctors, who support the public sector unions which are bankrupting the state, have been caught on film writing phony excuses for those teachers who pretended to be sick. It's an ever-growing web of corruption. Watch one of the videos:




USA Today reported: "Doctors from numerous hospitals set up a station near the Capitol to provide notes to explain public employees' absences from work. Family physician Lou Sanner, 59, of Madison, said he had given out hundreds (!) of notes. Many of the people he spoke with seemed to be suffering from stress, he said."

Ann Althouse has another video:




You can voice your concern about this to the Medical Examing Board of the Wisconsin Department of Regulation and Licensing. The email address is:  DRLBoards@wisconsin.gov

Thursday, November 18, 2010

Are the Airport Scanners Safe?

Are the scanners as safe as TSA claims? My guess is probably not. The fact that they haven't been properly studied, but are being pushed so hard elicits some red flags. TSA and GE have neglected to do the tests that doctors and scientists are demanding. They have disregarded expert questions repeatedly (when these experts have zero to gain and GE has 30 million).

Scientists and doctors (in the fields of biochemistry, biophysics, cancer research, x-ray crystallography and imaging) at UC San Francisco have raised some important concerns that are summarized below.

  • There has not been a meeting of an impartial panel of experts, including medical physicists and radiation biologists, where ALL of the available relevant data is reviewed.
  • The majority of the energy dose is delivered exclusively to the skin, which is dangerously high because it is not dispersed to the entire volume of the body. This is where TSA lied--see the next point.
  • TSA and GE misled the public by only getting indirect radiation testing (which shows the diluted dispersion throughout the body) rather than quantifying the Flux (the dose being deposited to the skin). They avoided the independent safety data so they could falsely claim that "It's like being on an airplane flight for 3 minutes".
  • If determining the Flux data (which is more relevant anyway) would put the whole radiation concern to rest, why hasn't this been done? Why are they avoiding it?
  • The danger to susceptible groups (children, elderly, the immunocompromised, pregnant women, those at risk for testicular and breast cancer) has not been studied sufficiently and specific guidelines have not been released regarding their risk.
  • Any glitch in the hardware or software that stops or slows the scan may cause an intense dose of radiation to a single spot on the skin. Will the TSA agent even notice the glitch? Who oversees it being fixed and ensures it is "safe" to use again?
  • What keeps a TSA agent from raising the dose just a bit to get higher resolution on a certain area they need to see clearly? What if the higher resolution is needed at particularly sensitive anatomy? Is this justified?
TSA has not been honest with the American people. Until the proper testing is done, why should we have to subject ourselves to these risks? (The solution is not to simply get the pat down instead. Groping of sexual areas by strangers doesn't increase our safety since the the likely location to hide things would require internal manual examination by airport staff).

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