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June 15, 2009

On Proposed Healthcare Reform (tmi3rd)

As many of you know, I'm working on getting into medical school, and it goes without saying that I'm watching with unmitigated dread what's going on with Obama's proposed healthcare reform plan, which by all accounts comes right out of Tom Daschle's book on the same subject.

This is really long, so bear with me...

(slight update added - someone)

Here's the text of the speech, coming from the WSJ...

The first seven paragraphs are the somewhat predictable stories... a cancer patient whose breast cancer metastasized (spread) to her bones, and doesn't want to pay for more aggressive treatment while she spends time with her kids to get better... a physician who says he spends too much time doing administrative duties and therefore can't spend time with his patients... small business owners who've had to lay off workers due to high insurance premiums... and closes with GM's woeful money problems due to providing health care.

This is followed by my favorite line...

"This is a test of whether we – Democrats and Republicans alike – are serious about holding the line on new spending and restoring fiscal discipline.

Amazing. With all the debt spending Obama has signed off, that is an audacious line indeed.

This takes us to the next line of interest...

"First, we need to upgrade our medical records by switching from a paper to an electronic system of record keeping.

Sounds like a good idea... or does it? In a discussion about this very topic with my father (an ear, nose, and throat surgeon), he said that his office could do the conversion... for about $60,000, and that's just for the gear. He didn't want to guess how much it would cost in labor.

Who wins in this case? For one, General Electric just happens to have a program to do just that. I don't have a list of software companies who are in the loop to write this software, but I'm sure that when the companies begin advertising, it will be interesting to check out who they made political donations to...

We've already seen with the Joe the Plumber incident what can happen when private records fall into the hands of unscrupulous public officials- that argument is fairly ironclad. Doctors are required by law to maintain patient confidentiality- public officials have no such legal obligations.

The second step that we can all agree on is to invest more in preventive care so that we can avoid illness and disease in the first place.

Here he throws out the usual boilerplate about fitness and diet... which rings remarkably similarly to Carter-era remarks about conservation. The one point of interest that bears some further study is this...

And it will take employers following the example of places like Safeway that is rewarding workers for taking better care of their health while reducing health care costs in the process. If you’re one of the three quarters of Safeway workers enrolled in their “Healthy Measures” program, you can get screened for problems like high cholesterol or high blood pressure. And if you score well, you can pay lower premiums. It’s a program that has helped Safeway cut health care spending by 13 percent and workers save over 20 percent on their premiums.

Safeway's program was profiled in the WSJ recently. I can only assume that Obama intends to give tax incentives for being healthier, which translates into "We're going to tax you for being unhealthy." The fact that the left-libertarians are not howling like gibbons about this mystifies me, but that's a discussion for another time.

Here's the part where I start getting pissed off.

That starts with reforming the way we compensate our doctors and hospitals. We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease.

I see. So what becomes of paying the audiologist who performs hearing tests, the nurse who administers injections, the surgical team who works with the surgeon, and so forth? I suppose those are just going to magically take care of themselves?

He goes on to say something about lowering the costs of medical school for primary care physicians... about the same time he's talking about taking more money out of their pockets in the first place.

The second structural reform we need to make is to improve the quality of medical information making its way to doctors and patients. We have the best medical schools, the most sophisticated labs, and the most advanced training of any nation on the globe.

Wait, I thought our medical system wasn't up to the drill?

Now, I recognize that it will be hard to make some of these changes if doctors feel like they are constantly looking over their shoulder for fear of lawsuits.

Obama deviated from the text to tell the AMA he wasn't going to introduce tort reform to cap medical malpractice suits. (deep breath)

I anticipate, if I get into a surgical residency, that upon beginning practice, I will start with a malpractice premium of about $45,000 annually. OB/GYN premiums are typically more on the order of $80,000 per physician. States like Mississippi, who have no cap on their malpractice damages, can't keep a lot of cancer doctors, pathologists, and OB/GYNs in state, and 31 total states have caps that usually run somewhere around $250,000. I can't give you a hard number on what their malpractice premiums are, because they aren't listed, even on average. The only thing I can tell you is that they are lower than they are in the 19 states that don't have damage caps.

He moves on to talk about a public option being something to compete with private insurers and keep them honest. As of the moment, most of us get our health insurance from our employers. It isn't cheap, so why would any employer offer something other than public insurance? Especially when it's been repeated in a number of places that Congress would like to tax health benefits as income?

Obama says that he wants to still have a private insurance industry in this country. The bottom line is, if we're getting taxed for insurance in the first place, there won't be any money to spend on private insurance. Whether or not the intention is to kill private insurance, it will still be a consequence. I am no big fan of what it costs, but again, the proposed plan is a nightmare- Romney/PatrickCare, TennCare, and so forth both provide appallingly bad coverage and damn near bankrupt the system. Win-win for everyone... not.

...let me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we’ve put aside $635 billion over ten years in what we are calling a Health Reserve Fund. Over half of that amount – more than $300 billion – will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level it was at the end of the Reagan years.

He says it won't affect charitable giving. Great, but most of the folks I know who run non-profits aren't convinced. On to the real punchline...

...we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat.

Hospitals are running in the red all over the country at the moment, laying off staff right and left. In talking to the administrators in a couple of key markets, they are getting their asses kicked precisely because they are unpaid for many surgical and emergency procedures.

So here's where it hits home for me, as an aspiring physician. I'm not going to abandon that dream- I've worked very hard to get to the precipice of it, and the decision has been made. It is entirely possible that by the time I get into (to say nothing of getting out of) medical school, what has been the most coveted medical system in the world will be a mere shell of itself.

We didn't even get to the notion of rationing, but ultimately, if you read through the text of the speech, rationing is inevitable. I welcome the opportunity to take care of each and every moron reading this, and I do not approve of the notion that the feds (the same ones who handle the DMV and VA) are going to tell me who I may and may not treat.

You've read enough of this, and there are a million important things going on today. It looks like public support for this plan is deflating quickly, and I certainly hope so. I don't debate for a moment that the system is over-bureaucratized, and needs to be reformed, but the bill being proposed is a Rube Goldberg-esque nightmare that needs to be stopped before it gets going.

Thanks for reading- sorry about the length.

Update (someone) -- sorry to interrupt and make this even longer, tmi3rd, but you missed a rather big gotcha point. You know that Safeway program Barry claimed to like? His plan would -- you guessed it -- ban the thing! No coverage would, from here on out, be allowed to charge more for more risky behaviors. This plus preventing anyone (read: the young and healthy) from opting out of coverage altogether means a massive tax on the generally healthy to subsidize the voluntarily unhealthy... Until, of course, everything's nationalized and some bureaucrat decides to cut the latter off altogether.

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posted by xgenghisx at 10:39 PM

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