The ACA vs. Insurance Brokers

The arbitrary restrictions on Medical Loss Ratios (MLR) established by the ACA are having a number of detrimental effects, including destruction of the business of insurance brokers. By serving as experienced and educated advisers, these small businessmen provide a valuable personalized service to purchasers of insurance. Claims that such "administrative activities" of insurance companies are wasteful are quickly debunked when you compare the amount of fraud and waste within Medicare and Medicaid to the the fraud and waste in the private insurance industry.

Analyzing, aggregating and disseminating both information and products are activities which add value and contribute to overall economic efficiency. Putting arbitrary caps on how much a business can spend to make their business function efficiently is just one of many ways that central planners demonstrate their ignorance of basic economics.

The new limits on MLRs are forcing insurance companies to cut expenditures in ways which will reduce consumer choice and in the long run lead to greater waste and expense.

The National Association of Insurance Commissioners has submitted a resolution to HHS explaining this detrimental effect and requested the following corrective actions:

The Department of Health and Human Services should take whatever immediate actions are available to the Department to mitigate the adverse effects the MLR rule is having on the ability of insurance producers to serve the demands and needs of consumers and to more appropriately classify independent producer compensation in the final PPACA MLR rule. The potential options available to HHS include: (1) approving state MLR adjustment requests; (2) placing an immediate hold on implementation and enforcement of the MLR requirements relative to independent agent and broker compensation; and (3) considering the NAIC’s finding that a significant portion of insurance producer activities are dedicated to consumer advocacy and service and therefore classifying an appropriate portion of producer compensation as a health care quality expense for purposes of Section 2718 of the PPACA.

It is an outrage that companies have to beg government officials for the freedom to operate their businesses as they see fit. Americans must not be blinded to how the ACA ramps up this inappropriate use of government power.

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Calling All Doctors

Docs-4-Patient-Care

National Annual Meeting

Washington DC

November 2-4 2011

Dr. Lee Hieb explains how regulation hurts patients

When is rationing not rationing?

When is rationing not rationing, a mandate not a mandate and price-fixing not price fixing?

When the government says so.

Supporters of the PPACA react to opponent’s charges of rationing by claiming that the Independent Payment Advisory Board (IPAB) can't ration because the law says it can't. 

"The proposal shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary costsharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria. [Emphasis added] Pub. L. 111-148, § 3403"

But when the government takes your money to fund a program (e.g. Social Security and Medicare) and then in any way limits your access to the benefits of that program, that's rationing. Since the law prohibits restricting benefit restriction and increased cost sharing by patients, the only effective way left for the IPAB to achieve mandated spending decreases is to lower payments to doctors and hospitals. But if you end up with less access to doctors and medical care because the government pays them less, that’s rationing. No matter how much you try to deny it, or what you call it instead of rationing: a rose is a rose...and government controlled health care is rationing.

The same people who say the IPAB cannot and will not ration will tell you that markets ration through prices. This is a complete misrepresentation of the role of prices in a free market. Free market prices are a signal. They provide information. Prices do not ration any more than a bathroom scale makes you fat or thin. Free market prices give you information about the relative scarcity of resources and then allowyouto decide how to allocate your own private resources. Free market prices are a reflection of what individuals voluntarily pay. Government rationing is an act of force. It's a fundamentally different kind of interaction when the government determines for you how your resources are to be allocated--whether the government expropriates them first, as in the case of Medicare, or simply mandates how you must spend them, as in the case of the individual mandate to purchase health insurance.

While we are talking about mandates—in the legal challenges to the PPACA, the government is currently arguing before the courts that the “requirement to maintain minimal essential coverage” is not a mandate to buy coverage. The government’s top lawyer, Solicitor General Neal Katyal, argued in court:

Congress is not regulating the failure to buy something, but the failure to secure financing.

The New York Times reports:

Mr. Katyal…argued that the law’s insurance mandate, which takes effect in 2014, does not so much require individuals to buy coverage as it does regulate the way they pay for health care they will inevitably consume. 

This is a distinction without a difference. Lawyers are good at word games, but if you look at the actual real life effect of the law, it is a mandate which offers you no real choice: you can either obtain a government-defined product or you can break the law and pay a penalty.

In language similar to the restrictions placed on the IPAB, the new heath care control law also forbids the use of quality-adjusted-life-years (QALYs) “as a threshold to establish what type of health care is cost-effective or recommended.” But thousands of cost-utility studies use QALYs to determine cost-effectiveness.  Realistically, QALYs are the yardstick currently used to measure and compare outcomes to various medical treatments. It is hard to imagine how this ban could be any more meaningful than the ban on rationing discussed above.

Just over a year ago, The Christian Science Monitor reported:

[T]he Antitrust Division, [of the Dept. of Justice] joined by Idaho Attorney General Lawrence Wasden, forced a group of Boise orthopedists to accept price controls for worker’s compensation and HMO contracts as part of a settlement accusing the doctors of “price fixing”… [T]he Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing”… The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices.”

Through a simple decree, the government thinks it can turn prices set by voluntary exchange into price-fixing, and government-determined prices into market prices. Who are they trying to convince? Must be themselves because any one with a bit of common sense can see that changing the terminology can not change the reality.

Other equivocations by government officials and their defenders include denying that clinical guidelines accompanied by sanctions and rewards do not amount to promoting “cookbook medicine.” And that as long as you call it “evidence-based care,” you can ignore the fact that much of the “evidence” is controversial and that many of the guidelines are written or funded by those with vested interests in a particular outcome.

Lest you think that this verbal trickery is restricted to health care, you can find much of the same in the politicization of energy policy. Regarding the elimination of the incandescent light bulb, Penelope Green writes in the New York Times:

The [Energy Independence and Security Act of 2007] does not ban the use or manufacture of all incandescent bulbs, nor does it mandate the use of compact fluorescent ones. It simply requires that companies make some of their incandescent bulbs work a bit better, meeting a series of rolling deadlines between 2012 and 2014.

Yet, a short week later, again in the NYT, Andrew Rice informs us:

[O]ne day very soon, traditional incandescent bulbs won’t be available in stores anymore. They’re about to be effectively outlawed…Conservatives like Rush Limbaugh have denounced the “light-bulb ban” — actually, [it’s] a new set of federal efficiency regulations that the traditional incandescent can’t meet.

You see, a ban on light bulbs isn’t really a ban on light bulbs, because the law doesn’t call it a ban.

As Richard Ralston so aptly warns:

“When the clear meaning of words is replaced with government fiat in this way, all limits on arbitrary government power and its use of force are destroyed.”

Rationing, mandates, price-fixing, and bans are al terms with precise meanings in plain English. Shame on us if we are fooled by the deliberate distortion of these simple definitions. Stick and stones can break our bones, and words can actually hurt us --when they are used to obscure instead of clarify our understanding of reality.

(This post was published in Townhall.com in a shorter version here.)

What can medicine learn from McDonald's?

Apparently a lot.




(For some reason I can't resize this to make it fit. You can also view this clip here.)


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Amicus Brief filed to FL v HHS

Docs 4 Patient Care, Benjamin Rush Society, and Pacific Research Institute,

File Amicus Brief Against Obama Care

May 12, 2011 – Docs 4 PatientCare, the Benjamin Rush Society, and the Pacific Research Institute issued the following statements after filing an amicus brief in the U.S. Court of Appeals for the 11^thCircuit supporting the district court’s decision that Obama Care is unconstitutional.

Hal Sherz, MD, FACS, FAAP, President and Founder of Docs 4 Patient Care said: “We believe that it is vitally important for a physician group to stand up and speak out on behalf of all of the doctors in this country who oppose this law, but feel disenfranchised and disheartened. As opposed to other medical organizations that have failed to stand up for its constituents and have instead urged them to accept the onerous changes being forced upon them by a statist administration, we are conveying hope by challenging the legality of this law and the brazen attempt of the government to control healthcare.”

Sally C. Pipes, founder of the Benjamin Rush Society and President and CEO of the Pacific Research Institute said: “We believe that the district court was correct that the mandates imposed by the federal government in the PPACA are not a constitutional exercise of governmental power. Forcing Americans to purchase expensive health insurance or face a penalty is not the responsibility of government. Doctors and patients – not the government -- should be in charge. Only then will America achieve affordable, accessible, quality care for all.”

Google docs web link of amicus brief

(Addendum: better link)  Amicus Brief

That's the official press release.

In my new role as Senior Health Policy Analyst for Docs 4 Patient Care, I was able to contribute behind the scenes by providing a comprehensive bibliography of peer-reviewed articles on cost-shifting in health care, as well as participate in strategy discussions while the brief was being written. Very exciting--and educational--process.

Although the D4PC leadership initially wanted to argue from fundamental principles, we were advised that such arguments, especially at the appellate level, would be dismissed almost out-of-hand because of the past 70 years of Supreme Court rulings on Commerce Clause interpretation. The more effective place for those more fundamental arguments is in the media and the political arena--places we are doing our best to speak out frequently and consistently.

If we are to rid ourselves of the PPACA and its disastrous effects on personal health care freedom, popular discontent must be loud and clear. Chances for complete repeal )after a successful 2012 election), as well as Supreme Court comfort with over-turning legislative action, both depend on public opinion of the law.

I am convinced that the more people know about the details, the more they will oppose the law.

Continue to write letters to the editor.

Speak up and speak out.

Invite conversations by wearing the Black Ribbon.

The battle for the sanctity of the private doctor-patient relationship is still going strong.

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There is no moral case for Obamacare

Economist John Goodman asks "Is there a moral case for Obamacare?"

The short answer is "no."

Goodman's longer answer:

What cries out for moral justification are the mandates and regulations being forced on the other 300 million people. Why are they being forced to pay more, or allowed to pay less, than the true cost of their insurance? What moral principle can justify that?

Search the world’s ethical codes and you will have a hard time finding any that are consistent with a health reform that:

• Gives people in health insurance exchanges up to 10 times as much federal subsidy as people at the same income level getting insurance at work.
• Forces young people to pay two or three times the real cost of their insurance in order to subsidize older people who have more income and more assets.
• Takes from low-income seniors in order to provide subsidized health insurance for non-seniors who have higher incomes.
• Takes from people who use tanning salons and people who need crutches and wheelchairs and pacemakers and gives to … well …. who knows?

Read the rest here.



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The Benevolence of Inequality

If we accepted inequality in health care, instead of insisting on instant equal access for everyone to the newest, best and most expensive treatments, where would health care be today? It's impossible to even imagine what treatments and cures would be available and affordable.

A multi-tiered healthcare system which respects individual property rights (instead of violating them through coercive wealth redistribution ) is not only the right thing to do, but we would all be better off in the long run.


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The Fight Against Tyranny Never Ends

On the 4th of July, we must remember why we celebrate. Today I will rejoice in the freedom we have in this country--but not for a second will I forget the fact that there are many who do not understand what a precious and fragile gift we have inherited.

The eight pillars of the federal government healthcare takeover:

1. Federal mandates on individuals
2. Federal mandates on employers
3. Expanding federal entitlements
4. Squeezing funds out of Medicare and choking off private plan choices'5. New federal taxes
5. New federal taxes
6. [federally controlled] Health insurance exchanges
7. Federal government-sponsored health plans [public options]
8. Federal control over private health insurance 

from Why ObamaCare is Wrong for America

The new government mandated cigarette labels:

“If they’re going to take truthful, non-deceptive advertising and put extraordinarily evocative and gruesome pictures on them and force the companies to use their money to present the government’s message, that’s a big step in a free society,” says Dan Jaffe, executive vice president of government relations with the advertisers’ association.--Shawn Zeller, CQ.com

ObamaCare also requires insurance companies participating in exchanges to have their marketing approved by the government.

What we can expect if the individual mandate to purchase health insurance is upheld:

“Mandatory Life Insurance,” Cries California Congress Person

BROADMOOR, CA. June 29, 2011: “Tomorrow I plan to introduce the Affordable Life Insurance Empowerment Act in Congress,” said Arly Esperson, Congressperson from California’s 54^th Congressional District. “Now that the Sixth Circuit Court of Appeals has ruled the health insurance mandate is constitutional, I think it’s time we take the next step.”--[Not a real bill, but it could be.]-- DaveRacer, posted at The COHR Man

Supporters of ObamaCare may find that title offensive, but it is a more accurate and neutral moniker than a title which claims the law is affordable or that it protects patients.

ObamaCare is more than an attack on our healthcare freedom. If allowed to stand, it will push us further toward the collectivist end of statism. Either a man owns his own life, or he does not. Our country was rightly founded on the belief that he does. ObamaCare is premised on the collectivist premise than a man's life is held hostage to the will of the majority and needs of "society." Compassion for the sick, poor and disadvantaged are essential parts of being human but can never justify initiating force. To maintain a peaceful, prosperous and civil nation, we must devise solutions to our problems while ruthlessly respecting every individual's right to life, liberty and the pursuit of happiness.

Have a glorious 4th of July.

Book Review: The Truth About ObamaCare

The Truth About ObamqCare by Sally Pipes Regnery Pub. Inc., 2010


This book provides an easy to read synopsis of the recent health care reform. Pipes does a good job of bringing up the counter arguments to those who defend ObamaCare as a necessary step in the right direction. 

1. She provides a brief summary of the history of health care in the US which brought us to our current situation. 
2. She presents the data to show the problem of the uninsured is not 15% of our population but closer to 3%. 
3. She explains how the PPACA (aka ObamaCare) will exacerbate rising health care costs because it misidentifies the causes of rising costs. 
4. She provides a succinct explanation of how laws, government policies and regulations make medical care unaffordable for a significant segment of our population. 
4. She explains how ObamaCare will increase the problems of inaccessibility to medical care, restrict our choices and eventually lead to rationing. 

But no need to despair. In her last chapter, Pipes offers some alternative solutions which will increase choice, increase affordability and set us back on the path of ever-improving medical care. 

For anyone who has been closely following the health care debate and the development of PPACA, this book adds nothing new. It does put into one easy-to-read place a brief outline and introduction to the major issues involved. 

For those just getting interested in the topic, it's a great place to start. 

220 pages. Large type. Well referenced.

Black Ribbon Project: New Poster

The Black Ribbon Project is working along side several other great health care freedom organizations. Be sure to check them out.

Docs 4 Patient Care
AAPS
The Galen Institute 
The Benjamin Rush Society
Freedom and Individual Rights in Medicine
The Lucidicus Project
PatientPowerNow.org
Citizens' Council for Health Freedom
MediBid

Not pictured:
National Center for Policy Analysis

"Nutrition Reform Act" And Accountable Grocers

Accountable Grocers: A Culture and Payment Change

In today's environment, Grocers are generally paid a fee for each food item purchased. Therefore, Grocers increase revenues by increasing the number and variety of foods sold, and by keeping their stores open for longer hours. But too many Americans are obese from overeating high calorie food with low nutritive value. The new Centers for Food and Nutrition ("CFN") policy and program initiatives are going to drive a new model, Accountable Nutrition. Accountable Nutrition takes the old fee for service model and turns it upside down. 



Under an Accountable Nutrition program, Grocers are paid based on their quality outcomes. The Citizen Protection and Affordable Nutrition Act ("Nutrition Reform Act") created the Shared Calories and Savings Program which promotes Accountable Nutrition Organizations ("ANO"). The ANO model is intended to require Grocers to create a new legal organization that is financially and nutritionally integrated.
This financial and nutritional integration is intended to coordinate sales among restaurants, Grocers and other food suppliers as well as integrate reporting on financial and nutritional metrics. The ANO would be paid for the services rendered, but instead of increasing revenues with increased sales, if the ACO can minimize the costs associated with feeding 5000 beneficiaries then the ANO gets a share of the monetary savings. Thus, Grocers will be motivated to reduce food sales and instead focus upon the customers achieving quality outcomes. However, if the Grocers fail to achieve quality outcomes, the Grocers will not be eligible to share in the savings. Specifically, the proposed ANO require Grocers to report on sixty-five (65) measures that focus upon the following policy priorities: (1) shopper experience; (2) maintenance of balanced diets;  (3) shoppers attaining ideal body mass and (4) managing at risk shopper populations--such as those who purchase tobacco and alcohol. The Grocers will be scored on each measure within each policy priority. If the quality benchmark is achieved, the ANO Grocer is eligible to share in the monetary savings.


This initiative of scoring a Grocer's service will likely change the culture and behavior of Grocer practices. Because the Grocer will be scored based upon the shoppers' perceived experiences, Grocers must focus upon the factors that impact shopper satisfaction scores, i.e. length of check out lines, friendly staff, ease of parking. Grocers must also consider what information technology systems will be used to coordinate nutrition monitoring with other food dispensers and what support tools can be used to prevent junk food binges and promote shopper weight loss. Likewise, engaging the shoppers to modify their behavior will be a critical component of improving quality outcome scores and protecting the Grocer’s ability to receive payment. This concept of reporting on quality measures and tying payment to the quality outcomes will change not only a Grocer’s business plan for profitability/sustainability, but should change the sales patterns of Grocers.


In addition to the ANO concept, CFN has established other programs that require quality reporting to obtain reimbursement. For example, Grocers can receive an increase in their reimbursement from CFN if they participate in the E-coupon program. Likewise, Grocers that report on quality benchmarks in the Grocer Quality Reporting Initiative (“GQRI”) are also eligible for financial incentives. Further, the Centers for Food and Nutrition Innovation (“CFNI”) demonstration projects also focus upon improving quality outcomes and reducing costs. Therefore, the focus on quality nutritional outcomes will likely continue to drive change in behavior while facilitating payment reform.


Don;t know why someone didn't think of this before.


(Original article:

Accountable Care: A Culture and Payment Change

The Changing Character of Medicine: Are We Headed in the Right Direction?

As our country moves from being a nation of small business owners to a nation of employees, we are losing an important avenue for understanding the benefits and benevolence of capitalism.  This trend makes it all the more important to speak up on the morality of profits, private property and voluntary exchange to counter the loss of the direct, concrete experience gained by self-employment.

Physicians are no different. As the quality and integrity of our medical care depends upon free and independent thinking, in medicine,  it's even more directly a matter of life or death.

Read more:

The Changing Character of Medicine: Are We Headed in the Right Direction?

PJ Media June9, 2011

Why You CAN'T Keep Your Current Coverage

No time to write a post myself on this important topic--especially as Chris Jacobs has already written on it so well.

From today's email:

The Wall Street Journal has coverage today of Monday’s McKinsey study suggesting that more than half of all employers could decide to drop coverage by 2014 – both a news article and an op-ed by Grace-Marie Turner (copied below).  The op-ed notes that if half of all employers dump their employees in Exchanges, that will meanabout 78 million Americans would lose their current plan.  As the news article notes, this potential change by employers is entirely rational: While the health care law does include a modest $2,000 penalty for employers who do not offer “affordable” coverage, as the article notes, “Health-policy experts have questioned whether that is high enough to discourage companies from health coverage.”  Indeed, Credit Suisse in a Monday note to clients reiterated that employers dropping coverage is “exactly what was intended” by the law in the first place.

The White House was quoted in the news article as saying the McKinsey study was “an outlier amid other research suggesting that employers overwhelmingly would keep coverage.”  But in reality, the studies saying that employers will drop coverage continue to mount:

·         A PWC survey of employers released just two weeks ago found that nearly half of all employers “indicated they were likely to change subsidies for employee medical coverage” thanks to the law.

·         Former Congressional Budget Office Director Doug Holtz-Eakin’s analysis confirmed that many more firms than originally projected will have a rational economic basis for dropping their plans come 2014 – resulting in up to $1 trillion more in new federal spending on insurance subsidies than official estimates.

·         An Associated Press story from last fall, titled “Employers Looking at Health Insurance Options,” included quotes from a Deloitte consultant saying that “I don’t know if the intent was to find an exit strategy for providing benefits, but the bill as written provides the mechanism” and from the head of the American Benefits Council claiming that the law “could begin to dismantle the employer-based system.”

·         Former Tennessee Governor Phil Bredesen – a Democrat – wrote an op-ed explaining very succinctly why employers will drop their existing coverage options.  Gov. Bredesen noted that Tennessee could drop coverage for its state employees, pay the $2,000 per employee penalty to the federal government, give their workers cash raises to compensate for the loss in health benefits, and STILL come out at least $146 million per year ahead.

Even worse than the prospect of 78 million Americans losing their current health coverage would be the trillions of dollars in new federal spending on the taxpayer-funded insurance subsidies many of these individuals would receive.  At a time when America faces a looming entitlement crisis regarding Medicare and Medicaid, these recent developments illustrate just how significantly worse Obamacare will make our fiscal predicament.

Chris Jacobs

Health Policy Analyst

Republican Policy Committee

(202) 224-2946

Book Review: In Defiance of Death

In Defiance of Death: Exposing the Real costs of End-of-Life Care
by Kenneth Fisher, MD with Lindsey Rockwell, DO and Missy Scott


End-of-life care has tragically been lumped together with the bruha over "death panels." Given the dire need to reign in the rising costs Medicare, and the looming threats of rationing under the auspices of "comparative effectiveness" and cost-control via the Independent Payment Advisory Board, these concerns are understandable but misplaced. But, assuring that people have humane and appropriate end-of-life care in line with their own wishes should have nothing to do with government rationing and everything to do with good medicine.


Drs. Fisher and Rockwell along with free-lance writer Scott  have written a compassionate, extensively researched appeal for rational end-of-life care. Their long over due discussion has the potential to improve the quality of medical care, while at the same time help eliminate wasting our wealth on futile treatments.

We spend a very large proportion of our health care dollars at the end of our lives. The reasons for this are multiple, but include an inadequate legal definition of death, the shifting of decision-making away from medicine and into the legal realm, lack of adequate communication between patient and medical care-takers about end-of-life wishes and realities (aggravated in part by the Patient Self-Determination Act), unrealistic expectations of what medical science can accomplish, and the divorcing of medical decisions from economic considerations. 

Dr. Fisher offers some very intriguing solutions which are worth further discussion. 

Death should be defined not as "absence of all brain activity" but the absence of cerebral cortex functioning. This would clarify the futility of continuing to keep bodies alive when the person who once inhabited them no longer exists. 

Hospitals could form Appropriate Care Committees to assist families and physicians provide the best possible care for individual patients. We must actually apply what we already know about which interventions are futile in which contexts, and when further treatment is merely prolonging suffering and death. Where I part ways with Dr. Fisher is his recommendation that these committees extend into a government-managed hierarchy. I can see them as a selling point for hospitals ("We provide only the best, appropriate care.") but it frightens me to think of the government making those determinations. 

Another idea of Dr. Fisher's  is to eliminate CPR as the default action for cardiopulmonary arrest. Upon hospital admission, each patient fills out a fresh advance directive form (a good idea), and if CPR is desired, an order for its use would have to be expressly written. The danger, of course, is that the order for CPR could be absent due to oversight rather than as a true reflection of the patient's wishes--and potentially lead to an irreversible error. Dr. Fisher points out that CPR-as-default was instituted when most hospital patients had acute, reversible problems. That is no longer the case. A growing proportion of hospitalized patients are admitted with debilitating chronic illnesses and aggressive treatment is frequently not beneficial.  I am still not sure what to think on this issue--but it is a discussion which needs to occur. 

A useful clarification in the book is the differentiation between the absolute right of individuals to refuse any and all treatment and the non-existence of a right to demand treatment that is not medically indicated. The tricky part is who gets to define what is "medically indicated." Dr. Fisher recommends only limiting treatments which are not controversial (such as attmepting to keep an anencephalic infant alive via mechanical ventilation.) These non-controversially futile actions are where there is no right to demand treatment. 

Dr. Fisher also calls for more training of medical personal in end-of-life matters and palliative care. The goal is to do our best to assure patients do not pointlessly suffer by receiving futile treatments, and families do not deplete life savings for inappropriate care. I heartily agree that a deeper understanding of this aspect of medicine is sorely needed. 

In summary, I support the following improvements recommended by the author: 

1. Implement a mechanism to keep advance directives fresh and timely. 
2. Develop Appropriate Care Committees for hospitals and long-term care facilities. 
3. Alter medical education to emphasize continuity of care. 
4. Increase training in palliative care/end-of-life 
5. Redefine death to loss of cerebral cortex functioning. 
6. Consider changing CPR away from being the default action. 
7. Address the issue of a shortage in nurses through expansion of 2-year hospital-based nurse training programs.

Some of the recommendations with which I differ: 

1. Making the Appropriate Care Committees a government function. 
2. Create a central agency to mandate uniform insurance billing (with the rationale that it will decrease administrative costs.) This is properly a market function. 
3. Government support of primary care over specialists, or vice versa. Again, the balance of primary care to specialists needs to be a market discovery by free individuals choosing what is of value for themselves. 
4. Legally restricting or eliminating the direct advertising of drugs and medical devices. Yet again, this is an appropriate free market activity. 


These areas of disagreement in no way detract from the over all value of the book. Dr. Fisher presents much valuable information accompanied by a number of concrete practical actions we could take to address a very real and serious problem within our current health care system. This book is an excellent place to start several long over-due conversations.

In the end, the way for us to assure the most cost-effective use of resources is by doing what is best for the patient in his or her entire context: medically, psychologically and economically. This can not be achieved in the collectivized, centrally controlled system of a medical commons where treatment decisions are divorced from economic consequences. As physicians, we can do a better job by understanding and then communicating the limits of beneficial treatment. As a society, we need to return personal responsibly and a respect for property rights, which means accepting the consequences of living in a world of limited resources and limited life. 

There is a time to defy death, but in the end, no one gets out of here alive. And nothing in life, not even death, is free.

Medicare Reform: Paying for the Cake You Want to Eat

Today's post is up on PJ Media.

Since Medicare and Medicaid became law in 1965, people have been told: “You can have your cake and eat it too.” You can have the medical care you need and not have to pay for it. (You may think you are paying for Medicare with your payroll taxes, but in fact those taxes cover less than 1/3 of your projected health care costs.) 

For decades, Medicare and Medicaid have been paying for health care with no one facing the difficult question: “Is what we are purchasing worth the cost?” Not the doctors, nor the “beneficiaries” — and especially not the politicians. Doctors get income; patients get health care; politicians get votes — all with the carefree ease of paying for it with other people’s money.

Check it out--and leave lots of comments!!

Doctors Speak to Congress on behalf of Patient Care

Dr. Jane Orient, executive director of AAPS, congressmen Dr. Burgess (TX-R)  and Dr. Amerling testified last week before the House in support of freedom of choice for doctors and patients.

This clip is just shy of an hour long but is well worth the time to watch. The PPACA is tragically misnamed: it neither protects patients, nor will it bring down costs. Entitlements are driving federal and state budgets over the cliff, and the PPACA adds significantly to the momentum.These three doctors provide explanations for why this is true.

The new law is specifically designed to disrupt the direct doctor-patient relationship which is the foundation of private practice medicine. This fact is illustrated by what Dr. Berwick, the current head of Medicare, wrote in his book New Rules:

Today, this isolated [doctor-patient] relationship is no longer tenable or possible. Health care has become an industry, with numerous loci of authority well beyond the doctor’s office. In many ways, the relationship of the patient to the doctor is less important. Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care.

In place of a direct doctor-patient relationship, Berwick advocates (and the PPACA strengthens) our current dysfunctional third party payment system which places a bureaucrat into the middle of our medical decisions. More and more, doctors are being required to make treatment decisions based on population-based clinical guidelines rather than the customized needs of individual patients.

Regulatory requirements  are making it more difficult for physicians to survive as small businesses, driving physicians to either retire early or work as employees. It is possible that the physician-as-employee model is less expensive (which is not the same as more efficient or cost-effective,) but shifting to that model should occur voluntarily through a free market, not by the government stacking the deck against the option of private medicine.

For more details on how the new health care control law will take away freedom of choice without solving problem of rising costs, watch the video clip below.
If you prefer to read their statements instead of watch, you can find them here: Dr. Orient's, Dr. Amerling's. I don't have a link to Br. Burgess' statement, but he comes first in the video after a brief introduction by Dr. Orient.

Advancing Liberty, Creating Change, Part 2

See here for Part 1

Randy Barnett was the speaker I came to hear at the recent symposium, Advancing Liberty, Creating Change, --and he did not disappoint.

Mr. Barnett is a constitutional law professor, author of Restoring the Lost Constitution, argued before the Supreme Court in Gonzalez v. Raich (a key case in Commerce Clause precedent), written multiple amicus briefs in support of the unconstitutionality of the individual mandate, and is now the legal representative for the NFIB in the appeals case of Florida v. HHS (the same case in which Docs4PatientCare has filed an amicus brief).

Barnett briefly summarized how the case against the mandate developed, illustrating how a small number of people can make a big difference. A conversation between Barnett and someone from the Heritage Foundation led to a paper on the unconstitutionality of the individual mandate. The paper was published just before the bill was passed Dec. 23, 2009, setting out the terms of the debate, and providing Senate Republicans with a basis to place on record a constitutional objection to the mandate.

Currently, there are five individual mandate legal challenges on expedited repeal. The government has ramped up the seriousness with which it is defending the mandate by having the Solicitor General argue the case at the appeals level. This is a very unusual move as the government's top lawyer usually only becomes involved, if at all, when a case is before the Supreme Court.

Barnett expects the cases on appeal will wrap up around August or September allowing for a petition to the Supreme Court in the fall. Oral argument would then be heard by SCOTUS in January of 2012 with a decision by the end of its term in June. You can read Barnett's estimate of how the judges may rule in his article Commandeering the People.

Barnett emphasized the importance of having a viable alternative to the PPACA pass in the House. It doesn't have to become law, but something must exist as an expression of Congress' will and a potential means to prevent the total dislocation of health care reform. He also maintains that if we win, the gains are important but not that large. If we loose this battle, however, we lose the nature of this country as one of limited government (and I would argue, because of the gigantic regulatory power delegated by the PPACA, Rule by Law takes a crippling blow.)

At the reception after the talks ended, I spoke briefly with Mr. Barnett, thanking him for all of his work defending health care freedom. He recommended the ACA Litigation Blog as a good source of information for those interested in following this case closely. The site also has links to the official documents of the 5 legal challenges making their way to the Supreme Court.

If you are interested in delving further into the constitutional issues, I would recommend starting with three documents: Judge Vinson's ruling of FL v. HHS (which provides a concise and cogent summary of the history of Commerce Clause cases), Barnett's brief to the 9th Circuit Court of Appeals (which presents the key arguments of the unconstitutionality of the mandate consistent with current legal precedent), and his article "Commandeering the People" which takes a closer look at the role of the Necessary and Proper Clause in light of the current constitutional debates.

To rid ourselves of this onerous law, popular discontent must be the dominant mood of the country. To maintain discontent, we must avoid resignation by keeping the hope of affecting a change alive. One way to do this is to announce to each other support for repeal by wearing or displaying the Black Ribbons. The more Black Ribbons that are out there, the more people can see they are not alone, that there is hope of change.

Let's make a difference, now.

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Advancing Liberty, Creating Change

Two days ago I had the wonderful opportunity to attend a symposium co-hosted by the Institute for Humane Studies and the Mercatus Center. Held on the 25th floor of the Hotel Nikko, the views were as stunning as the speakers were inspiring.

The formal part of the symposium was opened by economist Dr. David Henderson who described the almost miraculous success of the Liberal Party in Canada which, through real and significant cuts in government spending, brought Canada back from the precipice of economic disaster. In 1995, the WSJ called the Canadian dollar the "peso of the north" and Moody's put Canadian credit on watch. At that time, Canada had a debt-to-GDP ratio of 70%. Following these cuts and important changes in unemployment benefits, Canada then ran budget surpluses from 1997 until the international recession of 2008. The big lessons from this Canadian experience for U.S. politicians are the following:

You can cut spending and still get reelected.

You can cut spending and the world does not fall apart.

You can cut spending and grow the economy.

As our Congress continues the Budget Debates, let's work to remind them that these truths will also hold for health care spending.

Next, Adam Thierer spoke on the very important battle to preserve internet freedom. Although his talk was equally fascinating as the others, it wasn't as directly relevant to health care so I refer you to his written body of work for the details of his ideas.

Adam was followed by Matt Mitchell, speaking on the growing problem of unsustainable trends in state government spending and debt. The two largest contributors to this problem are Medicaid and the effects of public employee retirement benefits. From his talk, I took away two key points.

Unions in the private sector increase the wages of some workers at the expense of other workers, but are limited in what they can demand from their employers because of business' need to make a profit. (What came to my medical mind was the fact that a successful parasite doesn't kill off its host.) If profits decrease too much, the business (and the jobs) will disappear. Unions in the public sector don't have customers paying for goods and services--they have taxpayers, who can't choose to go away. Also, in the public sector, unions get to vote for and select the people with whom they negotiate for their benefits. In the private sector, unions don't get to vote for their employers (other than with their feet.) The fundamental incentives for public unions have no brakes. To improve the situation, we need to change the rules and alter the incentives. Tweaking the numbers will never be enough.

With regard to Medicaid, Matt showed that the problem goes beyond the incentives for expansion that the current system holds. (Because of Federal matching funds which shift state costs to the country as a whole, States have the incentive to continually expand Medicaid programs.) He also pointed out that whenever government funds a program, it creates a powerful vested constituency which pushes for continued spending and expansion. Data shows that when the Federal government reduces payments for state programs--the programs don't shrink or go away. The states just continue to fund them through state debt or raising taxes. A looming danger of the PPACA is the enormous new entitlement constituency it creates, not only through the expansion of Medicaid, but also through insurance premium subsidies.

The formal talks were punctuated with opportunities to talk personally with the speakers and fellow attendees. It was an exciting chance to meet face-to-face several people whose works I have admired from afar, or have met only in the cyber-world of Yahoo groups. In spite of the very real and significant challenge to individual rights which our country currently is facing, the general mood of the speakers and the audience was decidedly optimistic. I left encouraged and inspired, knowing that people of such intellectual caliber and integrity are fighting for the cause of freedom.

(Report on the symposium will be continued next post.)

Update: New paper out from the Mercatus Center-"Public Sector Unionism: a Reivew"
Update: Paper on-line by David Henderson CANADA’S REVERSED FISCAL CRISIS

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Cookie Cutter Medicine

Patient Diana Hsieh relates her personal experience with a health problem to illustrate why "cookie cutter" medicine and government "quality control" through adherence to clinical guidelines is bad for your health.



For a more technical discussion, don't miss the following posts by two practicing physicians who regularly blog on health care policy.

"Dangers of strict adherence to clinical guidelines" by Doug Perendia

and

"Who Writes these guidelines anyway?" by Dr. Rich Fogoros

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Medicare "As Is" is Not an Option

The Budget War has reignited the Medicare War with both Republicans and Democrats fearful of angering Seniors (and potential Seniors) about diminished access to blank-check health care.

Polls show people want Medicare to continue "as is" --but this is not a fiscal possibility.

Medicare must be changed, and both Pres. Obama and Rep. Ryan offer ways to change it.

The President calls for top-down restriction of care by a government-appointed panel of experts. Ryan's plan calls for restriction of government payment to individuals and more individual choice.

Neither plan ends Medicare --just Medicare as it currently exists.

Neither plan supports Seniors' ability to pay for care when Medicare won't.

The debate must continue.

More information here, here and here.

Just ask

5 Questions from WTRC Films on Vimeo.

Black Ribbon Project Goes to Washington

D4PC "Crash Card" report:

(Although not visible in this photo--every doctor proudly wears a Black Ribbon.)

Charging the Hill

Dr. Hal Scherz's Field Report from the Capitol

Speaker of the House John Boehner prioritized a meeting with the leadership of Docs4PatientCare just before meeting with President Obama in the midst of the political fight over the Government shut down.

On April 6 & 7, a group of leaders from Docs 4 Patient Care went to Washington for meetings on Capitol Hill with Senators, Congressmen and their staff, for policy meetings and to participate in a healthcare symposium with the Galen Institute.

Docs4PatientCare staging outside the
Capitol to "Charge the Hill" on behalf
of the Doctor-Patient Relationship.

On this trip to DC, as compared to previous ones, we had no trouble arranging meetings with Senators and Congressmen. That is because after 2 years of work, they recognize that we are a bona fide organization and worthy of their time.

We would have had meetings with many more Senators and Congressmen then we did, had it not been for an imminent government shutdown, which occupied most of their time and attention.

Nonetheless, the highlight of our trip in many respects was our 30 minute meeting with Speaker of the House, John Boehner, which immediately preceded his first meeting with President Obama over the budget impasse.

Most of the time, groups come to DC with their hand out, trying to get a bigger slice of the federal pie. They gain entry into these offices because they have spent an enormous amount of money through lobbyists, who are hired guns, but have no real skin in the game.

We were received differently, because we are different.

New Congressman and
Docs4PatientCare member,
Dr. Dan Benishek came to
Washington to prevent the
trampling of the Doctor-
Patient Relationship.

We did not come asking for anything except for the opportunity to help them fix healthcare. We told them who we were (although many already knew), and what we had done. We shared with them our successes in the 2010 elections- helping Congressmen Dan Benishek MD, get elected in Michigan, and Joe Walsh in Illinois.

We shared with them our Prescription for Healthcare Reform and that we believed that with our expertise, we could help them with the healthcare message far better than policy experts or media professionals. We explained how our organization worked- which is not to have lobbyists, but instead to develop personal relationships between doctors and their elected officials in Congress.

We offered to help with Congressional testimony and to give assistance in healthcare matters that affect our patients and us every day, because as opposed to the faux doctors who gave up taking care of patients in favor of becoming bureaucrats, we are on the front lines daily. Finally, we shared a vision of what we can do in 2012 to help put people into Congress and the White House who will be serious about fixing healthcare in America. This can be done through the media but is better accomplished through the influence that we have on the 2000-10,000 patients that each of us sees in our offices and clinics.

We informed them about our new web site and how we had transformed it into the trusted source for healthcare information by keeping it current with updated daily content. Many of them already knew about this and had been following us.

This was a powerful message.

Speaker Boehner and everyone else that we met with acknowledged just how powerful it was. They all appreciated that we were there and had given up time at our practices and with our families and traveled to DC at our own expense. They all told us essentially the same thing:

1. We need a continued presence in Washington and we need to bring doctors from as many Congressional districts as possible.
2. We need to build our membership. There is a palpable need for a group like Docs 4 Patient Care, but the best way for people to notice us is to have as many members as possible.
3. We need to work to change control of Congress and the White House in 2012, otherwise, the prospects for healthcare will be bleak.

D4PC's rising influence after
the mid-term elections.

In addition to the meeting with Speaker Boehner, we met with the GOP healthcare leadership team in the House (Boehner, Cantor, McCarthy) and the Senate (McConnell). We met with Senator John Barrasso MD from Wyoming and his team, the team of Sen. Tom Coburn MD and Sen. Rand Paul MD. Also with 3 of the 5 freshmen GOP physician Congressmen- Scott DesJarlais (TN), Andy Harris (MD), and Dan Benishek (MI). We chatted with John Fleming MD (LA), Joe Wilson (SC) and John Culberson (TX). We also met with the healthcare specialists for Reps. Mike Burgess and Michelle Bachman.

We had an excellent healthcare symposium with the Galen Institute and Congressman Tom Price MD, helped out by delivering an impassioned speech about why this healthcare law is a disaster for America and what we must do to get rid of it.

The Heritage Foundation is one of our most important strategic partners and we were hosted to an afternoon session by Bridgett Wagner, the Director of Coalition Relations and attended by Galen Institute President Grace-Marie Turner to discuss Docs 4 Patient Care, healthcare policy issues and strategy, and Grace-Marie's new and excellent book- Why Obamacare is Wrong For America; an essential must read book for anyone who hopes to understand this difficult and convoluted subject.

Just a couple of other items to share-

Congressman Tom Price presents
the case to repeal ObamaCare.

We have filed an amicus brief in Virginia in support of the Virginia case against the Federal Government which challenges the mandate that people must purchase healthcare insurance in the Affordable Care Act. We are looking to get involved with other court actions in the near future.

We are in the process of forming Docs 4 Patient Care state chapters. We have chapters in Arizona, Colorado, and Illinois. We formally launched the Georgia Chapter this week. We are looking to have 20 state chapters by the end of 2011.

So there you have it.

Docs 4 Patient Care is very much real and vibrant.

We need those of you that have never joined as a member to do so- what more do we have to do to prove ourselves to you? Just go to our web site- docs4patientcare.org now and click on Become a Member.Those of you who have not sent in dues for this year- you are not a member, so please renew by clicking on the same link. (unless you signed up as a Gold Member since September).

We cannot succeed without every one of you. We will do the heavy lifting if you do not want to - just help us do it by supporting us. No one else will help you (or your patients) if you don't start now, by becoming a member.

Those who want to get into the fight- just let us know and we will give you something to do.

Thank you.

DEFUND, REPEAL, & REPLACE

The full framework of our plan for America can be viewed here. We invite all Americans to join us in the true effort to reform healthcare.