In 2009 I wrote an article about President Obama's intention to slash payments to Medicare Advantage plans.  Turns out I was right, as reported last week.  It is a controversial move, as reported by Jim Angle at Fox News on Friday.  For seniors enrolled in these plans, the move will make it much less likely they will be able to "keep their plan."

Now, it appears that more cuts are on the horizon that will affect seniors.  Home health services are slated for a 14% cut over the next four years under the new law, and as a doctor who makes house calls, I'm concerned that the essential members of my team, the home health workers I depend upon, will be less available to my patients.  When I initiate a plan of care for a homebound patient, I rely on nurses, physical therapists, and others to carry out that plan in the home.  At Doctors Making Housecalls, we strive to help our patients remain out of the ERs and hospitals, unless absolutely necessary.  This is better for patients, and it saves money (imagine that!).  We can't do it alone, and cuts to home health services will make it even harder for us to provide quality home medical care as home care physicians.

Tonight on Fox News Special Report with Bret Baier we will hear more about these looming cuts, and their impact on frail, homebound seniors and their caregivers.  Tune in at 6pm ET and check back here for video.

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This week's New York Review of Books features an article by Jerome Groopman, MD, author of one of my favorite books on the practice of medicine, How Doctors Think.  In the article, Dr. Groopman explores the idea of "comparative effectiveness research" and the role it might play in our health care system if a reform bill passes.  He also points out that many politicians leading the push for reform believe that doctors should be forced to follow certain "standards of care" or "best practices" as determined by government panels and commissions.  Dr. Groopman brilliantly explains why forcing these government-mandated protocols on physicians will harm patients.  Read the article here.
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F2CMy thanks to Janet Parshall and Talking it Over for a great conversation today about protecting the rights of conscience for health care workers.  The best source of information that I have found on this issue is Freedom2Care.  Visit this website to learn more about this important issue and to find out what you can do to ensure that our health care system preserves your right to receive care from a physician or health care worker who is freely able to practice according to their deeply held beliefs, whatever those may be.

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In June, I wrote about why the proposed health care reforms will end up reducing benefits for seniors.  This week, a major nonpartisan agency agreed.  Today's Washington Post has a story about the report from the Centers for Medicare and Medicaid Services.  It reads:

"The report... found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether."

Read the full article here.

Good intentions do not always equal good results.  Congress needs to consider the unintended consequences of asking our health care system to do more with less.  As the Post article explains, the weakest and most infirm could still end up out in the cold.  We need different solutions to the problems with our health care system than the ones currently being proposed in Congress.  The bill offered by the Republicans, while not perfect, offers more common sense solutions, like giving incentives to individual States for reducing their numbers of uninsured, increasing tax benefits related to Health Savings Accounts, and at least addressing problems with medical liability.  Before the Senate votes on health care reform, let your Senators know that the current proposals are a bad prescription for America.

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Today's article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

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Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn't it? What they don't mention is that these documents are already available for free, and you don't even need a lawyer in order to complete them.

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Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an "advance care planning" discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will "start us down a treacherous path toward government-encouraged euthanasia". I disagree.

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If you watched President Obama's press conference Wednesday night, you may have come away with the impression that doctors are often thinking about how much money they can earn from your illness as they make decisions about your health care. Here are his comments from the transcript at CBS News:

"Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out....Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

In my experience, this dynamic rarely happens in primary care. Sure, if you are seeing a specialist whose earnings are based on performing one or two highly specialized procedures, he or she is more likely to recommend that you have that procedure. In the vast majority of cases, however, doctors are not calculating what decision is going to earn them the most money. For one thing, repayment schedules are so complicated these days, that it is difficult for doctors and medical office managers to know if and when they will be reimbursed at all for a day's work. Many insurance companies' payment schedules, including Medicare and Medicaid, are designed to pay only a percentage of what the doctor actually bills, so even if a doctor wanted to figure out how much he or she would make based on a specific decision, it would be nearly impossible to do so in today's system. (If you've ever seen a hospital bill that your insurance company paid, and you were shocked at the numbers, you should know that the hospital and doctor probably only received a percentage of what was actually billed, and they were forced to mark up the fees in the hopes that what they are actually paid would at least cover their costs for the hospitalization or procedure).

For President Obama to imply that doctors are performing unnecessary surgeries on children for their own financial gain is an insult to the medical profession. The very procedure that he referenced disproves his own theory. Tonsillectomies have dramatically decreased over the past 2 decades because doctors recognized that removing a child's tonsils did not prevent infections like it was once thought. Therefore, ENT specialists and pediatricians stopped recommending tonsillectomy as often because it became clear that the risk of the surgery, though small, outweighed the potential benefit in most cases. Financial factors played no role in this trend. Practice guidelines published by doctor's associations are always rooted in data about patient outcomes. If a procedure or treatment produces good outcomes, it is recommended. If it does little to help patients or is too risky, it is not recommended. The doctors I know and work with attempt to follow these guidelines as closely as possible, whether or not they will benefit financially. Practicing medicine is a lot different from practicing law, where lawyers can bill an hourly rate for just about everything they do. I hope President Obama is not relying on his background in law as he conjectures about what doctors think when they look in your throat. Your doctor is almost certainly thinking about what decision will help you the most, and not what will help his or her pocketbook.

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If you watched President Obama's press conference Wednesday night, you may have come away with the impression that doctors are often thinking about how much money they can earn from your illness as they make decisions about your health care. Here are his comments from the transcript at CBS News:

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I am not an economist; I do not claim to understand the complexities of the health care market, nor can I accurately predict how the proposed health care legislation will impact our nation's health care industry. However, many aspects of the proposed reforms make me uneasy.

1) Creating a centralized oversight committee in Washington puts too much power in one place. This group of doctors and other professionals will be making decisions about what treatment or procedure is appropriate for what person at what age or stage of their illness. Those decisions should remain between you and your doctor, not a committee in Washington. Further, many of the decisions will inevitably be made for political rather than medical reasons, as swarms of lobbyists and special interest groups will exert their influence over this committee to obtain results that benefit their own self-interest instead of the patient's. Imagine, for example, the frenzied efforts of drug companies to sway the government-approved formulary to choose their medication over their competitor's. Billions of dollars and tens of thousands of jobs could be at stake. Such far-reaching power over the industry will lead to corruption, no matter how well-intentioned the President or his oversight committee may be.
2) Like it or not, health care is a business. That cannot be changed, and attempting to change it will lead to laziness and stifled creativity. The most successful businesses succeed because they provide their services better than anyone else. In a market system, a business cannot survive unless it stays one step ahead of its competitors. Incredible innovations in health care technology and health care delivery have come from the opportunity to compete and succeed in a competitive market. Introducing more government-supported players into the market will dilute creativity and distort the field of innovation. Private health care companies must provide quality health care within a limited cost, or they go out of business. A universal government health plan has no survival accountability; if it fails to control costs or deliver quality services, it can simply be bailed out with more tax dollars. There will be no real consequences for poor performance, and therefore, I fear that the federal government's health care bureaucracy will become more and more bloated and eventually crowd out private health care companies that have to play by the tougher rules of a free market. Furthermore, competition among health care providers is the factor most responsible for the high level of patient satisfaction that exists in this nation (I believe our system needs reform, but I also believe that claims of imminent collapse and widespread dissatisfaction with our system are vastly overstated for political gain). One of the leading indicators being looked at by doctors, hospitals, and insurance companies is patient satisfaction. This is because patients can, for the most part, choose who will provide their health care. I believe the proposed reforms, despite President Obama's promises to preserve choice, will actually limit patient's choices, and the health care industry will begin to care less and less about patient satisfaction when their clientele no longer have the option of going to the doctor across the street if they are dissatisfied.
3) While I do not think tort reform would answer all of our health care problems, leading experts from diverse political backgrounds agree that the medical malpractice industry is draining resources from our health care system. Yet, no attempt was made in the proposed reform to address this issue. If we are really trying to control costs by any means, shouldn't tort reform be part of a broad health care reform package?
Though I have not read the 1000 page House bill, I will say that I am encouraged in hearing about increased funding for Federally Qualified Health Care centers that provide much of the health care in areas stricken by poverty. I am also encouraged by the proposal's promise to redirect resources toward prevention and primary care. Even so, I think the overall philosophy of increasing government's involvement in health care will have disastrous results.
As an alternative, I have read much of Senator Tom Coburn's proposed plan, and I agree with much of it. He is a physician and he understands the importance of preserving the doctor-patient relationship, something I think the President's plan will damage even further. Sen. Coburn also understands the value of having doctors and insurance companies compete for patients, and attempts to preserve that dynamic in his plan. Links to the entire bill or a summary can be found here.
It will be interesting to see how this unfolds and I would love to hear what you think.
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