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(HealthNewsDigest.com) – I agree there are problems with the present health care system and reform is needed. Much of the system is the best in the world. The challenge is how to reform the weak parts without destroying the rest. The problem is not whether there should be reform– that is clearly needed. The issue is in the details of the bill with many of the proposed changes being disastrous for both the health care system and our economy. Unfortunately I believe both political parties are looking at this for political advantage rather than looking at what is best for this country.
Democratic Congressional leaders tried very hard but failed to pass a bill before the summer recess. Few people had had time to even read the bill let alone digest its contents. Since then, considerable national debate has ensued with several alternatives proposed, some of which I believe have considerable merit. Fixing problems such as portability of insurance, pre-existing conditions, subsidies to the “working poor”, and others will clearly be part of any bill proposed. The more difficult part is how to pay for the expansion of health care, whether or not there will be a public option, the question of care for illegal aliens, and in the end, how much the leaders of the majority party in Congress and the President are willing to oppose the Party’s left wing to make the bill acceptable to the majority of our population.
Although clearly House Bill 3200, passed by a House committee prior to the summer break, will not be the final version, it DOES represent the clear views of many of the Democratic party in the House and, as such, I feel should still be carefully examined. Parts of it will clearly be a significant part of any final legislation. The House bill, as it is written, will have the worst of all effects – destroying the best and not fixing the bad parts of our health system, as well as having major detrimental effects on our economy and significantly abridging individual rights.
1. (Page 30) the bill establishes a Health Benefits Advisory Committee (HBAC). The problem with this is that those appointed to it are directly and only responsible to the president and the executive branch. A significant majority are appointed by the President. Congress has absolutely no input into this. It will by definition be completely biased to the party in power. This results in a significant part of our economy being directly controlled solely by the Executive branch. Where are the checks and balances clearly defined by the constitution? Congress should appoint most of the members of a committee that has this much power, not just the President. Physicians are one of the key players in the equation. They “drive” the vehicle. The bill says “at least one practicing physician” will be appointed. Many more physicians in practice should be involved.
2. (Page 42, 58, 59,132, and others). In the proposed public option the bill allows government to have access to any individual’s financial picture including their bank accounts. In a later section it allows the government to take monies out of an individuals account. It also allows HBAC to get data from the IRS. I thought the IRS data was private and not totally accessible to the government. The potential abuse in this is frightening.
3. (pg 72, 84, and others). The way the bill sets up the Health Insurance Exchange it gives them TOTAL power to define what is covered and what isn’t, not only by the government health plan but also by private insurances. Although technically the insurance will be private the government will determine what and what cannot be covered – clearly ending private control. Although at the beginning this will be reasonable, as the amount of funding runs out ( which everyone accepts will happen) the government has the power to set rules that will ABSOLUTELY ration health care and define what people can have and not have. The right to determine what is paid for clearly defines this authority. This bill also states that there is NO APPEAL, either administratively or through the courts for these decisions. This statement appears in many places and in my mind is dictatorial and a violation of legal rights.
4. (pg. 124,125, 250-255, and others). The “Secretary” is essentially empowered to set all physician payment rates. The RVRBS system, while far from perfect, at least was based on some data. Here the Secretary is empowered to adjust any RVRBS rate to what they feel is “correct” – clearly both proceeding to progressively reduce physician rates as well as rationing by selecting stopping or reducing below the cost of providing them payment for certain expensive procedures. It also, potentially, give the HBAC the ability to make decision of coverage based on “social issues”, such as alcoholism, obesity, etc, something that would further push the government into everyone’s private life. Again, the bill defines that there is NO APPEAL, either administratively or through the courts for these decisions. This is unfair both for the physician and for the patient.
5. (pg. 228). Under rules for skilled nursing facilities, the Secretary shall be allowed to unilaterally adjust case mix indexes. This results in denial of patients with some illness who had been covered in the past to be paid for in SNFs. An example of this occurred a few years ago in hospital rehabilitation units in which the case mix ration was adjusted and patients with knee and hip fractures were not paid for by Medicare to be in a hospital rehab unit. The potential abuse for this is high as available funds decrease and there is, again, no established grounds of appeal to this.
6. (pg 256). The bill tries to pay physicians for increased efficiency. The methodology however has no relationship to an individual physician. It defines “regions” of health care costs, determined by postal zip codes, and all physicians in the lower cost regions get extra money. This has no redeeming virtue. It does not in any way accomplish what was set out – to increase quality and improve utilization of individual physicians. Increased efficiency is essential to control costs but a different methodology needs to be found to define this. This also is stated as having no administrative or judicial review.
7. (pg. 298). The bill redefines penalties for readmissions to the hospital soon after discharge. Some readmissions, I agree, are the result of poor discharge planning, too early discharge, or lack of communication from the hospitalist to the out patient primary physician. However, many are unavoidable. Patients do not follow directions. Patient’s illnesses truly recur. Patient’s may refuse treatment or care and leave the hospital but get sick soon and are readmitted. Unanticipated events can occur. To make this worse the physicians, including those who are not involved in the discharge process, are also penalized when the patient is readmitted. A different method needs to be found to approach this problem.
The major cost saving issue that is NOT included in the bill is TORT REFORM. Studies have shown that total health care can be reduced by 10-15% and no one disputes the significant effect this would have. There is no single other item that can realistically same as much money. Many expensive procedures are solely done defensively because of the potential of malpractice suits if “everything” isn’t being done. The political power trial attorneys have on our government must put aside if health care reform is to be affordable and not bankrupt the country.
What is also not by word included in the bill but is clearly part of it is rationing, especially in Medicare. It is naïve to claim this will not occur. One example: the stimulus bill set up a program to derive computer programs of quality care that would be applied to medical practice and also programs that would define ‘Quality Adjusted Years of Life’, or abbreviated, QALY. Should, for example, a functional, healthy, 85 year old individual who has a hip fracture accept the rest of their life in a wheel chair instead of having a hip replacement that would allow him or her to function normally? Should the number of years to live a person statistically have decide whether they have needed care or not? I heard the President in an interview say that elderly people should just take pain medicines and not have expensive orthopedic procedures. A speech in Congress regarding cardiac stents and angioplasty took place recently. In many studies conservative treatment ends up with the same life expectancy as invasive procedures, but there is a significant improvement in the quality of life with angioplasty. Should the government say that no money is available to pay for necessary elective treatment such as this? Should the “Secretary” say, as in England, that some cancer medications are too expensive and are not on the acceptable list of therapies? Will government health care and Medicare, as was recently done by Medicaid in Oregon, refuse a cancer drug because it was too expensive and offer in a written letter to the patient instead, to pay for assisted suicide? Shouldn’t quality of life count for elderly individuals, something all of us, we hope, will eventually become, even if computer programs cannot easily define this?
A public option will leads to rationing, as it has through the rest of the world wherever there is a National Health Service. While monies budgeted by the government for health care are finite and limited, the demand for health care in many cases is unlimited. The result is rationing, whether directly by fiat, or indirectly by restricting the growth of the number of physicians and facilities while demand continues to increase.
There is no reason to rush in deciding such a complicated issue. It needs careful evaluation to arrive at the best proposal, not just the most politically expedient one. I see nothing wrong with demonstration projects to see what will work. We cannot afford to make a mistake and destroy the system. If the President can take six months to choose a dog, clearly health care reform should take much longer.
Edward J. Feller, M.D. is a practicing physician and also a councilman from the Village of Palmetto Bay in Miami-Dade County. He has been involved in the past as a leader for many years in organized medicine on the local, state, and federal level, as well as with the management of health care organizations, and has considerable experience in medical economics and the delivery of health care. He is writing this as an individual with his own views.
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