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Counter Point: Healthcare Reform Won’t Impact Your Freedom

Congress is going into recess without completing its work on health insurance reform, and the advocacy groups are eager to use this time to whip up voter sentiment for or against reform.  Unfortunately, the anti-reform pundits are all-too-ready to dip right back into the 1993 playbook that gave us Harry & Louise, playing on the fears of consumers with distortions and outright lies.

Ramona alerted me to one such piece published in the CNN/Money-Fortune segment, a “Special Report,” scarily titled:

5 freedoms you’d lose in health care reform

Nice lede, eh?  Can you guess without reading the article where this author is coming from?

The subsequent bits range from “accurate-but-deliberately distorted” to “complete BS that I made up but is really scary.”

Let’s start with the latter, as it’s more fun:

5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges [...] must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. [...]

The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges.

So, just to recap: You won’t be able to choose your doctors because your primary care doctor (that you chose) might, under certain reimbursement schemes that aren’t actually mandated in the bill, have a hypothetical incentive to limit access to specialists.

Um, what?

Never mind the fact that TODAY, right now, your access to a specialist is limited by some drone at your insurance company who doesn’t have a medical degree and does have a very powerful direct financial incentive to deny authorization for referrals.  Never mind the fact that there is nothing in the bill which states you will be “assigned” to a primary care doctor.  Never mind that fact that the “Medical Home” is not in any way related to an HMO, conceptually or practically. This “gatekeeper” function isn’t in the bill at all!  The medical home concept is designed not to ration care (which is the unspoken subtext of the above passage) but to coordinate and improve the quality of care.  Never mind that, if a referral is granted by the wicked & parsimonious gatekeeper, your choice of a doctor is still not restricted under the bill.

Never mind all those inconvenient little facts that each individually or all together totally invalidate the thrust of the author’s argument.  The problem for the whole concept is that there will be many plans offered for purchase on the exchange. If you don’t like the one you picked because it is too restrictive, you can switch to another plan! If WellPoint requires too much hassle to get to see a specialist, then you can dump them and pick Cigna!  Granted, the ones which are more restrictive are also probably going to be cheaper, but that’s for the consumer to choose!

And yes, before you bother to say it, yes, this might result in adverse selection of sicker patients into the more lenient plans, but they will be risk-adjusted to correct for imbalances in their patient populations.

So that’s the easy point to debunk, and I would think that finishing up with the BIG LIE like that, there would be little need to review the rest of the hit-piece, but I’ll make the effort, my love of truth and good policy being as strong as it is.  Other “freedoms” you would lose, according to the esteemed and honorable author:

1. Freedom to choose what’s in your plan
3. Freedom to choose high-deductible coverage

I put these together, because it’s a bit of a cheat on the author’s part to list them separately.  I mean, it’s the same thing, innit?  This is basically an assault on the concept of the mandate that all Americans be insured: you can’t just buy crappy insurance that doesn’t really cover anything meaningful and say that you’re covered.  I respect those libertarians I have clashed with when they say that they should be free to “go naked” if they so choose, and have no or minimal insurance if that is their choice.  I disagree, but I respect their honesty.  This piece is a little less direct, but it’s basically the same thing — defending the right of people to choose crappy insurance that wouldn’t actually cover their health care needs should they fall ill.

There are two problems with that sort of policy approach.  First, a fig leaf just ain’t clothing.  You can glue one on and walk around town without getting arrested, but everybody who sees you knows you’re naked.  Insurance that has the “We never pay” clause just isn’t actually insurance.   It doesn’t accomplish the actual goal of getting every American access to quality health care.

The other problem, a bit more subtle, is that letting people opt out of health insurance, either explicitly or de facto by buying cheap fig-leaf insurance, defeats the purpose of the individual mandate: risk pooling.   It’s a certainty that some of us are going to get sick.  It’s also certain that those of us who do become sick will not be able to pay our individual costs, as health care is now so expensive that no individual can hope to pay their actual bills.  By requiring all of us to have insurance, you create a situation where those huge costs are spread out among the largest possible number of people.  Allowing opt-outs ensures that everybody who can, will, and these will be the healthier people who don’t see a need for insurance, at least not today.  The result is a concentration of costs among the sick people who generate the most costs, which, as noted, exceed the ability of these individuals to pay.  Of course, as people who were healthy become ill, according to nature’s inexorable dictates, they will transition from the low-cost insurance products they previously favored to the ruinously expensive plans that actually cover for people who are sick.  And the system literally falls apart.  No funding exists for the sick to pay for their (hugely expensive) health care, and the healthy contribute little (until they become sick).

2. Freedom to be rewarded for healthy living, or pay your real costs

This is pretty tightly related to the above point, with a slight distinction.  Again, as pointed out, nobody who is sick can pay their real costs.   So again, there’s the risk-pooling issue.  But there’s another, more pernicious assumption here: that health is a controllable feature of lifestyle.

Bullshit.  I’m healthy, and I like to assume that’s because I’m virtuous and athletic and take care of myself.  Right?  Except that it’s strictly a matter of luck that it was not my kid that got sick and died of neuroblastoma.  Or medulloblastoma.  It was a matter of luck that my wife pointed out a funny-looking freckle that turned out to be a very thin melanoma (and lucky for her that she married someone who could tell the difference).   Cancer is easy to cite, but the list goes on and on of health conditions that have nothing to do with lifestyle: crohn’s disease, MS, bipolar, Type 1 diabetes, glomerulosclerosis, etc, etc, etc.   And none of us know in advance when our — or our family’s — number is up.

So we are all in this together.  We all pay a premium: and bet or a hedge against illness.  Those of us who win the genetic lottery and stay healthy lose the “bet” and wind up paying for a service we didn’t need.   If you let some people hitch a free ride and pay a minimal premium, they are not paying their fair share to cover the cost of those who have already become ill.  When President Obama talks about “Shared Responsibility,” this is what he means.

There’s a lot more chicanery in this article — I’ve neglected Point #4 entirely, as I covered that the other day.  No plan will remain the same in perpetuity.  I’ll stick to the main policy points and leave, for the moment, the sly little insinuations and falsehoods scattered throughout the article like so many candy sprinkles on an ice cream cone.

Strangely enough, I’ve finally found a point of serious, substantive agreement with (former) Alaska governor Palin.  She and I are united in wishing that the gosh-darned liberal media would just stop making stuff up.

*This blog post was originally published at Movin' Meat*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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