It’s impossible to watch the news these days. Whether you’re conservative, liberal, independent or non-committed, it’s impossible to avoid the political bickering these days as the US Presidential campaign enters its final countdown. As a physician, seeing the video of Granny being pushed off a cliff is about all I can handle.
No politician I know has to deal directly with Granny, but I do. I have to look her in the eye. I have to talk to her. I have to be there when she comes in with a heart that’s not beating. I have to look at her struggling to breathe. I have to decide, based on the available information like her current and past medical history, social situation, family member concerns, prior surgical history, medications, lab tests, and a myriad of other variables whether to given granny a pacemaker or not.
Not you, Mr. Politician. Not Obamacare. Not my hospital. Not the insurance company. Not Big Data.
And for the moment, I’ve got granny’s back. No matter what, if she wants and needs a pacemaker, she’ll get it.
But everything that is being proposed to save costs in health care these days threatens my ability to make the right choice for granny.
For Democrats, they want a 15-member non-elected panel that might set a limit on certain aspects of when I can give granny a pacemaker despite what she and I might think. For Republicans, they want to allow insurance companys and their Big Data (or a pre-programmed supercomputer called “Watson”) to tell be when I can or cannot give Granny a pacemaker despite what we might think. And both political parties want to do this in the face of a tort system that hasn’t had to change at all to account for these financially-imposed ultimatims for care.
In addition, both political parties seem to be aligning behind ideas that cut payments for what I do directly, and somehow pay me for my “outcomes” of care via “bundles” (or some other concocted payment scheme) that defines how to distribute the bundle to the various “stakeholders” in granny’s care, including me. Even more telling, we see another new iniative currently being rolled out: if Granny gets an infection despite perfectly acceptable care and comes back for follow-up management, guess who won’t get paid for her ongoing care after January 1, 2013? Neither my hospital nor me.
Talk about shifting risk!
So the risk of Granny’s pacemaker care in our current capitated ACO world is shifting ever-so-quickly from a company who is in the business of taking risk (insurers), to hospitals and me who are not in the business of taking risk. I am in the business of caring for patients and expecting I’ll get paid for that care. I do not have a big, fat, holding pen of reserves that people pay in to for assuming their health care risk like an insurance company. I just have a personal checking and savings account. (No wonder hedge funds are lining up behind insurance companies – it’s a win/win for their profits!)
This trend is only getting worse. In a piece entitled “Tackling Rising Health Care Costs in Massachusetts” that appeared in the New England Journal of Medicine, we find that the near-universal health care law in Massachusetts (upon which our current health care law is modeled and was sold as cost-cutting) has the “highest personal health care spending per capita of any state.” As a result, we also learn of a new law that was just passed to counteract this fact that contains measures that further shifts the cost risk further from insurers to the hospitals and doctors. In fact, as one former Boston hospital CEO has pointed out:
Even if you believe that capitated contracts are the best thing that could happen in health care, you should not and cannot believe that the transfer of risk inherent in such contracts should go unrecognized. The state’s failure to account for this gift to the insurance company represents an example of incomplete policy-making.
But doctors in Massachusetts have recognized the problem. The legislature there forgot to consider what doctors are actually doing in Massachusetts … they’re leaving.
Hey Granny! Maybe we should push the insurers and these well-funded politicians off the cliff.
Wes Fisher is a cardiologist who blogs at Dr. Wes.