Tuesday, October 30, 2012


A baseball player that hits at three hundred does not make it to first base 7 out of 10 times and is labelled really good. A player that hits at four hundred won't make it to first base 6 out of 10 times and is called legendary. What should the success rate for a cardiac surgeon be?

Given that doctors are human and make mistakes just like anyone else, what role should malpractice insurance, medical liability, and tort fees play? To what extent should a person be able to sue for a real or imagined mistake? Should there be a financial limit set to how much a patient can be affected by a mistake? Who should pay the legal fees?

The system as we have it favors malpractice suits. Malpractice law currently supports the use of contingency or conditional fees for lawyers 90% of malpractice cases are dismissed without payment, but since the loser (patient in 90% of the cases) does not have to pay the legal fees of the doctor, the doctor pays more than $110,000 just to defend that one case. Additionally, the patient's legal fees are covered by the representing lawyer by a "no win no fee" agreement  There is no disincentive for a patient to sue and such cases are usually only limited by a cherry picking lawyer who think the case is meritorious enough to sue.

This isn't to say that malpractice serves no purpose or that it has no place in our healthcare system. There are always going to be glaringly obvious or grossly negligent actions with unfortunate outcomes. One reason medical tourism to the United States is high because there is a system in place for recompense should things go wrong.

There is some evidence that litigation can be avoided in some cases where the hospital or doctor has a habit or culture for expressing empathy when something bad has happened and giving an apology when it results in an unfortunate outcome.

Other countries have different options that drive down the costs and defensive medical procedures. Some countries have caps or maximum allowable amounts for claims. Others raise the standard for the 'burden of proof' ("the necessity of proof lies with the person who lays the charges") which makes it more difficult to prove that a doctor committed a fault. Most Western democracies (with the exception of the United States) operate under the 'English rule' in which the loser pays the legal fees of both parties. In Australia malpractice insurance is only three or four digits instead of  five or six digits. One reason is that lawyers are prohibited from practicing on a contingency basis which means that only the patients who are willing to pay legal fees out of their own pockets get to sue. Obviously, only the most terrible mistakes go to court.

Is tort reform necessary? The Journal of the American Medical Association discussed how defensive medicine impacts physicians and patients.

Results  A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. “Assurance behavior” such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums.

Tuesday, October 16, 2012

Healing Healthcare

Liberals like to pretend that you can, with impunity, spend unlimited money and that tax dollars are a blank check. This fosters an environment that culminates with using tax dollars to pay for the sex change operation of inmates. Conservatives tend to avoid admitting that society has any obligation to provide healthcare for its members. This leads to an unsavory 'let him die' attitude.

In order to provide a discussion for answers instead of simply pointing out problems, I have included the basic models of healthcare that are sustainable, but which also have varying levels of government interference, regulation, and use of tax dollars.

The Bismarck Model operates solely in the private market. The providers (doctors, clinics, and hospitals) as well as the payers (insurance plans) are all private entities. The payers are nonprofit, tax exempt entities that are required to dump a certain percentage of premium dollars into actual healthcare costs. There are over 200 competing insurance companies and there is a governmental individual mandate. The countries operating in this manner are Germany, France, Belgium, and Japan.

The Beveridge Model is a bit different. All healthcare services are provided by the government much like the fire and police departments. Hospitals are all owned by the government and doctors are either government employees or private practitioners that contract with the government. Patients get no bills and this model is seen in Britain, Italy, Spain, Sweden, and Cuba.

The National Health Insurance Model is the classic single payer system seen in Canada, Taiwan, and South Korea. The government collects taxes, pays a set amount for services provided, and providers are private entities that bill the government.

The Out of Pocket Model is the one probably most familiar to everyone. There is no insurance and providers are private entities that bill the patients who are directly responsible for the costs.

For most working people under 65 we operate in the Bismarck Model where employers and employees share the premium and the insurance pays most of the tab to private providers. For Native Americans, military personnel, and veterans we operate in the Beveridge Model where the providers are government employees working in government-owned clinics and hospitals and the patients never get a bill. For those over 65 we operate in the National Health Insurance Model where Medicare is the single payer, costs are paid by collecting and dispersing taxes to private providers. Those who are uninsured, either through choice or extreme indigence, operate by paying out of pocket for any medical expenses.

I find the least to dislike about the Bismarck Model because it has the least amount of government regulation, it fosters competition among providers, and one person subsidizing another is minimized.. In order to make it the most palatable for the greatest number, the individual mandate would be necessary as well as government assistance with the premiums for those near the poverty line. However, helping to pay for the premiums of health insurance is a small price to pay for doing away with government funded operations, pharmaceuticals, medical equipment, hospital stays, labors and deliveries, and health maintenance of 130 million people: 3 million federal, 20 million state, and local government employees not counting their dependents or contractors, 2 million inmates, 104 million people on Medicare and Medicaid, and the miscellaneous Native Americans and Alaskan Natives.

Monday, October 1, 2012

Unaffordable Care Tax

I have avoided writing about the Affordable Care Act aka Obamacare until I felt like I understood it a little bit better. One blog post can hardly do justice to the Act in it's entirety, but here's for starters. The SCOTUS affirmed that the mandate that everyone must purchase health insurance is Constitutional under the ability to tax so I will refer to the Act as the Affordable Care Tax.

The two goals of the ACT are to expand access to coverage and slow healthcare costs which are both laudable endeavors. As part of the plan, there will be no denial of insurance for preexisting conditions, no lifetime caps, covering kids until 26, and even rates for insurance despite medical history. Obviously, there is an increased payout on the part of the insurance companies to meet this requirement that they can't pass on directly to the previously or currently unhealthy individual. This means that insurance rates for everyone will go up in order to pay for those increased costs, right? Anticipating this obvious move, the ACT mandates that insurance companies justify premium rate increases of 10% or more per year starting in September 2012 (never mind the fact that rates skyrocket until then in anticipation). Additionally, if insurance companies do not spend 80% of premium rates on actual healthcare and quality improvement measures, they must refund the difference to the customers. You might wonder why you didn't hear more of a fuss from insurance companies in response to these proposals. To keep insurance companies happy Congress had to throw in the 'individual mandate' - every American citizen is required by law to purchase health insurance or face a fine.

The Affordable Care Tax mandates that insurers can only charge older individuals three times more than they charge young, healthy counterparts. That's a great deal for the elderly who generally pay six times more for healthcare than youngsters and the numbers wash out such that the younger are asked to pay 75% more for insurance so that the elderly can pay 13% less. That isn't so much insurance as it is a subsidy defensible only under the tax clause. 

This mandate, along with the 'justifiable' cap on increasing yearly premium rates, has caused my personal private insurance to jump (before the cap takes effect) from $1450 in 2011 to $1980 (37%) in 2012 for the exact same coverage. Can I subtract the difference on my taxes for next year?

Those who refuse to pay for insurance (either individuals who can't afford it and qualify for expanded Medicare coverage or businesses who decide it's cheaper to pay the fine than pay for insurance) get dumped into the Medicare system. The problem with that is that compensation over the long term goes down for future doctors like me.

This is a chart available from the American Hospital Association demonstrating how the different insurance payouts compare. The horizontal grey bar represents the actual cost to a hospital of providing care for any given patient. As you can see, publicly funded patients do not reimburse hospitals the full amount that it costs to provide treatment. You might point out that hospitals make up the difference on the private insurance patients, but then you realize that there are lots more Medicare and Medicaid patients than there are private insurance patients.

Additionally, the 50% worst performing hospitals in terms of patient satisfaction, 30 day readmission rates, and a few other criteria lose 1% of reimbursements the first year of implementation, 2% the next, and 3% thereafter. This money goes to reward the top 50% of hospitals. Can anyone think of why it might be a bad idea to reward hospitals and doctors based on patient satisfaction? At the basis of any profession is the notion of client advocacy. I am asked to be willing to make a narcotic drug seeker mad and say no to his request for a prescription for oxycodone. A diabetic being treated for hyperosmolar hyperglycemia syndrome whose friend brings her a McDonald's Mcflurry ought to be told she can't have it without worrying whether that will affect reimbursement for her treatment. Smoking cessation has to be documented in each encounter with a smoker regardless of whether he wants to hear me nag or not. A 450 pound male probably needs some frank words. An ER physician might suggest to a 7th time ATV rollover patient that it's time to find a new hobby. I'm absolutely not advocating permission to be rude, belligerent, or insulting, just for the freedom to do what I am trained for: taking care of patients.

The faith in collective social effort required by this piece of legislation is commendable as this article illustrates, but is prohibitively large and therefore naive.

 --I'm very afraid, because I don't think we are making adequate preparation for what's coming. Governors must get busy passing smoke-free legislation so we can afford the burden of 2014. Decreasing cancer, heart attack, stroke, and emphysema expenditures are all that will save states like Kentucky. Hospitals had better get busy implementing programs that promote compliance, decrease 30-day readmit rates, and improve discharge planning. Patients better start eating the Mediterranean diet, exercising, and avoiding sodium so that stroke rates, heart attack rates, and the incidence of diabetes plummet. Communities should help each other by promoting legislation that allows for easy sharing of unused medications by making pharmaceutical repositories not only legal but desirable. Small towns should find ways to get blood-pressure cuffs into places where their citizens congregate weekly to affect heart-failure and stroke rates. Small clubs in conjunction with their local healthcare providers should offer more screening programs. Emergency departments should develop programs that decrease unnecessary office visits by allowing competent nurses to screen calls, make appointments, and facilitate communication between covering physicians and office physicians who will see the patient the next day. Elementary schools and high schools should design programs that teach children how to eat, how to exercise, and how to recognize disease states. The cost to enter and complete med school had better be subsidized, or doctors will become extinct.--

I object to the Affordable Care Tax for the same reason I object to every piece of legislation that asks me to voluntarily surrender my money either in the form of increased taxes or in the form of decreased compensation. This does both. I also object to this piece of legislation for the same reason I object to the existence of Medicare and Medicaid: my money subsidizes poor lifestyle choices. I would agree to this only if they also outlawed tobacco, alcohol, overeating, under eating, obesity, fast food, and added a provision that denied payments for noncompliants, drug addicts, drunk drivers, overdose patients, and thrill-seeking accidents. It's not that I don't think they should receive health care. I just think it's not unreasonable to object to paying for it.