The Clare Spark Blog

March 29, 2012

James V. Pagano M.D. on Affordable Care Act

Filed under: Uncategorized — clarelspark @ 10:08 pm
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There are a lot of things not to like about the Affordable Health Care Act, including the fact that it isn’t actually affordable, but I feel certain that the great majority of people, those who favor the law and those who do not, would agree that two of its purported benefits are good things.  Those would be near-universal coverage and improved access to medical care.  The problem is that the law does not provide either.

To achieve near-universal coverage the law seeks a huge expansion of the Medicaid program.  Some twenty million people or so will be added to the various state-run programs, which in my state is known as MediCal (i.e., Medicaid).  Proponents of the law call this providing health insurance to those currently without it.  But MediCal isn’t insurance.  It’s welfare.  There’s a difference.

Insurance is something you buy.  You pay premiums, deductibles, and co-pays for a product that, in theory, indemnifies you against large financial losses in the case of illness or injury, helps with the cost of medications, and avails you of the services of a wide range of physician specialists.  Because it is expensive, you use it judiciously.

Medicaid is something provided to the medically indigent as a safety net.  There are no premiums, deductibles, or co-pays.  It is paid for by tax dollars.  As a practicing emergency room physician for over thirty years I can attest to the benefits it provides those who must rely on it for their healthcare needs.  I also understand its limitations.

Reimbursement rates under the Medicaid program are absurdly low.  As a result most specialists, especially surgical specialists like orthopedists and ENT’s, don’t take it.  Increasing numbers of primary care doctors don’t take it, either.  Which leads to the AHCA ‘s second false promise, that of improved access to health care.

Simply having a Medicaid card does not guarantee you will get to see a doctor.  Unless that doctor is working in an emergency room.  We who work in the specialty of Emergency Medicine have always provided care to all comers, insured or not, and the EMTALA law codified that practice when it was passed in 1986.  Under the new health law we will continue to see and treat all who come seeking care, but it will become even more difficult to do.

In the face of twenty million more patients with nowhere else to go our ER’s are going to become more crowded than they already are and waiting times will increase.  Compounding the problem will be patients needing a specialist with no specialist on-call.  This is already the case in many hospitals where trying to find an orthopedist, neurosurgeon, plastic surgeon or otolaryngologist is nearly impossible because these physicians have taken themselves off the ER back-up panels as a means of protecting themselves from having to provide high-risk, uncompensated care.  The Medicaid patient needing a fracture reduced or repaired surgically will be splinted, treated for pain, and parked in an ER bed until a transfer can be made to a County hospital.  That ER bed remains unavailable to another patient until the transfer can be made, and the overcrowding and wait times get worse.

To pay for the new health care law over half a trillion dollars will be taken from the MediCare program.  MediCare is still accepted by most primary care physicians and a sufficient number of specialists and sub-specialists to make the treatment of those covered by it reasonably easy.  Once the MediCare budget is cut, that will change and then seniors and the disabled will find themselves in the ER waiting room alongside the Medicaid patients.

Although there is speculation that the Supreme Court’s decision about the law’s constitutionality might render this entire discussion moot it is nevertheless an important discussion to have.  One way or another our system of healthcare delivery and the way we pay for it is going to be revamped.  If the Court gives us a do-over we must use that opportunity to construct a system that can actually do what the current law only pretends to do, namely make quality healthcare available to all Americans at a reasonable cost.

As I said at the top of this piece there are many reasons not to like the Affordable Health Care Act.  If the Court allows the law to stand I will likely be writing about some of them between now and the November elections, which will then be our only chance to avert this impending disaster.

James V. Pagano, M.D., FACEP

Dr. Pagano is the author of two novels, The Bleed, and The Drain    

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November 21, 2010

Dr. James Pagano on ObamaCare (2)

Filed under: Uncategorized — clarelspark @ 3:24 am
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Rembrandt: The Anatomy Lesson of Doctor Tulp, 1632

Two weeks have passed since the midterm elections.  The anxiety, anticipation, and exhilaration they inspired have had time to dissipate and now a clearer picture of where we stand, and what we have to do to move forward, is beginning to emerge.  While there are many fronts on which battles should, and will, be fought I will confine my comments to the one issue I am most qualified to critique—ObamaCare.

 It was crafted in secret with no bipartisan support.  It is monstrous in its scope.  It is being touted by those who created it as being about ‘healthcare for all’, and yet to get it passed, with supermajorities in both the House and Senate, votes had to be bought outright.  It has to go.

 While everyone agrees that there are problems with the cost and delivery of healthcare in this country I can guarantee you this law will not solve them.  It will make them worse and the cost for this ‘de-provement’ will be an American public indentured to the Federal government for the foreseeable future.

 This country was founded on the principle that individuals have value and rights.  Nowhere is this more apparent than in our system of healthcare.  Doctors are trained to treat patients as individuals, each with his own problems and circumstances, and patients have come to expect their doctors to make decisions regarding their care based on what is best for them.  Period.

 The architects of ObamaCare see things differently.  Our president, a self-proclaimed ‘progressive’, believes what all progressives believe.  Namely, that the welfare of society is more important than the welfare of any individual.  Individuals don’t matter in general, and when they cease to be ‘productive’ members of that society, they matter even less.  The fact that a society is nothing more than a collection of individuals working to achieve some common goals is somehow lost on these people.

 This belief in the primacy of ‘society’ underlies the key element of ObamaCare—stripping half a trillion dollars from MediCare to pay for thirty-some million people soon to be enrolled in various forms of Medicaid.  This is a disaster on a few different levels.

First, patients on MediCare are by definition older, sicker, and more in need of medical services, services that by and large they have earned during their ‘productive’ years by paying large amounts of money into the system via MediCare taxes. 

 Second, Medicaid is not what people think it is.  Specifically, it is not ‘insurance’ but merely a free pass for those who have it who will then never face a premium payment, a deductible, or a co-payment.  This creates a class of healthcare consumer with no skin in the game.  This is exactly what we don’t need if we want to control overuse of services and spiraling costs.

When I say it isn’t insurance I’m referring to the fact that very few physicians accept Medicaid patients.  They can’t afford to.  This is true for most primary care physicians and even more so for the great majority of specialists and subspecialists.  So when the Medicaid patient comes to the ER with a broken arm, we see him, do the exam, take the x-rays, make the diagnosis, and apply the splint.  But if that broken arm needs to be reduced, or operated on, we can’t get the orthopedist to take the case. 

 Some have suggested that a physician’s license to practice be dependent on his willingness to care for these patients.  I hope we’re not considering bringing back slavery. 

 The true goal of ObamaCare is to squeeze out private insurance companies and force everyone into a single-payer, government-run healthcare system.  Why seemingly intelligent people think this is a good idea baffles me.  In countries where this is being practiced, notably Canada and England, there is widespread acknowledgement that it doesn’t work very well.  Private clinics are popping up in Canada and doctors in border cities are doing a brisk business caring for Canadians who feel they can’t wait six months to a year for their joint replacement or their MRI.  My British friends are equally unenthusiastic about their system.

If we want to reform healthcare in this country then that’s what we should do.  Identify the specific problems that need to be addressed, the recisions, the denials for pre-existing conditions, the lifetime caps on benefits, and the availability of coverage for the great majority of people in this country, and then do the work of finding specific solutions in concert with physicians and insurers.

 We do not need the Federal government using healthcare as an excuse to commandeer a sixth of our economy.  We do not want bureaucrats deciding who gets what care and when.  We don’t need rationed care, we need rational care.  There’s a difference.

Hygeia

 If Obama succeeds in destroying the current private healthcare system his appointees, like Dr. Berwick, will be instituting a large number of ‘practice guidelines’ as a means of making healthcare delivery more homogeneous across geographic and social lines, and more affordable.  There are already such guidelines in place for certain diagnoses and they are referred to as ‘Core Measures’.  These guidelines are supposed to be the result of rigorous scientific study and are supposed to represent ‘best practices’ for the diagnoses they cover.

 In some instances they make sense, in others they seem arbitrary.  But even the most egregious of these guidelines—the one requiring us to obtain blood cultures on patients suspected of having pneumonia, which most physicians realize is a waste of time and money, remains in force.  Such is the inertia of government.

 The guidelines to come are not going to be anywhere near as pleasant as our current ‘Core Measures’.  My guess is that they will be closer to Draconian.  They will be designed to shift care, and the money it costs, away from the ‘non-productive’ members of society.  And yes, if this sounds like the ‘death panel’ stuff people were ranting about a year ago, well, it is.

 It is true that something like eighty percent or so of healthcare dollars are spent on the last 2-3 years of life.  We don’t need the government to fix this.  We need to promote rational care, where physicians feel free to discuss end-of-life issues with patients and families and where they do not have to live under the threat of being sued every time one of their patients has a bad outcome.  If you believe that death is a bad outcome, then we are all bound to have one.  It is not necessarily your doctor’s fault.

Educating the public about what we can and cannot do for the terminally ill, and having the courage to make decisions on that knowledge, will eventually save the dollars we are looking to save.  All without the government taking over, without Dr Berwick, without Obama.

 James Pagano, MD

Dr. Pagano’s first blog can be found here: https://clarespark.com/2010/03/19/dr-james-pagano-on-obamacare/. Dr. Pagano has just published a novel, The Bleed, “about ER doctors, sleazy trial lawyers, ne’er-do-well patients, gangs and girls–and what happens when their worlds collide.”  I have just read the novel, and its detailed account of a medical malpractice case and the current administrative difficulties that discourage doctors from a one-to-one relationship with patients should alert us to the dangers to individual and public health being advanced by left-liberals today. In Pagano’s own words to me, it is a good airplane read.

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