Confusion

"There’s too much confusion, I can’t get no relief." These lyrics, sung by Jimmy Hendrix in his famous song All Along the Watchtower, can be used to describe the present state of organized Medicine concerning quality indicators. For almost two decades, there has been a movement toward a uniform set of practice guidelines which would elevate the quality of care delivered to the American public. Practice Guidelines, Evidence-Based Medicine and Comparative Effectiveness are just three of the buzzwords used by the groups promulgating these movements. Medicare has set a number of quality indicators, which they measure accurately, as indicators of how well a practice or an institution is performing in delivering quality healthcare. The problem has become that many of these quality indicators are falling by the wayside. The latest to go is the quality indicator which measures how often Beta Blockers are prescribed after myocardial infarction (heart attack). Beta Blockers were believed to significantly reduce the incidence of second heart attack over the long run. A recent long-term study, published in the Journal of the American Medical Association, seems to have disproved the value of Beta Blockers in this setting. This is not the first, nor will it be the last, quality indicator to have….well….quality issues. Inhaled steroids for asthma have been questioned. Hormone replacement for women has certainly fallen aside; in fact, the incidence of Breast Cancer in the USA has fallen by 15% since hormone replacement therapy, once a leading quality indicator, was exposed as harmful 10 years ago. Yearly mammography, once a solid quality indicator, has been under fire recently, both scientifically as well as politically. Yearly PSA, another quality indicator, has been shown to be more harmful than helpful. Colonoscopy every five years as opposed to every ten years is another. As we look to get more bang for our buck from our healthcare dollars, it appears that what we consider to be quality is somewhat elusive. One can make the argument that Medicine is an evolving science and as such will have forward movement as well as setbacks. The bigger question is why is so much of Medical Research so wrong? Conflict of interest, career advancement, income, regression to the mean and bad public policy are a few of the short answers. The present crisis in Medicine revolves around how little real good we get from all the money that we throw at it. Until we reform how medical research and progress are actually carried out, the course to bad outcomes and bankruptcy will continue to be paved with the best of intentions.

Back Door Single Payer

The Supreme Court will be deciding on the Constitutionality of Obamacare in June. Pundits are already proclaiming victory for the right who has fought this legislation tooth and nail. While most agree that the individual mandate will be struck down, few agree that the entire bill will be swept aside. For one thing, the justices did not want to do the work of reading the entire document; who can blame them since few in the House or the Senate read the entire bill either. The Court is also concerned about its legacy (as too activist) if they send the entire bill into the dumpster. If they strike down the individual mandate only, this will eventually end up as a victory for the far left. Yes...you heard me.... a victory for the far left. The far left wants a single payer system as the ultimate goal; think of it as Medicare for all from birth to death. They may have to wait a while and they may have to deal with a few speed bumps, but the elimination of the individual mandate is the first step toward that ultimate goal. If the remainder of the bill is preserved, the insurance companies will be left saddled with all sorts of expensive new regulations which will eventually destroy their current business model. Chief among those is the elimination of the pre-existing condition problem. Under the new paradigm, people with no insurance (or lousy insurance) can buy gold-plated insurance AFTER they are diagnosed with a serious medical condition. This is akin to buying collision insurance after you have had your auto accident. Under the original bill, the individual mandate would have covered the cost of eliminating the pre-existing condition dilemma. With the individual mandate toast, the economics of eliminating the pre-existing condition problem do not work. The new bill also calls for a massive expansion of Medicaid by about 40%. Medicaid (Medicare's ugly sister) is a shared federal/state program which provides medical care for the poor. Under the new bill, it will also serve much of the middle class. Medicaid is a low cost, low quality, least common denominator form of health care; it contributes mightily to America's low quality world ranking of medical care delivered. Much of Medicaid's budget goes to ancillary health care matters (Nursing homes, transportation etc.) as opposed to direct medical care. Stuck with all these new unfunded liabilities, the big insurance companies will put a bigger squeeze on hospital and other providers and further ratchet down their medical payments. This will force many hospitals and providers into bankruptcy (or at least, have a very significant impact on the quality of the care that can be delivered.) Many insurance companies will quickly pivot into models that cherry pick only the profitable segments of the entire apple or abandon medical insurance models altogether. As this evolves over the next 3-10 years, the government will incrementally continue to expand Medicaid deeper and deeper into the middle class until almost all Americans have either Medicaid or Medicare as their only available coverage. Of course, the top 5% will continue to have private insurance because they will be the only one's who can afford it. Medicare and Medicaid will, at some point, merge and become one entity.... probably Medicare. The end result will be that we will have a single payer for 95% of the population. Isn't this the system Great Britain has right now? The National Health Service covers about 95% of the population with the other 5% covered privately. As George Orwell famously said in Animal Farm: "All animals are equal but some animals are more equal than others." So, as the right savors its victory upon the striking down of the individual mandate, the left will be sitting pretty with its ultimate dream of a single payer. It makes you wonder if the Obama administration threw the case.