In recent months I have been forced to dig into the ins and outs of Obamacare more than I or any approving congressional member had ever planned to. I usually read it with my head on a swivel like a depressed bobble head doll. Still, I can usually stimulate my fellow conservatives’ gag reflex (cranial nerve X intact) when I say that there is some good in the bill. Now, before you vomit all over your keyboard let me amend by saying that even a turd has some nutritional value.
I’m not going to focus on those few details that are potentially good, but I would like to point out one terrible unintended consequence of the bill. The key words for this section of the bill are “quality care” or “pay for performance”. On the surface this sounds great. Nobody wants to go to the doc and pay him only to return for the same uncured illness/problem. While there is little doubt that docs can sometimes oversee, or even purposely not treat some illnesses for cost benefits, it is an uncommon occurrence. Being in the health care setting, it is abundantly obvious that providers want to help patients as efficiently and as well as possible in order to free up beds and time slots for more patients. Keeping patients in beds is hardly beneficial, even from a cost benefit point of view.
Still, we wouldn’t want to pay doctors for low quality care, so it makes sense at face value to pay them for their quality of performance not just act of performing. So, without getting into the numbers (which are mostly based on Medicare’s “Value-Based Purchasing”, that is precisely what this portion of the law intends to do – pay for outcomes. Performance measures are set up by the Secretary of H&H Services (just another way for government to tell us what is best for us) and the outcomes fall into reimbursement brackets. For the simple; if you break your leg and it isn’t healed in the time frame that the Sec. of H&HS deems appropriate, the hospital isn’t going to get as much money.
So there are some good things that can come from this, but there are also some unintended consequences that government, in their non-existent wisdom, always fall victim to. These are what I would like to highlight.
1. The relationship you have with your doctor in regards to your recovery actions will be compromised.
Think about it. Who knows more about medicine you or your doctor? For the vast majority of us, that is the doc. Most of the time we just listen to what he/she tells us to do and everything turns out fine. But, if you’ve got a chronic and debilitative illness (we’ll say cancer), then there are certain aspects of treatment that the doctor will leave to you for options. In fact, health care providers have been trained over the past decade to try and leave as many options of care to the patient as possible because we’ve found that it helps them feel like part of their recovery and we get better outcomes. Well, that might change. Doctors will be less apt to leave options open to patients because the outcomes will mean less money in their pocket. Not only that, but another part of the HC law will make the outcomes of the hospitals public so that patients can chose their providers. So if your oncology department leaves treatment options open (alternative medicine, opt out of chemo, opt out of radiation, chose palliative care for a few examples) then your health outcome might, according the bureaucratic definitions, fall short of standard. That hospital will receive less compensation for your case and, if they continue in that way, will get downgraded as a hospital on the public databases. In short, the hospitals won’t do it.
2. Quality isn’t a broad understanding.
What is quality care to you might not be quality care to the law. This ties in a little with the previous point. If you have cancer and you just want to die (your right) in dignity, relative comfort, etc. then your standard of quality might be different from that of the Health and Human Services. Perhaps a quiet room and a nurse that isn’t constantly coming in and nagging you is quality. Perhaps you prefer one doctor as opposed to many. Maybe you want someone that takes time and sits down and comforts you in these difficult times. Quality care is a very personal thing and HC providers must figure out the individualized standard from patient to patient. “Standardized care” negates that individuality and replaces it with a broad definition.
3. Sometimes quality outcomes aren’t quality outcomes.
Case and point can be made with a local hospital. Over the years they found that patients who come in with Heart Failure (HF) have better outcomes if they revisit the hospital within 30 days. The new legislation disagrees in a typical bureaucratic fashion. It will specifically penalize hospitals for higher admission rates. The hospital is suddenly put in the position of either losing funding (and that dreaded database score) by readmitting patients or having higher death rates in their community.
4. Humans are human, and doctors are too.
So if health outcomes are the measure of how you are reimbursed, then why would you care for someone who has a low probability of a good health outcome? Further, why would you work on a patient whose illness/problem there is no quality measurement? They are out there. If you have a hall way full of patients and your staff is juggling everyone to meet their health needs, then why would you spend more time in Jane Doe’s room when she is most likely to die? It flips the current practice of health care provision on its head. Right now, we are usually spending most of our time in the rooms with patients who are most ill and less likely to fully recover because they present in a manner that requires attention. If you come in with a sniffle or you come in with catastrophic heart failure, you are less likely to receive the attention of the middle ground people…typical socialism.
5. He is me and I am him.
One of the great things about doctors is that they get good at their art. They take years of studying, practicing, researching, and collaborating to develop practices that they prefer and hopefully work best on patients. The standardized care will rob many of these doctors of that sense of autonomy. The safe road will too often be the road most traveled and our health care evolution may become stagnant.
6. Doctors aren’t magicians and they aren’t in charge of your health.
This is perhaps the most frustrating part from my perspective. Doctors will be punished for your negative health outcomes. Never mind that you smoke 2 packs a day, eat tenderloin by the pound, and have a permanent imprint of your butt in your rightly named “lay-z-boy”, the doctor is going to get robbed if you die from a stroke. Have COPD from years of smoking? Come in and get your meds and then leave with Marlboro in your mouth and see how well your outcome is. I’ve had patients with recently amputated legs jump out of bed after the doc told them they had to stay in it for days. Hemorrhage and a rush to surgery is usually the outcome. That price will now fall on the hospital. Does any of that make sense to you? Most of our illnesses are preventable and self induced, but suddenly your health outcome falls on the health care providers?
So how many docs, nurses, therapists, etc. do you think are going to want to stay in this mess? How many hospitals are going to be able to put up with such ignorant and stupid legalities? After reading this, you may have a better understanding of where much of the “health care cost savings” is going to come from. Think on that next time your life is in their hands.
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