Tuesday, March 31, 2009

Those Who Pay the Bills Run the Business

Several news stories and political developments drive home an important point in health care delivery: Money is power. The person who pays the bills runs the business.

Take for example the dwindling autonomy of businesses and industries that accepted government aid over the last couple of months. 1) The Obama Administration forced CEO Rick Wagoner out of GM after rejecting GM's restructuring plans. The Obama Administration paid to keep GM alive and now runs GM. 2) Recently, the House tried to hammer AIG, another bailout recipient, and passed a 90% tax on AIG's executive bonuses. The federal government owns AIG. It's freedom as a business only extends as far as good favor from the government. 3) Now Barney Frank is pushing a bill that would establish government control of the salaries of all businesses that received bailout funds. If the government pays the bills, they run the business.

Health care providers need to decide who they want calling the shots at their own clinics: do they want government-directed care, insurance company-directed care, or patient-directed care? That will be determined by who they allow to pay the bills.

I believe that most physicians truly believe that patients should be their own health care executives. They should have the final say on all medical decisions. Physicians and other health care workers are contracted to the patient to provide services under the patient's direction. Patients can hire and fire physicians at will. That is the ideal in medicine- the patient is in charge.

Experience and reason show that the responsibility of physicians to patients extends only to the degree that patients pay their own bills. The patient remains the health care executive only as long as they pay the medical bills. As soon as they delegate that responsibility of paying, they are no longer in charge of their care.

Patients' and doctors' experience with health insurance companies supports this idea. When clinics begin working with insurance companies, the whole nature of the practice changes. The insurance company is now making the calls. They determine treatment regimens- declaring some treatments acceptable and ruling others out despite patient wishes. They mandate diagnostics, both requiring redundant screenings and denying more expensive essential diagnostics. They even require additional staff hiring at the clinic, requiring the hiring of billing personnel exclusively for correspondence with the insurance company. Insurance-paid medical care is not patient-driven medical care. Many patients are okay with this- they've contracted insurance companies to manage their care. Insurance pays the bills and insurance runs the business.

What about when the government pays the bills for health care? It seems that the federal government has demonstrated a light touch in the cases of Medicare and Medicaid. Here the government is paying the bills, but they have allowed remarkable autonomy to patients and thus practitioners. Thus the common claim: Medicaid is the best health insurance! However, the reality that government-paid health care is government-controlled health care is present in each health care regulation or bill that rolls through the legislature.

Take for example the conscience-clause regulations that President Obama is about to overturn. Which health care providers do conscience-clause laws and regulations actually effect? Only those who receive federal funding through programs including Medicare and Medicaid. For another example, consider the health care legislation that was buried in the February stimulus package. The legislation establishes a National Coordinator of Health Information Technology with potential powers to establish and enforce a national standard of care. What health care providers will be responsible to this Coordinator? As far as I can see in the bill, only "government-sponsored" health care programs (pp 470) and recipients of Medicare, Medicaid, and state children's health insurance programs (pp 481) are currently marked for integration into the HIT program. When the government pays the bills, government runs the business.

If patients want to control their health care, they must pay the bills. If health care providers want patient-driven health care, they must establish practices where patients pay the bills. As government control increases in the health care industry, the best way to maintain autonomy over a practice may be to refuse third-party funding, especially government funding. Cash-only practices may become the only venue where patients remain health care executives and the doctor-patient relationship is preserved.

The federal government is trying to work up a steam push through government-run health care. They don't call it that, in fact many will sell the package as patient-run or patient-centered health care. But those who pay the bills run the business. You can bet that the same House, Senate, and White House that had so much to say about AIG and GM will have plenty to say about health care. Patient control over health care will be as remote as my control of the House of Representatives. After a few unanswered letters to the legislature, they will be left powerless and blogging.

Rusty Scalpel

Thursday, March 26, 2009

Conscience-Clause Law and Religous Freedom in Health Care

Do health care practitioners have the right to refuse treatment based on religious grounds?

On March 10 the Obama Administration announced a 30-day comment period before rescinding (overturning) conscience clause regulation established during the last days of President Bush's term. To put these soon-to-be challenged regulations in perspective, let's quickly look at the recent history conscience clause laws and religious freedom in health care.

When Roe v. Wade was decided in 1973, there was concern that physicians and other care practitioners would be legally compelled to perform abortions or sterilizations even if they found the procedures religiously repugnant. At that time, Senator Frank Church of Idaho sponsored an amendment that protected federally-funded physicians or hospitals who objected to the procedures on a moral or religious basis from having to perform the procedures. The amendment passed the senate 92-1 and became the first conscience-clause law.

The conscious clause laws were popularly accepted and promoted. Over the next years, nearly every state passed conscious-clause laws. Even Supreme Court Justice Harry Blackman, who had authored Roe v. Wade, approved of such laws as appropriate protection for physicians and hospitals.

In December of 2008, the White House announced that it would be enacting new conscience- clause regulation that would further define the 'right of conscience.' As stated in the new regulation, "The Department is concerned about the development of an environment in sectors of the health care field that is intolerant of individual objections to abortion or other individual religious beliefs or moral convictions. Such developments may discourage individuals from entering health care professions. Such developments also promote the mistaken belief that rights of conscience and self-determination extend to all persons, except health care providers..." The regulation also stated a purpose of aiding for religious entities (such as Catholic hospitals) that might suffer penalties for their abstention from objectionable practices. Bush regulation here

The new regulation established that any health care worker with "reasonable connection to the procedure" could refuse to participate if they found it morally objectionable. This could include nurses, technicians, pharmacy techs, etc. The regulations also left the door open for objections to procedures beyond abortion and sterilization. It could be interpreted to apply to any procedure that health care providers morally oppose.

The Bush regulation stirred controversy and were immediately followed by lawsuits in seven states claiming that the regulation "sacrifices the health of patients to the religious beliefs of medical providers." Organizations like Planned Parenthood called for a recision of the regulation to defend "the rights of patients to receive complete and accurate reproductive health information and services, without fear that health care providers will withhold vital information and services based on their personal biases."

On March 10 the Obama Administration announced a 30-day comment period before rescinding the Bush regulations. The recision of the regulation would not annul standing laws like the Frank Amendment or the Weldon Amendments, but would strike down in its entirety the Bush regulations. And so we return to our original question: What right do medical care practitioners have to decline treatment based on religious beliefs?

The Bush regulations also compel us to us ask specifically, should practitioners' choice to deny treatment be limited to certain procedures? Also, should conscience-clause law protection be limited to the primary provider? Do doctors have more of a right than nurses or technicians to refuse to participate in an abortion?

In contemplating these questions, I can't help but agree with the statement of the Bush regulation that there is a "mistaken belief that rights of conscience and self-determination extend to all persons, except health care providers..." I find myself very uncomfortable with the political wrangling and showdowns between the pro-lifers and pro-choicers when the First Amendment of the Constitution is already explicit:

"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof..."

Perhaps the executive branch can get away with these regulations because the Amendment specifies only Congress' limits to such lawmaking. At any rate, the practice of legislating through White House regulations is probably far outside of constitutional limits.

I believe that it is 'self-evident' that these 'God-given', 'inalienable' rights are truly universal. They apply to doctors, the same as nurses, the same as all Americans and all humanity.

To be truthful, I don't know how meaningful these regulations really are. My understanding of the Bush regulation is that it simply enforces current law. With it being struck down, current conscience-clause law still stands and has not been changed. However, I believe that conscience-clause law will continue to be severely trampled if the regulation is rescinded.

With regards to the Bush regulation. I think it should stand. It upholds current laws, whereas striking down the regulation encourages the disregard of standing law. Striking down the regulation will encourage evil organizations in their fear mongering and efforts to subject American health care providers to their practices. I believe that the right to religious expression, in the workplace or elsewhere, is a God-given right. Infringement of that right is tyranny.

The comment period before recision (overturn) of the Bush regulation ends on April 9. Comments can be sent to proposedrescission@hhs.gov. Or comments can be directly submitted here. Remember that these comments go directly to the Department of Health and Human Services. Demands and impassioned pleas will probably not go as far as well-constructed argument. In particular, the department has asked for:
  • "The scope and nature of the problems giving rise to the federal rulemaking," including specific examples, "and how the current rule would resolve those problems."
  • Information, with examples, to support or refute allegations that the regulation "reduces access to information and health care services, particularly by low-income women."
  • Whether the rule is clear enough "to minimize the potential for any ambiguity and confusion" that might result from it.
  • Whether the objectives of the rule could be accomplished "through nonregulatory means, such as outreach and education."
Rusty Scalpel

Tuesday, March 24, 2009

Letter from Reader

After a couple weeks of break for finals, FMP is back online. We thank Nathan Reed for this submission, with which we wholeheartedly agree.

I've been pretty outraged on a daily basis since January 2009 about the happenings in Washington D.C. Now I'm just sad for our country. What is happening now is the death of the chance for success. That is the “American Dream”; the CHANCE (not guarantee) to raise your lifestyle through dedicated hard work and innovation in any field of your choosing. The “American Dream” is NOT entitlement to free healthcare, housing, etc. It is NOT allowing congress to choose which companies must be saved, which the government should take over, and which companies and EVEN INDIVIDUALS to tax at confiscatory rates. This country is currently on a path that Ayn Rand depicted decades ago. A 90% tax (that members of BOTH parties voted for) on a select few individuals! A confiscatory power that president Obama is now seeking to extend to anything/anyone that our D.C. prima donnas don't like. After legislators ENABLED the behavior they feign outrage about by saving these failing companies in the first place! They are KILLING the wealth, dreams and motivation for anyone aspiring to be more and do more with their lives than merely subsist. Anyone that manages to make a good living is suspect.

Liberals and socialists would like to assume that most people operate from purely humanitarian motivations – that this is how it should be, but our country has proven in the last 230+ years that self-interest is the greatest motivator of the human spirit. This country rose to relative success in the world by refusing to deny that universal truth. Furthermore, self-interest is individual, and the freedom to pursue the goals that tickle our self-interest is another bedrock of our past success. Society cannot reasonably expect an individual to put their all into any task when the effort of their work is not met with some form of compensation that the worker finds acceptable. That is the beauty of money – its buying power allows you to reward yourself in an acceptable way for the job that you completed.

To change tracks due to personal interest, I’d like to predict the consequences of universal healthcare provided by the government. Like with government subsidized housing, costs will inflate as demand increases because going to the doctor is “free”, or at least “cheaper” after D.C. picks up some of the tab. Why go to the family physician in the morning when it costs the same to get fixed right now at the ER? Doctors will be expected to pay off hundreds of thousands in student loans in a payout system that doesn’t rise with inflation, but actually decreases from time to time because government has to squeeze them to help control costs. There will be fewer people that train for the minimum of 11 years to become physicians due to the lack of benefit from that training (that dirty self-interest thing again). After some years comes rationing of care. No, the legislators (not doctors) in charge of deciding what kind of care you can receive won’t come out and say that you’re too old, or the therapy you require is too expensive to be worth saving your life. Instead, they will make people jump through hoops to get their care. You can’t get your lung cancer treatment unless you’ve stopped smoking for at least a year. You can’t have more than one heart surgery every 10 years because it’s been “proven” to congress’ standards that you should be able to go at least 12 years if you had eaten right and lost that extra weight. I know that there are people that don’t believe me, but just look at some of the news coming out of the U.K., our “model system” as touted by Tom Daschle. Good thing he didn’t get the Health and Human Services secretary position he was offered (tax cheat writing/voting for taxing legislation), but do you think the model will change? Yeah, let’s be just like the U.K. because they should be our model, not the other way around? Oh, and throw a little Chavez in there when we don’t like your business.

It’s all just so sad, as well as stressful that I’m going to have to find some place in the not too distant future to make a living doing what I love, and to MY standards. Hopefully it’s here, but then again, who is John Galt?

Nathan Reed