Congressional health care reform relies heavily on both Evidence-based guidelines and evidence-based individual decision making to set the standards of care for medical treatment and outcomes. In fact, House bill 3962, in an effort to control costs, creates a new layer of government bureaucracy that inserts itself between the doctor and the patient. A national health commissioner and task forces will evaluate and decide everything from what medications a physician will be allowed to prescribe for a patient, to what surgery will be approved, to what outcomes will be expected for a particular medical condition. The ‘universal healthcare Czar’ along with the task forces will also decide whether or not hospitals will be reimbursed for care rendered based on predetermined outcomes. For example, if a patient is re-admitted within a prescribed number of days after discharge, the hospital will not be reimbursed for care given. It does not take into account factors such as how ill a patient may be. This new layer of government effectively removes the power of the individual physician and patient to decide what is the best course of treatment.

Why should you care?

You should care because the application of evidence-based medicine can potentially limit health choices of both patients and physicians.  In the reformed healthcare system recommended by Congress, alternative treatments will be pressured to end, and physicians who practice alternative medicine in extreme cases will be criminalized. The money in the system will continue to flow to well funded studies underwritten by the pharmaceutical industry, and those companies without deep pockets will continue to be unable to afford the cost of  in depth studies to critically evaluate the efficacy of such treatments. Alternative treatments will fail to pass the standard of evidence-based medicine precisely because they lack the funds to enter the game, and thus the cycle will continue. In short, if alternative treatments are not evaluated by the guidelines of evidence based medicine, they will never be accepted as a valued treatment option.

It can also be argued that evidence-based medicine has exponentially increased the cost of health care. In theory, the essence of evidence-based medicine is science. However, in practice it has become more about money. The system has become one where the pharmaceutical industry has been given the edge. For example:

• Many of the prescription drug trials are not independent

They are often funded by the very drug companies that stand to gain if their drug is found to be effective in trials and is approved

• The relationship between medical societies and the pharmaceutical industry raises questions.

Over the past 10-15 years there has been a change in the parameters of our most common diseases (hypertension, obesity and high cholesterol ). For example, in the past normal blood pressure was 120/80, and now  it is 115/75. In fact,those with a blood pressure of 120/80 are now considered to be pre-hypertensive and are eligible for medication. The body mass index (BMI) number for obesity decreased from 40 to 30 while the parameters for being overweight have expanded from a BMI of 27.8 in 1995 to less than 25 today. High cholesterol (LDL) is now < 200 instead of the old parameter of  < 250. The change in parameters have meant both a dramatic increase in the number of people who meet criteria for treatment with prescription drugs along with a resultant rise in the cost of healthcare. The question that has yet to be answered - why are we less healthy despite taking ever increasing amounts of prescription medication?

• There is a tight financial relationship between the pharmaceutical industry and the medical industry.

The AMA, medical education and the underwriting of medical research has given the pharmaceutical industry a great advantage in the shaping of medical opinion and by extension evidence-based medicine.

• There is a revolving door between those who work for the FDA and those who have worked in the pharmaceutical industry.

This cozy relationship raises the importance of Big Pharma and relegates natural/alternative methods to junk science. Inherently, this should make those of us who are critical thinkers question the statements that summarily denigrate the supplement industry which makes products, that in many cases are in direct competition with the drugs that are manufactured by pharmaceutical companies, but don’t need patents.

A more balanced approach to our healthcare system is necessary. If the same standard is applied to both alternative and conventional treatments, each will be given a level playing field to determine efficacy. This change would go a long way towards accomplishing the task of improving the health of Americans without bankrupting them.

Let’s try something new like  promoting prevention and wellness instead of just talking about it or actually giving  doctors and patients the freedom to choose how they approach health choices. No one can argue with the fact that a healthier population, will lead to a significant decrease in healthcare costs.  The current system clearly is not working.

Medicare has already begun the process of backdoor rationing. Facing overwhelming budget shortfalls, Medicare needs to trim its books. Washington found a clever solution: eliminate the billing code for “physician consults.”

As a hospital physician, I often admit Medicare patients with chest pain or shortness of breath. If my patient needs urgent help from a cardiologist, I call a colleague for assistance.

Until December 31, 2009 the cardiologist could charge a “physician consult” fee for getting out of bed, coming to the hospital, and evaluating a patient with a potentially life threatening problem. Medicare paid $195.76 for this middle-of-the-night work (the same rate as when done during the day).

By eliminating the “physician consult” billing code, Medicare now advises the specialist to charge for a “hospital admission.” For two more months, Medicare will pay $175.67 for this service. However, without a change in current law, the physician’s reimbursement for a “hospital admission” will drop to $141.63 on March 1. This is why the “Doc Fix” is so important for working physicians and their Medicare patients.

Other recent and obscure changes in Medicare guidelines are potentially even worse.

As of January 1, Medicare will not pay the consultant at all unless the admitting physician uses an “HI modifier” when billing Medicare for the initial admission. This means in order to get paid, the consulting physician must rely on another physician’s billing practice. Many physicians remain unaware of this obscure change (Medicare guidelines were altered as recently as December 17). The result? Many consultants will be denied payment altogether—yet another way to “save” Medicare dollars.

Most physicians function as small business owners. Consider what becomes of this $141 per consultation (assuming they are lucky enough to receive that):

Interventional cardiologists pay approximately $50,000 a year for malpractice insurance. If they work 40 hours a week, 50 weeks a year this means they pay $25 an hour for malpractice coverage. If they spend two hours in middle of the night coming in to see my patient, this effectively cuts their salary by $50. Earning $91 for middle of the night work simply does not cover the rent, utilities, and salaries for office staff that must be paid each month to keep the office doors open.

Why should seniors care?

Even before these cuts, Medicare already underpaid physicians by 15 to 25 percent compared to traditional insurance companies. No business can survive when expenses exceed revenue—no matter how well intentioned the physician.

When the pending $500 billion cut to Medicare (used pay for healthcare reform) is added to the cuts outlined above, physicians will be forced to limit their exposure to patients on Medicare. They will shift their work to younger, healthier patients who are less complex, require less time, and have traditional insurance. This kind of “reform,” even as millions of baby boomers enter the system, will only exacerbate the physician shortage for Medicare patients.

There are ways to “bend the curve” without sacrificing our seniors. But sadly, Washington chose another path. Politicians chose to reward political allies and pay off key Senators rather than protect American seniors.

Several common sense reforms would “bend the curve” without backdoor rationing. But Washington continues to ignore these ideas. These solutions include:

1. End abusive medical litigation by passing patient-centered tort reform.
2. Let businesses purchase insurance across state lines.
3. Give younger, healthier Americans tax incentives to purchase low cost/high deductible plans and let them put pre-tax dollars into a healthcare savings accounts.

If Washington continues to protect political allies and buy Senate votes rather than pursue patient-centered reform, then let backdoor rationing begin. This is not overheated rhetoric. This is reality. Mayo Family Clinic in Glendale Arizona just announced it will stop accepting Medicare as of January 1.

From the beginning of the debate and the resultant bills in Congress there has been no thought put into the root cause of the high cost of healthcare. As usual the players who were allowed to sit at the table were the ones who had the most to lose if the status quo really changed. Special interest groups (i.e., unions, hospitals corporation, medical insurance industry, pharmaceutical industry, and the AMA) each flooded Washington with money and controlled both the argument, and the perceived solutions for the mess that has become our healthcare system. At no point were physicians on the front line who deliver patient care or patients who are victims of the health insurance maze given a voice in the process let alone a seat at the table.

The reality is that the government’s insertion into healthcare has led to the high costs that we are living with today. It began when the Medicare reimbursements to physicians were disconnected from the costs of delivering quality healthcare. For over 10 years the reimbursements for physicians has dropped every year while the cost of supplies, malpractice premiums and overhead expenses have continued to rise. This is the underlying engine for the cost shifting to both insured and self pay patients that we have seen over the years. It has become an untenable situation leading physicians to seek paid positions in hospitals, form large single and multispecialty groups, opt out of the system and move towards a concierge model or leave the practice of medicine completely. Overall, this has led to a fracture in the doctor patient relationship, and a rise in the number and clinical expansion of providers such as physician assistants and nurse practitioners in an effort to fill the gap left by the physician’s need to see an ever increasing patient load per day to keep the doors open.

In addition, the range of services that are eligible for reimbursement has narrowed so that doctors are offering Medicare patients less service. This problem will only get worse if the congressional reform bill is passed. Expanding who is eligible for Medicare, controlling what medical services will be covered, determining standards of medical care through task forces (like recent recommendations about mammograms), and expanding the powers of the HHS secretary are all examples of the government expanding its role into healthcare delivery. It is hard to imagine that the involvement of the government will lead to a different outcome than what is happening with other government run entities like the postal system, Medicare and Social Security, each of which is an example of inefficiency and is either losing money or is in the process of going bankrupt respectively.

There are six arguments in favor of reform that have been stated as fact that will actually work against true healthcare reform.

1. Medicare coverage is less restrictive than commercial insurance

In reality, Medicare has a higher denial rate compared to the top commercial insurance plans. Expanding Medicare will lead to less choice in the form of an ever decreasing panel of physicians who actually take it and less coverage for services.

2. Medicare for all will improve access to doctors

Nationwide about 25% of doctors no longer accept Medicare. In some large cities like NY that number is as high as 30%. In 2010, Medicare has announced that they will no longer pay for consultations. That means that specialists such as cardiologists, gastroenterologists, ophthalmologists will lose over 25-30% of their reimbursements. This will likely have a chilling effect on access of Medicare patients to specialists. If and when the commercial insurance companies adopt this payment system, it may also lead to less access to specialists for all insured people.

3. There is a shortage of primary care doctors

There is a shortage of physicians. Less people are choosing to go to medical school and because of that an increasing number of students who attend foreign medical schools are matching at US residency programs. It is difficult to ignore the fact that the growth in the number of medical schools in the Caribbean (from 4 in the 1970’s to approximately 60 today) and a growing relationship between these medical schools and US residency programs has likely been tied to the need to fill empty residency slots.

4. Health care costs are driven by specialists who perform procedures

Healthcare costs are driven by many factors, but one of the major problems is the emphasis on treating chronic disease. Another factor are the administrative costs of insurance companies which account for approximately 23 cents of every healthcare dollar is spent. The treatment of chronic disease will be difficult to contain. For example, it is estimated that the cost of treating diabetes will be three times higher and increase to 336 billion by 2035.

5. Rising healthcare costs can be disconnected from Tort reform

The practice of defensive medicine is a powerful driving force in rising healthcare costs. It must be included to achieve real reform and bring down costs.

6. Medical technology is a cause of high healthcare costs

Taxing medical devices could have a chilling effect on innovation and access to state of the art medical devices (e.g., the hardware for knee/hip replacements) that make our healthcare system unique.

As it stands now, the healthcare reform effort by Congress will not achieve its stated goals. 30 million more people will carry insurance by mandate. However, it is not likely that they will get what they pay for. There will be a decrease in: 1) easy access to physicians; 2) access to recommended services/testing, and 3) access to state of the art medical devices. By contrast the insurance industry will get a boost in customers without having to take on increased risk from those people age 55-65 that choose to enter the expanded Medicare program instead of purchasing private insurance.

The rules of the game have not really changed. Insurance companies will still be able to deny payment AFTER the procedure has been pre-certified, they can still play games with computer claim software to underpay physicians for services rendered, they can still arbitrarily pay claims late, they can collude with each other since they are exempt from anti-trust laws, and they can raise premiums and shift the burden of costs to patients at will with deductibles and co-insurance fees. The only difference now is that they just get a bigger pool of insured from which to collect premiums.

The United States Preventive Services Task Force, comprised of 16 appointees, decreed that:

1.       Women in their 40’s no longer need routine yearly mammograms

2.       Women aged 50-74 are to have mammograms only every other year

3.       Self breast exams are no longer to be done at any age

Of note, this Task Force does NOT have even one member who is a cancer specialist or oncologist, let alone a breast cancer specialist. This panel based its recommendations NOT on comprehensive new clinical studies or research, but rather on computer projections of certain data points.  A review of previous recommendations by the same Federal Government reveals that these recommendations are diametrically at odds with recommendations made just six months ago. So, what changed in six months?

New studies? No.  What changed was the introduction of the Obama-Pelosi-Reid Health Care Reform legislation, whose heart and core is based on rationing and denying care. (Note the omission of the word “soul.”) This method is the most inhumane and unethical means of cutting costs.

Let’s NOT let this Panel’s rationing objective get in the way of the real facts about breast cancer:

1.      Breast Cancer is the number 1 killer of women globally…..500,000 women will die this year

2.      Seventeen percent of Breast Cancer deaths occur in women diagnosed in their 40’s

3.      Twenty-two percent of Breast Cancer deaths occur in women diagnosed in their 50’s

4.      One of the leading factors in INCREASED survival rates in breast and other types of Cancer is based on EARLY diagnosis and intervention.

5.      Those countries with higher death rates from Cancer have health care delivery systems based on rationing tests and treatments.

The recommendations made by the “Ivory Tower” Federal Panel do not even pretend to address these five points.  However, they are completely in line with The Obama-Pelosi-Reid Health Care Legislation agenda— to deny and ration care as a means to cut costs.

On Sunday, November 22, Fox News Sunday interviewed Senator Arlen Specter, who was a Democrat before he was Republican before he was a Democrat.  Senator Specter let the “secret agenda” of Obama-Pelosi-Reid slip . When questioned on the fact that The Senate Bill cuts $500 Billion in Medicare spending over ten years, yet in ten years there will be 30 percent more people in Medicare, Senator Spector stumbled. He admitted that  Congress has NEVER cut Medicare benefits in its history and then confessed, “This Bill has a provision….a CURE….in how we can CUT Medicare—a Commission.”  That’s right, a non-elected Commission will be appointed by The President.  Starting in 2015, this Commission will oversee Medicare and its expenditures, but this Commission will NOT be accountable to the public. Initially, it will oversee cuts to Medicare Advantage, the same program that services 10 million Seniors. Using this type of panel to make such cuts, when it is NOT accountable to or elected by the public, is like bombing an enemy from 40,000 feet…..destruction occurs but you don’t see their faces.  And, by 2019, ALL limits are off, and every American can become the target of the carpet bombing.

The bad news is that through this legislation authored by Obama-Pelosi-Reid, every American is facing more than one bomber.  Through the hidden health care portion of The Stimulus Bill we are facing a squadron of bombers:  The Federal Coordinating Council of Comparative Effectiveness Research, The National Coordinator of Health Information Technology Office, and The Medicare Commission in The Health Care Bill.. Their mission is to deny and ration care, and, as stated in The Stimulus Bill, “To guide medical decisions at the time and place of care.”  Say so long to your privacy, doctor-patient privilege, choice, and control over your health care options and access.

Today it is mammogram screening tests.  Tomorrow it will be the rationing and denial of treatment, if Obama-Pelosi-Reid have their way.  Every American will become a victim of their rationing boards.   Faceless, unaccountable, and unelected, these commissions will control 17% of this country’s GNP, and 100% of your health care options.

So, how is that “Hope” and “Change” looking so far?

When opponents claim that Obamacare will lead to rationing of medical services, defenders counter with an irrelevant but true retort that care is already rationed by insurance companies.  By this logic, everything is rationed by economics.  Housing is rationed by the availability of capital to invest in housing which is a collective market choice.  Cars are rationed in that you can’t just walk into a dealer and drive off the lot.  So, yes, currently the health care market, mostly in the form of third-party payers (insurers and public programs), rations care in that there are finite resources to pay for treatments and everyone cannot have everything any time they wish.

The reason that argument is irrelevant is that the debate here is about government rationing of care, which represents an entire new level of restrictions on individuals.  When the government sets up panels of “experts” to make recommendations of what kind of care is appropriate under what circumstances and those recommendations are implemented in the form of regulations over what care will and will not be paid for by both private and public insurance, it limits the rights of patients to control their care in consultation with their physicians.  It also destroys the market for those excluded treatments which then become either prohibitively expensive or entirely unavailable.

Under Obamacare, new cost effectiveness panels will join the advisory panels like the Preventive Services Task Force.  Instead of just making clinical recommendations primarily intended to improve the quality of patient care, they will make recommendations intended to also contain the cost of care.  So when the cost effectiveness folks decide that mammograms are only indicated every two years and only for women over 50, that will become the reimbursement policy for Medicare and Medicaid, and the mandate for private insurance that must comport with coverage standards.  Sure, you could pay higher premiums for more coverage or pay out of pocket if your and your doctor think it wise to have annual mammograms at age 40, but wait, we were told Obamacare would save us money and wouldn’t decrease our coverage.

So we have a federal panel of “experts” setting policies for medical treatment.  That will hopefully prevent people from consuming unnecessary care that drives up the total cost of health care.  (Never mind that defensive medicine caused by liability concerns are strictly off the table.)  But we have just seen the knee jerk reaction of Congress and the White House to what is only a non-binding recommendation, where they instantly caved to public opinion and special interests (in the form of radiologists and the American Cancer Society) and disavowed the recommendations and assured American women that they could go right ahead and keep getting all the mammograms they want.

What will Congress do when the cost effectiveness folks decide that expensive colonoscopies should be denied to all but a limited group of patients?  Is it possible that when voters start calling their offices that Congress will step in to protect access to limitless colonoscopies?  Every time Congress or future administrations bow to pressure cost containment becomes more and more impossible.

Health and Human Services Secretary Sibelius made the farcical excuse that the Preventive Services Task Force doesn’t make policy or coverage decisions so all the controversy is a political ploy.  But that is not the point.  The entire purpose of the various new panels created under Obamacare (and already created in the stimulus bill) is precisely to make policy and coverage decisions.  In fact, the Preventive Services Task Force will play just such a role in the new world order.  So if everyone is reacting this way to a mere recommendation, how will they react to an actual policy dictate that meets opposition from some constituencies?  And when they create political pressure and the politicians give in, what happens to cost containment?

Health care professionals who agree with the Task Force recommendations to reduce the use of mammograms recognize this for exactly what it is—politicization of health care.  Under Obamacare, the most effective lobbying efforts will have more impact on the care you can get than the opinion of your physician.

The White House has launched its usual ad hominem attacks against those who have pointed to this instance as a taste of things to come.  They accuse opponents of lying and being disingenuous. They even try to imply some sinister motive to the Task Force by pointing out that its members were appointed by the Bush administration.  Since they have reduced this debate to the level of a playground back-and-forth, the “rubber and glue” principle applies and these charges are beginning to bounce right back on to the administration.