What Doctors and Patients Have to Lose Under ObamaCare

A couple of pieces in the Wall Street Journal from Thursday. First, Dr. Gottlieb, who is an internist and a resident fellow at the American Enterprise Institute, a former senior official at the Centers for Medicare and Medicaid Services, and partner to a firm that invests in health-care companies, writes: What Doctors and Patients Have to Lose Under ObamaCare

It all starts with the sweeping power that the Senate bill gives to the Centers for Medicare and Medicaid Services. The agency will be given the authority to unilaterally write new rules on when medical devices and drugs can be used, and how they should be priced. In particular, the Obama team wants to give the agency the power to decide when a cheaper medical option will suffice for a given problem and, in turn, when Medicare only has to pay for the least costly alternative.
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The Senate health-care bill also exempts Medicare's actions from judicial review, taking away the right of patients to sue the government. Unlike existing Medicare coverage laws, patients won't have the ability to appeal any of the decisions of this new Medicare Commission.

Ironically, private health insurers must comply with new patient appeals rights under the Senate bill. The government has exempted itself from the same sort of protections.

Thus Medicare will have the power to control which medical devices surgeons use. But clamping down on expensive procedures also means the agency will need to have authority over the specialists themselves. The organization of doctors into mostly small, disaggregated practices always made it hard for a central bureaucracy to control individual physicians. ObamaCare tries to fix this by putting doctors on the financial hook for their treatment decisions.

Primary-care doctors who refer patients to specialists will face financial penalties under the plan. Doctors will see 5% of their Medicare pay cut when their "aggregated" use of resources is "at or above the 90th percentile of national utilization," according to the chairman's mark of Section 3003 of the bill. Doctors will feel financial pressure to limit referrals to costly specialists like surgeons, since these penalties will put the referring physician on the hook for the cost of the referral and perhaps any resulting procedures.

Next, the plan creates financial incentives for doctors to consolidate their practices. The idea here is that Medicare can more easily apply its regulations to institutions that manage large groups of doctors than it can to individual physicians. So the Obama plan imposes new costs on doctors who remain solo, mostly by increasing their overhead requirements—such as requiring three years of medical records every time a doctor orders routine medical equipment like wheelchairs.

The plan also offers doctors financial carrots if they give up their small practices and consolidate into larger medical groups, or become salaried employees of large institutions such as hospitals or "staff model" medical plans like Kaiser Permanente. One provision, laid out in Section 3022, allows doctors to share with the government any savings to the government they achieve by delivering less care—but only if physicians are part of groups caring for more than 5,000 Medicare patients and "have in place a leadership and management structure, including with regard to clinical and administrative systems."
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Regulation of medicine has always been a local endeavor, and it's mostly the province of medical journals and professional medical societies to set clinical standards. This is for good reason. Medical practice evolves more quickly than even the underlying technologies that doctors use. This is especially true in surgery, where advances flow from experimentation by good doctors to try different surgical approaches.

The regulation of medical devices and their pricing will also have consequences for patients by discouraging innovation. Most improvements in medical devices come incrementally, with each generation of a device having small but clinically relevant advance over prior versions. This owes to the underlying hardware, which turns on embedded software and microprocessors that themselves undergo constant upgrades.

But if Medicare starts pricing similar devices off one another—a form of the same "reference" pricing schemes used in Europe—manufacturers will start holding back the small changes. Instead, they will introduce new models every four or five years that are sufficiently unique to fall outside of Medicare's pricing scheme. Meanwhile, patients will have lost the benefit of regular improvements and annual upgrades that characterize medical devices today.

The impact of these provisions won't be confined to Medicare. Private insurance sold in the federally regulated "exchanges" will take cues from Medicare, since they're both managed from the same bureaucracy. Medicare will set the standard for medical care across the entire marketplace.

Mr. Obama promised that under his plan people wouldn't have to change their doctors. But it's clear that doctors will be forced to change how they make their medical decisions.

And then Karl Rove has: The Real Price of the Senate Health Bill

By now Majority Leader Harry Reid's explanation for how he is getting his health-care bill through the Senate has pinged its way across the country. "I don't know if there is a senator that doesn't have something in this bill that was important to them," he said this week. "And if they don't have something in it important to them, then it doesn't speak well of them." But take these comments two steps further and it becomes clear that how Mr. Reid reached unanimity in his caucus could hurt Democrats more than they realize.

First, taking Mr. Reid at his word means every Democratic senator got something. That implies there are even more howlers to discover that will dog Democrats next year.
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... what we'll get for it all is rationed care and exploding deficits. Taxes start going up now, Medicare cuts begin after next fall's election, and spending for subsidies commences in five years. The price tag is not the first decade's announced $871 billion cost: It is $2.4 trillion. That's the cost of the tax credits in insurance exchanges, and the additional Medicaid costs the reform generates, over the first 10 years it's fully up and running, according to Congressional Budget Office numbers compiled by Republicans on the Senate Finance Committee.

Mr. Reid greased a Christmas Eve Senate passage of his bill, but he did so in a way that taints the product. It will hinder the Obama administration's efforts to fashion a House-Senate conference bill, as well as that 40-year majority Democrats once thought was within their grasp.