Patterico's Pontifications

11/26/2010

The Law of Unintended (But Wholly Predictable) Consequences: Medicare Cuts Edition

Filed under: General — Aaron Worthing @ 2:23 pm

[Guest post by Aaron Worthing; if you have tips, please send them here.]

Remember folks, all that talk about Death Panels, reduction of doctors’ availability, etc. under Obamacare was just a series of Republican lies.  And pay no attention to stories like this:

Doctors say Medicare cuts force painful decision about elderly patients

Want an appointment with kidney specialist Adam Weinstein of Easton, Md.? If you’re a senior covered by Medicare, the wait is eight weeks.

How about a checkup from geriatric specialist Michael Trahos? Expect to see him every six months: The Alexandria-based doctor has been limiting most of his Medicare patients to twice yearly rather than the quarterly checkups he considers ideal for the elderly. Still, at least he’ll see you. Top-ranked primary care doctor Linda Yau is one of three physicians with the District’s Foxhall Internists group who recently announced they will no longer be accepting Medicare patients.

“It’s not easy. But you realize you either do this or you don’t stay in business,” she said.

As they say, read the whole thing.  And which evil, right wing newspaper am I linking to?  Um, the Washington Post.

Gee, it’s almost like as if the first mistake regulators make is to forget that those they regulate might either flee the jurisdiction or change their behavior so they are no longer under their regulation…  you know, someone should put that in a blog post or something, right?

So now that we passed it, and we are beginning to see what is in it, how does it look?  Do you think maybe we should have figure out what was in it, before we passed it?

Oh, and if that isn’t nice enough, Sen. Mark Warner is urging that we give even more power to the board to carry out more Medicare cuts.

[Posted and authored by Aaron Worthing.]

48 Responses to “The Law of Unintended (But Wholly Predictable) Consequences: Medicare Cuts Edition”

  1. “We pretend to work, and they pretend to pay us!”

    AD-RtR/OS! (7ae1ad)

  2. I don’t doubt this is true. I am sure there will be cuts…but you know what? I have listened to so many conservatives complain about Medicare Part D over the last few years that it seems kind of silly to complain about other Medicare cuts…unless of course you make note of the fact that you are not bothered by the cuts, but by the fact that they will just be using the cuts to justify increased costs elsewhere.

    BTW, Part D is a very popular program that came in 43% under budget. If conservatives are really serious about cutting the drug discount program then they should open the markets to cheaper imports of drugs and medical supplies. Let big Pharma live by the same rules that so many other American industries have to live by. After all, short of catching a bus and going to Canada to buy medicine there really is no alternative for the American consumer.

    Terrye (7d99e4)

  3. So now Republicans are against entitlement cuts?

    AJB (d64738)

  4. Why can’t they just pass a law “regulating interstate commerce” that forces doctors to have a certain percentage of medicare patients. If Obamacare’s insurance mandate is constitutional, why would this not be?

    Kevin M (298030)

  5. Medicare Part D was seriously flawed because it did not include negotiated prices. It was necessary because, in 1965, drugs were pretty primitive. I know because I was just starting to prescribe them. They are a much bigger part of therapy now than they were then.

    The cuts in payment is stupid because the CMS is still trying to force doctors to accept the payment as payment in full. All they have to do is allow balance billing. Then, patients who want a special doctor will pay extra and those who can’t afford extra will find doctors who are willing to accept less, although with nurse practitioners and clinic settings. Medicare was intended to give every person over 65 first class medical care but we can’t afford that anymore.

    What I would do is have clinics for the poor who can’t pay extra and staff them with new graduates with large student loans. Forgive the loan 10% per year. Younger doctors are often more up to date than the older ones anyway.

    They are being stupid about this but that is no surprise.

    Mike K (568408)

  6. They are trying to force participation in Massachusetts now. The bill would make it a condition of licensure. I suspect that would lead to an exodus of specialists. Most states are not that dumb. If Congress tried it (there is no chance now), I doubt it would be constitutional. Once again, they could do something with student loans but that would be voluntary.

    Mike K (568408)

  7. Mike, there’s even a worse aspect to such requirements: there are people over 65 who prefer to pay for higher-quality medical care than Medicare. The law says that a doctor who accepts ANY Medicare cannot serve them outside the system. Forcing all doctors into the system would ALSO force all patients into the system.

    Kevin M (298030)

  8. My office quit taking Medicare patients 6 months ago. When you see the all you are doing is increasing your liability.

    Flashman (80fe3d)

  9. The AARP supports the dirty socialization of medicine wholeheartedly.

    America’s codgers definitely should keep giving AARP their monies.

    happyfeet (42fd61)

  10. those discounts are freaking awesome

    happyfeet (42fd61)

  11. My practice has a small portion of Medicare patients in it however the wife’s side of the practice is almost 100% Medicare. Is there one congress critter who would be happy taking a 20% pay cut? Rhetorical question.

    Social inSecurity and Medicare as a whole need to be fixed. I have 90 year old patients using vast resources and who paid a total of $1300 in thier lifetime into the SS system. Until this Ponzi scheme is fixed things will just continue to get worse.

    Note to Mike, No need to bash NP’s as inferior care givers. Every study I have read suggest the care we give is no different than what a doctor provides. Lets join together and stay focused on the problem- congress.

    Azygos (39b9d4)

  12. More regulations should be able to cure any of these unintended consequences. Double Heh.

    daleyrocks (df87cd)

  13. I want my sockpuppet thread!!!

    either orr (6713b4)

  14. Mr Worthing called this part of the law of unintended consequences, but I sometimes wonder just how unintended these consequences really are. It’s really simple: physicians won’t treat people for whom they are insufficiently paid, so the government simply steps in, nationalizes the whole thing, and declared physicians to be employees of the Reich state, with set salaries, and that they must treat everyone, at the rates set by their employers, or they will forfeit their licenses to practice medicine.

    The realistic Dana (bd7e62)

  15. Dana, Dana, Dana;

    In a sensible world what you propose might be true, but if doctors were state employees then malpractice suits would not be allowed and lawyers would suffer, which is certainly unacceptable to the people who passed Obamacare. Some way will found to keep the doctors as non-governmental employees so they can be sued.

    max (2f2a28)

  16. max, your reasoning has a lot going for it, but I’m not sure. I have also thought that higher malpractice will also be used to leverage doctors into the system. “They” can’t limit doctor’s activities and income all at the same time while keeping malpractice attorneys happy. I’m not sure what is going to give.

    MD in Philly (cac12c)

  17. MD,

    Are there differences between how you think American doctors and other health care professionals will respond to greater government control, vs how Canadian and British doctors responded?

    DRJ (d43dcd)

  18. In other words, can we look to the Canadian and British models for guidance here?

    DRJ (d43dcd)

  19. No, because Beveridge and Douglas, respectively didn’t design the system to fail deliberately, as this plan assumes

    narciso (9d0688)

  20. DRJ-

    I don’t have the kind of contacts or do the kind of reading that can answer the kind of question that you are asking.

    I do know there is much to be desired in the Canadian system, as well as in the British, and we are not Brits. The average 60 year old Brit may be happy wearing a truss and put up with his hernia, the American will not. Maybe the average 60 year old Brit with a medical emergency from an incarcerated (strangled) hernia will just say, “That’s life”, the American will sue.

    MD in Philly (cac12c)

  21. ““They” can’t limit doctor’s activities and income all at the same time while keeping malpractice attorneys happy. I’m not sure what is going to give.”

    MD in Philly – The obvious solution is the standard Democrat response of a “Jobs Bill” to retrain Med Mal attorneys in other torts.

    Barack (df87cd)

  22. Sock off

    daleyrocks (df87cd)

  23. Barack-

    That’s one response. The other is to employ all of those attorneys as officials in the health care bureacracy, they may not earn as much, but maybe they will settle for the satisfaction of still intimidating doctors.

    MD in Philly (cac12c)

  24. MD,

    you’re thinking of this in terms a politician cannot understand. You see a problem and try to figure out how to solve it. A politician (or a lawyer) sees a problem and tries to figure out how to blame someone else for it. Don’t think in terms of solutions, think in terms of blame when you want to figure out what politicians will do.

    max (2f2a28)

  25. Brits with money get private medical insurance. Canadian doctors incomes are capped so when they reach the cap it’s vacation time until next year. Of course having the US to subsidize prescription drug prices makes things cheaper for Canada and the UK than they otherwise would be.

    cubanbob (409ac2)

  26. cubanbob – what makes you think that the US subsidises prescription drug prices for Canada and the UK ?

    Or do you consider that the lack of “Loser Pays” in the US is a subsidy for other countries ?

    Alasdair (205079)

  27. Mike:

    Actually there was no negotiation in the original Part D plan, that was what the Democrats did not like about the original plan..that and the doghnut hole that required more input from the private sector. When they passed Obamacare the Democrats changed Part D so that the government does the negotiating rather than letting that take place in the private sector between competing private plans that worked with Part D…and they did away with the doghnut hole as well in the hopes that they could buy support from the elderly. They did not, people liked the plan the way it was. In other words the Democrats took a public/private plan and turned it into a public plan.

    Terrye (ce0d6f)

  28. I am typing too early…I meant to say there was negotiation in the original Part D plan…but I think the larger point is that Bush agreed to this plan because it was cheaper than the one the Democrats were pushing and because he wanted Health Savings Accounts and Medicare Advantage, both of which were supported by conservatives.

    Terrye (ce0d6f)

  29. max-

    well, that does explain a lot.

    MD in Philly (cac12c)

  30. I suspect the following scenario will play itself out multiple times at the rate things are going:

    Doctor: Sorry, pal, but there’s no way I can see your mother about her kidney problem before next year.

    Upset Son: Are you serious?

    Doctor: No, there’s no way. My schedule is full.

    (Upset Son pulls out a pistol and sticks it in the doctor’s face)

    Upset Son: So, doc, would you care to give me a second opinion on that?

    MarkJ (42fe5b)

  31. The law says that a doctor who accepts ANY Medicare cannot serve them outside the system.

    This is why docs are dropping Medicare.

    I wasn’t demeaning NPs but was making the point that the Medicare patients will not be seeing the doctor. Workers comp is run this way for the most part. I do review of WC claims. I’d just as soon talk to the PA since they are the ones actually seeing the patient. Work comp is mostly run in mills where the PA or NP sees the patient and the doc does procedures; lots of procedures.

    Mike K (568408)

  32. ____________________________________________

    If conservatives are really serious about cutting the drug discount program then they should open the markets to cheaper imports of drugs and medical supplies. Let big Pharma live by the same rules that so many other American industries have to live by.

    I have to agree with that. If the conventional rightist/Republican position is to respond otherwise, then I have to say I’m a “progressive” when it comes to this issue.

    However, the big bucks donated to politicians of all stripes from big pharma make this sort of a “limousine liberal” phenomenon. IOW, I’m sure quite a few on the left — as much as those on the right — find it hard to say “no” to the drug industry when its lobbyists are so nice about greasing not just Republicans’ but Democrats’ extended palms too.

    I’m aware that big American pharmaceutical companies, most of them headquartered in the Northeast (full of blue-state sentiment galore), rely on the profits generated in the US — and not elsewhere — to keep their operations running at a fast pace. So we, in effect, are subsidizing the lower-cost structure of drugs in other parts of the world. And why!!? For crap like this?:

    Examiner.com, August 18, 2010:

    According to Donald Light, Ph.D., a professor of comparative health policy at the University of Medicine and Dentistry of New Jersey, the pharmaceutical industry is a “market for lemons” and the pharmaceutical industry spends much more marketing those lemons to the public and physicians than on researching the safety and efficacy of drugs.

    Light points out that drug studies are typically rigged or misrepresented to minimize evidence of drug hazards and side effects while creating a misleading impression of drug benefits. Few researched medicines fare better than placebos and those which do are rarely tested for long-term effects. Light found that about 85% of newly approved drugs failed to demonstrate significant benefits while many did appear to pose risks of significant adverse effects.

    ^ If the type of populism associated with the Tea Party can’t start nailing the BS of such a protected industry, then I say it’s missed a big target.

    Mark (411533)

  33. Mark,

    It costs almost a billion (with a ‘b’) dollars and many years to get a drug through the FDA required testing. How much more do you want Pharma companies to spend on efficacy and safety testing? Remember, as soon as they patent a drug, which happens before the FDA testing starts, they only have 20 years to make back all that money spent on testing.

    You can complain that the current testing regime produces lots of questionable efficacy studies, but I’d say that’s a indictment of the testing requirements, not the studies themselves.

    Xmas (f72f61)

  34. Light found that about 85% of newly approved drugs failed to demonstrate significant benefits while many did appear to pose risks of significant adverse effects

    I doubt this information. A drug has to be proven effective to be marketed. Either the FDA is passing drugs without the proof, which I find hard to believe in today’s litigious society, or Dr. Light has his own standards, or the article is mistaken in its presentation.

    MD in Philly (cac12c)

  35. DRJ asks, “Are there differences between how you think American doctors and other health care professionals will respond to greater government control, vs how Canadian and British doctors responded?”

    Well, the Canadian and British doctors left Canada and Britain. They came to the US.

    Here’s the result (Times Online, Feb 2008).

    “Doctors from India, South Africa and other Commonwealth countries are to be barred from the NHS in an attempt to preserve health service jobs for British graduates….the health service has been sustained by immigration but yesterday the Home Office moved to end a crisis that has prevented thousands of highly trained British doctors from advancing their careers. Last year the system for selecting doctors for higher training collapsed in what was described as the greatest disaster for medical training in a generation.

    The change will end a long tradition of importing doctors to the NHS. Among the 277,000 now registered with the General Medical Council, almost half got their first medical qualifications abroad — the majority from India, Pakistan, South Africa and Australia.”

    And from the Globe and Mail (2004)
    “Canada is not training enough doctors to replace those who emigrate, retire or leave practice each year, the study confirmed. Ontario alone is facing a shortage of up to 1,500 physicians, a coalition of politicians and doctors told the Ontario Medical Association last month…Many foreign-trained doctors are well qualified but have gaps in their training, or they may need to improve their knowledge of diagnostic techniques, technology or language skills to work in Canada, Dr. Dauphinee said.”

    Essentially, the Brits and Canadians got trained, and left. The result was a lot of poorly trained foreign MDs entering practice in Britain and Canada.

    Good luck, America. You’re going to get what you deserve. Good and hard, I might add.

    orthodoc (5bbba1)

  36. Many years ago when I was a relatively new grad with my Masters in Psych in hand, I worked at San Antonio State Hospital. I recall a scene where a doc from England was sitting with a group of us extolling the virtues and superior care in England. One of our psychiatrists looked at him with and asked, pointedly, “If it so great to practice medicine in England, why are you practicing here in the States with our inferior medicine.” The next minute or so was filled with an “Uhhhh,” or an “errr.” Both of which he managed with an English accent. :)

    GM Roper (4a1023)

  37. I can’t remember, is the right wing for or against medicare cuts?

    imdw (7b0243)

  38. “(Upset Son pulls out a pistol and sticks it in the doctor’s face)”

    Did you see the movie “John Q” ?

    imdw (02672e)

  39. The VRWC is for cutting off the Medicare/SocSec benefits for all of the Dems phantom voters
    (especially after finding out that SocSec/Medicare has sent benefit checks totaling several Billion Dollar$ to dead people over the last decade – WSJ article).

    AD-RtR/OS! (0ac8fd)

  40. “(especially after finding out that SocSec/Medicare has sent benefit checks totaling several Billion Dollar$ to dead people over the last decade – WSJ article)”

    Some to Florida’s new governor!

    imdw (5973d8)

  41. ____________________________________________

    A drug has to be proven effective to be marketed.

    I’m not sure it’s wise to have more faith in the FDA than any other big government bureaucracy—and I’m not even referring to various drugs that the FDA has approved through the years but which later turned out to be either ineffective or even dangerous.

    Moreover, the cost of medical care has rocketed way too much in the US, which should bother everyone regardless of his or her politics. When it comes to the issue of dollars, the huge pharmaceutical industry in America hasn’t helped matters. That’s why I personally don’t feel too much more sympathy towards them than I do towards Obamacare or ambulance-chasing lawyers.

    Speaking of which, because big bucks are involved in both the selling of pharmaceuticals and the filing (and certainly winning) of lawsuits, a lot of corner cutting and gameplaying with the truth will occur in either setting. Therefore, folks who sell prescription drugs and folks who offer legal services are like the different side of the same coin.

    wired.com, August 2009:

    From 2001 to 2006, the percentage of new products cut from development after Phase II clinical trials, when drugs are first tested against placebo, rose by 20 percent. The failure rate in more extensive Phase III trials increased by 11 percent, mainly due to surprisingly poor showings against placebo.

    Despite historic levels of industry investment in R&D, the US Food and Drug Administration approved only 19 first-of-their-kind remedies in 2007 — the fewest since 1983 — and just 24 in 2008. Half of all drugs that fail in late-stage trials drop out of the pipeline due to their inability to beat sugar pills.

    The upshot is fewer new medicines available to ailing patients and more financial woes for the beleaguered pharmaceutical industry. Last November, a new type of gene therapy for Parkinson’s disease, championed by the Michael J. Fox Foundation, was abruptly withdrawn from Phase II trials after unexpectedly tanking against placebo. A stem-cell startup called Osiris Therapeutics got a drubbing on Wall Street in March, when it suspended trials of its pill for Crohn’s disease, an intestinal ailment, citing an “unusually high” response to placebo. Two days later, Eli Lilly broke off testing of a much-touted new drug for schizophrenia when volunteers showed double the expected level of placebo response.

    It’s not only trials of new drugs that are crossing the futility boundary. Some products that have been on the market for decades, like Prozac, are faltering in more recent follow-up tests. In many cases, these are the compounds that, in the late ’90s, made Big Pharma more profitable than Big Oil. But if these same drugs were vetted now, the FDA might not approve some of them.

    Two comprehensive analyses of antidepressant trials have uncovered a dramatic increase in placebo response since the 1980s. One estimated that the so-called effect size (a measure of statistical significance) in placebo groups had nearly doubled over that time.

    It’s not that the old meds are getting weaker, drug developers say. It’s as if the placebo effect is somehow getting stronger.

    ^ I think ALL Americans should start being a lot more skeptical about their and other people’s use of prescription drugs, certainly about the price of those items. In turn, I think ALL Americans should start doing everything possible to avoid consuming so much sugar (or carbohydrates) on a daily basis.

    IOW, it’s foolish for we Americans to be so worried about our healthcare — in terms of both its availability and cost — when we’re eating like gluttons and chowing down regularly on cruddy food loaded with sugar and over-processed junk in general.

    Mark (411533)

  42. So, IMaDickWad, are you alleging that Medicare payments made to Columbia/HCA (which he left in 1997!) did in fact go to Rick Scott personally?
    And, you have proof of that, right?
    And have personally conducted that proof to the proper legal authorities for action against Mr. Scott?

    …….

    AD-RtR/OS! (e2c6d2)

  43. I think it’s more complex than that, Mark. For instance, the enhanced placebo effect may be a function of expectations rather than drug failure. It’s similar to the way believers do better medically than non-believers.

    DRJ (d43dcd)

  44. ______________________________________

    I think it’s more complex than that

    At the same time, we’ve become far too accepting of a drug culture — referring to pharmaceuticals — far too willing to nod in approval as a doctor writes a prescription, and we then run off to the pharmacy and happily take just what he (the doctor) ordered. The mindset behind this is one reason our healthcare system is becoming too expensive.

    I know things have gone off the deep end when I’ve heard repeated stories about doctors prescribing drugs to no less than young children — supposedly for attention deficit disorder — merely because their parents have a tough time dealing with children for being…children.

    Mark (3e3a7c)

  45. So now that we passed it, and we are beginning to see what is in it, how does it look? Do you think maybe we should have figure out what was in it, before we passed it?

    NOTHING regarding Medicare in the “Obamacare” bill has been enacted. NOTHING. So anything happening to Medicare PRE-DATES Obamacare and has nothing to do with it.

    Further, impending cuts to Medicare are a result of Clinton-era calculations. There is, again, NOTHING in Obamacare that affects this. There were attempts to correct this problem, but they were blocked by Republicans.

    Keep trying to blame Obama for problems he did not create. I’m sure someone will believe you soon enough.

    JITC (139a25)

  46. Yes, there is no way that people in the marketplace could react to obligations forthcoming, mandates that will be in effect, and other such douchenozzlery, and act accordingly. You leftists are imbeciles.

    JD (ab60db)

  47. The Obama cuts to Medicare are still impending. Does that make you feel better JITC ? Nobody was saying that they were the current issue.

    Mike K (568408)

  48. Alasdair, these United States of America subsidize pharmaceuticals in other countries by doing most of the work of producing them. More medicines are developed here than anywhere else. And it is expensive, and the process is unwieldly.

    @all: And yes, the system is being gamed.

    http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/

    Recently Senator Charles Grassley, ranking Republican on the Senate Finance Committee, has been looking into financial ties between the pharmaceutical industry and the academic physicians who largely determine the market value of prescription drugs. He hasn’t had to look very hard.

    the pharmaceutical industry has gained enormous control over how doctors evaluate and use its own products. Its extensive ties to physicians, particularly senior faculty at prestigious medical schools, affect the results of research, the way medicine is practiced, and even the definition of what constitutes a disease.

    The suppression of unfavorable research is the subject of Alison Bass’s engrossing book, Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial…

    Read the whole article; it’s enlightening.

    Willow (4c6bed)


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