Surviving the Medical Meltdown (7 page)

According to the US Constitution, the only body of people
that can write laws is the United States Congress. But Congress has abrogated this constitutional responsibility and has allowed unelected bureaucrats to write millions of pages of regulations that can land you in prison or fine away your life’s savings. Only a few months into Obamacare its 2,400 pages were already dwarfed by the pages of regulations being spewed out at a rate unfathomable to the normal nonbureaucratic human mind. Now, this is not unique to HHS. EPA, Treasury, Agriculture, and other departments put vast ink to vast paper, but the leaders, by orders of magnitude, in pumping out economically damaging regulations, are HHS toadies. In 2011 five departments – Treasury, Commerce, Agriculture, Interior, and EPA – won the prize for prolific regulation writing by collectively pumping out 1,733 regulations.
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In fact in 2014, the Competitive Enterprise Institute’s annual survey of the federal regulatory state,
Ten Thousand Commandments
, estimated the total federal regulatory burden at $1.8 trillion per year. The tax burden Americans face is less than the regulatory burdens imposed on them.

But if you look specifically at the number of regulations that have more than $100 million impact on our economy, the Department of Health and Human Services is in the lead all by itself. Sixty-five regulations with more than a $100 million impact on the economy were in the pipeline of HHS by the close of 2011. The next closest contender was the Environmental Protection Agency, with only twenty-one regulations. And I used to think the EPA was pretty damaging.

Keep in mind that this nation once existed with only eleven written pages of law – the Constitution if typewritten today. Now we have more than fifty-four feet of the Federal Register used to imprison and enslave us. (We have nine pages just on the disposal of the newly mandated curlicue lightbulbs!) We have people in jail for unwittingly importing the wrong subspecies of crustacean or for choosing the wrong CPT code for billing a medical procedure.

The upshot of all this regulation is that medicine has become like a very inefficient machine, spewing out heat but not moving
anything forward. We spend so much time in “compliance” with regulations that little actual medical care can get done. Look around at the hospitals. There are fewer patient care areas and vastly more administrative suites. And God help the private practitioner who does not have the large workforce to navigate the regulatory stream.

Now enter ACOs – accountable care organizations. If I were intending to create collapse of the free market health system, I could do no better than in implementing ACOs. As I write this, ACOs are being created all over the country. Today ACOs are “virtual” patient care areas centered on a regional medical center or large urban hospital. In phase one, a bureaucrat negotiates with a hospital center and gives it an ACO designation. He goes to a map and draws a circle around the hospital to create a patient catchment area for which the new hospital/ACO is responsible. At first these ACOs are “virtual,” meaning that patients can get care wherever they want, but if they fall into a particular circle, they become simply a statistic for that ACO.

To better understand how this plays out, let’s take a prototype patient, Jane Doe. Mrs. Doe is a widow living on the family farm in Guthrie County, Iowa. The nearest hospital is in the town of Guthrie Center, but her doctor is in Panora, which is closer to her home. She is now a member of the Guthrie County Hospital ACO centered at the hospital in Guthrie Center. She signed no papers, is not yet aware of any change in her health care options because she receives Medicare benefits, and is still with her long-term doctor. She has no knowledge of being a member of the ACO, because it is “virtual,” like a computer game, and she is represented by an avatar who is just an ACO statistic at this point.

Unlike a computer game, though, this has real-world consequences, because now, the “virtual” ACO begins to send volumes of data about its patients – including Jane Doe – to the federal government. This information includes every bill generated on every patient – whether they are government or private pay. It includes the most private medical information. Mrs. Doe’s history of depression is now in the hands of a government bureaucrat, as is her history of
pregnancies, abortions, her past smoking history, and her weight and height – her body mass index. The government compares the cost of her care through the ACO to the cost of the same care outside the ACO. If the ACO care is cheaper, the ACO is rewarded with bonus money equal to one-half of the so-called cost savings.

So Mrs. Doe sees her private non-ACO doctor for wrist pain. He knows the biggest issue is really depression and loneliness, so he spends some time with her to talk about her life and coping with being recently widowed. For this he charges a certain CPT code based on the extra time he spent and the diagnoses. This price is then compared to the cost of seeing an ACO physician in the multiphysician complex. Those physicians may or may not have long-term relationships with their patients, so they may or may not be as sensitive to her as a whole person. It is my experience in big, government-funded groups that patients are treated generically, not as individuals, and shuttled from doctor to doctor. (Think the Veteran Affairs or Indian Health Service where doctors come and go every few years.) And it is my experience that private care is generally cheaper than big organizational care, but in this scenario, the ACOs will have the advantage of reporting. They will mobilize countless minions to massage the data so the ACOs look good to the government and garner the money prize. (We just saw this happen in the recent VA scandal where the numbers were massaged to improve bonuses for the administrators.) Just the reporting alone will drive many private docs to give up and join the ACOs.

The ACO statisticians in the federal government will also compare apples to oranges. Whereas the private doc will charge for the time he spent with the patient – and it was time well spent but not really about her wrist – at the ACO, such a patient will be seen briefly only about the wrist, so the cost will be cheaper, but the care will be more superficial.

The upshot of all this is that the private doctors will be “shown” to be more costly and will not be the ones favored to win the bonus money. Notice that even if the private guys give cheaper care, they
reap no monetary reward – only the ACOs get a bonus for cost-effectiveness and no penalty for the times they exceed private cost. So who will win? Predictably, private practice will be squeezed out of existence. It is already now scarcer and scarcer to find young people going into truly private practice. And according to a 2012 physician survey, only 48.5 percent of physicians are in private practice, but private practice was nearly universal before the advent of Medicare and Medicaid. And the decrease in numbers of private practitioners is a fact agreed upon by all parties looking at the ACO effect.
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(The issue is whether one believes this to be good or bad and whether one believes this is a conscious effort of the ACO push.)

During phase two, the government will harden these ACOs into
real
catchment areas, and patients – at least those enrolled in Obamacare, Medicare, and other federal programs – will not have a choice of mobility. They will have to stay with a particular ACO. At this point, Mrs. Doe now knows she is a member of an ACO. She has been registered and been given identification data. She will be told who her primary care doctor is (or physician’s assistant or nurse practitioner. Since there are already insufficient physicians to go around, those in practice are working fewer hours on average and seeing fewer patients than four years ago, and 62 percent are planning on early retirement
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). Mrs. Doe may be unhappy at losing her longtime doc, and she probably doesn’t like driving farther to the new conglomerate ACO hospital complex. But while she is unhappy, the ACO administrators will be rejoicing at all the bonus money they are now receiving and the proverbial “pats on the head” they are getting from their masters at HHS for being “the chosen” to practice great, cost-effective medicine. These ACO fat cats are naive at best, corrupt at worst, because the government never leaves free money on the table and because the goal is not to make ACOs succeed but to make them the “fall guy.”

With phase three, the sucker punch hits. When the last remnants of private practice are driven out of existence, there will be no “cost savings,” as there will be no one left for the ACOs to be compared
to. America will have been totally divided up into these government-funded ACOs, and, as the money is generally withdrawn, they will all start to fail – virtually simultaneously, from smallest to largest systems. Under a free market, or even Medicare, hospitals individually would sometimes fail. But others would prosper. In the third phase of the ACO collapse, however, the government, by ensnaring everyone into the same economic quagmire, will have staged a great orchestrated collapse. And just like the Reichstag fire – a crisis perpetrated by the Nazis so they could supply their own totalitarian solution – this crisis will be the excuse for more government. As hospitals all over the nation become financially distressed and medical care delivery begins to fall apart, the government will call for
single-party payer universal health care
to save the day. (Of course this single party Canadian plan was the goal all along.)

What is happening now to our Mrs. Jane Doe? Well, at first her appointment times were a little delayed, but now she may wait months for routine appointments. Her small hospital system failed and has been consolidated into the closest large system, but this now means a drive of more than sixty miles. For her routine care she usually sees a PA or nurse practitioner, no longer a physician, and even then sees a different one nearly every visit. Her records are all on the computerized system, and her data have long been in the hands of Washington paper pushers. These “reviewers” have run computer scans on records to look for outliers and have determined that she is receiving care that is not warranted at her age of seventy-two. She will be taken off her Coumadin for atrial fibrillation (a heart rhythm disorder) and just given an aspirin a day, since her “disability-adjusted life-year” cost benefit analysis shows that a stroke would not cause too many productive life years lost (as it would if she were thirty-five).
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And the same nonmedical bureaucrats are denying her cardiologist’s request for a pacemaker to solve the atrial fibrillation problem – for the same reason: she is just too damn old to warrant such expenditure of government funds. (This is already happening under Medicare but will ramp up in the new world medical order.)

And you will know, when you see the collapse of more and more small hospital centers, that the end is near – not just the end of high-quality medical care but the end of America as we know it. We will be breathing our last gasps of liberty. Because if the government controls your very health, what will it not take from you – mostly in the name of “safety”?

Needless to say, there will be pockets of resistance – doctors who quit and doctors who will continue to operate for cash. Since the cash practices will be more caring, patient centered, and will provide real medicine, they will have to be eradicated so the public will not see the contrast. Doctors will most likely face prosecution if they attempt to take payment for services rendered. This has happened elsewhere. For years, it has been illegal in Canada, North Korea, and Cuba for physicians to take direct payment from their patients. Currently, since Canada is actually allowing some cash pay and Cuba has renounced total communism, there is only one country that totally criminalizes private medicine – North Korea. But we are working on it. The state of Vermont has voted in a single-party payer system, and it remains to be seen if they will actually prosecute those doctors who choose to opt out. If they do, they will be in fine company – North Korea and Vermont – what a pair.

A black market of sorts will no doubt develop, as it did in the Soviet Union. One former Soviet citizen’s husband recalled to me how his wife’s uncle got his gall bladder surgery. Although Soviet health care was free and universal, it was like commodities in the GUM, the state-controlled department store – nonexistent. When the uncle became desperately ill, the family saved up anything they could buy – shoes, food, household goods, and so forth, and bribed the surgeon and the anesthesiologist. That former Soviet citizen recalled to me how the doctors “borrowed” equipment from a local hospital, took it to the family’s tiny apartment, and removed the diseased gall bladder on the family’s kitchen table – probably a cleaner spot than the hospital operating room.

Single-source medical care is lousy. The longer such a system
exists, the worse it becomes. By the time the Berlin Wall fell and we could peek into the world of Soviet medicine, for example, 57 percent of Soviet hospitals had no hot water, and 36 percent had no running water at all. There were dead cats lying in the hallways, and a legion of babies were exposed to HIV because needles were reused without sterilization. While the free market was advancing to MRIs and sophisticated robotic surgery, the Soviets, with vast natural resources, were descending into a level of medicine about on par with the czarist era. And this system was created proclaiming it would “eliminate waste” and “reduce cost.”
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Where have we heard that recently? The National Health System in Britain, after fifty years, is seeing hospitalized patients die from neglect, more than a million people waiting for surgery, and a general decline in longevity. By their own research, the British published data showing that men in America have a 66 percent average five-year survival from cancer, while British men have only a 45 percent five-year survival – a number that rivals the old Soviet system and is about what men experience with no cancer treatment at all.
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