During last Thursday’s GOP presidential debate, Herman Cain told
the audience that he’d be dead if Obamacare had been in effect when
he was diagnosed with colon and liver cancer in the spring of 2006.
Cain has often made this statement on the campaign trail, so the
moderator asked him to elaborate. Cain answered by
pointing out that “from March 2006 all the way to the end of
2006, for that number of months, I was able to get the necessary CT
scans, go to the necessary doctors, get a second opinion, get
chemotherapy… go to get surgery, recuperate from surgery, get more
chemotherapy in a span of nine months.” He went on to suggest that,
under Obamacare and its bureaucratic red tape, his diagnosis and
treatment would have unfolded far more slowly and that probably
would have been fatal.
This provoked a predictable flood of fact-free derision
from numerous progressive pundits. Steve Benen’s
response was typically snide: “What Cain is peddling is little
more than ‘death panel’ garbage without the literal phrase.” More
surprising was the skepticism with which some critics of
Obamacare responded. David Whelan at Forbes, for example,
wrote that Cain was overstating his case: “ObamaCare’s main
feature is throwing money into the current system. There’s very
little change to how care is delivered.” This is particularly naïve
coming from a writer whose bio says he has “a job in hospital
finance.” A key feature of Obamacare is the Accountable Care
Organization (ACO), and it will affect the delivery of care more
profoundly than any development since Medicare introduced the
Prospective Payment System (PPS).
For readers sensible enough to have avoided careers in
health care finance, PPS is a price control scheme whereby Medicare
began paying hospitals a fixed fee based on diagnosis rather than
the patient’s length of stay or cost of treatment. Within a decade
of its implementation during the early 1980s, a tectonic shift
occurred in the way care was delivered. Because PPS applied only to
patients who spent at least one night in the hospital, it created a
powerful incentive to treat patients on an outpatient basis
whenever possible. And, as any health care economist would have
predicted, the number of outpatient surgery procedures skyrocketed.
As the New York Times
reported a decade after the introduction of PPS, “The shift… to
outpatient surgery accelerated in the 1980’s, growing at a rate of
more than 10 percent a year.”
ACOs will affect patient care in an equally dramatic
fashion. However, instead of merely shifting the setting of care,
they will slow down the speed at which it is delivered. How? As
with the PPS system, it’s all about the incentives. The ostensible
purpose of an ACO is to achieve high quality and efficient care by
encouraging a group of hospitals, physicians, and other providers
to work closely together on a particular population of patients.
But, under the ACO rules proposed by Donald Berwick and his fellow
bureaucrats at the Department of Health and Human Services (HHS),
“quality” and “efficiency” will be measured in terms of
money. “If the ACO is not successful it… is at risk of having
to pay money back to CMS, and its participating providers may find
that their own Medicare reimbursement is subject to recoupment by
CMS.”
Dr. Paul Hsieh, of Freedom and Individual Rights in
Medicine, recently phrased it
thus: “Under the ACO system, patients basically become cost
centers for hospitals and doctors.” In other words, a system
purportedly designed to promote quality and efficiency actually
creates disincentives that discourage physicians from pursuing
those goals. As Hsieh goes on to ask, “If his patient has chest
pain and needs to see a cardiologist, should the physician
recommend the better but more-expensive expert across town — or
steer him towards the cheaper but not-quite-as-good cardiologist in
the same ACO?” Obviously, this puts the physician in an awkward
ethical position. Obama’s HHS apparatchiks have fashioned a system
that will sometimes force him to choose between his financial
wellbeing and the health of the patient.
And if you’re thinking you can avoid the clinical
dithering and ethical ambiguity that will inevitably result from
the incentives HHS has built into their system, think again.
Another distinctive feature of Obamacare’s ACO system is “blind
assignment.” Unless someone imposes some sanity on the proposed
rules, it is entirely possible that you could be retroactively
assigned to an ACO without even knowing it. This means, in theory
at least, that your doctor could be prescribing care according
financial imperatives of his ACO rather than your best interests.
Will he hesitate to send you to a pricey specialist or think twice
before sending you to the hospital for an expensive diagnostic
test, like an MRI or a CT scan? Will your doctor temporize if your
symptoms are ambiguous, as they often are for patients with colon
cancer?
If Herman Cain’s doctor had been beset by such concerns,
and had succumbed to them, we would probably be referring to him as
“the late CEO of Godfather’s Pizza.” The man’s chances of surviving
his colon cancer were, according to his physician, about 30
percent. As to the tumors on his liver, which she didn’t know about
until she saw the results of his CT scan, she broke it to him
thus: “I’m not sure what I’m going to do about those until
after I open you up.” So, despite the snide remarks of DNC shills
in the blogosphere, the skepticism of media “fact-checkers,” and
even the doubts of more serious critics of Obamacare, Cain was
absolutely right when he said, “I’m here five years cancer free
because I could do it on my timetable and not on a bureaucrat’s
timetable.”
The good news is that the ACO rules proposed by Donald
Berwick and his minions at CMS, like the bleak prognosis provided
to Herman Cain in March of 2006, are not the final word. Obamacare
has been metastasizing at a rapid pace, but it isn’t too late to
stop the disease in its tracks. If the voters are willing to endure
a harsh course of therapy that will often leave us nauseated,
tired, and depressed, the cancer can be eradicated from the body
politic. And it may well be that the specialist we need to call in
is Herman Cain himself.
