Doomed to Failure

My initial impression of President Obama's healthcare plan is one of suspicion laced with grave concern and sprinkled with disdain. Surely he must realize that expanding Medicaid is not providing universal healthcare - Medicaid patients are turned away from many (most?) outpatient facilities already because the reimbursement rates are so low that each patient is a money-loser for the practice. I'm suspicious that he's using this plan as a token gesture to claim that he's fixed the uninsured problem. Guaranteeing coverage does not guarantee access, particularly when that coverage is pathetically insufficient. Even raising reimbursement to Medicare levels would still leave many patients without access to healthcare.

Another of his proposals is to eliminate Medicare payments for patients who are re-admitted to a hospital within 30 days of their last discharge. Like many liberal ideas, this sounds good in theory; if patients were appropriately treated the first time, then they should not require readmission for at least another month, right?. Improving the quality of care is a worthy goal, but when one's initial assumption is wrong then the conclusions will be wrong too.

A noncompliant dialysis patient, for example, may miss a couple of his outpatient treatments and present to the ER with life-threatening hyperkalemia (elevated potassium) or pulmonary edema (fluid in the lungs). Some of these patients don't go to their dialysis centers at all, they just come to the ER when they can't breathe. Instead of admitting these repeat offenders to the ICU, our incentive will be to dialyze them emergently in the ER and discharge them after several hours of critical care. That's good for ER docs (cha-ching!) since we can run up huge critical care bills on Medicare's tab, but not so good for the long line of patients in the waiting room who have discovered that they can't get an appointment with a doctor because nobody takes their newly-provided Medicaid.

Medicare patients, by definition, are either old, sick, or both, so they are more likely to require frequent admissions. When grandma has a TIA ("mini-stroke") 27 days after her last admission for pneumonia, the hospital's (and any on call physician's) incentive is going to be to discharge her from the ER rather than admit her to the hospital for an uncompensated megaworkup. So the ER docs stuck in the middle will do an 8-12 hour TIA workup with Neurology consultation in the ER, further backing up the waiting room. I could go on and on, but these examples should suffice. Patient care will suffer under this plan, and costs will not be reduced.

Other Obama initiatives like "Expanding the Hospital Quality Improvement Program" and "Improving Medicare and Medicaid payment accuracy" are just JCAHO-like regulatory mandates and excuses for payment denials which will not increase access to care in any way whatsoever, but will definitely make it harder for hospitals to stay in business. This plan is simply bureaucracy at its worst. My plan is better.

UPDATE: More concerns from Buckeye Surgeon and Dr. Whitecoat, great reads both. And 911doc reminds us that socialists were trying the same crap decades ago.