Sunday, November 17, 2013

There's a dark cloud in my silver lining...

I was doing some research for yet another post about Obamacare and I can across a timeline for Obamacare. Delving into that, the very last thing listed was this:
2015: Physicians will be paid on the quality of care, not the volume
That got me to wondering exactly what that meant? A little digging led me to this site where the 'quality initiatives' were documented and defined. As a long time software developer I am more than familiar with the nonsense that SEI and the quality assurance gurus foisted on the development community. I will note that their intention was well meaning, but when the government and industry realized just how costly (and ultimately useless) implementing total quality initiatives were, they by and large backed away from it. So when I saw quality mentioned in the context of Obamacare, I detected the stench of a very large rat.

Saying the noted web site documented and defined the quality measurements is being a bit generous. Like most implementations of quality goals,  the actual mechanics of the thing is a bit hard to root out from all the glowing happy talk about quality and measurement. This is not some esoteric subject for doctors. Their actual compensation will be tied to how good they can make their numbers look, which in turn will be used to compute a quality multiplier (or divider) that will be applied to their compensation. These documents (zip file if you really want to study them) define how those numbers are computed, and therein lies the bloated body of a fetid rat.

Let's take one example here. Consider a preventative measure, like a colonoscopy. Here's what the measure looks for:
Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening
Sounds great right? If the doctor is making sure his patients are getting the screenings they need, then he is doing a good job. Now, consider for a minute how he proves that. Here is the proof that he has to submit:
Numerator Instructions: Patients are considered to have appropriate screening for colorectal cancer if any of the following are documented:
• Fecal occult blood test (FOBT) within the last 12 months
• Flexible sigmoidoscopy during the reporting period or the four years prior to the
reporting period
• Colonoscopy during the reporting period or the nine years prior to the reporting period
NUMERATOR NOTE: Documentation in the medical record must include a note indicating the date when the colorectal cancer screening was performed. A result is not required if the documentation is clearly part of the “medical history” section of the record. If it is unclear whether the documentation is part of the medical history, then the result or finding must be present (this ensures that the screening was performed and not merely ordered).
That's right. The doctor, in order to get paid, will be submitting your records to a government bureaucrat who will check off every blood test and butt probe to make sure that the doctor deserves credit for remembering to do the test. If for some reason they decide that say, white males of the age of 65 or older no longer need cancer butt probes, then they will just tune the award parameters accordingly. The doctors will respond to the tuning, and stop remembering them.

So you have some very disturbing things happening here. First, you are virtually guaranteed that some government bureaucrat will be pawing through your detailed health history. If you think that data will remain private then think again. There is nothing that will remain private. Take this little quality measure action that your doctor must take if your BMI measurement indicates your are fat:
Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions, dietary supplements, exercise counseling, or nutrition counseling.
There you go. The doctors will be evaluated (and ultimately paid) by checking to see how many fat people they send to the shrinks for re-education. 

It actually gets worse. Consider this definition of unhealthy alcohol use:
Unhealthy Alcohol Use – Covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. Risky use is defined as > 7 standard drinks per week or > 3 drinks per occasion for women and persons > 65 years of age; > 14 standard drinks per week or > 4 drinks per occasion for men ≤ 65 years of age.
So if you have more than two glasses of wine with your evening meal, or drink that whole six pack while once again watching the Redskins do truly stupid things on the gridiron, your doctor will be reporting that he found that out to the appropriate комисса́р. There is nothing in there that says what he has to do if he finds out information, only that he must report it. The important thing to understand that the framework for large scale social engineering is being erected. The incentives mean that your doctor's pay will be directly tied to his willingness to divulge the most intimate details of your health. There are clues that also tied to these incentives are his action to refer you to the state approved re-education facilities. All in the name of affordable health care.

If this does not make you nervous, then you are just not paying attention. 2014 will literally be a red letter year for us. If the Republicans fail to get the White House, and also fail to win control of the senate, then this law will stand and the machine will be firmly cemented in place, where nothing but it's own weight or a revolution to alter its course.

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