by Kristin Held

Insanity: the perverse incentives of Obamacare

After reading an update from the American Academy of Ophthalmology on Medicare payment to surgeons, I am literally laughing at the insanity of government-run medicine. It is a sick, sorrowful sort of laugh, one of disbelief, fear and despair. 

Government is cutting payment to surgeons because we have reduced the time it takes to perform even the most difficult, intricate and tedious surgery. Think about that for a minute. The very best surgeons, who innovate and perfect their techniques, are paid less because they are the most adept, efficient and skilled. It’s like the government paying the best athletes the least because it takes them less time to run the bases or the length of the field. 

When I was a beginning surgeon, I was tentative, cautious and slow. As an experienced surgeon, I am confident, skilled and fast. When the operation takes a long time, the patient is exposed to more problems — prolonged anesthesia, increased risk of infection, blood loss, deep venous thrombosis, pulmonary embolus … even death. When complications occur, the operation takes longer. When things go as planned, the operation takes less time. Recall days gone by, Civil War times or the Old West, back before anesthesia; the best surgeons were the fastest. Imagine having a leg amputated without anesthesia. Would you choose the slow surgeon and the longer operation? Wherein does the value lie? In the surgeon’s time, or the surgeon’s skill? The latter obviously. But try explaining that to a government health bureaucrat.

Last year, I attended the “government liaison" session at the American Society of Cataract and Refractive Surgery. The speaker told us it was our fault that we were not being paid well to operate on patients. You see, the government uses a system whereby it pays physicians based on the time it takes to do something — Relative Value Units (RVUs). The speaker implied that we should have said it took longer to do surgery than it actually does — to get paid more. She essentially told us we should have lied. She then showed a slide that actually said, “If you can’t beat ’em, join ’em,” and went on to tell us how to “game Obamacare.” She gave us tips on how to lie. 

If America’s physicians will lie to game the government, what won’t they lie about?

I am humbled and blessed to operate on my cherished patients. The vast majority of people fear the loss of sight more than the loss of any other sense, and many fear blindness more than death itself. The restoration of sight is indescribable, nothing short of a gift from God. What a surgeon does can change lives. Doing this kind of surgery requires physical, mental and intellectual skill, experience, wisdom, faith and courage — as well as great sacrifices by me and my family, for it exposes us to great risk. 

If a patient is blind, a surgeon can try to help. If things go well, no problem. If things go awry, the surgeon can be sued, punished, subjected to loss of livelihood, licensure, money and property — and even jailed. The individual surgeon and family can be destroyed. At some point, it becomes foolish for a surgeon to take on the risk of trying to help the patient under government jurisdiction. Not only does government pay surgeons according to operative “time,” but with Obamacare, government may not pay at all if the patient has an outcome less than government measures deem “quality.”

My favorite case this week was that of a 58-year-old diabetic male architect who was blind. He was depressed and disheartened. He could see nothing more than hand motion in either eye. He was on blood thinners for heart problems, prostate medications that complicate eye surgery, dialysis for kidney failure, was post-leg amputation (also associated with diabetes), and had already undergone extensive laser and surgery for bleeding in his eyes from diabetes. 

Having done nearly 10,000 eye operations, I “cowgirled up” and partnered with this precious patient in a sacred patient-physician relationship to give him a shot at seeing better. We went into this together, knowing it would be difficult. I prayed. He and his family prayed. The case was physically and mentally challenging, but went beautifully. When his eye patch was removed, he smiled. It was the first time I had ever seen him smile. Then he giggled and kidded me, “Nice to meet you!” — because before that moment he had never seen me. 

My patient now sees dramatically better and can return to reading, working and living an independent life, although he will not see 20/20 because of the coexisting diabetic problems. 

According to the “quality outcomes-based/value-based medicine” of the Affordable Care Act (ACA), I may not be paid if my patient does not achieve 20/20, or whatever arbitrary level of visual acuity the Secretary of Health and Human Services (HHS) decrees. Under section 3007 of the law, the secretary is to “establish appropriate measures of the quality of care furnished by a physician ... such as measures that reflect health outcomes.” The secretary will then apply a payment modifier that will determine each physician’s pay. There will be no administrative or judicial review of the “value-based” payment modifier, the evaluation of “quality” of care, the establishment of the “measures of quality of care” or the determination of pay.

In yet further expansion of the central government’s powers over the practice of medicine in the U.S., the secretary will under section 3001 of the ACA publish information such as “performance scores” of hospitals on a website — again subject only to narrowly circumscribed and toothless review. And Section 3002 empowers the secretary to report on individual physician and physician groups.

Think about it — a non-doctor, partisan presidential appointee is granted the authority to determine how much and for what hospitals and doctors are to be paid! 

Remember — if my patient develops a problem, I can be sued, lose my license, lose my profession and expose my family to bankruptcy. Now, thanks to Obamacare, if I continue to operate on such difficult patients, who might be dramatically improved yet not achieve the HHS secretary’s desired outcome, I could be stigmatized on the secretary’s “Physician Feedback Program” public report as a bad surgeon for not meeting arbitrary, nonsensical government measures. The hospital could sanction me for contributing to a poor “performance score” on the Hospital Compare website. What surgeon of sound mind will dare operating on a patient such as the one I’ve described with all the inherent risk and for potentially no pay? 

Consider again the perverse incentives created by government medicine. If I take a really long time operating — even though it subjects the patient to greater risk — and if I pick and choose who I will operate on, refusing the sickest, neediest patients, I am rated more highly by the government’s published “physician feedback” reports and hospital “performance scores” — and paid commensurately. If, on the other hand, I am skilled and quick and tackle the sickest, most challenging cases, subjecting me and my family to great risk, I am paid less or nothing and potentially punished. 

Government-run medicine cannot be tolerated. I will not do it. I will not play this game. I will not lie. I will stand for the patient. I will stick my neck out. If all physicians will do this, we can stop the insanity, save the patient and save American medicine, the best in the history of the world. 

Kristin S. Held, M.D., is an opthalmologist in San Antonio, Texas and director and co-founder of AmericanDoctors4Truth.


Opthalmologist Kristin Held, above, decries the Affordable Care Act's perverse incentives and broad expansion of government power over the practice of medicine in the U.S.

Opthalmologist Kristin Held, above, decries the Affordable Care Act's perverse incentives and broad expansion of government power over the practice of medicine in the U.S.

Opthalmologist Kristin Held, above, decries the Affordable Care Act's perverse incentives and broad expansion of government power over the practice of medicine in the U.S.