Tuesday, January 3, 2012

Medicine ~ The Pot at Rainbow's End

The future is purchased by the present ~ Samuel Johnson

The other day, as the story goes, I was in a phone shop updating my dysfunctional cellular phone, since it had acquiesced to the planned obsolescence command. The manager, a congenial, totally out of shape with “male-pattern-balding” fellow in his forties, started the discussion about healthcare. If he only knew he had stumped his toe on the wrong root in this forest. As the apples started crashing down upon him, I could see that this was more information then he could have ever hoped to gather in one short dialogue. Much less being capable of bearing its burden of the truth the deluge left him speechless.

“So, what kind of a doctor are you?”
“The healing kind, I think.”
“Seriously, you guys are the elite.”
“Yeah!” he smirked and then went on, “Man if every phone I fixed and charged what you guys charge, I’d be living in a penthouse in New York and driving around in an Aston.”
“How much do you charge?” I asked him.
“I am on salary here.”
“But if you could how much would you?”
“Say, fifty dollars?” His thumb and forefinger cradled his chin in introspection, while his other hand tapped some imaginary theme drumming through his head..
“That sounds like a nice round number.”
“It is and it is the right amount,” he said sure of himself, even though his body was shifting under the weight of his statement.
“Hmm,” I paused. “What do you think a doctor gets paid for, say a gallbladder surgery?”
“I don’t know. Probably a lot, I would think?”
“Well if you had to guess, what would you think it would be?”
“Oh maybe $5000 at least.”
“Why do you say that?”
“I mean you guys drive in your foreign cars and all.”

This gentleman needed some education in medical-fiscal matters and in a hurry. Maybe it was time to educate this mind.

Study the past, if you would divine the future ~ Confucius

“Ok, let me tell you what is involved with the surgery, then you decide the right payment.“ I said, as I carefully pieced the scenario. “Before surgery, the doctor has to consider all other relevant issues with a patient’s health, like for instance, heart, kidney and lung function etc. Once cleared of any additional co-morbid illnesses that might impose a hardship in recovery, the patient is taken to the Operating Room and put under general anesthesia. For all practical purposes besides all the inherent risks involved with the anesthesia, the patient is essentially on life-support and under constant close surveillance by the anesthesiologist. The surgeon then takes a knife and cuts the abdominal wall,” I drew an imaginary line on my abdomen, where the cut would be. He winced a bit. “Then the surgeon has to move all the other organs, such as the stomach, intestines and liver out of the way to get to the gallbladder. He carefully figures out the blood vessels and the ducts that come in to and go out from the gallbladder and isolate them, tying them as he goes.” His left cheek now got pulled up and a painful smirk cast its shadow on his face. Yes, I thought, he was listening. “Tie the wrong one and another organ dies from lack of blood. Sometime locating tissues can prove difficult if there has been previous abdominal surgery, from scarring or if the patient is obese or has other unknown altered anatomy.” The cheek now quivered in empathic discomfort. “Or in an emergency when minutes count to save a life, the surgeon has to keep his cool, remain confident and put all his skills test. The surgeon, then isolates and removes the gallbladder, tying up all the necessary tubes, while jeopardy waits at every corner. And as a reminder,” I emphasized, “the inside of the body is not like the cartoon surgeon game kids play with. The insides of a living breathing person are all living and breathing structures too. The whole interior is different shades of red and yellow. Meanwhile cutting through tissues leads to bleeding from the smaller blood vessels that has to be controlled constantly, which can obscure the surgical field.” His eyes grew wide as the image of blood punched into his inner eye. “After all the issues have been satisfied,” I continued relentlessly, “the surgeon closes the wound and then the skin and then monitors the patient in the recovery room, through the surgical Intensive Care Unit and the surgical ward all the way till discharge and follows up the patient for 90 days for any required care related to the surgery. Now during the surgery any complications that might arise and not infrequently they do, they have to be dealt with, since the life of the patient is literally in the surgeon’s hand!” The manager had an “O” sign for a mouth with two white and black orbs gazing at me. In fact by now the eyelids had completely retracted into the skull. I figured it was time to let him digest the information.

“Wow!” he said, “wow! I never thought through that… ever!”
“So now tell me what should the doctor get paid for all that?”
It took him a while and after several sighs that seemed to echo in the shop, he replied, “Oh at least $10,000 or maybe $20,000. Man you guys are flirting with someone’s life! …yeah I’d say $20,000 would be fair price.”
“Actually Medicare pays $350-500 for the entire “encounter” and by encounter, I mean from beginning to the end of 90 days. Soup to Nuts!”
“But with all the other expenses like malpractice insurance and all, how can you make a living?”
“There in lies the problem that the real world does not see. And I forgot to mention that the surgery is never at a convenient time either, it maybe needed at any hour of the day or night. You know emergencies happen not by the hour hand on the clock face but by a time of their own choosing.”

“Wow! I had no idea. Wow! Man!” He then shook my hand for a whole minute, shaking his head with beads of sweat populating the deep horizontal furrows on his forehead.  His face now all forehead, nose and wide black and white orbs for eyes, resolved into a Disney caricature.

He expedited retrieving the new phone for me. I walked out with my new gizmo in hand to the car. I switched it on. A circle with a line appeared on its “smart-face”. I was back in the shop.
“Oops, I tied the wrong blood tube?” his tripped over his words in embarrassment.

That the general population has “no idea,” is correct. There is no virtue in demanding from a position of illiteracy. Most people who sit and contemplate, extrapolate, and then come up with formulae and mandates have, similar to this manager, no, I repeat no understanding of what goes on.  So, I figured at least one individual was informed that day. Anyway, it dawned on me about healthcare costs hue and cry that rattle the airwaves.

The future ain’t what it used to be ~ Yogi Berra

Why is it so expensive? Yeah, why? I asked myself. It must be excess usage of the system or something? Now no one wants to have two gallbladders out, since there is only one captioned under the liver. So what gives? Is it time to take our heads out of the sand and see the hot, barren desert ahead, or should we just continue onwards towards the pot of gold at rainbow’s end?

Here are some interesting facts:

1. Healthcare is 18% of GDP. Why? Because, of an aging “boomer” population, duplication of services and CYA mentality to stay free of unnecessary litigation.

2. Almost 50% of all expense happens at the last 6 months of life and $50 Billion is spent in the last 2 months.

3. Medicare Fraud is estimated at a whopping $70 Billion!

4.  Smoking and Obesity constitute between 80-90% of all chronic related illnesses such as heart disease, cancer and diabetes. And in the U.S. in 2003 the requisite costs were estimated at $351.8 billion, $189.5 billion, and $132.0 billion. The total bill equals $743 billion! That is where the major cost of a $1.3 Trillion dollar health budget lies and don’t forget that was in 2003. A lot has changed since then.

5. Billing Errors: The constant tinkering with codification and computerized input by the health sector leads to $17 Billion in losses to the claimants (doctors and hospitals), which in other words,  means a bonanza for the insurers.

6. The cost of Insurance has skyrocketed in past 2 years at unsustainable levels hence 49.9 Million US citizens as of 2010 still remain unchanged in their coverage as uninsured. So much for good intentions.

7. The cost of newly discovered cancer medicines has escalated with some cancer drugs costing $93,000 to $110,000 per year per patient. The FDA keeps raising the demand for more and more studies before approval and raising the prices for NDA (New Drug Application) submissions, costing companies more and more on research and development. Something's gotta give! 

8. Hospital Costs have surged to maintain compliance with the regulatory bodies. Where one compliant officer was enough, now whole departments with scores of individuals are needed. (Unfortunately, these departments do not generate any revenues). Meanwhile the MBAs that have found a niche in hospital management, are cutting and pasting on their computer screens, jobs of the valued doctors, nurses and other paramedical staff to keep the shareholders, bondholders and the hospital board members happy – until one of them needs the hospital services. 

9. It is estimated that regulations will cost the private industry $1.752 Trillion! The Ten Thousand Commandments that continue to place a submissive burden on enterprise: http://cei.org/sites/default/files/Wayne%20Crews%20-%2010,000%20Commandments%202011.pdf

10. Declining Reimbursements from Medicare and the ambiguous, arbitrary and capricious policy dictates to the physicians has led to “volume-based practice” by many leading to some decline in the quality of care. Time has become a precious commodity that rears its ugly head in a nod or a shake of a head, where more detailed explanations are needed. Physicians have to see more patients to keep up with the incurred costs or they have to bow out gracefully from the profession. Meanwhile the Congress guts out a monthly "fix" for the sustaining the unsustainable SGR (Sustainable Growth Rates) created in a dimly lit room by people with equal luminosity.

11. Patients having no responsibility for their own health, they frequent the doctor offices and the hospital emergency rooms with complaints as trivial as a toe ache or sniffles. All that is covered under a very low price of a $10-$20 deductible. (I wish I had gone into that discussion with the manager too. Maybe there will be time enough for that later with someone else). A national dialog on personal responsibility might be a venture with better ROI then these boleadoras they keep flinging for "gotcha" moments.

12. New rules suggest non-payments for readmissions to hospitals within 30 days. Didn't know there was a warranty patch on the human body that determined MTBF (Mean Time Between Failure)! 

There are unintended consequences that pave the road to the healthcare nirvana. Unfortunately no one sees the precipice beyond the visible horizon until the “Tipping Point.” Oh woe!

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