Tuesday, April 1, 2014


     The wish for healing has always been half of health - Seneca
You finally get into the exam room and your physician enters and greets you. For a brief moment he looks at you and then his head is turned towards the computer screen. He asks questions and you answer in a sort of mechanical way. There is very little reaching across the divide. When he is done he briefly examines you and then writes an order for a test. He smiles and wishes you well, you see him turning back to the computer screen and frowning at the blinking message, as a nurse escorts you into another room, where you sit while the office staff member call various agencies to gain authorization for the tests the doctor has ordered, so you are told. A half an hour later the nurse comes in and apologizes that the insurance carrier has refused to pay for the tests today and that you might have to go to another facility or return again should the insurance company prove to be accommodating.

Welcome to the Mousetrap! Nay welcome to the perfect mousetrap!

The perfect mousetrap is one with four corners, a door and no exits. The mice are supposed to be baited with peanut butter and then disposed.

Now let’s look at the this healthcare trap. The four corners represent the four sentinels guarding the boundaries and the trap is laid for the physician-patient duo. The lure of this intriguing mechanism is its gilded bling as expressed by the designers. This, “they” say, is the perfect lodging for the practitioners of this noble of professions called medicine. Who are “they?” You might ask. And the answer will reveal itself shortly…
Healthcare costs are high in the US. But is it all about the doctors providing the care? Seriously comparing Sweden or Switzerland with the US one is really comparing apples and oranges. The personal responsibility is taken seriously in those countries. They exercise and have a limited diet, hence their life spans are better. Not because of the wonders of the healthcare dollar but by their own volition. Ah but the experts won’t tell you that. Besides there is very minimal if at all any discoveries, experimentation, innovation that is being generated from those countries, yet the drumbeat goes on to serve a purpose.

The first corner and wall is inhabited by the Federal Government with the likes of HHS, CMS (Medicare and Medicaid) and now the IRS. The initial buy-in in 1965 by the populace was that Medicare would provide care for the elderly at a reasonable affordable cost – a kind of a safety net. Those that could not pay would receive the Medicaid benefits free of costs. Well realizing that most doctors were not enchanted with the formula since the patient would spend the reimbursement checks and the doctors would be left holding the empty collection bag. The HHS/CMS came up with a solution for the doctor buy-in with “accepting assignment.”  The logic was that the physician would get paid directly for services rendered, albeit at a lower rate. This seems good on its face since collection issues would be rendered moot. And so it went until SGR formulas were created to limit reimbursements to the physicians and over a10-year period while the cost of living continued to rise as all federal employees and private sector employees garnered the appropriate increase in revenues, the doctors were mired in the perceptible risk of being raked over the coals with a 21%, then a 24% and now a 30% cut in reimbursement fear tactic. Each cut faced a deadline and the doctors held their collective breath each time. But each time the dark clouds passed since Congress realized the drama that would unfold for the Medicare beneficiaries as doctors would stop accepting Medicare. But now, get this, now the government through its agencies has decided to determine the right cookbook methodology of treatment for all high reimbursable ailments. It is now determined by experts like Ezke Emmanuel that 80% of the care can be rendered by Nurse Practitioners and Physician Assistants, so why educate more doctors. Plus, and this is a big plus, reimbursement for the NPs and Pas would be lower, hence the healthcare costs would be lower. But no one has ever looked at the real costs of healthcare and where the money is flowing. For every $1, 12% goes to physicians for services rendered and expenses. 36% to the hospitals, 35% to the pharmaceuticals and device managers, 17% goes to administrative purposes. Oh and if you missed this, you might want to know that CMS (Medicare and Medicaid) spends $385 billion annually on administrative expenses to its own employees.

The second corner belongs to the Private insurers and the Hospitals. I lump them in one as the lobbyists groups from both are strong and tend to change the Congressmen and women’s minds about how much they should be paid. While paying millions of dollars as benefits to its upper managers, the insurers and hospitals cry poverty in front of the lawmakers. ‘We cannot survive this without charging a higher premium or lower corporate taxation or both.” And there are many more excuses. The insurers delay, and deny payments to the physicians and at times to the hospitals making them jump through hoops that take time and effort away from actually helping patients. The hospitals in their theatrics, cry poverty and throw the risk of closing their doors and hurting the large community of hundreds of thousands if they don’t get the proper reimbursements through their active lobbyist the American Hospital Association.

 And every congressman or women knows that (s)he will never be reelected should this come to pass that the hospital will close its doors. No, not ever, Nyet! Meanwhile the cost of a single aspirin charged by the hospital to the private insurers goes to $50, which they collect from other write-offs in their ballooned 10Ks. 

And equally befuddling is the United Healthcare’s recent payout to a New York Podiatrist for $178,080.00 for surgical repair of two hammer toes that took less than an hour. Truly the left hand does not know what the right hand does! And to rub this wound into a mound of salt, the reimbursement for a open surgical cholecystectomy (gall bladder removal the doctor makes between $485-745 for the surgical procedure and the 90 day of care thereafter). Go figure that out!

The third corner and realm belongs to a new rising star in the private arena and it is the American Board of Medical Specialties and the American Board of Internal Medicine. These two entities have crafted a calculated strategy of requiring physicians to pass the Certification examinations in the specialty that the physician practices medicine. The physician buy-in initially was that they wanted to distinguish themselves as having achieved the “Board certification status.” If you were certified, you could keep that certification for ever. Recognize that phraseology? The revenues to ABMS and ABIM were modest and so they determined the revenue cycle had to be modulated to yield higher values. Enter the need for re-certification.  After 2000 everyone would receive a time-limited certificate of 10 years. Doctors entering the medical arena did not know any better so accepted the formula, while those grandfathered kept quiet. Now however, even time unlimited, (grandfathered) certificates will also need re-certification.  Ah, but that is not all, the revenues recovered from just the re-certification consequently doubled from this minor fiat, but the ABMS and ABIM were not done, they, then created the Maintenance of Certification or MOC as it is called, rule. Every two years a doctor would need to fulfill the criteria of MOC and only then they would be allowed to take the re-certification examination. Well then the 2010 revenues of ABMS rose to $49 million and the salaries of their President went to $750,000.00. Turns out that the president Christine Cassel MD (who had not practiced medicine or never was recertified) also happened to be on patient safety commissions and other boards influencing the needs of the certifications and the MOC processes (No one saw the conflict of interest, until maybe now and that scenario has yet to be played out). The conflict of interest was recently discovered and investigation is ongoing. But here is the kicker, MOC, no less the Board certification has NEVER been proven to show that a certificated physician is a better physician than non-certificated ones. (Disclaimer: I was certified in Internal Medicine and twice certified in Medical Oncology) I have never found that my expertise or knowledge was ANY BETTER than those who had not sat through this examination.” And what does ABMS have to say about the benefits, "MOC is recognized as an important quality marker by insurers, hospitals, quality and credentialing organizations as well as the federal government."  (Nothing about patient care or patient outcomes or patient well-being or differentiating quality of healthcare rendered by certificated and non-certificated physicians, however they imply the potential but are unable to provide a factual impartial relevant study.) So, what gives? Money, as in $$$ that one would quickly guess. And to formalize and ossify the need there is a continuous push by the ABMS and the ABIM to make MOC the necessary criterion for Maintenance of Licensure in each of the 50 States so the revenue cycle continues unabated and increases with each passing day. Oh and if I haven’t said this before, did you know that the pass rate of the certification examination just started to fall in the last two years. Why? You ask....Elementary my dear Watson they fail the physicians so that they have to come up with the $5000 again for the next year examination…Another productive solution to increase the ROI (Return on their Interests), Top line and Bottom line for these unaccountable entities. Wikipedia states: "Maintenance of Certification (MOC) is the process of allegedly keeping physician certification up-to-date through one of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) as well as some of the medical specialty boards of the American Osteopathic Association (AOA).[1] Some studies, funded and performed by highly conflicted employees of the member boards, have shown that board certified physicians deliver may higher quality care than their non-certified colleagues and that board certification is correlated with." :

The last corner of this mouse trap is the Litigation. 

The legal eagles spend $1500 per capita in PAC money to lobby the Congress so as not to allow any bills on Tort reform, cap damages for pain and suffering and definitely not consider those filing frivolous law suits should have to pay the court fees. No that would hurt the poor indigent people who have been wronged they preach. No, never, that will never pass, because the trial lawyers (And Shakespeare had them right on) do not wish to let this golden goose lay its eggs in another’s basket. Thus the tort reform sits and sits while Law firms hire and hire and get bloated with hundreds if not thousands of lawyers in each firm, while the solo practicing doctor finds it difficult to keep his or her practice open. By the way a Trial by Jury is unheard of in non-criminal cases in most if not all other countries except, you guessed it, the United States.

And that now brings us to the two little people in the middle, “The patient and the physician.” The one that ultimately suffers from all these concocted mechanisms of care delivery is the patient. He or she will ultimately pay for limited, substandard care while the doctor is made to become a secretary to check boxes for the governmental mandates and get the insurer’s pre-authorization checklists toiling away to build a large database for the enormous Big Data warehouse so that analytics will define what is and what is not medicine. The patient will pay more out of pocket because that is the next step to limit access to the doctor or the emergency room or the hospital and he or she will pay more in premiums to pay for those that do not or cannot pay for insurance coverage. Not only is the patient in danger of sub-optimal care as a consequence of this recipe-style medicine but he or she is also at risk of being marginalized for proper care if the costs outweigh the productive benefit as it is related to age and ability.

Lastly the doctor, he or she will have to live by the cookbook style of guidelines in medical care, thus going against the Hippocratic oath at times, especially if (s)he is a hospitalist and the job depends on a productivity contract. Admissions in the hospitals are being scrutinized and hospital stay days are the metrics for reimbursement by the CMS in most areas thus discharging patients in an untimely fashion to garner a larger margin from the admission might jeopardize the patient’s health to say the least. The constancy of cost as it relates to care might become the overriding concern of most hospital employed physicians who want to go-along to get-along and maintain their job security. Medicine will fail and that is exemplified in the National Health System (NHS) in the United Kingdom where there is nary a day when some hospital, a part of the NHS, isn't shown to be understaffed, dilapidated structurally, where employees show lack of concern with the conditions, patients and at least in one hospital where aborted fetuses were burnt to heat the hospital interior- their new HVAC system!

So there you have it, the perfect healthcare mousetrap that will catch a lot of sub-optimal, substandard, sub-par healthcare for the patients that fall into the trap.

Please think beyond today and beyond your paycheck. This format hurts everyone. It rips the nobility in medicine, destroys the faith between the healer and the patient. It renders moot humanity and glorifies the silicone chip and the almighty $dollar$.


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