Monday, June 5, 2017


In thinking back, sliced bread was a pretty good idea. It made for some delicious sandwiches, ask Bluto or Dagwood for that matter. But the greatest ever “sliced bread” for the bureaucratic management tycoons was the slow, methodical, tantalizingly preacher-worthy subservience of the physicians.

Ha, you say, there you go preaching the doldrums of the doctors again. Seriously, stick with me on this one and proof should follow.

Back when free markets reigned and all things were humming, bureaucrats at expensive dinners in fancy restaurants decided they needed to enter in the medical community since it was replete with unfettered tax-payer money. The first element in this strategy was to encourage physicians to participate in insurance. This mechanism, they claimed, would avoid physicians from not receiving their payment if the reimbursement was sent to the patient directly.  As more and more physicians accepted the notions, the insurers figured by simply constricting payments to the physicians was an easy mechanism to reduce their costs. To the hospitals, the curbs brought forth restriction of the “Length of Stay.” Everyone worth his salt, be it the Chief of Staff of a hospital, an MD or the member doctor in the medical staff was trying his/her best to keep those patients from occupying the hospital bed longer than necessary. Each extra day in the hospital was running the deficit cash register into the millions for the government and the private insurer. With back-channel support and intense lobbying efforts, as Aspirin costs skyrocketed for the private insurers and self-paying individuals, a new paradigm was created. Ah yes, they cried in unison, decrease the length of stay and you could be promoted as the most efficient and best physician in the hospital. Why wouldn’t anyone ascribe to that fame and strut the stage for that brief-moment. It was a briefer moment, since the “Average length of stay” for any malady continued to shrink to the point that birthing babies was a 24-hour event and then out went the mother and the child to their family care. Some good did come out of it though, cataract surgery, which had been a week stay in the hospital with sand-bags to keep the head stable turned into a one-hour outpatient ritual. But that was to a large extent the function of innovation, physician dexterity, risk recognition, safety profile of the surgical procedure and not necessarily a bureaucratic policy mandate, done well.

Then came the “reimbursement” issue where a patient could not be readmitted to the hospital within 30 days for a similar diagnosis without an abject rejection of payment from the insurer. Many patients suffered the consequences, due to emergent complications being managed at home without necessary resources. That however was not the thrust of the argument, the managers exploited graphs and power-point slide shows to regale their point of cost reduction without an eyelash in the direction of real harm done to scores of vulnerable patients.

What followed was by changing the paradigm and giving the physicians a new name. The Physicians were turned into “Providers” to reduce the esteem of their years of knowledge into the low subterranean grey of commodity. A rose by any other name still smelled sweet, but it was withering under this growing bureaucratic mushroom cloud. Suddenly, or maybe not so suddenly the integration of the physician elites from top notch universities began taking seats at the table of the government and medical societies where decision making became a collective groupthink. “Yes!” they all cried in unison, medical care in the modern world was stealing a quarter of the GDP, while they sucked up 7-figure incomes, bonuses and exotic travels to far away island retreats to conjure up their next costly mansion, boat or an airplane. These experts compared the U.S. costs to other western democracies and graph upon graph graced the society spawned journals. Everyone cried out that U.S. medicine was raping the nation of its treasure. The variables they used were irrelevant but made for an excellent News Story worthy of television coverage. There was no mention about the Administrative Costs for the middling managers that accounted in some cases for as much as 30-40%. But the busy-bodies were looking for heads to roll under the banner of “Public Good.” Who, to blame?

The finger it seems always points in the direction of the doctors. Yet the U.S. government’s own data revealed that physician payments were only 7.7% of all expenses incurred in medical care via the CMS. The Physician Data Dump by the U.S. Government, to show transparency, revealed; physicians were paid $70 Billion in 2012 out of an estimated $985 Billion in Medicare. Hmm… it doesn’t take a genius to figure out the percentages. Simply divide $70 Billion by 850,000 active physicians and you get $82,352.90 payment per physician. Oh, and just for completeness sake $385m Billion was ascribed to the administrative expenses. Yet the drumbeat about fraud and other rackets continued to keep the think-less vacuous minds engaged with the dog and pony show. “Never you mind, Look over here!” The bureaucratic intellectual honesty seemed the latest oxymoron.

by Charles Kroll

Physicians were jostled around with “This is More” and “That is Egregious.” Soon physician exits from the field of medicine followed, some forced by finance others by fiat and still others by demonization. Meanwhile self-appointed non-practicing physicians assumed power in non-profit agencies (ABIM/ABMS), created to govern the physician’s knowledge and education, costing physicians time away from their patients and money, while these agencies paid their staff of “experts” million dollar salaries from the revenues received. Meanwhile they failed to show an proof that such rigor improved physician care or their patient’s outcomes. The shortages followed suit and the non-physicians were given authority to practice medicine without a medical license in some U.S. states where the shortfall was more intense. These non-physician “Providers” were however exempt from any of the education, training and retraining efforts employed against the physicians. Anecdotal stories proliferated about how wonderful the care was under these non-physicians while simultaneously undermining the physician expertise. “Oh, what a web we weave…”

Where does this end? The answer is quite easy to come by. The new in-training doctors are being indoctrinated with the art of this form of care. Treat an individual through the lens of population medicine. If the one size does not fit all, too bad. We now live in a world so far away from where we started that the past no longer evokes a memory. Perhaps it was in a parallel universe? Who knows?

These policy experts and non-practicing physicians forget that innovation in medicine is not all borne out of a computer statistics and groupthink, which they seem to employ in every decision-making. The eventual price to pay gets steeper and steeper as we go down this rabbit hole. Eventually the masses will realize the folly forced upon them. IT might be too late, but brinks and abysses are relative terms and doing a 180 takes discipline, time and effort. Imagine that huge barge in the Hudson river? Good luck at that!

Currently the bureaucratic managers and their cronies are in full control, extracting large paychecks for their deeds while pointing the fingers of blame elsewhere. The finger of instability in this sand pile is wiggling and I have seen the sand pile shudder.

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