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: "
See also http://www.changeboardrecert.com/
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 $dollar$.
Think!
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