Wednesday, April 8, 2015

Healthcare by Schmucks

There must be some intelligent people in government. They are hard to find,and if they rise to the top it is not infrequent they will last perhaps one term or even one year. When one is promoted to a position above the glass ceiling it is at first a rush to have been elevated to a place where you are seen,sometimes listened to maybe respected, and an easy target for those who think they know better about leading. It is not unique to healthcare. Only 17% of physicians are in solo private practice. What this means is a loss of economic freedom, the loss of integrity and honesty as an individual. Perhaps physicians are really not so unique as I once thought. Admittedly this was a primary reason for my entering the field of medicine. My other reasons are buried somewhere in a space where my MRI shows that my brain has shrunk. My physician (neurologist) showed me the MRI The ventricles were slightly enlarged, but the condition is 'stable' (what condition ?) Imagine that ! A former ophthalmologist with a shrunken brain). Perhaps I can use that as a marketing tool. "Lasik Surgery by a former pioneer and early user of Lasik" A one year special for $--.00/ Prices subject to change and we don't guarrantee results. 50,000 cases. All proceeds to go to the Alzheimer Foundation. My former patients took some solace in having a surgery by laser. It must be better...it's not surgery. It does not take much physical skill to perform lasik other than to affix several robotic tools which make the laser cuts according to a pre-determined algorithm. The skill and over-riding is judgment honed, and carved out from years of experience, a qualitative measure almost impossible to measure metric other than the length of a career. Perhaps it can be measured by the amount of brain shrinkage as indicated by an MRI. I digress, which is often the case discussing things not relevant to the theme of my paper. Back to health care by schmucks ( I love that word. I don't think it can truly be translated, summing up many people who are highly educated, trained and just don't quite get it.) They often are elected to positions of high esteem and leadership. Personally I have found in my career a certain resistance to following many of them. Perhaps it is my lack of respect for authority, a bit like my feelings for the IRS. They just don't get it, and they are led by Congress, and whoever is sleeping in the Lincoln bedroom, or in the bathroom of the oval office. No matter, usually they move on to a 'highly respected group of foundations (all non-profit, of course), such as the IOM, AHRQ, the Institute for Quality Improvement, and others. All of this brings me to the topic of today's article by Richard Amerling M.D. He is the current leader of the AMA. This position supposedly represents most or all of physicians. I don't know him personally, but he is trying to do a good job. Unfortunately Dr. Amerling does not represent any majority of U.S. physicians. I am sure he goes to sleep every nite tossing and turning thinking how truly powerless he is against HHS, CMS, the SGR and an alphabet soup of 'authorities'. Poor Richard (sorry,Dr. Amerland no disrespect intended) There seems to be no other way, so we live with compromise, the story of life, except perhaps for the Ayotollahs and those who cannot think for themselves a skill rarely taught in school these days. The article in the AMA has caused my brain to shrink even more. It is time to have a followup MRI for which I will wait two weeks to do, and then another two weeks to have a result, all while knowing that my brain is either shrinking or over-inflating with fluids. (does anyone need a spinal fluid infusion or replacement) I am willing to donate my spinal fluid for free, tested for STDs, Prions, and other infectious diseases. I cannot promise that you wont get Alheimer's or suffer the same process I seem to be going through now. I have had an epiphany about aging. I am surprised it took me this long. I have treated thousand of people over the age of 65 and I had no idea of what they were experiencing. After all they and I use denial to survive. It has taken me ten years to realize what I am experiencing. My spouse, who was an R.N. and 7 years younger than I am seems to know the story of aging. In my next article I will venture into what my cognitive powers have rendered. Scientific description with vocabulary that most people do not understand whether young, educated or not is not adequate to the task. It is a bit like watching black and white TV, never having seen color TV (that should summarize how old I am. My earliest recollection of TV is Howdy Doody and Dave Garroway. No one was capable of taking over NBC and they are still at the helm or Dave is directing NBC from wherever he may be. I would look at my elderly patients and observe forgetfulness in some, missing appointments, not complying with medication instructions and being unable to remember what they had for breakfast. My neurologist gave me a short mental status examination. ie, count backwards by 7s from one hundred while standing on one foot, or on my head. Who is the President of the U.S now. My answer was 'No one' My answer resulted in his retiring the next week,and he is ten years younger than I am. Sorry Dr. F, I meant no disrespect. i have known Dr. F all my career, and he has an excellent reputation, even if he works for a competing multi-specialty group. Damn I wish I had gone into that group when I came to town. But no I wanted to own my own practice and prove that I was 'better'. . I guess that makes me the 'ultimate schmuck' I did not mean it as a joke, however I will contribute that to the new man at the helm for Jim Colbert. However after blurting out what I thought was an original thought and now I realie just how funny it was. They say that great comedians are fast on their feet, a bit like Robin Williams R.I.P., Steve Martin, Jackie Gleason and Bob Hope R.I.P. If you are still with me and have not sucumbed to internet inattention by jumping to another site I will reward you with fact from those who I think may be schmucks but know their 'stuff' (no disrespect to my esteemed colleague Dr. Amerling, who I know would think the same things. That is what is so good about physicians, it' the 'elevator or doctor's lounge talk. That is, if it has not been turned into an administrator's office to crunch numbers to save money. I do miss those hospital sponsored lunches with filet mignon, lobster, fine wine, ice creams with fudge before going back to my office in a state of euphoria, refreshed, somewhat somonolent and content with my plight. Missing From the Debate Over The Medicare Sustainable Growth Rate: Sanity Click here to read online and comment. A popular definition of insanity---doing the same thing over and over and expecting a different result---could well be applied to the Sustainable Growth Rate. Understanding the origins of this failed policy is highly instructive as to the effects of government price controls in the Medicare system. Costs within the Medicare system started to rise faster than predicted as soon as the program was instituted. This should have come as no surprise. Millions of seniors were handed an entitlement to medical services, which of course increased the demand for these services. Physicians were allowed to charge their “usual, customary, and reasonable” rates and did so. Concern over rising costs led to various responses from the Health Care Financing Administration (HCFA, the bureaucratic precursor of the Center for Medicare and Medicaid Services), to rein in spending. These mostly took the form of price controls on physicians’ services. On its face, this is stupid policy, as payments to doctors were between 10 and 15% of total program spending. Cuts in this sector couldn’t reasonably be expected to produce much in the way of savings. And of course, going back to the dawn of civilization, price controls have never worked and have more often than not been disastrous. In 1983, HCFA began a fee freeze on Medicare payments to doctors. This was extended through 1986. Total Medicare spending increased dramatically during this period. Why? Doctors, to maintain income, increased the volume of services provided. The more patients seen, the more tests, prescriptions, consultations, and hospitalizations occur. Limiting the payment for an office visit invariably leads to less time per patient encounter. This must result in loss of quality. In 1989, HCFA moved away from paying doctors based on their UCR charges to the Resource Based Relative Value System, a socialistic construct that assigned dollar amounts to the myriad services provided by doctors. Balance billing of wealthier patients (not all seniors are poor) was severely restricted. Non-participating physicians could only charge a bit over the Medicare “maximum allowable charge.” Since they were also penalized with a lower payment rate, this increased the physician Medicare participation rate. The net result was another big pay cut to physicians, which was again followed by a major increase in total Medicare spending. It also brought larger numbers of doctors into the Medicare system, where they became highly sensitized to the dictated pricing. In 1997, the Medicare Modernization Act introduced the SGR. The idea was to base Medicare physician fees on total program performance the prior year. If total Medicare spending were above a certain target, payments to physicians would be frozen or cut in the current year. But pay cuts to doctors predictably cause total spending to increase. The Medicare Payment Advisory Commission (MedPac) recently reported that from 2002-2012 Medicare spending on physician services per beneficiary increased by 72%. A 9% increase in rates during this period was dwarfed by the growth in volume of physician services, including lab tests (91% increase), imaging (79% increase), and other procedures (up 68%). If SGR doctor pay cuts had been allowed to take place, doctors would now be getting paid pennies to see Medicare patients! This would have forced many doctors out of Medicare completely, creating a shortage (the legacy of most price controls). The SGR meets the definition of insanity. As it is, the net effect of pay cuts and freezes has been to force many physicians out of private practice, and into hospital systems, where costs are much greater. From 2002-2012, Medicare fee-for-service rates increased 9%, while the cost of operating a practice increased 27%. What’s the solution? The bill just passed by the House of Representatives and awaiting Senate action does away with the SGR, but enshrines Medicare price controls and an arbitrary update formula guaranteed to be substandard. It also furthers the push away from fee-for-service payment in favor of newer forms of managed care, such as the Accountable Care Organization. These, despite the bells and whistles, are doomed to fail. Since much of the current Medicare disaster can be traced directly to the effect of price controls, and direct payment of doctors through mandatory assignment, we should do away with these. Congress should insist that Medicare physician payments go through patients, and restore to physicians the right to balance bill. This would include being able to provide care for free to a truly indigent beneficiary (a practice that is now illegal). This would stem the flow of doctors exiting Medicare, and private practice, improve quality of care, and empower patients. Payments to physicians would likely remain flat, as volume of services would immediately decline. And this would moderate total program spending. Richard Amerling, MD (New York City) is an Associate Professor of Clinical Medicine and an academic nephrologist at Mount Sinai Beth Israel in New York. Dr. Amerling received an MD from the Catholic University of Louvain in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is President of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians' Declaration of Independence and is a seasoned speaker and on-air contributor.
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