The Maze – Part 7
Is There an Exit? – I

This is a part of an ongoing series on medical coding, billing, and reimbursement.

Previous posts are here:

MazeWhat started off in concept as a few posts on some of the craziness in the medical billing and reimbursement arena has been turning into something of an opus magnum on the subject–yet surprisingly, even at that has not even touched upon all of the complexity or contradictions inherent in this maze of regulations, bureaucracy, and inefficiency which we call our health care system. Such systems–complex, increasingly unworkable and counter-productive–do not arise by design, but rather by a sort of perverse evolution, growing a brier here and a bramble there, creeping tentacles and spiraling vines sprouting to address difficult problems, but increasingly choking the life out of their intended benefactors, strangling both those in need of help and those committed to providing it.

A regular question in comments throughout this series has been, “What, then, are your solutions?” Fair enough question–it is far too easy to dissect and depreciate the medical system we have at once inherited and created: it is, in soldiers’ parlance, a “target-rich environment.” A house built on sand cannot stand — and the mansion of American medicine, still rich in grand gables and ornate glass, is sagging from a rotting foundation, swaybacked from footings set on unsteady soil. The termites eroding its timbers are many, rooted in men’s souls as much as in Senate halls. We demand the finest care for ourselves, sparing no expense to others. We demand perfection of those capable only of imperfection. We hide behind our terror of death, unspoken yet unrelenting, seeking false hope in technology and technique against that dark looming fortress which stands unbending against our extravagant but ultimately fruitless endeavors. We pass law upon law and regulation upon regulation, engorging a byzantine monster so immense it can no longer ambulate–yet still we feed the beast, hoping against hope it may someday become the chrysalis which will carry us to a better world. It will not, and can not, for it has not the wherewithal to do that which is most needed: its own dismantling.

The complexity of our current system is both the cause and the result of its dysfunctionality. We have created an environment of perverse motivation and punitive legalism. Patients are shielded from the true costs of their decisions by insurance rendered nearly free to them by their employers or the government. Physicians, seeing their medical decisions challenged and checkmated by capricious clerks and aggressive algorithms, work the complex system to outmaneuver its clear intent to squeeze more work from them for less pay, while their patients are denied the care they have recommended. Insurers, pressured by employers to cut spiralling premiums, make cold calculations from afar which infuriate physicians and injure patients. Attorneys play Monday-morning quarterback, second-guessing complex decisions years after the fact, before gullible juries with Jerry Springer ethics, reaping personal windfalls far exceeding the benefits of their wounded plaintiffs. And government, having opened the financial floodgates of health care entitlements, now seeks to stem the rising waters by sandbagging the banks rather than repairing the dam.

Each player in this dysfunctional drama plays their part, driven in no small part by incentives which drive up costs and increase inefficiency and complexity. Health insurance, while necessary to avoid financial disaster in a health crisis, serves also to buffer patients from the cost implications of their health care decisions. Costly and sometimes unnecessary tests, drugs, or treatments are demanded because “insurance pays for them”–and because media and internet hype inflate their usefulness while minimizing their risks and costs. End-of-life care is extraordinarily expensive in part because patients and families refuse to accept the inevitability of death. Physicians play along, fearing lawsuits if they do not–while themselves refusing to recognize their own impotence against death and the futility of their own technological railings against the darkness. Government, desperately trying to reign in rampaging health care costs, responds by increasing regulation and complexity while decreasing reimbursements–greatly escalating pressure on physicians to manipulate the complex rules for their patient’s welfare and their own financial survival–and compounding the risk that by doing so they will run afoul of its legal and ethical clutches.

To restore a measure of sanity to this system we must return to core principles and truths, long since lost in the maze of regulations and rules we have allowed our health care system to become. In attempting to arrive at a better way to deliver health care, it may be best to start first with doesn’t work–and why:

 ♦ Managed care: Managed care works–or at least it used to–as long as you defined its success as the reduction of health care costs. Managed care uses several models. Most involve the use of a gatekeeper–a primary care provider who is the übermeister of who, when, and where you as a patient get care. Need a specialist? No go, unless Herr Pförtner approves. Got to see that specialist (finally), who recommends you have an MRI or CT scan? Gotta get a piece of paper from the Gatemeister before you go. And in many arrangements, the primary care gatekeeper has strong financial incentives to Just Say No–or strong disincentives should he break down and say Yes. So for you to see that specialist, your family doctor has to: 1) do extra work, filling out and sending more paperwork and forms, and 2) lose money. Bet he or she finds some way to treat you without that visit or test. Even good, ethical doctors get beaten down by such a system.

Another variation on managed care makes the insurance carrier the gatekeeper, making decisions about what care you may have, under what conditions, by which doctors. If you like having your primary care physician giving a thumbs up or down on your tests and referrals, you’ll just love having this process run by insurance clerks, secret policies, and computer algorithms. Of course, the carriers constantly remind us they don’t practice medicine. They’re right, of course: no one would call making regular decisions about your access to referrals, tests, and medications purely for financial gain practicing medicine, no siree. Malpractice of medicine would be a better description.

Managed care saves money by restricting access to care–and hence it resulted, after its introduction, in a significant drop in health care costs. But patients got wise to the game, and became more demanding–and media stories about kids denied cancer treatment and women with breast cancer denied bone marrow transplants, made the managed care companies pariahs. And so, managed care was forced to become more flexible, allowing more specialty visits and looser restrictions on certain tests and procedures. The result? The savings melted away, and after several years of declining costs, premiums and costs for managed care are on the rise–at about the same rate as health care costs across the board.

 ♦ More regulations and harsher penalties for their violation: So here’s the plan: Medicare costing taxpayers tons of money, having covered all those eligible regardless of ability to afford care and opened the entitlement floodgates? Time to micromanage where all that money goes. Create highly complex rules about what services can be provided, under what circumstances, and then change them constantly based not on medical need or progress but simply to stem high cost areas. Make the rules so complex no one can understand them–then go after the bastards who are “cheating” the system by violating the rules. Well, fear works–up to a point. Most doctors will try to ignore the rules and simply code at lower service levels to minimize their risks and the time needed to master the maze; others will buckle down and try to master them. Then, when even this doesn’t work to stem costs, it’s time to lower reimbursement levels. Eventually, this brilliant plan–increasing the costs of providing care while paying less–will result in payments which fall below the costs of providing the care–and doctors either have to game the system to stay afloat, or stop seeing federally-insured patients. The end result: more “fraud”–and rapidly shrinking health care access for covered patients (the elderly, disabled and the poor). Brilliant theory, Einstein. Got any more like that?

 ♦ Paying for quality: This is one of the latest gimmicks the health care policy wonks have dreamed up, more commonly known as pay for performance. It’s based on the (highly disputable) notion that bad doctors are running up the cost of care by ordering unnecessary tests, recommending unneeded procedures and surgery, practicing costly medicine which lies outside the mainstream–renegades all, ransacking the health care treasury. The good guys in the white hats, on the other hand, walk carefully between the lines, following established standards of care, don’t cost the system nearly as much–and should be rewarded with better reimbursements.

Ten solid seconds of thought by anyone with an IQ over 50 should see problems with this idea. A superbly-trained physician saving the life of a desperately ill patient, on a ventilator in an ICU, will be spending a whole pile of money–whereas ol’ Doctor Feelgood, passing out antibiotics for your sniffles and pain pills like candy may not be spending many health care dollars at all. High quality — while not invariably more expensive–is often so. And what about those guidelines? Well, one problem is, by and large, they don’t exist — except in a few relatively straightforward areas of medicine. The reason, in no small part, is that quality medical care is a complex and constantly moving target: what was excellent care ten years ago may be marginal or even poor care today. Once you ossify guidelines into regulations governing payment, you run a great risk of freezing health care advancement. You will be paid for care meeting the guidelines–but not for better care, based on advances in medical knowledge and technology, which will tend to fall outside the guidelines. And any physician who thinks they’ll get paid more for following the guidelines needs a long session on Dr. Sanity’s couch: they will pay those physicians not meeting the guidelines a lot less, and the “good guys” better than them — but still less.

I could continue, but enough of bad ideas. More of the same is not the answer to our health care system. In my next post I hope to lay out a few ideas which are based, I believe, more solidly on reducing complexity and aligning our health care more solidly along the lines of simplicity, accountability, and transparency. Stay tuned, back soon.

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3 thoughts on “The Maze – Part 7
Is There an Exit? – I

  1. I have no answers, but some thoughts:

    1. Demand for health care is in fact elastic–as the cost to the individual buyer goes down, the demand goes up. Shifting the cost to the gummit or the employer-paid insurer thus increases the demand.

    2. There will never be enough resources to provide all the health care people might want, especially if third parties pay for it. It follows that the consumption of health care must somehow be limited. The labyrinth you describe is composed of various not-very-good ways of rationing health care.

    3. One kind of solution might be to return some health decision-making to the individual, for example by increasing deductibles. If we do that, though, we would be admitting that differences in income and wealth affect access to health care. Because the language of “rights” has been applied to health care (even though “rights” to benefits are categorically different from “rights” that are restrictions on the power of gummint), I suspect that any approach that included such an implied admission would run up against strong political opposition.

    I await Dr. Bob’s ideas with bated breath. Meanwhile, our health care system will continue to live by lies.

  2. The problem here, Doc, is a that a different perspective is required to understand the system. Try this one:
    ‘This entire country belongs to the insurance companies, and as long as we agree to keep paying them, and don’t break anything that they want to keep, they’ll let us continue.’

  3. The maze today seems to be indestructible. As much as I detest govermental control, the US need some form of health care for all. Sounds wonderful – but seems impossible. The closest approach appeared to me to be a variant of the “Oregon Plan”. Dr. K, a ER physician I chatted with gave a brilliant lecture at a Calfornia Medical Association meeting and who later became governor of Oregon.
    His basic concept was simple: there will never beenoughphysicians to trea all ills and there will never be enough money availoable to pay for all medical services chosen. The answer? Human value. Is a “cabbage” for an 80 year old worth the same as a pre-term baby? No physician would ever wish to answer that – but if money is avalable for only on option, a decision is required and it’s a tough one. But presume simpler choices, say should government pay for cervical cancer protection by a new vaccine or should it go for further research in lung cancer?
    This is far from a simple answer, but it may be the closest to what we may have to offer.

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