Medicine

Revolt of the Poster Boys

Dr Bob

And the hits just keep on comin’ from our enlightened masters in government-run health care:

‘Poster Boys’ Take A Pass On Pioneer ACO Program:

During the health care debate, the Mayo Clinic, the Cleveland Clinic, Geisinger Health System and Intermountain Healthcare were repeatedly touted as models for a new health care delivery system.

Now, they have something else in common: All four have declined to apply for the “Pioneer” program tailor-made by the Obama administration to reward such organizations.

“When the poster boys ask that the posters be taken down, you have a problem,” says Michael Millenson, president of Health Quality Advisors LLC…

The four health systems are considered the most promising models for “accountable care organizations,” a new approach to delivering health care services that rewards doctors and hospitals for providing high-quality care to Medicare beneficiaries while keeping costs down. The ACO provision became one of the most highly anticipated elements of the health care overhaul, and providers embarked on a frenzied race to join in as quickly as possible.

But when the proposed regulation for the program was announced in March, excitement fizzled.

Hospital and doctor groups complained that the program created more financial risks than rewards and imposed onerous reporting requirements. The American Medical Group Association, which represents nearly 400 large provider organizations, responded with a letter to CMS warning that more than 90 percent of its members would not participate because of the reporting requirements and financial disincentives. In particular, the proposed rule would impose penalties for ACOs that do not achieve savings.

In response, HHS announced the Pioneer program in May, promising it would “provide a faster path for mature ACOs” like the Mayo Clinic that would allow the high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk. HHS estimated that the Pioneer program could save Medicare as much as $430 million over three years.

The big boys in health care were so impressed by the latest-and-greatest rendition of Obamacare’s hot new ACO “reform” (which is little different than the disastrous capitated HMO model which went down in flames not so very long ago) that they responded, “Thanks, but no thanks.”

No doubt a new rendition of ACOs will be forthcoming soon, complete with a host of new regulations, onerous reporting requirements, and penalties for care which does not meet “quality” (AKA, low-cost) standards set by the government. After all, who knows more about “quality” than our sharp-witted wizards in Washington? Be afraid — be very afraid…

Centralized funding and control of health care is beyond disastrous. It is paving the road to national bankruptcy. The answer to this monstrous failure is, as always, more control, more regulations, more centralization. Sadly, like a runaway train, it hurtles down the tracks toward an inevitable trainwreck.

Let’s just hope and pray that there will be some salvageable pieces left when it all jumps the tracks. Physicians who have wedded themselves to hospital-based and other large ACO-aligned medical groups for security will find themselves among the wreckage.

The only hope for physicians in the long run is to move outside the current system of third-party payers and decentralizing toward a cash-based practice. The inevitable outcome of the coming disaster in health care (and no, our politicians won’t prevent it) is severe rationing of care, long waits for doctors visits, diagnostic studies, and surgery. For patients, catastrophic coverage (if you can get it) with HSAs will ultimately prove the safest and most reliable way to get access to health care.

Welcome to health care in the millennium.

Is There an ACO in Your Future?

Dr Bob

As individuals and small groups, physicians have proved to be an independent lot — “herding cats” a common metaphor for getting the profession to toe the line, even on matters beneficial to them. Once they have been herded under one roof, however, the job of controlling and coercing them becomes far easier.

Ever hear the term “ACO”? No? Better get familiar with it, because this is your future.

Accountable Care Organizations are the government’s new carrot & stick to control costs and micromanage the health care profession and industry. Those of you who’ve been around a while may remember HMOs — the insurance industry’s innovation in the late 80’s to get control of spiraling health care costs. Using a mechanism called capitation, the HMO would pay a lump sum to physicians and groups to manage “patient lives.” The theory — which worked, unfortunately — was to flip the incentives: rather than “reward” physicians for providing medical services and ordering tests and procedures, remunerate them instead for doing less: the less care provided, the more money the physicians got to keep.

Can you say, “moral hazard”, boys and girls?

It worked–all too well. Primary care physicians became “gatekeepers” whose job it was to make sure no “unnecessary” care was given. Need to see a specialist? No can do. CT scan? Unnecessary, don’t you know. Every time the doctor said “no”, their wallet got a bit fatter. It cut costs dramatically when introduced. Of course, patients got sicker; cancers took longer to diagnose and treat; needed diagnostic and necessary but expensive treatments were deferred or not done at all. While some unnecessary and redundant care did get eliminated, the overall effect was disastrous. Since the HMO’s bore significant financial risks, it became a fine art to “manage” those risks, to wit: you had to make sure that the “patient lives” you contractually managed were not very sick, lest you break the bank taking care of medical disasters, poorly-compliant patients (typically the poor), and the elderly. The system imploded when patients revolted, followed shortly thereafter by politicians (who had been prime movers behind the HMO juggernaut) demonizing the monster they themselves had created. No worries: they now had a new straw man to attack, the “evil insurance companies” of their own design; this ogre lives on to this day.

They say that insanity is repeatedly doing the same thing, while expecting different results each time: enter ACOs.

So what are ACOs?

Like most bad ideas, the concept originated in the think tanks of academia, where “health care experts” who never take care of patients dream up idyllic solutions to problems they don’t understand. ACOs are defined as follows:

ACOs can generally be defined as a local entity and a related set of providers, including at least primary care physicians, specialists, and hospitals, that can be held accountable for the cost and quality of care delivered to a defined subset of traditional Medicare program beneficiaries or other defined populations, such as commercial health plan subscribers. The primary ways the entity would be held accountable for its performance are through changes in traditional Medicare provider payment featuring financial rewards for good performance based on comprehensive quality and spending measurement and monitoring. Public reporting of cost and quality information to affect public perception of an ACO’s worth is another way of holding the ACO accountable for its performance.

ACOs have three main characteristics:

  1. The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care;
  2. The capability of prospectively planning budgets and resource needs;
  3. Sufficient size to support comprehensive, valid, and reliable performance measurement.

In English, for those fortunate souls unschooled in the lingo of academic health care policy , this means a health care organization, comprised of hospitals (with their associated services, such as radiology, operating rooms, inpatient beds, physical therapy, etc., etc.), doctors and other health professionals (e.g., PAs and nurse practitioners), all centrally managed with an eye toward controlling costs and those who generate those costs (see “providers”, above), large enough to generate meaningful statistics on costs and health care “outcomes”, reportable back to Medicare and Big Insurance for their “review.”

The benefits to providers of aligning with such a cumbersome, micromanaged, top-heavy beast? You got it: the lure of filthy lucre:

In exchange for investing in this reformed health care provider structure, the ACO members will share in the savings that results from their cooperation and coordination. Thus, ACOs can–theoretically–act as a reform tool by incentivizing more efficient and effective care. This would help to combat the current perverse incentives of overutilization and overbuilding of health care facilities and technology.

So what could possibly go wrong with this model?

[The ACO model] was built on what is (to my consulting colleagues, anyway) a stunningly obvious discovery: Medicare spending for physician services tends to cluster around hospital service areas.

The policy leap that led to the ACO idea was that since these “communities” already use hospitals, let’s assume that they and their hospitals are actually “virtual organizations” and give them a global budget. Consumers would not be aware that they were being treated by ACOs. Rather, they would be “attributed” to them: virtual patients of virtual organizations. Aggregate health spending for attributed patients would be tracked, and increases in that spending would be capped using a form of “shadow capitation.” ACOs that lived within the caps would get their fees increased. Those that overspent would see their fees reduced or frozen.

Some policy types on the Medicare Payment Advisory Commission (MedPAC) became intrigued with the ACO idea and saw it as a solution to the Sustainable Growth Rate (SGR) problem, a durable policy headache bequeathed by Congress to physicians in the Balanced Budget Act

The SGR cuts payments to physicians when health care costs rise, nominally maintaing “budget neutrality”, and has been routinely overridden by Congress because of real concerns over restricting access to medicare patients.

If a national SGR didn’t work to constrain physician behavior, why not create a hospital service area–specific SGR?

Fisher and colleagues theorize that when you cap the total resources coming into a specific “community,” hospitals and physicians would form organizations to accept and manage the global payments. This would create an economically motivated community lobby for not building more hospital beds, not recruiting additional cardiologists, not putting CT scanners in physician offices. Little delegations from the ACO would visit the high utilizers and work with them to get them to give up their diagnostic equipment and reduce their incomes. (As Dave Barry would say, “I am not making this up.”)

The problem with this movie is that we’ve actually seen it before, and it was a colossal and expensive failure. During the 1990s, many hospitals and physicians believed that the Clinton health reforms would force them into capitated contracts with health plans. This catalyzed a flurry of mergers and physician practice acquisitions, all motivated by a desire to control the stream of payments from health plans, rather than being subcontractors to those who did. Many system builders assumed that they would increase their market share through selective contracting at the expense of docs and hospitals that remained unorganized.

Risk-bearing physician/hospital organizations and hospital-sponsored preferred provider organizations (PPOs) sprang up all over the country. They typically paid their docs a discounted fee based on prevailing rates in the community … in anticipation of capitated health plan payments. Some of these hospital/physician efforts actually succeeded …

However, these were outliers in an expensive failure. Employers and patients preferred open panels managed by health insurers to closed panels managed by providers. Billions of dollars were lost. After rivers of red ink, most bold 1990s hospital risk-sharing experiments were terminated, along with the CEOs and physician leaders who created them. Many of the practice acquisitions were reversed, as hospital systems sought to rein in their expenses and adjust to an open-panel world dominated by point-of-service style health plans.

Why did they fail?

The State of Massachusetts seems headed toward imposing an all-payer mandatory, communitywide ACO model for cost containment purposes. There is time to reconsider what I think is a reckless decision. … the Massachusetts ACO experiment is likely to be a gory and comprehensive failure. Virtual assignment of patients, virtual organizations, “shadow capitation” superimposed on fee-for-service based economically independent docs, further consolidation of local hospital monopolies: we really ought to know better….

The sad reality is that most hospitals, even the well-managed ones, simply lack the tools, leadership, and leverage to enable them to bear and manage global risk. Many will not possess them in a decade. The mandatory ACO (apparently still a live option in the June 2009 MedPAC report) is one of the worst health system reform ideas since the Health Systems Agency. Fisher and his colleagues are attempting to broaden the idea to encompass independent practice associations (IPAs), existing multispecialty groups, even academic health centers. But the core idea remains that physician communities and hospitals in defined geographies are viable economic units. They are not.

The elephant in the room — never addressed in this grand schema to control costs — is the medical liability monster. Huge amounts of medical services and costs are driven by defensive medicine. ACOs will provide no protection to their physicians as they drive down costs by haranguing them while denying services, diagnostic tests, and procedures based on cost, thinly disguised as “quality.” Every physician hears the voice of an attorney when he decides to order a medical test, which may be of marginal benefit to the patient: “Doctor, didn’t you realize that by ordering a CT scan, Mrs. Jones’ cancer could have been diagnosed earlier, and cured?” The defense that “My ACO told me it was unnecessary and expensive” will be no defense at all: “And when you refused to order that scan, Doctor, you stood to make more money, didn’t you?” Devastating–and inevitable.

But the bottom line is that medical decision-making will become further removed from the patient and his physician, decisions now moved to faceless bureaucrats with Excel spreadsheets and no medical degree. Once again, the “experts” will win — and you will lose.

Be afraid — be very afraid.

Almost Cut My Hair…

Dr Bob

Almost cut my hair,
Happened just the other day.
It was gettin’ kinda long,
Could’ve said it was in my way.

But I didn’t and I wonder why,
I feel like letting my freak flag fly,
And I feel like I owe it to someone…

I’m suffering from whiplash — perhaps I should call one of those attorneys whose ads I see at bus stops and on the back of grocery carts…

In a recent post, I waxed euphoric about a big transition in my professional life, wherein I would move from being a solo practitioner to a hospital group employee, working predominantly in an inpatient capacity, with a much reduced load of office paperwork and business responsibilities, with the expectation of significantly more free time. I was truly excited about these possibilities, and felt great relief at the promise of unloading the crushing burden of paperwork, compliance with endless government regulatory demands, intrusive and abusive audits, and a host of other ugly and unpleasant parasites which suck all the life out of the profession of medicine.

More pay, less work — what’s not to like?

That was yesterday. And this is today: I have decided not to pursue this course — or perhaps, more accurately, this is not the course chosen for me to pursue.

The decision is, in a way, rather shocking, a wrenching change of direction for which I was wholly unprepared, and which is still deeply unsettling. I feel in some ways like the shipwreck sailor, watching a passing ship — recently his only hope of salvation — sail slowly into the distance, as he floats, unseen and unsaved. At yet there is a certainty that this sudden change of course is the correct one — though I’m quite in the dark about what comes next.

So what changed?

Nothing whatsoever about my current situation: private solo practice, as it is now configured, has become an enormous burden in so many ways. It’s ugly — and getting uglier in a hurry.

Much of the non-medical world seems dimly aware, if at all, of the tectonic changes occurring in health care. Patients are beginning to notice that their doctor’s practice name has changed to something like “Big Hospital Medical Associates”, but otherwise see little change: they can still see their doctor, the staff is, by and large, the same familiar faces, no worries, carry on.

Behind the scenes, however, the changes are enormous. As of 2009, 65 percent of established doctors were in hospital-owned practices. That percentage is growing rapidly, as physicians and other providers, such as nurse practitioners, flock to the perceived safety and security of large groups and hospital-owned practice affiliations.

The attraction is undeniable: offloading the burden of burgeoning administrative and regulatory requirements; attractive first year salaries and sign-on bonuses, combined with the promise of more free time and predictable schedules; and the lure of better reimbursement for services due to a large organization’s greater heft in negotiating contracts with insurance companies. It’s easy to overlook the potential downsides when the eye candy is so attractive.

After much happy talk and eagerness from the hospital recruiters and medical administrators, the process of merging my practice with the hospital group moved like continental drift. Months passed with no action; emails and phone calls were answered slowly, if at all. My frustration was enormous, but the delay proved a blessing in disguise.

The bad news trickled in slowly, as I waited, impatiently. A large local hospital group announced layoffs of nearly 400 people, for starters — no administrators or middle managers, of course: only the clerical and support staff that keeps a practice running. A busy surgical practice with an incompetent scheduler could not fire her (her race guaranteed a discrimination lawsuit), so they simply eliminated her position — and now they have no permanent scheduler for a year. Other schedulers were moved offsite, far removed from the physicians and practices whose lives they controlled. A former associate, a true workaholic who routinely saw 50-60 patients a day, had his salary cut because he wasn’t productive enough(!!). Highly-trained support staff were told they could not perform certain procedures because the hospital legal department decided their license did not permit them to perform them — although the procedures themselves were not restricted under their state licensing privileges, and they were far more highly skilled and experienced at these procedures than those “credentialed” to do them.

Big picture insights also came into play:

Hospitals lose $150,000 to $250,000 per year over the first 3 years of employing a physician — owing in part to a slow ramp-up period as physicians establish themselves or transition their practices and adapt to management changes. The losses decrease by approximately 50% after 3 years but do persist thereafter. New primary care physicians (PCPs) contribute nearly $150,000 less to hospitals than their more-established counterparts; among specialists, the difference is $200,000. For hospitals to break even, newly hired PCPs must generate at least 30% more visits, and new specialists 25% more referrals, than they do at the outset.

Chained to the oar, the galley master pounding out the cadence…

After 3 years, hospitals expect to begin making money on employed physicians when they account for the value of all care, tests, and referrals. … Outpatient office practices of employed physicians seldom turn a profit for hospitals.

Interesting — most private outpatient office practices are profitable, although less and less so.

Hospitals are willing to take a loss employing PCPs in order to influence the flow of referrals to specialists who use their facilities. In the 1990s, hospitals usually guaranteed physicians nearly 100% of their previous year’s salary during their transition to hospital employment. This arrangement invariably led to losses, since drops in productivity were coupled with higher overhead expenses and less-effective revenue-cycle management. Today, aggressive hiring of PCPs is returning, in part because hospitals fear physicians’ becoming competitors by aggregating into larger integrated groups that direct referrals and utilization to their own advantage. Hospital-employed PCPs generally direct patients to their own hospitals and specialists affiliated with them. In addition, by employing physicians, hospitals retain maximum flexibility in the market, should health plans change their reimbursement structures to require providers to bear risk and manage population health…

Though hospital employment may offer physicians some protection from system reforms, it comes with more performance management than it once did, and the option of reverting to independent practice later may be far less attractive in the future. Employment choices that physicians make today may not be able to be undone.

The hospitals hope to make up for their physician employment losses by improvements in productivity and “performance management” [read: controlling physicians’ decision-making based not on quality, but on cost]. That these economic “efficiencies” are largely illusory — and will harm patient care — will become evident in time. This scenario played itself out in the early 90’s, when hospitals bought up practices in anticipation of Clinton Care. They proved financially untenable and ultimately imploded, after massive cuts in support staff and physician salaries made continued hospital group affiliation untenable. The enormous economic pressures soon forthcoming through ObamaCare and ACOs (more on these anon) will invariably result in similar scenarios — with far fewer escape hatches for increasingly unhappy physicians. They will be locked down by highly restrictive regulation and “care standards”; locked in by non-compete clauses and the insurmountable hurdles to starting or returning to practice; and locked out completely of the decision-making processes which control their lives and their profession. Expect a tsunami of early retirements and career changes when this is fully implemented.

And in the unlikely event the hospitals succeed economically at this venture, through the will to power, you may be assured that the vultures will soon descend to strip the pink flesh off their bones:

The consolidation wave [hospitals acquiring practices] is raising red flags among some regulators, researchers and health insurers, who warn that bigger health systems can use their leverage to push for higher rates. “We’ve always been concerned about combinations that are being done to increase prices,” said Karen Ignagni, chief executive of America’s Health Insurance Plans.

These factors made for a long and poignant pause in my rush to employment. But the final straw proved to be the realization that my reconstructive infertility specialization, built laboriously over 30 years with much hands-on care and effort, would die on the vine under hospital management. I would lose control over pricing; lose control over my superb supportive employees who are masters at communicating with patients an the many issues involved in these cases; and lose the freedom to provide discounted and charity care when the Spirit leads.

So my “Dear John” letter went out, two weeks ago. My employees were ecstatic at the news, my wife enormously supportive of the decision (she had previously been a major force prompting me to seek the security of hospital employment, and has now done a complete 180), and I have an enormous peace with the decision in my own soul. Perhaps, like Odysseus, I have been tied to the mast, lest the Sirens lure me onto the rocks of disaster.

Of course, the problems of sustaining and surviving in the hostile environment we now inhabit in health care remains; thus it becomes now a journey of faith.

Ah, faith: not the blind confidence in the unbelievable, but trust in the eminently Trustworthy, without the clarity of vision one might wish, but with the vision of hope based on experience. He has never let me down; He will not do so now.

It should be a most exciting journey.

Well, Isn’t THAT Special…

Dr Bob

Church LadyWell, now, isn’t that special…

Forbes reports on a new investment vehicle, tailor-made for the get-rich-quick crowd:

Playing The Odds: Hedge Funds Finance Medical Malpractice Claims:

An entirely new industry has cropped up in recent years as trial lawyers set their sights on making money off physicians, corporations and other targets–particularly financing malpractice suits through hedge funds. In 2010, hedge funds invested $1 billion in these types of suits, much of it for medical malpractice cases…

… the rewards can be remarkable for investors, which is why dollars are flowing into these hedge funds. Payouts can result in tens of millions of dollars.

George Soros, call your office…

Having milked all the money they can from sub-prime mortgages, derivatives, credit default swaps, and political largess from wholly-owned and operated politicians, and after causing a depression or two, our financial wizards now turn their attention to where the real money is: suing doctors. Gotta love it. Ya think, maybe, just maybe, our tort system is a little out of control?

In days gone past — when there was hope about changing such things — I would have launched into a diatribe about the need for reigning in the lawyers, tort reform, etc. etc. Perhaps age, experience, and a touch of wisdom have led me to see the futility of such righteous indignation. Simply put: the system is never going to change. Sadly, we are locked in: the consequences of our current tort system is carved in stone, and they will be both inevitable — and ugly.

The system will never change because the system is the problem: most politicians are lawyers, and lawyers pour ungodly amount of money into the politicians’ pockets — the Democratic Party is a wholly-owned subsidiary of the Trial Lawyers Association (90 percent of its $30.7 million in contributions since 1989 went to Democrats). The AMA — purportedly representing physicians — is now a political, socialist animal, having embraced the dark side themselves, making hundreds of millions selling the diagnosis and procedure codes to physicians required to be (under)paid by the Feds and big insurance.

Tort reform? Fuggeddaboutit. When it has been passed at the state level, it has been gutted by the courts (need I mention that judges are lawyers, too?). And tort reform will do nothing to change the enormous cost increases brought about by defensive medicine — at best it may moderate malpractice insurance premiums, when it survives the courts, which it rarely does.

So what’s the inevitable consequence of this disastrous medicolegal monster? Access, my friend, access — as in: none:

Frivolous lawsuits are helping drive physicians out of the profession and pushing up the cost of health care. A Gallup-Jackson health care survey released last year found that $1 in every $4 spent in health care is for unnecessary tests and procedures that doctors order to prevent from being sued.

As 32 million new patients acquire health insurance under ObamaCare and the number of Medicare recipients doubles over the next decade, the physician shortage will be worse than ever. Hedge funds that target doctors will not only make health care more expensive, but they will make a doctor very hard to find.

The parasite has grown fat and happy sucking blood from its host — but at some point the host weakens and dies. Best pick his pocket now, while the gettin’ is good. His days are numbered.

Stay healthy, folks — the doctor will likely not be around when you need him. Maybe you can call your lawyer instead — or your friendly hedge fund manager.

Still Breathing…

Dr Bob

Word of my demise, widespread and nefarious as it has been, is most assuredly premature. I must put these scurrilous rumors to rest…

But life has been, well, most interesting…

The past year or so has been one of the most challenging in many a season, on a number of fronts. Professionally, the passage of Obamacare has made it abundantly clear that the independent private practitioner is a dying breed, and likely will disappear — with the exception of cash-only, concierge-style arrangements — within the next few years. The administrative burden is crushing — unfunded mandates, such as pay-for-performance, compliance programs, HIPAA, mandated “government certified” EMRs (even though existing, non-certified ones are fully functional), and intrusive, abusive audits by the Feds and third party carriers. Such mandates and regulatory excesses place, or will soon place, such an overwhelming burden on the solo physician or small group as to make their continued existence unsustainable, even in the near term — and the full implementation of Obamacare will put roses on their grave. Reimbursements are dropping precipitously (my income dropped about 25% last year), as expenses spiral upward (employee health insurance rates are up 25%; malpractice rates up 15%, etc., etc.). The small business model of solo practice or small medical group is rapidly becoming extinct: its executioner, Big Government and Big Insurance.

The medical-legal environment remains as hostile and capricious as ever — I have endured two lawsuits in the past three years, both resolved with decidedly mixed outcomes while taking an enormous toll both in time wasted and emotional sobriety. I hope to share some insights thus gleaned on this horrendously dysfunctional system in the not-too-distant future.

Personally, although my health remains good, the exhaustion borne of these and other struggles had taken much of the joy and energy from life. The time for renewal was long overdue.

And so, big changes are in store: my practice will be sold in the next few months to a large medical group affiliated with a nearby hospital, and I will have as a primary responsibility inpatient hospital care, with a much diminished office practice focusing primarily on my specialty of male infertility and vasectomy reversal. I have decidedly mixed feelings about this change — I anticipated going to my deathbed as a private, solo practitioner, loving the independence and rich patient relationships which this brings.

But I am weary. After nearly 30 years in private practice, I am not sure which straw broke the camel’s back, but it is most surely broken. It is a weariness born of 14 hour days; of dictating charts and finishing paperwork until 8 or 9 pm each night, after starting the day at 7 am; of endless audits by the insurance industry and Medicare; of the constant threat of litigation; of the crushing burden of one more federal requirement mandated but never recompensed; of a host of ever-expanding administrative burdens having nothing to do with patient care, and everything to do with bureaucratic micromanagement of the profession. And this before we have even begun to see the nightmare which Obamacare will inflict. Camels weren’t designed to carry such a load.

But the change is nevertheless much anticipated in a host of other ways, with its reduced administrative and regulatory burdens, and substantial increase in free time. For me, the war is over: I have fought the good fight, and no longer see it as profitable to battle the inexorable forces which threaten to crush a beloved profession. My spirit is in many ways free now, as though a great burden has been lifted. God is good, and has been gracious and kind to me in so many ways.

I have needed an extended break from blogging to process these many life changes, but in its absence have heard the siren call of the muse quietly whispering to my soul.

So I am back — bitterly clinging to God, guns and guitars — and hope to speak of each in their turn, among others, as the spirit moves. For those who have checked back regularly, only find a petrifying post from the past, you have my great gratitude for your loyalty. I hope to reward that loyalty with something of worth in the coming days.

The Doctor Will See You Now – Or Else!

Dr Bob

 
It has been clear since the passage of Obamacare, with its ludicrous economic projections and Enron-accurate accounting, that the outcome of this gargantuan medical gewgaw will be enormous shortfalls in funding for healthcare. The long-term consequences of its financial chicanery are legion, from spiraling deficits, to drastic cutbacks in funding to hospitals and health care providers , to the hyperbolically-described “death panels”: restrictions in payment for health care services as determined by faceless bureaucrats, based on cost considerations masquerading under the paper-thin guise of “medical consensus.”

One of the most disastrous aspects of this plan, both economically and practically, has been the decision to provide coverage for the low-income uninsured by rolling them into Medicaid, the joint federal and state health insurance program for the poor. Medicaid in virtually every state has been an economic disaster, leading to massive state budgetary deficits, and reimbursements to physicians and other health providers substantially below the costs of providing services. This has resulted in the inevitable migration of physicians out of Medicaid, and increasingly from Medicare as well, as Medicare treads the same path of massive bureaucratic burdens on providers and sharply declining reimbursements. The end result has been a crisis of access, where covered patients under these federal programs are increasingly unable to find physicians who will see them. The massive expansion of beneficiaries in Medicaid will drastically worsen this access problem, leaving many, if not most, of the newly covered without health care.

In a classic statist response to this inevitable and impending crisis, our aristocratic masters have discovered, anew, the joys of coercion and intimidation in solving another of their self-engendered debacles:

Justice Department declares war on doctors

Today the Antitrust Division, joined by Idaho Attorney General … forced a a group of Boise orthopedists to accept price controls for worker’s compensation and HMO contracts as part of a settlement accusing the doctors of “price fixing.” According to the complaint, the conspiring orthopedists engaged in two antitrust conspiracies, which took place from 2006 to 2008. In the first conspiracy, through a series of meetings and other communications, the orthopedists agreed not to treat most patients covered by workers’ compensation insurance.

They entered into a group boycott in order to force the Idaho Industrial Commission to increase the rates at which orthopedists were paid for treating injured workers. The Idaho Industrial Commission sets the fee schedule that determines the amount that orthopedists and other healthcare providers receive for treating patients covered by workers’ compensation insurance. The boycott resulted in a shortage of orthopedists willing to treat workers’ compensation patients…

In the second conspiracy, all of the defendants … and other conspiring orthopedists agreed to threaten to terminate their contracts with Blue Cross of Idaho. They jointly threatened to terminate their contracts to force Blue Cross of Idaho to offer better contract terms to orthopedists.

The proposed settlement prevents the Idaho Orthopedic Society and the named orthopedists from agreeing with their competitors on fees and contract terms. The settlement also prohibits them from collectively denying medical care to patients, refusing to deal with any payer or threatening to terminate contracts with any payer.

To say this action is chilling is a profound understatement: the implications of this settlement are nothing less than the erosion and ultimate destruction of our current system of providing health care in this country.

At first glance, this appears to be a legitimate attack on a price-fixing scheme by physicians to increase their income. The reality is far more sinister.

The Justice Department, in cooperation with the Idaho State Attorney General, brought suit against the physicians under the Sherman Antitrust Act. Passed in 1890, it was designed to prevent collusion by Standard Oil and other oil companies to raise prices by creating monopolies or cartels. The Act and its application has been controversial since day one, and it has morphed over the years to address real or perceived commercial malfeasance far removed from its original intent.

The case against the physicians in Idaho represents a tectonic shift in the way government deals with the physicians they pay. As the Mises Economics blog points out:

This case is a watershed for two reasons: First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense. Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system … This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This leaves little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.

Please read the whole article, in particular the update at the end. This settlement is nothing short of stunning.

Has the nickel dropped yet?

Virtually all health care provided in this country is contractual, whether by the Federal Government or third party private insurers. The consolidation of the insurance industry and the growth of government-funded health care — which Obamacare vastly expands — means that, with the exception of certain cash-based niches such as cosmetic surgery and Lasik procedures, physicians are legally obligated to accept the contractual fee for any covered service. The cartel in health care lies not with the physicians — who remain loosely organized if at all and prohibited (rightly and ethically so, in many ways) from unionization — but with the government and the insurance industry. The insurance industry closely tracks federal actions, both in regulation and fees — and hence both private insurance and the Federal Government collude in very real ways to fix physician fees.

In most areas of the country, a small number of major national insurance carriers insure the vast majority of patients not covered under Federal programs — thus leaving physicians largely powerless to refuse the increasingly austere payments these plans offer, lest they find themselves without patients. Thus the government and private insurance carriers are free to ratchet fees downward to the point where there can no no longer be economic viability for physicians. This is exactly the scenario under which the Idaho orthopedists declined to see patients — very reluctantly — who were covered under workman’s compensation, and threatened to withdraw en mass from their Blue Cross of Idaho contracts. They quite simply had no other leverage against the government/insurance cartel.

Now they have none.

It is important to realize that under antitrust law, there does not need to be a formal agreement or conspiracy to “fix prices” — collusion can be inferred by the behavior of competitors, to wit: if enough physicians in an area decline to see, say, Medicaid patients, because of unsustainably low fees, the Justice Department may infer that they are colluding to fix prices, and move against them with an antitrust action.

Checkmate.

It should not be difficult to see the inevitable outcome of this coercive economic thuggery. Physicians will inevitably be forced into large organizational relationships — primarily hospital-based (toward which there is a virtual stampede from private practice over the past 2 years) for economic security. But this financial haven will prove short-lived, as the endless financial pressures of burgeoning health care costs and spiraling federal and state deficits will drive many physicians from practice altogether as burdensome regulation and plummeting incomes ultimately drive the best and the brightest to find employment elsewhere. There will then be no doctor to see you — coerced or not — and the answer, as always the case in such government-engendered crises — must be a government solution: government-employed physicians. Hello, National Health Service.

Hyperventilatory, catastrophizing rhetoric? Right-wing extremist fear-mongering? Hysterical overreaction to loss of income? No, none of the above. Mark my words, we are witnessing the disassembly of the American system of medicine — a system which, for its many flaws, has provided the best and most advanced health care the world has ever known. For some, its destruction will be a victory, flush with the naive Utopian vision of universal, government-controlled health care.

For you, the patient, the outcome will prove far less sanguine.

In the Doldrums

Dr Bob

Down dropt the breeze, the sails dropt down,
‘Twas sad as sad could be ;
And we did speak only to break
The silence of the sea !

All in a hot and copper sky,
The bloody Sun, at noon,
Right up above the mast did stand,
No bigger than the Moon.

Day after day, day after day,
We stuck, nor breath nor motion ;
As idle as a painted ship
Upon a painted ocean…

Her lips were red, her looks were free,
Her locks were yellow as gold :
Her skin was as white as leprosy,
The Night-mare LIFE-IN-DEATH was she,
Who thicks man’s blood with cold.

The doldrums.

Samuel Taylor Coleridge, in his epic poem Rime of the Ancient Mariner, depicts the dread of all ancient sailors: becalmed, abandoned by nature and fate, powerless to move forward and at the mercy of vast forces and spirits beyond their control.

In some measure, these have been days much like that. The past few months have been some of the most difficult of my professional career. There has been a sense of fatigue, of purposelessness, of weariness with the routine and the rush, the frustrations and failures inevitable in any life pursuit, but perhaps nowhere more so than in the practice of medicine.

It is a high calling, this profession — words which, while true, seem fatuous and hackneyed in an age marked by hard science and even harder cynicism. It is a vocation fraught with paradoxes and contradictions: compassion and cold steel; empathy and enervation; arrogance and humiliation; deep satisfaction and bone-wrenching sadness. Its rewards, while rich, seemingly come at the cost of your very life, as the slow extravasation from countless battle wounds weaken the spirit and shock the soul, sapping your strength, leaving but an empty, fractured vessel, gloriously engraved on the outside but pervious and parched within.

It is no one thing, this weariness, but a score.

It is the two hours spent filling out a mandatory online recredentialing form for an insurance company, insisting on intrusive and irrelevant information (“What is the mailing address and contact phone number of your high school (required)?”) so that their marketing department can claim they only use the “finest” physicians.

It is the three hours spent dictating charts after a 10-hour office, missing no detail that might lead to an insurance denial, a government audit, or a later lawsuit — and knowing you will be back before sunrise to finish those charts you no longer have the mental or physical energy to complete.

It is the mandate to comply with the endless and every-engulfing tsunami of government compliance regulations, demanding coding quality assurance, privacy protection, identity fraud, or pay-for-performance “programs” which would overwhelm entire QA departments at Lockheed-Martin or Raytheon, but which you are expected to implement, by yourself, for free, in your spare time.

It is the countless hats you wear every day: employer; small business owner; conflict resolution manager; IT consultant; accountant; complaint department clerk; therapist; social worker.

It is the garrulous patient who talks endlessly but never answers your questions, while you run ninety minutes behind schedule; the sullen patient who refuses to fill out your history form or answer your questions, demanding you “get that information from my other doctors”; the demented patient from the nursing home with no records, accompanied by an aide who knows nothing about her or why she is here; the angry patient who blames you for their disease, refuses to follow your advice, and who is certain that you are only seeing his sorry ass to make a buck off him; the uninsured patient who needs major surgery or expensive medications but has no way to afford it.

It is the patient in intractable severe pain, incurable by every means modern medicine has to offer, who sits weeping before you, her shriveled life constricted to never leaving her home or getting out of bed, who begs you for answers you do not have. It is the insurance company who refuses her next treatment because it does not meet their “treatment guidelines.” It is the state regulators who harass and threaten you as you manage her severe pain with carefully-managed, medically appropriate chronic opiates while they perceive you as an addict-enabling criminal.

It is the perfectly-performed surgery with a disastrous outcome; the excellent outcome that leaves a bitter patient because it did not meet their wildly-unrealistic expectations — which you told them it would not and could not meet; the out-of-town and out-of-touch daughter who demands everything be done for her dying father’s terminal cancer to assuage her guilt, hating you almost as much as she hated him.

Add to these the seemingly-daily debacles the freakonomics of health care in the new millennium: overhead costs spiraling at multiples of the inflation rate, as income dives inversely; ever larger numbers of legitimate treatments and services denied or criminally underpaid by government and the insurance industry cartel; the ludicrous notion that you can somehow provide the highest quality (or even barely adequate) care while being reimbursed substantially less than the costs to provide it; the horrifying freak show in Washington where corrupt and prevaricating politicians shamelessly conspire to destroy a noble profession and an extraordinary health care system to line their own pockets and acquire perpetual power and control.

And then there are the lawyers — aah, the lawyers.

I spent the better part of twenty years in the practice of medicine avoiding their clutches. I came to believe that careful, conscientiously-practiced professionalism, a willingness to spend substantially more time than my peers teaching and communicating with my patients, constantly striving to treat them with dignity, kindness, and respect, would prove a bulwark against the woes my professional peers suffered at the hands of an out-of-control legal system.

What a fool.

My first two malpractice suits came within a year of one another, now over ten years ago. Both were frivolous, and were tossed out of the courts for lack of evidence — after tens of thousands of dollars were spent on their defense. Both, incidentally, were triggered in large part by inappropriate comments by another physician (anyone who thinks physicians cover up for their peers is badly misguided — we are an arrogant lot, shooting our wounded and eating our children). During this same period, several other suits were threatened but never filed. Small comfort, indeed.

It is difficult to express the personal devastation afforded when accused in a medical malpractice lawsuit. It is an existential crisis, cutting to the heart of who you are as a professional, challenging motive, integrity, and competence. Anger, betrayal, self-doubt, fear, and sleeplessness become your daily bread. Every patient becomes a future litigant. An invisible attorney sits in the examining room on every visit, condemning and second-guessing your every decision and action, as you wildly check off every test and x-ray you can imagine to defend yourself against his future judgment: “Doctor, could you explain to the jury why you did not order this study, which could have diagnosed her disease before it became so advanced?” Check. “Doctor, could you read page 1235 of this medical reference — which you stated you have in your office — which points out how all patients with this disorder should be evaluated thus?” Check. “Doctor, isn’t it true that you dismissed his complaints as nothing to worry about, when in fact his cancer was eating away at him and you ignored its warning signs?” Check.

My current litigation, scheduled to come to trial this June after nearly three years in process, of course cannot be discussed here; perhaps I will discourse on the lessons learned therein — for they are legion – when it is resolved, one way or the other. Suffice it to say for now that it involves a child, and that the damages sought exceed the limits of my malpractice coverage by multiples of seven figures.

Sleep well, Doctor.

In truth, why would anyone choose to go into this profession today? Why would any sane man continue to practice medicine in this environment? Why, indeed, do I continue in this insanity?

As a man of faith, a Christian physician, the answers to these questions are far from simple. They cut to the very heart of free will in the service of God and man; of matters of purpose in life and submission in faith; of trust and obligation, gratitude and motives, prayer and practice. The high-sounding principles of pew and pulpit are now tested in the fiery crucible of life, and you discover that lofty ideals and strong convictions alone are insufficient ground on which to stand. The dark night of the soul strips away your props and annihilates all your pretensions; will there be anything left but ashes when the flames have died out?

Time will tell, I suppose, whether I stand on rock or sand.

May God be with me. May God be with us all.

Medicaid, Anyone?

Dr Bob

In my prior post I highlighted some of the problems with Medicaid, the joint state and federal health coverage for the poor. In case you might think that physicians won’t participate simply because the reimbursement is so poor (which would certainly be reason enough), check this out, from my state medical society today:

The WSMA has complained to both the Centers for Medicare and Medicaid Services (CMS) Region X and the Washington Department of Social and Health Services (DSHS) about the egregiously burdensome requests made of physicians’ practices by the Audit Medicaid Integrity Contractor (MICs). CMS has awarded the Medicaid audit contract for Washington to Health Management Services (HMS) of Irvine, Texas.

HMS is making unrealistic requests of practices in preparation of “field audits:” An eight page detailed request for information on each of the practice’s “providers,” with a 15 calendar day deadline; complete medical records on claims selected for audit, in some cases hundreds of records, and for records dating back to January 2004. Even worse, the lengthy list of records requested does not include patients’ names, only identification numbers and dates of birth!

So, let’s see: Medicaid pays far less than the cost of providing care, and often take 6 months to pay that poor pittance. For those dwindling number of physicians foolish enough to remain in this system, they pursue aggressive audits which require enormous amount of practice resources in response, and then, after such an audit, almost certainly will require large “refunds” of money “fraudulently” paid to physicians, who have failed to master the Byzantine and inscrutable regulations which no mere mortal can understand, much less comply with.

Is it any wonder that physicians are are heading for the lifeboats of this sinking vessel?

So, let’s move the uninsured in large numbers into this very same system, shall we?