CAT Scams

The Wall Street Journal reports on a recent New England Journal of Medicine study which concludes that doctors are over-utilizing CT scans, exposing their patients to excessive, and potentially harmful, radiation doses:

Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers.

The researchers, writing in this week’s New England Journal of Medicine, conclude that in the coming decades up to 2% of all cancers in the United States may be caused by radiation from computed tomography scans performed now. Children face the most danger, they said.

In ordering CT scans, doctors are underestimating the radiation danger … In many cases, the researchers say, older technologies like X-rays and ultrasound that expose patients to lower radiation doses or no radiation at all would work just as well.

Since CT scans were introduced in the 1970s, their use has grown to an estimated 62 million annually. An estimated four million to five million scans are ordered for children, Mr. Brenner said. Adults receive scans for diseases of the stomach, colon, breast and other areas. Children most often are scanned for appendicitis. It has become a favored technology because it provides detailed information about patients’ bodies, is noninvasive and typically is covered by health insurance.

While the scans save lives, the authors say, doctors are leaning on them over safer diagnostic tools because they underestimate the levels of radiation people receive from the scans.

The authors measured typical levels of radiation that CT scans emit. They found levels they say were comparable to that received by some people miles from the epicenters of the 1945 atomic blasts over Hiroshima and Nagasaki, Japan.

There can be little doubt that CAT scans, as well as other expensive medical imaging studies, are overutilized in medicine today. There is also no doubt that the overutilization of CAT scans in particular, with their ionizing radiation, does expose patients to significantly more radiation. It may be worthwhile to pause and think about why so many CAT scans are being performed.

Hint: It’s not because doctors don’t know that CAT scans deliver more radiation.
Continue reading “CAT Scams”

Train Wreck

It is difficult to stand by and watch the slow-motion train wreck which is our current health care financing system. The Wall Street Journal reports that Medicare is proposing sweeping changes to hospital reimbursement in keeping with their new emphasis on “pay for performance.”

Medicare has proposed to cut payments to all hospital facilities by between 2 and 5%. This money would purportedly be used to fund an incentive pool which would then be distributed to hospitals showing the most improvement or which surpass certain quality thresholds.

Pay for performance is a philosophy of reimbursement which, ideally, establishes quality guidelines and creates incentives to improve quality by paying more for services which exceed these standards. While this approach has a certain amount of folk appeal, it is fraught with enormous difficulties, not the least of which is the development of the standards themselves, and Medicare and third-party carriers’ obvious conflict of interest as both payer of services and arbiter of what qualifies as “quality” in those same services.

The real intent of these programs is cost reduction, not quality improvement, which can be easily discerned from Medicare’s own statement:

The agency he said the program is designed to be cost-neutral to the government, and could even save money if congress decides not to require redistribution of all the withheld cash.

Gee, I wonder why they would do that? Can you say “earmarked pork”, boys and girls?

It is would seem pertinent that Medicare’s own studies on pay for performance show that it has little or no effect on either quality or cost-containment. The fact that this program does not improve quality, of course, will not prevent the government from instituting it as a blunt club to purportedly improve quality. The train just keeps rollin’ on down the tracks, full throttle. Casey Jones, you’d better watch your speed

One can foresee a host of significant problems with this particular proposal. 50% of all hospitals had a net profit less than 3.75% in 2005 — and therefore would almost certainly be forced to operate at loss. This will put them at severe financial disadvantage to even implement the quality improvements which Medicare supposedly seeks to encourage. It should be noted that many of these hospitals are smaller facilities serving rural areas, and it seems likely that at least some of these would be required to close, severely restricting access to care for many people in rural areas. For you non-MBAs out there, running a business which costs more money to run than it brings in does not a good business model make.

But let’s for a moment assume a perfect world: spurred on by new government standards, all hospitals immediately improve their quality to meet the new Medicare standards. Therefore, they would get all of their money back, and nobody loses, right? Not so fast. Medicare is notorious for constantly moving the goalpost, and when faced with the dearth of hoped-for cost savings, would almost certainly make the standards increasingly more difficult to meet. The standards will become detached from real improvement in quality — if they ever hoped to achieve this even at the outset — and would increasingly become the bureaucratic nightmare that current documentation and coding standards have become for physicians.

Also unspoken in this proposal are the additional costs to the hospitals of added administrative expenses required to document and report compliance with Medicare’s quality standards in order to receive better (or actually, the same) reimbursement. The net effect would be far more money siphoned from actual patient care into administration and paperwork.

Medicare officials said they would monitor the program closely and adjust it as necessary, and at the same time to expand the quality criteria used to determine whether hospitals earn back the lost revenue. “We want to make sure we’re not causing some unintended or perverse consequences.”

That scraping sound you hear is the moving of goalposts.

The history of Medicare is a history of regulatory tyranny which invariably results in “unintended and perverse consequences.” When your local hospital closes, after this proposal is implemented, be sure to write your Congressmen and local Medicare officials to express your deepest appreciation for their efforts to improve health care quality.

Health Wonk Review

Welcome to the September 6, 2007 edition of health wonk review.

I discovered, to my considerable surprise, that I had been tagged to host Health Wonk Review. To be honest, I have no idea how that happened (I’ve never submitted a post to the review, and didn’t volunteer). The submissions rolling into my inbox over the past few weeks were therefore confusing, and it was only a day or two ago that I had the dawning realization that I was on the hook. But being a can-do kinda guy, I rose to the challenge, so here it is.

Thankfully, the Blog Carnival folks made life easier by assembling all the submissions in one place, making the job immensely easier.

So the long and short of is: this will be neither clever, nor fancy, nor terribly erudite — but there’s some great stuff in the submissions, so check them out:

Shaheen Lakhan presents Medicare Begins its “Never Pay” Category posted at GNIF Brain Blogger.

Karen Halls presents How Do I Avoid Drinking Too Much Alcohol? posted at Addiction Recovery Blog, saying, “If you are trying to prevent yourself from drinking too much alcohol at social gatherings, here are a few ways that you can keep your alcohol intake under control.”

Henry Stern, LUTCF, CBC presents No Docs in This Box posted at InsureBlog, saying, “Retail medical clinics are popping up all over. They’re an inexpensive alternative to a full-blown practice or the ER, but “traditional” providers are crying foul. InsureBlog’s Bob Vineyard explores the hypocrisy.”

Warren Wong presents How To Overcome Fear And The Obstacles It Creates posted at Personal Development for INTJs, saying, “Are there things you are afraid of? Here’s how to overcome your fears, permanently, and overcome all the obstacles that fear creates.”

Alvaro Fernandez presents Brain Fitness Program 2.0, MindFit, and much more on Brain Training posted at SharpBrains, saying, “Review and commentary on several New York Times articles related to “brain training””

Shahid N. Shah presents Make sure your online SaaS vendors are appliance-capable posted at The Healthcare IT Guy, saying, “Shahid over at The Healthcare Guy provides some sage advice on how you should not count on “software in the cloud” for your mission critical healthcare IT needs without a backup plan. With big outages from Microsoft, Skype, eBay, and PayPal recently making headlines it’s a great time to make sure you’re protected.”

Jason Shafrin presents What are the Major Clinical Pathways to Disability posted at Healthcare Economist, saying, “This post reviews an NBER working paper discussing findings regarding how the elderly move from healthy to disabled states. Hopefully, this data can be used to aid health service providers on how to better prevent and treat disabilities which occur in old age.”

Richard Eskow presents Medical Justice League of America posted at The Sentinel Effect, saying, “Richard Eskow examines “Medical Justice.” a new service group that provides “gag order” forms to dissuade patients from reviewing their docs online, and also promises to “relentlessly” fight med mal lawsuits.”

Michael D. Horowitz presents What are the real savings in medical tourism? posted at MedTripInfo, saying, “An analysis of the costs of hip replacement in Costa Rica demonstrate that Americans can save 80% or more by going there.”

Dean presents Top Ten Fast Food Meals That Make You Fat posted at Mr. Cheap Stuff, saying, “Avoid these fast food meals.”

Daniel Goldberg presents On Epstein v. Relman (& Public Health Policy) posted at Medical Humanities.

David E. Williams presents Abusing the orphan drug law to rip off customers posted at Health Business Blog. Questcor Pharmaceuticals has announced “a new strategy and business model for H.P. Acthar Gel(R).” Translation: the company has obtained orphan drug status for a product that has been used for decades –including for the orphan indication of Infantile Spasms– and is raising the price 20-fold, from about $1000 per vial to $20,000 per vial.

Anthony Wright finishes up with a submission which snuck in this morning:

Small Business of California, Unite!

A spotlight on a poll of small business owners, showing that they are not reflexively opposed to health reforms, as they are sometimes portrayed. The scientific poll casts some doubt on “membership surveys” of some national organizations.

And a last minute shameless plug: for those interested in an in-depth look at the insanity which poses as our health-care system, check out The Maze — a multi-part series of posts on our billing and coding system, federal and third party carriers, and thoughts on fixing this mess.

That concludes this edition. I may have missed a few submissions, due to the last-minute scramble — my apologies for any such oversights.

Submit your blog article to the next edition of health wonk reviewusing our carnival submission form.

Past posts and future hosts can be found on our blog carnival index page.

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health wonk review, blog carnival.

Swindler’s List

“I have here in my hand a list of two hundred and five (people) that were known to the Secretary of State as being members of the Communist Party and who nevertheless are still working and shaping the policy of the State Department”

Senator Joseph McCarthy, in his famous accusations about Communist influences in the U.S. government, had a list. A secret list. And he wasn’t revealing his sources.

Fortunately, we’ve come a long way since those dark days. No longer do senators keep secret lists with which to malign the reputation of those who displease them.

The only ones with such lists today are the health insurance companies.

The Wall Street Journal reports the following:

New York Attorney General Andrew Cuomo demanded last week a “full justification” of the rankings that Aetna Inc. and Cigna Corp. have rolled out in the state. He warned the companies that the ratings are confusing and potentially deceptive, in part because insurers don’t disclose how prone to error their rankings are. The move follows rankings lawsuits by doctors accusing insurers of libel, unfair business practices and breach of contract in other states.

Health plans say the designation of preferred doctors is meant to aid patients by calling attention to the best physicians. To that end, UnitedHealth Group Inc., for example, is rolling out a system called United Premium Program. Aetna gives select doctors an “Aexcel” label in its plans. And Cigna launched its Cigna Care Network in at least parts of 26 states and Washington, D.C., early this year.

Sounds pretty benign, doesn’t it? Your health plan publishes a list of “best doctors” based on their interest in keeping you healthy, and promoting their new emphasis on quality. It’s all in the best interest of their customers, after all. Whatever could be the problem with that?

As you might guess, there’s more here than meets the eye:

…critics accuse insurers of concentrating more on cost than quality when handing out the preferred labels. Data from health claims are commonly used to produce the ratings. But the information, while standardized and widely collected, is prone to error, Mr. Cuomo and physicians say. Medical conditions can overlap and doctors’ offices vary in how they assign billing codes to care … Mr. Cuomo warned that rankings based on claims data can be badly flawed, and said insurers have conflicts of interest because of financial incentives to contain costs.

Of course the insurance industry has taken great pains to ensure that their quality rankings are fair and balanced:

An Aetna spokeswoman said the company consults with physicians in developing the ratings. Aetna considers its rating system transparent and posts the criteria and other details about it on the company’s Web site.

UnitedHealth also calls its system transparent, and said it had sent Mr. Cuomo a 25-page response but declined to make it available.

A Cigna spokesman said the company measures doctor performance by “what we believe is the best data available.” However, the measures “represent only a partial assessment of a provider’s quality and cost efficiency” and shouldn’t be the only reason patients pick a doctor, he added.

The emphasis above is mine, BTW — more on that in a minute.

Now, color me skeptical about such claims from insurance companies; having dealt with them first-hand for nearly 30 years does leave one with a certain hardened cynicism about their motives. But being a fair-minded type of fellow, I decided to check out some of their transparency claims. So I moseyed on over to Aetna’s web site, used my considerable influence as a physician to register, and started snooping around.
Continue reading “Swindler’s List”


Michael Cannon over at Cato takes issue with my conclusions regarding pay-for-performance — the federal and third-party steamroller which is the health care bureaucracy’s latest ill-considered idea for reigning in health care costs. In pay-for performance, guidelines for quality (read: less expensive) care are established, and those physicians who color between the lines get paid more (or, more likely, don’t get paid less).

Dr. Bob argues:

1. “High quality — while not invariably more expensive — is often so.”
2. “[B]y and large,” the guidelines that physicians are supposed to follow “don \'t exist — except in a few relatively straightforward areas of medicine.”

I agree with those statements, but I disagree with their conclusions.

Though the first statement is true, it is also true that a lot of the expensive stuff that doctors deliver is not high quality. For 30 years, researchers at Dartmouth Medical School have found it very easy to demonstrate that some doctors do a lot more expensive stuff than other doctors do (e.g., specialist consultations, hospital stays, etc.). But they have found it very, very hard to find any evidence that that extra stuff makes patients any healthier or happier. Thus, a lot of the expensive stuff that doctors do isn \'t high-quality care.

Though the second statement is true, it is also true that where evidence-based guidelines do exist, patients still don \'t get the “high-quality” care that the guidelines recommend. According to Elizabeth McGlynn and her colleagues, patients receive such recommended care only about 55 percent of the time. (I put “high-quality” in quotes because not every patient should receive what the experts recommend. But it would be a stretch to say that 45 percent of patients are outliers.) Even when evidence-based guidelines exist, doctors don \'t follow them.

Quality suffers both because physicians don \'t do enough of what they should, and do too much of what they shouldn \'t.

Michael makes some good points here, but is looking at the forest while missing some very big trees.

There is little question that a substantial amount of medical care, much of which is very high-cost, is performed with little measurable benefit. I would emphasize here the word “measurable.” For example, a patient who comes in with blood in the stool will generally be advised to have a colonoscopy, which is an expensive procedure. In many cases, the colonoscopy will be normal, and therefore, in retrospect, be unnecessary. The patient, however, will receive the reassurance that he or she does not have cancer, and more appropriate treatment for the bleeding problem will result. This is an important outcome, but difficult to measure in purely economic terms.

Furthermore, in those cases where cancer is detected, this finding will lead to much more care, which is often quite expensive. This situation points out another flaw in our current enchantment with the cost savings of preventive medicine — particularly by those who believe it will somehow magically save us millions of dollars to spend on the uninsured. The economics of most screening programs make little sense, for the screening generates a large number of expensive follow-up tests, and in many cases the initial symptom or abnormality proves to be a false positive.

The second issue about ordering expensive studies speaks to another favorite solution of the cost-cutters: primary care. The knowledgebase of medicine has grown exponentially in the past 50 years, with increasing numbers of specialties being spawned to master it. The specialist, dedicated to a single subset of medical knowledge, must still spend substantial effort to remain current in his or her field of specialization. The primary care provider, however, must attempt to master, at least to some degree, a substantial amount of the knowledge in multiple specialties in order to make wise decisions about evaluation and treatment in his or her patients.

In my experience, it is the primary care physician who often orders expensive studies inappropriately. I have seen patients who have come to me, having had an MRI (costing well over $1000) to diagnose a scrotal hydrocele — a benign condition which is almost always harmless, and should be easily diagnosable by physical examination, or much less expensive ultrasound. The point here is not to denigrate the primary care physician, but simply to point out that it is becoming virtually impossible for the primary care provider to achieve mastery of the many complex subspecialties of medicine. Education can of course resolve some of these problems, but this is likely to grow worse as medicine becomes increasingly more complex. The primary care provider is under substantial pressure to keep patients away from expensive specialists– which can prove to be a false economy in many instances.

The last tree in the forest is a giant Sequoia, which is our current liability system. It is very difficult to estimate how many of the expensive, unnecessary studies are driven by our current malpractice system — but it is unquestionably huge. In a perfect world, we would weigh the risks and benefits of diagnostic studies, and order expensive studies or treatments only where the benefits substantially outweigh the risks. In the real world, every physician mentally plays out the scenario of failing to do an expensive but low-yield study, and having to answer for this decision — entirely rational at the time — under the cynical cross-examination of a plaintiffs attorney in a courtroom. Measuring this impact is extremely difficult, and its effect is minimized in the extreme by the trial attorneys, but it is in fact a huge financial black hole in our health care system. Unfortunately, tort reform alone will not solve this.

The institution of rigid pay for performance guidelines will also introduce new legal opportunities for second-guessing sound medical decision-making. There will certainly be instances — the percentage of which will depend on the quality of the guidelines — where physicians will need to make recommendations which fall outside of these guidelines, in order to provide high-quality care. Such decisions will provide rich fodder for Monday morning quarterbacking by attorneys. Furthermore, anyone who believes that such guidelines, studiously followed, will provide protection against malpractice, should stop smoking that funny tobacco and to seek treatment immediately.

I think third-party P4P, where insurers reward providers for high-quality care, is a fine idea – provided the patient gets to choose her insurer.

This last point which Michael makes regarding third-party payers instituting quality guidelines needs a reality check. The simple fact in every physician’s experience is that insurance companies have no interest whatsoever in quality care, except as a marketing tool. For third-party payers, quality = low-cost. Our local Blue Cross provider recently sent out letters to patients, indicating that a number of physicians in their panel had been dropped from one of their large plans because they did not meet “quality standards.” Turns out, the only standards applied were financial and not medical, and physicians had no knowledge of or access to the so-called standards. The carrier has as a result found themselves in court defending a class action suit for defamation of character. Expect to see much more of these sort of shenanigans as pay for performance becomes more common.

The best way to assure quality in healthcare is a high level of transparency in our medical system — something which is currently impossible due to the current liability environment — combined with placing the decision-making process regarding care back in the hands the patients, by making the patient the purchaser of healthcare rather than government or the insurance carriers.

Little Pay for No Performance

If you’ve been following some of my previous posts on the insanity of the U.S. health care system, such as the Maze series, you will recall the looming ogre in payment “reform” called pay for performance. Medicare, and the me-too sycophants in the insurance industry, have been promoting and implementing a payment system which nominally will pay more for care which meets certain quality standards. This concept is based on a host of unproven assumptions — the most egregious of which are the unspoken assumptions that much care delivered is substandard, and that trivial increases in reimbursement will correct shortcomings in quality (which are vastly more likely to be due to system complexity than individual error or incompetence). Nevertheless, this lumbering freight train is rumbling down the rails toward our health heroine Nell, lashed to the tracks by Snidely Whiplash, your dastardly federal and private insurance bureaucrat.

Today’s Wall Street Journal (subscription required) reports on a JAMA study of just how well this system works. In a pilot project funded by Medicare, the stunning results are in: it doesn’t. Color me shocked:

Researchers at Duke University, examining heart-attack treatment at 500 hospitals, found that hospitals that received financial incentives to follow treatment guidelines didn’t improve their practices significantly more than hospitals that got no financial benefit.

The federal Centers for Medicare and Medicaid Services launched the pay-for-performance pilot in 2003. Participating hospitals provided the CMS with performance information for five conditions, including heart attack. Hospitals in the two highest performance levels for a condition received a bonus.

In the Duke study, published in this week’s Journal of the American Medical Association, 54 of the hospitals were participants in the CMS pilot and received the financial incentives. The other 446 “control” hospitals didn’t get such payments.

The findings showed that “the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction,” or heart attack, Duke cardiologist Eric D. Peterson and colleagues wrote in the journal article.

Of course, the usual special pleading is immediately evident: perhaps the carrots weren’t juicy enough (like that will ever happen, in a system which is economically hemorrhaging), or the sticks weren’t nasty enough (now you’re talkin’! Keep beating that dead horse, and surely it will run faster):

It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.

“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.

Now that the data is in, you can be sure that our bureaucrats will rethink their foolish ways — or not:

Still, the findings raise the question of what the Medicare system will do next. A Medicare spokesman said the agency hadn’t seen the study and so couldn’t comment on it.

Nice. Medicare, who funded the study, hasn’t seen the results. Never let the facts get in the way of a bureaucrat on a mission — it just confuses them.

Health Care Coverage Takes a Hit

Recently Barack Obama released his proposed health care plan, which bears a resemblance to several other proposals, such as Mitt Romney’s in Massachusetts, Arnold Schwarzenegger’s in California, and a number of others. Such proposals have a number of common themes: mandating insurance coverage, provided through private insurers and monitored through a government bureaucracy; taxes or penalties on businesses who do not provide coverage for their employees; often a tax on physicians and hospitals; tight regulation of insurance premiums; removal of preexisting condition restrictions; financial assistance for the poor in paying for coverage; cost “efficiencies” brought about by an increased emphasis on preventive medicine, information technology (electronic medical records), and a hoped-for reduction in premiums due to an enlarged risk pool.

At first glance, some of these proposals appear to use the existing network of health insurance plans to extend healthcare coverage to the uninsured. They also seem designed to avoid the tar baby of government-run, single-payer healthcare, which is anathema to many Americans. But the difference between these plans and single-payer, practically speaking, is far more illusory than real.

I am on record as favoring mandatory catastrophic healthcare insurance. While generally I do not favor government mandates in such areas, I find catastrophic healthcare insurance to be analogous to mandatory auto insurance: in both cases, the uninsured pass the expenses of their misfortune onto society as a whole, either directly or indirectly. I would favor such a mandate at the state, rather than the Federal level, enforced by showing proof of health insurance at the time of driver’s license renewal. Such insurance should be major medical only, covering catastrophic illness with very large deductibles. It should be purchased by the individual, rather than provided by employers. In such a scenario, the vast risk pool, large deductible, and coverage limited to major medical events should keep premiums relatively low. There should, however, be little regulation of what such policies cover, as opposed to the micromanaged mandates common in most states today. Supplemental policies to cover other services would still be available, tailored to the needs and economic abilities of the insured.

The recent sweeping proposals of presidential candidates are far removed from such simplicity, however. They will create a massive healthcare bureaucracy which will no doubt be involved in setting specific coverage requirements (doubtless at the whim of politicians), will engender cost-shifting by price controls on insurance premiums, and will almost certainly create a very large problem of access. There is no free lunch — if insurance companies are forced to lower premiums below levels required to fund their outlays, they will invariably respond by drastically reducing reimbursements to healthcare providers and hospitals. Health care providers will by necessity no longer be able to see patients in these plans, as reimbursements drop below the cost of providing the service — which is exactly the problem which Medicaid and Medicare are encountering currently. Federal control of private insurers will breed a million mini-Medicares, with so-called “private” insurers micro-managing medicine under the harsh glare of Federal hyper-regulation.

The continued linkage of health insurance to employment perpetuates the current environment where the consumer of healthcare is insulated from its costs. Taxes on businesses — whether by mandates to purchase insurance for all employees, or penalties or taxes on those who do not — are nothing more than surrogate taxes on the general population, as businesses will pass these costs through to consumers in the form of higher prices and reduced productivity. New employment will likewise be constrained due to the high entry cost of hiring and keeping workers.

The challenges manifest in our current healthcare system are legion, and highly complex. The difficulty is not merely greedy insurance companies with high administrative costs — although many insurers exemplify these problems. The insurance giants are indeed unscrupulous and unethical — but in the proposed plans they are a convenient political straw man. The real problem is that the insurance companies are no longer accountable to their customers. The camel’s nose is not merely under the tent; the camel is inside the tent — and is eating your lunch, while leaving large camel pies on your Persian carpet.

When you purchase auto insurance, you shop for coverage using price, service, and covered benefits. When you have an accident in your SUV, you expect your insurance company to pay promptly and honestly for the damages you have incurred. If they refuse to do so, or have poor service, or very high rates, you will shop for another insurer.

In health insurance, this normal accountability relationship between the insurance company and the client is broken. Your insurance premiums are not paid by you in most cases, but by your employer — and therefore you have neither flexibility nor options for seeking out the best rates for the coverage you desire. Your coverage is also likely determined by your employer, rather than by you — with some unnecessary services thrown in by state benefit mandates.

When you need healthcare services, you do not pay the physician or hospital directly, other than a small co-pay or deductible. You receive the service, and the provider then bills the insurance company to be reimbursed. The provider is constrained by contract with the insurer, and will only be paid a fixed amount determined by that contract (which, amazingly, the insurers will often refuse to disclose to the provider). If he or she excels in their field, they are not free to make separate arrangements with you at a higher price — even if your are willing and eager to pay for such excellence. If your insurance company chooses to deny a claim and refuse payment — which they do on a regular basis — you may be entirely unaware of this fact.

Hence the insurance company is shielded from accountability to you, the consumer. Your employer also has little or no influence over the insurance companies rates or payment policies. Therefore the insurance company is essentially accountable to no one — a fact which they use to gain a huge financial advantage. It is well established that insurance companies frequently deny claims filed by physicians arbitrarily, knowing that the high volume of claims processed by a physician practice will allow them to do so without consequence: over 50% of practices will simply write off the denial of payment, even if the payment was legitimately due. Practices simply do not have the time or manpower to appeal each and every one of these endless claim denials.

We have allowed the insurance companies — and Federal payers as well — to come between the patient and the insurer. In older, simpler times, it was quite different: you paid the physician directly, and submitted your bill for his or her services to the insurance company, who in turn sent you a check. Under this system, you were fully aware of what the physician was charging, and were fully aware of how promptly and appropriately the insurance company reimbursed you for your healthcare expenses. If they denied a claim, you, their customer, would be on the phone demanding to know why, and if you were not satisfied with the answer, would ultimately change insurance carriers. The physician required far fewer employees to massage and process claims, and as a result their overhead — and fees — were lower.

When politicians — or anyone else — begin talking about “efficiencies” brought about by preventive medicine or information technology — be afraid, be very afraid. Preventive care, as I have discussed elsewhere, is a healthcare talisman, wildly shaken with chanted incantations and ritual dancing as the solution to most, if not all, of our healthcare problems. Other than in selected areas such as prenatal care, or screening for hypertension, cholesterol, or diabetes (which are already routinely done), preventive medicine largely comes down to the Big Three: weight loss, smoking cessation, and regular exercise. If you believe you can get the population at large to embrace these lifestyle changes en mass through some national healthcare policy, you have been spending entirely too much time at the bong.

The idea that large financial return may be gained by simply implementing electronic medical records is beyond naive, bordering on moronic. The entry costs of such systems are enormous, and the complexities of integrating them into healthcare are extraordinary. Keep in mind that much of the current demand for electronic medical records has been driven by the government’s extraordinary documentation requirements imposed by their own reimbursements system. The benefits of electronic medical records are substantial, but cost savings is quite simply not one of them. Any long-term cost-savings would not be seen until there is near universal utilization and standardization — a scenario which is many, many years in the future. In the short term, conversion to electronic medical records substantially increases expenses and complexity, and tends to drive costs up, not down.

The current crop of healthcare reform proposals are an intoxicating blend of wishful thinking, heavy-handed government regulation, and unfulfillable promises. The politicians are inhaling deeply on their health-care hookahs — and hoping that the sweet aroma obscures the reality that they are only blowing smoke.

My Favorite Medical Myths

A recent post over at the Advice Goddess regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the liberal side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part:

I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. …

One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician…

Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.

Now, my intent is not to beat up the poor fellow; he is, after all, a liberal, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.

So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error.
Continue reading “My Favorite Medical Myths”