October 23, 2010

Bringing all the fun of bureaucracy to medical decisions

Posted in Uncategorized at 2:30 am by Dr. J

Great article here that I found which details how far the “health care reform” train has run off the tracks.  Simpler?  Less Expensive?  Easier to Navigate?  Really?  Follow this link to see just how bad the bureaucratic mess created by the bill actually is.  And keep in mind that the chart condenses 151 agencies into a couple of grouped icons.  If all were included the chart would be three times as large.  No wonder we had to “pass it to figure out what’s in it.” It’s taken almost a year to figure out what’s in it really, and the Dems wouldn’t want all of this stuff being bandied about the Senate floor right before the election, would they?

And don’t believe the current Republican policy makers have all that many brilliant ideas.  Remember the fact that Obamacare draws many of its prime tenets from Romneycare, which has been a fiscal disaster that only accomplished one of its goals:  Insure more people.  It’s not better medical care.  It’s not cheaper medical care.  It’s not less ER care, or shorter lines, or patients actually taking their medications, or anyone deciding that maybe its not worth $1000 just to take a look with an MRI when they are not going to use it for surgical planning…  It’s generally one giant plop.

As I have said before, I am on the inside of health care.  I see patients without insurance everyday.  I do what I can to help them out.  I dictate a note that would qualify for only the barest of payments – cause if I do a real one and don’t charge them for it, I get fine $10K per occurrence.  All because of Medicare.  Awesome, ain’t it?  Let’s get more government involvement!!!< YEAH >  /sarcasm.

September 8, 2010

Anti-Trust Laws and Medical Practice

Posted in Uncategorized at 3:12 pm by Dr. J

Getting back into the swing of things after moving to a new practice in a different state.  Once everything settles a bit more and I meet all the new people here, I will be able to post regularly again.  I have not lost my passion for the cause.

Let me detail something I heard about a lot during the debates on healthcare reform, but never really understood until recently.  Politicians often talked about how insurance companies being exempt from the antitrust laws.  I always assumed this allowed them to monopolize the healthcare system in their state, much like we see in Alabama.  The truth is that this is directed more toward physicians than anything.  Physicians are currently forbidden from organizing “against” insurance companies.  We are not allowed to discuss the payments we get with anyone outside of our group.  We cannot publish the fees we collect from insurers.  We can’t even disclose this information to other doctors outside of our practice.  I suppose it is designed to prevent collusion between doctors to present a united front to raise reimbursement rates.  But I think it also prevents us from determining what a fair payment for a procedure is and prevents patients from being able to understand the cost of the “free” healthcare insurance they get from their place of business.  On the other hand, patients who know the rates that physicians get may be inclined to go to the highest paid doctors assuming ( usually incorrectly ) that they are the best.  It may therefore raise the costs of healthcare if people continue to stay insulated from the direct payment of fees for their services.

I think its another example of making broken rules to patch other broken rules rather than fixing the fundamental flaw in the system.  Making people directly responsible for more of their health care payments through higher deductibles, lowering monthly premiums, and improving the tax status of health savings accounts would take a step out of the process and reduce the amount people spend on healthcare.  Right now we abuse the insurance system and wonder why it costs so much.  Then people decide that they are going to “get the most” out of their insurance companies and drive utilization and premiums up even higher.

What do you think is the best way to go on this issue?

August 10, 2010

Test Flight of Obamacare Has Already Crashed

Posted in Uncategorized at 4:33 pm by Dr. J

If anyone has any doubt about where our national health care plan is headed, you have only to look as far as Massachusetts.   Several years ago, then-governor Mitt Romney signed into law a bill that was identical to Obamacare in all the major points.  It has an insurance mandate, an expansion of Medicaid, subsidized insurance for low-middle income families, and major restrictions and regulations on insurance companies.  How did it do?  TERRIBLE!! The only thing anyone can say about it that is positive, is more poor people are insured.  But the Massachusetts debacle shows us the wrong way to go about achieving that goal.

Expensive ER visits have increased instead of dropping like predicted by the government.  Every one else could see the increase coming – and in response to the Obamacare bill hospitals are looking to rapidly expand their ER capacity.  In fact, my friends who are ER physicians say that they get people coming in every shift thinking that they already have insurance through the government.  You are talking about people so unsophisticated that they assume they all have free health care without filling out any paperwork, or registration, or any of the other things that a government system makes you do.    Do you really expect them to understand, or even care about, the financial and health benefits of going to see a regular primary care physician?  So much for saving money through increased coverage.

The state of Massachusetts is embattled with insurers in the court systems, the new entitlement is bankrupting the state, and private health care insurance premiums have increased at nearly TWICE the national rate.  Several articles that detail the flailing mire are below:

“Train Wreck”

Increased ER Visits

Massachusetts Miserable

Health Insurance Rate Increase

5 Lessons from RomneyCare

Gaming the Insurance System

Have fun reading!  Sorry for so few posts lately, but I am finished with my fellowship down South now.  I am in the process of moving the family back North again and we have not gotten internet access established yet.  Yeay for Panera’s free WiFi!

July 21, 2010

Don’t be confused…

Posted in Uncategorized at 4:22 am by Dr. J

I had to throw out a quick post counteracting another blog.  In this post, Jonathan Cohn tries to make the argument that new government regulations on health care have nothing to do with increases in premiums, decreases in patient choice, and small businesses dropping insurance benefits to employees.  He claims that these things were already happening and now the government is just getting victimized and blamed for it. Let me be VERY clear on this:


Obamacare is forcing insurance companies to ensure people with very expensive medical problems that they were side-stepping before.  Whether that tactic is right or wrong on the part of the insurance industry, it was keeping premiums down.  In anticipation of a metric crap-ton of unhealthy people requiring expensive treatments, the companies are raising their rates.  That causes insurers to try to manage care more aggressively, it causes small businesses to be unable to afford the cost of offering insurance, and it causes more people to be forced into the government-run systems.  Oh but WAIT!  Those systems don’t go into effect for a few more years… sooo… yeah.  Until then, I hear Guinness is good for what ails you!

So what is the net effect?  Honest, hardworking people with actual productive jobs lose their health insurance or are forced out of it by the price increases.  But those on the lowest end of the spectrum, like the guy who lived downstairs from me when I was a medical student?  Yeah, the one who’s only sources of income were hustling people on the basketball courts and selling some pot, had 6 kids with three women and didn’t take care of any of them, and paid no taxes on his illegal cash businesses?  He gets all the free frickin health care he wants!  Bravo, Mr. President.  Bravo.  /Golfclap

July 14, 2010

Health Care Insurance: Something for Nothing

Posted in cost containment, irrational behavior, Politics at 3:11 am by Dr. J

America’s attitude toward health care insurance is that of “something for nothing.”  People want to get rid of pre-existing condition clauses, but then also expect to be able to sign up for cheap health care plans only after they develop some expensive medical condition.  Patients used to occasionally ask me to avoid listing a diagnosis in their medical record just so they would be able to get it paid for by a new insurance company at a later time.  I admit I was torn between my usual M.O. as a doormat who felt that people would like me more if I gave them what they wanted, and my own instinct toward self-preservation that kicked in because I know what a terrible liar I am, and how I would crack at the first questions of a fraud investigator.  Obviously, the self-preservation  won out.

If you want to force insurance to cover anyone no matter what expenditures they may require, then you can’t allow them to come into the system whenever they feel like it.  You HAVE to mandate that all people purchase health insurance.  That’s why it is insurance:  you pay a little bit over time hoping you will never have to use it.  You are betting that you will gain money by someday getting sick enough to win back all the money you have paid in premiums.  The insurance industry is betting that you will not require much medical care and hopefully die in a sudden and fiery blaze of glory in late-middle age.  That’s how it works in auto, home owners, disability and life insurance.  You can’t buy a cheap life insurance plan for $1,000,000 immediately after you learn that you have two weeks to live.   Why should you be able to do the same with medical insurance?

The difference is that auto, home, disability, and life insurance are really rather affordable.  This is in part due to the fact that the majority of people won’t require large or frequent payouts on them.  But, health insurance costs enough that people start to take a calculated risk on it.  Young healthy people realize that maybe it would be better if they just saved that money for a rainy day instead.  Then you have a smaller pool of people paying in, so the costs are shared between fewer people and the premiums go up.  That causes fewer people to want insurance, and the death spiral begins.

It is a basic truth that if you want health insurance to be devoid of practices like charging based on risk factors and pre-existing conditions, then you have to mandate that everyone take part in the risk-sharing.  If you penalize non-conformers in ways that still make it cheaper to go without insurance, all you have done is create a tax on the middle-class to fund the government subsidies of those in lower economic brackets while the middle-class get nothing out of it themselves.  It also does nothing to defray the costs of insurance over a larger population base.  So it allows the private insurance death spiral to continue.

You can choose to believe that those in power really have no intimate understanding of how badly they screwed things up with a bill like the one that was passed (probable, but only about half of the legislators are this dumb, blind, or callous).  Or you can believe that they were so intent on creating a bigger safety net and firmly wedging themselves into the pantheon of great democratic leaders that they were willing to make any slipshod compromises they had to just to cobble together a bill that would pass without giving solid consideration to all of the other provisions in it (ahem… Mrs. Pelosi and her brilliant idea that we have to pass the bill to see what is really in it, I’m not sayin’…. I’m just sayin’).  Or you can believe that politicians could foresee the way it would expand government-run health care while continuing to ensure the downward spiral of the private health insurance model and eventually lead to self-destruction that would pave the way for a nationalized health system, instead of the crass system we have now where people dare to make a living providing services that other people need. Not that I’m a conspiracy theorist, but you have to admit, the idea probably crossed your mind about 30 seconds before you read it.

In case you think I’m just some Nazi Republican Doctor, just remember that I did vote for Obama.  And I’m really sorry that I got what I wished for.  It’s been like Pet Semetary – I got what I wanted, just a horrible, mutated, evil form of what I wanted. And although I arrived at the above ideas on my own, I have some pretty good company in my thoughts.  Here is a post from Prof. Uwe Reinhardt, an economist at Princeton.  He verifies my thoughts on the subject, and has a fantastic blog on economics and health care on the NY Times website.

July 13, 2010

The problem with doctors who try to save money

Posted in Uncategorized at 3:03 am by Dr. J

As a doctor who is very cost conscious lately, it can be very frustrating to attempt to save money.  There are really only a couple ways I can save the system money: order fewer tests and do fewer surgeries.  These are really only savings if the tests and surgeries are unnecessary.  If they are needed, then failure to act on that need can be a short term gain for a long term loss.  Just a “for instance” here:  You can live with a torn meniscus.  But a torn meniscus is functionally like having no meniscus.  And if you live with a knee like that, you will almost certainly need a total kneee replacement within 30 years, but repairing the meniscus now can prevent the knee replacement totally.  You see the dilemma.

More over, the insurance companies see this savings.  They have no incentive to pass the money on to the consumer.  When you have a 96% market share, and all of your options for insurance plans are confusing as Hell, why worry about lowering prices?  Now if the market were opened up nationally and getting health insurance was like getting car insurance, they would have a reason to lower their rates, streamline their overhead, and have “discussions” with doctors that spent too much money.  I mean, my God!  Can you think about what some entreprenuers could do by starting a health care plan that directly employed the most cost-effective surgeons and doctors, kept its expenses low, and had the lowest premiums around?

What about other things I can do to save money?  I can do surgery with old standby equipment that can be reused like Ronguers instead of Disposable Saw Blades.  I can use cheaper bone anchors and other materials.  But that just saves the hospital money, so their profits go up.  Again, you never see that money.  But what if you did.   If we all paid more out of pocket for our health care, we would bargain shop a lot more.  Yes, there would be different levels of care – you would have good doctors and bad doctors.  You would have expensive doctors and inexpensive doctors.  And the two would not necessarily correlate.  But that is the same as every other market out there; you have some stores selling high-quality at high price, some that sell good items at low prices, and some that sell a subpar product based on brand recognition alone.  But if you actually had to pay for it out of pocket, I’ll tell you what we would get.  I see it pretty regularly: people without insurance but who need surgery will call all the hospitals that we operate at and find out which one is the cheapest.  And that is where they want their surgery.  Why am I the only one who sees where this ends up?  When consumers are more directly involved in paying for their health care, we get lower prices overall as hospitals compete!  As they lower prices they knuckle down on the suppliers of drugs and instruments to further drive down costs.  And since this accounts for 90% of the cost of a surgery (while the doctors’ fees makes up about 10%) the return on investment for this move would be huge.

And it would also remind people that no health care is free.  If you get $1400 a month spent on you insurance by your employer, it’s money not in your bank.  If they only had to spend $700 your income goes up.

Ways to reduce health care spending

Posted in cost containment, Rising medical costs at 1:56 am by Dr. J

Here are a few of my suggestions, as a surgeon, for reducing spending on health care.  Now, keep in mind some of these are tongue-in-cheek, but others are fairly serious.  The topics range from reducing useless or redundant services, to decreasing usage of expensive tests, to forcing people who stick things up their butts to pay out of pocket if they want them out.


June 17, 2010

Fewer Uninsured Than You Think

Posted in cost containment, irrational behavior, Obamacare, pulling the wool over your eyes at 4:01 am by Dr. J

Ok, so this comes from a Republican Senator’s Website, so who knows how far it can really be trusted but it has to have some kernel of truth to it.  It reflects the kind of demographics I have seen for uninsured people during my training at a University Hospital that accepted all patients regardless of insurance ( and got government subsidies to pay for the free care it gave out.)  Just over a third of these people are actually slipping through the holes in our safety net.  20% of them are eligible for Chip, Medicare, or Medicaid already and are too ignorant, uninformed, strung out, proud, or dumb to get signed up for it.  13% could be getting it through work but are not, ostensibly because they don’t realize it is offered or because they would rather take home the money than give it up in pre-tax premiums.  Another 19% would not be eligible for the new programs set up in Obamacare because they make too much.  These are people making over $75K  per year.  now one would assume that with an income above average that they can probably afford it, but are also fairly intelligent and able to understand that they are paying too much in premiums for insurance than the value of goods and services received.  SO one could argue that by taking real actions to make health care more affordable, and  by reaching out to the people who are already eligible for our socialist programs that we could do a far better job of getting people insured in this country than the Obamacare route.  One way involves giving people good value for their money, the other involves putting the bootheel of the government on the necks of people who choose not get insurance while screaming at them about how they are bankrupting our country when nothing could be further from the truth.

Has Push Toward Outpatient Treatment Caused an Increase in Spending?

Posted in cost containment, Rising medical costs at 3:42 am by Dr. J

One of the tenets of decreasing costs in medicine has been a push to prove that treatment of many conditions does not require prolonged treatment in a hospital.  If you can do something outside of the hospital it should save loads of money by eliminating the hospital costs, decreasing the amount of medications given, and reduce the fees of doctors for consulting in the hospital.  My own sister recently had a spontaneous collapsed lung because a small portion of it popped.   During my general surgery training, this sort of injury would have been treated with a tube into the chest to draw off excess air leaking from the lung and allowing it to reinflate.  She would be on monitors in the hospital and getting an Xray every day.  When the air stopped leaking from the tube, it would be pulled out and she would be checked with xrays for another day or two.  Not any more!

She had a tube placed in the ER by a surgeon and then was sent home with a special valve to allow the air to steadily flow out.  After a couple of weeks, the tube was taken out in the office and everything turned out all right.  Sure sounds like a cost savings to me.  How could something like this lead to the rise in health care spending?  Take the Red Pill and follow me down the rabbit hole…

June 14, 2010

Games Insurance Companies Play

Posted in Doctor's Life, irrational behavior at 8:42 pm by Dr. J

This is a column about games that insurance companies play.  They are not very fun games.  It’s like going to a casino, except your only options are lose or break even.  There is no way to win.

I thought I was just describing exactly what I did in surgery the other day while dictating my procedure note for a knee arthroscopy and meniscus surgery.  I had dictated that we had debrided a meniscus tear.  I explained in detail in my note that the meniscus had a large, unstable tear that I resected with the use of arthroscopic scissors, a rotary shaver, and a cauterizing device.  I explained how I had taken the two ragged ends of the tear and trimmed them back in a fine taper to avoid repeated tears, and that the affected area was roughly one third of the meniscus.  I dictated that the procedure performed was a “meniscal debridement.”  No lie there, I debrided the torn portions of the meniscus.

I had our billing and coding expert (yes nearly every doctor’s office has someone on full-time salary to make sure we aren’t getting screwed by the insurance companies too badly) came to tell me that I should be sure to dictate that we did a “partial meniscectomy” instead.  I asked her what the difference was.  She said “Surgically, nothing.  Billing-wise, they pay $600 more for a meniscectomy.”  I asked “Why?” She told me that it was a sort of sneak-attack by the insurance companies.  They realized that a meniscal debridement was the most commonly billed procedure in orthopedics.  They figured they could save a ton of money by paying less for it.  They left the value of a meniscectomy the same though.  Their arbitrary explanation was that a meniscal debridement was less work.   This came as news to many surgeons.  Since we had coined the phrase and created the surgery and used “debridement” and “partial meniscectomy” interchangeably, we thought we had a monopoly on the word and its definition.  Apparently we were wrong.
And again,  remember that insurance companies are not required to let doctor’s know how much they pay for procedures.  They can change those rates with little notice.  And when I do a procedure less expensively than another surgeon, I don’t see the savings.  Your premiums don’t drop.  But the company’s profits do go up.  That’s why we need to encourage medical savings accounts for individuals and stop paying a middle man to distribute your money.  We should have medical insurance for catastrophic need only, not because you got a cold.

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