Universal People Care

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Have you ever owned a dog? If so, did you ever take him to the vet? I’m sure that even if you don’t own a pet, you understand the gist of the question, but now I’d like to ask it again in a different way. Before taking your animal to the doggie doctor, do you ask the little guy which vet he wants to see, or what treatment he wants to have? Of course not, that’s ridiculous. The animal doesn’t understand anything about their illness or injury, and besides, who is paying for their care? They should just be grateful that their magnanimous owner provides for their needs.

I’m saddened to say that in today’s healthcare environment many, if not most patients are being treated as if they are owned by their insurance company, or in the case of older patients, the disabled and the poor, it’s the government that functions as the de facto pet owner. This comparison also extends to most of America’s physicians who, like their veterinarian counterparts, work for and take their marching orders from “the owners.”

There are two basic problems with comparing “people care” to veterinary medicine. First, people are not domesticated animals, George Orwell’s satire not withstanding. For the most part humans have the ability to reason for themselves, make their own choices, complain when they are not treated fairly, and even possess the right to pursue litigation as circumstances demand. Despite these clear advantages, most people have passively allowed a set of faceless third party payers to dictate the who, what, when, where and how surrounding their healthcare, then blame the lack of personal service on the provider. Second, unlike government or corporate entities, the average pet owner actually loves the pet, and it is that affection that leads them to make compassionate decisions on behalf of their charge. It goes without saying, neither insurance companies nor the government love you.

Perhaps many find this comparison objectionable, and I can certainly appreciate that opinion, however, a closer inspection shows the American healthcare system is inching closer to veterinary clinic status every day. Payers contract with the providers for discounted payments without the knowledge of those who are most impacted. Eventually, when payments are slashed to the point of economic insolvency, the service is simply no longer available. This is precisely why many seniors are having trouble finding a doctor that will accept new Medicare patients and why a growing number of physicians are breaking the bondage of insurance contracts.

Much of what is being discussed in the media about death panels and rationed care is the direct result of the government’s attempts to control costs. In a veterinary clinic the overall cost of any animal’s care is determined not by what can be done as much as it is by what the pet owner is willing to pay for. Needless to say, there are not a lot of animals who receive hip replacements, heart transplants, chronic dialysis or chemotherapy. What makes us think that our healthcare owners will be any less willing to employ this same philosophy when it comes to decisions about your care, or mine.

We are already seeing the effects of the hundreds of thousands of pages of federal regulations on individual choices and fundamental freedoms. This is in spite of the fact the majority of Obamacare hasn’t even been implemented as yet. Starting with the mandate that all people buy health insurance and now mandating that insurance pay for specific reproductive related services is social engineering on its most basic level. What’s next, mandating that every American over the age of 50 get a colonoscopy based on the presumption that it is good for us, and therefore we should just take it?

The constitutionality of the new law is being argued before the Supreme Court of the United States this coming week, and a decision is anticipated sometime this summer. Perhaps the whole thing will be thrown out based on the Individual Mandate and the lack of a “severability clause”, but the outcome is anything but assured. Even if the court finds it unconstitutional, there will be an immediate cry from those who have become dependent on government support, both patients and physicians, to replace it with another version. Eventually, we could still end up with a system much like they have in Great Britain, where healthcare is “free”, taxes are high and rationing is an obvious reality for all those who can’t afford private care.

Perhaps the most troubling and dehumanizing aspect of a government take over of “people care” is the loss of the individual’s legal rights. Unlike private insurance companies, the federal government has “Sovereign Immunity” from litigation in all cases of tort law, unless they specifically wave that right. Quite simply this means that if you are denied care based on a decision by a government board or bureaucrat, you will have no legal recourse.

The framework for the feds to take action that will ration certain types of care was included in the economic stimulus bill of 2009. Tucked inside that bill is a provision to spend $1.1 Billion on research to determine “Comparative Effectiveness” of various treatments. According to Robert Pear who authored an article in the New York Times, February 15, 2009, “The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.”  (Read the entire article) What they fail to say is that this same method has been in use for some time in Great Britain, specifically to assess the relative effectiveness of costly treatments when weighed against the anticipated life expectancy of the individual. At some point you are simply too old to “benefit” from a hip replacement or coronary bypass.

One of the most difficult things that every pet owner eventually faces is the decision about how to deal with those final days. Rover’s cataracts have rendered him blind and he’s no longer able to make it outside to do his business. He’s not been eating, has lost several pounds and seems to have trouble even getting out of his bed. You take him to the vet and then comes the ultimate discussion. He’s had a long and healthy life, and its so sad to see him suffering like this. It really is the humane thing to do, isn’t it? Long pregnant silence… Okay, I guess it’s really for the best…

When you go home you find Rover’s empty feeding bowl and that old bed he slept on for all those years, and you feel bad about your heart wrenching decision for weeks, right? This is only natural, but under “universal people care” don’t expect the government to feel bad. Remember, they don’t love you, they just own you.

Obama: A Modern Day Roman Plebeian Tyrant

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My friend Frank Rosenbloom, MD wrote this piece for “The American Thinker” and I believe it should be read by every freedom loving American. Actually it should be a mandatory part of the public school curriculum, but it isn’t and won’t be anytime soon. Please enjoy:
Obama: A Modern Day Roman Plebeian Tyrant

2012′s Top Healthcare Priority

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For nearly a year now I’ve been writing this blog in an effort to provide one physician’s perspective on the changes that have been occurring in America’s healthcare. I’ve tried to make my points using clever metaphors and logical comparisons to other events, and at times attempted a bit of humor; admittedly without much success. But now is the time for the gloves to come off.

For the last three years my profession and my relationship with my patients has come under direct attack by the leadership of the United States of America. The President and his minions in the Congress have imposed laws and bureaucratic regulations which are systematically demolishing the best healthcare system the world has ever seen. No, it is not perfect, but government regulation of the most personal of all human services is not the way to improve it. In surgery we have an adage, “the enemy of good is better.” In their effort to supposedly improve healthcare in America, they are destroying it.

The media continues to carry story after story of the political maneuverings among those who sit in the halls of power in Washington. They argue about Billions here and Trillions there with apparent total disregard for those they are supposed to be representing. It is difficult to trust any of them. Re-election is the bye word of every politician.

However, there is one individual who is more responsible than anyone for the government takeover of my profession and his name is Barrack Hussein Obama. He is the face of a progressive attempt to seize the rights and freedoms of all Americans by an ever more intrusive federal government, starting with healthcare. It is time for the American people to wake-up to that fact, and I intend to do everything I can to defeat him in the November election before he destroys all I hold sacred.

I’m sure that many will call me a lunatic, fringe right-winger; one who is out of step with the realities of the day. But, let me suggest that such an opinion is easy to spout until you find yourself trying to find someone to treat your sick child or ailing grandmother. There is a reason why the Congress and the Administration and their allied unions are not subjected to the new healthcare law. They know it will result in indirect rationing through physician shortages and long waiting periods for critical services. Two years ago as Obamacare was being debated (if that’s what you want to call what transpired) an amendment was offered that would have included all federal workers under the new law. It was soundly defeated. It is good enough for you, but not for them.

It is vital that the Patient Protection and Affordable Care Act be repealed if it is not found to be unConstitutional by the Supreme Court this summer. It is hard for me to even say the name of the law without being overwhelmed with nausea. But, there is no chance that this law will be repealed if this president wins another term in our White House. Even if the law is declared unConstitutional, he has demonstrated a wanton disregard for the separation of powers as defined by that document, and will undoubtedly attempt to execute his agenda by executive fiat. He must be shown the door by all freedom loving Americans and that includes me.

Don’t get me wrong, I’m not suggesting that Obama is the only problem. I’m only saying that when your house is on fire you try and put out the flames before you worry about replacing the carpeting. Once the current regime is no longer in power, then We the People can get about the task of straightening out the rest of our broken government.

Healthcare War Games

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Nearly 20 years ago, Matthew Broderick and Ally Sheedy starred in the original movie “War Games”, a rather forgettable cold war drama that was remade in 2008. The real star of the first version was a mega-computer named WOPR, War Operation Plan Response, which was programed to analyze the threat of nuclear attack and develop appropriate responses. When a computer whiz kid hacks into the government system in search of the newest computer game. The WOPR computer, which responds to the name Joshua, agrees to play an ultimate game of global thermonuclear war. The game escalates as the kid assumes the role of an aggressive Soviet Union in this virtual encounter with the United States, controlled by Joshua. Problems develop when the Soviet attack simulation appears all too real to the American military brass, causing them to prepare for the ultimate attack.

The drama builds when Joshua locks the humans out of the system and attempts to launch a counter attack against what it sees as a Soviet first strike. In desperation to prevent the actual launch of the entire American nuclear arsenal, the whiz kid distracts the machine by getting it to play another game – tic-tac-toe. He gets the machine to play itself in a flash of hundreds of games, all of which end in a tie. Once Joshua realizes the futility of this game it can not win, it decides to run through all the simulation options available in the game of global thermonuclear war. Attacks and counter attacks are graphically shown, one after the other, with each resulting in the total destruction of both sides. Then, in a dramatic climax, the huge computer display goes black with only a single blinking cursor for several seconds. The machine then types and speaks the statement, “Strange game. The only winning move is not to play!”

As I watched this movie again recently on one of those classic movie channels, I couldn’t help but draw a comparison to today’s healthcare game, in which America’s physicians and patients are compelled to participate. Our entire healthcare system is evolving into one where the payers, both government and private, are seizing total control. Patients and physicians have become mere pawns in this game, which has an annual trillion dollar plus prize going to the winners. For many corporate and government players, healthcare is indeed a game with the goal being either financial rewards or political power. But for patients it is not a game; their individual lives and health is at risk. And for physicians, it is their very profession that hangs in the balance and along with it their time-honored ethics.

This past weekend I attended a lecture by Dr. Jill Vecchio on the impact of the Patient Protection and Affordable Care Act, otherwise known as Obamacare. She spoke for nearly two hours and used no less than one hundred slides in an attempt to provide the audience with some understanding as to the breadth and depth of this new law. The vast complexity of this 2,000 plus page law, as well as what promises to be over a million pages of regulations to implement it, is virtually impossible for mere mortals like us to comprehend. Dr. Vecchio only scratched the surface of this mammoth reform effort, but one thing was perfectly clear; through this law our government attempts to seize total control of all aspects of the American healthcare system, much the way the WOPR computer controlled all aspects of the game it was playing.

The American healthcare system is still the envy of the world based largely on the remnants of the personal relationship that exists between patient and physician. If one takes a 30,000 foot view of what has transpired over the last few decades, not just with Obamacare, but with Medicare, Medicaid, corporate insurance coverage, managed care contracts, capitation plans, pay-for-performance initiatives, physician employment along with a variety of other destructive ideas, it becomes clear what is actually happening. The personal patient/physician relationship is being systematically ripped from the system, leaving it to function just like a heartless robotic computer.

The “Healthcare War Games” being played out all across this nation rely on the active or passive participation of both patients and physicians. Sooner or later the individuals who comprise both of these groups will begin to recognize that their individual and collective welfare is being usurped by others who play the game solely to obtain more power or money. At that point, their screens too will go black, as they recognize the futility of participating in a game where “the only winning move is not to play.”

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com

Renewing the SPIRIT of Healthcare

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Over the last few years much has been written and said about the problems facing physicians within the American Healthcare System. The purpose of this particular post is not simply to further define those problems, but to offer a logical solution. The title of this writing is also the “Mission Statement” of my own practice, and the action being suggested is one I have personally employed.

Throughout the western world, universal healthcare has become a touchstone for the progressive, socialist movement. It is after all, relatively easy to argue that everyone deserves access to medical care when they are sick or injured; it is simply the humane thing for a society to provide. But, once the state defines healthcare as a basic human right, they are then faced with the challenge of allocating adequate resources to ensure that everyone has access.

Proponents of “universal health coverage” argue that there are only two viable choices, either mandate that everyone purchase insurance, as called for under the Patient Protection and Affordable Care Act of 2010, or have a government run single payer system where healthcare is paid for through taxation of the population. But a “one size fits all” healthcare system has proven to be unworkable. Even in mature socialized system such as the National Health Service in Great Britain, a significant private healthcare system has emerged. This is analogous to the rise of private schools in America, despite the fact that public education is available and essentially free to everyone. This is obviously a natural phenomenon based on individual expectations and the will to control one’s own destiny.

Another major challenge to various attempts to manage individual healthcare from the top down is the independent behavior of those who actually provide the care. Government bureaucrats and insurance executives have assumed “providers” can be controlled through financial incentives, corporate directives, or government mandates. What they failed to consider is that physicians will consistently attempt to resist doing or not doing things that are contrary to their training and their professional ethics.

Physicians are by nature inclined to put the interest of individual patients ahead of their own, or those of the payer; a concept that is vital to the establishment and maintenance of a meaningful patient-physician relationship. But in recent years, economic motivations and not so subtle pressures from elements of the “third party payment system” have gradually drawn many physicians away from their most basic obligation, like sailors to a sirens song. Such conflicts have created a loss of practice satisfaction, anger and frustration, and a practice environment where many physicians have opted for an early exit from the profession they spent a lifetime pursuing.

Perhaps the best evidence of this changing paradigm is observed simply by calling a physician’s office to arrange an appointment. The first question you will likely be asked is “What kind of insurance do you have?” Healthcare has become all about payment, yet patients rarely even ask what it costs. The system has insulated patients from the payment process, while at the same time doctors who participate in Medicare and Medicaid, or who work under insurance contracts, have virtually nothing to say about how they are compensated.

So what’s the answer? The only logical solution is for physicians to take the lead by returning to their professional roots. This means independently treating their patients according to their knowledge and training, and then looking to the patient for appropriate payment for those services. The ability to truly serve as the patient’s advocate can only come when the contractual bondage to outside payers is broken. As long as physicians continue to sign contracts with entities other than their patients, their true allegiance will be questioned.

The solution is therefore not an AMA solution, or a legislative solution, or a specialty society solution. It is an individual physician solution, which requires a personal introspective analysis. Such self-examination is certainly difficult and the issues are obviously complex. In the end, each physician must decide for himself or herself whether or not a divided allegiance is being used to “manage” the care they provide.

I’m not so naive as to believe that America’s physicians will suddenly receive a collective epiphany, leading to a mass exodus from the insurance roles. The fact is that most physicians are in one or more business relationships that may prevent them from taking such action. Others will not be willing to risk the loss of their financial security, based on “guaranteed” insurance payment. Thus, for a variety of reasons, truly independent physicians are likely to remain a relatively small minority well into the future. But over time they will differentiate themselves by appealing to those patients who recognize the value and wisdom of controlling their own healthcare decisions.

Some will argue that by opting-out of insurance contracts physicians are actually promoting a two tiered healthcare system. Perhaps that is true, but like it or not some consumers want the opportunity to choose from a group of independent physicians rather than being compelled to accept whomever happens to be “on duty” at the local clinic. Certainly the majority of Americans will continue to accept whatever providers are available through their insurance carrier’s network or government program. But, these two options are indeed complementary in an overarching system which seeks to provide healthcare to everyone according to their own choice.

To meet the expectations of a growing consumer-driven, private healthcare system, independent practitioners must work to re-establish a level of trust that has been undermined in recent years. It is time for a new and more modern independent physician’s pledge; one that considers both the rights of patients and the rights and obligations of physicians. To be relevant, this pledge must address the specific challenges of today’s complex world, while at the same time reaffirm the traditional ethics that made the practice of medicine an honored profession over the centuries.

The Independent Physicians’ Rights and Obligations Pledge outlines a new covenant between physicians and their patients based on “mutual trust, mutual respect and mutual responsibility”. Any physician who is considering breaking the bonds of third party contracts should embrace this pledge as a new contract, entered into directly with each patient whom they are privileged to serve. Each physician should also consider this pledge as their personal commitment to the renewal of their own SPIRIT as they continue to pursue professional excellence.

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The Independent Physician’s Rights and Obligations Pledge

 

As an independent practicing physician I hereby acknowledge my role is central to ensuring quality care for all patients. I further recognize the potentially disruptive nature of outside influences on the patient-physician relationship, including various methods of payment. Through this pledge I hereby reaffirm my unconditional commitment to my patients, my colleagues and my profession, and to maintaining my SPIRIT as a physician.

I pledge, to provide personal healthcare to all those who I am privileged to treat, in accordance with my training and experience with a spirit of Service.

I pledge, to uphold, defend and perpetuate the time-honored ethics of the medical Profession.

I pledge, to conduct my practice with openness, honesty, fairness and personal Integrity.

I pledge, to keep the time-honored patient-physician relationship based on mutual trust, mutual respect and mutual Responsibility.

I pledge, to establish just and appropriate fees for the services I provide, treating all patients fairly and with compassion, free from any third party attempts to influence my professional judgment or Independence.

I pledge to work within the community of physicians to ensure the medical profession remains self-regulating and self-governing with respect to education, training, quality assurance and peer review, according to our time-honored Tradition.

Now, before all who are my witness, I accept and embrace these fundamental rights and obligations freely and without reservation, and declare my willingness to abide by them to the best of my ability.

The Healthcare Bubble

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It appears we live in the age of the “bubble”. The current recession was the result of the collapse of the Housing Market bubble. We know about the Credit bubble in Europe with forecasts of countries defaulting. Then there is the periodic Energy bubble here at home, which surfaces every time there is an increase in Mid-East turmoil. It seems we continually go from one economic bubble to the next, but what about the “Healthcare Bubble”?

Recently my son, who is a college student, sent me an article published in Forbes entitled “The Dumbest Idea In The World: Maximizing Shareholder Value” by Steven Denning. This is an essay on how the American capitalist system is being threatened by the practice of executives manipulating corporate performance expectations on Wall Street, in an effort to maximize the value of their companies’ stock. It is a rather intricate discussion, but the conclusion is that over the last 40 years the focus of CEOs has shifted from their products, customers and employees, to pleasing their shareholders with higher stock prices. This is in large part because top level executive compensation is tied directly to the value of the company’s stock.

As I read through this article I couldn’t help but draw a comparison to what has been going on in the healthcare arena over that same period of time. But, instead of shareholders, the priority parties in healthcare are often referred to as “stakeholders”. They include payers (public and private), hospitals and other facilities, regulatory and certifying entities, pharmaceutical companies, medical device manufacturers, a myriad of management companies and numerous other minor players. Oh wait! I almost forgot, there is another stakeholder group known simply as providers. Each of these entities has contributed in one way or another, and often in combination, to a progressive shift away from what has traditionally been a very personal and individual service, to a “system” where healthcare is now doled out as a commodity, largely to the benefit of the stakeholders.

Jack Welch, the former CEO of General Electric, was once the darling of Wall Street because he was the undisputed king of playing the game of maximizing shareholder value. But after his retirement he apparently saw the light. In a 2009 interview he said, “On the face of it, maximizing shareholder value is the dumbest idea in the world. Shareholder value is a result, not a strategy…” I’d like to paraphrase that statement for healthcare; On the face of it, stakeholders managing individual’s healthcare is the dumbest idea in the world. Stakeholder value is a result, not a strategy.

The movement away from the patient as the center of healthcare has been gradual, but it took a major leap forward with the passage of federal healthcare reform in 2010. The Patient Protection and Affordable Care Act is precisely the opposite of what its name implies. It does little to protect patients, is far from affordable and is more about controlling costs than it is about providing care. The true effect of “Obamacare” is to homogenize the delivery of care, with the various stakeholders lead by thousands of unelected bureaucrats, ultimately determining the who, what, when, where and how healthcare services are provided. Moreover, all this is done under the guise of quality improvement and cost effectiveness. The fact the entire federal government, including Congress, and now countless special interest groups have been exempted from this law should provide ample proof of the undesirable nature of such a system.

While CEOs are, by definition, the ultimate decision makers in America’s corporate world, it is the physician who has traditionally held that role in healthcare, but that is changing rapidly. Over the years America’s physicians, the “Chief Health Officers” for their patients, have allowed themselves to be progressively manipulated by the other stakeholders, who’s strategies and tactics have included various financial incentives, regulatory mandates, credentialing guidelines and the most recent trend, physician employment.

An obvious comparison can be made between the corporate CEO who is compensated based on the value of their company’s stock and a physician whose compensation may be based on the profitability of his or her practices to the hospital or insurance company that employs them. Likewise, if the customer suffers when a company fails to respond to their needs, it is the patient who will suffer when their physician’s incentives are misaligned. To date, the only thing that has stood between the patient and stakeholder mandated rationing of care has been the moral and ethical compass of the physician. Now even that is under constant attack by some stakeholders who view the Hippocratic Oath as an inconvenient or outdated philosophy.

The ultimate impact of shifting incentives and conflicting priorities has been the creation of a practice environment where many established physicians feel trapped. On the one hand they can hold to their traditional values and focus exclusively on their patients’ needs and risk financial ruin, or they can compromise those values and learn to play the stakeholder game. Most are struggling in an attempt to do both, but with little success. Many older physicians are opting out of healthcare altogether, while others are simply focusing their practices on services that are outside mainstream medicine. The supply of young physicians, who are in large measure being trained as “shift-workers”, is insufficient to fill the gap created by early retirements and career changes within the older guard. The result is a growing “Healthcare Bubble” where demand for services will soon outstrip supply.

Not surprisingly, one quick-fix being pushed by various stakeholders is a broad expansion in the scope of practice of various paramedical personnel. There is rarely any mention of the level of competence required to safely remove your appendix or manage your high blood pressure.

Many of my physician colleagues have expressed a defeatist attitude, suggesting that changing the healthcare system is impossible. Again, borrowing from Denning’s article, which quotes Vince Lombardi: “We would accomplish many more things if we did not think of them as impossible.”

Clearly, the first step in getting back to patient centered healthcare is the total repeal of Obamacare. This will only happen if the majority of the population demands it, and that is precisely what the next Presidential election is all about. Should Mr. Obama win another term in the White House, there will be virtually no chance that his version of healthcare reform will ever be repealed. If that happens, the Healthcare Bubble is very likely to burst within just a few years. Healthcare will indeed be “free” to all American’s, but will they be able to find it?

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com

The Medicare Gordian Knot

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In recent months, and for that matter for several years, there has been much said and even more implied by media pundits and government officials about the so-called “Doc-Fix” being debated in Congress. Rarely have you heard anything substantive from the docs themselves; that is until now. Pay close attention, because what follows is the unbridled TRUTH!

The Medicare program payment system for physicians is defined under Part B.  Back in 1965 Medicare was designed to function like any other insurance policy, but just for seniors. Much has changed over the years, and I won’t get into those details except to refer you to an earlier post where the history of Medicare payment is outlined. (“The Future of Healthcare in America” http://www.spiritofhealthcare.com/?p=52) The result of those changes has been to progressively bind America’s physicians to the program through a complex system that now resembles a Gordian Knot.

Here’s how it works, from a physician’s point of view. When you start your practice you are asked to sign-up to be a Medicare provider. Sounds like a good idea, so virtually every doc does just that. In fact, in today’s “job market”, where more and more physicians are being hired as employees of hospitals or large group practices, the employer typically requires the doc to be a Medicare provider.  It is certainly possible to practice medicine without “enrolling” with Medicare, but very few physicians even consider that option, largely because they don’t have a clue what a mess they’re getting into.

The first decision the doc must make is whether or not to accept Medicare’s assignment of benefits for all patients. Medicare refers to those who accept assignment as “participating” providers. But, participating comes with an additional caveat; you also agree to the Medicare fee schedule. Unfortunately there is no way to know what the fee schedule is before signing-up, and there are actually several different fee schedules depending on the part of the country where you practice.

When a claim is submitted, the amount Medicare allows for each code is based on a process known as RBRVS (Resource Based Relative Value System) developed more than 20 years ago. Once a determination is made as to how much Medicare allows for the specific service they will pay 80% of that amount. As a participating provider, the physician can then bill the patient or their secondary insurance carrier, but only for the 20% that Medicare approves but doesn’t pay. Any amount the physician bills above what Medicare allows, must, by law, be written off. This is the definition of price fixing.

The other category available to the physician is “non-participating”, which sounds like it would provide more freedom, but not really. Physicians who decide on this option are allowed to bill their patients for 15% more than the Medicare allowable, but even that isn’t quite as it appears. Medicare adjusts the allowable fees for non-participating physicians down to 95% of what is allowed for participating physicians. So, once you do the math, the maximum a non-participating doc can actually receive, assuming the patient pays the full amount allowed is only 9.25% more than participating physicians. Not many docs opt for the “non-par” status.

On top of these decisions regarding participation, every physician is personally responsible for electronically submitting an accurate claim. Medicare employs a complex coding system known as CPT (Current Procedural Terminology) to determine what they will pay, and there are nearly 8,000 individual codes for all the various services that physicians offer. Each code may potentially be further modified using one of a dozen or more “modifiers”, depending on the specifics of any given circumstance. There are also a complex set of criteria that must be met to justify using certain codes, and if a claim is submitted using a code that is paid at a higher amount than what the doc can document, that is considered “Medicare fraud” and is punishable by a fine of up to $50,000 per occurrence. Needless to say, most physicians tend to “under-code” to avoid a visit from the Department of Justice or the FBI.

There is still another option for docs who don’t want to be bound by the Medicare system and that is to “opt out”. This means you are not recognized by Medicare as a provider, and are free to contract with your patients on an individual basis. To discourage this type of “greedy” and “mean-spirited” behavior, Medicare requires that any physician who opts out of Medicare must remain out of the program entirely for a minimum of two years. During that time it is illegal for the doc to submit any claims to Medicare. Oh, and one more minor detail; if a Medicare patient seeks care from a physician who has opted out, the patient is also prevented from submitting a claim to Medicare or obtain any reimbursement for those services, even if they are covered benefits. This is a convenient way of coercing both physicians and patients to just play by the Medicare rules.

All of this might be tolerable if Medicare payments were reasonable, but in many cases the amount Medicare allows is insufficient to cover the cost of providing the service, and the problem is only getting worse. With growing concerns in Congress about Medicare potentially running out of money, a formula was developed 15 years ago designed to adjust the physician fee schedule annually, depending on how much was spent the year before. It is called the SGR (Sustainable Growth Rate), which is anything but sustainable and is the opposite of growth. Each year since 2002 this formula has mandated cuts in physician fees of between 3% and 5%. However, such cuts threatened the viability of the Medicare program since they would force many docs to “opt-out”. So, on each occasion the Congress intervened at the eleventh hour (late December) to halt the cuts and on a few occasions actually authorize a slight (1%) increase in physician payments.

Over the past 10 years the SGR mandated cuts have accumulated and now call for physician fees to be reduced, across the board, by 27.4%. To repeal the SGR requires Congress to come up with a way to pay for the $220B that is sitting on the books as a debt owed to Medicare, and that is what they mean by the “Doc-Fix”. Unfortunately this is a political “hot-potato” with no easy solution. Or is there?

In May 2011, Rep. Tom Price, MD (R), GA, introduced HR-1700, the “Medicare Patient Empowerment Act” (MPEA), and Sen. Lisa Murkosky (R), AK, introduced a companion bill in the Senate, SB-1042. This legislation would change the physician participation restrictions, allowing docs to independently and privately contract with any Medicare patient for a mutually agreed to fee, specifically for non-emergent services, which might differ from the fixed-fee allowed by Medicare. The reason this bill is called the Medicare Patient Empowerment Act is quite simple. Should the system be allowed to go on as is, Medicare patients will soon find themselves unable to find a physician willing to work for what Medicare pays. Then, if the patient decides to go to an ‘opted-out” physician they will lose the benefits they have paid into for many years. This is quite simply unfair. This bill would solve the problem by “empowering” each patient to use their Medicare benefits however they see fit when seeking the care they need and desire.

So, in the final analysis, what the media should be talking about is not a “Doc-Fix” but rather a “Patient-Fix”. And the Congress should cleave the Medicare Gordian Knot before the entire program deteriorates into total chaos.

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com

With Freedom Comes Responsibility

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How in the world did we get ourselves into this gigantic healthcare mess? Well, it started following World War II when health insurance was offered by employers as a valuable benefit in lieu of higher wages. Americans quickly became accustomed to having their employer provide for their healthcare, and soon this benefit became a major bargaining chip that management used in every negotiation with labor.

But what about the elderly who were subject to losing their employer-based insurance coverage upon retirement? The answer was a Federal Government Program called Medicare. But, what about the poor and disabled? The answer was once again the Federal Government, only this time in conjunction with the States, developing a program called Medicaid. But, don’t we need a special program for children who might otherwise fall through the cracks? The answer again came from the government in the form of the State Children’s Health Insurance Program (SCHIP). Okay, this all sounds very noble and commendable, so what went wrong? The American people have quite simply been duped by those who would assume your responsibility and in so doing steal your freedom.

 

It isn’t just the general public who has been duped. Over the past three decades, physicians have also become dependent on insurance/government based payments. These contractual arrangements use a system whereby allowable charges for their services are established not by the physician, but by the payer. If independent physicians attempt to bargain collectively with an insurance company they risk violating the Federal Sherman Anti-Trust Act. So, as a result, your doctor is compelled to see more patients and spend less time with each one. Some physicians have resorted to offering services that are not covered by insurance, like laser hair removal and botox injections, on a cash basis, just to make a living. I have two friends who are highly skilled and highly trained surgical specialists who have essentially converted their practices into a cash based, cosmetic vein ablation clinic.  The effective loss of their talents to the community of medicine is an incredible tragedy for everyone.

If the systematic takeover of American healthcare is allowed to continue unchecked, within just a few years the entire free market system will cease to exist, replaced by “Uncle Barack’s European style healthcare system.” What’s ironic is how most western European countries are actively trying to privatize their existing socialist healthcare programs, because they promote mediocrity and are financially unsustainable.

Everything our government attempts to micromanage becomes more expensive, less available and of poorer quality. Witness the US Postal Service. So, what’s the answer? First, we must repeal The Patient Protection and Affordable Care Act of 2010 (Obamacare). Then, we, the citizens of this country, must emphatically tell our government to stop trying to dictate to us how we can access our own personal healthcare.

While the Republicans have actively called for “Repeal,” they have been quick to add the word “Replace.” But replace with what, more regulations? We must emphatically tell them NO, unless their new laws specifically eliminate existing restrictive regulations and reestablish a free enterprise system. Any new legislation must include the following principles:

  1. Allow individuals to deduct the cost of their insurance premiums on their personal taxes, the way businesses currently do.
  2. Allow for any person to buy health insurance from any company, in any state, and carry their policy with them wherever they go.
  3. Allow insurance companies to offer “good health” incentives similar to “good driver” incentives to encourage healthy behavior that will ultimately lower the overall cost of care.
  4. Promote “real” health education in our public schools, including specific information about how communicable diseases are transmitted and how specific lifestyles and behaviors lead to costly chronic diseases.
  5. Encourage insurance companies, through incentives not mandates, to offer high-risk pools, which would include coverage for pre-existing conditions.
  6. Allow patients and physicians who participate in existing government programs the right to privately contract for services for fees that may differ from the government established payment without penalizing either party.

Obviously, the liberal pundits will vehemently object, “Wait! We can’t do that! Who will be in charge of ensuring healthcare for everyone, especially those who can’t afford it?” With those words they actually betray their ultimate objective. “In charge of” can be translated “in control of”, and it is that control that must be vigorously resisted. Healthcare is a personal service and is therefore the responsibility of each individual, even if they are considered “underprivileged.” We have systems in place such as Medicaid and SCHIP that serve as a safety net for the truly impoverished and they should be actively promoted as public assistance for those in need. We also have tax supported county and state hospitals, which were originally built to offer care to those who otherwise couldn’t afford private care. But laws like the Emergency Medical Treatment and Active Labor Act (EMTALA) actually discourage their use by those most in need, and it too should also be repealed. We should spend more time. effort and resources educating people who qualify, as to precisely how they can access these existing programs and facilities, instead of trying to convince the entire population of the virtues of a government run system.

Beginning about 65 years ago, Americans started to progressively relinquish many of our rights and our personal liberties to a group of faceless insurance executives who promised us financial security. By allowing the government to complete the take over of the healthcare system we are simply exchanging one set of controls and restrictions for another.

The time has come to break our dependence on “the system” and regain control of this most personal of all human services. Eleanor Roosevelt once said, “With freedom comes responsibility.” That has never been more true than it is today with healthcare. Both patients and physicians must exercise personal responsibility by breaking our unhealthy dependence on the current third party payment system and regain our freedom, lest we will forever become wards and agents of the state.

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com

Thanksgiving

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We tend to think of Thanksgiving as a uniquely American holiday, and in many ways it is. In 1620 a group of English Puritan separatists, after taking temporary refuge in Holland, made their way to the new world on the Mayflower in search of religious freedom. They established the second English settlement at what is now Plymouth, Massachusetts. These settlers, known as Pilgrims, brought with them the European tradition of an “after harvest” feast. The natives of the region also had a tradition of celebrating the end of the harvest season. So, in 1621, history tells us that they feasted together, giving thanks for their crops. But who did they thank?

While the native Americans worshiped the spirit of their ancestors or the gods of the earth, the Pilgrims gave their thanks to the God of Abraham. Every year since then it has been the offering of thanks to our Creator that has made Thanksgiving a very unique and special day throughout America.

Amid all the anger and demonstrations we see everyday on television, and the constant political finger-pointing and accusations by our political leaders, all Americans should step back for just a moment and acknowledge that we are privileged to live in the most prosperous nation the world has ever known. We must also remember that our prosperity is due to the fact that our nation was founded on a faith in God, not in men.

It is hard to argue with those who express their growing concern over a general decline in America. This trend can be traced to our gradual shift away from our foundational belief in a supreme Creator, to a growing trend toward self-indulgence, self-aggrandizement and self-admiration.

As we celebrate the tradition of Thanksgiving, all Americans would do well to rededicate ourselves and our country to the traditional principles that gave birth to our nation; the God-given rights of freedom and liberty. Our Thanksgiving prayer should include the words Abraham Lincoln spoke nearly one hundred and fifty years ago on the battle field of Gettysburg, Pennsylvania, “that this nation, under God, shall have a new birth of freedom, and that government of the people, by the people, for the people shall not perish from the earth.”

Honor Those Who Serve

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This week we pay tribute to our veterans, and rightfully so. Whether you agree with the policies of American leaders from Washington through Obama, the fact is that America’s soldiers, sailors, airmen and all others in support of our military, have consistently fought and in many cases died with honor on behalf of this great nation.

I’m reminded of the words of Alfred, Lord Tennyson in his signature poem Charge of the Light Brigade; “Theirs not to reply, Theirs not to reason why, Theirs but to do and die…” While this is perhaps the most often quoted phrase from this classic work, it is the final stanza that we should all embrace as we celebrate our veterans. “When can their glory fade? O the wild charge they made! All the world wondered. Honor the charge they made, Honor the Light Brigade, Noble Six Hundred.” May all our fallen heroes rest in peace wherever they lay,  knowing their sacrifice was not in vane.

And, may God bless all our veterans and their families for the sacrifices they have made on behalf of, and under the name of the United States of America.