Archive for the ‘Health Care Reform’ Category

My Love-Hate Relationship With Healthcare

March 8, 2016

As a seasoned clinical respiratory therapist and clinical manager with an advanced degree in health care management, I have developed a love-hate relationship with allopathic medicine.

The Bright Side

I love the advanced technologies and medical interventions that can change and literally save lives.  Many times, I have been part of an emergent health care team employing such advanced technologies and medical interventions in various life-threatening situations.  I have witnessed seemingly miraculous recoveries—people virtually coming back to life when none of us thought it possible, or at the very least, probable.

Years ago, I participated in the mechanical ventilation of a patient, who for several weeks had been virtually on the verge of death—showing no signs of cognitive function, which was confirmed by multiple unpromising EEGs suggesting irreversible brain damage.  Then (and this is not typical), when all hope was gone and everyone knew it was way past time to pull the plug, a glimmer of consciousness appeared.  Slowly, day by day, we watched his life return.  First, his eyes began to make contact with ours.  After a week or so, his eyes began to follow us as we walked about the room.  Within a couple of weeks his eyes began to respond to our questions.  Then his head began to move, and one day, he mumbled a few words.  Soon he was talking.  Eventually, he walked out the door.

A few years before that I participated in the nearly hour-long CPR of a 12 year-old girl, whom, it was believed, had an allergic reaction to anesthesia.  After exhausting every possible option without results, her condition continued to deteriorate until her heart simply would not beat at all, not even erratically.  At last, we were mere seconds away from giving up; the discussion to cease our efforts had already begun, when suddenly her heart began to beat with a regular rhythm.  She has since grown into a beautiful young lady.

More than twenty years ago, I managed the ventilation of a middle-aged man ravaged by disseminated intravascular coagulation (DIC); it was to a degree that none of us had ever seen, consuming every limb and much of his torso.  We all knew he could not survive.  Days turned into weeks and somehow he was still hanging on.  Then he started getting better, the DIC reversing.  But after several days of promise he suddenly took another turn for the worse.  Again the DIC started to spread, though not as extensively as it had the first time.  Once again his condition looked dire; and then, after several days, the DIC began to reverse again.  He was eventually discharged, minus one leg.  I watched him hobble to the car on his new crutches.

Many medical procedures and medications are all but miraculous; and, as one who administers some of these services, it is an honor to be part of them.  I love that part of medicine.  I also love the genuine compassion and personal sacrifice on the part of the caregivers.  Most doctors, nurses and therapists of various disciplines, enter the medical field with a true desire to help, to make a difference in society.  Through the years, I have watched many of them weep (I have wept) when faced with the realization that nothing more could be done for their patient, and death was imminent.

I have heard physicians chastise uninsured patients for neglecting their office visit simply because they had no money to pay for the service.  They would assure the patient that their health was more important than the ability to pay.  I knew one physician who paid the cable bills for several of his nursing home patients because they could not afford it themselves.  I love that part of medicine, the human part, the empathy, the concern, the desire to make a difference.

The Dark Side

But there is also a part of medicine that I hate.  It is the dark side.  It is ever before us but seldom discussed; and it runs deeper, far deeper, than the benevolent bright side.  It is the white collar criminal element, endemic, even intrinsic to the system.  Without this element the current system (even under the Affordable Care Act) would simply implode.

I hate the misinformation, the widespread misallocation of resources and the fraud upon which the system is structured.  But this is only one aspect of this convoluted system, for it is broken at virtually every level.  In the following pages I attempt to peel back these layers and expose this system for what it is.  Some harsh things are said about the system, and consequently, about physicians; but I want the reader to understand this is not so much a condemnation of physicians as it is of the system of which they (and all of us really) have necessarily become a part.

As for the hint of sarcasm and cynicism strewn across these pages, it is not without cause.  From both a professional and a personal vantage point, through the years I have developed a very healthy sense of skepticism toward the dogma of allopathic medicine (western medicine).  For both your personal wellbeing and your financial stability, I would advise you to do the same.  Barring a relatively few and some nearly miraculous procedures, the majority of services provided by allopathic medicine are anything but honorable, or even necessary for that matter.  Not that particular services or procedures are themselves without value, but their superfluous and careless use, whereby they are employed without sufficient cause are, indeed, without value.  Not only does this create additional expenditures, it fills the patient with false hope and misinformation.

Having carefully considered the many troublesome layers to America’s health care system, I believe I have the answer to this dilemma.  The solution does not reshape the system but replaces it all together.  And I do mean altogether, the clinical as well as the fiscal elements.  However, I truly doubt those legislators with the power to fix this debacle seriously want to know the cure.  The cure is not a matter of resources but a matter of clinical reform—a reform that must initiated via legislation. It would be controversial legislation for it would affect one of Capitol Hill’s greatest lobbying groups: the pharmaceutical industry and its plethora of dealers—AKA, medical doctors.  Therefore, I suspect the cure is not welcome.

Furthermore, this work indicts the American medical establishment for its conscious and unethical neglect of promoting health; and, even worse, for actively engaging in the destruction of the same, by ignoring and even opposing proven natural therapies while promoting useless, yet profitable, medications that it might advance its own self-serving agenda of self-preservation.  Although many physicians at the clinical level might be excused for unwittingly disseminating misinformation, the medical establishment which knowingly advances this misinformation cannot; and be not deceived, this medical establishment is a very real and elite society of powerful movers and shakers within, or closely tied to, the pharmaceutical industry, which is the driving force behind our health care system.

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Congress Has No Desire To Fix Our Broken Healthcare System

March 8, 2016

America’s health care system is broken and nothing Congress has done, is doing, plans to do, or has even debated, will fix it.  The fervent arguments from either side of the isle are fallacious; for neither address the crux of the matter.  It is not who should have access to health care, or even how to pay for it; the issue of concern must be the health system itself, which is grossly bloated with misallocated resources and fraudulent services.  So that (and I say this without hyperbole) the vast majority of dollars spent on health care pay for an unimaginable volume of absolutely unwarranted doctor’s office visits, medical tests, hospitalizations, and medications that accomplish little more than to fill the coffers of service providers.

The health care system is not merely riddled with overutilization, misallocation, and fraud, but these form the framework upon which the entire system is built.  These are the foundation of the medical economy.  If taxpayers knew the extent of superfluous, gratuitous and fraudulent health care procedures and services I am certain they would force politicians to fix it.  It is so bad that if politicians truly understood the degree of waste and fraud, they might even be tempted to fix it themselves.

I submit that the health care system itself is sick, terminally ill. Like an irreparable myopathic heart, hopelessly destroyed by disease, no amount of money can cure this sick system.  More personnel cannot cure it.  Better trained clinicians cannot cure it.  It needs to be replaced.  It must be cut away and a new system put in its place.  Herein, I suggest a viable replacement, a new system that would provide necessary health care to all.  But it will take an act of Congress, for many laws concerning medical service providers and reimbursement for medical services must be changed.  The current medical system will fight it to the bitter end. So too will the medical malpractice trial lawyers, for the cash cow from which both of them suck will be removed.

One day, in my frustration at a couple of physicians admitting more patients to the hospital (unnecessarily so) and writing useless medical orders for unwarranted services,  I said, “If we would only admit truly sick patients to the hospital, and only provide the services that were necessary, the whole country could have affordable health care.”

One of them responded, “I know, but everybody wants their money: the doctors, the hospitals, the pharmacies; everybody wants to make money.  We have to do this to keep the system going.”  They both chuckled, brushing it off as if it were merely a game they played.

With more than four decades of clinical and managerial experience in the medical system, I am speaking out, blowing the whistle, and biting the hand that feeds me.  Not that I haven’t spoken out before.  Indeed, I’ve been speaking out for decades, writing articles, doing radio shows and even writing a previous book on the topic.  But in light of the newly passed legislation of the Affordable Care Act, I felt I had to speak up yet again because this monstrosity of a mess is merely going to increase the already bloated system of misallocated and fraudulent medical service.  I hope someone listens.

Hopefully, at the very least, these blogs will cast enough light on the severity of this fixable problem to get people thinking and talking about it.  Reader’s Digest often publishes an article entitled something like, “Twenty Things some profession Will Not Tell You;” and they have published one about physicians.  But they left out the most important one, which virtually every physician knows but will absolutely not tell the public.  “If they provided only that medical care which is necessary and beneficial, the total cost of quality health care in America would be a very small fraction of the current exorbitant cost.”  The problem is that such a practice would put most of them out of business.  It is the current high volume of unwarranted, superfluous medical services (provided largely to the minority of the population) that keeps their practices thriving.  The foundation of America’s healthcare system is rooted in this sanctioned waste fraud and systemic abuse.

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Lower Taxes and Provide Universal Healthcare

September 7, 2009

True healthcare reform must start at the clinical level.  The medical system itself is broken and no amount of money alone, from any source, can fix it.  After briefly identifying certain clinical issues that must be addressed, I propose the specific financial and clinical reforms that could solve our national healthcare crisis.  These reforms would reduce the present tax burden while simultaneously providing free hospitalization and catastrophic healthcare coverage to every American.

The combined volume of conveniently over-utilized to blatantly fraudulent services — spawned by our convoluted pay-per-service reimbursement paradigm, controlled by virtually unregulated medical doctors — has created a medical system that knowingly exists and even thrives on the misappropriation of resources.  So that the over-utilized/fraudulent services of this obscenely bloated system far outweigh the relatively small volume of useful and essential services it provides.

Unfortunately, what Congress is presently debating is merely how best to fund the acquisition of more sour grapes, when the issue should be how can we dispose of the sour grapes and eat only the good?  In its present form, the more money we throw at healthcare, the more gluttonous it will become for the sour grapes.

You will not hear these truths from the AMA or any other physicians’ group.  They are so ingrained in and dependent upon these over-utilized/fraudulent services that asking their advice on reform is like asking a committee of foxes how to fix the hen house.  But there are individual physicians and nurses and therapists who speak up from time to time; essentially marking themselves as whistleblowers.  As a therapist with three decades of clinical experience and a PhD in health administration, I know firsthand how the medical industry is fleecing America with countless misallocated diagnostic tests, inappropriate treatments and superfluous hospitalizations of “patients” whose primary problem is having shown up for a doctor’s visit on a day their doctor had a few hospital beds to fill.

Over-utilized and Fraudulent Services

An effective healthcare reform must address the following clinical issues.  Any attempted reform that avoids these issues will merely complicate and worsen the problem.  First on the agenda are the vast majority of medical services ranging from menial to completely unnecessary.  For example, most doctors’ office visits are for frivolous matters such as post nasal drip or a common cold.  At the same time, the vast majority of hospitalizations are just as frivolous, even fraudulent; with far too many patients admitted for a wide range of general symptoms or conditions that could easily be treated at home.  Or just as fraudulent, patients are hospitalized with an untreatable, end-stage disease that should be treated with palliative care by the hospice system, or simply in a nursing home.

Most hospitalized patients (both those who merely have the misfortune of visiting their physician on a day hospital beds needed to be filled, and those at the end of their life who simply need the palliative care of hospice) will endure a series of unnecessary tests; tests that require a physician’s interpretation, which, of course is a separate billable item.  And of course they will receive a daily visit from their physician (another separate and quite costly billable item), and probably even get a consult visit from a specialist (another costly billable item).

You do not have to be a physician to recognize questionable routine practices such as daily serial EKGs on a 92 year old suffering severe and chronic dementia.  Although the physician only receives $10.00 for each EKG interpretation, when we consider that even in a small rural hospital this may total 30 to 50, largely unnecessary, tests every day, we realize this is a considerable sum.  Especially once we know the physician’s interpretation might merely be dictated from the EKG machine’s automated analysis.  Without his knowledge, I once timed a physician as he interpreted/dictated 33 EKGs in less that three minutes.  That translated into $330.00 for less than 3 minutes of reading.  Later that day he had another stack to “interpret.”  This happens daily in every hospital and clinic in America; and EKG’s interpretation is the least lucrative fee of the many tests that require a physician’s interpretation.  Other studies such as PFTs, EEGs, ultrasounds, MRI’s, sleep studies, CAT scans and numerous other x-rays, each command an interpretation fee above and beyond the cost of the test, some fees being hundreds of dollars.

Preceding the interpretation are many tests and test facilities that are totally worthless; nothing short of perpetual scams perpetrated on the American public.  Like any good scam our healthcare industry provides just enough truth and reality to make it appear legitimate; but behind the white coats and closed doors, at both the administrative and the clinical levels, is a world of deceit and fraud.  Not that the fraud is overtly illegal (most of it anyway); but it is definitely overtly unethical.  And it is not that the primary players have conspired to perpetrate this scam; not that most of them are even aware of their involvement.  But the scam is there none the less, with many of the perpetrators themselves being willingly deceived; for after all, it is their livelihood.

Two examples of many such scams are the Sleep lab and the ill-equipped cardiac cauterization lab; both of which exist to meet the needs of special interest lobbyist, not patients.  Sleep labs, for example, are lavishly designed to record EEG readings to determine the presence of sleep apnea.  A worthwhile cause except all that is really needed to make a definitive diagnosis is simply to watch the patient sleep while recording his/her oxygenation level with an inexpensive pulse oximeter; or even easier, just ask the patient’s spouse if he/she has periods of apnea while sleeping.  CPAP machines, used to treat this condition, have an automatic mode, which dynamically adjusts settings to the patients need; so that no one, not even the physician, needs to determine the optimal setting for treatment.  Even worse, for they can be lethal, is the multitude of minimally equipped cardiac cauterization labs throughout the county.  I say minimally equipped because they are not prepared, either with the necessary equipment or the necessary surgeons, to provide subsequent treatment, if necessary.  Here, the procedures are merely elective and explorative; and very dangerous.  If a condition is found that needs treatment the patient must be sent, often by ambulance, to a facility that can actually provide treatment; once, of course, the procedure is repeated.  Needless to say, none of the staff, or their family members, at these facilities would consider having such procedures done at their own little lab.  They would go straight to the facility that could treat them.

Then there are the now ritualistic, mostly useless, and always expensive, heroic procedures that nearly every dying person must endure.  While these procedures can work quite well on certain patients, they do not work for everyone, or even most everyones.  The fact is they seldom work at all; and when they do work it is on relatively health patients who happened to suffer a sudden injury of medical mishap.  They definitely do not work well on those for those with advanced end-of-life degenerative diseases, nor advanced diseases involving multiple body systems.  In the end the extraneous and misallocated use of these procedures is a gruesome and unethical process that does nothing more than offer cruel and false hope to the patients and their loved ones, while filling the pockets of the “caregivers”.   Our modern technologies are amazing, but they are not appropriate for everyone and thus have created some decidedly ethical issues.  We must come to grip with the fact that these technologies need not be employed in futilely simply because we have them.  As amazing as they are, they cannot stop the dying from dying.

Herein lays the single most important issue for resolving America’s healthcare crises; putting an end to abuse: from frivolous offices visits to unwarranted hospitalizations and the over-utilization and misallocation of advanced technologies and diagnostic procedures.  While a fraction of modern medical services are essential, the vast majority of allocated services are unwarranted and even useless.

Pharmaceutical Gatekeepers

The second clinical issue of concern is the role of the largely useless pharmaceutical gatekeeper (i.e. the physician).  Although many patients already know what medication they need, they must still go through the legislated and nothing less than bureaucratic hoop of seeing the pharmaceutical gatekeeper for a prescription.  Up to 70% of the gatekeepers prescribe what the client asks for.  Those patients who do not know what they need, if anything at all, can find out from many sources other than the mandated gatekeeper (who by the way misdiagnoses from 40% to 60%60% [i]  of the time and can make incorrect prescriptions up to 71% of the time). [ii]

Indeed, as we see in the next point of discussion, well-informed patients often know more about their condition than does their physician.  Forcing everyone to conform to the ritual of seeing the pharmaceutical gatekeepers is an enormous waste of cash that largely does little more than feed the foxes.

Medical Education

The third clinical issue of concern is the absolutely inept medical education provided by all medical colleges; including the big name schools.  While there are some very skilled surgeons and diagnostic physicians, this is not the norm.  They are indeed the minority among their peers.  And they will gain their skills and advanced knowledge after medical school, not during it.

It is not merely the previously mentioned, ill-equipped, cardiac cauterization labs that hospital staff members in-the-know avoid for their personal treatment; such staff members also avoid the majority of physicians on staff.  In many facilities, if said staff members have a serious medical condition, they are likely to avoid the entire medical staff and seek treatment elsewhere.  Unfortunately, they are not allowed to alert or worn patients with their inside knowledge.  No matter how inept a patient’s physician might be staff members must bite their lip, put on a good face and promote confidence in the physician.  The stress of this daily thespian role when other’s health and even lives are at stake causes many simply to leave the medical field altogether.

As demonstrated by Abraham Flexner’s 1910 report, the pitiful state of the medical education model is well known.  Because of his scathing report medical schools were eventually attached to the universities.  Unfortunately, while a general university education was added, nothing significant in the actual medical education changed.  Medical school lasts no longer today than it did more than 100 years ago (even before surgeons realized they should wash their hands between surgeries).  And admission requirements for most medical colleges are minimal at best; none requires a master’s degree and most do not even require a bachelor’s degree.  Except for the 25 or so medical colleges that actually admit students directly from high school, admissions requirements generally include a few years of college with a few specific science classes and (barring the competitive big name schools) an ever so modest GPA – a GPA that would not qualify for most master’s degree programs.  And a requisite GPA for graduation is virtually none existent; in that most medical schools have converted to a simple satisfactory/unsatisfactory grading system.

Due to the inferior and incomplete nature of the medical education, graduates are necessarily incompetent; and sadly, most doctors seldom bother to learn much more than that which was required of them in medical school.  All medical schools (including the big name colleges) have virtually the same program: two years of rote memory (this is the extent of the academic learning), and either one year or two years of clinical clerkships (basically, job shadowing).  Now they graduate and become licensed physicians.  The subsequent year of internship (little more than a fraternal hazing), and a few years of residency (on-the-job-training) in a teaching hospital are served as licensed professionals being paid (albeit meagerly) for their services.  Like all OJTs their primary objective is production verses education.

Medical knowledge has advanced far beyond what was known when Flexner submitted his report, but still medical college is the same meager two years of academic work and one or two years of clerkships.  Today, the physical therapist has a doctorate degree with more postgraduate academic education than does the medical doctorate.  So too does the pharmacist with his requisite doctorate.  Even nurse practitioners, with master’s degrees have as much or more postgraduate academic education as the medical doctor; yet merely due to legislation, certainly not expertise, the MD continues to control healthcare; and, as previously mentioned, in a virtually unregulated process.

Because the primary purpose of the medical degree is to train pharmaceutical gatekeepers, evidently it is deemed that further education is unnecessary.  The current nature of this role satisfies the system: diagnose, prescribe a pharmaceutical, bill for services.  Correct or incorrect, the diagnosis and prescription seem secondary to the act itself.  As a result litigation is rampant; and it is not all or even mostly frivolous.  Largely, it is for good cause.  Medical error is one thing; medical incompetence is another, and it abounds.

For example, and on an admittedly anecdotal note, I once suggested to a physician that we ship his very sick early middle-aged patient to a larger hospital, a medical center that would be better equipped to deal with the ARDS.  He replied, “No, it wouldn’t make any difference, we (i.e. physicians) are all just guessing, none of us know what we are doing.”  Now you might think this is an isolated case, but from more than thirty years experience in critical care I can tell you that other than the use of the superlative modifier “none” he was largely correct.  Literally, most physicians have no clue as how best to treat ARDS; but there are some scattered around the country with established strategies that, although not always successful, certainly increase the patient’s chances of survival.  Needless to say this particular patient was not one of the survivors.

 

Proposed Pharmaceutical Reforms

I propose healthcare reform should take place in the following manner.  First, deregulate pharmaceuticals.  Other than narcotics and certain concentrated poisons, patients should be able to treat themselves if they so choose; thus, making a patient’s visit to a pharmaceutical gatekeeper largely optional.  Simultaneously, pharmaceuticals should be made readily affordable; largely by opening up the free market.  Shorten the current length of pharmaceutical patents.  Do away with all patent renewals; and refuse additional patents for minor variations and additional uses of an already patented drug.

Proposed Medical Doctorate Reform

Secondly, to take care of the truly critically ill and patients in need of hospitalization, a genuine academic doctorate of medicine must be instituted; perhaps the MD, PhD CC (doctor of medicine, doctor of philosophy in critical care).  This advanced degree would require another 4 years of intense academic and clinical work beyond the present minimally educated MD.  These MD PhD CCs would take care of the critically ill and hospitalized patients while the MDs cared for the lesser, common conditions of those who chose to see them.

Proposed Reform to Achieve Optimal Care

Thirdly, to contain over-utilization and promote optimal care, hospitals would pay the MD PhD CCs handsomely for their time; versus the current system that pays MDs handsomely for their piecemeal, individually-billed services, which fosters fraud and over-utilization.  And just as important; proven medically effective protocols (for both hospitalization and treatment) would be instituted to replace the historic and often haphazard physician’s-personal-opinion method of medical treatment.  These protocols would be constructed by and subject to a centralized peer review panel consisting of experts form several disciplines within the medical community: physicians, nurses, therapists, economists, administrators and ombudsmen.

Hospitals would be reimbursed solely by federal funds.  However, it must be noted that by arresting the volume of over-utilization and fraudulent services (which currently account for the majority of care provided), the requisite funds would be substantially less than the present cost.

If they so choose, for an out of pocket fee (or a privately paid insurance fee) patients could consult private physicians, or nurse practitioners, or nutritionists to attend to their lesser and common medical issues.  However, because most pharmaceuticals would be accessible to the public, these visits would be optional.  And because no federal funds would be available to these practitioners the market would be competitive and affordable to the average citizen.

Thus, the savings realized from appropriate utilization and public access to affordable pharmaceuticals (without having to see the gatekeeper), would lower the current tax burden while permitting everyone to receive free catastrophic healthcare and hospitalization.

To implement this reform immediately, a coalition of prominent physicians and surgeons from major universities and hospitals, could select those physicians and surgeons to be grandfathered in as the first of the new breed of MD, PhD CCs.

Conclusion

The aforementioned reforms would improve the entire healthcare industry on all fronts.  Standardized protocols, implemented by physicians truly trained for the task, would maximize care to hospitalized and critically ill patients, contain cost by preventing over-utilization and outright fraud; and decrease frivolous as well as legitimate litigation.  Allowing the public to take charge of their own health by providing affordable and accessible medications without the bureaucratic approval of a pharmaceutical gatekeeper would revolutionize our national health status.  Most people are not stupid; and the argument that physicians must supervise the prescription of medications is old and worn out.  As evidenced by traditional and current medical practice (that is virtually incorrect as often as it is correct) physician control is clearly not an efficient or effective model.  In all, the implementation of such reforms would drastically change both the economics and the quality of healthcare for the better.

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ENDNOTES


[i]. Kirch, Wilhelm and Schafii, Christine.  Misdiagnosis at a University Hospital in 4 Medical Eras Report on 400 Cases.  MEDICINE. 1996;75(1):29-35.

[ii]. Chassin, Mark R, Galvin Robert W.  The urgent need to improve healthcare quality.  JAMA 1998 Sep;280,11,1000, p. 1004.