Archive for the ‘Medicare’ Category

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.

Debunking The Healthcare Debacle - biting the hand that feeds me

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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.