Nurses are a lot more powerful than they were 30 years ago and they were the noncoms of medicine even then. You alienated them at your peril even then. My niece is an OR nurse in a big Chicago hospital. She decided not to apply to medical school because she did not want the debt and the income is not that much less. She has degrees from U of I and Loyola and the nursing school was very happy to waive her tuition. She would have been accepted to most medical schools. She is happy with her decision. She and her boyfriend also have a successful rock band.

I have attended meetings on lean methods. One such organization is Lean Healthcare West which will go into a hospital and conduct training sessions. The biggest roadblock is the hospital culture which is very resistant to outside advice.

http://www.leanblog.org/

The blogger, Mark Graban, gained extensive experience in manufacturing before shifting his writing & consulting focus to healthcare.

I spent years on the board of the Medicare peer review organization, called CMRI, and one time we were trying to figure a way to diversify the customer base for the company. If you have one customer, you have little leverage. Anyway, we sent a letter to the state DHS which administers the MediCal program asking if they had any interest in contracting out any services, like quality review. They did not have any interest and it went no farther but I did learn that the state DHS had over 5,000 employees. That was more than HCFA had to administer Medicare. That was 15 years ago. Medicare at the time had about 20 times the enrollees.

If an insurer (especially the self-insured companies) want to speed things up (such as ordering an MRI sooner rather than seeing how a patient responds to a rehabilitation-based approach), the system allows for this. Well-designed treatment guidelines do control cost and usually reduce inappropriate treatment, so the system isn’t all bad.

The difference is that the Colorado workers’ comp system uses private insurers, rather than paying for treatment out of state coffers, so the Colorado guidelines place treatment decisions at arm’s-length from payment obligations. The feds, on the other hand, make both the guidelines and the payments, through Medicare (now) and the so-called public option (perhaps in the future)–a typical fox/henhouse scenario.

The reason that there isn’t one fee for Medicare, insurance companies and private pay is that most practices lose money on Medicare. Just think of it, Medicare pays $193 for a colonoscopy. A colonoscopy, from start to finish takes about an hour. That is an hour that a room is being tied up that can’t be used for something else. It has to pay a highly trained physician, a nurse who is trained in administering conscious sedation, the monitoring equipment, the colonoscope, the sterilization equipment, the ancillary personnel who check you in, the billing personnel, the recovery personnel, buying and laundering patient gowns, the drugs used for sedation, the overhead for the office, etc. I think you could probably understand why $193 doesn’t begin to cover the actual cost of the procedure.

This is why so many practices have stopped accepting Medicare. The fact of the matter is that private pay patients and insured patients subsidize Medicare patients. The Medicare rate is fixed by the government – to charge more than the proscribed government rate to a Medicare patient is Medicare fraud. Incidentally, Dr. Kennedy is absolutely correct, for a Medicare provider to charge less than the Medicare rate (e.g. – free services to the poor) is also Medicare fraud. My father was a general practitioner for years. He used to provide free care to clergy and their families and he would donate his services at a homeless shelter. When, during the Clinton administration, the Medicare rules were changed to prohibit this, he’d have to tell his patients that he was required to send them a bill, but he didn’t expect them to pay it. Of course, in doing so, he was committing Medicare fraud.

In fact, if I read a CT scan with contrast, but forget to mention that contrast was utilized and my billing office underbills it as a CT scan without contrast, I am committing Medicare fraud. (There are no mistakes. Every deviance is considered fraud.)

Don’t even get me started on the intrusion of the government into the practice of medicine and all the pitfalls of the proposed electronic medical records.

Like Woodward & Bernstein, the Occam’s Razor principle applied to determining political motive says “follow the money”.

Already doctors are coerced into using electronic medical records to track “outcomes” and “quality,” to prove to the government they’re behaving the way the government commands. The logic is inescapable. Medicare or Medicaid or some agency is paying medical bills. To be sure they’re getting their money’s worth, agencies demand doctors measure the “quality” of care. What is quality? “Quality” is matching some easily measured statistic with a target. A target some smart guy in DC came up with. A federal employee has decided what your cholesterol should be, and he’s given your doctor a target, an overall average cholesterol for your doctor’s patients.

So you and your doctor are free to discuss the costs and benefits of your cholesterol control, and decide the treatment that’s right for you. Only, see, if your doctor’s patients, on average, fail to meet the government target, your doctor is punished financially. So how free are you, really?

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President Obama say’s he’s going to mandate all medical records be electronic. The doctor in the Denver ER can supposedly access your records back in LA. Who could argue? What the headline misses is, the EMR isn’t a .pdf scan or a text file. It is a database. Let that sink in. A database. Every symptom you have, every lump on your body, every diagnosis you have ever had, every drug you have ever been prescribed and every drug you have ever admitted taking, every sexual secret you whisper to your doctor is going into a database. In a computer. With a wire. Connected to Washington DC. But they’ll never look. Promise. OK they’re already looking. But they won’t look at your name. Promise.

Two things about this.

#1. If the government is paying for something, the government will regulate it . Anything your doctor knows about you can be regulated. Your smoking. Your weight. Your trans fats. Your alcohol. Your seat belt use. Your exercise. Your bike helmet use. Your gun ownership (a standard yearly physical question nowadays). Your sexual activity. The National Health Agency will set targets. The healthcare company your doctor works for will meet those targets or its payments will be cut. Your doctor is about to become the government’s agent in enforcing encouraging lifestyle regulations suggestions.

Consider the Keith Emerich story http://www.getmadd.com/DontDrinkatHome.htm I’ve read (but can’t find the blog again) that the medical board approved the doctor’s action. Nationalized healthcare will leave us with Emerich’s choice: do we admit our habits and risk being reported to the state and punished, or do we keep our habits secret and risk our doctor missing and not treating important diseases.

#2 The non-computer costs of electronic medical records are staggering.

a) With an EMR the doctor’s opportunity costs are high. Detailed data entry must, by regulation, be done by the doctor. Particularly primary care doctors must now spend much of the day as data entry clerks. The shortcuts and workarounds for this make the “facts” in the medical record unreliable. They make medical care worse.

b) The business killer is regulation compliance costs . Now that the government can measure everything, they can regulate everything. For example, one regulation says doctors must have a language translator available for every patient. California’s state guidelines for language translation services are 112 pages long. Another regulation: if you’re overheard saying a patient’s name in the elevator, you can be fined and go to jail. Translation. Elevator speech. They plan to micro-manage everything.

Practicing medicine this way cannot be done. It is literally not possible. It is simply not possible for small medical offices, particularly primary care offices that generate lots of paperwork, to comply with industrial level regulation. The kind of small office primary care doctor you and I grew up with is being regulated out of business. Which is probably why in the US now, today, half the doctors in primary care training are foreign medical graduates.

It seems to me that the best way to make medical care affordable is to eliminate Medicare. People who do not have insurance have an enormous freeloader problem which is Medicare and its 90% discounts.

I have Medicare and I know that the premiums I pay per month when combined with the premiums I paid since 1965 when I was 23 are enough to pay my medical bills (including my stroke and open heart surgery) even if I paid twice what medicare pays or even if I paid the same as BCBS. I am sure the same is true of everone who is currently forced to use Medicare.

Hoping to capitalize on patients who might otherwise go to the U.S. for speedier care, a network of technically illegal private clinics and surgical centers has sprung up in British Columbia, echoing a trend in Quebec. In October, the courts will be asked to decide whether the budding system should be sanctioned.

The ruling supported the clinics. I also know of many Canadians who have US private insurance. Spokane has four big medical centers. They aren’t all for the northern Idaho population. Just like Mall of America is not just for local residents.

Michael Kennedy – I learn so much from your comments! If more physicians are taking themselves ‘off the grid’, I wonder how long it will take for requisite authorities to notice, and then, tax said behavior(even more)?

Tatyana – that was the point I was getting at; we are adding another layer of distrust to the relationship. Already, it’s not healthy. As this thread shows, lots of people are unhappy. I’m not defending the current system so much as pointing out the problems with the supposed ‘fix’.

Mrs Davis – I miss living in the ‘stix’ sometimes, too, but that’s mainly related to noise and traffic….

Charles Silver – I think distrust exists in all systems, because as a physician, you implicitly ask for trust. “Trust me to treat you.” The amount of distrust, and the object, changes depending on the system.

Jimbino – I agree with you, actually. I feel ashamed every time I pass a Health Care Clinic in a CVS, or other drugstore, and think this all should have started earlier, and be championed by the standard medical organizations.

Sol Volason – what happened is that it all got so complicated, by historical accident and willfull regulation. Well, that’s my opinion.

Anonymous – Ha!

Laura(southernxyl) – it sounds cliched, but you have to be your own best advocate. I instruct patients to keep careful copies of their own medical reports (I work in the lab) and not to rely on anyone else for this.

Thanks again for the comments!

You are damn right that I experience “distrust”.

Tatyana’s right, you have to be your own doctor. I been knowing that.

Anyway, the DRG system came in in 1986 and hospitals went to flat fee payment for Medicare. They continued to produce “retail” bills for private insurance but private insurance soon went to negotiated payment using the Medicare model and the DRG schedule. The retail bills survived but meant little for most of their business. The insurance companies were in competition with each other and the bigger “discount” off the retail price they could get, the better they were in competition with small competitors. One place the retail bill survived is in outpatient surgery. Since the DRG did not apply to outpatient units, hospitals quickly built outpatient surgery facilities. Soon, negotiated prices took over here but with a twist. Many of us have high deductible insurance with a typical 20% co-pay.

Let’s say we have a bill from the surgery center of $8,000 for some procedure. Our 20% co-pay is $1600. The insurance pays “the rest.” What do you think the rest is ? Probably less than your 20% co-pay. That’s one reason why it is so difficult to find out the retail price. You might be unhappy to learn that your 20% amounted to more in real dollars than the “80%” paid by your insurance.

This is a complicated business and some of my information is out of date but my wife is an OR charge nurse and I hear all her stories plus docs still gossip about things. The pricing system has become so distorted that the incentives are all screwed up. That’s one reason why so many docs are just dropping quietly out of the system. Most of them are older and have established practices and have probably gotten enough commitment from patients that they know it will work.

New docs are out of luck.

I assume in Jimbino’s case that the $4500 colonoscopy is the price for people without insurance, that $1930.00 is the “profule” fee and $193 is the 90% off medicare price. What keeps MDAnderson from charging $193 to people without insurance? Is it against the law?

In the 1950s doctors had 1 true price and that was what they were paid. But if you were poor you got a discount. Hospitals did the same.

What happened?

I assume you realize that MD Anderson will not be paid $4500 by Medicare. If MD Anderson lowers its cash price to $193, Medicare will change their profile fee to that amount, then discount it 90%. This is part of the problem with HSAs. Honest prices are not allowed. The doctors who are dropping out of Medicare are adjusting their prices to the real payments they have been getting and lowering their overhead by eliminating the staff that fought with Medicare intermediaries for months and years to get paid. Medicaid in California, when I was still in practice, took about two years to pay and the payment was about 20% of the private payment.

The HSA user must submit all the claims through the insurance to get the insurance discounted price. That removes the benefit of decreased administrative costs. In fact, the insurance companies that slipstream behind Medicare, firmly resist any attempt to determine real prices as they consider the discounts to be confidential corporate information. My last year in practice, I had 276 contracts with different entities and they all had different payment schedules and requirements for authorization. For example, an HMO once fined me $500 for sending a culture specimen to the “wrong” lab, one down the hall from my San Clemente office. The lab test cost was $15. After that experience, I would not see their patients in my San Clemente office. They had to drive to Laguna Hills, about 15 miles.

You can blame the professionals but they are doing the best they can in a hostile environment, except for the crooks of course, and Medicaid is full of them. Most physicians do not accept Medicaid in California, just as most good orthopedic surgeons don’t accept workers comp. I’m talking about private practice, of course, and not institutions with salaried physicians. Kaiser does workers comp as another line of business and can generally be trusted. There are many groups in workers comp where one physician may have 20 offices and only visit each one once a month. The care is all by PAs and NPs. The same applies to Medicaid.

There is an ugly underbelly that is mostly in government programs. It will be interesting to see places like MD Anderson adjust to government care. If we are lucky, we won’t ever know. Complex care is expensive and will be the first to go.