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  • So, doesn’t change mean change?

    Posted by onparkstreet on February 17th, 2010 (All posts by )

    “The small bill aims to make health insurance more accessible, affordable, and portable — without increasing government control, jeopardizing the quality of care, or breaking the bank” Small-Bill Proposal for Sensible Health-Care Reform

    “We have to learn to do health care in fundamentally new ways in the next twenty years. The changes needed are much more radical and sweeping than anything envisioned in the current legislation — and it will take a very different mindset to make them happen. The current bill is a classic example of steady state, blue social model thinking: it is more interested in keeping the status quo going by pumping more money into it than it is in the basic restructuring needed to build a system that will work in the future.” Walter Russell Mead

    The latter excerpt (thanks to LG for the link) highlights, in a way, the frustration I experience practicing in a teaching hospital. It’s all chasing zanaflexhome state and federal dollars and arguing reimbursement rates. Well, naturally. But the really innovative things that we could do? Who, exactly, is doing them stateside? The “cash-only” doc drop-outs? Walmart, Walgreens and CVS clinics? Concierge practices and out-sourced medical diagnostics? I suppose government regulation makes it impossible to be innovative in the most radical way.

    Seriously, I am so in the weeds with the day-to-day – just crushed by it – that I have no idea. We should be thinking innovation and nimbleness, and instead, our thinking is staid, staid, statist-ly staid. Because the Walter Russell Mead post makes the point that technology is going to throw the medical profession for a loop, and I think we are not ready to absorb those changes as a profession. Despite all the academic blather (because of ?), we are not ready.

    What do you think are the important health care trends the current national “discussion” is missing?

     

    9 Responses to “So, doesn’t change mean change?”

    1. Michael Kennedy Says:

      We cannot afford the model we have. Megan McArdle has a post on this. She had a huge response to a previous post. We cannot afford the model we have had for the past 50 years. I am old enough to remember when there was “indemnity” health insurance. If you had appendicitis, it paid $600 for the surgeon. Any more than that, and you were on your own. Surgeons, of course, preferred the UCR model (Usual, Customary and Reasonable), which always seemed higher than the month before. Medical inflation got into high gear about the time I went into private practice in 1972.

      The academics are scolding the private guys because they aren’t on salary. Have you ever gotten a bill from a faculty medical group ? I have. It was a classic example of unbundling. I don’t know how many of you know what that is. An example. I had, in 1993, a transthoracic spinal fusion for a spine fracture. The surgeon, the chief of ortho at UCSF, opened my chest to fuse my thoracic vertebra. Now, you can’t do that operation without opening the chest. The usual rules of the CPT (Current Procedural Terminology) are that, if the procedure requires opening the chest, that is included in the global fee. Yet, here was an extra charge for opening the chest. That’s cheating. It’s as though the plumber charged you for opening your front door to fix your faucet. The surgeon’s total fee was $46,000. I had good insurance but not that good. I squawked and they wrote off $14,000 but, if I hadn’t known any better, they would have pursued it.

      I got a call from my sister in Chicago last week about a similar issue. And that was a Northwestern hospital. I told her to tell them to sue her.

      What we need to do is go to $2500 deductible and pay for routine care with the money we save from not paying the first dollar premiums. Try telling that to the people with first dollar coverage paid by someone else, though.

    2. Mrs. Davis Says:

      What do you think are the important health care trends the current national “discussion” is missing?

      Almost by definition if any one knew what they were, they would insert them into the discussion. And that is why Mead is correct. No one can know what will ameliorate the problems in a system this complex until new things are tried and found to work or fail. And the more we constrain things from changing, the less likely it is we will improve things.

    3. TMLutas Says:

      The first problem is that to have a market you have to be able to speak sensibly about what is offered. The way this is done in the US is through the Common Procedure Terminology or CPT. The problem is that the CPT is universal and copyrighted and the copyright holder (the AMA) is very aggressive about pursuing their rights. Imagine if you couldn’t refer to unleaded, leaded, regular, plus, or super grades of gasoline without fear of having to pay a license to Exxon. We would lose something there and there’s a very good case to be made for the US government to buy the CPT and free it from licensing or to gain a blanket US license so that we can all be free of this nonsense. Once we can actually refer to specific products, like say 99213 (a mid grade primary care office visit) without fear of being sued, I think that innovation will be significantly less blocked.

      I think that innovation can come from any direction, not just from some academic elite. The problem is that the state has trained us to be poor evaluators of innovation because the state has taken over the evaluation role and frankly, the state isn’t doing a very good job of it.

    4. david foster Says:

      TMLutas..that is very interesting. How does the AMA get compensated for use of the CPT codes? Are the amounts of money material in the scheme of things?

    5. Michael Kennedy Says:

      Typically, the AMA stole it from the California Medical Association which devised the Relative Value Scale in the 1930s. The RVS was the way everybody billed from 1936 until the Federal Trade Commission ruled it was illegal in 1972. They said it contributed to the trust-like behavior of the medical profession which used the RVS to calculate fees. You figured out what your conversion factor was for Beverly Hills or Merced and multiplied by the RVS number. The number had been figured out in the 30s by comparing procedures with a committee of the CMA. They decided to use “hernia units.” One hernia unit was worth five office visits, for example (I don’t remember what they were). A gallbladder was two hernia units and a gastric resection was three. That is how the system was built up. Friends of mine sat on the commission. Anyway, after the FTC sued the CMA, they demanded that all RVS books had to be turned in to FTC. For a while, we were using Xeroxed copies since the insurance companies and Medicare would not accept a bill without the correct RVS codes.

      A year later, typically, the AMA came out with the CPT that looked exactly like the RVS. The AMA have been weasels for a long time. They sold out surgeons in 1986 with the RBRVS, which was supposed to “level” the field between surgeons and internists. The internal medicine associations all supported it and got screwed. The surgeons, especially vascular and cardiac all saw big fee cuts. The idea was to de-emphasize high technology.

      I respect the AMA like I respect the NY Times.

    6. malthus Says:

      Michael Kennedy is right on. But there is no reason the Feds cannot come up with a numbering scheme alternative to the CPT and put the AMA out of that business.

      I have had to file an Open Records request here in Texas to get the Medicare schedule for payment by CPT code when I was challenging charges and fees levied by a public hospital.

      Simple solutions to our USSA healthcare problems:

      1. Force all healthcare providers to publish all fees, as do Walmart, Sears and Lowe’s for their products.

      2. Force all healthcare providers to abandon price discrimination, as have Walmart, Sears and Lowe’s.

      3. Abolish all licensing of medical professionals (RIP Milton Friedman).

      Failing that, charge Walmart with providing all drugs and healthcare in the USSA, employing healthcare professionals as needed.

    7. TMLutas Says:

      David Foster – The AMA puts CPT licensing terms on their website. Imagine the license fees that yahoo or google might have to pay. $12.50 per user times 190M households occasionally checking in is a lot of money.

      I am not entirely sure that the AMA is properly using copyright here. I am not a lawyer. It certainly is stifling competitive products that could innovate us out of our medical payments mess.

    8. onparkstreet Says:

      “Almost by definition if any one knew what they were, they would insert them into the discussion. And that is why Mead is correct. No one can know what will ameliorate the problems in a system this complex until new things are tried and found to work or fail. And the more we constrain things from changing, the less likely it is we will improve things.” – Mrs. Davis

      Fair enough! I didn’t word the last part of my post properly – I wanted to hear from others about what is going on outside of my narrow slide of the medical world.

      I am not a member of the AMA and do not plan on joining.

      The CPT code thing is insane – I should do a post on it! Rushed for time – hopefully, I will have time later to explain a little further! Thanks for the comments.

    9. onparkstreet Says:

      Ha ha! I wrote narrow slide when I meant narrow slice – I look at slides all day so it must have been a Freudian typo…. :)