Medicine and Obama’s Third Term.

Obamacare changed American Medicine forever. I am becoming convinced that was a major purpose. Since 1978, Medicine and doctors have become the most regulated sector of the American economy.

Five years ago, I predicted one consequence. A doctor shortage. Why ?

A few years ago, it was reported that 10,000 doctors were leaving UK every year. How has the NHS dealt with this shortage?

By importing third world doctors.

The UK’s National Health Service (NHS) will soon begin a major campaign to recruit health workers from other countries to meet growing staff shortages.

Reports suggest a strategy has been drawn up to target a number of countries around the world, including poorer nations outside Europe.

One estimate in March this year said the NHS will need 5,000 extra nurses every year – three times the figure it currently recruits annually.

But what about the countries that it will recruit from – what impact will it have on them?

Where do non-UK staff come from?
The NHS already recruits globally to meet its staffing needs.

More than 12% of the workforce reported their nationality as not British, according to a report published last year.

How are we dealing with our doctor shortage ? By adding “Practitioners” instead of doctors.

How did this begin? In 1978, a new federal program was created called “Professional Standards Review Organizations.”

Since Public Law 92-603 was enacted in October 1972 considerable progress has been made in the establishment of Professional Standards Review Organizations (PSROs) for the purpose of determining the necessity, appropriateness, and quality of medical care provided beneficiaries of the major programs authorized in the Social Security Act. Sixty-five conditional PSROs are implementing review in acute care hospitals in their geographic area, and 55 planning groups are developing plans to qualify for conditional PSRO designation. The PSRO hospital review system is based on three interrelated review mechanisms. These are concurrent review, which includes admission certification, and continued stay review through discharge; medical care evaluation studies; and analysis of hospital, practitioner, and patient profiles. This article describes the review system in some detail and the potential opportunities the PSRO program offers to occupational therapists.

In fact, the focus of the program was totally on cost. Quality was a distant second concern.

The control of costs was unsuccessful so a second program appeared in 1986. Diagnosis Related Groups.

Patients who have similar clinical characteristics and similar treatment costs are assigned to an MS-DRG. The MS-DRG is linked to a fixed payment amount based on the average treatment cost of patients in the group. Patients can be assigned to an MS-DRG based on their diagnosis, surgical procedures, age, and other information. Hospitals provide this information on their Medicare claim, and Medicare uses this information to decide how much the hospitals should be paid.

Now, the aim of cost control was obvious. The consequence of this law was that patients were discharged “sicker and quicker.” “Discharge Planning” began the day the patient was admitted.

Next came the “Resource Based Relative Value Scales”

In 1992, Medicare significantly changed the way it pays for physician services. Instead of basing payments on charges, the federal government established a standardized physician payment schedule based on RBRVS.

In this system, payments are determined by the resource costs needed to provide them, with each service divided into three components:

Physician work
Practice expense
Professional liability insurance (PLI)
Payments are calculated by multiplying the combined costs of a service times a conversion factor (a monetary amount determined by CMS) and adjusting for geographical differences in resource costs.

In fact, the AMA sold out the specialties by joining the Harvard School of Public Health to set up this system of rationing specialty care.

The original “Relative Value Scale” was established by the California Medical Association to rationalize medical charges. I knew some of the physicians who volunteered time on this committee. The idea was to come up with a formula that estimated the value of various treatments. For example, what was a hernia repair worth compared to an office visit? No fixed amount was set. It was all relative value and the doctor using the scale could estimate his (or her) own fees. A doctor in Beverly Hills could charge more than one in Bakersfield. Previously, insurance companies had offered “Indemnity style” policies that paid a fixed amount for the procedure. This system was replaced by “Usual, Customary and Reasonable Fees.” The result was medical inflation and trouble ahead.

“RBRVS” was another attempt at top down control with increasing regulation. As long as this was limited to Medicare and Medicaid, it was tolerable. Also, this was the beginning of the profession’s loss of control of its own destiny. When RBRVS came out in 1992, there was no fee schedule that was usable in my area of Orange County CA. I spent a week end with the Congressional Record and my office manager and we set up a spread sheet with the fees as determined for our geographic area. For months, I had the only usable fee schedule and every doctor asked for a copy of my spreadsheet for their own use. The medical associations dropped the ball. The AMA had sold us all out. The purpose of the RBRVS was to lower the cost of specialty care and procedures. I knew internists who applauded the result because they thought they would be paid more. One cardiologist told me “We will see cardiac surgeons driving Chevrolets while we drive Mercedes.” Such are the foolish fantasies of those who trust government.

Then came Obamacare. The ultimate top down system. Of course, they had to solve the fiasco of the rollout. There we saw the incompetence of the ruling class. The real hammer on the medical profession was the EHR rule. The web of controls and regulations was the trap. “Electronic Health Records” had been an interest of mine for years. I had been a member of the professional association and attended conventions. The methodology was very promising. It could diagnose an acute myocardial infarction in the ER. That was not how it was used by Obamacare.

It became the instrument of regulation, requiring hours of data entry for each patient. The penalty for not adopting the EHR was a 3% deduction for Medicare reimbursement, significant since Medicare only pays about 13% of billed charges. The EHR systems, in addition to be clumsy to use, were expensive. If you want to see the price for a product jump, have government make it mandatory. When I was still in practice, I bought an office EMR system to deal with the 250 contracts I had with various payers. It cost $30,000. The various HMOs and PPOs had different rules for members, often requiring certain labs and pharmacies. I was once fined $500. for sending the patient to the “wrong lab” for a $16 wound culture.

The Obamacare EHR was so expensive that doctors chose to sell their practices to the hospital and thus surrendered the last of their independence. The consequences have been severe. A year before we moved to Arizona, my wife had an episode of pneumonia. She had multiple such episodes until we discovered she had an immunological disorder, which has been successfully treated with a biological drug she takes every two weeks by injection. Anyway, her pulmonary specialist, who I had known for 30 years, was unable to order admission to the hospital for her. Instead, he was required to send her to the ER to be examined by a hospital employee physician who would approve her admission.

The EHR requirement now takes approximately 25% of physicians’ time and has led many to retire early. It is the most common cause of physician “burnout.”

The digitization of healthcare promises significant improvement, including more efficient and more personalized care at lower costs, but it has also brought challenges to the industry. Notably, clinicians have reported feeling burdened by the reporting demands of EHRs—responsibilities that take away from their time and focus on patients. These burdens are so weighty that they’ve become a chief cause of physician burnout.

Clinician impact aside, the EHR is here to stay. With billions of dollars spent on electronic systems, healthcare organizations aren’t likely to step away from these investments. CIOs are now focusing on proving the value of EHRs and making the technology work for clinicians.

The billions is no exaggeration. The University of Arizona Medical Center, previously referred to as “UMC” and considered the top medical center between Los Angeles and Houston, got over stretched by an expensive EHR and ended up selling the UMC to a for profit health care company called “Banner Health Care.” The reputation has declined and some faculty have left.

Now, the final step in the debasement of American Medicine has come. Diversity, Equity and Racism.

They meet once a month on Zoom: a dozen doctors from around the country with distinguished careers in different specialities. They vary in ethnicity, age and sexual orientation. Some work for the best hospitals in the U.S. or teach at top medical schools. Others are dedicated to serving the most vulnerable populations in their communities.

The meetings are largely a support group. The members share their concerns about what’s going on in their hospitals and universities, and strategize about what to do. What is happening, they say, is the rapid spread of a deeply illiberal ideology in the country’s most important medical institutions.

This dogma goes by many imperfect names — wokeness, social justice, critical race theory, anti-racism — but whatever it’s called, the doctors say this ideology is stifling critical thinking and dissent in the name of progress. They say that it’s turning students against their teachers and patients and racializing even the smallest interpersonal interactions. Most concerning, they insist that it is threatening the foundations of patient care, of research, and of medicine itself.

The collapse of the system is almost complete.

My wife’s internist, a black Jamaican physician, announced in January that he was quitting his group, dropping all Medicare and insurance, and would be practicing for $200 a month cash per member of his panel. I told her to sign up but she hesitated. By a month later, his panel was closed and there was a waiting list of 55 applicants. She had waited too long. Now, she is going to my internist who is a bit short in the personality department and spends office visits staring at his laptop. Her prior internist went from 4000 in his group panel to 400 cash patients. I suspect we will see more of this.