Some late breaking comments on medical politics (from Med-Events)

>The system in US is now designed

>to fail. The AHCA of 2008 will destroy

>American Healthcare as we know it.

>It is all over. “The government is here

>and they are here to help”.

Crippen:  The above cluster of sour grapes is political in nature and ordinarily, I would scotch it immediately but I can’t let you get away with it as a stand-alone without an alternative view.

In 1965, the medical establishment, including the AMA and my father the surgeon loudly exclaimed that Medicare and Medicaid would “destroy American health care as we know it”.  In fact, those services made my father’s generation of physicians rich and created the Medical-Industrial Complex which has now grown to the point where it threatens to “destroy American health care as we know it” by it’s sheer volume and weight. The Affordable Health Care Act of 2008 is not needed to hasten that eventuality.

The bill for a typical 6-day hospital stay for childbirth in 1951 was $85—well within the out of pocket range of most families. A 6-day hospitalization for cardiac workup at a large urban hospital in 2010 has recently been calculated to be $19,254; the facility lost $2,695 of that amount after reimbursement.

This cost situation arose in part because physicians in such a system have little motivation to reduce costs, given that the care is paid for by a third party relatively unable to process the value of need versus desire. Similarly, consumers of health care are not the purchasers thereof and so have little motivation to assess cost versus value. More is always better, especially when it is free.

Virtually every other civilized country in the global village has evolved to lowest common denominator of health care for ALL of their citizens, and that is single payer, government sponsored health care indemnification. The price paid for that is enforced prioritization of entry and “saying no” to expensive treatment that has a dismal benefit at great cost. It isn’t perfect, but in the end, everyone is covered and it’s more or less affordable. America runs on a consumer satisfaction mode, a situation that everyone agrees is unsustainable even if it were not for the global recession of 2008.

In 2009, the USA spent (all told) twenty five trillion dollars on health care but only indemnified about 40% of its population (some are underinsured). That’s US$8,000 per person, 17.3% of the GDP and increasing about 6% annually.  The USA ranks below Portugal in preventable mortality.  California increased its cost of health insurance 20% this year and there is no end in sight. As the price of health care goes up, fewer businesses can afford health care for their employees.  62% of all personal bankruptcies involve medical bills in 2010.

So, the AHCA of 2008 is not anywhere on this screen. We’re on our way to insolvency all by ourselves right now, and we’re still only covering a small portion of our population doing it, expensively and inefficiently.

The AHCA of 2008 purports rectify three glaring omissions we don’t have now. It effectively ends insurance payment discrimination, adds an estimated 31 million needy potential patients to an already overloaded system and it’s portable. These are all GOOD things, and I might add GOOD things that most if not all of the other civilized countries in the global village provide for their citizens.

The argument against the AHCA of 2008 is twofold:  a) Straight up political partisanship. ANYTHING that comes out of this sitting President is spawn of the devil, and: b) It will be expensive.  However, complaining that the AHCA is going to break the bank implies that the bank would remain solvent without it. Nothing could be further than the truth. The bank is hemorrhaging right out into the street and is reliably headed for insolvency all on it’s own. The worst that can be said about the AHCA is it will hasten the process. Maybe.

So if you ignore the political aspects, which you definitely should, what remains is how to finance it. Of course the best way is to mandate everyone buy into it to keep the cost of participating down. If anyone is allowed to opt out, our culture mandates we still have to treat them anyway. So if opt-out is allowed, it will collapse instantly. We’ll see how that works out.

Otherwise, there is another reality that must be faced. There is NO possibility of a system that creates demand and then supplies it in a customer satisfaction mode can remain solvent. So, if the whole system is swirling around the bowl, which it is, there are several options available, two of which are painful prescriptions for providers.

1.    Allocate resources toward health care and away from other previous priorities such as entitlement programs, military security, and bureaucratic priorities.

2.    Pay providers less for the same (or increased) workload.

3.    Reorganize health care spending so that more money is spent on some services and less or nothing is spent on others; essentially, say no more often.

History suggests that it is unlikely any modern society can or will decrease support of entitlements such as social welfare, unemployment insurance, social security benefits, or retirement benefits that citizens depend on and have paid into during their working careers. Cutting military security funding is equally unlikely. Most if not all national budgets include little else that can be reallocated in any meaningful amount. That leaves options 2 and 3. It is virtually certain that providers will have to reorganize their priorities one way or the other, and accept less remuneration in the process.

So denigrating the AHCA because it will break the bank is (I think) a “straw man” argument. We’re pointing our finger at something that hasn’t even happened yet as we descend into the depths. We can continue on the path we’re on into insolvency while indemnifying only a portion of our patients at huge expense and great inefficiency, or we can continue toward insolvency indemnifying 96% of our patients more efficiently avoiding personal bankruptcies, asking our providers to work harder for less pay. Then we can just pay for it and get over it.

If we decide not to just pay for it and get over it, we’re going to crash, and when we do, we’ll discover the reason why most of the other civilized countries of the global village have evolved to single payer system, prioritization, saying no and standing in line.

BTW, the government is indeed here and it’s helping. MOST health care in this country is government funded. All care for Washington politicians, military, VA system, Medicare, Medicai

>In critical care, the trend is to use Nurse

>Practitioners and Physicians

>Assistance to do the grunt work,

>especially at night, with the physicians

>evolving to executive managers.

Crippen:  The problem of course is the eventuality of all chiefs and no Indians. Critical Care fellows are clearly showing signs of wanting to get away from clinical responders to become managers. So the practical problem then becomes who will do the grunt work to be managed by suits. I see the model as the rise of NPs to fill the available niche field where doctors once grazed.

I would be surprised if Physicians Assistants moved much into that niche, not because they are any less competent than NPs but simply because the NPs have more experience in ICU patients care. Most of them, including ours are former ICU nurses. That’s just my initial thought, and again, I hasten to add that I know PAs here and elsewhere and I would NOT disparage them, all other factors remaining equal. It’s a matter of local experience in the field where they work.

The issue of ICU (in my case, NICU) nurses taking orders from NPs is going to be interesting to sort out. In my case, the NCU nurses feel a bond with Danielle because she is one of them, and also of course, that she knows how to generate confidence and when to call me to get involved when needed. So they feel comfortable with her because they trust her nursing judgment that has come u a level and they know she knows when to call, and if she doesn’t, they know they can call me anytime. This issue has not expressed itself with Danielle, but it might in the future with others. I might add that I am also impressed with the NP over in the neuro-trauma unit next door to me and she has similar trust and acceptance from their nurses. I think this issue will sort itself out in time for no other reason than if an individual is found wanting, they won’t be working here.

I am very concerned that doctors are abdicating direct patient care because it’s too time and energy consuming and there are too many hassles.  OK, here comes the “I slogged to school in three feet of snow” speech.  When my ilk and I were residents, we were expected to have a head of steam because that was how the game was played, and the rules had been established long before us.  Our job was to deal with ALL the patient care issues, and do them well or we would be fired. Every buck stopped with us. If any of us couldn’t take it, there were lots of other things to drop out into, like dermatology and ophthalmology.

The upscale of that, especially in surgery and critical care is that helpless, defenseless people had at least a shot at reversal of a death spiral, especially after hours when it was inconvenient and everyone was tired. Maybe not perfect, but at shot at it.  Once “intermediate” providers replace that ethos, then the disasters in the middle of the night will have a shot, but that shot will be holding on till the suit arrives. Better deal? More cost effective? Depends on which side of the bed you’re on.

Will NPs eventually evolve to the former expertise and experience of doctors, rendering them moot?  It’s possible. Is that a good thing?  I don’t know. Remains to be seen. Will NPs be more “cost effective”?  Not as they increase in expertise and experience. They’ll unionize and get into collective bargaining. (Unless they live in Wisconsin).

I lament the hard working, chronically tired resident that held the seams of the hospital together.

I am the last of my kind.

>WASHINGTON – The Obama administration

>said Monday that states could cut

>Medicaid payments to many doctors

>and other health care providers to hold

>down costs in the program, which insures

>60 million low-income people and

>will soon cover many more under the new health >care law.

Crippen:  You and I and everyone else knew this was coming.  If you’re a conservative Republican you lay it all at the feet of ANY Democratic President, but it goes infinitely deeper than that, deeper than even the Prince of Darkness himself (Bush).

The fact is that all of it has been going bust for a very long time. Long enough for each political party in turn to blame the other for having to do what it takes to control it. The fact also is that there is no inherent limit to the expenses of government funded health care programs because they are consumer satisfaction driven. There is no upper limit of expense and no one can “say no”.  This in the face of a virtually unlimited demand.

It’s political malfeasance to tell consumers in this kind of market that you’re “limiting” their care, especially if it in evolved saving YOU money. They don’t care about YOUR money. They go on TV talk shows and whine about how the “government” is trying to kill them to save a buck or two. Anyone that advocates limiting anything it immediately voted out of office with a strong odor of tar & feathers in the air.

So you can bet your sweet bippy no one on the reimbursement side is going to the demand side talking resource allocation. They have NO choice but to go to the supply side because that’s the only side there is.

Go to providers and ask that they voluntarily become more efficient (saving money).  Ha. When was the last time you saw that happen? Providers make their living by doing as much as they possibly can, and in the process expending other people’s resources. In an ICU, an empty bed is a loss so it’s filled with whatever comes down the line. An ED bed that isn’t filled is a money loss.  So, if the reimbursers don’t do SOMETHING, they will quickly go broke in a scheme of maximum demand and providers happy to fill it.

In the past they have tried limiting access to the system by the Clinton Plan (refuse to let them in on pre-determined algorithms). That resulted in anger and retribution that waxed political. Then they tried rationing by inconvenience (didn’t pay for paperwork omissions). Providers became expert paper shufflers. Then they devised DRGs, but followed quickly by endless outliers that still paid.  Providers are like terrorists. They’re always one step ahead of any attempt to limit them. The American way of resourcefulness.

So now that everything else has been tried, there are only two ploys to avoid going broke left.

1.  Simply pay providers less and let a bunch of them go out of business or quit.

2.  Bundle everything and don’t pay a cent for anything extra.

For # 1, the long-term detriment will be some hospitals will go belly up and some providers will quit in fits of pique.  The reimbursers don’t care, and the big hospital systems that can negotiate sweetheart deals don’t care either. You hear all the time doctors loudly claiming “I’ll quit if they do X…Y  or Z”.  Trust me, they won’t. They all have mortgages, kids in private school, Jaguars and high maintenance females on the side (for the males. Maybe for some females too). Remember back in the 70s on Saturday Night Live, the gaggle of adolescent girls at a slumber party discussing what it might feel like (to them) to have sex?  They all said “Ewwwwwww  I’d never do that!!!.  All but one in the back who quietly opined: “Well….I might”.  That’s the way it will go. It doesn’t matter how much of a cutback, there will always be those that will work. The “best and the brightest”?  Maybe not, but the establishment doesn’t care.

#2 is the almost perfect relief. A patient comes in for treatment or hospitalization and the reimbursement is what it is. No more. Just like DRGs except ironclad and no “DRG creep”.  The fallout will fall out on providers and institutions, neither of who will have any wiggle room because the patient anger and frustration will fall on them, not the reimbursers.

So the hospitals will admit a 90 year old with unresponsive Grade 5 subarachnoid hemorrhage and maintain them in an ICU as long as the family wants, but only at a flat rate. The hospital and/or provider get to decide whether to tell the unrealistic family “no more”.  The reimbursers say: “not our problem, you’re (patient) “insured” as we promised, work out the details with those other guys”.

Hospitals going belly up rather than offend patients and their families?  Providers quitting in fits of pique?  So much the better. The point was to limit demand and also limit the supply induced by it.

>The issue of providers as popularity

>contest- about an ER doc who was

>called in to the admin office for making

>the highest score on a patient survey.

>He made the first 100% ever and

>everyone was so impressed.

>They were all showering him with praise…..

Crippen:  It should be well understood that no hospital administration anywhere cares even a little bit about who’s naughty or nice in terms of direct patient care. It’s straight up marketing.

Previously they did more or less “anonymous” polls, then they advertise to the public that they have “nice” doctors (ergo, they must be “good” doctors as well) so prospective visitors to an ED should take this information into account.

Shortly before the late St. Francis Medical Center went under, the administration allotted a bunch of money to advertise their ED. The gist was to get more ED admissions by advertising convenience and rapidity of service. I told them they would lose money, but they, being the power players, disagreed, and so several weeks thereafter, several big billboards went up in the area featuring the then head of the ED sitting on his bed putting on a pair of running shoes.

The blurb went something like: “Dr. X X is getting ready for his day serving you and he will be running all day doing it”, or some such. So of course, months later, the statistics showed a decrease in hospital revenue (but an increase in the revenue of the private group running the ED. Convenience clinic patients that liked fast service increased, but none of them were admitted, most had trivial complaints that didn’t bring in any billing and many of them were not insured.

To a hospital, EDs are all about getting their clutches on patients that need to be admitted. That’s where they make their money. Admissions occurred when family practice and Internist types admitted patients from their office or electively.

No now a new tack of actually identifying specific doctors that are naughty, not nice. Everyone knows good” providers are nice. This is now a ploy for identifying individuals that can be moved to lower reimbursement because if they’re not nice, they must be poor quality providers.

And what does “nice” entail?  Do they give out clear, understandable information? Do they pay any attention to the patient? Did the patient get better?

Maybe.  Or does the patient feel like his or her “customer satisfaction” needs are met irrespective of how realistic or how stupid they are? Do you think an “administration” is capable of sorting out these concepts on the basis of a poll?

>”Welcome back my friends to the

>show that never ends

>We’re so glad you could attend

>Come inside! Come inside”!

ELP from Brain Salad Surgery (1973)

>Medicine keeps getting harder.

>And fewer and fewer folks are doing it.

>America has no idea that the weight of

>it all is falling on the shoulders of the

>emergency physicians and hospitalists

>who lurk inside the trauma rooms and

> inpatient floors, the fast tracks and

>ICUs of their community and university

> hospitals.

>The pasty-pale, coffee-sucking,

>junk-food-eating Spartans of health

>care who will bear the full assault

>of health care reform when there

>aren’t enough primary care doctors

>to manage an AARP convention,

>much less all of America.

Edwin Leap, Emergency

Medicine News,

January 2013.

Crippen:  Maybe not much longer. I continue in touch with a congressional committee on some of these things (as a resource for my last book), and it is clear that the government has the above issue in its cross hairs. It takes the government a while to sort these things out but when they finally do, they’re pretty ruthless and efficient in fixing it. And by fixing, I mean fixing by two means:

1.  Insuring it’s someone else’s problem

2.  Not suffering any liability for cost

There are numerous literature cites stating that the number of patients entering an overheated (ED) provision system could be reduced safely and effectively by simply identifying those that don’t need urgent care and referring them elsewhere. This would, of course, go a long way in solving the overcrowding problem. It would also deep six the need for building and staffing more EDs to handle the load, so ACEP has reliably come out against it much like the NRA reliably comes out against gun control. Lobbyists are as lobbyists do.

It has been the thesis of ACEP that a runny nose only a runny nose until meningitis is ruled out (by an emergency physician) and that since Americans have zero tolerance for mistakes, these patients must be seen anytime they feel like it and someone must pay for it. I think as I sit here the current charge for actually walking into an ED and sitting down breathing room air is somewhere in the range of US$300.00. That’s before anything else is done. Most folks get a few tests. EGKs and CXRs are read (and billed for) by ED physicians and cardiologists and radiologists later.  It isn’t uncommon to ring up a bill for US$1000.00 to evaluate a common cold. After all, pneumonia and early system sepsis must be ruled out, after all:” can be sued if I’m wrong and I don’t do enough tests”. And so it goes.

Some (not all) insurance grudgingly pays for that, but as I remark freely, the bottom of the barrel is slowly coming into view. So now as the worm slowly turns, we are hearing the President of the United States decry overcrowding in EDs and people using EDs as primary care facilities. This was a good selling point for expanding health care benefits via the Affordable Health Care Act of 2008. But not so fast…..Expanding health care benefits and paying for it by blank checks are two different things. It’s possible, even likely that expanding health care benefits may also come to pass by directing patients to the “right” venue (cost effective) instead of allowing them to go where it’s most convenient.

Now, I hasten to add that this was tried under Clinton and was an abysmal failure. But remember that the government is slow to learn from its mistakes but they eventually get around to it. Denying admission to an ED at the door for a seemingly bullshit complaint historically doesn’t work, but actually screening a patient (EMTALA style) and THEN referring them elsewhere is a different breed of cat.  Patients MUST be admitted to an ED on demand (EMTALA) but after screening, they don’t necessarily have to stay there.

So I’m told by somewhat occult sources, the government is considering a new reimbursement deal where it will pay (presumably doctors or even NPs) not to evaluate and treat in the ED, but to screen for need to be in an ED. Naturally, that reimbursement will be dramatically less than an on-site E & M. If no emergent issue found, they will be referred out.  The ACEP lobbyists will squeal like pigs in hot oil, but anymore, those holding the purse strings define the rules of the game. ED’s refuse to screen?  The President of the United States then decries the Medical Industrial Complex holding up fiscal responsibility progress for their own pocketbooks. Here we have a way of saving money and increasing efficiency of medical care. Why are these guys dragging their feet?

Next problem is where are all those ragged unwashed found wanting for ED care going to go?  Unclear how that will work, as it is as unclear how the AHCA of 2008 will work. Probably make a lot of it up as it goes along.

The point is that using EDs for convenience care at exorbitant prices enriches individuals (ED provider groups.  Remember “Coastal”?  These guys operate to their own benefit and to the detriment of the whole system.  They bill differently than hospitals and they have no incentive to conserve anything. Those paying for health care have an intense incentive to bring providers’ incentives into line with global conservation. That fact has been identified and will be fixed. As I have mentioned before, I think my bias is that Private Practice is going the way of the funny looking animals in Stephen Streat’s back yard.  Any “independent” provider has a much stronger incentive to enrich him or herself at the expenses of the system and must be controlled by the system. There is no guarantee it will be fixed efficiently or even effectively, but it will definitely be fixed.

Pin me to a guess after marinating in hospital/ED soup for 30 years, I look down the road and I see three species of “Emergency’ Services”. Joe Lex’s mileage will probably vary.

1.  Straight up convenience clinics, staffed by NPS, reasonable out of pocket fees. No insurance.

2.  Screening centers. Authentic “urgencies” identified?  Transfer to a mother ship by ambulance or private car if the relatives are willing and it’s deemed relatively safe. Insurance will pay for this service, but not anywhere near what an ED bills for an ED evaluation.

3.  A genuine “Emergency Center”. No walk-ins. Only referrals. Insurance will pay for all of it.

Will that “solve” the problem of inappropriate ED admissions and people using EDs as convenience/primary care centers? Will it save money? Maybe, maybe not, but it will definitely invoke the Principle of Unintended Consequences that will then guide future evolution.

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