Thursday, January 10, 2013

Medicine and government: A bad mixture

by Roderick T. Beaman

When I first started medical practice in 1972, a physician could get started in practice on a shoestring budget. All you needed was a couple of rooms, some furnishings, a few pieces of equipment that you could add too later, a telephone and possibly someone to answer it and schedule appointments. The joke was that you could set up your office in early orange crate style. Overhead was about one-third of the usual expected incomes. Those days are long gone.

One of the first causative things to spring to mind is the cost of medical malpractice insurance. Certainly, that’s part of it but far from the only part and may not even be a major part. The daily costs of simply operating an office have soared as well.

If you go into any medical office consisting of two or more physicians, for starters, you are likely to find a receptionist and one person for the billing. In essence, she chases money. Her salary, including benefits is likely to be in the $80,000 a year range. The receptionist answers the telephone and primarily does the scheduling. Her services come at a cost also.

Each physician is likely to have one or two people assisting him, directly, in patient care. That would include ensuring follow-ups and tests including laboratory and imaging studies such as x-rays. They come at their own costs. There also might be laboratory and x-ray technicians who actually perform those tests if the office does them in-house.

In addition, there is likely to be an office manager who is responsible for office staff scheduling and other tasks which might include PR work. The office manager may be just as likely traipsing around town drumming up referrals. She is the future of the office but the billing manager is the lifeblood of the office. There would be no future without the present lifeblood.

The billing manager spends her time on the telephone talking to claims representatives and sometimes several of them when there are multiple carriers involved. This happens with regularity when a patient has different private insurers and each expects the others to pay. It can get really complicated if, for instance, a patient has also been involved in an automobile accident.

No third party payer issues reimbursement without absolute proof of coverage and a requirement to pay. That proof sometimes will require multiple exchanges of information. It is usual for payment to be delayed months and each day it is delayed, can mean, in aggregate, tens of thousands of dollars in interest. This is a huge unspoken bonus incentive for them, whether government or private.

There is often some blurring of these roles and the physicians’ assistants may do some scheduling and answering of the telephones or assist in the billing but there is a lot that is required in a medical office today as opposed to years ago when a physician might need but one person, a receptionist, to help. All of this personnel and overhead come at costs that you as a patient are paying for, directly or indirectly.

Sometimes the payer demands records so it can determine the appropriateness and necessity of the treatment. The payer can then deny payment and demand a refund and even charge fraud. This is a part of the worry but, sometimes from sheer exhaustion or oversight, the office gives up on obtaining payment and thus the office loses that income for the services rendered. The third party is that much richer.

One of the most worrisome aspects of practice is medical records. Just twenty years ago, a few lines used to suffice. Today, it’s unlikely that any visit generates less than half a page and two or three pages are possible. As you can imagine, this has meant an explosion in the size of records, not to mention an explosion in the consumption of paper. Records of twenty visits used to be able to fit into a thin manila folder. Now they can be the size of a small telephone book.

Often, the job of being a physician includes small talk with a patient. It rarely adds much to the overall impression but it often helps the patient which is, after all, our primary function. In the past, such comments would hardly merit more than a brief blurb in the record but, with a little imagination, that off-the-cuff comment can be parlayed into three paragraphs of logorrhea to snow any reviewer. It takes a while to adjust to this mentality. A maxim of college English is to say the most with the least number of words and physicians experienced this in undergraduate school. Generations of college freshmen have had their papers savaged by an English teacher for verbosity but when you deal with a bureaucrat, the reverse is the operative rule. No one likes verbiage more than a bureaucrat. If you can say the same thing three different ways, you have a leg up. Professor Irwin Corey would have loved it.

When you add up all of the salaries of the ancillary personnel and lost income, it is a staggering percentage and contributes to physician discouragement. It is rampant in the various health care professions. It is only going to get worse under Barack Obama’s Affordable Care Act. You can expect overhead to soar with little of it contributing to medical care.

Litigation will skyrocket with attendant costs. There are many potential new avenues for litigation. Medical journals are already issuing warnings about possible future liability actions, many of which may not be covered by medical malpractice insurance. It could be years before they are all fully explored. Nothing fills the legal profession with more glee than new laws. You could wind up needing a lawyer every time you seek medical care and every medical office could conceivably need to have one on retainer. “Do you have a question about your rights under the Affordable Care Act? Call the law firm of Dewey, Scruem and Howe.” There’s a maxim in the legal profession that in a small town one lawyer does poorly but two lawyers do well. Just think about that.

To show you how liability can be contorted, a New Jersey attorney once tried to sue every member of a staff due to the purported malpractice of one physician on the grounds that they had tolerated his incompetence and should have done something about it! The case was thrown out but it had to be defended at a cost, possibly by each and every physician and after it was over, the attorney still maintained the case had merit!

Another problem is, when the last round of inflated demands becomes the norm, and physicians have adjusted to them, they up the ante. The monster just grows and grows and grows and adds to the need for more office personnel by both physicians, hospitals, insurance companies and the government, etc., again all at a cost.

It’s no accident that many of the recent great fortunes are governmentally related. H. Ross Perot made much of his fortune designing computer systems for Medicaid. You can hardly turn on the TV, especially to a cable station, without seeing an ad for some product that is ‘guaranteed’ to be covered by Medicare. The Scooter Store is one and there are numerous others, diabetic supplies for example. Indirectly, they’re all feeding at the public trough and you pay for it either with your health care premiums or taxes.

As a government program, health care has become a political football. The budget battles are simply analogues of the school budget battles and they are both approaching break points. Within the past year, there were several proposed reductions of Medicare ’s physician reimbursements. One was nearly 30%. Since many private companies base their reimbursements on the Medicare rates, the effect would have had huge ramifications on physicians’ incomes and their abilities to even pay their staffs. Physician payments are often targeted for cost control but I have never seen the regulations and their costs of administration targeted or even discussed by the politicians and government.

Numerous hospitals across the country have had to close under the burdens of Medicare and Medicaid regulations. In Rhode Island alone, at least two hospitals have closed completely since Medicare and Medicaid were enacted and two others became simply outpatient facilities.

In the late 70s, I was talking with another physician about the financial burdens of those two entitlement programs. He told me that before them a local hospital had gotten along with just two vice-presidents. By our decade and a half later, the hospital had 17 or 19 v.s., all because of Medicare and Medicaid and their regulations. Of course, they all had to be paid salaries with benefits that came out of the health care dollar.

At our small 80-bed hospital, the proliferation of bureaucrats was obvious. We had a woman who used to talk to patients about their follow up care. She’d review their coverage, make arrangements for them and label the talk ‘crisis intervention.’ A fifteen-minute talk - crisis intervention. Wow!

To even get a handle on what Obamacare may mean for the country, consider how our compulsory educational system has become a force for things only very marginally related to education in just our lifetimes. Among them you have the sensitivity, sex education, diversity issues, etc. Now contrast that with what it was in your school days and compare that to what it was probably like when the first governmentally sponsored schooling started in Dorchester, Massachusetts in the 1830s.

Now turn your attention to the medical system and begin contorting your mind as to potential costs, legal, administrative, etc. No matter how far fetched or how unlikely you think it might be, it is likely tame next to what is coming.

Around 1984, (an interesting year for such a thing), the Department of Education decided that if any student used a Basic Educational Opportunity Grant (BEOG) for college tuition that should be considered a subsidy to the college, not just the student. It then demanded that Grove City College in Pennsylvania comply with its Title IX regulations. The college fought it and the court agreed.

Ted Kennedy was the most dangerous American demagogue of my lifetime, a peddler of hatred and paranoia, lolling on the lunatic left fringe of American politics. Subsequently, he sponsored his Orwellian titled Civil Rights Restoration Act that required it. It was vetoed by President Ronald Reagan but then Congress overrode his veto. Note, that this entire case arose and came to a head under the most avowedly conservative president of the 20th century. Just think of what will happen under this Marxist administration.

Other seemingly benign things such as government sponsored basic education resulted for years in Jim Crow segregation (bad), later desegregation (decent) and busing to achieve integration (bad) that was opposed even by many blacks. Many people dismissed the possibility of school busing when the idea was first floated during the mid and late 1950s. Hubert Humphrey scoffed at the suggestion that the 1964 Civil Rights Bill would lead to quotas by stating he would eat a copy of the bill on the floor of the Senate if it did. It did and he didn’t.

Finally, (I am sure any reader by now has just heaved a sigh of relief that this is a finally), think the unthinkable. Remember that the involuntary and unknowing sterilization of American citizens was done in this country as late as the 1960s and maybe even more recently. It was ruled constitutional by the Supreme Court and continued well after the collapse of Germany’s national socialist government. Realize further, that the sterilizations and exterminations under the eugenics program of German National Socialism and they all occurred under this same banner of Progressivism, something progressives will never address. It is not a question that such horrors can happen here, they have happened here!

The scoffed at Death Panels will emerge with their calculations of comparative worth of the lives of various people. Failures and runaway expenses will be blamed on everything but government just as all they have throughout history, such as the failures of Soviet Socialism.

Get ready for a very rough ride.



My Recent Kafkaesque Experiences

Tibor R. Machan, a refugee from Communist Hungary, experiences the Soviet USA

It may not be the kind of experience many others have had other than at the Department of Motor Vehicles but I recently went through one that brought to mind Franz Kafka.

I have been trying to refinance my house for months but my bank, Wells Fargo, refused to even talk about it. I had there one of the brusquest bankers, as bad as any bureaucrat I’ve dealt with from the feds. But in time my tenacity won out and I divorced Wells Fargo but not before I went through a pretty wild bureaucratic side trip.

To get refinanced I was told I had to come up with my social security card. I received that back in 1956 and haven’t seen it since so I didn’t even try to find it but went straight to trying to get a replacement copy. To do this I had to send Social Security my passport to prove that I am a citizen. (I am a naturalized one of those and having been smuggled out of Hungary, I have no birth certificate.)

I filled out the needed forms and sent in the passport but never heard back from them with the new card I needed. Well, since I was planning a trip abroad, I had to have a passport but social security played deaf and dumb. Finally I went to Los Angeles, a 100 mile round trip, and got a brand new passport (after spending hours on the phone about it all), which cost me a couple of 100 mile road trips to the federal building there, plus some $200 and price of passport pictures, etc., etc. I was to pick up the new passport at 1 PM one day but of course they didn’t get it ready until 2 plus. And dealing with these folks is a pain since they all treat you like you are some subject, never mind being a citizen of a supposedly free country by whom they are supposedly employed.

So in time I did get the new passport into my hands and was ready to board my plane. Since where I was to go requires a visa, that added another small bureaucratic step to the proceedings. (My private sector travel agent was very helpful with this, also very pleasant, in contrast to the public servant federal agents I encountered.)

Of course all the steps I needed to take were routine but no less drab and annoying for that. The federal building in Los Angeles reminded me of that monstrosity in Bucharest that the Romanian dictator Nicolae Ceau┼česco built over several acres, an architectural obscenity if there ever was one. This American version was just a little bit more tolerable and no more user friendly.

Mind you, thousands go through the experience of dealing with the feds and paying for their ineptitude. I was told that the reason I needed to come up with the social security card is that Homeland Security now requires it when one refinances or buys a home but then just after I did my best to comply with this, I was informed that it wasn’t really needed, after all. But by then I had mailed my passport off and the loss of it was pretty much guaranteed. (It’ll probably turn up somewhere “in the system” over the next year and I will be able to stick it away as a souvenir.)

One element of these relatively petty experiences is that one just has no leverage with the several functionaries one must deal with. Since any one of them can put a monkey wrench in the proceedings, standing there and looking intimidating in their uniforms, even I refrain from arguing with them. (Why do they say 1 PM when it is actually 2 PM? Why do they say they needed the Social Security card but then it turns out they do not?)

Not that these are earth shaking matters but if one multiplies them by several hundred thousands, even millions, one begins to grasp just how inefficient governments are and how readily they muck things up in society. The functionaries certainly do not treat you as citizen-customers to whom they need to show some deference! They all comport themselves with the attitude that they have the upper hand and you should be grateful that they do their jobs for you. Or something.



Chuck Hagel: another RINO

Biographically, the former Nebraska senator and decorated Vietnam War hero makes a great choice. As the president noted, "He'd be the first person of enlisted rank to serve as secretary of defense, one of the few secretaries who have been wounded in war and the first Vietnam veteran to lead the department."

But temperamentally, not so much. While Obama lauded Hagel for representing "the bipartisan tradition we need more of in Washington," I think that what the president really meant is that Hagel is his favorite kind of Republican, the self-loathing kind.

Make that: the kind whom Democrats like because Republicans do not.

Hagel alienated some on the right when he turned against the Iraq War, for which he had voted in 2002. A lot of people changed their minds about that war, but Hagel went so far as to say in 2007 that "of course" the Iraq War was about oil.

Hagel angered folks from both parties when he said during a 2006 interview, "The Jewish lobby intimidates a lot of people up here."

The Jewish lobby? Not the Israeli lobby? That's why Sen. Lindsey Graham, R-S.C., told CNN on Sunday that the Hagel pick was an "in-your-face nomination."

Hagel's opposition to sanctions against Iran led Bill Kristol, editor of the conservative Weekly Standard, to warn that "nominating a person who is clearly soft on Iran would send exactly the wrong message to Tehran."

The Washington Post, which endorsed Obama in 2012, editorialized that Hagel is the wrong choice because his "stated positions on critical issues, ranging from defense spending to Iran, fall well to the left" of the president's first-term policies.




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The Big Lie of the late 20th century was that Nazism was Rightist.  It was in fact typical of the Leftism of its day.  It was only to the Right of  Stalin's Communism.  The very word "Nazi" is a German abbreviation for "National Socialist" (Nationalsozialist) and the full name of Hitler's political party (translated) was "The National Socialist German Workers' Party" (In German: Nationalsozialistische Deutsche Arbeiterpartei)

Franklin Delano Roosevelt was a war criminal. Both British and American codebreakers had cracked the Japanese naval code so FDR knew what was coming at Pearl Harbor.  But for his own political reasons he warned no-one there.  So responsibility for the civilian and military deaths at Pearl Harbor lies with FDR as well as with the Japanese.  The huge firepower available at Pearl Harbor, both aboard ship and on land, could have largely neutered the attack.  Can you imagine 8 battleships and various lesser craft firing all their AA batteries as the Japanese came in?  The Japanese naval airforce would have been annihilated and the war would have been over before it began.


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