Psychicwolf wrote:
kbot, I am a retired RN and my sister is the VP of Revenue for a pretty good size healthcare system out here in the Puget Sound area.
Her healthcare system is NOT operating at a loss, even with Medicare restrictions. And "regular" Medicare requires no pre-auth, only if the patient is "locked into" a private carrier.
I have watched with my own eyes the over deliverance of care at the end of life and the over-use, but very expensive and lucrative dependance on technology in older patients.
Then, being a former nurse, then you probably know firsthand that end-of-life care issues are typically driven by family members, not the patient, who prior to sinking into a diminished state have signed over their durable power of attorney and established healthcare proxies to family members. Many times, family are reluctant to see loved ones pass on, and they demand that extraordinary measures be taken to save the life of their loved one. Physicians often give-in because they don't want to be sued. Also, because of DRG regulations, as I am sure that you are aware, all of the costs of these tests are rolled-into the admission into a med-surg unit, or ICU, so, for all intents and purposes, these tests are performed essentially for free. I can't explain why your sister's organization is not operating at a financial loss. Her facility is an exception to the rule. I received this information today.
http://imagingbizcom.cmail2.com/T/ViewE ... E1CEBE89F9http://imagingbizcom.cmail2.com/T/ViewE ... E1CEBE89F9 which details the most current plans by CMS to ration healthcare access, especially as it pertains to imaging services. As you will see by reading the attached articles, CMS is extending the cuts further into the next few years.
Now, the question can legitimately be raised, why do these tests at all? Aren't they wasteful? A case can be made for that, surely. However, let's look at why imaging studies are performed: primarily to make a diagnosis. Can a similar finding be made by performing a good clinical exam? Probably. But, in many cases because of the hoops physicians must jump through doing government-mandated paperwork, instead of providing patient care, it it just easier to order the test. It also protects them from liability. It also provides them with definitive findings that they can act on. Recent advances in imaging modalities such as 3-D reconstructed CT and MR images were not available a few years ago, and they can quickly provide a diagnosis where in decades past, exploratory surgery was the only option. PET/ CT scans can provide early detection of cancer - and these tests are all being targeted by Medicare as being un-necessary. So, what's the alternative? Exploratory laporotomies at a cost many times higher than a CT or MR? Waiting out a course of treatment to determine if it is effective, or performing the PET/ CT instead, confirming the efficacy of the treatment, or providing proof that current treatment doesn't work, and allowing for time to switch to another, better-suited treatment?
I like to make an anology, and many people will probably find this a cold and heartless analogy, but here it is anyway. In healthcare, someone decided back in the 1970s that the field was no longer a "vocation", but a "business" and as such, for good or bad, new mindsets came into being. Look, for example at Demmings theories regarding the integration of quality control. This was a field, largely ignored for decades by American industry. But, once Demming's principles bore fruit in the reconstructed economy of post WWII Japan, people here took notice. In healthcare, Quality Assuance is now mandated - another layer of bureaucracy. Staff are required to be hired just to perform QC and QA and PI studies, and submit data to national databses where facilities are ranked and their payments adjusted based on past performances. Not a bad idea, but these systems add hidden costs to healthcare. As a nurse, you know all about chart reviews. All this costs money. "Non-productive" (as they are referred to by the beancounters) staff rely upon the monies generated by "productive" staff who have direct patient care skills, whether in Nursing or Lab, or Imaging departments to provide the hands-on care, for which they can bill the insurer and then in turn, pay the salaries of all involved - as well as pay for the building, utiliities, equipment, etc. Some costs are fixed, some rise with inflation and other economic pressures. And, in most sectors of the economy, market forces decide the pay for services provided. So, I like to use the analogy of an auto mechanic. I bring my car in, he looks at it and says, "Such-and-such is wrong with your car, and it's gonna cost you $1,000 to fix it." No negotiation on the price. I would LOVE to do to the mechanic (or anyone else, such as the super market or at the gas pump) what Medicare does to hospitals and say "Yeah, I know you are saying that it will cost me $1,000, but kiss my butt, I'm only gonna pay you $100, AND you're gonna have to suck it up, pay your staff, your bills, provide for your family and so on - and oh, stop your whining about it"
I would like someone to give me another example in society where the government mandates what fees can be charged the way fee structures are in healthcare. It may be that in Washington State, healthcare is in fine shape, but I am willing to bet that it's the exception. Many facilities across the country are gushing millions of dollars annually. It's a pace that can't continue forever. Many are also closing up shop because they can't pay their bills. And, with this new healthcare plan, it's only going to worsen. Here in Massachusetts we have universal healthcare, which was initiated by then-Governor Mitt Romney. It's a disaster. And, it's being proposed for expansion nationwide.
President Obama may need to get all his recess appointments in now, as we may see real "obstruction" (as opposed to simply Democratic allegations of it like we have seen so far) of almost all of his agenda in the next Congress. 
