I was thinking of dumping politicians.
No, wait.... that would be pollution. It's against the law to dump fecal material in the waterways.
Obamacare is NOT working
Moderator: Super Moderators
Re: Obamacare is NOT working
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
How Government Killed the Medical Profession
By Jeffrey A. Singer - This article appeared in the May 2013 Issue of Reason.
LINK TO STORY
I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks.
Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.
The Coding Revolution
At first, the decay was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Any provider wishing to get compensated was required to use International Statistical Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to describe the service when submitting a bill. The designers of these systems believed that standardized classifications would lead to more accurate adjudication of Medicare claims.
What it actually did was force doctors to wedge their patients and their services into predetermined, ill-fitting categories. This approach resembled the command-and-control models used in the Soviet bloc and the People’s Republic of China, models that were already failing spectacularly by the end of the 1980s.
Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn’t matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.
Hospitals’ reimbursements for their Medicare-patient treatments were based on another coding system: the Diagnosis Related Group (DRG). Each diagnostic code is assigned a specific monetary value, and the hospital is paid based on one or a combination of diagnostic codes used to describe the reason for a patient’s hospitalization. If, say, the diagnosis is pneumonia, then the hospital is given a flat amount for that diagnosis, regardless of the amount of equipment, staffing, and days used to treat a particular patient.
As a result, the hospital is incentivized to attach as many adjunct diagnostic codes as possible to try to increase the Medicare payday. It is common for hospital coders to contact the attending physicians and try to coax them into adding a few more diagnoses into the hospital record.
Medicare has used these two price-setting systems (RBRVS for doctors, DRG for hospitals) to maintain its price control system for more than 20 years. Doctors and their advocacy associations cooperated, trading their professional latitude for the lure of maintaining monopoly control of the ICD and CPT codes that determine their payday. The goal of setting their own prices has proved elusive, though—every year the industry’s biggest trade group, the American Medical Association, squabbles with various medical specialty associations and the Centers for Medicare and Medicaid Services (CMS) over fees.
As goes Medicare, so goes the private insurance industry. Insurers, starting in the late 1980s, began the practice of using the Medicare fee schedule to serve as the basis for negotiation of compensation with the doctors and hospitals on their preferred provider lists. An insurance company might offer a hospital 130 percent of Medicare’s reimbursement for a specific procedure code, for instance.
The coding system was supposed to improve the accuracy of adjudicating claims submitted by doctors and hospitals to Medicare, and later to non-Medicare insurance companies. Instead, it gave doctors and hospitals an incentive to find ways of describing procedures and services with the cluster of codes that would yield the biggest payment. Sometimes this required the assistance of consulting firms. A cottage industry of fee-maximizing advisors and seminars bloomed.
I recall more than one occasion when I discovered at such a seminar that I was “undercoding” for procedures I routinely perform; a small tweak meant a bigger check for me. That fact encouraged me to keep one eye on the codes at all times, leaving less attention for my patients. Today, most doctors in private practice employ coding specialists, a relatively new occupation, to oversee their billing departments.
Another goal of the coding system was to provide Medicare, regulatory agencies, research organizations, and insurance companies with a standardized method of collecting epidemiological data—the information medical professionals use to track ailments across different regions and populations. However, the developers of the coding system did not anticipate the unintended consequence of linking the laudable goal of epidemiologic data mining with a system of financial reward.
This coding system leads inevitably to distortions in epidemiological data. Because doctors are required to come up with a diagnostic code on each bill submitted in order to get paid, they pick the code that comes closest to describing the patient’s problem while yielding maximum remuneration. The same process plays out when it comes to submitting procedure codes on bills. As a result, the accuracy of the data collected since the advent of compensation coding is suspect.
Command and Control
Coding was one of the earliest manifestations of the cancer consuming the medical profession, but the disease is much more broad-based and systemic. The root of the problem is that patients are not payers. Through myriad tax and regulatory policies adopted on the federal and state level, the system rarely sees a direct interaction between a consumer and a provider of a health care good or service. Instead, a third party—either a private insurance company or a government payer, such as Medicare or Medicaid—covers almost all the costs. According to the National Center for Policy Analysis, on average, the consumer pays only 12 percent of the total health care bill directly out of pocket. There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.
As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.
Then, as the 1990s gave way to the 21st century, demographic reality caught up with Medicare and Medicaid, the two principal drivers of federal health care spending.
Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on America’s physicians through a centralized bureaucracy. Using so-called “evidence-based medicine,” algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups.
While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individual—that every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.
Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that don’t follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.
What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution.
Once again, the medical profession cooperated. The American College of Surgeons helped develop Surgical Care Improvement Project (SCIP) protocols, directing surgeons as to what antibiotics they may use and the day-to-day post-operative decisions they must make. If a surgeon deviates from the guidelines, he is usually required to document in the medical record an acceptable justification for that decision.
These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.
Operating room and endoscopy suites now must follow protocols developed by the global World Health Organization—an even more remote agency. There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.
Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don’t provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.
A large Veterans Administration study released in March 2011 showed that SCIP protocols led to no improvement in surgical-site infection rate. If past is prologue, we should not expect the SCIP protocols to be repealed, just “improved”—or expanded, adding to the already existing glut.
These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.
One of my colleagues, a noted pulmonologist with over 30 years’ experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that “ ‘evidence-based’ means you are not interested in listening to anyone.” Another colleague, a North Phoenix orthopedist of many years, decries the “cookie-cutter” approach mandated by protocols.
A noted gastroenterologist who has practiced more than 35 years has a more cynical take on things. He believes that the increased regimentation and regularization of medicine is a prelude to the replacement of physicians by nurse practitioners and physician-assistants, and that these people will be even more likely to follow the directives proclaimed by regulatory bureaus. It is true that, in many cases, routine medical problems can be handled more cheaply and efficiently by paraprofessionals. But these practitioners are also limited by depth of knowledge, understanding, and experience. Patients should be able to decide for themselves if they want to be seen by a doctor. It is increasingly rare that patients are given a choice about such things.
The partners in my practice all believe that protocols and guidelines will accomplish nothing more than giving us more work to do and more rules to comply with. But they implore me to keep my mouth shut—rather than risk angering hospital administrators, insurance company executives, and the other powerful entities that control our fates.
Electronic Records and Financial Burdens
When Congress passed the stimulus, a.k.a. the American Reinvestment and Recovery Act of 2009, it included a requirement that all physicians and hospitals convert to electronic medical records (EMR) by 2014 or face Medicare reimbursement penalties. There has never been a peer-reviewed study clearly demonstrating that requiring all doctors and hospitals to switch to electronic records will decrease error and increase efficiency, but that didn’t stop Washington policymakers from repeating that claim over and over again in advance of the stimulus.
Some institutions, such as Kaiser Permanente Health Systems, the Mayo Clinic, and the Veterans Administration Hospitals, have seen big benefits after going digital voluntarily. But if the same benefits could reasonably be expected to play out universally, government coercion would not be needed.
Instead, Congress made that business decision on behalf of thousands of doctors and hospitals, who must now spend huge sums on the purchase of EMR systems and take staff off other important jobs to task them with entering thousands of old-style paper medical records into the new database. For a period of weeks or months after the new system is in place, doctors must see fewer patients as they adapt to the demands of the technology.
The persistence of price controls has coincided with a steady ratcheting down of fees for doctors. As a result, private insurance payments, which are typically pegged to Medicare payment schedules, have been ratcheting down as well. Meanwhile, Medicare’s regulatory burdens on physician practices continue to increase, adding on compliance costs. Medicare continues to demand that specific coded services be redefined and subdivided into ever-increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimes—as in the case of John Natale of Arlington, Illinois, who began a 10-month sentence in November because he miscoded bills on five patients upon whom he repaired complicated abdominal aortic aneurysms—the penalty can even include prison.
For many physicians in private practice, the EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. This allows them to offload the high costs of regulatory compliance and converting to EMR.
As doctors become shift workers, they work less intensely and watch the clock much more than they did when they were in private practice. Additionally, the doctor-patient relationship is adversely affected as doctors come to increasingly view their customers as the hospitals’ patients rather than their own.
In 2011, The New England Journal of Medicine reported that fully 50 percent of the nation’s doctors had become employees—either of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two-thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continue to mount, we can expect this trend to continue.
Accountable Care Organizations
For the next 19 years, an average of 10,000 Americans will turn 65 every day, increasing the fiscal strain on Medicare. Bureaucrats are trying to deal with this partly by reinstating an old concept under a new name: Accountable Care Organization, or ACO, which harkens back to the infamous HMO system of the early 1990s.
In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain benchmarks established by Medicare with respect to cost, length of hospital stay, re-admissions, and other measures, they will get to share a portion of Medicare’s savings. If the reverse happens, there will be economic penalties.
Naturally, private insurance companies are following suit with non-Medicare versions of the ACO, intended primarily for new markets created by ObamaCare. In this model, an ACO is given a lump sum, or bundled payment, by the insurance company. That chunk of money is intended to cover the cost of all the care for a large group of insurance beneficiaries. The private ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.
In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally planned practice guidelines are the primary goal.
ACOs are meant to replace a fee-for-service payment model that critics argue encourages providers to perform more services and procedures on patients than they otherwise would do. This assumes that all providers are unethical, motivated only by the desire for money. But the salaried and prepaid models of provider-reimbursement are also subject to unethical behavior in our current system. There is no reward for increased productivity with the salary model. With the prepaid model there is actually an incentive to maximize profit by withholding services.
Each of these models has its pros and cons. In a true market-based system, where competition rewards positive results, the consumer would be free to choose among the various competing compensation arrangements.
With increasing numbers of health care providers becoming salaried employees of hospitals, that’s not likely. Instead, we’ll see greater bureaucratization. Hospitals might be able to get ACOs to work better than their ancestor HMOs, because hospital administrators will have more control over their medical staff. If doctors don’t follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the “problem” doctors.
Doctors Going Galt?
Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft. It’s no surprise that retirement is starting to look more attractive. The advent of the Affordable Care Act of 2010, which put the medical profession’s already bad trajectory on steroids, has for many doctors become the straw that broke the camel’s back.
A June 2012 survey of 36,000 doctors in active clinical practice by the Doctors and Patients Medical Association found 90 percent of doctors believe the medical system is “on the wrong track” and 83 percent are thinking about quitting. Another 85 percent said “the medical profession is in a tailspin.” 65 percent say that “government involvement is most to blame for current problems.” In addition, 2 out of 3 physicians surveyed in private clinical practice stated they were “just squeaking by or in the red financially.”
A separate survey of 2,218 physicians, conducted online by the national health care recruiter Jackson Healthcare, found that 34 percent of physicians plan to leave the field over the next decade. What’s more, 16 percent said they would retire or move to part-time in 2012. “Of those physicians who said they plan to retire or leave medicine this year,” the study noted, “56% cited economic factors and 51% cited health reform as among the major factors. Of those physicians who said they are strongly considering leaving medicine in 2012, 55% or 97 physicians, were under age 55.”
Interestingly, these surveys were completed two years after a pre-ObamaCare survey reported in The New England Journal of Medicine found 46.3 percent of primary care physicians stated passage of the new health law would “either force them out of medicine or make them want to leave medicine.”
It has certainly affected my plans. Starting in 2012, I cut back on my general surgery practice. As co-founder of my private group surgical practice in 1986, I reached an arrangement with my partners freeing me from taking night calls, weekend calls, or emergency daytime calls. I now work 40 hours per week, down from 60 or 70. While I had originally planned to practice at least another 12 to 14 years, I am now heading for an exit—and a career change—in the next four years. I didn’t sign up for the kind of medical profession that awaits me a few years from now.
Many of my generational peers in medicine have made similar arrangements, taken early retirement, or quit practice and gone to work for hospitals or as consultants to insurance companies. Some of my colleagues who practice primary care are starting cash-only “concierge” medical practices, in which they accept no Medicare, Medicaid, or any private insurance.
As old-school independent-thinking doctors leave, they are replaced by protocol-followers. Medicine in just one generation is transforming from a craft to just another rote occupation.
Medicine in the Future
In the not-too-distant future, a small but healthy market will arise for cash-only, personalized, private care. For those who can afford it, there will always be competitive, market-driven clinics, hospitals, surgicenters, and other arrangements—including “medical tourism,” whereby health care packages are offered at competitive rates in overseas medical centers. Similar healthy markets already exist in areas such as Lasik eye surgery and cosmetic procedures. The medical profession will survive and even thrive in these small private niches.
In other words, we’re about to experience the two-tiered system that already exists in most parts of the world that provide “universal coverage.” Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
We already see this in Canada, where cash-only clinics are beginning to spring up, and the United Kingdom, where a small but healthy private system exists side-by-side with the National Health Service, providing high-end, fee-for-service, private health care, with little or no waiting.
Ayn Rand’s philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:
“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”
By Jeffrey A. Singer - This article appeared in the May 2013 Issue of Reason.
LINK TO STORY
I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks.
Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.
The Coding Revolution
At first, the decay was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Any provider wishing to get compensated was required to use International Statistical Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to describe the service when submitting a bill. The designers of these systems believed that standardized classifications would lead to more accurate adjudication of Medicare claims.
What it actually did was force doctors to wedge their patients and their services into predetermined, ill-fitting categories. This approach resembled the command-and-control models used in the Soviet bloc and the People’s Republic of China, models that were already failing spectacularly by the end of the 1980s.
Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn’t matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.
Hospitals’ reimbursements for their Medicare-patient treatments were based on another coding system: the Diagnosis Related Group (DRG). Each diagnostic code is assigned a specific monetary value, and the hospital is paid based on one or a combination of diagnostic codes used to describe the reason for a patient’s hospitalization. If, say, the diagnosis is pneumonia, then the hospital is given a flat amount for that diagnosis, regardless of the amount of equipment, staffing, and days used to treat a particular patient.
As a result, the hospital is incentivized to attach as many adjunct diagnostic codes as possible to try to increase the Medicare payday. It is common for hospital coders to contact the attending physicians and try to coax them into adding a few more diagnoses into the hospital record.
Medicare has used these two price-setting systems (RBRVS for doctors, DRG for hospitals) to maintain its price control system for more than 20 years. Doctors and their advocacy associations cooperated, trading their professional latitude for the lure of maintaining monopoly control of the ICD and CPT codes that determine their payday. The goal of setting their own prices has proved elusive, though—every year the industry’s biggest trade group, the American Medical Association, squabbles with various medical specialty associations and the Centers for Medicare and Medicaid Services (CMS) over fees.
As goes Medicare, so goes the private insurance industry. Insurers, starting in the late 1980s, began the practice of using the Medicare fee schedule to serve as the basis for negotiation of compensation with the doctors and hospitals on their preferred provider lists. An insurance company might offer a hospital 130 percent of Medicare’s reimbursement for a specific procedure code, for instance.
The coding system was supposed to improve the accuracy of adjudicating claims submitted by doctors and hospitals to Medicare, and later to non-Medicare insurance companies. Instead, it gave doctors and hospitals an incentive to find ways of describing procedures and services with the cluster of codes that would yield the biggest payment. Sometimes this required the assistance of consulting firms. A cottage industry of fee-maximizing advisors and seminars bloomed.
I recall more than one occasion when I discovered at such a seminar that I was “undercoding” for procedures I routinely perform; a small tweak meant a bigger check for me. That fact encouraged me to keep one eye on the codes at all times, leaving less attention for my patients. Today, most doctors in private practice employ coding specialists, a relatively new occupation, to oversee their billing departments.
Another goal of the coding system was to provide Medicare, regulatory agencies, research organizations, and insurance companies with a standardized method of collecting epidemiological data—the information medical professionals use to track ailments across different regions and populations. However, the developers of the coding system did not anticipate the unintended consequence of linking the laudable goal of epidemiologic data mining with a system of financial reward.
This coding system leads inevitably to distortions in epidemiological data. Because doctors are required to come up with a diagnostic code on each bill submitted in order to get paid, they pick the code that comes closest to describing the patient’s problem while yielding maximum remuneration. The same process plays out when it comes to submitting procedure codes on bills. As a result, the accuracy of the data collected since the advent of compensation coding is suspect.
Command and Control
Coding was one of the earliest manifestations of the cancer consuming the medical profession, but the disease is much more broad-based and systemic. The root of the problem is that patients are not payers. Through myriad tax and regulatory policies adopted on the federal and state level, the system rarely sees a direct interaction between a consumer and a provider of a health care good or service. Instead, a third party—either a private insurance company or a government payer, such as Medicare or Medicaid—covers almost all the costs. According to the National Center for Policy Analysis, on average, the consumer pays only 12 percent of the total health care bill directly out of pocket. There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.
As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.
Then, as the 1990s gave way to the 21st century, demographic reality caught up with Medicare and Medicaid, the two principal drivers of federal health care spending.
Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on America’s physicians through a centralized bureaucracy. Using so-called “evidence-based medicine,” algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups.
While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individual—that every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.
Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that don’t follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.
What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution.
Once again, the medical profession cooperated. The American College of Surgeons helped develop Surgical Care Improvement Project (SCIP) protocols, directing surgeons as to what antibiotics they may use and the day-to-day post-operative decisions they must make. If a surgeon deviates from the guidelines, he is usually required to document in the medical record an acceptable justification for that decision.
These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.
Operating room and endoscopy suites now must follow protocols developed by the global World Health Organization—an even more remote agency. There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.
Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don’t provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.
A large Veterans Administration study released in March 2011 showed that SCIP protocols led to no improvement in surgical-site infection rate. If past is prologue, we should not expect the SCIP protocols to be repealed, just “improved”—or expanded, adding to the already existing glut.
These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.
One of my colleagues, a noted pulmonologist with over 30 years’ experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that “ ‘evidence-based’ means you are not interested in listening to anyone.” Another colleague, a North Phoenix orthopedist of many years, decries the “cookie-cutter” approach mandated by protocols.
A noted gastroenterologist who has practiced more than 35 years has a more cynical take on things. He believes that the increased regimentation and regularization of medicine is a prelude to the replacement of physicians by nurse practitioners and physician-assistants, and that these people will be even more likely to follow the directives proclaimed by regulatory bureaus. It is true that, in many cases, routine medical problems can be handled more cheaply and efficiently by paraprofessionals. But these practitioners are also limited by depth of knowledge, understanding, and experience. Patients should be able to decide for themselves if they want to be seen by a doctor. It is increasingly rare that patients are given a choice about such things.
The partners in my practice all believe that protocols and guidelines will accomplish nothing more than giving us more work to do and more rules to comply with. But they implore me to keep my mouth shut—rather than risk angering hospital administrators, insurance company executives, and the other powerful entities that control our fates.
Electronic Records and Financial Burdens
When Congress passed the stimulus, a.k.a. the American Reinvestment and Recovery Act of 2009, it included a requirement that all physicians and hospitals convert to electronic medical records (EMR) by 2014 or face Medicare reimbursement penalties. There has never been a peer-reviewed study clearly demonstrating that requiring all doctors and hospitals to switch to electronic records will decrease error and increase efficiency, but that didn’t stop Washington policymakers from repeating that claim over and over again in advance of the stimulus.
Some institutions, such as Kaiser Permanente Health Systems, the Mayo Clinic, and the Veterans Administration Hospitals, have seen big benefits after going digital voluntarily. But if the same benefits could reasonably be expected to play out universally, government coercion would not be needed.
Instead, Congress made that business decision on behalf of thousands of doctors and hospitals, who must now spend huge sums on the purchase of EMR systems and take staff off other important jobs to task them with entering thousands of old-style paper medical records into the new database. For a period of weeks or months after the new system is in place, doctors must see fewer patients as they adapt to the demands of the technology.
The persistence of price controls has coincided with a steady ratcheting down of fees for doctors. As a result, private insurance payments, which are typically pegged to Medicare payment schedules, have been ratcheting down as well. Meanwhile, Medicare’s regulatory burdens on physician practices continue to increase, adding on compliance costs. Medicare continues to demand that specific coded services be redefined and subdivided into ever-increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimes—as in the case of John Natale of Arlington, Illinois, who began a 10-month sentence in November because he miscoded bills on five patients upon whom he repaired complicated abdominal aortic aneurysms—the penalty can even include prison.
For many physicians in private practice, the EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. This allows them to offload the high costs of regulatory compliance and converting to EMR.
As doctors become shift workers, they work less intensely and watch the clock much more than they did when they were in private practice. Additionally, the doctor-patient relationship is adversely affected as doctors come to increasingly view their customers as the hospitals’ patients rather than their own.
In 2011, The New England Journal of Medicine reported that fully 50 percent of the nation’s doctors had become employees—either of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two-thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continue to mount, we can expect this trend to continue.
Accountable Care Organizations
For the next 19 years, an average of 10,000 Americans will turn 65 every day, increasing the fiscal strain on Medicare. Bureaucrats are trying to deal with this partly by reinstating an old concept under a new name: Accountable Care Organization, or ACO, which harkens back to the infamous HMO system of the early 1990s.
In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain benchmarks established by Medicare with respect to cost, length of hospital stay, re-admissions, and other measures, they will get to share a portion of Medicare’s savings. If the reverse happens, there will be economic penalties.
Naturally, private insurance companies are following suit with non-Medicare versions of the ACO, intended primarily for new markets created by ObamaCare. In this model, an ACO is given a lump sum, or bundled payment, by the insurance company. That chunk of money is intended to cover the cost of all the care for a large group of insurance beneficiaries. The private ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.
In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally planned practice guidelines are the primary goal.
ACOs are meant to replace a fee-for-service payment model that critics argue encourages providers to perform more services and procedures on patients than they otherwise would do. This assumes that all providers are unethical, motivated only by the desire for money. But the salaried and prepaid models of provider-reimbursement are also subject to unethical behavior in our current system. There is no reward for increased productivity with the salary model. With the prepaid model there is actually an incentive to maximize profit by withholding services.
Each of these models has its pros and cons. In a true market-based system, where competition rewards positive results, the consumer would be free to choose among the various competing compensation arrangements.
With increasing numbers of health care providers becoming salaried employees of hospitals, that’s not likely. Instead, we’ll see greater bureaucratization. Hospitals might be able to get ACOs to work better than their ancestor HMOs, because hospital administrators will have more control over their medical staff. If doctors don’t follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the “problem” doctors.
Doctors Going Galt?
Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft. It’s no surprise that retirement is starting to look more attractive. The advent of the Affordable Care Act of 2010, which put the medical profession’s already bad trajectory on steroids, has for many doctors become the straw that broke the camel’s back.
A June 2012 survey of 36,000 doctors in active clinical practice by the Doctors and Patients Medical Association found 90 percent of doctors believe the medical system is “on the wrong track” and 83 percent are thinking about quitting. Another 85 percent said “the medical profession is in a tailspin.” 65 percent say that “government involvement is most to blame for current problems.” In addition, 2 out of 3 physicians surveyed in private clinical practice stated they were “just squeaking by or in the red financially.”
A separate survey of 2,218 physicians, conducted online by the national health care recruiter Jackson Healthcare, found that 34 percent of physicians plan to leave the field over the next decade. What’s more, 16 percent said they would retire or move to part-time in 2012. “Of those physicians who said they plan to retire or leave medicine this year,” the study noted, “56% cited economic factors and 51% cited health reform as among the major factors. Of those physicians who said they are strongly considering leaving medicine in 2012, 55% or 97 physicians, were under age 55.”
Interestingly, these surveys were completed two years after a pre-ObamaCare survey reported in The New England Journal of Medicine found 46.3 percent of primary care physicians stated passage of the new health law would “either force them out of medicine or make them want to leave medicine.”
It has certainly affected my plans. Starting in 2012, I cut back on my general surgery practice. As co-founder of my private group surgical practice in 1986, I reached an arrangement with my partners freeing me from taking night calls, weekend calls, or emergency daytime calls. I now work 40 hours per week, down from 60 or 70. While I had originally planned to practice at least another 12 to 14 years, I am now heading for an exit—and a career change—in the next four years. I didn’t sign up for the kind of medical profession that awaits me a few years from now.
Many of my generational peers in medicine have made similar arrangements, taken early retirement, or quit practice and gone to work for hospitals or as consultants to insurance companies. Some of my colleagues who practice primary care are starting cash-only “concierge” medical practices, in which they accept no Medicare, Medicaid, or any private insurance.
As old-school independent-thinking doctors leave, they are replaced by protocol-followers. Medicine in just one generation is transforming from a craft to just another rote occupation.
Medicine in the Future
In the not-too-distant future, a small but healthy market will arise for cash-only, personalized, private care. For those who can afford it, there will always be competitive, market-driven clinics, hospitals, surgicenters, and other arrangements—including “medical tourism,” whereby health care packages are offered at competitive rates in overseas medical centers. Similar healthy markets already exist in areas such as Lasik eye surgery and cosmetic procedures. The medical profession will survive and even thrive in these small private niches.
In other words, we’re about to experience the two-tiered system that already exists in most parts of the world that provide “universal coverage.” Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
We already see this in Canada, where cash-only clinics are beginning to spring up, and the United Kingdom, where a small but healthy private system exists side-by-side with the National Health Service, providing high-end, fee-for-service, private health care, with little or no waiting.
Ayn Rand’s philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:
“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
Medicine’s Top Earners Are Not the M.D.s
By ELISABETH ROSENTHALMAY 17, 2014 - New York Times
Link to Story
THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.
That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.
The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.
And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.
The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.
“At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”
She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”
Who Makes What
National average annual salaries in 2013 for health-related job titles. Figures do not include bonuses or incentives, which can be far greater than base salaries.
She said that executive salaries in health care “increased hugely in the ‘90s” and that the trend has continued. For example, in addition to Mr. Del Mauro’s $21.7 million package, Barnabas Health listed more than 20 vice presidents who earned over $350,000 on its latest available tax return; the new chief executive earned about $3 million. Data released by Medicare show that Barnabas Health’s hospitals bill more than twice the national average for many procedures. (In 2006, the hospital paid one of the largest Medicare fines ever to settle fraud charges brought by federal prosecutors.)
Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices.
Ellen Greene, a spokeswoman for Barnabas Health, said Mr. Del Mauro’s retirement package was “a function of over four decades of service and reflects his exceptional legacy.” Nearly $14 million was a cumulative payout from a deferred retirement plan, she said, and the remainder included base compensation, a bonus and an incentive plan
Ms. Greene also said Barnabas’s compensation program follows I.R.S. rules and is established by an executive compensation committee with “guidance from a nationally recognized compensation consultant.”
In many areas, the health care industry is home to the top earning executives in the nonprofit sector.
And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund.
As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the “navigators” created by the Affordable Care Act.
Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.
“Most doctors want to do well by their patients,” said Dr. Abeel A. Mangi, a cardiothoracic surgeon at the Yale School of Medicine, who is teaming up with a group at the Yale School of Management to better evaluate cost and outcomes in his department. “Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”
Doctors are beginning to push back: Last month, 75 doctors in northern Wisconsin took out an advertisement in The Wisconsin State Journal demanding widespread health reforms to lower prices, including penalizing hospitals for overbuilding and requiring that 95 percent of insurance premiums be used on medical care. The movement was ignited when a surgeon, Dr. Hans Rechsteiner, discovered that a brief outpatient appendectomy he had performed for a fee of $1,700 generated over $12,000 in hospital bills, including $6,500 for operating room and recovery room charges.
It’s worth noting that the health care industry is staffed by some of the lowest as well as highest paid professionals in any business. The average staff nurse is paid about $61,000 a year, and an emergency medical technician earns just about minimum wage, for a yearly income of $27,000, according to the Compdata analysis. Many medics work two or three jobs to make ends meet.
“It’s stressful, dirty, hard work, and the burnout rate is high,” said Tom McNulty, a 19-year-old college student who volunteers for an ambulance corps outside Rochester. Though he finds it fulfilling, he said he would not make it a career: “Financially, it’s not feasible.”
Correction: May 18, 2014
An earlier version of the headline for this article was revised to more precisely capture the principal insight offered by the news analysis.
By ELISABETH ROSENTHALMAY 17, 2014 - New York Times
Link to Story
THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.
That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.
The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.
And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.
The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.
“At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”
She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”
Who Makes What
National average annual salaries in 2013 for health-related job titles. Figures do not include bonuses or incentives, which can be far greater than base salaries.
- HeathCareCosts.jpg (91.13 KiB) Viewed 2747 times
Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices.
Ellen Greene, a spokeswoman for Barnabas Health, said Mr. Del Mauro’s retirement package was “a function of over four decades of service and reflects his exceptional legacy.” Nearly $14 million was a cumulative payout from a deferred retirement plan, she said, and the remainder included base compensation, a bonus and an incentive plan
Ms. Greene also said Barnabas’s compensation program follows I.R.S. rules and is established by an executive compensation committee with “guidance from a nationally recognized compensation consultant.”
In many areas, the health care industry is home to the top earning executives in the nonprofit sector.
And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund.
As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the “navigators” created by the Affordable Care Act.
Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.
“Most doctors want to do well by their patients,” said Dr. Abeel A. Mangi, a cardiothoracic surgeon at the Yale School of Medicine, who is teaming up with a group at the Yale School of Management to better evaluate cost and outcomes in his department. “Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”
Doctors are beginning to push back: Last month, 75 doctors in northern Wisconsin took out an advertisement in The Wisconsin State Journal demanding widespread health reforms to lower prices, including penalizing hospitals for overbuilding and requiring that 95 percent of insurance premiums be used on medical care. The movement was ignited when a surgeon, Dr. Hans Rechsteiner, discovered that a brief outpatient appendectomy he had performed for a fee of $1,700 generated over $12,000 in hospital bills, including $6,500 for operating room and recovery room charges.
It’s worth noting that the health care industry is staffed by some of the lowest as well as highest paid professionals in any business. The average staff nurse is paid about $61,000 a year, and an emergency medical technician earns just about minimum wage, for a yearly income of $27,000, according to the Compdata analysis. Many medics work two or three jobs to make ends meet.
“It’s stressful, dirty, hard work, and the burnout rate is high,” said Tom McNulty, a 19-year-old college student who volunteers for an ambulance corps outside Rochester. Though he finds it fulfilling, he said he would not make it a career: “Financially, it’s not feasible.”
Correction: May 18, 2014
An earlier version of the headline for this article was revised to more precisely capture the principal insight offered by the news analysis.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
Every Industry Gets Worse When Government Gets Involved
Isaac Morehouse - April 30, 2016
This is easily provable with Public Choice Theory, and consistently proven in practice.
Contrary to the absurdly naive belief that monopolizing an industry will produce “efficiencies”, it has the opposite effect. All the wrong things are incentivized and no one has any clear signal of what creates value. (See “Socialist Calculation Problem“)
Antony Davies shared this depressing graph with me last week. If you’ve been to a health care provider in the last few years, you’ve felt the pain this causes in the realm of customer experience.
Isaac Morehouse - April 30, 2016
This is easily provable with Public Choice Theory, and consistently proven in practice.
Contrary to the absurdly naive belief that monopolizing an industry will produce “efficiencies”, it has the opposite effect. All the wrong things are incentivized and no one has any clear signal of what creates value. (See “Socialist Calculation Problem“)
Antony Davies shared this depressing graph with me last week. If you’ve been to a health care provider in the last few years, you’ve felt the pain this causes in the realm of customer experience.
- GrowthOfDrs.jpg (62.54 KiB) Viewed 2746 times
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
Just like schools and what ever else we have not noticed yet. 
KARMA RULES
Those Who Can Make You Believe Absurdities, Can Make You Commit Atrocities': Voltaire
Those Who Can Make You Believe Absurdities, Can Make You Commit Atrocities': Voltaire
OK... Now What?
Federal Judge Rules The Administration Is Improperly Funding Obamacare Subsidies In Violation Of The Constitution
http://www.latimes.com/nation/la-na-oba ... story.html
http://www.latimes.com/nation/la-na-oba ... story.html
A mind should not be so open that the brains fall out; however, it should not be so closed that whatever gray matter which does reside may not be reached. ART BELL
Everything Woke turns to
-Donald Trump 
Everything Woke turns to
Meanwhile, Back At The Capitol
How Congress Mysteriously Became A ‘Small Business’ To Qualify For Obamacare Subsides
http://www.cnsnews.com/commentary/rober ... -obamacare
http://www.cnsnews.com/commentary/rober ... -obamacare
A mind should not be so open that the brains fall out; however, it should not be so closed that whatever gray matter which does reside may not be reached. ART BELL
Everything Woke turns to -Donald Trump
Everything Woke turns to
Re: Obamacare is NOT working
Here in Massachusetts, we recently had a tragedy when a patient with mental health issues - who was also on Medicaid, presented at a local hospital. because the patient was a Medicaid recipient, state law required that he be "served" by a state agency. Even though the hospital had beds available, the state-appointed psyche rep evaluated and released the patient, after which he went on a killing spree in a local home and mall killing a number of people. Sad situation that we have this system with multiple tiers......
Snippet:
DaRosa was brought by ambulance to the emergency room Monday evening after relatives said he was threatening to kill himself and had told them the devil was playing tricks on him and trying to poison his children.
DaRosa was released hours later, about 4 a.m. Tuesday.
Morton Hospital has not explained why DaRosa was not held for treatment, saying it is barred from disclosing confidential patient information. It is not clear what specific role the state-run Taunton/Attleboro Emergency Services played in DaRosa’s case.
But the hospital said, “If the state-contracted agency responsible for conducting evaluations in the Emergency Department had requested an admission to a psychiatric bed, there were beds available within the hospital’s network.”
After he was released, DaRosa went to work and then to his child’s soccer practice.
Authorities say he then went on a rampage, fatally stabbing an 80-year-old woman in her Taunton home and a 56-year-old man dining with his wife at a Bertucci’s restaurant in a mall four miles away.
DaRosa, 28, was then shot and killed by an off-duty sheriff’s deputy who had been eating dinner at Bertucci’s.
DaRosa’s relatives have criticized Morton Hospital for releasing him.
“If Morton could have done a little bit more and kept him there, none of this would have happened,” DaRosa’s aunt, Liz DaRosa, said Wednesday. “He wanted the help. He asked for help.”
Told Thursday about Morton’s decision to pull out of the state-run system, Liz DaRosa said: “It’s pretty sad they have to wait for a tragedy” to act.
“If they knew the company was bad and not giving good service, why wouldn’t they get rid of them before this?” she said.
The hospital, which is part of the Steward Health Care System, said it has long complained about a two-tiered system used to evaluate mental health patients.
Under the system, privately insured patients who show up in emergency rooms with mental health issues are screened by the hospital’s own doctors and nurses.
But when most Medicaid patients arrive in an ER, they are evaluated by clinicians from a contractor selected, overseen, and paid for by the state departments of public health and mental health.
The outsider then decides whether the patient should be admitted to the hospital for treatment or released.
The system, established more than two decades ago, was designed to ensure that patients who did not need hospitalization were treated in less expensive settings, such as community clinics and group homes.
But some hospitals have expressed concerns about the arrangement, saying their own doctors and nurses are better suited to determine patients’ needs.
“As we have said in the past, the current policy mandating that the evaluation process must be carried out by a third-party state contractor is misguided,” Julie Masci, another Morton Hospital spokeswoman, said in a statement.
Many have questioned whether the separate screening system for MassHealth patients violates the state’s mental health parity law, which requires that mental health patients be treated no differently than those with other ailments, said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, which represents 44 psychiatric and substance abuse hospitals.
“We have been back and forth with the state for many months and years on this,” said Matteodo, whose association is officially neutral on the issue. “The state believes this is another level of care, that it is not a violation of parity, that they’re diverting a lot of people from hospitals and, therefore, they are serving a valuable role.”
In withdrawing from the system, Morton said it would use its own hospital staff to evaluate Medicaid patients with mental health issues. It is not clear, however, if the state will reimburse the hospital for those services.
“If a hospital admits a MassHealth patient without using the Emergency Services Program, they won’t get paid,” Matteodo said.
https://www.bostonglobe.com/metro/2016/ ... tory.html
Snippet:
DaRosa was brought by ambulance to the emergency room Monday evening after relatives said he was threatening to kill himself and had told them the devil was playing tricks on him and trying to poison his children.
DaRosa was released hours later, about 4 a.m. Tuesday.
Morton Hospital has not explained why DaRosa was not held for treatment, saying it is barred from disclosing confidential patient information. It is not clear what specific role the state-run Taunton/Attleboro Emergency Services played in DaRosa’s case.
But the hospital said, “If the state-contracted agency responsible for conducting evaluations in the Emergency Department had requested an admission to a psychiatric bed, there were beds available within the hospital’s network.”
After he was released, DaRosa went to work and then to his child’s soccer practice.
Authorities say he then went on a rampage, fatally stabbing an 80-year-old woman in her Taunton home and a 56-year-old man dining with his wife at a Bertucci’s restaurant in a mall four miles away.
DaRosa, 28, was then shot and killed by an off-duty sheriff’s deputy who had been eating dinner at Bertucci’s.
DaRosa’s relatives have criticized Morton Hospital for releasing him.
“If Morton could have done a little bit more and kept him there, none of this would have happened,” DaRosa’s aunt, Liz DaRosa, said Wednesday. “He wanted the help. He asked for help.”
Told Thursday about Morton’s decision to pull out of the state-run system, Liz DaRosa said: “It’s pretty sad they have to wait for a tragedy” to act.
“If they knew the company was bad and not giving good service, why wouldn’t they get rid of them before this?” she said.
The hospital, which is part of the Steward Health Care System, said it has long complained about a two-tiered system used to evaluate mental health patients.
Under the system, privately insured patients who show up in emergency rooms with mental health issues are screened by the hospital’s own doctors and nurses.
But when most Medicaid patients arrive in an ER, they are evaluated by clinicians from a contractor selected, overseen, and paid for by the state departments of public health and mental health.
The outsider then decides whether the patient should be admitted to the hospital for treatment or released.
The system, established more than two decades ago, was designed to ensure that patients who did not need hospitalization were treated in less expensive settings, such as community clinics and group homes.
But some hospitals have expressed concerns about the arrangement, saying their own doctors and nurses are better suited to determine patients’ needs.
“As we have said in the past, the current policy mandating that the evaluation process must be carried out by a third-party state contractor is misguided,” Julie Masci, another Morton Hospital spokeswoman, said in a statement.
Many have questioned whether the separate screening system for MassHealth patients violates the state’s mental health parity law, which requires that mental health patients be treated no differently than those with other ailments, said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, which represents 44 psychiatric and substance abuse hospitals.
“We have been back and forth with the state for many months and years on this,” said Matteodo, whose association is officially neutral on the issue. “The state believes this is another level of care, that it is not a violation of parity, that they’re diverting a lot of people from hospitals and, therefore, they are serving a valuable role.”
In withdrawing from the system, Morton said it would use its own hospital staff to evaluate Medicaid patients with mental health issues. It is not clear, however, if the state will reimburse the hospital for those services.
“If a hospital admits a MassHealth patient without using the Emergency Services Program, they won’t get paid,” Matteodo said.
https://www.bostonglobe.com/metro/2016/ ... tory.html
There you go man, keep as cool as you can. Face piles and piles of trials with smiles. It riles them to believe that you perceive the web they weave. And keep on thinking free. (Moody Blues)
Re: Obamacare is NOT working
voguy wrote:Every Industry Gets Worse When Government Gets Involved
Isaac Morehouse - April 30, 2016
This is easily provable with Public Choice Theory, and consistently proven in practice.
Contrary to the absurdly naive belief that monopolizing an industry will produce “efficiencies”, it has the opposite effect. All the wrong things are incentivized and no one has any clear signal of what creates value. (See “Socialist Calculation Problem“)
Antony Davies shared this depressing graph with me last week. If you’ve been to a health care provider in the last few years, you’ve felt the pain this causes in the realm of customer experience.
I can tell you that mine is a full time job doing nothing more than compiling stats and doing other administrative work for nothing else other than compiling with all of the federal and state mandates required for the hospital to operate a radiology department. The amount of paperwork and studies showing various quality measures is astounding - and all dreamt up by various groups who's sole jobs it is to find various ways to justify their existence. And, my job is duplicated around the country at each and every hospital adding little "value" to the service provided other than to say that we have qualified staff and meet certain metrics. Honestly, I'd rather be caring for patients........
There you go man, keep as cool as you can. Face piles and piles of trials with smiles. It riles them to believe that you perceive the web they weave. And keep on thinking free. (Moody Blues)
Bad By Design
Government doesn't want you helping patients. Something of value like that?? That doesn't help THEIR bottom line does it -kbot wrote:I can tell you that mine is a full time job doing nothing more than compiling stats and doing other administrative work for nothing else other than compiling with all of the federal and state mandates required for the hospital to operate a radiology department. The amount of paperwork and studies showing various quality measures is astounding - and all dreamt up by various groups who's sole jobs it is to find various ways to justify their existence. And, my job is duplicated around the country at each and every hospital adding little "value" to the service provided other than to say that we have qualified staff and meet certain metrics. Honestly, I'd rather be caring for patients........voguy wrote:Every Industry Gets Worse When Government Gets Involved
Isaac Morehouse - April 30, 2016
This is easily provable with Public Choice Theory, and consistently proven in practice.
Contrary to the absurdly naive belief that monopolizing an industry will produce “efficiencies”, it has the opposite effect. All the wrong things are incentivized and no one has any clear signal of what creates value. (See “Socialist Calculation Problem“)
Antony Davies shared this depressing graph with me last week. If you’ve been to a health care provider in the last few years, you’ve felt the pain this causes in the realm of customer experience.
OTOH, a bullsh!t job? That's something the state understands all too well.
A perpetual motion machine contributing nothing of value? Bureaucratic Nirvana! No health, no care. A perfect world, now if only the patients'd see it that way
Related Reading
Death By Bureaucracy
As we learn the NHS is bankrupt, read this excoriating attack on its managers by a senior consultant
EXCERPTS:
"Put doctors and nurses back in charge of our health service.
There are volumes of empirical and academic evidence that without the leadership of these two groups of front-line staff, hospitals fail.
At best they become inefficient; at worse they become enormously dangerous."
"This deterioration in the quality of care provided by many hospitals has happened despite all the targets imposed upon hospitals which were supposed to improve performance, as well as a significant rise not only in the number of doctors employed by the NHS but also of managers."
FULL STORY
A mind should not be so open that the brains fall out; however, it should not be so closed that whatever gray matter which does reside may not be reached. ART BELL
Everything Woke turns to -Donald Trump
Everything Woke turns to
Re: Obamacare is NOT working
The only thing I'll say on this subject for now is the more the medical side brings up what they did, and have to do under the law, the more they indite themselves. At one time I was skeptical of winning the case, but now I think I stand to walk away fairly happy.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
Walk away VO while you have the chance...... This system is a train wreck waiting to happen as each passing week brings more cluster fu*cks to the forefront. I read an article today about how the interval between when a patient is discharged from a hospital and admitted to another realm of care - visiting nurs, nursing home, rehab, etc) is h worst possible nd most dangerous time as the level of miscommunication raised. As an example, a patient's care was highlighted where the patient was d/c from the hospital and sent to a nursing home. Among the list of meds was a diuretic she was taking a few times over the course of the day. What was mis-communicated was a cancer med o be taken once a week. After taking a few doses, her daughter, who is a nurse, noticed marked changes in her mother including bleeding from her nose and mouth. The nursing home and pharmacy transcribed the med order as the cancer med, keeping the dosage and timing as if they were giving the diuretic. NO ONE picked up on the obvious mistake and the patient died. Med errors in healthcare settings is one of the top causes of death in this country.
The thing is, this single mistake went unnoticed by a LOT of people from the discharge team at the hospital to the receiving facility, to the nurses caring for the patient, to the pharmacy providing the meds - multiple shifts missed this on single mistake.
The thing is, this single mistake went unnoticed by a LOT of people from the discharge team at the hospital to the receiving facility, to the nurses caring for the patient, to the pharmacy providing the meds - multiple shifts missed this on single mistake.
There you go man, keep as cool as you can. Face piles and piles of trials with smiles. It riles them to believe that you perceive the web they weave. And keep on thinking free. (Moody Blues)
Re: Obamacare is NOT working
I have two goals. To take a lot of their money, and take their dignity. If they want to keep their dignity it's for sale at x4 their money.kbot wrote:Walk away VO while you have the chance...... This system is a train wreck waiting to happen as each passing week brings more cluster fu*cks to the forefront.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them." - Thomas Jefferson
Re: Obamacare is NOT working
voguy wrote:I have two goals. To take a lot of their money, and take their dignity. If they want to keep their dignity it's for sale at x4 their money.kbot wrote:Walk away VO while you have the chance...... This system is a train wreck waiting to happen as each passing week brings more cluster fu*cks to the forefront.
Unfortunately, its a self-perpetuating system that is constantly looking for, and finding ways to mandate ways to keep themselves "important" and "relevant"........ Most times, things can be done far, far less expensively and with better care IF al the administrative crap (and lawsuits) would go away. These two sectors drive the increased costs.
There you go man, keep as cool as you can. Face piles and piles of trials with smiles. It riles them to believe that you perceive the web they weave. And keep on thinking free. (Moody Blues)
Re: Obamacare is NOT working
Obama Care is Working Perfectly , just not for the soon to be "Slaves"
"This Is How Much Your Health Insurance Payment Is About To Jump By"
CHART Here...
http://www.zerohedge.com/news/2016-05-2 ... about-jump
"This Is How Much Your Health Insurance Payment Is About To Jump By"
CHART Here...
http://www.zerohedge.com/news/2016-05-2 ... about-jump
KARMA RULES
Those Who Can Make You Believe Absurdities, Can Make You Commit Atrocities': Voltaire
Those Who Can Make You Believe Absurdities, Can Make You Commit Atrocities': Voltaire