Monthly Archives: April 2014

Gratuitous Doctor Bashing

This week’s award for the best doctor bashing compound sentence in a major national media so-called news article goes to USA TODAY for this gem on page 1 of the April 25-27 Weekend edition:

 “The 10 drug companies that make the most money from doctors using their products on Medicare patients spent more than $236 million to lobby Congress and the executive branch between 2009 and 2013, according to lobbying records compiled by the Center for Responsive Politics and new federal data.”

Wow! That’s going after several birds with one stone.

While I admire the journalistic effort to shine light on the real bad guys – Big drug companies, their lobbyists, and the bribes – er, contributions, sorry — they distribute at the congressional and executive levels, I fail to see why doctor bashing had to be included in the initial sentence.

Yes, doctors prescribe the drugs that USA TODAY is critical of – mainly Lucentis vs. Avastin ($2000 vs. $50 per injection) for macular degeneration. But those are the same two drugs the national media have been citing for years now. And they have used this issue to bash all doctors who care for Medicare patients, even the lowly primary care doctors who make nothing from Lucentis, while toiling in the trenches listening to a myriad of complaints while not having the time or the money to get to a Mercedes dealership to press their noses against the window and view the overpriced $60K Mercedes CLA 45 that USA TODAY features on page 4B of the Money Section.

But the real villains who allow this bribery to go on are members of Congress who take the contributions and protect the big drug companies.

USA TODAY could have asked why there is no competitive bidding for Medicare drugs?  And why did it take so long for there to be some competitive bidding for durable medical equipment, like the infamous seat lift chairs that I reported on for local TV news in the early 1990s?  Maybe USA TODAY would like to investigate that?

What is even more interesting is how the print edition of the story differs from the electronic version:

http://www.usatoday.com/story/news/nation-now/2014/04/24/drugmakers-lobbying-medicare-payments/8055901/

The electronic version is much longer and actually deals with some specific examples of drug company lobbying that might have increased costs to Medicare. Doctors were not involved in those political decisions. Those decisions were made by politicians and bureaucrats.

Yes, I know that doctors prescribe the drugs that make drug companies rich. With the exception of a few abusive eye MDs, most doctors don’t get rich prescribing brand name drugs.  USA TODAY should have constructed the lead sentence of the print version of the story this way:

“The 10 drug companies that make the most money from Medicare patients spent more than $236 million to lobby Congress and the executive branch between 2009 and 2013, according to lobbying records compiled by the Center for Responsive Politics and new federal data.”

Besides, it’s Medicare patients who USE the drug products. Its doctors who prescribe them, along with nurse practitioners and physician assistants.

The print article implies that there is wrong-doing in the Medicare program promoted by the lobbying efforts but doesn’t provide one shred of such evidence.  All the people who read USA TODAY while traveling and at hotels deserve the full story – free of doctor bashing.

Biased Reporting on Medicare Advantage Plans by the Chicago Tribune

The Chicago Tribune ran an article on 4/22/14 about the resignation of a top Medicare bureaucrat, Dr. Jonathan Blum.  According to reporter David Morgan and his editor Andrew Hay, Dr. Blum was responsible for a lot of reforms including “efforts to move the $635 billion healthcare program for the elderly and disabled away from costly fee-for-service medicine.” (my emphasis added)

I posted the following comment to the article on the Chicago Tribune’s Facebook page:

 Your biased reporting and editing calls fee-for-service practice “costly.” If that is so, then Medicare Advantage (Medicare HMO) care should be called “even more costly,” as numerous studies have shown it to cost from 11-22% more than comparable Medicare fee-for-service care. And that is why the Obama Administration tried to cut payments to Medicare HMO plans. But that didn’t work, no doubt due to heavy lobbying efforts.

It’s amazing that the reporter and his editor published such a biased comment, but it shows the true feelings of the media.  As I have said in these posts before, the national media believe with all their hearts that fee-for-service (“FFS”) medicine is the root of all evil in medicine. If only they could do away with FFS medicine, then they wouldn’t get any bills and they could afford a better lifestyle on their meager reporter’s salaries.

In writing such nonsense, reporters and editors not only show their biases, they also show their ignorance.

There is a mountain of published studies showing that Medicare HMOs – whatever they have been called for the last 30 years – have not saved taxpayers any money. In fact, they have always cost taxpayers more money than FFS medicine. Don’t take my word for it. Read all the studies – - starting with a Mathematica study in the 1990s. Here’s the link to the NY Times article from December 27, 1993:

http://www.nytimes.com/1993/12/27/us/medicare-to-stop-pushing-patients-to-enter-hmo-s.html

That article says the HMOs cost 5.7% more than FFS medicine. But more modern studies of the plans that were renamed “Advantage” showed them to be from 11-22% more costly.

And in another display of biased reporting, they are almost always referred to a “private plans.” The media know that people dislike HMOs. So they call these plans “private plans” so as not to engender dislike for what these arrangements really are: HMOs.

Taxpayer dollars have been paid to Medicare HMOs run by the likes of Humana and UnitedHealth Group (and prior to that Secure Horizons) to enrich the HMO executives and lobbyists who sell this stuff. Fortunes have been made gulling the public and Congress who has been only too happy to accept the re-cycled taxpayer dollars — now called political contributions — to stay in office and further screw the Medicare beneficiaries enrolled in these plans.

The enrollees, particularly in places like San Antonio, where there are a lot of poor people, think they are getting something for nothing. The politicians make them think they are getting “free” goodies that come from rich folks and particularly rich doctors who can no longer give them a bill.

But it has all been a scam.

Virtually every study done on the cost savings of Medicare HMOs show they are more costly than FFS Medicare.  But you can’t make them go away. The Wall Street Journal frequently editorializes that Medicare HMOs give patients more choices? Choices of what?  Gym memberships?  Certainly not doctors and national treatment centers. The narrow networks everybody is deriding as a bad part of Obamacare plans got their start with the narrow networks of Medicare HMOs.

Here’s my financial analysis pearl of the day: If you want to see if funding is going to be cut to Medicare Advantage HMOs, just look at the charts of the stocks of Humana ( symbol HUM) and UnitedHealth Group ( symbol UNH). As long as those stocks keep going up, you’ll know that funding to them is robust and the defunding called for by the ACA is not going to happen. You can at both of these stocks and see that their stock prices have been going up steadily since the passage of the ACA.

I would bet that Dr. Blum goes to work for a company that benefits from Medicare Advantage stock prices or the policies that promote Medicare managed care.  He certainly did a lot to enhance the value of the companies that sell those plans.

 

 

 

Medicare Data Release: Media doctor bashing

It’s open season on doctors in the national media sport of doctor bashing. Doctors have been blasted by innuendo by media of all stripes in a hail of articles trumpeting the release of Medicare payment specifics about how much Medicare paid to each of over 800,000 Medicare providers.

This release of Medicare payment specifics has been the Holy Grail of media doctor bashers. But even though they have reached the Promised Land, so to speak, the question remains whether the data dump serves the media’s purpose in discrediting fee-for-service payments and drive hapless medical consumers – formerly known as patients – into the Holy Grail, Part II – capitated and bundled payments at the hands of managed care arrangements.

I first wrote about the media’s attempts to tar doctors with charges of massive “fraud, waste, and abuse” way back in 1996 in an article for Forbes MediaCritic. In that article I traced the oft-quoted figure of 10% of all medical care being due to “fraud” and “abuse” to a flawed consumer survey by Aetna. And I reviewed how, in 1992, the Cox Newspaper Group had published a list of “million-dollar doctors” in six states based on some data on Medicare payments they were able to cobble together.

For that article, I interviewed Bruce Vladeck, the then Administrator of the entity that ran Medicare, the Health Care Financing Administration (HCFA). (It’s now called CMS.)

Mr. Vladeck was not bashful in stating that measuring (and publishing) how much Medicare pays individual doctors was not a particularly useful way to detect fraud. He said, “There are an awful lot of ways of cutting the data to try to identify physicians or other providers whose claims need to be investigated. Cutting it by gross billings is not a particularly effective way of doing it.”

But that never stopped the national media.

I haven’t read all the articles on this topic linked on my daily American Health Lawyers Association newsfeed.  But I did read the April 9, 2014 USA TODAY article while traveling.  Charitably speaking, it’s a joke. No, more correctly, very bad journalism.

On page 1A (April 9, 2014), the headline screamed: “Doctors’ Medicare pay revealed. Data show 7 received more than $10 million.” The two reporters, Meghan Hoyer and Kelly Kennedy, state, “Releasing the data could help consumers understand health costs, help providers deliver better care and enable journalists and advocacy groups to sniff out fraud, experts say.”

But the reporters don’t tell us say who those experts are on Page 1A. But does it really matter? Does anyone think these two reporters are going to report how these data will help consumers understand health costs and “sniff out fraud?”

If sophisticated fraud detection units of Medicare, Medicare payment contractors, Medicaid, and private insurance carriers can’t make a case for fraud now, just how are journalists and consumers going to figure out fraudulent claims? How many consumers can unleash FBI agents to raid a doctor’s office? How many journalists can get access to medical records to see if a medical test was necessary?

On page 4A of yesterday’s USA TODAY, the two reporters then go on to report in an article, “Looking under hood of Medicare,” that “… this could be a tool for outsiders to look for trends that computers miss.” Lots of luck with that one.

I can just see some seniors in rural Iowa having breakfast meetings at the only café in town (You know, the one the presidential hopefuls will be appearing at soon to bash doctors.) to go over their suspicions about which of their doctors is doing unnecessary tests that Medicare computers haven’t been able to detect.  While they’re at it, they can compare notes as to which doctors are still taking Medicare patients. They may have seen that one of the top billing doctors fingered by the data and by the media hounds runs the laboratories at the Mayo Clinic in Rochester, MN, and Medicare attributed millions in payments to this one doctor when in fact the monies went for “tens of thousands of analyses” at the Mayo Clinic — many of which are for Iowans who regularly go there for medical care. But, I digress.

Here’s a part of the article that I can’t understand. Maybe you understand it:

“Still he (an attorney) said the data could show which types of providers are overvalued, and which are undervalued. The data include repayment rates for various specialties, which can vary widely based on how much “work” is included: if it’s a surgery, are there technicians involved? Does a specialist do more “work” than a nurse practitioner? Does a speech pathologist require the same technology as a radiologist? Does a physician assistant require the same training as a cardiologist?    HUH????

Let me try to answer the incoherent questions posed for the two intrepid reporters:

Yes, technicians are usually required for surgery in a hospital or surgery center. And nurses are involved, too.

It depends on what the specialist and the nurse practitioner are trying to do. Did you have something in mind?

Maybe:  Are you talking about a speech pathologist doing a barium swallow to evaluate reflux and aspiration vs. a radiologist?

I hope not. A physician assistant might require the same training as a cardiologist for doing an EKG. But for putting in a cardiac stent, probably not.

Then, there are quotes from Deborah Ness, the president of the National Partnership for Women and Families, an organization with a track record of doing good work to secure equal pay for women and reproductive rights, and even attempts to see that women had access to appropriate specialty care in managed care arrangements.

But when it comes to using Medicare pay data, USA TODAY reported Ms. Ness opined, “Even though the data do not include outcomes, Ness said, experts could see whether unnecessary care added to costs while necessary care was overlooked.”

Memo to Ms. Ness and the two reporters:  The release of Medicare pay data will furthermore undermine public confidence in doctors and in the fee-for-service payment method. That will drive most consumers into managed care arrangements where there is virtually no transparency. If you think it’s hard now to figure what part of care is over care vs. what care has been skipped ( under care), just try to figure over care vs. under care out when Medicare pays hospitals and HMOs lump sum payments as in capitation and bundled payment arrangements.  You won’t be able to tell which corners were cut and who died sooner than necessary.  Throw in some tort reform to keep attorneys from using subpoena powers and courts to try to get at under care, and you will have an HMO executive’s dream outcome.

Ms. Ness only has to look at her board of directors, with executives from the UnitedHealth Group, CVS Caremark, and several law firms that represent large health care entities to see how her support of the Medicare data release serves the political and financial interests of her board, rather than the interests of women trying to get access to doctors they can trust.

Don’t get me wrong: I am all for transparency in both process and outcomes. But big data doesn’t lead to understanding the complexities of what consumer advocates want access to: lower costs and figuring out which doctors and hospitals give high value care. That will require the much more difficult process of measuring and reporting outcomes of care. Gross charges and payments received only muddy the waters and distract us all from measuring real patient outcomes in a clinically meaningful way.

In my next blog, I’ll review more articles on this subject.

Doctors in Distress: Same song umpteenth verse

Roni Caryn Rabin’s article for Kaiser Health News, “ Burnt Out Primary Care Docs Are Voting With Their Feet,” is a nice piece to file in my big clip file “Doctors in Distress.” http://www.kaiserhealthnews.org/Stories/2014/April/01/doctor-burnout.aspx

I’ve been keeping that file since the 1980s. The mother of all articles on the subject appeared as a three-part series in the New York Times starting on February 18, 1990 – that’s 24 years ago – almost a generation ago. The title was “Changes in Medicine Bring Pain to Healing Profession. Doctors in Distress.”

Ms. Rabyn’s excellent article is just the same song, umpteenth verse. But I do have criticisms of her article because it fails to put people like Dr. David Blumenthal – President of the Commonwealth Fund, former Harvard Professor, architect of aspects of the ACA, and longtime media darling — in the hot seat and ask him whether he was responsible for what is being reported and why did it all happen. After all Blumenthal David Blumenthal, MD, was the National Coordinator for Health Information Technology from 2009-2011. He ought to know how practicing physicians in many cases despised the IT systems that were forced on them. Ivory tower academics like Blumenthal were the architects of most of what is described by Rabyn in her section about electronic records, yet they escape criticism. That’s because connected reporters like Ms. Rabyn – who writes regularly for the New York Times –always want access. They want good relationships with the politically powerful and don’t ask hard questions of their electronic Rolodex favorite sources for fear those sources won’t take their calls or respond to their emails or texts in the future.

I understand that nobody has sympathy for those whom the media have spent the last 40 years portraying as rich, greedy, incompetent doctors. But the public should know that ordinary doctors didn’t bring about a system that gives hapless patients 8 minutes at most to tell their doctors what’s on their mind. Reporters like Rabyn know full well that Blumenthal was one of the “experts” responsible for the imposition of systems of hard to use and impossible to query for meaningful outcomes medical records that the doctors she quotes despise. But she didn’t ask Blumenthal how it was that an idea that seemed so sharp up in the ivory tower went so bad down in the trenches.

Another doctor who used to be in distress was featured in a CNN Money story: “Doctors looking for an out” last month. http://money.cnn.com/gallery/smallbusiness/2013/01/09/doctors-quitting-reasons/ Dr. Lissa Rankin says she quit medicine when she could only spend 7 minutes with each patient. You can see how the 15 minute visit shrank to 8 minutes and now it’s down to 7 minutes. All by edict of the HMO and ivory tower gurus who pretend to know the right way to practice medicine and convince their hired hands in Congress and state legislatures to follow their commands.

Dr. Rankin now makes money by life coaching and writing books.

Speaking of my big clip file on “doctors in distress,” it is interesting to re-read an editorial by then New England Journal of Medicine editor Jerome Kassirer from November 19, 1998, in which he states what Ms. Rabyn just reported: “ “…disgruntled, cranky doctors are not likely to provide outstanding medical care.” So, 16 years later, Ms. Rabyn is finding the same thing. Amazing! And maybe that’s why as she reports that the American Medical Association now has Dr. Jay Crosson as vice-president of professional satisfaction.

Or should it be VP of professional dissatisfaction? In any case, it’s a good example of your AMA dues at work.

What the AMA really needs is a Vice President of Work Stoppages.