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.”

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. 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.

UPDATES: Humana coverage and Zeke Emanuel

1. Follow up on my March 18, 2014 post on the problems one insured had with Humana’s Obamacare product HMOx in Texas. This insured was assigned to a nurse practitioner as the “primary care physician.” ( PCP) The insured had to go to an urgent care facility for an acute medical problem and pay $128 out of pocket when Humana couldn’t find where the NP practiced and couldn’t immediately get the insured into another practice. The insured was eventually assigned to another medical practice. Meanwhile the problem was not solved and the insured now tried to go to the PCP who was actually a medical doctor. The doctor’s office said they couldn’t see a new patient until July 2014. So the insured yesterday had to call around and find a PCP who takes HMOx and says their practice can see someone urgently. Now the insured is calling Humana to get that PCP declared the doctor of record. The prior PCP’s office said that just because the patient was on their panel of patients didn’t mean they had to or could see the patient right away. So much for access to care.

2. Greg Scandlen posted a great blog criticizing Zeke Emanuel today. It’s worth a read and full of good content.

3. The Wall Street Journal published several letters today critical of Zeke Emanuel. One was from the president of the Texas Medical Association and was critical of the ACA’s emphasis on bundling payments to hospitals. While I applaud the TMA’s opinion, it’s still not enough to make me join. I’m still harboring grudges from 1995 when they opposed then Gov. George Bush’s nomination of me (a TMA member) to be chair of the committee supervising the Texas Department of Health. I’ll write about that in a future blog and in my memoir.

4. Speaking of Zeke and hospitals, he’s at it again predicting the Kaiserization of medicine by hospitals forming de facto insurance companies that deliver care. Read about it in the Fiscal Times:

5. Meanwhile Zeke’s brother Hizzoner Rahm Emanuel was on CNBC defending the ACA – sorta – but trying to distance himself from it a little.

All Zeke All The Time

I don’t know about you, but I’m fed up with hearing and seeing Ezekiel Emanuel in the news. “Zeke,” as he’s known, is Rahm’s little brother and the current media darling in charge of making pronouncements about health care policy, the bright status of the Affordable Care Act ( ACA) also known as Obamacare, and who should live and who should die. He was one of the White House’s principal advisors on the construction of the ACA and hailed as the ultimate guru on health care policy.

The recent publication of his new book, Reinventing American Health Care. How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System, has resulted in a media orgy –book reviews, news articles, TV show appearances, NPR interview, New York Times pieces – by both conservative and liberal press outlets. And throughout it all, Zeke is there grinning and delivering his happy doctor-bashing patter with nary a tough question to answer. The media interviews I have seen and read – with the exception of one Wall Street Journal (“ WSJ”) book review and the few letters to the editor published by the WSJ in response to the massive WSJ Review piece ( March 8-9, 2014, page C3) by Emanuel they published have all been very docile. Even the outspoken conservative Bill O’Reilly was fumbling and inarticulate when trying to challenge Emanuel about his book. That’s easy to explain: the media have been bashing doctors for as long as I’ve been tracking and documenting the process and are rooting for and hoping that those rich arrogant doctors (smilin’ Zeke excluded) will get their comeuppance. Never mind that the journalists and their families might well get done in by those narrow networks of specialists –er now called “high value networks” – that somehow failed to include places like national cancer centers with the latest cutting edge cancer treatments. That’s just a bump on the road to lowering health care costs and improving American’s global competitiveness and freeing up dollars so people can buy a new GM car – subject to recall – once a year or so to keep the car dealers advertising and the media outlets profitable. But I digress.

Back to Zeke. He ran into some trouble back in 2009 when the details of the proposed ACA were being divulged. You recall the big flap about “Death Panels.” That flap was supposed to be about the end of life counseling proposed by the bill. It prompted a Facebook post by Sarah Palin which cited a Lancet article authored by Zeke and two other colleagues at National Institutes of Health, where he was head of the Department of Bioethics. That article was published in the British medical journal The Lancet on January 31, 2009 and titled “Principles for allocation of scarce medical interventions.” The authors proposed principles for allocating scarce resources such as organs for transplants, vaccines in epidemics, and ICU beds when demand exceeds supply. The one “figure” used in the Lancet article says it all:

The Reaper Curve: Ezekiel Emanuel used the above chart in a Lancet article to illustrate the ages on which health spending should be focused. “Principles for Allocation of Scarce Medical Interventions” The Lancet, January 31, 2009 . Figure from The Lancet. Caption of graphic from op ed piece by Betsy McCaughey published in the Wall Street Journal, August 27, 2009.
As you can see, your worth to society — according to Zeke — drops off precipitously after age 40. As he puts it, “ When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated(figure).”

“Attenuated” as in “See you on the other side.”

Now Zeke got all bent out of shape in 2009 when he was attacked for being a “deadly doctor” and promoting euthanasia. But what are people to think when they read such a plan to axe seniors – before they even get to be seniors? Zeke complained that he didn’t want to hurt the infirm as he had a sister with cerebral palsy. I have no doubt that Zeke – and Rahm- would do everything within their considerable political power to help their sister and get her the very best medical care.

But what would they do for your sister? Or your mother? Or anyone who isn’t a big political contributor or an influential lobbyist or a powerful politician?

We all know the answer to that one: Find out where your loved one falls on the complete lives allocation curve above and apply the rule to determine who has a life unworthy of life.

Yes, I deliberately used the term “life unworthy of life” and will deliberately use the “N” word – Nazis – because this is how the Nazis operated. They adopted that term, first used in the 1920s to decide who was too weak or too infirm or too mentally ill or too Jewish or too Gypsy or too homosexual and then killed those they decided didn’t fit into their criteria for a purer, stronger race.

And don’t think that kind of thinking wasn’t operative in the U.S. long before Zeke came along.

In the early 1900’s eugenics was an accepted “scientific” program in the U.S. – touted by the leading scientists and medical journals – to sterilize those with mental illness, abnormal sexual behaviors, and even seizure disorders. Some say that the Nazis based their actions in part on the U.S programs and entered into a kind of medical /eugenics arms race to improve the human species. First, the Nazis started with forced sterilizations, I will write more about eugenics in later posts and how it continued in North Carolina and even shamefully at my medical school alma mater, Duke, into the 1970s.

Zeke falls into that group of arrogant doctors who think they know the right way to practice medicine and the right way to decide who lives and who dies. It’s all a matter of being the “smartest” guy in the room and having the right Ivy League credentials.

But back to Zeke. On page 429 of the Lancet article, he gives us a glimpse of how he feels about doctors who take care of sick patients but don’t apply his allocation rule:

Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates ”

Please read that again. That is an astounding charge.

Zeke is saying that those of us who have taken an oath to do no harm and work hard to keep every patient alive and free of disease are deliberately and/or intentionally sickening patients or letting them be sicker than necessary or sick longer than necessary all for the purpose of making money.

To understand where Zeke is coming from, you also have to know that he has tirelessly worked to change the way doctors are paid from a fee-for-service system to a capitated or bundled system, in which the HMO executives or the hospital administrator in an Accountable Care Organization controls the doctors and probably, under Zeke’s most hopeful scenario, applies the complete lives rationing er allocation curve.

Sarah Palin did the country a real favor by posting the citation to Zeke’s Lancet article. She was right for the wrong reason, in that the real Death Panel in the ACA is in the form of the Independent Payment Advisory Board that will decide who lives and who dies in the Medicare population. But I’ll save that analysis for later posts. The best news about the IPAB is that its members have still not been appointed, because our so-called political “leaders” are too scared to activate the board before any major election, especially the way voters are reacting to the rollout of the ACA.

You would think that with Zeke Emanuel’s various criticisms of practicing physicians and his proposal to allocate scarce medical resources on the basis of age, major medical organizations like the American Medical Association would take issue with him. Would it surprise you to learn that Zeke has been put on the editorial board of the Journal of the American Medical Association? Imagine that: a big time practicing doctor-basher on the board of the very medical journal that hard-working doctors are paying dues to enable. That’s typical of the AMA. And I promise to write more about the AMA and so-called “organized” medicine in later posts. It’s editorial board reads like a Who’s Who of doctor-bashers.

If you don’t think Zeke is a doctor-basher, look at the Viewpoint article he wrote in JAMA on January 25, 2012, “Physician Autonomy and Health Care Reform.” I love the sentence that begins, “Furthermore, solo practitioners will be able to decide whether to join an ACO, with which other physicians they want to collaborate with on a bundled payment, and how to work together to define the care the group of physicians should deliver.” HUH? Where is the “or,” as in “or not join an ACO and not subject themselves and their patients to the abusive practices of hospital administrators with a managed care mentality who want to save dollars as opposed to saving lives?”

Today, there is a report that 60% of doctors don’t want to join an ACO. Zeke would probably say that’s because they want to “sicken” their patients to make more money.

Zeke went on in the JAMA article to assert, “Indeed, greater physician autonomy in the future is linked to accepting more financial risk.”

Memo to Zeke: We tried that in the 1990s. Doctor groups took on risk and rationed care. There were news articles about medical disasters befalling patients. Most of the doctor groups went broke. Lawyers made a lot of money picking up the pieces. Health care costs kept climbing.

The reality is that the ACA has unleashed a wave change to induce frightened doctors sell their practices to hospitals (and some to the likes of Humana) who are consolidating power and patients. Most hospital run ACOs don’t have a clue as to how to manage the bundled payments or doctors under their control. The administrators want the money. That’s the first principle. Get the money. Pay ourselves first, and then we’ll figure out the rest while guys like Zeke keep the media happy and off our backs.

The most interesting thing about the JAMA Viewpoint article by Zeke is that JAMA didn’t see fit to publish one comment or letter in response to the article. Wow! In this connected day and age: not one doctor wrote to JAMA to protest Zeke’s views. I know I didn’t. Why write to JAMA, as I’ve done in the past, only to have the letter rejected?

Just like JAMA didn’t allow challenges to Zeke, so the media have stopped asking him about the Lancet article and whether he believes that harsh rationing of “scarce” medical resources ought to come in at age 40 and really be applied stringently at age 55 as his complete lives curve suggests. Most of the network TV producers who are booking him have fancy Ivy League degrees. They should be able to understand that rationing curve.

Zeke Emanuel is a dangerous man. He was a principle architect of the ACA, and he has the ear of the media – and you don’t — unless some loved one gets done in by the ACA and then you’ll get 2.5 minutes on some news channel to shed tears and tell your edited story and your loved one will be six feet under and Zeke will still be going strong.

You can be sure of this: Zeke Emanuel is the face of current health care reform promoting rationing schemes that are tantamount to genocide for senior citizens and anyone over age 40 who is not politically connected.

Now after stints at Harvard and the National Institutes of Health, he’s teaching health policy at the University of Pennsylvania.

The nation needs a strong antidote to his lethal brand of policy snake oil.

For the record, here’s the letter to the editor I sent to the WSJ that they didn’t publish:
To the Editor:

Re: The Making of Obamacare, Review, page C3, March 8-9, 2014

It is fitting that the illustration you chose to accompany this piece by Dr. Emanuel features a caduceus rather than the rod of Aesculapius. The Caduceus, with two serpents surrounding a staff, was the symbol of the Greek god Hermes, who was associated for deception and thievery.  The rod of Aesculapius which has one snake surrounding a staff is the image most often associated with healing and is the image used by the American Medical Association.

Dr. Emanuel deserves the caduceus illustration for deceptively promoting bundled payments as superior to fee-for-service medicine. We have already tried lump sum payments in the form of capitated payments in the 1990s. That led to all sorts of abusive practices by HMOs and large doctor groups who cut corners to save a buck, with the media having a field day with stories of patient harm. Fee-for-service became plea for service.

Dr. Emanuel makes it sound like all the ivory tower theorists and politicians want to do is fix the price of procedures like hip replacement and pacemaker insertions. But he fails to disclose that real cost savings come from decreasing the volume of services to the aging Baby Boomers not by cutting prices. He deceives people into thinking that their political leaders are giving them a price break – something for nothing – when in fact what is actually happening is that doctors and patients are being herded into organizations facilitated by Obamacare that will in fact usher them out of this world sooner than necessary in the name of corporate greed.

If you think that the only procedures that will be cut are the “unnecessary” ones, think again. Ask Dr. Emanuel why his friends in HMOs and the insurance industry won’t make public their criteria for medically necessary care. After all, if they’ve all figured out the right way to practice medicine, publish the guidelines so everyone can benefit.    

 And if he were honest, Dr. Emanuel would tell the readers how many restaurants in the U.S. have fixed price menus rather than a la carte menus. The answer is very few. But he wants patients to have not only fixed prices, but narrow networks of doctors and hospitals, as in you can’t keep the doctor you like.

Deceptively, Dr. Emanuel says that the ACA ushered in only 10 demonstration projects of fixed prices. That is a lie. The ACA promoted accountable care organizations of which there are hundreds. These are de facto HMOs run mostly by large hospital systems where highly paid administrators tell salaried physicians how to practice medicine.

Whether in hospital run accountable care organizations, or in insurance company owned HMOs, the managing entity has the legal authority to tell doctors what is medically necessary and that is almost never disclosed to the patient.

Zeke Emanuel arrogantly thinks he knows the right way to practice medicine and is not bashful about imposing his will on our hapless population who think they’re getting something for nothing in Obamacare.                   

Unlike Greek mythology, when you’re dead from Dr. Zeke’s political machinations, no amount of touching you with a caduceus will bring you back to life. Dr. Emanuel’s painful prescription presages the death of American medicine and many innocent victims of his vast social experiment.



A Computerized Algorithm for Writing Healthcare Reform Stories

A recent story about the LA Times’ computerized algorithm for reporting earthquakes, suggests this model can be extended to other types of stories, such as reporting about health care reform.

Here is a suggested computerized algorithm for a robot writing stories about health care reform and the Affordable Care Act ( ACA).

Key Concepts:

Doctors do unnecessary tests.

Doctors do a lot of unnecessary tests.

Doctors who own medical imaging equipment do the most unnecessary tests.

Unnecessary testing costs $_____ billion dollars per year.

Unnecessary medical imaging exposes hapless U.S. patients to as much radiation each year as the equivalent of _____ bombs dropped on ( Hiroshima or Nagasacki – alternate according to style.)

Health care spending has slowed since the inception of the ACA.

Health care spending has slowed dramatically since the inception of the ACA.

Health care fraud is estimated to represent 10% of all health care spending. That translates to $______ billion in 20(13) dollars.

Medicare is going broke.   Medicare is projected to go broke in ______.

Primary care doctors are more cost effective than specialists.

Nurse practitioners and physician assistants are more cost effective than physicians.

Narrow networks of doctors and hospitals are just as effective as broader networks. There is no loss of quality medical care with narrow networks.

Narrow networks are really high value networks.

Every patient should have a primary care gatekeeper to limit access to high paid specialists who order too many tests, largely because they own the equipment.

Most doctors accept payments from drug companies to influence their writing prescriptions for expensive brand name medications.

Medical school professors don’t take money from medical device companies and pharmaceutical companies and limit their students’ access to such t take money from medical device companies and access to such interactions based on good ethical considerations.

Doctors who see drug company representatives are unethical and order too many brand name drugs.

Most drug company representatives who visit doctors’ offices are former cheerleaders.

Tort reform with strict limits on what victims of alleged malpractice can collect will hold down health care costs.

Most medical malpractice lawsuits are frivolous filed by predatory attorneys who take way too much in fees from the hapless victims of their legal chicanery.

Health care spending at current levels in unsustainable.

Health care spending is destroying America’s global competitiveness.

Emergency room visits are ineffective and too expensive.

If we give patients a medical home, emergency room visits will decline.

Paying doctors for performance will improve quality.

Fee for service medicine must be replaced with capitated or bundled payments.

All doctors must be salaried to rein in skyrocketing health care costs.

The Mayo Clinic is a good example of a cost effective health care system.

We must now focus on the culture of health.

We must shift our attention from the care of people with diseases to prevention of disease.

We must shift our resources from the care of diseases to the care of populations.

The United States ranks ____ in the world in ______(life expectancy) or (infant mortality) or (total expenditures per patient).

Managed care saves money.

Kaiser is a good example of a high quality cost effective managed care system.

Having doctors work for managed care executives and hospital administrators will bring down the cost of health care (dramatically).

Robodial these experts for quotes:
Karen Ignagni
Ezekiel Emanuel
Rita Redberg (for “less is more” quote)
Christine Cassel ( for “parsimonious” medicine quote)
Harold Sox ( for don’t do PSA or mammogram screening quotes)
Gail Wilensky
Don Berwick
Uwe Reinhardt
David Blumenthal
Any official of the Robert Wood Johnson Foundation
Any Harvard professor at the School of Public Health, Medical School, Business School, Kennedy School of Government, or Department of Economics.
Any spokesperson for Humana, Aetna, Cigna, or the United Healthcare Group.

Special instructions for the algorithm:
Quote any “doctor” according to the following code: a medical doctor=a doctor of pharmacy= a doctor of chiropractic=a doctor of podiatry=a doctor of nursing=a doctor of economics=a doctor of psychology

Always report how much medical doctors make in annual salary. Never report how much hospital administrators and managed care administrators make in annual salary.


In Texas, Humana is saying in writing that a nurse practitioner is a Primary Care Physician.

Today, a young enrollee in HMOx, a Humana Obamacare product, woke with up a potentially serious medical problem.  He looked at his enrollment card and saw the name of the “primary care physician” he had been assigned to. He tried to find her telephone number. He couldn’t find any practice location for this practitioner. He didn’t understand what the letters “FNP” behind her name meant.

03182014 Blog photo final

In case you’re wondering, FNP stands for family nurse practitioner. That’s a Registered Nurse with master’s degree level training. The Texas Board of Nursing licenses such individuals and allows them to practice as Advanced Practice Nurses.

They have to be supervised by a physician. Furthermore, they have to practice under written protocols and these protocols have to be signed off on yearly by both the nurse and the supervising physician.

So, the real question, is: Who is the supervising physician? You can’t figure it out from Humana’s enrollment card.

And when the enrollee went on the Humana website, he couldn’t find the nurse’s name.

And did Humana tell the enrollee that he was going to be cared for by a nurse, and not a doctor? The answer is a resounding, “NO.”

And why did Humana represent in writing to the insured person that an advanced practice nurse was his “primary care physician?”

I looked up the nurse in question on the Texas Board of Nursing website. She is listed only as “residing” in a local city near San Antonio.  There is absolutely no mention of her supervising physician.  Does she even have one?

Then I called the Texas Board of Nursing.  I was told to press “1” to speak to a representative. When I did so, the response was “The line is busy. Call back later.”  That’s great. My questions will be, when I get to talk to a representative, “Does the Texas Board of Nursing even know that Humana is telling people in writing that an advanced practice nurse is a “primary care physician?”  Isn’t this a violation of their rules?

If it’s not a violation of the rules of the Board of Nursing, is it a violation of the rules of the Texas Medical Board, which licenses physicians and physician assistants?

And why doesn’t the Board of Nursing have a link to who the supervising physician of this nurse is since she’s being assigned patients by Humana?

A call to Humana revealed that the telephone representative   couldn’t find the nurse practitioner in their database.  The telephone representative stated “Maybe she is no longer in the plan as a provider,” and later advised that “You can have a nurse practitioner as a primary care physician.”

So, now, with Obamacare, you not only can’t keep your doctor, you can’t even see a doctor. You have to see a nurse as your “primary care physician.”

Don’t get me wrong. I’m all for advanced practice nurses.  I just think that Humana and other insurers should disclose to patients the credentials of the practitioners they are being assigned to and give them a choice of seeing a doctor or a nurse.

I would give the nurse in question here a call to find out her take on all of this, but there’s no way to figure out where she practices.

Still, I’m pretty sympathetic to the plight of this nurse. She probably doesn’t know what Humana is doing.

But what about Humana?  Let’s just agree that here in Texas,  this isn’t their first rodeo.

ACA: Obamacare weekend review

Today’s post is a short one about the effects of Obamacare on the front lines of medicine – how it’s affecting doctors, and patients and even insurance agents. I’m doing some reporting based on what I’m hearing here in San Antonio.

Here are some observations that I will expand in future posts:

  1. Doctors who are seeing lower than expected reimbursements for services from Obamacare plans and refusing to see more patients are getting calls and visits reminding them that they agreed to see all comers for that particular insurance company.  Blue Cross Blue Shield of Texas is being particularly forceful in its warnings to doctors. But a visit to the BCBS website shows not all doctors are in all insurance offerings.
  2. Some doctors are saying that they never were shown the specific payment schedules for the Obamacare plans.  There are a lot of doctors worrying about how many ACA patients they can afford to take who have Obamacare coverage.
  3. Patients are still having trouble getting to keep their doctors. One patient told me today how she and her husband were promised by a telephone representative of Blue Cross Blue Shield of Texas that they could keep their primary care doctor and then got a card assigning them to a doctor 21 miles away.  Her current PCP’s office is about 8 miles away.  They are fighting to get to stay with their current doctor, who was going to see them at no charge this week so they don’t run out of critical medications.   Its dedicated doctors that have to worry about keeping patients well, not insurance company medical directors who are far away from the front lines of medicine.   I hope you have a PCP you can trust and who worries about your health more than satisfying insurance company bureaucracy.
  4. A doctor’s office told me that a patient who is a Humana employee told them that the way they got their network of doctors for the Obamacare products was to send out letters to doctors and then see who responded. So to be in their network, a doctor had to 1) get a letter and 2) respond to that letter. What we don’t know is how Humana decided which doctors to invite into their network for Obamacare products. That of course is “proprietary” information.
  5. An insurance agent told me that she got 5 calls this week from employees of major corporations saying that they had lost their health benefits and needed coverage. Other such employees have been in touch with that same agent because they have lost health benefits, had their work hours reduced, or both.  According to the agent, all of this is a direct result of Obamacare whether the White House or Paul Krugman and the NY Times want to acknowledge it or not.  Employees are finding their hours reduced and health benefits either cut or eliminated completely. This information is coming from the front lines, folks, not from some political think tank.
  6. By the way, if you all think that Obamacare Navigators know anywhere near what trained insurance agents know, think again.  It was interesting to read the report of the former Palestinian terrorist turned Navigator, who had served 10 years in an Israeli prison and then got a job explaining Obamacare to potential enrollees. Only in America!
  7. My insurance agent source predicts that toward the end of 2014, around August to September, massive notifications of insurance plan cancellations will go out in time for the November open enrollment season.  This agent predicts 30-50% premium rate increases in many plans, because they were underpriced at the outset in an attempt to capture market share.
  8. If you want to see how complicated it is to figure out what Obamacare will cost and how the insurance companies will be protected  by taxpayer dollars, read a post by Dr. David Blumenthal, who was one of the architects of Obamacare,  risk adjustment, reinsurance and risk corridors :  Be sure to click on all the links for a more complete analysis of these topics.  You need to have a firm math background to follow all the computations.  You need a firm background in Inside the Beltway lobbying to figure out how much the insurance industry will be bailed out by we the taxpayers and who cut these deals at the White House and in Congress.
  9. Today I learned of a Texas Obamacare enrollee who filled out an application to BCBS of Texas through the website.  But she didn’t think she had officially enrolled. She had a change of heart before paying any premium.  She wanted to enroll in a different policy. So she went back into the government website to make the change. She took screenshots of what she was now told.  Her application was termed “inactive.” The ACA enrollment site told her “If you need to cancel your enrollment go to your “Plans & Programs” and select “Terminate All Coverage” from your Plan Details. If you need to remove the application because here were errors or issues … call the Marketplace Call Center. A customer service representative can remove your application or update your information.” But when the applicant called the Call Center on several occasions, and even spoke to a supervisor, she was told that she was out of luck.  A supervisor read from a script and went on hold while fumbling trying to determine when the enrollment period ends – it’s on March 31. The applicant was told that she missed the opportunity to enroll this go around and would have to wait until November. In other words, no coverage for most of this year.   So, now, an agent is helping the applicant fight through this maze of taxpayer funded bureaucratic red tape. But everything is going swimmingly well according to Nobel Laureate Paul Krugman and the NY Times editorial page editors. I’ll report more on this story in future blogs.  Stay tuned to see if this lady gets an Obamacare policy in spite of the not helpful call center employees.
  10.  Be sure to read Dr. Zeke Emanuel’s op ed piece in yesterday’s NY Times, called “In Health Care, Choice is Overrated.”  President Obama’s favorite doctor policy expert thinks you don’t need choice because the insurance industry will make sure you get access to all the care they think you need.  Dr. Emanuel has been busy this week making the rounds of all the TV talk shows promoting his new book called Reinventing American Health Care.  His op ed is full of contradictions and unfounded assumptions like his assertion that insurance companies can include in their networks physicians who are more efficient, order fewer unnecessary tests, and  keep patients healthier and out of hospitals.  Yes, they can, but what they mean by “efficient” may be dangerous to your health. Most HMO doctors know they have to keep people out of hospitals – or they’ll lose their jobs.  The evidence for all this magical thinking by Dr. Emanuel is virtually non-existent, and we’ll examine all these myths in future blogs. Read the article and the 400+ comments. The comments are for sure better than the column.


Doctors joining health care networks: Beware

Today’s New York Times has a Page 1 article on one intended consequence of ObamaCare: inducing the stampede of private practice fee-for-service doctors into salaried positions with hospitals.

Here in San Antonio that process has been in full swing since the passage of the ACA in 2010.

The article contrasts the experiences of two family doctors in Kentucky. One sold his practice to a hospital system, sees 30 patients a day, doesn’t worry about money any more, takes new Medicaid patients, and now can take a 5 week vacation to his native South Africa. The other PCP is seeing fewer patients a day, has money problems, doesn’t take Medicaid, and has trouble recruiting a fourth physician to her 3 doctor medical practice. She also found out that Humana’s ObamaCare policy in Kentucky, where Humana is headquartered, didn’t pay very well – 20 percent less than what Humana pays for health insurance plans outside the new exchanges.

I really liked the part about how the Times reporter followed the private practice doc up to the Kentucky legislature where she met with two state representatives to ask to pitch an idea for state scholarships for primary care doctors who agree to practice in rural areas. Of course, the legislators poured her out and promptly passed a bill favoring nurse practitioners.

The message should have been clear to the naïve PCP: In Kentucky, legislators listen to Humana and the big hospital corporations first, and doctors last. Right now, nurse practitioners are in favor as a way to replace doctors with more cost effective providers. And national pharmacy chains like CVS and Walgreens are busy setting up primary care clinics staffed by NPs. Now if the doctor had been pleading for more tort reform, she might have gotten some response. But the response would not have been to enhance access to or the quality of health care. It would be tort reform to protect the insurance industry so they could hang on to more premium dollars. Embedded Tip of the Day: Tort Reform is about protecting insurance companies who are big political contributors, not about protecting doctors or patients for that matter.

As usual, the over 280 comments posted to this article are often better than the article itself.

One anesthesiologist from Atlanta who calls himself “Gasman” (Anesthesiologists pass gas to put people to sleep.) reports that he gets paid after expenses about $65 per hour for Medicare patients and $50 per hour for Medicaid patients. In comparison, I just paid a plumber here $125/hour to unstop a commode and fix a pressure valve on my water meter. But there are already too many jokes about plumbers who used to be doctors. For sure, most car mechanics at big city dealerships make at least that hourly rate or more.

A California physician wrote to explain that the newly hired Kentucky MD will soon find that his hospital masters will call him in and tell him that he is losing money for the system, and has to see more patients, make fewer specialist referrals, and take a salary cut. It’s all very predictable. The Times told how this new hire saw a new Medicaid patient who had not had care in years and ordered “referrals to an orthopedist, a urologist and a cardiologist, and an appointment for a colonoscopy.” Sounds great. But the Times reporter and her editors didn’t take the time to talk to the many physicians who have been directed to cut corners as employed physicians and are courageous enough to go public with their experiences.

I recall the testimony of the PCP in one managed care lawsuit who testified under oath that his office managers in the managed care organization rang a bell outside his exam rooms every 8 minutes to remind him it was time to move on to the next patient. That’s efficiency in action.

Then, too, the Times, had they asked, would have reported that one of the real dangers to physicians employed by hospitals is when the hospital takes a contract issue, where physicians have legal rights to representation to the courts, and turns it into a quality issue, where the hospital’s bylaws control the dispute and the doctor has little or no chance of winning. That’s becoming more frequent and is an ominous change for doctors that almost never appears on their radar screens until it’s too late. Just to be clear. A hospital wants to get rid of Doctor A. That becomes a lot easier if the hospital does an audit of Doctor A’s charts or admissions or work product and finds quality problems – of course, determined by its own quality assurance employees. Then the hospital can institute quality peer review proceedings presided over by its loyal physician staff members who are of the opinion that Doctor A has to go. After that, there really is no way Doctor A is going to get a fair shake. Yes, the bylaws may call for a hearing at which Dr. A may or may not be allowed to have an attorney present. The hospital usually gets to pick the “judge,” who is called a Fair Hearing Officer. But state laws of civil procedure don’t apply and adverse decisions against Doctor A get appealed to the Hospital Board — that group of car dealers, home builders, and Junior Leaguers picked by Hospital Administrator to be rubber stamps for his policies. So, in most cases, Doctor A is as good as gone once he runs afoul of the Administrator.

So, Doctor A, if he knows what’s good for him, will agree to see 40 patients a day and take a pay cut. And if he wants to keep his paycheck coming, he better call more “chest pain” “indigestion” and go light on the cardiology referrals.

As I have predicted for a long time, they’ll be Death Panels coming to your community whether you believe they exist or not.

Veterans Administration (VA): overprescribing narcotics/little media coverage

Yesterday’s hearing on VA Accountability by the House Committee on Veterans’ Affairs Subcommittee on Health produced no major public pressure on the VA, as I commented in this blog yesterday.

The only major media entity to cover the hearing was ABC News Radio. That report is linked here:

It was written by The Center for Investigative Reporting reporter Aaron Glantz and ABC News Senior Producer Teri Whitcraft. They are the same two who wrote the report seen on ABC World News Tonight on February 25, 2014, as previously noted in this blog.

Props to these two reporters for doing some good follow up. What is heartening is that Subcommittee Chairman Dan Benishek was quoted in yesterday’s ABC News Radio report as being skeptical of VA’s explanation at the hearing that the problem of pain treatment and opiates is under control, saying, “ VA still has a lot of explaining to do on how this problem escalated in the first place and why it’s taken so long to do anything about it.”

But the VA also has a lot of explaining to do about a lot more:

1. Why aren’t the 2010 clinical practice guidelines for the use of opiates in pain control being followed?
2. What are you doing specifically to get VA physicians to follow your own practice guidelines?
3. Can’t you use your much heralded electronic record system to monitor whether or not practice guidelines for opiates are being followed? If not, why not?
4. What were your staff pharmacists doing while all these opiate prescriptions were being dispensed?
5. Why have you fired physicians who didn’t follow administrator’s orders to dispense opiates against their better medical judgment? What are you doing to investigate these physicians’ allegations?

I was heartened by one part of VA’s Under Secretary for Health Robert Petzel’s written statement which was posted on the Subcommittee’s website after the hearing. He said that “Whenever clinically feasible, the concomitant use of opioid and benzodiazepine medications should be avoided.” Now let’s see if he can get that rule to be followed by the VA medical, nursing, and pharmacy staffs. I guess that will be a function of what is meant by “clinically feasible.”

I was disappointed by how the major print and electronic media largely failed to report this story. The Wall Street Journal and the New York Times were silent. The Wall Street Journal today devoted page 1 space to a military story – the Marines allowing soldiers to roll up their sleeves and bare their forearms.

I guess that is a more important story than thousands of veterans being addicted to opiates through no fault of their own.

And the New York Times: What’s their excuse? It’s not news fit to print? Perhaps Seth Rogen and Ben Affleck testifying on Capitol Hill yesterday were a big distraction.

And what is Fox News’ excuse? They always appear to wrap themselves in the American flag and stand for veterans. I wish Fox would tell us why this story is not newsworthy.

But then so should CNN, NBC, and MSNBC. They have all been MIA.

Veterans Administration (VA): overprescribing narcotic painkillers/ Congressional oversight

Just listened to the 1 hour and 57 minute House Committee on Veterans Affairs Subcommittee on Health hearing today (2/26/14) where the VA was supposed to answer the very serious charges levied against the VA on October 10, 2013 by 2 widows, 2 surviving veterans, and 2 whistleblower physicians.

The VA officials got off easy today. No tough questions about opiate misadventures in the VA system. There was no testimony about how the VA got 27,000 veterans off opioids since October 2013. Do they want us to believe that acupuncture works for severe chronic pain syndromes? Zero testimony about why the VA has not been following their 2010 clinical guidelines for pain management and how they are getting their pharmacists to monitor narcotic dispensing for dangerous combinations of drugs like opioids and benzodiazepines e.g. generic valium. This hearing was a complete whitewash.

The VA apparently put out some sort of news release trumpeting their “Opiate Safety Initiative Program” which coincidently was launched in October, 2013, after the House Committee on Veterans’ Affairs hearing. The VA claims it has gotten 27,000 veterans off opioids since October 2013. How did they do that? Did they send them all to rehab? Did they cold turkey them?

One Facebook entry from a veteran in Kentucky posted yesterday reports that the VA just suddenly started reducing her Tramadol dosage without telling her why.

She says she has spinal/cervical pain and a “bad case of leg neuropathy.” She said they told her to take Tylenol to “boost” the effect of reduced Tramadol. Good luck with that. What about specific drugs for neuropathic pain? Or the use of a TENS unit? Or use of a spinal cord stimulator?

Speaking of spinal cord stimulators, ABC TV finally got around to covering this story yesterday on World News Tonight with Diane Sawyer.

ABC did the story with the Center for Investigative Reporting (CIR), specifically reporter Aaron Glantz. Glantz has done a good job reporting the opiate problem and I recommend you go to the CIR site and look for his stories on this subject. You can find an interactive map that shows the rate of opiate prescribing for various VA facilities around the country. Glantz was also the only national reporter who reported some of the testimony of the 2 whistleblower physicians who testified last October. And in December 2013, he followed up by reporting the findings of the VA Inspector General in its investigation of opiate prescribing problems at the San Francisco VA Medical Center.

ABC featured a real hero, Justin Minyard, whom I met at the October 10 hearing. Minyard is straight out of central casting. Tall, good looking, articulate, and he hurt his back digging survivors out of the rubble of the Pentagon after the 9/11 attack. He told a harrowing tale of being addicted to narcotic painkillers that began when he was on active duty and was continued by the VA. His most shocking (and funny at the same time because it was so typical of the VA and what someone has to do to fight their outrageous bureaucracy) story was how he had to go door to door at a VA facility to find a pain specialist when he couldn’t get a referral. He actually barged into a doctor’s private office and demanded he be considered for a spinal cord stimulator. He eventually got one and got off narcotics.

ABC reported the VA’s Opiate Safety Initiative matter –of- factly with no critical questions about how or if it’s working.

ABC never brought up the 2010 VA clinical practice guidelines and didn’t ask any VA official what they were doing to make sure that doctors and pharmacists were following those guidelines.

Their interview of a pretty boy VA MD picked for his Looks Good on TV appearance was tepid to say the least.

Meanwhile, back at the ranch, at today’s hearing, there was ZERO mention of the issues raised by the widows, Kim Green and Heather McDonald and the two veterans who so eloquently testified last October. And ABC didn’t follow up on those issues. Yes, they told Minyard’s story, but that should have been “old news.” Four months after the hearing, which only CBS covered, (that’s right not even flag- waving, lapel-wearing Fox covered the story) ABC did not ask tough questions to find out how such outrageous overprescribing even occurred in the first place with all the VA’s sophisticated computerized medical records and practice guidelines.

ABC did feature one whistleblower physician who talked about VA doctors prescribing escalating doses of narcotics to those already addicted. Again, there was no mention of the two whistleblower physicians who testified in October, Drs. Pamela Gray and Claudia Bahorik.

For all of you who have been hoodwinked by the likes of Rick Perry, and think that lawyers file nothing but frivolous lawsuits, you need to consider how you can get justice for veterans who are addicted to narcotics through no fault of their own and for those who die because of VA negligence.

Can these American heroes and their families get justice in the halls of Congress? Or do they have to go to court to get justice?

The best part of today’s hearing came when Subcommittee Chairman Dan Benishek, himself a general surgeon who worked 20 years at a VA hospital in Michigan and also in private practice, redressed the VA under Secretary for Health, Dr. Robert Petzel, who had testified that VA medicine is as efficient as private practice. Dr. Benishek called Petzel’s answer “completely ridiculous” and “a complete fabrication of what actually occurs at the VA.” True!

I wish the honorable Chairman had been as critical of the VA’s anemic responses to the critical issues of how to reduce VA opiate prescribing and ensure that the 2010 clinical practice guidelines are followed – before more veterans die.

Today the VA officials who appeared before Congress got a hall pass. They needed to be sent to detention.