Saturday, March 25, 2006

Pieces of Silver: The Price We Pay When the Dollar Trumps Good Health Care

Got money? Good for you. In America, you get the best health care money can buy. Keep up the good work and best of health to you. Not to make you feel bad, but the multitudes of unrich Americans aren't so lucky.

While the wealthy operate blissfully above our health-care system, millions of ordinary people must make do with a system that would love them to just go away if they have no money or health insurance.

For sniffles, the wealthy can get head-to-toe tests on demand and leisurely 2-hour consults with personal physicians. The ordinary Joe, even with health insurance, may have to wait weeks or even months to get an appoinment with a specialist.

If someone well-heeled needs major surgery, he just orders it up from a top surgeon in a top hospital and afterwards gets on with the good life. Millions of others may never even learn that life-saving surgery is needed and die needlessly. Before surgery can take place, third-party insurors (see previous post), have procedures that must be followed and for which approval for payment is the last resort.

At the lowest level of the economic ladder, the poorest among us have Medicaid which guarantees minimum levels of care. In America, the one plus of destitution is Medicaid. Yet it is a hardy myth that the poor have all their health needs met. The truth is that people on Medicaid are the sickest among us, suffer the most, and die the earliest.

People 65 and older who have worked enough quarters to be eligible for Social Security have Medicare. But like Medicaid, Medicare far from meets the considerable health needs of the elderly. The U.S. Government health insurance program pays 75% of hospital costs and most doctor costs after modest deductibles.

But without medigap insurance, that 25% of hospital costs can be enough to wipe out many seniors financially. And while the new prescription drug benefit does offer important coverage of catastrophic drug costs for the poor and for those using many expensive prescription medicines, it offers little benefit to everybody else for a new monthly premium.

This premium ranges from $9.00 a month to ten times that, depending upon the plan. The premium can be expected to rise fast. Total out-of-pocket costs are $5,100, including the infamous "donut" in which there is no coverage, before significant coverage kicks in. Realistically, only the very poor and the fairly well-to-do can afford to take "advantage" of this "benefit." For illustrations and dollar figures, see

Why? Because the Medicare Modernization Act of 2003 was literally written by lobbyists for the insurance and pharmaceutical industries. They, not the elderly, are the big beneficiaries. The insurance companies get huge upfront federal subsidies; in effect, billions of tax dollars to compete -- unfairly -- against traditional Medicare. The big insurors are salivating over using the new Medicare Part D as a "springboard" for their Medicare Advantage plans to steal patients from traditional Medicare, hopefully killing it.

The 2003 law expressly forbids the government from negotiating for lower drug prices as the VA does, which means that drug companies can charge what they want. We all know about today's windfall oil profits. Coming soon: windfall pharmaceutical profits.

Because the prescription plan was drawn up by commercial interests without the needs of seniors in mind, it is a mess. Even after two years of preparation, it came out of the gate broken and remains broken. It is hopelessly complicated and costly because of all the federal subsidies handed to commercial interests. It would have been simpler, much less costly, and more suited to the needs of the elderly if the drug benefit had been simply added to Medicare.

However, money trumps care.

Seniors have until May 15 to choose from among dozens of plans, all with different premiums, co-pays, and formularies. Some who are computer-savvy are able to navigate the Medicare website at and find a plan that both meets their prescription needs and saves them money. Others get help from family and Medicare and insurance counselors and manage to come out ahead.

But many seniors are not computer-savvy or do not have family members able and willing to help or are not up to engaging counselors. They are baffled by all the choices and fearful of making the wrong decision. As May 15 approaches -- after which late enrollees pay a hefty penalty -- many older people don't know what to do. Still others are incapable of making a decision because they are too frail or suffering dementia.

Dr. M.Jean Root, a geriatrician in Tulsa Oklahoma, who has several hundred Medicare patients, says that about half of her patients like the new prescription benefit and are saving money. She said the other half, including those with dementia and terminal illnesses, "don't have the energy, the interests, or the mental capacity to work through the system."

For those of us not poor or old, getting the health care we need and paying for it is an often consuming and frustrating struggle. People between 50 and 65 are old enough to be bounced from jobs and company health benefits to make way for younger workers but not yet eligible for Medicare. After working all their lives, at a time when their expenses are highest, millions of these in-between Americans are reduced to health-care beggars.

The system's exploding costs are frightening by any standards, causing great family hardship, disbelief, and anger. Health insurance rates for workers and businesses are rising at multiples of the inflation rate. Carol Scannell, pictured below, early sixties, divorced, and working full-time for the Catholic Free Press in Worcester, Mass, said she has just gotten a $25 a week cut in pay.

“Another increase in my health insurance premium,” she said. “Do you realize that is a hundred dollars a month more, or twelve hundred a year, coming right out of my pay? No wonder I can't keep up with my bills. I'm never going to be able to retire.”

For her money, she becomes one more patient with a medical-care horror story to tell. “I have neuropathy in my feet. That means dead nerve cells. I can hardly walk to and from my car because of it. But it's taken me three and a half years to find out, after different doctors, medicines, treatments, useless surgery, and really painful physical therapy.”

Her ordeal had begun after her car broke down one early evening on a bitterly cold winter day. She waited in the freezing cold for nearly two hours for help to come and by the time it arrived, her feet had gone numb. When she got home, she soaked her feet in cold water but it did not help.

“The doctor who operated on me thought the problem was with a few nerves and he took them out. As I learned later, the problem was with many, many nerves. The surgery didn't help at all. All it did was put me in painful physical therapy, which was also useless. The physical therapists said, 'we're going to fix this,' but they didn't fix anything.

"A lot of people made a lot of money over a long period of time and here I am right where I started. If I had gone to my present doctor first, I would have learned that I had neuropathy, that there is no cure for it, and I would have saved myself a lot of trouble and unnecessary pain. And all that wasted money – what a shame!”

Seniors on Medicare are being whacked with big premium increases along with everyone else. The monthly premium, which is deducted from the Social Security checks of most elderly, is rising at a blistering rate. In 2005, the premium went up 17%, from $66.60 to $78.20, the highest increase in the 40-year history of Medicare. In 2006, it went up to $87.70 a month, still another double-digit increase.

At this rate, and in the not too distant future, the entire Social Security check will go to Medicare and Medicare Part D. The insurance and drug companies will be flush, but what will old people live on? This is a question that will become increasingly more urgent.

Richard Foster, the chief actuary for Medicare, says that, looking ahead, if such increases continue, “many of tomorrow's Social Security beneficiaries might not be able to afford their Medicare benefits. That could slow down their consumption of health care in a way that none of us wants.”

That is already taking place and not just with older patients. The wait for a doctor's appointment is getting longer and longer. For a routine OB/GYN exam, the wait ranges from eight days in Washington, D.C. to 45 days in Boston, according to a study of physician specialists' offices in 15 major cities by the consulting firm Merritt, Hawkins & Associates. For an initial orthopedic appointment at Mass General Hospital in Boston, I had to wait 58 days.

And when you do get in, don't blink; the doctor will probably be in and out in a flash. Face time with a doctor is evaporating so fast for ordinary folk that pretty soon it may not exist at all. Some third parties are providing incentives for doctors to care for patients by e-mail. The near future may be: The doctor will e you now.

MinuteClinics are springing up in Target stores and supermarkets in response to long waits and the high costs of seeing a doctor. A nurse practitioner is on hand to diagnose and treat a dozen or so common ailments such as strep throat, sinus and ear infections, and seasonal allergies. The nurse also provides vaccinations and screens for cholesterol and blood pressure problems.

The motto of MinuteClinics, which operates in ten stores and is due to be in many more, is “You're sick, we're quick.” The concept is catching on and competitors are springing up in other cities. Walmart has also begun opening clinics in stores in which shoppers can see nurse practitioners for routine tests, exams, and care.

More evaporative yet of actual medical care, supermarkets and malls are beginning to install medical testing equipment in little corners where, between shopping, people can self-test vital signs. Doctor-less self-diagnosis and care!

Like self-checkout in the supermarkets, self-pumping at the gas station, self-solving problems with corporations through touch-tone multiple – and maddening – choices, self-service has been enthusiastically embraced by our health-care system. We have suddenly become more medically skilled than anyone had ever imagined.

Consumers of health care gradually being transformed into their own providers. According to Maine author Nicols Fox, the latest in health-care thinking suggests that people can “take their own blood pressure, give themselves injections and enemas, and starve themselves before surgery. Then they could find someone to drive them to the hospital at 6 a.m., wait, and then take their tottering bodies, still exhaling anesthesia, back to their beds at home where another friend could take care of them. In short, they could do what nurses had once done, allowing hospitals to concentrate more heavily in machines to do what doctors once did.”

In 1943, doctors averaged a leisurely 26 minutes with patients. By 1985, it was down to 17 minutes. In 2000 it was 8 minutes. In 2003, while undergoing major knee surgery at Massachusetts General Hospital, I experienced -- no lie-- 20-second bedside consults.

And this was at a famed hospital considered one of the best in the country and in a city, Boston, renowned as a center of medical excellence. Despite the briefest of doctor face time, I received received excellent care. One reason was that my wife, Barbara, the world's greatest patient advocate, was right there watching everything and insisting on changes when she saw something not quite right.

One thing is clear. Money is the number one issue in health care. While doctors are not supposed to be in it for the money, no physician can afford not to pay attention to money. A doctor or doctor's group that pays more attention to giving top-quality care than to money will soon be out of business.

Because of all the outside financial pressures, few physicians can realistically lavish time on patients or go the extra technological mile required to maintain the highest quality of care. Preventive care? Forget it. There's no money in it. By design.

My doctor explains in a handout to patients:

"Medicare is a type of insurance that pays only for the treatment of illnesses. The breast examination, prostate examination, rectal examination, and time spent reviewing your general health are not considered covered benefits under the typical Medicare insurance program.... However, if during the course of your evaluation your provider identifies another health problem that requires special attention, evaluation or treatment, we will submit to Medicare a bill for these services. Medicare will then pay for the services provided for the care of your health problem or illness. Medicare, however, will not pay for the health care maintenance portion of your visit. It requires that you pay for that portion of today's bill."

A doctor whose patients all stay healthy won't be able to pay the rent. But if they all get sick, ideally chronically ill, there is an assembly line of paid procedures and the money rolls in. It is a perverse incentive, it is upside down from what it should be, it defies common sense, it's icy cold, it's mercenary, and everybody in health care knows it.

However, money trumps care.

So, reluctantly, doctors compromise every day. Almost without realizing it, they gradually become transformed from physicians to "providers" servicing "customers." Inevitably, the once sacred patient-doctor relationship dies, replaced by a get-them-in-and-out, bloodless, money-grubbing commercial transaction.

New doctors are often shocked at the importance of money in every aspect of medicine, though it is almost entirely unspoken. A general surgeon, Dr. Atul Gawande, has broken the general and longstanding taboo in medicine against talking money.

In an article in The New Yorker (April 4, 2005), he described how money pervades medicine while managing to remain unmentionable. He wrote of going for an interview for a surgical staff position at the Brigham and Women's Hospital in Boston after finishing his final year as a resident in surgery.

The interview was in the wood-panelled office of the chairman of surgery, who promptly offered Dr. Gawande the job. The chairman explained that the job came with a guaranteed salary for three years and that after that Dr. Gawande would be on his own: he would make what he brought in from his patients and would pay his own expenses.

So how much should we pay you? the chairman asked the new hire, who had expected to be told his salary not asked his opinion about it.

“How much do the surgeons usually make?” Dr. Gawande asked, sincerely in the dark and sincerely wanting to be enlightened.

“Look,” the chairman said. “You tell me what you think is an appropriate income to start with until you're on you own, and if it's reasonable that's what we'll pay you.”

The young doctor, who was excited about the opportunity to specialize in certain tumors that interested him, didn't have a clue about how much money to ask for. Luckily, his new boss gave him a few days to ponder his market value.

He tried asking various members of the surgical staff. All he got were “awkward conversations. I'd pose my little question, and they'd start mumbling as if their mouths were full of crackers.... Nobody would give me a number.”

Despite the silence he met about money, Dr. Gawande managed to come up with a figure.

“That'll do fine,” the chairman said and the two shook hands.

After chatting for a while about how many nights he would be on call and how to fit in research and his family, Dr. Gawande realized that the meeting was ending and he had not asked an important question.

“What are the health benefits like?” he asked. He meant for patients.

Dr. Gawande learned that the health care system would require him to give “inordinate attention” to matters of costs and payments. A member of a physician's group today, he has a master fee schedule that runs more than 600 pages with 24 columns across the top of each page. Every possible medical procedure is in there, set forth a la carte, with a dollar amount attached. Each procedure has a number.

This standardized fee schedule seeks to make payments to doctors commensurate with the amount of work involved in every conceivable procedure. Note the word "procedure." Spending time talking with a patient, getting to know the whole person in order to personalize care is not a procedure; it is therefore not billable.

According to Dr. Gawande's master fee schedule, a Medicare patient with “low complexity”(No: 99203), pays $77.29. A “high-complexity” visit (No. 99205) pays $151.92. Other examples: setting a dislocated shoulder -- $275.70; removing a bunion -- $492.35; removing an appendix -- $621.31; removing a lung -- $1,662.34. The best-paying service is surgical reconstruction for a baby born without a diaphragm: $5,366.98. The lowest-paying is trimming a patient's nails: $10.15. The hospital has separate charges which it bills and collects separately.

For the background of how this billing system came to exist and a full explanation -- the best I have ever read -- see It is by a veteran Pacific Northwest physician (and a terrific writer). Understandably, many physicians throw their hands up in despair at such a complicated fee schedule. Even with the fee schedule in front of him, Dr. Gawande has a hard time figuring out how much money he will earn.

In practice, how much money he receives will depend on not how well he performs surgery but how he handles the business side of doctoring, including mastering mind-numbing insurance requirements.

If a doctor leaves out anything on a insurance form, such as a diagnosis code or a procedure code or a pre-approval number, the bill is rejected and the doctor does not get paid – unless he is willing to slog his way through automated telephone menus to get in touch with the insurer.

Financial consultants to physician groups and practices say that to make money doctors must cut the insurance rejection rate to 15% or less (compared to a common rejection rate of 30% and higher).

Did Dr. Gawande reveal his own income in his New Yorker article? True to medicine's code of silence on money, he did not. “Now I am the one who's too embarrassed to say what I earn,” he wrote.

But not too embarrassed to take the money.

So long and keep moving.


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