As Goes the Post Office, So Too Medicare?

With the announcement that the Center for Medicare and Medicaid Services (CMS) will begin auditing 100% of expensive cardiovascular and orthopedic procedures in certain states earlier this week, we see their final transformation from the beneficient health care funding bosom for seniors to health care rationer:

The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas- based hospital operator, plunging 11 percent to $4.18, the most among Standard & Poor's 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6 percent to $34.61.

The program means hospitals won't receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said.

This is not at all unexpected. In fact, in our field of cardiac electrophysiology, we have known this day would be coming; our expensive, life-saving gadgets and gizmos are easy targets upon which the government can cut its rationing teeth. And so as it will go for us at first, and then for many other areas of health care.

But the government has no idea how to do this, really. They don't have the data, the cerebral wattage, acceptable information systems, nor manpower. So, the government will grow further to offset it's shortcomings in order to assure they can "save money" for our health care system.

But CMS, like the U.S. Post Office, has a dirty little secret: they don't pay very well. To offset their low pay, they have to offer some pretty nice benefits to attract their best and brightest. And because the government is now going to bite off trying to manage an entire country's medical procedure rationing during a limited eight-hour government workday, they are going to be flooded with calls, many of which will be frustrated, angry calls that have been on hold a very, very long time.

And so they'll hire more people to improve services.

And pretty soon it will dawn on them: this is expensive to do. It will just be a matter of time when, like the Post Office that was seiged by their inability to keep up with pension and health care costs, they'll surrender and turn over their efforts to private enterprise.

That's because health care is local. Health care is complicated and needs lots of data, systems, and capable facile people to make decisions on data the government wants but knows it doesn't have. (Remember when the Department of Justice had to "consult" with the Heart Rhythm Society to "understand" defibrillator implant practices by tapping into their NCDR database?) Further, because the government moves slowly, can print money when it runs short, and must work through politics, government rarely works under budget. (In fact, when money runs out in government, they just shut down - not a great idea when working in health care.)

Of course the insurers don't want this. They already know it's too damn expensive to take on the risk of our paying for the health care of our aging seniors. (They were one of the main proponents of health care reform, remember?) So the government will have to have their back somehow. (Those details still have to be worked out, but it'll happen because politically, it must).

And the final transformation of our health care system of the future will be complete.

Amen.

-Wes

More info available at Larry Husten's Cardiobrief blog.

When Hoop-Jumping Becomes Patient Care

"Doc, I've got good news and bad news."

"What's that?"

"Well, I've lost six more pounds!"

"Wonderful! What's the bad news?"

"Well, you know that new-fangled drug you gave me that works so well for my atrial fibrillation?"

"Yes."

"We'll, I'm part of that AARP Medicare Advantage Part D drug plan, and I just got the "partial" approved drug list for 2010 in the mail. My drug's not on the list, so I called and found the drug's been moved from a Tier II drug to a Tier III drug. That means it will cost me twice what I paid for it this year. That's gonna be tough, doc. I can't afford it.

But I also read that if you call this '800' number and speak to them, they'll allow me to obtain an exemption to keep the drug on Tier II for next year."

I called the number as I typed his note. The patient seemed pleased that I'd be so attentive to his needs during their office visit. A sophisticated voice-recognition triage prompt answered:

"If you're calling about an injectable insulin question, say 'insulin,' drug issue say, 'drug,' if not part of this list, say 'other,'..."

"Drug," I said. a brief pause occurred, then:

"Just a moment..." (Soft music played in the background.)

Finally, a woman answered. he was quite pleasant as I explained the situation. Finally, I got to the part about the patient's drug not being on the 2010 drug list.

"Oh, 2010?" she asked.

"Just a moment."

On hold again. We continued our office visit. "So, how often are you having those episodes of..."

"Dr. Fisher?"

"Yes?"

"What other drugs has the patient failed?"

We listed them: "Atenolol, Sotalol, Amiodarone..."

"And when were those drugs used?"

"Um, seriously?"

"Yes, I need dates."

"Well, according to the fancy-schmancy electronic record, he's been on this Wonder Drug since November 12, 2007... his Amiodarone was stopped then."

"But the other drugs, when were they started and stopped."

I made up some dates. I was not about to spend time culling the record for these dates, but it was clear that data entry fields were being placed on the opposite phone line. I suggested to my patient he write down those dates.

"And why was the Amiodarone stopped?"

I looked at my patient. He quickly reminded me about the lung findings and liver toxicity he had experienced. I spewed the information to the inquisitor in hopes of expediting the interview. It was taking entirely too long. I looked at my patient. This would be his visit. His priorities were set: money talks after all. So I continued. After submitting the answers, she responded:

"Just a moment while I give this information to my supervisor."

Soft music played again. I looked up at my patient. "Um, where were we? Oh, yes, how often have you been..."

"Dr. Fisher?"

"I've given the information to my supervisor."

"Okay, will he receive his Tier exemption?"

"Oh, we've not received the final list yet for 2010."

"But my patient called and discovered this drug was moved from Tier II to Tier III. Why does he know the information and you seem puzzled by the list?"

"As I said, we're still waiting for the final list..."

It was obvious that the discussion was going nowhere.

"So how will Mr. Smith know if he's been granted the exception?"

"My supervisor will review the application for the Tier review and make a decision. Is there anything else you need?"

Realizing that there was no way I was going to get an answer, I acquiesced. "No, I think we've handled the application. Thanks for all you help. By the way, in case my patient would like to check on the application, what's your name?"

"Christine."

"Thanks, Christine. And your last name?"

"It's just Christine."

"Uh, okay. And how about your supervisor's name?"

"Jericho."

"Jericho who?"

"There's only one Jericho here," she said.

I could only think one thing at that point as I hung up:

... I bet he's a "wall."

-Wes

Health Rations And You

How the government will make rationing palatable:



Heh.

-Wes

h/t: American Digest via Instapundit.

Crossroads

It was a case like so many others, an elderly man who tripped and broke his hip. During his physical examination, a soft murmur was heard so an echocardiogram was ordered. His heart muscle was quite weakened. Cardiologists were contacted, symptoms reviewed, electrocardiograms compared, and soon he was off to surgery to fix his hip.

Rehabilitation was remarkably fruitful – he was weight-bearing quickly and some five days later, he was looking strong enough to consider discharging, shuffling, walker assisted gait and all.

But an abnormality was found before his surgery that must be addressed – to do otherwise would not comply with guidelines for his management: his weaken heart. Mind you he was 78, had been declining physically and mentally over the past several years and did not lose consciousness with this hip fracture, but he was loved by his wife and daughter who were eager see him continue to improve. The hope, if you will, of a better time ahead.

What is a doctor to do in this instance?

From the earliest years, the discipline of medicine requires rigorous study and exhaustive hours of training. By and large, physicians are driven souls, vetted carefully from our formative years of school by exemplary grades, grueling study, competition for residencies, and taxing selection processes. Those that push the norm, strive for excellence, and go above and beyond excel, those that do not, wither. In essence, it’s the epitome of Darwinian selection.

The trend continues when one enters practice as a young doctor. It is, in short, all about productivity: productivity academically, productivity clinically, and productivity economically. That’s the way the ball currently rolls in medicine. And really, that’s the way the patients have benefited in our system, too. Going the extra mile, even when hope seems impossible or the hour is inconvenient has benefited many, many people.

But we are at a critical crossroad in medicine today. Forces are masterfully aligned to impose restrictions or recommendations of care upon the doctor-patient relationship. Just like the patient above who has never had an arrhythmia but has a known weakened heart muscle detected anecdotally after an unrelated fall. Do we treat him, because we “should,” based on guidelines that others in positions of “authority” have vetted and our practice managers have urged, or turn a cheek on our obsessive reliance on “evidence” in favor of “art,” realizing that doing so directly threatens the core of our economic, academic, and clinical productivity-based health care model and exposes us legally?

The only logical resolution to this dilemma is for the doctor is to turn to their patients. But will patients or their families accept anything less than doing everything, just for the common good of the system? Will careful discussion about costs and absolute (rather than relative) risk reduction with preventative measures perceived as responsible or lackadaisical? Can we afford to withhold therapy when our economic survival continually demands more volume, more procedures, and more patients in the system? What incentives exist for doctors to do nothing in the circumstance I have described?

Given the economic, legal, and professional climate in vogue today, there are none. As a new public health care plan is deployed, will we ever be able to achieve cost control in our new system?

At present, it seems unlikely. We have gravitated to models and systems that automate our profound inefficiencies and deem them “highly efficient.” We advertise to load the system more. We leave the cost of the defense of the wrongfully accused to the defendant rather than the plaintiff. All while costs, and volumes, and regulatory infrastructure spiral. Without incentives that reward doing less for both the doctor and the patient, we won’t see any meaningful reduction to health care costs in America irrespective of the ultimate system deployed.

-Wes