When you’re watching a puppet show, do you really want someone to pull the curtain aside and show you all the strings at work? Or would you rather enjoy the show and indulge in the illusion? Of course we know someone is manipulating things, but there are pleasures in temporarily “suspending disbelief.” Sometimes, we’re better off taking the performance at face value.
These questions come to mind this week when I read a headline in the May edition of “Reason” magazine. Dr. Jeffrey A. Singer, a general surgeon, authored a piece titled “How Government Killed the Medical Profession.” I’m not suggesting that America’s medical providers are staging an elaborate puppet show — not yet anyway. But Dr. Singer’s analysis may indicate we might be headed in that direction.
Let’s start with some baseline assumptions. When we go to doctors or hospitals, we assume a fair balance is being ordered. On the one hand, we know that the health care provider has to “make a living.” We expect them to charge a fair amount for the services they provide. On the other hand, we expect our health needs to carry equal weight in the balance. It would be nice to think that patient needs come first, but this is unexpected and when it happens, it’s bonus. If the balance is equitable, the patient pays a fair price for good service.
In the modern American health care model, the patient pays a fraction of the costs. Dr. Singer quotes statistics from The National Center for Policy Analysis indicating that consumers pay 12 percent of the health care bill. This means we’re no longer dealing with a two-way balance. Someone else has an interest — and a say — in the transaction.
This “someone” is either an insurance company or the government. This means, of course, that a third party has the opportunity and, arguably, the right to muscle in on the patient’s health care arrangements.
These third parties are now exerting much more control over these arrangements than the patients. The rationale is, “If we pay the bill, we have the say.” To this end, there are gimmicks like The International Statistical Classification of Disease (ICD) and The Resource-Based Relative Value System (RV RV), which assign codes to medical complaints and procedures for Medicare patients and, based on the determination of a panel of experts, decide how much a doctor or hospital should be paid for this code. Private insurers routinely tie their payments to these codes.
These systems essentially transform the patient’s complaints into lubricants for the bureaucratically weighted medical machinery.
Consider a couple of illustrations. Scenario No. 1: Patient “A” comes in with a rotator cuff injury. Dr. No.1 enters the appropriate code, treats the injury and gets paid X dollars. Patient “B” comes in with a rotator cuff injury. Dr. No. 2 asks, “Does this affect your ability to sleep?” “Yes.” Enter code for insomnia. “Does your lack of sleep cause headaches?” “Sometimes.” Enter code for headaches. Dr. No. 2, for the same condition, gets X dollars plus.
Scenario No. 2: Patient “C” comes in with a difficult diagnosis that doesn’t fit into a convenient coding pigeon hole. The doctor who takes the time to “track down” the obscure cause is losing money. From a strictly financial standpoint, doctors are better off “picking a number” or “passing the buck.” The more pressure on doctors to become absorbed in the numbers games with bureaucrats, the less time doctors spend relating to their patients as human beings.
Dr. Singer raises the specter of Accountability Care Organizations (ACO’s), which seem to be the next big government health care brainchild. Doctors will be encouraged to organize teams who will be assigned groups of 5,000 or more Medicare patients. The team will be given “guidelines” on “costs, length of hospital stay, readmission and other benchmarks.” If the ACO comes in under the “benchmark” figures, the doctors in the group will “divvy up” the savings. If they go over the benchmarks, the doctors will be penalized. The incentives in this type of medicine are obvious. Do the least you can as fast as you can and take it to the bank.
Dr. Singer presents some alarming statistics concerning the trends in primary medicine. According to the New England Journal of Medicine, in 2005, more than two-thirds of the doctors in the United States were in private practice. In 2011, 50 percent of those doctors have become employees of hospitals, corporations, insurance companies or the government. Unfortunately, we may be witnessing the transformation of American health care into a puppet show where bureaucrats and CFOs pull the strings. I’m Hink and I’ll see ya.
MIKE HINKLE is an Edmond resident and retired attorney.