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Monday, September 26, 2011


What can one do but party hearty? The Chief keeps walking around making comments about "putting on your marching shoes" and advises me to "stop complaining". I'm glad he's getting a charge out of this, because I am less than amused.

There's an article up on Drudge about the AMA, ObamaCare and actual doctors. SuperDoc quit the AMA in disgust years ago. The article is fine as far as it goes, but it doesn't go far enough.

In 2012, Medicare physician reimbursements are scheduled to drop 29.5%. The final rule is due November 1st, but the proposed rule gives a good feel for what this is going to cost doctors. That's 176 pages and hard going, so try this short article to get a feel for things. Excerpt chart:

Needless to say this sort of thing provokes either limitations on patients seen or cost-shifting to other patients.

Paying $16.53 for an X-ray is a bit ridiculous, don't you think?

SuperDoc is going to make about $48 per office visit on Medicare patients in 2012. This is not enough to keep the lights on (older patients are far more complex to deal with, require more time spent with them, and require far more follow-up), and he may have to limit Medicare patients, because if you don't keep your non-gov/gov ratios up, you're dead. This causes him great agony, because he is already 70 (working six days a week) and he keeps wandering around woefully wondering who is going to care for these people, and then, evincing considerable angst and threatening to leave the country. He claims Australia is the best bet, but his wife is holding out for Canada.

But this is the first of many projected Medicare cuts under ObamaCare. Five years from now things are going to get much worse.

I don't think the average person realizes how the medical industry works. Aside from the fact that SuperDoc does a tremendous amount of research on each patient with complex conditions (and many of the elderly have complex conditions), the administrative staff often does hours of work behind the scenes to get the required testing and medications through.

SuperDoc maintains a list of doctors he likes and thinks highly of, and over the last few years I called some of them to find out what they were doing. Almost all of them are cutting the vast majority of Medicare patients out of their practices, because they just can't practice quality medicine any more. The bitch of it is that many of the elderly respond superbly to good medical care (ultimately SuperDoc's way of practicing medicine is cheap), so that by shunting these people into practices that provide a much lower standard of care, we are probably costing the system a lot more.

Another problem is that as our arsenal of weapons against various conditions grows, the interactions between the weapons and the living being grow ever more complex. Without carefully balancing out risk factors, the risk of doing real damage to the patient grows. SuperDoc and I have been working on a project to apply some of the P-Nat risk-mapping techniques in the medical field, and so far it is promising. But I am also finding it terrifying, because he'll hand me a medication or condition to analyze, and I keep coming up with these risk holes (if you don't pay attention to them you run a very high risk of harming the patient), and then I take this stuff and the data back to SuperDoc and he gets very excited and tells me it is right.

If SuperDoc is correct, then medicine has reached a point at which it must learn to manage complexity in a different way and at an individual level. There seems no hope of doing that with the direction our current system is taking. The other "good" doctors I have spoken to all reiterated one of SuperDoc's worries - that they were seeing a high incidence of what they regarded as malpractice by specialists, due to a failure to take into account all the patient's conditions.

It seems pretty obvious that assessing general risk is going to be important in delivering workable medical care, and I don't see how we can do it on our current path. You can't defund primary care and basic diagnostics without fubaring the whole darned thing. Also we have to be realistic about the costs of medical care for the non-governmentally covered patients - these costs are going to show up in medical care costs for 40 year-olds, and that is neither fair nor sustainable.

I've been on Medicare for 13 years. I have seen the reimbursements shrink and have known that eventually things would get sticky. They are getting really sticky!

We are going to have to cough up more money or there won't be any care or it will be sub-standard care. Well, we've got some extra bucks and can afford more, but what about those who don't?

Politicians who promised all this ought to be made to get their care under it. But NO, they've got their cushy, gilt-edged coverage. Bastards!
The complexity problem will be somewhat mitigated when we aren't getting any care beyond 5 minutes and a generic, which is what we'll be able to afford in three years.
Sadly, doctors' future cash flow as well as the future of customized health care comes down to one question: Which political party will manage to hang Medicare cuts on the other?
If you look at CRE, medical offices of all sorts
fill up a lot of that space. Problems for medical
practitioners will mean further problems for CRE.
Peak medicine ?
If SuperDoc is correct, then medicine has reached a point at which it must learn to manage complexity in a different way and at an individual level.

My sister at Harvard Med just told me the exact same thing.

It remains to be seen how that butts up against insurance/government bureaucracy. I suspect there will be a LOT more paperwork and subsequently more delays in payment.
Its even worse than you think. Added costs for no benefits to degradation of care (electronic records), added paper work for no benefit and worse data (ICD 10), dueling "safety Mandates" which increase death and morbidity (think diabetes goals), and the ever favorite civil and/or criminal liabilites for a human system which is not inhumanly perfect. Medicare is close to a tipping point where most physicians will just drop out although the sickest will be dropped first (ACOs don't work with sick patients. Been there tried that in the 90s)
I believe you have said SuperDoc is in the North East. If he is taking new patients new patients, I'd love to investigate having him as my doctor (I'm in Boston). I am relatively young (under 50) and in mostly good health so I could help both his Non-Medicare/Medicare ratio and his time-per-patient workload. If you think it's possible, I'd be grateful if you could send me his contact info at jrinma98ATyahooDOTcom. TIA.
My experience is anecdotal. I went to Target's nurse clinic last week for a swollen eye, after having been exposed to pink eye from three different people. At the Target clinic, the PA refused to treat me, because my eye was swollen, and their protocols only cover actual pink eyes (swelling is a side effect, sometimes, of pink eye). The cost would have been $57 (not including medicine).

So I went to my primary clinic instead. At the front desk I told them I was paying cash, and asked what sort of discount could I get (the normal urgent care fee is about $110). I was told the fee was $46. Then I noticed that they had posted a schedule of minor problems much like those treated by the Target (and Minute) clinics.

I saw a PA and he took the time to check my eyes carefully, and also my ears, nose and throat. He told me I didn't have pink eye, and that the swelling was caused by a pimple near my eye. He prescribed a generic antibiotic which would help the pimple, and just in case I had bacterial pink eye, it would treat that also.

The clinic-within-a-clinic was new to me, but I was very satisfied with the speed of service and the cost. It's more convenient than the big store clinics, and I don't get rejected if my illness presents anything other than classic symptoms (this is the third time I've been rejected at Target's clinic).

I've been told that if I have an emergency room visit, the fees can be negotiated down by as much as 90 percent if I'm willing to pay cash.

I've read about a clinic in Nevada that won't accept patients with insurance. The fee schedule is about half of what is normally billed to insurance. Perhaps SuperDoc could eliminate insured care, go to a straight cash system, and set the fees such that the overhead of the Medicare patients is covered.
Regarding Elder-Patients-Require-Complex-Care:
My Dad had diabetes, congestive heart failure, and poor kidney function. Back home, he had a dedicated and caring cardiologist who kept him on the knife-edge of OK and functioning. After Mom died, he sold their house to move in with me (in Colorado). We had to get him all new doctors, of course, and it was back to medicine-as-butchers-diagram: the kidneys belong to one doctor, the heart to another, etc. So nobody was balancing the overall system: the new cardiologist said "reduce fluids", the new nephrologist said "more fluids"; I'm sure they tried to take into account his other ailments but I'm also sure their own specialties were FIRST on their list. Sadly, he didn't last a full year here.
So- if you've got a Super Doc, DO NOT MOVE AWAY. They're irreplaceable.
Don't worry MOM, Obama hired Rahman Emanuel's brother to address the care of the elderly, and he has found a solution, which was incorporated in the Obamacare bill: after a certain age, the elderly will simply be denied care under Medicare.
Jon - I have to ask permission from SuperDoc, but I am relatively sure he will say "yes". So expect an email tomorrow. Best of luck.
Anon @ 5:25 PM. Maybe you're joking, but the details of the new Medicare cost-cutting proposal say you're not. Before, all medically necessary procedures were covered. Now you are going to have to get approval for lots of imaging.

So while one of the few benefits of Medicare were that you could actually get most of the diagnostics you needed, it looks like your description is all too accurate. And the ACO proposal is just going to add up to killing people cheaply.

The horrible thing is that whereas the Chief is fine now, in just a few years a patient with a condition like his won't be able to get the same treatment.
A_Nonny, I am so sorry about your dad. That had to hurt terribly.

I think you are right - if you have a good doctor, the thing is to keep up that relationship.
Ummm, what's that cutoff age for imaging?
Gordon - SuperDoc told me that a good nurse or PA now usually provides much better routine care than many doctors. He says they take the time to do the examination and are more careful.

Of course when you are dealing with the more complex stuff like A_Nonny's father you need a doctor, but all the credentials in the world don't compensate for not taking the time. And it does take a lot of time often to consider all the patient's conditions and do the adjustments and assessments that keep the patient on the middle road of health, which for many gets narrower and narrower. When you are dealing with compromised organ systems, it's really easy to throw the patient into a descending spiral.

As to the cash stuff, SuperDoc does take cash patients and he certainly doesn't sting them. But I don't think going all cash would work, because a lot of poorer patients don't have the upfront money.
Neil - being on Medicare. I was reviewing the details of the proposal today, and I think the pre-approvals for complex imaging was supposed to start in 2013.

CMS doesn't have the setup, so of course they will contract for this with an insurance company, which will follow the same standards they normally do. And they routinely deny quite a bit.

The goal is to turn Medicare into an HMO type thing, but that will really suck.
Jimmy J - Yep, that's exactly it. Medicare will still be decent insurance for those who have money, but the vast number of retirees who don't will be in deep trouble.

If you can't even get a CTA when you need one, Medicare will mean crap.

And I think a lot of places will stop taking it due to the fact that it will put them out of business. There are going to be a lot more people on Medicare, so the impact of these measures will only grow.
Anon @ 7:42AM. The ACOs are nonsense. It's the same stupid thing as the HMOs. Cost over 10 years is not even remotely the same as cost over a year or two - they are promising to pay for something they can't measure.

So that means they'll really be paying for denial of care. And that's how ACOs will make their money. They'll kill 'em quickly and cheaply.
I've been telling my parents for 15 years at least that by the time I need Medicare, it won't be worth having. I honestly didn't think that was going to apply to them, and so soon!
PS: Don't get me started on the expletive expletive expletive EMR crap.

It's beyond bad.

And oh, yeah, I've got piles of messages from insurance companies about diabetic care that's
A) Either already been done, or
B) The necessity has been ruled out, or
C) Not even applicable because the real situation of the patient is more serious than the subsidiary risk they are talking about.

There is no substitute for proper clinical care, and if the doctor is not going to do it, having someone that's never even seen the patient trying to figure out what's necessary is hardly going to help.

It's like having me try to tell a doctor how to practice medicine. Utterly lunatic, and a true time-waster.

I bet half the endocrinologists in the country would like to firebomb some of these insurance companies. It's as if you were standing with a hose trying to put out your house-fire, having the fire company roll up, and try to give you safety course about the dangers of leaving your house unlocked.

I've got the 5010 ready to go, and we will probably roll over in October and go live on that. I can't even express the sensation of epic joy with which I look forward to ICD-10.

The end of this will be that a lot of doctors will just shut their doors and head off into the sunset.
Neil - you should send them into their doctor and make sure that anything they MIGHT need gets done next year. It's right around the corner. What I was discussing with the doc (we didn't finish) was that we had to pull all the Medicare patient files and do whatever is needed while we still can get it. Normally he's chary on the tests unless it's need for immediate clinical decisions - all of these things have a bit of negative - but now all bets are off.

In a few years I bet they won't even be putting in stents. The "CW" is going towards managing it with medicine. And that's why they don't want the coronary artery scans - unless the person is already experiencing shortage of blood flow to the heart they don't want you to refer for angio and stenting.

But a nuclear stress test is more expensive and doesn't pick up a substantial number of patients endangered. My neighbor down in GA had a massive heart attack less than three weeks after his, and SuperDoc told me that he's lost all faith in them. From looking at the plaque in the arteries you can tell who's most in danger.

Also, the guidelines for the medication may work much of the time, but a lot of times in older patients you've got moderate functional problems in the liver or the kidneys or both. So you want to do as much as you can with diet and exercise and be moderate with the medications.

Without looking at how severe the artery clogs are, you can't tell what's the real risk.

Rates of organ failure are going up and some of it is due to medication.
I'll try hard to talk my Dad, at least, into an MRI (or is it a CAT?). I had one (for unrelated reasons) a few years back, and was delighted to get my cardiac condition checked out as a by-the-way. (It was totally healthy at the time, btw.)
The feds, just to give us a flavor of life under and ACO are requiring all physicians to re-apply to be a medicare approved MD in the 2012 time frame. App form reported to be 60pp long and not only must be complete, preliminary reports by those having done so in the past 6mo, report "lost applications",
apps returned for failure to put marks completely inside boxes and turn around times of 4-6mo even if no glitches occur. "lost apps" mean
the doc has to bird dog the process to be sure the app has been received. And if you are not an
approved medicare MD no payments may be made to you for services rendered. With 600-800k MD being
recerted over the next 18 mo look
for a lot of clogging of the system.
Sch - SuperDoc handed me that letter with a pathetic look last week.

So I started on it. The local contractor is charging a fee of $505 for the paper app, and in any case I feel there is far more of a chance for that to be dumped.

But that means I need to do User ID and Password for PECOS, and they signed up and lost it.

No one replied at the number given for the company contracting as NPI Enumerator, which takes care of the ID/PWD issue. So I emailed them, and they promised a turnaround of seven days. I'm sure there will be an intermediate step there. I expect to be able to log on and fill out the freaking questionnaire by October 16th.

Single practices can't survive. That's all there is to it. But I think that if they overdo this one, he's just going to dump Medicare altogether.
It's not just that. It's everything. The paperwork is multiplying like tribbles, and the trouble and time the practice is spending fighting with insurance cos to try to get care for the patients is multiplying even faster.

Last month main admin staffer spent more than two days (it took almost a month) trying to get an insured patient scheduled for a biopsy of a bone lesion. She was just a kid, and it looked pretty bad. Everybody who had done imaging was alarmed and said a biopsy was warranted. The good news was that whatever it was, it was still contained in the bone. The bad news was that the insurance company was hellbent not quite on denying it, but making sure it never got done.

This was a new patient who had been for treatment with other doctors, and apparently they had just given up the fight.

First they ins co said it wasn't warranted, so we sent them three different doctor's statements saying it absolutely should be done. Then the Doc spoke to a specialist, and he told Doc to be very very worried and warned that if it was cancer, it could just explode.

So then they said they would give us a referral to a network doc. The network doc didn't reply, but after days of effort explained that he didn't even take these patients for that insurance. So then we went back to the first doctor we had picked to do it. He confirmed he WOULD take the insurance and accept whatever they paid. It took over ten more days of calling the insurance company every day (and usually waiting on the phone for at least half an hour), plus a referral to Sloan-Kettering doctor (that's what panicked them - they knew they couldn't get it past Sloan-Kettering, and the doc up there had agreed to see this kid and fight it out with the ins co.

For all of this - the net cost was over $300 dollars just in time, SuperDoc got paid $45.

It's a conspiracy to kill people. We have managed to combine the worst features of the NHS with a private medical system that has huge holes, and it is decaying by the week.
PS: - The lesion in that girl was first found in the summer of 2010, so you can see how great the system is working.

They say utilization is down. I think it's because the insurance companies are making it impossible to get care.
Single practices can't survive. That's all there is to it.

I'm convinced that's been the plan all along.
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