Archive for the ‘Funding Crisis’ Category

The Demise of American Health Care

Tuesday, December 1st, 2009

closedA couple of news headlines paint a bleak picture about the future of healthcare in this country.

First are some comments made by US Republican Senator George LeMieux. During a news briefing (video here), LeMieux expressed a concern that Obama’s healthcare plan would amount to “Medicaid for the masses” and would put all Americans on a government run or government controlled health care.

The Palm Beach Post News also ran a story regarding a speech given by Senator LeMieux where he stated that the cost of the bill over the next 10 years was grossly understated due to “funny math”. He estimated the true cost of the bill to be more than $2.5 billion over 10 years rather than the projected $849 million.
LeMieux stated that in order to decrease costs, the bill intends to cut Medicare spending by more than $500 billion – through $400 billion in cuts to home health providers, hospitals, hospices and others while decreasing subsidies to Medicare recipients by more than $100 billion.
My favorite quote from the article is the following: “If we really want to provide health care for Americans, why shouldn’t we give them the tools to go out into the marketplace and be a consumer, which we know will end up driving down costs.”
Another free market advocate. I love it.

As our legislatures plans to significantly cut spending on the Medicare program, today several Massachusetts hospitals are filing a lawsuit against the state of Massachusetts because the current reimbursements from Medicare and Medicaid are already too low. According to this article in the Boston Herald, Massachusetts currently reimburses hospitals for only 40% to 86% of the costs of providing care. Because at least 63% of patients going to these hospitals have Medicare or Medicaid, the low payments are pushing many hospitals “to the brink of financial ruin.” The state countered by stating that it recently increased payment to the hospitals by 10 percent. Unfortunately even a 10% increase still leaves hospital payments at 44% to 95% of the cost of providing care – still below the break even point.
No business can stay afloat when the costs of doing business exceed revenues.

Recall that in 2006, Massachusetts was the same state that established a mandate that every person in the state have health insurance … similar to the mandate proposed in the current US health care bill.
Also recall how, since this Massachusetts mandate was created, the number of visits to Massachusetts emergency departments increased 7 percent and how the cost of caring for patients in Massachusetts emergency departments increased 17 percent – due to the lack of primary care providers in the state.
Oh yeah, and in a survey last year, only 2% of graduating medical students in the country plan to go into primary care internal medicine.

So the plan in Massachusetts to insure all of its state residents has resulted in almost every state resident having insurance … and in more people having trouble finding care.
The greater number of insured patients increases the costs of providing care to those patients.
Then, to control costs, the government cuts or maintains ridiculously low payment schedules to providers – to the point that the providers are having difficulty staying in business.

Welcome, ladies and gentlemen, to your new national health care system.

The current health care bill plans to cut Medicare spending by $500 billion.
Medicare plans to cut physician reimbursement by 21% next month.

What good will your new health insurance be few providers are willing or able to provide care for you?

The biggest myth of this health care debate is that having “insurance” is equivalent to having “health care.” The two are not the same, nor will they ever be the same. Just ask people who have Medicaid “insurance.”

If the hospitals in Massachusetts want to get more reimbursements, suing the state is the wrong way to go about doing so. In this case, lawsuits are a costly lose-lose situation. All the money the hospitals spend in attorneys’ fees and court costs could be put to better use. Boston Medical Center already tried suing the state for the same reason and the litigation is still dragging out in court.

A lobbyist once told me that the quickest way to enact change is to cause a public outcry.

You hospitals want an increase in funding? Drop the lawsuits and just shut your doors. Take your ball and go home. Too many patients and almost every legislator in our government take their access to health care for granted. Let patients walk up to your facility with their insurance card in hand and let them jiggle the handle on on the door a few times before realizing that they cannot get inside. Stop providing care until the state and federal government provide better reimbursement.

If it costs these hospitals more to provide care than the hospitals are being paid, closing the doors would save the hospitals money each day that the doors are closed. Divert ambulances. Transfer admitted patients to other facilities. The 1.5 million patients each year, including more than 300,000 emergency department patients each year that are being treated at the near-bankrupt Massachusetts hospitals will have to be redirected to another facility to find their care – if care is available.

At the entrances of each closed hospital, post giant pictures of the state and national legislators and an explanation of how their actions or failures to act have caused the hospital to close. Make sure to include the date that the legislators are up for re-election.

Then give the local news stations a call to let them know what’s happening.

They’d have funding within a week.

Here is the Problem

Saturday, October 10th, 2009

ERP here again while WC recovers from the revelling in Boston

Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.

The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.

Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.

Effects of Saving Money

Friday, September 25th, 2009

In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits.
In February 2009, the two hospitals went bankrupt and closed.
In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity.
Guess what happened?
Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.”
The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs.
One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.”

At the heart of the hospital closures was funding.
New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt.
Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available.

Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending.

But we need to be very judicious in where spending cuts are made.

Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community.

Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.

Healthcare Policy Roundup 7/22/09

Wednesday, July 22nd, 2009

The Mayo Clinic – touted by the Obama administration as a system that provides quality care at a reduced cost – turned around and smacked House Democrats in the face over the recent health care reform proposals. A Washington Times article quotes Mayo Clinic officials as stating that the plan will lower quality and increase costs because the outcomes are not patient-focused or results-oriented. “The real losers [with this plan] will be the citizens of the United States.” Ouch.
In other news, President Obama mentioned in a White House press conference that he changed his mind and now thinks that the Mayo Clinic sucks.

Comparing healthcare systems in different countries may help the US come up with a viable alternative to our current system. John Aravosis from America Blog describes a situation in France where his emergency department visit at a specialty hospital cost him a rocking $32. Something doesn’t sound right about that story. If it is really true, insurance companies would spend less money by purchasing an air fleet and sending patients with potentially expensive medical problems to France for emergency care. Anyone else have experience with the French system that could comment more about it?

More violence in the emergency department. An ED admitting clerk was shot three times by her former boyfriend outside the hospital and then stumbles inside full of blood.

I usually don’t believe that the number of malpractice suits against a physician should be used as a measure of a physician’s competence. I know several excellent physicians who have been sued 5-10 times. I have been sued several times myself. Unfortunately, when there’s no reliable way of measuring a desired metric such as physician quality, pencil pushers will take things that can be measured and try to make the argument that the data apply to the metrics. That being said, should an ophthalmologist who has been sued 50 times be subject to discipline just because of the number of lawsuits against him?

The largest medical malpractice verdict in Tennessee history was just handed down against an OB/Gyn physician that allegedly ignored a patient’s complaints about an unusual breast lump, stating that the lump was probably a cyst or a fatty deposit. Instead, the lump was a cancer that later spread to the patient’s liver. The jury awarded almost $24 million to the patient and her husband.

Here’s a WTF moment for you. Two nurses wrote a complaint with the Texas Medical Board after they became concerned with patient safety when a physician kept trying to sell patients herbal medications. Kind of like an IRS agents offering to sell you tickets to the IRS ball just before an audit? The nurses included patient identification numbers, but no names, with the complaint. The story isn’t clear, but apparently medical records were also sent to the Medical Board. When contacted by the county sheriff, none of the patients complained about their care. The District Attorney then filed criminal charges against the nurses after the doctor complained about being “harassed”.
In other news, the Winkler County District Attorney could not be immediately reached for comment, but later was found at home taking a chamomile extract bath with vanilla bean infusion prescribed by the involved physician.

Defensive medicine may not exist, but this doctor does a pretty good job of describing this figment of our imagination. Interesting that Congressional Budget Office statistics show that $30 billion was spent to defend against and pay malpractice claims in 2008, but that money was only 1.5% of the total 2008 healthcare expenditures. Also interesting that hospitals provided more than $35 billion in uncompensated care in 2008.

I admit that this ACEP article isn’t a “news flash” and leans toward being propaganda. Even if it is propaganda, the article and the story it tells raise a valid point. In some larger cities, ambulance diversion is a huge problem. According to this Washington Post article, diversion happens all the time in Washington, DC. You may not get to go to the closest hospital if you are having an emergency. In addition, the overburdened EMS system may not be able to get to you in a timely manner. Will these problems improve with socialized medicine?

The medical practice climate is tenuous in the Los Angeles region. LA hospitals are reportedly having difficulty finding subspecialists willing to take call for emergency department patients. Big problem. For example, even if patients make it to an emergency department with a life-threatening subdural hematoma, it won’t do them much good if there’s no neurosurgeon there to operate on them. ED physicians can try to stabilize patients, but we can’t do the lifesaving surgery. To maintain coverage, hospitals are paying physicians $250 to $4000 per day to take call and provide patients with care. How long will they be able to continue those payments with massive state budget cuts?

California’s attempts to erase a $26 billion budget deficit by cutting health care will likely push California’s economy further toward bankruptcy according to this LA Times article. Instead of paying for home health care, California will force patients receiving those services to go to nursing homes – at triple the cost. Poison control services and insurance for children of low-income families will be eliminated ending up in more of those “low cost” visits to the emergency department. California’s plan may be as much about cost shifting as it is about cost saving, though. If California cuts payments to the hospitals for emergency services, the hospitals eat the costs of indigent care, not California.
There’s more to the game than direct costs, though. According to the article, a 2006 study tracking similar budget cuts in New York City back in the 1970s found that less than $10 billion in cuts to healthcare, education and law enforcement in New York City over four years led to at least $54 billion in additional costs over a 20-year period. Consequences included higher rates of HIV, a worsened tuberculosis epidemic and a spike in homicides.
Looks like a good trade-off to me, there, Arnold.

New Brunswick, Canada apparently has a poor reputation with Canadian physicians and not too many docs want to work there. ED physicians working in clinics and smaller hospitals are then pulled to work in larger regional emergency departments. Then the clinics and hospitals close. Guess what happens next? All the patients go to other nearby emergency departments and cause an even greater crowding problem. “Then the waits just get longer and longer and there’s more consequences and more possibility, or probability, that something might happen while you’re waiting.” Sound familiar?

Promises Promises …

Sunday, June 14th, 2009

Very poignant article in Yahoo news about how the federal government is failing to meet the needs of many patients in the Indian Health Services – and the disastrous effects the broken promises are having.

  • A five year old with stomach pain who stopped eating who visited the clinic ten times and was diagnosed with “depression.” Later the family discovered she had terminal cancer. She died at age six.
  • Another patient was given cough syrup for his congestive heart failure and sustained damage to his heart. He died while waiting for a transplant.
  • Another patient visited the clinic with stomach pains for 4 years and was diagnosed with possible tapeworms and stress. Later, she discovered she had metastatic cancer.
  • Yet another patient couldn’t get a prescription filled despite repeated trips to a clinic because of lack of appointments. She died before she was able to see the doctor.

Few doctors are willing to work in remote reservations, there is a lack of funding (some reservations warn “don’t get sick after June,” when the federal dollars run out), and care is rationed. In fact, one third more funding is provided for the health care of felons in federal prison than is provided for American Indians on reservations.

Then read this Yahoo news story about the massive budget cuts that are coming down the pike in the healthcare reform package.

Not too hard to connect the dots.

Two Thoughts on Health Reform

Wednesday, June 10th, 2009

I don’t always agree with Uwe Reinhardt’s insights into the health care system, but he is so incredibly spot on with this quote that I had to post it.

[Countries with functional socialized systems] all mandate the individual to be insured for a basic package of health care benefits.

Many Americans oppose such a mandate as an infringement of their personal rights, all the while believing that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it. This immature, asocial mentality is rare in the rest of the world. An insurance sector that must insure all comers at premiums that are not contingent on the insured’s health status — a feature President Obama has promised — cannot function for long if people can go without insurance when they are healthy, but are entitled to premiums unrelated to their health status when they fall ill.

A central concept of medical systems in many other countries is “social solidarity,” not irrational demand for the best medical care someone else can pay for.

The US is going to have to emulate another functioning system if it is going to survive. The German model deserves some consideration.


In addition, Alexander sent me a link to an Investor’s Business Daily editorial about how Oregon is working on health care reform. Oregon has compiled a list of 680 treatments for medical conditions and has ranked them in order of importance. Oregon will only pay for the top 503 on the list. Treatment for everything below number 503 must be paid out of pocket. Patients with broken toes, cracked ribs, and liver cancer are out of luck – they’re all ranked below number 503. However, treatments for obesity, schizophrenia, pathologic gambling and sexually transmitted diseases are fully covered.

I foresee such a system as a way that health care spending will eventually be curtailed in this country. Liver cancer isn’t covered because not a lot of patients get liver cancer. Therefore, their collective voices are relatively small. When treatment is expensive and relatively few patients are affected, the treatments will be cut. Collectively, patients will receive more care for less expensive conditions that affect more people, but to keep things budget-neutral, patients who have less common diseases will receive less care. Even though Oregon admits that malignant neoplasms are a leading cause of death in anyone 11 years old and older (report pages PT4-PT11), it won’t pay for the care of “ill-defined malignant neoplasms” (#612). Doesn’t say anything about “well-defined” neoplasms, either. Refusing to pay for treatment of malignant neoplasms is great for saving money, but it is essentially a death sentence if you develop an ill-defined malignant neoplasm. Just hope to God that any neoplasm you get is benign. Those are still covered … unless you have a benign neoplasm of the eyelid (#516), kidney (#529), nasal cavities (#539), bone (#540), genital organs (#577 and 603), breast (#638), skin (#646), or digestive system (#656) – then you’re still SOL.

Also note how many of the things that will not be reimbursed are conditions with “no or minimally effective treatments or no treatment necessary.” Who determines whether a treatment is “minimally effective”? Why the same entities that pay for the treatments, of course: U.S. to Compare Medical Treatments

It’s the Golden Rule: He who has the gold makes the rules.

Healthcare Policy Roundup June 9, 2009

Tuesday, June 9th, 2009

One way to get rid of your chest pain … threaten the nurses and hospital staff with a knife in the emergency department. Police will come and shoot you dead.

Quote from the director of Calgary’s three emergency departments: “We have huge numbers of very sick patients essentially left behind in hallways and on ambulance stretchers for long periods of time, and across the country, in every major Canadian city, in every large urban emergency room, you have patients who are deteriorating or having adverse events as a result of these delays to care.”

Canadian ED overcrowding isn’t due to non urgent patients clogging the EDs according to this study. Instead, the study author, a 25 year old master’s student, states that overcrowding is “rooted in insufficient physical and human resources and poor integration within and between hospitals.” Before the problem of ED overcrowding can be cured, he suggests “determin[ing] the purpose of EDs in order to best serve the patients, health care professionals, communities and the country.” Good advice.

Sutter Roseville Medical Center is at risk of losing federal funding after a patient “walked away from the emergency room … and hanged himself in a wooded area 500 yards away.” CMS alleged that the hospital did not adequately screen the patient under EMTALA. Part of me wonders whether this action is somehow related to Suter’s decision to close another emergency department in its system. I may be wrong, but I just get the impression that there’s more than meets the eye going on here.

Ten previously blogged about how his group had been surreptitiously ousted by hospital administration. This article shows that having a good relationship with hospital staff can save your job. When Mercy San Juan Medical Center tried to fire their current emergency docs and hire docs from California Emergency Physicians, the hospital staff got up in arms and the deal fell through.

One way to cut state Medicaid costs … address high utilizers. This New Hampshire editorial states that frequent “ER” users only represented 5% of the Medicaid population, but those users accounted for 41% of the total Medicaid “ER” visits in the state during 2006.

Another way to cut state Medicaid costs … stop providing services. North Carolina Medicaid recipients may soon feel the “bite” of budget deficits as state legislators propose to cut payments for dental visits by 50%. Think this through, folks. It’s not like people with cavities will just go away. Where do you think people with dental problems will end up? Receiving that nice inexpensive care in state emergency departments. I’ll bet that the state Medicaid costs will increase if they go this route.

Funding issues causing problems with access to Connecticut hospitals as well. Connecticut hospitals lost $156 million in the last quarter of 2008 and $200 million in the first quarter of 2009. The state is underfunding its Medicaid program and hospital emergency departments are “busier than ever,” with uninsured patients making up 45% of hospital emergency department visits. Some hospitals are now requesting payment in advance for elective procedures.

Want to reduce your risk of malpractice? Be nice.Developing a rapport with the patient — is any physician’s best protection from eventually being sued by that patient.” One thing I don’t get – was this doc so busy that he couldn’t take off his surgical mask before posing for a picture in the article? Or is a surgical mask hanging around the neck the new fashion statement for surgeons?

A House Subcommittee recently approved a bill that would limit the Feres Doctrine for armed service members. Currently, members of the military and their families cannot sue the military for negligent medical care – regardless of how egregious the care was. The Carmelo Rodriguez Military Medical Accountability Act was named after a sergeant in the military whose bleeding buttocks lesion was repeatedly misdiagnosed as being a wart or a birthmark. Sgt. Rodriguez died from metastatic melanoma. I agree that doctors should be responsible for egregious care, but if we turn the armed services court system into another civilian medical malpractice system, how many military docs will leave? Another point of view from Walter Olson at Point of Law here. Fast care, free care, quality care – pick any two.

Physician’s Reciprocal Insurers, a med mal carrier that insures 25% of New York’s physicians has one foot in bankruptcy court and the other foot on a banana peel. State mandated insurance premium rate freezes appear to be partly to blame. How could this happen if insurers are raking in the money and are really responsible for the medical malpractice crisis?

Anybody Wanna Buy A Bridge?

Sunday, May 10th, 2009

MSNBC posted an article stating that “Top representatives of the health care industry plan to offer $2 trillion in cost reductions over 10 years” to satisfy President Obama’s plans to overhaul the health care system.

Does this mean that they’re going to spend $200 billion less each year for the next 10 years? Doubt it.

I’ll wait to hear the plan in depth, but my cynical side is getting the better of me right now. I’m betting that the plan will just be pulling the ol’ grocery store trick of marking a 79 cent can of beans up to 99 cents then putting it on “sale” for 89 cents so that everyone thinks they’re getting a bargain — when in fact they’re actually paying more.

With health care spending at $2.4 trillion in 2008 and rising each year, I imagine the plan will go something as follows:

“We were projecting that we would have to spend $40 trillion for health care over the next 10 years, but, through a complex mathematical model, we’ve figured a way to spend only $38 trillion instead. Check us out … Now where’s that stimulus money at?”

My View

Tuesday, April 14th, 2009

I started blogging because I enjoy telling stories. Always have, always will. I think that many people read what I write because they like reading stories.

A recent comment by Max Kennerly, an attorney that frequently comments on this blog, made me sit back and think quite a bit. I don’t always agree with Max or with Matt, the other attorney whose comments drive me nuts sometimes, but I do respect their opinions. Another goal of this blog is to create an atmosphere of debate and debate runs deep on some posts. That’s a good thing.

Max wrote:

I still don’t understand your EMTALA obsession; the Chicago example makes quite clear an ER can cheaply and quickly comply, and still engage in profitable patient dumping. EMTALA isn’t a big deal from the policy perspective, you just find it personally annoying.

Frankly, the ease with which you (and other physicians) conflate issues makes it very hard to take any of you seriously. Do you want to be treated like a private industry or like a public utility? In the same breath you complain that the state is not providing funding and that the state imposes too many limitations on you. Who you think you are, Wall Street?

Normally, we do not give an industry state funding without substantial controls on it, including controls to ensure widespread availability of the industry’s services. But you apparently want the former but not the latter. Well, so do I. I want taxpayer money to go about my private business. Ain’t gonna happen.

I, personally, favor the public utility route, and would be happy to pay the extra taxes to fund it. Where do you fall?

After reading Max’s comment, I read back through my most recent posts on this blog (some imported to this blog – see Archives at right). Then I read back through the earlier posts on my old blog. Max is right. My mindset has definitely changed.

Then I thought about why my focus has changed.

I’m worried about health care in this country. I’m not worried for myself, but I am worried for so many hardworking people  who are denied health care or who have no access to health care. Policies like “never events,” agencies like JCAHO, misguided and medically unsubstantiated sites like “HospitalCompare,” and laws like EMTALA all start out with noble intent (I presume), but they all end up causing ripple effects that degrade the practice of medicine.

So in answer to Max’s comment, my “EMTALA obsession” wasn’t intended to be focused on EMTALA. Rather, my focus is on the ability of every American citizen to access healthcare. I have several Google news feeds that arrive in my e-mail each day. One of them is for the term “emergency room.” I know. I know. I cringe when I type it, but people haven’t caught up with the times. “Emergency department” hardly gets any news … yet. Every day I read posts about how hospitals are closing or losing money because of unfunded medical care. At the heart of unfunded care is EMTALA. So many of my posts reference EMTALA because EMTALA is abused to the point that medical care in this country is doled out arbitrarily. Patients that need urgent care are often neglected or do not seek timely care because they cannot afford it while patients who want “free” pregnancy tests or narcotic prescriptions pillage the system.

I have repeatedly said that a free market approach to medicine is the only way to save the system. Patients must have some “skin in the game.” Unfortunately there will never be a truly free market because, unlike almost any other industry, medicine is a human “need” – not a human “right,” but a human “need.” What other industry has such a closely entrenched human need? Those who can’t pay for a Lexus simply don’t get their Lexus. They can ride a bike or hitchhike. Those who can’t afford a civil lawyer may have their rights trampled, but they still get to go on with their lives. Those who can’t pay for health care – especially emergency health care – will die. Lack of medical care has an immediate and significant effect on morbidity and mortality. I can’t think of any other industries more necessary than medicine – including law. Sorry, Gerry Spence, you’re just flat out wrong.

The intent of all my policy posts is to make people think about the secondary effects of the choices they make, not to force my opinion down anyone’s throat. For example, many who clamor for true “socialized medicine” have this dream that they will get fast, free, and quality care. Such a system will never occur. NEVER. Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems. If we’re going to choose this system, at least we should have an idea of what we’re in for.

You want me to pick public versus private industry? I pick private industry. You pay me, I treat you. No third parties. Screw the government. Every medical provider would have free choice to choose who to treat and who not to treat. No provider would have to treat patients without insurance any more than a grocery store would have to give groceries to someone without money. “Patient dumping” wouldn’t mean anything other than a medical provider making sound business practices. Lawyers couldn’t threaten health care providers with EMTALA violations or all of their other creative iterations of negligence solely because providers choose to make a profit. If patients can’t afford their cardiac catheterization or their expensive medications, they die. Sucks to be them. Is that the system you want? You wouldn’t hear very many providers complaining, but at the same time, thousands of people would die because they had no money for medical care. I’m all for free market, but we can’t let purely “free market” medicine happen to patients.
So let’s impose strict “state controls” on medicine. Everyone is a comrade and gets their government-sponsored Yugo and bowl of gruel. We can already see what happens with a purely government controlled model. Look up North or across the pond. Sure, care for healthy patients is easily accessible. But become one of those “high utilizers” and it’s a different story. Long waits. Less care. People die waiting for surgery. Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” Impose your controls. Go ahead. You won’t be able to pay enough in extra taxes to fund a system that provides good and timely care to every denizen in this country.

What I foresee happening is a system similar to the legal system in this country. For emergency care and surgical care/hospitalizations, there is a “public defender” type system. If you can’t afford to pay for a top notch “defense” physician, then the “courts” appoint a “public defender” physician for you. You get average care if you don’t have the cash, but you have the option to pay for Mark Geragos if you can afford him. Top surgeons or emergency physicians could demand and receive a premium. Just like the Mayo Clinic or M.D. Anderson, now. People pay extra for extraordinary care. Market forces at work. The “public defender” system is already emerging in emergency medicine with the proliferation of freestanding emergency departments that can cherry pick paying patients. Those without money go to the “public defender” emergency departments at public hospitals that still fall under … EMTALA laws. See, I mentioned it again.

Routine medical care will drift toward the “civil law” practice model. Pay to play. No money, no care. Maybe you can go to public clinics – the equivalent of law schools or charitable organizations – to get primary care if you demonstrate a need. Once the governments decide to cut funding to public clinics, patients will either have to pay up or go sit in the untenable lines in the emergency departments for their care.

I will be able to care for myself and my family regardless of the system that is chosen in this country. I have the contacts, the resources, and the knowledge to do so. One of the benefits of having a six figure student loan debt, I guess.
I truly fear for the health and livelihoods of those who aren’t as fortunate as I am.

That’s where my posts are coming from.

On the flip side, I really do have to get out of my writing rut. Thanks for setting that straight, Max.

Down For The Count

Monday, April 13th, 2009

knockoutMedical care in this country is rapidly heading for a K.O.

Baltimore’s Bon Secours Hospital considers closing as it is getting crushed under the costs of providing uncompensated care. The hospital lost $22 million last year.

Northeastern Hospital in Philadelphia is also preparing to close. Its emergency department usually sees 50,000 patients per year. The hospital lost $6 million last year and expects to lose $15 million this year. Charity care has increased by 33% in the past 12 months and more than three quarters of the patients at the hospital are Medicare or Medicaid – “insurance” plans which “do not pay the full cost of care.” State lawmakers and community activists are trying to force the hospital to stay open.  State Sen. Michael J. Stack stated that “closing this ER is going to have a devastating effect.” The article made no mention of how the good senator planned to fund his grand initiative .

A Chicago Tribune “Watchdog” article criticizes “for profit” hospitals that pass the buck on uninsured patients, showing how for profit hospitals provide patients with an “EMTALA screen” in the emergency department, stabilize any emergencies, and then send indigent patients to public hospitals for further care – sometimes with directions on how to get to the public hospitals. The article quotes one University of Pennsylvania emergency physician as stating that the practice amounts to “legalized patient dumping.” No word on how much of a pay cut the emergency physician has taken to curtail such problems in his own state. Also no word on when the Chicago Tribune is going to stop “advertiser dumping” – a process that requires all advertisers to pay in advance for advertisements in its newspaper.

A Naples Daily News (Virginia) article shows how communities are creating more and more “freestanding” emergency departments that cater to patients with the ability to pay. The article notes that out of 12,000 patient visits per year, the freestanding emergency department “is seeing very few people with no insurance”. Incidentally, wait times are 10 minutes in the freestanding emergency department and 5 hours in the traditional emergency departments.

The manner in which healthcare providers fight for financial survival is causing rapid market adjustments. Hospitals that cannot afford to comply with the federal EMTALA laws are either curtailing emergency services or closing. Patients with public insurance or no insurance that depend on EMTALA laws to survive are being herded into larger public institutions where waits become untenable. Private physicians increasingly refuse to care for patients with public insurance due to low reimbursement and administrative hassles.

Government-created market forces are pushing us toward a two-tiered socialized system at a dizzying pace. Those fortunate enough to have insurance will receive faster and likely more competent care, but care that will come at an increasing financial cost. Those patients without insurance will receive “free” care that is time-rationed and haphazard. Emergency medical care for all Americans will be less accessible because of continuing hospital and emergency department closures.

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