“Beep,” went the machine.
I left a message and hung up.
My patient, Mr. G, had just been denied a medicine by his health insurer. It’s the same medication for the same condition that he had been taking last year.
I was leaving a message on his behalf.
You can be assured that if you hand an insurance card to the front desk employee at your doctor’s office, your doctor deals with health insurers every day. It’s the system we’ve come to expect for both the extreme and the routine in our medical care.
Most of us dislike it.
But, we’ve been taught we can’t afford it any other way. The cruel paradox—of course—is that the majority of us are being out-priced by the status quo.
Mr. G’s medicine was working fine. It’s the only one of its type that he has tolerated without side effects. The insurance company covered it last year. They changed their mind about it this year. And, until we accept the logic that entrusting third parties to pay for our health might be harmful to our health, they will be the ones who keep getting to decide.
I was told I could appeal the decision waged upon Mr. G by getting in touch with a “doctor” working for the insurance company.
If you read that again, it’s an unbelievably humorous statement.
Physicians, scientists, and researchers are routinely condemned by the most virtuous of stone throwers for having even the slightest lean toward a conflict of interest. Yet, having me appeal your insurance case to someone who works for the insurance company remains noticeably absent from their aim.
It’s become a major problem in our quest to obtain a perfect healthcare system.
It’s called science.
Now, don’t get me wrong. I have nothing against observation and experimentation. But, since blind pursuit of anything can lead to destruction, it’s time to take more notice.
To be fair, it’s not science, per se, we are talking about. It’s our interpretation of it—how we perceive its role to be within the framework of medicine.
I’ll begin with a simple illustration.
I will flip a coin 10 times. I will tabulate the number of instances the coin returns heads or tails. Then, I will repeat the experiment 10 more times.
In fact, here are the results:
We are assembling too many panels of people in the name of health these days. Too many.
They usually seem like a good idea. I’ve been supportive before. I assumed we needed them. More of them.
I might have been wrong.
There was a day when I believed my food would be toxic, my medicine harmful, and my safety gone without them. But, I’ve come to believe I was mistaken.
I was wrong because the medical world is now full of panels. And, paradoxically, it seems more confusing and arbitrary than ever before.
Recently, I’ve taken some interest in economics. I thought I understood it before. That was when I didn’t understand it at all. I used to believe the goal was to create jobs, since jobs obviously drive the economy. I was almost on the right track. Until I realized I wasn’t tracking at all.
I’m obsessed about finding ways to better deliver high-quality and affordable medical care.
And, yes, it obviously starts by eliminating the medical waste that’s preventing it. What’s on the chopping block for today?
Mandated medical documentation.
Follow me around for a single morning. It’s the most obvious waste you will recognize.
Ninety-five percent of it might as well be monkeys typing on a typewriter. No one providing care wants to read any of it. Because it’s not helpful.
There are lots of letters on the page. And, there are lots of pages.
Frequently, it’s an unsolvable puzzle. In fact, I challenge you to find much of anything that really matters inside a patient’s chart anymore.
I guarantee you the insurance companies don’t read any of it. I send them records all the time trying to get studies approved for my patients. They read absolutely none of it.
They just deny the test. Then, I have to call them. Wait on hold. Talk to a nursing supervisor. I just hung up the phone with one a few minutes ago. Do you know what she asked me?
“Doctor, can you tell me the reason you are ordering this test?”
I sent you two-dozen pages of notes. You are looking at them now. Why don’t you read what I send you?
I’ve got my theory on this one.
WE HAVE ALL JUST GIVEN UP.
My recent post appeared to catch the attention of Mr. Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS):
My article recapped another day of insanity within our healthcare enterprise, and yes, taking a look, Mr. Slavitt, would be greatly appreciated.
Choosing to see, however, is my challenge for you—for as a friend reminded me, you seem to be very good at “feeling our pain.”
But, I must admit, thanks to you, I was contacted by a CMS official overseeing the startup of MACRA.
For those that don’t follow healthcare policy closely, MACRA is our government’s latest medical project. Another soon-to-be-implemented healthcare law with 962 pages of rules, including the most recent method devised to pay physicians, something known as the Merit-Based Incentive Payment System (MIPS).
CMS was seeking my perspective on MACRA and MIPS.
My written response to them—edited only somewhat for brevity—is shared below:
My satellite clinic is about an hour away. I drive there with my nursing staff each month.
We load up ECG equipment, pacemaker programming machines, and a few other doctoring items in my truck.
I provide services to an area that has no permanent resident doing what I do.
Then, I return home.
Today is one of those days. I arrive back to my main office. It’s after 5pm and officially closed for the evening. I hurry to help my remaining staff return numerous phone calls to patients who had left messages while I was away. I hope to finish up at the office soon. Then, I intend to check on a patient at the hospital before making it home for dinner with my family.
I peer down at a piece of paper on my desk, given to me by one of my staff. It’s a printed email message. Sent by the Centers for Medicare and Medicaid Services (CMS).
The message is arguably from the most descriptive email address on the planet—and I’m not making this up—it’s from DONOTREPLY@CMS.GOV.
It’s rather fitting.
Because they definitely don’t want you to reply. That would be easy for me. Too efficient, perhaps. No, they don’t want a reply. They just want me to DO what they say.
It’s been a chatterbox kind-of-week for evidence-based medicine.
First, an article appeared in the New England Journal discussing its limitations. Then, a rebuttal came from an established bull in the China shop, and we were well on our way. Ultimately, all sides made a point.
Seemingly bored by the chatter, however, may have been Medical Progress herself. She has and will continue to move forward on her own terms—sometimes with and sometimes without randomized controlled trials.
There are not many novel ideas to discuss here. Evidence frequently has claimed to be guiding medicine. Sometimes it has originated from the experience of a single person or two. Sometimes pseudo-clarity has required the trials of ten-thousand. Only very recently has evidence even existed for some in hierarchical structure—”hard” or “soft” these people now say.
But, what does “hard” or “soft” evidence really mean anyway? And, who gets to define these terms?
The policy makers?
The New England Journal?
The bull? The baker? The candlestick maker?
Almost contrary to what the gnostics of evidence proclaim to be best, the majority of individual medical decisions are made using so-called “soft” evidence. And, no, this isn’t some atrocity.
I arrived with my family. I handed the usher our tickets.
We entered the auditorium. The stage was lit. We were directed to our seats.
We were there to watch an OPAS Junior production—a performing arts play for families and children.
The performance would soon be what we paid for, an enjoyable Sunday afternoon event with my wife and boys.
The actors and actresses did their job. They appealed to us, the audience. They danced, sung songs, provided humor, and so forth. They were there for us that day. And, we were there for them.
We paid for their performance. And, they gave us one.
* * *
A compelling strategy has consumed American healthcare. It’s known as pay-for-performance. It’s trying to replace our unknown fee-for-service model, because it seems more logical.
I enjoy documentaries. My wife says she enjoys watching them with me. The way I usually see it, they help her fall asleep.
But, not this one.
Not Poverty, Inc.
If you haven’t watched it, you should. We both enjoyed it.
It’s not one of these pick-a-political-side kind of shows. For the record, people across the political spectrum have endorsed it. The film has won like forty honors and twelve awards that I know absolutely nothing about. But, if you watch it, you’ll get the gist why.
We occasionally need disruptive thinking. Something to challenge our perception of reality. We actually need more of this when contemplating healthcare delivery, too. But, I’m not talking about that right now.
Poverty, Inc. is about poverty… and the humanitarian aid we use to fight it.
It’s also about government. And, business. And, how the collusion of these things isn’t solving poverty at all. Like I said, you should watch it. It provides you a fascinating perspective.
I won’t give it all away, but there are a few predominant themes that unfold in the film as you watch it.