A Pre-existing Dilemma

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Tom is a forty-three year-old self-employed painter and father of two.

He’s currently in remission from lung cancer, having been first diagnosed five years ago. At the time of his diagnosis, he did not have health insurance.  Thankfully, for him, American law had finally made it illegal for health insurance companies to discriminate against individuals with preexisting conditions.

This means Tom had to be offered insurance at community rates. And, this was a good thing for him. His medical expenses exceeded $100,000 annually for his first two years of treatment. No one deserves to go without care for a serious medical condition.

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Jenny is a married mother of two.

She in employed by a local small business where she has worked for the last 12 years. Her daughter has an uncommon but treatable blood disorder that requires occasional laboratory testing and infrequent blood transfusions.

Jenny’s employer has provided for the health insurance of both Jenny and her daughter for the last decade. It has been a part of Jenny’s benefits plan.

Unfortunately for Jenny, over the last few years, the cost to her employer to provide this plan has risen dramatically. The small business she works for has had no choice but to pass down many of these rising costs to her.

Jenny now pays her employer a markedly higher monthly premium for her family to be included on her plan. Her medical deductible is 10 times what it was just six years ago. And, her coverage is far worse.

Forced to cut costs even further last year, her employer only offered insurance options with more narrow networks of physicians. Jenny is currently driving 90 minutes for her daughter to receive the specialist care she requires. Five years ago, she drove four miles down the street.

Thankfully, Jenny has still found a way to make ends meet despite these obstacles. But, next year is looking to be even worse regarding the cost and quality of her insurance.

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Healthcare is once again a major focus of political conversation, so it’s important we understand a few things.

Our President-elect has said he will work to repeal “Obamacare,” but at this point, the details are not clear. Will his replacement product be better than what it’s replacing?

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Freedom’s Last Stand

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We’ve been trading freedom for security.

One day at a time.

The former previously defined us—the “Land of the Free”—but apparently that’s less so, now.

They tell us we’ve dwindled down to being the 15th most free nation in the world.  Fourteen other countries provide their citizens more personal freedom.

There was a day when someone said if we lost freedom here, there would be no place to escape to. That we were the last stand on earth. But, our actions seem to suggest we find freedom to be over-rated.

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Two things that are frequently misconstrued about healthcare came to my attention after reading a recent article by a writer I respect.

I don’t agree with this author on everything. Far from it. But, she comes across as someone you can discuss legitimate issues with—regardless of your point-of-view.

She’s a self-proclaimed Liberal, who apparently voted for Trump. (Seems she wasn’t the only one.) In her article, she provided healthcare advice to our next President.

My intent is not to refute it. Much of it, in fact, I agree with. But, I want to elaborate on two things that came to me after reading a quote in this article. I will examine the concept of (1) shopping for healthcare, and (2) how it relates to your life.

Here’s the quote:

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Business As Usual

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It’s business as usual at the office.

Another Fall season is here.

It’s time, once again, to sort through all the madness.

I wish it were “Midnight Madness.” Because, I like college basketball. That’s the name we give to the first formal practice of the season. The one where you get a glimpse of your local team’s talent.

Unfortunately, that’s not what I’m talking about at all. But, there are some similarities.

For example, the madness (I speak of) spans numerous midnights and deals with a practice—albeit a physician operated one.

My office is currently back at it again trying to figure out how we can continue to see Medicare patients. One day soon, we might just give up. But, if you are one of my Medicare patients, don’t call me in panic. Call your congress member instead. Click here if you don’t know who that is.

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What the *Beep*?

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“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.

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Evidence Based Medicine & The Art of Flipping Coins

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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:

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How Arbitrary Feels

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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.

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Documentation Gone Awry

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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?”

Tell you?

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.

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Open Letter Response to CMS on MACRA & MIPS

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My recent post appeared to catch the attention of Mr. Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS):

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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:

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Enterprise Gone Overboard

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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.

DONOTREPLY.

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.

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