Why is healthcare a such mess? How can it be fixed?

Your Question:  The healthcare system is a mess.  How did it get this way? What is the solution?

My Answer:  Let me start by saying that in front of me right now is a bill from Paula Sterns Hospital in Ludington, Michigan, from March of 1943.  It is the bill for my grandma's entire three day stay when she had my dad.  The cost was $23.00.  The ambulance bill was $2.  If you adjust these bills for inflation, they come to $317.26 and $27.59.

The cost of just one breathing treatment today is $123.00, so you can easily see that something occurred in healthcare that inflated the cost of it by a stunningly high margin way over the rate of inflation.  What happened was that, during the 1960s, the progressives decided that the healthcare system was messed up and they could fix it. So they created regulations. So now hospitals have to hire people to make sure the regulations are met.  To pay these people the cost of healthcare increases.

In the 1970s they realized that the prices were too high for many people, so they had to come up with another solution. This time they created medicare and medicaid and DRGs and more regulations.  To make sure regulations are met, more people must be hired.  To cover the cost, prices go up.  But now people still can't pay, so third party system is created.  So now the hospital bill does not come directly from the hospital at all, but from insurance companies.  So not only do you have to pay the hospital bill, now you have to pay an insurance bill as well.

So this is the system until 2010.  Now you have healthcare prices that have skyrocketed beyond belief. You have 40 million people who have no insurance at all, some by choice and some not by choice.  You have the same people who messed up the system in the first place try to fix the problem, once again, with more government.  More regulations are created.  Hospitals now have to hire hundreds more personnel just to make sure regulations are met.  This is done at the expense of patient care, even though it is meant to improve patient care.  Instead of prices dropping, they skyrocket once again.

So who is going to solve the problem now.  Hopefully not the government.  The government got involved in healthcare during the 1960 and created the same problems they propose to fix.  And the more they try to fix it with their ideal solutions the more they make it worse.  They do not ever solve the problems they propose to fix, they only succeed at creating chaos.

The solution to all of this is simple: let capitalism work.  That's the only thing that has not been tried, at least since the 1960s.  When you go to the hospital to seek a service, you should get a bill from the hospital for that service.  The price would not include any middlemen, and therefore would be very inexpensive, like it was in 1943 when my grandma only paid $25 for an entire hospital stay.

Surely the price would be a little higher due to inflation and technology, but price of healthcare today is beyond reasonable.  Why? Because, back in the 1960s, government officials, sitting around a table in leather chairs drinking coffee, decided they could make it better.  Did they? Absolutely not.  These people need to get out of the healthcare industry, and let the people, the markets, the states, solve the healthcare crisis.

The real solution is capitalism. Here you would have individual hospitals compete for your services.  What one hospital did best to win you over, other hospitals would copy.  When one hospital creates a program that fails, other hospitals will not copy that program. That is what's needed. Competition is the best method of driving down prices.  If you charge too much, people can go somewhere else.  If you provide good service at a good price, then your hospital will be the one chosen.

I am not naive.  I understand there are outside forces involved in price increases.  There is better technology today, there is better education that costs more, etc.  But, still, the healthcare solutions since the 1960s have all come from Washington, and everyone of them has failed to solve the problem.  And so many people say, "Well, what else can we try?"  I propose to try capitalism, because it is the only solution that has yet to be tried -- at least not since 1943.

What do you think of Obamacare?

The Patient Protection and Affordable Care Act (PPACA), a.k.a. Obamacare, has forced upon hospitals a new program that will punish hospitals as far as reimbursement is concerned for any COPD patient who is readmitted within a two week period of being discharged. This does not include emergency room visits, only hospital admissions. 

This provision of the law was made with the idea of giving hospitals an incentive to pay special attention to their COPD patients to make sure they are educated about their disease, are on all the best medicines, and their are follow up appointments made to make sure the patient is taking his or her medicine. 

Other people disagree with that claim. They say that the provision was implicitly placed into the law to give CMS an excuse not to reimburse hospitals for said patient.  There is some credibility to their claim considering it does not matter what the patient is readmitted for: heart failure, COPD exacerbation, high blood pressure, low blood pressure, rickets, a hand nail, or anxiety.

These patients have a high rate of morbidity, and it's nearly impossible to know, even if the physician is being proactive, what ailment might plague that patient in a day or two.  Our hospital, and every other hospital I've ever worked for, has had a steady flow of COPD patients, many who are admitted often enough to become good friends with the hospital staff.  With this law, there are many hospitals that will go under. 

There is also a stipulation in Obamacare to make it easier for hospitals to merge, and many hospitals in the geographical region where I live have merged since Obamacare went into effect.  Some of my friends claim that these provisions, and the entire Obamacare law, was implicitly put into place with the intention of causing the health care system to fail.  When the health care system fails, people will come calling to the government to bail them out with universal health care. 

With most hospitals already joined into large conglomerates, taking away competition and the incentive to lower prices, the government will have fewer companies to combine.  When Obamacare fails, they say, so too will the health care system. 

I think it was worded best by a physician friend of mine:  "The government caused the mess with health care by becoming involved in it in the 1960s, before that time it was a pay for service system, and the cost of health care was low.  Since the 1960s, health care costs have increased, making it so most people cannot afford it.  So then career politicians, the same people who caused the problem, purported to fix it with even more government. This is a system set up for disaster." 

I personally, as my regular readers already know, am among the 54-58% of Americans opposed to Obamacare.  What do you think of it?  Be nice. 

Changes due to Obamacare will collapse healthcare system????

The following is a guest post by our friend Will Lessons. I asked him to write his opinion about a recent article in RTMagazine.com called, "Reducing Readmissions in the COPD Population," by Robert Messenger (I wonder if that's a pen name).

Okay folks, I have no choice but to write about the future of healthcare.  Yes, I will delve into politics here, although it's something I must write about on this blog, because some of the changes that are coming to healthcare, compliments of the Patient Protection and Affordable Care Act, -- Obamacare, Affordable Care Act, Healthcare law, or whatever you want to call it.

This was a serious topic at our recent RT Meeting.  My boss says the newest measure that took effect October 1, 2013 is COPD reimbursement.  CMS already set reimbursement criteria for CHF, MI and Pneumonia, and now it is setting such criteria for COPD.  The goal is to diminish the cost the government has to pay.

The new COPD criteria for reimbursement says that if a COPD patient is readmitted to the hospital (ER and observation visits don't count) for any reason -- even if it's a stubbed toe -- the government will not reimburse for that patient.  Plus if the hospital has a poor showing overall -- a high rate of COPD re admissions -- CMS will punish that hospital by 1% this year, 2% in 2014, and 3% in 2015.

The goal here is that we need to work harder to prevent these patients from getting readmitted.  We need to be proactive.  We need to spend more money so the government doesn't have to.  This is not market driven, and it is not common sense.  It's impossible.  This is according to my boss, and, he says, according to his boss too.

He said government basically sat down one day and decided to look at diseases that cost the government a lot of money, and decided to set goals that were impossible for hospitals to meat.  In this way, the government won't have to pay, my boss said.  The problem, he said, was that the government costs will go down, but hospital costs will skyrocket.

The new criteria are impossible to meat, and within the next few years our hospital will be forced to close its doors.  The only hospitals that will be able to stay open will be large hospitals, and therefore there will be universal healthcare.  "I think this is the goal of Obamacare," he said, "to collapse the healthcare system and so people cry to the government for help."

Think of it this way: COPD patients usually have co-morbidities.  A patient could be admitted today for COPD, next week for CHF, the week later for kidney failure, next month for diabetes, and later on for GI bleed, and then  for a blockage in the intestines.  You see, you simply cannot prevent these patients from being readmitted.  These are our bread and butter.

Yes, the government knows COPD is the fastest growing disease, and #4 on the list of most common ailments.  So they simply are creating criteria that cannot be met so they don't have to pay.  Our hospital has already hired 30 people -- lawyers, statisticians, QA analyzers, accountants, etc. -- just to make sure we will comply with Obamacare.  This is all wrong, because the focus is no longer on patient care, it's on: how can we make money?

Some COPD patients are noncomliant, and there's no way you can get them to take their medicine.  Some patients won't wear oxygen, some won't wear BiPAP, and some won't take some unproven cancer medicine.  and I can't say I don't empathize with these concerns.  I wouldn't want to wear BiPAP, for example.

My boss said, "And you can disagree with me, but people get readmitted not due to poor quality of care (most of the time), they get readmitted because they are very sick people.  The government is too stupid or too blind to see this. Either that, or they are bound and determined to create a system that is guaranteed to fail.  Do they have an agenda here?  You decide."

I personally think it's good to create programs to decrease admissions, although I also believe a better incentive should be in place other than cutting government costs.  People talk about not fair, it's not fair that the government gets to pay less if hospitals fail, and there is no benefit to the hospital if the government fails hospitals.  That, to me, is not fair.

I personally cannot say I disagree with my boss.  I think the intent of Obamacare was to collapse the healthcare system.  I think all those people who said the following were either lying to sell the law, or are ignorant altogether:

• Obamacare is not a tax (the Supreme Court said it is)
• People won't lose their own insurance (many people are)
• Healthcare costs won't go up for you (they are, and by a lot, up to 146% in California alone)
• Healthcare costs will not go up they will go down (hmmmm?)
• Obamacare will only cost????? Every government program eventually costs most than they say!

Note: this post was not written with the intent to political bash a certain party.  Both parties are equally responsible for the current position of healthcare.  This is our problem, although it's one created by our government.  Our government, the one we have elected, has failed us big time. That's why Congress has a popularity rating less than 5% (and this rating has been consistent regardless of who controls it).  

And all of this stuff I predicted on this blog, and many of you guys said I was nuts.  I even got hate mail from some of my readers.  Trust me, I don't want to write about this stuff.  I am forced to.  It definitely effects what we do on the job, and it shouldn't.  Doctors should be deciding how to treat patient, not politicians.  It makes me sick just thinking about it. 

Thanks for allowing me to write my opinion.  Will

Now it's your turn.  Be nice!!!! However, before commenting, please educate yourself by studying the law, and reading posts like this over at RTMagazine.com. I believe the best way to improve healthcare is through education and passion.

The opinions expressed in this post may or may not be the shared by the authors of this blog.  

Hospitals, Doctors Blackmailed by the Government

We have to face the facts, fellow RTs, that one of the main reason we are doing so many non--indicated procedures, and our morale diminished, is because the government is blackmailing hospitals and doctors.

You heard that right. Hospitals are being told by CMS they have a choice whether they want to do something, yet if they don't do it they will not make as much money. Hospitals and doctors, in essence, are being blackmailed.

A perfect example of this is the smoking cessation program. Chances are your hospital board has discussed the smoking cessation program. The choice is this: You do a smoking cessation on a patient you get reimbursed more for that patient, and if you don't do it you get reimbursed less

In my opinion this is not a choice. It's more of a nudge. If you don't do the smoking cessation on a patient, the hospital will get paid less. So the hospital is basically forced to do it. This is blackmail.

CMS actually says it's a choice to make it look good to us, because most of us Americans love to have choices. Yet a true choice would be one of many options, including the option to do nothing. You also have an option to be smart and an option to be stupid. You should not be punished if you decide to be stupid.

So instead of choosing to use common sense, many hospitals are doing smoking cessations on every patient just to cover their bases. This means that even if you don't smoke you will be educated.

Now this isn't so bad, as even people who say they quit smoking are still hanging around people who do smoke. These new ex-smokers are not aware second hand smoke is bad for them. Believe it or not, there still are uneducated people like that. So education on our part is good.

Yet we RTs don't necessarily have time to do smoking cessation on every patient. We barely have time to do the ones that are needed, yet we certainly don't have time to do them on every patient. We are overwhelmed already as it is due to all the order sets and lack of RT Driven protocols at most hospitals.

So you can see how the blackmailing of hospitals to do smoking cessation programs has unintended consequences. It results in burnout and apathy of workers. Yet Administrators don't care so much because in any business, the bottom line is that we get reimbursed, or that we make money.

Another good example is the so called "death panels" as passed by the Obamacare legislation. The death panels really aren't death panels, but they do create a script doctors must follow with each of their patients about discussing end of life care.

Now, a part of me likes this. I think all doctors should discuss with patients what they would want at the end of their life if they are unable to make decisions. If a person has terminal cancer, do you want CPR done on you, and do you want to be kept alive on a ventilator.

I think this is good. And I also it should be up to the doctor to discuss this with a patient. So this is what Obamacare does: it gives doctors a choice. The choice is this: You do end of life care and you get reimbursed for that patient visit. If you don't do end of life care, you still get reimbursed, but you make less money.

So what doctor in his right mind will not do end of life care, and use the government script. In this way, CMS is nudging the doctor to do what an expert sitting in an office in Washington believes is idea. It's blackmail.

Is this choice? Yes! Is it a good choice? No really. It's a nudge. It's forcing us to do it your way. It's blackmail.

A government script is an attempt to convince people that death is imminent and we shouldn't be spending money on you, then the death panel discussion is valid. Now end of life counseling is good, and it should be done on all patients, yet it should not be a mandate by the government.

Likewise, it allows doctors to decide if a 90 year old lady should get a hip replacement, or 100 year old lady a hearing aide. The patient and the family should be deciding if the cost is worth it, not Uncle Sam.

It will, in essence, become nothing more than a screening program to cut out the most expensive years of your grandma's life. It will save the government millions of dollars per year, if not billions. To the government, it's all about saving money. To hospitals, whether they agree with this blackmail or not, it's all about making as much money as they can. So they have no choice but to "COOPERATE!"

One concerned mother asked a famous person in Washington about whether Obamacar would pay for her 100 year old mother to get a hearing aide she wants so bad. The politician answered, "No, no, we gotta start talking quality of life, too, we can't calculate spirit and how much she wants to live. Give her a pill. People like that we should just give 'em a pill."

He later said, "I don't think we can make judgements based on people's spirits." If you are terminally ill, or if you have a bad heart, or if you have the beginnings of a disease like Altzeimers or Parkinsons, your doctor will, by law, have to encourage you to not seek any procedures that will prolong your life.

That means no expensive CPR or breathing machines. That means no expensive life saving medicine. That also means no hip replacements. No nursing homes. No hearing aides. No pacemaker.

Some people, even at 105, have a certain spirit, a certain joy of life, a certain love of live, a high quality of life and they want to do whatever they can to live another day. These people should be able to get the hip replacement, the hearing aide, the pacemaker or whatever.

Will a government in Washington be able to see this spirit, this joy, this quality of life. Or will that government official, that government expert, only see her as a 105 year old burden on society who will die anyway soon so let's not waste our time or money on her.

That government expert will see it as a government shut off at some age, perhaps 75, or 65, or if the cost of healthcare becomes too much of a burden, perhaps even 55 or how about 45? Where does it stop?

Will my mother have to go to the government to get a procedure done? What if it's a lifesaving procedure? By the time the government has an answer it may be too late anyway. This kind of thinking sends chills down my spine. This is America not Cuba.

Since the government's flipping the bill, This sounds Orson Wellish, 1984 type stuff. I never in a million years could have imagined we'd be having this discussion in America.

Now you might say, "well, it's not a mandate." But it is. When the government tells you you won't get paid if you don't do it, then doctors who accept Medicare will have no choice but to do it. Thus, it's mandatory. Either that, or it's blackmail.

Granted, this is not an opinion, it's fact.

What do you think?

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Less government equals less healthcare costs

Here's a perfect example of why healthcare costs so much. I went into the patient's room and she said the following:

I have no insurance. I have all the stuff to take a breathing tx at home. I know as soon as you start the treatment it's going to cost me $100, and I'm going to have to pay it. If you can talk to the doctor and have him write me a prescription for Albuterol solution, I can get it for $4 and I can give my self treatments for free at home."

You see, she is paying for her own medicine, and so she questioned what the doctor ordered. Because she was paying on her own, she didn't want to pay for it.

Now if she had health insurance, and if she had medicaid or medicare, and she never saw the bill, then she wouldn't care what the cost of that treatment was. She wouldn't have questioned the order.

This is a perfect example of why we need to have a healthcare system where there is an incentive to question the order. The truth is, at present, most of us don't. And that's why healthcare costs so much. It costs so much because people keep getting, and they don't pay. Since someone else is paying, they don't question the order.

Think about it. If you give something away for free, everyone is going to come running to buy it. So while supply of hospitals, doctors and medical equipment stays the same, demand for it goes up because it's free. Per basic economics 101, the price has no choice but to go up.

The best way to get the price of medicine to go down is to force people to pay for it themselves. Back in the 1960s this is how it was, and medicine was affordable. Ever since the advent of Medicare and Medicaid and HMOs and third party payers, healthcare has skyrocketed.

It's not a coincidence. The way to get healthcare costs down is to get the government out of it. The way to get healthcare costs down is to get Jane and John Doe to question the therepy they are being provided.

That way, what isn't needed won't be given. What's needed they will pay for. And yet the healthcare reform bill passed 6 months ago does exactly the opposite of that. It places more patient's on the government dole, which means more free (but it's not free) medicine for more people.

Look, there are some people who really, truly cannot work and really, and truly could use a helping hand. I'm all for them getting help. Yet that system of helping out the needy, or our retired parents, has gotten out of hand or out of control.

It's time we had more patients like I had today. The patient who says, "Hey, before you open that and charge me $100 bucks..."

Crossfire appreciated, yet no flames aloud.

Two well respected doctors discuss health care

After the code in the critical care unit I was standing behind the nurses station listening to the anesthesiologist and the Internist discuss how much they hate President Obama. I did not participate other than to say:

"You better not say that in front of Susan." Susan, of course, is the CCU RN who was in charge of the patient we just coded.

The Anesthesiologist said, "I think he is wrecking the country."

The Internist said, "I voted for him, and I think he is doing a terrible job. He's not doing what he said he would do when elected. He is trying to solve all the world's problems."

"I'd have to agree."

"And now he wants to screw up the health care system. You would agree that we do have the best health care system in the world do you not."

"I do."

"The only problem is not the health care system, but the cost. The government has made some stupid laws in the past that make it too easy to sue doctors. Because of this, we doctors have to order procedures that often are not indicated."

I was shocked they were saying this in front of me. I stood as still as a deer hiding in the woods during rifle season hoping they wouldn't figure I was standing right behind them.

"I mean," the Internist said, "He's trying to solve all the world's problems, to rush all these bills through Congress, when it's not even possible that he nor any one else has even read the bills. This is what you call anarchy. I say this and I voted for him."

The anesthesiologist said, "I don't see why you are surprised, because he's doing exactly what he said. But I completely agree with you he is rushing too much too fast."

Susan arrived at the station, and the discussion stopped on a dime.

A Canadian's opinion on Federalized Medicine

It is estimated that 40 million people in the U.S. do not have healthcare insurance. Therefore some politicians have proposed we go to a nationalized healthcare system, where the government makes healthcare available for free to everyone.

I've done a ton of research on this, and have decided this type of system sounds great on the surface, until you consider somebody has to pay for it. Well, we all know that will be you and me via more taxes. So, in essence, it will not be free (more on this tomorrow).

“But the fact that taxes will go up is the least of your worries,” wrote a friend of mine who lives in Canada.

She explained it this way to me: Lets say such a program passes through the legislature and is signed into law by the president. Within a week, since healthcare is now free, people start to rush into hospitals to get that knee replacement they couldn’t afford a week ago. Or, maybe it’s to finally see a doctor about that ailing back, bum shoulder or mole on your ear that you’ve been living with fine the past 10 years.

These surgeons will become inundated with new patients, and will be reaping in the profits. Right out of high school young kids will be filing in droves to attend medical school so they can participate in this profitable business. New surgical doctor’s offices will spring up all over the United States, and they will all be filled with new patients -- it’s all free, the government pays.

Dishonest and honest surgeons are having a field day while they are all making tons more money than they ever would have dreamed of making under the old system, but the government starts to get all stressed out. “How are we going to pay for this? We are running out of money.”

New government offices spring up filled with bureaucrats and red tape, and they start to require permits as to who is going to be allowed to perform surgery in an attempt to cut down on the number of surgeons, and as to what types of equipment surgeons will be allowed to buy.

Then there will be new laws limiting the types of surgeries surgeons will be allowed to perform, and potential patients will have to file for permits to get operated on. Officials will be asking, “Is this mole really bothering you? You’ve been getting along fine with that heart your whole life, why do we need to replace it now?”

There is so much red tape now that long lines develop. People that just want to be routinely checked will have to wait in line with the person with a clogged artery in his heart. Of course, this heart patient won’t be able to escape his country to go see an American doctor, because that’s the medical system that is now broken.