Regulatory Capture

db makes some good points about the problems in medicine today

My responses:

I would like to find anyone with half a brain in Washington and be able to strip all of this away.

1. Meaningful use – this is just silly now that most people are using EHR. I have been 100% electronic for 7 years but still do not meet “meaningful use” requirements without jumping through hoops. The government spent 40 years developing VISTA/CPRS – they should just say we all have to use that and give it to us. (it is already available in some form for free due to FOI requests)

2. Approval forms – I think I should be paid for everything I fill out. Lawyers bill for all paperwork. We should as well.

3. Prior authorization – You do of course recognize that ‘prior authorization’ is purely devised to save the insurance companies money, right? It is an entirely meaningless hoop to jump through, because the studies prove that adding hoops/regulations means that you get less of that activity. They know that a good percentage of studies will just not be done because it is too much of a hassle.

4. Billing requirements (E&M coding) was put into place to try to compensate appropriately due to complexity but it is a joke. Templates have made the notes meaningless. The only way to do away with this is to have some TRUST in the doctors. How about the old Reagan doctrine of TRUST but VERIFY. Doctors can write whatever they want in their notes to make a meaningful contribution to the care of the patient and to communicate to other doctors, like the old days. Doctors then bill at whatever level they deem fit for their services. Random audits of say 10% of the notes would be performed, and people abusing the system would be drummed out.

5. Performance measures are meaningless. Let good doctors charge more for their services. People will pay if they like their doctor. If you are a crappy doctor, people won’t pay.

6. Admission diagnosis is the dumbest thing that some hospital bean counter ever thought of. I usually admit people to the hospital because I have no idea what their diagnosis is, and I need to do some tests to figure it out.

The bottom line is that doctors have allowed business people to take over medicine. The business people were the C students when we were busting our asses and making As. Why do we let these losers come in and take over the whole show?

We have had pitiful leadership in medicine. People are too busy taking care of patients, or to scared to stick their neck out. Our “leadership” of non-practicing physicians has gotten into bed with the politicians and have gotten fat and happy sucking the teat of the government. The entire system is hopelessly corrupt. The AMA makes its money from the coding system. The ABMS/ABIM make their money making doctors jump through hoops filling out satisfaction surveys and taking tests. And now all of this is being codified by nameless and faceless bureaucrats in Washington under the aegis of MACRA.

The “SGR fix” was a scam and has taken more power away from the doctors.

The doctors have to take back the system if we are to have any hope for American medicine.

We will have to strike or revolt or something – if anyone has ideas of where to start, let me know.

ABMS is Evil Incarnate

The Maintenance of Certification (MOC) program is a money-making scheme concocted by a group of non-practicing physicians who are paying themselves high salaries and living large on the backs of working doctors. This is a corrupt system, and ethically wrong, despite the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) putting out press releases about the “benefits” of MOC, and the importance of having “quality” physicians.

Unfortunately, this program has now been codified into law as part of the sustainable growth rate “SGR Fix” legislation. This is crony capitalism at its worst. There are major conflicts of interest here, and the ABMS and ABIM are colluding to extort money from practicing physicians to finance their high salaries.

And exactly what are these high salaries for? These doctors do not see patients. They sit in meetings and make themselves feel important by telling other physicians what they are doing wrong.

Most working physicians are too busy to have noticed what has been happening behind their backs, but when they do see the full consequences of the current legislation there will be an uprising. We will have to wait and see the fallout of the alternative National Board of Physicians and Surgeons (NBPAS) and the ongoing Association of American Physicians and Surgeons (AAPS) lawsuit, but I hope that enough physicians wake up to what is happening before it is too late.

The ABIM has failed us, the American Medical Association (AMA) has failed us, and even the American College of Cardiology (ACC) has failed us. Richard Chazal had the gall to tell the Alabama ACC that we should be working with the ABIM/ABMS because trying to get out of their corrupt MOC schemes is “complicated”. He says that the ACC reviewed the ABIM books and they were “clean”. He also defended the ACC support for MACRA, because he said that “we needed to end SGR”. Yes, and we got a poison pill in MACRA to do it. He was too blind to see the truth. MACRA puts in place APMs – the rules have not been written yet, but essentially, the hospital/ACO will get paid, take whatever they want, and give the doctor whatever crumbs are left. If you don’t join an APM you have to demonstrate “quality” – and who gets to define that, under MACRA? the National “Quality” Foundation led by Christine Cassell, who just golden parachuted out of the lead spot at the ABIM. It is time for physicians to reclaim the doctor-patient relationship – including the documentation and payment – from all of the bureaucrats and bean counters out there, be they MDs or not.

Doomsday

Time to stop whistling past the graveyard and face the reality that the United States will not be able to meet its credit obligations to its citizens much longer. Politicians continue to spin the truth as most Americans stick their heads in the sand and ignore what is really happening. Fast approaching is the day of insolvency, when the country defaults and the checks stop going out.

Look at the history of man and you will see that periods of stability and prosperity are few and far between. We have been fortunate to have lived in a bubble of relative harmony, but we are deluding ourselves if we believe that our current government will be able to sustain itself ad infinitum. This experiment called the United States of America is nearing an end. Our beginnings were inspired by the noblest ideals of the French revolution – liberté, égalité, fraternité – and we have spent the last two and a half centuries smashing those ideals into bits. As we stand on the shards of our values we must begin to look ahead and ask ourselves what comes next.

We are not likely to have an all-out anarchic civil war, but clues to what will happen here may be found in the remnants of the old Soviet Union, or more recently in Ukraine. It may start as a ripple but it will soon become a tidal wave. The markets will crash. People will be in shock. There will be outbreaks of protests, looting, and mayhem. I don’t think most Americans have even considered the thought of our government crumbling. But everything that is unsustainable must come to an end.

People do not realize that we are hitting the limit fast. We have seen the default of cities and counties. Several states are now at the point of default – California, Illinois. No one is willing to face the truth, so we will continue to lie to ourselves. The only choice is whether the government will delay the checks or just print money, and you can make an argument that printing money is exactly what has been going on with the ‘quantitative easing’ of recent years.

We continue to smile, laugh, and congratulate ourselves for the ‘progress’ we have made as a society, but the system is on tenterhooks. What will it look like when it comes? Hyperinflation? A crash? The trouble with finance is that it is a house of cards and any little thing could bring it down. A bad trade in Malaysia, a judicial decision, a corporate merger. If you went to the ATM tomorrow and it would not give you money, what would you do?

People say I am a doomsayer, that I think all is lost. Nonsense. We will still have sunrise and sunset. You, your families, your neighbors will go on living just as you do today. Hopefully most people will continue doing what they usually do in a sort of societal momentum, but they will find that the paycheck does not come. And so they won’t pay – bills, mortgage, utilities. And then some people decide not to go to work any more because they are not getting paid. The utilities go out. The system shudders to a stop. People will give anything for a gallon of gas. There will be heroes and martyrs. Winners and losers.

We may end up depending on corporations. If the state is gone, who do we turn to trust that the water is drinkable and food is safe?

In the aftermath we have to consider: what next? Do we accept the status quo? Will we accept a strongman who takes control of the military and leads us in the fashion of Putin? We throw around the ideals of ‘democracy’, but when it really matters, most people are not comfortable with ‘majority rules’.

The US is an airplane out of fuel, out of power. My dearest hope is that we can land it gently and walk away, rather than crash and burn.

PC police can go away

SCOAS does not do PC. We do not strive to be gender-neutral or gender-sensitive. In fact, we think that gender is rather important, and men and women are fundamentally different. When in comes to writing, however, using ‘man’ and ‘he’ and other such words is just a convenience.

You may assume ‘man and/or woman’ when the term ‘man’ is used, as it has been used through thousands of years of literature. Don’t throw your mamby-pamby “paternalism” and “heteronormative” crap out around here. If your mind is too small to understand the standard use of language, or your ears are too delicate to hear harsh words, then go home to momma and cry yourself silly.