dimanche, mai 14, 2006

my response to "How to Stop Medicaid Fraud" by Steve Malanga


Steve Malanga misses an important, though perhaps complex, point in his consideration of Medicaid fraud. (See the City Journal article linked above.) The first part of this missing piece of your assessment is that the cost of the medical services and providers that overbill Medicaid are themselves expensive to educate and maintain. The second part is that Medicaid itself pays very little for services rendered, causing all sorts of ethical dilemmas within our system. The third point is that Medicaid doesn't create an atmosphere for healthy Americans by encouraging preventative medicine, but a band-aid for sick Americans. Health care reform, if our country is ever wise-enough to implement it, would entail changing the way we practice medicine, so it covers an integrative approach rather than our current attempts at healing a patient's current complaint or assuaging symptoms. If we could ever do this -and it would require the compliance of medical schools, hospitals, insurance companies, pharaceuticals, etc., which bodes badly for this ever happening- we would do more for the American public and probably lower the incidence of these kinds of infractions.

Maintenance of Healthcare Infrastructure

Any ambulette service or hospital has operating costs and a desire to make a profit. Maintaining the equipment, facilities, and staffing in order to keep the hospitals working well is not easy, no doubt, but hospital administrations are working to pay their administrative staff the huge salaries required to keep people employed in the field. When we talk about staffing, we're not just looking at the dentists, MD's, nurses, and double billing from hospitals, we're also considerinng the security staff, the lab technicians, the check-in staff,the administrators who oversee all areas of the hospital. Your wording "even hospitals" implies that you are astounded the hospitals double bill and overbill. Such an implication if it is indeed correctly interpreted on my end would indicate you have not used hospital services in quite some time. Hospitals are notorious for overbilling and doublebilling all patients --not just Medicaid.

If you would go out of your office and interview people, ask anyone who has had to go to an ER or had to have treatment of some sort in a hospital what horror stories they might personally know of. You'd be astonished. A young woman I know had a biking accident. ER physicians sent her home with a leg brace that was unnecessary in addition to crutches and a vial of prescription pain medications. An assessment by another physician revealed that she should never have been put in a leg brace and that a costly MRI should have been done instead. Another young woman I know was taken to the ER complaining of fatigue. She was admitted by the hospital erroneously as a potentially suicidal psychiatric patient. The doctor for the case afraid that she might be sued in case the girl really might be suicidal insisted that the girl be held in the hospital for observation though the patient insisted she was fine and wanted to be discharged. The doctor insisted also on putting the girl on anti-depressant drugs. After a week of normal behavior, the girl was discharged. The girl immediately stopped taking the antidepressants. She filed a complaint at the hospital, which waived her portion of the charges, but kept their payment from the insurance company for her drugs, treatment, and weeklong hospital stay. How you can think hospitals are an afterthought in the medicaid fraud is amazing to me.

Nonetheless, I would argue in their favor that hospitals are terrible to maintain. In order to pay all the necessary personnel, administrators who manage healthcare protocol, public relations staff who win over the "marketshare" of patients to choose their hospital over another one, lawyers to manage malpractice issues, security and valets to win over public trust and keep order, etc. and still make money, each hospital has to not just pay for their facility costs -electricity, water, sewage, taxes to the town/city/village/borough for the property, couches in the lobby, possibly a water fountain, etc.- , their actual medical practioner staff, technical lab staff, but also cover the tremendous cost of auxiliary staff -janitors, medical records, secretaries, computer maintenance personnel, plumbers, etc. ad nauseum. Add on the fact that diagnostic technology is expensive to purchase, upgrade, maintain, and dispose of. Medicaid doesn't pay even a fraction of a patient's fair portion of this grand production. Forget how much goes into assessing similar costs for ambulette service -mechanics, garage, etc. These services aren't in use all of the time either, but a hospital still has to pay the personnel to be on hand for a certain amount of time in case the service is needed at least between certain business hours. Some staff like lab technicians or some kinds of nursing assistants aren't even needed for the full time they are on duty. So, of course, they overbill. Is there any wonder then that hospitals work hard at defrauding Medicaid?

Cost of medical education -time, tuition vs. payoff -vacation time, salary

There are also staffers who take advantage of the system. You have a tremendous disparity among medical practioner staff. There are those nurse practioners, interns, residents, and young doctors, who work inhumanely long hours and can hardly be expected to really provide excellent care given the stress and terrible shifts they are forced to work. We hardly take note of how those people are the slave labor of hospitals nor do we give any thought to how anyone can possibly learn how to be a good doctor under such conditions. We're teaching the young medical practioners of tomorrow that they will be pushed to their breaking point every day for several years at a low salary. Any human under those conditions can develop a sense of entitlement and a lower sense of ethics. What restitution do they demand? They want to be paid well later on. They want to pay off their medical school debt of $200,000-$275,000? Of course. It doesn't take rocket science to understand this. Pursuing what is wrong with our healthcare system today requires a serious look at medical education and a serious intent to reform that system. Contrast that for example, with the life of a PA, a physician's assistant. A PA can routinely take off vacations and choose how many hours he works. His quality of life is better than the physicians and nurses with whom he works. Often if he wants he can work at two places in a hospital to make the bigger bucks for 10-20 hours a week and then at a clinic where he can really help people (without the bureaucracy) for say another 10-20 hours a week. He takes home a paycheck that is anywhere between $40,000-90,000, depending on where he works, what hours he chooses, and what his specialty is. PA's spend a great deal less money and time in their education, but can often make a similar amount of money as a doctor if not more in the first 15 years of their career after training is completed. It is the hospitals that pay the bulk of a PA's annual salary. If you were a doctor wouldn't you be jealous? You go to school for two more years than this guy, endure a training of 4-12 years more than this guy, indenture yourself and go into debt for anywhere between 200K to 300K -- and he gets easier hours and a comparable salary?! Forgetting the unpleasant issue of a doctor who overbills to make up for his education costs, the bottomline is that medicine is a business and every doctor's practice has an operating cost with similar problems to those mentioned above in the case of hospitals.

Reduction in Payments by Medicaid for Healthcare

I read recently that Medicaid may again slash how much the government will pay per service. Practically speaking, this does not solve the issue of how much we pay per Medicaid patient, nor does it help the purpose of Medicaid -which was to give healthcare to those who could not afford it. As it is, most providers are not willing to take Medicaid patients unless they *can* get more money out of the system to cover their bottom-line. I have heard from off the record sources that many doctors, nurses, hospital staff are told by administrators that they have to limit the number of medicaid patients they see (say the doctor cannot take any more new patients or make it impossible to schedule the appointment) or else try to bill more so they can recoup the losses of having a Medicaid patient. It just doesn't balance out on the books. Healing people is a profession that is difficult to do when the bottomline is always going to be making a profit. In order to keep from going into more debt (when one begins to practice medicine add malpractice insurance onto your medical school bills!), taking fewer Medicaid patients or else taking the patient and overbilling Medicaid in order to cover your costs is the only way to go.

One Ethical Dilemma: who are we making into doctors? and why?

I have even heard one young doctor agonizing over how he's going to justify to his group/partners his having accepted another Medicaid patient, because he "just couldn't turn the guy away." I think we all would prefer this kind of a compassionate person to be a doctor over the sort of person who is business-oriented. Our medical schools are geared towards the sturdier, more business-like, less sensitive, and less compassionate students. Those are the ones who come out successful, because they can stomach the long grueling shifts. They're the ones who focus on the salary and benefits prize at the end and who perfect the system for the "5 minutes with the doctor" appointments, complete with sparsely written charts full of incorrect information. One young man I know who is now a young doctor told me that if he had known he was going to speak with and see patients only 15% of the time and spend 75% of his time doing paperwork for charts, billing, and insurance, he's not sure he'd have gone into medicine. Though many of the more sensitive and compassionate people who go into medicine are horrified and unhappy about such practices, it's the more businesslike and aggressive people who make it and who force the hand in the long run. These people find a way to work the gauntlet of hospital pressures, group pressures, and insurance pressures for number of patients seen, amount billed, number of drugs prescribed, and number of procedures done. Older doctors train younger ones. The young ones who are more efficient and see more patients, bring in more money are rewarded. Most training goes on in hospitals -who have too m any business professionals screaming about profit and sales. We are creating more and more of those kinds of doctors, because of how much the education costs, the way our medical education is set up, and because of the way that the medical profession is practiced today. A profession that ought to be about compassion at its core, has the least compassion for their own practitioners, and as a result has the least compassion for all people, including Medicaid patients and the taxpayer that pays for them.

At the end of the day, if you want to stop Medicaid fraud, you have to ask why these people are doing it. We've chosen some very clever people to be our nation's medical school students, I'm sure they'll find a way to fool the system even with a team of analysts in every state. Solving the problems that push them to defraud the Medicaid system may lead you a lot farther in the long run than hiring a bunch of analysts to go checking every medicaid claim... though that's a start for helping us to pay for the reform that surely must follow.