Surviving the Medical Meltdown (3 page)

• Physicians are becoming shift workers, working for hospitals and clinics, and in the process are contributing fewer man-hours to patient care and are worsening the maldistribution of physicians.

• Insurance companies, facing a business death spiral, are consolidating into bigger and bigger entities that insure fewer and fewer people for higher and higher prices.

No one can predict the day things will really go bad. It is possible that the decline will be quite gradual, with slow implementation of a Canadian-style universal health care system. In Canada, at first nothing much was different, until doctors and hospitals began responding to the perverse incentives in the system. Today it may take a Canadian six to nine months to get a CT scan, and two to three years to find a primary care physician. But since the decline has been very gradual, a younger generation has grown up expecting nothing more.

Some degree of gradual decline is happening now, and it will continue. But I believe that a catastrophic collapse will at some point befall us. This may occur in conjunction with a monetary collapse similar to the recent hyperinflation in Argentina. In this scenario farmers could still grow food and doctors could still practice medicine, but because the fiat currency has become essentially worthless, there is no easy way of exchanging goods and services. In modern history, during this kind of monetary collapse – witness Germany, Zimbabwe, Russia, and Argentina – the average time for real chaos was three to six months. But after a period of time, with barter and with issuing of a new currency, goods and services once again begin to flow. A worse and longer-lasting scenario is a “doctor death spiral.”

Catastrophic collapse due to a “doctor death spiral” will occur when we drop below a critical number of practicing physicians. As our population ages, it requires more physician man-hours of medical care. But as our population ages, so too do our physicians. More than half of the surgeons who cover emergency rooms are over
fifty. And although they are some of the most productive physicians, they are being overloaded and overstressed, and are beginning to burn out. Many are retiring early; others are dramatically reducing their patient loads. Recent surveys suggest up to 60 percent of physicians are preparing to do one or the other within two years.
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And the worsening conditions have lead to an increase in physician suicide. At present, we physicians have the highest suicide rate of any profession. “We lose over four hundred doctors a year” – the equivalent of an entire medical school each year.
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In areas where fewer and fewer physicians remain, it is very difficult to recruit new physicians to the job – since the new docs do not want to be forced to cover impossible patient loads. Around the country, there are already these medical “black holes” – areas without coverage for certain specialties. These areas are enlarging and are likely to become much larger in the next five years.

The one certainty? Things will be getting much worse because the current system is unsustainable – either in manpower or in dollars and cents. And in any of these scenarios, you will need to be medically prepared. That’s why I wrote this book. If you want to prepare yourself and your family to deal with – or better, prevent – a multitude of health care issues, keep reading. Forget what you have been told about preventive care. “Preventive care” government-style is
not
preventive care.

The information you will read in the pages ahead will help you negotiate the crazy medical world of today. We will talk about insurance purchasing, getting the most from your doctor’s visit, avoiding damaging foods and toxins, and more. But ultimately, you need to be prepared for a future where immediate access to the modern medical care of today is simply not available.

2
THE COMING DOCTOR SHORTAGE

I
practiced in Yuma, Arizona, for more than fifteen years. When I first started in 1995, Yuma had become the third-fastest-growing community in America. The hospital was expanding to meet the demand and was recruiting doctors to the community in nearly all specialties. In 1995, these doctors were all self-employed individually or in groups, but all were in “private practice.” I was recruited to practice alongside two other orthopaedic surgeons, one of whom was near retirement age.
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It was hard work and long hours, because we were covering nearly twice the population of the average orthopaedist. But we were able to recruit other young surgeons, and for a few years things got better. In spite of retirements and surgeons dropping off the ER call schedule as they got older, we had decent – if still too busy – practices, and some time off.

But things changed. ER call became worse, with more high-level trauma from extreme sports, and gunshot wounds became more common. Concurrently, the Center for Medicare Services dropped physician reimbursement over 30 percent and tacked on pages and pages of regulations, vastly increasing the paperwork required to get paid. The mobile elderly retirees who wanted to get out of the cold winters came south as “snowbirds” until 75 percent of my practice
was Medicare. And the government, in the form of Tricare (military) and Medicaid, filled most of the remaining percentage, until 90-plus percent of my practice and that of my colleagues was government funded. Less than 10 percent of patients had private insurance.

Here’s what that meant financially: whereas private insurance might pay the surgeon $4,500 for a spinal surgery (my specialty), Medicare paid less than $1,200. Now, that may seem like a lot of money, but consider that this fee covers ninety days of care in addition to the surgery, and every year I paid $60,000 in malpractice insurance mandated by the hospital and insurance companies. Additionally, the government took approximately 50 percent in taxes. In other words, I had to do forty to fifty spinal operations
just to pay my malpractice insurance
and still would not have paid myself, my staff, my electric bill, my rent, my taxes, and every other aspect of overhead in running a small business.

As government reimbursement dropped and more and more patients were covered by some form of government “insurance,” smart doctors moved to cities filled with private-pay patients. It became impossible to recruit new, young orthopaedic surgeons to our area. After all, why work in a town with 75 percent Medicare payment when you could do the same work for over twice the reimbursement elsewhere? Why ruin your health and personal life spending all night in the operating room, taking care of high-level trauma – often with no pay? As the town continued to boom, the need for trauma surgeons and general orthopaedic care increased at a time when we were losing surgeons. In general medicine and other areas, hospital on-call nights were so brutal – keeping doctors up all night in spite of working all the next day – that all the doctors who could function outside the hospital chose to leave the hospital staff for purely outpatient practices. Those who could afford to retire did so. And in orthopaedics, we were left with four surgeons doing the work that was being done elsewhere by ten or more. The hospital demanded 24/7 coverage, regardless of the burden on the physicians, and did not appreciate the impending collapse of the department, in spite of warnings we issued.

At that point, I was fifty-five and could no longer handle eighty-to-one-hundred-hour weeks. I could no longer stay up all night taking care of dune buggy open fractures and then do high-level spinal surgery all the next day. I resigned, which left only three remaining surgeons. Within six months, a fifty-three-year-old overworked former colleague died, then leaving two surgeons, one over fifty-five.

The hospital finally stepped in and hired a hospital-based orthopaedic traumatologist, at great expense. It also contracted with a group from Phoenix to cover night call. But who knows how long this type of arrangement will be possible, as even big cities are feeling the pinch of too few and aging surgeons.

This is my very personal example of a “business death spiral” applied to medicine. At some point, with too few doctors and too much work, the prospects for recruitment of physicians to resolve the problem became slim. You would think that doctors – eager to make a living – would gravitate to where there
was
a lot of work. After all, in the past it was desirable to grow your practice. But the point is not to be busy but to be profitable. In the old days, the busier you were, the more you worked, the more money you made – like any other
real job
. But not so today, where the government tells you what you will be paid regardless of the cost of your overhead. Between 1996 and 2003, doctors who saw increasing numbers of patients would nevertheless see a decline in income. Medicare and Medicaid paid less and less, and the cost of doing business became more and more expensive as the government added thousands of pages of regulation. Today there are more than 150,000 pages of Medicare regulation, and these regulations, although not written by an elected official (a highly unconstitutional situation), carry the force of law. So, in addition to getting paid less and less, doctors have the increasing likelihood of being prosecuted under Medicare fraud and abuse statutes.

To understand how horrible this threat is, first you must understand the insane world of Medicare coding. In the old days when my father saw a patient in his clinic, he charged cash, and for the most part the patient paid him on the spot. (In 1970 he charged three
dollars for an office visit, and six dollars for a house call.) He wrote a single-line office note on a large index card, and thirty years of his practice records fit in three drawers of a standard-sized filing cabinet. Today when I see a patient, I must consult a two-inch-thick CPT book and choose a code that describes my care. In the office I must choose the “level” of coding that is determined by a host of mostly subjective factors – how long I saw the patient, how “complex” the patient’s problem was, whether I took his or her blood pressure, etc. Then I must dictate an extensive note detailing all these “bullet points” and submit it to Medicare in order to get paid for the care.

Now, there is no way to win at this. I may think a knee pain evaluation is easy because I am an orthopaedic surgeon, while my friend the family practice physician may think such a workup complicated. But we use the same rules for coding, so on the same scale of coding, he will choose a higher level than I do. Who is correct? Well, you cannot be correct. If I do a new procedure for which no code exists, I am instructed to choose the closest code. But a Medicare bureaucrat may decide I did not choose the appropriate “closest” code. And nothing is an error – it is always fraud. So, physicians are like rats in a maze where, no matter which way they turn, they get shocked. The Medicare reviewer three thousand miles away, who has never seen the patient and who has no medical training, decides you have mistakenly coded the procedure or “up-coded” (meaning chosen a higher level and more expensive code) the clinic visit, and Medicare denies your payment. Or worse, they see a “pattern” of up-coding and come after you with gun-toting federal agents to get big sums of money from you (the now-deemed “criminal” doctor) for overpayment and fines.

You may have heard that Medicare is broke. Well, one day, some Medicare guru looked around and found out where all the money went. Oh my! It went to doctors and hospitals. That presented a simple solution. When the famous bank robber Willy Sutton was asked, “Willy, why do you rob banks?” He answered, “Simple: that’s where the money is!” Likewise, Medicare bureaucrats decided the simplest path to financial wellness was to go shake down doctors and
hospitals. Since every doctor can be found to have committed coding/billing errors, it is really just a matter of looking for easy assets and then bullying the physician into coughing up the dough. To do this, the government has turned to hired henchmen of the RAC (pronounced “rack”) program.
RAC
stands for “recovery audit contractor,” and the program makes me think of the Spanish Inquisition, or at least the Monty Python version of the Spanish Inquisition. The Pythons shout in their iconic skit, as they burst into an old lady’s apartment unexpected, “No one expects the Spanish Inquisition!” And no physician expects his office to be raided and his staff and patients terrorized.

The RAC program is a civilian business, organized state by state, hired by the government for a percentage of the take. RACs aren’t paid a dime by the government, but they receive 12 percent of all funds they collect from a medical provider. And they use the muscle of the government as the enforcer. If a staff member turns in a physician, that member can be rewarded with 10 percent of the reclaimed money. No doubt there is the occasional corrupt physician, but this is such a Robin Hood scheme rewarding the RAC and the “whistle-blowers” that considerable opportunity for corruption is apparent. (Keep this in mind when your longtime, seemingly honest physician is reported in your local newspaper as having committed Medicare fraud!)

Here’s how it works. First, RACs find a physician with assets who may fall outside the bell curve on his choice of codes. The RAC reviewers make a case for up-coding, and call out the federal dogs. Federal agents then show up unannounced at the doctor’s office (they don’t need a warrant because, in the Orwellian world of government, even though you can be imprisoned as a result of the raid, technically, it isn’t a “criminal” proceeding, just Medicare “compliance”). They may have guns drawn
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, may confiscate all your patient records (those that are not Medicare are taken so they can check for discrimination against Medicare patients), take your computers, and haul the doctor off in handcuffs.
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Then the extortion begins. The government plops down overwhelmingly large charges and tells the shaken physician that he or
she owes enormous sums of money. Then they offer a deal. If the doctor will sign a privacy statement promising not to disclose what happened, the government will reduce the fines to a manageable sum. Of course, the government will publish in the news that the doctor has been found guilty of Medicare fraud and has been fined – that is a matter of public record – but the doctor can say nothing if he or she takes the deal. It is like what happened to Soviet citizens under the Cheka. When they were being hauled off in the middle of the night to the gulag or the Lubyanka, they were cautioned, “Go quietly, comrade; we don’t want to disturb the neighbors.”