Physicians, Business, Professional and Information Technology

 Networking to Restore Accountability in HealthCare & Medical Practice

 Tuesday, July 22, 2003

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In This Issue:
1. Mandated Interpreters Exceeds the Cost of Care
2. Our Monthly Review of the Socialized Medicine
3. The British Medical Association: Forty Years with The National Health Service
4. Medical Gluttony or Excessive HealthCare Costs
5. The MedicalTuesday.Network for Restoring Patient Focused Private Practice

Mandated Interpreters Exceeds the Cost of Care
A physician cited that he once received a bill from an interpreter for $140 for the two hours spent interpreting a patient consult for which he would eventually receive $95 from Medicare. Just as we noted last month on how this mandate to provide interpreters forced a doctor to close his office, this doctor is also in the process of closing his office. The idea that a physician can spend $45 more for complying with federal laws than he will be reimbursed for providing the service reminds me of the patient who felt the government could certainly increase taxes to provide everyone with medical care, as the single-payer advocates would require. I asked what if it required that the tax rate increase to 100 percent. He stated, “Sure, the wealthy can well afford to pay 100% of their income in taxes.” I then asked him what if it required an increase of 200% in taxes and he said, “The wealthy can well afford to pay 200% income tax rate.”

And so the eventual collapse of our civilization will rest with the incompetence of our socialized education system, one that is unable to teach our people that 100 percent is the total amount of money available.

Our Monthly Overview of Socialized or Single-Payer Medicine
This week we interrupt our review of The Dangers of Socialized Medicine edited by Jacob G Hornberger, a former trial attorney and adjunct law and economics professor at the University of Dallas, and co-edited by Richard M Ebeling, in which they discuss the Real Free-Market Approach to Health Care. Hornberger contends that the debate over national health care is a debate over the future of the United States.

For a timely comparison, we bring you the farewell address by the Chairman of the Council of the British Medical Association in which he reviews his forty-year experience with the British National Health Service (NHS) which recently celebrated its fiftieth anniversary.  He paints a tragic picture of hopelessness and despair as he bows out of medicine and medical politics with   continued hope for a hopeless situation. The details of bureaucratic medicine finely honed over fifty years are instructive for American Medicine. It is something we should aspire to avoid at all costs. The entire address can be found on the BMA website at www.bma.org.uk.

Speech from the Chairman of Council, Dr. Ian Bogle, CBE, Monday, 30 June 2003, British Medical Association (BMA) www.bma.org.uk
“This is my last speech as Chairman of Council. . . . I must begin by offering my thanks to BMA staff and Council colleagues for their support over the past five years. . . .  I have been at the helm of the BMA during one of the most interesting and challenging periods in its history–its move towards greater openness and accountability in assessment of performance and fitness to practise, three major contract negotiations and a government modernisation programme that will have far-reaching consequences for the future of the health service and the future of the medical profession.

When I leave this stage for the last time on Thursday, I will be bowing out of medicine and medical politics for good.

“The one memory that will linger long after the sweet taste of negotiating successes and the sour taste of acid encounters with self-serving secretaries of state have left my palate is the creeping, morale-sapping erosion of doctors' clinical autonomy brought about by micro-management from Whitehall which has turned the National Health Service (NHS) I hold so dear into the most centralised public service in the free world. The stifling of innovation by excessive, intrusive audit and the imposition of Department of Health diktats.

“The shackling of doctors by prescribing guidelines, referral guidelines and protocols. The suffocation of professional responsibility by target-setting and production-line values that leave little room for the professional judgement of individual doctors or the needs of individual patients. . . .

“But the paranoid centralism which has characterised this and previous governments' handling of the NHS will not lead to improvements in patient care. It will turn professionals into bean counters answerable not to their patients but to politicians, auditors, commissioners and managers under pressure to deliver on edicts, priorities and targets emanating from Richmond House.

“I'm nearing the end of a 40-year career in medicine – a career that I have loved and from which I have drawn enormous personal and professional satisfaction. Nothing comes close to the unspoken but absolute trust that exists between patient and doctor, to the privilege of being let into people's lives and people's thoughts, to the patient who says 'Thank you doctor, that helped'. But when I look back over my career and how the practice of medicine has changed in that time, there is one thought I cannot shake from my mind. The challenge, the responsibility, the risk that I relished, and that I regarded as being fundamental to my professional status, have all but disappeared. When I first went into practice against the wishes of my father, who was a doctor himself but wanted me to be a dentist because the pay was better, I wasn't interested in financial rewards. I wasn't interested in adulation from awe-struck patients or being hero-worshipped by nubile young nurses. I wasn't interested in achieving immortality as the discoverer of some rare and exotic disease.

“I became a doctor because I wanted to help people who were ill or in distress. I earned £9 a week, and I was on duty for four nights out of seven. My motivation and my satisfaction came from knowing that I was able to apply my knowledge and exercise my judgement free from control or interference from outside the consulting room. I felt free, and safe, to do what I thought was best for those in my care. I was only in my early 20s when I faced my first life or death test - a seven-year-old boy with a congenital heart condition, in heart failure, and sent home from hospital to die because the surgeons didn't think he would survive an operation. I discussed the options with his mother – let him die or take a chance with radical treatment that might save him. With her consent, I administered four times the recommended adult dose of a powerful diuretic new on the market in an effort to get him fit for surgery. I wasn't even sure whether the drug was licensed for use in children, but I was sure that if I did nothing he would be dead within a week. His condition improved dramatically, and after I'd fought tooth and nail to get the surgeons to see him again, he was operated on and survived.

“That seven-year-old is now a strapping 48-year-old with children of his own.  I took a risk in the hope that it might save a boy's life. I wouldn't take that risk now. I am in no doubt that my career would be on the line if I acted outside accepted protocols for the treatment of certain conditions. . . .   Transparency and accountability are the counterweights to clinical freedom. But remove the responsibility, remove the risk, remove the challenge in practising medicine and you remove a large part of what being a doctor is all about.

“We spend a lot of time at the BMA talking about low morale in the medical profession and what needs to be done to address it. We have rightly identified workload, work intensity, patient demand and increasing bureaucracy as factors contributing to its continued downward spiral.

“For me, and I suspect for many of my colleagues who are contemplating early retirement, leaving medicine in mid-career or asking themselves early on in their careers whether medicine was the right choice for them, the biggest demotivator has been the deprofessionalisation of medicine brought about by protocols, guidelines and government targets.

“Ministers and managers have muscled in on the doctor-patient relationship, and we now have a healthcare system driven not by the needs of individual patients but by spreadsheets and tick boxes. Clinical decisions have been taken out of clinicians' hands and the fundamental NHS principle of care based on need and need alone has been superseded by the principle of care based on numbers. Targets are set nationally without any appreciation of what they might mean for individual doctors sitting in consulting rooms with individual patients.

“If you set targets for the treatment of one group, you automatically disadvantage others whose clinical need may in fact be greater. If you set targets for access to services, you encourage those providing the services to give more thought to throughput of patients than to what is actually wrong with those patients and what their individual treatment needs are.

“Our own survey of A&E consultants carried out in March this year after a preannounced seven day Health Department audit of waiting times in casualty departments in England uncovered the extraordinary lengths to which some hospitals will go to pull the wool over the auditors' eyes. More than half bussed in temporary staff, and bussed them back out again as soon as the audit was over. A quarter made staff work double or extended shifts. Sixteen per cent canceled routine surgery so beds would be available for patients admitted through A&E.

“There are countless other examples of the trickery and ruses used by managers to please their political masters. Keeping patients in ambulances because the A&E waiting time clock doesn't start ticking until they arrive in the department. 'Warehousing' patients in A&E departments because of a lack of available inpatient beds.

“Classifying patients on trolleys as 'admitted' to hospital even though they have no access to food or hygiene facilities. Putting patients on reserve waiting lists so they don't appear on the waiting list proper. Admitting patients who are near the waiting time target limit to hospital at the expense of patients whose need is greater but who haven't been waiting as long. Pushing through small, swift, non-essential operations at the expense of those that require a theatre or bed space.

“And if all else fails, cheat – or as the National Audit Office (NAO) more politely puts it, make 'inappropriate adjustments'. 'Inappropriate adjustments' identified by the NAO in its investigation into waiting list manipulation included excluding patients from lists until the month of their appointment and telephoning patients to find out when they were going on holiday then offering them admission dates during that period.

“You would think wouldn't you that the government would be distancing itself from these corrupt and immoral practices. Instead, it has turned a blind eye, been triumphalist about its 'achievements' and colluded in the deception and doublespeak.

“Did you know that the official definition of a bed according to this government is, and I quote, 'a device that may be used to permit a patient to lie down'? This rather conveniently means trolleys and examination couches can be counted as beds for statistical purposes. But why stop there? Why not put up hammocks in hospital car parks? Why not ask patients to bring sun loungers and sleeping bags from home?

“When the BMA criticises the target culture and warns that the billions of pounds of extra investment in the NHS aren't affecting the frontline delivery of services on a large enough scale to make a real impact on the public or on the professionals providing those services, we are accused by government of scaremongering and of wanting to veto reform.

“Only two months ago, the Commission for Health Improvement, the government's own health service watchdog, warned that recent improvements in the NHS were at risk because the concentration on short-term waiting targets meant managers were struggling just to keep the show on the road.

“Only three weeks ago, the Audit Commission warned that there were too many piecemeal targets which obscured real healthcare priorities, and that trusts were diverting money away from future projects in favour of quick fixes to keep services going. It called for fewer targets and for ministers to allow NHS managers and medical staff to be left to decide how best to achieve them.

“In its own press release on the launch of foundation hospitals, the Department of Health promised that 'the best hospitals will be freed from excessive Whitehall control' – a seemingly remarkable admission by the government about the misguidedness of its own approach. If Whitehall control is excessive, then why not remove it from all hospitals?

“The use of targets to drive up quality and measure improvement is not a bad idea. Good targets, like those for a reduction in death rates from heart disease and cancers, are drawn up by clinicians for clinicians, not by politicians looking for a quick fix to appease an expectant and impatient public.

“Politically-motivated national performance targets based on quantity not quality offer no room for local flexibility and encourage short-term gain at the expense of long-term improvement. Politically-motivated national performance targets based on quantity not quality offer no incentives for managers or clinicians to improve the standard of the services and care they provide. Politically-motivated national performance targets which come with a threat of penalties and punishment for those who fail to achieve them make honest people dishonest. Politically-motivated national performance targets have driven a wedge between doctors and managers.

“The consultant contract ballot went down in England and Wales not because there wasn't enough money attached, not because doctors are resistant to reform. It went down because consultants were not prepared to submit to a level of ministerial and managerial interference in clinical decision making that would have been intolerable, and would have made a mockery of their professional responsibility and their duty of care to their patients. . . .

“The father of the NHS, Aneurin Bevan, once famously remarked that the sound of a bedpan falling in Tredegar Hospital would resound in the Palace of Westminster. More than 50 years, and countless restructurings, later, Nye Bevan's words resonate loud and clear with those of us who have watched successive governments pay lip service to the ideal of decentralisation while at the same time trying to retain their iron grip on the NHS from Whitehall.

“Given this government's obsession with issuing diktats on the minutiae of NHS activity, I'm surprised there isn't a target for the passing of motions. The auditing of every bowel movement on every ward in every NHS hospital would be a fitting memorial to Alan Milburn now that he has decided to spend more time with his family. Mr Milburn may not have noticed, but consultants have families too. It is a pity he was not able to appreciate their predicament when he was trying to force them to work evenings and weekends.

“There are major challenges ahead for my successor, and for the BMA.
• We must persuade government that if it is prepared to engage the medical profession in a debate about the future of the NHS, it can restore the medical profession's confidence in its handling of the NHS.
• We must persuade government to re-open a constructive dialogue with parts of the profession where relationships have broken down.
• We must look at our own organisation – at how we work, at how we represent our members, at how we communicate with our members, at how we negotiate on behalf of our members.
• And we must not be resistant to change within our own organisation if it will mean improving the way we work, improving the way in which we represent our members, improving the way in which we communicate with our members, and improving the way in which we negotiate on behalf of our members.

“Above all, we must fight to restore our professional status, and to convince government that the way to deliver sensitive, patient-centred healthcare is to allow doctors to exercise autonomous clinical judgement, and to accept the risk, the responsibility and the accountability that go with it.

“At the risk of sounding pompous, medicine is an honourable profession, a noble profession.

“I am proud to be a doctor.

“The right to practise medicine as a professional and not a government bean counter is worth fighting for.

“Please don't give up that fight.”

Medical Gluttony or Excessive HealthCare Costs Caused by the Insurance Carrier
Some insurance carriers inform doctors that the diagnosis on the insurance form indicates that certain tests need to be done. It may seem a bit strange that insurance companies, who are in the business of saving costs and have developed managed care systems to help them reduce costs, are encouraging doctors to spend money on testing. It is also akin to practicing medicine without a license by protocol . There obviously has to be an ulterior motive or public relations angle to this.

I recently went through all the notices I received over several weeks. One set of notices demanded that I give to diabetic patients the enclosed requisitions for a chemistry panel, a lipid panel and a glycohemoglobin. There were also demands for patients with congestive heart failure, asthma, renal disease, ulcer disease and others. I spent an additional two hours, after seeing patients all day, going over patient charts to see if I had reduced their quality of care. In regards to the diabetic patients, I found that I had already obtained the requested testing, with the exception of one patient that did not have diabetes. There were similar insurance carrier errors in the other groups of patients.

I came to the conclusion that I would no longer do this for the non-medical reasons they demanded since my level of care is superior to theirs and much more cost effective. Had I implemented their requisitions, I would have added over $3000 to the cost of health care which would have been duplicative or unnecessary and thus inappropriate. This is the type of Medicare fraud for which doctors are prosecuted.

Furthermore, when the intermediary questioned my decision, I asked, “How would you like it if your employer at the end of a work day presented you with two hours of the work you already had done and asked you to recheck it for accuracy without additional pay?” He said I did more important work than he. I reminded him that the doctor is the primary patient advocate and the insurance company is normally considered an antagonist since laws are being passed to protect patients from insurance carriers. What other profession accepts such abuse and humiliation from a bureaucracy that has no genuine interest in health care or helping people in their struggles to improve their health? In what other instance does the tail wag the dog and beat it into submission? In all bureaucratic HMO or socialistic or single-payer systems.

Today, a representative of an insurance carrier came into my office to evaluate my record keeping. He marveled at the six typed pages of history and physical examination, chest x-ray report, pulmonary function testing and appropriate lab work. But he was incensed that I didn’t have a problem sheet in the front of the chart that he could check off on his “bean counter” work sheet, or a medication sheet in the front of the chart so that he could see what every patient was taking. When I pointed out that the extensive History and Physical exam has a quarter page of diagnoses, essentially a comprehensive problem list, and after that is a list of medications ordered, a very complete medication list, he replied that it was difficult for him to find these items that are essential for him to grade me on my work. I told him to grade my work as he saw fit while I attend to the 13 patients’ current and foreseeable medical needs and after their next appointment, I would ask them to have their insurance carrier, his boss, find them a new physician. He looked like I had mortally wounded him as I walked back into my consultation room to get some useful work done.

Bureaucrats actually feel it is appropriate in a time-demanding world to take additional time, like an extra two hours after the work day is completed, to do totally unnecessary and useless work that has no impact on patient care, except to reduce the quality of care and increase the chances for errors by needlessly copying to another page, so they can lord over the once noble profession they want to subdue.

Question: When will the public understand this toying with their health and life by bureaucrats who have no interest in their health or life as alluded to in address of the president of the BMA noted above? That he still feels hopeful in dealing with the bureaucrats of the National Health Service when the first 50 years reduced him to a bean counter, is a tragedy that brings the very existence of our country into perspective. It is truly a stroke of genius that after millennia of servitude to feudal lords, dictators, and kings, people came to our shores to seek freedom from oppression to live their lives without bureaucratic control, and prospered like no other people in the history of the human race in just a century and a half. It is unfortunate that a large vocal element of our society has American citizens convinced that we are indeed backward and not interested in poor people because we are not enlarging our social catch net as did the societies from which our ancestors escaped. Little do they realize that the best benefit for the poor who came to our shores was the freedom to succeed rather than the competition to fail and be on the public dole. Every day we see our patients compete to see who can get the most benefits at tax payers expense, such as a motorized wheel chair for flat feet or remodeled bathrooms for being old and unsteady as if that were a new illness, while many disabled continue to work regularly.

MedicalTuesday wants to bring these issues to the forefront before it’s too late--before we regress to the age before 1776. Our development of an affordable HealthPlanUSA for all Americans and their employers will solve both the access issue and the coverage issue. Stay tuned.

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MedicalTuesday Supports These Efforts in Restoring Accountability in Medical Practice by Restoring the Doctor & Patient Relationship Unencumbered by Bureaucracy:

• PATMOS EmergiClinic - www.emergiclinic.com - where Robert Berry, MD, an emergency physician and internist, provides prompt care for many of the injuries and illnesses treated in Emergency Rooms at a fraction of their cost. Dr. Berry also has an internal medicine practice. He won the King Pharmaceuticals' Cup of Kindness Award for Innovation. The following is the essay that was submitted: “The future [of healthcare] will be determined by aggressive dreamers and risk takers at the local level who see opportunities to create new ways of providing care or of paying for existing services.” Just click on “Awards” on the website to read the entire essay.

Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), www.sepp.net, for making efforts in Protecting, Preserving, and Promoting, the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals, with a special page for our colleagues in nursing. Several free newsletters are available.

• Dr Vern Cherewatenko for success in restoring private-based medical practice which has grown internationally through the SimpleCare model network, www.simplecare.com, which reminds us that any patient or person may become a member of SimpleCare. Whether you are insured, underinsured, uninsured, or on Medicare, Welfare or other government programs, SimpleCare may reduce your out-of-pocket medical expenses. Use SimpleCare when insurance does not pay for the health services, providers or alternative care you choose. Remember however, that SimpleCare IS NOT an insurance company nor does it provide any insurance services.

Dr David MacDonald has partnered with Ron Kirkpatrick to start the Liberty Health Group (www.LibertyHealthGroup.com) to assist physicians by helping them to control their medical benefit costs for their staff and patients. You can obtain a quote from eHealthInsurance.com at this site. He is available to speak to your group on a consultative basis. Contact him at DrDave@LibertyHealthGroup.com.

Robert J Cihak, MD, former president of the AAPS, & Michael Arnold Glueck, M.D, write an informative Medicine Men column that is now at NewsMax. Please log on to read or subscribe at http://www.newsmax.com/pundits/Medicine_Men.shtml. Every pundit in the land has his own diagnosis for the health care crisis. The current issue highlights A Campaign to Stop Prescription Drug Abuse and Halt 'War on Physicians.' Prosecutors and law enforcement officials throughout the country are egregiously targeting doctors for helping patients manage crippling pain with controlled, legal drugs. For some government officials, the "War on Drugs" has come to also mean a war on lawful drugs and against the doctors who prescribe them and the patients who take them. Some prosecutors try to make political careers out of high-publicity cases involving the hot "drug du jour" such as OxyContin. But this war is causing enormous collateral damage and deaths to innocent patients from "friendly fire." Doctors, pharmacists and law enforcement officials should work together to track and report potential drug abusers to each other. Read the entire column at http://www.newsmax.com/archives/articles/2003/7/1/35033.shtml.

The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943,  representing physicians in their struggles against bureaucratic medicine and loss of medical privacy. The monthly AAPS is archived on this site giving valuable information on a monthly basis. They have renamed their official organ the Journal of American Physicians and Surgeons, and named Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. The annual meeting is at Point Clear, Alabama on September 17-20, 2003. You'll hear practicing physicians who have cut the cord to managed care and Medicare - keeping their patients and creating a healthy bottom line. You'll continue to get the details on how to keep HIPAA claims problems from drying up your cash flow, and how to respond to expected privacy complaints.  Because of HIPAA criminalizing so much of what we do, there has been renewed interest in the AAPS. You may register on the website above.

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Del Meyer

Del Meyer, MD, CEO & Founder