Physicians, Business, Professional and Information Technology

 Networking to Restore Accountability in HealthCare & Medical Practice

 Tuesday, September 23, 2003

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In This Issue:
1. Targeting Doctors for Health Care Fraud
2. Criminalization of Medicine by States
3. License to Steal
4. Our Monthly Review of Socialized Medicine
5. Medical Gluttony or Excessive HealthCare Costs in Germany
6. The MedicalTuesday.Network for Restoring Patient Focused Private Practice

The Association of American Physicians and Surgeons (AAPS) held their annual three-day conference last week. We highlight several presentations that addressed important issues that interfere with the freedom to practice medicine.

Law Enforcement Bureaucracy Targeting Doctors: Health Care Fraud and Abuse Control Program (HCFACP). Ron Libby, PhD, Professor of Political Science at University of North Florida, spoke at the recent meeting of the Association of American Physicians and Surgeons. He outlined how the appointment of Richard P Kusserow as Inspector General of the Department of Health and Human Services in 1982 inaugurated a reign of terror against doctors. He called the HCFACP a self-financing and unaccountable bureaucracy targeting physicians for investigation and prosecution. Kusserow was able to convince Congress that health care fraud is rampant and the Office of Inspector General (OIG) had good “statistics” on convictions. He is the originator of the idea that 10 percent of health care was fraudulent. Kusserow inaugurated a merit-pay conviction quota system for his OIG agents and auditors. Investigators and Medicaid state fraud units were given statistical ratings for meeting conviction and Medicare exclusion quota and money penalties. Promotion was dependent upon agents meeting or exceeding their quotas. With this incentive, Kusserow claimed that the OIG collected $29 billion in fraud settlements from 1985 to 1989 and successfully prosecuted 5800 providers. His techniques included the involvement of related departments, the contact of previous employees more willing to testify against a physician and the use of search warrants at inopportune times such as right before the lunch hour. Funds taken from doctors are recycled for further investigation and prosecution of doctors. Essentially all physicians ran out of resources to defend themselves and were then advised by their attorney to plead guilty to a reduced charge. Most of these physicians did not realize until too late that this made them a felon, which resulted in losing medical licensure, hospital privileges and their medical practice. Some physicians were told that admitting guilt, even though they felt they did no wrong, would help them avoid jail. However, several still did jail time, sometimes life imprisonment, and in one case the physician was given a 480-year sentence.

Criminalization of Medicine by States
California’s legislature passed a law making it criminal for a doctor not to relieve pain and forced doctors to take post-doctoral courses in pain management. Florida’s Drug Czar pledges crackdown on painkiller abuse calling Florida’s rising death toll from prescription drug abuse “Mass Murder,” as he vowed to crack down on pain clinics and doctors who supply too many pills to addicts. “We want to make an example out of those doctors who are violating the Hippocratic Oath and the law,” said James McDonough, director of the Office of Drug Control. “Any professional who does that will suffer the consequences.” A large number of cases were presented. One doctor has sat in jail for five years awaiting trial. He refuses to take mind-altering drugs the state wants to give him. Should he be found guilty, the maximum penalty would be four years in jail--less time than already served!

What If Relieving Pain Doesn’t Occur until after Dying? This past year, an elderly patient requested a three-month supply of narcotics, eight tablets a day for 90 days or 720 tablets, for his chronic back pain. When asked how severe his pain would become if I didn’t fulfil his request, he stated that one of his previous doctors had declined. During the time it took to find another doctor, he admitted his pain was not any worse. So I gave him half his requested dose for 30 days to allow him time to again find another practitioner. This points out the difficulty in pain management with physicians frequently placed in an untenable position between “legally defined under treating” (e.g., in California) and “legally defined over treating” (e.g., in Florida and by the Feds). The uninformed lay legislature doesn’t understand that pain may never be relieved at any dosage, until the patient suffers respiratory suppression from the dose and is at risk of dying. Should the patient die of his terminal status, the doctor could be prosecuted by the State of Florida or the Feds for prescribing too much pain medication and by the State of California for not relieving pain (until after death). After forcing the 80,000 physicians in California to take a course in pain management, it is doubtful that this will improve the author’s understanding of the pain management problem in medical practice, which she is trying to micro-manage.

AAPS Project: Communicate and Cooperate
A number of cases were presented at the AAPS meeting of doctors being prosecuted for prescribing pain medications. As these doctors are being threatened with long-term jail sentences, they have helped develop the AAPS 3-Point Plan to stop the “Drug War on Physicians & Reduce Rx Drug Abuse.” They are working together to track and report potential drug abusers to physicians who will be grateful for the additional information that would stop the abuse at the source. They are providing joint reviews of potential cases before charges are filed and also mutual training. Attitudes toward the treatment of pain are rapidly changing. What was unacceptable a few years ago is now considered appropriate, both in medicine and in public opinion. For example, investigators frequently look at the volume and duration of drug use as the primary trigger for an indictment. Because accepted treatment has changed, this approach is no longer appropriate and leads to indictment of pain specialists simply due to the volume of their prescriptions. And finally, in the art of medicine, investigators must be able to distinguish between a difference of opinion in what is proper treatment and specific criminal intent.

License to Steal
Another presentation at the AAPS meeting was by Theresa Burr, who was in the Medicare insurance industry for almost a decade. She spoke of her work for a Medicare insurance carrier. She saw so much fraud and abuse against patients and doctors during that time that she finally acted on her conviction as a whistle blower on company practices.  She witnessed more than 10,000 claims that were changed. She was constantly told by superiors to find a way to reduce costs. She was offered a promotion if she promised to always do what she was told. Since she declined, she was never promoted to the position in which she worked. She was constantly told by the supervising RNs and MDs that certain claims were incidental and should be tossed. She witnessed Medicare claims being shredded. With electronic billing, it was easy for the superiors to delete a series of claims. At the hearing, she was told that Medicare could not change carriers since no other insurance carrier could be found that could handle this volume of work. Furthermore, the level of accuracy was probably on par with the other regional Medicare carriers. Her attorney tried to dissuade her from going to trial because she would go to jail. Mrs Burr said she was fine with that considering the magnitude of the problem.  If acting in the public interest included jail time for being honest, she would be willing to serve. She overheard the prosecutors say that they needed to get this case settled before Hilary’s national health plan was being presented the following year. She did not go to jail. No one apologized for the travesty against doctors and patients by the insurance carrier. Mrs Burr feels the only way that she’s alive today is because of Divine intervention and protection from God. She now spends her time with her family.

Socialized or Single-Payer Medicine–Our Monthly Overview of Universal HealthCare
Jacob G Hornberger, a former trial attorney and adjunct professor of law and economics at the University of Dallas, and Richard M Ebeling, the Ludwig von Mises Professor of Economics at Hillsdale College, discuss the Free-Market approach to HealthCare in The Dangers of Socialized Medicine. In chapter 2, National Health Insurance and the Welfare State, Richard M Ebeling writes in Part I: After the experiences of the totalitarian states in the twentieth century, logic suggests that the world would have learned the lesson that every growth in state power–every extension of government control in social and economic affairs–threatens the liberty of the people. The alternative is always and ultimately a choice between the freedom of voluntary association among the citizens of a community and the coercing dictates of the political authority. Whether those coercing dictates originate in the commands of a tyrant who usurps power through military force or through the democratic procedures of election and debated legislation, the end result is the same: the state takes upon itself the right to determine what social relationships will be permitted to exist among the members of the society.

Roots of Socialized Medicine and the German Welfare State. If you missed last month’s review of Part I, go to http://www.medicaltuesday.net/Aug2603.htmand scroll down to this monthly topic.

Imperial GermanyIn Part II, Professor Ebeling gives the background for the rise of the welfare state. Kaiser Wilhelm II and Chancellor Otto von Bismarck attempted to preempt the appeal of radical socialism by establishing a series of socialized insurance programs for retirement, unemployment and medical care. In the 1890s, Bismarck explained his rationale to American historian and sympathizer William H Dawson: “My idea was to bribe the working classes, or shall I say, to win them over, to regard the state as a social institution existing for their sake and interested in their welfare. . . . ”

Monarchial Socialism in Germany. This is the title of Elmer Roberts 1913 volume in which he explained the German welfare state. “The endeavor of German statesmanship has been to hold to everything in existing social arrangements necessary to produce individuality in the higher orders, and yet to intervene in education, sanitation, sick, accident and old-age insurance . . .  adding to the power of the state and the monarchy. The intervention of the government is to be determined by expediency . . . . Institutions are to be judged by their benefit to the greatest number. The government can bring this about for the community only by taking interest directly in the social and economic arrangements, and by limiting the freedom of individuals and groups should their activities appear upon examination [by the state] not to serve the general aims of the organized life.”

German Health Insurance. State-mandated health insurance began in Germany in 1884 and initially covered workers in factories, mines, foundries . . . The blanket of coverage was extended over increasing portions of the work force . . . and family members of workers were included after 1892. . . . and by 1928, practically every trade, occupation and craft in Germany was enveloped in the system. . . . The insurance funds mandated by the German state were organized on the basis of trades and occupations. But the state continually consolidated them, . . . Benefits first included thirteen weeks of free medical care and a cash payment equal to fifty percent of the prevailing wage in the pertinent occupation, with the cash benefit starting on the fourth day of an illness. After 1903, free medical care and cash payments were expanded to a period of twenty-six  weeks. In case of hospitalization, the cash payment was cut in half. Besides these basic benefits, the compulsory-insurance funds often provided cash benefits equal to seventy-five percent of the worker’s pay (depending upon family size), and by the 1920s, these cash payments often started only one day after an illness began. Financial coverage was also extended to include nursing services and convalescent treatment for up to a year after the end of cash benefits. Maternity benefits were mandatory as well.

The Results of German Health Insurance. The benefits paid out by the state-mandated health insurance system continuously exceeded contributions received from member employees and employers and required government subsidization. Total contributions received by the health-insurance funds from employers and employees in 1929 was 375 percent larger than they had been in 1913. But health-insurance benefits paid out by the funds in 1929 were 406 percent larger than what was paid out in 1913. Costs of administering the mandatory insurance funds had increased 288 percent between 1913 and 1929. And the government subsidy to the system had increased by 270 percent between 1924 and 1929.

The extension of socialized health insurance also saw an increase in what the German literature called “malingering.” As Walter Sulzbach expressed it in his study of the German Experience with Social Insurance (1947):
 Over a period of fifty years [1880-1930], during which medical science scored one triumph after another, it took the average patient under compulsory health insurance an ever longer time to recover.

In 1885, a year after socialized health insurance began, the average number of sick days taken by members of the system each year was 14.1. In 1900, the annual average number of sick days per member had gone up to 17.6; in 1925, it had increased to 24.4 days; and in 1930, it was an average of 29.9 days. People also were noticeably sicker around weekends and Christmas and New Year’s Day, particularly in those occupational insurance funds that waived the four-day rule before receiving cash benefits.

. . . .An essential ingredient of the fee system was that similar fees were paid for similar services, regardless of the patient’s ability to pay. In other words, the frequent practice of private physicians to charge higher fees to wealthier patients as a means to earn higher income and to subsidize voluntarily the treatment they provided to poorer patients was outlawed. Hence, the determination of income earned by doctors in the system was purely on the basis of “quantity,” i.e., the number of bodies examined at the fixed fee per period, as opposed to the quality of the service provided.

The . . .  conveyor-belt view of patients resulted in workers insured under the compulsory system demanding freedom of choice in selecting a physician . . .   . This was established as part of the agreement of 1913. But it also meant that a doctor now had an incentive for greater leniency in diagnosing an illness and prescribing sick leave. A less accommodative physician was in the risk of losing his steady patients and suffering a decline in his income as fewer patients entered his examination room. . . .

Under the Nazi regime after 1933, the compulsory health insurance system became even more centralized and controlled. The insurance funds lost almost all autonomy and became subservient to the Fuhrer principle. And the employer share of health-insurance payments was increased from one-third to fifty percent. The payments were increased from one-third to fifty percent once the Nazis were in power, explained Melchior Palyi, in Compulsory Medical Care and The Welfare State (1949):
 The ill-famed Dr. Ley, boss of the Nazi labor front, did not fail to see that the social insurance system could be used for Nazi politics as a means of popular demagoguery; as a bastion of bureaucratic power; as an instrument of regimentation, and as a reservoir from which to draw jobs for political favorites and loanable funds for rearmament.

Thus ended the first experiment in socialized health insurance. Begun by Bismarck as a tool of state policy to fight radical socialism through the implementation of Imperial State Socialism, it ended up as one of the cogs in the wheel of Hitler’s National Socialism.

The Collapse of Communism in Eastern Europe. Historian Gale Stokes states, “How was it possible that two movements whose claims seem so implausible, almost comical . . .  should have not only attracted millions of enthusiastic followers, but, on the basis of what these adherents considered high principle, sent millions of people to anguishing deaths?” Join us next month as we explore “how was it that so many people in practically every corner of the world shared the idea that some of the most personal and important matters of their private and individual and family lives should be placed in the care of the state.”

Medical Gluttony or Excessive HealthCare Costs in Germany
Excessive utilization of health care resources is not only an American problem. The current issue of Business Week reports on the revolt of the young Germans who are balking at the heavy cost of supporting retirees. Philipp Missfelder, chairman of the youth wing of the center-right Christian Democrats, griped that medical care for the old folks was creating an intolerable financial burden for the young.  It’s about time 85-year-olds started paying for their own hip replacements and false teeth, Missfelder declared. “In the old days, people got around on crutches,” he said. Although the elders in the party muzzled the 24-year-old politician, it did provoke a serious backlash. It’s dawning on German young people that Grandpa and Grandma, who typically retire by age 60, may collect a pension of more than $45,000 a year. It is estimated that current 30-year-olds will collect far less and Arndt Rauttenberg, the 36-year-old manager of software consultant Sapient, stated, “I have long given up any expectation of receiving a dime from the government when I’m 60.” This month Stern magazine featured in a cover story debate the soaring social security deductions driving companies and workers to other shores. Gerhard Schroeder’s own Young Socialists are also complaining. He has formed a high profile panel which has issued recommendations to push the retirement age to 67 and reducing benefits in line with declines in the number of people who pay into the pension system.

Yes, entitlements will always bring out the worse in human greed which will always exceed human need and/or resources. It’s time to move out of the eighteenth century box and join the innovation of the twenty-first century.

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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. Dr Berry has a unique view of health care practices in this country. In a Health Forum he reminds us of a patient who owns about 100 acres in the country worth perhaps $400,000 that he has clear title to.  He was able to get on Medicaid a couple of years ago to have bilateral total hip replacement at taxpayer expense.  He is one who thinks health care should be free (which of course means that I should have to provide it for free even though I have clear title to nothing).  Perhaps there is a story here for an investigative reporter.

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. 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. Remember, he cautions, 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, and 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. In the current issue, titled Single-Payer Plan a Medical Disaster, the Medicine Men discuss point by point the recent proposal by the Physicians' Working Group for Single-Payer National Health Insurance. Read the whole issue at http://www.newsmax.com/archives/articles/2003/9/8/153548.shtml. If you have not read the previous issue in August on Outlaw Prosecutors: Attack on Civil Liberties, be sure to go back to http://www.newsmax.com/archives/articles/2003/8/11/171722.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 “AAPS News” is archived on this site providing 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 60th annual meeting was at the Grand Marriott Resort at Point Clear, Alabama on September 17-20, 2003. Topics in addition to those included above: Policy Parading as Medicine, Perversion of Science by Politics, Case reports from the AAPS legal counsel, and Stories from the front lines. Because many branches of government, including the recent HIPAA regulations, criminalizes so much of what we do, there has been renewed interest in the AAPS. You may register to receive email alerts and post topics on the forum.

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Del Meyer

Del Meyer, MD, CEO & Founder