Surviving the Medical Meltdown (9 page)

A major problem with EMR is its lack of detail. People and their medical problems are analog – displaying infinite variety and complexity. But EMR is digital and finite. A digital record gives you only certain stylized options in recording a patient’s history. And although you have the option of dictating segments of the chart, this is often too cumbersome to be practical. So as time goes on, like water flowing to the lowest levels, a physician settles for less
and less specific patient history in favor of a generalized, “cookiecutter” description of the problem. So, for example, instead of a postoperative clinic visit that records the procedure as a “partial medial menisectomy with removal of 25 percent surface area of the meniscus and removal of a small firm plica,” the visit is for “post-op knee arthroscopy.” As a spinal surgeon, sometimes I need a neurologist to render an opinion on whether the patient’s problem stems from the spinal compression (stenosis) or from a more metabolic sickness of the nerves (polyneuropathy). In the old days of paper, I used to get dictated reports back from my neurologic consultant that outlined his reasoning and gave me a feel for the more probable answer. Now I get a digital summary that simply states “stenosis” and “polyneuropathy,” with CPT codes attached. So the patient is poorer – having just paid for a fairly useless consult – and I am no wiser, still unable to determine if surgery is likely to help him. Needless to say, I rarely ask for such consults anymore.

And then there is the issue of accuracy. The old saying “garbage in, garbage out” is as true with medical records as with any other computer function. It is very time-consuming to input the data required to set up a new patient chart, so clinic secretaries use cut and paste, taking snips from all the other records to make the new record. Of course, in the interim since that old data was generated, the patient may have been hospitalized and had major changes to his history and medications. The easier it is to hit a key and replicate old information, the easier it is to pass on falsehoods.

Is it any coincidence that Epic, the largest EMR system, was designed by one of Obama’s largest financial backers? Epic may be better than some, but it still decreases quality of care and makes doctors inefficient. There are all sorts of PR programs and rah-rah teams to convince us how great this is – signs around our facility say “We’re EPIC strong!” In contrast, PACS, the digital Radiology system designed by and for doctors years ago was an immediate hit because it solved problems we wanted solved, was high quality, and made us
more
efficient. We didn’t need cheerleaders to sell it to us.

The upshot of all this is that you will not be able to trust your health to this Orwellian medical record system. (See
appendix D
for detailed instructions on creating your own personal medical record that is optimized for the people who will be caring for you regularly or in an emergency.)

So what will the meltdown look like? There will be large wastelands where no organized medical care exists. You will be discouraged at all levels from high-level care, as most doctors will be working, not for you, but for the government and will be only too happy to do the bureaucrats’ bidding by denying you care – either overtly or covertly (by not making you aware of the latest medical options available). Supplies and medicines will be in shorter and shorter supply. You will not have the luxury of your doctor or hospital keeping accurate, accessible medical records for you. In short, you will be more and more on your own for yourself and your family. A good understanding of the endgame is found in Yuri Maltsev’s article, “What Soviet Medicine Teaches Us” (see
appendix A
).

When I debate socialists on health care, they object to being compared to the Soviet Union, but Soviet-style medicine is the endgame. It represents all the philosophy of today’s government health care proponents rolled into one great, disastrous experiment. If we cannot learn from that, what lesson can we learn?

6
THE ROLE OF INSURANCE

A
s the government consumes what is left of private practice medicine, the role of insurance becomes less clear. Recently, I gave a speech to medical students. Afterwards I was approached by one of the students who said, “I have never heard of catastrophic insurance.” I’m sure the student paid for
car insurance
, but because there is no crisis in car insurance, she didn’t give a thought as to how car insurance actually works. It is a sad fact that – thanks to the perversion of the free marketplace by government and corrupt insurance companies – we have raised a generation of young people who do not understand how
real insurance
works. They believe they have health insurance. In reality, what they purchase today in medicine is not insurance but “prepaid health care.”

Real insurance functions like this: For any given problem, a special mathematical genius called an actuary figures out the probability of some problem occurring to an individual subscriber. The actuary uses a person’s demographics, and can predict the probability of accident and project the cost of that accident or disease. For example, an actuary can tell me my probability of totaling my car. He has a vast array of statistics, can look up the data about middle-aged women driving sports cars, and knows that generally
we are harmless compared to young men armed with the same fast car. So my premiums are lower than my son would pay for the same coverage. Car insurance and house insurance are referred to as actuarial-based insurance. Neither government nor special-interest groups have skewed the market, so the cost is generally low, and coverage is typically understandable and predictable.

Furthermore, regarding your car insurance, you, not your employer, own it. It is, therefore, infinitely portable. You can choose how much or how little to self-insure, and what you want covered. You can buy it across state lines in a big national market. In sum, for all of these reasons, those types of insurance are not in crisis.

Health insurance, before Medicare and the more recent government meddling, was functional and cheaper in the same way. When it worked it was known as “major medical” insurance – a form of catastrophic, actuarial-based insurance. Most outpatient care was paid out of pocket. Insurance kicked in
only
for big-ticket items. When you saw a physician for things such as well child care, vaccinations, a runny nose, a routine checkup, and so forth, you paid cash because this fell outside actuarial probability. But when you got hospitalized and had surgery to remove your gallbladder, insurance kicked in.

Insurance companies, years ago, found they could woo customers by offering to pay for “trinkets” such as glasses, wellness, and outpatient testing. Patients, acting in their own self-interest, got more for their insurance dollar by availing themselves of these things, so they used their insurance to the greatest extent possible. Insurance companies then had to raise fees to cover costs, and it created a downward spiral of overutilization and failed attempts at cost containment. When it morphed to this prepaid health care, medical insurance became the only insurance we
wanted to use
. Think about your other insurance. Really, you hope you never need to use your home or auto insurance. When you need those insurances to kick in, it means something bad has happened. And that notion used to be true for health insurance – before big insurance companies wanted
to be all things to all people and before special-interest groups used the power of government to mandate insurance coverage of things such as mammograms.

Predictably, this approach to medical insurance has fueled escalating medical prices. It goes like this: An MRI costs $400 for cash. But then a screening MRI for some illness is mandated for coverage by the government. Now the MRI center must bill an insurance company and wait thirty days or more to get paid, so it increases the cost of the screening to $500 to cover its administrative overhead and late payments. The insurance company is having trouble with covering its costs because suddenly there is an increased utilization in MRIs that its actuaries did not factor in when computing insurance premiums. And the company cannot raise premiums on a daily basis to adjust, so it stalls payment and denies claims. This adds more administrative burden to the MRI center, which hires more staff to deal with the paperwork of disputed claims and which writes off more for nonpayment. Now it has to charge $1,000 per study to make an operating profit. Then the insurance premiums are raised. And this spiral continues without end.

Think what would happen to your car insurance if it covered oil changes and every little ding in your paint.

The solution to this problem, both on a national level and on a personal level, is to return to real, actuarial-based insurance. Today this is generally called “high-deductible” insurance. And the higher the deductible ($2,500 to $10,000), generally the better coverage you have when you are sick. It means you pay for most outpatient items, and insurance kicks in for the “big-ticket” illnesses and accidents. Think about your home insurance. When a shingle blows off, you don’t call your insurance agent. You reach into your pocket and pay for a new shingle and probably put it on yourself. (You don’t reach into your neighbor’s pocket, either, by the way.) When your roof blows off,
then
you call your insurance for help.

The saddest side effect of prepaid health care is the confusion and lack of transparency. It is nearly impossible to know what you
are actually paying for and what you will really be covered for if you fall ill. This confusion is a direct result of insurance companies’ vain attempts at cost containment by writing a million little rules to curb overutilization. In some cases this is abject fraud as they game play to avoid payment to hospitals and providers. (At one point, according to an insurance whistle-blower, a major insurance company shredded every third claim in its mailroom to stall payment.) And it is a result of uncertainty. In my office I could determine my monthly overhead down to the penny. But no matter how many contracts I signed, how many agreements I made, or how many people I talked to, I could never know how much I would be paid for a procedure or office visit. I never knew when I was getting paid from month to month. I never knew if the government or Blue Cross would write to me years hence and ask for the money back saying they had determined they had overpaid me or that the care I rendered was “unnecessary.”

Imagine if that were how you bought tomatoes. You told the grocer, “I’m taking the tomatoes but not paying you. Charge my insurance company, and they may or may not pay you. And if they decide to pay you, it may take you a year to get paid.” Can you imagine what that would do to the price of tomatoes? Do you understand why there is a lack of “transparency in pricing”? The cost of tomatoes is relatively low and stable, and you know how much tomatoes cost because you pay cash at the time of service. When you are paying for medical care through a third party, the third party may agree to one price but pay another. Doctors routinely sign contracts with insurance companies that are then violated as insurance companies and Medicare delay payment, underpay, or pay and then years later ask for all or part of the money back. How could a grocer, or any business, function within such a scenario? It can’t and we can’t – for long.

Buying high-deductible insurance and paying cash for the little stuff is generally much better. When you are hospitalized or need a study, such as a blood test or CT scan, then your deductible insurance kicks in. Period. Little guesswork. One of the secrets is to negotiate
all cash prices. Prices are set to reflect the insanity of the prepaid health care system. But if you are paying cash for a procedure or a pill or a doctor’s visit, you are relieving the provider of mountains of paperwork and an indeterminate wait for their money. Doctors and hospitals cannot by law charge less than Medicare rates, but Medicare rates often are acceptable if the provider can get the cash at the time of service and can circumvent all the office time to bill a third party.

In recent years, many people believed they could not afford health care when they actually could – at least before Obamacare kicked in.
Individual plans
were usually much cheaper than group, employer-based plans. A problem with group plans is they must cover everything for everybody. Therefore the sixty-year-old woman is paying for prenatal care and for pregnancy care, which she does not need. Before Obamacare, a twenty-five-year-old man with no medical problems could buy health insurance for less than $150 a month. Of course, it was much cheaper before the advent of Obamacare, which has already increased nearly everyone’s policy and made the “market” completely unpredictable.

I have been impacted in many ways by PPACA (or, to give credit where credit is due, “Obamacare”). But the most stunning attack on my person came recently in the form of insurance rate hikes. My older son is twenty-four, a medical student, and in perfect health. He has never smoked, is thin, has totally normal labs, is on no meds, and comes from a long line of hearty, healthy stock. It seemed appropriate to pay $47 a month for health insurance, which I have done for over a year now. Then, last month, I received notice from Coventry Insurance that, due to the new health care law, we had to make a choice from three options: (1) we could keep his insurance policy and pay four times as much – $167/month, (2) we could explore a different “ACA compatible” policy, or (3) we could try our luck at the Iowa “marketplace” – i.e., the Obamacare state exchange.

Each option had its own phone number.

Now, honestly, I’d rather sell my kid into indentured labor than put him on Obamacare, so I called the number for the new policy.
I did the appropriate button pushing but ended up at the state exchange. And I confess: after a short conversation with a probable navigator, I hung up, saying there was no way I wanted Obamacare. I also confess that I may have been a bit abrupt in my approach, thinking I would never talk to him again. So I dialed the number for option 1 – updating the original policy.