Awake at 2 o'clock?

In January of 2000 I was asked what I thought the first big change would be in the new century. I said (and it’s been documented elsewhere) that we would have a national health care plan by 2011. It wasn’t a brilliant conjecture. If you follow the percentage of GDP that we are expending on medicine as closely as I do, it has been obvious for a long time that what we have been doing up until now is unsustainable.

I further predicted that small business owners would lead the charge to Washington to demand relief from benefit premiums. I was wrong. As time goes on, I’m becoming less sure that small business owners will ever lead a political charge on anything. Instead they chose to opt out of the system in large numbers. Perhaps I should accept that as the driving force it became in reform. Business owners voted with their feet, and it was heard.

Many of our clients are asking me, “What does the health reform bill mean to us?” I don’t think I can predict the outcome of 2,000 pages (plus reconciliation bills) of new law. It will be challenged in the courts and interpreted by the regulators.Attorneys and medical billing consultants will find loopholes, and the government will acts (slowly) to close them.

I’ll admit I’m surprised that the bill passed without a national option. As a matter of principle I’m happy not to have another bureaucracy, but I haven’t seen anything in the current system to make me comfortable with pouring more money into it. The lack of meaningful cost controls is my biggest disappointment, and the one that scares me the most. I think we may have just bailed out the hospitals, insurance companies, pharmas and device manufacturers big time. Their executives can join the banks and hedge funds giving themselves huge bonuses from taxpayer dollars.Call me naive, but I figure there was a reason that all of the above industries spiked a new high on Wall Street on the day the Senate passed the bill.

Public sector employment and spending will account for 44% of the GDP this fiscal year. At 51%, if the government is officially bigger than the private sector, do we change our name to the People’s Republic of America? That doesn’t include most health care spending, of course, which is still officially “private” outside of Medicare/Medicaid. Health care is 18% of the GDP, and growing at two to three times the rate of the economy as a whole. You figure it out.

I had a screening procedure done last week. It was minor, but required general anesthesia. After I was prepped, just as they were putting me under, the doctor walked in (first time I met him) and said “If we see anything that needs taking care of, we’re just going to do it, OK?” What are you supposed to say after fasting for 39 hours, in a nightie with your butt hanging out and an IV in your arm? “No doc, I’d prefer that you wake me up, we’ll talk about it, and then if I agree I’ll go home and start this whole process again next week.”

Well surprise, surprise if it didn’t turn out that I needed something done! A couple of things, as a matter of fact. A small benign polyp was snipped (“Not a problem if we left it, but you never know for sure about these things.” $828 additional before lab fees) and my esophagus was a bit constricted, so “we” did a balloon dilation. ($1100)

Esophageal dilation is relatively new. At least I hadn’t heard of it, no one had briefed me on it prior to prepping, and it wasn’t mentioned a few years ago when I was last screened. In case you didn’t know it, unlike drugs there is no process in the US for approving new medical procedures. If someone thinks up something that they believe will work, they try it out. If they think it has good results (no studies or statistical analysis required) they start spreading the word. You may not be surprised to find that many new procedures are conceived by the device manufacturers.

So a couple of years ago the GI docs were at a conference, and the device reps paid for a nice dinner at which another doc, paid by the device companies, stood up and told them how happy he was with the new procedure. Afterwards, reps took the doctors aside and told them “This is a recommended (by whom?) procedure for any esophageal constriction over XX millimeters. It tales an extra 3 to 4 minutes while you are doing the screening procedure, and you can add $1,100 to XX% of your bills.” That is EXACTLY how it works. I’ve been there and watched it happen dozens of times when I was a consultant in that industry.This how fee for service medicine functions.

Does the procedure work? Who knows? I’m sure it is necessary in some folks, brings moderate benefit in others, and doesn’t do any harm (Hippocratic Oath) in 99.9%, so why not? An I’m certain an extra $330 a minute in incremental margin is tough to sneeze at.

When I woke up, I was pretty groggy, but they were in a big hurry to move me out of there. I had signed a form (one of many) on my way in agreeing to take payment responsibility for anything my insurer refused to cover. At the time of signature my estimated co-payment was about $285. When I woke up it was more like $1,800. They pushed the forms and credit card slip in front of me. Wait a minute! Didn’t I also sign a form before agreeing not to drive or execute any contracts for at least 8 hours after anesthesia? Wasn’t signing to pay a couple of grand a contract? Apparently that doesn’t count.

It occurred to me that my procedure was a lot like the health care reform bill. We went into it with the best of intentions. It will probably bring benefit to a lot of people. We really have no idea how much the final bill will be, and aren’t quite sure how the process will work. We do know that it will cost a lot more, that we will wind up paying for it, and that we won’t be in much of a position to make good decisions when the costs are incurred.

Just sign here.