healthy4u: bureaucracy

On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission. This speaks for itself.  I believe there are a great number of medical professionals who would speak out this way, if they did not fear retaliation (as does my colleague, hence anonymity) or if they were not suffering from the syndrome of clinician learned helplessness (<a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html</a>): <blockquote class="tr_bq">Scot, Yesterday I spent some time in a family docs office in [redacted] who has been experiencing an EHR failure in his office. Naturally its messed up his work flow not to mention occupying hours on end of his ostensibly personal time. His reaction was mostly one of frustration. In another situation, the ABMS is acquiring near dictatorial powers over physicians' livelihoods by essentially mandating an expensive, time consuming jumping through of hoops in the form of MOC requirements which may well evolve into MOL. Its a shakedown. Except for a few thousand members of AAPS that is seeking legal redress in Federal court, organized medicine is silent. Physicians who are undoubtedly frustrated just play the game in a grim resignation. Where is the moral outrage? Where is the righteous anger? Another physician, a close friend of mine, feels exactly the same way. This healthcare system is poisoning our souls and is engaged in a full frontal assault against our ability to ply our trade (which we have invested so dearly in) as critical, free thinking human beings. Extortion at its best. More ominously, we are being extinguished, not transformed,  as a profession. Remolded into subservient "providers". With little blow back. Can you even imagine any other profession allowing this to happen? Try bending a lawyer over a barrel. We are exploited blue collar workers without union representation. We are essentially working in a  meatpacking plant that Sinclair Lewis wrote of. I am so tired and ashamed of being associated with a gutless group of people who call themselves physicians. I just had to get it off my chest. </blockquote> If people remain indifferent to having their physicians bureaucratically overburdened and demoralized, the outcome will not be pretty in times of medical extremis. -- SS

On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission. This speaks for itself. I believe ...

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A Plague of Bureaucrats - Now 10 Per Physician in US Health Care

There seems to be a reasonable argument that the US health care system is more dependent on the private sector, and in particular the for-profit private sector, than systems in other developed countries.  Advocates of private, for-profit health care often tout the private sector as more efficient and less bureaucratic than government.   However, a <a href="http://blogs.hbr.org/2013/09/the-downside-of-health-care-job-growth/">post by Robert Kocher in the Harvard Business Review blog</a>, of all places, noted that US health care is increasingly inflicted by a proliferation - perhaps a plague - of bureaucrats. Dr Kocher looked at employment of physicians, other health care professionals and clinical workers, and bureaucrats in a more recent time frame, 1990-2012.  The key findings were: <blockquote class="tr_bq"> Using data from the Bureau of Labor Statistics (BLS) and the American Medical Association, my colleagues and I found that from 1990 to 2012, the number of workers in the U.S. health system grew by nearly 75%. Nearly 95% of this growth was in non-doctor workers, and the ratio of doctors to non-doctor workers shifted from 1:14 to 1:16.</blockquote> Furthermore, <blockquote class="tr_bq"> Today, for every doctor, only 6 of the 16 non-doctor workers have clinical roles, including registered nurses, allied health professionals, aides, care coordinators, and medical assistants. Surprisingly, 10 of the 16 non-doctor workers are purely administrative and management staff, receptionists and information clerks, and office clerks. </blockquote> So, in summary, for every doctor, there are 6 clinical workers (nurses, aides, etc) and 10 bureaucrats (including managers). Note that this data appears compatible with 1983-2000 employment data we <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">summarized</a> in 2005. During that period, the ranks of health care managers grew much faster than the ranks of physicians or nurses.  The growth rates from 1983 to 2000 were 1.39x (39%) for physicians, 1.54x (54%) for nurses, and a whopping 8.26x (726%) for managers. Another way to look at it is, in 1983 there was 1 manager for every 5.7 physicians and every 15.1 nurses. In 2000, there was 1 manager for every 0.96 physicians and every 2.9 nurses. Again, by 2000, the number of health care managers exceeded the number of physicians. There were more managers than any other species of health care worker other than nurses. So, by 2000, there was one manager per doctor.  By 2012, there were 10 bureaucrats, including managers, per doctor.  We have discussed the increasing power of managers, administrators and executives over health care.  Management gurus, such as Alain Enthoven, had advocated breaking the power of the supposed "physicians' guild" to reduce health care costs, and replacing physician leaders with managers (look <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-breaking-physicians.html">here</a>).  We have discussed the growing role of <a href="http://hcrenewal.blogspot.com/search/label/generic%20management">generic managers,</a> that is leaders trained only to manage, but not experienced in , and often not sympathetic to the values of health care.  Now there is increasing evidence that managers and bureaucrats are increasingly numerous in health care, the former somewhat and the latter greatly out-numbering physicians. We cannot scientifically prove that this plague of bureaucrats is responsible for US health care's mediocre quality and access, despite higher costs per capita than in any other developed country.  However, it does appear to be a reasonable hypothesis that increasing the relative numbers of health care professionals versus bureaucrats might produce at least more health care per dollar, if not also better health care per dollar.    This suggests that true health care reform requires decreasing the influence of generic management.  Health care leaders ought to be those with some knowledge of health care and some sympathy for its values. Such health care leadership might be less concerned with increasing bureaucracy, and more concerned with more and better actual care of actual patients.  (But do not expect such reforms to be popular with the very <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">well-paid</a> generic managers who now run health care, and hence do not expect such reforms to be easy to implement.)

A Plague of Bureaucrats - Now 10 Per Physician in US Health Care

There seems to be a reasonable argument that the US health care system is more dependent on the private sector, and in particular the for-pr...

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My doctor will now need to code for when I get bitten by George or Martha Goose

The bureaucrats always seem to find new ways to waste precious medical resources and capital to justify their existence. Here's the latest twist: I regularly feed swans, ducks and geese at my local park. In fact, I don't seek them out; the geese in particular come to me when they see me on the trail. They know me for years. They have tremendous vision, so I can't escape them. Per the WSJ, medical coding is about to become so hypergranular (could the reason be that bureaucrats needed work to do?) as to be reasonably considered insane: <a href="http://online.wsj.com/article/SB10001424053111904103404576560742746021106.html#printMode"> </a><blockquote><a style="font-weight: bold;" href="http://online.wsj.com/article/SB10001424053111904103404576560742746021106.html#printMode">Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way </a> New Medical-Billing System Provides Precision; Nine Codes for Macaw Mishaps Wall Street Journal Sept. 13, 2011 ... Billing experts who translate doctors' work into codes are gearing up to start using the new system in two years. They say the new detail is welcome in many cases. But a few aspects are also causing some head scratching. Some codes could seem downright insulting: R46.1 is "bizarre personal appearance (<a href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=bizarre%20personal%20appearance">see code</a>)," while R46.0 is "very low level of personal hygiene (<a href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=very%20low%20level%20of%20personal%20hygiene">see code</a>)." It's not clear how many klutzes want to notify their insurers that a doctor visit was a W22.02XA, "walked into lamppost, initial encounter" (or, for that matter, a W22.02XD, "walked into lamppost, subsequent encounter"). Why are there codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting—but not while shopping, wonders Rhonda Buckholtz, who does ICD-10 training for the American Academy of Professional Coders, a credentialing organization. ... Much of the new system is based on a World Health Organization code set in use in many countries for more than a decade. Still, the American version, developed by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, is considerably more fine-grained. The WHO, for instance, didn't see the need for 72 codes about injuries tied to birds. But American doctors whose patients run afoul of a duck (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=duck">see codes</a>), macaw (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=macaw">see codes</a>), parrot (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=parrot">see codes</a>), goose (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=goose">see codes</a>), turkey (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=turkey">see codes</a>) or chicken (<a style="font-weight: bold;" href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=chicken">see codes</a>) will be able to select from nine codes for each animal, notes George Alex, an official at the Advisory Board Co., a health-care research firm. There are 312 animal codes in all, he says, compared to nine in the international version. There are separate codes for "bitten by turtle" and "struck by turtle." (<a href="http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#term=Turtle">See codes</a>.)</blockquote>Examples: <blockquote>W6151XA Bitten by goose, initial encounter W6151XD Bitten by goose, subsequent encounter [Killer Goose?] W6151XS Bitten by goose, sequela W6152XA Struck by goose, initial encounter W6152XD Struck by goose, subsequent encounter W6152XS Struck by goose, sequela W6159XA Other contact with goose, initial encounter W6159XD Other contact with goose, subsequent encounter W6159XS Other contact with goose, sequela</blockquote> Sometimes my favorite Canada Goose couple, George and Martha, and their annual young'uns will overextend their beaks when being fed and nip my finger. They've never broken my skin (geese have no teeth, just ridges) but if they do ... my doctor is likely to have to code for "bitten by Canada Goose." I wonder if CDC will then send out the Goose Patrol. George and Martha, be careful, or your goose may be cooked! <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6XkUrBC9v9JI3_z1vZzaD7SRS3KZiDFUT-QxmGIJVfx14pvYTdMWaWBuiRvBLLM_aU6CWXdgVj7NOne0qYYqD6YPhmK9OJB_WY6eZc2j5PfNTPXUDySG-yaA_7Zckgu2ahU-YstxIQoCT/s1600/george.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5655569935392590242" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6XkUrBC9v9JI3_z1vZzaD7SRS3KZiDFUT-QxmGIJVfx14pvYTdMWaWBuiRvBLLM_aU6CWXdgVj7NOne0qYYqD6YPhmK9OJB_WY6eZc2j5PfNTPXUDySG-yaA_7Zckgu2ahU-YstxIQoCT/s320/george.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 296px;" /></a>George, I'm going to feed you, but don't W6151XD me (bite me) or the Feds will be after you ... (click to enlarge photos) </div> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAe5L0wj033ueltsLPJXXnedf8mLjn-omiaw3gaLKiIY7YktgdknAW7yyAC9ujlx2KRCCRwOtKbwFxYWjvcVtTH8DOBRqtpCJYUpc4tHAOtGRIb6HzKaxaFfvx5oPN5GP1xEtX8Q4LpIGq/s1600/younguns.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5655571722736097122" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAe5L0wj033ueltsLPJXXnedf8mLjn-omiaw3gaLKiIY7YktgdknAW7yyAC9ujlx2KRCCRwOtKbwFxYWjvcVtTH8DOBRqtpCJYUpc4tHAOtGRIb6HzKaxaFfvx5oPN5GP1xEtX8Q4LpIGq/s320/younguns.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 240px;" /></a>Young'uns, you better watch out, too! </div> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXo-FQb8mopRZE3moes-vRbr89rKLIhAWuRbW5gtrl9g76tMCsgDOOC7Tvpnys1OuKbk0LV0OpPg_vy6Y2OvXwi-58bqNM7LGveqzUfOxO67TBlY5wiLXBu_O9DEwWvw9Dap1zJmbJWpH_/s1600/molly.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5655632407985125138" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXo-FQb8mopRZE3moes-vRbr89rKLIhAWuRbW5gtrl9g76tMCsgDOOC7Tvpnys1OuKbk0LV0OpPg_vy6Y2OvXwi-58bqNM7LGveqzUfOxO67TBlY5wiLXBu_O9DEwWvw9Dap1zJmbJWpH_/s320/molly.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 240px;" /></a>This guy has already done a W6152XA and W6152XD to me with his wings, leaving me with a W6152XS (bruise on my leg) when I didn't feed him before the Canadas! You can just tell he's looking to create coding mayhem from that expression on his face. </div> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip1c7cDSM2ESwSl6Ktg6ILHijLkMH7uUEingai21n_-yBr43pxwUQDqLpdEkOnYZywmE5xzdiDllY9M-Hiiof6RNCnKe0xqyNHAVEKs8h943Y_4ggHNiRktvDK5GHMS8H9sPnx40mInWr5/s1600/duck.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5655571946029411026" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip1c7cDSM2ESwSl6Ktg6ILHijLkMH7uUEingai21n_-yBr43pxwUQDqLpdEkOnYZywmE5xzdiDllY9M-Hiiof6RNCnKe0xqyNHAVEKs8h943Y_4ggHNiRktvDK5GHMS8H9sPnx40mInWr5/s320/duck.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 240px;" /></a>Is there an ICD-10 code for "foot bitten by cute little Mallard duckie?" </div> What a perverse waste of resources this coding mania represents... Hat tip: <a href="http://www.galen.org/" style="font-style: italic;">The Galen Institute</a>/Grace-Marie Turner -- SS

My doctor will now need to code for when I get bitten by George or Martha Goose

The bureaucrats always seem to find new ways to waste precious medical resources and capital to justify their existence. Here's the late...

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Finding Out About Health Care Bureaucracy the Hard Way

A persistent theme for Health Care Renewal has been how concentration and abuse of power in health care trap patients and heath care professionals in a maze of bureaucracy, perverse incentives, deception, and conflicts of interest.  To anyone who has to make the transition from person to patient, some of these problems become immediately obvious.  Consider, for example,<a href="http://www.mediapost.com/publications/?fa=Articles.printFriendly&art_aid=129700"> this account</a> of "going into a hospital for a minor procedure": <blockquote>The very idea of being a patient is anathema. To people of my generation -- the 'me' generation -- who like to be in control, the experience begins with loss of control. First the paperwork -- three or four times paperwork has to filled out and given to a succession of strangers. Then they take all of your belongings, they tell you to take your clothes off, and make you put on a gown that leaves you nearly naked, put in you in very small room, bring you inedible food according to a schedule they determine. And if you try to sleep, they leave lights on, and do everything they can to make sure you can't. At the end, if you are lucky, they deign to discharge you. Those of us who are boomers, entering a period where we will be drawing the biggest healthcare expenditure, will not put up with this.</blockquote> This description of health care in the real world may not seem surprising to readers of <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>. When health care is run by <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">business people with no experience or training in actual patient care</a>, and controlled by a <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">proliferation of managers and bureaucrats</a> (whose numbers increased by a factor of 8.26x from 1983 to 200), usually with similar business backgrounds, all motivated by short-term financial incentives to "make the numbers" at all costs, what other result would one expect? Of course, many people outside of health care may not appreciate these problems until they become patients themselves. The person who wrote the description above apparently had avoided in-patient hospital care until the events he described, so on that basis his surprise can be excused.  On the other hand, his outrage was understandable. But wait - the above is actually a quote by a speech to the Innovation Forum by no other than Jeffrey Kindler, Esq, the current CEO of Pfizer, the world's largest pharmaceutical company. So his apparent surprise at what he found when he became a patient is ample evidence how unfamiliar he had been with real health care on the ground until this experience.  In fact, that the CEO of the world's largest drug company was so unfamiliar with the real world of health care until he had to become a patient ought to prompt some outrage too.  I am not recommending that all executives of health care organizations undergo procedures. However, making sure that no one gets to a top leadership position in a health care organization without some real world health care experience might lead to some salutary changes in how health care is run. Also, we noted <a href="http://hcrenewal.blogspot.com/2010/05/corporate-proxies-suggest-ceos-rewarded.html">here</a> that Mr Kindler had been rewarded last year by his board of directors for his "constructive participation in the US legislative process to advance Pfizer's goals of achieving a more rational operating environment...." Maybe had he had his minor procedure earlier, he might have also wanted to advance the goal of making health care less bureaucratic and more focused on the patients. Hat tip to Jim Edwards' <a href="http://industry.bnet.com/pharma/10008488/how-pfizer-ceos-hospital-stay-was-a-kafkaesque-prison-of-his-own-making/">blog</a> on BNet.

Finding Out About Health Care Bureaucracy the Hard Way

A persistent theme for Health Care Renewal has been how concentration and abuse of power in health care trap patients and heath care profess...

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Are the Health Plans of the Very Rich Different from Yours and Mine?

Yesterday, the New York Times published an intriguing <a href="http://www.nytimes.com/2009/07/27/health/policy/27insure.html">story</a> about "Cadillac" (that is, expensive) health insurance plans, <blockquote> Goldman Sachs is one of the nation’s richest banks, and hundreds of top Goldman employees have a health care package to match — one of the 'gold-plated Cadillac' plans cited by those involved in the health care debate in Washington. Goldman’s 400 or so managing directors and its top executive officers participate in the bank’s executive medical and dental program as part of their benefits, according to documents filed with the Securities and Exchange Commission. The program generally costs the bank $40,543 in premiums annually for each participant’s family. Those taking part in the plan include the company’s chief executive, Lloyd C. Blankfein, and four other top officers, as well as managing directors, whose base salary is $600,000. Goldman’s medical coverage entered the health care discussion on Sunday when David Axelrod, senior adviser to President Obama, cited the Goldman program as an example of the expensive benefits the administration might consider taxing to help pay for its health care program. 'The president actually was asked this the other day by Jim Lehrer, and what he said was that this was an intriguing idea to put an excise tax on high-end health care policies like the ones that the executives at Goldman Sachs have, the $40,000 policies,' Mr. Axelrod said. A proposal by Senator John F. Kerry, Democrat of Massachusetts, would impose an excise tax on the insurers that issue policies like Goldman’s, with the expectation that the insurers would pass along most, if not all, of the cost to employers who buy the plans. Leaders of the Senate Finance Committee, which is working on bipartisan version of the health care legislation in Congress, had long expressed interest in taxing some employer-provided benefits — a move many budget experts say would help slow the steep rise in health costs. Negotiators have not yet determined the value of the plans that would set off a tax on the insurance companies; the numbers under discussion range from $20,000 to $40,000 annually, a senior administration official said. The lower end of that range would increase the amount of money the tax would raise but would also hit some middle-class workers, whose unions in some cases negotiated robust health benefits in lieu of pay increases. Typical employer-provided plans cost $13,000 to $20,000 per family, depending on the location and the age of the plan participants. A health care package costing $40,000 or more a year would generally have no co-payments or deductibles, according to Paul Fronstin, an analyst at the Employee Benefit Research Institute, a Washington nonprofit that studies benefits. It would also have no limits on doctors or procedures, no restrictions on pre-existing conditions and no requirements for referrals. Few people have such policies, Mr. Fronstin said. 'It would only be top executives who run big businesses, mainly people in the C suite,' said Mr. Fronstin, referring to companies’ chief officers. </blockquote> It was not clear from this article how many top corporate executives have such plans, and whether leaders of other kinds of organizations, like large not-for-profits, also have them. My main concern about such plans is not how much they contribute to top corporate leaders' compensation packages. Such packages are generally already so outrageously huge that providing $40,000 rather than $13,000 worth of health insurance is a trivial increase. My concern is not that plan recipients' demands for health care will collectively increase health care costs, because they include only a tiny portion of the population. My main concern, instead, is how much these plans further insulate already cocooned top executives from the vicissitudes of daily life, particularly related to coping with our current dysfunctional health care system. What benefits executive health care plans provide is not clear, but presumably they insulate executives from having to deal with the managed care/ health insurance bureaucracy which frustrates patients seeking particular services, but not necessarily the most expensive, or least beneficial services. Such executives might thus not have gut level appreciation of how dysfunctional the health care system has become for even insured patients. Since top executives often are disproportionately influential members of the "<a href="http://hcrenewal.blogspot.com/search/label/superclass">superclass</a>," their disconnection from the realities of dysfunctional health care is likely to translate into little real support by the powers that be for meaningful health care reform. There support may be further retarded by the influence of their fellow superclass members whose personal fortunes depend on the status quo in health care. Real improvement of health care may depend on finding leaders who have better understanding of the plight of real people.

Are the Health Plans of the Very Rich Different from Yours and Mine?

Yesterday, the New York Times published an intriguing story about "Cadillac" (that is, expensive) health insurance plans, Goldman...

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Tommy Thompson on the US Department of Health and Human Services Bureaucracy

Tommy Thompson on the US Department of Health and Human Services Bureaucracy

This isn't new, but I just found it, and couldn't resist posting it. This quote appeared in the Milwaukee Journal Sentinel last mont...

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