It’s the dog days of what seems to have been an unusually hot summer (though DrRich does not know whether it has been sufficiently warm to affect the global cooling trend we’ve been in for the past decade), and as is all too common at this time of year, we are seeing extraordinarily heartbreaking stories, (like this one), about healthy, robust young athletes dying suddenly on the practice fields.
Most of these tragic sudden deaths are due to a heart condition called hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy often does not produce any symptoms prior to causing sudden death. But it can be easily diagnosed, before exercise-induced sudden death occurs, by screening young athletes with electocardiograms (ECGs) and echocardiography.
A couple of summers ago, the New York Times wrote about such an athletic screening program at the University of Tennessee. Based on the U of T’s results, “Cardiologists and other heart experts say that the screenings could help save the lives of the 125 American athletes younger than 35 who die each year of sudden cardiac death.”
The reason this routine cardiac screening is not widely used is because of the expense. Making the very conservative assumption that 1 million young Americans participate in athletic competition each year, and that (as the Times reports) the average cost of screening is $1000, then screening would cost us about $8 million to save one life. That’s pretty a steep cost-effectiveness challenge by any standard.
But Dr. Douglas Zipes (the perennial New York Times expert on matters cardiac) speaks for many of us when he says, “If it were my son playing ball, I would like him to have an echo, even though it is cost inefficient.”
In truth, the cost-effectiveness analysis here presents a problem only because the kind of screening being used is judged to be a medical service, and thus ought to be paid for through some centralized pool of money (whether the pool is controlled by insurance conglomerates or the government).
If we were to do a similar cost-effectiveness analysis on seat belts, smoke alarms, motorcycle helmets, or carbon monoxide detectors, we would reach a similar conclusion: Yes, those several hundred preventable deaths from house fires are indeed a tragedy, but we simply can’t afford to pay for smoke alarms for all those millions of American families, just to save those relatively few lives.
The difference, obviously, is that we don’t expect smoke alarms to be paid for out of public funds. We expect individuals to do their own cost-effectiveness calculation, and decide whether to buy smoke alarms from their own resources. Individuals tend to place a much higher value on their own lives than the value assigned to their lives by society (the self-assessed value of one’s own worth often approaching infinity), and therefore many people indeed find the cost-effectiveness calculation to come out in their favor. Thus, buying smoke alarms seems a reasonable investment for many individuals.
If Dr. Zipes wants his son screened by echo, by all means have it done. I agree it would be entirely worthwhile. But don’t ask me to pay for it.
It is especially noteworthy that the technology exists to place cheap, portable echocardiogram machines in the office of every primary care doctor, and every primary care doctor could be easily trained in less than an hour to rapidly screen athletes for hypertrophic cardiomyopathy. For probably less than $100, parents like Dr. Zipes could have their children screened with this kind of limited echo and an ECG at the same time they’re getting their flu shots.
But we can’t do this because a) professional groups like the American College of Cardiology will do everything they can to block the democratization of guild-based procedures like the echocardiogram (start-up companies that have developed such tiny, easy-to-operate echo machines have been very disappointed with the response of the cardiology community), and b) such screening is a medical service, and it’s generally acknowledged to be a travesty to expect (or, as DrRich points out, to allow) individuals to pay for any medical service themselves.
And if such obstacles result in the sudden deaths of a hundred or so young athletes each year (most of whom, by the way, are participating in pick-up or intramural sports, rather than the semi-pro variety we watch on TV every March), well, it’s too bad there’s nothing we can do about it.
DrRich entered medical school 40 years ago with every intention of becoming a general medical practitioner, and indeed he became one. But after only a year in practice as a generalist, he found himself so frustrated with the frivolous limitations and the superfluous obligations that even then were being externally imposed on these supposedly revered professionals, that DrRich altered course and spent several years re-training to become a cardiac electrophysiologist.
(Electrophysiology is a field of endeavor so arcane as to be mystifying even to other cardiologists. DrRich hoped that the officious regulators and stone-witted insurance clerks would be so confused – and possibly intimidated – by the mysterious doings of electrophysiologists that they would leave him alone. Happily, this ploy worked for almost 15 years.)
Still, DrRich has always held general practitioners (now called PCPs) in the highest regard, if for no other reason than these brave souls – unlike DrRich himself, who cut and ran at his earliest opportunity – have stuck it out.
But, as we all know, the practice of primary care medicine is today in crisis. Today’s PCPs are mostly looking to get out as soon as they can afford to do so, and today’s medical students are avoiding primary care in droves.
But not for the reasons most often claimed. DrRich’s contention is that doctors are abandoning primary care medicine for reasons that actually have relatively little to do with low pay and high educational debt. The real reasons have much more to do with the fact that primary care medicine has been systematically and purposefully demeaned and diminished, to the point that it has become nearly an untenable choice for most doctors.
Accordingly, every now and then DrRich likes to point out – for the edification of his readers – some of the ways in which this fundamental devaluing of primary care medicine is being accomplished.
And so, here’s another reason it sucks being a PCP:
PCPs whose patients fail to quit smoking are now at risk not only of being publicly labeled as low-quality physicians, but also of being sued.
To see how this works, dear reader, DrRich asks you to place yourself, for a few minutes and for the sake of empathy, in the position of a modern American PCP.
As a PCP, one of the major banes of your existence is the struggle you must make during each and every “patient encounter” to get through a long Pay-for-Performance Checklist (different checklists for different patients, depending on their insurer). Completing these checklists, within the 7.5 minutes that have been graciously allotted to you for such encounters, is of course critical in order to demonstrate to the appropriate healthcare accountants the adequacy of your performance as a modern, high-quality American physician.
One item that invariably appears on each of your mandatory checklists, doctor, has to do with counseling your patient on smoking cessation. It’s likely you may have thought this to be one of the less objectionable mandates you must accomplish during each patient visit. After all, you can get through your well-rehearsed pitch on smoking cessation in 20 seconds or less (unless you are dealing with one of those rare patients who is actually serious about trying to quit), and thereby make up some of the precious time, from your 7.5 minutes, that you have already spent achieving some more challenging check mark (trying, perhaps, to talk a diabetic patient into taking the extraordinary steps necessary to get his hemoglobin A1c down that last 0.5% to target).
So: 20 seconds spent on smoking cessation. Check.
But whoa. Not so fast there, Dr. Welby.
Did you know there are guidelines for physicians on smoking cessation? Did you know that these guidelines were devised under the auspices of the federal government, by a committee of individuals who are anti-smoking zealots (not that there’s anything wrong with that)?
From this latter fact, of course, there are certain things you will already know about these guidelines before you ever see them. You will know that the guidelines must be very long and detailed and tedious, because a) they are federal guidelines, and b) they are devised by people whose one and only mission in life – a mission they clearly believe is far more important than, say, oil spills, terrorism, global warming, jobs, or achieving fine and durable erections upon demand – is to save the world from the scourge of smoking. And now, these zealots have been granted the authority (i.e., the federally-approved authority to generate medical guidelines) to make it your primary mission in life, too.
Now, doctor, have a peek at the actual guidelines, which you can find here. Notice, first, that the federal guidelines for physicians on smoking cessation are 196 pages long. Notice how they step you through the process of counseling, and then step you through each of the measures you must take in order to guarantee that your patient achieves total success. And notice that an early branch point in the process of counseling is the one where the patient informs you whether he/she is willing to go any further with efforts at smoking cessation; and notice further that when the patient concludes that he/she is indeed NOT willing to go any further, thank you very much for your concern, the guidelines do not relieve you of further immediate obligations – no – but instead specify additional interventions you must now, at this moment, embark upon with this unwilling patient, which are “designed to increase their motivation to quit.”
The brash sales techniques required of you by the federally-sanctioned smoking-cessation guidelines would embarrass even a telemarketer, or an annuity salesperson.
This, of course, is all to say: Your 20-second spiel on the evils of smoking just doesn’t cut the mustard, doctor. To really earn that smoking-cessation chit on your P4P checklist, you need to do a lot more than that. The 196 pages of deadly serious federal guidelines detail what that is.
Lest you are tempted to dismiss as an absurdity the expectation that you are actually supposed to cram 2 hours of anti-smoking counseling into a 7.5 minute patient visit, there’s one more thing you ought to know.
One John Banzhaf, Executive Director and Chief Counsel for Action on Smoking and Health (ASH), who bills himself as the “law professor who masterminded litigation against the tobacco industry,” is not taking lightly, doctor, your obvious laxity in following federal guidelines on smoking cessation. Accordingly, some time ago he sent letters to each of the 50 state health commissioners warning them that he will soon begin instigating medical malpractice suits, on behalf of smokers who continue to smoke as the result of their doctor’s refusal to follow federal guidelines to the letter.
Mr. Banzhaf informs the commissioners that “physicians are killing more than 40,000 American smokers each year by failing to follow federal guidelines.” That’s right, doctor, you’re killing them. (Cigarettes don’t kill people; people kill people.) Specifically he invokes your sacred obligation to “warn the smoking patient about the many dangers of smoking and provide effective medical treatment for the majority who wish to quit.” (Emphasis DrRich’s.) That is, it’s your job not just to counsel them and treat them, but also to see that they actually succeed in quitting. If you don’t follow this mandate, you’re killing them. And you must pay.
When the federal government takes the pains necessary to draft detailed management guidelines for physicians, guidelines that, if followed as written, will save tens of thousands of lives each year, then surely society has every right to expect you to follow those guidelines to the letter – and to save those lives.
This is such a brilliant scheme for ending smoking-related death and disability, one must wonder why it hasn’t yet been applied to other intractable medical problems. Just think of all the good that could be accomplished, for instance, by federal guidelines requiring PCPs to assure that each of their patients maintain an optimal body weight, follow an exemplary diet, exercise vigorously for at least an hour a day, maintain unfailingly positive attitudes, and work diligently at their allotted tasks each and every day (secure in the knowledge that adopting right thinking and right behaviors will be invaluable to our dear leaders, as they bravely go forth to assure the good of the whole).
In any case, doctor, consider these anti-smoking guidelines carefully next time you’re putting that little check mark next to “Smoking cessation counseling” on your P4P checklist, and ask yourself: “Have I really done all that I am obligated to do, under the law, to guarantee that this patient has lit up his last smoke?”
Making PCPs responsible for their patient’s personal choices and behaviors, of course, is a time-honored method of covert healthcare rationing. It gives doctors powerful incentives to invent mechanisms for avoiding patients who display obviously unhealthful lifestyles, thus making it relatively inconvenient for these patients to gain access to expensive healthcare services.
But more to the point of this post, it is yet another example of how micromanagement by politicians, activists and bureaucrats has come to infest the practice of primary care medicine, and to relegate PCPs to the diminished role of simply following the checklists continually produced by such as these. If this is what primary care medicine has come to at last, why would you expect anyone who has a choice to take such a career path?
DrRich, for one, does not believe the 10-15% increase in pay hinted at by Obamacare will change the calculus for PCPs very much, and in fact, if it does – given all that is being done to primary care medicine – we should all be very much distressed by the implications.
DrRich is relieved to learn that the world’s most famous global warming experts have now been exonerated by three separate formal reviews. Dr. Michael Mann from Penn State University was cleared by a review conducted by Penn State University. Dr. Phil Jones, Director of the University of East Anglia’s Climate Research Unit (CRU), was cleared by a review conducted by the University of East Anglia, and also by a four-member “independent panel,” one of whose members was Prof. Geoffrey Boulton, a personage who had been on the faculty of East Anglia’s School of Environmental Sciences for 18 years, and who (prior to being placed on the “independent panel”) had been a vocal defender of Dr. Jones’ actions regarding Climategate.
Right-wing global-warming-deniers, of course, have decried the results of these reviews as a “whitewash,” pointing out, among other things, that Penn State and East Anglia both continue to receive tens of millions of dollars in federal “research” funds so they can continue to prove that global warming a) exists, and b) is man-made, thus suggesting that these institutions were determined to acquit their star grantsmen of scientific misconduct no matter what the objective findings. This kind of whitewash, they say, not only supports the global warming “hoax,” but even worse, further undermines the integrity of the scientific process upon which so much of modern society so utterly relies.
Of course, if right-wingers are correct, then reversing modern society and putting us all back in the glorious horse-and-buggy days is the very goal of the global warming mavens. (DrRich, a student of history, is well aware of how difficult it must have been 110 years ago to walk the streets of New York City without ending up splattered with dung to your knees, and he wonders what life would be like today, navigating the highways and byways of America, if all 300 million of us were relegated again to modes of transportation that defecate nearly continuously.)
It must be admitted, by anyone who has perused some of the leaked e-mails sent and received by Dr. Jones (making it doubtful that any of the three review panels had actually done so), that from any really objective viewpoint the global warming experts had engaged in some very questionable behaviors, which appear to have been aimed at advancing their theories, and suppressing any opposition, by any means at their disposal. The e-mails depict Jones and prominent colleagues discussing how to “tweak” climate change data in order to hide such embarrassing climatic phenomena as the Medieval warming period, “the little ice age” that followed it, and the global cooling we’ve been seeing over the past decade. Including these historical temperature fluctuations in their data would make their famous hockey stick graph look less like a hockey stick, and more like the random profile of a mountain range. (And once Al Gore won an Oscar for showing slides of the hockey stick, that was not an option.) They also collaborated to “control” the peer-review process so that only the “right” peers would be doing the reviewing, and the “wrong” peers would be cut off altogether. And, as a final deft touch, they all shared electronic high-fives when a noted global warming skeptic died unexpectedly.
Then, of course, just a few days after the embarrassing e-mail leak, the CRU was forced to admit (thanks to Britain’s Freedom of Information act) that they had, apparently intentionally, destroyed all the raw temperature data upon which their elaborate computer models were based. (They say they ran out of space to store it, apparently failing to recall the many forms of magnetic storage readily available to scientists today). The destruction of this data utterly precludes other scientists from checking, and attempting to reproduce, the critical predictive model upon which the theory of man-made global warming largely rests.
This inconvenient truth renders their climate change model a black box. It places the rest of us in the position of having to “just trust” the global warming experts, upon whose work (for instance) President Obama bases his proposal for a fundamental change in our economy, our way of life, and our foundational political philosophy.
So it is perhaps somewhat understandable that right-wingers object so vociferously to the alleged “whitewash.” Their general complaint seems to be that the scientific process should always be pristinely unbiased, and that the gross bias so clearly displayed by global warming experts in this case not only corrupts the case for global warming, but also corrupts the scientific process itself, to the extent that every scientist in the world should be screaming for the heads of the miscreants, and indeed, must do so, to salvage the very legitimacy of science.
DrRich is sympathetic to the argument that the implications of Climategate are troublesome, but not because the climatologists have behaved in a terribly biased way. Biased thinking within a scientific debate is not only common practice, but also it is a critically important part of the process. Raw contention between very biased scientists with very different viewpoints is how we get scientific progress in the first place. DrRich is not even disturbed that the currently-entrenched global warming experts have used their position of relative strength to suppress the upstarts who dared to oppose them. That’s also pretty much standard behavior in the academy, and it, too, serves a useful purpose.
Rather, what’s troublesome about the global warming controversy is that outside authorities of incredible power have taken an extraordinarily strong position in the scientific debate, and have lent their massive influence to one particular side. Whenever this sort of thing happens, the “winner” of the scientific contest is often not determined by superior scientific merit, but by other factors.
Scientific progress works like this: A new theory is conceptualized to explain some phenomenon, usually by a whippersnapper of one variety or another. The entrenched experts, whose careers, reputations, social status, incomes, and sexual fulfillment are based on the old conception, find the new theory to be absurdly wrong (or in some cases heretical), and probably dangerous. Since preserving the “truth” is the highest calling of all, the experts engage in every device they can muster (from “controlling” the peer-review process to burning heretics at the stake) to see that the truth (as they define it) prevails.
To the uninitiated – and certainly to the upstart whippersnappers – this process seems primitive and unkind. But actually it is quite useful and practical, and in the long term is very beneficial to mankind. For most of the new theories thought up by whippersnappers are, in fact, garbage. In order to break through the imposing barriers of bias constructed by the entrenched experts, the novices really have to believe in what they are espousing, and their new theory, ultimately, has to actually offer some substantial improvement over the currently accepted one. The whippersnapper, if very lucky, finally becomes the foundation of a new generation of experts – and the process begins all over again. Hence, science progresses. The process is geared toward the gradual discovery of truth, and not toward the nurturing and vindication of whippersnappers. And eventually, truth always does prevail – and often it does so within just a few generations.
In the short term, of course, this process can look very messy and unfair. It is certainly subject to great bias. In fact, we take pains to set up the accepted experts with lots of grant money, prestige, titles, &c. precisely to make sure they’ll do everything they can to preserve the status quo. We do this so that when the paradigm actually shifts, it shifts because the merits of the new paradigm are sufficient to overcome all the bias – and not because of a whim. This process keeps science – and society – from being whipsawed this way and that.
Where the process breaks down is when a powerful outside influence – say, a religion or a government – firmly takes a side in the scientific debate. For example, just ask any of the would-be astronomers from the time of the pre-Renaissance Popes how well the scientific process of competing biases worked out for them.
It seems apparent, to DrRich at least, that most of the world’s governments, including ours, find that the bias of the global warming experts very nicely aligns with the historical bias of governments, which is to say, accruing ever more power over the endeavors of the people. It may possibly be for this reason that governments have thrown in – body and soul – with this side of the debate, to the extent that “global warming” has now become largely sacrosanct. Man-made global warming is officially deemed (like the 2011 U.S. Budget) to be “settled science,” and is beyond reasonable question. No new scientific evidence to the contrary is admissible. Competing viewpoints are, in fact, heretical. And even when gross evidence of academic misbehavior on the part of global warming experts is revealed, that evidence is excused, paved over and ignored.
This mindset is the only one that fully explains the tone and the content of the Climategate e-mails, and the subsequent exoneration of the climate scientists who wrote them.
Most readers, DrRich expects, agree with him to this point. (For, how could it be otherwise?) But, you may be asking, what does any of this have to do with healthcare, or more specifically, with healthcare rationing?
As we enter into a new era of healthcare, where medical decisions will be taken out of the hands of imperfect physicians and entrusted to panels of federally-sanctioned (and thus pretty much infallible) experts, who will analyze the available data and construct the guidelines of behavior by which all physicians will henceforth be judged, we ought to keep the problem of unbalanced bias in mind.
Today we have a healthcare system in which competing interests, and their competing biases, battle for prominence. The process is messy, ugly and often unfair, but with long-term results that are generally reasonably favorable. Or at least, the damage is generally contained. But we are headed toward a healthcare system in which only one great interest – that of our government, with its overwhelming bias toward cutting the cost of healthcare – will predominate.
A great fallacy under which many of us labor is that the government has no strong biases, and that a process overseen by the government will be inherently far more “fair” than a process that incorporates the biases of for-profit enterprises. But in truth, the government is the biggest, meanest, special interest of all. And like all sovereign authorities, this one is not only able to, but is expected to get the results it deems necessary by the measured application of violence.
For those who believe any government, anywhere, which has total control over any human enterprise can still behave fairly, DrRich begs you to please have another look at history. When we allow government (and its agents) to have the only say over medical decisions, then those medical decisions will be made with all the robust, open-minded, free, give-and-take exchange of ideas we are seeing from the global warming experts today. And while medical progress – like progress in general – cannot be forever halted, it will become as sclerotic as the scientific progress enjoyed by those pre-Renaissance astronomers.
The scientific process will always be biased. Where we invite serious damage is where we admit only one form of bias, and forcibly stifle all the rest. It’s bad for climate science, and it will be bad for healthcare.
DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.
Since the late 1990s, American physicians have labored under a set of tortuous documentation requirements imposed upon them by our government. The E&M guidelines (for “evaluation and management”), apply to the documentation that physicians are now obligated to provide in support of their Medicare billing. The E&M guidelines, first instituted in 1995 and revised in 1997, were part of the Clintons’ great fraud reduction initiative. Ostensibly, the strict documentation requirements reduce the opportunity for fraudulent billing.
While doctors initially railed against the E&M guidelines, they now suffer them in relative silence. The E&M guidelines have become, in fact, just one more hurdle which doctors must navigate as they pick their way through the vast obstacle course that now defines the practice of American medicine. Indeed, younger doctors accept the odious documentation requirements as a matter of course, knowing nothing better, just as children born into the direst third-world slums accept their abject poverty without notable complaint.
But occasionally, physicians of a certain age, dimly remembering how it ought to be, will still complain about these guidelines. One of these is revered fellow blogger DB, who (unlike DrRich) is still in the trenches, and must deal with – and try to teach trainees how to navigate through – this abomination on a daily basis. Accordingly, DB is periodically moved to remind us of what he graciously believes to be the unintended consequences resulting from the E&M guidelines, which is to say, DB seeks to remind us that current medical documentation requirements get in the way of good and efficient patient care.
For some, however, even this sort of mild-mannered, exceedingly polite objection is not to be countenanced. One of DB’s correspondents fired back at him:
“The templates are there to serve as a guide, not a hinderance. If you don’t like your “guide” then work to change it. You shouldn’t look at this “guide” as a form of billing, but rather as a guide in making sure you have covered your bases when seeing the patient. Proper documentation can lead to quality care and positive patient outcomes.”
This, indeed, is the official government position on E&M guidelines. It is so official, in fact, that it moves DrRich to wonder whether Cass Sunstein has actually implemented his well-documented anti-conspiracy strategy, and thus has dispatched armies of government-approved agents to monitor and actively counter “untruths” which are unfriendly to government aims, wherever they are found.
In any case, DrRich is not as polite (or as circumspect) as DB, and so he will say it outright.
The E&M guidelines were established for the specific purpose of controlling the behavior of physicians, to further the goals of covert rationing.
First and foremost, they create a Regulatory Speed Trap of the first order, so that with each and every patient encounter the item that will be foremost in the physician’s mind is not the needs of the patient, but in filling out the complex documentation in such a way as to avoid the appearance of committing a fraud. In practical terms, this means filling out the documentation so as to blend in with the masses, so that one’s records will be passed over by the sharp eyes of the greedy forensic accountants (who are paid by commission for detecting instances of substandard documentation, which are now construed as “fraud”), or even worse, by the sophisticated software now being deployed to detect ever-more nuanced gradations of “outliers.”
A classic post by The Happy Hospitalist describes the mysteries of E&M documentation better than any other attempt DrRich has seen. HH’s description of the documentation hoops through which physicians now must jump is detailed enough that it’s actually difficult to read. Which is the point.
Through their utter opacity and complexity, only partially reflected by the 48 pages of dense prose that comprise them, the E&M rules (for “rules” is what they are) in fact greatly magnify the doctor’s opportunity for making inadvertent documentation errors, and thus of producing a “fraudulent” bill. HH’s post nicely demonstrates how writing a progress note according to the E&M rules requires assembling a complicated set of “elements” from Column A and Column B, as from a Chinese menu, for each of four subject areas of the patient encounter – the history, the physical exam, the assessment, and the plan. Then somehow, one must translate the result (which reads like – and often is – a computer-generated form letter) into the proper, fully-supported billing code.
Even if this mess led to a straightforward means of determining proper billing codes (which it does not), it results in a medical progress note that is virtually undecipherable. This means that when another doctor (or even the same doctor on a different day) tries to read the progress notes to figure out what’s been going on with the patient (which used to be the point of medical progress notes, before they became primarily a vehicle for auditors), they cannot. Compliance with the E&M guidelines can thus actively confound patient care.
When the E&M guidelines were first introduced, they were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians (and the arrival on the scene of a new Republican administration) caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The commission concluded that indeed, the E&M guidelines were entirely counterproductive to patient care, and in June, 2002 voted (20-1) to recommend abandoning them altogether.
But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in force “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care – knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignation of the medical community.
(This simple example ought to teach us how difficult it will be to roll-back any of our new healthcare reforms in the future, even ones that are officially deemed to be harmful.)
Accordingly, not only has HHS failed to take (or, alternately, succeeded in not taking) steps to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them. And, as the bureaucrats must have predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now.
What’s more, there never will be. Save for the occasional exhortation from an old fossil (sorry, DB), the E&M guidelines have been fully absorbed into modern medical practice. They have become normal.
Accordingly, a multi-million dollar industry has sprung up to help physicians better comply with these coding guidelines. Physicians across the country are spending the time and money allotted for their continuing medical education learning to become better accountants, rather than better physicians.
Which brings DrRich to his last point: It is not actually possible to follow the E&M guidelines to anyone’s satisfaction.
There is, in fact, no “correct” way to code, because correct coding is impossible. This verity was proven a few years ago when a group of specialized government-sanctioned coders took a sample of typical doctor-patient visits, coded them according to their own E&M guidelines – and they all got different answers. (The results of this study were published in the Annals of Emergency Medicine in September, 2002.)
Obviously, then, since there is no “right” way to comply with the coding rules, any doctor toward whom the fickle finger of fate points the Feds is very likely to be found guilty of abuse, if not outright fraud. And what we’ve got here is a well-documented, openly acknowledged, peer-reviewed and published Regulatory Speed Trap.
Here’s what happens to doctors who are found to commit coding abuse (which is to say, to any doctors who are visited by Federally-sanctioned auditors):
1) A small sample of their patients’ charts is audited.
2) The error rate (with the auditor determining retrospectively what an error is) is calculated for that sample, then that rate is applied by extrapolation to all the Medicare billing the doctor has done for the past 6 years (the statute of limitations).
3) For each violation in coding the doctor is calculated to have committed during those six years, the doctor must pay a) triple the amount of restitution, and b) $11,000.00 (per coding violation).
It is not unusual for audited doctors to be hit with hundreds if not thousands of coding violations over a 6-year period, and the fines will almost always amount to well over 7 figures, if not 8. Even rich doctors usually can’t afford that kind of damage. However – if it’s just abuse the doctor has committed and not fraud – often the Feds may offer a settlement deal in the low 7 figures.
And here’s what happens if the coding violations are judged to be fraudulent (which, unfortunately, often appears a somewhat arbitrary designation):
1-3) All the above.
In summary, DB makes a very legitimate point, and has made this point several times over several years. Namely, the E&M coding rules are highly counterproductive to patient care. They produce medical records that are fundamentally undecipherable regarding actual medical content, even by medical professionals; and they distract physicians, with every patient encounter, into a fraud-avoidance exercise.
Sadly, however, DrRich does not believe that merely pointing out the harm being caused to thousands of patients each and every day by the E&M guidelines will do any good. Believing that it might do some good to call the Feds’ attention to it assumes that the harm is an unintended consequence, or at least, that it would be considered too high a price to pay.
This, DrRich feels obligated to reiterate, is demonstrably not the case. The Feds know that the E&M guidelines are harmful to patient care. Their own commission came to that very conclusion in 2002. The Feds know that failing to comply perfectly with the E&M guidelines in each and every case does not really indicate fraud and/or abuse, but is the necessary outcome when you institute a complex set of rules that not even the government’s own coders can interpret. Reminding the Feds of these facts, in public, may make them angry, but it will not change their position on E&M guidelines.
That the Feds continue to impose the E&M guidelines on physicians, despite the harm that they know this causes, tells us something very important about their underlying motives. When you are in the business of covertly rationing healthcare, controlling the physicians is Job One. And as George Orwell observed for us, when you want to control the behavior of some population, a critical step is to control the mode, the rules, and even the very language of communication.
That physicians continue to comply with such oppressions, despite the harm they know this causes, and (with notable exceptions) without serious complaint, tells us something important about them, too. DrRich would rather not say what that is.
DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.
The following is a close approximation of a talk DrRich gave to a gathering of some of the world’s most promising young cardiac electrophysiologists, in Nice, France, on June 15, 2010. He was asked to talk to these young physicians about physician-industry relationships. The organizers of this gathering apparently did not know, as anyone who reads this blog would know, that DrRich should never, ever be allowed an opportunity to influence promising young physicians. But, what’s done is done.
* * * * * * * *
A worldwide controversy is now roiling over the appropriate relationship between physicians and industry. Superficially at least, this controversy has to do with the undisputed fact that a physician’s relationship with industry can unduly influence his or her behavior.
That is, this controversy is said to be related to the conflicts of interest (COI) that are always inherent, to some degree, in such relationships.
I believe there is a deeper, and far more disturbing, reason behind this controversy, and I will address it in a short while. But let’s first talk about COI, because it is ostensibly the chief concern, and it is in fact a very important issue.
A COI is present when an individual has a sacred, fiduciary duty (i.e., a duty of trust) to Entity A, but then develops a secondary relationship with Entity B, which (by creating self-interest, competing loyalties, or even just an inability to be objective), threatens to interfere with the primary duty to Entity A.
Physicians, especially academic physicians, have (at various times) at least three primary fiduciary duties that must take priority. These are: a duty to patients when practicing medicine; a duty to students (i.e., actual students, colleagues, or the public) when teaching; and a duty to society (and truth itself) when conducting medical research. It is clear that ties with specific companies and their products can easily create important COI that may interfere with each of these primary fiduciary duties, and it is equally clear that physicians have commonly allowed this interference to happen.
Far more often than we like to imagine, doctors have allowed bias to creep in when recommending a course of action for their patients, in imparting knowledge to trainees, colleagues or the public, or when designing, analyzing or reporting results of clinical trials. And typically, most doctors who exercise inappropriate bias have convinced themselves that they are really acting in the best interests of their patients, students or society at large. For it is quite difficult to be objective about one’s own COI.
And there is no question that industry has become adept at the gentle art of creating COI among physicians (subliminally whenever possible), and have carefully incorporated the creation of such conflicts into their business models.
Obvious abuses we have all seen include doctors “shilling” for companies or their products at national meetings; clinical guidelines committees seeded with biased members; unbelievable amounts of money (well above “fair market value) being paid to key doctors for consulting services; long advertisements disguised as CME events; and ghost-writing scientific papers, then recruiting prominent physicians to sign on as “authors” after the fact. There are many others.
Such ongoing abuses of our fiduciary duties ought to be deeply embarrassing to us in the medical profession.
And if it’s not embarrassing, it is at least becoming painful. In the US, physicians who are discovered doing some of these things are being called out publicly, being investigated by Congress if not the Justice Department, losing their prestigious academic positions, and having their reputations destroyed. It is hard to be sympathetic toward them.
Despite all the negative attention – both public and legal – that such COI have brought to our profession in recent years, many of us continue to have tin ears. A recent example, which has caused a stir in the blogosphere if nowhere else, happens to relate to the EP community. (Thanks to Larry Huston of Cardiobrief who did the heavy lifting on this one. )
Recently, the ACC/HRS collaborated in the launch of a new website, called AFibProfessional.org, which is described as “a unique collaboration to address atrial fibrillation for the cardiology community.” The site has only one corporate sponsor – Sanofi, the maker of Multaq.
At the time of launch, all the content on this new website consisted merely of old, recycled material from older ACC and HRS websites, with a single exception. The single exception was a slide lecture by a prominent electrophysiologist, who we all know and love, on “Managing Atrial Fibrillation.” This lecture makes a strong case for the off-label, off-guideline use of Multaq. The lecture was posted without any COI disclosure statements, though the lecturer, it turns out, has significant financial ties to Sanofi. When the matter became a public issue, the lecture was pulled from the site, and the ACC promised to investigate. A few days later, the investigation apparently completed to the ACC’s satisfaction, the lecture was reposted, this time with a COI disclosure.
While one hesitates to suggest malfeasance here, it certainly looks bad. For the ACC and HRS to co-sponsor a brand new website that , by all appearances, is chiefly a vehicle for advertising Multaq suggests, if nothing else, that we in the medical profession, and our professional organizations, still don’t get it. If we don’t police our own COI, it will be policed for us.
What remedy should be applied? A reasonable approach would be to recognize that physician-industry ties will always bring at least some COI, and to manage the problem by strictly limiting inappropriate COI, and fully disclosing any that remain.
Accordingly, a number of groups – most prominently the Institute Of Medicine – have recently made formal, and tough, recommendations regarding physician-industry relationships. The final “rules” under which we will all have to live are still being negotiated.
But it is highly likely that they will include many if not all of the following:
- Doctors should not accept any gifts, no matter how small, from industry. These include trivialities such as pens and notepads, and more substantial gifts such as meals and travel.
- Doctors should not give presentations in which content is controlled or influenced by industry.
- Doctors should not consult for industry without a written contract, nor should they receive more than “fair market value” for consulting activities.
- Doctors should not accept drug samples from industry.
- Doctors who have a financial interest in a product or company should not participate in clinical trials in any capacity that involve that product or company, including patient enrollment, data collection, analysis or reporting.
- Doctors who have industry ties should not participate in the development of clinical guidelines.
- Medical schools and professional organizations should not accept direct funding, or attributable funding, for CME.
- Any interaction with industry will be fully disclosed, and made publicly available.
What this “full disclosure” will look like can be seen in the Physician Payment Sunshine Act, a law which is pending in the US. Under this act, all “transfers of value” totaling $100 or more in a year to any physician will be reported by each company to the government annually, along with each physician’s identifying information. Such “TOV” includes food, trinkets, entertainment or gifts; travel; consulting fees or honoraria; funding for research or education; stocks or stock options; ownership or investment interest, and any other economic benefit. This information will be posted on a public, searchable government website. Companies will be fined $10,000 for each incident of an unreported TOV.
You younger physicians will be spending your careers in a COI environment that is significantly different from that which we, your elders, have experienced. Activities that have been acceptable, and even encouraged, will now cause you to be publicly stigmatized, or worse. This matter is in great flux, and you need to pay close attention to it as the rules are changing. In the meantime, you need to choose your interactions with industry very carefully, and very circumspectly.
Everything I have just discussed assumes that the real issue regarding doctor-industry relationships is COI. Indeed, everything I have discussed assumes a particular way of looking at industry relationships, which I will call Theory A. Theory A, goes as follows:
- Medical progress is Good, and benefits mankind.
- Industry is responsible for a high proportion of medical progress.
- Industry-driven progress requires the active participation of physicians.
- Therefore, a well-managed cooperation between industry and physicians is beneficial to mankind, and ought to be encouraged.
If you subscribe to Theory A you believe that, because well-managed physician-industry relationships benefit mankind, these relationships are good. So, fundamentally, it’s the management of these relationships which is at issue. These beneficial relationships produce unavoidable COI, which we must manage by strictly limiting their extent, and fully disclosing the ones that are left.
On the surface, at least, that’s what the debate is about – where to draw the necessary limits. But just below the surface, the debate is about something else entirely. Beneath the surface, Theory A is rejected outright.
Today we hear prominent voices telling us that merely managing COI does not go far enough. No amount of COI is acceptable, and ALL physician-industry ties should be prohibited. Among these is Jerome Kassirer, former editor of the New England Journal of Medicine, who says, “The ideal handling of COI is not to have them at all.” For these voices, Theory A simply does not apply. Rather, (I submit) they subscribe to Theory B:
- The greed of medical industry creates excessive costs, and produces far more harm to society than good.
- Physician-industry alliances strengthen industry, and increase the harm.
- Therefore, crippling these unholy alliances is critical to the interests of society.
A corollary of Theory B is that it can only be the State’s job to cripple these alliances.
Proponents of Theory B, noting, not incorrectly, that medical industry is chiefly concerned with profits rather than the public good, conclude that industry will always behave in ways that are counter to the interests of society. While many proponents of Theory B will agree that industry provides at least some benefits, they are convinced that these benefits are far outweighed by the harm they produce. Therefore, Theory B proposes to stifle, if not cripple, medical industry. And a very useful strategy for achieving this goal is to de-legitimize any practical relationships whatsoever between medical industry and physicians.
Proponents of Theory B rarely say what their real goal is. Most of them give lip service to Theory A. One must discern their real motives from their behavior.
Much of that behavior, in practical terms, has to do with controlling the flow of information. Let industry develop whatever it wants (perhaps), but don’t let profit-drunk industry – or its greedy physician spokespersons – instruct doctors and patients on who gets to use industry’s products, or when and how.
That kind of information can only be managed by unbiased sources. Proponents of Theory B invariably refer to government-appointed panels of experts to determine which products of industry are good and bad, and to manage the flow of information about them. Information coming from anywhere else is to be regarded as being charged with bias and greed, and should be ignored, or even suppressed.
Inherent in this viewpoint is the notion that the State is an honest broker, with no bias of its own, except to do what is best for the population. The State, in its disinterested beneficence, is the only civil entity which can pass judgment on which medical information is suitable for general consumption.
But even as a general proposition, no government is an unbiased and honest broker. Politics, according to Harold Lasswell, an early Progressive political scientist, is determining who gets what, when and how. Government officials do not cancel their own human nature when they put on a government name tag. As they go about the business of determining who gets what, when and how, they inevitably – and most often intentionally – create various favored constituencies, fiefdoms, and clienteles to suit their own goal. That goal is to consolidate and expand their own authority. In this way, in the exercise of its political mandate the government always creates co-dependencies, and determines winners and losers. So even in the general case, the government cannot be an honest broker.
But with regard to healthcare, government bias goes far beyond the general case. Healthcare spending is the chief problem governments face today. In the US, projected Medicare expenditures over the next 30 – 40 years will be $35-55 trillion. Numbers like this are deeply destabilizing, and simply cannot be abided, and promise nothing but chaos, revolution, and societal disintegration.
To the State, controlling healthcare spending is an existential problem, a matter of life and death, an issue that justifies any solution that has even a slight chance of working.
Why is the cost of healthcare rising so rapidly? Fundamentally, it is medical progress. Medical progress has greatly increased overall healthcare expenditures. Simply consider, for instance, the many fatal illnesses we have converted to chronic, and chronically expensive diseases – coronary artery disease, kidney disease, HIV/AIDS, various forms of cancer, and heart failure, to name a few. Medical progress has made great strides in early detection and prevention, and preventive medicine always increases the cost of care. And thanks at least partly to medical progress, life expectancies are on the rise, and people have many more years to consume healthcare.
Medical progress is very expensive, and the more we have of it the more it costs. The State can only look at medical progress and say, “Medical progress is killing us.”
But it is not politically feasible to come right out and say that stifling medical progress is necessary to the survival of the State. Rather, the State must assert that what it is stifling is greed.
Hillary Clinton gave us the State’s operative formulation in 1993: “There are just too many greedy doctors using too much expensive technology.” So, to control costs, the State must control the doctors; and the State must control the technology, which is to say, industry.
I submit that an underlying theme within the debate over doctor-industry relationships is a desire to greatly slow or even stop the real threat to the State: medical progress, and the vast expenditures which medical progress produces.
The State has several means for stifling medical progress. The State can institute increasingly oppressive regulations, which can have the effect of hamstringing industry, but more importantly, has the effect of converting industry to a client of the State, dependent on the State’s favors for its success. The State can demonize industry, trying to convince the public that drug companies and medical device companies are evil entities that would just as soon harm them as help them, and indeed, without the strong hand of the State would prefer to distribute pain and suffering as the more favored pathway to windfall profits. But more to the point of today’s discussion, the State can stifle the doctor-industry relationships that are so critical in steering medical progress in a clinically relevant direction.
So the interests of industry must be represented as being fundamentally counter to the interests of society, and the doctors who have relationships with industry must be painted as their evil (or, at best, deluded) minions.
Yes, industry is biased, and industry will act on that bias whenever they can get away with it. Industry just can’t help itself. That’s just the way it is.
But the State is also biased. And the State will also act on that bias whenever they can get away with it. The State can’t help itself. That’s just the way it is.
Industry will try to exercise its influence over us by data-driven persuasion, and when that fails they will try to sweeten the persuasion, perhaps even with subtle or not-so-subtle bribes.
But the exercise of persuasion is even more dangerous when done by the State. While the State may also try to influence us with data-driven persuasion, it is very quick to resort instead to propaganda (i.e., the art of information-control by which the unwashed masses are told only what the specialized classes have determined is best for them), and when that fails, the State will resort to its ultimate form of persuasion – the enforcement of new and suppressive regulations at the point of a gun.
So, while industry is indeed biased, and needs to be kept at arms length, de-legitimizing industry altogether would be disastrous. It would create an open field for extraordinarily powerful forces which are at least as biased, but in the opposite direction. If we value medical progress, we need the balance that industry provides – and that includes not only industry’s products, but its voice.
Medical progress driven by industry-physician collaboration is good for mankind. But that collaboration inevitably creates conflicts. We physicians need to control those conflicts, or the collaboration will be forcibly terminated altogether. Our professional history to date is bleak in this regard, and we only have one chance left to get it right, if that.
But in controlling our COI, we should not allow ourselves to be pushed too far. We should agree to reasonable limits on conflicts, and on full disclosure of any conflicts that remain. But we should draw the line when we are urged to forgo all relationships with industry altogether. We must recognize that industry and its selfish goals provide a necessary counterbalance to even more powerful forces whose goal is to stifle medical progress.
I don’t ask that you accept my synthesis of this problem at face value. I simply ask that you listen to what I am suggesting, and observe for yourself what is happening out in the wild. Then challenge yourself to come up with a better explanation for what you see happening out there. I sincerely hope you can, as I would much rather that my conclusions were not true. So if you do come up with a better explanation, I will greatly appreciate hearing about it.
DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.
It is quite popular for certain medical bloggers who count themselves as scientifically sophisticated to disparage so-called “alternative medicine.”
Indeed, some have built entire websites to demonstrate (Penn-and-Teller-like) that various forms of alternative medicine – such as homeopathy, therapeutic touch, the medical application of crystals, Reiki, naturopathy, water therapy, bio-photons, mindfulness training, energy healing and a host of others – are completely devoid of any scientific merit whatsoever; are pablum for the uneducated masses; are, in short, irreducibly and irredeemably woo.
These same bloggers are scandalized into virtual apoplexy by the fact that the NIH has funded an entire section to “study” alternative medicine, and worse, that some of the most respected university medical centers in the land now seem to have embraced alternative medicine, and have established well-funded and heavily-marketed “Centers for Integrative Medicine,” or other similarly-named op-centers for pushing medically suspect alternative “services”.
(An astounding list of prestigious institutions of medical science now sporting Centers of Woo is maintained by Orec.)
Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.
Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.
So, for several years alternative medicine was seen by DrRich pretty much as it is seen by all of the anti-woo crowd – as an unvarnished evil.
But in recent days the scales have fallen from DrRich’s eyes. He now realizes he was sadly mistaken. Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.
What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.
The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.
This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.
One reason so few primary care doctors have taken this route (choosing instead to retire, to change careers and become deep-sea fishermen, or simply to give up and become abject minions of the forces of evil) is that they do not believe patients will actually pay them out of their own pockets.
Well, ladies and gentlemen, this new report from the CDCP demonstrates once and for all that Americans will, indeed, pay billions of dollars from their own pockets for their own healthcare – even the varieties of healthcare whose only possible benefits are mediated by the placebo effect. DrRich believes that many of the people buying homeopathic remedies are doing so less because they believe homeopathy works, and more because they feel abandoned by the healthcare system and by their own doctors, and realize they have to do SOMETHING. The CDCP report, in DrRich’s estimation, reflects the magnitude of the American public’s pent-up demand for doctors whose chief concern is for them, and not for the demands of third party payers.
Perhaps more importantly, this new report implies that it may be somewhat more difficult than DrRich has thought for the government to outlaw private-sector healthcare activities. As DrRich has carefully documented, a government-controlled healthcare system will require the authorities to make it illegal for Americans to spend their own money on their own healthcare, thus rendering direct-pay medical practices illegal, and putting the final stake into the heart of the doctor-patient relationship.
But the rousing success of the alternative medicine universe will make such laws difficult to enact.
To see why, consider just how encouraging this new CDCP report must be to the third-party payers. Thanks in no small part to the efforts of the government (and the academy) to legitimize alternative medicine, Americans are spending $34 billion a year on woo. This amount indicates tremendous savings for the traditional healthcare system. The actual amount saved, of course, is impossible to measure, but has to be far greater than just $34 billion. Some substantial proportion of patients spending money on alternative medicine, had they chosen traditional medical care instead, might have consumed expensive diagnostic tests, surgery, expensive prescription drugs, and other legitimate medical services. Furthermore, those legitimate medical services (as legitimate medical services are wont to do) often would have generated even more expenditures – by extending the survival of patients with chronic diseases, by identifying the need for even more diagnostic and therapeutic services, and by causing side effects requiring expensive remedies. (While alternative medicine is famous for being useless, it is also most often pretty harmless, and tends to produce relatively few serious side effects – except, of course, for causing a delay in making actual diagnoses and administering useful therapy, but if you’re a payer, that’s a good thing.) So the amount of money the payers actually save thanks to alternative medicine must be some multiplier of the amount spent on the alternative medicine itself.
What this means is that payers (which, let’s face it, will soon mean the government) will be loathe to do anything that might discourage the success and growth of alternative medicine, and this fact alone may stop them from making it illegal for Americans to pay for their own healthcare.
Still, we musn’t be too sanguine about these prospects. Under a government-controlled system, the imperative to control every aspect of healthcare (in the name of fairness) will be very, very strong, and it will be very tempting to the Feds to declare at least some varieties of alternative medicine to be covered services.
But the alternative medicine establishment (bless it) will be largely impervious to government control. Practitioners of alternative medicine are expert at designing vague products and services whose techniques, theories, processes and protocols are fluid, nebulous and ill-defined. So if the Feds declare, say, homeopathy and therapeutic touch to be legitimate, covered services under the Fed’s health plan, why, the alternative medicine gurus will simply come up with entirely new forms of alternative medicine, specifically to remain outside the government plan. (New varieties of alternative medicine already appear with dizzying speed, and can be invented at will. No bureaucracy could ever hope to keep up.)
Therefore, as long as the central authorities depend on alternative medicine as a robust avenue for covertly rationing healthcare, the purveyors of woo will always be able to flourish outside the real healthcare system. And this, DrRich believes, represents the ultimate value of woo, and establishes why we should all be encouraging and nurturing woo instead of disparaging it.
DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.
Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.
The success of medical woo, in other words, can provide American doctors who want to practice the kind of medicine they should be practicing with the cover they need to do so. And this is why we must support medical woo, and celebrate its continued growth and success.
Recently, DrRich wrote a series of posts detailing how the American healthcare system – even before the new reforms kick in – is taking steps to prevent individual citizens from being allowed to spend their own money on their own healthcare. Part of that effort, of course, is to restrict physicians from offering direct-pay medical services to their patients.
DrRich may have given the impression that only primary care doctors are affected by efforts to restrict their practices in this way. If so, he apologizes.
He particularly owes an apology to his friends the dermatologists. Indeed, DrRich has been reminded of an article that appeared in the New York Times a while back, which castigated dermatologists for the sin of establishing direct-pay practices, and in particular, for creating their own brand of a two-tiered healthcare system – one for patients with skin disorders, and one for “cosmetic dermatology.”
As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally several months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, fuzz balls on the floor, old magazines, the unruly children of other patients, and surly office personnel. Eventually the now-even-more-disheartened patient’s name is called by an indifferent nurse practitioner, who, operating from a checklist of questions, will “triage” her to the appropriate patient-category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), then have her strip in order to fully expose the large organ (i.e., the skin) for which she has sought assistance, hand her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see His Holiness, the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern, and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, placing her bundle of clothing into her arms and wishing her a good day, the doctor shoves her out into the hall to finish dressing, as the formal interview is completed, and the exam room is at a premium.
Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.
Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.
The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of their clients who have an impending public engagement, and thus need to look their best. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a careful assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, studying, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitude and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose, with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the outcome.
Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?
DrRich has a word of advice for the scandalized reporters of the New York Times, and any other concerned Americans who are worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.
Allow DrRich to support this friendly recommendation with two observations.
1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. A second tier is necessary if for no other reason than political leaders and other individuals critically important to the collective effort must have somewhere to go for their healthcare. The second tier, like the poor, will always be with us.
2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re not really patients but widgets on an assembly line, then spends Wednesday in her other, much more amenable offices, treating the merely cosmetically-challenged like they are minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, on Tuesday she is practicing real, true, prescribed-by-society, by-the-book American healthcare, just as our leaders (in their wisdom) have carefully set it up for us, and on Wednesday she is doing Something Altogether Different.
Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.
Furthermore, when one looks at it objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, most folks would do just fine with it.
The sheer arbitrariness by which injecting Botox is deemed by the authorities to constitute the practice of medicine can also be illustrated by considering a somewhat different, equally well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the actual skin itself than Botox injections (which do not really affect the skin itself, but only the muscles under the skin). DrRich speaks, obviously, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly technical skill like that. The point being, of course, that if you were to describe Botox injections and tattooing to a visitor from Mars, then ask him/her/it which of these two dermatological procedures ought to require a medical license and board certification, the Martian would get it wrong every time.
DrRich understands, of course, that while administering Botox is, in practical and objective terms, no more practicing medicine than is applying an ice-pack to a bruised knee, legally it is indeed deemed to be the practice of medicine. Accordingly, doctors in general (and dermatologists in particular), relying on this nonsensical designation, have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing – which, in contrast to Botox injections, is an actual surgical procedure which is intended to result in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious crime.
But fundamentally, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Not when ear-piercing and tattooing are not. Rather, in real life, injecting Botox is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.
To say it another way, when the dermatologist goes to her “other office” to cater to a self-paying variety of clientele, she is practicing medicine only from the most arbitrary and strictly legalistic viewpoint. In real life, she is doing Something Else. She is engaging in a Pastime.
Doctors, of course, often have Pastimes. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some do charity work, or go to graduate school for an MBA. Still others have opted to work part time in order to raise their families.
Society generally finds such activities acceptable, and – to this point – does not insist that all doctors forgo all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty to the collective, it has not reached this point quite yet.
Until society sees fit to legislate otherwise (which, DrRich supposes, could happen really very soon now), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming direct-pay practitioners.
One last word of advice for DrRich’s dermatology friends: Have fun with your Botox clinics for now, fellas and ladies, but please don’t become too invested in them. This is definitely a shallow-moat line of business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control – say, Congress or the FDA – could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots, or even learn a real skill, like tattooing – but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.
In his previous post, DrRich offered some general issues to consider before one dives into black market healthcare, and reminds his readers why this will not be an endeavor for the faint-hearted. In this post, we will get into some specifics.
DrRich must first assure his readers (and any government officials who may inadvertently stumble upon this blog) that he is a law-abiding citizen, and does not condone illegal activities. So he will suggest here only activities for black market healthcare which, strictly speaking, will not be illegal under American law; though not so much by complying with the law, but by avoiding it.
DrRich trusts that his readers can think up the more illegal kinds of black market activities for themselves, and thus they do not need his help with this aspect of the endeavor. Many of these more obvious illegal forms of black market healthcare (e.g., “medical speakeasies,” located in back alleys for the proletariat, and in swanky office buildings for public officials; rolling surgical suites hidden in semi-trucks; smuggling rings for drugs and medical equipment; an “underground-railroad-style” transport system for itinerant physicians who need to ply their illicit trade while on the move; etc.), can be established by individuals, or by relatively small groups of entrepreneurs, and with relatively little up-front capital or lead time – and with no coaching from DrRich.
But the varieties of black market healthcare which DrRich has in mind – certain “less illegal” activities, which will drive the U.S government into states of apoplexy but over which it will have little legal jurisdiction – will require a much larger scale, and a significant investment in time and energy. So anyone who is interested ought to get started with the necessary organizational activities right away.
DrRich has three such suggestions. With all three of them, DrRich envisions that implementation would be driven by a major private healthcare organization (or a consortium of them) which has a record of innovative thinking, as well as access to significant financial resources through their own holdings, or through their connections with rich benefactors from around the world. He is thinking of organizations like the Cleveland Clinic, the Mayo Clinic, or the Kaiser system.
For the sake of mankind, DrRich offers these suggestions free and clear. They may be taken up, with his blessings, by any institution or organization that wishes to employ them, with no obligations or strings attached whatsoever.
1) Floating Off-Shore Medical Centers. In this scenario, the Cleveland Clinic (say), with the help of their friends in Abu Dhabi, buys or leases a mothballed former Soviet aircraft carrier (nuclear power preferred), and refurbishes it into a floating, world-class medical center. The ship will ply the international waters off the American coasts, providing regular helicopter transport to and from major cities. There’s a lot you could do with an aircraft carrier, of course, to make it an attractive destination aside from medical care, including (for instance) establishing a world class hotel, food services, casinos and other entertainments. But the chief attraction would be that Americans will be able to buy the best healthcare services in the world, without fear of being arrested.
The fact that this floating medical center will be based on a former warship may turn out to be an advantage. Obviously, it would be useful to maintain at least some weaponry on board, if only to repel “pirates” But given the anger this ship will generate among American government officials, the Cleveland Clinic (or whoever) might be wise to remain intentionally ambiguous about just how much firepower the ship has retained. Just sayin’.
2) Native American Medical Centers. There are two things about the current state of Native American culture which make this approach to black market healthcare at least feasible, if not compelling. First is the recognized “sovereign status” of Native American reservations, the same status which has allowed various tribes across the land to open gambling casinos, even in states which otherwise do not allow such establishments. If their sovereign status justifies casinos (establishments of mere entertainment, which, in fact, encourage bad behaviors of all sorts such as alcoholism, prostitution, smoking and – gasp!- obesity), then surely the same sovereign status would justify establishing advanced institutions of healing.
Second is the deep guilt that Americans rightly feel about the treatment Native Americans have suffered over the years, much of which was arranged by the U.S. government. Note, in particular, that one of the ongoing claims which Native Americans have against the larger American culture is the chronically substandard state of the healthcare services they are provided. So, who will dare stand in the way of these oppressed peoples, when they propose to dedicate a portion of their pitiful remaining sovereign lands (with the help of, perhaps, the Mayo Clinic and its benefactors) to the development of world-class medical centers?
One advantage of the “Native American Strategy” for black market healthcare is that it would allow medical centers of various sizes and emphasis to be established in numerous convenient tribal locations around the U.S., as the need and logistics allow. Within a decade or two, if they play their cards right, Native American tribes may even find themselves controlling nearly 20% of the American economy – which would be justice at its finest.
3) Medical Centers Across the Mexican Border. There are several potential benefits to this suggestion. Converting Tijuana, Nogales, Laredo and Juarez from hotbeds of human and drug smuggling into hotbeds of illicit healthcare would probably be a boon to the local populations on both sides of the border. It would create tens of thousands of good jobs in Mexico, for Mexicans. The heavily-armed gangs of Mexican drug-runners along the border could be hired by the Cleveland Clinic Juarez, or the Mayo Clinic Nogales, as security guards, thus absorbing their “talents” into a more legitimate economy. (Being located so close to the border of a powerful nation which will badly want to terminate these medical centers would, one must understand, create a certain need for security.)
If nothing else, world-class medical centers just across the Mexican border would reverse the flow of illicit border crossings. Americans (and Canadians, who, bless them, would now have to travel much farther south for their healthcare) would suddenly be streaming across desert border crossings into Mexico in the dark of night – and Mexicans would be staying put. And its desperate need to get rid of black market healthcare would, at long last, give the U.S. government a compelling reason to control the borders once and for all. We would suddenly see American troops all along the Mexican border, supported by such features as a “no-man’s land” seeded with land mines, and constant surveillance by drone aircraft armed with cluster bombs.
And before long, Californians wanting to go to the Kaiser Tijuana Medical Center would have to get there by way of Cuba.
DrRich recently finished a four-part series describing our government’s attempt to prohibit individual Americans from spending their own money on their own healthcare. He believes that any open-minded person who reads this series, what with its numerous, well-documented and specific examples, related in DrRich’s own engaging and erudite prose, will become convinced that our government is very serious about, and much dedicated to, affecting this harmful prohibition.
DrRich’s critics have insisted that he is simply making too much of this. Our government, they insist, whatever its tendencies, will not really act in this way, for the simple reason that Americans would never put up with such limitations on their individual freedoms. And in fact, DrRich fundamentally agrees with his critics, at least to this extent: Americans – many of us, anyhow – just won’t put up with it.
Where he quibbles is in the specifics. DrRich’s critics insist that our government (presumably, taking American character into account) would never actually try to limit the freedom of Americans in such an egregious way. In contrast, DrRich (having carefully demonstrated for his readers that the government will indeed use every means at its disposal to make it illegal, infeasible, or both, for Americans to spend their own money on their own healthcare), finds, sadly, that the many Americans who “won’t put up with it” will find themselves having to act counter to the wishes of their government. That is, Americans who insist on exercising their natural right to become “the proper guardians of their own health,” will have to do so extra-legally.
To say it even more bluntly, Americans wishing to enjoy the individual liberties which our Constitution promises us will, in this instance, need to engage in black market healthcare. DrRich has talked about this before, but finds this a propitious time to discuss it again, and to offer some words of wisdom and caution to anyone who might be inclined in this direction.
Black markets develop naturally whenever a society’s controlling authority attempts to prevent its citizens from acquiring an otherwise available good or service which they very much want (or need). In fact, it is a law of nature that, wherever a group of people exists who badly desire a certain product, and another group of people exists who very much want to provide that product, there is no force in the universe – governmental or divine – which can keep those two groups from engaging in commerce.
To see what is likely to happen when the government institutes its healthcare prohibition, we ought to think about what happened when that same government instituted its alcohol prohibition (i.e., Prohibition). The 18th Amendment (one of the big triumphs of the Progressive Era, and one which, quite typically, relied for its ultimate success entirely on a fundamental change in human nature), went into effect at midnight, January 1, 1920. By noon that day, an entirely new industry had sprung up. This industry – the alcohol black market – eventually employed hundreds of thousands of Americans in various capacities, such as distillers, alcohol “re-naturizers,” bootleggers, rum-runners, speakeasy proprietors, accountants, individuals who today might be called “lobbyists,” and various species of “muscle.”
DrRich’s own dear grandfather, who had only recently arrived from Eastern Europe to work in the steel mills, found more profitable employment instead, through the ’20′s and into the Great Depression, as a gun-toting rum-runner. Each weekend he filled the hidden tank under the back seat of his big Buick sedan with 250 gallons of prime home-made spirits, and would place DrRich’s young grandmother (wearing an impressive hat) next to him, and seat their three innocent little children (among them DrRich’s toddler mother) over the hidden contraband in the back – the very picture of a happy young family out for a Sunday drive – and in this guise would make his deliveries across northeastern Ohio. DrRich will never understand why, at the end of Prohibition, Grandpa ended up as a laborer for the city street department, instead of the filthy-rich Ambassador to England like his fellow bootlegger, Joe Kennedy. (But on second thought perhaps it is better this way. If Grandpa had ended up like Ambassador Kennedy, DrRich today would be spouting the Progressive mantra, like all those other guilt-ridden souls burdened by unearned wealth.)
In any case, the government took great issue with the new industry that had been created, overnight, by Prohibition, and attempted to end the new black market by employing the ultimate expression of any sovereign authority – the legal exertion of violence. (The enforcers, it happens, were Treasury Agents, the very same enforcers who now will be ensuring compliance with certain mandates being imposed by our new healthcare system.) This effort on the government’s part led to an organized response, and resulted in the maturation of American organized crime. (Interestingly, this organized crime effort happened to be centered in Chicago, a happenstance which resulted in a persistent and evolving thugocracy within that city, whose ultimate ramifications – some say – are now affecting current events on a much broader scale).
When its concerted application of force against the the bootleggers failed to end the black market, our government turned to applying a different kind of force, this time to the consumers. The recalcitrant consumers of illicit alcohol were, after all, guilty of failing to change their behavior, despite all the heroic efforts which were being made to educate them about the pitfalls of demon rum. The understandable frustration this caused finally led our government resort to deadly force against the obstinate public itself. Author Deborah Blum has recently documented how the U. S. government caused poisonous substances to be added to the alcohol supply, an act that is estimated to have eventually killed 10,000 people. The chief medical examiner of New York City at the time called this action “our national experiment in extermination.” And in 1927, the Chicago Tribune said, “It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.” It was partly the revulsion against such official atrocities that forced the end of Prohibition in 1933.
DrRich relates this little-remembered episode merely to illustrate the lengths to which our government will go when its attempts to control human nature through legislation fail. It is worth keeping in mind as we conjure up ways to establish what he hopes we will not need, but fears we’ll not be able to avoid, namely, a black market in healthcare.
Black market healthcare will not be for the faint of heart. But then, no great human endeavor ever is.
In his next post, DrRich offers some concrete suggestions for black market healthcare.
DrRich has long praised Pay For Performance as a particularly effective tool for covertly rationing healthcare.
Traditionally, pay-for-performance efforts (modeled after time-honored techniques used on trained seals), produce checklists of approved “activities,” which physicians of quality will always perform when engaged in a “patient encounter.” By examining filled-out checklists, the payers (both health insurance companies and the government) can thus determine which doctors are of sufficiently high quality to deserve their full reimbursement allotment, and which doctors are of substandard quality, and therefore deserve at least to have a portion of their reimbursement withheld, and possibly to be sent away for “re-education,” or to have their names published on a potentially embarrassing list.
When these pay-for-performance checklists are combined with the need to see one patient every 7.5 minutes, thus leaving no time for the discussion of health problems (or other issues) that the payers have not seen fit to include on their checklists, pay-for-performance becomes a very serviceable addition to the covert rationing armamentarium. Which brings us to the latest good news about the success of pay-for-performance.
This week, at Digestive Disease Week (the year’s major scientific gathering of gastroenterologists), doctors from Johns Hopkins will present a paper demonstrating that pay-for-performance reimbursement schemes create financial incentives for surgeons to shun obese patients.
Under this species of pay-for-performance, surgeons are “rewarded” (i.e., not punished) for meeting specified quality standards which have to do with certain patient outcomes. (For pay-for-performance to occasionally equate quality with outcomes is a particularly useful formulation, since expressing reservations about such pay-for-performance measures immediately brands one as being against good medical outcomes, in the same way that being concerned about illegal immigration brands one as being against immigrants, or having reservations about certain of President Obama’s policies brands one as being a racist.)
The Johns Hopkins researchers have found that performing surgical procedures on obese patients results in substantially more complications than performing the same surgical procedures on non-obese patients. For instance, fat people had 27% more complications after gall bladder surgery, and 11% more complications after appendectomy, than thinner people. They also had substantially longer hospital stays, and generated much larger medical bills. The researchers conclude that surgeons (some of whom are literate and understand rudimentary statistics, and therefore not only have access to this kind of information, but are also capable of processing it to at least some extent) can only conclude that, in order to maintain a viable surgical practice, they will need to avoid operating on obese patients. At the very least, they will need to avoid doing elective surgery on fat people, waiting instead until they are in extremis, and require emergency surgery (since at least some effort is made to “adjust” the expected outcomes in these situations).
This result, of course, is similar to the result DrRich reported some time ago regarding the publication of Physician Report Cards. Namely, thanks to publicly-available report cards, cardiologists in the state of New York have been more reluctant than cardiologists in other states to aggressively treat patients with severe heart attacks, and as a result (while the report cards are cleaner) the mortality of these patients is higher in New York.
And the situation with surgeons being quite similar (i.e., doctors being incented to avoid treating higher-risk patients, for fear of being punished because of an unavoidably higher rate of complications), DrRich feels quite confident in offering his surgical friends the same advice he offered the New York cardiologists. Namely, he suggests the Designated Driver strategy.
The Designated Driver strategy requires the Chief of Surgery (ideally, an imposing and feared figure) to approach a promising young surgeon who is just entering practice after the end of a very long course of training, and saying, “Son, you are going to have a brief but spectacular career. You are going to be our Designated Driver.”
For an extraordinary annual salary and immediate vesting in a generous pension plan, this young surgeon is going to have the honor of being the one who gets all the high-risk surgical cases for the group. He will agree to do this as long as it is feasible, that is, as long as he’s not run out of practice because his pay-for performance reports, or his physician report card, have become so abysmally bad. With careful management, and with his colleagues tossing him a few “easy” cases now and then in order to extend his longevity, he may be able to survive as a surgeon for five or ten years (longer, for instance, than the average NFL player), after which he can enjoy a lucrative retirement, or simply change careers. (There are obviously other approaches for conducting the Designated Driver strategy, for instance, as a way for surgeons nearing retirement age to go out in a blaze of glory. But you get the idea.)
The Designator Driver strategy is a win-win for everyone except the government – so surely it will eventually become illegal. But what doctors have to realize, when practicing medicine in a healthcare system driven by the covert rationing imperative, is that one either gives in to the bizarre incentives created by programs like pay-for-performance (which will cause measurable harm to their patients), or one fights back guerrilla-style, striking where one can, and changing tactics as the enemy adjusts.
To the government, however, such guerrilla activities amount to a mere nuisance, an annoyance which (like the poor and the uninsured) will always be with us. Looking at the big picture, our government will doubtless rejoice to hear the Johns Hopkins research results. The Feds will be particularly pleased to learn that their pay-for-performance efforts are achieving both of the desired effects (i.e., reducing the volume of elective surgical procedures, and advancing prospects for demonizing and discriminating against the obese.
Say what you will about pay-for-performance. It’s working.