Starting over on health care reform

So, the lot has been cast, the balance has changed, and we must start over. This is a good thing. Let us now look at our health care mess, not as the open mouths of baby birds that we are trying to satiate by shoving a huge ball of worms down their throats, but as the knotted mess it is. The answer to starting over is to untangle, isolate the issues and address problems within the realm of each problem - financial assistance, business practices, non-profit characteristics - and not the way too big a project to control "health care." Even on the most basic level, health wellness issues and health healing from sickness issues are two very different things that need to be addressed separately for clarity. We failed to solve the business of health care as a unified whole, but I would offer that the reason is that we were actually addressing too little, and not too much. By aiming to assign a price tag and method to the whole problem, we were treating health care like it is a business to be tended. But it is not. Health care is an element of life, a problem of the individual and collective in multiple ways. It is not mearly business as Marley responds to Scrooge: 'Business!' cried the Ghost, wringing its hands again. 'Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!' The health care initiative rebellion was because the people see that far too much is involved to simply assign this to a governmental business plan. Like the Ark of the Covenant in Indiana Jones, we won't let charity, mercy, forbearance and benevolence be put on the shelf with the listed treasures. Let the government attend to its drop of water in structures and allow the rest of us to be free to deal with the common welfare.

Uncontrollable

I have little time to pontificate today, but I have been in serious prayer about the health care issue of the day. The health care issue of the day is the vote in Massachusetts. Will they or won't they maintain the 60 vote majority that would guarantee a health care reform package by people who believe the government should control such things. In law school I took election law and my greatest glee was to discover just how uncontrollable the vote can be. In spite of laws, campaigns, efforts, passion, or attempts to influence or buy the vote it is a beast without direction. One may carve off a portion and be confident about certain things, but as a whole, it is uncontrollable. I would like to compare the vote to the Urim and Thummim of the ancient Israeli religion. Only after it is tossed and read will the people know what direction to take. If the great powers of the universe bring an unimaginable victory to upset the current control, the government better take a second look at what they think is really good for the nation. As a nurse for thirty years, I know the government will be torn apart by their inability to control health care if they try to do that. While they will no doubt look at the upsetting of the Democratic majority as a serious blow, they may realize down the line that it saves them, too.

Useless gates, bad keepers

What has been nagging me all week about what I wrote last week is the assumption that resources are unlimited. It is all well and good to say that once the rule is set up the doctor decides what does or doesn’t fit the rule, and the government gives the money based on the doctor’s decision, but what about when there is not enough money to meet all of the doctor’s decisions all of the time. How does the government get control of the spending?

If I had never done anything but nursing, I might not ask or answer this question, but after many, many years of being a nurse I also went to law school. I never worked as a lawyer, it not being near the wonderful job that being a nurse is, but it was very good information.
What we forget is that law always speaks about an artificial world. This is vital to the “Justice is blind” part of law that says everyone will be treated equally. The most obvious example of this is the old adage “innocent until proven guilty.” Obviously, the guilty murderer was guilty even before he is proven guilty by law, but at a certain point in the process, he is “deemed” innocent for the sake of the law and justice. An artificial world is set up to make sure that arbitrary opinions do not take precedent over good legal process.

The artificial world of Medicare is that if everyone makes honest and proper decisions at all times, then there will be no shortage of resources. This is about as real as every indicted defendant being innocent until proven guilty. There is a limit to resources whether people work the processes honestly or dishonestly. Resources are limited. They are limited by tax income, by medical cost charges, and most importantly, they are limited by the will of the caretakers. The art of healing is like other arts. It is not a product to make and sell, it is a skill and the skilled must be willing to care for the needy.

The point is, that the lack of resources cannot be fixed by making sure everyone follows the rules to Medicare to the last dime. Even totally approvable charges to Medicare will result in limited resources. It is not useful for Medicare to conscript millions of dollars in salaries and overseers to second guess every choice doctor’s and hospitals make. What would be far more useful is to keep an eye on the limited resources and find out from the doctors and caretakers how that can be best used.

The will of the caretakers is a big wild card in resources. It is not a will to charge money for services; it is a will to provide services. When talented people refuse to provide services because of the burdens of government paperwork or oversight, then people who are motivated by money step in to provide those services. This of course jacks up the costs. The primary goal is no longer to seek for expertise in healing the patient, but to charge up services that are attached to healing. Can anybody deny that this has already happened? Medicare’s problem with responding to lack of resources as an “overcharging” and “defrauding” issues – as if it were an entity to be robbed instead of a government service- has obscured the fact that healers don’t like to be harnessed by anyone, especially not the government. Medicare has taken its artificial world beyond reason. It has changed from a provider of money for services from the skilled to the needy, to a dictator of services based on what it “thinks” are the best ways to maintain its resources. It has gone from policy to policer because it has reacted to its own inevitable lack of resources as if it is being robbed instead of facing that resources were always limited. Total review of the program’s law and administrative traditions needs to occur at this time, but that is an issue for another time.
The point of this writing is that when the actual laws have to have artificial assumptions (assume no lack of resources) then gatekeepers are the only way to keep the system from toppling in on itself. The world of medicine has totally abandoned good gate keeping as I discovered when I went to law school.

First of all, the doctors, the skilled practitioner, should be the ones overseeing the decisions. Only lawyers are allowed to own or run law firms. If you are a business man who just wants to run the business of a law firm, wonderful, but you have to go to law school first. If only people who had subjected themselves to the discipline of medicine and the Hippocratic oath were allowed to be the final word in medical management, the face of health care in America would be much different. The fact we manage at all with the mess we are in is at least due to the honorary respect doctors have as independent practitioners, but that is declining rapidly and the doctor is becoming a brick in the wall just like all the other pieces of health care.
An absolutely unspoken part of the now demonized concept of doctors being in charge of the money surrounding their practice is the huge amount of free service they were able to do and did (and still do). They didn’t go door to door making sure everyone’s needs were met, but they were in a position for needs to come to them, and they fulfilled them in their own creative ways. This is something the government will never have the flexibility to do.The other matter of gate keeping that the government mishandles is the administrative gate keeping. I’ve been a hospital nurse for over thirty years and it makes me cringe when people brag about the government handling their administrative costs at only 3% of their budget when institutions and insurance companies have a much higher rate. That’s because they make other people do the administrative work. If the paperwork obligations for receiving Medicare were directed to the States instead of to profit or non-profit incorporations, the complaint would be “unfunded” mandates. I don’t have a statistic, but it seems like every government dime comes with a dollar’s worth of administrative costs. Doctors have to hire so many workers to code and research and manage money that they can’t keep their costs down. Inspection should be done by the one who needs it – ie government. The healer can’t heal if their every move has to be self inspected. This has gotten so bad that medical institutions, far from being the place of ethical prowess that they used to be have become ethically numb when it comes to charges. I had an advanced test done last fall where I was told the fee would be about $600.00 to $700.00. By the time all of the ancillary lab tests, doctors who read the tests, hired hands at the clinic, and space charges were independently billed, the bill was $1,600.00 with my insurance credits (I was still under my deductable so had to pay all). The farce that health care is now run by business rules and should function more and more that way is clear in this completely unethical portrayal of my costs. No business could get away with that kind of presentation and billing pattern. The whole “business model” that health care tried to turn to in the ‘80’s was just a wolf in sheepdog’s clothing. It has bled the money out of the system, but it has not made the system more of a fair market entity subject to the Uniform Commercial Code. We have lost the excellent foundation that true charity was built on and now the real decisions are more arbitrary than they ever could have been in the artificial world of the legal structure

The broken spirit of health care in America

In 1979 I took my first job as an inpatient psychiatric nurse. I left inpatient psychiatry in 2009 to become a psychiatric assessor. I decided to start a blog because of a conversation at lunch.

I am posting this writing a week late, but I will write again today and hopefully catch up.

The incredibly efficient, competent, sharp utilization review nurse sitting across from me at lunch was speaking a mile a minute, as usual. We share an office, but have different jobs, and I learn a lot about the money matters of healthcare from her. In spite of the snow on the ground, we were eating pineapple and oranges on our coconut shrimp salad, the specialty of the hospital chef to take us to the tropics in the midst of winter. And she said, “But the hospitals did used to defraud Medicare when it came to discharges to nursing homes.” As she was rushing on, she used the word defraud a few more times. I simply had to stop her. Now I am aware that the Medicare rule requires three days of acute hospital care before follow-up in a nursing home will be paid for by Medicare, but the term defraud was driving me crazy. In her explanation, since the three days were needed, doctors and hospitals who knew a patient could not go home for some reason, but wasn’t necessarily sick enough to warrant staying in the hospital, would get extra days “on Medicare’s tab” so that they could go to a nursing home on Medicare’s money. It was good for everybody, and she said Medicare used to have so much money they “didn’t care” that they were being defrauded.
No, and again I scream, NO! To defraud is to use falsehood to deprive someone of something of value. I am well aware that these days Medicare thinks it was deprived of the value of two days pay for a hospital stay as well as the obligation for nursing home care, but it has no right to look at the situation that way even though it tells utilization review to report that way.
The value that was to be provided by Medicare was care to the elderly. The hospital is the institution that was charged to do that job .The doctor is the judging professional. Of course Medicare has to have some guidelines, but they do not become expert in individual evaluations just because there is a question as to whether someone fits into the guidelines. It is the doctor’s decision whether or not to keep a patient. If the doctor declares the service is needed, it is defrauding the patient if someone overrules the doctor. It is easy for someone to look at a spread sheet of statistics and think they know what is going on, but they don’t. You must see people to know about people. This is the missing spirit of all the healthcare bedlam. They have forgotten how people are because they are so caught up in how insurance is.
Sometime in the 1980’s, we went from a charity model of money management for health care institutions to a business model. Charity is when money comes in, and the institution is then allowed to use it for the greater mission. Business is when someone outside the institution is directing the use of money down to the dime.
So my response to my co-worker was that Medicare had been set up knowing that at times doctors would make judgments that did not always save Medicare money, but since hospitals are set up to take care of social needs that government cannot really address, the extra money was considered an appropriate grant due to the overall work of the hospital. In the past, the honest judgment of the doctor was not considered defrauding. When the “business model” of health care (things like charging for every gauze pad used and individualized medicine packets for efficient charging) started overtaking the hospitals, those bigger global uses of money to care for the poor and allow special expenditures for unusually ill patients got pinched out, because the government decided it was going to parse its part to the dime. O.K., that is a figure of speech, they probably only really parse it to the dollar, but never-the-less, it was a change in the spirit of the law from the beginning of Medicare to now that makes smart, good working nurses think that what used to happen was fraud. It wasn’t fraud; it was care. People were supposed to be first, not money.
“I don't read no papers, and I don't listen to radios either. I know the world's been shaved by a drunken barber, and I don't have to read it.” Walter Brennan as The Colonel in “Meet John Doe” Directed by Frank Capra-1941.

Trigger Conversation

In 1979 I was hired as an inpatient psychiatric nurse. In 2009 I worked my last day as a bedside nurse and became a "gatekeeper" in the system. A conversation at lunch today made me decide to start a blog.