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