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      "title": "The crisis in US medical care: A doctor’s perspective, Part 3. Some inequities in physician reimbursement for medical services (OR: Cheating Uncle Sam for some extra dough)",
      "body": "My name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice and not for the better. In fact, we all know it’s broken. The question is how to fix it. I don’t know the answer. But, as an “insider” I probably have a different perspective than you and can speak from first hand knowledge. Through this series, I will attempt to unravel aspects of our health care delivery system you may be unaware of in an effort to show you how complicated things have become and why the solution is so difficult.\n\nMy wife and I just returned home from my 40th medical school reunion weekend. What a walk down Memory Lane. We had a large class for a medical school; 250 compared to the usual 80-100. We were 20% out-of-state students; not unusual. Oh how I hated it when frequency was described as not unusually, not uncommonly or not infrequently (did that mean frequently?). Sadly, I understood what they meant. But, I digress. We were 25% women; an unusually large percentage. Instead of letter grades, we were Pass/Fail for the entire curriculum; unheard of, especially among medical schools. We had a cross-section of society. My point is, as with society in general, people go into the field of medicine for many different reasons. It was obvious in 1973 who were genuinely interested in helping people who were sick, who were interested in prestige, who were fulfilling their parents’ dreams and who signed up to make a lot of money. This led to thinking about just how screwed up getting paid became.\n\nIn the ‘old days’ insurance companies paid physicians pretty much what they billed, the “usual and customary” fee. You could increase your billing, say for inflation, and build up your profile.Your reimbursement would gradually increase. A newcomer could collect either the ‘usual and customary’ fee for the group joined or the community average if starting a new solo practice. Some fees were reasonable, some were outrageous. Fees differed from neighborhood to neighborhood, town to town and city to city. There was no one coordinating how much was paid for any particular service rendered. A lot depended on how long you were in practice and how quickly you increased your fees. There was no rhyme or reason to the value of any particular service. Some physicians got very rich pumping up the reimbursement for their services, giving the entire medical field a deteriorating reputation. Even worse, nobody discussed fees before service was given, so there was no way to comparison shop among physicians. And, there was no way to dispute the amount charged once service was given. Patients were stuck between a rock and a hard place.\n\nEventually (1980’s) the government decided medical care was too expensive and created a schedule for reimbursement of medical service provided based on relative value. Medicare publishes a book of relative values (for Anesthesiology it’s called the RVG - Relative Value Guide. For hospitals, medicine and surgery practices it’s called the DRG - Diagnosis Related Group) providing one payment for one service which is updated occasionally. At first, it was supposed to be “dollar neutral,” meaning DRG payment should be equal to “usual and customary” payment. After the initial introduction, DRGs were scheduled to decrease 5-10% annually to lower the cost of medical care. That ‘logic’ is beyond the scope of today’s discussion. Private insurers, of course, gradually introduced the relative values Medicare assigned. For example, if a 15 minute office visit to a Family Practitioner (FP) is worth 1x dollars, then an extended 25 minute visit may be worth 1.25x dollars and a new patient 45 minute visit may be worth 1.5x dollars. The fee schedule necessitates one payment for one service. It doesn’t matter if the 15 minute visit takes 15 minutes or 12 or 18 minutes. “It averages out” over time, so they say. But, slower doctors suffer, while faster doctors make more because they can see more patients in a day. A major problem is “up-coding” visits. This is when a physician codes for a higher level of service (e.g., extended visit) than was actually performed (e.g., regular 15 minute visit). Case reviewers look for trends (i.e., too many extended visits for a particular physician) and, if discovered to be purposeful rather than accidental, in addition to paying back the excess reimbursement, there are fines (with triple fines for the most egregious) and perhaps expulsion from Medicare for life. In Florida, where practices easily average 80% of patients insured by Medicare, expulsion effectively means losing your practice.\n\nLooking further, the trickier part of reimbursement is navigating the values between specialties. Is a regular 15 minute office visit to a FP worth the same as a 15 minute appendectomy? Reimbursement has to take into consideration many factors, including: (1) Each service requires a different skill set. (2) After the Internship year, different specialties require differing numbers of years of training (residency). A Family Practice residency is shorter than either a General Surgery or Internal Medicine residency with a sub-specialty. (3) A Family Practitioner has to rent an office and hire staff while a surgeon operates in a hospital that provides operating room staff. (4) Does it require more skill to perform open heart surgery or remove a gall bladder? \n\nShould the more demanding operation be compensated more or has sufficient additional compensation already been included because of the additional training required to perform such surgery? In general, reimbursement for medical specialties has always lagged behind reimbursement for surgical specialties and the reasons are beyond the scope of this article. Suffice it to say, instead of getting closer, the disparity has increased. Family Practitioners’ and Pediatricians’ incomes are a lot lower than general surgeons’ incomes. General surgeons make a lot less than specialists (heart surgeons, neurosurgeons, ENT surgeons, vascular surgeons). And, everyone makes a lot less than today’s DRG winners: invasive cardiologists, ophthalmologists and radiation oncologists.\n\nThere is also the issue of bundling. Open heart surgery requires certain monitors being placed for safety such as an arterial line (catheter placed in an artery to directly measure blood pressure) and a central line (a large bore catheter placed into a large vein closer to the heart to deliver medications and large volumes of fluids versus the usual small bore catheter placed in the hand or arm), both of which are already included in the DRG for the operation. However, some unscrupulous individuals bill separately for all three - another form of up-coding or unbundling. There are many other examples.\n\nWhat if there are complications? If a wound gets infected after surgery the patient will require additional attention by the surgeon, additional care and, often, additional time in the hospital. However, the DRG does not increase. The additional workload has to be absorbed by the surgeon, taking away time that could be spent seeing another patient which would generate additional income (or the surgeon must work later into the evening generating an entirely different discussion about stress, lifestyle, burnout for another time).\n\nAt first, Medicare said not to worry. the original DRG and RVG were huge undertakings and corrections for obvious errors would be forthcoming. Some problems were corrected over the years, but, in reality, DRGs were a way for the government (through Medicare) to control and lower the cost of medical care.  Careful inspection still reveals too many inconsistencies and glaring errors. There are so many over- and under-valued DRGs that can make or break an entire practice.\n\nExtreme examples of over-payments were mentioned above. They are glaring inequalities. In 1985 it took 30-45 minutes to perform cataract surgery. With all the technical improvements since, it now takes an ophthalmologist literally less than 5 minutes to perform cataract surgery. According to the latest numbers I could locate online (very protected and difficult to find) reimbursement hasn’t changed much despite technical improvements and is still around $2,500. Most surgicenters can accommodate 40 patients in a day netting the surgeon $100,000. And this fee does not include the administrative fee to the surgicenter or the fee for supplies.\n\nRadiation Oncologists determine how much radiation is necessary to treat your cancer, what area of the body must be included and what duration of radiation is required. Then they turn over the information to their technicians who perform all the work: fitting the shielding, setting all the dials on the machine, delivering and monitoring the treatments, etc. The fee to the MD, again to the best of my knowledge, is $10,000 per patient. They can see many patients in one day.\n\nBack in the day, Cardiac Surgeons were the “main man” in every hospital since a CABG (Coronary Artery Bypass Graft) procedure was the best paying surgery a hospital could offer (and the Operating Room has always been the major money producer in any hospital). The number of cardiac centers (hospitals approved to perform CABG) was limited. Hospitals had to apply for and be granted a Certificate Of Need (CON) for bypass surgery based on population and distance between cardiac centers. The fee to the cardiac surgeon was, to the best of my knowledge, approximately $2,500 per bypass (1980’s dollars). That means a “4 way bypass” netted $10,000. A good surgeon could perform 3-4 operations per day. Today, an invasive cardiologist (not a surgeon but a medical cardiology physician specializing in invasive procedures) collects, to the best of my knowledge, $5,193 for deploying (placing into a coronary artery) a drug eluding stent. Often 2-3 stents are deployed per patient. The procedure takes about 1-2 hours (for a good cardiologist). This can add up.\n\nHere is the most important example of extreme under-payment (to me). Anesthesia reimbursement was decreased more than any other specialty when relative values were first introduced. Anesthesiology reimbursement is different than any other specialty because there is no single DRG for anesthesia.  Reimbursement is divided into two parts. There is one fee (RVG) for ‘putting a patient to sleep’ which includes the difficulty of the procedure and the severity of the patient’s condition. There is a second fee (Time units) determined by the length of the operation. The reasoning is the Anesthesiologist should be reimbursed for the skill required in a particular operation but should not be penalized for the speed of the surgeon. We do not select patients for surgery nor do we choose the surgeon (we shouldn’t avoid slow surgeons although some do by the way they assign operations to the anesthesiologists in their group). \n\nAnesthesia reimbursement was decreased inappropriately, partially because there is no correlation between the RVG and the DRG guides. In fact, it was decreased so much that 65% of anesthesia practices required subsidization from the hospital they contract with just to break even with pre-DRG reimbursement. Although promised by Congress but delayed over and over again, the correction has never materialized. With the tight margins most hospitals work with, annual contract negotiations with Anesthesiology groups, just to keep up with inflation, have become strained, stressful and often unsuccessful. Between this and other rules and regulations imposed by organizations that credential hospitals, most independent Anesthesiology groups have been forced out of existence. They have been replaced by large (impersonal) corporate organizations. Anesthesiologists, I mean, anesthesia care providers (MDs, CRNAs and AAs) are becoming expendable and interchangeable corporate negotiating tools.\n\nLet’s face it. Although some doctors purposefully unbundle procedures and frankly mis-bill insurance companies, the vast majority of physicians are honest and hard working. Yes, whether by plan or dumb luck, many physicians have excessively lucrative practices. And, the opposite is also true - many struggle to make ends meet due to underpayment. Medicare isn’t helping by ignoring billing problems (purposefully?) that already exist. Although universally blamed for the “high cost” of medical care, are physicians really responsible?\n\nThere are many pieces to the healthcare puzzle. Doctors and nurses take care of patients in hospitals, clinics, outpatient facilities and urgent care centers to name a few. Medical care requires medicine, tools such as stethoscopes and equipment such as X-Ray machines. If discharged from the hospital, but not ready to be on your own, there are visiting nurses, admission to a nursing home, if necessary and everything inbetween. A wheelchair or mechanical bed may be necessary (durable medical goods). According to the latest statistics I could find, physician reimbursement accounts for approximately 8-10% of the total healthcare dollars spent in the US. The other 90+ % is spent on all the rest. Doctors do not drive the cost of medical care. That is a national fallacy intended to create a scapegoat to bear the blame.\n\nFrom another perspective, one recent study I found indicates US physicians receive a smaller percentage (8.6%) of their nation’s total healthcare expenditure than in many developed countries. Sweden is less (8.5%). However, Germany (15%), France (11%), Australia (11.6%) and the UK (9.7%) pay more to doctors. What are the implications? The United States is trying to control costs and contain the national debt in any way it can.\n\nI am reminded of the interview given by Alan Shepard, the first American in Space, after his historic suborbital flight aboard the Mercury spacecraft, Freedom 7, on May 5, 1961. He was asked about his last thought before blasting off into space. It may be fact or fiction, but I remember his reply as “I realized that every component on this spacecraft was built by the low bid company.”\n\nSometimes you really do get what you pay for.\n\n\nFuture topics I am considering include:\n1. What is Anesthesia and how does it work?\n2. Are there different types of Anesthesia and what should I choose for my operation?\n3. Don’t go near a hospital on July 1st (everyone ‘graduates’ and moves up on July 1st)\n4. Non-Anesthesiologists don’t understand anesthesia yet are permitted to give certain types of anesthesia for their procedures (remember Joan Rivers)?\n5. Possibly the most disruptive force in medicine today: The EMR (Electronic Medical Record)\n6. We used to strive for the best care for each patient. Now we (must) strive for the most economical (cheapest) care for each patient. However, attorneys still hold us to the highest standards.\n\nLet me know if you are interested in any of these by giving it a yea or a nay. Thanks",
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      "author": "scotts",
      "permlink": "5qjayk-the-crisis-in-us-medical-care-a-doctor-s-perspective-part-3-some-inequities-in-physician-reimbursement-for-medical-services-or",
      "title": "The crisis in US medical care: A doctor’s perspective, Part 3. Some inequities in physician reimbursement for medical services (OR: Cheating Uncle Sam for some extra dough)",
      "body": "My name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice and not for the better. In fact, we all know it’s broken. The question is how to fix it. I don’t know the answer. But, as an “insider” I probably have a different perspective than you and can speak from first hand knowledge. Through this series, I will attempt to unravel aspects of our health care delivery system you may be unaware of in an effort to show you how complicated things have become and why the solution is so difficult.\n\nMy wife and I just returned home from my 40th medical school reunion weekend. What a walk down Memory Lane. We had a large class for a medical school; 250 compared to the usual 80-100. We were 20% out-of-state students; not unusual. Oh how I hated it when frequency was described as not unusually, not uncommonly or not infrequently (did that mean frequently?). Sadly, I understood what they meant. But, I digress. We were 25% women; an unusually large percentage. Instead of letter grades, we were Pass/Fail for the entire curriculum; unheard of, especially among medical schools. We had a cross-section of society. My point is, as with society in general, people go into the field of medicine for many different reasons. It was obvious in 1973 who were genuinely interested in helping people who were sick, who were interested in prestige, who were fulfilling their parents’ dreams and who signed up to make a lot of money. This led to thinking about just how screwed up getting paid became.\n\nIn the ‘old days’ insurance companies paid physicians pretty much what they billed, the “usual and customary” fee. You could increase your billing, say for inflation, and build up your profile.Your reimbursement would gradually increase. A newcomer could collect either the ‘usual and customary’ fee for the group joined or the community average if starting a new solo practice. Some fees were reasonable, some were outrageous. Fees differed from neighborhood to neighborhood, town to town and city to city. There was no one coordinating how much was paid for any particular service rendered. A lot depended on how long you were in practice and how quickly you increased your fees. There was no rhyme or reason to the value of any particular service. Some physicians got very rich pumping up the reimbursement for their services, giving the entire medical field a deteriorating reputation. Even worse, nobody discussed fees before service was given, so there was no way to comparison shop among physicians. And, there was no way to dispute the amount charged once service was given. Patients were stuck between a rock and a hard place.\n\nEventually (1980’s) the government decided medical care was too expensive and created a schedule for reimbursement of medical service provided based on relative value. Medicare publishes a book of relative values (for Anesthesiology it’s called the RVG - Relative Value Guide. For hospitals, medicine and surgery practices it’s called the DRG - Diagnosis Related Group) providing one payment for one service which is updated occasionally. At first, it was supposed to be “dollar neutral,” meaning DRG payment should be equal to “usual and customary” payment. After the initial introduction, DRGs were scheduled to decrease 5-10% annually to lower the cost of medical care. That ‘logic’ is beyond the scope of today’s discussion. Private insurers, of course, gradually introduced the relative values Medicare assigned. For example, if a 15 minute office visit to a Family Practitioner (FP) is worth 1x dollars, then an extended 25 minute visit may be worth 1.25x dollars and a new patient 45 minute visit may be worth 1.5x dollars. The fee schedule necessitates one payment for one service. It doesn’t matter if the 15 minute visit takes 15 minutes or 12 or 18 minutes. “It averages out” over time, so they say. But, slower doctors suffer, while faster doctors make more because they can see more patients in a day. A major problem is “up-coding” visits. This is when a physician codes for a higher level of service (e.g., extended visit) than was actually performed (e.g., regular 15 minute visit). Case reviewers look for trends (i.e., too many extended visits for a particular physician) and, if discovered to be purposeful rather than accidental, in addition to paying back the excess reimbursement, there are fines (with triple fines for the most egregious) and perhaps expulsion from Medicare for life. In Florida, where practices easily average 80% of patients insured by Medicare, expulsion effectively means losing your practice.\n\nLooking further, the trickier part of reimbursement is navigating the values between specialties. Is a regular 15 minute office visit to a FP worth the same as a 15 minute appendectomy? Reimbursement has to take into consideration many factors, including: (1) Each service requires a different skill set. (2) After the Internship year, different specialties require differing numbers of years of training (residency). A Family Practice residency is shorter than either a General Surgery or Internal Medicine residency with a sub-specialty. (3) A Family Practitioner has to rent an office and hire staff while a surgeon operates in a hospital that provides operating room staff. (4) Does it require more skill to perform open heart surgery or remove a gall bladder? \n\nShould the more demanding operation be compensated more or has sufficient additional compensation already been included because of the additional training required to perform such surgery? In general, reimbursement for medical specialties has always lagged behind reimbursement for surgical specialties and the reasons are beyond the scope of this article. Suffice it to say, instead of getting closer, the disparity has increased. Family Practitioners’ and Pediatricians’ incomes are a lot lower than general surgeons’ incomes. General surgeons make a lot less than specialists (heart surgeons, neurosurgeons, ENT surgeons, vascular surgeons). And, everyone makes a lot less than today’s DRG winners: invasive cardiologists, ophthalmologists and radiation oncologists.\n\nThere is also the issue of bundling. Open heart surgery requires certain monitors being placed for safety such as an arterial line (catheter placed in an artery to directly measure blood pressure) and a central line (a large bore catheter placed into a large vein closer to the heart to deliver medications and large volumes of fluids versus the usual small bore catheter placed in the hand or arm), both of which are already included in the DRG for the operation. However, some unscrupulous individuals bill separately for all three - another form of up-coding or unbundling. There are many other examples.\n\nWhat if there are complications? If a wound gets infected after surgery the patient will require additional attention by the surgeon, additional care and, often, additional time in the hospital. However, the DRG does not increase. The additional workload has to be absorbed by the surgeon, taking away time that could be spent seeing another patient which would generate additional income (or the surgeon must work later into the evening generating an entirely different discussion about stress, lifestyle, burnout for another time).\n\nAt first, Medicare said not to worry. the original DRG and RVG were huge undertakings and corrections for obvious errors would be forthcoming. Some problems were corrected over the years, but, in reality, DRGs were a way for the government (through Medicare) to control and lower the cost of medical care.  Careful inspection still reveals too many inconsistencies and glaring errors. There are so many over- and under-valued DRGs that can make or break an entire practice.\n\nExtreme examples of over-payments were mentioned above. They are glaring inequalities. In 1985 it took 30-45 minutes to perform cataract surgery. With all the technical improvements since, it now takes an ophthalmologist literally less than 5 minutes to perform cataract surgery. According to the latest numbers I could locate online (very protected and difficult to find) reimbursement hasn’t changed much despite technical improvements and is still around $2,500. Most surgicenters can accommodate 40 patients in a day netting the surgeon $100,000. And this fee does not include the administrative fee to the surgicenter or the fee for supplies.\n\nRadiation Oncologists determine how much radiation is necessary to treat your cancer, what area of the body must be included and what duration of radiation is required. Then they turn over the information to their technicians who perform all the work: fitting the shielding, setting all the dials on the machine, delivering and monitoring the treatments, etc. The fee to the MD, again to the best of my knowledge, is $10,000 per patient. They can see many patients in one day.\n\nBack in the day, Cardiac Surgeons were the “main man” in every hospital since a CABG (Coronary Artery Bypass Graft) procedure was the best paying surgery a hospital could offer (and the Operating Room has always been the major money producer in any hospital). The number of cardiac centers (hospitals approved to perform CABG) was limited. Hospitals had to apply for and be granted a Certificate Of Need (CON) for bypass surgery based on population and distance between cardiac centers. The fee to the cardiac surgeon was, to the best of my knowledge, approximately $2,500 per bypass (1980’s dollars). That means a “4 way bypass” netted $10,000. A good surgeon could perform 3-4 operations per day. Today, an invasive cardiologist (not a surgeon but a medical cardiology physician specializing in invasive procedures) collects, to the best of my knowledge, $5,193 for deploying (placing into a coronary artery) a drug eluding stent. Often 2-3 stents are deployed per patient. The procedure takes about 1-2 hours (for a good cardiologist). This can add up.\n\nHere is the most important example of extreme under-payment (to me). Anesthesia reimbursement was decreased more than any other specialty when relative values were first introduced. Anesthesiology reimbursement is different than any other specialty because there is no single DRG for anesthesia.  Reimbursement is divided into two parts. There is one fee (RVG) for ‘putting a patient to sleep’ which includes the difficulty of the procedure and the severity of the patient’s condition. There is a second fee (Time units) determined by the length of the operation. The reasoning is the Anesthesiologist should be reimbursed for the skill required in a particular operation but should not be penalized for the speed of the surgeon. We do not select patients for surgery nor do we choose the surgeon (we shouldn’t avoid slow surgeons although some do by the way they assign operations to the anesthesiologists in their group). \n\nAnesthesia reimbursement was decreased inappropriately, partially because there is no correlation between the RVG and the DRG guides. In fact, it was decreased so much that 65% of anesthesia practices required subsidization from the hospital they contract with just to break even with pre-DRG reimbursement. Although promised by Congress but delayed over and over again, the correction has never materialized. With the tight margins most hospitals work with, annual contract negotiations with Anesthesiology groups, just to keep up with inflation, have become strained, stressful and often unsuccessful. Between this and other rules and regulations imposed by organizations that credential hospitals, most independent Anesthesiology groups have been forced out of existence. They have been replaced by large (impersonal) corporate organizations. Anesthesiologists, I mean, anesthesia care providers (MDs, CRNAs and AAs) are becoming expendable and interchangeable corporate negotiating tools.\n\nLet’s face it. Although some doctors purposefully unbundle procedures and frankly mis-bill insurance companies, the vast majority of physicians are honest and hard working. Yes, whether by plan or dumb luck, many physicians have excessively lucrative practices. And, the opposite is also true - many struggle to make ends meet due to underpayment. Medicare isn’t helping by ignoring billing problems (purposefully?) that already exist. Although universally blamed for the “high cost” of medical care, are physicians really responsible?\n\nThere are many pieces to the healthcare puzzle. Doctors and nurses take care of patients in hospitals, clinics, outpatient facilities and urgent care centers to name a few. Medical care requires medicine, tools such as stethoscopes and equipment such as X-Ray machines. If discharged from the hospital, but not ready to be on your own, there are visiting nurses, admission to a nursing home, if necessary and everything inbetween. A wheelchair or mechanical bed may be necessary (durable medical goods). According to the latest statistics I could find, physician reimbursement accounts for approximately 8-10% of the total healthcare dollars spent in the US. The other 90+ % is spent on all the rest. Doctors do not drive the cost of medical care. That is a national fallacy intended to create a scapegoat to bear the blame.\n\nFrom another perspective, one recent study I found indicates US physicians receive a smaller percentage (8.6%) of their nation’s total healthcare expenditure than in many developed countries. Sweden is less (8.5%). However, Germany (15%), France (11%), Australia (11.6%) and the UK (9.7%) pay more to doctors. What are the implications? The United States is trying to control costs and contain the national debt in any way it can.\n\nI am reminded of the interview given by Alan Shepard, the first American in Space, after his historic suborbital flight aboard the Mercury spacecraft, Freedom 7, on May 5, 1961. He was asked about his last thought before blasting off into space. It may be fact or fiction, but I remember his reply as “I realized that every component on this spacecraft was built by the low bid company.”\n\nSometimes you really do get what you pay for.\n\n\nFuture topics I am considering include:\n1. What is Anesthesia and how does it work?\n2. Are there different types of Anesthesia and what should I choose for my operation?\n3. Don’t go near a hospital on July 1st (everyone ‘graduates’ and moves up on July 1st)\n4. Non-Anesthesiologists don’t understand anesthesia yet are permitted to give certain types of anesthesia for their procedures (remember Joan Rivers)?\n5. Possibly the most disruptive force in medicine today: The EMR (Electronic Medical Record)\n6. We used to strive for the best care for each patient. Now we (must) strive for the most economical (cheapest) care for each patient. However, attorneys still hold us to the highest standards.\n\nLet me know if you are interested in any of these by giving it a yea or a nay. Thanks",
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      "title": "The crisis in US medical care: A doctor’s perspective, Part 3. Some inequities in physician reimbursement for medical services (OR: Cheating Uncle Sam for some extra dough)",
      "body": "My name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice and not for the better. In fact, we all know it’s broken. The question is how to fix it. I don’t know the answer. But, as an “insider” I probably have a different perspective than you and can speak from first hand knowledge. Through this series, I will attempt to unravel aspects of our health care delivery system you may be unaware of in an effort to show you how complicated things have become and why the solution is so difficult.\n\nMy wife and I just returned home from my 40th medical school reunion weekend. What a walk down Memory Lane. We had a large class for a medical school; 250 compared to the usual 80-100. We were 20% out-of-state students; not unusual. Oh how I hated it when frequency was described as not unusually, not uncommonly or not infrequently (did that mean frequently?). Sadly, I understood what they meant. But, I digress. We were 25% women; an unusually large percentage. Instead of letter grades, we were Pass/Fail for the entire curriculum; unheard of, especially among medical schools. We had a cross-section of society. My point is, as with society in general, people go into the field of medicine for many different reasons. It was obvious in 1973 who were genuinely interested in helping people who were sick, who were interested in prestige, who were fulfilling their parents’ dreams and who signed up to make a lot of money. This led to thinking about just how screwed up getting paid became.\n\nIn the ‘old days’ insurance companies paid physicians pretty much what they billed, the “usual and customary” fee. You could increase your billing, say for inflation, and build up your profile.Your reimbursement would gradually increase. A newcomer could collect either the ‘usual and customary’ fee for the group joined or the community average if starting a new solo practice. Some fees were reasonable, some were outrageous. Fees differed from neighborhood to neighborhood, town to town and city to city. There was no one coordinating how much was paid for any particular service rendered. A lot depended on how long you were in practice and how quickly you increased your fees. There was no rhyme or reason to the value of any particular service. Some physicians got very rich pumping up the reimbursement for their services, giving the entire medical field a deteriorating reputation. Even worse, nobody discussed fees before service was given, so there was no way to comparison shop among physicians. And, there was no way to dispute the amount charged once service was given. Patients were stuck between a rock and a hard place.\n\nEventually (1980’s) the government decided medical care was too expensive and created a schedule for reimbursement of medical service provided based on relative value. Medicare publishes a book of relative values (for Anesthesiology it’s called the RVG - Relative Value Guide. For hospitals, medicine and surgery practices it’s called the DRG - Diagnosis Related Group) providing one payment for one service which is updated occasionally. At first, it was supposed to be “dollar neutral,” meaning DRG payment should be equal to “usual and customary” payment. After the initial introduction, DRGs were scheduled to decrease 5-10% annually to lower the cost of medical care. That ‘logic’ is beyond the scope of today’s discussion. Private insurers, of course, gradually introduced the relative values Medicare assigned. For example, if a 15 minute office visit to a Family Practitioner (FP) is worth 1x dollars, then an extended 25 minute visit may be worth 1.25x dollars and a new patient 45 minute visit may be worth 1.5x dollars. The fee schedule necessitates one payment for one service. It doesn’t matter if the 15 minute visit takes 15 minutes or 12 or 18 minutes. “It averages out” over time, so they say. But, slower doctors suffer, while faster doctors make more because they can see more patients in a day. A major problem is “up-coding” visits. This is when a physician codes for a higher level of service (e.g., extended visit) than was actually performed (e.g., regular 15 minute visit). Case reviewers look for trends (i.e., too many extended visits for a particular physician) and, if discovered to be purposeful rather than accidental, in addition to paying back the excess reimbursement, there are fines (with triple fines for the most egregious) and perhaps expulsion from Medicare for life. In Florida, where practices easily average 80% of patients insured by Medicare, expulsion effectively means losing your practice.\n\nLooking further, the trickier part of reimbursement is navigating the values between specialties. Is a regular 15 minute office visit to a FP worth the same as a 15 minute appendectomy? Reimbursement has to take into consideration many factors, including: (1) Each service requires a different skill set. (2) After the Internship year, different specialties require differing numbers of years of training (residency). A Family Practice residency is shorter than either a General Surgery or Internal Medicine residency with a sub-specialty. (3) A Family Practitioner has to rent an office and hire staff while a surgeon operates in a hospital that provides operating room staff. (4) Does it require more skill to perform open heart surgery or remove a gall bladder? \n\nShould the more demanding operation be compensated more or has sufficient additional compensation already been included because of the additional training required to perform such surgery? In general, reimbursement for medical specialties has always lagged behind reimbursement for surgical specialties and the reasons are beyond the scope of this article. Suffice it to say, instead of getting closer, the disparity has increased. Family Practitioners’ and Pediatricians’ incomes are a lot lower than general surgeons’ incomes. General surgeons make a lot less than specialists (heart surgeons, neurosurgeons, ENT surgeons, vascular surgeons). And, everyone makes a lot less than today’s DRG winners: invasive cardiologists, ophthalmologists and radiation oncologists.\n\nThere is also the issue of bundling. Open heart surgery requires certain monitors being placed for safety such as an arterial line (catheter placed in an artery to directly measure blood pressure) and a central line (a large bore catheter placed into a large vein closer to the heart to deliver medications and large volumes of fluids versus the usual small bore catheter placed in the hand or arm), both of which are already included in the DRG for the operation. However, some unscrupulous individuals bill separately for all three - another form of up-coding or unbundling. There are many other examples.\n\nWhat if there are complications? If a wound gets infected after surgery the patient will require additional attention by the surgeon, additional care and, often, additional time in the hospital. However, the DRG does not increase. The additional workload has to be absorbed by the surgeon, taking away time that could be spent seeing another patient which would generate additional income (or the surgeon must work later into the evening generating an entirely different discussion about stress, lifestyle, burnout for another time).\n\nAt first, Medicare said not to worry. the original DRG and RVG were huge undertakings and corrections for obvious errors would be forthcoming. Some problems were corrected over the years, but, in reality, DRGs were a way for the government (through Medicare) to control and lower the cost of medical care.  Careful inspection still reveals too many inconsistencies and glaring errors. There are so many over- and under-valued DRGs that can make or break an entire practice.\n\nExtreme examples of over-payments were mentioned above. They are glaring inequalities. In 1985 it took 30-45 minutes to perform cataract surgery. With all the technical improvements since, it now takes an ophthalmologist literally less than 5 minutes to perform cataract surgery. According to the latest numbers I could locate online (very protected and difficult to find) reimbursement hasn’t changed much despite technical improvements and is still around $2,500. Most surgicenters can accommodate 40 patients in a day netting the surgeon $100,000. And this fee does not include the administrative fee to the surgicenter or the fee for supplies.\n\nRadiation Oncologists determine how much radiation is necessary to treat your cancer, what area of the body must be included and what duration of radiation is required. Then they turn over the information to their technicians who perform all the work: fitting the shielding, setting all the dials on the machine, delivering and monitoring the treatments, etc. The fee to the MD, again to the best of my knowledge, is $10,000 per patient. They can see many patients in one day.\n\nBack in the day, Cardiac Surgeons were the “main man” in every hospital since a CABG (Coronary Artery Bypass Graft) procedure was the best paying surgery a hospital could offer (and the Operating Room has always been the major money producer in any hospital). The number of cardiac centers (hospitals approved to perform CABG) was limited. Hospitals had to apply for and be granted a Certificate Of Need (CON) for bypass surgery based on population and distance between cardiac centers. The fee to the cardiac surgeon was, to the best of my knowledge, approximately $2,500 per bypass (1980’s dollars). That means a “4 way bypass” netted $10,000. A good surgeon could perform 3-4 operations per day. Today, an invasive cardiologist (not a surgeon but a medical cardiology physician specializing in invasive procedures) collects, to the best of my knowledge, $5,193 for deploying (placing into a coronary artery) a drug eluding stent. Often 2-3 stents are deployed per patient. The procedure takes about 1-2 hours (for a good cardiologist). This can add up.\n\nHere is the most important example of extreme under-payment (to me). Anesthesia reimbursement was decreased more than any other specialty when relative values were first introduced. Anesthesiology reimbursement is different than any other specialty because there is no single DRG for anesthesia.  Reimbursement is divided into two parts. There is one fee (RVG) for ‘putting a patient to sleep’ which includes the difficulty of the procedure and the severity of the patient’s condition. There is a second fee (Time units) determined by the length of the operation. The reasoning is the Anesthesiologist should be reimbursed for the skill required in a particular operation but should not be penalized for the speed of the surgeon. We do not select patients for surgery nor do we choose the surgeon (we shouldn’t avoid slow surgeons although some do by the way they assign operations to the anesthesiologists in their group). \n\nAnesthesia reimbursement was decreased inappropriately, partially because there is no correlation between the RVG and the DRG guides. In fact, it was decreased so much that 65% of anesthesia practices required subsidization from the hospital they contract with just to break even with pre-DRG reimbursement. Although promised by Congress but delayed over and over again, the correction has never materialized. With the tight margins most hospitals work with, annual contract negotiations with Anesthesiology groups, just to keep up with inflation, have become strained, stressful and often unsuccessful. Between this and other rules and regulations imposed by organizations that credential hospitals, most independent Anesthesiology groups have been forced out of existence. They have been replaced by large (impersonal) corporate organizations. Anesthesiologists, I mean, anesthesia care providers (MDs, CRNAs and AAs) are becoming expendable and interchangeable corporate negotiating tools.\n\nLet’s face it. Although some doctors purposefully unbundle procedures and frankly mis-bill insurance companies, the vast majority of physicians are honest and hard working. Yes, whether by plan or dumb luck, many physicians have excessively lucrative practices. And, the opposite is also true - many struggle to make ends meet due to underpayment. Medicare isn’t helping by ignoring billing problems (purposefully?) that already exist. Although universally blamed for the “high cost” of medical care, are physicians really responsible?\n\nThere are many pieces to the healthcare puzzle. Doctors and nurses take care of patients in hospitals, clinics, outpatient facilities and urgent care centers to name a few. Medical care requires medicine, tools such as stethoscopes and equipment such as X-Ray machines. If discharged from the hospital, but not ready to be on your own, there are visiting nurses, admission to a nursing home, if necessary and everything inbetween. A wheelchair or mechanical bed may be necessary (durable medical goods). According to the latest statistics I could find, physician reimbursement accounts for approximately 8-10% of the total healthcare dollars spent in the US. The other 90+ % is spent on all the rest. Doctors do not drive the cost of medical care. That is a national fallacy intended to create a scapegoat to bear the blame.\n\nFrom another perspective, one recent study I found indicates US physicians receive a smaller percentage (8.6%) of their nation’s total healthcare expenditure than in many developed countries. Sweden is less (8.5%). However, Germany (15%), France (11%), Australia (11.6%) and the UK (9.7%) pay more to doctors. What are the implications? The United States is trying to control costs and contain the national debt in any way it can.\n\nI am reminded of the interview given by Alan Shepard, the first American in Space, after his historic suborbital flight aboard the Mercury spacecraft, Freedom 7, on May 5, 1961. He was asked about his last thought before blasting off into space. It may be fact or fiction, but I remember his reply as “I realized that every component on this spacecraft was built by the low bid company.”\n\nSometimes you really do get what you pay for.\n\n\nFuture topics I am considering include:\n1. What is Anesthesia and how does it work?\n2. Are there different types of Anesthesia and what should I choose for my operation?\n3. Don’t go near a hospital on July 1st (everyone ‘graduates’ and moves up on July 1st)\n4. Non-Anesthesiologists don’t understand anesthesia yet are permitted to give certain types of anesthesia for their procedures (remember Joan Rivers)?\n5. Possibly the most disruptive force in medicine today: The EMR (Electronic Medical Record)\n6. We used to strive for the best care for each patient. Now we (must) strive for the most economical (cheapest) care for each patient. However, attorneys still hold us to the highest standards.\n\nLet me know if you are interested in any of these by giving it a yea or a nay. Thanks",
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      "title": "The crisis in US medical care: A doctor’s perspective, Part 3",
      "body": "Part 3 is delayed due to Hurricane Irma. We live in Central Florida, almost in the direct path of Irma. Although we were spared and our house is intact, there is much to clean up. And, we are still without internet service (I was able to sneak this on using my Verizon cell phone hot spot!).\n\nHopefully we will be back to normal soon and I can finish and upload Part 3.\n\nSincerely, Scott",
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      "title": "The crisis in US medical care: A doctor's perspective, Part 2",
      "body": "Much Ado About Everything Medical\n\nMy name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice. In fact, we all know it is broken. The question is how to fix it. I don’t know the answer. But, as an “insider” I probably have a different perspective than you and can speak from experience and first hand knowledge. Through this series, I will attempt to unravel various aspects of our health care delivery system to show you how complicated things have become and why the solution is so difficult.\n\nMany aspects of our health care have failed. Attempts to fix these failures have not always been successful. Some have made matters worse. But each decision affects adjacent aspects of the health care delivery system. In addition, corrective decision making has often been misguided, often ill-conceived, often without input from medical authorities, often fueled by ulterior motives but many have resulted in medical care getting off track.  In Part 1, I used a simple example, a visit to the Emergency Room, as an overview of a health care delivery system gone awry. Today, I will discuss money as It influences almost every aspect of medicine. I’m limiting this section to a loose framework because It will keep coming up in later discussions where more detail will make sense. \n\nPhysicians charge for their services, of course. Most payments are made by insurance companies. When I started medical school (in Michigan, 1973), the insurance company was usually a private one (Blue Cross/Blue Shield, for example). Medicare covered a small percentage of patients, Medicaid was a minor payor and some patients had no insurance. Most doctors made a comfortable income. Some made a lot of money, either by being in a busy practice or by specializing. I was still naive. I didn’t realize even others got rich by cheating the system (topic for a later chapter). I knew from early childhood I wanted to be a doctor. I wanted to help people, just like the doctors my family used as I was growing up. It was a “noble” profession and I inherently knew I would be helping sick people while not worrying about making a good income.\n\nPrivate insurance was the gold standard. Physicians negotiated their fees with the different insurers. Rates were determined by the profile you built up with the company or by accepting their regional “usual and customary” fee. This was the bulk of a doctor’s income. Medicare/Medicaid paid ridiculously low fees based on their own fee schedule, always a source of jokes among physicians. But it was tolerated because everyone deserved medical care no matter their financial status and it didn’t really hurt the bottom line. In fact, income was so comfortable that most physicians I knew treated people without any insurance as a “public service” either for free or for a discounted fee with a payment schedule the patient could afford (usually $10 to $20 per month).\n\nThere were positives and negatives with this financial arrangement. Most people were seen in an office by a GP (General Practitioner). A GP is a doctor who did a one year internship after medical school and went directly into practice (“hung out a shingle”). Although a nurse checked you in and took your vital signs, the doctor saw all his patients. GP’s even made house calls back then. He (yes, the vast majority were male and American) would either treat you or refer you to a specialist, if necessary. The specialist would then send a report back to the GP who would coordinate the care and follow up on the treatment. This included visiting patients in the hospital, if admission was necessary.\n\nHowever, “paying customers” (those with insurance) often received more attention (and probably more technology). Those without insurance (aka “indigents”) were worked in around them. Extra tests were ordered, often unnecessary. And they might be expensive tests. A doctor could justify any expense if it was in the patient’s best interest. Hospital stays could be extended, even if just for convenience. After all, the insurance company was paying (and the cost passed along to and shared by all the insureds). There were no financial repercussions to the physician. His fee remained intact. In fact, physicians were being wined and dined for their authorization to spend money by any and all companies even remotely connected to medical care. Continuing education became a joke. “Conferences” took place at the best resorts, all around the world, and some even seemed like extended parties. Of course, this was not universal. The majority of physicians were honest, hard working and cared for their patients.\n\nHowever, abuses like these were the beginning of the end and financial reimbursement started changing in the 1980’s. Medicare roles grew to larger numbers and became a significant portion of everybody’s practice. More-so in the South, I noticed when I moved to Florida (1983), a “retirement” state, where most practices were 60-70% Medicare patients. In addition, it was a period of expansion. Medical knowledge was booming. Technology was exploding with newer and more expensive treatments. It became harder for one general practitioner to keep up with such a diverse knowledge base, creating the need for more specialties and specialists. In fact, the Family Practice (FP) physician became the primary office physician, specializing in family medicine and replacing the generalist (GP knowledgable in basic medicine and surgery). The number of medical school graduates quickly increased to meet the need. All this growth cost money and the prevailing social winds started preaching that medical care was becoming too expensive.\n\nThe Government, through Medicare, began limiting the fees paid to physicians. At first they maintained current fee schedules and even allowed a physician to charge a non-Medicare patient more than a Medicare patient, but only up to 110% of the Medicare fee schedule. Of course, if you wanted nothing to do with Medicare, you could “not participate” in Medicare and still charge whatever you pleased. Later, the fee schedules were rolled back, a little at a time. It began negatively impacting Medicare participating physician’s income, obviously starting with those practices with a higher percentage of Medicare patients (the warmer South with more “retirement” states).\n\nThe next step was to limit all fees charged. The Government could only control physician charges through Medicare imposed fee limitations.  That is, a physician had to agree to join Medicare and follow it’s rules. In high Medicare percentage areas, social and financial pressures literally forced physicians to accept Medicare patients and therefore, participate. Up North (traditionally low Medicare populations), physicians could still maintain a practice because there were enough patients with private insurance and a physician could simply choose to not participate in Medicare. The Government found a way to coerce these northern physicians into accepting Medicare by linking medical licensure to Medicare billing rules. That is, if you wanted to keep your medical license, you had to agree to follow Medicare fee limitations and not balance bill Medicare patients for any amount over what Medicare allowed even if you were a non-participating physician. Hospitals treated Medicare patients and, therefore, required physicians on their staff to accept Medicare patients also. It became almost impossible to avoid participating in Medicare. \n\nWatching this progression from afar, private medical insurers followed the Government lead and began limiting physician fees. Now when you negotiated with an insurance company, they asked what percentage of Medicare would you agree to. At first, they paid (approximately) 150% of Medicare rates and later lowered them to almost Medicare levels. When HMO’s (Health Maintenance Organizations) were the rage, they offered less than Medicare rates, signing up desperate physicians to 90-95% of Medicare fees. Medicaid still paid even lower rates than Medicare. All of a sudden, the “ridiculously low” Medicare fee schedule of the 1970’s became the gold standard of the 1990’s.\n\nPhysicians are the only group of professionals, that I know of, who are legally limited in how much they can charge for their services.\n\nThat is a powerful statement. There are no limits to what an attorney can charge. There are no limits to what a plumber can charge. In addition, there were never any limits placed on durable medical goods charges or pharmaceutical company charges for prescription drugs. But, if a physician charges a patient more than the Medicare allowed fee, the result may be fines and/or expulsion (for life) from participating in Medicare. In fact, if two physicians even discuss their non Medicare (private insurance) fee schedule, they may be criminally charged with fee fixing (anti-trust and racketeering laws) and prosecuted, with possible expulsion from Medicare for life and possible jail time. \n\nMedicare fees have been ratcheted down so much that, across the board, most physicians earn approximately 60-70% of what they earned in the 1980’s (without considering inflation). One interesting fact is that limiting physicians fees has not helped Medicare control their costs. In 2016, physician charges accounted for only 10% of the Medicare budget (Source: Congressional Budget Office, June 2017 Medicare baseline). Let’s consider the practical aspect. The costs of running a practice keep increasing: rent, equipment, office personnel salaries, licensing, et cetera. The cost of raising a family keeps increasing. The cost of life keeps increasing. Yet, physician salaries keep decreasing.\n\nHow has all this affected medical services? If a physician cannot increase a patient’s fee, the only way to keep making the same annual income is to see more patients. Have you ever noticed your doctor’s nurse (advanced registered nurse practitioner, ARNP) does a lot of the work your physician used to? Does your family physician just pop his head in and say hi during your office visit? Does your entire office visit seem rushed? If you have had surgery recently, did you meet your surgeon before the day of surgery? Have you seen your actual surgeon post operatively for a follow up? Or did you only see his nurse? Did your anesthesiologist spend more than five minutes with you prior to going to sleep? One unexpected, but inevitable, result of being financially restricted is: doctors don’t have enough time to spend with each patient. \n\nHospitals are under similar pressures. Nurses now take care of more patients at a time. LPNs and nurses’ aides are doing more of the work. Your hospital stay is shorter - whether you are ready to go home or not. But if you’re not ready to go home and care for yourself upon discharge from the hospital, you are sent to a rehabilitation facility. Or perhaps you go home anyway and a visiting nurse checks in on you now and again, but only for a few visits before Medicare benefits run out.\n\nThere has been a massive shift to cost containment, away from the best interest of the patient. What used to be justifiable if it served the patient’s best interest is now disallowed in favor of cost containment. One example: In 1970, it was considered good practice to order a screening chest X-ray for an otherwise healthy 40 year old smoker. If, out of 1,000 X-rays, one curable lung tumor was detected and a life was saved by operating early enough, it justified the cost of 999 normal X-rays. In 2017, you would not be allowed by the insurance company to order a chest X-ray on an otherwise healthy 40 year old. In the name of cost containment, it is less expensive to let one person die of a curable lung cancer than to pay for 1,000 X-rays. This is a not so subtle example of the shift of priorities in medicine today. The pendulum has swung too far in the wrong direction. Hopefully, you (and public sentiment in general) will notice and help correct the situation.\n\nIf this article is interesting to you and you want to know more, please consider upvoting it. If there is enough interest, I will continue with more articles that will explain the above in more detail and explore other medical issues.",
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      "body": "Thanks for your comment. I am new to Steemit and getting used to the system. Since I am working full time (60+ hours per week) as an anesthesiologist, it may take a while to put together the next piece. Please be patient. Any suggestions you have to make my posting more noticeable/increase the number of readers is appreciated. Also, any comments on the information itself is appreciated. I am really trying hard to present information without being confusing.",
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      "body": "Thank you for this informative post. Looking forward to your next installment.",
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      "title": "The crisis in US medical care: A doctor’s perspective",
      "body": "My name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice. In fact, we all know it is broken. The problem is how to fix it. As an “insider” I can tell you none of the recent solutions will work. The system is just too complicated. Each aspect of medical care is intertwined with others. Medical decisions are influenced by multiple factors: insurance company authorization, oversight by State and/or Federal agencies, medical malpractice insurance company guidelines, reimbursement concerns, hospital administration concerns, defensive practice in today’s litiginous society, Emergency Room overload, medical society ‘best’ practice guidelines, cost of care and unfortunately, last on the list is the patient’s well being. Here is a “simple” example:\n\nA patient comes to the Emergency Room. The reason may be an actual emergency, or may not be an emergency, like it’s after hours for their family doctor, they don’t know where else to go or they don’t have insurance. The ER doctor knows if he or she doesn’t diagnose the problem correctly he/she and the hospital may be sued. So, every test in the book is ordered. If anything is abnormal, the patient gets admitted. One admitted, the hospital is responsible for treatment - whether the patient has insurance or not (i.e., whether the hospital will get paid or not). Their own family doctor doesn’t make rounds in the hospital anymore, so the patient is admitted to the hospitalist on call (a primary care physician hired by the hospital). The clock is now ticking because the hospital gets paid a fixed amount by Medicare or Medicaid based on the diagnosis only (most of the ER admissions are Medicare or Medicaid here in Florida, although many insurance companies are following the government lead and also reimbursing by diagnosis only - called a DRG, diagnosis related group). So, although the hospital bills a HUGE amount to the patient, they actually receive a small amount, according to the DRG. A self-pay patient (no insurance) generally can’t afford the full price billed to them and works out a deal to pay $10 a month, for example. In reality, they wind up rarely paying for their treatment.\n\nBut I digress. Back to our “simple” example. Here’s the next problem. While the hospital gets paid a fixed amount, hospitalists get paid by the number of days they care for a patient. Their incentive is the opposite of the hospital who is ‘on the clock’ payment wise. In fact, each DRG has an associated LOS (length of stay). If a patient stays in the hospital longer than their LOS, the hospital’s fixed DRG payment gets cut a certain percentage. So, after the hospitalist studies all the tests and gets numerous consultations from specialists for 3-4 days (their payment starts to get cut after 4 days), they refer the patient to a specialist (e.g., a surgeon) for definitive treatment.\n\nMost of my experience as an anesthesiologist is with surgery. If the patient’s problem is surgical, the surgeon (specialist) takes over care. Now, the surgeon knows he can’t let a patient go home without treating the condition, so he schedules surgery. After surgery, the surgeon is pressured by the hospital to get that patient out of the hospital (remember, the hospital is running out of LOS days and can’t afford to lose money). There is a whole department of nurse/administrators (case managers) whose only job is to keep track of LOS and push for a discharge or look for legitimate reasons to appeal for additional LOS days. Often, a patient is discharged before they are truly ready due to LOS payment issues. This is one reason a rehabilitation facility may enter the picture. Patients who can’t take care of themselves after discharge go to one of these because there is different payment available for rehab. This is also where there is opportunity for an attorney to convince a patient he or she was not treated properly and can sue their physicians and hospital. But that is another story for another time.\n\nIn the “good old days” of medical care, a person with a stomach ache went to their family physician. Let’s say a gallbladder attack was suspected. Tests would be ordered (specific for gall bladder disease) and done as an outpatient (less expensive than in the hospital). If positive, the person would be referred to a surgeon who would schedule surgery (again, as an outpatient, less expensive) and the problem gets treated.\n\nToday, once that same patient goes to the ER, it’s a different story. Many hours of agony are spent in the ER waiting to be seen and waiting for a host of test results. Several days are spent in the hospital, still in pain, until surgery is performed. The net result is the same, but with a lot more time spent, with a lot more pain endured and with a lot more cost.\n\nMost people don’t understand what is happening within the world of medicine. I feel too many people who aren’t doctors are making decisions affecting the practice of medicine and ultimately will destroy it. Yes, it needs to be fixed. But, it needs to be fixed properly and that can only be accomplished through understanding what the problems are. In my small way, I hope I can help fix things by spreading understanding. This article is only a small peek into my world. It’s the tip of the iceberg, if you will. So many factors, some listed above, affect how medical care is delivered and, ultimately, the health of every individual.\n\nIf this article is interesting to you and you want to know more, please consider upvoting it. If there is enough interest, I will continue with more articles that will explain the above in more detail and explore other medical issues.",
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