Surgery Center of Oklahoma Blog

Check out the Foundation for Economic Education. This outfit was founded by the great libertarian Leonard Read.  There is absolutely no way to better acquaint oneself with the great political philosophy of non-aggression than familiarizing yourself with his works.  My favorites are “Anything That’s Peaceful,” “Elements of Libertarian Leadership,” and “I Pencil.” …you can read “I Pencil” here.

I thought of him this weekend while visiting with a friend who is going through the angry phase of the wake up to reality that I believe many libertarians go through on their philosophical journey.  This anger finds its way into the politics of medicine.  Forcing people to undergo drug tests.  Forcing sterilization or abortion.  These are the methods of the aggressive, non-peaceful men that are tired of being robbed.  The right approach was, according to Read, always a non-aggressive, loving approach.  He was an intensely Christian man and his political views were as consistent with his faith as any man that has written about political economy or political philosophy, in my humble opinion.  His writings had an intense impact on me, not only his philosophy but his faith.

His answer, by the way to the above scenario would be to characterize the event that led to the creation of the welfare check as an aggressive, violent act of robbery.  Why discuss how to dispense with the money?  What about the original crime and victim?  His writings always seem to bring peace in troubled times.

G. Keith Smith, M.D.

The old joke is, “Mr. Williams, I think you have a problem with your gallbladder.”  ”Doc, could I get a second opinion?”  ”Why, yes,” says the doctor.  ”It might be your kidney.”

The son of a friend of mine suffered a broken bone recently.  I asked who was taking care of him and the answer was one of the truly outstanding orthopedists that works at our facility.  This very experienced and ethical doctor knew that surgery was not indicated and that this young man would heal without any surgical intervention.

I had a few thoughts when I heard this.  My first thought was that when I heard who was taking care of this young man, I relaxed.  There was no doubt in my mind that the right diagnosis was made and that the right treatment will be forthcoming….no doubt….none.  No second opinion needed.  Get it?  One of those guys that always gets stuff like this right. Then I realized that the number of world class surgeons that Dr.’s Lantier and I are surrounded by at the Surgery Center of Oklahoma is impressive.  Our facility is loaded with guys like this.  Surgeons who get it right the first time.  Surgeons who fix other surgeons’ mistakes.  Surgeons who find and diagnose problems every day that many others would miss.  Surgeons who regularly make diagnoses that don’t involve surgery.  Surgeons who are really great people and have been kind and generous with the staff at our facility.

Then this thought:  many of these guys would like to be busier.  Yet, insurance plans prefer many times to send patients to hospitals where none of these great doctors will work.  So some less- able surgeon works on folks that would be better served by great surgeons who would actually like more business.  This cartelization of care has interfered with the discipline of the free market and channeled  patients where they were harmed and kept them from the best qualified physicians in many instances.

As a patient you should keep this in mind when your insurance plan financially punishes you for “going out of network.”

G. Keith Smith, M.D.

You need your knee fixed.  Your orthopedist wants you to go to a facility that’s out of your network.  You are miffed because this is going to cost you alot of money.  Or is it?

Your benefits are 80%/20% in network and 60%/40% out of network.  What does this gobbledegook mean?  It means that your out of pocket responsibility is 20% if you go to an in-network facility and it means that your out of pocket responsibility is 40% if you go out-of-network.  OK…SO?  If the charge or the allowable billed amount of the in-network facility is $12,000, your responsibility is 20% of that, or $2,400.  If the charge or allowable amount of the out-of-network facility is $3740 (our online price) your responsibility (40%) is $1496.  What?  You mean that your out-of-pocket expense for a surgical experience at the Surgery Center of Oklahoma is less than that at a big (not-for-profit) hospital?  How can this be?

Why are the insurance companies determined to direct you (scare you) to a facility where you will be out of pocket more money?  What could possibly motivate them to do this?

You live in Dallas.  You go to see your trusted family doctor.  You need your gallbladder out.  He goes online.  He has paid for a service called iRefer.  This gives him access to online ratings of facilities and their quality of care.  He can even search for price where it’s available.  He tells you that you can stay in Dallas and pay $28,000 for your gallbladder removal.  Or you can go to Oklahoma City and have a “5 diamond rated” surgeon at  a “5 diamond rated facility” remove your gallbladder  for $5655.”

What would you do?  What do you think the company you work for (if they are self-insured) wants you to do?  What if your company told you that your deductible would be waived and you would have no co-pay if you went to OKC?

Check out Medical Home Exchange. This may be the new paradigm of health care in the old USA.  Unless the government outlaws this innovation.

G. Keith Smith, M.D.

Why is health insurance tax deductible for businesses and not for individuals?  Could this possibly be a benefit to big insurance companies?

Put yourself in the shoes of the insurance company.  Wouldn’t you rather deal with a company’s human resources staff than to deal with each and every one of the employees of a 1000 employee company?  Wouldn’t you rather sell one policy that covers “1000 lives”  than to issue 1000 policies?

Now, consider Obamacare.  Five, maybe six regions of the country.  Each covered by one of the giant insurance companies.  Done.  No competition.  No need to provide customized insurance coverage to individuals.

Wonder why the insurance industry supported this fiasco?

G. Keith Smith, M.D.

Years ago I was at a dinner for some Oklahoma State legislators.  I was new to the political scene.  The fellow that set up the dinner was aware of my libertarian philosophy and sat me next to the most conservative legislator in the State senate.  He told the legislator, “ok…here is someone that makes you look liberal!”  The senator accepted the challenge.  He said, “where do you stand on ‘scope of practice?’”

Without hesitating, I said, “Let God sort them out.”

He turned to the dinner host that arranged the seating and said,”O.K.  You are right.  He is a libertarian.”

I have always marveled at the anesthesiologists and ophthalmologists that fight with nurse anesthetists and optometrists.  Nurse anesthetists want autonomy.  The anesthesiologists don’t want them to have it….they want to supervise the nurses.  Yet, in rural Oklahoma, nurse anesthetists are all that’s available when an emergency C-section is needed…or an emergency appendectomy.  Maybe they only need this “all-knowing” supervision when they are in the “big city.”

Optometrists want to do laser surgery.  Ophthalmologists don’t want them to do this.  Why?  Because patients are in jeopardy?  Or because they want protection from this group?

Money flows into the state capitol from both sides.  Statements are made.  Facts and figures are produced.  Statistics and studies are cited.  Year after year, the same result.  Nothing.  Why?  What kind of idiot would a legislator have to be to solve this?  Once it is solved, the game (money) is over.

Why not let the market work?  As anesthesiologists, our training should provide us with skills that place us in a position to compete with nurses that have not attended medical school and therefore lack the rigor of our training.  As ophthalmologists, the training necessary to complete this difficult path dwarfs the path taken by their optometry counterparts.  So why fear competition?  Why ask the legislator to get involved?  Why not embrace the discipline the free market provides for those unable to complete the task/service advertised on their shingle?

I know anesthesiologists that I would not let touch me.  I know nurse anesthetists that I would feel completely comfortable anesthetizing me.  Why not leave the government out of it.

I stand by my original statement:  ”..let God sort them out.”

G. Keith Smith, M.D.

Over the years I think I have had trouble distinguishing between cowardice and evil.  I am now realizing that awful and evil results are often the result of cowardice, not evil intentions, as only the rare individual has evil intentions (most politicians, for instance).  Cowards are everywhere.  They are in government and in the private sector.  They are in industry, energy, medicine and law.  Many laws are the result of cowards trying to “buy” protection from the government from their competitors, for instance.

The average physician is no match for the savy hospital administrator or insurance executive.  These corporate types are risk takers by nature and often times are taking risks with corporate money (the so-called moral hazard scenario).  I have faulted physicians that signed up as hospital employees and have failed in the past to recognize that this compromise is a result of fear, not some failure of character.  I believe that the same is true for those signing up for insurance contracts such as HMO’s and other rationing  instruments that are horrible arrangements for the physician and the patient.  This enrollment is an act of fear or cowardice even though the results are regularly awful and evil.

Some physicians ask the legislator to protect them from someone on their turf.  This, too, is an act of fear.  Anesthesiologists are notorious for their attacks on nurse anesthetists.  Ophthalmologists are always after the optometrists.  Otologists are after the audiologists.  I could go on and on.  The argument is always the same.  ”We, the annointed ones, are here to protect the public from those with inadequate training from certain harm/death/you name it.”  This is cowardice, pure and simple.  If hospitals need “protection” or “certificates of need” to keep the specialty hospitals from competing with them, they are, quite simply, cowards, not evil actors.  If surgeons are afraid that their referral base will dry up unless they surrender to the big and powerful hospitals, they are cowards, not evil people.  Wimps not devils.

Or does the fearful trait present in so many physicians represent a flaw in their character?  I think it represents a flaw in our training.  This fear serves to make us short-sighted and poor decision and people managers and incapable of dealing with the hospital administrator types.  I throw this blog out there hoping to start a dialogue not so much to be provocative or judgemental.

Let me know what you think.

G. Keith Smith, M.D.

A very good friend and colleague asked me today if I knew a place that a relative of his could obtain an ultrasound test for possible gallbladder dysfunction.  This relative had no insurance and was looking for an affordable facility/radiologist.  They had called their local hospital in an Oklahoma City suburb.  The price:  $875.  This, however, did not include the radiologist’s fee.

I gave him a phone number.  Who did I recommend?  Why, a greedy doctor-owned facility, not three blocks from the $875 hospital.  Their price?  Ready?  $187.50.  Including the radiologist’s fee.

Opinions are opinions.  Facts are facts.  The above is only one illustration of the fact that physicians are generally not the problem with the high price of health care.

G. Keith Smith, M.D.

This is what a Tampa hospital billed the estate of a deceased patient. Now, in defense of the hospital, the patient was there for 5 years.  For those of you that are following this blog you know that I’m wondering how the whole “uncompensated care” thing factors into this.  Well, it turns out that the hospital expects to collect no more than 1 million of this incredible charge…ok…maybe 2 million.  But that means…cough…they lost 7.2 million! Right?  And guess who pays this? You do!  See my previous blog (uncompensated care) on how they will pull this off.  This 7.2 million dollar “write off” will also help them maintain the fiction that they are a not-for-profit facility, as well.

Think they will use this to justify cost-shifting?  Think they will use this to bolster their argument for a provider tax?

G. Keith Smith, M.D.

What in the world is this?  This is fraud, that’s what it is.  This is a number that hospitals come up with at the end of the year.  It’s a number that supposedly represents the amount of charitable care delivered for which they were not paid.  The hospitals report this number to the feds.  Then….ready?….they get car dealer like rebates from….ready?….YOU!  Yes, that’s right.

“But wait,” you say!  “Hospitals are all losing money because they have to see everyone that comes to their emergency room!  The uninsured are breaking the backs of our health care system!  The hospitals have to charge more for you and me to cover these losses sustained by caring for the uninsured!”

Ahhh.  If only that were true.  I suppose that’s why there’s a crane in front of every emergency room to build on and expand!  The hospitals are actually incentivized to overcharge the uninsured and poor to maximize their take at the end of the year!  What?!  That’s right.  The less you obviously have, the more you will likely be charged. Take a look at the state of Arkansas questionnaire on how to calculate eligibility for the “disproportionate share” program (what I’m calling rebates). To confuse matters further, the “rebates” don’t arrive until the subsequent year (what is called “prospective payment”).

Now, in all fairness, there is some argument amongst the hospitals about all of this.  You see, some of the hospitals, although participating in this scam, are angry at some of the others that are taking advantage of the “program.”  Some of the hospitals calculate this number differently than the others.  While the number is supposed to be the amount of uncompensated charitable care, some are actually using the difference between what they billed and collected…..for everyone receiving care.  What?  If the hospital charges $100 for an aspirin and insurance only pays them $5 for the aspirin…well, you see, they lost $95.  This number then is added to the big tally and the feds (your money and mine) compensate them for this terrible loss.  This loss also helps the hospitals maintain the fiction of their not-for-profit status.

The discipline of the free market is absent in so much of medicine.  The free market is the medicine that so much of American medicine needs (sorry that came out kind of corny).  The idea that more government, not less, will make things better in any way in the delivery of health care is simply idiotic.  This example illustrates that, I think.

G. Keith Smith, M.D.