Surgery Center of Oklahoma Blog

If I didn’t know better I’d say that someone from our local newspaper is reading this blog.  In the Sunday paper there was one article on Medicare Fraud and another on un-needed scooters for the elderly!  In the last blog on private contracting, I listed “risk” as one of the reasons that many physicians will no longer see Medicare patients.  In today’s newspaper, a U.S. attorney for the western district of Oklahoma was urging seniors to recognize and report Medicare fraud and abuse.  Sounds good so far, huh?  Half way through the article, seniors are told that if something doesn’t make sense on their bill or statement they should contact the Medicare fraud hot line.  Starting to get the picture?  Are you imagining thousands of confused elderly people calling this hotline because something doesn’t make sense to them?  Do medical bills make sense to anyone?

Now put yourselves in the shoes of the physician (perhaps a neurologist or an internist specializing in geriatrics).  They have lots of patients that are confused on a good day.  They are being encouraged to call the Medicare fraud hot line.  The storm-troopers arrive at the physician’s office looking for “fraud and abuse.”  They will find it.  A simple mistake on one out of tens of thousands of forms will be found.  This will be determined to be fraud.  Why?  Because that is what the thugs from Medicare are hired to do….they are just doing their job, you know.  The physician can fight this in court (and face certain bankruptcy trying to win this case against the leviathan) or he/she can surrender and pay the fines/penalties and settle up with those in charge of this extortion/shake down/stick up…whatever you want to call it.

When you read that Medicare fraud is on the rise, it is because Medicare and our wonderful public servants in the Dept. of Justice say it is on the rise, not because it is, necessarily.  ”Physicians surrendering to bogus charges of fraud rather than face bankruptcy is on the rise,” is actually more accurate.  Is there fraud in Medicare?  Of course there is.  There is fraud in all types of insurance.  This is the nature of having third parties pay bills, rather than those receiving the product or service pay the bills.  How about this?  ”Dr., I’m writing my check for today’s visit and you have charged me for a urine check that wasn’t done and I don’t want to pay for what wasn’t done.”  Isn’t that where the accountability should be?  Dr. says,” I’m sorry.  I checked that box and didn’t mean to.”  Or alternatively, the physician says,”Nurse!  Why didn’t you get a urine sample like I asked you to?”  Could this be interpreted by the Medicare police as fraud?  Yes it could.  Yes it has.  Physicians are in jail for this kind of stuff.

“Doctor?  Can’t you do a full blood workup on me?  I know my last one was a month ago but I sure would like to have that re-checked.  It’s not going to cost me anything ’cause Medicare will pay for it.  Just go ahead.”  Is this fraud on the patient’s part?  ”I see other folks riding around on those scooters at the grocery store and I can’t afford one but my buddy who has the same Winnebago I do said that if you will just write me a prescription then Medicare will give me one.”  Only when patients are responsible for payment of their care will the incidence of fraud and abuse on both ends decrease.

How about this for fraud?  All of the money that people have paid into social security and Medicare over the years is gone.  Now that’s fraud and abuse.  Hospitals increase prices for those of us who are paying to “cover” those who can’t pay……all the while knowing that they will be paid later for this “free” care….now that’s fraud.

I predict that fewer and fewer physicians will see Medicare patients as demented old folks light up this hotline with items that “just don’t make sense” on their bills/statements.  Most of the elderly will never understand that recruited as brownshirts, they may completely lose access to the physician that has taken care of them.

G. Keith Smith, M.D.

Many physicians are no longer accepting Medicare.  Some  are continuing to see Medicare-covered patients but with the understanding that Medicare will not be involved in the payment of care rendered by the physician.  Why would a doctor do this?

Risk:  if a physician makes a mistake on a Medicare claim (no matter how innocent) he/she is eligible for a stay in a federal prison and bankrupting fines.  The Medicare storm-troopers descend on his/her practice and rifle through all of the physician’s files and find all of the “mistakes” they could possibly need to put the physician in jail or bankruptcy.

Payment:  payments to physicians for Medicare patients are often times below the costs incurred to see Medicare patients.  Legal caps are placed on these payments and contrary to what many Medicare patients think, physicians can’t just bill them whatever they want.  Secondary insurance is therefore a scam, as physicians can’t bill beyond the limits imposed by Medicare in the first place.

Oath:  Some physicians (fewer and fewer, sadly) took their Hippocratic oath seriously.  As physicians we are obligated to do what we think is in the best interest of the patient…..PERIOD.  If a third party has a restrictive formulary or otherwise places obstacles preventing what is best for the patient, that represents an impossible dilemma for the physician and one many are increasingly unwilling to face.

Philosophy:  Some physicians believe that Medicare money is stolen property.  I, for instance, have no right to the income of my neighbor for an anesthetic that I provided to some guy for his knee replacement that my neighbor doesn’t even know.  Many times physicians represent themselves as fiscal conservatives, wanting small government, but at the same time will lobby Congress’s gang of 535 for more money from Medicare!

Dedication:  some physicians are dedicated to their patients….hard to believe, huh?  This is why many are willing to turn to a method of payment known as “private contracting.”  Medicare patients typically sign a waiver in which they acknowledge that no Medicare claim will be filed by either them or the physician and that payment will be made directly to the physician.

Private contracting will, I believe, become an increasingly common practice as Medicare’s bankruptcy becomes more apparent.  Physician payments will be slashed again and again and the delays in payment will increase over time.  Fewer and fewer services will be covered and in order for a Medicare patient to be seen in a timely manner (wow!…sounding kind of like the mess north of the border, huh?!) they will have to pay the physician directly or even go to a foreign country if this practice is made illegal.

I have mixed feelings about private contracting.  I have done this to some degree, but see it as a way to prop up “the system” for a longer time than it would otherwise stand on its own.  People that are sick or hurt need care, though.  But the entitlement mentality among the Medicare population is very distressing.  I don’t believe that any real changes to Medicare or abolishing this Ponzi scheme are likely until widespread shortages of physician services to this group of people emerge.  Only the distress and the complaints of the Medicare population will result in the dissolution of this wealth transfer scheme.

I believe that this is coming and that there is hope for the wonders of the free market in medicine for the elderly once again.  Ironically it will be the bankruptcy of Medicare that is the salvation of the health of the individuals that are held captive by this “program.”

G. Keith Smith, M.D.

I stopped taking federal money in 1994.  I realized that government was huge and out of control and thought that anyone taking federal money was on the dole.  It finally dawned on me that I too was on the dole as a physician accepting Medicare money.  This money, after all, ultimately comes from a taxpayer stick-up by Uncle Sam.   But to be frank, the federal government made it easy for me.  When I started practice in 1990, Medicare paid me about $1100 for the anesthetic management of an open heart procedure (about 3 to 4 hours of my time depending on the surgeon).  When the Harvard cretins came up with the RBRVS (resource based relative value scale) the government took the opportunity to “stick it” to the hospital-based physicians (anesthesiologists, radiologists, pathologists and emergency room physicians).  Our reimbursement was cut in half.  One year later….ready?….they cut that in half.  The last open heart anesthetic I did was an extremely difficult case that took about 6 hours due to many unsuccessful attempts to wean the very sick patient from the bypass machine…he eventually did well.  Medicare paid me $287.  The last anesthetic I gave for a Medicare patient receiving a knee replacement paid me $78.  This kind of reimbursement for my work made it easy to leave this work behind.  I must at this point pay homage to the people that helped me see the light and eliminate Medicare from my practice:  Dr.’s Lois Copeland, Michael Schlitt and Jane Orient.

I could do multiple blogs on this and probably will but for now will focus on this point:  the federal government is an unreliable and bankrupt customer.  What I mean is that doing business with Uncle Sam is a risky proposition at best and is becoming even more so.  I saw where the latest “F” series fighter jet contract might be jeopardized by the failure to increase the debt ceiling and come to a budget deal in Washington.  Maybe it’s time for military and other vendors to realize what physicians have known all along.  As a customer, Uncle Sam is an unreliable bill-payer.  If the physician experience with Medicare is any indication, this will only get worse.  Cuts in pay are a constant threat and Lord help any physician that makes an innocent mistake on a Medicare claim.  Jail time and bankrupting legal proceedings have become common-place.

I did notice in today’s local paper that Lockheed is planning on selling 30-odd “F” series fighters to Iraq (wait?…aren’t we still at “war” with them?).  Maybe Lockheed has figured out they need to sell their planes to folks that are reliable and have the money.  Maybe Afghanistan, Libya and North Korea are Lockheed’s next customers!

G. Keith Smith, M.D.

A friend of mine told me that his mother called him the other day and told him that she wasn’t feeling well, had a 100.2 fever and was going to the emergency room.  He asked, “what kind of symptoms are you having, mom?”  She said she was just feeling kind of under the weather and had this fever.  He said,”don’t go to the emergency room.  Wait until Monday and go see your doctor or go to one of the AM/PM clinics.”

What was it about the emergency room that made this son caution his mother about a visit there?  He was afraid that it would cost a fortune.  Why did the mother want to go there (by the way, she did go to the emergency room)?  The real question is,”why not?”  Her out-of-pocket exposure is virtually zero so it is human nature to match the demand with the perceived price.

This is the nature of entitlement.   Something  perceived as “free” makes folks demand things they don’t even need.  Ever been to a store that had some items for 80% off?  Ever thought, “I’ve got to get me one of those…I don’t need it but boy if I ever did I’ll sure be glad I got it now.”

“I was feeling ok but just thought I’d come in for a check-up all the same.”  ”Why did you come in to see me?”  ”Because Medicare will pay for so many visits a year.” Physicians see this type of behavior all the time.  I think things would be very different if people had to pay for their own care themselves.  I think there would be fewer emergency room visits if people had to pay for this service themselves.  I think that without major changes that make individuals more responsible for their health/actions this bankrupting behavior will continue and worsen.

Phil Gramm, the former senator from Texas once said,” ..our safety net has become a hammock.”  This, as the above illustration shows, has proven true.

G. Keith Smith, M.D.

Imagine for a moment  that you are poor…really poor.  You read in the paper that the gang in Washington is going to cut Medicare benefits and make you pay more…money you don’t have.  What is your reaction?  Fear would be understandable.  Possibly even anger.

Imagine for a moment that you live in the most affluent neighborhood in Oklahoma City.  You are really rich.  Seriously rich.  You read in the paper that the gang in Washington is going to cut Medicare  benefits and make you pay more….money you have.  What is your reaction?  It might surprise you to know that the anger from the wealthy Medicare beneficiary would dwarf the fear of the poor person in the first example.

One of the most disgusting things I have ever experienced in my 20 years of anesthesia practice is the intense entitlement attitude…..of the ultra-rich.  The entitlement mentality is bad enough.  But when someone whose net worth is 10,000 times what  I could earn in a lifetime and they demand that I provide them free medical care (Medicare) I must admit to shock.

I hope that there are enough elderly folks who want an alternative to Medicare.  I am afraid though that the elderly will dig in and lobby hard  so that “no one touches my Medicare!”  All that the elderly will understand, I’m afraid, is rationing and denial of care….only then will they demand an alternative.

Time for the elderly to let their children and grandchildren off the hook.  Time for the elderly Medicare beneficiary to let these spineless politicians off the hook and demand an end to this  and other Ponzi schemes from which they benefit.

I’m not holding my breath.

G. Keith Smith, M.D.

I haven’t written much about free market health care on this site yet, so let’s get started.   Free market health care means no-government health care.  To the extent that the government is involved in any market, that market ceases to be free.  Government is force, pure and simple.  The brilliant Austrian economist Murray Rothbard defined government as “…a monopoly on violence.”  Any time that government funds are involved in any market, there are strings attached and usually price controls, fraud, bribes and corruption as those in power morph their position into wealth.  Medical markets are no exception.  There is nothing “free market” about Medicare.  That is why it is a disaster and a bankrupt Ponzi scheme. Government Ponzi schemes like Medicare and Social Security make Bernie Madoff  look like a saint.  Current workers are taxed for the current elderly.  There is no Medicare trust fund just as there is no Social Security trust fund.  There is simply a transfer of earnings from the young to the old.  The demand for medical care from the elderly is huge because this care is so heavily subsidized that little out-of-pocket exposure exists for the beneficiary.  Seriously, how many of the scooters you see old folks running around in would be sold if they were coughing up their own dough to buy them?  This is only one of  the countless examples of market distortions in a non-free market.  How many scooters are needed?  What should their price be?  These basic questions can never have accurate answers as long as the government is involved in their purchase.

What should a heart surgery cost?  How much should a month cost in a nursing home?  How much should my blood pressure medicine cost?  Once again, no one is asking these questions in a hardware store, are they?  If the water hose or the paint sprayer or the nails or hammer cost more at one store than at another a natural give and take and balancing takes place that insures that the buyer and seller end up at the right price.  This beautiful dance of the free market has been thwarted  in the practice of medicine and is in large part due to the presence of government payments and the politics and fraud that go along with socialism.

Someone I know just back from Israel, a country with a socialist health care system,  had a friend take an ambulance ride over there.  He said, “it only cost $100.” I quickly pointed out that it didn’t cost $100.  It may have cost only $100 to the one riding in the ambulance, but it cost people who were not riding in the ambulance  money, as well.  This is part of the sickness of socialism….no one really knows what anything costs.  I have heard patients say that they were going to wait until they turned 65 and enrolled in Medicare before they had their knee replaced so that it would be free.  But it’s not really free, is it?  What they really mean is…”I am going to wait to have my knee replaced until that young struggling family down the street where both parents are working two jobs will pay for my surgery.”  Too harsh?  But wait, you say, “didn’t this old person ‘pay into Medicare’ all of their working life?”  Of course they did and the money was squandered by politicians buying their votes, promising not to “touch their Medicare.”   So the money the current 65 year old person paid in is gone….long gone…and the care they receive is paid for by the current working young. But wait!  ”I’m elderly,” you say.  ”I pay Medicare premiums every month!”  This “premium” doesn’t even cover the drug benefits.  When does this Ponzi scheme madness stop?  It stops with bankruptcy.  It won’t stop suddenly.  It will begin with rationing and price controls (think drug shortages, waiting lists for surgeries, deaths from neglect), the usual bag of  government tricks that never works.  Aren’t there any other solutions?

I think that there may be one.  It is politically possible and consistent with the mood of the people in this country now. It is an expression of what is called “the doctrine of subsidiarity.”  Simply, the government that governs best governs closest to home.  Why not send Medicare to the individual states?  Why not let Oklahoma or Texas deal with the health issues in their own respective states temporarily on the way to eliminating federal Medicare?   Make private insurance available to the elderly who can afford it, and enroll those who can’t in Medicaid temporarily.  This would, of course, mean that the taxes that go to D. C. for this would no longer make the trip.   A transition to a situation and market where individuals take care of themselves, and local communities made up of volunteers and charitable organizations taking care of those who can’t care for themselves may be possible, I think, if this first step (getting Washington, D.C. out of the picture) is taken.  Many of the elderly in this country are waking up and realizing that “their Medicare” represents a black mark, not a benefit.  Fewer and fewer physicians are willing to see Medicare patients and their access to care will continue to be limited.  More and more of the Medicare population are clamoring for an alternative, as sadly they have none now, other than going completely uninsured. This new awareness on the part of the elderly may make bold changes more politically feasible than the gang in Washington perceives.

Medicare and other federal “entitlements” need to end or we are all bankrupt.  Maybe the best way to make this happen is to first send it home for the individual states to deal with.  Tinkering with the age of eligibility or deductibles simply delays the inevitable and doesn’t begin to solve this huge problem….it just “kicks the can farther down the road,” as the columnist Gary North has said.  Maybe one of the reasons that we have so many folks that are  uninsured  is that they are paying (through Medicare taxes) for scooters and heart surgeries and total knees for people they don’t even know.  Thankfully, more and more of the elderly in this country are sick with the thought of bestowing this burden on their children and grandchildren.

G. Keith Smith, M.D.