Surgery Center of Oklahoma Blog

A small article in our local paper yesterday stated that an investigation by the inspector general’s office found that the EPA report the current administration cited and relied on to implement new and tough environmental regulations was exagerated and flawed.  This is not some politically charged right wing think tank.  This is the government’s own inspector general’s office findings.

Ok.  Here’s the translation.  The EPA lied.  They issued a false report because that’s what the current trash in the executive branch (as opposed to the previous trash) wanted them to do.  Then the executive branch used this pack of lies to implement new regulations that simlutaneously crushed their political foes in business while boosting the businesses of their buddies (like Solyndra).  Who said the current president wasn’t a fan of crony capitalism?

Lew Rockwell once said that “…we are ruled by the stupid party and the evil party.  Once in a while they get together and do something stupid and evil.  We call that bipartisanship.”   The EPA and the FDA alone are bad enough.  When they get together, we get regulations that can result in deaths.  Like outlawing over the counter Primatene mist.  Because it will hurt the ozone layer.  But they didn’t lie about that did they?

Right. 

G. Keith Smith, M.D.

Pretend that you own a business with 40 employees.  You provide them health insurance.  You have figured out that self-insuring makes sense for you and you have saved loads of money by doing this and your employees love it.  The company you used to buy your insurance from still acts as your “third party administrator.”  In other words, even though it is your money being spent, they have the checkbook and are authorized to pay and negotiate medical claims on your behalf.

Every year your “insurance guy” shows up about a month prior to renewal of your contract with him and his company to provide you with this “third party administrator (TPA)” service.  He shows you how much money his TPA has “saved” you and your company by comparing what you were initially billed and what, ultimately, you wound up paying.  This “huge savings” is due, of course, cough..ahem…to his company’s powerful presence in the market and their tough negotiating stance and the desirability of their “network.”

Ok.  Now the fun part.  You are not an idiot like this insurance guy thinks you are.  You quickly realize that he is full of crap.  Your employees go “out of network” most of the time because either the physician they want to see or the facility to which they want to go is infrequently “in network.”  The “network” tries to force your employees to big expensive hospitals with penalties and extra deductibles and other tricks.  You and your employees have figured out that for all of this coercion, it still makes sense to go “out of network” almost every time as the prices away from the big hospitals are so low and competitive, the employees are usually out of pocket less money if they avoid the network. 

But here’s the part the broker really doesn’t want you to know.  You actually pay the TPA “ PPO repricing fees” based on how much they “saved” you.  Whoa, wait a minute!  That means that the TPA actually makes more money if the difference between the original bill and the final bill is huge.  The TPA is actually incentivized to find the most expensive place in town for your employees.  (WHAT?!)  They really don’t care ultimately how much you pay, just the difference between the giant original bill and the final bill.  And this guy has the gall to tell me how much he “saved” me?  The higher the bill is the more the broker makes on these repricing fees. 

One insurance broker recently told me that these “repricing fees” make up 40-50% of the net profit of big health insurance companies.  He is concerned that once this gets out that he is out of a job and that the days of this sweet deal are over.  This particular broker told me that if our transparent pricing model catches on the big insurance companies will once again have to play by the “rules of the market.” 

Let’s hope he’s right.

G. Keith Smith, M.D.

The Surgery Center of Oklahoma received news this week that our  accreditation has been extended for another three years.  This is the biggest “thumbs up” that the accrediting body can give a facility like ours.  We received the best marks in all categories with no deficiencies, having been surveyed by two examiners for two days last month.  The examiners were particularly impressed with the roominess of our facility, the cleanliness, our low infection rate and our having posted our prices online.  Also noted by them was the incredibly low turnover of staff.  The nurses and techs that work at our facility love their jobs and it shows.  This extension of our accreditation is a tribute to all of our staff, our head nurse, Marilyn Robertson, in particular…thank you Marilyn for guiding us through the process.  Every attention to detail by all of our staff has resulted in a level of care rendered such that the standards that accreditation agencies set for us are far below what we demand and expect from ourselves.

Hats off to the staff.  As I have said before, I have never worked with a finer group of individuals.

G. Keith Smith, M.D.

I think the best way to do this one is to start with the punch line and then back in to it.  You should provide for your own health care, not your employer, not the government.  This is not going to happen until the tax laws change and you can purchase health  care with pre-tax dollars just as your employer does for you now.  Otherwise, you are not in control, as those paying for your care are not the ones receiving it and are always going to minimize their cost/risk/exposure in every way they can.  I don’t think I need to tell readers of this blog why it is a bad idea for the government to control your health care.  They just want you to die when you get sick.  You represent a liability to Uncle Sam as long as you are alive and sick.  Better for you to be dead.  Ok…enough for Uncle Sam.

Why does the government care if I smoke?  Why do they care if I’m fat?  What business is it of theirs?  Money.  As the risk and payment of unhealthy habits has been socialized, one man’s disease becomes everyman’s problem.  You say,”..it’s none of anybody’s damn business whether I wear a motor cycle helmet or not!”  O.K. I’m with you.  But if you have no health insurance or any ability to pay, do you expect others to pay for your mashed skull when you wreck?  If you answered “NO” to this, then you are a true libertarian and I am sympathetic to your desire to wear no helmet.  Otherwise, what is the answer?  Helmet laws?  Certainly not.  Why not give the free market a chance?  Let everybody take care of their own problems and leave everyone else alone.  If someone with nothing gets into trouble, let churches and charities (who would be loaded with funds were we not fleeced by government at all levels) handle it.  The way things are now, we actually subsidize risky behaviors.

Why does your employer care if you are fat or unhealthy?  Money.  Your employer is either self insured and pays medical expenses for you directly or they buy expensive insurance, the premiums for which increase to the extent that the employees are unhealthy (smoke, fat, etc.).  That’s why employers set up wellness plans and have gyms and workout areas handy.  They are trying to minimize their cost.

You can buy insurance on your own.  This is expensive, however, particularly if the purchase of the insurance is made with “after-tax” dollars.  There is some talk of allowing associations to purchase group insurance.  For instance, you could buy insurance through your church or soccer club or bridge club or rotary  and receive the benefits of group discounting.  You would therefore not be subject to whatever cost saving measures your employer might be entertaining that year.  Maybe you want to buy a policy with no obstetrical coverage, because you and your wife are finished having children.  Maybe you want to take the risk of not covering certain diseases like lung cancer because you don’t smoke.  Maybe…you get the idea.  The market would respond (if it was allowed to) with insurance policies that could be customized for individuals or even groups.  As it now stands, Uncle Sam dictates to insurance companies what must be included in the policies and therefore dictates what you must buy.  This is one of the reasons that health insurance is so expensive.  This setup is great for insurance companies because people are mandated to purchase insurance that they don’t need….insurance companies charge the premiums without the risk of payments…sounds like a money maker to me!

This stuff is so obvious, I have to wonder why, if people are really serious about the cost of health care, doesn’t the tax law change to allow for the deductibility of health insurance purchases?  Why can’t the association health insurance co-op thing become a reality?  The answer is that too many folks with gobs of money and power benefit from the way things are right now and they purchase protection from market competition from legislators, state and federal.  As the market provides even more obvious solutions, the bribery of legislators becomes even more intense.  As Dr. Tom Coburn has said, “…political careerism has trumped good policy.”

I think that things are going to get better soon because economically our backs are against the wall.  The current model of government/corporate medicine is not sustainable, regardless how many fat cats get spayed/neutered.  The opportunity for individual responsibility is here.  I just hope that the policy makers understand that it may finally be in their best political interest to embrace these market innovations.  However, there is always the possibility that the bribery will escalate and they will prove themselves to be unprincipled human trash.

G. Keith Smith, M.D.

G. Keith Smith, M.D.

This might be the question you would ask if you lived in Canada.  Or, this might be the question you would ask if you enroll in an HMO.   After waiting for years in line for a coronary artery bypass procedure or a total hip arthroplasty, you could easily die from something else.  You would be well within your rights to want your hip replaced after your death, having waited so long for it.  I think this is reasonable as the Canadian government and the medical directors and investors in HMO’s actually want you to die prior to your surgery date. 

This is crazy, of course, but might keep those honest that would otherwise benefit from denying you care, don’t you think?

G. Keith Smith, M.D.

In a strange twist, a patient death due to the strike of unionized California nurses has spurred the California Nurses Association  to file a complaint about the quality of nursing care in that state.  Yes you read that right.  Nurses go on strike.  Patient dies as a result.  Same nurses file a complaint regarding the shortage of quality nursing care. 

Seriously?  We live in a crazy world.

G. Keith Smith, M.D.

The FDA ( one of the most corrupt parts of the federal government) announced this past Thursday that in an effort to protect the ozone layer, cheap epinephrine asthma inhalers, available over the counter, will be banned.  Only the prescription inhalers containing albuterol will be available.  This will triple the cost for the occasional asthmatic that needs relief, forcing them to use drugs they will not have immediate access to at prices many cannot afford.  Seriously, if someone is treating their asthma with Primatene, they probably are poor and can’t afford albuterol, much less a doctor’s visit.  Keep in mind that the epinephrine inhalers have been used for decades and are known to be safe for patient use.  It is the infamous “ozone layer” the FDA is concerned about. 

In one of the most outrageous displays of callous disregard for human beings I have ever seen, Badrul Chowdhury, the director of the FDA’s pulmonary division, said “…in the worst case scenario we are looking at 1 to 2 million people using Primatene.”  I think he meant that 1 to 2 million people was not a significant number of people.  If so, why not leave them alone?  He can’t leave them alone and simultaneously  maintain the consistency of what many believe is the  ozone lie.  To admit that a little bit of chlorofluorocarbons (CFC’s) are not a bad or significant thing is to admit that the whole ozone scare is a hoax.  Interestingly, Dupont’s initial opposition to the anti-CFC legislation suddenly vaporized once they had two new patents in hand that allowed the government to grant them a monopoly on coolant sales (don’t think any money changed hands on that one do you?).   I’m continually amazed at how the “green” leftists unwittingly line the pockets of the crony capitalists they supposedly hate. 

This is yet another example where concerns like the “environment” or “society” or “the greater good” trump  the individual and the rights of individuals.  This is the operational ethic of HMO’s and of government managed health care.  Multiple intermediaries interfere with the normal doctor patient relationship and with the collection of the funds for the care given.  This disenfranchisement of the patient is always done with the idea that some brilliant but remote person knows better than the patient and their doctor about what is needed in any given situation. 

In this case, some brilliant all-knowing, life and death giving thug has decided that the preservation of the ozone myth trumps that of the lives of 1 or 2 million people.  This government brown shirt will probably hide behind some EPA law or the Montreal Protocol and wash his hands of the brutal fate awaiting the asthmatic poor.  And these clowns claim to be concerned about the cost of health care?  This is how governments kill people.  Maybe killing the sick is part of the plan to balance the budget.  After all, what’s 1 to 2 million people anyway?

G. Keith Smith, M.D.

Someone once told me that the difference between the care your pet receives and that of someone enrolled in an HMO is that the person paying for the pet’s care actually cares about the pet.  Funny, but tragically, true.  The veterinarian has the best interest of the pet in mind.  The HMO board or medial director has something else in mind.  Whatever it is, it is not the patient.  This is an incredibly important departure from what is considered the traditional doctor-patient relationship.  This important relationship champions the individual.  Period.  Not the collective.  Not society.  Not the HMO stock holders.  Not the taxpayers.  Not the environment or upper atmosphere.  It is no coincidence that this consideration of the individual was jettisoned for the larger impact on the collective in Bismarck’s Germany in the 1920′s.  The birth of national health care in Germany made any man’s illness every man’s problem.  This predictably led to limits on what would be treated, as the collective masses were actually better off economically to let the sick die.

This mob rule of the sick is the scariest part of any national health care plan.  If you are sick and are a drag on society and are of no use to “the state” then the mob is better off without you and this or that medicine or procedure you need might not be available.  OK.  Let’s try this if you aren’t following me so far.  Your child is sick.  Some stranger in a suit in the hospital tells you that they have done an economic calculation and saving your child simply isn’t cost effective.  Think this can’t happen?  It did happen in Germany. 

Many physicians have fought and resisted this vicious twist in their patient relationships.  This resistance has taken the form of severe financial hardship at times when the corporate medical types have tried to crush the hold-outs by excluding them from “the network” or actually hiring salaried competitors.  These primary care doctors are heroes in the truest sense.  They are battling for the very lives of the patients in their care.  They have not sold out, sticking instead to the principles embodied in the oath all physicians take.  Others have surrendered under the most hostile conditions, working within the system for the benefit of their patients in spite of threats and consequences like sham peer review and medical board water boarding.  Some (the Vichy doctors) have run to Darth Vader as soon as he appeared to find out how they can help him.

If your physician treats you and your family like individuals, slaying medical dragons in your best interest, in spite of the hostile environment we work in,  you have a champion like no other.  If, on the other hand, your doctor ever says “… things other than what’s best for you must be considered..”…or some version of that….find another doctor.  The fatal conceit has infected him and he will not likely recover.

G. Keith Smith, M.D.

PPO’s were set up ostensibly to help with the escalating price of health care, the idea being that if you include only the highest quality physicians and facilities in “a network,” effectively eliminating the unethical or incompetent players, you could theoretically curtail complications and minimize unecessary surgeries/care.  Physicians and facilites would then theoretically provide discounts in return for an increase in the number of  patients they would see.

  The PPO’s have become precisely what the insurance and big hospital industry wanted:  cartels.  They have been extremely effective in shutting out competitors for the big players.  They have done nothing, as we all know, to eliminate unscrupulous physicians or hospitals from “the network.”   In fact, as the pay rates drop for physicians and the PPO’s become increasingly abusive, it is the doctor who is already busy and doesn’t have to mess with this crap who is likely to drop out of “the network.”  The PPO’s tend to run off the best in the crowd over time. And they have actually been one of the primary factors in the escalating costs of health care in the U.S., eclipsed only by Uncle Sam.   Once again, if you’ve been following this blog, none of this is new to you.

 Now imagine a cigar smoke filled room full of insurance executives laughing uncontrollably.  Pouring the scotch are the big hospital administrators when they aren’t dancing around the room high-fiving one another.  This is why they are laughing: .  many PPO’s are actually incentivized to seek out the highest priced facilities.  What?!  Oh yeah!  Nobody talks about this one:  PPO repricing.  You see, some PPO’s (actually all of them I think) charge PPO repricing fees.   This means that if the PPO pays $10,000 to a facility for a surgery or hospitalization that the facility charged $20,000 for, the PPO, by virtue of having “repriced” this procedure or hospital stay, gets a percentage of the money they” saved” whoever was paying the bill…usually no more than 25%.

“Wait a minute,” you say!  “You mean the PPO collects the premiums, then maximizes their profit by ratcheting down the payment to the physician and facility but also makes a percentage on the difference between the beginning and ending bill amounts?   So the higher the bill is to start with, the more they make?” 

“So if a better doctor at a better price is across town, that is the last place this PPO wants to go?”  ”So the PPO’s get  giant bills from the hospitals and the hospitals get exclusivity from the PPO’s?” Maybe I’m not anticipating all of your questions here.

 What do you think those in the repricing business think of transparent, fixed and direct pricing like that on our website? 

Tranparent pricing spells the end of this game.  Hopefully the consumers of care in this country will be laughing and dancing soon, celebrating the high quality and low pricing in health care that is inevitable when the government and the corporate schemes like this are eliminated and the free market is allowed to work its magic.

G. Keith Smith, M.D.

Ok.  This is really important so let’s go over this again.  Health maintenance organizations are organizations designed to make money by denying you health care. I decided to write this blog after seeing an editorial in our local paper pushing people to consider HMO’s as a way to decrease  ”out-of-pocket” costs.  Deeper in the newspaper was a large HMO ad aimed at teachers,  picturing our former governor’s wife.  These organizations have come and gone through the years but not before causing great pain and suffering. Check out this article on the origins of HMO’s. Your primary care doctor in this scheme is compensated by the extent to which money is not spent on you.  Bonuses are typically paid at the end of the year based on the primary care doctor’s gatekeeping skills.  That is, if your diabetes is complicated and difficult to manage, the primary care doctor makes more money by making damn sure you never get to see an endocrinologist.  There may not even be an endocrinologist on the plan. If your hemorrhoids are difficult to manage and all of the ointments and steroids aren’t working, you will be told that “..you just need to give it more time..”..or something like that.  It is very unlikely that you would be able to see a colorectal surgeon for your condition, let alone have anything done about it.  Here’s my favorite, though.  Your child needs their tonsils removed because of their apnea and frequent throat infections.  You are told that “tonsillectomies are a thing of the past.” “This operation is just not necessary.”  ”We can manage this with antibiotics.”  You watch your child suffer and notice that the families whose children had their tonsils removed aren’t sick all the time like your little tyke.  You get angrier and angrier, and are now on to the HMO denial game.  You mention to your pediatrician that you have decided to file suit against him for denying your child appropriate care and PRESTO!! ..you have an appointment with an ear, nose and throat surgeon…..in 5 months.  ”That’s the soonest we could get you in.”  Why?  Because there is only one ear, nose and throat surgeon on the HMO plan.  And he is horrible.  A reputation so bad that even you as a non-physician know that you will never let him touch your child.  And the only reason he is signed up for this crappy plan is that the folks running this HMO guaranteed him that he would be the only one….he would get all of the business.  He would get all of the business, not because he is any good, but because he was on the plan and whose practice is so bad that he would sign up for anything.  The HMO pays him horribly, but his waiting room is full.  This idiot would be out of business were it not for schemes like this.  The free market would have crushed him many years ago.

HMO’s are a little like Canadian health care, but worse.  If you poll Canadians, the vast majority will tell you that their health plan is great.  Why?  Because the vast majority of Canadians have never tried to access their health plan.  It is a great plan until you get sick.  HMO’s are the same sort of thing….with this caviat:  in Canada the physicians aren’t incentivized to deny you care like they are in HMO’s. In Canada, everything is limited by the government.  In HMO’s, your suffering translates in to larger dividend payments for the shareholders holding HMO stock.  Your child’s chronic infections and denial of their tonsillectomy results in a bigger Christmas bonus for your pediatrician.

Get it?

If you are a teacher working for the state of Oklahoma, you will probably be increasingly pressured to sign up for crap like this.  You will likely be told that it is for your own good and will save you money.  Herding you into an HMO is very much like taking away the health benefit portion of your compensation entirely.  You are probably better off uninsured.

G. Keith Smith, M.D.