Surgery Center of Oklahoma Blog

I’ve decided that I’m not finished with Karen Regier (see my previous blog, “Medical Economic Cretinism”).  Remember her ultimate blunder:  “Direct employment (of physicians) is beneficial because it provides greater collaboration in the delivery of care…..”  Not to beat a dead horse, but there’s so much more that needs to be said in response to this.

A friend of mine had surgery at a local hospital recently.  His surgery was done by a physician who “collaborates” with a hospital.  The benefit of this “collaboration” follows.  You see, this friend of mine is perfectly healthy.  The procedure he was having done was a minor procedure.  He went to pre-register for his surgery the day before at the hospital and was sent to the lab.  There he was told that he would need  an EKG and blood drawn.  He called the anesthesiologist who was doing his anesthesia the next day to ask if he wanted all of this lab work.  “No.”  “That’s not needed.”  He called the surgeon’s office to ask if this was something they wanted.  “No.” “But the hospital requires it and there’s nothing I can do about it.”  Is it possible that this “not for profit” hospital in collaboration with physicians they control or employ is racking up lab charges that are completely unnecessary?  Is this an example of the “beneficial collaboration” that Ms. Regier is referring to in making her case for hospital employment of physicians?  The money required to pay for this unnecessary lab work multiplied by the large number of patients seen at this facility is a staggering amount and a complete waste.  Beneficial collaboration for the hospital, though.

I made the statement in my previous blog that employed doctors basically don’t care whether they see 15 or 45 patients.  They make the same either way if they are on salary.  While this is true, there are some hospitals that have modified their employment agreements with physicians because they have found that simple salary payment turns previously hard working physicians into beach bums.  These modifications are called various things but essentially amount to performance incentives or bonuses.  But wait a minute!  If doctors are kind of getting paid for what they do, how is that different from the “fee for service” concept Ms. Regier finds so inefficient?  Her argument is not against “fee for service” arrangements as she would have us believe.  Her argument is for control of physicians by hospitals. Once the hospitals control the physicians then they can make them order unnecessary lab work I guess.

Once physicians are employed by hospitals, “who is best” no longer applies.  I have written prior blogs on how “integrated” doctors (employees of hospitals) receive referrals from other “integrated” doctors, not because they are any good (in many cases they are dangerous and are thought of within the medical community as dangerous, unethical or both) but because they are “integrated,” you know, part of the club, part of the cartel.  This is, of course, money -driven by the hospital employers (always seeking to not make a profit).  A friend of mine not long ago got trapped in the quicksand of a hospital network and wound up in the office of a notoriously incompetent surgeon who recommended immediate emergency surgery.  My friend called me and after hearing who they had seen, I made arrangements to see another surgeon, one who has been shunned by this hospital network, even though he is thought of as one of the pre-eminent surgeons in this entire area of the country.  He told my friend that they didn’t need surgery at all, did a simple office procedure, placed them on antibiotics and that was that.  The surgery that the “collaborator” had recommended would have incapacitated my friend for about six weeks and carried a significant risk of life-altering complications.  I guess when patients “leak” out to a non-integrated doctor the hospital loses revenue and well we just can’t have that, can we?

Wow!  I guess Ms. Regier didn’t know any of this stuff, right?  Don’t make me laugh.

G. Keith Smith, M.D.

What do you think of when you hear someone described of as “liberal?”  Do you think of someone who is a fan of big government and big taxes?  Do you think of someone who is a rabid environmentalist?  You know it wasn’t always that way.  Until recent times, liberal meant “liberty loving.” A liberal was someone who despised government at all levels, as government is inimical to liberty.  A person previously described as a “liberal” is now more accurately labeled a “classical liberal.”  How did this happen to the word “liberal?” What a successful perversion of the language that a word now carries the meaning of its prior antonym.

What does it mean to be a socialist?  I think that these days it is more provocative to label someone a liberal or “progressive” than a socialist.  ”Socialism” is making a come back.  For a while a socialist was thought of no differently than a communist.  To label someone with either term was to label them with the other.  Socialism implies that we’re all in this together and that one purpose of government is to confiscate then pool money to take care of everyone’s problems. Just as the original meaning of “liberal” is gone, the derogatory nature of the socialist label has been tempered.  How can socialists be called out then if their liberty-crushing activities are to be smeared with deserving labels?

For years I have resented the desire of socialists (yes, they are on both sides of the aisle) to use Uncle Sam to confiscate my earnings and the future earnings of my children.  Now I am thinking about things differently.  You see, while I resent “sharing” property against my will, what I have come to understand is that it is the justification for this confiscation that commands resentment.  Basically, others are sharing with me against my will:  their problems, not their wealth.  It occurs to me that this is the essence of socialism.  One person’s problem is everyone’s problem.  Your problems are mine, mine are yours.  Embracing this concept precedes the theft necessary to “tidy things up,” to make things fair, to treat another’s problems.  I wonder now if that should be the focus of property rights advocates, the denial of this concept, or, “your problems are yours, not mine.”  After all, private property is secure once this problem sharing paradigm is rejected.  Sharing problems with others that want no part of it is like giving someone tuberculosis or a venereal disease.  I think this is a perfect analogy and therefore, I will henceforth refer to socialism as “gonorrhea socialism,” as this loaded phrase inevitably leads one to the faulty premise.

You say, “health care is a right!”  I say, “you are trying to infect me with your gonorrhea socialism.”  I say, “I don’t want your gonorrhea.” “Your gonorrhea is your problem.”  ”I have no desire to share your venereal disease.”  If I refuse to share your problems you will possibly realize that they are your problems to deal with not mine and therefore my property is safe.

If, however, I feel sorry for you and decide to shoulder some of the burden of your problems, that would be entirely up to me and would be called charity.  My property would still be under my control and I would be dispensing with it as I see fit.  That the gonorrhea socialists aren’t willing to make their own way supported by the good will of others explains the entitlement mentality in this country.  I think it justified that those who believe that health care is a right should be labeled gonorrhea socialists.  I would like to know of any alternative epithets that you can come up with.

G. Keith Smith, M.D.

In the business section of the 12/9/11 edition of the Daily Oklahoman, Karen Rieger, head of a large law firm’s health care practice group is interviewed.  She makes some observations that could not be more mistaken.  .  She states for instance that “consumers should see benefits from closer collaboration between physicians and hospitals in the delivery of health care services.  In the past, independent physicians billed on a fee-for-service basis and did not have incentives to provide efficient, high quality care.”  I wonder how Ms. Regier’s law practice would change if she were paid a salary by her law firm regardless of the quantity or quality of  work she did?  Or maybe she thinks that billing a fee for a service is only a bad idea for doctors.  It’s the end of a long hard day and a patient calls and is very sick and wants to be seen.  The salaried doctor tells them that the office is closed for the day.  I’ll see you in two weeks.  The greedy “fee for service” doctor tells them to “come on in.”  I could go on and on, but her statement is so idiotic I’m boring myself countering it.

Next she discusses the new Shared Savings Program, a part of the wonderful Obamacare fiasco.  “Under the program, Medicare will share the savings it realizes from the provision of health care services by groups of physicians, hospitals and providers, called Accountable Care Organizations, to groups of Medicare beneficiaries.”  Translation?  If doctors and hospitals (probably the doctors’ employer) get together and figure out a way to cheat patients out of their benefits and take the cheapest path on everything, they will make more money.  Denying care or only providing the cheapest care will become the order of the day and everyone makes more money and Medicare saves money and WOW isn’t this fabulous!  Yeah, unless you are the person called a patient. 

Finally, Ms. Rieger, saves the ultimate blunder for last.  “Direct employment (of physicians) is beneficial because it provides greater collaboration in the delivery of care, minimizes antitrust and other legal risks, reduces the administrative burden on physicians and simplifies the development of integrated electronic medical records systems.”  Readers of this blog are familiar with the “great collaboration” between an Oklahoma City hospital and the gastroenterologists they employ.  Having found that the age old and tried and true sedation provided by Versed and Demerol not nearly lucrative enough for colonoscopies and other endoscopic procedures,  the hospital simply required their employed gastroenterologists to use Propofol sedation.  You see, if Propofol is used, an anesthetic is said to have happened.  If an anesthetic happens, the hospital can bill an extra $1000.  There is also an expense for the anesthesiologist, but let’s not muddy the waters with an extra $400.  Let’s just call it an extra $1000.  This extra $1000 will help the “return on investment” that the hospital has ”invested” in these doctors they have hired.  And since the doctors are employees they must do what they are told.  No longer the advocates of the patient or the patient’s pocketbook, these physicians are compromised by this employee arrangement that Ms. Regier calls “beneficial.”  Notice also what has happened to the price of a colonoscopy at this hospital by virtue of this “beneficial” arrangement.  It is certainly beneficial….to the hospital, working ever so hard each and every day to “not make a profit.” 

A county hospital recently installed an electronic medical records system.  The physicians they employ were “integrated” in to this system, by which I mean that the system in the hospital was the same system in the doctors’ offices.  After the system went “live,” one surgeon told me that while he could have previously seen about 45 patients in a day, he would now be lucky to see 15 in a day due to the additional workload created by data entry into the electronic medical record.  The funny part is that he doesn’t care.  He is an employee and is paid the same whether he sees 45 or 15 patients in a day.  What does this say about the future of access to care?  What does this say about efficiencies in medical practice?  What could this possibly mean for the future of the cost of care?  Who is John Galt?

My guess is that Ms. Regier’s law practice consists primarily of creating contracts between hospitals and their employed physicians.  Maybe this all sounds wonderful to talk about in fancy board rooms.  Out here in the real world, this simply doesn’t work. 

G. Keith Smith, M.D.

I frequently read articles written by (probably for) certain “civic” minded folks saying things like “..obesity is a national problem and we must all do our part, for the good of society, to stay fit and trim…”…or something like that.  Or, substitute, “smoking” for “obesity” in the above sentence. Let’s break this down and translate what is just below the surface of statements like this.

Family “A” is parented by a man and woman each working hard.  Taxes at all levels take about 40% of their earnings and they pay them because they don’t want to go to jail or lose their home.  They are saving diligently for their three children’s college.  They have a mortgage and pay their bills.  Mom gives a lot of thought to keeping the family meals healthy and dad has made outside play and regular sports and exercise a routine for his children.

Family “B” is hopelessly dysfunctional and mostly eats snack foods from convenience stores.  All of the members of this family are ridiculously fat and sedentary.

Now the questions:  why is family “B’s” obesity and poor health family “A’s” problem?  Why can family “B” claim part of family “A’s” income to treat the consequences of their poor health, their diabetes, heart disease and hypertension, for instance?  Why does family “B’s” poor health take precedence over family “A’s” college savings plan?  Why are family “B’s” problems, family “A’s” problems?  By what right can family “B” withdraw from family “A’s” checking account, money they want to treat their issues? Why do the nightmares that await  family “B” have to represent an open ended financial liability for family “A?”

Have you answered?  Did you answer, “from each according to his ability, to each according to his need?”  Did you answer, “we are all obligated to provide a social safety net for our fellow citizens?”

If you are inclined to believe that we should help our fellow man, I am in agreement with you.  If you believe that a goon with a gun and a badge, rather than a representative of a charity should collect your “contribution,”  I am firmly opposed to you and that preference.

Failure to expose the false premise (“health care is a right and therefore if I get sick, what’s yours is mine”) allows very silly and time-wasting subsequent discussions to take place.  Whatever happened to the concept of freedom?  How about this:  ”if you want to smoke, go for it.”  ”If you develop chronic lung disease or cancer, that is your problem, not mine.”  Or,”if you choose to lead a high calorie, sedentary existence and develop any and every problem that we all know is inevitable, that is your problem, not mine.”  ”If I choose to donate to a charity that helps take care of folks like you, that is my decision, not yours.”

Is this too free for you?  Can you imagine what people in this country 100 years ago would think about how eroded the freedoms are that they took for granted?  I would challenge you to try to think of national health care as government as an even larger agent of theft, robbing family “A” for the benefit of family “B.”  40 million more family “B’s.”

G. Keith Smith, M.D.

Kudos to the newspaper here in Oklahoma City, The Daily Oklahoman,  for outing the outrageous and luxurious expenditures of the head ambulance driver. Here is a list of the accusations against the CEO of the taxpayer subsidized company, EMSA,  and his response.

$405,000 spent on first class airfare, $500/night hotel rooms, $100 car wash, $600 meals, room service charges in excess of $70 and a $2800 retirement party:

First class airfare:  the CEO has health issues.  He has had knee replacements.  He has a note from his doctor dated 1984.  The CEO defended all of this spending “as necessary to secure Medicare payments and said it is a cost of doing business in an industry that involves complicated billing procedures, a need for high-tech dispatch and medical systems and building relationships with peers across the country.” The paper quotes the CEO as saying “..his position at the ambulance association (he is currently president of the American Ambulance Association) has been crucial in securing an annual renewal of a federal law regarding Medicare payments to ambulance services.” Williamson takes credit for his role in securing an extra 2 or 3 percent payment.  ”That extra percentage equates to about $400,000 annually for EMSA, records show, and Williamson said that justifies the travel expenses to lobby Congress to renew the law.” Where does that extra Medicare money he “found” come from?  Oh yeah!  It comes from you and me!

$500/night hotel rooms:  whoops no excuse for this one!

$100 car wash:  the receipt said it was for his Lexus, but Williamson said it was for an EMSA-owned vehicle he drove (note he did not dispute the amount!)

$600 meals:  he defended the spending on the meals as professional courtesy, “and that the meal at Morton’s (in Virginia) was because it was his turn to buy.”  ”Do I think it’s O.K. occasionally?  I think I’ve done it three times in four years.” “I don’t think it’s out of line that at some point I pay for one.”  He then stressed that the relationships formed on such trips are important.  ”A lot of business is done on relationships, and I’m able to develop those relationships that help us locally.” Easy to spend someone else’s money, no?  Imagine the wine and booze with a tab like that!

Big spending on room service:  ”..the room service meals allow him to get work done instead of venturing out and eating on his own time.” Wait a minute.  On his own time?  Is EMSA paying this guy by the hour?

Lavish retirement party:  ”..Williamson said the well-regarded Singer (the now retired vice president Ann Singer) deserved the party for more than 24 years of crucial work.”  Why not a $100,000 party then?  Maybe her “crucial work” was only worth $2800.

Miscellaneous:  $3,000 gas cookout grills and interdivisional loans at EMSA:  whoops..again no excuse.

Notice there is no disputation of the facts.  This guy is unapologetic. A later article in the newspaper sounds a plea for diaper donations at a truly wonderful place, The Children’s Center in Bethany, Oklahoma.  Maybe Mr. Williamson could drive his ambulance over to Bethany and provide some diapers and community service as penance for his unapologetic and luxurious over-indulgence at taxpayer’s expense.

This is a great example of what happens when third parties (Medicare and other “insurance”) get involved in the payment for goods and services. The price of the ambulance ride (just like the price of all health care) is simply not justified and the granting of monopolies to companies like EMSA invites the kind of abuses listed above.  I think Mr. Williamson’s arrogant justification of these expenses is as bothersome, if not more so, than the expenses themselves.  City leaders are calling for more oversight.  All EMSA needs is a competitor.  Competition raises quality and lowers prices every time.  Heard that before?

Good luck to EMSA next time they ask for a rate increase.

G. Keith Smith, M.D.

Ever met an Ethiopian farmer?  No?  Could be because there aren’t any.  What?  Seriously, how could you farm in Ethiopia when your competition is free food?  Folks are all around you starving to death but waiting on the next “foreign aid” shipment with free food.  They’re not about to buy food from a farmer when with just a little more waiting they can get it for nothing.  Many economists over the years have written about this.  If you want to stop starvation, end food subsidies, as these destroy the market for growing or producing food in the target area.  After all, how does a food producer compete with “free?”

I had dinner one night last week with a new friend in Washington, D.C.  He, like me, has a high deductible health plan and mostly pays as he goes, the high deductible saving him lots of money in the form of lower premiums.  He, like me, is probably going to be declared a criminal once this wonderful new health law goes into effect.  You see, our idea of pay as you go and buy the catastrophic policy for something really bad is soon going to be a crime.  We will have to pay a fine if we continue to operate this way.  If we don’t pay the fine…well…you know where the government takes it from there.  My new friend said, “I’ll just drop my insurance and go with the guaranteed issue policy.”  He means the government policy.  Because it’s “free.”  Why wouldn’t he do this?  Why wouldn’t everyone do this?  And if you are an insurance company that is providing health policies and you are not connected with Uncle Sam to administer this insanity, how are you going to compete with free?

Of course, our fearless leaders know this and know that you can’t compete with free and know that all but the huge insurance companies will go out of business.  The big boys will be left to administer this plan and will…well…you know the rest of the crony capitalism story by now, don’t you?

G. Keith Smith, M.D.