July, 2017

Collusion Course

By Michael J. Katin, MD

This has been a very eventful several months, and in the midst of all types of contemporary topics, many publications have taken the opportunity to express their recognition of the first day of this month as being Candida's 150th anniversary. In the process of honoring this date we discovered that, in fact, Candida was first accurately described in 1839 rather than 1867, although its genus was not definitively categorized until 1923 by Christine Marie Berkhout. Although this was not directly related to this month's topic, correction of this chronologic misunderstanding would seem the yeast we could offer.

It is usually in the first week of July that the Centers for Medicare and Medicaid Services (CMS, since adding an extra"M" would be too time-consuming and expensive and therefore not consistent with government policy) release the proposed rule for Medicare fee schedules for the following year. Since there is an attempt at budget neutrality, any increase that is given for emotionally-favored entities such as primary care has to be offset by decreases in other fields, which, in many previous years, has often included radiation oncology. This is a lot of work for staffers at CMS and one potential solution is to start packaging all care for a certain diagnosis into one large item in the fee schedule, with division of that amount to be determined after the fact. Bundling is a good idea intellectually but has the potential to go very wrong when implemented in practice.

CMS generate (generates?) decisions after guidance from the Secretary of HHS and multiple consultants, including MEDPAC, Interestingly, MEDPAC, the Medicare Advisory Payment Commission, is "a nonpartisan legislative branch agency that provides the U. S. Congress with analysis and policy advice on the Medicare program," but of the 17 commission members, there are six Ph.D.'s, one D.Sc, one actuary, one R.Ph. (from Express Scripts), two M.B.A's including one M.D/M.B.A, one MPA, one J.D., and four M.D.'s, including the M.D./M.B.A person. In addition, there is one R.N., which might be the saving grace in terms of having someone there who truly knows what is going on with patient management in real life, although it is noted she is currently senior vice-president at Unity Point Health, described as an "integrated delivery system." Of the four M.D.'s, one is a physician executive at Kaiser Permanente, one is a critical care specialist and anesthesiologist, one is a cardiologist at UCSF, and the M.D./M.B.A. person is executive vice-president and chief medical office at Anthem. Although one must respect the knowledge of these 17 persons, it can be accurately described that there are very few involved in the daily management of patients and, at best, only one involved in private practice to any extent. In other words, the same government pattern of behavior that give us a $19 trillion dollar national debt, defense projects that are years overdue and billions of dollars over budget, and horrendous foreign policy decisions, is at work fine-tuning healthcare.

It is both before and following publication of the proposed rule that professional organizations, individuals, and, of course, the industrial-oligarchical complex, have to make their comments known in order to make sure their interests are recognized. This usually makes the private practitioner feel fairly helpless, as if knowing that an asteroid strike is eventually coming and not having trust that something will be done about it.

The irony is that when most charges for medical procedures are set in some ratio to Medicare allowances, practitioners are not allowed to band together to . . . fix prices? It would be nice if this were possible to at least have more clout in the decisions made by CMS and other entities, even to have some leverage with managed care organizations. Although there have been efforts to organize physicians legally, only a few have made any progress, such as with hospitalists In Oregon, a state that also endorses assisted suicide and recreational marijuana. Usually there is considered to be a very fine line between collaboration and collusion.

Even when everything seems to be done according to the law, there still has to be concern that there is constant surveillance that will look for anything that can be interpreted as being illegal. Regardless, any medical practitioners would have to be considered rank amateurs compared to the efforts put out by pharmaceutical and equipment manufacturers, although even these occasionally are called out (e.g., the evil European vitamin cartel). In fact, even when in other countries physicians are able to stick together, usually the outcome is far from optimal. Can you believe that on December 5, 2016 the Kenya Medical Practitioners Pharmacists and Dentists' Union (KMPDU) went on strike following failed efforts to upgrade the working conditions of 5,000 medical personnel working for the state hospital system. To make it even more ironic, the strike was in response to the government's failing to implement a 2013 agreement, and not even asking for any new benefits. After 100 days and after 7 leaders had been jailed and the government had threatened to fire the strikers and replace them with foreign doctors, the lowest salary was raised to 182,000 shillings per month ($1,755). Interestingly, the average Kenyan legislator makes 1,200,000 shillings per month, equivalent to $11,500. It might be helpful to keep this information away from the U. S. Congress.

So we beat on, boats against the current, with faith that things will work out and we can continue to deliver quality medical care...at least until we can pay off our college and medical school debts by time of retirement.
Or until election to the Kenya National Assembly.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including July 1, 2017, this leaves 5,663 days to his goal.