July, 2019

A Decent Proposal

By Michael J. Katin, MD

Nothing lasts forever ... pain and troubles included.
Paulo Coelho

It has come around already to be time to re-enact the annual anguish about what CMS will propose as the physician fee schedule for the next year. We were never taught about this in medical school and, as with sex education, it is knowledge that is generally picked up more likely from trial and error and comparing notes with our colleagues.

Briefly, in July of each year the Centers for Medicare and Medicaid Services (CMS) publish (publishes?) their (its?) proposal for the fee schedule (PFS) to start January 1 of the following year. There is then a period of time for comments (PTC) and then publication of the final version (PFS) in December. This has been unfairly compared to the mayfly life cycle (MLC), in which the larval forms lie on the bottom of lakes (BOL) until suddenly filling the skies with billions of flying mayflies which mate, lay eggs, and die, and the cycle then starts all over again. Obviously, the difference is that CMS do (does?) not have a larval stage.

How did CMS find themselves (itself?) charged with this responsibility? It's a major responsibility, to say the least, just as if the Department of Agriculture were asked to set prices of all foods since the Supplemental Nutrition Assistance Program (SNAP) pays for it! That would be a crazy idea! Anyway, when Medicare and Medicaid were invented, in 1965, they were initially administered by the Bureau of Health Insurance, headed by Arthur E. Hess, an attorney. Further bureaucratic engineering placed Medicare under the Social Security Administration (SSA) and Medicaid under the Social and Rehabilitation Service (SRS). Medicare administration was then headed by Robert M. Ball, who had a bachelor's degree in English and master's degree in labor economics from Wesleyan University. These were both under the Department of Health, Education, and Welfare (HEW). In 1977 Medicare and Medicaid were both included under the jurisdiction of the Health Care Financing Administration (HCFA). In 1979 the Department of Health, Education, and Welfare because the Department of Health and Human Services (HSS), since Education was moved to its own department (where it has produced remarkable results ) and it was thought that "Welfare" was no longer considered an affirmative word whereas "Human Services" was a more friendly term and acceptable to almost everybody except PETA.

HCFA was now responsible for figuring out how to spend Medicare and Medicaid funds without bankrupting the systems. It proved to be a thankless undertaking and HCFA finally found its way out of its morass by ceasing to exist. The new entity, Centers for Medicare and Medicaid Services, came into existence on June 14, 2001, which also happened to be Flag Day and Donald Trump's 55th birthday. This was one of the first acts of the George W. Bush Administration and either because of or despite this there seems to have been no reason whatever for this to have been done. Conspiratorialists, however, might take interest in the fact that the first CMS administrator was named Scully.

It is of interest that the background of Thomas Scully, JD, includes his having worked on the campaign of George H. W. Bush before becoming Deputy Assistant to the President (DAP) and Counselor to the Director of the Office of Management and Budget (OMB) and later Associate Director of OMB for Human Resources, Veterans, and Labor, certainly an interesting combination. His most intriguing role, however, was as President and CEO of the Federation of American Hospitals (FAH ) just before he became Administrator of HCFA and then, as if by magic, suddenly Administrator of CMS without even having to change offices.

The current Administrator of CMS, Seema Verma, has a master's degree in public health and previously was founder and CEO of SVC, Inc. a company that worked with states for implementation of Medicaid including compliance with the Affordable Care Act. SVC was acquired by Health Management Associates (HMA) in 2017. Among the eight additional officers in the CMS administration are two JDs and no one with a direct connection to clinical practice of medicine. It is of note, however, that the Chief of Staff and Chief Principal Deputy Administrator, Paul Mango, was a Baker Scholar at Harvard Business School but, of more interest, is a graduate of West Point Military Academy and was in the 82nd Airborne Division and was an Army Ranger, making him the most appropriate person to try to achieve discipline in physicians.

It is of no relevance whatever that another Baker Scholar, Sanjay Gupta, was CEO of McKinsey & Company, a management company, from 1994 to 2003 and in 2012 was sentence to two years in prison for securities fraud/insider trading. After Mr. Mango left the military he worked for McKinsey & Company for 27 years, including being head of the company's Center for U. S. Health System Reform (incorrectly listed in the CMS biography as the U. S. Center for Health Reform), until he left in 2017 to unsuccessfully seek the Republican nomination for Governor of Pennsylvania. The concept of reforming health is definitely more challenging than reforming health systems. The current director of McKinsey's Center for U.S. Health System Reform is Dr. David G. Knott, who has a Ph.D. in political philosophy and, as with all the persons mentioned above, is knott a medical doctor.

This is not to argue that having medical doctors in charge of health care programs would necessarily be an improvement, but management by non-medical professionals has not solved the problem so far. Perhaps the secret is to assign a different type of non-medical person to be in charge -- someone with extensive general knowledge and a sixth sense of how to manipulate money to get the best outcome. Suggestions would be welcome, but the optimal candidate has probably already materialized.

Emanuel Countdown: The Emanuel Countdown is at least temporarily being suspended since Dr. Ezekiel Emanuel has seemed to have faded from the news cycles. For now, this will be replaced by the

Asteroid 2006 QV89 Countdown: Asteroid 2006 QV89 will be impacting with or passing by Earth September 9, 2019, which, counting September 9, is 71 days from now. Plenty of time left to short the stock market.

BONUS: In honor of the 25 candidates seeking the Democratic Party nomination for President of the United States, and the Fourth of July:
To the tunes of "Yankee Doodle Dandy and "You're a Grand Old Flag "

I'm a Yang, my name is Andy
Andrew Yang's what I'm known by
Even though they closed my microphone
My donations continue to climb.
We must deal with automation
We can do it if we try.
Taking care of human needs is my main motivation
With Medicare and UBI.

It's a grand a month, and I hope it's enough
To make sure our economy's fair
You don't have to show you need the dough
We'll pay you for just being there.
It'll get you through when the rent's coming due
Or the ceiling begins to leak.
But when all the theories don't work out
We'll go up to a grand a week.