September, 2020

The Eleven Per Cent Solution

By Michael J. Katin, MD

The year 2020 has consisted of one disaster after another, with the novel coronavirus pandemic affecting nearly everyone, with giant Asia murder hornets causing anxiety in the Pacific Northwest, the vilification of Ellen DeGeneres, hurricanes bringing destruction to the Southeastern United States, massive oil spills in the Indian Ocean, and tragic encounters producing demonstrations and riots in multiple cities. There is now even one more disaster to absorb: CMS' proposed Medicare fee schedule for 2021.

As dedicated readers of this column are aware, every year in July the Centers for Medicare and Medicaid Services, abbreviated to three rather that four letters as CMS (except before July 1, 2001, when it/they was/were HCFA), has published its/their proposal for the Medicare physician fee schedule for the following year. It was determined that each medical intervention deserved a score, a Relative Value Unit, to then be multiplied by a conversion factor to determine the allowed cost. Maybe the conversion factor could go up a little bit every year to account for inflation and increasing expense of doing business. The RVUs could be tweaked to try to keep the different specialties at each others' throats. Actually a very clever plan, in retrospect.

So what happened? Well, the conversion factor didn't change very much compared to everything else in the past two decades. It actually went from 31.000 when first calculated in 1992 to 36.6873 in 1998 and.........36.0896 in 2020! Except for long distance telephone charges, there aren't too many things that are lower in 2020 than in 1998. The average price of a Big Mac was $2.50 in 1998 and $4.93 in 2016. Granted, food is more essential than medical care, but still....

In fact, there is a logical, straightforward formula for calculation of the conversion factor, which is:

It was, therefore, somewhat of a surprise that when CMS came out with its/their proposal on August 3 (not July---COVID-19 restrictions, you know---) the conversion factor had mysteriously been lowered by eleven per cent, down to 32.2605!!

This then allowed widescale manipulation of Relative Value Units, with the intent to reward intellectual input required for primary care specialists and reduce payment for brainless automated procedure-oriented specialties, such as radiation oncology, while keeping the Medicare budget neutral.

Needless to say, those of us in the radiation oncology field have no prejudice about this intention, but it may be worthwhile calling attention to another government-related agency that has recently been publicized as needing more and more money to keep afloat -- the US Postal Service

This hybrid government agency has estimated that it needs $75 billion infused to keep it running to the end of the year. The Postal Service Emergency Assistance Act, S4174, proposed to supply $25 billion immediately. This was then passed by the House of Representatives in August. The argument for supporting the postal service is that it has unexpected expenses related to the pandemic (as have medical practices) and the unspoken need to have a viable postal service to deliver voter registration forms and mail-in ballots for the 2020 election. Apparently being in good enough health to intelligently fill out a mail-in ballot is not a consideration.

Obviously, the US Postal Service has much better public relations and friends in high places than does the medical community. Why would that be? Here's a brief comparison of the two:

The price of a first-class stamp was 33 cents in 1998, 55 cents in 2020 Conversion factor was 36.6873 in 1998, 36.8906 in 2020, and 32.2605 proposed for 2021
Computerized and automated advances result in decreased price and increased efficiency Scientific advances result in increased price due to increased complexity and liability
Decreased charge for mass mailings HMOs
"Forever" stamps available Medicare lasts for lifetime (beware of Medicare replacement plans, however)
Misdelivered mail goes to the dead letter office Misdiagnosed patients go to the morgue
Citizens can choose to use private services but have to pay to support USPS anyway Citizens can choose to use private services but have to pay FICA anyway
Letters that are overweight generate more money in postage Patients that are overweight generate more time and effort
Regardless of delays, the mail eventually gets delivered (usually), even if the recipient no longer exists If there are enough delays, the patient will no longer exist

It appears, therefore, that the continued existence of a viable medical care system should be given the same preference as that of a bloated antiquated bureaucracy that claims financial distress due to creative bookkeeping including prefunding benefits, that a medical practice is not able to imitate.

If nothing else, maybe we need to learn from those with better coping abilities than we have. We can continue our professions, but, from now on, whenever possible, mail it in.

Bonus: Mr. Putin (to the tune of "Mr. Postman")

Note: It has been well-established that the Russians had no role in assisting the Republican win in 2016 and also that recent proposals for changing policies of the US Postal Service are unrelated to any attempt to interfere with delivery of mail-in ballots for the 2020 election. The following is presented for humor value only.

Hey-ay, thanks a million Mr. Putin
Your help last time we're saluting.

Mr. Putin, look and see
You've got a message from the GOP
We won't be needing you, they say in the letter
We've got a plan that's gonna work even better.

The Biden-Harris team just won't have a prayer
If mail-in ballots never get anywhere
And even if we don't get Congress' approval
We'll go ahead with major mailbox removal.

We'll keep the postal service unprepared
Make sure equipment isn't ever repaired
Cut down on overtime and hiring replacements
We'll get it done if we just have enough patience.

Mr. Putin, I hope you're impressed
But maybe it's because we learned from the best
Nobody's ever going to find out the details
Just like you helped us out with Hillary's e-mails.

We'll have to thank the Democrats for promoting
This whole idea of doing long-distance voting
Now we won't care if the pandemic should worsen
Since they'll be more afraid to go vote in person

Mr. Putin, without your help
We can get this done all by ourselves
But we hope you'll keep in touch with us, please
You're so much better than those awful Chinese

We're gonna cheat a little, cheat a little
Cheat a little, cheat a little
Mr. Putin
But if you have some suggestions
Please get Rudy's attention.

Asteroid JF1 Countdown: Asteroid JF1 will be impacting with or passing by Earth May 6, 2022, which, counting May 6, is 613 days from now. Plenty of time left to stock up on batteries, plywood, hand sanitizer, bubble wrap, Tang, and duct tape.