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AHIP, the trade group representing the nation’s health insurers, released a study decrying excessive physician charges.  There’s some amazing stuff in there: office visits being billed at $6200, a lap chole being billed at $9,000 (just for the physician’s portion).  Truly egregious, if true — and that’s the qualifier.

The methodology of this “survey” is not really honest.  They cherry-picked an insurance database looking for the highest billed charges for various CPT codes.  Supposedly they “excluded high charge outliers that may reflect billing or coding errors.”   Really?  How on earth, one wonders, could they have concluded that an office visit billed at 5,000% the medicare rate was not an error?  Were there more outrageous charges that were excluded?  Sounds fishy.

Moreover, the survey is promoted as exposing the outrageous fees that doctors charge, when in no way are these fees representative of physician fees.  Physician fees, as any other group of data points, fall into a more-or-less normal distribution.  There’s a median point around which most practices cluster, and the further out you get the fewer physicians that are charging those fees, high or low.  The cited fees are certainly in the 3+ standard deviation tail of this graph, but you wouldn’t know it from the AHIP press release.

They present these outrageous charges as if they are accurate and as if they represented a widespread abuse of consumers by greedy doctors.

The annoying thing about this is that there is a valid argument to be made that the uninsured do face higher fees than the insured.  This is of course more of a factor with the much-higher hospital costs, but physician fees are also higher for the uninsured.  The reason for this is that insurers demand a discount off the standard fee in order to contract with physicians.  This gives physicians an incentive to crank up their fee schedule as high as they can get away with.

So if UnitedHealth comes to me and offers to pay me 75% of billed charges (I wish!), I need to make sure that my fee schedule puts that figure at a level that is going to return a reasonable per-patient compensation.   This is less of an issue nowadays, since most insurers prefer to settle on a conversion factor and contract by the RVU, or as a percentage of the standard medicare rates (110-150% most commonly).  That’s easier for their billing systems to manage.  So there is less incentive for us to keep charges high.  But still, a few insurance plans like to do the old way, and there are occasional patients who are insured but we don’t have a contract with their insurer.  In those cases, we expect compensation in full, and the insurer usually pays some arbitrary sum that they feel is reasonable, with the patient responsible for the balance.

Does this screw the folks without insurance?  Yes, to a degree.  Most of the uninsured don’t pay a dime.  They just throw out the doctor’s bill, along with the much-bigger hospital bill, and we wind up writing it off as bad debt.  Most hospitals, and our practice, will also write it off as charity if the patient asks for it and can show some hardship.  So the uninsured will get a huge bill, but they very very rarely have to pay a huge bill.

The ultimate solution for this “problem” of the uninsured being “overcharged” is not, as AHIP implies, to somehow regulate physician charges, but to eliminate the uninsured.  Get everybody covered under some sort of insurance plan, and this problem goes away.

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The sense of smell is a very powerful sensation.  A distinctive fragrance can stir up a long-forgotten memory, or put you in a place you haven’t been in years.  There’s a certain clean, dusty smell that always reminds me of the cottage on Wisconsin’s Lake Koshkonong, which we used to rent every year when I was a kid. There’s a perfume that always reminds me of a girl who I briefly dated in high school.  The girl was forgettable but the aroma was not.  We all have these triggers and associations.

All this occurred to me last night as I hunched over the face of an intoxicated gentleman who had lost a fight with the pavement.  He was unresponsive, and I was painstakingly stitching back together the tattered pieces of his lips and forehead.   Every time he exhaled, I was subjected to an intense and pungent smell of dried blood, saliva and alcohol.  It’s an acrid scent, sour, with an overlying cloying sweetness.  Very distinct and unpleasant.

And that, my friends, is the smell of the ER.

At least for me.  I will never be able to smell that in my life without being immediately transported back to this place and activity (repeated so many times over the years).  Fortunately, I am unlikely to ever experience this particular smell outside of the ER.  Later, after the ER emptied out for the night, I discussed this with a few nurses & others.  Not surprisingly, there was quite a diversity of opinion.  One nurse insisted that the smell that, for her, screamed “ER” was that of melena (bloody stool from a brisk GI bleed — also very pungent)  It can fill the entire department when you have one GI bleeder.  You come into work, smell the melena the moment you walk in, and you just know what sort of shift it’s going to be.  A tech said that the scent he thinks of as “ER” is the sweet plastic smell of freshly opened oxygen tubing.  Another nurse came up with an inventive and hysterical bit of slang that I just can’t bear to repeat for, um, how shall I say it, the ammonia and fishy smell of unclean or diseased lady parts.

Ultimately (of course) we came up with a list of “Smells of the ER”:

• Alcohol, Saliva & Dried Blood
• Fresh Plastic Tubing
• Melena
• Feminine Issues
• A Freshly Incised Abscess
• 80-proof Vomit
• Clostridium Difficile (a GI illness producing a distinctive smelly diarrhea)
• “Hobo Feet”
• Coffee Grounds in a tray (used by nurses to freshen the air and cover some smells)

Surely there are more — perhaps you can contribute some in the comments.  It’s gotta be distinctive to the ER, though, or at least a medical setting.  Just poop or vomit doesn’t cut it.  And, like the plastic tubing, it doesn’t have to smell bad, necessarily.

So what do you think?

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Congress is going into recess without completing its work on health insurance reform, and the advocacy groups are eager to use this time to whip up voter sentiment for or against reform.  Unfortunately, the anti-reform pundits are all-too-ready to dip right back into the 1993 playbook that gave us Harry & Louise, playing on the fears of consumers with distortions and outright lies.

Ramona alerted me to one such piece published in the CNN/Money-Fortune segment, a “Special Report,” scarily titled:

5 freedoms you’d lose in health care reform

Nice lede, eh?  Can you guess without reading the article where this author is coming from?

The subsequent bits range from “accurate-but-deliberately distorted” to “complete BS that I made up but is really scary.”

Let’s start with the latter, as it’s more fun:

5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges […] must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. […]

The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges.

So, just to recap: You won’t be able to choose your doctors because your primary care doctor (that you chose) might, under certain reimbursement schemes that aren’t actually mandated in the bill, have a hypothetical incentive to limit access to specialists.

Um, what?

Never mind the fact that TODAY, right now, your access to a specialist is limited by some drone at your insurance company who doesn’t have a medical degree and does have a very powerful direct financial incentive to deny authorization for referrals.  Never mind the fact that there is nothing in the bill which states you will be “assigned” to a primary care doctor.  Never mind that fact that the “Medical Home” is not in any way related to an HMO, conceptually or practically. This “gatekeeper” function isn’t in the bill at all!  The medical home concept is designed not to ration care (which is the unspoken subtext of the above passage) but to coordinate and improve the quality of care.  Never mind that, if a referral is granted by the wicked & parsimonious gatekeeper, your choice of a doctor is still not restricted under the bill.

Never mind all those inconvenient little facts that each individually or all together totally invalidate the thrust of the author’s argument.  The problem for the whole concept is that there will be many plans offered for purchase on the exchange. If you don’t like the one you picked because it is too restrictive, you can switch to another plan! If WellPoint requires too much hassle to get to see a specialist, then you can dump them and pick Cigna!  Granted, the ones which are more restrictive are also probably going to be cheaper, but that’s for the consumer to choose!

And yes, before you bother to say it, yes, this might result in adverse selection of sicker patients into the more lenient plans, but they will be risk-adjusted to correct for imbalances in their patient populations.

So that’s the easy point to debunk, and I would think that finishing up with the BIG LIE like that, there would be little need to review the rest of the hit-piece, but I’ll make the effort, my love of truth and good policy being as strong as it is.  Other “freedoms” you would lose, according to the esteemed and honorable author:

1. Freedom to choose what’s in your plan
3. Freedom to choose high-deductible coverage

I put these together, because it’s a bit of a cheat on the author’s part to list them separately.  I mean, it’s the same thing, innit?  This is basically an assault on the concept of the mandate that all Americans be insured: you can’t just buy crappy insurance that doesn’t really cover anything meaningful and say that you’re covered.  I respect those libertarians I have clashed with when they say that they should be free to “go naked” if they so choose, and have no or minimal insurance if that is their choice.  I disagree, but I respect their honesty.  This piece is a little less direct, but it’s basically the same thing — defending the right of people to choose crappy insurance that wouldn’t actually cover their health care needs should they fall ill.

There are two problems with that sort of policy approach.  First, a fig leaf just ain’t clothing.  You can glue one on and walk around town without getting arrested, but everybody who sees you knows you’re naked.  Insurance that has the “We never pay” clause just isn’t actually insurance.   It doesn’t accomplish the actual goal of getting every American access to quality health care.

The other problem, a bit more subtle, is that letting people opt out of health insurance, either explicitly or de facto by buying cheap fig-leaf insurance, defeats the purpose of the individual mandate: risk pooling.   It’s a certainty that some of us are going to get sick.  It’s also certain that those of us who do become sick will not be able to pay our individual costs, as health care is now so expensive that no individual can hope to pay their actual bills.  By requiring all of us to have insurance, you create a situation where those huge costs are spread out among the largest possible number of people.  Allowing opt-outs ensures that everybody who can, will, and these will be the healthier people who don’t see a need for insurance, at least not today.  The result is a concentration of costs among the sick people who generate the most costs, which, as noted, exceed the ability of these individuals to pay.  Of course, as people who were healthy become ill, according to nature’s inexorable dictates, they will transition from the low-cost insurance products they previously favored to the ruinously expensive plans that actually cover for people who are sick.  And the system literally falls apart.  No funding exists for the sick to pay for their (hugely expensive) health care, and the healthy contribute little (until they become sick).

2. Freedom to be rewarded for healthy living, or pay your real costs

This is pretty tightly related to the above point, with a slight distinction.  Again, as pointed out, nobody who is sick can pay their real costs.   So again, there’s the risk-pooling issue.  But there’s another, more pernicious assumption here: that health is a controllable feature of lifestyle.

Bullshit.  I’m healthy, and I like to assume that’s because I’m virtuous and athletic and take care of myself.  Right?  Except that it’s strictly a matter of luck that it was not my kid that got sick and died of neuroblastoma.  Or medulloblastoma.  It was a matter of luck that my wife pointed out a funny-looking freckle that turned out to be a very thin melanoma (and lucky for her that she married someone who could tell the difference).   Cancer is easy to cite, but the list goes on and on of health conditions that have nothing to do with lifestyle: crohn’s disease, MS, bipolar, Type 1 diabetes, glomerulosclerosis, etc, etc, etc.   And none of us know in advance when our — or our family’s — number is up.

So we are all in this together.  We all pay a premium: and bet or a hedge against illness.  Those of us who win the genetic lottery and stay healthy lose the “bet” and wind up paying for a service we didn’t need.   If you let some people hitch a free ride and pay a minimal premium, they are not paying their fair share to cover the cost of those who have already become ill.  When President Obama talks about “Shared Responsibility,” this is what he means.

There’s a lot more chicanery in this article — I’ve neglected Point #4 entirely, as I covered that the other day.  No plan will remain the same in perpetuity.  I’ll stick to the main policy points and leave, for the moment, the sly little insinuations and falsehoods scattered throughout the article like so many candy sprinkles on an ice cream cone.

Strangely enough, I’ve finally found a point of serious, substantive agreement with (former) Alaska governor Palin.  She and I are united in wishing that the gosh-darned liberal media would just stop making stuff up.

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From the department of “Credit where it’s due,” in the comments of my post on the Lewin Group, Nurse K pointed out the following:

Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.

Much as I (really, really) hate to admit it, she’s absolutely right.  In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts.  I started keeping track of the number of uninsured I saw every day, just as a pet obsession.  It was a sobering number.  After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc.   For me, this cause became something beyond the personal a long time ago and became a moral imperative.

But K is right to note the potential for bias, and it’s fair for me to acknowledge it.  I hope that my integrity on this point is evident.  The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)

This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser.  Quite a few docs mounted their high horse and with great indignation denounced this:

Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…

Now it’s a clumsy clinical scenario written by someone who has no clue about medicine.  But it’s a damned fair point.   Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more.  It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab.  It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).

Whether there’s a “fix” for that in the current reforms is debatable.  It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified.  I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests.  The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point.  Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.

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Long, long ago, when I was a medical student, we joked that you could tell how senior a physician was by how much junk was in their lab coat pockets.  As students, we tended to carry around big bags full of every medical gadget we could think of, plus a few reference texts.  The attendings were slim and graceful in their long white coats with empty pockets.

When I became an intern and moved into the hospital full-time, all that crap became just too much to lug around.  I ditched the bag, and my short white coat (with interior pockets, thank god) became loaded down with tons of stuff: reflex hammers, pocket reference guides, photocopied research papers for reading, patient lists, a procedure log, a PDA with epocrates, a bit of a snack maybe, and more.  The coat weighed at least ten pounds fully loaded.  As a junior resident, I pared it down to the few references and gadgets I actually used frequently, and the coat got a lot lighter.  With each succeeding year I have lightened the load somewhat, down to the absolute essentials.  I shed the white coat years and years ago.  Now the only things I bring with me to the hospital are:

Three items.  It’s very liberating.  Of course, I have epocrates and more on every computer workstation, so the references are there in the ER for me, but still, it’s something of a victory over inanimate junk and my own packrat tendencies that I can go to work with only three things in my pockets.

The downside is that if I happen to forget any one of these three sacred totems, it totally ruins my whole day.