Monday, March 22, 2010

Field Trips are Fun! Random Op-Ed is Fun Too!

I received a link this morning to a cutesy video wherein Doctor Marshall advocates for Congress to come visit a hospital on a field trip and truly learn what's broken in health care. Obviously, a day late for me, but nonetheless it sparked a few thoughts which I've jotted down below.

Doctor John L. Marshall of Georgetown University is a very respected and highly regarded oncologist leading the charge against cancer. I'm sure the guy is a wonderful doctor, and has contributed enormously to his field.


I watched the video, and those of you with a Medscape login can too, it's here:

After watching it, I got just a tiny bit annoyed about how simplistically the argument was made with no actual proposals, solutions or advice given, just this grumbling about congress-doesnt-know-jack-about-my-problems rhetoric I've heard time and time again. So I decided to pick apart the arguments a little, my response after the jump.

1. About not having Congressional representation: DC has three electoral votes for Presidential elections, and a delegate in the House who can vote on House committees and many other procedures, just not on the floor of the House. DC of course has no-one in the Senate, because last time I checked DC was not a state that had ratified the Constitution. Just like Puerto Rico. If you want Senate votes, stop whining and become a state. Or rejoin Maryland. In the meantime, here's a record of Congresswoman Eleanor Norton's work as DC delegate including the bills she has introduced:

I also find it oddly contradictory that someone not overly-happy with government interference in his chosen profession then implies he wants more government in the form of diluting State's rights by giving votes to a federal district. Again, with no proposed solution or desire, just a complaint that he doesn't have representation.

2. About changing or picking a health insurance plan: Elected representatives are not born that way. While they have a decent health plan as members of the House or Senate, they (assumedly) had health care insurance *before* they were elected. His argument that all Congresspersons are ignorant of the ins and outs of acquiring health care insurance is misguided. Each of these people held jobs prior to holding office, and experienced the American life and system alongside everyone else. Many of them as self-employed professionals or small business owners.

3. About being on hold waiting for someone who doesn't know what you do day-to-day to judge your performance: I believe for an elected representative they are called "constituents" and "elections".

4. About being audited on their procedures and activities: Elected representatives are under constant scrutiny, myriad rules; are subject to ethics committees; are audited by the Government Accountability Office; furthermore they are then judged by hundreds of lobby groups who pore over each representative's and senator's voting record. The accountability of your average elected official in the federal government far exceeds that of a medical doctor, and comes with the added bonus of having to do a decent job to get re-elected.

5. About getting paid for good documentation:,,,, - I would like to see how fast this or any other oncologist can pull up records for a given patient he saw ten, twenty years ago. All other shortcomings aside, you can't possibly fault the government for it's record-keeping nor it's accessibility to same.

6. About pay-for-performance: (a) the federal government has *zero* pay-for-performance affecting doctors, there are a few pilots going on but no doctor in the USA is subject to pay-for-performance involuntarily and none at all from the feds. (b) Elected representative are very much paid by performance. Don't perform? Don't get re-elected. Doctors can lose their license and simply pick up and go practice in another state. Yay freedom. (c) The only thing the feds have done is told hospitals they, and by they I mean Medicare, will no longer pay for avoidable errors. Prior to the rule, a doctor could cut off the wrong leg, bill for it, then cut off the correct leg and bill for that too. Not anymore. Boo-hoo.

7. About being told what you as a doctor are allowed to do for your patient: No insurance company tells you what you are allowed to do. They tell you what you are allowed to bill for. Correction, you can bill for whatever you want, but an insurance company tells you what they will pay you for. The most current data on health insurance denials are 2.36 percent (AHIP) and 2.65 percent to 6.8 percent (AMA). AHIP has an interest in the number being low, AMA has an interest in the number being high, so cut that down the middle however you like.

Total denials for non-covered services were 1.2 percent. The number for denials in the raw is much higher, but much of this is simply billing the wrong insurer - which counts as a technical denial but some other insurer then gets the bill and pays up - or having to resubmit and getting paid the second time. Not perfect, but not denial of service either.

8. About Congress not having a clue what is wrong with health care: Congress has 16 doctors right now, plus two dentists, three nurses, a psychologist, an optometrist, a clinical dietician, and a pharmacist which by my math (25/535) is just under five percent of Congress. Seems to me the medical community is well represented in Congress.

The implication that the legislative branch of the United States federal government is tackling this problem with too little background, understanding and general knowledge of the problem is - in my not very humble opinion - a disservice to the viewers of the video. There is plenty wrong with Congress. And plenty wrong with hospitals. But the easy target of "the government is a bunch of morons" seems a particularly poor choice for such a learned gentleman.

9. About taking a field trip to a hospital to fully understand what's broken: Hospitals are not the universe of health care, an issue I see at way too many hospitals who forget they only account for under one third of health care in the USA. Hospital care is 31% of health care expenditures in the USA. Health insurance, of course, reaches all aspects of health care.

In summary: for sure, there are plenty of things wrong in all parts of health care, including hospitals. The notion that Congress should have taken some time to explore the issue before writing and passing legislation is of course, sound. Hmm. I wonder if any of them did? Do you think any of them ever spent time in side a hospital? Hmm.


Michael Hickins said...

Nice. Just one slight adjustment. DC can't "rejoin Maryland" because otherwise it would technically become part of the South, which would overturn the outcome of the Civil War. Then we'd have to revote on every single law and Constitutional Amendment ever passed, and that would take a lot of time.

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