Healthcare: Feeding of The Hungry Giant

The complexity of our health care delivery system is at the root of the problem.

The chain of care starts with a patient, as it should. It ends with the government devising the policies and providing the funding for the delivery of medical services. Or maybe it’s the other way around? The health care bill this year stands at $4.3 trillion. It’s an exorbitant sum, and I also know that after $1 million, most of us have problems with comprehending this enormity. But it’s a lot. The cost per person is $12,000, and way above the $8,000 spent by the next on the list, Switzerland and Germany. The administrative costs take 25% of the expenses, and here too, we’re leading the world. That’s a big pot of money, and there are many hands dipped in it. The healthcare is overregulated. Each new bill makes the system more convoluted and takes funds away from the pool ultimately designed to benefit the patient. With a long chain of often clandestine financial custody, there is always an ample opportunity for corruption.

The best example was the Universal Health Care idea, which was signed in to the Affordable Care Act in 2010.

When it was said and done, it was neither Universal not Affordable.

The name ‘universal’ is one of these catchy misnomers. Again, those who control the language control the masses. It’s impossible to provide the uniform healthcare for all the people in any country. The government can provide more or less universal access to primary physicians for most of its people, but the next step in care, which is the visit to a specialist’s office, has to be triaged. We avoid the word ‘rationing’ since it sounds terrible. And the one who controls the language. . . This form of rationing is usually expressed by not enough doctors, long waiting times, or imposed restrictions on life-saving procedures. Here, doctors providing care accordingly with rules of the regulators and payers often conflict with their own ethical values and their patients’ wishes.

The main advertised objective was to decrease the cost of health care delivery. It didn’t.

The access didn’t change much, except for people with 100%-400% of the US poverty level, who got the subsidies. They got funding, but for their waiting time even for a primary care is still long. For this narrow segment of population, the ACA was obviously significant. The main insurance vehicles remained the same: private insurance for the richer, and medicaid for the less fortunate.

But ACA came with the avalanche of the restrictive layers of regulations.

I will describe how it impacted my practice in a small group of cardiovascular surgeons.

The ICD-10 coding requirement got detailed so much, it became a new language, a new lingua franca. The codes were so detailed that often sounded like good jokes. And a wrong code applied to the service often meant reduced payment, or no payment at all. The new, highly specialized and trained bureaucracy of a new class of coders had been created. The reports were so long, that most of them were irrelevant.

The Electronic Medical Records idea was ruthlessly implemented. While in principle a groundbreaking innovation, EMR’s costs were exorbitant. Monetary and logistical. It started with buying the equipment, training the personnel, servicing the hardware and software, and upgrading every so many years. Smaller practices with older staff had an understandably harder time than larger offices with younger, tech-savvy personnel. The subsidies from the government were silly, and the penalties severe. If doctors did not implement EMR’s in a regulatory time, the flow of money from the government stopped. And that meant a death sentence to the medical practice.

So, small groups of doctors, not able to comply with regulations, were bought by larger health care systems. Small groups of practitioners vanished, whereas bigger centers got even bigger.

Next, small hospitals, not able to comply with regulations, were bought by larger hospital systems. Small hospitals vanished, whereas bigger hospitals got even bigger.

Did you notice that I just rewrote the sentence, changing only the subjects?

This trend of concentration of power had an enormous effect on the delivery of healthcare in this country. And a dramatic change in a distribution of funds from the big pool of health care money.

So why so bad when it is so good?

There’s a long path from the place where money is printed to its final beneficiary, which is a patient. With each new legislation, the river of money gets weaker, the stream loses speed and volume, it meanders above the surface, often disappears below, and comes to a trickle when it reaches its final destination, the patient. On each level, there are distributaries, like in the delta of Amazon, feeding marshes. Many entities take their gulp before water gets to its final destination. The aqueduct is leaking. A lot. The people at the top come up with the money and devise the regulations, the ones in the middle on each level take their share, and the patients, and doctors, have to be satisfied with whatever is left.

The doctors, nurses and all other health workers are the ones responsible for delivering the services to the patients. And dealing with humans who are sick, often are not getting what they want and when they want, is often hard. Health care workers are people too, and have the same personal problems as we all have. But their job is to listen and ease the suffering of a human being. They use their knowledge and skills within the rules and resources created by the legislature to ease their suffering. The doctors take an oath to be an upholder of the patient, not to the paying entities. Here where the most of the conflicts are created.

When their work is badly needed, the health workers are called ‘heroes’. When they don’t perform according to the imposed rules, they are being fired.

The people who fund the system, middlemen from the institutions producing medical devices, insurance executives, all pharma researchers and bureaucracy, they all have 9 to 5 jobs. None of them has to get up at 2 am to treat a gunshot wound to the chest, deliver the baby, or explain to the grieving family why their father died. They answer to the people who sign their paychecks. For doctors and nurses, the primary obligation is the wellbeing of their patients. It’s seductively called a vocation to distinguish it from the financial relationship. The words are important. He who controls the language. . .

Doctors and nurses are in a service business, and, willingly or not, our success is measured by the approval of our patients, our clients. Every patient’s visit is an emotional encounter. Not every decision has life-or-death consequences, but in an essence many feel that way. And we all know how easy it is to fall off the rails. We are all humans, and we feel the pressure. And irreparable damage is done when trust, the fundamental cornerstone of the healthcare delivery, trust between a doctor and his or her patient is broken.

So, the bureaucrats don’t get burned out. Doctors and nurses do.

And do you know what the kicker is? A person, who was one of the architects of ACA, and whom I count as a friend, now uses the ‘concierge’ medical care, for which he pays extra from his own pocket. How cool is that?


  • The way the government does not work is lying when they say they will cut health care spending. They use inflated estimates and then tell the public they are saving money from that estimate. As long as there are government departments that inevitably grow they add to the expense of anything within their scope of responsibility. The only way to cut the budget is to eliminate the redundancy that the federal government adds to programs that the individual states already have. For example when I worked in the administrative end of education. The principal of a school has a budget. The district has oversight. The state has oversight. The federal government has oversight. Every layer adds expense. In healthcare the government keeps manipulating the ICD9 codes which adds to the expense of annual training for billing clerks and education for the physicians to know what code to use in order to get paid for procedures. Where will it all end? Sooner than later hyper inflation and bankruptcy. Thank you for sharing your insight.

  • Even more fun is the Byzantine way fees are “set”. The RVS(relative value systems) was established by Ivory Tower medicine in 1974, with each service done by a physician a “multiple” of a certain basic fee. This method was adopted by Medicare, and as Baby Boomers became the main consumers of medical dollars, mimicked by private insurers. At a certain point fees were not allowed to “increase”—an RVS based fee for a particular service might be $150.00, but Medicare “recognized” a fee of $95.00 and paid 80% of that. Private insurers followed. In order to assure faster payment (usually requiring 45-90 days), physicians could “accept” Medicare, which meant they had to accept just the Medicare fee and couldn’t collect the 20%. Now Medicare (following private insurers for once) is captitating certain medical specialties—the doctor gets so many $/patient/month, similar to HMO models (wonder why you can’t get in to see the doctor? The more you “see” the doctor, the less they make due to overhead costs/visit). Hospitals have not charged real fees for services for years—Medicare pays a fixed fee per diagnosis, and private insurers do the same or pay one basic “per diem” fee. Thus both doctors and hospitals end up with at least two sets of financial “books”—one based on fees and the real one based on expected reimbursement which has nothing to do with fees. Don’t worry; most doctor visits will be replaced with phone calls/video calls with an “extender” such as Nurse Practitioner, Physician Assistant, etc, and some of those calls will be replaced with AI resources. Prevention disappears in the Disease/Pharma model. Triage will be all—off my desk onto someone else’s.

    • The absurdly over regulated and over complicated system of taking care of patients goes in the wrong direction. You touched the real problem at the end of your detailed observation from years of dealing with patients. There’s no prevention. So many health problems could be avoided 10-20 years earlier with a proper education of the younger people, well before they became our patients.
      More about it later.


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