Basic Arithmetic for Beginners
There are few things in life more dependable and, at the same time, less respected than basic arithmetic. The majority of Republicans want to increase military spending by some 54 billion dollars. They want to cut taxes. They want to eliminate “Obamacare” and substitute what would appear to be an even more expensive alternative, given that medical costs were rising at an even higher rate before the ACA was instituted. They would like to cut or literally “streamline” Medicare by privatizing the program.
“Progressives,” very liberal individuals with laudable goals and generally no long term plan as to how the goals can be achieved, apparently would like to have Medicare for everyone without fixing the program first. Congressmen and women in both parties have generally conceded that their lobbies are far more important to them than those of their constituents who depend on Medicare and Social Security. Representatives Stark and Dingle sponsored bills allowing medical laboratories to collect fees up to ten times more than they would cost with honest competitive bidding. Durable goods and oxygen companies, Democratic lobbies, were permitted to charge Medicare three to four times normal retail prices.
Medicare Part D- Still the biggest non military scam in U.S government history
While the cost to taxpayers due to these Democratic congressional representatives’ criminal activity may have cost anywhere from ten to twenty billion dollars per year, the rank amateurs could not compete with the Republican party’s professional criminals, Congressmen Tom Delay and Billy Tauzin. Meeting with the pharmaceutical lobby and utilizing bribes and illegal threats, the two coerced their colleagues into voting for Medicare Part D in a reconciliation bill. Despite multiple rejected attempts by members of both parties to reasonably amend the bill, including the addition of competitive bidding and using the Medicare membership to obtain better prices, the bill was passed in 2003 and put into effect in 2006. Tauzin, in 2003, was already in the process of negotiating a contract and became the president of the pharmaceutical lobby that he and Delay had coauthor the Medicare bill. Delay was later arrested for accepting illegal contributions, but was unfortunately released on technicalities. According to the latest figures I had, in 2014 costs for Part D ran to 11% of the 595 billion dollars spent on Medicare. This comes out to approximately 65.45 billion dollars. Meanwhile, of the 26% of Medicare costs shifted to HMO’s, 11% of their costs represents another 17 billion dollars in outpatient pharmaceutical payments. The total is a staggering 82.47 billion dollars in one year.
Assuming the obvious, that negotiated pharmaceutical prices at the VA are approximately 40% of Medicare prices and Canadian prices approximately 50%, Mr. Delay, Tauzin and their lame duck Congress have cost taxpayers between 33 and 49 billion dollars per year in graft for each of the past three years and somewhat lesser amounts per year ever since 2006. The figures do not reflect the copays for the overpriced medications nor do they reflect the similar prices paid by the average American for the same pharmaceuticals, nor does it include hospital drugs or other drugs overpriced on Part A of Medicare. The only “legitimate” excuse for no competitive bidding is that we may end up in a formulary which excludes certain medications due to their pricing. As a practicing primary care physician over the past 35 years, all I can say to that is: “Welcome to the real world of medicine where effective, safe generic medications are retired to make way for new and more expensive newly patented ones, where many specialists are bribed by pharmaceutical companies to hawk new drugs and others are afraid they will be sued if they don’t prescribe them!”
Hospitalization by DRG (Diagnostic Related Groupings)- Congressional scam or stupidity?
DRG’s or Diagnostic Related Groupings determine how much a hospital receives for a patient’s inpatient hospital stay based on the diagnosis, with a few extenuating complications taken into account as well. The hospital is given the incentive to be as economical as possible within the flat fee that they are paid. Unfortunately, the actual cost of inpatient hospital services is extremely expensive compared to outpatient services. Nevertheless, Medicare pays up to three times as much for the same exact procedure done as an outpatient procedure in the hospital as it does for the identical inpatient service. For example, repair of my patient’s fractured cervical vertebra as an outpatient admission was quoted as 50,000 dollars in hospital costs, while the inpatient admission cost was 17,000 under the DRG. For those who cannot subtract, a difference of 33,000 dollars! Talk about “bass ackwards!!!!”
Patient Noncompliance and Fraud
The wasted billions are adding up faster, even faster than Progressives and Republicans can count on their fingers and toes. We haven’t even mentioned abuse of emergency rooms, lack of any penalties for patient total noncompliance, patient fraud, keeping dead patients alive on ventilators, and end of life care, things they are deathly afraid of discussing for fear some attorney will have them sued or, worse yet, arrested. If Medicare Part D, durable goods, oxygen providers, medical lab costs and manipulation of hospital admissions represent the first 30% of Medicare waste and graft, end of life care represents the second 30% of Medicare overspending. Unfortunately, this 30% is a moral, not a mathematical dilemma, so let’s concentrate on patient initiated waste for now.
As physicians, we all have patients that are noncompliant. Some overeat, some smoke, some drink too much, while some may indulge in other more unsavory activities. All of these things come with the territory and physicians do the best we can and “live with it.” While Medicare HMO’s have initiated patient incentives to address some of these issues, I think the Medicare program needs to do the same. What should not be acceptable is for patients, especially Medicare recipients to use the emergency room instead of the primary care physician’s office as a regular doctor. Meanwhile, ER physicians continue to admit these people either out of fear of lawsuits or to pad hospital admissions. Worse yet, I’ve seen patients who invent symptoms when they are short on cash, being admitted in order to collect from Aflac or a similar insurance. Some suitable fine or legal action needs to be available to dissuade this sort of behavior as well.
The simple arithmetic in Medicare is that close to 150 billion dollars is totally wasted every year and stolen due to a runaway Congress that can not be trusted with the management of some 600 billion dollars in Medicare funds. It is simply too enticing for them to pilfer the funds for their favorite lobbies. There clearly is no authority, currently, to keep them from indulging in the world’s oldest profession, especially with the direct encouragement of half of the members of the U.S. Supreme Court in favor of the Citizens United decision. Before Obamacare, arbitrary medical insurance rates were totally in the hands of the insurance companies. At least the ACA limited the insurance companies to a market based rise in premiums, therefore less rate hikes than would otherwise have resulted. The responsibility has shifted. Now, after some seventy years of falsely elevated premiums, the actual costs of the medical care have become the primary driver of medical premiums. It’s time for a criminal Congress to clean up its act or not let the door hit them on the way out!
It is also time for President Trump to put his money where his mouth is and address the real problems with Medicare, i.e. Congress and its lobbies. Then conservatives and liberals can have a legitimate battle over the idea of a single payer system and even a “Medicare for all” plan versus whatever alternative Republicans wish to provide.
Allen Finkelstein, D.O., M.Ed.