No politician has to deal directly with Granny, but I do

It’s impossible to watch the news these days. Whether you’re conservative, liberal, independent or non-committed, it’s impossible to avoid the political bickering these days as the US Presidential campaign enters its final countdown. As a physician, seeing the video of Granny being pushed off a cliff is about all I can handle.


No politician I know has to deal directly with Granny, but I do. I have to look her in the eye. I have to talk to her. I have to be there when she comes in with a heart that’s not beating. I have to look at her struggling to breathe.  I have to decide, based on the available information like her current and past medical history, social situation, family member concerns, prior surgical history, medications, lab tests, and a myriad of other variables whether to given granny a pacemaker or not.

Not you, Mr. Politician. Not Obamacare. Not my hospital. Not the insurance company. Not Big Data.


And for the moment, I’ve got granny’s back.  No matter what, if she wants and needs a pacemaker, she’ll get it.

But everything that is being proposed to save costs in health care these days threatens my ability to make the right choice for granny.

For Democrats, they want a 15-member non-elected panel that might set a limit on certain aspects of when I can give granny a pacemaker despite what she and I might think. For Republicans, they want to allow insurance companys and their Big Data (or a pre-programmed supercomputer called “Watson”) to tell be when I can or cannot give Granny a pacemaker despite what we might think.   And both political parties want to do this in the face of a tort system that hasn’t had to change at all to account for these financially-imposed ultimatims for care.

In addition, both political parties seem to be aligning behind ideas that cut payments for what I do directly, and somehow pay me for my “outcomes” of care via “bundles” (or some other concocted payment scheme) that defines how to distribute the bundle to the various “stakeholders” in granny’s care, including me.   Even more telling, we see another new iniative currently being rolled out: if Granny gets an infection despite perfectly acceptable care and comes back for follow-up management, guess who won’t get paid for her ongoing care after January 1, 2013?  Neither my hospital nor me.

Talk about shifting risk!

So the risk of Granny’s pacemaker care in our current capitated ACO world is shifting ever-so-quickly from a company who is in the business of taking risk (insurers), to hospitals and me who are not in the business of taking risk. I am in the business of caring for patients and expecting I’ll get paid for that care. I do not have a big, fat, holding pen of reserves that people pay in to for assuming their health care risk like an insurance company. I just have a personal checking and savings account. (No wonder hedge funds are lining up behind insurance companies – it’s a win/win for their profits!)

This trend is only getting worse.  In a piece entitled “Tackling Rising Health Care Costs in Massachusetts” that appeared in the New England Journal of Medicine, we find that the near-universal health care law in Massachusetts (upon which our current health care law is modeled and was sold as cost-cutting) has the “highest personal health care spending per capita of any state.”  As a result, we also learn of a new law that was just passed to counteract this fact that contains measures that further shifts the cost risk further from insurers to the hospitals and doctors. In fact, as one former Boston hospital CEO has pointed out:

Even if you believe that capitated contracts are the best thing that could happen in health care, you should not and cannot believe that the transfer of risk inherent in such contracts should go unrecognized. The state’s failure to account for this gift to the insurance company represents an example of incomplete policy-making.

But doctors in Massachusetts have recognized the problem.  The legislature there forgot to consider what doctors are actually doing in Massachusetts … they’re leaving.

Hey Granny! Maybe we should push the insurers and these well-funded politicians off the cliff.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • raspberry ketones

    Post is very intresting,keeps the attention…keep posting

  • Jeff Shaham

    As a member of a family with many doctors I do sympathize with what Dr. Wes says, especially with the arbitrary power and treasury allocated to the insurance companies and taken from us and all others involved.
    But Dr. Wes left out an important part of the puzzle: how do we, as a nation pay for any treatment decided by the doctors in a limited government means environment. The budget for health care is already near 20% of GDP. What will stop its increase?
    I see two solutions:
    1. Guidelines for limiting care. I don’t see a way around it.
    2. One payer system. Will cut by a factor of two what it costs us now, and is wasted on the current insurance companies system.
    Unfortunately the situation is not yet horrible enough, the insurance companies too rich and strong, the government institutions too weak, and the people too split between the haves and the have nots to come to an effective solution.

    • WarmSocks

      Why should we, as a nation, pay for any treatment? Doctors aren’t treating the nation. Doctors aren’t treating the government. Doctors are treating people. We, as people, should pay for our treatment. Individual people, individual treatment, individual payment.
      There’s no reason to have middlemen come between patients and their doctors. If patients paid doctors directly, they could lower their fees and still make a good living. The guidelines for limiting care could be set by the people directly impacted, not imposed by bureaucrats. That would reduce costs significantly, because we wouldn’t be paying the salaries of all those paper pushers. How many people work for insurance companies? How many people work in doctors offices trying to assure that the doctor jumps through the insurance company’s hoops? How many millions in salaries could be funnelled back to doctors and patients if we got rid of the middlemen?
      Unfortunately, too many people want someone else to take care of them, instead of taking personal responsibility for themselves. As long as people say, “Medical care is expensive, so someone else should pay what I can’t/am unwilling to pay for myself,” there won’t be a solution that we can all agree on.

  • Laura Curtis

    A single payer system will also limit care, Jeff. While sometimes, some care is readily available, it’s also true that many people in the U.K. and Canada often suffer extraordinarily long wait times for tests & procedures that we in the US would get within a couple of days. People in Massachusetts are starting to get a taste of what it’s like to have “access to healthcare” meaning an insurance card, yet no way to actually get the care they need in a timely fashion. That’s not going to go over well, nationwide.

  • AnonRD

    I think the elephant in the room on this subject is that we do not, as a culture, accept that we all must die. Everyday I see people being maintained on tube feeding, TPN, and other aggressive (and expensive) life-sustaining therapies when there’s little to no chance for recovery and no meaningful quality of life for the patient. By quality of life, I mean they are unable to communicate with loved ones, they are bedbound, and dependent on drugs and machines. They must be cared for 24/7 by their family members or in (expensive) care facilities. Whether people like it or not, our healthcare costs will not be reduced if doctors and spiritual/social counselors are not comfortable with having honest conversations with people before these life-sustaining therapies are initiated. Obviously, most scenarios are not black and white but the reality is that there are, and always will be, limited resources and we must accept that.

  • Steven Reznick

    If we are looking to sanely reduce health care costs we must first look at true fraud in the Medicare system. I am not talking about some practitioner billing a level 4 visit instead of a level 3 or ordering a PSA for screening. I am talking about organized groups of criminals deciding that it is easier and safer to set up a PO Box in Hialeah, Florida selling non existent durable medical goods and health care services and being reimbursed by Florida’s Medicare intermediary First Coast millions of dollars BEFORE anyone thinks to check out the location and the organization with a site visit. This is safer for them than selling drugs, human beings or racketeering.
    We must next look at end of life issues and regional variability. A national program to require patients to define their goals and wishes attached to the annual signup for Medicare Part D . This could include living wills, medical directives , do not resuscitate forms etc. With regard to regional variability in services provided and volume of those services we need as practitioners to know what works and what does not.
    Tort reform to begin to attack defensive medicine would be very helpful. I believe practitioners have become so used to ordering to cover their asses that many can no longer distinguish between what they need to know to diagnose and treat and what they order to just buff the chart.
    I would like to see what health care spending looks like just by first attacking these areas. Then we can discuss fee for service vs capitation vs one payer systems.
    The author wrote a wonderful piece and clearly pointed out that as clinicians we are always our patients advocates and we need to remain to be so.

  • WarmSocks

    Well stated.
    Those “for now” qualifiers are important. I was recently talking with an old friend whose current project – working for the state government – is helping design a program in which all medical treatments will be approved by the government, not selected by the physician or patient. Anticipated rollout is 2018.

    • JannyPi

      Medicare is already doing some of this, and I expect they will get better as more and more information is gathered.
      An example is some blood labs that I had done recently, and how they were compared to prior results before the individual tests were done or billed. I was a Type II Diabetic, diagnosed in March 2011, with A1c @ 7.6. My Dr prescribed Metformin, exercise and a diabetic training class run by the hospital. Over the past 15+ months I lost weight and began to take better care of myself in ALL ways. In May 2012, my A1c was 5.3 and the Dr took me off of the Metformin. I’ve had two labs since, and in both cases Medicare wouldn’t pay for the A1c because my fasting sugar was within normal range (one result 78, other was 85, I think).
      I think this is a pretty good example of how technology will work for us, and how if/then coding makes perfect sense and will reduce unnecessary tests.
      My understanding of the Affordable Care Act is that the 15 member panel’s role will be to look for ways to save money, such as what I just outlined. They will not be dictating patient care (or creating death panels!), and I don’t think there’s anything that an honest, legitimate physician has to worry about.
      Also, the ACA requires that private medical insurance companies spend a certain percentage of the insured’s insurance costs on their care, or they have to refund the overcharge. This has already rolled out, and I know a couple of friends have gotten refunds from their medical carrier.
      I do agree with the author 100% on tort reform though, it’s way overdue.

  • petromccrum

    There is fraud thoughout the entire system; not just with Medicare. There has to be tort reform,
    a completely new/improved billing protocol, and less government involvement. Control needs to be given back to the doctors and patients.

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