You know the dilemma. You have a car/computer/outdated electrical system — something whose workings befuddle you, but you want it improved, made more efficient. You could hire the best licensed professional, or you could use a friend, maybe a relative or a client. You might congratulate yourself for finding somebody who promised to do what no other professional promised. You hire the wunderkind. Down the pike, even weeks down the pike, you discover the folly of that hire as the gizmo breaks down. The repairs upon repairs cost time and money.
The innards of health regulations mirror the innards of a lot of devices — they are complex. The four years of the Trump administration showed us what happens when we discard those professionals for friends of friends who promise nirvana without knowing much about the itty gritty. The Biden administration will spend time and money repairing those ill-advised “changes” made under the guise of “improvements.”
The Medicare regulations demonstrate what happens when know-nothings seize control.
Consider the respective costs of outpatient versus inpatient surgical procedures. The former cost far less than the latter. So why not have heart surgery? Neurosurgery? Spine surgery? Done in an outpatient clinic? Why do you need a hospital? “Inpatient” stays in hospitals cost so much more. A nifty cost-saving idea would be to reclassify 1,740 surgeries, now paid when done overnight in hospitals, into “outpatient” reimbursement. The Trump bureaucrat-wunderkinds in the waning days of his administration did just that. The change, which began with shoulder, spine, and other musculoskeletal surgeries, will include the gamut in 2023. Think of the bottom line of the Medicare budget.
The expressed goal of the Trump-wunderkinds was two-fold: give physicians greater latitude in choosing the setting — the buzzword was “competition” among settings; and at the same time encourage them to use cheaper settings.
On the matter of physician choice: there is no real competition for settings. The complexity of some of those surgeries warrants hospitalization. Indeed, the federal government considers some surgeries appropriate for hospitals, not outpatient ambulatory clinics. (Patients would agree: most would quake at the prospect of outpatient heart surgery.) Yet the reimbursement arm of Medicare will pay for surgery done in outpatient clinics. The bureaucrats in the reimbursement section acted independently of the medical panels. (The fine print of the change allows a physician to petition for a specific patient to have the surgery not just performed in a hospital, but reimbursed as a hospital procedure. But in the real world of saving lives, physicians do not need one additional insurer’s hoop.)
On the matter of saving money: the reclassification will do just that - but it will be Medicare money. The patient will go to a hospital if the surgery warrants, but the patient will pay far more, since the arcana of “outpatient” billing will leave the patient with extra charges for medications, for the “excess” facility fee, with higher co-pays. In addition, if a patient needs home care or nursing home care after the procedure, Medicare will not cover the cost. The requirement for Medicare coverage is three days as an inpatient in a hospital, not an outpatient stay, not a hospital stay for “observation” post-procedure.
In the autopsy of the Trump Years, we will focus on the egregious lies, the Jan. 6 revolt on the Capitol, the fomenting of racism, the flaunting of scientific wisdom about the “hoax” virus, the endorsement of Clorox as a cure, the “super spreader” presidential rallies. Happily, President Biden has embraced science, has urged harmony, has pushed vaccination, and has started to undo the malicious assault on the environment.
It will take far longer to undo the ravages of incompetence. Four years of inept cost-cutters wreaked havoc on our country’s health care bureaucracy.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.
From The Progressive Populist, May 1, 2021
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