Abuses made possible by coding

Let me briefly connect some dots on the Wall Street Journal’s (WSJ) recent coverage of private Medicare Plans known as Medicare Advantage (MA) plans. The investigation of this 11/14 article concludes that the sickest patients eligible for Medicare are “fleeing” MA plans because of inadequate insurance coverage. At the same time, these private plans collect 20 percent more from the taxpayers for their patients because the MA plans claim they care for sicker patients. The MA plans use coding to assert that their patients are sicker. This 10/24 WSJ article offers compelling evidence that the MA plans manipulate the coding system (rather than care for sicker patients) to receive higher taxpayer payments.

To make matters worse, MA plans also pay less to doctors and hospitals for care than regular Medicare. They achieve this outcome by denying claims and paying providers lower payments. This lower payment level has caused providers to cancel contracts with MA plans because they are losing too much money on these contracts, as noted in this USA Today article.

In summary, taxpayers and Medicare are overpaying MA plans by billions of dollars, and patients and providers are being harmed by these plans. The coding system, which is ridiculously complicated and easily manipulated, makes all this abuse possible. These abuses will continue as long as healthcare utilizes coding to determine insurance and provider payments. Alternatives to coding exist for paying providers and insurers. Visit www.thejourneys-end.org to learn more about these options. Hopefully, the new Administration will be open to these innovative solutions.

Meaningfully Reforming Healthcare is Possible

September 16's Wall Street Journal Opinion Comment ("Blame Friction, Not Fraud, for the Cost of Healthcare") by Robert Charrow, the past general counsel for the U.S. Department of Health and Human Services (HHS) is revealing. Mr. Charrow states: ”Of our $4.6 trillion annual health bill, anywhere from 20% on up goes to costs, many of which have been dictated by Congress. Transaction costs include electronic health records, HIPAA code sets, anti-kickback and Stark compliance, preauthorization paperwork and unnecessary diagnostic tests designed to thwart malpractice suits.”

Few people seem to understand or appreciate the accuracy of this observation. After a lifetime in healthcare coping with these mostly ineffective regulations, hearing these observations from a senior member of HHS brings solace to my heart. These regulations and the dominant use of coding as the driver of all healthcare payments are powerful acknowledgments of why U.S. healthcare today is in shambles. Regulations and coding, in particular, are destroying healthcare and costing taxpayers trillions.

As Mr. Charrow highlights, Congress self-induces this cost and destruction. Alternative solutions to healthcare are possible. My book, The Journey’s End, offers practical and meaningful alternatives. Reforming healthcare is possible, but it requires cooperation from Congress.

Why you should consider a DNR order and how to make it stick

Kate Raphael’s New York Times article, What is a DNR Order and Should You Get One?, offers an excellent education for all of us. DNR stands for Do Not Resuscitate. This order needs to be initiated by the patient or the patient’s health proxy; it is essential knowledge for consumers. This patient order instructs workers in and outside a hospital not to restart your heart if it stops. So, the order prohibits CPR and associated resuscitation measures like electric shock to the heart, intubation, ventilation, and certain medications.

This prohibition is an unnatural act for health professionals and frankly for patients/families as

well. So why might someone want a DNR? This quote from the offers a wise response.

In many cases, if you are sick or frail, the harms of CPR “significantly outweigh the benefits,” said Mathew Pauley, a bioethicist at the Kaiser Permanente hospital system in California. Even if CPR revives you, which research shows is unlikely, chest compressions and shocks can cause debilitating injuries like broken bones, punctured lungs, and burns. Some who survive CPR have lasting cognitive impairments because of oxygen deprivation.

As the article states, "People with DNRs tend to be older adults with severe health conditions. In a 2011 study in Canada, some DNR patients wanted to avoid resuscitation because their quality of life was already low or because they feared resuscitation would lower it even more. Others wanted to minimize the emotional and financial burden on their families and the costs to society. Some DNR patients said they wanted to die naturally when their time came.”

Because DNR orders seem drastic, particularly to health professionals, they are often not followed for various reasons/excuses. So, making your DNR order a reality requires persistent communication. One way to communicate your preferences is to have your patient-directed order converted into a physician order. This conversion is called “physician orders for life-sustaining treatment” (POLST). Getting a physician to make this order is a

powerful form of communication and carries more weight with other health professionals. The POLST order is also more precise for health professionals to follow.

A few key points: CPR seldom works for frail elderly patients but is often used. The DNR and POLST orders can be changed at any time. These orders frequently avoid unnecessary suffering for patients and families.

More detailed information on this topic is covered in my book, The Journey’s End, and is available on my website.