Doctors Who Refuse Medicare or Medicaid Should Lose Licenses

There is a simple and fair solution to the increasingly common problem of doctors refusing to accept Medicare and Medicaid patients.

What point is there to giving seniors, the disabled and the insolvent Medicare and Medicaid if many doctors refuse to accept them as payment?

What kind of person refuses to accept Medicare and Medicaid? An anti-social person. A person who entered the medical profession driven by greed, not by the desire to help people. A person who does not even care about other doctors, whose own incomes are hurt when they have to take too high of a ratio of Medicare patients to make up for sociopath doctor behavior. In short, a criminal, but a white collar criminal who can do far more harm to people through negligence than an ordinary street criminal can do through theft.

Before going further, let me say that, on the whole, Medicare and Medicaid pay scales are fair. When a doctor or hospital says they are losing money when they accept Medicare or Medicaid, in truth they are saying they cannot ream these patients, and the taxpayers, the way the ream private insurance companies and the poor saps who come in without any bargaining power over the price of services. Medicare payments are enough to cover costs and provide an upper middle-class standard of living for doctors and fair wages to other health workers. If some payments for some services need to be raise a bit to be fair, I have no problem supporting that.

What happens when a doctor refuses Medicare patients? A senior will likely end up on a long waiting list, their health deteriorating while they wait. In some cases there may be no similarly qualified specialist in their area. Turning away a sick person because Medicare will pay for their treatment is a form of malpractice.

The solution is obvious. Any doctor who refuses Medicare/Medicaid patients should lose their license and pay a hefty fine. There should be a regular system to check for these abusers of our system.

In writing legislation to include good social behavior as a licensing requirement, there does need to be care taken to be fair. For instance, the Medicare load differs by location and specialty. It would not work to set a specific percentage of Medicare patients all doctor must see in order to keep their licenses. An individual doctor might reject a new patient because they are truly already fully booked, perhaps even mostly with Medicare patients.

The current Medicare bureaucracy should be sufficient to monitor physician compliance and take into account variations in locality and specialty. Some parts of America have a high percentage of seniors, others low percentages. That should not be hard to take into account with a formula that would flag potential bad eggs. Area doctors can be surveyed. If, of ten in the same specialty, nine complains that 70% to 90% of patients are on Medicare or Medicaid, while the tenth is near 0%, it should be clear what is going on.

Of course the first thing the bad doctors will do is stop saying why they are refusing patients. They might also try seeing patients, charging Medicare, but not actually treating patients, something that already happens all too much.

We all (or almost all) pay into Medicare throughout our working lives. To be denied care in our old age by a doctor is a crime. We should be able to call an authority to report such criminal behavior, and they should be happy to end up with only a suspended license, not behind bars with the other criminals, where they really belong.

It is difficult to get a slot in medical school, and so the number of doctors is limited. With a license to practice comes the responsibility to practice fairly, including taking a fair load of Medicare and Medicaid patients.

Republicans Celibate Labor Day Weekend

Good thing working people have the Republican Party looking out for them, as demonstrated by recent speeches and the Republican Party Platform.

Working people, defined as the people who don't have the initative to inherit wealth or the personality to risk what little they have on starting a small (let's be honest quantum-microscopic) business, need jobs to go to. They need bosses, and they need rich people to invest their money in setting up bosses in businesses.
The lack of jobs in America can be directly attributed to government regulations and the fact that rich people are not rich enough.

The Republican Party already controls the Supreme Court and House of Representatives. If you just vote for their candidates they can control the Senate and the Presidency, then no one can stop their job creation program.

First, they are going to lower the minimum wage, maybe even abolish it if they can get the support of moderate Republican politicians. Then retail chains and other minimum wage employers will be able to hire twice as many hamburger flippers and check-out clerks to serve you, without increasing their budgets. Or better still, since they already have an adequate number of workers, they can pay them a lot less and make a lot more profit. Which is good for working people because it will make rich people richer, which will create more jobs.

Then, they are going to deregulate the healthcare system. This is the main reason I am voting Republican this year. This will create a lot of jobs because you will not longer need to go to medical school to become a doctor, or to nursing school to become a nurse, or to junior college to become a licensed technician. I have my shingle ready to hang out the moment the law is changed. I am stocking up on herbal remedies and aspirin dyed to look like real drugs and hope to do a good business. I will cure the sick for much less than one of those government-licensed doctors. And who needs the Food and Drug Administration when we've got Free Markets to deliver quality food and drugs?

Which is a good thing for the elderly people near my future office in Point Arena, California, because the Republicans are going to Save Medicare. They are going to do this by privatizing it. So seniors will get vouchers to buy medical insurance. I have already told my Republican friends who own medical insurance companies how much money I can save them with their future Republican Care policy holders. They are keen on Hope and Real Change, in particular deregulation allowing me to kickback some of my income stream to them. Which will make the rich richer, which will create more jobs.

The Bush Tax cuts to the Rich will stay in place. Workers of the world, cheer! This will make the rich richer, which will create jobs. It will also mean less government safety net types of stuff, which will encourage you to take three of four new jobs to make ends meet.

Paul Ryan is a particular favorite of mine. He has a lot of experience in private industry: he mowed lawns for neighbors when he was a teenager. After that he went into government and stayed there for decades, reading Ayn Rand novels and fighting to get high profit margins for military contractors so they could create jobs for you and me.

The list of Republican reforms that will help working people is much longer, dear blog readers, but I know you don't want me to get into wonky details. But there is one more important reform we can look forward to with eager anticipation.

No Inheritance Tax! This is even cooler than eliminating the Capital Gains Tax (don't ask me, its a rich people thing). No matter how much you save up from your mowing lawns and other unregulated, non-minimum wage jobs, your children can inherit it all. More important, children of the rich can inherit every honest untaxed penny their parents have earned. Then they will be able to create more jobs for the rest of us.

What a wonderful place America will be,
Filled with Love and Liberty,
Vote for Paul Ryan and Romney too,
Vote for Jobs, red white and blue.

Healthcare Where Everyone is Above Average

In this essay, above average is bad. Out of range is bad. It is there on black and white, on a piece of paper: you need drugs. And more frequent doctor visits. And frequent diagnostics, mostly involving sucking your blood out, to make sure there are no side effects to the pharmaceuticals and to monitor just exactly where you are in the range.

It is a scam worthy of such greats as Ponzi, Madoff, and Joseph Kennedy. Going to a doctor in the U.S. is like walking into a casino: the odds are against you, the house always wins. When every last penny has been drained from your pocket, they toss you out, to go an earn some more money or to die impoverished in the streets.

Look at the nature of averages. Or more precisely, in this case, what the statistics boys call "median." Half of the population will be above the median, and half below it. The median is defined that way.

Now take some blood tests. Typically blood pressure, triglycerides, glucose, white blood cell count, and a couple of different kinds of cholesterol.

What are the chances, per the statistics boys, that you will have nothing above average, and therefore need no medication (if the average or below is the standard of health)?

Keep in mind this is not about sickness in the ordinary sense of people who feel sick or have obvious symptoms. This is a test that includes healthy people.

Each test is independent, so to get the answer, you just keep multiplying by 1/2. The order does not matter, but let's say it goes like this:

You have a 50% chance of having high blood pressure. 1 times 1/2 is 0.50.

You have a 50% chance of having high triglycerides. 0.50 times 1/2 is 0.25.

You have a 50% chance of having high glucose. 0.25 times 1/2 is 0.125.

And so forth: white blood cells, 0.0625. Cholesterol 1, 0.03125. Cholesterol 2, 0.015625. That is about 1.6%.

In other words, of 1000 people getting this set of tests from a doctor, only 15, maybe 16 will be fully healthy. Everyone else will need some help from the pharmaceutical industry to get "at the lower end of the risk factors."

Just to be sure to pick your pocket, they don't test you against your age class. Most people see a gradual increase in blood pressure as they age. The doctors don't say to you, "for a 60 year-old male, you are below average! See me again in five years." No, you get compared to the healthy 30 year olds. If you are 60 or older, the chances that you have average or better blood pressure are thin. In fact, there may be something wrong with you, like a weak heart.

The human body has been evolving for some 3 billion years. Modern medical science has been around for about a century. Who are you going to trust, Mother Nature or some gal or guy who went to medical school dreaming of making big money?

We don't need everyone to be below average for all health risks. We need to look at what is normal, and only treat conditions that are at least two standard deviations outside of normal. Which means only the roughly 2% of people who get extremely high results, and 2% of people who get extremely low results. May 4% at each end, just to be safe. [This would not apply to actual diseases like diabetes. Everyone with diabetes should get treatment. Almost everyone in the U.S. needs to eat less and exercise more.]

There is likely a good reason that blood pressure increases as we get older. Lowering the blood pressure to a pre-defined standard probably just insures that blood is not getting to where it is needed in our bodies. [This is my hunch, and if someone will grant me a few tens of millions of dollars, I would be happy to hire professionals to test it.] Someday some enterprising scientist will find that "normal" blood pressure causes senior dementia, or some other result worse than the slight increased risk of dying of a heart attack before your kidneys or liver or brain fails.

They never give you unbiased statistics. When have you ever seen a chart of how many people have heart attacks and strokes who don't have high blood pressure? In fact lowering blood pressure, unless you have really, really high blood pressure, is not likely to change your cause of death.

Scientists — real scientists, not the ones funded by industry — will tell you that even when you are trying to do totally honest, accurate science, there is a danger called selection bias. This amounts to rejected data that would prove your bet hypothesis is wrong.

Selection bias can happen even in an academic context. The reason is that certain results, interesting results, are publishable, but the negative results are not. Scientists like to publish. Their careers usually depend on it.
The pharmaceutical companies themselves have found that out when buying potential drugs that academic scientists claimed would be cures. One study by a major pharmaceutical company found that, for almost all of the drug candidates in a batch they bought, they could not replicate the "good" results.

I believe that doctors can help some people some of the time, and in good medical science. But you can't always believe the medical consensus.

Recently a panel of medical experts recommended against a test that has always been supposed to be indicative of prostate cancer, PSA. The knew that PSA results only correlate loosely with prostate cancer. Yet doctors turned high PSA results into a lucrative business of "cures." Looking at a broad range of statistics, the panel found that the negative results from all that expensive "curing," including death during surgery, more than washed away the occasional live saved. Cancer sounds scary, but most prostate cancers evolve slowly. Most men with prostate cancer die of something else, something unrelated. So the panel suggested stopping PSA tests unless there was a good, obvious reason for them. [New Data on Harms of Prostate Cancer Screening, New York Times, May 21, 2012]

Oh, the howls of the financially wounded. The oncologists and urologists, the main beneficiaries of the PSA scam, attacked the panel with vigor. They only care about Science when it is in their financial favor.
The average person is not in a position to argue knowledgeably with their physician about whether they really need a blood pressure or cholesterol pill. Half the American population does not believe in evolution. They don't believe the human body has evolved to optimize its own health and longevity. Sadly, the other half tends to believe in anything presented as science uncritically. In theory they know there is good science and bad science, but in reality they have to rely on their doctors.

We need to rethink medicine from the ground up. We need to ask ourselves how it fits into our other values. Do we let children live in poverty, or underfund our public schools or other important public while paying vast sums for cancer therapies for the over-80 set that, at best, extend miserable lives for a few weeks?
We have evolved a culture that has made us a nation of pill-popping hypochondriacs. Part of this is because costs are masked: for most people, someone else is paying the bill.

I am not against wonder drugs. I am not against necessary surgeries, or preventative medicine that really prevents disease. I want a science-based health system that takes into account economic realities. That is what we need, not what we have.

Predators, Doctors and Wage Slavery

Society is probably too strong of a term for living among fellow human beings in these mostly United States.

I was thinking about writing a science fiction novel in which (on another planet, in a different time) doctors are predators, a sort of subspecies of the regular denizens of my imaginary civilization. Where could I get such an outrageous idea? Well, there is the opening section of B. Traven's The Rebellion of the Hanged, in which Marcelina, a Mexican peasant, falls deathly sick. Her husband Candido takes her to town to see the doctor. Candido's life savings consist of 18 pesos, but the doctor wants 200 pesos to operate. The town's leading citizen offers to loan money to pay for the operation, with the Candido to work off the loan at a timber camp, cutting old-growth mahogany. Candido accepts the loan, the Doctor operates, Marcelina dies anyway, and Candido becomes an enslaved timber worker. Thus setting the novel in motion. It is a great novel, which is why you probably never heard of it before.

Yes, I recently had a walletectomy performed. Walletectomies are the most common medical operation in the United States, and most are 100% successful. Fortunately for me they only did local anesthesia. I jumped out in the middle of the operation, so I have half a wallet left. I am hoping the rest of the wallet will grow back eventually, or that half will keep me going until I die of some other cause.

According to the American Bankruptcy Institute, 1,362,847 people filed for bankruptcy in the United States of America in 2011. According to Medical Bankruptcy in the United States, 2007, published in The American Journal of Medicine, in 2007 "using a conservative definition," 62.1% of all bankruptcies were medical. Do the math and you have about 850,000 people who went bankrupt due to medical bills or health issues in 2011. And probably more this year. It adds up.

Note too, that the habitually poor don't go bankrupt, and have their medical bills paid by Medicaid. The rich go bankrupt on occasion, but usually from bad investment decisions or cocaine habits. Bankruptcy from medical bills is a working and middle class phenomena. It typically involves losing home ownership. After you are totally impoverished, you too can qualify for Medicaid, food stamps, and Section 8 housing (warning: there is a very long waiting list for section 8 housing).

Some say maybe people should buy better insurance, then they could survive an expensive illness. The problem with that theory is that most people don't make enough money to buy the best insurance policies. Given the level of prices and wages now existing in the U.S., most people would have to live in a tent and eat grass so that all their wages could go to medical insurance. So we take our chances with less than wonderful policies.

The problem is not entirely caused by a predatory medical profession. The bigger problem is low wages. While low wages is also a complex problem, it mainly comes from decisions made internally within corporations. The people who divide up the pie take the biggest pieces, leaving crumbs for the workers. Also, some sectors of the economy are just less profitable than others, and yet someone has to do that work.

Workers today are too busy fighting each other for crumbs to organize themselves to fight for a fair share of the pie.

Modern science has provided some nearly-miraculous healthcare technology, including a few wonder drugs and amazing surgical techniques. It has also created a bunch of drugs that have little benefit to patients and yet cost tens of thousands of dollars a year to take.

Society has to be built on trust. We can't each of us be jacks-of-all-trades. We must each have our place. We also can't all be millionaires. But it seems like everyone who enters medical school thinks they are getting a ticket to be a millionaire, if they can just stick out the hazing. Because that is the way the American Medical Association set up the system over a century ago, by limiting the number of doctors allowed to graduate from American medical schools each year.

If I ran things one of the first things I would do is open a bunch of competing medical schools, maybe doubling the number of seats there are now. Then I would choose students not strictly by their grades, or ability to pay tuition, but largely by their desire to alleviate the suffering of the sick. I would guarantee them a decent, above-average salary once they were trained. And I would nationalize the health insurance industry.

Then we could trust doctors to do what is good for us, instead of what is good for their own wallets.

But that would be socialism.

Ruinous Competition: Doctors and Healthcare

According the free-market theorists, the best of all possible economic worlds is one in which there is no government regulation. First developed coherently in Adam Smith's Wealth of Nations, this theory was based on practical observations of a society, England, that had been high regulated by a monarchical government working with feudal institutions that tried to determine most people's occupation by their status at birth.

Business men and trade-guilds that had done quite well for themselves in the past found it hard to make a profit, or even a living, once anyone could compete with them. In a free market, if a profit can be made in a certain occupation, new people will enter that occupation until competition for customers results in profit levels becoming unattractive. We call that ruinous competition.

Certain industries require quite a bit of capital to enter, so even back at the dawn of this new era, around the time of the American Revolution, profits could be made in those industries without the help of government restrictions on entering the business. Just as a beggar cannot enter the farming business without the price of at least a down-payment on a piece of land, so a laborer or small merchant would not have the capital to set up an iron-mill or buy a coal mine. So even under the growing free market system, larger enterprises had some shelter from ruinous competition.

The United States of America began as a sort of natural free-market area, and people generally benefited from that (neglecting here the use of slave labor and violent capture of Native American Indian real estate) for some time.

In the course of the 1800's, however, mainly at the level of individual states, those who did not want to be exposed to ruinous competition developed a strategy. Aside from the practice of the law, which was always limited by the government, it was argued that professions having a direct impact on the health and safety of the public needed to be vetted by the government. For instance, it was argued that not anyone could simply declare themselves to be a medical doctor. And again, there was some truth to it, although in the 1800's it appears that trained medical doctors were so ignorant of basic biology that many were just as dangerous to the public as the so called fake doctors, or charlatan (originally, sellers of Roman Catholic indulgences, but a term that came to be applied to untrained healers).

Allowing only doctors licensed under the authority of the government, and making sure there was always a shortage of such licensed doctors, would allow the group to charge more than the free market value of their medical services. In short, to overcharge the sick. This was the purpose of the American Medical Association, formed in 1847. The AMA did some good things, which don't concern us here. What they did on the economic front was require that medical practitioners be licensed (and they set up boards of their own members to decide who would qualify for a license) and they also licensed medical schools. In licensing such schools they carefully studied the demand for doctors and made sure that not enough doctors were graduated to meet the demand.

Now of course practically every profession, from cutters of hair to real estate agents to accountants and carpenters, requires a license. Some professions have not been as successful at keeping their numbers small and profits high as the doctors have done, but the general idea is there. Barriers to entry, no free market, no ruinous competition. Those who work without license are sucked dry by the fees of those who are licensed to work.

Those doctors who scream for free markets and against "socialist" government health care plans should take a good look at themselves and their ill-got millions. Because of the government preventing the operation of free markets in doctoring, in the 1950's and 1960's the term millionaire-doctor was synonymous with doctor.

If doctors don't want socialized medicine, we should open up doctoring to anyone who feels they can heal. Pharmacists should be able to make diagnoses and sell basic drugs without a doctor's prescription. For that matter doctors should be able to sell drugs in their offices, rather than having to write a prescription. People should be able to self-diagnose, if they wish to take that risk, and get any legal drug without a prescription.

If someone puts out a shingle and causes harm, they could be sued for malpractice. If they claim to have graduated from a medical school, but did not, they could be charged with fraud. If the government wants to certify people, or the AMA wants to identify their members, that is fine, but there should be no rule that you have to go to the AMA men or government men.

What do you say, Republicans and Tea-Party people? Are you really ready to give free markets a chance? I'm certainly ready to hang out a shingle, if the Republican run government is willing to let me. I'll start a medical insurance company too, a coop that benefits the members. That should put some pressure on Anthem et. al.

Note: many doctors have come out for Universal Health Care. For instance see Physicians for a National Health Care Program.