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View Diary: Medicare also going over the "cliff" (108 comments)

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  •  I was on a team that developed one of (6+ / 0-)

    the first Medicare systems. This system soon became the most widely used Medicare system, and within a few years was used by various Medicare administrators to process Medicare claims in more than forty states. That same  system served as the foundation for the most widely used Medicaid system as well.

    One of my Medicare responsibilities was to devise ways to detect possible fraudulent claims. We found plenty of them. It was amazing to me how quickly utilization jumped. There were several  data bases that were available that showed utilization data by diagnosis. These data bases were regional mostly but they were significant. CA, TX, OH, and MN had solid data. Utilization went up across the board. I worked with panels of physicians to help us understand the significance of these data, and after adjustments that satisfied the objections of the most vocal defenders of Medicare practitioners we were still left with the fact that utilization had increased more than could be explained.

    Furthermore, utilization in non-Medicare also began to track Medicare utilization. This was true for Blue plans, private insurers such as Equitable, and for self-insured groups.

    Later, I developed and sold administrative systems for the many companies that materialized when HMO's burst forth. Growth in utilization was even greater than it was in the early days of Medicare. As a result I developed a small profit center to consult with Individual Practice Associations, who were suddenly under water. IPA's would negotiate contracts with various groups of potential patients. The IPA would base its premiums on the utilization of its member providers. But when they started serving patients utilization went up fast. I helped them deal with severe cash flow problems, and some of the meetings with member physicians got quite nasty as the finger-pointing exploded. It was not unusual for the IPA Physicians to agree to 30% reductions in what they had originally billed. There are many complications that arose from this predicament, but this not the place for that discussion.

    Within the last month I bought a new book written by a physician in which he exposes over utilization and competency issues that currently exist in the medical profession. It is thorough and consistent with my decades of experience in helping payers to control their medical expenses. Unfortunately I am traveling right now and I can't remember the name of the book, but the author was interviewed on BookTV within the past month.

    So, even though I have had the good fortune to be treated by wonderful physicians whenever I needed help, and even though there are great inequities in pay for our physicians, it is my opinion that they have brought it on themselves. Over decades I have watched a mixture of outstanding medical practice and medical greed and selfishness which have the damaged the profession.

    All I can say is, "Physician, heal thyself." Your profession has always had it in its power to change things for the better, but you have not. It is not Medicare's fault, it is the fault of the medical profession. If you want to stop serving Medicare patients then do it, but you get no sympathy from me.

    Might and Right are always fighting, in our youth it seems exciting. Right is always nearly winning, Might can hardly keep from grinning. -- Clarence Day

    by hestal on Mon Dec 31, 2012 at 08:46:54 PM PST

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