As a health IT professional who did try, and will try again in 2013, this article is spot on.
There are differences between France and the US - especially in the mindset - but the payment system is very similar. In fact, the current french system (used for hospital billing since 2004, and tested for 10 years before that) was based on the US medicare DRG approach.
My job is to make patients pay as much as we can legally make them pay, using any mean necessary as long as it is legal.
In the past, my unit was the single most profitable in the whole hospital, by large. So I tried to sell things, and failed.
I would like to insist on the "incentives" topic with a quick example: I previously developed production analysis software to find and exploit the cases where an hospital could be more efficient and thus make more money (long story short, see one of my previous posts on http://news.ycombinator.com/item?id=4826314 for more details)
As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file.
I can calculate an expected return, so that on small cases you can use unqualified personnel, while it might be worth to have a doctor study every page of the patient file for high profile cases (since, if you don't have evidence to back your billing claim, you are legally liable - it's not unusual for a large hospital to be fined sums with 6 digits if during an audit mistakes are found)
I tried to sell the software, with a commercial partner. In a year, we could only find a single client in the whole french public hospital system!!
Want to know why? The improved productivity - short term financial gains - can be used to demonstrate that the civil servants in charge were not as efficient as they should have been, or that they should hold to that level of efficiency in the future.
That's just like the OR example in the article - they don't want to be more efficient because basically, making more money is a liability to the top management personal career.
I was quite disgusted by this twisted way of seeing things. Medical credentials did not help me. Efficiency was not welcome. Improving one's profile, even at the expense of whole hospitals profitability, was.
I did not explore that much, but there seemed to be a demand for a service to selectively reduce profits, to maximize government subsidies in some units - something utterly disgusting for a libertarian. I didn't think I could do that, so I stopped.
I will try again very soon, but now I will make sure to carefully study the incentives, and do something I can morally agree with.
> My job is to make patients pay as much as we can legally make them pay, using any mean necessary as long as it is legal.
> I did not explore that much, but there seemed to be a demand for a service to selectively reduce profits, to maximize government subsidies in some units - something utterly disgusting for a libertarian.
So your morality teaches that it's OK to scam patients, but not OK to scam the government?
If it is legal it is no scam. Making patients pay as much as legally possible is legal.
For ex, on preexisting conditions, the burden of proof is almost reversed. I'm simplifying, but more or less in an audit the opposite party has to prove the charge could not have been caused by the preexisting condition. It is almost impossible (good luck if you are trying to prove say that the chest x-ray had absolutely nothing to do with a physician making sure a cancer did not relapse - so I'll add that preexisting condition to the bill. it has a multiplier effect on the whole bill after a threshold)
This is also moral, according to my beliefs, since it helps improving reliability (here, giving a financial incentive to always check for relapses) and efficiency.
Reducing profits by accounting trickery is illegal. Reducing profits is also immoral in the belief system I have.
I very much disagree with this moral view. Just because something is legal doesn't make it moral.
See, when I'm being up-sold almost anywhere, in a store, eating place, etc., I can make good judgement on whether it makes sense to agree to a sale. However, when it comes to medical procedures, I can't make the same good judgment, because I lack the knowledge. So I trust the doctors to make good decisions, firstly medically, but secondly financially.
If I knew that they are adding many of these "reliability" checks, it would break the trust, and I would need to start making much more judgement on my own, this way probably making the matters even worse.
You would be shocked to know how some physicians would like to speed it up and quickly give you a diagnosis and have you out of the hospital, or just plain don't know stuff.
Like you, I do believe most people can not make a good judgement, because they lack the medical knowledge, so they expect a professional to make the decision for them.
Yet medical science is evolving - very quickly, with an ever reducing half-life for medical knowledge. Financial decision OTOH have a strong incentive (likewise for reliability checks)
I'm sorry if it would break your trust, but for someone who has been on the both sides of the hospital business, "Doctor Doom" scenarios are far more worrisome, and unfortunately not that rare.
There was a story on the NYT IIRC about a doctor his colleagues called "doctor doom and destruction" because his failings were so obvious. Yet he had a medical license and a great reputation, because of his excellent bedside skills.
There are some parts of the business I'm not comfortable with (diverting MDs from patient care to billing - that's a negative externality)
But this is something I now fully believe to be in the interest of both the patients and the hospital - ie something I would personally be very happy to pay for (or to have charged to me) if I was incapacitated and unable to take a decision by myself.
Here are additional takeaways from your statement: things that sell in healthcare include 'time savings' and 'empathy extension factor' in addition to financial factors.
> It is almost impossible (good luck if you are trying to prove say that the chest x-ray had absolutely nothing to do with a physician making sure a cancer did not relapse - so I'll add that preexisting condition to the bill. it has a multiplier effect on the whole bill after a threshold)
This is a somewhat emotional reply, but: as someone with a pre-existing, chronic condition -- this disgusts and terrifies me. I'll never get cover for it. I'm resigned to that, and am fine with dealing with it. I've put a lot of effort into establishing a reasonable savings account that can help to cover me; something's that not easy due to my dietary requirements and constant medical expenditure.
However, because the medication I'm on is an immunosuppressant, there's a very real chance that other illnesses -- bacterial infections, for instance -- can ultimately be said to be caused by my preexisting condition. I might be able to buffer myself against immediate medical malady, but invalidating all of my insurance due to that condition is gross.
"First do no harm" means to me having everyone perform efficient medicine - going by the book, not cutting corners or adding useless tests (they won't be billable)
I am very sorry if you feel that the system works against you, but IMHO the consequence of the financial incentives is your physician will make sure you have no actual infection if you are in the hospital for any other reason. he will also check for possible bad consequence of your immunosuppressant - something otherwise he might have forgotten, say for a wrist problem.
It's an incentive. It has bad sides and good sides. I believe there is more good than bad.
Regarding providing coverage, the French market is different from the US system. It will certainly be changed soon, so I don't think I can provide an interesting/useful comment.
The french system is interesting and had many strengths, but it need some serious tweaks. Putting a big chuck of the US system (medicare) was a great idea - 8 years ago. Now we have to keep evolving it.
> Reducing profits is also immoral in the belief system I have.
People who tie up profit with morals utterly baffle me. Whether it's "profit is evil" or "profit is morally good", it's all nonsensical. It's just fucking money. Are your actions helping people or hurting them?
Profit is a synonym for efficient. I couldn't care less about the money part.
Yet where there are no profits, efficiency is also generally lacking. (and don't mention free software, because the profits are just different - just not directly financial, but bankable - like reputation, experience, passion - people write free software for good selfish reason, "to scratch their own itch")
> If it is legal it is no scam. Making patients pay as much as legally possible is legal.
Really.
M.D. in U.S. here. Your profile page says you're an M.D., too.
Please reassure me that you are not a licensed physician and that you have no patient care responsibilities.
However, if you do see patients (or ever have), please comment on your medical licensing board's "belief system" on unethical (but legal) practices (even "business practices") as they pertain to the practice of medicine.
Maybe we're just having a little language breakdown here. Your parent comment sounds like you advocate for the use of "unqualified personnel" if it improves the profit margin. You comment below about "massaging the bill". Just above you seem to be winking and nudging your way to the idea that it's ok "legally" exposing your patients to the risks of certain tests like chest x-rays even if they're driven more by your own pocketbook or client's pocketbook (or your own paternalism) than by what's best for the patient, or perhaps what the patient chooses.
Unless there's some misunderstanding here, your actions are taking place in the wrong field. Medicine isn't a business.
Trying to turn it into a shady profit center is driving your actions toward grave difficulties with ethics, if not "legality".
No medical system charges the average patient as much--legally--as the U.S. system does. When it comes to ethics vs. legalities of patient payments, U.S. doctors have the shortest legs in the world to stand on.
The French system, for all the praise it gets in the U.S., is a fiscal mess. That system does need to find a way to charge their patients more, or it will eventually go bankrupt. Conversely, the U.S. system needs to find a way to charge its patients less.
Really, it's legal in France. We have a mixed public and private for-profit system. And studies have revealed a tendency to underbill - ie forget codes.
FYI, I am licensed, board member, and I do see patients.
However I strike a line between patient care and billing analysis. And I love both.
For patient care, my consults are provided for something like $30/consult. Keep in mind these are lengthy consults (~30/45 min per patient) in a demanding specialty. I do them far below costs, in a public hospital, to help - because I know how much the only alternatives in town costs.
For billing analysis, however that's another story. If it is legal (as in allowed by the law and the code of deontology) it goes.
But given your message, there might in fact be a language difference. I'll try to clarify my terms.
Regarding "unqualified personnel", I call anyone who is not a nurse or a practicing physican "unqualified". Ex: a medical coder or medical secretary. They do not see patients, so they are "unqualified". I see it as a good thing if they can do this work, considering the alternative is putting someone "qualified" (ie who could be with a patient providing actual medical care) on an administrative job, something that worries me as a waste of rare resources. If it actually improves the profit margin, that is great : it will provide excellent arguments against wasting rare resources! Anyway, that doesn't make a lot of differences. The laws might be different in the US than in France, but here physicians are legally personally responsible for anything the law call their "subordinates" do. Your nurse leaks medical info about a patient? Your fault by default, unless you can prove otherwise.
Regarding "massaging the bill", that's not the language I use, but it seems to be what the other poster was using. I guess that's how it's called in the US. If it has a negative connotation, I'm sorry. I personally call that billing analysis. There is no need to do anything shady - it would be stupid to do so, given how profitable just following the law can be.
Regarding "tests", it is not about exposing patients to the risks of certain tests - however, if the tests have already been performed and adding them to the bill results in a higher bill, it's about making sure they are not forgotten in the bill. Just like preexisting conditions.
The laws in the US might also be different, but here it's the prescribing physician responsibility to order tests and exams. Billing happens after the patient has left, and therefore can't directly influence the patient care ex post facto.
The medicare inspired system was adopted in France for a lot of reasons - including to help standardize care a little more.
I have had a patient I send to an hospital for chest pain in an ambulance with a case highly suggestive of infarction leave the hospital without troponin, even while he had a antecedents. I've had a patient I personally brought to the ER (we call that medical transfert) with a diagnosis of pulmonary embolism and a prescription for nuclear medicine returned after an echography and a written note saying 'there was no embolism' (how can you tell that with an echography???) - and subsequently dying of pulmonary embolism.
IMHO, this is totally unacceptable - I came to that conclusion, when as a patient I also experience such grave inefficiencies, with consequences. Some people will try to slither their way out of responsibility and consequences.
I take a great pride in bearing full consequences of my actions. I have seen patient wishes completely disregarded, something I decided to refuse - and therefore got more involved in the administrative side than the clinical side, even if I still do both.
There is a quality problem with some colleagues, one that only financial incentives or legal liability can solve. The US system is far from perfect, but it can give us some inspiration on these points.
I think there's a misunderstanding here. From what you said here:
> As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file.
I understand that you, or your system, adds items to patients' bills for tests that either have never been performed, or that have been performed unnecessarily.
Is that the case, or does your system check what probably was performed, and makes sure that it wasn't left out of the bill?
> I understand that you, or your system, adds items to patients' bills for tests that either have never been performed, or that have been performed unnecessarily.
The first one would be illegal. You can't bill for things that were not done.
The second one is a matter of interpretation : I do not judge whether it was necessary or not. If it was performed, I try to see how it logically could be argued, using the probability of finding matching evidence, that it was necessary given the case or preexisting conditions - and thus bill for it.
> Is that the case, or does your system check what probably was performed, and makes sure that it wasn't left out of the bill?
The third one, making sure things that were performed were not left out of the bill, is most of the work. The files are incomplete and it requires a probabilistic and interpretative approach, before sending in a human for fact checking.
It's all about providing incentives. The billing rules are complex, but there is some logic in them, and physicians see that too - it change their behaviour. #3 and #2 will directly result in other physicians becoming very careful that everything which should have been performed was - because doing this is highly lucrative, "it is as good as printing money". No need to do anything but following the law and the billing rules.
Truly useless tests won't increase the bill, and therefore they will be weeded out.
I see that as a financial incentive to change behaviours.
By making patients pay as much as legally possible you are effectively denying medical attention to all the ones who otherwise could pay for it; not to mention many diseases come back (as cancer) so the patient may eventually run out of money for their treatment; making you partly responsible for their pain and death.
Not to mention the country with the best health care system is also the one with the highest taxes; so by increasing the cost for the patient and consequently decreasing the amount of money that he can pay in taxes you are indirectly hurting the quality of overall health services.
You are also encouraging the market to produce more of the relevant test in the future, and encouraging more competition to go for those treatments because they can make it profitable at a lower cost.
The problem with your very static analysis is that you end up breaking both of those second-order effects, so while you may get to feel good in the short term, in the long term you are doing much more harm. You have to analyze this problem dynamically. It's the more subtle approach, but more fruitful long term.
(Of course hypothetical situations can be constructed in which this general principle does not hold... but nevertheless, it is the general principle and you will be producing exceptions.)
> and encouraging more competition to go for those treatments because they can make it profitable at a lower cost.
They can make it more profitable but only helps a smaller subset of people because is better to sell 1000 $10 needless than 10000 $1 needles (transportation, packaging, liability, etc); plus is a strong incentive to use any procedure that makes the patient believe that he is getting better even if he actually don't; because ultimately is the profit margin that matters. And that is not an exception; is the number one rule for business.
And data also goes against your view; the country I am talking is Denmark, the health system is 100% subsidized by the government itself; it haves a 95% health services satisfaction rate because all those events generated from the need to generate profits are non-existent.
"They can make it more profitable but only helps a smaller subset of people because is better to sell 1000 $10 needless than 10000 $1 needles (transportation, packaging, liability, etc);"
You implicitly make the error that the same person faces the choice of selling a few expensive needles or lots of cheap ones. In a free market, if one person tries the former, someone else can do the latter.
The medical market is not very free, unfortunately, and the proposed solutions to the resulting problems are always to make it even less free. The results are so boringly predictable it hardly seems sporting to talk about them. Shortages, inefficiencies, you name the usual consequence of centralized planning and meddling and our medical systems are full of them, but ever and always the solution is to increase centralization. Pity we must once again grind ourselves to dust on the alter of government control en masse again.
The data I see does not match your assertion. For all people bitch about the US, and for all our neutering of the free market advantages we are desperately trying to jam into our system to keep up with the Euro-Joneses, it still has better outcomes than Europe in many key areas. I'm sure that will change soon enough, though.
I am living the consequences of this in my country itself; they make you wait months for one date, even if they suspect cancer; you know why they make you wait so much time? Because they want to make sure you health insurance payments are the ones pre-paying for the specialist service (or at least a good part of it) before you stop paying or before you die. There is people with cancer standing long hours in queues just because some guys through it was really smart to overprice common medical resources and lobby in the congress for laws that help them abuse their clients (aka patients) and government subsidies.
"they make you wait months for one date" - that is unacceptable, just like overpricing is.
The medical market has far too much friction and rent seeking behaviour. I do not agree with the short version, but I agree with your long version.
I dream about the day when (if?) the medical market become a perfect market in the economical sense - price taking behaviour, pure and perfect competition, factors of production being paid at their marginal productivity
I believe that, among other things, the financial incentives are a step forward. We apparently have different ways, but a same goal.
"I would like to insist on the "incentives" topic with a quick example: I previously developed production analysis software to find and exploit the cases where an hospital could be more efficient and thus make more money (long story short, see one of my previous posts on http://news.ycombinator.com/item?id=4826314 for more details)
As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file."
There are entire companies devoted to nothing more than this - taking a ICD9/10 diagnosis, some procedure codes and massaging the bill to get the biggest possible bill (and vice versa, as an insurer, minimizing the same).
Yes, that's the easy part - massaging the bill, testing.
Providing an accurate estimation of the expected gains however require both domain knowledge and statistical analysis.
Ie if your hypothesis is to add "morbid obesity", and you know how much it will gain in the bill, how likely are you to find that in the patient file, given the patient history and (hopefully) some text from the release letter?
Enough to send an unqualified worker who does not understand medical speech?
(you won't get paid for ideas, but for actual results - and too many false positives cost money, because humans have to do the fact checking)
Do you believe it's worth putting a MD on the case? It will cost more in fixed costs, and thus reduce potential gains.
Can you automate that for one patient file consisting of multiple inputs? Can you still do that for 100'000 files? How long does it take for your software to produce its result? Can it still work when it is missing some critical information you believed in your early development would never be missing - like the release letter?
Textual analysis, datamining, Bayes, even sentiment mining (see http://news.ycombinator.com/item?id=4908056) etc - everything is fair game (ex: "the patient did not seem morbidly obese, but upon calculating BMI score, was")
Then you have to convert the lead to a sale. I'm talking about having money in the bank. This requires more than a nod and a signature for hospitals. I know firsthand - in the end, only one hospital paid.
Interest and traction are irrelevant. What matters is how much money you get in the end, and how satisfied the customer is to recommend you to others (it's a small world, especially in the health-IT field)
Very true - on a slightly different note, my company cleans up in the insurance / claims management side by implementing a system of policy management not based on table lookups but by allowing our providers to build rules and flows of their own. You wouldn't (well, perhaps you would) believe how many claims processors rely on database tables hundreds of columns wide to cover every permutation for a policy possible, and how (relatively) easy it is to convert those into boolean logic and simple rules along the lines of "IF AmountPaid > Deductible THEN" etc.
We achieve auto-adjudication of claim rates into the low-mid 90th percent, whereas most of our competitors are in the 60s to 80s (and some clients, inefficiently using those competitors, are as low as 30% auto-adjudication when they come to us).
But working on the insurance side of things increasingly tweaks my moral compass the wrong way...
Indeed, there are many things that can be done simply at first, then you have to reach for the higher hanging fruits.
However I would not call that "the wrong way" - for me, it's moral and logical. Maybe I'm too zen about that, but for me it's about increasing efficiency.
Generally speaking, if somethings feels wrong to you, you shouldn't do it. Works for every topic - because we each have our own morals, and it's soul damaging to go against it.
There are differences between France and the US - especially in the mindset - but the payment system is very similar. In fact, the current french system (used for hospital billing since 2004, and tested for 10 years before that) was based on the US medicare DRG approach.
My job is to make patients pay as much as we can legally make them pay, using any mean necessary as long as it is legal.
In the past, my unit was the single most profitable in the whole hospital, by large. So I tried to sell things, and failed.
I would like to insist on the "incentives" topic with a quick example: I previously developed production analysis software to find and exploit the cases where an hospital could be more efficient and thus make more money (long story short, see one of my previous posts on http://news.ycombinator.com/item?id=4826314 for more details)
As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file.
I can calculate an expected return, so that on small cases you can use unqualified personnel, while it might be worth to have a doctor study every page of the patient file for high profile cases (since, if you don't have evidence to back your billing claim, you are legally liable - it's not unusual for a large hospital to be fined sums with 6 digits if during an audit mistakes are found)
I tried to sell the software, with a commercial partner. In a year, we could only find a single client in the whole french public hospital system!!
Want to know why? The improved productivity - short term financial gains - can be used to demonstrate that the civil servants in charge were not as efficient as they should have been, or that they should hold to that level of efficiency in the future.
That's just like the OR example in the article - they don't want to be more efficient because basically, making more money is a liability to the top management personal career.
I was quite disgusted by this twisted way of seeing things. Medical credentials did not help me. Efficiency was not welcome. Improving one's profile, even at the expense of whole hospitals profitability, was.
I did not explore that much, but there seemed to be a demand for a service to selectively reduce profits, to maximize government subsidies in some units - something utterly disgusting for a libertarian. I didn't think I could do that, so I stopped.
I will try again very soon, but now I will make sure to carefully study the incentives, and do something I can morally agree with.