Tag: bureaucracy

Fix The Broken Foundation Before Building A Skyscraper On Top Of It

My biggest beef with Health Care Reform right now is that we’re building a new tower on top of a broken foundation. Medicare and Medicaid are badly broken, and we’re building more programs on top of that. Bad idea.

Insurance company bureaucracy is even worse, but federal programs have to be significantly better in the future for there to be meaningful competition. Right now, the government health care system is still far too fail. Medicaid is deeply corrupt, admitting people to nursing homes because institution owners and their lobbyists line the pockets of state legislators; people are even stripped of home care just for turning 21, and forced into institutions. As far as Medicare goes, its fee schedule encourages procedures over responsible diagnosis and management, causing the death of primary care and creating a costly and disastrous situation for patients. An old man will have no problem finding a cardiologist to do an angioplasty, but may find it near-impossible to find a primary care specialist who can manage him with meds instead.  A crude example, but it speaks to how costs can explode when so few primary care docs are around and it’s mostly proceduralists who have survived the extinction. Most new doctors the past few decades have stayed away from family practice because Medicare’s the AMA‘s drastic undervaluing of the E&M (evaluation and management) reimbursement codes make it difficult to survive financially as primary care physicians. You get what you pay for, and Medicare (and the private insurance industry that follows Medicare’s lead) pays for procedures, procedures, procedures, NOT talking to patients and thinking about what’s best for us. According to Medicare, taking a detailed history from a patient is worth nothing more than something like the first 27 seconds of a proctoscopy; I rarely see doctors taking detailed histories anymore, outside of residents in university hospitals who are ordered to do so. Do plenty of docs have to do more and more procedures just to stay afloat and keep their doors open? YES!!

Aside from a fee schedule that has buried primary care and incentivized unnecessary procedures, Medicare has also become such an unwieldy bureaucracy that even the most basic functions are drowning in red tape.

Read this personal experience from primary care specialist Dr. Toni Brayer:

Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.

But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.

May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.

I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.

I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.

I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.

I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.

Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.

A loyal American,
Internal Medicine (aka: primary care) physician

Source: EverythingHealth: Fix Medicare

It seems like the government doesn’t want doctors participating in Medicare, and makes the reimbursements so low and the hassles so high (they can’t even manage a simple change of address without a half-year bureaucratic nightmare) that more and more providers just give up. Yes, this is yet another case of the government’s unfortunate cranial-rectal inversion.

Dr. IcedLatte lists more aspects of modern medicine that desperately need to change here.

The Tower of Babel
The Tower of Babel
I support a public option in the new health care reform package, but (unlike some conservatives) I realize we already have several widely-used public options, Medicare and Medicaid, that the government runs, and should fix as a core part of health reform. If a new government program just continues the failures of Medicare and Medicaid, that’s not reform. We have to include the CCA in the bill, include a wider adoption of the PROMETHEUS bundled payment system (PROMETHEUS stands for Provider payment Reforms, Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understandability, Sustainability) so that the government’s skewed, guaranteed-to-fail fee for service billing system doesn’t bankrupt Medicare. Don’t build a tower of babel that’s just going to fall. Listen to all the experts, doctors and patient advocates, and FIX MEDICARE AND MEDICAID. I agree (mostly) with this article by David Ignatius, focus on health system reform, not just “health insurance.” We have to fix the foundation or the new skyscraper is going to collapse.


Ninth “Nick’s Crusade” Video Blog: Too Many Setbacks To Count

The Ninth “Nick’s Crusade” Video Blog

Ninth “Nick’s Crusade” Video Blog: Too Many Setbacks To Count (June 15, 2009) from Alejandra Ospina on Vimeo.

Too Many Setbacks To Count

Videographer: Alejandra Ospina
Writer/Director/Editor: Nick Dupree

Music by The Eagles

Footage of The Count from this YouTube video

Finished video made with Corel VideoStudio by Nick Dupree

Full transcript of the video, with links and footnotes:

This is Nick Dupree for the Nick’s Crusade Blog. I’ve now been in the institution for over 8 months now. I came here because there’s a lot more services, a lot more programs here, and a lot more flexibility and opportunities for people with disabilities. But the problem is, we’ve found that even though there are more programs here, bureaucracy makes it hard to get to them. We’ve had so many setbacks that it would take The Count to count them.

“I am The Count. Do you know why they call me the Count? Because I love to count things.” [maniacal laughter] [The Count counts]

First of all, the hospital is not familiar with discharging ventilator patients, because if you’re on a ventilator, this place is a lot like the Hotel California – you check in and you never leave…

“Mirrors on the ceiling,
The pink champagne on ice
She said ‘we are all just prisoners here, of our own device’
In the master’s chambers,
They gathered for the feast
The stab it with their steely knives,
But they just can’t kill the beast

Last thing I remember, I was
Running for the door
I had to find the passage back
To the place I was before
‘relax,’ said the night man,
We are programmed to receive.
You can checkout any time you like,
But you can never leave!”
[guitar solo]

So, because they’re not familiar with the discharge process, it’s been hard for them here at the hospital to get together the paperwork so I can get nursing and go home and have home nursing to support me at home. So what’s happened is, they do it wrong, the Dept. of Health in Albany sends it back and says, no do it again, and then they send it again, and then they say, “no, something’s missing, you need to train the caregiver and document it again, you need to send the documents from the home visit…” so we’ve experienced setback after setback, and it’s costing the government over $1000 a day, but that doesn’t seem to motivate them to expedite this. Hey, it’s not their money, it’s yours!

When people with disabilities are not as able to advocate for themselves or be persistent, they end up stuck for years and years and years unnecessarily institutionalized and watching the world and the people around them enjoying life while they’re stuck in an nursing home. So we’ve had setback after setback, and this week, after we finally got all the paperwork figured out, the nursing agency flaked out on us, so now we have to get another nursing agency. And it’s setback after setback, enough setbacks that The Count would love to count them.

[maniacal laughter] [The Count counts] [maniacal laughter]

Obama’s Blunder: Hiring Too Many Cooks

I like Barack Obama; I voted for him because I wanted a fresh start beyond the stale 1960s debates, Olbermann vs. O’Reilly daily “hot button issue” and endless socialism vs. capitalism rock ‘em-sock ‘em robots that lead us nowhere and accomplish nothing.  We can’t afford that crap in times like these.  And I wanted a serious overhaul of the health care system (Obama’s opponent pledged not to touch the employer-based health insurance concept that’s been hurting us for so long).

I don’t consider most of the right-wing criticism of Obama to be very valid, but I do have my list of beefs with Obama, like the lame inaction over Darfur, ignoring the previous administration’s illegal acts, denying due process to prisoners, and more.  I’m also deeply skeptical of Obama’s Afghanistan plan (as I discussed here).

But something else disturbs me that is rarely mentioned: the problem of too many cooks.  Obama is adding a “czar” for every occasion, and new offices for many of the czars.  It’s making an already overly complex and large bureaucracy even moreso, and leaving the system even more byzantine for successor governments.



highly complex or intricate and occasionally devious; “the Byzantine tax structure”; “Byzantine methods for holding on to his chairmanship”; “convoluted legal language”; “convoluted reasoning”; “the plot was too involved”; “a knotty problem”; “got his way by labyrinthine maneuvering”; “Oh, what a tangled web we weave”- Sir Walter Scott; “tortuous legal procedures”; “tortuous negotiations lasting for months”

From: byzantine – dictionary.com.

Ridiculous bureaucracy, of which I am an (all too familiar) opponent, is dubbed “byzantine” because of what happened to the Byzantine Empire, with its enormous and complicated legal codes only understood by a cadre of royal bureaucrats.  When the law is only understood by the few, that breeds corruption.  When government is too huge and complex to be easily accessed by the public, it, paradoxically, reduces government’s functioning and power.  The Byzantine Empire, actually a great milestone in cultural and administrative achievement, collapsed when it became too weakened by its own complexity and corruption to resist invaders (though there’s a lot more to it).

I don’t want the U.S. government to be “byzantine.”  Clinton tried fixing some of this with his “Reinventing Government” initiative (he usually gets no cred for this). They really did reduce some government forms from 30+ pages to 1 page, disbanded Reagan’s personal furniture maker and bought from Office Depot instead, and “cut the fat” from a lot of departments. They didn’t make much headway on consolidating and downsizing agencies like they wanted to, because of fierce resistance from bureaucrats prepared to defend their jobs Thermopylae-style, and they were occupied by other things (subpoenas for the White House xmas card list, etc.)  I would like to see “Reinventing Government” on steroids…radically streamlining federal agencies and attacking waste.  I want Obama to use an iron fist to override administrators defending their sacred bureaucratic turf, and radically consolidate our insanely duplicative, bloated bureaucracy. Dept. of Treasury and Dept. of Commerce should be one agency, for example. The Dept. of Homeland Security (Bush’s massive expansion of government) should be abolished and whatever is actually useful within it would be consolidated into the FBI and other existing agencies.

But streamlining is not the direction Obama’s going in.  Instead, we’ve got the newly created Office of Health Reform headed by Health czar Nancy-Ann DeParle, Urban affairs czar Adolfo Carrion Jr., Economics czar Paul A. Volcker, Regulatory czar Cass R. Sunstein, Climate Change czar Carol Browner, Border czar Alan Bersin, and more.  And, of course, a government performance czar (Jeffrey Zients) to help manage all the czar (“czar of czars!”)

Aside from the fact that a parade of “czars” in the White House may make the vehemently anti-monarchist Founding Fathers rise from their graves in a rage, triggering the much anticipated zombie apocalypse, there are serious concerns that “czars” greatly reduce transparency and consolidate power in the White House.

Zombie Jefferson will be the first to go on a rampage, devouring the brains of the innocent
Zombie Jefferson will be the first to go on a rampage, devouring the brains of the innocent

Cabinet officers are subject to Senate confirmation and oversight; czars are not.  Czars are hired directly by the president (“serve at the pleasure of the president,” always an odd, dirty-sounding phrase) and can refuse to provide documents or public testimony based on “executive privilege.”  Senator Robert Byrd raised his objections in a letter to Obama.  Czars “inhibit openness and transparency, and reduce accountability,” Byrd said.  “The rapid and easy accumulation of power by White House staff can threaten the constitutional system of checks and balances.”

My biggest concern is what this monster turns into 10-20 years down the line.

Known for their intellect and experience, these appointees could become rivals or advocates of competing ideas that could hinder White House operations if not skillfully coordinated.

Administration officials will have to “watch and see when it starts to become dysfunctional,” said Stephen Hess, a Brookings Institution scholar who has held several top government jobs going back to 1959. “It’s a very high risk because you’re adding without subtracting.”

When naming Volcker to his team, Obama could have scrapped either Romer’s or Summers’ agency, and divided the advisory duties between two groups, Hess said. “Instead, he adds a third.”

Paul Light, a specialist on government organization at New York University, said, “They’re kind of addicted to czars right now. I think they’re more trouble than they’re worth.”

Obama obviously disagrees. He has signaled plans to name Bronx politician Adolfo Carrion Jr. to a new White House post coordinating urban housing and education policies. And he has named Nancy Killefer to the new job of “chief performance officer,” which oversees many agencies.

He is hardly the first president to have a close aide coordinating several agencies. For years, a White House-based national security adviser has tried to put together information from the military, State Department and intelligence agencies.

But Obama’s creation of new policy czars and special envoys is pushing White House centralization to new levels.

Some government veterans say the strategy can help a president shape policy with minimum interference from Cabinet agencies. Under the right circumstances, a White House czar “can cut through some of the interagency disagreements that slow down and clog the policymaking process,” said Bill Galston, a University of Maryland professor and former Clinton White House aide.

But the system can be cumbersome, rife with jealousies and hampered by conflicting efforts and messages, Galston said. To make it work, he said, Obama “will have to be a way-above-average president,” which he has the “intellect and temperament” to be.

Source: AP: Obama’s White House: Big posts, overlapping tasks

Obama likely has above-average skills.  But what about his successors?  What will America become?


Medical Personnel’s Hands So Tied By Liability Concerns They Hesitate To Save A Life

Months ago, a serious incident happened on Unit A13. Suddenly, I heard the operator blast over the loudspeaker “CODE BLUE A-APPLE-13!! CODE BLUE A-APPLE-13!!” Aides frantically checked all the patients, coming to me first (because I’m in the first room). They ran up and down the hall. Everyone was fine. “WHERE’S THE CODE??”

It wasn’t a patient coding, it was one of the staff. A phlebotomist (guy who draws blood for tests) collapsed near the elevator, evidently of a major heart attack.

He is a grimly depressed looking guy with dark cones under his eyes that give him a bat-like appearance, big ears and chubby jowls, and I have been stabbed by him numerous times. I think he’s Pakistani, but he and the other phlebotomists who’re part of my life here rarely talk (blood tests are srs bzn).

Phlebotomist dude
Phlebotomist dude

a quick sketch by me, approximating the guy’s appearance

This guy was in bad trouble, and they had to work hard to get his heart started again (heavy duty CPR). An ambulance raced to the scene. The paramedics helped with CPR, but then a problem; they didn’t want to transfer him to the gurney.

“He’s not a patient here, so we don’t know if we’re covered.” A heated argument ensued. In cases of cardiac arrest, there’s not a second to waste.

The aides jumped in and angrily did it themselves, putting him on the stretcher, then the paramedics rushed him to the emergency room. “He’s an employee! he’s one of us! it could be me on that floor” an aide told me when she relayed the story that night. They didn’t know if he would make it when he left.

Fortunately, he lived, and is now over 6 months later he’s back at work, silently and efficiently stabbing me and others, though he lost lots of weight.

But this incident exposes some very serious issues. Has the morality in our society sunk so low, that a remote risk of liability is worth more than a man’s life?

This man survived; how many haven’t because of this madness?? When medical personnel’s hands are so tied by liability concerns that they hesitate to saves lives, does that mean the medical system is too f’d up to function and is pretty much finished? Are we so weighed down by our tangle of draconian rules and regulations that we would, even for an instant, consider the liability of moving someone a greater risk than the liability of letting him die?

Is covering yourself now more important than humanity, morality, and even saving a life? I’m usually a calm person, but stuff like that makes me want to throw down!

I really don’t understand what the health care industry is becoming, but it seems to me the antithesis of the bold, pioneering American spirit. Refusing to transfer a code blue guy to a gurney due to liability concerns is cowardly and selfish, and at worst possibly “negligent homicide” if death results, or “criminal indifference,” and at best “reckless endangerment.”

Is the American medical culture in code blue? How do we resuscitate it?