Friday, November 8, 2013

Guest Post: A Doctor tells us how Obamacare saves money

As a Medical Oncologist and Hematologist I would like to share some issues to come with Obamacare control of the health system. Would you pass it on to your list.

As you know I was a young officer under ALee in 3/1. That experience taught me that standards can be met, excellence can be the normal, and hope means striving to always be better. ALee still gives me a hard time about going to med school but I think taking ALee's Philosophy into medicine improved medicine. 

In order to explain the difficulty in execution of Obamacare I'll use an example.

A patient presents with a breast mass, obtains a mammogram, undergoes a biopsy and is found to have adenocarcinoma. She is seen by and Oncologist and certain questions need to be addressed. First, Stage or extent of disease, there are 4 stages, classified under the TNM system With possible results. Stage=15 possible results, T=15, N=10, M=3, so 15x10x3 =450 possible Answers with 15 staging results from the TMN data. The patient could be male or female so, 450 x 2= 900. While an adenocarcinoma cell type under the microscope, there are about 40 pathological (histology) types so, 00x40=36,000 possible variable combinations. The grade or Aggressiveness of the cancer is 10 grades so, 10x36,000=360,000. Next, hormone sensitive E.g. ER/pr status = 8 possibles so, 360,000x8= 2,880,000 and menopausal status=2 so, 5,760,000 possible computer input combinations. Note, I ignored the male breast
menopausal Status as only 3% of cases are male. You follow the ER pr status on the men.

These are the possible combinations on just one page of data in staging. So the computer system has to evaluate these combinations. In practice we use stage, ER/PR status, age <50> Years, and pathology grade=3, so 15x8x2x3=720 combinations that we use. 

Ok, to get that answer we need x-rays, c-t's etc. I generally cat scan head to toe and look For metastasis and get a baseline. In the past, it was ok, not now. Over the last few years all the X-rays have to be approved so there are companies now that have algorithms to evaluate Your request, they process 1,000' of requests a day. So, if no headache no ct of brain, if a normal chest x-ray then no ct of chest, ok, I want to challenge the decision, we call them, I have to discuss this with the "medical director" who will say yes if I use certain key words or says No, "it does not fit the guidelines!", more on those later. 

I have no legal protection here, if I miss a lesion in the brain in someone who is symptomatic, I am liable, let along damage to patient. Also, the medical director does not have to be qualified. I had a young patient with Hodgkin's disease and I needed a follow-up CT of the chest, it was Refused, I challenged the decision(I challenge all of them) and called. The medical director was a retired GP playing golf, in Florida. The review companies intentionally have out of state physicians as medical director so, they do not have a state license that can be challenged.

Ok, the pathways, go to which has the recommended treatment paths for Patients with malignancy, there are over 30 subjects paths. You need to match a pathway With the data, that 720 combinations, we discussed. The insurance companies are already Restricting our treatment options by placing approvals on therapy. 

We are still on the first visit, or second visit it something was challenged. It now takes 45-60 Minutes to register as new patient, I get an hour for the history, exam discussion of plan And then load everything into the computer and fit out forms. Each visit we review all the data For accuracy, again report data, 

All this for one patient on the first visit. Less time but similar recheck and reporting on every other visit. If we make an error on a Medicare bill submission, the fine is $5,000 PER LINE in The submission. A typical chemotherapy visit may have 20 or more lines of code per visit. One year we used 250 cc bags of IV fluids for chemotherapy, it was more than enough fluid For treatment, but Medicare retroactively decided not to pay for 250 cc bags so, we had to repay Reimbursement for all the 250cc bags for an entire YEAR! We then changed to 1000 cc bag, Charged more, threw out most of it but got paid. 

So, you get surgery, some radiation, and chemotherapy and are in remission. All of those procedures will have to be reviewed and approved. 

Unfortunately, you relapse, and this is we're it gets interesting. Normally, we restage then treat again and can do this over multiple cycles of chemotherapy. In the past, I can keep you going for years. Enter the "death panels", I actually read the ACA law. They are not death panels Per say, but panels appointed by the President, NOT reporting to Congress, that establish the Funding and treatment for patients' oh, they are not physicians' . This is why the pediatric lung Transplant case is important. Ms. Sebilous refused to approve the transplant and the family had To go to a federal court. She followed the pathway, transplant was not approved at that age so The kid was out of luck. These panels can define care based on finances and treatment. Remember that these panels are intentionally set up NOT to report to congress, more Like a central committee in the Soviet System.

Back to NCCN guidelines. They are fantastic for guidance in treatment plans, but imagine writing a program for any of the guidelines and then constantly change it for changes in care. Check out the Palliative Care guidelines, there is a section explaining how to order an IV infusion To sedate a terminal patient, plan is not to wake up, and recommends that nurses who feel Uncomfortable ethically with this order should be assigned elsewhere. This is a concern because Hospice is recommended over and over in the guidelines more than ever before

This is the real cost savings in Obamacare, as money runs out, you change the parameters For treatment. Age, stage, and diagnosis care exclude aggressive therapy. Where before this Is a decision of a patient, minister and family your have an insurance company/ government IRS agent make an "impartial" decision of no further treatment. You can get it but we do not pay. 

In a progressive secular society, ethics are not base on God, but the common good of the state. That is why abortion, bill control, B-Plan pills are triggers as the left wants to impose By law, ethical positions that are against non-secular individuals. 

While we will still have 20-30 million without insurance, it will be a different group, and this Whole thing Obamacare is based on a set of repeated lies we have been told. This is not about Medical care but rather social and government control of the population. 

John D. Conroy, Jr. DO, FACP, FACOI
Hematologist/Medical Oncologist


  1. So, in my words: Unless you are 'filthy rich'....DIE, SUCKER, DIE!!!!

  2. It's a very helpful article, in fact when it comes to health; there is nothing more important than managing to eat healthy food and doing exercise regularly.