Health care - administrative incompetence

[xjx388]

But - and apologies if I appear to be jumping down your throat on this - that's all it is.

I don't take anything personally, so no worries there. And you are right, it's only my opinion.

If we look (and I just have) at French guidance on sore throats, it's broadly the same as the UK. Does that mean it's a conspiracy by the two UHC systems to cost save or, as I would suggest, does it suggest that perhaps the US is over-treating the complaint?

It could suggest either. I think it's just as reasonable to conclude that the US over treats and is wasteful as it it to conclude that National Healthcare Systems under treat in order to save money. Reasonable people will differ on their interpretations of things like this.

I think you've misread the article. It talks about low priority work, for example, being put to the bottom of the pile.

Well, what's considered low priority work? That sounds too much like basic medical care being compromised to save money to me.

Logical fallacy, I'm afraid. Your system produces broadly similar clinical outcomes for something approaching double the cost in the UK. Unless you're arguing that health in the US is significantly worse that the UK, then there must be something eating up the money. What is it, if not waste?

Well, it could be that the demographics in the US are vastly different than in the UK. There are more Hispanics and Native Americans here, for example and they have much higher rates of Diabetes than other ethnicities. I think, if we are going to go down this road, we have to define terms like "outcomes" and "waste."

Same point again. The US system costs more than the government programmes in place in the UK, Canada, and mainland Europe. I would suggest that your problemis not the government but rather private sector involvement and in particular the drive for profit.

Why is the drive for profit so bad in healthcare? It works in other fields that are even more important to human survival than healthcare. Food, for example. Nobody is complaining that the local grocer is making a profit from selling food, a vital and necessary thing for human life. I say that no one complains because the "for profit" model ensures that grocers charge a fair value for their goods. If they don't people will go elsewhere and the grocer will be out of business. Why couldn't the same work in healthcare?

 

[Rolfe]

You wouldn't care to actually read this, would you?

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

Rolfe.

 

[Emet]

You wouldn't care to actually read this, would you?

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

Rolfe.

It's really worth reading. Really.

 

[Tatyana]

But is there any clinical advantage to using one or the other? I'm not a biochemist, I just run my wife's family practice clinic (or surgery to use an archaic British term ). I don't see any evidence, however, that the British units of measurement are somehow more accurate or, better yet, make diagnosis any better. It's just a different way of doing it and both work equally well. I can understand how it would be a hassle for British doctors to convert units and such, but we Americans aren't in the habit of changing our ways to suit the conventions of other countries. My god, we still use the archaic inches/feet system! So if you are saying we are archaic because we use old units, well you have a very good point! But "old measurement units" does not necessarily translate to "outdated Laboratory Science."

When the US uses different units than the rest of the world, and we have doctors that work in both countries and patients that are also in both countries, differences in units can lead to accidents.

Most medics pay no attention to the units, it is the number they are used to.

This is especially critical when dealing with drugs and drug overdoses. This has been an issue with paracetamol/acetaminophen in particular (which is the most common drug people overdose on), that I think has resulted in the death of a few patients.

The US is also not consistent, so for example, they use mmol/L for things like sodium and potassium, but mg or ng/dl for everything else.

It isn't consistent with modern scientific practice.

I will see if I can find a set of results somewhere, I am fairly positive I have saved a few US case studies.

As I mentioned before, it is things like still relying on total hormone levels with a binding globulin to get an index.

Take testosterone for example, historically, it has been notoriously difficult to measure (this has improved within the last year in the UK).

Testosterone is mostly bound to sex hormone binding globulin (SHBG), so this would be measured to created a free testosterone level (which is not measured directly at all).

Two somewhat dodgy and error ridden analytes combined only compound the error. As well, it is totally unnecessary clinically, with the rare exception of odd genetic disorders of SHBG, for 99.9% of the population, if your total testosterone is high, your free T is high, if your total testosterone is low, your free T is also low.

This logical application of laboratory medicine to the clinical practice is typically not done in the US, the sentiment is that more information is better, even if the information is error ridden and, really, clinically unnecessary in 99.9% of cases.

This is just one hormone, but it is also hit and miss to even a worse extent for thyroid function tests where I had to dig out textbooks from the 1970s to even figure out what the hell a reverse T3 is.

I am also not entirely sure how well established the external QC system is for the US, and the phenomenal number of consumer direct on-line laboratories with bizarre and often useless 'panels' for screening for everything from cancer to autism.

 

[Architect]

It could suggest either. I think it's just as reasonable to conclude that the US over treats and is wasteful as it it to conclude that National Healthcare Systems under treat in order to save money. Reasonable people will differ on their interpretations of things like this.

I've just browsed guidance material from the Australian healthcare system, which is a UHC type. Their practitioner advice takes a similar (dashed near identical) view to that given by the UK NHS authorities quoted earlier and the French system (at least inasmuch as I can translate the material).

One would have to examine the minutae of reporting data in order to see whether this difference in treatment between the UK/France/Australia and the US led to more adverse outcomes. I don't have the medical knowledge to do so, nor do I have access to that level of data (if it's available).

Well, what's considered low priority work? That sounds too much like basic medical care being compromised to save money to me.

Can you provide us with more accurate data than news reports, because I'm having trouble finding anything online.

Well, it could be that the demographics in the US are vastly different than in the UK. There are more Hispanics and Native Americans here, for example and they have much higher rates of Diabetes than other ethnicities. I think, if we are going to go down this road, we have to define terms like "outcomes" and "waste."

Let's break that down.

Firstly we need to consider whether there are, statistically, underlying health issues that would contribute to the massivley higher expenditure in the US - and remember that we're talking double the cost here, not 10-20%. If you have data on this - and I assume the reference to Hispanic people comes from somewhere - then I'd very much like to see it. You in turn might wish to look at heart disease rates in the Celtic countries, especially Scotland.

Secondly, we need to look at how we measure clinical performance. Infant mortality and life expectancy are often used as key indicators, but are a clumsy tool. Cancer diagnosis and recovery rates are perhaps more helpful, but there are difficult differences in reporting regimes.

What we know from other threads, however, is that Europe and Canada tend to come out on a par with, and in many areas ahead of, the US. BaC here, for example, has been desparate to prove that us Europeans drop dead earlier but is having great difficulty proving it - he's debunked himself several times IIRC.

Why is the drive for profit so bad in healthcare? It works in other fields that are even more important to human survival than healthcare. Food, for example. Nobody is complaining that the local grocer is making a profit from selling food, a vital and necessary thing for human life. I say that no one complains because the "for profit" model ensures that grocers charge a fair value for their goods. If they don't people will go elsewhere and the grocer will be out of business. Why couldn't the same work in healthcare?

Your problem here is that countries such as the UK deliver a perfectly adequate system, at least on a par with yours, without the profit motive and at generally much lower cost. Remember, we're talking about 50% here. This could, of course, be due to massive maladministration on the part of the US healthcare bodies. In reality it could be both. Either way, it's not serving the US people very well.

 

[blutoski]

Like I said, it's merely my opinion. I could be wrong. But it's possible that the NHS guidelines were drafted in order to save money. I think it's at least a valid question.

Yes, saving money: as in "delivering healthcare with the least waste."
ie: Saving money.

Well, the newspaper article I quoted above illustrates the fact that money is a big factor in cutbacks that various NHS Trusts are implementing.

No doubt. Seeking efficiencies.

Oh for sure! I'm not saying our system isn't wasteful, I'm saying it's not necessarily more wasteful than other systems.

It's obviously more wasteful.

Twice the cost with worse outcomes = less than half as efficient.

This is grade five math.

More spending does not necessarily mean more waste than other countries. My larger point is that there is no perfect system. My opinion, based on nothing more than my own experience, is that the least wasteful system would be the one where patients are more financially responsible for their own medical care. Eliminate the government programs; eliminate the insurance companies. Then, doctors can charge reasonable amounts and competition will keep costs in check.

Yet, this obviously isn't working. When theory does not jibe with the facts, it's time to adjust the theory (*).

Just as a useful datapoint: there are millions of Americans not covered by government programs (too much income) but not covered by HMOs (no employer plan) and they don't have insurance (too little income, or denied for pre-existing conditions). They're in the cash market and are solidly the worst off.

Health is just about the only industry where a legal salespitch is "Your money or your life." There is very limited patient capacity to refuse bad offers, wait for a sale, or substitute with a similar product. In marketing terms: there's weak elasticity. ie: a permanent seller's market.

Businesses are not here to 'charge reasonable amounts' - they are here to extract as much money from the customer as possible. That's not a cynical view: that's my observation as somebody who has been in business for over 20 years and set prices for hundreds of products in various markets.

Heavy price discrimination^WP (yield management) is precisely what we're seeing with the HMOs because of this seller's market context. My example above where the HMO invoiced $350K for my friend's care... Everybody here who's experienced with this is confident they'll negotiate down to 'ability to pay'. They'll say, "Well, how much can you pay? We'll settle for that. We'll adjust the bill to take only all your money, instead of all your money plus debt. That's how generous we are."


(*) My friend used to describe "The French Problem" as "Certainment, eet obviouslee works een practice, but we do not do eet here, because eet does not wheerk in theyoree. You see?"

 

[Uncayimmy]

All we need is someone to post some of their blood results.

I may be able to find some that I have seen on line before.

I think I know what you're asking. I have my latest blood work in front of me, but I have no easy way to scan it (not that I want everyone seeing my numbers). I hope this is what you're asking about. It's the test followed by the units for a metabolic panel, lipid panel, and thyroid cascade profile.

Metabolic Panel
Glucose, Serum - mg/dL
BUN - mg/dL
Creatinine, Serum - mg/dL
eGFR - mL/min/1.73
eGFR AfricanAmerican - mL/min/1.73 (I'm Caucasian)
BUN/Creatinine Ratio - (just a number with a reference range of 8 to 27)
Sodium, Serum - mmol/L
Potassium, Serum - mmol/L
Chloride, Serum - mmol/L
Carbon Dioxide, Total - mmol/L
Calcium, Serum - mg/dL
Protein, Total, Serum - g/dL
Albumin, Serum - g/dL
Globulin, Total - g/dL
A/G Ratio - (just a number with a reference range of 1.1 to 2.5)
Bilirubin, Total - mg/dL
Alkaline, Phosphatase, S - IU/L
AST (SGOT) - IU/L
ALT (SGPT) IU/L

Lipid Panel
Cholesterol - mg/dL
Triglycerides - mg/dL
HDL Cholesterol - mg/dL
VLDL Cholesterol Cal - mg/DL
LDL Cholesterol - mg/dL

Thyroid Cascade Profile
TSH - uIU/mL

 

[blutoski]

What we know from other threads, however, is that Europe and Canada tend to come out on a par with, and in many areas ahead of, the US. BaC here, for example, has been desparate to prove that us Europeans drop dead earlier but is having great difficulty proving it - he's debunked himself several times IIRC.

This is one reason comparisons with Canada are close to being a 'control' - we share a lot of their culture in terms of leisure activities, food choices, &c, and we have a similar demographic - a mix of white, asians, blacks, and first nations.

When the US and Canada had identical private systems, the US outlived us by almost a year on average. Now, we outlive them 3 years on average. The US and Canadian demographic shift in such a way as to explain this growing gap. The significant difference I can identify is that Canadians took control of our healthcare and Americans relinquished control to a handful of corporations and prayed for the best.

 

[Ivor the Engineer]

<snip>

Why is the drive for profit so bad in healthcare?

<snip>

Because I have far more information and knowledge that I need to select food products than I do to choose medical care.

Do you select which apples to buy in a supermarket? Do you feel confident you can determine which are the good apples from the bad? What's the cost to you if you make a mistake?

Do you debate the diagnosis and recommended treatment with your doctor? If you're feeling like crap and a doctor says you need X, Y and Z to make you feel better do you ask for a second opinion? What's the cost to you if you make a mistake?

 

[Professor Yaffle]

Because I have far more information and knowledge that I need to select food products than I do to choose medical care.

Do you select which apples to buy in a supermarket? Do you feel confident you can determine which are the good apples from the bad? What's the cost to you if you make a mistake?

Do you debate the diagnosis and recommended treatment with your doctor? If you're feeling like crap and a doctor says you need X, Y and Z to make you feel better do you ask for a second opinion? What's the cost to you if you make a mistake?

Do you go for years without having to buy any food and then suddenly need to buy really expensive caviar or you will die?

 

[blutoski]

Secondly, we need to look at how we measure clinical performance. Infant mortality and life expectancy are often used as key indicators, but are a clumsy tool. Cancer diagnosis and recovery rates are perhaps more helpful, but there are difficult differences in reporting regimes.

Comparison is very hard, and a lot of discussion goes into attempts to make the comparisons fair. Assumptions should be as transparent as possible.


Of note is that some analysts will include 'choice' as a valued outcome. Freedom of the MDs to control their practice, and freedom of patients to control their treatment. Also 'degree of privatization' and similar ideologically-based valued outcomes.

I warn about this, because I feel it is question-begging. ie: the Fraser Institute scored Canada's healthcare system very poorly on a weighted scorecard a few years ago. The conclusion was that private models were more effective. When I looked at their scorecard breakdown, they were weighing privatization as 50%. Well, what this means is that they were assigning higher scores to private models by definition and then reporting that private models achieved higher scores.

I thought it was obviously deceptive, but my 80-year-old dad didn't grasp the fallacy, and wrote the MP Ted White a $100,000 cheque to 'stop this commie medicine'

 

[Tatyana]

I think I know what you're asking. I have my latest blood work in front of me, but I have no easy way to scan it (not that I want everyone seeing my numbers). I hope this is what you're asking about. It's the test followed by the units for a metabolic panel, lipid panel, and thyroid cascade profile.

Metabolic Panel
Glucose, Serum - mg/dL
BUN - mg/dL
Creatinine, Serum - mg/dL
eGFR - mL/min/1.73
eGFR AfricanAmerican - mL/min/1.73 (I'm Caucasian)
BUN/Creatinine Ratio - (just a number with a reference range of 8 to 27)
Sodium, Serum - mmol/L
Potassium, Serum - mmol/L
Chloride, Serum - mmol/L
Carbon Dioxide, Total - mmol/L
Calcium, Serum - mg/dL
Protein, Total, Serum - g/dL
Albumin, Serum - g/dL
Globulin, Total - g/dL
A/G Ratio - (just a number with a reference range of 1.1 to 2.5)
Bilirubin, Total - mg/dL
Alkaline, Phosphatase, S - IU/L
AST (SGOT) - IU/L
ALT (SGPT) IU/L

Lipid Panel
Cholesterol - mg/dL
Triglycerides - mg/dL
HDL Cholesterol - mg/dL
VLDL Cholesterol Cal - mg/DL
LDL Cholesterol - mg/dL

Thyroid Cascade Profile
TSH - uIU/mL

Your blood results look like the lab is more progressive and changing, for example, stating both the modern scientific term ALT, but also having to list it in the older term (SGPT), so at least they are trying to educate the clinicians.

As well, there is a calculation for eGFR, which is one of the best ways to interpret the creatinine and renal function.

The ratio like BUN/Creatinine and Albumin/Globulin are just old fashioned and provide no modern clinical information.

VLDL is from a calculation (as is LDL), however, I am not really sure why it is necessary.

The thyroid function is also more in line with current clinical practice as it is only a TSH, which, if normal, pretty much indicates that thyroid function is normal.

What was the reference range for TSH given?

 

[Uncayimmy]

Stated in incredibly simple terms, when it comes to something that's a universal "need" such as electricity, clean water, sewers, waste disposal, roads and so forth, citizens are best served if the government exerts a very high level of control. It generally keeps the costs down, but more importantly, it provides price stability and greatly increases access to for everyone.

Health care, it seems to me, has become a universal need. In the USA it's expensive, unstable in price, and not easily accessed by many people. The level of government control is either too little or too high. I think the current level of "interference" is counterproductive. Either back-off (probably not a good idea) or just take over like other countries have done. Some people consider that socialist, but the government is already socialist in many respects, health care and otherwise. It's not like health care isn't already heavily regulated by the government. It's far from a being a free market.

 

[Uncayimmy]

Do you go for years without having to buy any food and then suddenly need to buy really expensive caviar or you will die?

This is a crucial point that is often overlooked. Younger people (not unreasonably) don't want to pay for health insurance. Still others will "gamble" that nothing bad will happen. When it does, it can be crippling financially. The costs are ultimately paid by those who pay into the system. Personally, I'd rather have a relatively constant cost over my lifetime. If I don't get out of it what I paid into it, so what? That just means I was healthy and didn't have to worry about being bankrupted. Poor me!

It's not like socialized medicine isn't profitable for those in the medical field. I'm not in the medical field, but I've done small government contracts. It's good money, but they get my best deal. Many, many years ago I worked in the accounting department for government contractor where we billed the government at a set profit margin over our costs. It was a win-win situation that kept costs low and profits reasonable.

 

[Uncayimmy]

Your blood results look like the lab is more progressive and changing, for example, stating both the modern scientific term ALT, but also having to list it in the older term (SGPT), so at least they are trying to educate the clinicians.

That's good to know. It's my first and only blood work in which I've seen the results, so I have no idea how prevalent or recent it is.

What was the reference range for TSH given?

0.450 - 4.500

 

[Ducky]

This is a crucial point that is often overlooked. Younger people (not unreasonably) don't want to pay for health insurance. Still others will "gamble" that nothing bad will happen. When it does, it can be crippling financially. The costs are ultimately paid by those who pay into the system. Personally, I'd rather have a relatively constant cost over my lifetime. If I don't get out of it what I paid into it, so what? That just means I was healthy and didn't have to worry about being bankrupted. Poor me!

It's not like socialized medicine isn't profitable for those in the medical field. I'm not in the medical field, but I've done small government contracts. It's good money, but they get my best deal. Many, many years ago I worked in the accounting department for government contractor where we billed the government at a set profit margin over our costs. It was a win-win situation that kept costs low and profits reasonable.

Young folks "gambling" isn't the only problem. I've written extensively on my situation which is not that uncommon. The fact of the matter is costs of health care forced me to shut down my work running my own business as a sound engineer because I simply couldn't afford when I got sick. Within 5 years of starting the production company/studio it was down to me in massive debt thanks to medical costs simply to stay alive and no ability to work in my field of study.

I am fortunate that I was able to adapt my skill sets and find a company willing to overlook that I had no actual enterprise IT experience (and thrive in that job as well as I have - 3 promotions in 3 years), but that still doesn't save me from the massive debt entirely and I can now never afford a private plan of my own to go back to running my own studio thanks to being a cancer patient. I have no choice but to slip in on group policies and continue to flirt with bankruptcy until I can get something sorted that is workable.

I can almost guarantee that I owe more on my spine than 90% of americans do on their mortgage.

 

[Uncayimmy]

Young folks "gambling" isn't the only problem.

Perhaps I wasn't clear. I don't mean that only young folks gamble. I think people in all walks of life gamble, with ability to pay being the most prominent factor in that regard. And I don't mean "gamble" as something negative.

I am fortunate that I was able to adapt my skill sets and find a company willing to overlook that I had no actual enterprise IT experience, but that still doesn't save me from the massive debt entirely and I can now never afford a private plan of my own to go back to running my own studio thanks to being a cancer patient. I have no choice but to slip in on group policies and continue to flirt with bankruptcy until I can get something sorted that is workable.

That plays into what I was trying to say. If everybody pays into a single system, then we all share the costs equally (in concept). The current system in the USA is a pain in the ass. In your case (and mine, with a pre-existing expensive condition), getting "individual" insurance is very expensive. Your employer negotiated a deal with a health insurance company and got a better rate. If you (or somebody else) ends up needing a lot of expensive treatment, the insurance company will raise the rate on that group. Your employer has to either suck it up, reduce benefits, or negotiate a deal with another company.

So, instead of a one big group with a "fixed" risk level and centralized administration, any given state has a vast number of groups paying varying rates into companies, each with their own administration. Overall, any particular insurance company will statistically have about the same "fixed" risk level just because of sheer numbers. However, they will charge varying rates to each "group" in order to get their business.

Meanwhile, people such as ourselves have no leverage to get a better rate. We pay a higher rate because as individuals we are a higher risk. We, in effect, subsidize the lower rates given to businesses because the insurance companies aren't looking so much at individuals. Eventually, though, they do look at what the group costs.

Really, it's just screwed up as far as I'm concerned. I'm willing to trade my chances of getting the "best price" for the guarantee of getting a stable, affordable price. Truth is, if you're employed by someone else, you have almost no say in your insurance anyway. At the last company I worked for (about 50 people), we had a few people who cost a whole lot one year. The following year we had to switch insurance companies because the existing company wanted to jack up the rates.

So, in reality, my chances of getting the "best price" are pretty slim anyway.

 

[Ducky]

Perhaps I wasn't clear. I don't mean that only young folks gamble. I think people in all walks of life gamble, with ability to pay being the most prominent factor in that regard. And I don't mean "gamble" as something negative.


That plays into what I was trying to say. If everybody pays into a single system, then we all share the costs equally (in concept). The current system in the USA is a pain in the ass. In your case (and mine, with a pre-existing expensive condition), getting "individual" insurance is very expensive. Your employer negotiated a deal with a health insurance company and got a better rate. If you (or somebody else) ends up needing a lot of expensive treatment, the insurance company will raise the rate on that group. Your employer has to either suck it up, reduce benefits, or negotiate a deal with another company.

So, instead of a one big group with a "fixed" risk level and centralized administration, any given state has a vast number of groups paying varying rates into companies, each with their own administration. Overall, any particular insurance company will statistically have about the same "fixed" risk level just because of sheer numbers. However, they will charge varying rates to each "group" in order to get their business.

Meanwhile, people such as ourselves have no leverage to get a better rate. We pay a higher rate because as individuals we are a higher risk. We, in effect, subsidize the lower rates given to businesses because the insurance companies aren't looking so much at individuals. Eventually, though, they do look at what the group costs.

Really, it's just screwed up as far as I'm concerned. I'm willing to trade my chances of getting the "best price" for the guarantee of getting a stable, affordable price. Truth is, if you're employed by someone else, you have almost no say in your insurance anyway. At the last company I worked for (about 50 people), we had a few people who cost a whole lot one year. The following year we had to switch insurance companies because the existing company wanted to jack up the rates.

So, in reality, my chances of getting the "best price" are pretty slim anyway.

Absolutely agreed. Also I question the logic of defending a system that cuts out small business startups via this type of prohibitive costs. If the goal is wonderful capitalistic endeavors, how is it profitable or even logical to force small business owners to have to give up their work and look elsewhere (most likely not in their own field)?

Some very important innovations and businesses have started in garages as small endeavors. Imagine if Bill Gates or Wozniak had come down ill and needed to scramble for work just to get health care coverage they could afford.

 

[blutoski]

Absolutely agreed. Also I question the logic of defending a system that cuts out small business startups via this type of prohibitive costs. If the goal is wonderful capitalistic endeavors, how is it profitable or even logical to force small business owners to have to give up their work and look elsewhere (most likely not in their own field)?

Yes, that's why in Canada, it's paradoxically very popular with self-employed entrepreneurs like I used to be before I sold my last business.

We realize its value in cultivating ease of entry - and therefore competition - in all other markets.

It's not like an injury won't set back an entrepeneur (if you're injured you may not be able to work at all and will sustain lost income) but it means you don't return to work with crippling debt.

 

[xjx388]

Health care, it seems to me, has become a universal need. In the USA it's expensive, unstable in price, and not easily accessed by many people. The level of government control is either too little or too high. I think the current level of "interference" is counterproductive. Either back-off (probably not a good idea) or just take over like other countries have done. Some people consider that socialist, but the government is already socialist in many respects, health care and otherwise. It's not like health care isn't already heavily regulated by the government. It's far from a being a free market.

Food is much more of a universal need than healthcare is. Government regulation is not the best way to distribute food. Your last sentence is exactly my point. Medicine in the US is nowhere near a free market. We should make it more privatized.

If healthcare is so much of a universal need, then why don't individuals prioritize it in their budgets? I hear a lot about how uninsured people struggle to pay their health bills. Well, let me ask you this: How many of those uninsured (or even insured) people are saving anything towards their future health care needs? If it's such an important universal need, why do they spend so much money on cigarettes, HD TV, sporting events, alcohol -all the luxuries? Until we tell people that "Your own healthcare is your own financial responsibility," things will never get better. Individual budgets should prioritize Food, Shelter and Healthcare, everything else is disposable.

As for the New Yorker article, I've not only read it, I live it. Dr. Gawande makes some good points that line up with my views on overutilization. However, I can't support his conclusions that doctors are the primary contributors. One simple example is Home Health services. I'm pretty sure that the Rio Grande Valley is the only place in the country where HH is utilized so highly. The reason for this overutilization is outright fraud on the part of HH agencies. I've reported it many times, but nothing ever happens. Doctors are not the only problem, it's also the direct-to-patient marketing that these agencies do. It creates a demand that must be filled and if one doctor won't sign off on it, another will to please the patient. Another good example is Durable Medical Equipement companies. They visit patient's homes and convince them that they "need" diapers, walkers, scooters, hospital beds, etc. This creates the demand from patients for these mostly unnecessary items. Visit a flea market in the RGV and you will find these supplies on sale by the people who supposedly "needed" the equipment.

I've reported these companies to Medicare and nothing is ever done. It seems to me there is no interest in fixing the problem. Oh, but my clinic has gotten audited by Medicare twice. We passed with flying colors of course, but things like that just add to costs.

However, if we just told patients that they are financially responsible for their care, these companies would disappear overnight. Wal-Mart could stock most of that stuff and provide it at much reduced costs. Instead of hiring nurses to do simple things like glucose blood checks, people would get their family members to help out instead. So much cost-savings is available if the governments and insurance companies would just get out of the way.