The Big Squeeze

Some colleagues of mine brought this scary phenomenon to my attention last evening.

As insurance and Medicare reimbursement to doctors and hospitals fall (Medicare is enacting a series of substantial cuts, which will be followed by the private health insurers), you would expect the use of hospital procedures to drop. Makes sense, right? Less money paid per procedure, less incentive to do them.

Unfortunately, that's not how it's playing out in the real world. Your neighborhood interventional cardiologist or cardiothoracic surgeon is accustomed to a level of income and lifestyle. That lifestyle is now threatened by shrinking reimbursement. True to the Law of Unintended Consequences, rather than reducing use of procedures, diminishing procedural fees are prompting a good number of practitioners to do more.

In other words, if each heart catheterization pays less, why not do more of them, along with more stents, pacemakers, defibrillators, and the like? If four heart catheterizations per day pays less, why not do five to make up the difference?

Voila! Income protected. Of course, it comes at the cost of more work. But I will give one thing to my colleageus: They are a generally hard-working bunch who rarely balk at 12-16 hours days in the hospital.

How do you do more procedures? Easy. Just lower the bar on who to do a procedure on. Use more aggressive criteria for pacemaker implantation. Interpret the always-fuzzy nuclear stress tests weighed more towards abnormal. Use scare tactics: "You never know--that chest pain could be the last warning you're going to have!" Because the criteria for performing procedures is "soft" in the real world, it is easy to bend the criteria any way you want.

It's too early to measure the full impact of this unintended consequence of reduced reimbursement. But don't allow yourself to become a casualty in the reimbursement war. Remain vigilant. Recognize that, despite the fuzziness at the edges, there are still rational reasons for performing heart procedures. Always be armed with information and the right questions. Never submit unquestioningly or without satisfactory answers to your questions.

Comments (5) -

  • Anonymous

    6/20/2008 6:03:00 PM |

    Absolutely incredible!  What a perverted system!  

    I was speechless with my mouth open when my new cardiologist looked at me and wondered aloud why the previous cardiologist had installed a pacemaker!  Installed supposedly for bradycardia (keep my heart rate from dropping below 60) but the new cardiologist questioned the diagnosis (shaking his head all the while)!  I'll tell ya why -- $65,000.  I have a nice computer installed in me!  

    On my last visit to the previous cardiologist he did not know how my pacemaker worked -- incredible as it may seem!  He said that it was set to prevent my heart rate from dropping below 60 AND going above 130.  I told him that I often achieved heart rates higher than 130 during exercise.  To clarify I asked him three times.  He said I must be mistaken because it was not possible.  Huh?  He had an assistant call me the next day to explain how the pacemaker worked.  Yup.  He was mistaken.  Unbelievable.  I never returned.

    It was shortly thereafter that I discovered the Track Your Plaque program!!  Thank the Good Lord!


  • Anonymous

    6/21/2008 12:16:00 AM |

    Dr. Davis, thank you for the heads up on this unconscionable trend in cardiology.

    I shudder to think of the numbers of patients who either through ignorance, or timidity, may undergo life-altering procedures. Every surgery has an inherent risk, does it not?  We don't live in a "Marcus Welby" world anymore, so why are people still so uninformed, and so intimidated by doctors?  This just mystifies me...

    I bought two additional copies of _Track Your Plaque_ again today.  At least I will have them on hand to give to people I know who find themselves on the slippery slope of cardiology (which seems to happen all too frequently these days).

    Yes, I know, it's like trying to put Starbucks out of business... one cup at a time!  [laugh!]  Anyway, I can at least be personally responsible for educating a few people I care about on their alternatives, and especially on the TYP alternative to invasive cardiology nostrums.

    Thank you!

    in Houston, TX

  • Anonymous

    6/21/2008 11:15:00 AM |

    I can still remember when my grandfather had a "heart attack" all those years ago.  And yet today with what I've learned here I'm not sure if he did have a heart attack.    

    10 years ago, one morning before work grandma calls to say that granddad has collapsed, will I run over?  I suspected what had occurred, granddad was a life long pipe smoker and he loved his steak and potatoes.  When I got there, granddad had recovered, he was awake, sitting up rubbing a sore head from the fall.  He wasn't having breathing problems but I said to him I'm calling 911.  I didn't want to take a chance of loosing him like we had Stan.  A year before an employee at the company named Stan had died of a sudden heart attack while preparing Christmas decorations at home.  

    The ambulance comes, I followed behind in my car, we get to the emergency room, and a nurse begins a series of tests.  I remember when the testing was over the nurse said in what I thought was a sarcastic tone, "yeah your granddad had a heart attack, it's a good thing you called." I thought that was strange.  

    At the time I was working in the health food industry.  And while there I used to receive many magazines and news letters about health care.  I always have loved reading and pretty much read what ever health magazine that came my way.  There was one doctors news letter in particular, Dr. Julian Whitaker (sp), that constantly wrote about the dangers of cardiac care in America.  He wrote about the unnecessary procedures that were going on, lack of preventive care in cardiology, etc.  I didn't know what to make of Whitaker's news letter, he was the only one I knew writing such things about doctors and hospitals. Was he saying such things to sell his vitamin line?  At the time I suspected that might be the case.  

    Basically though I knew that for my grandfather's sake it would be best to be on my guard - not to be taken if I could avoid it.  

    Granddad was wheeled up to a room upstairs to await a visit from a Cardiologist.  While there I meet with the new nurse looking after him.  I don't remember the exact words she said, but remember she seemed to be indicating that she didn't think granddad needed to be there.  She didn't come out and say that, but that was my impression.  More strangeness. She ended our talk with "I should keep my mouth shut."  Wow, I thought, OK.  

    By this time granddad was scared.  He had been hooked up to a heart rate monitor and he had been told that when ever his heart rate was too high an alarm bell would go off and a nurse would check on him.  And it was a loud alarm bell - I heard it and nurses came running in a panic when it went off.  At the time I was a jogger, and I got to looking at the alarm setting and saw that the alarm went off at 10 beats higher than his resting heart rate.  It doesn't take much effort to raise the heart rate 10 beats higher.  Just rolling over in bed should do it I imagine.  Was the heart rate monitor alarm and panicked nurses for show, I thought?    

    Later that afternoon a cardiologist stopped by, along with the nurse that seemed to have doubts.  He immediately recommends bypass surgery, scheduled for the next day.  I spoke up and said I have some questions for the doctor.  The nurse next to him seemed to perk up, smiled.  I didn't know enough of what to ask, other than the basic of "are you sure granddad needs bypass surgery?"  "are there alternative treatments, granddad is in his late 70s?"  I remember asking a few more questions, the last one being can the surgery be done with the heart still beating so that loss of blood to the brain does not occur?  I had read about what Fanatic Cook wrote about our former President a week ago in one of Whitaker's news letters.  The nurse by this point seemed to loose interest.  The doctor was smooth and reassuring in his answers.  Granddad spoke up and said he wanted the surgery, he was concerned.  And that sealed the deal.  

    He didn't get any rest all night as the heart rate alarm bell kept going off.  After the surgery there were no alarm bells.

  • Dr. William Davis

    6/21/2008 12:10:00 PM |

    Thank you for your sad story, though wonderfully told.

    Please clarify something: Where did the heart catheterization fit into this? This is always performed before any conversation about bypass surgery can proceed.

    If no catheterization was performed and bypass was recommended, then we've got a full-fledged scam on our hands, one worth investigating further.

  • Anonymous

    6/21/2008 12:30:00 PM |

    Events are fuzzy after 10 years, but I believe one of the tests done was catherization.  I remember a dye test was done to look for blockages.