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What’s gross behavior?

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On Deming's Hell and Hailstone Numbers

There is a fair amount of upper-level manipulation of the American medical industry. It lives on the premise that it is good, and what is wrong with it are factors external to its purpose and vision. It perceives that its ability to survive depends on the values held by the public at large. Therefore, it engages in propaganda and subterfuge to manipulate the public.

The first principle, often credited with a tip of the hat to Josef Stalin, is "Divide and Rule." I am struck by how the medical world is riven with strife today. Doctors are set upon NP's; PA's on doctors and nurses - and the expansion of the scope of practice of other licensed professionals is used as a club to frighten all. Patients perceive that the system is broken, and are manipulated to direct their anger at targets in a manner which benefits the system controlling the current mess.

I notice that the old epithet "leave the doctors on their golf courses" appears. I laughed. I have not played golf since an adolescent, and I am not a member of a golf club nor buy tee time, as it is simply too expensive. I am not alone. I believe that golf is a rarely played enjoyment by doctors, other than perhaps on vacations. I have not had one of those since residency. Too expensive.

On Deming's Hell: W. Edwards Deming was a student of management several decades ago. He offered the perspective that failures in a process are mostly due to management's failure to improve processes, and rarely due to individual worker deficiency. Here are several of Deming's principles:

* Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.

* Eliminate work standards (quotas) on the factory floor. Substitute leadership.

* Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.

In the current management world, these suggestions would provoke surprise, outrage, and perhaps even cries of "socialism!" They are certainly heretical to the culture of medical management.

Deming's Hell is a term I use to describe the deliberate choice of management to blame systemic defects beyond the power of the work force, upon individuals in a work force. If there is a bad outcome, identify and publicize the individual "at fault" and use them as a scapegoat for systemic failure.

Police shootings? "Bad Cops" Poor education? "Selfish teachers." Bad medical process? "Lousy doctors!" We are trained to turn on OURSELVES to cull a miscreant from a herd, rather than blaming a system for producing a bad outcome. That way, management does not experience disquiet or need to change.

Hailstone Numbers - an intriguing concept we don't have to look at here in detail, but it represents a sequence on numbers that wildly go up and down, almost appearing random. When they go high, they can go very high. And they make a reasonable model for executive compensation - it goes up and down in unpredictable fashion. But you get to keep the "up" stuff, the $300,000 bonuses. So competition and "success" goes along with the cash you get, and supporting the system is the pathway to golden random bonuses.

These are some of the overarching elements that make the system bad, keep the system bad, and are used to fleece the patient.

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Outstanding post, but admittedly, I say so because I'd not heard of Deming until you mentioned him.

After reading a bit, it appeals to my confirmation bias; I've been saying and living those principles for four decades.

If you're going continue making great posts like the one above, a link to the material would help in emphasizing your excellent points.

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Primary Care physicians are the death of US.

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I do not blame the Primary Care physicians. They are being used as drones in a system that was broken by regulation and then taken out by Obamacare. Regulations have taken all the fun out of being a doctor, a nurse and an accountant.

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My father, a Surgeon, had two strong dislikes. One, insurance companies (I worked in Insurance Defense), and two the Car Salesman.

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Until Americans start to take responsibility for their personal healthcare, the situation will only get worse.

Metabolic disease is rampant across the country perpetrated by poor health care choices and fuelled by addictions to what is causing the damage and an inability to overcome them.

It's. not rocket science.

Avoid tobacco, alcohol, and any other mind-altering drugs

Sleep 7-8 hours every night and exercise for an hour every day.

Avoid sedentary behaviour by moving as much as possible and work hard to control stress levels.

Be very proactive in controlling blood pressure, diabetes. and most importantly the quality and quantity of the food that you choose to pass between your lips.

Doctor proof your lives ladies and gentlemen and save your precious $ for the things that give you pleasure

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Yes, but...how about the single woman in our society who is offered no protection against gross behavior.

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So true. Case in point-hubs recently came home from work trip with super sore throat, mild fever, body aches. Went to urgent care-they did rapid strep (neg) but a covid test that took 3 days before they called him with results. He'd taken a home covid test so already knew he was positive. By time urgent care called with paxlovid he was mostly over symptoms anyway! We have a great primary care but they often can't fit in many "sick" visits.

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Actually as I practiced family medicine during the introduction of the ACA, I found it to be quite the contrary. In California CaliforniaCare, as it was called, expanded the number of insured patients by essentially providing a federal taxpayer subsidy of commercial insurance companies by paying premiums and out of pocket expenses for the near poor. It also markedly expanded Medicaid (MediCal) enrollment beyond the categorically needy to include, for instance, adult males. This greatly expanded medical access and equity and my clinic saw many new patients for which I now received payment.

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Aug 19, 2022Liked by Mary S. LaMoreaux

Great read Mary! Right on point! I spent 37 great years in the medical profession and became disenchanted around 2017. Too much government intervention! Loved the patient care, but not enough to continue!

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Aug 19, 2022Liked by Mary S. LaMoreaux

Could not agree more, but I am a family nurse practitioner who has published researched papers on the role and legal scope of NP’s.💕💕

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Is the solution not to be found in the market? In Canada, I have socialized medicine, but essentially the same problems. My pcp quit during last 2 yrs, so now I’m without a doctor and it’s very hard to get one. I can’t get a referral to a specialist w/out one. My option right now is a walk-in clinic and then wait another month or more if the specialist gets the referral. I would gladly pay for a visit or pay a dermatologist (for example) directly, but this is not an option. I wish we had a concierge system or pay-per-use option but we don’t.

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Aug 22, 2022·edited Sep 3, 2022Liked by Mary S. LaMoreaux

We're catching up to you, down here. The vertical integration of our various medical practices has resulted in corporate refusal to allow specialists to see patients without a primary care referral.

Turns out that it doesn't matter if the policy-making bureaucrat is on a public or private payroll; the policies are the same. It is deceptively framed as managing medical outcomes, but what it does is to reduce marginal costs by directing treatment reimbursements from a higher scarcity tier to a sector with greater supply and lower per-transaction costs.

From an actuarial standpoint, the numbers pencil out very well indeed. Everyone is "working their pay plan," including the bureaucrats.

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Because Canadian medicine is not "socialised". Canadian medicine profits and policy are all within the Medical Industrial Complex, Canadians simply have some degree of public access. "Socialised" would be like Québec's electrical grid and power generation which were wrestled away from private corporations in the 70s. All policy and revenue now goes to government.

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author

Don't the specialists take you without a referral? Dermatology does down here.

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There are so many misconceptions about Canadian un-healthcare.

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No, they won’t.

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We do NOT have "socialised" medicine in Canada. We have public ACCESS to a very private system where the Medical Industrial Complex sets ALL policy according to profit. That's not socialised, that's a monopoly.

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Please explain? I would like to understand how you see the structure. I see it as a gov’t monopoly.

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Aug 19, 2022·edited Aug 19, 2022

The profits go to a handful of companies. The policies are made by that same handful of companies.

"Socialised" is like Quebec's electrical grid where ALL hydro-electric power was nationalised in the 70s. There are no private profits and all policy is decided by government.

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As a solo practice family doc, I think you did a good job at explaining part of our absurd health care system. It is actually satisfying to see a non-medical person have the same insightful observations about a system that drives me crazy. Basically you are soooo right.

BUT - there's more - this administrative elaboration is put together by modern day administrative and business types (so removed from the scared, crying patient in front of me) to patch together a system designed to look pseudo-rational, but having no capacity to optimize care or caring. Our medical system is designed to suck money from sick people and ACOs are merely a misplaced band-aid approach to limit the sucking sound. Furthermore, even you, as a CPA, failed to recognize the mostly unmentioned aspect of the ACO system - it requires up front capital investment to create an ACO and more to manage it. Thus the paradigm is impossible for small medical practices (thus putting them out of existence in droves) and supercharging the consolidation of medical practices into large corporatist enterprises., the better to make $$$, but the worse for the patient. ACOs suck!

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author

I agree with you. It makes me sick what is happening to the small medical practices. Either sell out or be pushed out.

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"Either sell out or be pushed out" is what's happening to businesses everywhere, Mary, which is a fact that has not escaped your notice.

Thanks for a well-written essay on how government-imposed market distortions are driving concentration. Medical care is where concentration delivers outcomes that are deadly.

Ordinary citizens do not understand the simplest tenets of business, and rarely seem to understand that doctors have to eat, just like other human beings. Forgive the slightly sarcastic tone, but it's discouraging to see folks supporting the ACA, with all of its rhetorical legerdemain and accounting tricks. Medical practices are businesses. The forces being applied are toward marginal costs and economies of scale.

As a person with an accounting background, those tricks become apparent to you, as soon as you evaluate the money flows.

When we apply that movement within a context of research studies, a pattern begins to emerge.

When we consider the metrics, we see that incentives are offered to delay and deny care. This is because "access" is the metric. Outcomes are measured differently.

With primary care, we have a supply-side deficiency. When small practices are destroyed, it is by means of imposed efficiencies. Looking at it from a labor supply point of view, we see that the financial incentives are focused on worker productivity. Economically, doctors are no different from auto mechanics, food production workers or carpenters; they are compensated in X fashion for Y number of billable activities.

So when it comes to the gatekeeping aspects; these have always been part of an economic calculus. The problem with bureaucratic interference is that incentives become perverse in order to declare success at meeting the political objective.

Anyway, I'm partly rambling and the rest of me is preaching to the choir. Thanks for the essay.

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Speaking as a family doc I agree you are basically correct. However, I have to strongly disagree with you on one main point.You say " Economically as workers doctors are certainly no different than auto mechanics." Therein lies a major problem. Medical services need to be wholly removed from the market and recognized as a "public good." The main reason for this is because in the real world docs are very different from auto mechanics. On a day to day basis we have to deal with scared, sentient people, in pain, worried at risk of disability or dying. We have to assume responsibility for life and death situations involving the very gist of existential existence. Auto mechanics and in fact no other economic actors (in the sense of classical economics) have much on off the books responsibility. A wise society recognizes this an removes health care from the crude discipline of the market. The USA has not done this allowing insurance companies, pharma, hedge funds all to exploit the situation to maximize rents.

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I am against big pharma and big business and the power they have in Washington, DC, but be careful what you wish for in asking the market to be removed from healthcare. I have doctor clients who have moved here to get away from the United Kingdom system, they were extremely disenchanted with it. My understanding from them is that after the age of 65 the government limits your healthcare. I think one of the problems here is that AARP has so much power that there are no limits.

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Aug 22, 2022·edited Aug 22, 2022

I agree with you completely about the "off the books responsibility," Doctor, as well as the concept of public good.

I was devastated to discover that my wonderful doctor of three decades was forced to close his practice and accept corporate employment.

I work in private industry as a coding and billing administrator with a reputation for dogged persistence and dedication to duty. I'm not a medical biller, but the parallels overlap almost completely. One of my deepest regrets has been that I did not cross over into medical billing and office management, and bully my physician's office into hiring me. I think it plausible that I could have made it possible for their office to stay open.

The first thing that happened after the practice was sold, was that thirty percent of the patients were refused access by the new corporate masters, because the corporation did not succeed in bullying the patients' insurance company into a discount structure they found advantageous to their vertically-integrated expansionist business model. When your primary directive is to build more facilities, you need greater profits to provide the seed capital with which to apply leverage for financing growth.

To be clear; when I speak of the economic similarities between doctors and auto mechanics, I'm speaking only of how the numbers pencil out.

An auto mechanic is responsible for brakes and steering, and their errors cost lives. The practical difference is that human physiology prevents doctors from obtaining the spare parts required to guarantee a repair. You doctor-types cannot just replace an entire harness for an intermittent wiring system problem, or "shotgun" every single steering system safety-related component to guarantee a result.

There are NO guarantees for what you do.

But that's a matter of procedure, not accounting or economics.

An auto mechanic wants to fix cars. A doctor wants to fix people. An aggressive, dedicated, competent and tirelessly-devoted office manager/biller lets both "repairmen" concentrate on their work, and can make or break the ability of the "shop" to stay open for business.

Was it not a tiresome burden for you to have to spend countless hours dealing with office management tedium?

Did that sort of tedious distraction have a significant influence on your decision to retire?

A "public good?" Yes, absolutely, but also a vital resource subject to the same scarcity issues as any other good or service of vital necessity and high levels of demand.

Many thanks for your reply, Doc. Please understand that I mean you honor, not offense. You doctor-types have stood between me and serious illness and injury for over six decades. I am heartily sorry that I haven't used my own considerable but very different skills to stand between you and the economic forces that have caused you harm.

Small private medical practices have saved me. It is one of my deepest regrets that I have not returned the favor.

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The medical profession is like the proverbial frog in the warming water. For maybe 80 or 100 years, coasting on the explosion of applied biological science, the medical profession basked in public esteem and stature. In its hubris and arrogance (and fierce commitment to its own small business model of practice) it was institutionally incapable of appreciating or avoiding or fighting (and often supporting) the corporate exploitation of illness for profit (enhanced by lobbyists' power over government policy). Now the water is close to boiling - dedication to caring and compassion, professional autonomy, and evidenced based treatments and outcomes are being restricted, snuffed out or rejected with hostility. (I am thinking of burnout, the damn EHR, medical deserts for the poor and rural areas, the loss of women's bodily autonomy, and the anti-vax movement.)

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I believe what you described was exactly the point of Obamacare--it was designed to drive solo and small practices out of business, and make it impossible to to offer healthcare without massive corp/gov't involvement in your business. It's working like a charm!

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Aug 19, 2022·edited Aug 19, 2022

"So, you are increasing longevity, which is a good thing,"

Why?

I'll never understand the compulsion to live forever longer. It sounds to me like people are way too obsessed with Spock's "live long and prosper".

Outside of socio/medical intervention, a "natural" lifespan in "nature" is more or less reproductive years.

In humans, we saw that moment get trashed after "retirement" was invented. When the Brits invented "retirement" there were two years of retirement (65 to 67). Today people want to retire at 55 and then live off "retirement income" for the next 50 years. It's completely ludicrous and unsustainable.

Some people have incredible genetics and/or good luck, they have always lived longer, but the rest of us of average genetic makeup can only make it to old age through medical intervention.

In Canada, this is the average look of retirement:

-20 years of "retirement"

-of which 10 years of ill health.

Who the hell wants that??

The obsession with prolonging life is faulty. It's not just two years, as we push life "expectation" farther and farther past reproductive years, the years of ill health will continue to increase.

If this was just the obsession of a few people with THEIR OWN money, I'd have no issue with it, but I'm completely opposed to what Canada's healthcare system as become, not based on health in the least, but VERY focused on life-extension and life-addition, because THAT is what drives guaranteed profit.

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My fibroid does not bother me. I barely knew I had it! I have my former PCP to go back to…who flys under the radar and has his own practice. No group think and they barely do the electronic record…they use an iPad and it’s very casual…don’t ask you a lot of stupid ass questions either! And I have NEVER been a ‘go along to get along person’ ! I barely got into the Industrial Medical/Big Pharma Healthcare Delivery System less than 5 years ago when I had to sign up for Medicare! I paid for all my Healthcare needs in cash, and rarely saw a medical doctor. I saw alternative Healthcare practitioners like chiropractic care, acupuncture, naturopaths, & Chinese medicine practitioners!

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Aug 19, 2022Liked by Mary S. LaMoreaux

The only winners have been the EMR tech industry that has sold their cookie cutter systems to hospitals and offices guaranteeing the correct language populates their notes to receive all the extra incentives and are able to substantiate billing a more expensive code even if the stipulations aren’t met in reality or that higher lever code wasn’t required. As usual with these socialistic price setting sort of initiatives the providers and health care facilities need to game the system to acquire normative pay levels, but then the largest hospitals and groups game it to the max and really go in for a killing. All the while the patient receives no better, and usually worse care. As long as health care is not exposed regularly to the free market pressure and the patient does not play a direct part in payment cost will continue to rise. On the up side there is a significant expansion in direct care these days I.e. cash for service. That’s the only thing that will keep this entire thing from imploding.

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Think this mindthink was really really evident in early days of covid-docs couldn't go outside of "protocols" for respiratory virus and ended up with more harms-like putting people on vents early.

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EXCELLENT insight into the difficulty of the way the system fails everyone - doctors, patients, but seemingly not “not for profit corporate systems.” I worked for a large healthcare organization in addiction, and once money started flowing from CARES and opiate lawsuit winnings, I knew that my way of caring for patients would go away. And it did; gave way to harm reduction that funds pharma and keeps a low bar low for many addicts, as well as keeps people in the system. I prided our program on “being fired” within 6 weeks of treatment, bc everything a recovering person needs is available in the community for a 1$ donation at best.

Our system incentivized prescribers with big bonus $ to prescribe harm reduction meds, not aiding in the lifestyle change necessary for serene sobriety, and it kept people connected to the healthcare system rather than freed them from it.

Once money comes in care follows it. Patient care is taken over by how much one can get for the care given. Makes me sad.

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I would love to read more about this. Especially what the 6-week method was & why it was successful.

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I hit send before I finished… The method was holistic and 12 step based. It also required exercise in the form of physical therapy for those with chronic non-cancer pain who are addicted to opioids. Yes we weeded out the dependent vs true addiction folks, but ultimately the population with chronic pain and chemical dependency did lots of CBT groups together. We also did family dynamics, behavioral modification, and had stringent RUDS, consequences for positives and non-compliance, And most importantly it was an attraction based program.

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It was more tongue in cheek… Basically the program requirements were very similar to how nurses and physicians in our state were required for accountable recovery. The way our program worked is that if you went through it you were always able to return for free after care. I figure if I’m running a group of 15 people, an extra few people that day who needed the boost and weren’t paying weren’t costing me anything so I always allowed this. Bean counters didn’t like it and I was taken to task a few times. Not being very corporate, I ignored this and kept an open door policy for the entire time I worked there.

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Don't hold your breath!

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Aug 18, 2022·edited Aug 18, 2022Liked by Mary S. LaMoreaux

The ACO model has effectively been a disaster. The "excess payments" for keeping patients healthy have, by in large, not materialized. ACO's have all of the issues of the now-defunct (except for traditional Medicare) indemnity insurance model with no particularly notable upside.

As with almost all such flawed-from-the-beginning government overreaches to control medical care, the understanding of patient health on an individual basis (which might make it work) is completely missing -- replaced with population health measures which are completely defined by being "easy to count" and having almost nothing to do with the health of anyone. One cannot care for a population, and as von Eye has shown beautifully, knowing everything about a population tells you nothing about an individual. In the end the $$ are just reduced because that is what the government does (look back at their forced collapse of the subacute care and home nursing care sectors over the past 25 years).

Another of those "sounds good to politicians" and "rewards big players" but virtually inimical to good patient care initiatives. Part of this is the lack of PCPs, but much of this is far more structural than that.

Interestingly, and unexpectedly to me, the rise of concierge care, which is essentially primary care without the government, has been extraordinary with patients generally far happier. Someone should learn from this...but they will not.

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I want to like this a gazillion times. Wish the "sounds good" to people with power would actually listen to people who work in the field!!!

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