The Truth Will Make Us Free

The job of a well-trained and experienced physician is to understand diseases and predict the natural progression, duration, and outcome of those diseases, whether treated or not.  That is why it takes so many years to get good at it.  This forecasting or prognosis is then related in simple terms to the patient and establishes the doctor-patient contract, good medical and surgical treatment, and the highest standard of care in the community possible.  

Because of this dialogue, patients trust doctors and allow them to take control of those diseases and their lives and carefully and caringly get them back to full tilt activity. At the same time, doctors trust the patients to pay them in full for the services they render.  Would you agree that if the contract goes well, that goodwill (kindness) and well-being (increased quality of life) are guaranteed for both parties?  Of course they are.

The proof of a successful business contract between a doctor and a patient is that the patient gets well and the doctor gets paid and both walk away having made a friend and satisfied.  This is the stuff of good repute, trust, truth, and business justice for all involved.

In the consideration of MEDICAL ECONOMICS, doctors are not nor have they ever been savvy as to what is going on in California medicine (healthcare).  There is a complete disconnect between their clinical skills and judgment and the complicated, confusing, CORRUPT, CONTROLLING, and crumbling reality of the healthcare industry. Modern doctors are the victims of the vicious California world called the healthcare industrial complex unawares of their vulnerabilities (by design), because of their inadequate medical economics education.  Both doctors and patients are being cheated right out of the power of their contract.

The traditional financial arrangement between a doctor and a patient was very, very simple, not complicated at all!  I know.  I participated in it in Sacramento when this nice city was known as “The City of Trees”.  Here is how it worked.  A patient was referred to me for an operation and if indicated, I operated. The patient got better, I got paid, and everybody was happy.

Let’s define where medical economics took a turn in the wrong direction, leading up to the Medi-Cal mess we have today, tyrannically dictated and administered by Governor Gavin Newsom.  But first, I want you to understand the definition of a “quack”.  

There is an amusing book called “Quackery, A Brief History of the Worst Ways To Cure Everything”, by Lydia Kang, MD and Nate Pederson.  It is surprisingly and soberingly very pertinent to our presently broken California Medi-Cal medical economics mess. Within the introduction to this book, quacks are described as “those who prey on our fear of death and sickness by peddling wares that don’t work, or hurt us, or sometimes kill us.  Behind every misguided treatment is the incredible power of the human being’s desire to live.  This desire leads to incredible innovation.  That desire to heal and live longer is about as addictive as opium itself.  Political scientists impersonating Icarus (a Greek mythological inventor) try to best one another in making drugs more effective and more potent and more expensive”, (italics mine).  

The destructive interference of the previously successful caring and healing process called the doctor-patient contract, governed by the Constitutional laws defined in the Hippocratic Oath, is evident in the fraud, waste and abuse of Medi-Cal.

Medical economics took a turn in the wrong direction when our government, in conjunction with healthcare insurance companies, took over the administration of medical billing and payment for services and initiated the worst way to “cure everything economic”.  The entire push for this method of billing was to keep doctors honest and protect patients from high-cost medical care and it began with the baby-boomer generation, right after World War II (Two, not eleven!). 

This imposition was deemed necessary because of the alleged spiraling out of control pricing gouging of doctors and hospitals relative to the rest of our industrial capacity in terms of inflation. Doctors and the hospitals they worked in were cheaters according to the government.  It was a call for management of both.  The entire premise was and remains a scam.  Why?  It is because this interference was and remains the exact opposite of what it was designed to do and is the worst way to cure everything, a boomerang effect.  Government healthcare insurance in the name of Medi-Cal and Medicare now have our state and federal debt at 1 trillion and 39 trillion dollars respectively, if you believe those numbers.  It is time to STOP THE HEMORRHAGE. 

When healthcare insurance came on the scene, the vernacular of these health insurance companies changed the term “patients” to “lives”.   In the medical education complex, “doctor visit” changed to “patient encounter”.  

Lives is an actuarial insurance term that de-personalizes large groups of patients. Visit is a warm, subjective, human-centric clinical term which implies a caring partnership between the doctor and patient.  Encounter is a cold, objective clinical term (now taught in all medical schools around the USA, used for billing, coding and legal documentation.  It strips away the emotional or relational aspect and reduces the interaction to an event where medical services, assessments, and data collection take place.

In essence, Medi-Cal healthcare insurance and Governor Gavin Newsom are a quack that has removed “the human element” from the doctor patient contract and replaced the doctor visit with a “life encounter”.

Technology, electronic health (medical) records, and artificial intelligence have become the standard and standardizer of “healthcare”, and the warm intimate, interpersonal connection between doctor and patient, and caring, flew the coop!

In 1983, Current Procedural Terminology (CPT) codes, originally introduced by the shameful American Medical Association (AMA) in 1966, were adopted by the Centers for Medicare and Medicaid (and Medi-Cal) Services (CMS).  THAT IS WHERE THE SUBTERFUGE BEGAN.  

It was 1985 when I began my practice of general surgery in “The City of Trees”.   My small business private practice was invaded and trashed by a medical billing system that reduces a patient’s unique human health experience, and the specific care required, into generic, or one size fits all alphanumeric and standardized codes.  This is a cold and calculated process of translating human suffering and clinical skills and judgment into a data set for insurance billing and reimbursement.

When Newsom and his predecessors took over medical health insurance billing via Medi-Cal interwoven with all the touted (crooked) health insurers, the method of payment introduced the “middleman”.  They have been hard at it ever since and have piled it high and deep with the International Classification of Diseases (ICD)-10 alphanumeric codes, introduced in 2015.

Their argument?  This is the only way our California healthcare system could go on, and for our healthcare economics to remain solvent and healthy.  What is the reality for the doctor and patient?  Nonsense, confusion, complication, manipulation, legal issues, and ethical washout!  We are getting ripped off and dying, physically and financially.

There is a fraudulent billing practice associated with this evil coding system that has been described since the start by the healthcare insurance provider (Medi-Cal) called “upcoding”.  Medi-Cal is a liar, because the doctor is blamed for price gouging when it is really Medi-Cal that is doing the price gouging!   And the doctor is blamed when it’s really the healthcare insurance provider (Medi-Cal) that is the culprit.  The truth is that Medi-Cal “downcodes”.  

Here are some common examples of “upcoding” that are truly “downcoding”.  Each example demonstrates manipulation of alphanumeric (CPT and ICD-10) standardized codes by Medi-Cal, a very easy thing to do, because alphanumeric codes are a foreign language to both doctors and patients! 

1. A 35-year-old woman comes to the doctor’s office for a consultation about a sore throat.  The doctor performs a comprehensive physical examination upon hearing the history, which includes auscultation of the lungs, feeling the neck region for any adenopathy, obtaining a throat culture, ruling out the various causes via a differential diagnosis, and initiates treatment by providing a prescription for antibiotics.  The office visit takes 45 minutes.   The office biller submits a claim to Medi-Cal who defines that service as a standard office encounter with well-defined CPT and ICD-10 codes which determine a price-fixed payment, which is way, way too low, the result of upcoding or downcoding medical expertise and patient suffering, all with ethical washout and theft!  Neither do the doctor or the patient get the bang for their buck because Medi-Cal is ripping both off.  This is fraud, waste, and abuse.
2. A 48-year-old accountant reports to the emergency room after being seen the night before with a belly ache.  A CT scan was obtained that prior night by the emergency room physician that was normal.  The surgeon is consulted by the same ER the next day to evaluate this patient because she unexpectedly bounced back, and she is very sick, almost in septic shock.  The surgeon evaluates her, initiates wide open crystalloid, broad spectrum antibiotics, calls the OR, bumps the elective schedule, gets her into the operating room promptly, and removes a perforated acute appendix, before she dies of septic shock.  The CPT code and ICD-10 codes DO NOT reflect the stress laid upon treatment and prognosis from the standpoint of the physician or the actual amount of labor needed to carry out the tasks, or the intense suffering, fear, and pain experienced by the patient who is way sicker and requiring a protracted convalescence.  All that was blown off by the “cold” Medi-Cal and Governor Newsom and this billing and payment system.  To Newsom, what was important was how much money was stolen to promote his power and for those wicked elites working along with him.  Shameful!  There is absolutely NO CONCERN for the doctor and patient.  This is fraud, waste, abuse, and endangerment of life and vocation of the highest order!

There are literally thousands of upcoding and downcoding events occurring every day in California doctors’ offices (clinics) and community hospitals.  We have been and continue to be CPT’d and ICD-10’d to death and it is now time for this nonsense to stop.  

We must take control of our medical and surgical price discovery, billing, and payment systems again and trim down Medi-Cal for what it was intended for; namely a gap insurance for when a patient gets caught off guard and doesn’t have enough money to pay their medical bills, and gets back to work and pays his bills once he gets well again!  Medi-Cal IS NOT a gravy train.

This can be accomplished very handily by Tax Exempt Medical Savings Accounts (TEMSA) for EVERY SINGLE man, woman, and child in California, and it will work.  How does everybody in California deal with the veterinarian and their pets?  Correct!  They pay that wonderful vet CASH.  There is no well-established animal insurance yet because there is no pet industrial medical complex yet!   Their sick dog gets well, they pay the vet, and everybody walks away happy.

It is time to STOP THE HEMORRHAGE!  We must make a change, and we are doing it!  Two basics components of a powerful economic dynamite doctor-patient run healthcare system must be TEMSA and the ESTABISHMENT CLAUSE EXPANSION of the First Amendment of the Bill of Rights, presently applied to churches, and expanded to hospitals.  These events are going to put Medi-Cal in the history books as a threat to free enterprise private practice medicine, and provide Californians with the best medical system ever, with safeguards (including powerful ethics) built in, alerting future Californians to always be on guard, protecting and making California Golden Again (MCGA)!