Today Medicare provides health care coverage for the majority of Americans over age 65, and it’s a great benefit.
Yet when a payer such as Medicare becomes the largest revenue source for hospitals, the consequences for patient care are not necessarily optimal.
Since January 2019 I’ve served the citizens of Missouri District 123 as their House Representative, but I’m also a Registered Cardiovascular Invasive Specialist.
In my 23 years as a medical professional, I’ve dealt with heart and circulation issues while working in catheterization labs as a patient service representative and as an ED Tech of the hospital emergency department.
What I see today in health care is disturbing, especially since most hospitals accept Medicare coverage and are bound to its mandates. Through its Centers for Medicare and Medicaid Services (CMS), the federal government has taken over hospitals and makes decisions for patients based on cost rather than need, and private insurance companies are following the CMS precedent.
Overreaching federal control in the health care industry has happened slowly. Today, the CMS sets all standards for care, policy, procedure, and payment (what it accepts through Electronic Health Records coding and how payment will be made). Physicians and nurses – the health care professionals who use their training, experience and intuition to recognize what the patient needs – have little, if any, control over patient care.
Why? Because of government control:
- CMS standards mandate when and if a physician can perform a treatment, in what order, the sequence of testing and procedures, and when a patient can be discharged. Physicians are required to justify their decisions and complete additional paperwork. They can no longer issue orders based on patient need. Additionally, CMS requires physicians to complete so much paper and computer work they don’t seem to have time to focus on the patients or their families.
- CMS mandates how all hospital staff performs – by setting the standard of care for nursing and regulating the number of patients each nurse can care for. Nurses ask the questions, check off boxes on a computer program, and have little time to adequately answer questions and address each patient’s needs and concerns.
So, why have we handed health care control to the government and let private insurance companies follow suit? The reasons are many.
When mistakes are made, we often look to the government for fixes, because it’s easier to follow orders than to solve challenging problems on our own. We also tend to do things as they’ve been done before, even if a treatment is ineffective and because a payer wants it done "a certain way."
We also do it "their way" in order to get paid. And unfortunately, the consequences can be tragic. The following case still haunts me.
When I worked in the hospital emergency department, I often witnessed sick patients return shortly after being discharged. They were weak or in pain, frequently exhibiting the same symptoms they had in their previous visit.
The patients who come to the ER with chest pain are regularly diagnosed based on EKG, lab work, and stress test results. If anything is detected, additional tests are taken to confirm diagnosis and treatment options, which include echocardiogram and cardiac catheterization procedures.
In this case, a cardiologist already had personally examined and evaluated the patient in the office. Although the patient had normal test results, the doctor made the decision to send him directly to the catheterization lab for treatment.
In these situations, time is always critical. Yet due to CMS treatment mandates, our cardiologist was required to seek peer review approval before treatment could be administered. In other words, he had to explain the case over the phone to the private insurance company doctor, one who was not necessarily a cardiologist.
In short, he was required to obtain permission from a doctor who had never met or even spoken with the patient. Despite our cardiologist’s pleas, the insurance company denied his recommendation, because company rules required a stress test before it would cover the cost of catheterization. So the stress test was ordered.
The outcome was horrific. I witnessed our patient begin the stress test, have a heart attack during the test, collapse, and die. Had he been treated in the catheterization lab, it’s very possible he would have recovered completely. Instead, he died due to the cost-conscious bureaucratic mandates of government-run health care.
The concept of "gut feel" is difficult to explain, but doctors and nurses live it every day on the job. It comes from experience, intuition, observation, and compassion. In this tragic case, our cardiologist knew in his gut what needed to be done for this patient. And yet, his expertise was ignored.
I firmly believe physicians should be the decision-makers when ordering needed medical care for their patients. This is not the case in our current medical environment. It’s time we take back control.
The future of our medical system and our health care depends on it.
