Why Complexity Persists in Medicine

This month’s Medical Image of the Month is a cartoon illustrating the complexity of medical billing (1). It illustrates that there are many people involved in the billing process who add nothing medically. However, they do add work, chaos and cost to both the provider and the patient. These along with other administrative costs are likely responsible for the largest portion of increasing healthcare expenses (2). Healthcare costs have far outpaced inflation and inflation adjusted reimbursement to providers has decreased (3,4). Costs of healthcare have become an increasing issue in political campaigns for both National parties. So why is no one doing anything about the issue? The truth is that some are benefitting from the complexity and have a financial incentive to maintain the status quo by opposing change.

The Centers for Medicare and Medicaid Services (CMS) and state Medicaids need to accept some of the responsibility for these cost increases. There has been a public sentiment doctors are overpaid, so actions taken by CMS and other government agencies have made physicians an easy target for policies that have led to instability in compensation. The declining income of private practice has led many physicians to flee to employed models (4). Not only has CMS contributed to driving physicians from self-employment by underpaying independent physicians but they have over compensated physician employed by hospitals. CMS estimates that it is now paying about $75 to $85 more on average for the same clinic visit in hospital outpatient settings compared to physician offices (5). Not surprisingly, these and other compensation disproportions have led to higher healthcare spending (6).

So, why does CMS rob the independent physicians to pay the hospitals and large healthcare organizations? An answer might be found in the recent actions regarding site-neutral payments. Many hospitals have bought physician and walk-in clinics to take advantage of the increased compensation from CMS and other insurance carriers. When the Trump administration proposed a “site-neutral” policy where payment would be lowered to hospitals and other healthcare organizations employing physicians, the American Hospital Association (AHA) and Association of American Medical Colleges (AAMC) sued (7). Government agencies are reluctant to challenge hospital, insurance or pharmaceutical companies and their lobbyists who are powerful and well-funded. This gives the appearance that it is much easier to be tough on independent physicians who are poorly organized, politically weak and not likely to sue.

Political tactics have been taken by the pharmaceutical companies who persuaded Congress not to allow US agencies such as CMS and the Department of Veterans Affairs to negotiate drug prices. It was in 2003, under then President George W. Bush, that Congress added a Part D benefit, through which CMS pays for seniors’ prescription drugs. The enactment followed a controversial House roll call vote, which was held open for several hours as House leaders maneuvered to secure enough votes for passage. One bargaining chip to attract votes from “market-oriented” Congressmen was the so-called “noninterference clause” which banned negotiations between CMS and pharmaceutical companies on drug prices and prevented the government from developing its own formulary or pricing structure. In other words, US Government agencies are forced to pay whatever prices the manufacturers set (8).

Sadly, our professional societies have also contributed to rising healthcare costs. An example is the Joint Commission which was formed in 1951 by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association (AHA), the American Medical Association, and the Canadian Medical Association. However, the Joint Commission has become dominated the American Hospital Association which has continually pushed a hospital administrative agenda (9). Standards leading to or encouraging administrative efficiency appear nonexistent. Even our own professional societies have fixated on programs such as Choosing Wisely which emphasizes physicians not performing unnecessary testing or procedures. Although this is important for our patients, it is has not, nor is likely to, make any difference in healthcare costs.

All this is occurring at a time when the hospital-private practice physician partnership has largely dissolved. Hospitals want employed physicians because of the financial benefits of higher reimbursement but also because physicians as employees are much easier to control. As hospitals hire their own physicians, often in open competition with private practice physicians on their staff, the hospitals and private practice physicians are no longer partners but adversarial competitors. It is naïve to believe that hospitals will not take advantage of their position of power to eliminate the private practice competition or make changes to a system such as the complex reimbursement system which has benefited them so greatly. Even something so basic as stating the cost of a procedure has been vigorously opposed by the AHA (10). Similarly, the pharmaceutical industry has opposed transparency or government negotiation on drug prices (11). And why should the any of these healthcare administrators, pharmaceutical companies or insurance companies agree to any change? They are growing rich at the American public’s expense.

Rather than throwing up our hands in disgust or going to our windows, opening them and sticking our heads out to yell – “I'm as mad as hell and I'm not gonna take this anymore!” it is time to do something. However, as physicians we need to realize that we are weak and need help. First, we need to elect political candidates at all levels of government not based on their political affiliation but on their willingness to take action to curb healthcare costs. Second, if the politicians do not take action, we need to hold them accountable by voting for someone else. Third, we should lobby through our professional societies that administrative change needs to happen. If the societies will, we either need to serve in a society leadership role or change the leadership. Fourth, we need to oppose actions to further intrude into or control the practice of medicine at the local hospital level. For example, physician leaders are often chosen by the hospital administration not for their abilities by their amenability to a hospital administration’s agenda. As physicians we have let healthcare become controlled by greedy businessmen and correcting their intrusion into medical practice will be difficult. However, we should maintain hope, the alternative simply costs too much.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Umar A, Robbins RA. Medical image of the month: complexity of healthcare payment. Southwest J Pulm Crit Care. 2020;20(2):59. [CrossRef]
2. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
3. Kacik A. Rising prices drive estimated 6% medical cost inflation in 2020. Modern Healthcare. June 20, 2019. Available at: https://www.modernhealthcare.com/providers/rising-prices-drive-estimated-6-medical-cost-inflation-2020 (accessed 1/30/20).
4. Morris SS, Lusby H. The physician compensation bubble is looming. American Association of Physician Leadership. January 16, 2019. Available at: https://www.physicianleaders.org/news/physician-compensation-bubble-looming (accessed 1/30/20).
5. Dickson V. CMS slashes clinic visit payments, expands 340B cuts. Modern Healthcare. November 2, 2018. Available at: https://www.modernhealthcare.com/article/20181102/NEWS/181109978 (accessed 1/30/20).
6. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
7. Terry K. Court overturns CMS' site-neutral payment policy; doc groups upset. Medscape Medical News. September 19, 2019. Available at: https://www.medscape.com/viewarticle/918744?nlid=131645_5401&src=wnl_dne_190920_mscpedit&uac=9273DT&impID=2101100&faf=1#vp_2 (accessed 1/31/20).
8. Lee TL,  Gluck AR, Curfman GD. The politics of Medicare and drug-price negotiation (updated). Health Affairs Blog. September 19, 2016. Available at: https://www.healthaffairs.org/do/10.1377/hblog20160919.056632/full/ (accessed 1/31/20).
9. Gaul GM. Accreditors blamed for overlooking problems. Washington Post. 2005. Available at: https://www.washingtonpost.com/wp-dyn/content/article/2005/07/24/AR2005072401023.html (accessed 2/1/20).
10. Evans M. Hospitals turn to courts as lobbying fails to block price-transparency proposal. The Wall Street Journal. December 5, 2019. Available at: https://www.wsj.com/articles/hospitals-turn-to-courts-as-lobbying-fails-to-block-price-transparency-proposal-11575551412 (accessed 2/1/20).
11. Parramore LS. Prescription drug costs in Americans are sky-high. And yes, Big Pharma greed is to blame. NBC News. January 2, 2020. Available at: https://www.nbcnews.com/think/opinion/prescription-drug-costs-americans-are-sky-high-yes-big-pharma-ncna1109076 (accessed 2/1/20).

Cite as: Robbins RA. Why complexity persists in medicine. Southwest J Pulm Crit Care. 2020;20(2):60-2. doi: https://doi.org/10.13175/swjpcc006-20 PDF 

Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del paciente y del publico: Unir dos idiomas

Carol M. Baldwin, PhD, RN, AHN-BC, FAAN

Edson College of Nursing & Health Innovation, PAHO/WHO Collaborating Centre to Advance the Policy on Research for Health, Arizona State University, Phoenix, AZ

Stuart F. Quan, MD, FAASM

Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Asthma and Airways Research Center, University of Arizona, Tucson, AZ

Editor's Note: The following editorial is in both Spanish and English with the Spanish first. It refers to the article published in Spanish "Declaración de posición: Reducir la fatiga asociada con la deficiencia de sueño y las horas de trabajo en enfermeras". There is a link in the article to the original English version published in Nursing Oulook in 2017.

“Ahora ... tráeme ese horizonte” - Capitán Jack Sparrow

Estas palabras, pronunciadas por Capitán Jack Sparrow al final de Piratas del Caribe, presagian un nuevo comienzo, una aventura, un potencial en expansión. Así, también, con el Southwest Journal of Pulmonary and Critical Care. La revista está ampliando sus horizontes con la publicación de artículos de investigación y comentarios en español para desarrollar relaciones con investigadores de pulmón, cuidados críticos y sueño en todo el continente americano. Esta primera publicación en español, “Declaración de posición: reducir la fatiga asociada con la deficiencia de sueño y las horas de trabajo en enfermeras,” por Caruso y sus colegas, es una reimpresión traducida por los Centros para el Control y la Prevención de Enfermedades del Instituto Nacional de Seguridad y Salud Ocupacional (CDC NIOSH). Si bien el contenido es específico para las enfermeras, las implicaciones para la fatiga y la deficiencia del sueño son relevantes para otros proveedores de servicios de salud, personal de primera respuesta y profesiones y organizaciones adicionales que requieren turnos y horarios extendidos en todo el mundo. Dada la epidemia mundial de deficiencia de sueño, que es especialmente generalizada en las sociedades modernas, este documento debería ser un ejemplo para otras profesiones de la salud. (1) Se puede acceder a la versión en inglés de esta Declaración de posición en la cita a continuación. (2) La versión en español publicada en esta revista será la primera incursión en una "conversación" con nuestros colegas de habla hispana. Ahora ... ¡tráeme ese nuevo horizonte SWJPCC!

Referencias

1. Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci. 2018 Mar-Apr;11(2):56-64.
2. Caruso CC, Baldwin CM, Berger A, Chasens ER, Landis C, Redeker NS, et al. (2017). Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook 2017;65:766-768.

Carol M. Baldwin y Stuart F. Quan desean reconocer a Gerardo (Jerry) González, Oficina de Relaciones con los Medios, Universidad Estatal de Arizona por su cuidadosa revisión y comentarios para la versión en español de este editorial.

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Nurse Fatigue, Sleep, and Health, and Ensuring Patient and Public Safety: Bringing Two Languages Together

Carol M. Baldwin, PhD, RN, AHN-BC, FAAN

Edson College of Nursing & Health Innovation, PAHO/WHO Collaborating Centre to Advance the Policy on Research for Health, Arizona State University, Phoenix, AZ

Stuart F. Quan, MD, FAASM

Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Asthma and Airways Research Center, University of Arizona, Tucson, AZ

“Now... bring me that horizon” – Captain Jack Sparrow

These words, uttered by Captain Jack Sparrow at the close of Pirates of the Caribbean, presage a new beginning, an adventure, expanding potential. So, too, with the Southwest Journal of Pulmonary and Critical Care (SWJPCC). The journal is broadening its horizons with the publication of Spanish-language research and commentary articles to grow relationships with pulmonary, critical care and sleep researchers throughout the Americas. This first Spanish-language publication, “Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses,” by Caruso and colleagues is a reprint translated by the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (CDC NIOSH). While the content is specific to nurses, the implications for fatigue and sleep deficiency are relevant to other health providers, first responders, professions and organizations that require shift work and extended shift hours across the globe. Given the worldwide epidemic of sleep deficiency, which is especially pervasive in modern societies, this document should be an exemplar for other health professions. (1) The English version of this Position Statement can be accessed at the citation below. (2) The Spanish version published in this journal will be the first foray into a ‘parley’ with our Spanish-speaking colleagues. Now... bring me that new SWJPCC horizon!

References

1. Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci. 2018 Mar-Apr;11(2):56-64.
2. Caruso CC, Baldwin CM, Berger A, Chasens ER, Landis C, Redeker NS, et al. (2017). Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook 2017;65:766-768.

Carol M. Baldwin and Stuart F. Quan wish to respectfully acknowledge Gerardo (Jerry) Gonzalez, Office of Media Relations, Arizona State University for his careful review and comments for the Spanish-language version of this editorial.

Cite as: Baldwin CM, Quan SF. Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del paciente y del publico: unir dos idiomas. Southwest J Pulm Crit Care. 2019;19:175-6. doi: https://doi.org/10.13175/swjpcc076-19 PDF 

CMS Rule Would Kick “Problematic” Doctors Out of Medicare/Medicaid

Last week CMS announced that beginning January 1, 2020, they assumed a new power to bar clinicians' participation if agency officials can cite potential harm to patients based on specific incidents (1). CMS created this new authority through the 2020 Medicare physician fee schedule. CMS claimed that it had no pathway to address "demonstrated cases of patient harm" in cases where clinicians maintain their licenses (2).

The rule drew criticism from multiple physician groups with none supporting it. The Alliance of Specialty Medicine said CMS has been using "vague and subjective" criteria to evaluate physicians for some time. The new revocation authority "just compounds the problem," the Alliance told Medscape Medical News (2).

In drafting the final version of the rule, CMS rejected many suggestions offered in comments about the revocation authority. The AMA pointed out that CMS hid such a major change in the annual physician fee schedule under the opioid treatment program section (2). The Association of American Medical Colleges (AAMC) said CMS should defer to state medical boards and other state oversight entities regarding issues associated with protecting beneficiaries from patient harm (2). In the final rule, CMS argued that it needs the new revocation authority due to cases where "problematic" behavior persists despite detection by state boards.

During the past week two examples of CMS’ bureaucratic nature were observed in my practice. First, I was told from a durable medical equipment provider that a new CMS requirement was that when reordering patient continuous positive airway pressure (CPAP) supplies that I would need to check, initial and date each item from a long list of supplies whether it was ordered or not. Second, an asthma patient was referred to me that was using daily albuterol. I recommended a long-acting beta agonist/corticosteroid combination but was told that the patient must fail corticosteroids alone before prescribing the more expensive combination therapy. Nearly every physician and many patients have seen some nameless and faceless clerk at CMS give them the “ol’ run around”. CMS’ argument that they are improving quality and protecting patients would be more believable if these and the many other instances of bureaucratic overreach were rare rather than common. 

Many “quality” programs have been thrust on clinicians in the past without any demonstrable improvement in healthcare for patients (3). Rather quickly these programs morph from a quality program to a hammer used to control clinicians and suppress dissent. In seems likely that CMS’ new self-assumed authority will be the same. If CMS wishes to improve care, they should deal with examples such as those above and many more instances of time wasting paper work and poor care that they mandate. Two recommendations to reduce these poor decisions are: 1. List the name of the licensed practitioner responsible for each CMS decision; and 2. Establish an efficient appeals process not controlled by CMS. These would reduce the instances of poor, anonymous decision makers hiding behind the anonymity of the CMS bureaucracy and could go a long way in improving patient care.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Medicare and Medicaid Services. November, 2019. Available at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf (accessed 11/9/19). Scheduled to be published in the Federal Register on 11/15/2019 and available online at https://federalregister.gov/d/2019-24086.
2. Young KD. CMS sharpens weapon to kick 'problematic' docs out of Medicare. Medscape Medical News. November 7, 2019. Available at: https://www.medscape.com/viewarticle/920994?nlid=132505_5461&src=wnl_dne_191108_mscpedit&uac=9273DT&impID=2159379&faf=1 (accessed 11/9/19).
3. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]

Cite as: Robbins RA. CMS rule would kick “problematic” doctors out of Medicare/Medicaid. Southwest J Pulm Crit Care. 2019;19(5):146-7. doi: https://doi.org/10.13175/swjpcc066-19 PDF 

Not-For-Profit Price Gouging

Kaiser Health News reports the case of Brianna Snitchler (1). She had a visible cyst on her abdomen which was biopsied using ultrasound as an outpatient at Henry Ford Health System’s main hospital. The cyst was found to be benign, but she received a $3,357.52 bill for her biopsy, ultrasound, lab tests and physician charges but the bill also included a $2,170 additional charge.

Although the initial bill from Henry Ford referred to “operating room services”, Ford later sent an itemized bill that referred to the charge for a treatment room in the radiology department. Both descriptions boil down to a facility fee, a common charge that has become controversial as hospitals search for additional streams of income, and as more patients complain to have been blindsided by these fees.

David Olejarz, manager of the media relations department of Henry Ford, said the “procedure was performed in the Interventional Radiology procedure room, where the imaging allows the biopsy to be much more precise. ...We perform procedures in the most appropriate venue to ensure the highest standards of patient quality and safety.” The need for a biopsy before removal of this cyst is questionable since the lesion had been present for years and had not changed. Furthermore, the need for the radiology procedure room and an ultrasound would seem superfluous since it could probably have been biopsied efficiently and safely in a physician’s office for considerably less money.

Ted Doolittle, with the Office of the Healthcare Advocate for Connecticut, called these facility fees “a black box” (1). In Connecticut hospitals are required to notify patients in advance about facility fees. Connecticut hospitals billed more than $1 billion in facility fees in 2015 and 2016, according to state records. Furthermore, Henry Ford would collect fees for every part of the procedure including the ultrasound, the lab tests, and probably the physician fees. Additionally, it is likely that the physician who referred Ms. Snitchler worked for Henry Ford and they would have collected a fee there, also.

Hospital officials argue that medical centers need the boosted income to provide the expensive care sick patients require, 24 hours a day, 365 days a year. However, Henry Ford Hospital already receives Medicaid disproportionate share (DSH) payments to help offset Henry Ford Hospital’s Medicaid shortfall because of its high portion of poor and Medicaid patients (2). Many “facility fees”, like Snitchler’s, are higher than would be considered reasonable or fair and are exploitative and unethical. In Snitchler’s case the facility fees nearly tripled the cost of the biopsy which despite having United Health Care insurance she will need to pay out of pocket. All this and she still has not had her cyst removed.

Hospitals appear to have solid finances. Although balance sheets are often inaccurate and misleading, most have greatly expanded their administrative personnel paying them record amounts (3). Henry Ford’s former CEO and trustee, Nancy Schlichting, was paid a salary or $4.77 million in 2016 (4). However, CEO salary is often only a portion of the total compensation with some tripling their salary through other compensation (3). Furthermore, Henry Ford lists page after page of administrative personnel which likely translates into hundreds of millions of dollars annually (5).

Henry Ford Health System was founded in 1915 by auto pioneer Henry Ford and is a leading health care provider for the poor in the Detroit area (6). Legislative action should be taken not only to notify patients of facility fees available prior to services but also to limit these fees to a reasonable amount of the total charges. The Centers for Medicare and Medicaid services could reexamine Henry Ford’s safety net designation or their tax-exempt not-for-profit status could be reexamined.

Henry Ford’s mission statement is, “We improve people's lives through excellence in the science and art of health care and healing” (6). However, as Henry Ford said, “Business must be run at a profit, else it will die. But when anyone tries to run a business solely for profit, then also the business must die, for it no longer has a reason for existence” (7). In this case, the Henry Ford Health System seems to be price gouging the poor rather than serving them. If profit is their sole goal, Henry Ford Hospital and medical centers like them have no reason to exist and are best left to perish.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Anthony C. Her biopsy report was benign. But the bill is a spot of contention. Kaiser Health News. September 30, 2019. Available at: https://khn.org/news/bill-of-the-month-facility-fees-biopsy-bill-september/?utm_campaign=KHN%20-%20Weekly%20Edition&utm_source=hs_email&utm_medium=email&utm_content=77684052&_hsenc=p2ANqtz--ET6FHWzEGP_A7C5P7POEonKEpK9CvrI-71lI6WxyIZ1hwGzbaD0LxeJv0kE7B8vvPpZqCJsYWmtxxXeGIAt4tSW_tlg&_hsmi=77684052 (accessed 10/5/19).
2. MACPAC. Fact sheet: Henry Ford Hospital. March 2017. Available at: https://www.macpac.gov/wp-content/uploads/2017/03/Henry-Ford-Hospital.pdf (accessed 10/5/19).
3. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
4. Welch S. Turnover, retirements factor in big changes in nonprofit compensation. Crain’s Detroit Business. May 20, 2017. Available at: https://www.crainsdetroit.com/article/20170521/news/628871/turnover-retirements-factor-big-changes-nonprofit-compensation (accessed 10/5/19)
5. Henry Ford Health System. Henry Ford Health System governance leadership. Available at: https://www.henryford.com/-/media/files/henry-ford/about/annual-reports/2017-system-report-leadership-listing.pdf (accessed 10/5/19).
6. Henry Ford Health System. About us. https://www.henryford.com/about (accessed 10/5/19).
7. AZ quotes. https://www.azquotes.com/quote/830473 (accessed 10/5/19).

Cite as: Robbins RA. Not-for-profit price gouging. Southwest J Pulm Crit Care. 2019;19(4):121-2. doi: https://doi.org/10.13175/swjpcc063-19 PDF 

Some Clinics Are More Equal than Others

In January the Centers for Medicare and Medicaid (CMS) site-neutral policy went into effect (1). Under this policy payments to some off-campus hospital clinics were reduced to those of private practice physicians. However, Judge Rosemary M. Collyer said in her decision, "The Court finds that CMS exceeded its statutory authority when it cut the payment rate for clinic services at off-campus provider-based clinics". According to her decision, in the Bipartisan Budget Act of 2015 Congress allowed hospitals to bill CMS at the higher outpatient department rate if they existed prior to Nov. 2, 2015.

This is how hospitals gamed the system. Hospitals acquire a doctor’s office or an emergency care clinic; hire salaried doctors to staff it; and raise the charges to what CMS would allow. They were able to do this because the doctor or practice was “grandfathered” and the fees are often 2-6 times the reimbursement for private physicians’ offices (2).

This ruling is consistent with a long-standing trend in Congress to restrict free market forces in healthcare. Congress has “squeezed” physicians to an extent that most have little choice but to work for hospitals. There has been a meteoric growth in hospital-employed physicians and hospital-owned physician practices. From July 2012 to July 2015, the number of hospital-employed physicians increased 49% (3). The number of hospital-owned physician practices increased by 31,000, which amounted to an 86% growth. Today more physicians are employed by hospitals than are in independent practices.

Also consistent with Congressional action to restrict free market forces has been its drug payment policy. CMS is forbidden from negotiating drug prices and is essentially forced to pay the price set by the pharmaceutical manufacturer. Private insurance companies follow CMS’ lead and pass these increased costs to the consumer.

Several bills have been introduced in Congress to curb drug pricing. The Congressional Budget Office has repeatedly stated that in order to decrease drug prices it is necessary to allow the federal government to negotiate prices (4). However, this is apparently a “socialist” act according to Senate Majority Leader, Mitch McConnell. McConnell has long been a supporter of the pharmaceutical companies and hospitals by doing nothing to alter the present system, and thus allowing hospitals and pharmaceutical companies to avoid free market forces, fix prices, and ensure maximal profits.

The Trump administration’s site neutral policy and allowing HHS to negotiate with pharmaceutical manufacturers are good policies that would likely lower healthcare costs and benefit patients. They are not “socialist” but instead attempt to restore to healthcare a free market economy that has long been missing. In George Orwell’s “Animal Farm” the pigs control the government and proclaim that “All animals are equal, but some animals are more equal than others”. The politicians who support inequitable reimbursement for the same healthcare service or allow pharmaceutical companies to overcharge for a drug are saying much the same.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Robbins RA. Court overturns CMS' site-neutral payment policy. Southwest J Pulm Crit Care. 2019;19(3):101-2. [CrossRef]
2. Carey MJ. Facility fees: the farce everyone pays for. Medical Economics. August 16, 2018. Available at: https://www.medicaleconomics.com/blog/facility-fees-farce-everyone-pays (accessed 9/19/19).
3. Cheney C. Hospital-physician consolidation growth trends moderate. Health Leaders February 28, 2019. Available at: https://www.healthleadersmedia.com/clinical-care/hospital-physician-consolidation-growth-trends-moderate (accessed 9/21/19).
4. Cubanski J, Neuman T, True S, Freed M. What’s the latest on Medicare drug price negotiations? Kaiser Family Foundation July 23, 2019. Available at: https://www.kff.org/medicare/issue-brief/whats-the-latest-on-medicare-drug-price-negotiations/ (accessed 9/21/19).

Cite as: Robbins RA. Some clinics are more equal than others. Southwest J Pulm Crit Care. 2019;19(3):103-4. doi: https://doi.org/10.13175/swjpcc61-19 PDF