If you’ve never seen it, let me assure you that Oregon is a very lovely place.  The climate in the western part of the state is relatively mild, and the fertile Willamette Valley will grow anything the weather allows – from wheat and hops to grapes, apples and hazelnuts.  But you probably didn’t come here to read a story promoting Oregon tourism and agriculture, which is why I need to tell you about the dreaded Himalayan Blackberry.

Himalayan Blackberries are the single worst invasive plant species in Oregon.  (The second worst is probably English Ivy.)  They were originally brought to the U.S. by the renowned botanist Luther Burbank because he thought that they would make a good backyard crop.  He was right in that the berries proved popular with people, but before you know it birds had spread the seeds all over the Pacific Northwest.  As it turns out, Himalayan Blackberries (or, “those $^%@^#$ blackberries” as they’re known to millions of Oregonians), form thickets nine feet high, have big thorns, spread like a rash, rapidly crowd out desirable and productive plants, and are nearly impossible to kill unless you rip them out by the roots.  Oregonians spend a fortune very year just trying to keep them from taking over the place.  Luther Burbank meant well, but as the saying goes, the road to Hell is paved with good intentions.

That’s certainly one thing that Himalayan Blackberries and the healthcare bureaucracy have in common.

First sweet, then smothering. Acres of Himalayan Blackberries take over a field.

In my last post, we discussed the adventures of Dr. Anna Meenan, and how her small circumcision suite got caught up in a labeling program that was obviously intended to promote safety in more complex surgical settings.  In her case “safety” rules promulgated by the Joint Commission had led to wasting lots of sterile pens and a few million dollars each year.  Now no one in the trillion-dollar-debt-ridden United States is going to get their knickers in a twist over a few million healthcare dollars wasted here or there.  (You might even say that the amount we waste on circumcisions is just the tip of the fallacy.)  What’s really interesting about this particular case is not the amount of money, but how easily it was siphoned off from providing actual healthcare services.  Because if you can find a good reliable way to waste a few million, wasting an additional half-trillion dollars per year is child’s play.

Dr. Meenan’s experience is, in fact, prototypical of the way America has gotten itself into the galaxy’s largest healthcare mess.  The story almost always goes something like this:

1. Something bad happens to someone somewhere as the result of a screw up. In the case of this particular Joint Commission ruling, it’s almost certain that someone, somewhere accidentally confused two or more unlabeled and incompatible liquids during surgery.  I will be the first to admit that, in most cases, mixing up your liquids is clearly a bad idea.  You don’t want to rinse someone’s abdomen with alcohol by mistake, and then start a bonfire in the wound when you use an electrical instrument to stop a little bleeding.
2. In response to the adverse event, a government agency or private sector healthcare “quality” organization issues a broad edict or “guideline” to healthcare providers and facilities. This will almost certainly be drafted with the assistance of an “expert panel”, be overly broad, and include some type of punishment or reward intended to encourage the desired behavior.
3. While helpful in preventing repeats of the original transgression, the mandates also create a large number of circumstances in which the actions required are either pointless, or many actually make things worse. Nonetheless, they are strictly tracked and enforced.
4. Each of these mandates and guidelines require new administrative spending and hiring by everyone involved. These include new personnel hired by the government or regulatory agencies to enforce the regulations.  At the same time, healthcare providers have to pay a myriad of fees to support the new effort, and hire new personnel to adhere to carry out the mandates.  New administrators are also hired to ensure that providers are filling out whatever paperwork is required.
5. The cost of all of this new administrative overhead gets factored into successive years’ total healthcare-related spending. These costs accumulate on many levels simultaneously.  State and federal spending increases as new people are hired to formulate, promulgate and enforce new regulations.  Non-governmental “regulatory” agencies issue new rules and requirements of their own and develop new programs (and correspondingly profitable fee schedules) to implement and monitor them. Healthcare facilities and providers are stuck doing and paying for extra labor, materials and paperwork that does not generate a dime of new revenue.  They then increase their own medical fees to cover these new costs, and voila!  Private insurance premiums are forced to rise yet again.  (Medicare and Medicaid payments generally don’t increase, since those prices are fixed by the government.  In order to avoid losing money, these providers simply reduce their exposure to Medicare and Medicaid patients.  So the net result is that these new regulatory costs are shifted onto the backs of those who purchase private insurance or self-insure.  And, of course, the Medicare and Medicaid beneficiaries who now have nowhere to go to receive care.)

Nonetheless, they are strictly tracked and enforced.

So there we have it.  “Waste” in action.  We’ll see this theme repeated over and over again in posts to come.

At this point you are probably wondering: “If our political and healthcare leaders know about all of this waste, why don’t they do something about it?”  The short answer is that like Himalayan Blackberries, healthcare rules, regulations, commissions, certifications, accreditations, and their ilk are easy to introduce, but terribly hard to restrain or eliminate.  Armed with the thorny defense of “protecting the public interest”, it hardly matters whether or not the rules cost a fortune, work as intended, have adverse consequences, or even provide any benefits.  Hey, no one ever bothers to check!  When’s the last time you saw a cost-benefit analysis done on mundane but expensive mandates such as forcing medical offices to purchase electronic medical record systems, “pay for performance” programs or expanding the testing requirements for physicians trying to maintain their “certification and accreditation” status?  (Hint, you’ve never seen one.  No one bothers to regulate the regulators, or certify the certifiers.  It’s just not done.)

It’s easy to see that the only way to restrain invasive regulatory creep in healthcare is to prevent its spread.  Then one has to roll it back, one offending provision at a time.  Of course this is fraught with hazard, since every governmental and private regulatory agency involved in healthcare will feel threatened by the mere thought.  They’ll claim that “people will die” if their efforts are restrained.  Of course, that also depends upon whether you count the people who die as a result of not being able to afford care at all as a result of excessive regulation.

There’s a saying in Oregon’s Willamette Valley that, “if we all left the valley, in three years Himalayan Blackberry would prevent us from getting back in”!  If you’re on Medicare or Medicaid and are having trouble getting in to see a doctor, you already know the feeling.

It’s always a great comfort to know that one’s life, health and pocketbook are safe and secure in the hands of government and large corporations. Unlike the rest of us, these are people who have the time and money to study things thoroughly and know how to deal with problems. Like all of that troublesome “waste, fraud, and abuse” in the American healthcare system.

Of course, “waste” is a very different thing from “fraud”, and they’re both very different from “abuse”. But at least our government knows what and where they all are, and what to do about them. President Obama said so in the speech he gave to Congress in September. When describing where all of the money to pay for his party’s massive healthcare “reform” plan would come from, he assured America’s beloved taxpayers and overseas creditors that:

“…Most of this plan can be paid for by finding savings within the existing health care system, a system that is currently full of waste and abuse. Right now, too much of the hard-earned savings and tax dollars we spend on health care don’t make us any healthier. That’s not my judgment — it’s the judgment of medical professionals across this country. And this is also true when it comes to Medicare and Medicaid.”

That’s great news, because it means that our leaders know how much waste and abuse there is, where to find it and how to stamp it out. Otherwise how could they use the savings to pay for anything? The other wonderful thing is that his speech gives us the definitive and presidential definition of “waste”. Waste consists of “dollars we spend on health care that don’t make us any healthier.” There’s a good, sound, verifiable definition if there ever was one.

All of which brings us to the topic of circumcision.

One of the big trends in healthcare over the past twenty years has been the exponential growth of programs designed to provide “oversight”, “quality” and “performance” to a healthcare system infested by derelict doctors and nurses. These “quality” initiatives are invented by both government regulators and private businesses eager to carve out their niche in a growth industry.

One of these private organizations is the enormously powerful non-profit Joint Commission. As stated on its website (http://www.jointcommission.org) , the Commission’s job is to “help health care organizations help patients”. In practice, this involves collecting many millions of dollars in fees in exchange for surveying and inspecting the various hospitals, clinics, labs and other facilities who wish to be accredited and certified. The stakes for those seeking accreditation or certification are high – many insurers, and state and government agencies require that healthcare facilities be Joint Commission accredited or certified as a condition of doing business. Many hospitals and other facilities will do almost anything to garner and maintain Joint commission approval.

So what happens when “quality and oversight” precipitate “waste”?

Dr. Anna Meenan, was lucky enough to find out. As a family doctor in an Illinois hospital, Dr. Meenan frequently pulls duty in the circumcision room next to labor and delivery. The room is a simple affair, dedicated to circumcisions and outfitted only with a steel table, sink, overhead light and a counter and cupboard containing circumcision supplies. As part of a quality initiative (almost certainly precipitated by some sort of bad mix-up that happened in a real operating room), the Joint Commission decided that all fluids on any sterile field must be rigorously labeled. Although circumcisions are done under mostly sterile conditions, there are only two fluids used in the process: soap and water. These are, of course, used for washing off the little boy’s private parts prior to performing the operation. One dips a cotton ball or piece of gauze in the water and then in the soap (or vice versa), scrubs the little bugger, and then it’s on to business at hand.

At Le Cirque du Circ, everyone wears a hat like this...

With the advent of the new Joint Commission rule, that simple routine became more elaborate. Now, before Dr. Meenan or anyone else can do a circumcision, the medical technician must don sterile gloves, and peel open a package containing six sterile labels and a sterile pen. He or she then writes the words “soap” and “water” on two of the labels, peels them off and sticks them to each side of the divided dish that will hold the soap and water. The previously sterile pen and remaining labels are then thrown away. The technician then checks a box in a new “Fluids Labeled” column added to the log sheet. The log is then routinely checked by a quality control nurse who is hired to make sure that all of the boxes are filled in. If a sterile pen doesn’t happen to be available when the circumcision is supposed to be done, the procedure has to be postponed until one can be located. All of this happens for each of the two to ten circumcisions that are done each day.

While only a curmudgeon (or possibly an accountant) could begrudge the cost of the sterile pen, six labels and five minutes of total staff time to a good cause, it’s pretty clear that the overly broad implementation of this safety guideline is a bona fide source of wasteful healthcare spending. It’s hard to conceive of a circumstance in which labeling circumcision soap and water has improved the healthcare of anyone. And while it’s just a drop in the proverbial bucket, drops have a way of adding up. After all, Dr. Meenan’s hospital is only one of thousands who collectively perform almost 900,000 circumcisions in the United States every year. If we conservatively assume that a sterile pen pack costs $1 and that hospital technicians earn $20 per hour, then simple math tells us that we’re spending roughly $3.4 million each year on Joint Commission-mandated labeling of soap and water. Not a lot of money, really. Just enough to insure 250 American families each year. Fortunately, the folks in the government probably already know about this particular source of waste, and are planning to stamp it out any day now, right?

Well no, and we’ll explore why in my next post. But in the meantime, does anyone need about a million slightly used pens?