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.
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:
- 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.
- 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.
- 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.
- 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.
- 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.