Blog | Monday, June 20, 2016

Why I don't subscribe to the notion that Medicare and CMS are a 'big evil empire'


With all the changes happening in health care and the increasing weight of federal mandates and requirements, it's easy to view Centers for Medicare & Medicaid Services (CMS) as the big, bad enemy. After all, if they just left all physicians and healthcare institutions on their own, everything would be okay wouldn't it? It's an occasional line of thinking I've heard from many esteemed colleagues and also appears to be a prevailing theme online too. To be fair, this is the easy and default viewpoint for any physician or health care organization to take, as they feel crushed by bureaucracy and other relatively newer requirements such as Meaningful Use. It's a classic “us” versus “them” mindset, that I must admit I occasionally feel as well.

Last week, I was reading the comments section of a healthcare article, and was struck by one particular comment about how Medicare simply doesn't have enough funds to sustain the current model. The particular viewpoint was as follows. It's all very well for physicians to pine for the good old days of the 1960s to 1980s (or even more recent), but back in the mid-twentieth century there were something like 7 working people for every Medicare recipient. In a decade, that figure is going to be closer to 2.5. Do the Math. Some figures even suggest that if current Medicare growth continues, it would account for over 30 percent of the entire nation's wealth in just over 50 years, with total health care expenditures accounting for 99 percent of GDP! How can such a model possibly be sustained?

This doesn't mean that physicians (and nurses) shouldn't lobby and push hard for what they believe is the right way forward. I wrote a piece a few weeks back about the craziness of the Observation versus Inpatient distinction, and how I believe that when you add up all the additional resources, manpower, and spin-off industries that have come with this, I'd be surprised if it even saved the country a dime. Similarly, Meaningful Use may have had some noble intentions at its core (i.e. making the U.S. health care system fully electronic and computerized), but the way it was rapidly rolled out with immature and cumbersome IT systems that were not ready for prime time, has caused something of a disaster at the frontlines of medicine.

Physicians who complain and moan without getting together and pushing for positive change, are not taking the correct course of action. Cynicism and negativity are not signs of learned wisdom, but of laziness. As part of my work with the Society of Hospital Medicine, I have twice had the honor of going to Capitol Hill to meet congressional leaders and advocate on behalf of issues important to hospital physicians. While any change requires a monumental effort to take effect, I don't think most physicians (or even the general public for that matter) realize how open and accessible our great democracy is, and if you have the time, power and energy—you really can meet some high level people and draw attention to your cause.

Medicare is overall a good system for our elderly, especially in a country that does not have socialized medicine. There are plenty of areas that CMS can improve, and these need to be highlighted by the professionals at the coalface. I've encountered many people high in the healthcare bureaucracy, and on the surface they are perfectly decent and normal people, doing their day job to the best of their abilities. They just may not be doing what we'd like all the time. But to simply expect that Medicare can exist like it has up till now, without some acknowledgement that it needs to contain costs, tighten its belt and change a few things, is simply unrealistic.

There's an old popular saying that I grew up with, used in England a lot, that's something of an eternal truth when it comes to those who hold the purse strings. He who pays the piper calls the tune. It happens in any arena in life, and even when any of us ourselves are paying people for their services—be it a building contractor, hairdresser or an event coordinator. We pay you, therefore we decide what you do for us and what resources you work with. As long as that's the system, that's the way things will be. The best one can do is try to influence that tune in any way they can.