Medical Waste

In his column “Better, Cheaper, Easier” (December 21, 2012), Charles Morris extols the wonders of the U.S. health-care system. He is overly optimistic. The whole system is wildly overpriced—largely the result of government obstacles. I have been a practicing ophthalmologist for over forty years. Here are just five examples of waste in the system (there are many more):

1. Medicare suffers from government price fixing. Anytime there is price fixing, providers will try to get around the fixed prices. Every time you visit a medical office or have a procedure done, there is a code assigned to which a specific payment is attached. Doctors are besieged by “coding experts” who offer to teach them how to increase their income by clever coding. Many large medical practices have a coding expert on the payroll. The trick is to code an office visit or a procedure with the highest-paying code that can be justified and to write down in the patient’s medical record whatever is needed to justify that code. There are thousands of codes. The system of codes should be simplified to ensure fair payments to all—not higher payments to better coders.

2. The average Medicare facility fee for cataract surgery performed in the hospital is $1,691. That money goes to a hospital where the surgery is performed, not to the doctor. That amount is 77 percent higher than the $953 Medicare pays for the same surgery performed in an outpatient clinic not owned by a hospital. Naturally, hospitals are buying up independent surgery centers as fast as they can. By a few strokes of a lawyer’s pen, a hospital can convert such clinics into parts of the hospital in order to reap the larger fee. This practice is so egregious that Congress has held hearings on it. The obvious solution is to pay $953 as a facility fee no matter where the surgery is performed, yet Congress does nothing. There are 1.5 million cataract surgeries done yearly in the United States—most paid for by Medicare. Imagine the how much we could save by correcting this situation.

3. Cataract surgery is the most common operation performed on Medicare patients. Typically people develop cataracts in both eyes at the same time. In the United States, cataract surgery is almost never performed on both eyes at the same time. The rationale given for this is that if one eye gets infected it could spread to the second eye. But in Canada and many other countries, patients routinely have surgery on both eyes at the same time, and eye infections haven’t been a widespread problem. The risk of infection in both eyes is less than the risk of dying in a car accident during the extra trips required for the second procedure. The real problem is financial. If surgery is done on both eyes on the same day, then Medicare pays the surgeon only half the normal fee for the second eye. Medicare should raise the fee for a second eye done the same day as the first. That would also cut the total facility fees in half. I haven’t done eye surgery for the past seven years, but I do see patients and almost never encounter any who have had surgery on only one eye. Almost never does a person get a cataract in only one eye. Medicare could save a great deal by changing this fee structure.

4. A condition known as wet macular degeneration is treated mainly by two drugs. One costs about $100 per dose and the other costs about $2000 per dose. The inexpensive one, Bevacizumab (Avastin), has not been approved by the FDA because the manufacturer (Genentech) does not want it approved. Genetech took the formula for Avastin, changed the molecule, did the required studies on the changed molecule, and called the new drug Ranibizumad (Lucentis). That was approved by the FDA, and now Medicare now pays $2000 for each dose of the drug. Independent studies have shown that both drugs are equally effective. Medicare should allow Ranibizumad (Lucentis) to be used only if the prescribing doctor fills out paperwork to justify its use.

5. Medicare pressures doctors to switch to electronic medical records. The software for an electronic medical-records system is very expensive. It costs about twenty-five thousand dollars per doctor to switch to electronic records. And it’s not easy to tell a good system from a bad one. When it was proposed that the software should be open source—that is, free—lobbyists intervened. Senator Jay Rockefeller (D-W.V.) tried to introduce a bill to make the software open source, but it never saw the light of day. If the system was open source there would probably be just one system, and all doctors and hospitals could be on the same page. As it is, each doctor and hospital has its own system, and the systems are not integrated into one another. All this makes electronic medical-record systems expensive and unwieldy—certainly not in patients’ best interests.

These are but five problems that inflate the cost of medicine in the United States. There are many more. But these issues show why we are spending more on health care than we should be. Solutions are available, but, in the end, politics rules the day.

Art Fleming, MD
Pittsburgh, Pa.

The Author Replies

I have no argument with any of Art Fleming’s points. Ideally, we should have an independent board oversee Medicare (and Obamacare) pricing rules in order to whittle away at all the little backroom deals. But on my general point that medical-care productivity has been advancing quite rapidly, the writer, as an ophthalmologist, can well attest to that fact. Modern cataract repair would have looked miraculous not that long ago; choosing whether to do one or both at the same time would have been almost inconceivable.

Charles R. Morris

A Jones for Jones

Many thanks to Anthony Domestico for his article “Words in Action” (January 11, 2013) on the poetry of David Jones. As Domestico argues, while Jones’s verse presents considerable difficulties to readers, the allusive and innovative nature of his style is essential to the poetry’s riches. Jones is not widely taught or read. There are, however, good aids to appreciation, chief of which is by the Canadian scholar Thomas Dilworth, whose reading of David Jones is clear and comprehensive. There is also a very active David Jones Society in Wales, and an American society. Flashpoint magazine recently published an issue on Jones, featuring many of the contributors to the David Jones conference that was held in Washington last spring. There is a ready audience, though their numbers may be few.

Edward T. Wheeler
Quaker Hill, Conn.

Like a Fox

Your editorial “Lose-Lose” (January 11, 2013) was extremely rich in detailing the pitfalls involved in raising the age for Medicare coverage, details that are unknown or misunderstood by too many Americans. What could be easily understood is the idea (not new) of means-testing Medicare premiums. I am semi-retired on Medicare with a premium of about $114 a month, and make less than $35,000 a year. I would gladly suffer a 3-percent increase to my Medicare premium every month; it would cost me $41.04 over the course of a year. If I were to make $35,000 to $40,000, I would gladly suffer a 4-percent increase to my premium, and if I made $40,000 to $45,000, a 5-percent increase—for every $5,000 in annual income, a 1-percent increase in premium cost. Am I crazy, or do you think most Medicare recipients would support such a measure?

Jay Derringer
Phoenix, Ariz.