Will Americans Accept Second Class Medicine?
2013-09-14 · Guest: Dr. Jeffrey Singer (General Surgeon and Adjunct Scholar at the Cato Institute) · 82:34
The systematic destruction of private medical practice
Bob Zadek and Dr. Jeffrey Singer discuss the systematic destruction of the private practice of medicine in America. They explore how government interventions—from Medicare’s price controls and the complex coding system to the mandates of Obamacare—have transformed doctors from independent entrepreneurs into “data entry technicians” and hospital employees. The conversation highlights the emergence of a two-tiered system where a cash-based free market is being reborn as a reaction to the inefficiencies and rationing inherent in government-run healthcare.
Topics: Obamacare, Medicare, healthcare economics, medical coding, IPAB, concierge medicine, electronic health records, physician shortage, price controls, evidence-based medicine
Speakers:
- Bob Zadek – Host
- Dr. Jeffrey Singer – General Surgeon and Adjunct Scholar at the Cato Institute
- Rick – Caller (Former Cardiac Anesthesiologist)
Intro and the Woody Allen Quote [00:00]
Bob Zadek: Welcome everyone, welcome to the Bob Zadek Show. I’m your host, Bob Zadek, every Sunday at noon on News Talk 910. Thanks so much for listening. Follow us on Facebook, follow us on Twitter, join the conversation: 800-345-5639.
Woody Allen famously said, and I quote, “We stand today at a crossroads. One path leads to despair and utter hopelessness. The other leads to total extinction. Let us hope we have the wisdom to make the right choice.” What better way to start a discussion of healthcare in America than with that well-known Woody Allen quote?
And who better to have the conversation with than my friend, Dr. Jeffrey Singer. Jeff is a general surgeon in Phoenix, is an adjunct scholar at the Cato Institute, and has written extensively on the future of healthcare in America. And we have heard a lot about the effect upon us, consumers of medical services, the effect on us of Obamacare—how it’s going to cost and how the bureaucracy is going to affect us, and all of this, should we buy insurance and the individual mandate. Most of the conversation about Obamacare and healthcare in America has been focused, not inappropriately, on us patients, the consumers.
But there is another side to the story, as important, if not more important, because it affects us quite directly as well. And that is the effect of Obamacare, and the effect of Medicare before it, and the effect of all the government intrusions into the marketplace for medicine—the effect of all of these on the doctors, on the providers of healthcare services. There has been in the general media almost no discussion of this issue. Well, as it affects the doctors, it affects us. And who better than to explain how Obamacare and Medicare before it affects the doctors and how that will affect us than somebody who has been on the inside for about 20 years, 30 years, perhaps more, is Dr. Jeffrey Singer. Jeff, welcome to the show.
Dr. Jeffrey Singer: Hi Bob, thanks for having me. You actually flatter me. I’ve been in the business since private practice since 1981, so that’s what, 36 years or something like that.
Bob Zadek: You look younger, Jeff, that’s why I said so. You misled me. It must have been the hair transplants.
Dr. Jeffrey Singer: Yeah, right. I don’t have any.
The Vanishing Physician Entrepreneur [03:50]
Bob Zadek: Now Jeff, the issue is, and we’re going to devote the entire 90 minutes to this really important topic, and you have written extensively on this. I remember growing up, our family doctor was Dr. Siegel. He lived about 180th Street, and I lived on 196th Street. And Dr. Siegel would make house calls. If I remember correctly, he charged $10 for the house call. And he brought a little black bag that he opened up, and there was this scary-looking needle if I had an injection. But he was, of course, an entrepreneur. He was a business guy. He set his own rates. He set all his own rules. He was, of course, licensed, and he had to earn the license by having certain educational backgrounds, but he determined everything. And he knew what he could charge, he knew what he wanted to charge. If he decided that somebody didn’t have the money but he wanted to treat them, he would treat them. It was his money, his time. And that was just entrepreneurship. Now, there’s nothing special about medicine; it’s selling food, selling clothing, except it’s selling a different good and service. Now, you are, and you always aspired to be, an entrepreneur and to be in the same model as my family doctor, Dr. Siegel. But you can’t do that anymore. The days of entrepreneurship are gone, aren’t they?
Dr. Jeffrey Singer: Yes. I would add something else. It’s not just entrepreneurship. Just like the legal profession, of which you’re a member, we’re also professions. So a profession has its own sort of ethical code that it follows. So not only as a doctor was I in business for myself, making my own business decisions just like anyone else would, but I also did it according to the sort of the ethical teachings and the mission of the profession to which I chose to belong. So, you know, there’s a certain way of doing things. For example, our ethics told us that we always had to make decisions putting the interests of our individual patient paramount. So that if my patient’s spouse, for example, asks something of me, I can’t divulge any information between the patient and me to the spouse without the patient’s permission. I have certain ethical restraints that make it where all I—my entire focus is on my patient, just like with an attorney would be with the attorney’s client.
Bob Zadek: We call it a duty of loyalty, but it’s the same relationship.
Dr. Jeffrey Singer: Yeah, yeah. So, and that, you know, the professions are like sort of a subcategory of entrepreneurs in that they have a certain kind of ethical credo they follow. But, and by the way, that’s also being tremendously threatened and damaged right now by the current state of affairs. But you’re right. When what inspired me to go into medicine, I grew up with a family doctor. Now, of course, times have changed. There’s very little that a doctor can do except for routine care and triage with a house call. Sometimes they could do a lot of, you know, just comfort care in a person who’s maybe very seriously ill or something like that. But still, my entire exposure to the world of medicine was through my doctor, Dr. Heinrich, who, you know, had his own private practice. He worked out of his house. The first floor of his house was the medical practice, and the second floor is where he lived. And he seemed to know all of his patients on a personal level. He almost felt to most of his patients as if he was an extension of the family. And he had a transparent price list for his services. Yet he would sometimes adjust those prices depending on the individual circumstances of his patients. So if he had a patient of very limited means, he just charged them less. He wasn’t under any sort of external price controls. And he’d sometimes make up for that on somebody who can afford to pay more. Or sometimes he’d accept payment in trade, you know. If a patient is, let’s say, a carpenter and didn’t have any money to pay for his medical bills, that’s fine. “I’m going to need some shelves put up in my garage, and maybe we could work something out. You could put some shelves up in my garage.” And that’s the way things were done. And that was my exposure, and the exposure of most people of my generation and maybe the generation right after mine. And it was that kind of person that made me want to be a doctor. But of course, that doesn’t exist anymore.
The Ethical Dilemma of Employed Doctors [08:37]
Bob Zadek: And you have built—you own, you are a partner in your own practice, the senior partner, I believe. You have built it. And that model of a bunch of doctors who are comfortable with each other and want to be partners with each other and control their lives, and enjoy the benefits and suffer the failures of running your own business—that model is falling apart, compliments of nothing other than the government. Now, tell—what is happening, and we’re going to spend a lot of time on this, the whole model of a private practice, physicians working together in partnership who like each other—that whole model, which is your model, which feeds into your entrepreneurship, being your own boss, working the hours you choose to work, relationship with patients—that’s the cornerstone of, and has been the cornerstone of American medicine. And that model is about to be, maybe we are six months away from the accelerated destruction of that entire model. And what will replace it will be big, anonymous hospital complexes where it’s sort of like calling Comcast for your medical services in terms of the impersonality and the being converted from a patient to a number. So Jeff, what has happened and what is happening? What are the specific pressures that make a perfectly healthy business model, which is a private practice, fail?
Dr. Jeffrey Singer: Well, you know, first of all, the private practicing doctor who has a personal relationship with his patients is on life support already. More than half the doctors in the country, probably by now more than two-thirds of the doctors in the country, are employed either by hospitals or by big corporate entities and are basically—and that’s why I talk about the ethical challenge, because suddenly their loyalties to their patient become threatened because they have to take orders from a higher authority or they could lose their job. And this presents what I have—I’ve written about this where I consider this presents an ethical dilemma to us as a profession because, you know, we’re being caught between satisfying our employers and putting the needs of our patient first. But that’s a separate subject we could talk about maybe later.
And a lot of what’s happened, I’ll admit, members of my own profession are partly to blame, primarily because they didn’t see the big picture and they just, like most people in any field, they just kind of looked at the immediate short-term consequences to them and they tended to acquiesce to forces, to external forces.
The Medicare Monster and Price Controls [12:05]
Dr. Jeffrey Singer: So starting in the ’80s, actually, you know, Medicare, when Medicare first came into being, it turned doctors from being sort of comfortable upper-middle class to many of them being in the so-called 1%. And that’s because they basically took people 65 and older and said, “You can go to the doctor, get anything you want done, don’t give a thought to how much it costs, just have the bill sent to us and we’ll take care of it.” That’s back in, you know, when it first came out in the late ’60s and early ’70s.
Bob Zadek: Separating the one who spends the money from the one who pays the bill. And once you separate the spender from the payer, the spender stops caring about how much things cost.
Dr. Jeffrey Singer: And also the seller doesn’t care either because, you know, he—the seller doesn’t have to be concerned that the seller is offering the customer something particularly expensive because he knows the customer is not paying for it. So the doctors were initially, the medical profession was originally resistant to Medicare. The AMA opposed it. Then all of a sudden, you know, a lot of doctors said, “Wow, I’m getting paid a lot more than I usually get paid. People are coming to me much more frequently because money is no object. I’m able to recommend these additional tests for preventive care that, you know, preventive care, for example, it costs money.” And some people, when they’re given the option, “Would you like this, that, or the other?” Like when you go to the dentist, the dentist who most of us pay cash for, they’ll suggest things and you’ll say, “Well, on that, that’s a good idea, but on the second suggestion, I think I’m going to pass, I’ll take my chances.” Well, if there’s no—if you’re not paying for it, “Sure, I’ll have all those things.”
So all of a sudden, you may remember because we’re from the same era, back when our doctor was our doctor, Dr. Heinrich and probably Dr. Siegel, they drove a Buick. That was called the doctor’s car. But by the early ’80s, the Mercedes became the doctor’s car. So doctors started doing pretty well under this new system. So, you know, I’m not going to say we’re blameless here, at least my profession. I have personally had nothing to do with it.
Then as basically Medicare started realizing that they created a monster here, that they—there’s no way they’re going to be able to meet these promises because costs were going through the roof, they started coming up with methods to try to control the healthcare explosion.
The Tyranny of the Coding System [14:28]
Dr. Jeffrey Singer: So the first thing they did was create this coding system that started in the early ’80s where they came—there were actually several different competing code systems, but the AMA actually lobbied for and got Congress to grant them a monopoly. So the entire coding system is designed each year by the American Medical Association. And this is a list of thousands of codes that break down every procedure, service you could think of, and every diagnosis you could think of, and give it a computerized number. And we were told that we were going to have to submit bills to Medicare using this coding system. And the hospitals had a similar kind of coding system. And that was the first problem because now we had to basically let our services and our diagnosis be defined by some bureaucratic entity as opposed to individualizing our services. So now we found ourselves, if we wanted to get compensated, we had to come up with a way of describing the service that we did based upon the codes that were given to us, or else we couldn’t get compensated. Even if the code didn’t necessarily really describe my patient’s problem or describe the service I rendered, we had to come up with the thing that most closely fits it.
Suddenly, instead of saying, “This is ridiculous, you know, people do not fit into these little code boxes, they’re individuals,” you know, we started, because we were thinking about “I want to get paid,” we started acquiescing to this. The American Medical Association had a bonanza here. They had a monopoly. There’s no longer any competing coding systems. So they get paid a huge sum of money by Medicare and also by the insurance companies to develop these codes, which makes a situation where a significant, if not the majority of the income to the American Medical Association is from these codes rather than from their membership.
Bob Zadek: So Jeff, just to interrupt. In the old days, a patient would see you, you would spend as much time as was necessary, you would then determine how much was the bill, and it may have been a predetermined bill for the visit. Now, the patient is not a patient; he is a series of codes. And now you have to develop a special skill set, or your office does, which is to take the treatment and how you can convert it into as many codes as is possible so that you can maximize how much you get paid from Medicare or the insurance companies.
The Homogenization of Medical Value [17:00]
Dr. Jeffrey Singer: Exactly. And then right on top of that coding system in the mid-’80s during the Reagan administration, Medicare instituted price controls. So based upon those codes, they have some panel that comes up, a commission that decides what each one of those procedure codes is worth. I’m not just talking about doctors. They have a similar system for hospitals called diagnostic related groups or DRG codes, but you can imagine it’s a hospital operating under a very analogous system.
So basically, I get a book every October from Medicare that says, “This is what the reimbursement will be for these codes.” It doesn’t matter whether you’re the guy who is the best person in the world and invented this operation, or this is going to be the first one you’ve ever done. You get the same amount. This is what you get for this code. So the code for, let’s say, removing a gallbladder pays X amount of dollars. You could be the guy who’s got the best record in the state, the lowest complication rate, or this could be your first one you’re going to kind of learn on this patient. You get paid the same amount. It’s one size fits all. Unlike in any other professions where, you know, you could get rewarded for your excellence by charging more.
Bob Zadek: And lawyers, just by way of example, lawyers who consider themselves to be really much smarter than the others will just raise our hourly rate. And if we get—if we think too much of ourselves and we raise our hourly rate too much, we have a high hourly rate but no income because nobody is willing to pay it. So we are tested against the market every single day. But you don’t get to—you don’t get to say, Jeff, “I’m really good at this and therefore I am entitled to more.” You don’t get to say that.
Dr. Jeffrey Singer: Right. And you also reserve the right as a lawyer to—even if you have a high hourly rate, if a person seeks your help and doesn’t have the means to pay your rate, you reserve the right to make an adjustment based upon your decision.
Bob Zadek: I do it every day. Every day I try to.
Dr. Jeffrey Singer: I’m not allowed. Under Medicare rules, I cannot, for example, reduce my fee to a person who has very limited income because that’s discriminatory. So even if I wanted to charge less to the 80-year-old widow living on a fixed income hand-to-mouth, I’m not allowed to. That would be discriminatory.
Bob Zadek: Oh my god.
Dr. Jeffrey Singer: Yeah. So, anyway, so that started in the mid-’80s. And then what started happening is doctors started basically having to kind of fit—in order to survive and to do well financially, they would hire consulting groups who would tell them, “You know, this is the best way to code this particular service you gave.” And almost every doctor’s office today has one or more people who are certified coding specialists. There’s actually a field now. And so that when I finish providing a service to my patient, I write down what I did. I don’t even know how to describe it anymore. And I go to this certified coding specialist and I say, “This is what I did for this patient.” And then she says, “Oh, well, based upon that, you did a 11640 and a 23072-75 and a this, this, this, this.” And I’ll look at it and I’ll say, “Well, that’s not exactly what I did. I really did this.” And well, she says, “Yeah, but if you say that, then you’ll get 20% less. If you say this—I don’t want to put words in your mouth, doctor, but this pays 20% more. Are you sure? Let me see what you wrote in your report.” And that’s the kind of stuff that goes on all day long.
In addition, it affects our mentality because I sort of—when I’m trying to make my patient’s diagnosis, which also have to match those procedure codes, and my patient’s diagnosis and the services fit into these codes that were designed by some commission, some agency, as opposed to just, you know, looking at my patient and taking care of my patient and concentrating on my patient.
Also, it’s got some other ramifications. For example, when epidemiologic studies are done regarding, you know, the incidence of a particular disease or something like that, data is collected from various institutions to be able to make those kind of studies. But since none of us can get paid unless there’s a diagnosis to fit our procedure code, we have to come up with a diagnosis. So let’s say somebody comes to me because she thinks she has a breast mass. And I examine the patient and we do some tests and we determine there is no breast mass. Well, if I just say “normal exam” or “no breast mass,” I don’t get paid. Because even though I examined the patient, I looked at the studies, I spent time and all that, and I told the patient that she has nothing to worry about, there’s no diagnosis for “you have nothing to worry about.” There’s no code for that. And so if I want to get compensated for that effort that I took, I have to come up with some diagnosis. So the closest thing that may come to that, I come up with something like breast pain. There is a diagnosis code for breast pain. So okay, so we’ll say that. I need something or else I can’t get paid.
Well, you wonder how many when a researcher is doing epidemiology research and they’re trying to study the incidence of a disease to see if it’s on the increase or decrease or whatever, and they’re collecting how many cases of breast pain existed in the San Francisco area in the years 2005 to 2011. Well, how many of them are really were diagnosed as breast pain and how many were diagnoses that the guy had to put there in order to get paid for doing a normal breast exam, for example? So it makes all of a lot of epidemiological data suspect. But that’s a side—that’s a side issue. The issue as it pertains to the practice of medicine is that we find ourselves suddenly becoming slaves to a coding system as opposed to focusing on the way—focusing on our patient.
But that was just a small thing. That was just the beginning. The fact that we acquiesced to it, however, was the beginning of what I argue is a cancer that affected our professionalism because once we allowed that, then it became a slippery slope.
The Rise of Boutique and Concierge Medicine [28:10]
Bob Zadek: Jeff, we have spoken about the growing trend in what is called boutique medicine or concierge medicine. And just to set up the issue, the concept is called two-tiered medicine. And there seems to be a trend in our country where the masses—whatever that means, and I certainly don’t mean any derogatory comment—will have access to what they think is free medical care or subsidized medical care, but the quality might not be all that high. Those people who have the wherewithal or whatever will have access to a different quality of medical care done totally outside of the influence of both insurance companies and of governments. Sort of the old way: willing buyer, willing seller setting a price. And that will simply be a pretty unregulated, at least economically unregulated, free market system. And Jeff, explain to our listeners what this two-tiered medical system trend, boutique medicine or concierge medicine, is all about and what are the economic factors that are causing it to happen.
Dr. Jeffrey Singer: Yeah, what we’re going to start to see happen is actually happening in Canada. So just to give you an example, most people think that in Canada, you know, there’s this one-size-fits-all system, there’s long waiting lists and people wait a couple years for heart bypass, etc. And in Canada, you’re not allowed to go outside the system because they don’t want to have a two-tiered system. So the people just either suffer or they come south of the border for their healthcare, those who have the means to do it. Well, that’s slowly disappearing in Canada. Canada is suddenly becoming freer. There was a doctor named Jacques Chaoulli—he is a doctor, he’s a family doctor from Quebec who in the late ’90s became very concerned that all these people in Montreal were waiting so long for healthcare. So he started a little private house call business. And the government shut him down because they said that he can’t work outside the system and people can’t go outside the system.
Bob Zadek: Now tell the audience, because it’s interesting, what was he doing that was wrong?
Dr. Jeffrey Singer: He was going to people’s homes and giving them healthcare as house calls, if it was possible, rather than them having to wait sometimes weeks to months for a doctor’s appointment.
Bob Zadek: The snake. What a snake.
Dr. Jeffrey Singer: And they’d have to pay him cash for this. That’s against the law because the Canadian system wanted equality, which means everybody suffers equally in a bad system. So people rave about the free healthcare if all they ever request in a year is a once-a-year physical and a flu shot. But they get sick—if they get sick, there’s waiting lists. You know, depending on the province, you could wait sometimes a year for a CAT scan or an MRI. In New Brunswick, people wait over a year for a mammogram, things like that. So, and there’s no way out unless you want to come to the United States.
So he was upset because he was shut down in starting this little business. And he became so obsessed with this that he actually went and got himself educated in the law, and no attorney wanted to take his case, and he went and sued. And he probably was a very difficult person to be around because this is all he probably could talk about for a number of years. He became so obsessed with this. And at first, the Supreme Court of Quebec ruled that while his argument that this violated—they have a Bill of Rights in Canada too, they have a different name for it—but he basically argued that everybody has a right to use their own money to take care of themselves, for their own health. That’s part of their right to life. And the Quebec Supreme Court agreed that that’s true. Nevertheless, allowing them to do so is at conflicts with the Canadian vision of equality. And therefore, they were going to deny him his case. They—he lost his case. He then appealed to the Supreme Court of the entire country of Canada. And in 2005, he himself argued before the Canadian Supreme Court. And he won. And the Canadian Supreme Court said that you cannot—they didn’t—they sort of decriminalized private medicine, they didn’t legalize it. So they said, “You cannot punish a person for using their own private means to seek their own health. Nor can you punish a person for providing it because that’s part of the fundamental right to life.”
When that happened, all of a sudden a whole bunch of cash-only clinics started to spring up all around the Canadian provinces. Some mini-hospitals, surgery centers, etc. And as of 2011, there were some 300 of them in British Columbia alone and more than that in Quebec. And basically, there are people now who don’t have to come south of the border. They’re actually going to these private clinics and paying cash for healthcare rather than waiting on the queue. And they’ve been—these clinics have been warned by the provincial governments, “You’re not supposed to do this,” but they’re not doing anything about it because after the Supreme Court decision, they really can’t. So it effectively decriminalized private medicine.
Evidence-Based Medicine vs. Clinical Judgment [34:04]
Dr. Jeffrey Singer: Now in the United States, what’s going on is that coding thing that I was talking about earlier is just a minor symptom. In an effort to keep costs under control, the government in the last seven or eight years has imposed protocols and guidelines on all doctors regardless of specialty that we must follow, or else we will get penalized by Medicare. And the hospitals are required to get us to follow this or they’ll get penalized by Medicare. So suddenly these committees in Washington are drawing up these basically algorithms, these cookbook formulas that say, “When you get a patient who has this problem, this is the antibiotic you must prescribe. This is what you must do on the first day. This is what you must do on the second day,” etc.
Bob Zadek: They really micromanage the delivery of medical services to that degree?
Dr. Jeffrey Singer: Right. Every day the chart is being examined. In fact, that’s why one of the reasons why they are forcing all hospitals and doctors to become electronic, so there’s ways of surveilling this. And then if you deviate from the guideline, you must indicate in the record why you are deviating. And there are accepted reasons for deviating and there are not acceptable reasons for deviating. Now, a lot of the younger doctors being trained in medical school today are being trained: “This is, you know, okay, today we’re going to talk about the diagnosis and treatment of this particular disease. We’re giving a handout. This is the protocol. Memorize it.” And that’s the way they’re being taught to be doctors.
Bob Zadek: Oh my god. They’re being taught to memorize a government-designed protocol. That’s rather than being taught about the body, they’re being taught, “If you have these symptoms, here’s the four steps to follow.”
Dr. Jeffrey Singer: Right, exactly. And these protocols are based on what the politicians or the bureaucrats call evidence-based medicine. Now, evidence-based medicine is a euphemism for what every profession does anyway. So ordinarily, as a clinician who’s got experience under my belt, I read the medical literature about, you know, the latest approaches to treating a particular disease that I treat, the pros and cons of this latest approach. I may see conflicting data from in another journal. I combine that with my own personal experiences in the treatment of this, and that influences what I decide I want to use, what kind of method I want to employ in treating a disease. Well, basically they have this committee in Washington, and this is for every different specialty, and they sit and they read these journals. And based upon their interpretation of these journals—these are academicians—they make the decision as to what’s the best answer based upon the data. So somehow their opinion is the last word, not my opinion. And I have to go by their opinion, even sometimes I agree with them, but it doesn’t matter. I have to make my—
Bob Zadek: But Jeff, everything you do and your entire profession is quote “evidence-based.” You don’t take a guess. You don’t flip a coin. Everything is evidence-based. So why is their evidence better than your evidence? You’re the doc.
Dr. Jeffrey Singer: Exactly. In addition, as you know as a professional, there’s a certain amount of—and I’m not sure this is not limited to professions, this is probably in any field—there’s a certain amount of what people call intuitive practice.
Bob Zadek: Judgment.
Dr. Jeffrey Singer: Yeah, these are judgments based upon years of experience that sometimes you can’t even explain. I can’t think of how many times, for example, I’ve had a patient where I was asked to consult for some abdominal complaint because I’m a general surgeon dealing with a lot of abdominal problems. And don’t ask me why because it’s not in any protocol, but for some reason I decided to get a particular test on this patient that on the last 20 patients with the same problem I didn’t make that decision, and on the next 20 I won’t. But for something I can’t put my finger on, but something made me decide to get it on this patient. And sure enough, that got the diagnosis. That’s sort of intuitive. That, you know, there’s a certain amount of experience teaches us certain things, we get sort of hunches, okay? Well, there’s no room for that in this new protocol thing. Because if you want to order a test based upon a hunch, and that hunch is not one of the accepted reasons for deviating from the protocol, then you get dinged. And if you get dinged a certain amount of times, then the hospital at which you work gets a big financial penalty. And then the hospital, if you’re an employee of the hospital, which more and more of us are becoming, eventually says, “Either you toe the line or we’re going to have to ask you to leave.” So again, that becomes the ethical dilemma I was alluding to earlier where I’m being torn between the interests of the hospital and the interests of my patient. But in any case, as more and more of these things are going on, more and more people of my generation or the generations one or two before me are feeling like, “I’m not a professional anymore. I’m becoming forced to become a technician. I have to follow protocols and guidelines that are imposed upon me. I have to make my patients fit these codes, and I have to practice according to the interests of the payer, which is largely Medicare and then secondarily the insurance companies who piggyback onto Medicare.” Well, this isn’t what I signed up for when I was inspired by my doctor, Dr. Heinrich, back in the 1960s and ’70s, who was my icon, who was my model, my role model. So people like me are making decisions every day saying, “You know what? I was going to work until I was around 70, but I’m 55 right now. I think I’ve had it. I’m checking out. I’m going to go to work as a consultant for an insurance company, or I’m going to get out of medicine altogether.” And we’re seeing that happen right and left.
Caller: Rick from Palo Alto (Former Cardiac Anesthesiologist) [43:36]
Bob Zadek: Jeff, we have a caller. Rick in Palo Alto wants to talk about two-tiered medicine. Rick, are you still there?
Caller (Rick): I am. Hi Bob, how are you doing?
Bob Zadek: Hi Rick. Thanks so much for calling. Go ahead, Rick. What’s on your mind?
Caller (Rick): I’m a physician who actually left medicine when it got bad enough and just went into business. And I just want to point out that people talk about a multi-tiered system as if it is bad, as if there’s something nefarious about it, when actually a single-tiered system forces medicine to the lowest common denominator. A single-tiered socialized medicine system is the worst medicine for everybody. What we should strive for is actually a multi-tiered system, not just two tiers, but as many tiers as somebody can excel at providing medical care at, which is the same thing that we see in all of life when we believe in freedom. I mean, basic human necessities of food and shelter, we have a multi-tiered system for that as well. That’s what freedom is all about. Shoot for the highest level and it’ll bring everybody up.
Dr. Jeffrey Singer: Rick, I agree with you completely with one little modification in that, you know, as a medical profession, we’re a profession. So I could see tiers in terms of the degree of service, just like you have on an airplane, you have first class and you have coach. But as a profession, of course, we have a code of ethics. So for example, I’m not going to provide the wrong care because it’s cheaper. I’m not going to provide inadequate care to a patient for less money. But I may, you know, not provide the frills. That’s how I would do it because, again, I have a professional ethics.
Caller (Rick): Oh Jeff, I completely agree with you. My lowest tier would be better than Obamacare. My lowest tier of acceptable medicine is based upon my professional training. When I talk about multi-tiered, I talk about it that being the lowest level but there being better medicine available.
Dr. Jeffrey Singer: Right. And you also—you assented to your professional code of ethics voluntarily.
Caller (Rick): Oh, absolutely. Absolutely. And then not only is it multi-tiered as a society, but we also provide a safety net. I mean, even as a libertarian, I will say that as a society at this point in history, we can still provide a safety net for people. So nobody should be without medical care. There should be a lowest level and a safety net, and I have no problem with the government being involved at that end of it as long as they don’t knock out the top end.
Bob Zadek: And so the issue is what we’re all sort of saying is we sort of could—and I’ll add reluctantly identify my own views—agree that perhaps there is some level of care that everybody is entitled to. I don’t buy into it, but I can understand the argument. But what’s most importantly is when the government interferes with the operation of the market, of the market, so that willing buyer, willing seller cannot enter into a deal, that will—and the experience has been—that will drive the costs up. So in an effort to drive the costs down, the government is driving the costs up and removing the marketplace, which is really—once we damage that, there’s no coming back. And that’s the problem. I’m interested, Rick, what specialty did you practice?
Caller (Rick): Cardiac anesthesiology.
Bob Zadek: Okay. And what was your reason for leaving?
Caller (Rick): You know, when I got a call in the middle of the night that said somebody needed emergency open-heart surgery at the county hospital where I knew I wasn’t going to get paid, no problem getting out of bed and going and providing the best care I could. But then when I started to also have to deal with insurance companies outside on the business end and haggling with them to get paid after I had saved somebody’s life, it became so distasteful. When I spent more and more time outside of the operating room in the business end of medicine, I decided that it’s a really bad business. And cardiac anesthesia doesn’t lend itself to concierge medicine, obviously. So I just decided if I was going to be spending all of my time in business, why not just go into business?
Dr. Jeffrey Singer: Well, what’s happening now is all of us are being—having these protocols imposed upon us. That’s what’s driving me out because, you know, I’m at a point in my life where the financial aspects are less important because I’m towards the, you know, I’m in my autumn of my years so to speak. But what’s happening to me is I didn’t sign up to be told by some bureaucrats that this is how I treat colon cancer, this is how I treat gallbladder disease, this is what the antibiotic is that I must use or else, and I have to explain myself to some faceless entity. That’s not what I signed up for because I’m not a clerk working on an assembly line plant. I’m a professional. So this is what’s making me say I don’t want to be part of this world. And it’s only—I can see it’s going to get worse and worse.
Bob Zadek: I’d like to impose upon, while Rick is on the phone, I have two docs on the phone, a question. When I was in high school, the smartest of the smartest in my class, they were destined to be doctors. It was automatic. They were going to be doctors. And those less smart but were smart went into other professions. But that was the crème de la crème. Now, the doctors who are making a decision, or the to-be doctors making a decision to go from college into medical school, they don’t—when I was growing up, doctors were paid the best of all the professions as far as I knew and my high school buddies knew. If you were a doctor, you made the most money. And it’s—you’re allowed to want to make money, and these ambitious people who were smart chose that. Now, people who are looking at the practice of medicine today when they’re in college and they see medicine, what do they see and what kind of college and high school students are drawn into medicine today as compared to those that were drawn into medicine when I was younger?
Dr. Jeffrey Singer: I don’t—I can’t speak to their being in terms of their academic abilities. They’re still very smart people. But it’s a different type of personality type. Back when I was a pre-med student in the ’70s, it was—one of the attractions of medicine was an entrepreneurial attraction. It was a given that I was going to start my own practice, that I was going to control it according to the way I wanted to, and I had an opportunity to go as far as I could based upon how good I was. Now, like I say, nobody’s—private medicine is pretty much dead. Doctors are going bankrupt because of the decreasing reimbursements and all of the regulatory compliance costs. So they’re selling their practices and becoming employees of hospitals or big corporate clinics. So that the only opportunity out there right now after all those years of medical school and residency are to become a shift-working employee at a hospital where you must follow protocols and guidelines and meet benchmarks or else you’re fired. And so the kind of person to whom that has an appeal is a different kind of person that went into medical school back in the ’70s. It’s more of a kind of person who was comfortable—they’re people who that’s what they’re going in with that expectation and that’s fine for them. So it’s a different mindset, it’s a different type of ambition, a different type of willingness to take risks, to work hard.
Bob Zadek: Rick, your observation about who’s going into medicine now versus before all this government intrusion?
Caller (Rick): I’ll be a lot more blunt about it because I still have a lot of friends in residency programs. The quality of the applicants is nowhere near what it used to be. It’s not even close. My wife is also a nurse at a teaching hospital, and what she sees as, you know, the medical students, the residents, etc., the quality of those people now compared to what it was 20 years ago, completely different.
The Electronic Health Record Mandate [54:00]
Bob Zadek: Jeff, one of the issues that I find about the scariest is predictions I have seen about the growing and growing at a fast rate shortage of doctors and they’re being replaced by other healthcare professionals, perhaps nurse practitioners, medical technicians and the like. Is this overblown or are we going to suffer simply a shortage with the result being long waits à la Canada?
Dr. Jeffrey Singer: No, it’s not overblown. It’s acute, actually. When it comes to primary care, it’s a serious problem. The government back in the early part of the 2000s wanted to encourage doctors to go to electronic health records because they—even though there was no evidence-based data on this—they intuitively thought this was going to save money. With the stimulus bill that was passed in 2009, part of the stimulus package was forcing doctors and hospitals to become electronic by 2014 or face Medicare reimbursement penalties. They’ll be penalized.
Bob Zadek: So you were being told how to run your office.
Dr. Jeffrey Singer: I was told I must go electronic. But part of the stimulus money was to reimburse me for the cost of purchasing the software and the hardware to become electronic. So thank you for that, Bob. You paid for part of that. I appreciate that. Of course, you didn’t reimburse me for all of the costs. You reimbursed me for the cost of the software and the hardware, but you didn’t reimburse me for the fact that for about two months I had to take people off of what they were doing for the practice, which was productive, and take all of these paper charts and enter them into the computer rather than doing things that were for the practice and making money for me. And then for the next couple of months, because it’s underway now, I’ve been only to see about 50% of the patients that I usually could see because I’m still learning how to enter all this stuff into the computer and I feel more like I’m spending more time focused on that, like a data entry technician. So that’s a cost also because my productivity’s been cut significantly because I can’t see as many people as rapidly as before. That’s not being reimbursed.
Jeff, when we spoke, just a little vignette, when we spoke the other day, you told me this made my hair stand up on the back of my neck story about how you code—and god how I hate that word—how you code a plain old boring office visit. Tell the audience about that.
Dr. Jeffrey Singer: Well, I don’t want to get—I may want to plead the fifth here and not incriminate myself.
Bob Zadek: Well, how does a doctor, a theoretical doctor, go about coding an office visit?
Dr. Jeffrey Singer: A theoretical doctor. Okay. See, the idea was these geniuses who thought this was going to save money, which included Newt Gingrich, you might remember, was talking this up big in the ’90s. But it was all—even though they want us to practice so-called evidence-based medicine, our politicians don’t practice evidence-based public policy. So they, based on an intuition that this was going to save money, they passed this. There’s already data out now—you might have read it in the New York Times about six months ago—saying that since the hospitals have gone electronic, Medicare’s actually spending more money in payouts to hospitals than they did before. Because this is what happens: in order to submit your bill to the payer, Medicare, there’s these incredibly complicated codes. So for an office consultation, there are five different levels of codes. And each one depends upon, for example, how many body systems you inquired about when taking a history or examined, and things like that. So therefore, when you get this software—there are competing companies to sell you the software—what they sell it to you saying, “We’re going to actually, doctor, you’re going to be happy you bought this because your payments are going to increase.” And so what the software does is it prompts you to enter things that will enable you to legitimately offer a charge for a bigger code. So for example, if you ordinarily were going to examine three body systems and therefore charge for a level two consultation, it’ll prompt you to ask you, “Would you like to add these other two body systems into your examination because that will enable you to lift it up to a level three?” And you say, “Okay,” and you click a box. Now, it’s up to the honesty of the doctor whether he wants to actually examine those systems or just cut and paste from a previous encounter with that patient that body system exam and put it in there.
I could tell you when I go to the hospital to make rounds and I see these electronic records, it’s the same thing because when you bill for a hospital visit, there are different levels. So what a lot of doctors do is they cut and paste all of the really, for my purposes, not pertinent data—a person has a family history of gout, his uncle on his mother’s side had colon cancer—and they put that all in there. And they probably—I know they cut and pasted it from the other guy’s note. And then on the bottom, they put, you know, something that’s relevant to their visit today. But that enables them to charge for a higher-level hospital visit, okay? Now, if they were ever to get audited, of course, the auditor—how are you—it’s going to be the auditor’s word against the doctor’s word. The doctor says, “Yeah, I did it. I asked the patient all those questions. I examined all those systems.” You know, who’s going to say he’s wrong?
So what’s happening is the payers are actually getting now basically higher bills. And if they want to see electronically if the data matches the level of the code, it’s there. Of course, it also creates these very long, voluminous notes that are very difficult for a clinician to use. So when a patient comes—is referred to me by a primary care doctor, for example, for let’s say a hernia, and he brings with him his initial consultation from the doctor’s office, I’m looking through it, I’m seeing pages and pages of his aunt had gout, his sister had this, and all these kind of things which I know enabled the primary care doctor to bill for a highest-level initial office visit for the primary care doctor. But I’m just going through it and through it saying, “Where is the thing here which says why he’s sending this patient to see a surgeon?” And then finally I say, “Screw it, I don’t have the time to read this, it’s these pages and pages of tiny print. I’m just going to go in the exam room and ask the patient why the doctor so-and-so sent you over to see me.” And I’ll just forget about these notes that were sent. They’re so long and so voluminous that they become not clinically useful. And I just start from scratch. And also, I don’t trust half the things in there because I don’t know how much of that information is true and how much was just cut and pasted from someone else in order to get billed better. So the electronic health records, instead of decreasing healthcare costs, are actually increasing healthcare costs to the payers and, I would argue, are increasingly inaccurate. I don’t trust them. I trust much better before we went electronic.
But anyway, the requirement to go electronic is so expensive for a lot of practices that if you’re in primary care, which doesn’t get reimbursed well anyway, that’s forced most of them to go out of business. So right now there’s an acute shortage of primary care doctors. More and more doctors here in the Phoenix area, I know about a handful who are still in private practice. Almost every one of them now is working for a hospital. The hospitals, they go to the hospital and say, “Could you buy me out?” And the hospital acquires their practice and that way they’re able to tap into the hospital’s electronic health records system, they put their system and their computers in the office. And it looks to the outside world like it’s still that doctor, but the staff work for the hospital, the office is leased by the hospital, and the doctor’s an employee of the hospital. And the patient gets a bill from the hospital’s billing system. And it also affects the productivity of that doctor, obviously, because they’re not his patients anymore, they’re the hospital’s patients. It affects his attitude because they’re not his patients. And so more and more primary care doctors are going that way. And you’re seeing more and more nurse practitioners and physician’s assistants replace primary care doctors. I’m sure in the Bay Area, just like here in Phoenix, it’s very commonplace for a person to wait and wait to get a primary care appointment and they don’t usually get seen by a doctor, they get seen by a paraprofessional. Now, in many cases, that’s fine. I don’t want to denigrate the paraprofessional. But number one, in a market system, you should be able to decide whether you want to be evaluated by someone with a level of training of a paraprofessional or with a level of training of a physician. You know, the depth of knowledge does affect—
Perverse Billing: Office vs. Hospital Costs [63:10]
Bob Zadek: You know, Jeff, it’s what you say is so obvious. I think of my profession; it’s always interesting to draw the parallel. I’m a senior lawyer, so my billing rate is high. Many of my clients, even though they have work—I hope they’re not listening—even though they have work that can be done by a more junior attorney than me, they say, “Bob, we want you to do it. We know it’s more expensive. That’s—it’s our money, that’s what we want.” And they get to choose. And I like to think it’s economical because I’m more efficient, but they get to choose. And what’s really important, Jeff, and I know you’re aware of this but the audience is not, is that when these private practitioners come under the umbrella of a hospital, a large hospital system, the costs for the same process go up. Because under the perverse billing rules of Medicare, if you take, for example—and Jeff, there are a couple of examples I want to share with the audience—if you take something which is pretty routine, laser eye surgery. If an ophthalmologist does that procedure in his office, Medicare will reimburse the ophthalmologist for $389. If that same doctor with the same machine goes into a hospital, the hospital gets reimbursed about twice as much, $738, because the hospital gets to put on more costs because it’s more expensive to run a hospital. So even though a hospital is less efficient and it costs more, the perverse billing of Medicare forces this ophthalmologist into the hospital. The same with an echocardiogram. An echocardiogram, $143 on average with private practice, $319 in Medicare. Now, that costs the system about one billion with a B, billion dollars more just by forcing doctors, as Jeff explained, to leave private practice and go to work for a hospital.
Dr. Jeffrey Singer: Yeah, but they don’t make the—here’s what happens. We’re seeing that in cardiology too. Cardiology—Medicare’s paying cardiologists so little now for stress tests and echocardiograms that many of them don’t get paid enough to pay for the rent of the equipment if they don’t own the equipment. So cardiologists are now sending those to the hospital rather than lose the money doing it in their office. Now, the hospital is increasingly hiring all—it’s not just limited to primary care. So many specialists are between, like I say, the expense of going electronic and the regulatory costs and the reimbursement rates, they’re selling their practices to the hospital. So the hospitals have staff surgeons, staff cardiologists, staff pulmonary specialists, etc. Now, as a surgeon, if I in private practice do a laparoscopic gallbladder operation, I’ll get paid X amount of—I don’t want to talk about it on the radio, and it’s different from part of the country to part of the country. But if I’m an employee of the hospital and I do that same operation, the hospital when it bills for it, it’ll get paid for that procedure about double what I would get paid for the procedure. Now, that doesn’t go to me, that goes to the hospital because I’m on a salary when I’m working for the hospital.
Bob Zadek: So this is like the same person, Dr. Jeffrey Singer, does the same procedure with the same scalpel in your hand, the costs to society are double. And that’s forced upon society by the government. This is the government’s system.
Dr. Jeffrey Singer: Yeah, the Hospital Association’s done a much better job of lobbying the healthcare regulators for reimbursement fees than the medical societies have done. So they’ve been able to work in all of the—they have these formulas that reimburse them for all of the overhead of maintaining an entire acute care hospital. And they’re able to work that into the reimbursement for a simple procedure. And that’s another thing, you know, that you and I both understand and most of the listeners to this show understand: that if you don’t have a market, then all you have—the only other way to do this is through politics. So depending on how good you are at lobbying the various regulators who decide what the payment is, determines how you get paid. So basically, the hospitals have done a much better job of lobbying than the medical professions, and that’s why for the same exact procedure, they get paid a lot better.
The Rebirth of Private Practice [68:00]
Bob Zadek: For the same—and the important point is, the same procedure by the same doc using the same instrument in the same environment, just because it’s done by a hospital. And by the way, all of these costs, if you’re in the sound of my voice, you’re paying. So what we have is, we have this incredible—look where we are. Jeff, look what Jeff and I have talked about for the past hour and a quarter. We’ve talked about a system that pre-government was a free market system. The government comes in, destroys the free market, imposes its payment rules, undoes the free market so a doctor cannot be his or her own boss anymore. It sends doctors into hospital, increased cost to society. And now, as we discussed before the break, the private practice is being born again, like a forest fire and then the new growth comes. Now we have the growth of a private practice system, the so-called two-tiered medicine, which is totally free of government payment regimes. And so I end up in this very, very strange environment, or I see this very strange environment where there’s like this forest fire—it’s a great analogy—destroys the forest, and in no time up springs little seedlings called private practice of medicine.
Dr. Jeffrey Singer: I agree. And we’re going to see private cash-only—we’re already starting to see around this country and offshore, nearby offshore like in the Caribbean, doctors are quitting the whole system, they’re not taking any insurance, Medicare, anything, and they’re setting up private hospitals that take nothing. Because as part of the deal to get the Hospital Association to endorse Obamacare when that legislation was being made, the legislation prevents any new doctor-owned private hospitals from coming into existence.
Bob Zadek: Why is that?
Dr. Jeffrey Singer: Because they were competing too well with the big general hospitals and “skimming off” the better-paying patients. So those that still exist, these physician hospitals, they’re grandfathered, but in order to get the Hospital Association to endorse Obamacare back in 2010, they made it—Medicare will not certify any new physician-owned hospitals. But we’re starting to see hospitals formed by physicians who say, “You know what? That’s just fine because I’m not looking for Medicare certification because I don’t take Medicare.” So they’re creating these cash-only hospitals with very nice competitive price lists who the only thing they have to compete is on service and price and satisfaction. And we’re starting to see more and more doctors saying, “You know, I don’t care if I only have 20% of the patients I used to have, that’s fine with me because I’m going to practice the way I want to and with the decrease in my overhead costs, I’m probably going to be financially as well off if not better.” And so what’s going to start to happen is more and more Americans are going to find they’re waiting weeks to see a non-doctor for primary care, they’re going into the hospital and waiting weeks because the hospital’s all backed up because no private cardiologists are going to do stress tests anymore, so they’re going to send them all into the hospital, there’s only so many the hospital could see at a time, so there’ll be waiting lists for things that used to be routine, and then they’re going to cost a lot more, and their insurance premiums are going to be going through the roof because of the increased cost. And more and more people who are able to are going to say, “Screw this, I’m not doing this, I’m going private.” And we’re going to see gradually develop this private system. Meanwhile, as more and more of the people who want to pay for service and for personal attention leave the government-run system, the government-run system’s going to become more and more burdened with everybody else, which is going to make the cost go up more and more and more and it’s going to die, it’s going to collapse.
Bob Zadek: And it’s going to totally collapse. So what we’re going to see is, we’re going to see—and this almost gives you goosebumps because we’re going to see the free market system, which will not allow itself to be crushed by Obamacare. Obamacare will be—and this will be like Atlas Shrugged too. The everybody will—and I know Jeff you’ve written about this—the doctors will simply go Galt.
Dr. Jeffrey Singer: They’re going Galt already. And then if the government tries to do something about this two-tiered system, like they tried to do in Canada, I doubt that the United States Supreme Court would rule any differently than the Canadian Supreme Court and say that you can’t prevent a person from using their own means to seek their own healthcare, nor can you penalize a person for providing it. So that’s what’s going to happen.
The IPAB: The “Death Panel” of Payment [74:26]
Bob Zadek: Now, we have only a couple of minutes, but when talking about Obamacare, we have to talk about what I think is the scariest element of Obamacare, far and away the scariest. And that’s the IPAB. Now, the audience, my audience I suspect knows a little bit about the IPAB, the Independent Payment Advisory Board. But when you hear that phrase, anybody out there, you better—it should scare the bejesus out of you. This is—I don’t want to sound alarmist or silly, but when you remember with Obamacare, there were references to “death panels,” a pretty silly expression. But when they feared death panels, and this is not quite a death panel, what they were talking about is the Independent Payment Advisory Board. That sounds so neutral, but Jeff, it is so scary.
Dr. Jeffrey Singer: Yeah, actually, it’s also being challenged on constitutional grounds. But basically what it does, the idea was that in order to keep costs down, this board of 15 appointed individuals by the President will make—they’ll review quote-unquote “the evidence” and they’ll make recommendations to Medicare, of course, and then all the insurance companies follow Medicare’s lead. What—the way they’ll do it, they’re going to ration care through payment. That’s why technically they’re correct when they say, “We’re not going to ration care. We’re going to advise what Medicare should pay for something.” So for example, if they think that a particular service is not cost-effective, like for example, let’s say a total hip operation in someone over 70, or dialysis for someone over 65, which is denied to people in England, for example, because the cost-benefit ratio to society they don’t think it’s worth it.
Bob Zadek: Even though it’s worth a great deal to the person getting it.
Dr. Jeffrey Singer: Exactly. So what they’ll do is the Independent Payment Advisory Board will advise Medicare to drop the payment for that so low as to basically discourage providers from doing it because it’ll penalize them, it’ll cost them. So technically, President Obama was correct when he said it’s not right to say that the IPAB is going to ration care. It’s not rationing care at all. It’s just advising payment. But that’s the way it’s going to do it. Now, the way it was set up is questionably unconstitutional because the law—
Bob Zadek: Because Congress can’t overrule it.
Dr. Jeffrey Singer: Yeah, can’t overrule its decision. And by the year 2017, it cannot be dissolved.
Bob Zadek: That’s right. And let me just expand upon that, Jeff. What Obama did was, this is the most controversial part of Obamacare, the Independent Payment Advisory Board. And Congress, in their utter insanity and total abdication of their responsibility, in the statute it says a future Congress cannot eliminate the Independent Payment Advisory Board except during a three-month period in 2017. Now, there’s a question whether one Congress can limit what another Congress can do. There’s a question whether that can be effective, but it’s on the books right now.
Dr. Jeffrey Singer: And it’s not subject to judicial review or congressional review, which again is constitutionally, you know, questionable.
Bob Zadek: And so imagine if you are 65 and you have Medicare and you want dialysis, which is of course fearfully expensive. You are told you cannot have it. That is, you can have it if you can pay out of your own pocket, but Medicare will not pay for that. And you say why? And they say, “Well, we made a calculation that people over 65 are not worth the effort.” And so you are told that’s it, you’re on your own. Either you sell your house, cash in all your belongings and pay for your own dialysis, or you die. And that’s because 15 unelected bureaucrats in Washington whom you will never meet have decided your life isn’t worth the money. That is IPAB.
Dr. Jeffrey Singer: And the rationale, to be fair, they felt that if the IPAB was subject to congressional or judicial review, then it would never accomplish anything because the politicians would—the dialysis centers would make sure they always paid for dialysis. Right. But in their wisdom, they said, “Let’s take any political pressures out of this by making it sort of like an inquisition panel where it’s totally independent.” That’s why it’s called independent. Independent of anything, of any—nobody can stop it. Its word is the last word, like the Grand Inquisitor. But that was their rationale behind it. That’s frightening.
Bob Zadek: And they make a decision not what—and Jeff, we’re going to end with where we started, where the doctor in effect is denied the ability to provide for his patient what is in the best interest of that patient. And the doctor is going to be forced to follow the edicts of the IPAB and practice according to the protocols and guidelines that are drawn up by these different committees in Washington, so-called evidence-based protocols. And they’re going to be employees increasingly of hospitals that are going to be penalized unless they get their doctors to follow these guidelines and edicts and meet certain quote-unquote “benchmarks.” And that’s why more and more doctors are going Galt. And more and more doctors are retiring way ahead of their plans to retire because they don’t want to be part of this world. And I tell when people ask me why are you planning to retire in just a few years way ahead of schedule, I tell them because I love medicine too much to want to be a part of that world that’s going to exist in a few years.
Bob Zadek: I went to an orthopedist just on this past Thursday who was totally non-electronic. I mean, we’re talking fax machines, Post-it notes. He wrote down, he took my history while leaning on examination table with a ballpoint pen. And I asked him, “How come you’re not electronic?” He said, “Well, I can survive the first 1% fine, but after that, I may just retire from medicine. I just am not going to do it.” And here’s a doc—and also his observation was, he did a lot of expert witness work. And he said, “When I do expert witness work and the doctor whose work I’m examining for the purpose of testimony, if he keeps electronic records, they’re useless to me. I have to look at the paper records, which are always disorganized.” So the question—the point is, medicine will survive, will come back to a free market system, and Obamacare, which has the potential for destroying the private practice of medicine, will like the forest fire give birth to a thriving private practice. Thanks so much for Jeff Singer joining us for the 90-minute show. I’ll be back next two weeks after Fourth of July weekend. Thanks so much for listening.