I Love the Duplicate

A health system CEO on the day Washington finally found the waste, and it turned out to be a physician.

They found it!

After all these years. After every commission, every hearing, every white paper ever written about the cost of American medicine, Washington finally found the waste.

It was a physician.

Specifically, it was a physician who looked at a patient, understood what was wrong, and then treated it. In the same visit. On the same afternoon. One trip for the patient. One appointment. One parking fee.

They are going to pay him half for the second part.

I want to make sure you understand the crime, because it is subtle, and it is the finest thing I have read all year.

A dermatologist sees a woman. The patient is seventy-eight. She has driven forty minutes to get there. He examines a mole, does not like the look of it, and removes it right then, while she is already on the table, so she does not have to come back. He evaluated her and treated her in one visit.

That is the duplicate.

That is the redundancy the United States government has spent a decade hunting. Not the tower. Not the spread. The mole. The efficiency of a physician who did two necessary things for one frightened woman in a single hour, instead of making her return on a Tuesday.

So the most expensive thing he did that day will be paid in full.
And everything else he did will be paid at half.

Let me be honest about something.
I was never afraid of this rule.
Not for a single second.

Do you know why?

I read which rule it was in.
There are two rules.

There is the rule that pays the physician, and there is the rule that pays the building. This cut lives in the rule that pays the physician.

My facility fee lives in the other rule.

My drug spread lives in the other rule. My site premium, the one that lets me collect four times as much for the same scan because it happened under my roof, lives in the other rule.

Everything that pays the physician was placed under examination.
Everything that pays me was placed safely next door.

It was all quarantined, one rule over, in the room where the word duplicate is not permitted to enter.

Sit with that word a moment.
Duplicate.

I collect a facility fee, and a professional fee, and a drug margin, on the same patient, in the same hour, in the same building. Three fees, one visit. If duplication were a sin in this country, I would be the cathedral.

But the efficiency logic never came for me. It had a door, and it walked down the hall, past the hospital, past the health system, past the tower with my name on the side of it, and it knocked on the office of a dermatologist who owns nothing but a table and a light.

Doors do not do that by themselves.
Somebody built the hallway.

Not me, of course.
I merely walk through it.

I have two friends. You have met them before, though I will not name them here, because naming them is beneath the friendship.

They are the two associations who, some years ago, made certain a physician could never again own a hospital. One paragraph. An entire class of competitor, frozen where it stood.

They have simply moved down the hall.

First they made sure the doctor could not own the building.
Now they are making sure the doctor cannot afford to work outside of one.

The ownership rule froze his walls. The payment rule cuts his hands. And when he finally gives up, exhausted, and comes to me looking for a job, I will be there, with a contract already drawn.

That is not a coincidence. It is a pincer. And I did not have to design it, because it was designed for me, by people who love me, in a language patients will never read.

Now here is what makes this one vintage.
They did it in the name of your health.

There is a television doctor running Medicare and Medicaid now. There is a Secretary above him who stood in front of the entire country and promised to make America healthy again. Healthy. Again.

And this is how.

A frail woman of seventy-eight, who could have been evaluated and treated in a single visit, will now have the pleasure of coming back a second time.

A second drive.
A second forty minutes each way.
A second copay.

I find it rather beautiful. We used to make her heal in one appointment, like an animal. Now she gets two. Two visits with her doctor, in a nation that loves her. What could be healthier than more healthcare.

They will call the one-visit version the abuse.
They will call the two-visit version the reform.

They will say it in the vocabulary of wellness, from an administration that ran on healing the sick, and I will stand in my lobby and marvel at how much they have done for me while telling you they did it for you.

And do not comfort yourself that this only touches the independent ones.
That is the last thing I love about it, and it is the coldest.

The doctor who already surrendered, who sold his practice and took the badge and the parking space and the employment agreement, he eats this too. His pay is built on a formula wired to the very rates this rule cuts. When Medicare pays less for his work, the formula pays him less for all of it. Every patient. Every payer. All year.

He gave up his independence to be safe from exactly this.
And I still get him.

The independent doctor loses his collections. The employed doctor loses his compensation. And I own the formula that does it.

Both hands. Same man.
So yes. I love the duplicate.

I love that a country drowning in facility fees and drug spreads and site premiums went looking for the waste, and came back holding a dermatologist.

They spent ten years hunting duplication in American medicine.
And they found it in the one place it does not live.

The physician who did two things well, in one visit, for one patient, and had the terrible judgment to be efficient.

-Rojas out.