Bad Outcomes

Doctor Shortages, Surprise Medical Billing, Medicare Fraud, and Papa John

The Crisis of Care

This week’s newsletter is going to be about America’s health care system. Sound fun? For those of us fortunate enough to be healthy, we probably do not think about health care all that often. I’m of an age where I have to pay attention to my health, but I don’t have any chronic conditions, don’t take expensive medication, and don’t visit the doctor often. However! This is always subject to change. I will eventually get old. I will need to go to the doctor. I will develop illnesses. It’s going to suck.

What makes it suck much worse for Americans is our byzantine system of doctors, hospitals, and insurance companies. If you pay for health insurance, you will be healthy, and have good access to care. Right? Sometimes your employer pays for your coverage, sometimes you pay for it yourself. There is the expectation that if you get sick, you will have access to treatment. If you need to buy medicine, it will be affordable.

However! This is not the reality for a lot of people. If you are poor, or you live in the wrong town, you may not have easy access to medical services. If your insurer decides they don’t want to cover your medicine, it is not easy to switch to an insurer who will. I don’t think you’ll find many people outside of insurance company boardrooms who think our system works properly.

Merely breathing the word “inefficient” is enough to summon the most sinister of demons - the tech entrepreneur. They don’t see our broken health systems as a factory of human misery and think the government should step in and fix it - they see a business opportunity.

Molly Osberg has written a fantastic piece for Jezebel about these technologists and venture capitalists, who have descended on the rotting corpse of our nation’s safety net like turkey vultures:

This week, it was Tend, the dentist’s office that is miraculously also a “studio” and a “dental wellness brand,” where patients brush with Italian Amarelli licorice toothpaste and arrive to find their favorite HBO dramas pre-loaded on a screen. For its expansion it brought in $36 million late last year. A few months ago it was Parsley Health, the functional medicine startup that operates outside the indignities of the insurance system. “Primary care is broken,” according to its founder, and the solution, as rendered by Parsley, is a whole-body approach that includes microbiome and genetics testing.

As I say often, there is a fine line between marketing and fraud. There is an argument to be made that offering supplemental services for things not covered by standard health insurance is okay. Paying a little extra to go to a dentist with nice tablets? Sure, that’s fine. Forking over some money to get some handwavey genetic testing to see if you’re going to die from a rare disease in twenty years? It’s your money. When you start telling people that the care your company offers is superior to that offered by a standard physician? My scam senses start to tingle.

Rather than rant about all the ridiculous “lifestyle” start-ups masquerading as health practitioners, I want to talk about how our system of care got to this point. We don’t often talk about this, because we’re busy talking about ways to fix things.

First off, a confession - I have used a concierge doctor. When I lived in Vancouver, I signed up for a service. If memory serves, it cost around $200 a month. The primary benefits were that you could consult with your doctor via email or the phone, and they had a 24-hour turnaround for appointments. They offered other services like nutrition consulting, and gave me a stress test. At the time I was young, healthy, and didn’t really need the service, but I could see the value for older patients with ongoing health issues or chronic conditions that required specialized treatment.

However! Canada has socialized medicine, so the doctor visits and procedures were paid for by the government. I was essentially just paying for VIP service, and a doctor I could call or email. In the US, many of these concierge services are additional costs on top of our already expensive health system, they do not cover insurance co-pays or procedure costs, and some of them are entirely exempt from insurance - the patient pays full boat for all services. As Osberg argues, what this does is create a caste system for “good” health care - it’s not a secret that the rich live longer, and this due in part to better care options.

America spends more money per capita than any other country in the world on health care, nearly 20% more than second place Switzerland. Where does the money go? Mostly to doctors and hospitals, the government says:

Health care, where did it go?

Let’s talk about those hospitals and doctors. The reason I’m writing about Osberg’s article is that it brought to my attention a problem I didn’t even know existed - how our current system has cut access to primary care doctors, and is exacerbating a doctor shortage.

77 million. The estimated number of people in America who do not have access to a primary care doctor. An additional 30,000 doctors are expected to retire over the next five years, and many will not be replaced. Down the rabbit hole of writing about the primary care crisis I came upon this article which talks about why this is a problem:

There is strong evidence that people who have a primary care provider enjoy better health on average than those who do not, even after adjusting for patient demographics. New data suggest that a small investment in primary care would yield a six-fold decrease in Medicare services and an overall 2 percent drop in total Medicare costs.

And some of the root causes:

Why are we seeing this decline in primary care providers in this country? First, the number of residency slots is increasingly weighted toward specialties, not primary care. Some medical schools send not a single student into primary care; many teaching hospitals train no primary care physicians. Second, primary care professionals are paid approximately half what specialists earn.


Medical students also avoid primary care after watching primary care physicians struggle with short patient visits, large patient panels, increasing administrative burdens imposed by electronic medical record keeping and quality metrics, and significant night call responsibilities, all of which are disproportionate to the burden on specialists. Visits last no more than 15 minutes on average, and some providers see as many as 40 patients a day to pay for their overhead and medical school debt, which today averages about $190,000. More than 50 percent of primary care providers show objective evidence of burnout.

To sum up - primary care doctors are paid poorly, work harder, and are given less resources to do their jobs. I can’t imagine why there’s a shortage! When the average medical school debt load is almost two hundred grand and it’s difficult to even get accepted, you can see how the problem has been compounding for years. Our perversely incentivized health system pays the most money to people who treat the problems (specialists) and punishes those who try to prevent them (primary care doctors).

Concierge medicine is further exacerbating the doctor shortage, because now primary doctors have another job option - they can work less hours for similar or more pay at a VC-funded clinic, and treat only healthy, wealthy people. It’s easy to see why many doctors are making the jump, which is only making the shortage worse.

It also frees doctors up to cater to cases of affluenza:

Parsley centers a suite of tests—genetics, comprehensive hormone analysis—that will get to the root cause of symptoms from brain fog to asthma to bad skin. These are doubtlessly committed doctors, practicing medicine in good faith, but it’s hard not to notice that as 45,000 people die every year from lack of adequate care, the market has developed the attitude that people with resources are sick in more interesting or obscure ways than everyone else.

Preach! Insurance coverage aside, lack of access to primary care is a serious problem. Even if President Sanders were to convert us all to single payer tomorrow, it would take decades to train up enough new doctors to fill the existing holes in the system. Since I’d prefer to end on a positive note, Peter Bauhaus makes a compelling argument in Real Clear Health:

There is increasing support from researchers, analysts, federal agencies and health policymakers, for the idea of using [nurse practitioners] to fill the void left by the lack of primary-care physicians. This would also improve the uneven geographic distribution of primary care.

Unlike doctors, the number of NPs is growing, and is set to double within a decade. Giving them primary care responsibilities, along with unfucking our ridiculous health care system, could put us on a road to providing health care as a human right to everyone.

Just kidding about ending on a positive note - did you know that you can pay for VIP access in hospitals? Aaaahhh!

Best Health Care in the World

Since we’ve talked about access to care, let’s keep the train moving and talk about quality of care. Story time! Two years ago, I went to the doctor because I was having occasional heartburn. I was referred to a gastroenterologist, who - after spending maybe 5 minutes speaking to me, and ruling out any food allergies…somehow - said I should get an endoscopy to make sure I didn’t have an ulcer or throat issues. I said sure, and went through with it. They didn’t find anything wrong, and I got a prescription for a daily stomach medicine. No big deal, right?

Well. Not long after I received a bill for $4,000 for the procedure. Why? My insurance company had decided that the procedure wasn’t medically necessary. Because they didn’t find anything wrong. Had they found an issue, I assume, it would have been covered. Cool! The GI doc did not inform me of this, and I hadn’t thought to ask. I had good health insurance, and I’d only had a couple of minor surgical procedures in my life. Conveniently, my out-of-pocket max was $5,000, so I had to pay the entire amount myself.

I could have paid the full amount, but decided to pay it over a year on my credit card out of spite. I put it out of my mind, until 9 months later when they started sending me bills for $1,100 in the mail. I ignored them, assuming my auto-pay would take care of it. Then, I got a collection notice.

It turned out the credit card I’d used for auto-pay had expired and been replaced, so the payments started failing. Despite the hospital having my phone number and e-mail on file, and my file on their internal patient system, no one ever contacted me about it. They simply sent me to collections after I ignored two pieces of mail.

When I called the collections company, the guy on the phone was able to take 20% off my bill, without me having to ask. He just offered it. So I saved a couple hundred bucks, in the end.

To sum up - my insurance refused to pay for a procedure a doctor told me I needed because it didn’t find anything wrong, then the hospital billing department sent me to collections rather than calling me to update my credit card number, and the collections company gave me a 20% discount on the remaining balance on my bill. The hospital cared so little about receiving 100% of what I owed them that they sold my debt to a third party at the first possible opportunity, taking cents on the dollar, and that company turned around and took even less from me. I should have just refused to pay out of the gate and saved a thousand bucks. What a stupid fucking system.

The reason I bring this up is “surprise” billing is in the news once again, with a new AMA study finding that a fifth of patients who undergo elective surgery receive unexpected bills for the procedure. Olga Khazan for The Atlantic explains:

And now, a new study published in the Journal of the American Medical Association has found that surprise bills might be even more common than previously estimated: They happen about a fifth of the time that a patient has an elective surgery at an in-network hospital with an in-network surgeon. Having a surprise out-of-network bill raised the total bill by an average of $14,083. The dollars racked up while many patients were unconscious, and an out-of-network specialist simply walked into the room.

Even for patients who pick an in-network surgeon and hospital can be billed by specialists who are out-of-network. It isn’t limited to the operating room, either:

…though this study highlighted anesthesiologists and surgical assistants, surprise bills can also come from out-of-network pathologists, who analyze tissue and blood samples, or radiologists, who examine X-rays and MRIs. No matter who the surprise bills come from, “you don’t pick these people. You don’t know them,” Pollitz said. “You learn their name when the bill comes.”

This is an extremely American Health System set of problems. What are the causes? It appears to be the standard blend of bad government policy and vulture capitalism:

The risk of getting a surprise bill was higher on Affordable Care Act exchange plans compared with other plans, possibly because Obamacare plans have so-called narrow networks, with fewer participating doctors to keep costs down.


It could also have to do with venture-capital companies investing in physician practices, Pollitz said, and reasoning that “if you don’t accept many or any insurance networks … you can bill whatever you want.”

It reminds me of last year’s story about the aptly named Zuckerberg San Francisco General Hospital that was forced to change its billing practices after Vox reported on their exorbitant out-of-network costs to patients:

The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.

The theme here, and in our health system as a whole, is exploitation of people in a vulnerable state. When you have just been in a bike accident or have had a heart attack, you cannot reasonably be expected to tell the ambulance to take you to an in-network hospital. When you’re lying on an operating table under sedation, you literally cannot direct your doctor to only use in-network surgical assistants. As my story shows, many of these providers engage in patient gouging with the expectation they won’t receive anywhere near the amounts they’re charging - for them, it’s just a numbers game. Charge enough people $4,000, and enough of them will pay it to cover your boat payment and country club dues. The ones who don’t? Fuck em, let the predatory collections agencies sort em out.

It’s Always the Elderly

We’re not done yet! Let’s look at a story from last year about a vast conspiracy of incredibly shitty people to defraud both Medicare and the elderly:

Federal prosecutors on Tuesday said they dismantled one of the largest health care fraud schemes ever investigated by the FBI, charging 24 people in a $1.2 billion alleged scam involving telemedicine and durable medical equipment companies.

As part of the complex operation, doctors got kickbacks for prescribing unneeded back, shoulder, wrist and knee braces to elderly and disabled patients and charging the government's Medicare program, the Department of Justice said.

In this scheme, offshore call centers contacted Medicare recipients and convinced them they needed medical equipment. “Straw” doctors would write prescriptions without meeting the patients. The braces would ship, and the manufacturers would split the profits with the telemarketing firms. Somehow this netted them over a billion dollars which they laundered through shell companies and bought - of course - exotic cars, yachts, and luxury real estate.

They received $500 to $900 per brace, paid $300 in kickbacks to the manufacturers, so they sold millions of these unnecessary braces. Unbelievable. It does bring up an uncomfortable question about what happens when we eventually drag our country into something resembling socialized medicine - we still need private companies to manufacture braces and other medical equipment. Doctors may still have significant financial incentive to prescribe things that are not medically necessary, whether it’s via kickbacks or the money from repeat patient visits. Medicare is arguably the most successful government services program ever enacted, and it’s still losing billions a year to shady fucks! The agencies in charge of the program do appear to be doing a good job at combating fraud and theft, but it’s an uphill battle.

Access to care is critically important. Quality and cost are real issues. Waste and fraud is a reality we have to deal with. Going into an election year we have to decide, as a country, if the mess we currently live with is good enough. I don’t think it is.

Also, while the $1.2 billion fraud was impressive, it wasn’t as big as Senator Rick Scott’s Medicare fraud. He’s still got the crown.

Say it Ain’t So, Papa

John Schnatter

Normally this would be Short Cons material, but I just had to roast this bozo. In an incredibly sweaty interview back in November, “Papa” John Schnatter claimed he’d had 40 pizzas in 30 days. He also said this about the new CEO of his pizza chain:

"He has no pizza experience. He has never been in the pizza category. He doesn't really know quality. Probably most important, he doesn't have a passion for people."


"My metaphor is: There's no reason to be in the car when the car crashes even if you love the car,"


"Stay tuned. The day of reckoning will come," he said. "The record will be straight."

Well, Papa, it seems the record has been straight, and you have some explaining to do, buddy!!

Schnatter explained on the H3 podcast that when he said he’d “had 40 pizzas in the last 30 days,” he did not mean he was eating entire pizzas, rather he’d had slices from different pies.


Schnatter said that he still eats about eight or nine slices of Papa John’s per week, down from 12 to 15 when he was still in charge of things. With his decreased consumption, Schnatter would be averaging about four eight-cut pizzas in 30 days.

Four pizzas in 30 days? Get this weak shit out of here. Also worth remembering that Schnatter was ousted from his company for being a racist and a shitty boss. No one should feel bad for this rich, sweaty, bigoted dumbass who only eats four pies a month. He’s not in the pizza category.

Short Cons

Vice - “DoNotPay, the family of consumer advocacy services meant to protect people from corporate exploitation, is launching a new app aimed at helping end our long national nightmare surrounding robocalls by giving you a burner credit card to get their contact details then giving you a chatbot lawyer to automatically sue them.

WaPo - “And as the police in Florida’s Panhandle began examining the inside of the Kia sedan, they came across two bags helpfully marked “Bag Full of Drugs.”

Tips and bags full of drugs to