Keefe, Campbell & Associates, LLC

Editor’s comment: The American health care expectation is

• Unlimited,
• 100%-paid-for,
• On-demand medical care.

If/when you offer medical health care coverage, the richest and poorest of our citizens don’t just expect such treatment; they are fully prepared to openly and regularly demand it. We feel American citizens of all strata are geared up to make the clarion call of “off with their heads” to any politician, editorial writer, health care insurer, physician, attorney or miscreant who doesn’t wholly and intrinsically support that level of coverage whenever any kind of health care is offered to a U.S. citizen.

If you don’t know it, this precise business/health care model is codified in the Illinois Workers’ Compensation Act. The Illinois Workers’ Compensation Act has no defined limitation on the amount, nature or duration of medical care recommended by a treater to which the injured worker is willing to consent. None. Please don’t mumble anything about the hilarious “two-doctor” rule in Section 8(a-3); that rule is only a potential limitation on rookies or the non-initiated. Any Illinois physician, hospital or health-care provider worth their salt knows you need referrals to keep the “two-chains” running to the end of any selected path of care. If you have referrals in the medical charts, you have unlimited, 100%-paid-for, on-demand medical care codified for Illinois’ injured workers.

If you aren’t sure about the infinite provision of health care in this state at the sole cost of Illinois business, your editor handled a claim where a physician provided about $50K in relatively worthless injections to a claimant’s neck, shoulder and wrist. The patient admitted the “benefit,” if any, of the wildly expensive injections, lasted for a few scant minutes. When we deposed the doctor, he admitted he needed to stop the injections and the patient had undergone more than enough of such care. Following his deposition, in direct contradiction to his own opinions, the physician then provided another $50K in additional injections!! Our Commission and reviewing courts sanctioned all of it to the chagrin of your editor and his client. If you need a copy of the ruling, send a reply.

We want our President to understand unlimited, 100%-paid for, on-demand medical care would work, if we lived in paradise. On this grubby, dusty, imperfect planet, it is certain to bankrupt our society. If they don’t plan ahead, that “bankruptcy-thing” is coming sooner, rather than later.

We are petrified, truly scared-to-death to see the U.S. Government think they can “control” this monster. The special interests are spending billions as you read this to carve out their own little piece of what may be a giant federally-run pie. Within five years, we expect to see total chaos and skyrocketing costs—some folks peg the annual cost to be two trillion dollars per year. That is $2,000,000,000,000.00. Each year.

The current federal debt is a staggering $11.5 trillion — equivalent to over $37,000 for each and every American and one short guy from Croatia. And it’s expanding by over $1 trillion a year. The new health care initiative could triple that debt load.

We also point out every time our federal government tries to take over a business operation; they butcher it to the point of high comedy. We think the only thing the government does even reasonably well is to collect taxes. They do that solely to survive. They don’t have to “survive” in doing anything else.

Therefore, in our view, every other federal business operation could be run better by a sixth-grade class. Consider the creaky rail system, the inefficient postal service, the rapidly-becoming-bankrupt Social Security Administration. Consider the fact the U.S. Government still has elevator operators where all elevators have been running automatically by pushing one of those easy-to-read buttons for about four decades. If you don’t believe us, take a look on the web at: http://www.usajobs.org/listjobs/jobs/80497127/Elevator%20Operator.htm.

When someone starts talking about great presidents who were Republicans or Democrats, we point out Jack Kennedy, Lyndon Johnson, Dick Nixon, Gerry Ford, Jimmy Carter, Ronald Reagan, Bill Clinton, George Bush (H. and H.W.) and Barack Obama all ran or run governments that had elevator operators long after such work was completely automated. It is not possible to claim to run an efficient government when you have to admit you are using taxpayer money to pay people to push buttons and ride up and down all day like morons in new-fangled elevators. Only the shadow knows how many other ways the federal government is blowing money.

Trying to understand what a mess unlimited, 100% paid for, on-demand medical care means:

• We have one claimant who has literally been treating for her entire adult life.
• She is in her mid-fifties.
• She has had over twenty surgeries, many of them major.
• Some of them are arguably “related” to work, some of them are not.
• She is always getting ready for surgery, recovering from surgery or trying to find another area that needs surgery.
• Medical care for her is well into the millions—the cost has been split between various health care insurers and workers’ comp policies.

• We have another claimant who has had at least 40 surgeries to her internal organs.
• She injured her low back in the earlier 1990’s.
• Medical care is well into the millions and is still cooking with a “pain physician” recommending lots more.
• The most recent MSA value is well over $500K.
• We inherited the file about six months ago; the case is almost two decades old and still pending.

These sorts of folks have to be reined in with some meaningful objective guidelines. If the feds aren’t prepared to slow them down and sign up for all of it, the taxpayers better start expecting giant tax increases.

Looking at these folks from the perspective of Illinois WC, it is our assertion that, if a nutty claimant had the “right” claimant lawyer in front of the “right” arbitrator, they could legally “force” an Illinois employer or insurance carrier to pay for such unlimited medical care. The only limitation would be on the interest level of the claimant lawyer who would eventually grow tired of the game and tell the claimant to settle so they would be paid for their patience and efforts.

Most Illinois employers don’t like the basic IWCC model that controlling otherwise unlimited medical costs is left up to non-medical professionals who may become friends with or at least cordial to the many attorneys who appear before them. We don’t care if it is Republicans, Democrats or Independents; we are going to need some clearly defined way to control skyrocketing medical costs. We need it in Illinois workers’ compensation and we are going to need it in the federal health care system.

We think the best possible concept is utilization review. We learned about it from a claimant attorney who brought it to our state. We are certain UR is controversial, like the so-called “death panels” that are being ballyhooed in the press. But you have to draw a line somehow and somewhere. Medical care has to be limited in a fair and impartial fashion. If you have a concept better, faster and/or cheaper than UR, please send a reply and we will share it with our readers.

Editor’s comment: While looking up other things, we found an amazing article about medical cost controls that brings up chilling and crucial thoughts for doctors, hospitals, nurses, risk and human resources managers and everyone involved in the workers’ compensation and group health care matrix.

We are confident, medical costs are rising and are certain to continue to escalate. If you note our earlier articles about spinal fusion surgeries in this state now being billed at $75,000 to $300,000 for hospital costs only, you can readily see medical costs are clearly outstripping all other costs in the workers’ compensation arena. We have a number of pending claims where the main fight is claimant wanting full payment of 100% of the costs of such surgeries from their employers under the WC and not group side.

U.S. health care costs have grown from what was about the middle of the average of OECD countries (Organization for Economic Cooperation and Economic Development) to what is now double the average. The surprising thing here is during the last ten years, the increase in workers’ compensation medical costs is twice the rate of group health increases.

The National Council on Compensation Insurance or NCCI has demonstrated the rise in workers’ compensation medical costs is due to lack of utilization review in workers’ compensation systems, leading to over-utilization of health care services, especially those for nagging and chronic soft tissue claims. This problem is a crucial stage in Illinois that brought in UR but sometimes sporadically uses and enforces.  As we have told our readers, the “wise guys” who have a controlling say at the Illinois Commission don’t want it and feel it is bad for their business.

An observer named Atul Gawande, M.D. has published a must-read article in the June 1, 2009 issue of The New Yorker. He has demonstrated even more convincingly over-utilization of medical services, including testing, surgery and hospitalization, is the main cost driver of America’s health care system.

Dr. Gawande’s lengthy article, The Cost Conundrum, provides a clear position for why costs in the U.S. are becoming so wildly high, but outcomes remain mediocre. Dr. Gawande reduces the problem to its simplest terms. He outlines the American health care system has turned the medical profession into assembly-line work that focuses on lots of care at a spiraling cost. He states our physicians in primary care and specialties are economically incentivized to over-prescribe in all areas. He also clearly shows, the areas of the country that produce the highest costs due to over-prescribing also produce the poorest health care results.

Dr. Gawande analyzes health care in relatively rural McAllen, Texas, a town in a Texas county with the lowest household income in the U.S. He notes after Miami, this county has the second most expensive health care costs. Dr. Gawande wanted to know why. He also wanted to compare and contrast health care costs in El Paso County, eight hundred miles to the north with similar demographics that were 50% lower.

Dr. Gawande also analyzed the Mayo Clinic in Minnesota with some of the best medical technology on the planet and why it produces some of the highest quality medical care in the nation but has costs that rank in the lowest fifteen percent of the nation. He was also fascinated with why Mayo Clinic was able to replicate that amazing achievement when it opened a center in Florida that has one of the country’s highest cost states.

Dr. Gawande noted when he found excellence around the country, doctors worked together in teams. All of the doctors continuously peer-reviewed each other’s work. In low-cost, high-quality areas, physician income was somewhat neutralized; there was only a limited amount to be made. At Mayo Clinic, for example, doctors are all on salary and didn’t make more or less, no matter how much care was provided. Whether they order ten procedures or none, Mayo Clinic physicians and care-givers are paid the same. This is central to understanding how to fix the problem. As Gawande writes:

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care.

The Cost Conundrum, by Atul Gawande, should be required reading for anyone interested in understanding and participating in American health care reform.

The link is http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all. A bio on Dr. Gawande is at: http://en.wikipedia.org/wiki/Atul_Gawande

We appreciate your thoughts, comments and concerns; please send a reply.

Editor’s comment: What government program is run “well?” How do you like the U.S. Postal Service that is now hemorrhaging money? Does anyone feel the Social Security Administration operates efficiently? Do we all understand Medicare is presumed dead within a decade?

Try to imagine a truly poor person, let’s say a bag-man or bag-lady in Chicago. They don’t want to sleep on a park bench or under a bridge in January. If they have a sore back or a painful shoulder or demonstrate psychiatric impairment (what bag-person isn’t somewhat impaired?), they may soon be able to go to a hospital and have the government provide three square meals and a warm bed and round-the-clock care. Someone please tell me how to eventually kick them out of the warm hospital into the cold or snow? Utilization review? By a government worker whose job it will be to spend our tax money?

We will all have to keep a watchful eye on that issue that may be coming to a medical institution near you shortly. Some observers are telling us the program cost will exceed $2 trillion dollars we simply don’t have.

On the WC side, as our nation edges closer to universal health care, the implications for workers comp are both profound and troubling. Policy makers in Washington may be inclined to ignore the special needs of the workers’ compensation community and create problems for employers, insurers, TPAs and hearing officers who deal with comp issues.

There are a number of key reasons why reform of health care may undermine the ability of states to deliver a quality workers’ compensation system.

• The overall goal of the broader health care system is to preserve the life and health of individuals and families. This system provides treatment from conception up to the moment of death.
• In contrast, the workers’ compensation system provides treatment only to workers who are in the course and scope of employment.

• The general health system provides defined services to individuals and families. Virtually any illness or injury is covered, including many forms of mental illness.
• In contrast, workers’ compensation covers only what occurs during work and is proven to be work-related, with an almost phobic disregard for mental impairments.

• In the broader health care system, premiums for coverage are paid by individuals and their employers. Depending upon the plan, individuals and their family members assume at least some of the cost of treatment, through premiums, co-pays and deductibles.
• In workers’ compensation, employees never pay premiums and are never charged co-pays or deductibles. Thus, only the employer who purchases mandatory coverage and their insurer has the incentive to control costs. We are seeing a tremendous fight in Illinois over who gets to control medical costs—claimant attorneys or the employers. That fight will continue for years to come.

• The new mandates for health insurance coverage come from Washington, D.C.
• Workers’ compensation, in contrast, is strictly a state program. New federal mandates (for example, total and unfettered patient choice of doctor) may well conflict with long-established state systems.

Ultimately, the new direction for federally run health care may be driven by cost and coverage. Whether the providers are public, private or both, health care cost controls and rationing will lurk in the shadows: will there be a cap on total expenditures for any given individual and any given conditions? Will there be limits on end-of-life services? How much of the costs will be shifted to consumers? What incentives can or will be created to try to reduce utilization that we predict will run costs to the breaking point?

In contrast, workers’ comp is and will always remain an early 20th century system. It already provides virtually universal coverage for people who work. The costs belong exclusively to employers and carriers; there is no cost-shifting onto injured workers and there are no incentives for these workers to limit expenditures. The goals are returning injured workers to employment and providing lifetime benefits for the totally disabled.

We are all going to have to wait and watch and see what federal government’s provision of 100%, on-demand coverage of all medical conditions may bring. If they don’t meet that model, the weeping, wailing and gnashing of teeth will be heard ‘round the world. We would appreciate your thoughts and comments on this coming change to our lives and community.

Editor’s comment: We invite our readers’ thoughts and comments on these concepts. In the last week we have learned:

1. A treating doctor actively referred his patient to an attorney to insure the doctor’s medical bills were paid.
2. There is an Illinois mesothelioma physician who is advertising to seek patients with meso while simultaneously telling the world his son; the lawyer will handle their personal injury claims.
3. There is a medical clinic in California that is trying to become a one-stop-shop for workers’ compensation claimants—providing primary post-accident care, recommending surgeons, lawyers, physical therapists, every professional an “injured worker” needs.
4. We had a Petitioner’s attorney direct his client not to see one doctor he was referred to, and then quietly call the primary care physician to have that physician refer the patient to a doctor of counsel’s choice.
5. We reviewed a Petitioner’s attorney’s website where they are actively recommending and thereby advertising their approved list of physicians.
6. We are aware of a number of physicians that donate gifts or money to bar association functions in order to allow their names to be presented at attorney golf outings, dinners or other bar association events.

We note these issues continue to spring up and we want to hear how Illinois business and our various readers think of the many moral, legal and ethical issues raised by these interesting facts. We are certain it is illegal for:

• Lawyers and doctors to split fees or otherwise “kickback” monies to each other in handling the needs of a client/patient.
• Doctors to own diagnostic, physical therapy or other medical facilities and send all their patients to such facilities, and then receive secondary compensation.

The rest of this falls into a strange ethical netherworld. We have no true idea if any or all of this may be both ‘legal’ and ethical—whatever that may mean.

Do you feel:

• A doctor should be ethically able to refer a patient to a specific attorney to allow the doctor to get his bills paid?

Please assume there is no fee-splitting agreement in practice or in principle

The doctor is simply telling all his patients to go to a specific attorney for their legal needs and one of those needs is to get their bills paid.

Please note the attorney may be able to advise the doctor how to get monies for interest consistent with our Act. A sharp Illinois attorney may also be able to get penalties and fees on unpaid medical bills in a fashion considered punitive for the employer or insurance carrier.

• A doctor should join with a lawyer to jointly advertise their respective services for patients/clients with a specific medical condition.
• A doctor or medical clinic should be able to create a list of preferred providers for post-surgical physical or occupational therapy, legal work, vocational counseling or other services?
• It would be a conflict of interest for an attorney to take an active role in recommending physicians/surgeons their clients treat with?

Again, assume the attorney is not making any money in the process but is actively directing patient care. Please also assume the patient and primary care physician is not asking the attorney for such services.

• An attorney can create and promulgate an approved physician panel and advertise such doctors on their firm’s website? Can the same attorney “require” or actively encourage their clients to only treat with certain doctors?
• Physicians can ethically donate to bar association functions to advertise their practices?

On these issues, we don’t have the answers, we just know there are very troubling questions. The defense industry should address all of them and consider rule-making to insure your interests are protected.

We hate to see doctors actively befriending attorneys and then both work together to treat patients in the image and likeness of what the lawyers want done. We also dislike the spectre of treating doctors fomenting litigation against Illinois employers in the workers’ comp setting.

On the other side, we truly feel it is a conflict of interest for attorneys to actively guide or direct medical care of a client by telling them not to see one doctor and then seek referrals to specific physicians or surgeons who are not IME providers. It is no surprise that extensive medical care leads to higher awards and settlements.

Please reply with your thoughts and comments.