{"id":4038,"date":"2025-02-27T11:26:00","date_gmt":"2025-02-27T11:26:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=4038"},"modified":"2025-02-27T11:26:00","modified_gmt":"2025-02-27T11:26:00","slug":"what-would-a-rational-doggie-doo","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=4038","title":{"rendered":"What would a rational DOG(gi)E do(o)?"},"content":{"rendered":"
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By MATTHEW HOLT<\/p>\n

DOGE, or Doggie as Kara Swisher has been calling it, has gone from being a meme about Shiba Inus to a crypto scam to a group tearing the Federal government apart.So I thought I would use the title of this piece to make a joke. Like Musk\u2019s humor it\u2019s puerile and not funny. What\u2019s also not funny is what Musk\u2019s team has done to small government agencies, like USAID & CFPB that really help people, not to mention the irrational firing of thousands of government employees that appear to be screwing up the NIH, the National Parks, the FAA and much more. But it\u2019s all got me thinking, what in health care should an effort to quickly rationalize government spending do?<\/p>\n

Now I\u2019m not proposing that there\u2019s anything OK with the way Musk and his team have been blundering around the Federal government, telling lies about what it does and indiscriminately firing the people who have the most important responsibilities and then desperately trying to get them to come back<\/a>. This has been pure ignorance theater, and it would be hilarious if it wasn\u2019t so damaging. Equally importantly the places DOG(gi)E has started are stupid because they don\u2019t spend much money<\/em>. But the government spends a lot on health care \u2013between two and three trillion dollars, depending on how you count it.<\/p>\n

So if you wanted to save some money and potentially change the system, what would you do? First you\u2019d take a deep breath and get some real data, and improve your understanding about what is actually happening. There are some areas in health care where the issues are well understood and the data is clear and there are others where it\u2019s less obvious.<\/p>\n

Let\u2019s start with a relatively small one\u2013spending on Federal Employees health benefits<\/strong>. Chris Deacon\u2019s Linkedin posts are a constant source of fun and games, and she has been highlighting screwups in the FEHBP administration<\/a> for a long time. Essentially the government via the OPM pays lots of different insurance companies to manage Federal employees\u2019 health care. There is very poor oversight of what happens in those programs and when the OPM\u2019s OIG points that out, not much happens. The plans (including Horizon Blues in NJ and BCBSNC and many others) have been caught being sloppy or fraudulent but not much has happened. All DOG(gi)E needs to do is read the report on the audits<\/a>, or look at what GOA said about $1bn being spend on ineligible members in 2022<\/a> and apply their recommendations.<\/p>\n

Next let\u2019s get into something that requires a little more investigation. In America we buy (and sell) drugs<\/strong> in a mind-bogglingly complex way. <\/p>\n

<\/span><\/p>\n

The 340B program isn\u2019t understood well (here\u2019s an explanation from Blake Madden<\/a>) but is supposed to be a way that safety net hospitals can get paid to dispense drugs. Somehow it\u2019s turned into a slush fund that has $66bn pouring through it, and it\u2019s become a significant source of revenue to many huge hospitals. One investigation said<\/a> the\u00a0 \u201c340B program has offered a major financial windfall to covered entities with little of the benefit targeted toward safety\u2010net providers who care for low\u2010income patients\u201d<\/em>\u00a0 I have heard that some specialty pharmacies within big hospitals make up half of the entire health systems\u2019 profit. I don\u2019t know how much of that is laundered through 340B, but we already have a massive FTC investigation into the PBMs and their practices. We have just begun to buy drugs somewhat more rationally by negotiating directly with drug companies. The Federal government spends a lot on drugs via Part D, 340B, VA, Medicaid, FEBHP and more. Let\u2019s have DOG(gi)E figure that out and come up with a centralized plan that replaces all these different programs. Given the administration\u2019s love for billionaires, I suspect Mark Cuban might help.<\/p>\n

Another area that we need some clarity on is Medicare and Medicare Advantage<\/strong>. As I have whined about many times, there are competing assessments from MedPAC<\/a> and the Medicare Trustees<\/a> on how much is actually being spent on members in Medicare Advantage versus FFS. MedPac has estimates varying from 6-17% more, Milliman\u2019s assessment<\/a> (paid for the by MA plans) is that MA members apples to apples cost the taxpayer less and get more (see their chart below).<\/p>\n

We for sure know that there\u2019s a lot of effort by Medicare Advantage plans to upcode their members and also to deny them care. Hence the current investigations by the DOJ into United<\/a>. We also know there\u2019s a ton of overuse and poor care in Medicare FFS, as well as flat out fraud. But before we make more policy decisions on what is now a near trillion dollar program, wouldn\u2019t it be good to figure out what is actually going on?\u00a0 Wouldn\u2019t that be a great investigational role for DOG(gi)E?<\/p>\n

My last suggestion is to look at the nation\u2019s hospitals<\/strong>. I\u2019ll quote from one of my previous pieces<\/a> here<\/p>\n

Over the last 30 years America\u2019s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a <\/em>chart of 91 health systems<\/em><\/a> with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don\u2019t need me to remind you that many of those systems are guilty with extreme prejudice of <\/em>monopolistic price gouging<\/em><\/a>, screwing over <\/em>their clinicians<\/em><\/a>, suing <\/em>poor people<\/em><\/a>, managing <\/em>huge hedge funds<\/em><\/a>, and <\/em>paying dozens of executives<\/em><\/a> like they\u2019re playing for the soon to be ex-Oakland A\u2019s. A few got <\/em>LA Dodgers\u2019 style money<\/em><\/a>.\u00a0<\/em><\/p>\n

We know that health systems across the country are sitting on huge reserves and hiding what exactly they are doing with that money. Of course their for-profit brethren (HCA, Tenet et al) are extracting even more money from the system and sending much of it back to their shareholders. Let\u2019s recall who is paying for most of that? Yes. It\u2019s Medicare, Medicaid, and employers.\u00a0<\/p>\n

Meanwhile (by historical accident) employers are not being taxed on what they provide for their employees\u2013that alone costs the taxpayer another $300bn<\/a>!\u00a0<\/p>\n

Let\u2019s have DOG(gi)E make all that transparent. Let\u2019s have it examine the funds of the top 100 hospital systems. Let\u2019s have it assess what they are doing with that money. Let\u2019s have them clarify what got paid to them during the pandemic in CARES act funding. If America actually knew how this money was flowing through the health system, perhaps something might get done about it, rather than it being something that bloggers and insiders know is happening but scoff at the ability to change.<\/p>\n

There is some historical precedent for this. In 1941 then Senator Harry Truman created the bipartisan Special Committee to Investigate the National Defense Program<\/a>. Unlike the profiteering we saw during the \u201cwar on terror\u201d, Truman\u2019s WW2 committee was very successful at both hunting down corruption and gave the public faith that the government was spending money wisely. Why can\u2019t we do something similar today?<\/p>\n

If we really believe that we need government efficiency, let\u2019s have proper assessment, let\u2019s have rationality, let\u2019s have transparency. There are lots of places in health care to start.<\/p>\n

Matthew Holt is the Founder of The Health Care Blog <\/em><\/p>","protected":false},"excerpt":{"rendered":"

By MATTHEW HOLT DOGE, or Doggie as Kara Swisher has been calling it, has gone from being a meme about Shiba Inus to a crypto scam to a group tearing the Federal government apart.So I thought I would use the title of this piece to make a joke. Like Musk\u2019s humor it\u2019s puerile and not…<\/p>\n","protected":false},"author":0,"featured_media":4035,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-4038","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/4038"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4038"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/4038\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/4035"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4038"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=4038"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=4038"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}