Cooper: G$ + Cr2 = Reguloony

Lately, I have found myself drifting into the camp that less regulation is needed in the industry that I know the best and in which people could die without certain regulations.

Lately, I have found myself drifting into the camp that less regulation is needed in the industry that I know the best and in which people could die without certain regulations.

That would be health care which has got to be one of, if not the most regulated industry in our country. Government money in the form of Medicare and Medicaid has driven the creation of massive regulations related to quality, service, reimbursement, medical records, paying physicians and certifying hospitals to receive Medicare and Medicaid payments, just to name a general few.

Let me explain just which regulations concern me and why.

Once laws are handed down by Congress, I picture a few very left brain — and I don’t mean politically — persons sitting in their cubicles writing interpretations of those laws or what we call regulations.

I am pretty sure they are innocent bureaucrats trying to make the system work but it all runs amok when the system begins to rule and the physician and patient become mere subjects of a vast documentation system.

Some politicians claim that we only need to stop fraud and abuse and we will save tons of money in health care. Sorry we can’t seem to stop fraud and abuse without regulation but wouldn’t it be nice to have a better balance, one that didn’t punish the honest?

New Government $ (G$) = Crooks (Cr2)

My guess is that if we drilled deep into regulatory madness, we need only follow the money and we would soon find crooks present at the birth of many regulations. I’ve mentioned that my health care career was born the same year as Medicare and I have watched the explosion of the burden of regulation.

My first exposure was as a young skilled nursing facility administrator in the 1970s in the midst of great regulatory change to the industry. Medicare created levels of care outside of the hospital, one of which was post-hospital care in a skilled nursing facility. Existing nursing homes and new entrepreneurs, in some cases, Cr2 leaped at the opportunity.

It didn’t take G$ too long to figure out many of these new facilities were more interested in keeping patients in their facilities for full pay for 20 days than providing adequate rehabilitation services.

Not only were regulations established, offices of enforcement had to be established to assure compliance. Then, in the course of visiting some of these facilities, the surveyors discovered that long-term patients called residents and covered by Medicaid were getting poor care.

More regulations and more enforcement ensued and it was needed. Nursing homes were swept under new regulations that required such things as getting residents out of bed for most of the day, feeding them a variety in their diet, no more mac and cheese three days a week and no more sedating residents to keep them quiet.

A more recent example, although it’s been going on for a while, is stringent regulations governing hospital relationships to physicians or other health care providers. The regulatory object is to stop any “kick-backs” to health care providers for referring patients to their own businesses or to hospitals. Joint ventures or paying providers however discreetly for referral arrangements between providers and hospitals are very frowned on, as in a CEO could land in jail.

Congress was tough on this one and made it a crime so needless to say hospitals go to great lengths to document that any payment to physicians, employed or otherwise, is set at fair market value for an appropriate physician service.

Then there were and are the white collar crooks who bill for equipment not delivered to a patient or the physician who bills for services not rendered. More regulation, more documentation, more accountability and more money spent unrelated to care.

More spent on enforcement because the only way to catch a crook is to catch a crook. The foregoing concept is an anathema to some politicians who decry regulation and see defunding enforcement agencies as a means to reduce regulation.

$G + Cr2 + Reguloony = Self-flagellation

Increased self-regulation could well be one of the outcomes of needing to keep up with crooks without adequate enforcement funding. Brilliant regulation writers have turned health care providers into providers policing themselves through meticulous documentation.

In other words, systems for accountability have been built that result in providers spending a lot of money to point the gun at their own heads.

It won’t surprise any human being to learn that sometimes mistakes are made. For example, a coder may have mistakenly coded a certain procedure incorrectly over time which resulted in the provider receiving too much money for that particular service.

No problem, providers who learn about the mistake just turn themselves in and hope for mercy which is not guaranteed even with providers’ good intention. A failure to report, on the other hand, is considered punishable at least in the form of a large fine.

At some level it makes sense, but it costs the system a lot of money in developing information systems and staff to support detailed documentation.

Billing, accounting and patient care data are now being recorded in electronic records which could be beneficial if it weren’t so tedious.

Computer screens and needing to check lists to show the work was done separate us from our physician who wants to heal us and our nurse who wants to comfort us.

And coming soon are more metrics around which health care providers will be evaluated and paid. Sounds like more documentation and data gathering to me. No wonder we’re seeing more and more articles about the problem of physician burnout.

Yet another outcome is brilliant left brain people who program computers that will judge, yes judge, whether or not a provider is providing the care and seeking payment in the manner that most pleases the computer.

I would support all of this if I believed that even a quarter of health care providers were crooks, but I don’t and they’re not. It’s another example of building our systems around the exception, the crook.

The honest and hardworking in health care, like the honest and hardworking in every other industry, are the ones that suffer the consequences.


Bertha D. Cooper is retired from a 40-plus year career as a health care administrator focusing on the delivery system as a whole. She still does occasional consulting. She is a featured columnist at the Sequim Gazette. Reach her at


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