We are living the paradox of a concept meant to create societies, licensing authorities and associations. The forms of organizational unions which were developed to bring citizens from every professional background together into one safe-haven, devoid of corruption, monopoly, and favoritism. The rationale- brings to create unity between groups under common interests serving their basic initiatives by simplifying and protecting such interest from alternate opportunistic endeavors. It all sounds attractive, but the greatest problem entails the groups representing a particular community lose transparency, hence the commitment to their constituents. So, fall into the trap of their corrupt ambitions. That is what our healthcare resembles now! Not long ago- I published a story under the title: “The concept of collaboration and consolidation exploiting our differences to unify on common ground” within; I briefly touched on the disparities between the latter two on how consolidation despite peculiar attractiveness may lead to contradictory fallout.
In this article, I intend to allude to a distinct, yet controversial subject about another aspect of market control in the arena of skills and profession, and its applicability within the modern medical practice space. At a separate discussion, I also elaborated on how an overemphasis on protocols, guidelines, and standard operating procedures can be futile to clear-cut delivery of the service, more so on the historical utility of licensing and certification or re-certification to control a market that would be otherwise disciplined by the intellectual free minds.
Before one can conceptualize the fundamental aspect of holding control through possession of ultimate manipulative advantage over individual sovereignty, first we must approbate; contrary to old-fashioned simple strategies historically used by systems developed on hierarchy; the modern domination scheme is a Multi-layered and diversely faceted. For instance, in the healthcare system, the power of control begins right from its infancy; admission into medical school and continues to till the physician retires or loses the privilege to practice medicine through the merit put forth by the organizers of the system. Medical science is no harder of discipline to master than any other professional ventures, but is by far the most expensive and monopolized undertaking.
To become a physician requires significant diligence. In contrast, some of the applied sciences need even more talent and creativity. Admission into medical school has learned to encompass monopoly and politics. But the syndication does not end there, as it follows through to residency, licensing, medical practice and reimbursement. It would be out of the scope of the current discussion to get into specifics. Besides- almost all monopolies and corruption around the medical profession perchance traced retroactively around the accepted habits of profiling, bundling, and kickback that primarily involves some shape or form of unity formation like associations or societies.
The Concept of society and association
Within literal terms; societies and associations are by principle the encompassing network of social relationships that enclose selected phenomena constructing the primary object of analysis. They follow the utilitarian concept that common liberal mindset wishes to justify the argumentative opinion of the state. In the midst of developing said the critical doctrine, liberal scholars of the era such as John Locke FRS an English philosopher, and physician became the pioneers to separate the law of nature from the social contract. Locke also is known as the father of liberalism was recognized as one of the most influential enlightenment thinkers of the 17th-century European intellectual movement. He envisioned the concept of society as the form of institutional order. He believed; it’s not the population, but the complex systems of interaction in which the units of the population take part as a single unit. In highly organized societies, where its framework controls the relations between the units of population as well as members of other populations, it may be useful to treat interactions within the societal population as pertains internal to the society. Association is the state of the union or consolidation formation between two or more people with a common purpose. It resembles the commonality, but by the virtue of smaller size. American medical association and world health organization (WHO) are among those that follow the pattern of Locke’s ideals of social formation.
Billing and coding systems
The Concept of billing in a healthcare
Medical billing is the payment practice within the United States health system, where the physician submits an invoice, follows upon, and oftentimes appeals claims with health insurance companies to receive payment for services rendered. The process has been one universal to every 3rd party payer system; be it government or private programs. To accommodate the healthcare billing — system utilizes a set of the algorithm-driven medical coding system called the International Statistical Classification of Diseases and Related Health Problems (ICD) and The Current Procedural Terminology (CPT) code. The codes were implemented to report what the diagnosis and treatment were, so prices are applied.
The medical coding system is beyond perfect. Two of the most common gripes in the United States about the ICD-10-CM are the sundry list of potentially irrelevant codes for a given condition and the assigned codes for seldom seen conditions. CPT codes but is the medical codes created and maintained by the American Medical Association through a dedicated Editorial Panel. The CPT codes are copyright protected by the AMA and describe medical, surgical, and diagnostic services and are designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. ICD has codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It started with the earliest versions as ICD-1 in 1901. Thereafter, used in 1983, as became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. For the past decades, ICD coding has been subjected to modifications. The most recent version; ICD-10 is by far the most complex and burdensome. It has merely shifted the pay-per-encounter into a pay-for-performance or value-based reimbursement model. Data experts consider, ICD-10 the highway to healthcare big Data capture. I like to call it the “un-patrolled highway” to the legal breach of privacy. To be more precise, as being exploited indiscriminately, the traditional meaning of “ICD and CPT pertaining solely to the practice of documentation” does not necessarily apply to ICD-10. Nonetheless, the notion still stands; if the coder doesn’t see it written down somewhere by the physician, or code wrong, the doctor doesn’t get paid, and the bill may ultimately go to the patient.
The process of coding has always been perceived as a work that’s unpaid for the efforts put by the doctor, but the importance of documentation clamber up further. ICD-10 gathers more data and Doctors do the gathering.
The target of an organization’s failures, Monopoly, corruption
Association and societies by the mission are the representative and protectors of the profile of their elemental constituency. In the theoretical sense, even it may seem an ideal way to protect the common interest; yet, it does not always translate into equality practical outcome. Hence, in my opinion; the two fundamental reasons why unionized organizations have the susceptibility to failure, or more inclined to pivot away from their primary missions. One, when an association grows, so does the propensity to adapt bureaucratic overture; thus urging an environment somewhere within the spectrum of decay and dictatorship by overlooking the principles the particular organization was billed upon, to begin with. Second; large associations have the potential of becoming a target for the competitors. A target which easier is to shoot down as it grows. Once the leadership undermined or corrupted through bribery or the entities give into the bureaucratically driven monopoly and kickback practices, as a result, the whole system would clatter on its overruling. One can further break down the latter two into sub-factors of society corrupters. Some of the most common factors worth mentioning are Poor Leadership; conflicting incentives; discretionary powers; monopolistic powers; lack of transparency; low pay; and the culture of impunity. The deeds of malfeasance including bribery, extortion, and embezzlement in a system over the century have become the rule rather than the exception. The centralized vs. decentralized systemic corruption is the frameworks that outline the level the organizational corruption takes place, thus implying that smaller systems have the potentiality to be as venal as the large ones. For example, scholars exemplified the post-Soviet Union states as symbolizing the decentralized nepotism. Although, I would not necessarily disagree; the Soviet and post-Soviet states were tainted, hence representing the largest example of the consolidated system, yet I respectfully diverge on the merits as decentralization being the agent to slur for the failure of the communist ideology. The Soviet Union was a dictatorial system, relying merely on a strict bureaucratically contrived totalitarian system of governance. The typical state under collectivism would fail to fall under the category of a classic decentralized system, as by necessity must be independently governed and constitutionally revere individual reigns.
The organization size such as in American medical association (AMA) is one example of size-related failures. The prevalence of hypocritically shifty organizations is high because peripherally medium-sized unscrupulous organizations are becoming less prevalent. Probable cause— both large and small organizations might be galvanized to engage in unethical guise. Former for being determined to overgrow through potentiality; since the later to survive. The large system rolls out corruptness through a sophisticated, yet internal reign of controls. The smaller counterparts so thrive through intimate patterns.
American Medical Association’s mission and the public perception
The AMA’s mission has traditionally been towards promoting the art and science of medicine. The association has sworn into work towards the betterment of public health while supporting the interests of constituents it consolidated to serve; as for physicians. Agency publishes the Journal of the American Medical Association where within lists the name of Physician Specialty Codes. The identifiers have been the standard method in the U.S. for a card out physician and practice specialties. Still, The American public has long taken note of the American Medical Association’s failures to uphold its duties to them. To the contrary of what’s declared to represent as the defender of the interests and values of the nation’s doctors and patients, AMA has utterly been the public depiction embellishment of the private health insurance system in the US. That risks the public interest by putting the welfare of the corporations ahead of its constituency; hence contradicting the ideals put forth by the father of liberalism, John Locke.
Political influence and kickback practice Evil-Mongering Attitude
Over the decades, the American Medical Association has been oftentimes the topic of news discussion. The AMA along with other consolidated organizations has issued dire warnings of an impending physician excess in the United States in the past. They have even taken the privilege of convincing Congress to limit the number of residencies it funds to not exceed 100,000 a year. The same organization today is claiming that the country is facing an acute shortage of doctors. In reality- neither mentioned propagative is sensible. In fact, what this country is facing is the physician burnout, and their poor distribution into underserved areas. The physician power Maldistribution trend is universal to the bureaucratically driven syndicated system.
Over the years The American Medical Association on behalf of members has placed its seal of ratification on products and drugs, even though the organization has no capacity to test such drugs or products. Instead, the elite leaders have culled advertising proceeds from the approved products featured in AMA publications. The former editor of the organization’s Journal of the American Medical Association (JAMA) indictment on federal racketeering charges exemplifies such motives. At times through unethical footpath, AMA had to pull out of endorsement contracts with companies such as Sunbeam Corp. upon the protest of its members. The agreements were presumed to potentially harm the association’s apprehension. The deal along with other similar pre-arrangements would have given Sunbeam the AMA’s seal of approval on everything they plighted to sell in exchange for royalties without any plans to test the given products to make sure the legitimacy of their claim under the lawful representation of the entire medical community.
Today AMA’s scope of influence on healthcare has bolstered beyond its responsibilities, more so capabilities. Its radical expansion of power reaches the determination of what to reimburse for physician’s services, how medical services will be defined, Billed and so on. The association has relentlessly appropriated the privilege of retaining master files containing nearly every physician’s identifying information. The organization has been merely using its government-granted Healthcare Data Monopoly to fuel its fresh adventure in the path to what may resemble today— “ a Sketchy New Commercial Venture”, hence, a quasi-Big data gold rush. One of AMA’s recent ventures is Akiri, a blockchain-enabled data transmitting and sharing network, designed to flawlessly send patients and physicians data stored in centralized AMA database, within the health systems.
The history of how the AMA got in the position of being able to cartelize the pricing of medical services is a sad one, but real. According to a publication in ‘naked capitalism’ the author quotes:
“While these doctors always discuss the ‘value’ of each procedure for the amount of time, work, and overhead required of them to do it, the implication of that ‘value’ is not lost on anyone in the room: they are, essentially, haggling over what their own salaries should be. “No one ever says the word ‘price,’ ” a doctor on the committee told me after the April meeting. “But yeah, everyone knows we’re talking about money.”
AMA against the collaborative medical practice
Looking back in history again- one can note health care reformers, including those behind President Truman’s deplorably failed 1948 universal care proposal, who hoped to deliver the payer system around prepaid medical groups. Proponents of the plan reckoned, by federally funding prepaid programs, they could efficiently supply the entire population with comprehensive care. Even so, to the irony, as the prepaid physician groups gained popularity, the AMA took an opposing approach, thus began organizing schemes to kill the initiatives of its own constituents with defined prejudice. AMA leader’s reasoning for the motive was that— self-insuring multi-specialty groups would evolve into health care corporations! They feared that this “corporate medicine” would give physicians mere cogs in a bureaucratic hierarchy. The association leaders threatened physicians working for, or contemplating joining prepaid systems of harsh sanctions. While AMA members occupied influential roles in hospitals and on state licensing boards, practitioners who refused to heed their warnings lost their hospital admitting privileges and even medical license to practice medicine. Today we can acknowledge right before our eyes, corporate medicine is, in fact, being promoted by the AMA include American Hospital Association (AHA), health maintenance organizations (HMO), Private insurance companies like United health care and similarly the Amazon.
The birth of the insurance company model and AMA
To build up the private sector as a means for fighting government health care reform, AMA leaders designed the 3rd party payer system. Within the initiative AMA, leaders decided that rather than allowing doctors to insure patients, insurance companies would be permitted to offer medical coverage. Today; United Health’s Billing Codes of social determinants Of the Health has the backing of the AMA. “Health insurers are already paying for an array of services from food and nutrition to housing to make sure patients are getting the correct care in the exact place and at the right time,” says Forbes’s publication. This movement is well in line with how much the corporations have been able to tap into the public-private information!
AMA’s control over other medical societies at State and local levels along with its century-old affiliation with American Hospital Association (AHA) has set to motion new models of care that not factor into physician burnout, but also further deliberate their intention to monopolize the practice of medicine. In a recent report, the members of the Heart Rhythm Society (HRS) and American College of Cardiology have been forced to join AMA to avoid potential sanctions by the association. AMA’s warning outlines; if HRS did not meet a threshold of 20% of their members by sharing with AMA, the HRS would lose the right to have a seat at the table when CPT codes about Electrophysiology ((EP) reimbursement is discussed, thus having no EP experts helping to set the bar for these codes.
The core problem
Irrespective of size, mission and entity formation, the essence of the dilemmas in any organization is multilayered corruptness as well as the biased and pivotal inclination of its leadership. That, in turn, serves as a reflection of the particular organization’s structural and operational framework. Indicatively, healthcare system has been the victim of the paradoxical sentiment of medical societies and associations infecting the core of the medical education, medical establishment, physician mission through a three-century-old pseudo-utilitarian philosophy by taking advantage of patient and physician vulnerability through unsustainable corrupt protocols, procedures and its application to physician licensing, reimbursement, ICD / CPT coding practice, artificial value and most of all to the most vulnerable patients. The modern broken, yet outdated system embraces the poor rotted framework to host healthy execution of the originally sworn mission, thus has the potential to serve as the cutting sword for their bent crusade.
Hence, must meet control and power over every aspect of its evolution from education to Licensing, the value of services rendered, clinical judgment and reimbursement. The broken healthcare system has a double/dealing institution. Nonetheless, AMA’s large size, poor leadership structure, political initiative, weak physician constituency, the means of restrained admission to medical school, selective fellowship and specialty monopoly. Faulty reimbursement practices and overzealous manipulative licensing and certification processes have created a vicious circle of patient demise and control mongering.
The Road map to successful teamwork
To prevent venality the system must have a way to make sure transparency at every level of its stagnant as well as the dynamic framework. It must stride to cut reliance on a hierarchical approach by pinpointing its executive role. By the virtue of transparency, it must unleash the significance of unbiased accountability that would translate into an effective corrective action plan. Practically, the ultimate goal should be placing the value-based reward or punishment on the leadership. By knowing that the modern associations are adamantly pro-value based reimbursements for physicians, but have exempted them from such a model. Nonetheless; their value model and basis of assigning quality for a particular service is the elusive creation of biased corporate ambitions.
Along with said fundamental changes the system of a decentralized collaborative approach, if not utterly safe, would still decrease the risk of internal dishonorable conduct of its members by distributing targets among smaller units, thus reducing the incentives for alternate conducts. The collaborative effort requires much coordination, technology, and strategic planning, an effort worth utilized for the betterment of patient care. A decentralized system also requires concomitant empowerment of individuals while securing their transparency, and accountability.
Organizations must be retained smaller size as possible while maintaining high level yet focused regulatory oversight avoiding top-down micromanagement as workable. The ultimate inevitable necessity would pave the road to personalized healthcare to us via collaborative efforts of physicians, patients, providers and stakeholders of the medical system.