The Financial Times has a new story on one of RFK, Jr.s’ plans, should he be approved as director of the Department of Health and Human Services. He is threatening to end Medicare and presumably also Medicaid’s use of the current medical billing code system, which goes by the acronym CPT, with a new system. The reason for proposing a change is that the AMA charges hefty licensing fees. From the Financial Times:
Reforms to the CPT codes would also represent an existential threat to the AMA, which generates more than half of its $495mn annual revenues from its CPT work and other royalties payments. A person close to the lobbying group said reforms of Medicare’s billing system could unleash as much chaos as the hack of UnitedHealth’s Change Healthcare division, which affected 100mn patients and roiled healthcare providers for months.
And there is no long-term contract in force to obligate Medicare to keep using the CPT codes:
Medicare has no obligation to accept the proposals of the AMA committee, which meets three times a year to update physicians’ billing codes, but it typically accepts the proposals.
Mind you, RFK, Jr. isn’t wrong to see these licensing fees as a form of grifting. From the Financial Times comment section:
Progressive Patriot
The article talks about CPT (Current Procedural Terminology) codes that were developed by the American Medical Association (AMA) and are used within the US and around 60 countries internationally.
https://en.wikipedia.org/wiki/Current_Procedural_Terminology
One of the issues here is the “licensing fee” that the AMA receives just for someone using their coding system which, by all reasonable accounts, should be in the public domain. It is just a categorization system that has been amended countless times since its inception, maybe in the 1960’s or so.
It would be akin to having to pay to use the Dewey Decimal System or the Library of Congress Classification system.
And it may well be (or turn out in the end) that RFK, Jr. taking this issue to the press means he’ll seek to bargain the rates down instead.1 Perhaps RFK, Jr. is mainly interested in defunding or defanging the AMA, which has consistently and forcefully opposed single payer. But RFK, Jr. isn’t a supporter either:
RFK Jr. ran for president explicitly opposing single-payer and then campaigned for Trump, whose proposed 2020 budget would have cut $1.5 trillion from Medicaid over the next decade.
I could get these morons to chase a tennis ball across the freeway. pic.twitter.com/Pr7OsIRzG6
— Jesse Crall🕊 (@jessecrall) November 15, 2024
A longer discussion in Jacobin from early 2023 in Populist? RFK Jr Doesn’t Even Support Medicare for All.:
…it’s not hard to see why he might emerge as Biden’s most prominent challenger. On the one hand, he comes from a lineage of Democratic Party royalty. On the other hand, he’s an edgy antiestablishment “populist.”
Or at least that’s how he’s been widely portrayed — both by commentators who are repulsed by Kennedy’s proclivity for anti-vaccine conspiracy theories and by those who find his criticisms of the Biden administration compelling. But the populism label is false advertising. On key issues from Israel/Palestine to Medicare for All, RFK Jr’s politics are a thousand miles away from his branding….
In a recent interview with left-wing journalist Krystal Ball, Kennedy was asked whether, given the hostility to the pharmaceutical companies he often expresses while talking about vaccines, he’d be willing to support a “public option” for pharmaceuticals or maybe even the outright nationalization of the industry. He immediately dismissed this, saying, “Oh, I don’t think that’s the right thing,” and switching the subject to how to insulate regulatory agencies from the industry’s influence. He didn’t even pause to explain why it wouldn’t be the right thing. Apparently, he finds the suggestion too outlandish to even consider.
It’s worth noting that Kennedy’s hostility to even providing a public option to compete with privately manufactured medicine puts him to the right of California governor Gavin Newsom, a thoroughly mainstream Democrat who recently announced that California is going to start manufacturing its own insulin later this year.
In addition (unless MDs or hospital administrators can tell me otherwise), the AMA licensing of the codes is not even remotely the nexus where the abuse of billing codes come in. It’s not the codes themselves, but the massive gaming that takes place around them, the so-called upcoding. Procedures are regularly reclassified after the doctor puts in his description of the visit or procedure to depict it as more complicated and demanding than it often was. Big hospital systems are believed to regularly engage in upcoding, which is a fraud. However, it is very hard to root out because it occurs at the patient level across many records and takes many forms.
A 2024 study in the Health Economic Review addressed this very topic. From its abstract:
Upcoding in Medicare has been a topic of interest to economists and policy makers for nearly 40 years. While upcoding is generally understood as “billing for services at higher level of complexity than the service actually pro- vided or documented,” it has a wide range of definitions within the literature. This is largely because the financial incentives across programs and aspects under the coding control of billing specialists and providers are different, and have evolved substantially over time, as has the published literature. Arguably, the primary importance of analyzing upcoding in different parts of Medicare is to inform policy makers on the magnitude of the process and to suggest approaches to mitigate the level of upcoding. Financial estimates for upcoding in traditional Medicare (Medicare Parts A and B), are highly variable, in part reflecting differences in methodology for each of the services covered. To resolve this variability, we used summaries of audit data from the Comprehensive Error Rate Testing program for the period 2010–2019. This program uses the same methodology across all forms of service in Medicare Parts A and B, allowing direct comparisons of upcoding magnitude. On average, upcoding for hospitalization under Part A represents $656 million annually (or 0.53% of total Part A annual expenditures) during our sample period, while up- coding for physician services under Part B is $2.38 billion annually (or 2.43% of Part B annual expenditures). These numbers compare to the recent consistent estimates from multiple different entities putting upcoding in Medicare Part C at $10–15 billion annually (or approximately 2.8–4.2% of Part C annual expenditures). Upcoding for hospitalization under Medicare Part A is small, relative to overall upcoding expenditures.
Needless to say, if RFK, Jr. were to press forward, and HHS had developed a replacement coding scheme, the transition would nevertheless impose serious costs on medical providers. They would not only have to implement the new coding system, but would also be running two different systems for classifying procedures, one for CPT codes for non-Medicare patients, the other the new Medicare procedure codes for Medicare patients.
The next question is why did RFK, Jr. go public with this idea now? He must assume this will help and not hurt his chances of being appointed. While reducing the AMA’s lobbying budget and stopping what looks like rentierism sounds appealing, the transition costs and higher complexity for most medical providers of operating two billing approaches will increase medical administrative costs, which are already higher in the US than in other countries. But explaining that may take more than a soundbite, so perhaps RFK, Jr. and his allies will carry the day on this topic.
However, if RFK, Jr. does not unpack further what he intends to do here, this proposal will provide more grist for critics who say he does not understand the medical industry and wants merely to set up bogeymen to score press points while doing actual harm if he follows through with his schemes.
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1 It’s probably too much effort, but another angle if CMS wanted to be really bloody-minded would be to challenge the AMA’s ownership of its intellectual property, as in whether the licensees themselves have provided meaningful input, did not waive their rights and thus have claims o the intellectual property.
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Thanks, Yves. This reads like RFK is treating the symptoms and not the causes, which places him square in the middle of AMA praxis.
No love for the AMA. The Boys in Chicago are unnecessary. But when trolls get the upper hand, life goes sideways in the other wrong direction.
It is already becoming clear – this is going to degenerate into Obamacare level obfuscation. BIG MEDICINE and BIG INSURANCE and BIG HOSPITAL are going to throw everything they can at this – lies, half truths, propaganda.
I can see nothing inaccurate in this article – however, it is about one third of the story, and the parts that are left out are the parts that are destroying our health care system.
When I was a brand new doctor, there was a sign in the front with various visit types and the cost. The patients would pay at the time of service and they were handed receipts and they dealt with their insurance company. There was all kinds of wiggle room for people who had just lost their job, etc – I often did all kinds of things for free. Also, in order to maintain my license, I had to document that I had indeed done a certain percentage of free care. Well, all of that is gone. Indeed, it is even illegal. If you accept Medicare, you cannot have price lists anywhere. I work in hospital systems where there are 6-8 employees for every doctor, just sifting through all the charges and notes to maximize profit.
It is a complete entire joke. And the ICD codes are a big part of it.
When I see a patient’s chart from 30 years ago, I can look at every note – that is usually about 2 paragraphs, and know instantly what happened in that visit. Today, because of EMR bloat enabled by the ICD codes – the notes for a simple visit for ingrown toenails is often 10 pages long. There are employees spending all day going through the 10 pages on each visit to maximize income.
Yes, the ICD is a visit level. It tells NOT what level of care is actually given – it tells what level of care is on that chart note. It is a total lie most of the time. That is on the doctor’s end. But what is less well understood are the diagnosis codes. And that is how these corps are raking it in. And that part never gets discusssed. There are codes for every diagnosis. Just one example – there is a code for TYPE 2 DM. And that is what I use all the time. However, the army of people behind the scenes look over my chart notes – and often add 3-4 others – there is DM with kidney disease, DM with heart disease, DM with vascular disease and so on. Those codes are considered more “complicated”. And when these are added to the chart – they juice the income dramatically – AND in aggregate, huge bonuses are given to the hospital systems for taking care of more complicated patients. To my chagrin, the AI they are asking me to use now, will present me 4 or 5 of these codes to charge patients.
These are absolutely used to juice the system. This writer either did not talk to any practicing physicians, or they talked to academics who never see patients and have not a clue how it works. It is an enormous wealth extraction machine.
The AMA gets a cut every single chart that these codes are used. They could care less about the docs of America – their buttered bread is the income from these codes. So they are ALL IN for BIG HOSPITAL, BIG INSURANCE, etc – just keep the gravy train flowing.
Another very poorly understood problem with these is the impact they have on people’s individual lives. These diagnosis codes are all over your chart – they can do chart scouring going back years. As one example, if you are applying for life insurance, and they find the code for GOUT anywhere on your chart – even if it was one time only from 2013 – you are not getting insurance. The entire system is just abused beyond belief and is quite insane. It is also evil.
So, yes, the complete gutting of the system is in order. We should go back to the 1980s – with the signs in the windows and doctors taking care of patients, not staying up till 2 AM every night taking care of charts. These medical elites and companies know the extreme danger that RFK proposes – and they are going to lie just like they did in Obamacare…….How is that working out for you? Did you get to keep your own doctor? – How is the insurance working with not only exorbitant premiums but with a 15K$ deductible to even get access?
I am going to point out these problems going forward. It is my public duty to make people realize they are being bamboozled – however, this is the last time I will be getting involved. 1) I just do not have it in me going forward – retirement will be soon – 2). It does not matter what I do – if we keep this up the financial brick wall is right ahead – this wealth extraction unit will very soon bankrupt the country.
It is one of my big regrets in life that I signed up for a caring profession all those years ago – and have watched it turned into the greedy immoral leviathan it is today. I have one more fight in me.
Thanks, IM Doc. Very informative. Relatives in medicine have lamented how much time they have to spend on non-medical activities, taking away from diagnosis and treatment. Some left private practices to go to larger organizations with back office support, and others decided to ride it out until retirement. Neither approach was very palatable to them.
Across the world, there must be other examples of how to handle medical care. What could be learned from those, possibly even providing some migration path? What are global best practices? Given how much the US spends on care there have to be opportunities to lower costs and improve outcomes.
From the financial services world, there was much talk of how the legacy or core deposit and IT systems were hopelessly complex and difficult to maintain, let alone integrate any acquisitions. One suggestion was to set up a new organization with a streamlined, replicable system and then have a legacy bank, for example, merge into that. Maybe something similar could be on RFK, Jr’s. agenda, if he can survive the forces of Big Everything?
*Very* interesting, IM Doc. You have explained an anomaly in my medical treatment summaries that has gone unexplained for years. I have Type 2 DM (which I assume means, in your account, Type 2 diabetes mellitus). After each visit there’s a note after this diagnosis, “chronic kidney disease.” I’ve asked my various PCPs (actually, I no longer have a PCP but a DNP who doesn’t appear to know a whole lot, but that’s another story: I can’t *get* a PCP) what this means and have been cheerfully told to ignore it. So, by your account, the odds are pretty good that this addition has nothing to do with me and everything to do with the big bucks. Well, I’m near the end of the road anyway (86), so the next generation can deal with it…. I should add: your account parallels exactly my experience with useless and incompetent academic administrators over my career as a professor of English. Keep up the good fight.
Thank you IMDoc. It’s unfortunate that most people use their hate for JFK Jr. to dispute every change he wants to make. They conflate JFK’s opposition to modern day vaccines to all vaccines.
I wonder if there is any integrity (audit trail) in the EMR to track the doctor entered codes vs those changed by the number of people who change/add codes to increase the billing?
Big thanks for that descriptor.
Now I think I understand AI – if caring becomes code pushing and paperwork, and the pay is squeezed, the social incentives to become a doctor are gone, leaving minimum wage PAs under the supervision of an AI, with maybe a few docs at the CDC.
Seems like a dystopian future awaits.
Check this one out…
https://youtu.be/hcYbYhjdUb4
you read my mind. Idiocracy – The documentary, although Elysium, also comes to mind.
Thank you. This also explains the ability to have multiple prices for the same service. And I am not talking the difference for cash discount to avoid credit cards and their ridiculous charges.
If you can’t tell, the “discount” insurance companies including Medicare get annoys me. It is just as much a grift as Uber surge pricing.
I have a relative who was enrolled in a high school nurses’ training program in the 1970’s. She said that she could look at a chart and tell at a glance what was going on with a patient, e.g., the diagnosis, whether the patient was hard of hearing, needed assistance with feeding, etc. Many decades later she has a chronic illness and has undergone multiple hospitalizations. She said she is literally sick and tired of having to tell EVERYONE who walks into her room every little piece of information about her condition because they can’t glean the information from her records.
I hate to differ with you strongly but this is naive and it is frustrating to see you conflating independent issues.
We have LONG LONG beefed about EHRS. That is separate from the issue of coding. The EHRs are among other things full of “check the box” prompts that distract doctors from the patient before them and can impair diagnosis by focusing them on what the EHR thinks the problem or big liability risk might be. All that check the box stuff lards up the medical records.
That is ENTIRELY SEPARATE from the coding. You can do coding on paper as my two NYC MDs do and have a staffer do the insurance paperwork.
You are conflating widespread big hospital adminisphere-bloat practices with the coding. HHS not licensing AMA codes will NOT end EHRs. It will instead simply mean new different codes.
Insurers are a function of employer payment. That is turn persists because it is a not-well recognized tax subsidy. Employers get to deduct the insurance cost, but unlike other employee bennies, the insurance payment is not treated as employee income.
You may hate what these codes have done but there is no going back. The codes are there because we have a payment for service system.
Insurers will be unable to process claims., period. The transition time and cost would destroy medicine. Think doctors are quitting now? They will leave in droves because they will not be able to be paid.
You forget that doctors are hardly ever solo or small practice operators. They work for corporations. Obamacare forced many (most?) into accredited care organizations.
And now with AI, the insurers can find “gout” anyhow. The can search and mine massive volumes of text. So the idea that abandoning the ICD or as article calls them, CPTs will stop the practice of treating certain diagnoses as a scarlet letter will not stop.
Actually – no they cannot find gout anyhow. As I have seen the level of pain inflicted upon people over the years, I have done work arounds so on the charts I do and not just gout but many other diagnoses, this will never be known. So for example, on gout – I put in the following codes – “arthralgia, not otherwise specified” – which never gets flagged for anything. I do this to protect patients from what will happen going forward. That is just one example of many. The problem is this – it used to be illegal for ANYONE but the providers to document visits and codes. Over the past 4 years or so – that is no longer the case. So now, again, we have high-school educated people putting codes on charts – and it is likely they add gout. But it is also very likely that they add all kinds of other stuff that is just literally making shit up. The computers do too. So, for example, all of my very muscular young men are deemed to have the code “Morbid obesity” – with all the problems that will entail for them – when this is not even remotely the case – nor is it ever discussed. All because of BMI algos. I am not sure where the 2% fraud is coming from – that too is someone’s propaganda or misinformation. Since I am challenged on EVERY SINGLE CHART to code more – I hardly think 2% even begins to cover the problem.
Insurers did just fine with claims for decades. And in the old system – the doctors got paid right in the office. So, I do not think that is exactly what would happen. Interestingly, it was significantly cheaper back then without all the insurance bloat – I distinctly remember simple office visits being less than 20 bucks and physicals about 100 – The big difference is I did not have to pay for 6 employees to process all of this stuff – and another 1 or 2 to process authorizations.
It really does not matter – the way we are going now – the entire system will implode very soon anyway. So we either do major changes and fix it reasonably now or just wait for the detonation.
Medicare and Medicaid started requiring diagnosis and procedure codes in 1983.
My point is with AI (large language models), you can do the same sort of gaming and misapplication of norms that you complain about, even more efficiently, without the only high-school educated people you mentioned. The corruption and rentierism are now very well institutionalized.
Isn’t misdiagnosis with intent malpractice, i.e. putting the lablel “Morbidly obese” when that is not the case?
The BMI algoryhthm assumes the college football linebacker is ‘morbidly obese’ because he’s 6′- 220 lbs. The algo doesn’t see the powerful legs, chest, and arms full of muscle.
a complete aside: you write “…I have done work arounds so on the charts I do and not just gout but many other diagnoses, this will never be known. So for example, on gout – I put in the following codes – “arthralgia, not otherwise specified” – which never gets flagged for anything.”
I’ve had to do the same sort of thing in my IT position at a large uni when ordering networking wire and other IT components. For years I could order a “spool of X wire”, where X was widely understood as a specific type of wire. At some point, someone in the bureaucracy decided an order of “X” wire was unallowed. The work around was to order the exact same wire noting it by its IEEE specs instead of by its common name “X”. Bureaucracy! sheesh. / Your comment made me smile.
The other thing I would add – is that indeed the entire payment at the window system is very much alive and well. This is how the entire system that is called Direct Primary Care works – or to some extent the concierge model.
Patients have appointments, they pay at the window or through monthly fees, and no insurance accepted. It is on the patient, if they want to, to file claims with their insurance.
This has been a huge factor in crippling all of primary care in our big cities just because of the sheer number of doctors going this route. They definitely are doing well and making a living. I know so many of them. But this comes at the expense of those trapped in insurance having no access to this. It is an ethical dilemma – but financially, the doctors are doing quite well. Many if not most of them that I know do not even touch computers except to look up labs, etc. Their chart notes and office work solely on paper.
Again, this is becoming so prevalent that it is really causing problems with access all over the country.
In essence, the doctors themselves, many of whom are around my age, are taking themselves back to the 1980s – and actually practicing medicine. This is going to need to be dealt with going forward. It is very good for the docs and their mental health – it is good for the patients they take care of – but not so good for everyone else out of that system.
You know. or ought to know, that concierge doctors typically charge much more than PCPs. In hardly high cost Alabama, the annual fee was $3000, with tests on top of that. Specialists are obviously extra.
I have had a friend on the medical faculty at USCF (she also practices) contend that concierge doctors are on average not all that good medically because they treat the wealthy or at least financially comfortable who are generally easier to treat. So they are pulling the healthier patients out of the general pool.
I know you have a particularly affluent practice and patients who see a lot of Dr Moonbeams. But among my cohort (ex McKinsey, very comfortable), I know of no one who sees a concierge doctor. They all see MDs connected to the big teaching hospitals.
For some reason this BMJ article/essay seems pertinent here. From the essay:
Knowing our patients: it’s all in the detail
Francis W. Peabody wrote: “The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.”
“And finally, Plato tells us: “The slave doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill…
But the other doctor, who is a freeman, attends and practices upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.”
https://www.bmj.com/content/366/bmj.l4553/rr
As the wealth gap widens in the US, as the US becomes ever more unequal in finances, are we developing a recreation of a slave doctor vs a freeman doctor – but with using EMRs and AIs (what mere experience suggests) in place of careful knowledge of the patient – the difference again based on the wealth of the patient and patient’s ability to choose?
My family has had a good experience with concierge medicine. My mother followed her primary care doctor, an internist, into her concierge practice and was with her for more than twelve years until my mother’s death.. It was $1500 a year at the time (plus insurance). During my mother’s final illness her doctor visited her often in the hospital. She couldn’t do anything, as the hospitalist was in charge, but she wanted to visit. She was limited by the hospital to twenty-five visits a year total.
I see a concierge doctor who has a different model. There’s no insurance whatever. He drafts $75 a month ($900 a year). I think the model is called direct primary care. Both my doctor and my mother’s doctor got into it because they wanted to practice old fashioned medicine and spend time with their patients. This meant, of course, serving far fewer patients. I think my mom’s doctor went from 900 to 300, many of whom had far worse health than my mom (I saw the entire group in an auditorium before the concierge transition took place).
One benefit to the patient is that visits are quiet, even tranquil. There might be one other patient there, but I typically don’t see them. My mom’s visits to her doctor prior to the concierge move were loud and chaotic, in part because there were six other physicians in the practice and the lobby was full, and because the visits were necessarily much shorter, I presume because of financial pressure from the other partners. My sister-in-law called on that practice as a drug rep, and described it as ‘money oriented’.
Just for clarification –
ICD Procedure and Diagnosis codes are used by Traditional Medicare for Inpatient stays. They are used to assign the DRG to determine the payment.
CPT codes are used by Traditional Medicare for Outpatient Payment and determine the payment rate. There will be some cross checking against ICD Diagnosis for validity but the payments are tied to CPT.
ICD Diagnosis Codes are used to calculate Risk Scores for payments to Medicare Advantage plans. There will be some cross checking against CPT for validity but the payments are tied to diagnosis codes.
CPT are the only ones maintained by AMA. ICD is maintained by WHO.
Very much appreciated!
Thank you IM Doc, you said a mouthful there. I love it.
The ICD codes are just diagnostic codes, of what is the status of the patient what is the “acute” issue that led to the particular visit. The fee codes are a different thing, that describe what the service the doctor has performed on the patient. DM is a chronic disease, so you diagnose it once, after that you refill prescriptions, provide additional treatmen, give a referral to specialist, have a talk about diet, lifestyle, etc. This is what generates payment, not the reaplication of the ICD code…
Generally speaking, cabinet departments have secretaries, not chairmen.
Oops, will correct.
Maybe he knows that frontal attacks on the medical/pharma industry will fail. It’s too big, too rich, and too corrupt to handcuff quickly or easily. But stripping this income from the AMA, no longer much of a force in the industry (amirite?), will be easy to get started.
I know he’s a flawed politician with a few dark secrets, but he’s David with a slingshot in this battle, and the only ‘candidate’ who speaks the truth about much of this.
And can anyone explain what they all mean by ‘conspiracy theorist’? Earlier, when he was running, he was treated as a nutcase. But every time I clicked a ‘conspiracy theorist’ link in an article about him it took me to another opinion page that asserted the same libel, IMHO, as a fact with no evidence.
The pharma-medical industries have engaged in a longstanding and deadly conspiracy to deny us effective medical care. Vaccine opponents have been shunned, libeled, and censored, and the pandemic was practically promoted as an opportunity swell profits. That worked well for them, and we know how it’s working out for the rest of us.
I read the first chapter of his book about Fauci. That is all the further I had to get to indeed find out RFK, Jr. is a conspiracy theorist. And I was prepared to be persuaded. I could not stand to read more, the book was obviously such tripe.
For all the “facts” he cited supported by footnotes, well over 1/4 flat out misrepresented what the cited source (usually a study but sometimes a study) actually said. Another roughly 1/4 were of studies that had been decisively debunked.
And he’s even openly flogged conspiracy theories during his campaign. From the New York Times in 2023:
You cannot blame either of my examples on Big Pharma. RFK, Jr. is not a “flawed politician.” He is a dangerous nutter in areas where he professes to have acquired some expertise.
There is one thing to consider re. is RFK Jr. off the mark in stating that Corona Virus, or other bio weapons were targeting specific ethnic populations. Early in the Russian SMO, many biolabs were discovered before V. Nuland could “secure their records”. In a summary of documents found and presented by Russian scientists, included was “the US Department of Defence, using a virtually internationally uncontrolled test site and the high-tech facilities of multinational companies, has greatly expanded its research capabilities, not only in the field of biological weapons, but also in gaining knowledge about antibiotic resistance and the antibodies to specific diseases in populations in specific regions.” Ergo, “diseases in specific regions” related to attempts to develop bio-weapons to target specific ethnicities.
So RFK Jr. is not completely off base in saying that attempts to create bio-weapons targeting or avoiding Chinese, Jewish, Slavic, or others is documented.
Other links I couldn’t find but here’s one to start with: Briefing: analysis of documents related to U.S. military biological activities on Ukraine territory, 11 May 2022
Sorry, this is poorly informed. Someone in Ukraine had this as a cute pitch for research grifting. From GM:
So since it is impossible to target Russians as opposed to Ukrainians, since they are genetically not distinct. It is similarly inconceivable that you could carve out Askenanzi Jews from Germans or Eastern Europeans, and somehow also exempt Chinese (who are also ethnically diverse).
And then there is the vast complexity of the immune system itself to make things even more iffy.
A kidnapper takes a cardiologist and an immunologist prisoner. He demands of each that they tell him of their contributions to science and humanity stating that he will shoot the one who has achieved the least in this regard.
Cardiologist: “I developed a drug that has saved and prolonged the lives of many thousands.”
Immunologist: “Well, to begin with, it’s very complicated….”
Cardiologist: “Oh, for heaven’s sake, just shoot me now.”
And the Covid crankdom is not the only bogus genetic theory he has run:
https://www.telegraph.co.uk/global-health/science-and-disease/robert-f-kennedy-jr-us-health-secretary-trump-vaccines/
FWIW I had the same reaction to RFKJr’s book. He was early to the RiverKeeper concept in New York (maybe the first?), which was a great thing. We have several similar organizations in here and I am a member of the two for rivers that drain into the Atlantic. But on vaccines he is a crank. Does that invalidate his views on ultra-processed food and the horrible American diet or the emerging realization that modern medicine has lost the plot on many things? No. But until be repudiates his conspiracy mongering regarding “old” (not only “modern”) vaccines, he remains a politician in search of a reason for being. Regarding vaccines, IIRC he concentrated on thimerosal as the preservative in MMR. Thimerosal was removed from MMR but rates of autism have continued to rise. How can that be if thimerosal was the “cause”? The entire ridiculous but severely damaging story is told by the journalist Brian Deer in his book The Doctor Who Fooled the World.
And not too far off-topic, thimerosal/Merthiolate and Mecurochrome have been anti-fungal/anti-bacterial topicals for about 100 years (predating modern anti-bacterial and anti-fungal drugs) and were often used to “paint the throat” of those with sore throats. I remember this was the remedy of those in my grandmother’s (b. 1910) generation, and she felt that any cut or scrape should be painted with Mercurochrome. Good practice when tetanus was a killer. These are not used so much today but aside from intentional overdosing there is no evidence they are dangerous when used properly. And the dose from their use in the throat is much higher than that in a one-time intramuscular injection of a vaccine, which does not happen much anymore.
RFK, Jr. may have run the thimerosal theory in the article he published in Salon that was later yanked. Even if he did not, he has effectively endorsed it by praising the crank Dr. Wakefield who was behind it:
https://www.telegraph.co.uk/global-health/science-and-disease/robert-f-kennedy-jr-us-health-secretary-trump-vaccines/
Note that MMR never contained thimerosal but it seems Kennedy went on about thimerosal and MMR in similar time frames (or possibly in the same speeches and articles), leading to conflation.
Can the federal government use Eminent domain to take over the codes and give a one-time compensation to AMA? I suppose the work to update the codes and add new conditions periodically will be minimal. That can be done by a group of expert doctors paid for that specific task.
I don’t see why the government can’t just sue to make them public domain. Is this a normal use of copyright, to protect not a large unified work but a bunch of individual codes meant to be applied separately?
The codes are also used to add a ridiculous administrative burden to nursing homes, and a way to pay out as little as possible for patient care there, forcing for-profit outfits to chisel costs down in ways that harm patients.
What did we do before the coding system? We can go back to that. Sorry if it’s inconvenient for giant firms to use it to maximize profits. Who cares. Give care, submit a bill written in English to Medicare, get reimbursed, or maybe get a call from the fraud unit. We could afford lots of fraud investigation units if we didn’t have to pay hundreds of thousands of people to spend their time fooling with codes.
Hi Yves,
The licensing fees that go to the AMA for CPT codes are material for the AMA, but chump change for CMS.
Upcoding is a more subtle issue — it’s not that the codes aren’t real — that would be outright fraud, and actionable , were there a robust monitoring and enforcement mechanism — — it’s that the risk adjustment algorithm is trained on past behavior to calculate the weights (ie risk) for each diagnosis, but then the future billing (particularly from MA plans) games that to add diagnoses that were marginally present, in order to exploit the associated reimbursements and in the process degrades the information content of the diagnostic codes….
I would be hugely impressed if RFK and Oz went after the RUC — the AMA’s committee that ‘helps’ CMS decide how much to pay doctors. Yes, the AMA advises the government how much their members should get paid and CMS usually accepts it without fail.
It’s a linchpin of the incentive structure that supports super specialists and proceduralists while suppressing the value of primary care and cognitive services..
I did not state that but thought it would be readily inferred from the Financial Times except at the top of the post. It stated that more than half of the AMA’s $495 million in revenues came from CPT code licensing. That’s across 60 countries, and in the US, private sector licensing, so doctors, hospitals, and insurers. If you assume $300 million total for the AMA, it is hard to see even as much as $50 million being paid by Medicare.
As for upcoding, that is a fraud and the paper I cited estimates the raw fraud type as >2% outside Medicare A. And yes, there are subtler versions that manage to skirt being considered a crime.
I inferred. I mean, that’s just how I read it.
Maybe Elon Musk gets a government contract to buy and update CPT code. That would be fun.
Haven’t seen anything on Fox news about RFK Jr. Either because I’ve just missed it or they’re too busy cheering about the other picks, how much Kamala’s stepchildren and father hater her, and how great it is that Trump supporters like Hulk Hogan can stop cowering in the shadows.
Huh? They are the AMA’s intellectual property. This is a slam dunk intellectual property + Fifth Amendment takings case.
archive.ph for The Business-School Scandal That Just Keeps Getting Bigger
What a bizarre field of research, too.
It pays
Ha
(bold mine)
Sounds like this all fits right in with MBA culture. And these are “elite” business schools.
How much of this research is also literally garbage?
completely aside: Why are Americans more unhealthy than they were 30 years ago? Why is life expectancy dropping?
And in other news: If you’ve noticed a marked change lately in the TV ads for Wegovy, Ozempic and the like, the change might have something to do with the lawsuits that are coming.
https://www.aboutlawsuits.com/ozempic-wegovy-mounjaro-lawsuit/master-complaint-outlines-allegations-in-ozempic-wegovy-mounjaro-lawsuits/
(Yes, in America you can sue anyone for anything. But this suit looks to have some teeth in it; too many injuries. / my 2 cents)
A very big factor is the introduction of high fructose corn syrup, which IIRC was 1972. Another was telling everyone in the 1980s to eat more complex carbs, as in pasta.
I read a few years back that 25% of the average American diet was sugars. “Nuff said.
It’s a grift but $495mm is a drop in the bucket?
It seems to be the business model of most standards settings bodies to sell or license the standard. Don’t really see the AMA as unique here.
Internet has been an outlier with the IETF/RFC open source process.
Such as?
Groups like ISO may license their standards, but I didn’t think they were mandated by the government the way Medicare mandates these codes. Most government-mandated standards I can think of, like building codes and educational standards, are promulgated by the government itself.
Two exceptions I can think of:
X DSM: while it is copyrighted, they don’t license the individual codes, this website, for example, just posted them as an article: https://psychcentral.com/disorders/dsm-iv-diagnostic-codes
X All web and programming standards I have ever heard of are freely available, even if it’s closed source (like Microsoft programming).
Yes, codes should be public domain. Like everything, governance costs. The International Standards Organization governs code management through recognized authorities. Some full code sets cost, some of the governing authorities do great work and need to pay people for it. Some sell automated updates. Most code-description pairs are published for free, but more elaboration requires purchase. I used to subscribe to ISO country updates to keep the systems at my job up to date.
Makes sense to negotiate from a public interest POV with the people who govern the code set. Per use charge is crazy when the point is to foster accurate communication.
Common Procedural Terminology is used on X12 medical transactions, but it is a legacy of HL7 (medical transaction standard predating HIPAA) and the relationship is not a neat fit. It’s not a simple code set. The codes are wildly overloaded, with a lot of dependencies on other data. Most healthcare software includes, or the providers buy, an online tool that help figure out what code to use that looks at all those other factors. Those with a purchased license get to use it. Maybe there is a hope that those individuals are trained to understand what they are deal with in the interests of accuracy? I, who might be able to read the raw data because I supported installing updates, could not access or test the tool. But, I could tell a lot due to the tables built to drive validation.
While this is nice in theory, HHS and presumably governments around the world have been paying licensing fees. The AMA could take the position that any effort to reduce these fees, which have been paid without a peep for a long time, amounts to an unconstitutional government taking and could be challenged by a suit on Fifth Amendment grounds.
Agree, and. If the AMA were not governing the codesets, who does? It takes expertise and human labor to manage the code sets that needs to be paid for. At the same time, it’s very old fashioned style codes with too much embedded meaning and dependence on the programming that reads it against agreements and fee schedules. Not anything like how modern web based tech uses code sets. How it is deployed and priced does not meet modern technical practices. ANSI might be able to take a hand.
The entities governing many of the code sets monetize them. Maybe the governing authority for a codeset are not ideal, i.e., the folks who manage language codes started out as missionaries. I expect negotiation, day lighting and improvement. I realistically do not expect ISO to do anything other than facilitating what is. I’ve had more frustration in my life dealing with healthcare related X!2 standards, and it’s non-standard aspects than I care to relive.
X12 was developed to facilitate commerce, moving goods and $$$. HL7 was developed to communicate about and facilitate medical care, now with billing related functions part of X12. Add in our capitalist economic system and guess what is prioritized? EPIC and Cerner probably have all of our medical records anyway. Lots bigger fish to fry than how much any provider pays the AMA for use of codes.