Why Big Health Insurance Supported Obamacare, Part II

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 Why the Health Insurance Industry Supported Obamacare [14:52m]: Play Now | Play in Popup | Download (15)

The fact that the health insurance industry supported Obamacare from the very beginning was entirely missed by the mainstream press. This is perhaps understandable, since a) the mainstream press does not understand the dynamics of the healthcare system, and b) during the Obamacare drama, the health insurance companies had been assigned, and had graciously accepted, their vital role as the Forces of Evil. To the famously credulous members of the mainstream press, it was easy to imagine that the insurers were actually among the opposition.

But the insurance industry supported Obamacare from the start – and even before the start. During the Presidential race of 2008, for instance, managed care companies donated far more money to both Barack Obama and Hillary Clinton than to any Republican candidate, even though both of these Democratic candidates publicly castigated the insurance companies for producing most of the problems in American healthcare, and promised to institute reforms that would drastically cramp their style and reduce their profits.

Why would the insurance industry support the very candidates whose chief healthcare strategy was to demonize them? Quite simply, it was because the insurance industry had nowhere else to go.

By the time Mr. Obama became president, the once proud, self-confident, and even arrogant American health insurance industry had been completely humbled. Like the old Soviet Union twenty years earlier, it still may have looked formidable from the outside, but it was really an empty shell.  The industry had run out its string; it was entirely bereft of ideas. Its business model was completely broken, and it desperately needed an exit strategy. And it was due to the need to find a serviceable exit strategy that the industry supported Obamacare.

To understand what landed the insurance industry in this sad state of affairs, it is necessary to review its recent history.

The Rise of the For-Profit HMOs

When the Clintons set out to reform the American healthcare system in 1993, the health insurance industry initially claimed to support them. The Clintons had promised them a vast new market – the millions of heretofore uninsured Americans whose premiums would be paid, presumably, by the government.

But the alliance fell apart the moment the insurance industry began reading the massive tome of regulations the Clintons finally produced, and found in it much they didn’t like. Chiefly, they they didn’t like the parts that ceded full control of their industry to the government. So Big Health Insurance immediately turned against the Clintons, and spent millions of dollars introducing us to Harry and Louise (a “typical” American husband and wife who were viewed in numerous TV commercials discovering various appalling provisions of the Clinton plan). In the end, when the Clinton’s reform plan went down to ignominious defeat, the powerful health insurance industry, appropriately, got most of the credit.

Most of us Americans were happy at the time that the Clintons’ plan had been defeated, but during the debate over healthcare reform we had become convinced that the old way of doing healthcare wasn’t any good either. The healthcare system, we all knew by now, was bankrupting us.  And something needed to be done about it. But with the Clinton plan off the table, what were our options?

In the ashes of the Clintons’ failed effort, the health insurers saw their golden opportunity.  And they presented the American people with a savior. The savior was, of course, them.

The insurance industry made its pitch in a new guise which we Americans had never seen before. For the big fee-for-service insurance companies had transformed themselves into HMOs, and had fully assimilated the language of managed care. These were not the touchy-feely, non-profit HMOs that had been puttering around in the healthcare system for a decade or so.  These were meat-and-potatoes, for-profit HMOs, run for the most part by hard-nosed business executives, and newly formulated for a new era of American healthcare.

And here is what they said: “Citizens! We all – employers, patients, physicians, hospitals, manufacturers and insurers – have just dodged a bullet. Thanks to us, the frightening socialist reforms of the Clintons have been soundly defeated. But where does this leave us? We stand now between Scylla and Charybdis, between the specter of nationalized healthcare on one hand, and the continued profligacy of traditional fee-for-service medicine on the other. And we cannot countenance either. But here,” they continued, “is a third way. A painless way, based on the sound principles of managed care, open markets, and free enterprise. Let healthcare become a business like any other business, and the market forces will find ways not only to cut costs but also to improve quality, and with no government intervention.”

The offer, in other words, was to turn healthcare over to the business professionals now running the New Model HMOs, who were cocky with the certainty that they could harness the efficiencies of the marketplace to control costs, make a big profit at the same time, and be feted as saviors to boot. Because we’re Americans and we know the benefits of capitalism, and because the other choices we faced looked even worse, we all said, “Go for it.”

This change led to the most rapid transformation the American healthcare system has ever seen, and within a few short years, the majority of Americans were enrolled in HMOs, or some other species of corporate managed care.

So HMO executives set out to control the cost of American healthcare, and to make a spectacular profit doing it. And for a few years, they seemed successful. Healthcare inflation slowed dramatically in the late 1990s, and HMO profits soared.

But it was all an illusion.

The Fall of the For-Profit HMOs

The initial impressive profitability of New Model HMOs was due to the one-time reduction in cost you always get when you implement efficiencies of scale (made possible by merging enterprises), and by instituting the new standardization techniques favored by managed care theory. These steps reduced the cost of healthcare for a while, but the underlying rate of healthcare inflation (which is mostly caused by new medical technologies and an aging population, neither of which are cured by managed care) was pretty much unchanged. So by the early 2000s, when these one-time cost reductions had been fully realized, healthcare inflation was right back on the same unsustainable trajectory it had been on before.

Unfortunately for the HMOs, the big profits they enjoyed throughout the 1990s could not last. Their rapidly expanding valuations were attributable not to their efficient management of healthcare, but instead, to the frenzy of mergers that rapidly ensued, and to the acquisition and privatization of not-for-profit public assets for a tiny fraction of their true value.

So not long after the turn of the century the for-profit managed care companies were getting very nervous. For the very first time in their history, HMOs were faced with the prospect of having to earn their profits, profits sufficient to satisfy their shareholders, by actually managing the healthcare of sick people. This is something they had never accomplished before, and, by the time the election of 2008 approached, they knew they never would.

By that time they had tried everything. Beginning in 1994, filled with confidence and enthusiasm and cheered on (initially, at least) by the public and by public officials alike, the health insurance companies had more than 15 years of more-or-less unfettered freedom to institute any efficiencies it wanted to. In the ensuing years insurance companies tried all kinds of legitimate ideas for reducing healthcare costs, such as managed care, gatekeepers, clinical pathways, disease management programs, pay for performance, wellness programs, medical homes, and even a ruthless consolidation of the industry to achieve “efficiencies of scale.”

They also tried every sneaky and underhanded idea they could think of for reducing costs, like cherry-picking the healthy patients, treating chronically ill patients like pariahs so they would go away, making access to specialty care as inconvenient as possible, forcing doctors to sign “gag clauses” to prevent them from telling their patients about certain treatment options, browbeating primary care physicians into zombie-like compliance with handed-down care directives, refusing to cover expensive-but-effective medical services, and canceling the policies of tens of thousands of patients after they get sick, based on trumped-up technicalities. Indeed, they tried everything short of dispatching teams of Ninjas in the dark of night to slaughter their most expensive subscribers in their beds.  And finally, when all else failed, they instituted huge and unsustainable annual increases in premiums, to the point of driving their customers out of the market. (This latter move, of course, was an open acknowledgment that the industry had entered its death spiral.)

All these efforts were to little avail. The cost of healthcare continued to skyrocket, entirely unabated. And by 2009, when President Obama began his push for healthcare reform, the insurance companies knew they had no prospect of long-term profitability. Their business model was no longer viable, and, while telling soothing stories to avoid shareholder panic, they were urgently casting about for an exit strategy.

A drowning man will cling to any piece of flotsam that comes his way.  What the insurance industry found floating by was Obamacare.

What Health Insurers  Get From Obamacare

In return for its support in the healthcare reform battle, President Obama offered the insurance industry the graceful exit strategy it so desperately needed.  Under Obamacare, for at least a few years the insurers hope to get One Last Windfall – namely, profits from the influx of previously-uninsured Americans whose premiums will be paid – or at least subsidized – by taxpayers.  Here, the insurers are relying on the likelihood that the inflow of new premiums will, for a year or two at least, greatly outweigh the outflow of money they will have to spend caring for these new subscribers. Obviously, they will use every trick in their well-worn book to stave off expenditures for these new subscribers for as long as they can, but if they actually knew how to avoid paying healthcare costs indefinitely, they wouldn’t be seeking a government bail-out today. In any case, an inflow of new subscribers will be a very temporary source of profit for insurers. Hence, at best it is One Last Windfall.

What happens to the insurers after they exhaust this last windfall is still up in the air. Obamacare may, of course, eventually transition to a single-payer system, an outcome which many conservatives desperately fear, and many liberals fervently desire. In this case, there may very well be some final compensatory buy-out (or a buy-off) for the insurance companies. But more likely, the insurance companies under Obamacare will continue to exist essentially as public utilities. That is, they will exist as companies chartered by the government, which administer healthcare under the direction of the government, with the products they may offer, the prices they may charge, the profits they may keep, and the losses they may incur, determined solely by the government.  It’s not glorious, but it’s a living.

And it’s much better than where they would have ended up without Obamacare. Which is why they supported it from the start.

Now that we know why the insurance industry supported Obamacare, in the next post we will explore how the industry, at no small cost to its own public image, supported the President when it counted most.

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Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

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Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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Why Big Health Insurance Supported Obamacare, Part I

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 Another Reason He Should Have Kept the Bust [7:53m]: Play Now | Play in Popup | Download (33)

When President Obama moved into the White House in January of 2009, he found in the Oval Office a bust of Sir Winston Churchill, a gift from Great Britain to the United States during the Reagan presidency, a gift meant to symbolize the close ties between our two nations. The new President quickly decided he did not want to look at it. And, as one of the first acts of his presidency (before advancing his Stimulus Package, or pushing healthcare reform, or even inviting Andy Stern to dinner), he had that bust placed into a crate, packed with sawdust, and shipped by the afternoon mail right back to England.

DrRich can think of several reasons why it might have been a better idea, instead of beginning his reign with a completely gratuitous insult to America’s longest and best and most-needed ally, for President Obama to quietly have had the bust moved to the White House basement, where Sir Winston could have spent the next four to eight years contemplating all those other now-obsolete or embarrassing diplomatic trinkets, such as the gold plate from the Shah of Iran, and the fine old portrait of Ferdinand and Imelda Marcos.

And here’s one of them.

Despite the fact that President Obama was elected by a wide margin, and that he brought with him a filibuster-proof majority in the Senate and a large majority in the House, and that he had loyal, powerful and dogged leaders in each chamber of Congress who completely supported his agenda, and that the major American media was largely behind him all the way, the passage of the Obamacare legislation was very hard-fought, and a very close thing. Its ultimate passage was a major victory for the President, and a great tribute to his persistence. In fact, DrRich believes that President Obama has not received nearly enough credit for the utter doggedness and persistence he displayed in the face of the terrible headwinds he sometimes encountered while passing his healthcare reform agenda.

Indeed, during this arduous process, he was almost Churchillian in his steadfastness.

So, had he kept it, President Obama might now gaze upon bust of Churchill and see not the man who had campaigned against people of color in order to keep the British Empire together, but rather, a man who, not unlike himself, had almost single-handedly saved western civilization from the forces of evil.

But there is another striking similarity between these two men, aside from the remarkable singlemindedness they displayed under pressure, which is: neither of them could have succeeded alone. Their iron will, their persistence, their personal courage, and their (too often weak-kneed) support from political allies would not have carried the day, had it not been for the assistance of a powerful, if silent, partner.

In 1940-41, when Winston Churchill stood virtually alone against the Nazi onslaught, and with dwindling resources and a badly beaten military tried to face down a powerful enemy, he utterly relied on the support – often tacit, rarely public, only occasionally material, but always firm and unwavering – of Franklin Roosevelt. And no matter how bleak things looked, Churchill always believed that, one way or another, in the end President Roosevelt and the great might of the United States would provide a way to final victory.

Similarly, when the President’s initially smooth path to healthcare reform was suddenly interrupted by a blitzkrieg of contentious town hall meetings, followed closely by the formation of the vociferously anti-Obamacare Tea Party movement, followed next by the surprising victory of Chris Christie for the governorship of New Jersey, and capped by the stunning ascension of Scott Brown to the Senate seat long held by Ted Kennedy, an event that appeared to leave the prospects for healthcare reform so bleak that a week later the issue was barely raised in the State of the Union address, and that caused even the sympathetic press and some of his fellow Democrats to declare the prospects for healthcare reform to be dead, President Obama had to reach deep within himself to find the resolve for one last push. And in that dark moment he, too, was able to draw courage from the tacit, rarely public, only occasionally material, but strong and unwavering support of his own silent partner.

That silent partner, of course, was the American health insurance industry.

And as was the case with Sir Winston, in the moment of greatest crisis President Obama’s own silent partner threw itself into the fight with great abandon, and ultimately enabled a final victory.

Why the health insurance industry supported Obamacare, and how it did so, should be of more than mere casual interest to Americans. It has major implications for anyone who favors repealing Obamacare or major parts of it, or de-funding it, or declaring it unconstitutional. Anyone who is approaching the 2010 mid-term elections thinking that we can just get rid of Obamacare and go back to the way things were – or even to a substantial modification of the way things were – had better understand what just happened.

So in his next few posts, DrRich will examine the role that the American health insurance industry played in the passage of Obamacare, and what the recent behavior of that industry implies as we decide what we should – and can – do next.

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Why Big Health Insurance Supported Obamacare

Part II – Why the Health Insurance Industry Supported Obamacare
________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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 E&M Guidelines Undermine Patient Care, and That's The Point [14:43m]: Play Now | Play in Popup | Download (29)

Since the late 1990s, American physicians have labored under a set of tortuous documentation requirements imposed upon them by our government. The E&M guidelines (for “evaluation and management”), apply to the documentation that physicians are now obligated to provide in support of their Medicare billing. The E&M guidelines, first instituted in 1995 and revised in 1997, were part of the Clintons’ great fraud reduction initiative. Ostensibly, the strict documentation requirements reduce the opportunity for fraudulent billing.

While doctors initially railed against the E&M guidelines, they now suffer them in relative silence. The E&M guidelines have become, in fact, just one more hurdle which doctors must navigate as they pick their way through the vast obstacle course that now defines the practice of American medicine. Indeed, younger doctors accept the odious documentation requirements as a matter of course, knowing nothing better, just as children born into the direst third-world slums accept their abject poverty without notable complaint.

But occasionally, physicians of a certain age, dimly remembering how it ought to be, will still complain about these guidelines. One of these is revered fellow blogger DB, who (unlike DrRich) is still in the trenches, and must deal with – and try to teach trainees how to navigate through – this abomination on a daily basis. Accordingly, DB is periodically moved to remind us of what he graciously believes to be the unintended consequences resulting from the E&M guidelines, which is to say, DB seeks to remind us that current medical documentation requirements get in the way of good and efficient patient care.

For some, however, even this sort of mild-mannered, exceedingly polite objection is not to be countenanced. One of DB’s correspondents fired back at him:

“The templates are there to serve as a guide, not a hinderance. If you don’t like your “guide” then work to change it. You shouldn’t look at this “guide” as a form of billing, but rather as a guide in making sure you have covered your bases when seeing the patient. Proper documentation can lead to quality care and positive patient outcomes.”

This, indeed, is the official government position on E&M guidelines. It is so official, in fact, that it moves DrRich to wonder whether Cass Sunstein has actually implemented his well-documented anti-conspiracy strategy, and thus has dispatched armies of government-approved agents to monitor and actively counter “untruths” which are unfriendly to government aims, wherever they are found.

In any case, DrRich is not as polite (or as circumspect) as DB, and so he will say it outright.

The E&M guidelines were established for the specific purpose of controlling the behavior of physicians, to further the goals of covert rationing.

First and foremost, they create a Regulatory Speed Trap of the first order, so that with each and every patient encounter the item that will be foremost in the physician’s mind is not the needs of the patient, but in filling out the complex documentation in such a way as to avoid the appearance of committing a fraud. In practical terms, this means filling out the documentation so as to blend in with the masses, so that one’s records will be passed over by the sharp eyes of the greedy forensic accountants (who are paid by commission for detecting instances of substandard documentation, which are now construed as “fraud”), or even worse, by the sophisticated software now being deployed to detect ever-more nuanced gradations of “outliers.”

A classic post by The Happy Hospitalist describes the mysteries of E&M documentation better than any other attempt DrRich has seen. HH’s description of the documentation hoops through which physicians now must jump is detailed enough that it’s actually difficult to read. Which is the point.

Through their utter opacity and complexity, only partially reflected by the 48 pages of dense prose that comprise them, the E&M rules (for “rules” is what they are) in fact greatly magnify the doctor’s opportunity for making inadvertent documentation errors, and thus of producing a “fraudulent” bill. HH’s post nicely demonstrates how writing a progress note according to the E&M rules requires assembling a complicated set of “elements” from Column A and Column B, as from a Chinese menu, for each of four subject areas of the patient encounter – the history, the physical exam, the assessment, and the plan. Then somehow, one must translate the result (which reads like – and often is – a computer-generated form letter) into the proper, fully-supported billing code.

Even if this mess led to a straightforward means of determining proper billing codes (which it does not), it results in a medical progress note that is virtually undecipherable. This means that when another doctor (or even the same doctor on a different day) tries to read the progress notes to figure out what’s been going on with the patient (which used to be the point of medical progress notes, before they became primarily a vehicle for auditors), they cannot. Compliance with the E&M guidelines can thus actively confound patient care.

When the E&M guidelines were first introduced, they were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians (and the arrival on the scene of a new Republican administration) caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The commission concluded that indeed, the E&M guidelines were entirely counterproductive to patient care, and in June, 2002 voted (20-1) to recommend abandoning them altogether.

But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in force “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care – knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignation of the medical community.

(This simple example ought to teach us how difficult it will be to roll-back any of our new healthcare reforms in the future, even ones that are officially deemed to be harmful.)

Accordingly, not only has HHS failed to take (or, alternately, succeeded in not taking) steps to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them. And, as the bureaucrats must have predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now.

What’s more, there never will be. Save for the occasional exhortation from an old fossil (sorry, DB), the E&M guidelines have been fully absorbed into modern medical practice. They have become normal.

Accordingly, a multi-million dollar industry has sprung up to help physicians better comply with these coding guidelines. Physicians across the country are spending the time and money allotted for their continuing medical education learning to become better accountants, rather than better physicians.

Which brings DrRich to his last point: It is not actually possible to follow the E&M guidelines to anyone’s satisfaction.

There is, in fact, no “correct” way to code, because correct coding is impossible. This verity was proven a few years ago when a group of specialized government-sanctioned coders took a sample of typical doctor-patient visits, coded them according to their own E&M guidelines – and they all got different answers. (The results of this study were published in the Annals of Emergency Medicine in September, 2002.)

Obviously, then, since there is no “right” way to comply with the coding rules, any doctor toward whom the fickle finger of fate points the Feds is very likely to be found guilty of abuse, if not outright fraud. And what we’ve got here is a well-documented, openly acknowledged, peer-reviewed and published Regulatory Speed Trap.

Here’s what happens to doctors who are found to commit coding abuse (which is to say, to any doctors who are visited by Federally-sanctioned auditors):

1) A small sample of their patients’ charts is audited.
2) The error rate (with the auditor determining retrospectively what an error is) is calculated for that sample, then that rate is applied by extrapolation to all the Medicare billing the doctor has done for the past 6 years (the statute of limitations).
3) For each violation in coding the doctor is calculated to have committed during those six years, the doctor must pay a) triple the amount of restitution, and b) $11,000.00 (per coding violation).

It is not unusual for audited doctors to be hit with hundreds if not thousands of coding violations over a 6-year period, and the fines will almost always amount to well over 7 figures, if not 8. Even rich doctors usually can’t afford that kind of damage. However – if it’s just abuse the doctor has committed and not fraud – often the Feds may offer a settlement deal in the low 7 figures.

And here’s what happens if the coding violations are judged to be fraudulent (which, unfortunately, often appears a somewhat arbitrary designation):

1-3) All the above.
4) Jail

In summary, DB makes a very legitimate point, and has made this point several times over several years. Namely, the E&M coding rules are highly counterproductive to patient care. They produce medical records that are fundamentally undecipherable regarding actual medical content, even by medical professionals; and they distract physicians, with every patient encounter, into a fraud-avoidance exercise.

Sadly, however, DrRich does not believe that merely pointing out the harm being caused to thousands of patients each and every day by the E&M guidelines will do any good. Believing that it might do some good to call the Feds’ attention to it assumes that the harm is an unintended consequence, or at least, that it would be considered too high a price to pay.

This, DrRich feels obligated to reiterate, is demonstrably not the case. The Feds know that the E&M guidelines are harmful to patient care. Their own commission came to that very conclusion in 2002. The Feds know that failing to comply perfectly with the E&M guidelines in each and every case does not really indicate fraud and/or abuse, but is the necessary outcome when you institute a complex set of rules that not even the government’s own coders can interpret. Reminding the Feds of these facts, in public, may make them angry, but it will not change their position on E&M guidelines.

That the Feds continue to impose the E&M guidelines on physicians, despite the harm that they know this causes, tells us something very important about their underlying motives. When you are in the business of covertly rationing healthcare, controlling the physicians is Job One. And as George Orwell observed for us, when you want to control the behavior of some population, a critical step is to control the mode, the rules, and even the very language of communication.

That physicians continue to comply with such oppressions, despite the harm they know this causes, and (with notable exceptions) without serious complaint, tells us something important about them, too. DrRich would rather not say what that is.

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Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Why should you still read DrRich’s book, Fixing American Healthcare, even though our leaders have just fixed American healthcare for us?

Four reasons.

First, DrRich humbly suggests, you may be insufficiently paranoid about American healthcare, whether it’s the style of healthcare we have now, or the New Style Healthcare that is rapidly coming our way thanks to healthcare reform. DrRich’s book will quickly remedy this deficiency.

DrRich, of course (wise beyond even his not-inconsiderable-years), understands that in certain cases, free-ranging paranoia may not be the healthiest of conditions. So, Fixing American Healthcare not only shows you who’s out to get you, and why, and how they propose to do it, but also shows you what you can do to protect yourself and your loved ones. For paranoia is not always so bad, so long as it’s constructively actionable.

Second, Fixing American Healthcare introduces you to the Grand Unification Theory of Healthcare (GUTH), a simple and elegant model that permits even the novice to understand the essence of any healthcare system you can imagine. The GUTH will come in very handy as our new healthcare system unfolds, rooted as it is in layer upon layer of bureaucratic obfuscation, specifically designed to keep us (the unwashed masses) from understanding what’s really going on. With the GUTH, you will understand our healthcare system even better than the ones who are supposed to be running it.

Third, when is the last time you read a book on healthcare policy that’s actually entertaining?

And fourth, Fixing American Healthcare is now available in Kindle format, and for the low price of only $4.99. So, whether you prefer receiving electronic enlightenment on your Kindle, PC, iPhone, Blackberry, Android, or iPAD, now you can read DrRich’s book in its new, pixellated format.

Save a life or two. Read Fixing American Healthcare.

Get it here.

*****

Here’s what the reviewers say about Fixing American Healthcare.

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 Why the American NICE Will Not Be Like the British NICE [9:45m]: Play Now | Play in Popup | Download (138)

The United Kingdom’s National Institute for Clinical Excellence (NICE) has now issued its final ruling on the new cancer drug, Nexavar, which has proven effective in treating liver cancer. NICE will not cover Nexavar “because its high cost could not be justified by its marginal benefit.”

In a well-designed randomized clinical trial, Nexavar significantly prolonged the survival of patients with liver cancer, by an average of 2.8 months. Prolonging survival by a little less than 3 months may not seem like much, except for two things. First, that’s only the average. Some liver cancer patients treated with Nexavar have survived a year or longer, a result which is at least a little remarkable. And second, Nexavar represents a true and long-awaited breakthrough in the effort to find an effective treatment for hepatocellular carcinoma. Until Nexavar came along no chemotherapy had ever been shown to significantly prolong the survival of patients with liver cancer. For the first time, thanks to Nexavar, these unfortunate patients have been offered a real glimmer of hope.

But alas, Nexavar is expensive. Very expensive. It was a difficult drug to develop and test and bring to market, and it is expensive to make. So to recoup its costs, and to make the sort of profit that justifies its risk, the Bayer company is charging about $5000 a month for Nexavar. This means that any insurance company or government that agrees to pay for this drug is going to be out some big bucks.

The UK’s NICE was not being evil when it declined to pay for Nexavar. NICE simply did the math, and determined that spending money for the marginal benefit provided by Nexavar would create too high an opportunity cost – that is, that money would be better spent elsewhere, on other patients, for greater gain.

This is what open healthcare rationing looks like. It’s ugly, all right. But because it is open and transparent, making clear to everyone the rationale for its coverage decisions, NICE gives the British electorate all the information it needs to decide whether to accept the process, or to change it. This is far better – far more equitable and far less destructive to a society – than rationing healthcare covertly. DrRich tips his hat to NICE.

But DrRich notes that this recent decision by NICE has caused some of his conservative friends to descend into major bouts of caterwauling. Horrified that NICE has condemned liver cancer patients to an avoidable premature death, they insist we all notice that Obamacare creates an Outcomes Research Institute that is modeled after the British NICE, and so, we could soon have the same kinds of coverage decisions here in the U.S. American citizens, they demand, must consider how well they will like it when some government “panel” refuses to cover life-saving medical therapies because they are too expensive.

DrRich agrees that Americans will not like it much at all, but believes his conservative colleagues are overlooking an important difference between the British NICE, and any American NICE that might accompany our new healthcare system.

The Brits are plagued with a constant deluge of new medical products that are extremely expensive, and that, like Nexavar, offer real but only marginal improvements over current, cheaper therapies. Each time NICE has to render a coverage decision on one of these new therapies, the process is painful for everyone involved. But, being Brits, when faced with a difficult but necessary task they suck it up and carry on.

It is important to note, however, that the British NICE is required to deal with a constant stream of new medical products only because there is a ready market for those products elsewhere, and that market is in the U.S.

For, in the U.S., we have always recognized that medical progress usually occurs in incremental steps, and that to encourage continued medical progress we have to accept (and pay for) these incremental steps. That is, medical progress is much like all other forms of progress. Americans famously went to the moon, for instance, but did not do so all at once. Hundreds of incremental steps were required, several of which were seemingly trivial and expensive, and others of which involved catastrophe and tragedy. But we all understood that this is how one gets to the moon.

So a product like Nexavar, which does not cure liver cancer but gets us one step closer, would traditionally be viewed in the U.S. as an important incremental step toward the ultimate goal. And indeed, in contrast to the British NICE, the FDA has approved the use of Nexavar for liver cancer. This approval, in turn, encourages medical industry to keep going.

But consider: If a new American NICE steps in, and begins refusing to cover treatments that provide only incremental improvements, then the companies that invest hundreds of millions of dollars to achieve those incremental steps will simply stop doing so. After our new American NICE refuses to cover Nexavar-like therapies two or three times, medical industry will get the message loud and clear, and as a simple matter of corporate survival will change its business model. And the rapid succession of new medical therapies we have enjoyed will stop, or at least slow markedly.*

This means, of course, that if our new American NICE can just find the intestinal fortitude to make a few tough calls like the one the Brits have just made, and stick with those tough calls despite the firestorm that may ensue, then the hard part of their job will end. Forever. Pretty soon, they simply won’t be faced with any more Nexavars.

The healthcare bureaucrats in Britain and elsewhere around the world, whose jobs are made very difficult by the continual medical progress which is stimulated by the traditional American healthcare system, are cheering on our new reforms. Most especially, they are praying that the American NICE will have enough backbone to do what needs to be done. If the Americans can just make a few of the tough calls the Brits and others have had to make routinely, the job of healthcare bureaucrats will become vastly easier all over the world.

In any case, the prospect raised by conservative alarmists – of a NICE-like panel that is forever condemning American patients to an early death through their refusal to cover effective new therapies – will be only a very temporary phenomenon. After a very short time, such coverage decisions will no longer be necessary, and Americans will no longer be subjected to the anguish these decisions will provoke.

*If individual Americans are permitted to purchase with their own money medical products that are not approved for coverage by the government, then at least some stimulus will persist for continued medical progress. But as DrRich has documented in detail, the plan is to disallow such individual prerogatives.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

 

 Physician-Industry Relationships – What Is Appropriate? [21:13m]: Play Now | Play in Popup | Download (185)

The following is a close approximation of a talk DrRich gave to a gathering of some of the world’s most promising young cardiac electrophysiologists, in Nice, France, on June 15, 2010. He was asked to talk to these young physicians about physician-industry relationships. The organizers of this gathering apparently did not know, as anyone who reads this blog would know, that DrRich should never, ever be allowed an opportunity to influence promising young physicians.  But, what’s done is done.

* * * * * * * *
A worldwide controversy is now roiling over the appropriate relationship between physicians and industry. Superficially at least, this controversy has to do with the undisputed fact that a physician’s relationship with industry can unduly influence his or her behavior.

That is, this controversy is said to be related to the conflicts of interest (COI) that are always inherent, to some degree, in such relationships.

I believe there is a deeper, and far more disturbing, reason behind this controversy, and I will address it in a short while.  But let’s first talk about COI, because it is ostensibly the chief concern, and it is in fact a very important issue.

A COI is present when an individual has a sacred, fiduciary duty (i.e., a duty of trust) to Entity A, but then develops a secondary relationship with Entity B, which (by creating self-interest, competing loyalties, or even just an inability to be objective), threatens to interfere with the primary duty to Entity A.

Physicians, especially academic physicians, have (at various times) at least three primary fiduciary duties that must take priority. These are: a duty to patients when practicing medicine; a duty to students (i.e., actual students, colleagues, or the public) when teaching; and a duty to society (and truth itself) when conducting medical research.  It is clear that ties with specific companies and their products can easily create important COI that may interfere with each of these primary fiduciary duties, and it is equally clear that physicians have commonly allowed this interference to happen.

Far more often than we like to imagine, doctors have allowed bias to creep in when recommending a course of action for their patients, in imparting knowledge to trainees, colleagues or the public, or when designing, analyzing or reporting results of clinical trials. And typically, most doctors who exercise inappropriate bias have convinced themselves that they are really acting in the best interests of their patients, students or society at large. For it is quite difficult to be objective about one’s own COI.

And there is no question that industry has become adept at the gentle art of creating COI among physicians (subliminally whenever possible), and have carefully incorporated the creation of such conflicts into their business models.

Obvious abuses we have all seen include doctors “shilling” for companies or their products at national meetings; clinical guidelines committees seeded with biased members; unbelievable amounts of money (well above “fair market value) being paid to key doctors for consulting services; long advertisements disguised as CME events; and ghost-writing scientific papers, then recruiting prominent physicians to sign on as “authors” after the fact. There are many others.

Such ongoing abuses of our fiduciary duties ought to be deeply embarrassing to us in the medical profession.

And if it’s not embarrassing, it is at least becoming painful. In the US, physicians who are discovered doing some of these things are being called out publicly, being investigated by Congress if not the Justice Department, losing their prestigious academic positions, and having their reputations destroyed. It is hard to be sympathetic toward them.

Despite all the negative attention – both public and legal – that such COI have brought to our profession in recent years, many of us continue to have tin ears.  A recent example, which has caused a stir in the blogosphere if nowhere else, happens to relate to the EP community. (Thanks to Larry Huston of Cardiobrief who did the heavy lifting on this one. )

Recently, the ACC/HRS collaborated in the launch of a new website, called AFibProfessional.org, which is described as “a unique collaboration to address atrial fibrillation for the cardiology community.” The site has only one corporate sponsor – Sanofi, the maker of Multaq.

At the time of launch, all the content on this new website consisted merely of old, recycled material from older ACC and HRS websites, with a single exception. The single exception was a slide lecture by a prominent electrophysiologist, who we all know and love, on “Managing Atrial Fibrillation.”  This lecture makes a strong case for the off-label, off-guideline use of Multaq. The lecture was posted without any COI disclosure statements, though the lecturer, it turns out, has significant financial ties to Sanofi.  When the matter became a public issue, the lecture was pulled from the site, and the ACC promised to investigate. A few days later, the investigation apparently completed to the ACC’s satisfaction, the lecture was reposted, this time with a COI disclosure.

While one hesitates to suggest malfeasance here, it certainly looks bad.  For the ACC and HRS to co-sponsor a brand new website that , by all appearances, is chiefly a vehicle for advertising Multaq suggests, if nothing else, that we in the medical profession, and our professional organizations, still don’t get it. If we don’t police our own COI, it will be policed for us.

What remedy should be applied?  A reasonable approach would be to recognize that physician-industry ties will always bring at least some COI, and to manage the problem by strictly limiting inappropriate COI, and fully disclosing any that remain.

Accordingly, a number of groups – most prominently the Institute Of Medicine – have recently made formal, and tough, recommendations regarding physician-industry relationships. The final “rules” under which we will all have to live are still being negotiated.

But it is highly likely that they will include many if not all of the following:

-    Doctors should not accept any gifts, no matter how small, from industry. These include trivialities such as pens and notepads, and more substantial gifts such as meals and travel.
-    Doctors should not give presentations in which content is controlled or influenced by industry.
-    Doctors should not consult for industry without a written contract, nor should they receive more than “fair market value” for consulting activities.
-    Doctors should not accept drug samples from industry.
-    Doctors who have a financial interest in a product or company should not participate in clinical trials in any capacity that involve that product or company, including patient enrollment, data collection, analysis or reporting.
-    Doctors who have industry ties should not participate in the development of clinical guidelines.
-    Medical schools and professional organizations should not accept direct funding, or attributable funding, for CME.
-    Any interaction with industry will be fully disclosed, and made publicly available.

What this “full disclosure” will look like can be seen in the Physician Payment Sunshine Act, a law which is pending in the US. Under this act,  all “transfers of value” totaling $100 or more in a year to any physician will be reported by each company to the government annually, along with each physician’s identifying information. Such “TOV” includes food, trinkets, entertainment or gifts; travel; consulting fees or honoraria; funding for research or education; stocks or stock options; ownership or investment interest, and any other economic benefit.  This information will be posted on a public, searchable government website. Companies will be fined $10,000 for each incident of an unreported TOV.

You younger physicians will be spending your careers in a COI environment that is significantly different from that which we, your elders, have experienced. Activities that have been acceptable, and even encouraged, will now cause you to be publicly stigmatized, or worse. This matter is in great flux, and you need to pay close attention to it as the rules are changing. In the meantime, you need to choose your interactions with industry very carefully, and very circumspectly.

Everything I have just discussed assumes that the real issue regarding doctor-industry relationships is COI. Indeed, everything I have discussed assumes a particular way of looking at industry relationships, which I will call Theory A. Theory A, goes as follows:

Theory A:

-  Medical progress is Good, and benefits mankind.
-  Industry is responsible for a high proportion of medical progress.
-  Industry-driven progress requires the active participation of physicians.
-  Therefore, a well-managed cooperation between industry and physicians is beneficial to mankind, and ought to be encouraged.

If you subscribe to Theory A you believe that, because well-managed physician-industry relationships benefit mankind, these relationships are good. So, fundamentally, it’s the management of these relationships which is at issue. These beneficial relationships produce unavoidable COI, which we must manage by strictly limiting their extent, and fully disclosing the ones that are left.

On the surface, at least, that’s what the debate is about – where to draw the necessary limits.  But just below the surface, the debate is about something else entirely. Beneath the surface, Theory A is rejected outright.

Today we hear prominent voices telling us that merely managing COI does not go far enough. No amount of COI is acceptable, and ALL physician-industry ties should be prohibited.  Among these is Jerome Kassirer, former editor of the New England Journal of Medicine, who says, “The ideal handling of COI is not to have them at all.” For these voices, Theory A simply does not apply. Rather, (I submit) they subscribe to Theory B:

Theory B:

-    The greed of medical industry creates excessive costs, and produces far more harm to society than good.
-    Physician-industry alliances strengthen industry, and increase the harm.
-    Therefore, crippling these unholy alliances is critical to the interests of society.

A corollary of Theory B is that it can only be the State’s job to cripple these alliances.

Proponents of Theory B, noting, not incorrectly, that medical industry is chiefly concerned with profits rather than the public good, conclude that industry will always behave in ways that are counter to the interests of society.  While many proponents of Theory B will agree that industry provides at least some benefits, they are convinced that these benefits are far outweighed by the harm they produce. Therefore, Theory B proposes to stifle, if not cripple, medical industry. And a very useful strategy for achieving this goal is to de-legitimize any practical relationships whatsoever between medical industry and physicians.

Proponents of Theory B rarely say what their real goal is. Most of them give lip service to Theory A. One must discern their real motives from their behavior.

Much of that behavior, in practical terms, has to do with controlling the flow of information. Let industry develop whatever it wants (perhaps), but don’t let profit-drunk industry – or its greedy physician spokespersons – instruct doctors and patients on who gets to use industry’s products, or when and how.

That kind of information can only be managed by unbiased sources. Proponents of Theory B invariably refer to government-appointed panels of experts to determine which products of industry are good and bad, and to manage the flow of information about them. Information coming from anywhere else is to be regarded as being charged with bias and greed, and should be ignored, or even suppressed.

Inherent in this viewpoint is the notion that the State is an honest broker, with no bias of its own, except to do what is best for the population. The State, in its disinterested beneficence, is the only civil entity which can pass judgment on which medical information is suitable for general consumption.

But even as a general proposition, no government is an unbiased and honest broker. Politics, according to Harold Lasswell, an early Progressive political scientist, is determining who gets what, when and how. Government officials do not cancel their own human nature when they put on a government name tag. As they go about the business of determining who gets what, when and how, they inevitably – and most often intentionally – create various favored constituencies, fiefdoms, and clienteles to suit their own goal. That goal is to consolidate and expand their own authority. In this way, in the exercise of its political mandate the government always creates co-dependencies, and determines winners and losers. So even in the general case, the government cannot be an honest broker.

But with regard to healthcare, government bias goes far beyond the general case. Healthcare spending is the chief problem governments face today. In the US, projected Medicare expenditures over the next 30 – 40 years will be $35-55 trillion. Numbers like this are deeply destabilizing, and simply cannot be abided, and promise nothing but chaos, revolution, and societal disintegration.

To the State, controlling healthcare spending is an existential problem, a matter of life and death, an issue that justifies any solution that has even a slight chance of working.

Why is the cost of healthcare rising so rapidly? Fundamentally, it is medical progress. Medical progress has greatly increased overall healthcare expenditures. Simply consider, for instance, the many fatal illnesses we have converted to chronic, and chronically expensive diseases – coronary artery disease, kidney disease, HIV/AIDS, various forms of cancer, and heart failure, to name a few.  Medical progress has made great strides in early detection and prevention, and preventive medicine always increases the cost of care.  And thanks at least partly to medical progress, life expectancies are on the rise, and people have many more years to consume healthcare.

Medical progress is very expensive, and the more we have of it the more it costs. The State can only look at medical progress and say, “Medical progress is killing us.”

But it is not politically feasible to come right out and say that stifling medical progress is necessary to the survival of the State. Rather, the State must assert that what it is stifling is greed.

Hillary Clinton gave us the State’s operative formulation in 1993: “There are just too many greedy doctors using too much expensive technology.”  So, to control costs, the State must control the doctors; and the State must control the technology, which is to say, industry.

I submit that an underlying theme within the debate over doctor-industry relationships is a desire to greatly slow or even stop the real threat to the State: medical progress, and the vast expenditures which medical progress produces.

The State has several means for stifling medical progress.  The State can institute increasingly oppressive regulations, which can have the effect of hamstringing industry, but more importantly, has the effect of converting industry to a client of the State, dependent on the State’s favors for its success. The State can demonize industry, trying to convince the public that drug companies and medical device companies are evil entities that would just as soon harm them as help them, and indeed, without the strong hand of the State would prefer to distribute pain and suffering as the more favored pathway to windfall profits. But more to the point of today’s discussion, the State can stifle the doctor-industry relationships that are so critical in steering medical progress in a clinically relevant direction.

So the  interests of industry must be represented as being fundamentally counter to the interests of society, and the doctors who have relationships with industry must be painted as their evil (or, at best, deluded) minions.

Yes, industry is biased, and industry will act on that bias whenever they can get away with it. Industry just can’t help itself. That’s just the way it is.

But the State is also biased. And the State will also act on that bias whenever they can get away with it. The State can’t help itself. That’s just the way it is.

Industry will try to exercise its influence over us by data-driven persuasion, and when that fails they will try to sweeten the persuasion, perhaps even with subtle or not-so-subtle bribes.

But the exercise of persuasion is even more dangerous when done by the State. While the State may also try to influence us with data-driven persuasion, it is very quick to resort instead to propaganda (i.e., the art of information-control by which the unwashed masses are told only what the specialized classes have determined is best for them), and when that fails, the State will resort to its ultimate form of persuasion – the enforcement of new and suppressive regulations at the point of a gun.

So, while industry is indeed biased, and needs to be kept at arms length, de-legitimizing industry altogether would be disastrous.  It would create an open field for extraordinarily powerful forces which are at least as biased, but in the opposite direction. If we value medical progress, we need the balance that industry provides – and that includes not only industry’s products, but its voice.

Medical progress driven by industry-physician collaboration is good for mankind. But that collaboration inevitably creates conflicts. We physicians need to control those conflicts, or the collaboration will be forcibly terminated altogether. Our professional history to date is bleak in this regard, and we only have one chance left to get it right, if that.

But in controlling our COI, we should not allow ourselves to be pushed too far. We should agree to reasonable limits on conflicts, and on full disclosure of any conflicts that remain. But we should draw the line when we are urged to forgo all relationships with industry altogether. We must recognize that industry and its selfish goals provide a necessary counterbalance to even more powerful forces whose goal is to stifle medical progress.

I don’t ask that you accept my synthesis of this problem at face value. I simply ask that you listen to what I am suggesting, and observe for yourself what is happening out in the wild. Then challenge yourself to come up with a better explanation for what you see happening out there. I sincerely hope you can, as I would much rather that my conclusions were not true. So if you do come up with a better explanation, I will greatly appreciate hearing about it.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

 

 Even Dermatologists Have Skin In This Game [15:44m]: Play Now | Play in Popup | Download (176)

Recently, DrRich wrote a series of posts detailing how the American healthcare system – even before the new reforms kick in – is taking steps to prevent individual citizens from being allowed to spend their own money on their own healthcare. Part of that effort, of course, is to restrict physicians from offering direct-pay medical services to their patients.

DrRich may have given the impression that only primary care doctors are affected by efforts to restrict their practices in this way. If so, he apologizes.

He particularly owes an apology to his friends the dermatologists. Indeed, DrRich has been reminded of an article that appeared in the New York Times a while back, which castigated dermatologists for the sin of establishing direct-pay practices, and in particular, for creating their own brand of a two-tiered healthcare system – one for patients with skin disorders, and one for “cosmetic dermatology.”

As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally several months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, fuzz balls on the floor, old magazines, the unruly children of other patients, and surly office personnel. Eventually the now-even-more-disheartened patient’s name is called by an indifferent nurse practitioner, who, operating from a checklist of questions, will “triage” her to the appropriate patient-category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), then have her strip in order to fully expose the large organ (i.e., the skin) for which she has sought assistance, hand her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see His Holiness, the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern, and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, placing her bundle of clothing into her arms and wishing her a good day, the doctor shoves her out into the hall to finish dressing, as the formal interview is completed, and the exam room is at a premium.

Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.

Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.

The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of their clients who have an impending public engagement, and thus need to look their best. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a careful assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, studying, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitude and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose, with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the outcome.

Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?

DrRich has a word of advice for the scandalized reporters of the New York Times, and any other concerned Americans who are worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.

Allow DrRich to support this friendly recommendation with two observations.

1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. A second tier is necessary if for no other reason than political leaders and other individuals critically important to the collective effort must have somewhere to go for their healthcare.  The second tier, like the poor, will always be with us.

2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re not really patients but widgets on an assembly line, then spends Wednesday in her other, much more amenable offices, treating the merely cosmetically-challenged like they are minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, on Tuesday she is practicing real, true, prescribed-by-society, by-the-book American healthcare, just as our leaders (in their wisdom) have carefully set it up for us, and on Wednesday she is doing Something Altogether Different.

Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.

Furthermore, when one looks at it objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, most folks would do just fine with it.

The sheer arbitrariness by which injecting Botox is deemed by the authorities to constitute the practice of medicine can also be illustrated by considering a somewhat different, equally well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the actual skin itself than Botox injections (which do not really affect the skin itself, but only the muscles under the skin). DrRich speaks, obviously, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly technical skill like that.  The point being, of course, that if you were to describe Botox injections and tattooing to a visitor from Mars, then ask him/her/it which of these two dermatological procedures ought to require a medical license and board certification, the Martian would get it wrong every time.

DrRich understands, of course, that while administering Botox is, in practical and objective terms, no more practicing medicine than is applying an ice-pack to a bruised knee, legally it is indeed deemed to be the practice of medicine. Accordingly, doctors in general (and dermatologists in particular), relying on this nonsensical designation, have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing – which, in contrast to Botox injections, is an actual surgical procedure which is intended to result in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious crime.

But fundamentally, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine.  Not when ear-piercing and tattooing are not. Rather, in real life, injecting Botox is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.

To say it another way, when the dermatologist goes to her “other office” to cater to a self-paying variety of clientele, she is practicing medicine only from the most arbitrary and strictly legalistic viewpoint. In real life, she is doing Something Else. She is engaging in a Pastime.

Doctors, of course, often have Pastimes. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some do charity work, or go to graduate school for an MBA. Still others have opted to work part time in order to raise their families.

Society generally finds such activities acceptable, and – to this point – does not insist that all doctors forgo all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty to the collective, it has not reached this point quite yet.

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen really very soon now), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming direct-pay practitioners.

One last word of advice for DrRich’s dermatology friends: Have fun with your Botox clinics for now, fellas and ladies, but please don’t become too invested in them.  This is definitely a shallow-moat line of business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control – say, Congress or the FDA – could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots, or even learn a real skill, like tattooing – but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Now that President Obama’s healthcare reform has become the law of the land, it is time for us to prepare ourselves for the real fight. Namely, will individual Americans ultimately be restrained, by law or by subterfuge, from using their own resources to pay for their own medical care?  This notion is not as far-fetched as you might think. In this series of posts, DrRich explores this question, and demonstrates just how far we’ve already come in limiting the healthcare prerogatives of individuals.

Limiting Individual Prerogatives:

Part 1: The Real Fight Is Just Beginning

Part 2: Hillary Started It

Part 3: Breaking the Doctor-Patient Relationship

Part 4: Medicare Already Does It

Sure, nobody’s read the bill, and even if they had, what Nancy said is true: To find out what’s in the bill, they first had to pass it (so the bureaucrats could translate it into the hundreds of thousands of regulations that would finally determine its meaning). But there’s no need to wait for the regulators to sort it all out. DrRich can tell you what you need to know about our new healthcare system right now!

Healthcare Reform Explained – An Updated Guide For The Perplexed

PCP’s: Here’s All You Need To Know About Our New Healthcare System

Why the Health Insurers Saved the Day

The Individual Mandate Will Stand

The Audacity of Perpetuity

Some Powers of the Immutables

(A Heartfelt Plea To Certain Authors Of The Health Care Renewal Blog)

Podcast:

 

 Defending the Anti-Obesity Movement, Again [12:35m]: Play Now | Play in Popup | Download (53)

The other day, President Obama gave a commencement speech in which he pointed out one of the downsides of living in a new age of electronic communication:

“Meanwhile, you’re coming of age in a 24/7 media environment that bombards us with all kinds of content and exposes us to all kinds of arguments, some of which don’t rank all that high on the truth meter. . . .[I]nformation becomes a distraction, a diversion, a form of entertainment, rather than a tool of empowerment. All of this is not only putting new pressures on you; it is putting new pressures on our country and on our democracy.”

In other words, too much information can be bad (since it can be untruthful, and places pressure on our country and democracy). Clearly implied in this statement is the idea that something ought to be done about all that extraneous information out there. Presumably, disinterested truth-tellers in our unbiased government bureaucracies ought to sort out fact from fiction, and take the necessary steps to get rid of the fiction. This is not the first time the White House has offered to monitor the utterings of wrong-thinking Americans, and to do what is needed to correct their misapprehensions. Rather, it is simply another reinforcement of a consistent theme under our current administration.

We had best take it seriously.

And so, it is with some reluctance that DrRich finds it necessary at this time to perform an intervention. He does so with the kindest of motives, namely, to protect two people he greatly admires from finding themselves on the wrong side of a Federal disinformation bust.

DrRich speaks, of course, of Dr. Roy Poses and his colleague MedInformaticsMD (who had best not rely on an easily-decoded pseudonym for protection), two of the principle authors of the excellent Health Care Renewal blog. Both of these highly respected physicians and bloggers have posted articles this week which are critical of individuals who have spoken out against obese Americans.

Dr. Poses started it, pointing out that certain high-profile executives who have made recent public statements decrying obesity, and ridiculing (and offering to discriminate against) the obese, are pontificating on an issue about which they have no professional expertise.

MedInformaticsMD upped the ante by referring to these same executives as obesity bigots, and pointing out (rather colorfully) that such a person “talks stupidly and discriminatorily out of his anal orifice about how much people put in the other end of their GI tracts.”

Now, DrRich does not know how likely it is that Federal truth-tellers will stumble across these offensive posts. Given the stuff DrRich himself has said about healthcare reform and our government, he hopes it is unlikely indeed.

But Gentlemen of the HCR blog! Whereas DrRich habitually employs enough irony in his writings that most stone-witted bureaucrats (he hopes!) will have trouble discerning what he actually thinks, your prose is uncomfortably straightforward, and leaves no room for interpretation. If they find it, you are screwed.

And so, DrRich begs you to allow him an opportunity to set you straight on American obesity, and the importance of the anti-obesity movement.

To understand this, one must understand the underlying premise: Under any soup-to-nuts universal healthcare system (which, DrRich submits, is the ultimate goal), our central authorities, in the name of controlling costs, have got to be able to restrict, control and tax virtually any human behavior they can claim may lead to an increased risk of healthcare expenditures – which, really, encompasses virtually any human behavior you can think of.

Such power on the part of our central authorities will feel “unnatural” to many if not most Americans, if not developed judiciously. And so, it makes sense to develop such power – to set precedents which, once set, will be impossible to stop – by demonizing the obese, and making it not only OK, but imperative, for the government to control their unutterably selfish behavior, and, failing that, to punish them.

It is not difficult to demonize the obese. In literature and films the obese have long been portrayed as unreasonably jolly, slovenly and lazy, or just plain evil. (Hello, Newman!) Nobody likes to sit next to them on airplanes or buses. They block the aisles at the grocery store (their favorite haunts), and they reduce miles-per-gallon (and cause excessive tire wear) when they ride in our cars. On humid days, they sweat (and thus smell) more than you and I. So, with rare exceptions (and it is unfortunate that you two Gentlemen comprise one of these), nobody complains when the obese are criticized and attacked.

Given the current hypersensitivity to anything smacking of criticism of various races, ethnic groups, professions, political movements, sexual orientations, immigration status, victims of certain diseases, and scores of other categories of Americans, the obese present us with a refreshingly – and indeed the only – safe target. As the authors of the HCR blog point out, prominent and respected figures feel no compunction whatsoever against making the most offensive public statements against the obese, and when they do they receive (with rare exceptions such as provided by you HRC Gentlemen) applause rather than condemnation.

Obesity is a condition which is immediately visible to all – and from a great distance – and which immediately labels one as being selfish and lazy, and, now, as entirely unconcerned that their bad behavior is costing the rest of us our healthcare dollars, and thus, potentially our lives. Hating the obese has become nearly a patriotic imperative.

Fully government-funded and government-controlled healthcare (by whatever subterfuge we finally get there) permits – nay, demands! – that we declare to the obese that their unsightly physiques are no longer a matter of personal choice, but are now a matter of legitimate public concern. The choices they are making – that is, their gluttony, sloth and all other manner of self-indulgence – are placing unwanted and unsustainable demands on us purer, svelter, fellow-citizens, not to mention placing us in danger of not receiving the healthcare which we (in contrast) actually deserve.

It is already far too late, Gentlemen, to appeal to mere reasonableness, rationality, or, especially civility.  We are well past that stage. Observe: It has become acceptable to write, and accept for publication, “scientific” papers claiming that the obese are the chief cause of global warming. Observe again: It has become acceptable to write, and accept for publication, “scientific” papers claiming that obesity is contagious, and that – never mind associating with the obese themselves – it is risky associating with the very friends of the obese. (That is, even those who like, or tolerate, fat people are to be shunned.)

By their own selfish actions, actions which threaten the collective far more than merely themselves, the obese have become fair game for whatever manipulations our government can devise to cause them to either lose weight, or pay for their sins. Such maneuvers may begin with simple taxes on foodstuffs favored by the obese, but the sky’s the limit. A special “carbon tax” based on their BMI would be legitimate, for instance, since it will always cost a lot of energy to move a fat person from point A to point B, whatever the mode of transportation. The periodic mandatory public “weigh-ins” such a tax would justify would serve the useful purpose of public humiliation, an important incentive to weight loss. And it goes without saying that the ultimate censure – already employed in more enlightened cultures such as Great Britain – would be simply to withhold certain healthcare services if one is deemed too fat.

Demonizing the obese provides several important precedents to our central authorities. That it sets an important precedent – and establishes the mechanisms and techniques – for controlling the private behaviors of American citizens is obvious. But it also allows us to place the blame for a medical condition, which largely depends on genetic predisposition, solely on the chosen behavior of its victims. Discriminating against those who have genetically-mediated conditions thus becomes possible.

Discriminating against obesity also sets a precedent for discriminating against the lower economic classes (since obesity, rather than starvation, is the chief nutritional problem of the poor in America). This will prove a useful tool when we set future behavioral standards to reduce healthcare spending, since so much of that spending is for the economically disadvantaged.

And so, Gentlemen of the HRC blog, it ought to be painfully clear that successfully demonizing the obese is a vital pillar of our new healthcare system. And when you express the unfortunate ideas the two of you have published this week (namely, that discrimination against the obese is somehow unhelpful), you are placing a large target on yourselves, and on your otherwise excellent blog. (And by extension, you may be placing more innocent blogs, like this one,  under more official scrutiny than might be comfortable.)

DrRich sincerely hopes you will take these comments in the communal spirit in which they are intended.